{ "hospital_name": "Lawrence County Hospital", "last_updated_on": "2026-03-25", "version": "3.0.0", "location_name": [ "Lawrence County Hospital" ], "hospital_address": [ "1065 E Broad Street, , Monticello, MS 39654" ], "license_information": { "state": "MS", "license_number": "11222" }, "type_2_npi": [ "281932211851" ], "attestation": { "attestation": "To the best of its knowledge and belief, this hospital has included all applicable standard charge information in accordance with the requirements of 45 CFR 180.50, and the information encoded is true, accurate, and complete as of the date in the file. This hospital has included all payer-specific negotiated charges in dollars that can be expressed as a dollar amount. For payer-specific negotiated charges that cannot be expressed as a dollar amount in the machine-readable file or not knowable in advance, the hospital attests that the payer-specific negotiated charge is based on a contractual algorithm, percentage or formula that precludes the provision of a dollar amount and has provided all necessary information available to the hospital for the public to be able to derive the dollar amount, including, but not limited to, the specific fee schedule or components referenced in such percentage, algorithm or formula.", "confirm_attestation": true, "attester_name": "Mallory Ginn, CFO" }, "standard_charge_information": [ { "description": "Ecmo or tracheostomy with mv >96 hours or principal diagnosis except face, mouth and neck with major o.r. procedures", "code_information": [ { "code": "003", "type": "MS-DRG" } ], "standard_charges": [ { "gross_charge": 83614.72, "setting": "inpatient" } ] }, { "description": "Tracheostomy with mv >96 hours or principal 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procedures without cc/mcc", "code_information": [ { "code": "346", "type": "MS-DRG" } ], "standard_charges": [ { "gross_charge": 31979.04, "setting": "inpatient" } ] }, { "description": "Inguinal and femoral hernia procedures without cc/mcc", "code_information": [ { "code": "352", "type": "MS-DRG" } ], "standard_charges": [ { "gross_charge": 25261.94, "setting": "inpatient" } ] }, { "description": "Hernia procedures except inguinal and femoral with mcc", "code_information": [ { "code": "353", "type": "MS-DRG" } ], "standard_charges": [ { "gross_charge": 70307.48, "setting": "inpatient" } ] }, { "description": "Hernia procedures except inguinal and femoral with cc", "code_information": [ { "code": "354", "type": "MS-DRG" } ], "standard_charges": [ { "gross_charge": 55653.47, "setting": "inpatient" } ] }, { "description": "Hernia procedures except inguinal and femoral without cc/mcc", "code_information": [ { "code": "355", "type": "MS-DRG" } ], "standard_charges": [ { "gross_charge": 91100.35, "setting": "inpatient" } ] }, { "description": "Other digestive system o.r. procedures with mcc", "code_information": [ { "code": "356", "type": "MS-DRG" } ], "standard_charges": [ { "gross_charge": 38095.71, "setting": "inpatient" } ] }, { "description": "Other digestive system o.r. procedures with cc", "code_information": [ { "code": "357", "type": "MS-DRG" } ], "standard_charges": [ { "gross_charge": 33051.61, "setting": "inpatient" } ] }, { "description": "Major esophageal disorders with mcc", "code_information": [ { "code": "368", "type": "MS-DRG" } ], "standard_charges": [ { "gross_charge": 62240.93, "setting": "inpatient" } ] }, { "description": "Major gastrointestinal disorders and peritoneal infections with cc", "code_information": [ { "code": "372", "type": "MS-DRG" } ], "standard_charges": [ { "gross_charge": 21768.28, "setting": "inpatient" } ] }, { "description": "Digestive malignancy with mcc", "code_information": [ { "code": "374", "type": "MS-DRG" } ], "standard_charges": [ { "gross_charge": 31837.30, "setting": "inpatient" } ] }, { "description": "Digestive malignancy with cc", "code_information": [ { "code": "375", "type": "MS-DRG" } ], "standard_charges": [ { "gross_charge": 19432.88, "setting": "inpatient" } ] }, { "description": "Gastrointestinal hemorrhage with mcc", "code_information": [ { "code": "377", "type": "MS-DRG" } ], "standard_charges": [ { "gross_charge": 27260.93, "setting": "inpatient" } ] }, { "description": "Gastrointestinal hemorrhage with cc", "code_information": [ { "code": "378", "type": "MS-DRG" } ], "standard_charges": [ { "gross_charge": 17851.54, "setting": "inpatient" } ] }, { "description": "Gastrointestinal hemorrhage without cc/mcc", "code_information": [ { "code": "379", "type": "MS-DRG" } ], "standard_charges": [ { "gross_charge": 12210.70, "setting": "inpatient" } ] }, { "description": "Complicated peptic ulcer with cc", "code_information": [ { "code": "381", "type": "MS-DRG" } ], "standard_charges": [ { "gross_charge": 45535.88, "setting": "inpatient" } ] }, { "description": "Inflammatory bowel disease with mcc", "code_information": [ { "code": "385", "type": "MS-DRG" } ], "standard_charges": [ { "gross_charge": 19918.07, "setting": "inpatient" } ] }, { "description": "Inflammatory bowel disease with cc", "code_information": [ { "code": "386", "type": "MS-DRG" } ], "standard_charges": [ { "gross_charge": 12831.51, "setting": "inpatient" } ] }, { "description": "Inflammatory bowel disease without cc/mcc", "code_information": [ { "code": "387", "type": "MS-DRG" } ], "standard_charges": [ { "gross_charge": 21421.35, "setting": "inpatient" } ] }, { "description": "Gastrointestinal obstruction with mcc", "code_information": [ { "code": "388", "type": "MS-DRG" } ], "standard_charges": [ { "gross_charge": 39860.15, "setting": "inpatient" } ] }, { "description": "Gastrointestinal obstruction with cc", "code_information": [ { "code": "389", "type": "MS-DRG" } ], "standard_charges": [ { "gross_charge": 23865.69, "setting": "inpatient" } ] }, { "description": "Esophagitis, gastroenteritis and miscellaneous digestive disorders with mcc", "code_information": [ { "code": "391", "type": "MS-DRG" } ], "standard_charges": [ { "gross_charge": 23230.56, "setting": "inpatient" } ] }, { "description": "Esophagitis, gastroenteritis and miscellaneous digestive disorders without mcc", "code_information": [ { "code": "392", "type": "MS-DRG" } ], "standard_charges": [ { "gross_charge": 23343.65, "setting": "inpatient" } ] }, { "description": "Other digestive system diagnoses with mcc", "code_information": [ { "code": "393", "type": "MS-DRG" } ], "standard_charges": [ { "gross_charge": 27361.42, "setting": "inpatient" } ] }, { "description": "Other digestive system diagnoses with cc", "code_information": [ { "code": "394", "type": "MS-DRG" } ], "standard_charges": [ { "gross_charge": 6426.23, "setting": "inpatient" } ] }, { "description": "Other digestive system diagnoses without cc/mcc", "code_information": [ { "code": "395", "type": "MS-DRG" } ], "standard_charges": [ { "gross_charge": 17792.46, "setting": "inpatient" } ] }, { "description": "Appendix procedures with mcc", "code_information": [ { "code": "397", "type": "MS-DRG" } ], "standard_charges": [ { "gross_charge": 25405.22, "setting": "inpatient" } ] }, { "description": "Appendix procedures without cc/mcc", "code_information": [ { "code": "399", "type": "MS-DRG" } ], "standard_charges": [ { "gross_charge": 28385.05, "setting": "inpatient" } ] }, { "description": "Cholecystectomy except by laparoscope without c.d.e. with cc", "code_information": [ { "code": "415", "type": "MS-DRG" } ], "standard_charges": [ { "gross_charge": 44817.22, "setting": "inpatient" } ] }, { "description": "Cholecystectomy except by laparoscope without c.d.e. without cc/mcc", "code_information": [ { "code": "416", "type": "MS-DRG" } ], "standard_charges": [ { "gross_charge": 20831.60, "setting": "inpatient" } ] }, { "description": "Laparoscopic cholecystectomy without c.d.e. with mcc", "code_information": [ { "code": "417", "type": "MS-DRG" } ], "standard_charges": [ { "gross_charge": 23174.71, "setting": "inpatient" } ] }, { "description": "Laparoscopic cholecystectomy without c.d.e. with cc", "code_information": [ { "code": "418", "type": "MS-DRG" } ], "standard_charges": [ { "gross_charge": 31538.63, "setting": "inpatient" } ] }, { "description": "Laparoscopic cholecystectomy without c.d.e. without cc/mcc", "code_information": [ { "code": "419", "type": "MS-DRG" } ], "standard_charges": [ { "gross_charge": 21180.77, "setting": "inpatient" } ] }, { "description": "Other hepatobiliary or pancreas o.r. procedures with mcc", "code_information": [ { "code": "423", "type": "MS-DRG" } ], "standard_charges": [ { "gross_charge": 34822.64, "setting": "inpatient" } ] }, { "description": "Cirrhosis and alcoholic hepatitis with mcc", "code_information": [ { "code": "432", "type": "MS-DRG" } ], "standard_charges": [ { "gross_charge": 26281.50, "setting": "inpatient" } ] }, { "description": "Cirrhosis and alcoholic hepatitis with cc", "code_information": [ { "code": "433", "type": "MS-DRG" } ], "standard_charges": [ { "gross_charge": 24438.09, "setting": "inpatient" } ] }, { "description": "Malignancy of hepatobiliary system or pancreas with mcc", "code_information": [ { "code": "435", "type": "MS-DRG" } ], "standard_charges": [ { "gross_charge": 22880.46, "setting": "inpatient" } ] }, { "description": "Malignancy of hepatobiliary system or pancreas with cc", "code_information": [ { "code": "436", "type": "MS-DRG" } ], "standard_charges": [ { "gross_charge": 30728.44, "setting": "inpatient" } ] }, { "description": "Disorders of pancreas except malignancy with mcc", "code_information": [ { "code": "438", "type": "MS-DRG" } ], "standard_charges": [ { "gross_charge": 32124.45, "setting": "inpatient" } ] }, { "description": "Disorders of liver except malignancy, cirrhosis or alcoholic hepatitis with mcc", "code_information": [ { "code": "441", "type": "MS-DRG" } ], "standard_charges": [ { "gross_charge": 17237.33, "setting": "inpatient" } ] }, { "description": "Disorders of liver except malignancy, cirrhosis or alcoholic hepatitis with cc", "code_information": [ { "code": "442", "type": "MS-DRG" } ], "standard_charges": [ { "gross_charge": 16364.50, "setting": "inpatient" } ] }, { "description": "Disorders of the biliary tract with mcc", "code_information": [ { "code": "444", "type": "MS-DRG" } ], "standard_charges": [ { "gross_charge": 18235.76, "setting": "inpatient" } ] }, { "description": "Disorders of the biliary tract with cc", "code_information": [ { "code": "445", "type": "MS-DRG" } ], "standard_charges": [ { "gross_charge": 20867.07, "setting": "inpatient" } ] }, { "description": "Wound debridement and skin graft except hand for musculoskeletal and connective tissue disorders with mcc", "code_information": [ { "code": "463", "type": "MS-DRG" } ], "standard_charges": [ { "gross_charge": 30245.28, "setting": "inpatient" } ] }, { "description": "Wound debridement and skin graft except hand for musculoskeletal and connective tissue disorders with cc", "code_information": [ { "code": "464", "type": "MS-DRG" } ], "standard_charges": [ { "gross_charge": 31326.60, "setting": "inpatient" } ] }, { "description": "Revision of hip or knee replacement with cc", "code_information": [ { "code": "467", "type": "MS-DRG" } ], "standard_charges": [ { "gross_charge": 65287.19, "setting": "inpatient" } ] }, { "description": "Major hip and knee joint replacement or reattachment of lower extremity without mcc", "code_information": [ { "code": "470", "type": "MS-DRG" } ], "standard_charges": [ { "gross_charge": 32870.82, "setting": "inpatient" } ] }, { "description": "Amputation for musculoskeletal system and connective tissue disorders with mcc", "code_information": [ { "code": "474", "type": "MS-DRG" } ], "standard_charges": [ { "gross_charge": 66283.47, "setting": "inpatient" } ] }, { "description": "Amputation for musculoskeletal system and connective tissue disorders with cc", "code_information": [ { "code": "475", "type": "MS-DRG" } ], "standard_charges": [ { "gross_charge": 32023.67, "setting": "inpatient" } ] }, { "description": "Biopsies of musculoskeletal system and connective tissue with cc", "code_information": [ { "code": "478", "type": "MS-DRG" } ], "standard_charges": [ { "gross_charge": 22646.08, "setting": "inpatient" } ] }, { "description": "Biopsies of musculoskeletal system and connective tissue without cc/mcc", "code_information": [ { "code": "479", "type": "MS-DRG" } ], "standard_charges": [ { "gross_charge": 22646.08, "setting": "inpatient" } ] }, { "description": "Hip and femur procedures except major joint with mcc", "code_information": [ { "code": "480", "type": "MS-DRG" } ], "standard_charges": [ { "gross_charge": 36540.27, "setting": "inpatient" } ] }, { "description": "Hip and femur procedures except major joint with cc", "code_information": [ { "code": "481", "type": "MS-DRG" } ], "standard_charges": [ { "gross_charge": 32670.62, "setting": "inpatient" } ] }, { "description": "Hip and femur procedures except major joint without cc/mcc", "code_information": [ { "code": "482", "type": "MS-DRG" } ], "standard_charges": [ { "gross_charge": 32180.92, "setting": "inpatient" } ] }, { "description": "Knee procedures with principal diagnosis of infection with cc", "code_information": [ { "code": "486", "type": "MS-DRG" } ], "standard_charges": [ { "gross_charge": 17957.46, "setting": "inpatient" } ] }, { "description": "Knee procedures without principal diagnosis of infection with cc/mcc", "code_information": [ { "code": "488", "type": "MS-DRG" } ], "standard_charges": [ { "gross_charge": 42097.20, "setting": "inpatient" } ] }, { "description": "Lower extremity and humerus procedures except hip, foot and femur with mcc", "code_information": [ { "code": "492", "type": "MS-DRG" } ], "standard_charges": [ { "gross_charge": 69230.06, "setting": "inpatient" } ] }, { "description": "Lower extremity and humerus procedures except hip, foot and femur with cc", "code_information": [ { "code": "493", "type": "MS-DRG" } ], "standard_charges": [ { "gross_charge": 50433.70, "setting": "inpatient" } ] }, { "description": "Lower extremity and humerus procedures except hip, foot and femur without cc/mcc", "code_information": [ { "code": "494", "type": "MS-DRG" } ], "standard_charges": [ { "gross_charge": 27919.44, "setting": "inpatient" } ] }, { "description": "Soft tissue procedures with mcc", "code_information": [ { "code": "500", "type": "MS-DRG" } ], "standard_charges": [ { "gross_charge": 42946.61, "setting": "inpatient" } ] }, { "description": "Other musculoskeletal system and connective tissue o.r. procedures with mcc", "code_information": [ { "code": "515", "type": "MS-DRG" } ], "standard_charges": [ { "gross_charge": 46791.27, "setting": "inpatient" } ] }, { "description": "Hip replacement with principal diagnosis of hip fracture with mcc", "code_information": [ { "code": "521", "type": "MS-DRG" } ], "standard_charges": [ { "gross_charge": 59946.56, "setting": "inpatient" } ] }, { "description": "Hip replacement with principal diagnosis of hip fracture without mcc", "code_information": [ { "code": "522", "type": "MS-DRG" } ], "standard_charges": [ { "gross_charge": 33609.29, "setting": "inpatient" } ] }, { "description": "Fractures of femur without mcc", "code_information": [ { "code": "534", "type": "MS-DRG" } ], "standard_charges": [ { "gross_charge": 9851.75, "setting": "inpatient" } ] }, { "description": "Fractures of hip and pelvis with mcc", "code_information": [ { "code": "535", "type": "MS-DRG" } ], "standard_charges": [ { "gross_charge": 45147.99, "setting": "inpatient" } ] }, { "description": "Fractures of hip and pelvis without mcc", "code_information": [ { "code": "536", "type": "MS-DRG" } ], "standard_charges": [ { "gross_charge": 10573.07, "setting": "inpatient" } ] }, { "description": "Osteomyelitis with cc", "code_information": [ { "code": "540", "type": "MS-DRG" } ], "standard_charges": [ { "gross_charge": 38616.74, "setting": "inpatient" } ] }, { "description": "Septic arthritis with cc", "code_information": [ { "code": "549", "type": "MS-DRG" } ], "standard_charges": [ { "gross_charge": 31855.89, "setting": "inpatient" } ] }, { "description": "Medical back problems with mcc", "code_information": [ { "code": "551", "type": "MS-DRG" } ], "standard_charges": [ { "gross_charge": 14910.80, "setting": "inpatient" } ] }, { "description": "Medical back problems without mcc", "code_information": [ { "code": "552", "type": "MS-DRG" } ], "standard_charges": [ { "gross_charge": 18687.71, "setting": "inpatient" } ] }, { "description": "Bone diseases and arthropathies with mcc", "code_information": [ { "code": "553", "type": "MS-DRG" } ], "standard_charges": [ { "gross_charge": 16532.62, "setting": "inpatient" } ] }, { "description": "Aftercare, musculoskeletal system and connective tissue with cc", "code_information": [ { "code": "560", "type": "MS-DRG" } ], "standard_charges": [ { "gross_charge": 19809.97, "setting": "inpatient" } ] }, { "description": "Fracture, sprain, strain and dislocation except femur, hip, pelvis and thigh with mcc", "code_information": [ { "code": "562", "type": "MS-DRG" } ], "standard_charges": [ { "gross_charge": 31167.84, "setting": "inpatient" } ] }, { "description": "Fracture, sprain, strain and dislocation except femur, hip, pelvis and thigh without mcc", "code_information": [ { "code": "563", "type": "MS-DRG" } ], "standard_charges": [ { "gross_charge": 13655.35, "setting": "inpatient" } ] }, { "description": "Other musculoskeletal system and connective tissue diagnoses with mcc", "code_information": [ { "code": "564", "type": "MS-DRG" } ], "standard_charges": [ { "gross_charge": 22542.14, "setting": "inpatient" } ] }, { "description": "Other musculoskeletal system and connective tissue diagnoses without cc/mcc", "code_information": [ { "code": "566", "type": "MS-DRG" } ], "standard_charges": [ { "gross_charge": 14336.51, "setting": "inpatient" } ] }, { "description": "Skin debridement with mcc", "code_information": [ { "code": "570", "type": "MS-DRG" } ], "standard_charges": [ { "gross_charge": 30552.73, "setting": "inpatient" } ] }, { "description": "Skin debridement with cc", "code_information": [ { "code": "571", "type": "MS-DRG" } ], "standard_charges": [ { "gross_charge": 24125.54, "setting": "inpatient" } ] }, { "description": "Other skin, subcutaneous tissue and breast procedures with mcc", "code_information": [ { "code": "579", "type": "MS-DRG" } ], "standard_charges": [ { "gross_charge": 34637.21, "setting": "inpatient" } ] }, { "description": "Other skin, subcutaneous tissue and breast procedures with cc", "code_information": [ { "code": "580", "type": "MS-DRG" } ], "standard_charges": [ { "gross_charge": 21557.05, "setting": "inpatient" } ] }, { "description": "Breast biopsy, local excision and other breast procedures with cc/mcc", "code_information": [ { "code": "584", "type": "MS-DRG" } ], "standard_charges": [ { "gross_charge": 23154.73, "setting": "inpatient" } ] }, { "description": "Skin ulcers with mcc", "code_information": [ { "code": "592", "type": "MS-DRG" } ], "standard_charges": [ { "gross_charge": 18026.05, "setting": "inpatient" } ] }, { "description": "Cellulitis with mcc", "code_information": [ { "code": "602", "type": "MS-DRG" } ], "standard_charges": [ { "gross_charge": 26331.66, "setting": "inpatient" } ] }, { "description": "Cellulitis without mcc", "code_information": [ { "code": "603", "type": "MS-DRG" } ], "standard_charges": [ { "gross_charge": 22393.25, "setting": "inpatient" } ] }, { "description": "Trauma to the skin, subcutaneous tissue and breast with mcc", "code_information": [ { "code": "604", "type": "MS-DRG" } ], "standard_charges": [ { "gross_charge": 25488.26, "setting": "inpatient" } ] }, { "description": "Amputation of lower limb for endocrine, nutritional and metabolic disorders with mcc", "code_information": [ { "code": "616", "type": "MS-DRG" } ], "standard_charges": [ { "gross_charge": 30177.54, "setting": "inpatient" } ] }, { "description": "Amputation of lower limb for endocrine, nutritional and metabolic disorders with cc", "code_information": [ { "code": "617", "type": "MS-DRG" } ], "standard_charges": [ { "gross_charge": 18917.77, "setting": "inpatient" } ] }, { "description": "Skin grafts and wound debridement for endocrine, nutritional and metabolic disorders with mcc", "code_information": [ { "code": "622", "type": "MS-DRG" } ], "standard_charges": [ { "gross_charge": 45811.05, "setting": "inpatient" } ] }, { "description": "Skin grafts and wound debridement for endocrine, nutritional and metabolic disorders with cc", "code_information": [ { "code": "623", "type": "MS-DRG" } ], "standard_charges": [ { "gross_charge": 15358.83, "setting": "inpatient" } ] }, { "description": "Other endocrine, nutritional and metabolic o.r. procedures with mcc", "code_information": [ { "code": "628", "type": "MS-DRG" } ], "standard_charges": [ { "gross_charge": 17192.12, "setting": "inpatient" } ] }, { "description": "Other endocrine, nutritional and metabolic o.r. procedures with cc", "code_information": [ { "code": "629", "type": "MS-DRG" } ], "standard_charges": [ { "gross_charge": 15264.26, "setting": "inpatient" } ] }, { "description": "Diabetes with mcc", "code_information": [ { "code": "637", "type": "MS-DRG" } ], "standard_charges": [ { "gross_charge": 20398.25, "setting": "inpatient" } ] }, { "description": "Diabetes with cc", "code_information": [ { "code": "638", "type": "MS-DRG" } ], "standard_charges": [ { "gross_charge": 16185.27, "setting": "inpatient" } ] }, { "description": "Diabetes without cc/mcc", "code_information": [ { "code": "639", "type": "MS-DRG" } ], "standard_charges": [ { "gross_charge": 12119.45, "setting": "inpatient" } ] }, { "description": "Miscellaneous disorders of nutrition, metabolism, fluids and electrolytes with mcc", "code_information": [ { "code": "640", "type": "MS-DRG" } ], "standard_charges": [ { "gross_charge": 22657.26, "setting": "inpatient" } ] }, { "description": "Miscellaneous disorders of nutrition, metabolism, fluids and electrolytes without mcc", "code_information": [ { "code": "641", "type": "MS-DRG" } ], "standard_charges": [ { "gross_charge": 16204.32, "setting": "inpatient" } ] }, { "description": "Inborn and other disorders of metabolism", "code_information": [ { "code": "642", "type": "MS-DRG" } ], "standard_charges": [ { "gross_charge": 34519.87, "setting": "inpatient" } ] }, { "description": "Endocrine disorders with mcc", "code_information": [ { "code": "643", "type": "MS-DRG" } ], "standard_charges": [ { "gross_charge": 32953.40, "setting": "inpatient" } ] }, { "description": "Endocrine disorders with cc", "code_information": [ { "code": "644", "type": "MS-DRG" } ], "standard_charges": [ { "gross_charge": 24915.50, "setting": "inpatient" } ] }, { "description": "Kidney and ureter procedures for non-neoplasm with cc", "code_information": [ { "code": "660", "type": "MS-DRG" } ], "standard_charges": [ { "gross_charge": 19944.62, "setting": "inpatient" } ] }, { "description": "Kidney and ureter procedures for non-neoplasm without cc/mcc", "code_information": [ { "code": "661", "type": "MS-DRG" } ], "standard_charges": [ { "gross_charge": 19937.98, "setting": "inpatient" } ] }, { "description": "Prostatectomy with mcc", "code_information": [ { "code": "665", "type": "MS-DRG" } ], "standard_charges": [ { "gross_charge": 26080.08, "setting": "inpatient" } ] }, { "description": "Prostatectomy with cc", "code_information": [ { "code": "666", "type": "MS-DRG" } ], "standard_charges": [ { "gross_charge": 20984.81, "setting": "inpatient" } ] }, { "description": "Transurethral procedures with mcc", "code_information": [ { "code": "668", "type": "MS-DRG" } ], "standard_charges": [ { "gross_charge": 34724.05, "setting": "inpatient" } ] }, { "description": "Transurethral procedures with cc", "code_information": [ { "code": "669", "type": "MS-DRG" } ], "standard_charges": [ { "gross_charge": 20510.77, "setting": "inpatient" } ] }, { "description": "Urethral procedures with cc/mcc", "code_information": [ { "code": "671", "type": "MS-DRG" } ], "standard_charges": [ { "gross_charge": 17546.60, "setting": "inpatient" } ] }, { "description": "Other kidney and urinary tract procedures with mcc", "code_information": [ { "code": "673", "type": "MS-DRG" } ], "standard_charges": [ { "gross_charge": 36654.67, "setting": "inpatient" } ] }, { "description": "Other kidney and urinary tract procedures with cc", "code_information": [ { "code": "674", "type": "MS-DRG" } ], "standard_charges": [ { "gross_charge": 49543.62, "setting": "inpatient" } ] }, { "description": "Renal failure with mcc", "code_information": [ { "code": "682", "type": "MS-DRG" } ], "standard_charges": [ { "gross_charge": 34777.96, "setting": "inpatient" } ] }, { "description": "Renal failure with cc", "code_information": [ { "code": "683", "type": "MS-DRG" } ], "standard_charges": [ { "gross_charge": 20530.20, "setting": "inpatient" } ] }, { "description": "Kidney and urinary tract infections with mcc", "code_information": [ { "code": "689", "type": "MS-DRG" } ], "standard_charges": [ { "gross_charge": 22749.36, "setting": "inpatient" } ] }, { "description": "Kidney and urinary tract infections without mcc", "code_information": [ { "code": "690", "type": "MS-DRG" } ], "standard_charges": [ { "gross_charge": 20646.09, "setting": "inpatient" } ] }, { "description": "Urinary stones with mcc", "code_information": [ { "code": "693", "type": "MS-DRG" } ], "standard_charges": [ { "gross_charge": 11990.17, "setting": "inpatient" } ] }, { "description": "Urinary stones without mcc", "code_information": [ { "code": "694", "type": 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"payer_name": "Aetna Ppo Hmo", "plan_name": "701720_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Ms State Emplo", "plan_name": "401457", "standard_charge_percentage": 0.80, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Ms State Emplo", "plan_name": "401457_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Basic Pl", "plan_name": "400100", "standard_charge_percentage": 0.85, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Basic Pl", "plan_name": "400100_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Federal", "plan_name": "400110", "standard_charge_percentage": 0.85, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Federal", "plan_name": "400110_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." } ] } ] }, { "description": "Calcium polycarbophil 625 mg tablet [11046]", "drug_information": { "unit": 1.00, "type": "EA" }, "code_information": [ { "code": "0005-2500-02", "type": "NDC" } ], "standard_charges": [ { "gross_charge": 1.00, "minimum": 0.80, 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"methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Basic Pl", "plan_name": "400100_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Federal", "plan_name": "400110", "standard_charge_percentage": 0.85, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Federal", "plan_name": "400110_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." } ] } ] }, { "description": "Molnupiravir 200 mg capsule (eua) [195765]", "drug_information": { "unit": 1.00, "type": 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"payer_name": "Aetna Ppo Hmo", "plan_name": "701720", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Ppo Hmo", "plan_name": "701720_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Ms State Emplo", "plan_name": "401457", "standard_charge_percentage": 0.80, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Ms State Emplo", "plan_name": "401457_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Basic Pl", "plan_name": "400100", "standard_charge_percentage": 0.85, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Basic Pl", "plan_name": "400100_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Federal", "plan_name": "400110", "standard_charge_percentage": 0.85, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Federal", "plan_name": "400110_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." } ] } ] }, { "description": "Sulfasalazine 500 mg tabletdelayed release [7563]", "drug_information": { "unit": 1.00, "type": "EA" }, "code_information": [ { "code": "0013-0102-60", "type": "NDC" } ], "standard_charges": [ { "gross_charge": 9.40, "minimum": 7.52, "maximum": 7.99, "setting": "both", "payers_information": [ { "payer_name": "Aetna", "plan_name": "700700", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna", "plan_name": "700700_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Miscellaneous", "plan_name": "700720", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to 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amounts." }, { "payer_name": "Bc/Bs Ms State Emplo", "plan_name": "401457_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Basic Pl", "plan_name": "400100", "standard_charge_percentage": 0.85, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Basic Pl", "plan_name": "400100_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Federal", "plan_name": "400110", "standard_charge_percentage": 0.85, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Federal", "plan_name": "400110_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." } ] } ] }, { "description": "White petrolatum-mineral oil 56.8 %-42.5 % eye ointment [117955]", "drug_information": { "unit": 3.50, "type": "GR" }, "code_information": [ { "code": "0023-0312-04", "type": "NDC" } ], "standard_charges": [ { "gross_charge": 60.28, "minimum": 48.22, "maximum": 51.24, "setting": "both", "payers_information": [ { "payer_name": "Aetna", "plan_name": "700700", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna", "plan_name": "700700_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", 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"additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Ms State Emplo", "plan_name": "401457", "standard_charge_percentage": 0.80, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Ms State Emplo", "plan_name": "401457_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Basic Pl", "plan_name": "400100", "standard_charge_percentage": 0.85, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Basic Pl", "plan_name": "400100_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Federal", "plan_name": "400110", "standard_charge_percentage": 0.85, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Federal", "plan_name": "400110_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." } ] } ] }, { "description": "Cyclosporine 0.05 % eye drops in a dropperette [35209]", "drug_information": { "unit": 1.00, "type": "EA" }, "code_information": [ { "code": "0023-9163-30", "type": "NDC" } ], "standard_charges": [ { "gross_charge": 48.08, "minimum": 38.46, "maximum": 40.87, "setting": "both", "payers_information": [ { "payer_name": "Aetna", "plan_name": "700700", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna", "plan_name": "700700_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Miscellaneous", "plan_name": "700720", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Miscellaneous", "plan_name": "700720_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Ppo Hmo", "plan_name": "701720", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Ppo Hmo", "plan_name": "701720_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Ms State Emplo", "plan_name": "401457", "standard_charge_percentage": 0.80, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Ms State Emplo", "plan_name": "401457_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Basic Pl", "plan_name": "400100", "standard_charge_percentage": 0.85, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Basic Pl", "plan_name": "400100_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Federal", "plan_name": "400110", "standard_charge_percentage": 0.85, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Federal", "plan_name": "400110_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." } ] } ] }, { "description": "Brimonidine 0.2 %-timolol 0.5 % eye drops [87834]", "drug_information": { "unit": 5.00, "type": "ML" }, "code_information": [ { "code": "0023-9211-05", "type": "NDC" } ], "standard_charges": [ { "gross_charge": 912.00, "minimum": 729.60, "maximum": 775.20, "setting": "both", "payers_information": [ { "payer_name": "Aetna", "plan_name": "700700", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna", "plan_name": "700700_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Miscellaneous", "plan_name": "700720", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Miscellaneous", "plan_name": "700720_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Ppo Hmo", "plan_name": "701720", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Ppo Hmo", "plan_name": "701720_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Ms State Emplo", "plan_name": "401457", "standard_charge_percentage": 0.80, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Ms State Emplo", "plan_name": "401457_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Basic Pl", "plan_name": "400100", "standard_charge_percentage": 0.85, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Basic Pl", "plan_name": "400100_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Federal", "plan_name": "400110", "standard_charge_percentage": 0.85, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Federal", "plan_name": "400110_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." } ] } ] }, { "description": "Brimonidine 0.1 % eye drops [70262]", "drug_information": { "unit": 5.00, "type": "ML" }, "code_information": [ { "code": "0023-9321-05", "type": "NDC" } ], "standard_charges": [ { "gross_charge": 868.73, "minimum": 694.98, "maximum": 738.42, "setting": "both", "payers_information": [ { "payer_name": "Aetna", "plan_name": "700700", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna", "plan_name": "700700_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna 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"plan_name": "401457", "standard_charge_percentage": 0.80, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Ms State Emplo", "plan_name": "401457_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Basic Pl", "plan_name": "400100", "standard_charge_percentage": 0.85, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Basic Pl", "plan_name": "400100_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Federal", "plan_name": "400110", "standard_charge_percentage": 0.85, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Federal", "plan_name": "400110_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." } ] } ] }, { "description": "Verapamil er (sr) 240 mg tabletextended release [8531]", "drug_information": { "unit": 1.00, "type": "EA" }, "code_information": [ { "code": "0025-1891-31", "type": "NDC" } ], "standard_charges": [ { "gross_charge": 42.24, "minimum": 33.79, "maximum": 35.90, "setting": "both", "payers_information": [ { "payer_name": "Aetna", "plan_name": "700700", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna", "plan_name": "700700_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Miscellaneous", "plan_name": "700720", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Miscellaneous", "plan_name": "700720_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Ppo Hmo", "plan_name": "701720", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Ppo Hmo", "plan_name": "701720_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Ms State Emplo", "plan_name": "401457", "standard_charge_percentage": 0.80, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Ms State Emplo", "plan_name": "401457_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Basic Pl", "plan_name": "400100", "standard_charge_percentage": 0.85, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Basic Pl", "plan_name": "400100_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Federal", "plan_name": "400110", "standard_charge_percentage": 0.85, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Federal", "plan_name": "400110_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." } ] } ] }, { "description": "Hydrocortisone 1 %-pramoxine 1 % rectal foam [28849]", "drug_information": { "unit": 10.00, "type": "GR" }, "code_information": [ { "code": "0037-6822-10", "type": "NDC" } ], "standard_charges": [ { "gross_charge": 879.42, "minimum": 703.54, "maximum": 747.51, "setting": "both", "payers_information": [ { "payer_name": "Aetna", "plan_name": "700700", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna", "plan_name": "700700_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Miscellaneous", "plan_name": "700720", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Miscellaneous", "plan_name": "700720_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Ppo Hmo", "plan_name": "701720", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Ppo Hmo", "plan_name": "701720_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Ms State Emplo", "plan_name": "401457", "standard_charge_percentage": 0.80, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Ms State Emplo", "plan_name": "401457_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Basic Pl", "plan_name": "400100", "standard_charge_percentage": 0.85, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Basic Pl", "plan_name": "400100_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Federal", "plan_name": "400110", "standard_charge_percentage": 0.85, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Federal", "plan_name": "400110_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." } ] } ] }, { "description": "Lactase 9000 unit tablet [109044]", "drug_information": { "unit": 1.00, "type": "EA" }, "code_information": [ { "code": "0045-0910-32", "type": "NDC" } ], "standard_charges": [ { "gross_charge": 7.50, "minimum": 6.00, "maximum": 6.38, "setting": "both", "payers_information": [ { "payer_name": "Aetna", "plan_name": "700700", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna", "plan_name": "700700_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Miscellaneous", "plan_name": "700720", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", 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"percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Ms State Emplo", "plan_name": "401457_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Basic Pl", "plan_name": "400100", "standard_charge_percentage": 0.85, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Basic Pl", "plan_name": "400100_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Federal", "plan_name": "400110", "standard_charge_percentage": 0.85, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Federal", "plan_name": "400110_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." } ] } ] }, { "description": "Acetaminophen 500 mg tablet [102]", "drug_information": { "unit": 1.00, "type": "EA" }, "code_information": [ { "code": "0045044909", "type": "NDC" } ], "standard_charges": [ { "gross_charge": 1.00, "minimum": 0.80, "maximum": 0.85, "setting": "both", "payers_information": [ { "payer_name": "Aetna", "plan_name": "700700", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna", "plan_name": "700700_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Miscellaneous", "plan_name": "700720", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Miscellaneous", "plan_name": "700720_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Ppo Hmo", "plan_name": "701720", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Ppo Hmo", "plan_name": "701720_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Ms State Emplo", "plan_name": "401457", "standard_charge_percentage": 0.80, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Ms State Emplo", "plan_name": "401457_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Basic Pl", "plan_name": "400100", "standard_charge_percentage": 0.85, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Basic Pl", "plan_name": "400100_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Federal", "plan_name": "400110", "standard_charge_percentage": 0.85, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Federal", "plan_name": "400110_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." } ] } ] }, { "description": "Diphenhydramine 25 mg-acetaminophen 500 mg tablet [18836]", "drug_information": { "unit": 1.00, "type": "EA" }, "code_information": [ { "code": "0045048211", "type": "NDC" } ], "standard_charges": [ { "gross_charge": 1.00, "minimum": 0.80, "maximum": 0.85, "setting": "both", "payers_information": [ { "payer_name": "Aetna", "plan_name": "700700", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna", "plan_name": "700700_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Miscellaneous", "plan_name": "700720", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Miscellaneous", "plan_name": "700720_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Ppo Hmo", "plan_name": "701720", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Ppo Hmo", "plan_name": "701720_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Ms State Emplo", "plan_name": "401457", "standard_charge_percentage": 0.80, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Ms State Emplo", "plan_name": "401457_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Basic Pl", "plan_name": "400100", "standard_charge_percentage": 0.85, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Basic Pl", "plan_name": "400100_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Federal", "plan_name": "400110", "standard_charge_percentage": 0.85, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Federal", "plan_name": "400110_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." } ] } ] }, { "description": "Diphenhydramine 25 mg-acetaminophen 500 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"plan_name": "401457_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Basic Pl", "plan_name": "400100", "standard_charge_percentage": 0.85, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Basic Pl", "plan_name": "400100_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Federal", "plan_name": "400110", "standard_charge_percentage": 0.85, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Federal", "plan_name": "400110_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." } ] } ] }, { "description": "Lactase 9000 unit tablet [109044]", "drug_information": { "unit": 1.00, "type": "EA" }, "code_information": [ { "code": "0045091032", "type": "NDC" } ], "standard_charges": [ { "gross_charge": 7.50, "minimum": 6.00, "maximum": 6.38, "setting": "both", "payers_information": [ { "payer_name": "Aetna", "plan_name": "700700", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna", "plan_name": "700700_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Miscellaneous", "plan_name": "700720", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Miscellaneous", "plan_name": "700720_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Ppo Hmo", "plan_name": "701720", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Ppo Hmo", "plan_name": "701720_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Ms State Emplo", "plan_name": "401457", "standard_charge_percentage": 0.80, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Ms State Emplo", "plan_name": "401457_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Basic Pl", "plan_name": "400100", "standard_charge_percentage": 0.85, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Basic Pl", "plan_name": "400100_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Federal", "plan_name": "400110", "standard_charge_percentage": 0.85, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Federal", "plan_name": "400110_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." } ] } ] }, { "description": "Dronedarone 400 mg tablet [98329]", "drug_information": { "unit": 1.00, "type": "EA" }, "code_information": [ { "code": "0024-4142-60", "type": "NDC" } ], "standard_charges": [ { "gross_charge": 59.42, "minimum": 47.54, "maximum": 50.51, "setting": "both", "payers_information": [ { "payer_name": "Aetna", "plan_name": "700700", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna", "plan_name": "700700_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Miscellaneous", "plan_name": "700720", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Miscellaneous", "plan_name": "700720_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Ppo Hmo", "plan_name": "701720", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Ppo Hmo", "plan_name": "701720_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Ms State Emplo", "plan_name": "401457", "standard_charge_percentage": 0.80, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Ms State Emplo", "plan_name": "401457_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Basic Pl", "plan_name": "400100", "standard_charge_percentage": 0.85, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Basic Pl", "plan_name": "400100_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Federal", "plan_name": "400110", "standard_charge_percentage": 0.85, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Federal", "plan_name": "400110_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." } ] } ] }, { "description": "Bimatoprost 0.01 % eye drops [105410]", "drug_information": { "unit": 2.50, "type": "ML" }, "code_information": [ { "code": "0023-3205-03", "type": "NDC" } ], "standard_charges": [ { "gross_charge": 1123.19, "minimum": 898.55, "maximum": 954.71, "setting": "both", "payers_information": [ { "payer_name": "Aetna", "plan_name": "700700", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna", "plan_name": "700700_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Miscellaneous", "plan_name": "700720", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Miscellaneous", "plan_name": "700720_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Ppo Hmo", "plan_name": "701720", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Ppo Hmo", "plan_name": "701720_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Ms State Emplo", "plan_name": "401457", "standard_charge_percentage": 0.80, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Ms State Emplo", "plan_name": "401457_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Basic Pl", "plan_name": "400100", "standard_charge_percentage": 0.85, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Basic Pl", "plan_name": "400100_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Federal", "plan_name": "400110", "standard_charge_percentage": 0.85, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Federal", "plan_name": "400110_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." } ] } ] }, { "description": "Conjugated estrogens 0.625 mg/gram vaginal cream [9977]", "drug_information": { "unit": 30.00, "type": "GR" }, "code_information": [ { "code": "0046-0872-21", "type": "NDC" } ], "standard_charges": [ { "gross_charge": 2010.82, "minimum": 1608.66, "maximum": 1709.20, "setting": "both", "payers_information": [ { "payer_name": "Aetna", "plan_name": "700700", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna", "plan_name": "700700_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Miscellaneous", "plan_name": "700720", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Miscellaneous", "plan_name": "700720_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Ppo Hmo", "plan_name": "701720", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Ppo Hmo", "plan_name": "701720_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Ms State Emplo", "plan_name": "401457", "standard_charge_percentage": 0.80, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Ms State Emplo", "plan_name": "401457_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Basic Pl", "plan_name": "400100", "standard_charge_percentage": 0.85, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Basic Pl", "plan_name": "400100_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Federal", "plan_name": "400110", "standard_charge_percentage": 0.85, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Federal", "plan_name": "400110_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." } ] } ] }, { "description": "Conjugated estrogens 0.625 mg tablet [9974]", "drug_information": { "unit": 1.00, "type": "EA" }, "code_information": [ { "code": "0046-1102-81", "type": "NDC" } ], "standard_charges": [ { "gross_charge": 30.85, "minimum": 24.68, "maximum": 26.22, "setting": "both", "payers_information": [ { "payer_name": "Aetna", "plan_name": "700700", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna", "plan_name": "700700_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Miscellaneous", "plan_name": "700720", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Miscellaneous", "plan_name": "700720_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Ppo Hmo", "plan_name": "701720", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Ppo Hmo", "plan_name": "701720_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total 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billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Federal", "plan_name": "400110", "standard_charge_percentage": 0.85, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Federal", "plan_name": "400110_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." } ] } ] }, { "description": "White petrolatum topical jelly [28809]", "drug_information": { "unit": 368.00, "type": "GR" }, "code_information": [ { "code": "00521234500", "type": "NDC" } ], "standard_charges": [ { "gross_charge": 14.35, "minimum": 11.48, "maximum": 12.20, "setting": "both", "payers_information": [ { "payer_name": "Aetna", "plan_name": "700700", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna", "plan_name": "700700_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Miscellaneous", "plan_name": "700720", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Miscellaneous", "plan_name": "700720_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Ppo Hmo", "plan_name": "701720", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Ppo Hmo", "plan_name": "701720_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Ms State Emplo", "plan_name": "401457", "standard_charge_percentage": 0.80, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Ms State Emplo", "plan_name": "401457_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Basic Pl", "plan_name": "400100", "standard_charge_percentage": 0.85, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Basic Pl", "plan_name": "400100_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Federal", "plan_name": "400110", "standard_charge_percentage": 0.85, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Federal", "plan_name": "400110_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." } ] } ] }, { "description": "Flecainide 50 mg tablet [10043]", "drug_information": { "unit": 1.00, "type": "EA" }, "code_information": [ { "code": "0054-0010-25", "type": "NDC" } ], "standard_charges": [ { "gross_charge": 7.50, "minimum": 6.00, "maximum": 6.38, "setting": "both", "payers_information": [ { "payer_name": "Aetna", "plan_name": "700700", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna", "plan_name": "700700_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Miscellaneous", "plan_name": "700720", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Miscellaneous", "plan_name": "700720_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Ppo Hmo", "plan_name": "701720", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Ppo Hmo", "plan_name": "701720_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Ms State Emplo", "plan_name": "401457", "standard_charge_percentage": 0.80, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Ms State Emplo", "plan_name": "401457_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Basic Pl", "plan_name": "400100", "standard_charge_percentage": 0.85, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Basic Pl", "plan_name": "400100_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Federal", "plan_name": "400110", "standard_charge_percentage": 0.85, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Federal", "plan_name": "400110_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." } ] } ] }, { "description": "Morphine 15 mg immediate release tablet [5178]", "drug_information": { "unit": 1.00, "type": "EA" }, "code_information": [ { "code": "0054-0235-24", "type": "NDC" } ], "standard_charges": [ { "gross_charge": 7.50, "minimum": 6.00, "maximum": 6.38, "setting": "both", "payers_information": [ { "payer_name": "Aetna", "plan_name": "700700", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna", "plan_name": "700700_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Miscellaneous", "plan_name": "700720", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Miscellaneous", "plan_name": "700720_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Ppo Hmo", "plan_name": "701720", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Ppo Hmo", "plan_name": "701720_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Ms State Emplo", "plan_name": "401457", "standard_charge_percentage": 0.80, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Ms State Emplo", "plan_name": "401457_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Basic Pl", "plan_name": "400100", "standard_charge_percentage": 0.85, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Basic Pl", "plan_name": "400100_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Federal", "plan_name": "400110", "standard_charge_percentage": 0.85, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Federal", "plan_name": "400110_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." } ] } ] }, { "description": "Diazepam 5 mg/ml oral concentrate [109433]", "drug_information": { "unit": 30.00, "type": "ML" }, "code_information": [ { "code": "0054-3185-44", "type": "NDC" } ], "standard_charges": [ { "gross_charge": 214.85, "minimum": 171.88, "maximum": 182.62, "setting": "both", "payers_information": [ { "payer_name": "Aetna", "plan_name": "700700", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna", "plan_name": "700700_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Miscellaneous", "plan_name": "700720", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Miscellaneous", "plan_name": "700720_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Ppo Hmo", "plan_name": "701720", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Ppo Hmo", "plan_name": "701720_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Ms State Emplo", "plan_name": "401457", "standard_charge_percentage": 0.80, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Ms State Emplo", "plan_name": "401457_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Basic Pl", "plan_name": "400100", "standard_charge_percentage": 0.85, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Basic Pl", "plan_name": "400100_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Federal", "plan_name": "400110", "standard_charge_percentage": 0.85, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Federal", "plan_name": "400110_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." } ] } ] }, { "description": "Lidocaine hcl 2 % mucosal solution [109454]", "drug_information": { "unit": 100.00, "type": "ML" }, "code_information": [ { "code": "0054-3500-49", "type": "NDC" } ], "standard_charges": [ { "gross_charge": 62.70, "minimum": 50.16, "maximum": 53.30, "setting": "both", "payers_information": [ { "payer_name": "Aetna", "plan_name": "700700", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna", "plan_name": "700700_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Miscellaneous", "plan_name": "700720", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Miscellaneous", "plan_name": "700720_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Ppo Hmo", "plan_name": "701720", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Ppo Hmo", "plan_name": "701720_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Ms State Emplo", "plan_name": "401457", "standard_charge_percentage": 0.80, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Ms State Emplo", "plan_name": "401457_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Basic Pl", "plan_name": "400100", "standard_charge_percentage": 0.85, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Basic Pl", "plan_name": "400100_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Federal", "plan_name": "400110", "standard_charge_percentage": 0.85, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Federal", "plan_name": "400110_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." } ] } ] }, { "description": "Lidocaine hcl 4 % (40 mg/ml) mucosal solution [4450]", "drug_information": { "unit": 50.00, "type": "ML" }, "code_information": [ { "code": "0054-3505-47", "type": "NDC" } ], "standard_charges": [ { "gross_charge": 228.00, "minimum": 182.40, "maximum": 193.80, "setting": "both", "payers_information": [ { "payer_name": "Aetna", "plan_name": "700700", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna", "plan_name": "700700_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Miscellaneous", "plan_name": "700720", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Miscellaneous", "plan_name": "700720_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Ppo Hmo", "plan_name": "701720", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Ppo Hmo", "plan_name": "701720_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Ms State Emplo", "plan_name": "401457", "standard_charge_percentage": 0.80, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Ms State Emplo", "plan_name": "401457_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Basic Pl", "plan_name": "400100", "standard_charge_percentage": 0.85, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Basic Pl", "plan_name": "400100_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Federal", "plan_name": "400110", "standard_charge_percentage": 0.85, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Federal", "plan_name": "400110_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." } ] } ] }, { "description": "Midazolam 2 mg/ml oral syrup [24176]", "drug_information": { "unit": 118.00, "type": "ML" }, "code_information": [ { "code": "0054-3566-99", "type": "NDC" } ], "standard_charges": [ { "gross_charge": 1264.84, "minimum": 1011.87, "maximum": 1075.11, "setting": "both", "payers_information": [ { "payer_name": "Aetna", "plan_name": "700700", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna", "plan_name": "700700_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Miscellaneous", "plan_name": "700720", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Miscellaneous", "plan_name": "700720_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Ppo Hmo", "plan_name": "701720", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Ppo Hmo", "plan_name": "701720_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Ms State Emplo", "plan_name": "401457", "standard_charge_percentage": 0.80, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Ms State Emplo", "plan_name": "401457_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Basic Pl", "plan_name": "400100", "standard_charge_percentage": 0.85, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Basic Pl", "plan_name": "400100_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Federal", "plan_name": "400110", "standard_charge_percentage": 0.85, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Federal", "plan_name": "400110_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." } ] } ] }, { "description": "Furosemide 20 mg tablet [3294]", "drug_information": { "unit": 1.00, "type": "EA" }, "code_information": [ { "code": "0054-8297-25", "type": "NDC" } ], "standard_charges": [ { "gross_charge": 7.50, "minimum": 6.00, "maximum": 6.38, "setting": "both", "payers_information": [ { "payer_name": "Aetna", "plan_name": "700700", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", 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"Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Ppo Hmo", "plan_name": "701720_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Ms State Emplo", "plan_name": "401457", "standard_charge_percentage": 0.80, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Ms State Emplo", "plan_name": "401457_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Basic Pl", "plan_name": "400100", "standard_charge_percentage": 0.85, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Basic Pl", "plan_name": "400100_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Federal", "plan_name": "400110", "standard_charge_percentage": 0.85, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Federal", "plan_name": "400110_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." } ] } ] }, { "description": "Furosemide 40 mg tablet [3295]", "drug_information": { "unit": 1.00, "type": "EA" }, "code_information": [ { "code": "0054-8299-25", "type": "NDC" } ], 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"additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Basic Pl", "plan_name": "400100", "standard_charge_percentage": 0.85, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Basic Pl", "plan_name": "400100_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Federal", "plan_name": "400110", "standard_charge_percentage": 0.85, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Federal", "plan_name": "400110_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." } ] } ] }, { "description": "Lithium carbonate 300 mg capsule [4529]", "drug_information": { "unit": 1.00, "type": "EA" }, "code_information": [ { "code": "0054-8527-25", "type": "NDC" } ], "standard_charges": [ { "gross_charge": 7.50, "minimum": 6.00, "maximum": 6.38, "setting": "both", "payers_information": [ { "payer_name": "Aetna", "plan_name": "700700", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna", "plan_name": "700700_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Miscellaneous", "plan_name": "700720", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent 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charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Federal", "plan_name": "400110_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." } ] } ] }, { "description": "Calcium 500 mg/5 ml (as calcium carb 1250 mg/5 ml) oral suspension [1299]", "drug_information": { "unit": 500.00, "type": "ML" }, "code_information": [ { "code": "0054311763", "type": "NDC" } ], "standard_charges": [ { "gross_charge": 42.75, "minimum": 34.20, "maximum": 36.34, "setting": "both", "payers_information": [ { "payer_name": "Aetna", "plan_name": "700700", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna", "plan_name": "700700_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Miscellaneous", "plan_name": "700720", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Miscellaneous", "plan_name": "700720_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Ppo Hmo", "plan_name": "701720", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Ppo Hmo", "plan_name": "701720_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Ms State Emplo", "plan_name": "401457", "standard_charge_percentage": 0.80, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Ms State Emplo", "plan_name": "401457_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Basic Pl", "plan_name": "400100", "standard_charge_percentage": 0.85, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Basic Pl", "plan_name": "400100_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Federal", "plan_name": "400110", "standard_charge_percentage": 0.85, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Federal", "plan_name": "400110_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." } ] } ] }, { "description": "Mineral oil-w.petrolatum-cetylstearyl alcohol-sls-chol topical cream [113985]", "drug_information": { "unit": 397.00, "type": "GR" }, "code_information": [ { "code": "0064218014", "type": "NDC" } ], "standard_charges": [ { "gross_charge": 54.71, "minimum": 43.77, "maximum": 46.50, "setting": "both", "payers_information": [ { "payer_name": "Aetna", "plan_name": "700700", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna", "plan_name": "700700_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Miscellaneous", "plan_name": "700720", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Miscellaneous", "plan_name": "700720_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed 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"payer_name": "Bc/Bs Of Ms Basic Pl", "plan_name": "400100", "standard_charge_percentage": 0.85, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Basic Pl", "plan_name": "400100_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Federal", "plan_name": "400110", "standard_charge_percentage": 0.85, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Federal", "plan_name": "400110_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." } ] } ] }, { "description": "Glycerin lotion [110162]", "drug_information": { "unit": 480.00, "type": "ML" }, "code_information": [ { "code": "0064219016", "type": "NDC" } ], "standard_charges": [ { "gross_charge": 79.80, "minimum": 63.84, "maximum": 67.83, "setting": "both", "payers_information": [ { "payer_name": "Aetna", "plan_name": "700700", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna", "plan_name": "700700_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Miscellaneous", "plan_name": "700720", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Miscellaneous", "plan_name": "700720_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Ppo Hmo", "plan_name": "701720", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Ppo Hmo", "plan_name": "701720_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Ms State Emplo", "plan_name": "401457", "standard_charge_percentage": 0.80, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Ms State Emplo", "plan_name": "401457_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Basic Pl", "plan_name": "400100", "standard_charge_percentage": 0.85, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Basic Pl", "plan_name": "400100_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Federal", "plan_name": "400110", "standard_charge_percentage": 0.85, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Federal", "plan_name": "400110_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." } ] } ] }, { "description": "Carbachol 0.01 % intraocular solution [19704]", "drug_information": { "unit": 1.50, "type": "ML" }, "code_information": [ { "code": "0065-0023-15", "type": "NDC" } ], "standard_charges": [ { "gross_charge": 199.62, "minimum": 159.70, "maximum": 169.68, "setting": "both", "payers_information": [ { "payer_name": "Aetna", "plan_name": "700700", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna", "plan_name": "700700_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Miscellaneous", "plan_name": "700720", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Miscellaneous", "plan_name": "700720_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Ppo Hmo", "plan_name": "701720", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Ppo Hmo", "plan_name": "701720_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Ms State Emplo", "plan_name": "401457", "standard_charge_percentage": 0.80, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Ms State Emplo", "plan_name": "401457_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Basic Pl", "plan_name": "400100", "standard_charge_percentage": 0.85, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Basic Pl", "plan_name": "400100_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Federal", "plan_name": "400110", "standard_charge_percentage": 0.85, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Federal", "plan_name": "400110_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." } ] } ] }, { "description": "Cyclopentolate 1 % eye drops [2025]", "drug_information": { "unit": 2.00, "type": "ML" }, "code_information": [ { "code": "0065-0396-02", "type": "NDC" } ], "standard_charges": [ { "gross_charge": 160.27, "minimum": 128.22, "maximum": 136.23, "setting": "both", "payers_information": [ { "payer_name": "Aetna", "plan_name": "700700", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna", "plan_name": "700700_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Miscellaneous", "plan_name": "700720", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Miscellaneous", "plan_name": "700720_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Ppo Hmo", "plan_name": "701720", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Ppo Hmo", "plan_name": "701720_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Ms State Emplo", "plan_name": "401457", "standard_charge_percentage": 0.80, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Ms State Emplo", "plan_name": "401457_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Basic Pl", "plan_name": "400100", "standard_charge_percentage": 0.85, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Basic Pl", "plan_name": "400100_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Federal", "plan_name": "400110", "standard_charge_percentage": 0.85, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Federal", "plan_name": "400110_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." } ] } ] }, { "description": "Cyclopentolate 1 % eye drops [2025]", "drug_information": { "unit": 5.00, "type": "ML" }, "code_information": [ { "code": "0065-0396-05", "type": "NDC" } ], "standard_charges": [ { "gross_charge": 288.23, "minimum": 230.58, "maximum": 245.00, "setting": "both", "payers_information": [ { "payer_name": "Aetna", "plan_name": "700700", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna", "plan_name": "700700_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Miscellaneous", "plan_name": "700720", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Miscellaneous", "plan_name": "700720_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Ppo Hmo", "plan_name": "701720", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Ppo Hmo", "plan_name": "701720_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Ms State Emplo", "plan_name": "401457", "standard_charge_percentage": 0.80, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Ms State Emplo", "plan_name": "401457_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Basic Pl", "plan_name": "400100", "standard_charge_percentage": 0.85, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Basic Pl", "plan_name": "400100_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Federal", "plan_name": "400110", "standard_charge_percentage": 0.85, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Federal", "plan_name": "400110_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." } ] } ] }, { "description": "Cyclopentolate 2 % eye drops [9700]", "drug_information": { "unit": 2.00, "type": "ML" }, "code_information": [ { "code": "0065-0397-02", "type": "NDC" } ], "standard_charges": [ { "gross_charge": 209.76, "minimum": 167.81, "maximum": 178.30, "setting": "both", "payers_information": [ { "payer_name": "Aetna", "plan_name": "700700", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna", "plan_name": "700700_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Miscellaneous", "plan_name": "700720", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Miscellaneous", "plan_name": "700720_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Ppo Hmo", "plan_name": "701720", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Ppo Hmo", "plan_name": "701720_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Ms State Emplo", "plan_name": "401457", "standard_charge_percentage": 0.80, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Ms State Emplo", "plan_name": "401457_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Basic Pl", "plan_name": "400100", "standard_charge_percentage": 0.85, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Basic Pl", "plan_name": "400100_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Federal", "plan_name": "400110", "standard_charge_percentage": 0.85, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Federal", "plan_name": "400110_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." } ] } ] }, { "description": "Cyclopentolate 2 % eye drops [9700]", "drug_information": { "unit": 15.00, "type": "ML" }, "code_information": [ { "code": "0065-0397-15", "type": "NDC" } ], "standard_charges": [ { "gross_charge": 575.91, "minimum": 460.73, "maximum": 489.52, "setting": "both", "payers_information": [ { "payer_name": "Aetna", "plan_name": "700700", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna", "plan_name": "700700_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Miscellaneous", "plan_name": "700720", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Miscellaneous", "plan_name": "700720_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Ppo Hmo", "plan_name": "701720", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Ppo Hmo", "plan_name": "701720_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Ms State Emplo", "plan_name": "401457", "standard_charge_percentage": 0.80, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Ms State Emplo", "plan_name": "401457_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Basic Pl", "plan_name": "400100", "standard_charge_percentage": 0.85, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Basic Pl", "plan_name": "400100_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Federal", "plan_name": "400110", "standard_charge_percentage": 0.85, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Federal", "plan_name": "400110_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." } ] } ] }, { "description": "Peg 400-propylene glycol 0.4 %-0.3 % eye drops [35891]", "drug_information": { "unit": 15.00, "type": "ML" }, "code_information": [ { "code": "0065-0429-15", "type": "NDC" } ], "standard_charges": [ { "gross_charge": 31.86, "minimum": 25.49, "maximum": 27.08, "setting": "both", "payers_information": [ { "payer_name": "Aetna", "plan_name": "700700", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna", "plan_name": "700700_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Miscellaneous", "plan_name": "700720", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Miscellaneous", "plan_name": "700720_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Ppo Hmo", "plan_name": "701720", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Ppo Hmo", "plan_name": "701720_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Ms State Emplo", "plan_name": "401457", "standard_charge_percentage": 0.80, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Ms State Emplo", "plan_name": "401457_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Basic Pl", "plan_name": "400100", "standard_charge_percentage": 0.85, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Basic Pl", "plan_name": "400100_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Federal", "plan_name": "400110", "standard_charge_percentage": 0.85, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Federal", "plan_name": "400110_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." } ] } ] }, { "description": "White petrolatum-mineral oil 94 %-3 % eye ointment [30013]", "drug_information": { "unit": 3.50, "type": "GR" }, "code_information": [ { "code": "0065-0518-01", "type": "NDC" } ], "standard_charges": [ { "gross_charge": 43.08, "minimum": 34.46, "maximum": 36.62, "setting": "both", "payers_information": [ { "payer_name": "Aetna", "plan_name": "700700", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna", "plan_name": "700700_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Miscellaneous", "plan_name": "700720", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Miscellaneous", "plan_name": "700720_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Ppo Hmo", "plan_name": "701720", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Ppo Hmo", "plan_name": "701720_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Ms State Emplo", "plan_name": "401457", "standard_charge_percentage": 0.80, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Ms State Emplo", "plan_name": "401457_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Basic Pl", "plan_name": "400100", "standard_charge_percentage": 0.85, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Basic Pl", "plan_name": "400100_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Federal", "plan_name": "400110", "standard_charge_percentage": 0.85, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Federal", "plan_name": "400110_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." } ] } ] }, { "description": "Tobramycin 0.3 % eye ointment [19769]", "drug_information": { "unit": 3.50, "type": "GR" }, "code_information": [ { "code": "0065-0644-35", "type": "NDC" } ], "standard_charges": [ { "gross_charge": 1018.22, "minimum": 814.58, "maximum": 865.49, "setting": "both", "payers_information": [ { "payer_name": "Aetna", "plan_name": "700700", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna", "plan_name": "700700_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Miscellaneous", "plan_name": "700720", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Miscellaneous", "plan_name": "700720_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Ppo Hmo", "plan_name": "701720", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Ppo Hmo", "plan_name": "701720_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Ms State Emplo", "plan_name": "401457", "standard_charge_percentage": 0.80, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Ms State Emplo", "plan_name": "401457_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Basic Pl", "plan_name": "400100", "standard_charge_percentage": 0.85, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Basic Pl", "plan_name": "400100_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Federal", "plan_name": "400110", "standard_charge_percentage": 0.85, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Federal", "plan_name": "400110_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." } ] } ] }, { "description": "Tetracaine hcl (pf) 0.5 % eye drops [150683]", "drug_information": { "unit": 4.00, "type": "ML" }, "code_information": [ { "code": "0065-0741-14", "type": "NDC" } ], "standard_charges": [ { "gross_charge": 59.07, "minimum": 47.26, "maximum": 50.21, "setting": "both", "payers_information": [ { "payer_name": "Aetna", "plan_name": "700700", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna", "plan_name": "700700_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Miscellaneous", "plan_name": "700720", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Miscellaneous", "plan_name": "700720_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Ppo Hmo", "plan_name": "701720", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Ppo Hmo", "plan_name": "701720_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Ms State Emplo", "plan_name": "401457", "standard_charge_percentage": 0.80, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Ms State Emplo", "plan_name": "401457_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Basic Pl", "plan_name": "400100", "standard_charge_percentage": 0.85, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Basic Pl", "plan_name": "400100_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Federal", "plan_name": "400110", "standard_charge_percentage": 0.85, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Federal", "plan_name": "400110_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." } ] } ] }, { "description": "Balanced salt solution combination no.2 intraocular irrigation [10781]", "drug_information": { "unit": 15.00, "type": "ML" }, "code_information": [ { "code": "0065-0795-15", "type": "NDC" } ], "standard_charges": [ { "gross_charge": 54.36, "minimum": 43.49, "maximum": 46.21, "setting": "both", "payers_information": [ { "payer_name": "Aetna", "plan_name": "700700", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna", "plan_name": "700700_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Miscellaneous", "plan_name": "700720", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Miscellaneous", "plan_name": "700720_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Ppo Hmo", "plan_name": "701720", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Ppo Hmo", "plan_name": "701720_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Ms State Emplo", "plan_name": "401457", "standard_charge_percentage": 0.80, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Ms State Emplo", "plan_name": "401457_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Basic Pl", "plan_name": "400100", "standard_charge_percentage": 0.85, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Basic Pl", "plan_name": "400100_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Federal", "plan_name": "400110", "standard_charge_percentage": 0.85, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Federal", "plan_name": "400110_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." } ] } ] }, { "description": "Ketotifen 0.025 % (0.035 %) eye drops [25471]", "drug_information": { "unit": 5.00, "type": "ML" }, "code_information": [ { "code": "0065-4011-05", "type": "NDC" } ], "standard_charges": [ { "gross_charge": 62.75, "minimum": 50.20, "maximum": 53.34, "setting": "both", "payers_information": [ { "payer_name": "Aetna", "plan_name": "700700", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna", "plan_name": "700700_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Miscellaneous", "plan_name": "700720", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Miscellaneous", "plan_name": "700720_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Ppo Hmo", "plan_name": "701720", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Ppo Hmo", "plan_name": "701720_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Ms State Emplo", "plan_name": "401457", "standard_charge_percentage": 0.80, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Ms State Emplo", "plan_name": "401457_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Basic Pl", "plan_name": "400100", "standard_charge_percentage": 0.85, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Basic Pl", "plan_name": "400100_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Federal", "plan_name": "400110", "standard_charge_percentage": 0.85, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Federal", "plan_name": "400110_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." } ] } ] }, { "description": "Olopatadine 0.2 % eye drops [76979]", "drug_information": { "unit": 2.50, "type": "ML" }, "code_information": [ { "code": "0065-8150-01", "type": "NDC" } ], "standard_charges": [ { "gross_charge": 89.54, "minimum": 71.63, "maximum": 76.11, "setting": "both", "payers_information": [ { "payer_name": "Aetna", "plan_name": "700700", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna", "plan_name": "700700_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Miscellaneous", "plan_name": "700720", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Miscellaneous", "plan_name": "700720_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Ppo Hmo", "plan_name": "701720", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Ppo Hmo", "plan_name": "701720_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": 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"percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Federal", "plan_name": "400110", "standard_charge_percentage": 0.85, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Federal", "plan_name": "400110_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." } ] } ] }, { "description": "Nicotine 21 mg/24 hr daily transdermal patch [27863]", "drug_information": { "unit": 1.00, "type": "EA" }, "code_information": [ { "code": "0067-4900-14", "type": "NDC" } ], "standard_charges": [ { "gross_charge": 8.54, "minimum": 6.83, "maximum": 7.26, "setting": "both", "payers_information": [ { "payer_name": "Aetna", "plan_name": "700700", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna", "plan_name": "700700_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Miscellaneous", "plan_name": "700720", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Miscellaneous", "plan_name": "700720_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Ppo Hmo", "plan_name": "701720", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Ppo Hmo", "plan_name": "701720_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Ms State Emplo", "plan_name": "401457", "standard_charge_percentage": 0.80, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Ms State Emplo", "plan_name": "401457_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Basic Pl", "plan_name": "400100", "standard_charge_percentage": 0.85, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Basic Pl", "plan_name": "400100_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Federal", "plan_name": "400110", "standard_charge_percentage": 0.85, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Federal", "plan_name": "400110_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." } ] } ] }, { "description": "Terbinafine hcl 1 % topical spray [118690]", "drug_information": { "unit": 125.00, "type": "ML" }, "code_information": [ { "code": "0067-6293-83", "type": "NDC" } ], "standard_charges": [ { "gross_charge": 35.63, "minimum": 28.50, "maximum": 30.29, "setting": "both", "payers_information": [ { "payer_name": "Aetna", "plan_name": "700700", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna", "plan_name": "700700_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Miscellaneous", "plan_name": "700720", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Miscellaneous", "plan_name": "700720_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Ppo Hmo", "plan_name": "701720", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Ppo Hmo", "plan_name": "701720_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Ms State Emplo", "plan_name": "401457", "standard_charge_percentage": 0.80, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Ms State Emplo", "plan_name": "401457_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Basic Pl", "plan_name": "400100", "standard_charge_percentage": 0.85, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Basic Pl", "plan_name": "400100_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Federal", "plan_name": "400110", "standard_charge_percentage": 0.85, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Federal", "plan_name": "400110_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." } ] } ] }, { "description": "Diclofenac 1 % topical gel [100611]", "drug_information": { "unit": 50.00, "type": "GR" }, "code_information": [ { "code": "0067-8152-02", "type": "NDC" } ], "standard_charges": [ { "gross_charge": 53.91, "minimum": 43.13, "maximum": 45.82, "setting": "both", "payers_information": [ { "payer_name": "Aetna", "plan_name": "700700", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna", "plan_name": "700700_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Miscellaneous", "plan_name": "700720", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Miscellaneous", "plan_name": "700720_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Ppo Hmo", "plan_name": "701720", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Ppo Hmo", "plan_name": "701720_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Ms State Emplo", "plan_name": "401457", "standard_charge_percentage": 0.80, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Ms State Emplo", "plan_name": "401457_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Basic Pl", "plan_name": "400100", "standard_charge_percentage": 0.85, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Basic Pl", "plan_name": "400100_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Federal", "plan_name": "400110", "standard_charge_percentage": 0.85, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Federal", "plan_name": "400110_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." } ] } ] }, { "description": "Rifampin 600 mg intravenous solution [11291]", "drug_information": { "unit": 1.00, "type": "EA" }, "code_information": [ { "code": "0068-0597-01", "type": "NDC" } ], "standard_charges": [ { "gross_charge": 839.75, "minimum": 671.80, "maximum": 713.79, "setting": "both", "payers_information": [ { "payer_name": "Aetna", "plan_name": "700700", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna", "plan_name": "700700_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Miscellaneous", "plan_name": "700720", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Miscellaneous", "plan_name": "700720_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Ppo Hmo", "plan_name": "701720", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Ppo Hmo", "plan_name": "701720_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Ms State Emplo", "plan_name": "401457", "standard_charge_percentage": 0.80, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Ms State Emplo", "plan_name": "401457_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Basic Pl", "plan_name": "400100", "standard_charge_percentage": 0.85, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Basic Pl", "plan_name": "400100_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Federal", "plan_name": "400110", "standard_charge_percentage": 0.85, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Federal", "plan_name": "400110_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." } ] } ] }, { "description": "Methylcellulose (with sugar) oral powder [19739]", "drug_information": { "unit": 850.00, "type": "GR" }, "code_information": [ { "code": "0068041830", "type": "NDC" } ], "standard_charges": [ { "gross_charge": 30.94, "minimum": 24.75, "maximum": 26.30, "setting": "both", "payers_information": [ { "payer_name": "Aetna", "plan_name": "700700", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna", "plan_name": "700700_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Miscellaneous", "plan_name": "700720", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Miscellaneous", "plan_name": "700720_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient 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calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Basic Pl", "plan_name": "400100", "standard_charge_percentage": 0.85, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Basic Pl", "plan_name": "400100_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Federal", "plan_name": "400110", "standard_charge_percentage": 0.85, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Federal", "plan_name": "400110_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." } ] } ] }, { "description": "Clotrimazole 10 mg troche [9644]", "drug_information": { "unit": 1.00, "type": "EA" }, "code_information": [ { "code": "0054-8146-22", "type": "NDC" } ], "standard_charges": [ { "gross_charge": 16.32, "minimum": 13.06, "maximum": 13.87, "setting": "both", "payers_information": [ { "payer_name": "Aetna", "plan_name": "700700", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna", "plan_name": "700700_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Miscellaneous", "plan_name": "700720", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": 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remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Ms State Emplo", "plan_name": "401457_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Basic Pl", "plan_name": "400100", "standard_charge_percentage": 0.85, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Basic Pl", "plan_name": "400100_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Federal", "plan_name": "400110", "standard_charge_percentage": 0.85, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Federal", "plan_name": "400110_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." } ] } ] }, { "description": "Doxycycline hyclate 100 mg capsule [2623]", "drug_information": { "unit": 1.00, "type": "EA" }, "code_information": [ { "code": "0069-0950-50", "type": "NDC" } ], "standard_charges": [ { "gross_charge": 7.50, "minimum": 6.00, "maximum": 6.38, "setting": "both", "payers_information": [ { "payer_name": "Aetna", "plan_name": "700700", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna", "plan_name": "700700_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Miscellaneous", "plan_name": "700720", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Miscellaneous", "plan_name": "700720_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Ppo Hmo", "plan_name": "701720", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Ppo Hmo", "plan_name": "701720_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Ms State Emplo", "plan_name": "401457", "standard_charge_percentage": 0.80, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Ms State Emplo", "plan_name": "401457_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Basic Pl", "plan_name": "400100", "standard_charge_percentage": 0.85, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Basic Pl", "plan_name": "400100_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Federal", "plan_name": "400110", "standard_charge_percentage": 0.85, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Federal", "plan_name": "400110_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." } ] } ] }, { "description": "Phenytoin 50 mg chewable tablet [11018]", "drug_information": { "unit": 1.00, "type": "EA" }, "code_information": [ { "code": "0071-0007-40", "type": "NDC" } ], "standard_charges": [ { "gross_charge": 10.62, "minimum": 8.50, "maximum": 9.03, "setting": "both", "payers_information": [ { "payer_name": "Aetna", "plan_name": "700700", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna", "plan_name": "700700_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Miscellaneous", "plan_name": "700720", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Miscellaneous", "plan_name": "700720_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Ppo Hmo", "plan_name": "701720", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Ppo Hmo", "plan_name": "701720_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Ms State Emplo", "plan_name": "401457", "standard_charge_percentage": 0.80, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Ms State Emplo", "plan_name": "401457_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Basic Pl", "plan_name": "400100", "standard_charge_percentage": 0.85, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Basic Pl", "plan_name": "400100_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Federal", "plan_name": "400110", "standard_charge_percentage": 0.85, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Federal", "plan_name": "400110_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." } ] } ] }, { "description": "Phenytoin sodium extended 100 mg capsule [6257]", "drug_information": { "unit": 1.00, "type": "EA" }, "code_information": [ { "code": "0071-0369-40", "type": "NDC" } ], "standard_charges": [ { "gross_charge": 8.82, "minimum": 7.06, "maximum": 7.50, "setting": "both", "payers_information": [ { "payer_name": "Aetna", "plan_name": "700700", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna", "plan_name": "700700_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Miscellaneous", "plan_name": "700720", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Miscellaneous", "plan_name": "700720_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Ppo Hmo", "plan_name": "701720", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Ppo Hmo", "plan_name": "701720_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Ms State Emplo", "plan_name": "401457", "standard_charge_percentage": 0.80, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Ms State Emplo", "plan_name": "401457_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Basic Pl", "plan_name": "400100", "standard_charge_percentage": 0.85, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Basic Pl", "plan_name": "400100_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Federal", "plan_name": "400110", "standard_charge_percentage": 0.85, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Federal", "plan_name": "400110_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." } ] } ] }, { "description": "Nitroglycerin 0.4 mg sublingual tablet [5604]", "drug_information": { "unit": 25.00, "type": "EA" }, "code_information": [ { "code": "0071-0418-13", "type": "NDC" } ], "standard_charges": [ { "gross_charge": 192.02, "minimum": 153.62, "maximum": 163.22, "setting": "both", "payers_information": [ { "payer_name": "Aetna", "plan_name": "700700", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna", "plan_name": "700700_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Miscellaneous", "plan_name": "700720", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Miscellaneous", "plan_name": "700720_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Ppo Hmo", "plan_name": "701720", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Ppo Hmo", "plan_name": "701720_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Ms State Emplo", "plan_name": "401457", "standard_charge_percentage": 0.80, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Ms State Emplo", "plan_name": "401457_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Basic Pl", "plan_name": "400100", "standard_charge_percentage": 0.85, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Basic Pl", "plan_name": "400100_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Federal", "plan_name": "400110", "standard_charge_percentage": 0.85, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Federal", "plan_name": "400110_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." } ] } ] }, { "description": "Pregabalin 50 mg capsule [42163]", "drug_information": { "unit": 1.00, "type": "EA" }, "code_information": [ { "code": "0071-1013-41", "type": "NDC" } ], "standard_charges": [ { "gross_charge": 70.67, "minimum": 56.54, "maximum": 60.07, "setting": "both", "payers_information": [ { "payer_name": "Aetna", "plan_name": "700700", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna", "plan_name": "700700_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Miscellaneous", "plan_name": "700720", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Miscellaneous", "plan_name": "700720_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Ppo Hmo", "plan_name": "701720", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Ppo Hmo", "plan_name": "701720_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Ms State Emplo", "plan_name": "401457", "standard_charge_percentage": 0.80, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Ms State Emplo", "plan_name": "401457_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Basic Pl", "plan_name": "400100", "standard_charge_percentage": 0.85, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Basic Pl", "plan_name": "400100_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Federal", "plan_name": "400110", "standard_charge_percentage": 0.85, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Federal", "plan_name": "400110_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." } ] } ] }, { "description": "Pregabalin 75 mg capsule [42164]", "drug_information": { "unit": 1.00, "type": "EA" }, "code_information": [ { "code": "0071-1014-41", "type": "NDC" } ], "standard_charges": [ { "gross_charge": 70.67, "minimum": 56.54, "maximum": 60.07, "setting": "both", "payers_information": [ 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"plan_name": "701720", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Ppo Hmo", "plan_name": "701720_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Ms State Emplo", "plan_name": "401457", "standard_charge_percentage": 0.80, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Ms State Emplo", "plan_name": "401457_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Basic Pl", 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Emplo", "plan_name": "401457_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Basic Pl", "plan_name": "400100", "standard_charge_percentage": 0.85, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Basic Pl", "plan_name": "400100_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Federal", "plan_name": "400110", "standard_charge_percentage": 0.85, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Federal", "plan_name": "400110_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." } ] } ] }, { "description": "Pregabalin 100 mg capsule [42165]", "drug_information": { "unit": 1.00, "type": "EA" }, "code_information": [ { "code": "0071-1015-41", "type": "NDC" } ], "standard_charges": [ { "gross_charge": 70.67, "minimum": 56.54, "maximum": 60.07, "setting": "both", "payers_information": [ { "payer_name": "Aetna", "plan_name": "700700", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna", "plan_name": "700700_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Miscellaneous", "plan_name": "700720", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Miscellaneous", "plan_name": "700720_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Ppo Hmo", "plan_name": "701720", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Ppo Hmo", "plan_name": "701720_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Ms State Emplo", "plan_name": "401457", "standard_charge_percentage": 0.80, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Ms State Emplo", "plan_name": "401457_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Basic Pl", "plan_name": "400100", "standard_charge_percentage": 0.85, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Basic Pl", "plan_name": "400100_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Federal", "plan_name": "400110", "standard_charge_percentage": 0.85, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Federal", "plan_name": "400110_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." } ] } ] }, { "description": "Levothyroxine 75 mcg tablet [4422]", "drug_information": { "unit": 1.00, "type": "EA" }, "code_information": [ { "code": "0074-5182-11", "type": "NDC" } ], "standard_charges": [ { "gross_charge": 7.50, "minimum": 6.00, "maximum": 6.38, "setting": "both", "payers_information": [ { "payer_name": "Aetna", "plan_name": "700700", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate 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"payer_name": "Aetna Ppo Hmo", "plan_name": "701720_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Ms State Emplo", "plan_name": "401457", "standard_charge_percentage": 0.80, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Ms State Emplo", "plan_name": "401457_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Basic Pl", "plan_name": "400100", "standard_charge_percentage": 0.85, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Basic Pl", "plan_name": "400100_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Federal", "plan_name": "400110", "standard_charge_percentage": 0.85, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Federal", "plan_name": "400110_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." } ] } ] }, { "description": "Valsartan 160 mg tablet [31210]", "drug_information": { "unit": 1.00, "type": "EA" }, "code_information": [ { "code": "0078-0359-34", "type": "NDC" } ], "standard_charges": [ { "gross_charge": 44.41, "minimum": 35.53, "maximum": 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amounts." }, { "payer_name": "Bc/Bs Of Ms Basic Pl", "plan_name": "400100", "standard_charge_percentage": 0.85, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Basic Pl", "plan_name": "400100_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Federal", "plan_name": "400110", "standard_charge_percentage": 0.85, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Federal", "plan_name": "400110_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." } ] } ] }, { "description": "Sacubitril 24 mg-valsartan 26 mg tablet [170740]", "drug_information": { "unit": 1.00, "type": "EA" }, "code_information": [ { "code": "0078-0659-20", "type": "NDC" } ], "standard_charges": [ { "gross_charge": 51.23, "minimum": 40.98, "maximum": 43.55, "setting": "both", "payers_information": [ { "payer_name": "Aetna", "plan_name": "700700", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna", "plan_name": "700700_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Miscellaneous", "plan_name": "700720", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Miscellaneous", "plan_name": "700720_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Ppo Hmo", "plan_name": "701720", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Ppo Hmo", "plan_name": "701720_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Ms State Emplo", "plan_name": "401457", "standard_charge_percentage": 0.80, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Ms State Emplo", "plan_name": "401457_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Basic Pl", "plan_name": "400100", "standard_charge_percentage": 0.85, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Basic Pl", "plan_name": "400100_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Federal", "plan_name": "400110", "standard_charge_percentage": 0.85, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Federal", "plan_name": "400110_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." } ] } ] }, { "description": "Sacubitril 49 mg-valsartan 51 mg tablet [170741]", "drug_information": { "unit": 1.00, "type": "EA" }, "code_information": [ { "code": "0078-0777-20", "type": "NDC" } ], "standard_charges": [ { "gross_charge": 51.23, "minimum": 40.98, "maximum": 43.55, "setting": "both", "payers_information": [ { "payer_name": "Aetna", "plan_name": "700700", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna", "plan_name": "700700_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Miscellaneous", "plan_name": "700720", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Miscellaneous", "plan_name": "700720_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Ppo Hmo", "plan_name": "701720", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Ppo Hmo", "plan_name": "701720_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Ms State Emplo", "plan_name": "401457", "standard_charge_percentage": 0.80, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Ms State Emplo", "plan_name": "401457_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Basic Pl", "plan_name": "400100", "standard_charge_percentage": 0.85, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Basic Pl", "plan_name": "400100_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Federal", "plan_name": "400110", "standard_charge_percentage": 0.85, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Federal", "plan_name": "400110_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." } ] } ] }, { "description": "Ciprofloxacin 0.3 %-dexamethasone 0.1 % ear dropssuspension [36576]", "drug_information": { "unit": 7.50, "type": "ML" }, "code_information": [ { "code": "0078-0799-75", "type": "NDC" } ], "standard_charges": [ { "gross_charge": 1183.18, "minimum": 946.54, "maximum": 1005.70, "setting": "both", "payers_information": [ { "payer_name": "Aetna", "plan_name": "700700", 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"payer_name": "Aetna", "plan_name": "700700", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna", "plan_name": "700700_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Miscellaneous", "plan_name": "700720", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Miscellaneous", "plan_name": "700720_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Ppo Hmo", "plan_name": "701720", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Ppo Hmo", "plan_name": "701720_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Ms State Emplo", "plan_name": "401457", "standard_charge_percentage": 0.80, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Ms State Emplo", "plan_name": "401457_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Basic Pl", "plan_name": "400100", "standard_charge_percentage": 0.85, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Basic Pl", "plan_name": "400100_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Federal", "plan_name": "400110", "standard_charge_percentage": 0.85, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Federal", "plan_name": "400110_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." } ] } ] }, { "description": "Aluminum hydrox-magnesium carb 254 mg-237.5 mg/5 ml oral suspension [9018]", "drug_information": { "unit": 355.00, "type": "ML" }, "code_information": [ { "code": "0088-1173-12", "type": "NDC" } ], "standard_charges": [ { "gross_charge": 20.31, "minimum": 16.25, "maximum": 17.26, "setting": "both", "payers_information": [ { "payer_name": "Aetna", "plan_name": "700700", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna", "plan_name": "700700_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Miscellaneous", "plan_name": "700720", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to 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amounts." }, { "payer_name": "Bc/Bs Ms State Emplo", "plan_name": "401457_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Basic Pl", "plan_name": "400100", "standard_charge_percentage": 0.85, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Basic Pl", "plan_name": "400100_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Federal", "plan_name": "400110", "standard_charge_percentage": 0.85, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Federal", "plan_name": "400110_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." } ] } ] }, { "description": "Aluminum hydrox-magnesium carb 160 mg-105 mg chewable tablet [9016]", "drug_information": { "unit": 1.00, "type": "EA" }, "code_information": [ { "code": "0088-1174-47", "type": "NDC" } ], "standard_charges": [ { "gross_charge": 1.00, "minimum": 0.80, "maximum": 0.85, "setting": "both", "payers_information": [ { "payer_name": "Aetna", "plan_name": "700700", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna", "plan_name": "700700_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Miscellaneous", "plan_name": "700720", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Miscellaneous", "plan_name": "700720_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Ppo Hmo", "plan_name": "701720", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Ppo Hmo", "plan_name": "701720_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Ms State Emplo", "plan_name": "401457", "standard_charge_percentage": 0.80, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Ms State Emplo", "plan_name": "401457_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Basic Pl", "plan_name": "400100", "standard_charge_percentage": 0.85, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Basic Pl", "plan_name": "400100_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Federal", "plan_name": "400110", "standard_charge_percentage": 0.85, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Federal", "plan_name": "400110_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." } ] } ] }, { "description": "Ketorolac 10 mg tablet [10371]", "drug_information": { "unit": 1.00, "type": "EA" }, "code_information": [ { "code": "0093-0314-01", "type": "NDC" } ], "standard_charges": [ { "gross_charge": 7.50, "minimum": 6.00, "maximum": 6.38, "setting": "both", "payers_information": [ { "payer_name": "Aetna", "plan_name": "700700", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna", "plan_name": "700700_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Miscellaneous", "plan_name": "700720", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Miscellaneous", "plan_name": "700720_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Ppo Hmo", "plan_name": "701720", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Ppo Hmo", "plan_name": "701720_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Ms State Emplo", "plan_name": "401457", "standard_charge_percentage": 0.80, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Ms State Emplo", "plan_name": "401457_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Basic Pl", "plan_name": "400100", "standard_charge_percentage": 0.85, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Basic Pl", "plan_name": "400100_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Federal", "plan_name": "400110", "standard_charge_percentage": 0.85, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Federal", "plan_name": "400110_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." } ] } ] }, { "description": "Diltiazem 30 mg tablet [2475]", "drug_information": { "unit": 1.00, "type": "EA" }, "code_information": [ { "code": "0093-0318-01", "type": "NDC" } ], "standard_charges": [ { "gross_charge": 7.50, "minimum": 6.00, "maximum": 6.38, "setting": "both", "payers_information": [ { "payer_name": "Aetna", "plan_name": "700700", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna", "plan_name": "700700_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Miscellaneous", "plan_name": "700720", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Miscellaneous", "plan_name": "700720_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Ppo Hmo", "plan_name": "701720", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Ppo Hmo", "plan_name": "701720_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Ms State Emplo", "plan_name": "401457", "standard_charge_percentage": 0.80, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Ms State Emplo", "plan_name": "401457_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Basic Pl", "plan_name": "400100", "standard_charge_percentage": 0.85, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Basic Pl", "plan_name": "400100_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Federal", "plan_name": "400110", "standard_charge_percentage": 0.85, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Federal", "plan_name": "400110_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." } ] } ] }, { "description": "Diltiazem 60 mg tablet [2476]", "drug_information": { "unit": 1.00, "type": "EA" }, "code_information": [ { "code": "0093-0319-01", "type": "NDC" } ], "standard_charges": [ { "gross_charge": 7.50, "minimum": 6.00, "maximum": 6.38, "setting": "both", "payers_information": [ { "payer_name": "Aetna", "plan_name": "700700", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna", "plan_name": "700700_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Miscellaneous", "plan_name": "700720", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Miscellaneous", "plan_name": "700720_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Ppo Hmo", "plan_name": "701720", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Ppo Hmo", "plan_name": "701720_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Ms State Emplo", "plan_name": "401457", "standard_charge_percentage": 0.80, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Ms State Emplo", "plan_name": "401457_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Basic Pl", "plan_name": "400100", "standard_charge_percentage": 0.85, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Basic Pl", "plan_name": "400100_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Federal", "plan_name": "400110", "standard_charge_percentage": 0.85, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Federal", "plan_name": "400110_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." } ] } ] }, { "description": "Warfarin 1 mg tablet [11664]", "drug_information": { "unit": 1.00, "type": "EA" }, "code_information": [ { "code": "0093-1712-01", "type": "NDC" } ], "standard_charges": [ { "gross_charge": 7.50, "minimum": 6.00, "maximum": 6.38, "setting": "both", "payers_information": [ { "payer_name": "Aetna", "plan_name": "700700", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna", "plan_name": "700700_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Miscellaneous", "plan_name": "700720", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Miscellaneous", "plan_name": "700720_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Ppo Hmo", "plan_name": "701720", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Ppo Hmo", "plan_name": "701720_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Ms State Emplo", "plan_name": "401457", "standard_charge_percentage": 0.80, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Ms State Emplo", "plan_name": "401457_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Basic Pl", "plan_name": "400100", "standard_charge_percentage": 0.85, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Basic Pl", "plan_name": "400100_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Federal", "plan_name": "400110", "standard_charge_percentage": 0.85, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Federal", "plan_name": "400110_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." } ] } ] }, { "description": "Warfarin 3 mg tablet [19433]", "drug_information": { "unit": 1.00, "type": "EA" }, "code_information": [ { "code": "0093-1715-01", "type": "NDC" } ], "standard_charges": [ { "gross_charge": 7.50, "minimum": 6.00, "maximum": 6.38, "setting": "both", "payers_information": [ { "payer_name": "Aetna", "plan_name": "700700", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna", "plan_name": "700700_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Miscellaneous", "plan_name": "700720", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Miscellaneous", "plan_name": "700720_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Ppo Hmo", "plan_name": "701720", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Ppo Hmo", "plan_name": "701720_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Ms State Emplo", "plan_name": "401457", "standard_charge_percentage": 0.80, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Ms State Emplo", "plan_name": "401457_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Basic Pl", "plan_name": "400100", "standard_charge_percentage": 0.85, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Basic Pl", "plan_name": "400100_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Federal", "plan_name": "400110", "standard_charge_percentage": 0.85, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Federal", "plan_name": "400110_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." } ] } ] }, { "description": "Azithromycin 100 mg/5 ml oral suspension [15796]", "drug_information": { "unit": 15.00, "type": "ML" }, "code_information": [ { "code": 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"payer_name": "Aetna Ppo Hmo", "plan_name": "701720", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Ppo Hmo", "plan_name": "701720_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Ms State Emplo", "plan_name": "401457", "standard_charge_percentage": 0.80, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Ms State Emplo", "plan_name": "401457_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Basic Pl", "plan_name": "400100", "standard_charge_percentage": 0.85, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Basic Pl", "plan_name": "400100_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Federal", "plan_name": "400110", "standard_charge_percentage": 0.85, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Federal", "plan_name": "400110_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." } ] } ] }, { "description": "Metoclopramide 5 mg tablet [5006]", "drug_information": { "unit": 1.00, "type": "EA" }, "code_information": [ { "code": "0093-2204-01", "type": "NDC" } ], "standard_charges": [ { "gross_charge": 7.50, "minimum": 6.00, "maximum": 6.38, "setting": "both", "payers_information": [ { "payer_name": "Aetna", "plan_name": "700700", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna", "plan_name": "700700_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Miscellaneous", "plan_name": "700720", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed 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"payer_name": "Bc/Bs Ms State Emplo", "plan_name": "401457_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Basic Pl", "plan_name": "400100", "standard_charge_percentage": 0.85, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Basic Pl", "plan_name": "400100_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Federal", "plan_name": "400110", "standard_charge_percentage": 0.85, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Federal", "plan_name": "400110_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." } ] } ] }, { "description": "Amoxicillin 500 mg-potassium clavulanate 125 mg tablet [33227]", "drug_information": { "unit": 1.00, "type": "EA" }, "code_information": [ { "code": "0093-2274-34", "type": "NDC" } ], "standard_charges": [ { "gross_charge": 9.43, "minimum": 7.54, "maximum": 8.02, "setting": "both", "payers_information": [ { "payer_name": "Aetna", "plan_name": "700700", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna", "plan_name": "700700_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": 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remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Ms State Emplo", "plan_name": "401457", "standard_charge_percentage": 0.80, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Ms State Emplo", "plan_name": "401457_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Basic Pl", "plan_name": "400100", "standard_charge_percentage": 0.85, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Basic Pl", "plan_name": "400100_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Federal", "plan_name": "400110", "standard_charge_percentage": 0.85, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Federal", "plan_name": "400110_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." } ] } ] }, { "description": "Amoxicillin 875 mg-potassium clavulanate 125 mg tablet [33228]", "drug_information": { "unit": 1.00, "type": "EA" }, "code_information": [ { "code": "0093-2275-34", "type": "NDC" } ], "standard_charges": [ { "gross_charge": 11.29, "minimum": 9.03, "maximum": 9.60, "setting": "both", "payers_information": [ { "payer_name": "Aetna", "plan_name": "700700", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of 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"additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Ppo Hmo", "plan_name": "701720_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Ms State Emplo", "plan_name": "401457", "standard_charge_percentage": 0.80, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Ms State Emplo", "plan_name": "401457_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Basic Pl", "plan_name": "400100", "standard_charge_percentage": 0.85, "count": "0", "methodology": "percent of total billed charges", 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"payer_name": "Bc/Bs Of Ms Basic Pl", "plan_name": "400100", "standard_charge_percentage": 0.85, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Basic Pl", "plan_name": "400100_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Federal", "plan_name": "400110", "standard_charge_percentage": 0.85, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Federal", "plan_name": "400110_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." } ] } ] }, { "description": "Oseltamivir 6 mg/ml oral suspension [151808]", "drug_information": { "unit": 60.00, "type": "ML" }, "code_information": [ { "code": "0093-8180-64", "type": "NDC" } ], "standard_charges": [ { "gross_charge": 310.94, "minimum": 248.75, "maximum": 264.30, "setting": "both", "payers_information": [ { "payer_name": "Aetna", "plan_name": "700700", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna", "plan_name": "700700_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Miscellaneous", "plan_name": "700720", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data 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10.52, "minimum": 8.42, "maximum": 8.94, "setting": "both", "payers_information": [ { "payer_name": "Aetna", "plan_name": "700700", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna", "plan_name": "700700_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Miscellaneous", "plan_name": "700720", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Miscellaneous", "plan_name": "700720_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": 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remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Basic Pl", "plan_name": "400100", "standard_charge_percentage": 0.85, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Basic Pl", "plan_name": "400100_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Federal", "plan_name": "400110", "standard_charge_percentage": 0.85, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Federal", "plan_name": "400110_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." } ] } ] }, { "description": "Carbidopa 10 mg-levodopa 100 mg tablet [9406]", "drug_information": { "unit": 1.00, "type": "EA" }, "code_information": [ { "code": "0093-9701-01", "type": "NDC" } ], "standard_charges": [ { "gross_charge": 7.50, "minimum": 6.00, "maximum": 6.38, "setting": "both", "payers_information": [ { "payer_name": "Aetna", "plan_name": "700700", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna", "plan_name": "700700_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Miscellaneous", "plan_name": "700720", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Miscellaneous", "plan_name": "700720_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Ppo Hmo", "plan_name": "701720", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Ppo Hmo", "plan_name": "701720_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Ms State Emplo", "plan_name": "401457", "standard_charge_percentage": 0.80, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Ms State Emplo", "plan_name": "401457_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Basic Pl", "plan_name": "400100", "standard_charge_percentage": 0.85, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Basic Pl", "plan_name": "400100_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Federal", "plan_name": "400110", "standard_charge_percentage": 0.85, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Federal", "plan_name": "400110_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." } ] } ] }, { "description": "Hydrocortisone 1 % lotion [3728]", "drug_information": { "unit": 120.00, "type": "ML" }, "code_information": [ { "code": "0096-0732-04", "type": "NDC" } ], "standard_charges": [ { "gross_charge": 35.57, "minimum": 28.46, "maximum": 30.23, "setting": "both", "payers_information": [ { "payer_name": "Aetna", "plan_name": "700700", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna", "plan_name": "700700_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Miscellaneous", "plan_name": "700720", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Miscellaneous", "plan_name": "700720_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Ppo Hmo", "plan_name": "701720", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Ppo Hmo", "plan_name": "701720_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Ms State Emplo", "plan_name": "401457", "standard_charge_percentage": 0.80, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Ms State Emplo", "plan_name": "401457_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Basic Pl", "plan_name": "400100", "standard_charge_percentage": 0.85, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Basic Pl", "plan_name": "400100_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Federal", "plan_name": "400110", "standard_charge_percentage": 0.85, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Federal", "plan_name": "400110_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." } ] } ] }, { "description": "Guaifenesin 100 mg/5 ml oral liquid [3542]", "drug_information": { "unit": 118.00, "type": "ML" }, "code_information": [ { "code": "0113-0061-26", "type": "NDC" } ], "standard_charges": [ { "gross_charge": 5.22, "minimum": 4.18, "maximum": 4.44, "setting": "both", "payers_information": [ { "payer_name": "Aetna", "plan_name": "700700", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna", "plan_name": "700700_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Miscellaneous", "plan_name": "700720", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Miscellaneous", "plan_name": "700720_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Ppo Hmo", "plan_name": "701720", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Ppo Hmo", "plan_name": "701720_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Ms State Emplo", "plan_name": "401457", "standard_charge_percentage": 0.80, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Ms State Emplo", "plan_name": "401457_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Basic Pl", "plan_name": "400100", "standard_charge_percentage": 0.85, "count": "0", "methodology": "percent 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"methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." } ] } ] }, { "description": "Phenylephrine 10 mg tablet [40368]", "drug_information": { "unit": 1.00, "type": "EA" }, "code_information": [ { "code": "0113-0094-89", "type": "NDC" } ], "standard_charges": [ { "gross_charge": 7.50, "minimum": 6.00, "maximum": 6.38, "setting": "both", "payers_information": [ { "payer_name": "Aetna", "plan_name": "700700", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna", "plan_name": "700700_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Miscellaneous", "plan_name": "700720", "standard_charge_percentage": 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"standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Federal", "plan_name": "400110", "standard_charge_percentage": 0.85, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Federal", "plan_name": "400110_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." } ] } ] }, { "description": "Oxymetazoline 0.05 % nasal spray [5943]", "drug_information": { "unit": 30.00, "type": "ML" }, "code_information": [ { "code": "0113-0304-10", "type": "NDC" } ], "standard_charges": [ { "gross_charge": 7.50, "minimum": 6.00, "maximum": 6.38, "setting": "both", "payers_information": [ { 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"Dextromethorphan-guaifenesin 10 mg-100 mg/5 ml oral syrup [9774]", "drug_information": { "unit": 118.00, "type": "ML" }, "code_information": [ { "code": "0113-0359-26", "type": "NDC" } ], "standard_charges": [ { "gross_charge": 5.22, "minimum": 4.18, "maximum": 4.44, "setting": "both", "payers_information": [ { "payer_name": "Aetna", "plan_name": "700700", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna", "plan_name": "700700_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Miscellaneous", "plan_name": "700720", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to 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"additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Miscellaneous", "plan_name": "700720", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Miscellaneous", "plan_name": "700720_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Ppo Hmo", "plan_name": "701720", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Ppo Hmo", "plan_name": "701720_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Ms State Emplo", "plan_name": "401457", "standard_charge_percentage": 0.80, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Ms State Emplo", "plan_name": "401457_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Basic Pl", "plan_name": "400100", "standard_charge_percentage": 0.85, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Basic Pl", "plan_name": "400100_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Federal", "plan_name": "400110", "standard_charge_percentage": 0.85, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Federal", "plan_name": "400110_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." } ] } ] }, { "description": "Acetaminophen er 650 mg tabletextended release [13410]", "drug_information": { "unit": 1.00, "type": "EA" }, "code_information": [ { "code": "0113-0544-62", "type": "NDC" } ], "standard_charges": [ { "gross_charge": 1.00, "minimum": 0.80, "maximum": 0.85, "setting": "both", "payers_information": [ { "payer_name": "Aetna", "plan_name": "700700", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna", "plan_name": "700700_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Miscellaneous", "plan_name": "700720", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Miscellaneous", "plan_name": "700720_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Ppo Hmo", "plan_name": "701720", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Ppo Hmo", "plan_name": "701720_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Ms State Emplo", "plan_name": "401457", "standard_charge_percentage": 0.80, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Ms State Emplo", "plan_name": "401457_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Basic Pl", "plan_name": "400100", "standard_charge_percentage": 0.85, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Basic Pl", "plan_name": "400100_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Federal", "plan_name": "400110", "standard_charge_percentage": 0.85, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Federal", "plan_name": "400110_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." } ] } ] }, { "description": "Fexofenadine 180 mg tablet [25425]", "drug_information": { "unit": 1.00, "type": "EA" }, "code_information": [ { "code": "0113-0571-39", "type": "NDC" } ], "standard_charges": [ { "gross_charge": 1.22, "minimum": 0.98, "maximum": 1.04, "setting": "both", "payers_information": [ { "payer_name": "Aetna", "plan_name": "700700", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna", "plan_name": "700700_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Miscellaneous", "plan_name": "700720", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Miscellaneous", "plan_name": "700720_1", "standard_charge_percentage": 100.0, "count": "0", 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80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Miscellaneous", "plan_name": "700720_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Ppo Hmo", "plan_name": "701720", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Ppo Hmo", "plan_name": "701720_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Ms State Emplo", "plan_name": "401457", "standard_charge_percentage": 0.80, "count": 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"description": "Dextromethorphan 5 mg-guaifenesin 50 mg/5 ml oral liquid [186238]", "drug_information": { "unit": 237.00, "type": "ML" }, "code_information": [ { "code": "0113-1725-34", "type": "NDC" } ], "standard_charges": [ { "gross_charge": 25.88, "minimum": 20.70, "maximum": 22.00, "setting": "both", "payers_information": [ { "payer_name": "Aetna", "plan_name": "700700", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna", "plan_name": "700700_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Miscellaneous", "plan_name": "700720", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": 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"additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Miscellaneous", "plan_name": "700720", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Miscellaneous", "plan_name": "700720_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Ppo Hmo", "plan_name": "701720", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Ppo Hmo", "plan_name": "701720_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Ms State Emplo", "plan_name": "401457", "standard_charge_percentage": 0.80, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Ms State Emplo", "plan_name": "401457_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Basic Pl", "plan_name": "400100", "standard_charge_percentage": 0.85, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Basic Pl", "plan_name": "400100_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Federal", "plan_name": "400110", "standard_charge_percentage": 0.85, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Federal", "plan_name": "400110_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." } ] } ] }, { "description": "Naproxen sodium 220 mg tablet [13135]", "drug_information": { "unit": 1.00, "type": "EA" }, "code_information": [ { "code": "0113-4368-79", "type": "NDC" } ], "standard_charges": [ { "gross_charge": 1.00, "minimum": 0.80, "maximum": 0.85, "setting": "both", "payers_information": [ { "payer_name": "Aetna", "plan_name": "700700", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna", "plan_name": "700700_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Miscellaneous", "plan_name": "700720", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Miscellaneous", "plan_name": "700720_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Ppo Hmo", "plan_name": "701720", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of 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billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Basic Pl", "plan_name": "400100_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Federal", "plan_name": "400110", "standard_charge_percentage": 0.85, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Federal", "plan_name": "400110_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." } ] } ] }, { "description": "Fenofibrate micronized 67 mg capsule [22976]", "drug_information": { "unit": 1.00, "type": "EA" }, "code_information": [ { "code": "0115-0511-01", "type": "NDC" } ], "standard_charges": [ { "gross_charge": 7.50, "minimum": 6.00, "maximum": 6.38, "setting": "both", "payers_information": [ { "payer_name": "Aetna", "plan_name": "700700", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna", "plan_name": "700700_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Miscellaneous", "plan_name": "700720", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Miscellaneous", "plan_name": "700720_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Ppo Hmo", "plan_name": "701720", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Ppo Hmo", "plan_name": "701720_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Ms State Emplo", "plan_name": "401457", "standard_charge_percentage": 0.80, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Ms State Emplo", "plan_name": "401457_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Basic Pl", "plan_name": "400100", "standard_charge_percentage": 0.85, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Basic Pl", "plan_name": "400100_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Federal", "plan_name": "400110", "standard_charge_percentage": 0.85, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Federal", "plan_name": "400110_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." } ] } ] }, { "description": "Pyridostigmine bromide 60 mg tablet [11239]", "drug_information": { "unit": 1.00, "type": "EA" }, "code_information": [ { "code": "0115-3511-01", "type": "NDC" } ], "standard_charges": [ { "gross_charge": 7.50, "minimum": 6.00, "maximum": 6.38, "setting": "both", "payers_information": [ { "payer_name": "Aetna", "plan_name": "700700", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna", "plan_name": "700700_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Miscellaneous", "plan_name": "700720", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Miscellaneous", "plan_name": "700720_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Ppo Hmo", "plan_name": "701720", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Ppo Hmo", "plan_name": "701720_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Ms State Emplo", "plan_name": "401457", "standard_charge_percentage": 0.80, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Ms State Emplo", "plan_name": "401457_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Basic Pl", "plan_name": "400100", "standard_charge_percentage": 0.85, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Basic Pl", "plan_name": "400100_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Federal", "plan_name": "400110", "standard_charge_percentage": 0.85, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Federal", "plan_name": "400110_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." } ] } ] }, { "description": "Fludrocortisone 0.1 mg tablet [10054]", "drug_information": { "unit": 1.00, "type": "EA" }, "code_information": [ { "code": "0115-7033-01", "type": "NDC" } ], "standard_charges": [ { "gross_charge": 7.50, "minimum": 6.00, "maximum": 6.38, "setting": "both", "payers_information": [ { "payer_name": "Aetna", "plan_name": "700700", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna", "plan_name": "700700_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Miscellaneous", "plan_name": "700720", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Miscellaneous", "plan_name": "700720_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Ppo Hmo", "plan_name": "701720", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Ppo Hmo", "plan_name": "701720_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Ms State Emplo", "plan_name": "401457", "standard_charge_percentage": 0.80, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Ms State Emplo", "plan_name": "401457_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Basic Pl", "plan_name": "400100", "standard_charge_percentage": 0.85, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Basic Pl", "plan_name": "400100_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Federal", "plan_name": "400110", "standard_charge_percentage": 0.85, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Federal", "plan_name": "400110_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." } ] } ] }, { "description": "Chlorhexidine gluconate 4 % topical liquid [28188]", "drug_information": { "unit": 118.00, "type": "ML" }, "code_information": [ { "code": "0116-1061-04", "type": "NDC" } ], "standard_charges": [ { "gross_charge": 33.07, "minimum": 26.46, "maximum": 28.11, "setting": "both", "payers_information": [ { "payer_name": "Aetna", "plan_name": "700700", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna", "plan_name": "700700_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Miscellaneous", "plan_name": "700720", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Miscellaneous", "plan_name": "700720_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Ppo Hmo", "plan_name": "701720", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Ppo Hmo", "plan_name": "701720_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Ms State Emplo", "plan_name": "401457", "standard_charge_percentage": 0.80, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Ms State Emplo", "plan_name": "401457_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Basic Pl", "plan_name": "400100", "standard_charge_percentage": 0.85, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Basic Pl", "plan_name": "400100_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Federal", "plan_name": "400110", "standard_charge_percentage": 0.85, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Federal", "plan_name": "400110_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." } ] } ] }, { "description": "Chlorhexidine gluconate 0.12 % mouthwash [9516]", "drug_information": { "unit": 473.00, "type": "ML" }, "code_information": [ { "code": "0116-2001-16", "type": "NDC" } ], "standard_charges": [ { "gross_charge": 33.70, "minimum": 26.96, "maximum": 28.65, "setting": "both", "payers_information": [ { "payer_name": "Aetna", "plan_name": "700700", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna", "plan_name": "700700_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Miscellaneous", "plan_name": "700720", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Miscellaneous", "plan_name": "700720_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Ppo Hmo", "plan_name": "701720", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Ppo Hmo", "plan_name": "701720_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Ms State Emplo", "plan_name": "401457", "standard_charge_percentage": 0.80, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Ms State Emplo", "plan_name": "401457_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Basic Pl", "plan_name": "400100", "standard_charge_percentage": 0.85, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Basic Pl", "plan_name": "400100_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Federal", "plan_name": "400110", "standard_charge_percentage": 0.85, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Federal", "plan_name": "400110_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." } ] } ] }, { "description": "Lactulose 10 gram/15 ml oral solution [38245]", "drug_information": { "unit": 473.00, "type": "ML" }, "code_information": [ { "code": "0116-4005-16", "type": "NDC" } ], "standard_charges": [ { "gross_charge": 65.16, "minimum": 52.13, "maximum": 55.39, "setting": "both", "payers_information": [ { "payer_name": "Aetna", "plan_name": "700700", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna", "plan_name": "700700_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Miscellaneous", "plan_name": "700720", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Miscellaneous", "plan_name": "700720_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Ppo Hmo", "plan_name": "701720", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Ppo Hmo", "plan_name": "701720_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Ms State Emplo", "plan_name": "401457", "standard_charge_percentage": 0.80, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Ms State Emplo", "plan_name": "401457_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Basic Pl", "plan_name": "400100", "standard_charge_percentage": 0.85, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Basic Pl", "plan_name": "400100_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Federal", "plan_name": "400110", "standard_charge_percentage": 0.85, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Federal", "plan_name": "400110_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." } ] } ] }, { "description": "Magnesium hydroxide 400 mg/5 ml oral suspension [108978]", "drug_information": { "unit": 30.00, "type": "ML" }, "code_information": [ { "code": "0121-0431-30", "type": "NDC" } ], "standard_charges": [ { "gross_charge": 6.32, "minimum": 5.06, "maximum": 5.37, "setting": "both", "payers_information": [ { "payer_name": "Aetna", "plan_name": "700700", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna", "plan_name": "700700_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Miscellaneous", "plan_name": "700720", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Miscellaneous", "plan_name": "700720_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Ppo Hmo", "plan_name": "701720", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Ppo Hmo", "plan_name": "701720_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Ms State Emplo", "plan_name": "401457", "standard_charge_percentage": 0.80, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Ms State Emplo", "plan_name": "401457_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Basic Pl", "plan_name": "400100", "standard_charge_percentage": 0.85, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Basic Pl", "plan_name": "400100_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Federal", "plan_name": "400110", "standard_charge_percentage": 0.85, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Federal", "plan_name": "400110_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." } ] } ] }, { "description": "Docusate sodium 50 mg/5 ml oral liquid [36962]", "drug_information": { "unit": 10.00, "type": "ML" }, "code_information": [ { "code": "0121-0544-10", "type": "NDC" } ], "standard_charges": [ { "gross_charge": 2.89, "minimum": 2.31, "maximum": 2.46, "setting": "both", "payers_information": [ { "payer_name": "Aetna", "plan_name": "700700", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna", "plan_name": "700700_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Miscellaneous", "plan_name": "700720", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Miscellaneous", "plan_name": "700720_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Ppo Hmo", "plan_name": "701720", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Ppo Hmo", "plan_name": "701720_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Ms State Emplo", "plan_name": "401457", "standard_charge_percentage": 0.80, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Ms State Emplo", "plan_name": "401457_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Basic Pl", "plan_name": "400100", "standard_charge_percentage": 0.85, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Basic Pl", "plan_name": "400100_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Federal", "plan_name": "400110", "standard_charge_percentage": 0.85, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Federal", "plan_name": "400110_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." } ] } ] }, { "description": "Metoclopramide 5 mg/5 ml oral solution [77725]", "drug_information": { "unit": 473.00, "type": "ML" }, "code_information": [ { "code": "0121-0576-16", "type": "NDC" } ], "standard_charges": [ { "gross_charge": 139.30, "minimum": 111.44, "maximum": 118.41, "setting": "both", "payers_information": [ { "payer_name": "Aetna", "plan_name": "700700", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna", "plan_name": "700700_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Miscellaneous", "plan_name": "700720", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Miscellaneous", "plan_name": "700720_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Ppo Hmo", "plan_name": "701720", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Ppo Hmo", "plan_name": "701720_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Ms State Emplo", "plan_name": "401457", "standard_charge_percentage": 0.80, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Ms State Emplo", "plan_name": "401457_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Basic Pl", "plan_name": "400100", "standard_charge_percentage": 0.85, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Basic Pl", "plan_name": "400100_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Federal", "plan_name": "400110", "standard_charge_percentage": 0.85, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Federal", "plan_name": "400110_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." } ] } ] }, { "description": "Valproic acid (as sodium salt) 250 mg/5 ml oral solution [8428]", "drug_information": { "unit": 473.00, "type": "ML" }, "code_information": [ { "code": "0121-0675-85", "type": "NDC" } ], "standard_charges": [ { "gross_charge": 121.33, "minimum": 97.06, "maximum": 103.13, "setting": "both", "payers_information": [ { "payer_name": "Aetna", "plan_name": "700700", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed 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"payer_name": "Aetna Ppo Hmo", "plan_name": "701720_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Ms State Emplo", "plan_name": "401457", "standard_charge_percentage": 0.80, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Ms State Emplo", "plan_name": "401457_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Basic Pl", "plan_name": "400100", "standard_charge_percentage": 0.85, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Basic Pl", "plan_name": "400100_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Federal", "plan_name": "400110", "standard_charge_percentage": 0.85, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Federal", "plan_name": "400110_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." } ] } ] }, { "description": "Hydrocodone 7.5 mg-acetaminophen 325 mg/15 ml oral solution [37848]", "drug_information": { "unit": 473.00, "type": "ML" }, "code_information": [ { "code": "0121-0772-16", "type": "NDC" } ], "standard_charges": [ { "gross_charge": 204.34, "minimum": 163.47, "maximum": 173.69, "setting": "both", "payers_information": [ { "payer_name": "Aetna", "plan_name": "700700", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna", "plan_name": "700700_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Miscellaneous", "plan_name": "700720", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Miscellaneous", "plan_name": "700720_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Ppo Hmo", "plan_name": "701720", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Ppo Hmo", "plan_name": "701720_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Ms State Emplo", "plan_name": "401457", "standard_charge_percentage": 0.80, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Ms State Emplo", "plan_name": "401457_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Basic Pl", "plan_name": "400100", "standard_charge_percentage": 0.85, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Basic Pl", "plan_name": "400100_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Federal", "plan_name": "400110", "standard_charge_percentage": 0.85, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Federal", "plan_name": "400110_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." } ] } ] }, { "description": "Codeine 10 mg-guaifenesin 100 mg/5 ml oral liquid [78003]", "drug_information": { "unit": 473.00, "type": "ML" }, "code_information": [ { "code": "0121-0775-16", "type": "NDC" } ], "standard_charges": [ { "gross_charge": 153.25, "minimum": 122.60, "maximum": 130.26, "setting": "both", "payers_information": [ { "payer_name": "Aetna", "plan_name": "700700", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna", "plan_name": "700700_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Miscellaneous", "plan_name": "700720", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Miscellaneous", "plan_name": "700720_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Ppo Hmo", "plan_name": "701720", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Ppo Hmo", "plan_name": "701720_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Ms State Emplo", "plan_name": "401457", "standard_charge_percentage": 0.80, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Ms State Emplo", "plan_name": "401457_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Basic Pl", "plan_name": "400100", "standard_charge_percentage": 0.85, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Basic Pl", "plan_name": "400100_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Federal", "plan_name": "400110", "standard_charge_percentage": 0.85, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Federal", "plan_name": "400110_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." } ] } ] }, { "description": "Levetiracetam 100 mg/ml oral solution [36590]", "drug_information": { "unit": 473.00, "type": "ML" }, "code_information": [ { "code": "0121-0799-16", "type": "NDC" } ], "standard_charges": [ { "gross_charge": 132.56, "minimum": 106.05, "maximum": 112.68, "setting": "both", "payers_information": [ { "payer_name": "Aetna", "plan_name": "700700", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna", "plan_name": "700700_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Miscellaneous", "plan_name": "700720", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Miscellaneous", "plan_name": "700720_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Ppo Hmo", "plan_name": "701720", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Ppo Hmo", "plan_name": "701720_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Ms State Emplo", "plan_name": "401457", "standard_charge_percentage": 0.80, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Ms State Emplo", "plan_name": "401457_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Basic Pl", "plan_name": "400100", "standard_charge_percentage": 0.85, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Basic Pl", "plan_name": "400100_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Federal", "plan_name": "400110", "standard_charge_percentage": 0.85, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Federal", "plan_name": "400110_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." } ] } ] }, { "description": "Theophylline 80 mg/15 ml oral elixir [7820]", "drug_information": { "unit": 473.00, "type": "ML" }, "code_information": [ { "code": "0121-0820-16", "type": "NDC" } ], "standard_charges": [ { "gross_charge": 251.64, "minimum": 201.31, "maximum": 213.89, "setting": "both", "payers_information": [ { "payer_name": "Aetna", "plan_name": "700700", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna", "plan_name": "700700_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Miscellaneous", "plan_name": "700720", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Miscellaneous", "plan_name": "700720_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Ppo Hmo", "plan_name": "701720", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Ppo Hmo", "plan_name": "701720_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Ms State Emplo", "plan_name": "401457", "standard_charge_percentage": 0.80, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Ms State Emplo", "plan_name": "401457_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Basic Pl", "plan_name": "400100", "standard_charge_percentage": 0.85, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Basic Pl", "plan_name": "400100_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Federal", "plan_name": "400110", "standard_charge_percentage": 0.85, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Federal", "plan_name": "400110_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." } ] } ] }, { "description": "Morphine concentrate 100 mg/5 ml (20 mg/ml) oral solution [10655]", "drug_information": { "unit": 30.00, "type": "ML" }, "code_information": [ { "code": "0121-0825-01", "type": "NDC" } ], "standard_charges": [ { "gross_charge": 57.92, "minimum": 46.34, "maximum": 49.23, "setting": "both", "payers_information": [ { "payer_name": "Aetna", "plan_name": "700700", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna", "plan_name": "700700_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Miscellaneous", "plan_name": "700720", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Miscellaneous", "plan_name": "700720_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Ppo Hmo", "plan_name": "701720", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Ppo Hmo", "plan_name": "701720_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Ms State Emplo", "plan_name": "401457", "standard_charge_percentage": 0.80, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Ms State Emplo", "plan_name": "401457_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Basic Pl", "plan_name": "400100", "standard_charge_percentage": 0.85, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Basic Pl", "plan_name": "400100_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Federal", "plan_name": "400110", "standard_charge_percentage": 0.85, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to 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{ "payer_name": "Bc/Bs Of Ms Federal", "plan_name": "400110_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." } ] } ] }, { "description": "Acetaminophen 300 mg-codeine 30 mg/12.5 ml (12.5 ml) oral solution [160327]", "drug_information": { "unit": 12.50, "type": "ML" }, "code_information": [ { "code": "0121-1008-12", "type": "NDC" } ], "standard_charges": [ { "gross_charge": 7.22, "minimum": 5.78, "maximum": 6.14, "setting": "both", "payers_information": [ { "payer_name": "Aetna", "plan_name": "700700", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna", "plan_name": "700700_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Miscellaneous", "plan_name": "700720", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Miscellaneous", "plan_name": "700720_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Ppo Hmo", "plan_name": "701720", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Ppo Hmo", "plan_name": "701720_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Ms State Emplo", "plan_name": "401457", "standard_charge_percentage": 0.80, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Ms State Emplo", "plan_name": "401457_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Basic Pl", "plan_name": "400100", "standard_charge_percentage": 0.85, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Basic Pl", "plan_name": "400100_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Federal", "plan_name": "400110", "standard_charge_percentage": 0.85, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Federal", "plan_name": "400110_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." } ] } ] }, { "description": "Lactulose 20 gram/30 ml oral solution [154863]", "drug_information": { "unit": 30.00, "type": "ML" }, "code_information": [ { "code": "0121-1154-30", "type": "NDC" } ], "standard_charges": [ { "gross_charge": 11.54, "minimum": 9.23, "maximum": 9.81, "setting": "both", "payers_information": [ { "payer_name": "Aetna", "plan_name": "700700", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna", "plan_name": "700700_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Miscellaneous", "plan_name": "700720", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Miscellaneous", "plan_name": "700720_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Ppo Hmo", "plan_name": "701720", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Ppo Hmo", "plan_name": "701720_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Ms State Emplo", "plan_name": "401457", "standard_charge_percentage": 0.80, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Ms State Emplo", "plan_name": "401457_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Basic Pl", "plan_name": "400100", "standard_charge_percentage": 0.85, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Basic Pl", "plan_name": "400100_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Federal", "plan_name": "400110", "standard_charge_percentage": 0.85, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Federal", "plan_name": "400110_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." } ] } ] }, { "description": "Acetaminophen 325 mg/10.15 ml oral (wrapped) [507073]", "drug_information": { "unit": 10.15, "type": "ML" }, "code_information": [ { "code": "0121-1314-11", "type": "NDC" } ], "standard_charges": [ { "gross_charge": 5.91, "minimum": 4.73, "maximum": 5.02, "setting": "both", "payers_information": [ { "payer_name": "Aetna", "plan_name": "700700", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna", "plan_name": "700700_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Miscellaneous", "plan_name": "700720", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Miscellaneous", "plan_name": "700720_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Ppo Hmo", "plan_name": "701720", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Ppo Hmo", "plan_name": "701720_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Ms State Emplo", "plan_name": "401457", "standard_charge_percentage": 0.80, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Ms State Emplo", "plan_name": "401457_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Basic Pl", "plan_name": "400100", "standard_charge_percentage": 0.85, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Basic Pl", "plan_name": "400100_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Federal", "plan_name": "400110", "standard_charge_percentage": 0.85, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Federal", "plan_name": "400110_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." } ] } ] }, { "description": "Guaifenesin 100 mg/5 ml oral liquid [3542]", "drug_information": { "unit": 10.00, "type": "ML" }, "code_information": [ { "code": "0121-1488-00", "type": "NDC" } ], "standard_charges": [ { "gross_charge": 5.23, "minimum": 4.18, "maximum": 4.45, "setting": "both", "payers_information": [ { "payer_name": "Aetna", "plan_name": "700700", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna", "plan_name": "700700_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Miscellaneous", "plan_name": "700720", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Miscellaneous", "plan_name": "700720_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Ppo Hmo", "plan_name": "701720", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Ppo Hmo", "plan_name": "701720_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Ms State Emplo", "plan_name": "401457", "standard_charge_percentage": 0.80, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Ms State Emplo", "plan_name": "401457_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Basic Pl", "plan_name": "400100", "standard_charge_percentage": 0.85, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Basic Pl", "plan_name": "400100_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Federal", "plan_name": "400110", "standard_charge_percentage": 0.85, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Federal", "plan_name": "400110_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." } ] } ] }, { "description": "Guaifenesin 100 mg/5 ml oral liquid [3542]", "drug_information": { "unit": 10.00, "type": "ML" }, "code_information": [ { "code": "0121-1488-10", "type": "NDC" } ], "standard_charges": [ { "gross_charge": 5.23, "minimum": 4.18, "maximum": 4.45, "setting": "both", "payers_information": [ { "payer_name": "Aetna", "plan_name": "700700", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna", "plan_name": "700700_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Miscellaneous", "plan_name": "700720", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Miscellaneous", "plan_name": "700720_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Ppo Hmo", "plan_name": "701720", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Ppo Hmo", "plan_name": "701720_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Ms State Emplo", "plan_name": "401457", "standard_charge_percentage": 0.80, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Ms State Emplo", "plan_name": "401457_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Basic Pl", "plan_name": "400100", "standard_charge_percentage": 0.85, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Basic Pl", "plan_name": "400100_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Federal", "plan_name": "400110", "standard_charge_percentage": 0.85, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Federal", "plan_name": "400110_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." } ] } ] }, { "description": "Hydrocodone 7.5 mg-acetaminophen 325 mg/15 ml oral solution [37848]", "drug_information": { "unit": 10.00, "type": "ML" }, "code_information": [ { "code": "0121-1544-10", "type": "NDC" } ], "standard_charges": [ { "gross_charge": 95.18, "minimum": 76.14, "maximum": 80.90, "setting": "both", "payers_information": [ { "payer_name": "Aetna", "plan_name": "700700", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna", "plan_name": "700700_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Miscellaneous", "plan_name": "700720", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Miscellaneous", "plan_name": "700720_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Ppo Hmo", "plan_name": "701720", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Ppo Hmo", "plan_name": "701720_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Ms State Emplo", "plan_name": "401457", "standard_charge_percentage": 0.80, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Ms State Emplo", "plan_name": "401457_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Basic Pl", "plan_name": "400100", "standard_charge_percentage": 0.85, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Basic Pl", "plan_name": "400100_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Federal", "plan_name": "400110", "standard_charge_percentage": 0.85, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Federal", "plan_name": "400110_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." } ] } ] }, { "description": "Aluminum-magnesium hydroxide 200 mg-200 mg/5 ml oral suspension [37605]", "drug_information": { "unit": 30.00, "type": "ML" }, "code_information": [ { "code": "0121-1760-30", "type": "NDC" } ], "standard_charges": [ { "gross_charge": 15.37, "minimum": 12.30, "maximum": 13.06, "setting": "both", "payers_information": [ { "payer_name": "Aetna", "plan_name": "700700", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna", "plan_name": "700700_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Miscellaneous", "plan_name": "700720", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Miscellaneous", "plan_name": "700720_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Ppo Hmo", "plan_name": "701720", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Ppo Hmo", "plan_name": "701720_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Ms State Emplo", "plan_name": "401457", "standard_charge_percentage": 0.80, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Ms State Emplo", "plan_name": "401457_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Basic Pl", "plan_name": "400100", "standard_charge_percentage": 0.85, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Basic Pl", "plan_name": "400100_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Federal", "plan_name": "400110", "standard_charge_percentage": 0.85, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Federal", "plan_name": "400110_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." } ] } ] }, { "description": "Aluminum-mag hydroxide-simethicone 400 mg-400 mg-40 mg/5 ml oral susp [9015]", "drug_information": { "unit": 30.00, "type": "ML" }, "code_information": [ { "code": "0121-1762-30", "type": "NDC" } ], "standard_charges": [ { "gross_charge": 11.78, "minimum": 9.42, "maximum": 10.01, "setting": "both", "payers_information": [ { "payer_name": "Aetna", "plan_name": "700700", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna", "plan_name": "700700_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Miscellaneous", "plan_name": "700720", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Miscellaneous", "plan_name": "700720_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Ppo Hmo", "plan_name": "701720", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Ppo Hmo", "plan_name": "701720_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Ms State Emplo", "plan_name": "401457", "standard_charge_percentage": 0.80, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Ms State Emplo", "plan_name": "401457_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Basic Pl", "plan_name": "400100", "standard_charge_percentage": 0.85, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Basic Pl", "plan_name": "400100_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Federal", "plan_name": "400110", "standard_charge_percentage": 0.85, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Federal", "plan_name": "400110_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." } ] } ] }, { "description": "Codeine 10 mg-guaifenesin 100 mg/5 ml oral liquid [78003]", "drug_information": { "unit": 5.00, "type": "ML" }, "code_information": [ { "code": "0121-1775-05", "type": "NDC" } ], "standard_charges": [ { "gross_charge": 30.17, "minimum": 24.14, "maximum": 25.64, "setting": "both", "payers_information": [ { "payer_name": "Aetna", "plan_name": "700700", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna", "plan_name": "700700_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Miscellaneous", "plan_name": "700720", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Miscellaneous", "plan_name": "700720_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Ppo Hmo", "plan_name": "701720", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Ppo Hmo", "plan_name": "701720_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Ms State Emplo", "plan_name": "401457", "standard_charge_percentage": 0.80, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Ms State Emplo", "plan_name": "401457_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Basic Pl", "plan_name": "400100", "standard_charge_percentage": 0.85, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Basic Pl", "plan_name": "400100_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Federal", "plan_name": "400110", "standard_charge_percentage": 0.85, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Federal", "plan_name": "400110_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." } ] } ] }, { "description": "Ibuprofen 100 mg/5 ml oral suspension [10246]", "drug_information": { "unit": 10.00, "type": "ML" }, "code_information": [ { "code": "0121-1828-10", "type": "NDC" } ], "standard_charges": [ { "gross_charge": 3.95, "minimum": 3.16, "maximum": 3.36, "setting": "both", "payers_information": [ { "payer_name": "Aetna", "plan_name": "700700", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna", "plan_name": "700700_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Miscellaneous", "plan_name": "700720", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Miscellaneous", "plan_name": "700720_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Ppo Hmo", "plan_name": "701720", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Ppo Hmo", "plan_name": "701720_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Ms State Emplo", "plan_name": "401457", "standard_charge_percentage": 0.80, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Ms State Emplo", "plan_name": "401457_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Basic Pl", "plan_name": "400100", "standard_charge_percentage": 0.85, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Basic Pl", "plan_name": "400100_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Federal", "plan_name": "400110", "standard_charge_percentage": 0.85, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Federal", "plan_name": "400110_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." } ] } ] }, { "description": "Docusate sodium 50 mg/5 ml oral liquid [36962]", "drug_information": { "unit": 10.00, "type": "ML" }, "code_information": [ { "code": "0121-1870-10", "type": "NDC" } ], "standard_charges": [ { "gross_charge": 6.01, "minimum": 4.81, "maximum": 5.11, "setting": "both", "payers_information": [ { "payer_name": "Aetna", "plan_name": "700700", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna", "plan_name": "700700_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Miscellaneous", "plan_name": "700720", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Miscellaneous", "plan_name": "700720_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Ppo Hmo", "plan_name": "701720", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Ppo Hmo", "plan_name": "701720_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Ms State Emplo", "plan_name": "401457", "standard_charge_percentage": 0.80, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Ms State Emplo", "plan_name": "401457_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Basic Pl", "plan_name": "400100", "standard_charge_percentage": 0.85, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Basic Pl", "plan_name": "400100_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Federal", "plan_name": "400110", "standard_charge_percentage": 0.85, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Federal", "plan_name": "400110_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." } ] } ] }, { "description": "Acetaminophen 650 mg/20.3 ml oral solution [119323]", "drug_information": { "unit": 20.30, "type": "ML" }, "code_information": [ { "code": "0121-1971-21", "type": "NDC" } ], "standard_charges": [ { "gross_charge": 6.60, "minimum": 5.28, "maximum": 5.61, "setting": "both", "payers_information": [ { "payer_name": "Aetna", "plan_name": "700700", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna", "plan_name": "700700_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Miscellaneous", "plan_name": "700720", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Miscellaneous", "plan_name": "700720_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Ppo Hmo", "plan_name": "701720", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Ppo Hmo", "plan_name": "701720_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Ms State Emplo", "plan_name": "401457", "standard_charge_percentage": 0.80, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Ms State Emplo", "plan_name": "401457_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Basic Pl", "plan_name": "400100", "standard_charge_percentage": 0.85, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Basic Pl", "plan_name": "400100_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Federal", "plan_name": "400110", "standard_charge_percentage": 0.85, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Federal", "plan_name": "400110_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." } ] } ] }, { "description": "Hydrocodone 7.5 mg-acetaminophen 325 mg/15 ml oral solution [37848]", "drug_information": { "unit": 15.00, "type": "ML" }, "code_information": [ { "code": "0121-2316-15", "type": "NDC" } ], "standard_charges": [ { "gross_charge": 47.89, "minimum": 38.31, "maximum": 40.71, "setting": "both", "payers_information": [ { "payer_name": "Aetna", "plan_name": "700700", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna", "plan_name": "700700_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Miscellaneous", "plan_name": "700720", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Miscellaneous", "plan_name": "700720_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Ppo Hmo", "plan_name": "701720", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Ppo Hmo", "plan_name": "701720_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Ms State Emplo", "plan_name": "401457", "standard_charge_percentage": 0.80, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Ms State Emplo", "plan_name": "401457_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Basic Pl", "plan_name": "400100", "standard_charge_percentage": 0.85, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Basic Pl", "plan_name": "400100_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Federal", "plan_name": "400110", "standard_charge_percentage": 0.85, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Federal", "plan_name": "400110_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." } ] } ] }, { "description": "Lactulose 10 gram/15 ml (15 ml) oral solution [150549]", "drug_information": { "unit": 15.00, "type": "ML" }, "code_information": [ { "code": "0121-4577-15", "type": "NDC" } ], "standard_charges": [ { "gross_charge": 12.68, "minimum": 10.14, "maximum": 10.78, "setting": "both", "payers_information": [ { "payer_name": "Aetna", "plan_name": "700700", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna", "plan_name": "700700_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Miscellaneous", "plan_name": "700720", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Miscellaneous", "plan_name": "700720_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Ppo Hmo", "plan_name": "701720", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Ppo Hmo", "plan_name": "701720_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Ms State Emplo", "plan_name": "401457", "standard_charge_percentage": 0.80, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Ms State Emplo", "plan_name": "401457_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Basic Pl", "plan_name": "400100", "standard_charge_percentage": 0.85, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Basic Pl", "plan_name": "400100_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Federal", "plan_name": "400110", "standard_charge_percentage": 0.85, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Federal", "plan_name": "400110_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." } ] } ] }, { "description": "Valproic acid (as sodium salt) 250 mg/5 ml (5 ml) oral solution [154866]", "drug_information": { "unit": 5.00, "type": "ML" }, "code_information": [ { "code": "0121-4675-00", "type": "NDC" } ], "standard_charges": [ { "gross_charge": 10.43, "minimum": 8.34, "maximum": 8.87, "setting": "both", "payers_information": [ { "payer_name": "Aetna", "plan_name": "700700", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna", "plan_name": "700700_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Miscellaneous", "plan_name": "700720", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Miscellaneous", "plan_name": "700720_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Ppo Hmo", "plan_name": "701720", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Ppo Hmo", "plan_name": "701720_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Ms State Emplo", "plan_name": "401457", "standard_charge_percentage": 0.80, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Ms State Emplo", "plan_name": "401457_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Basic Pl", "plan_name": "400100", "standard_charge_percentage": 0.85, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Basic Pl", "plan_name": "400100_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Federal", "plan_name": "400110", "standard_charge_percentage": 0.85, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Federal", "plan_name": "400110_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." } ] } ] }, { "description": "Valproic acid (as sodium salt) 250 mg/5 ml (5 ml) oral solution [154866]", "drug_information": { "unit": 5.00, "type": "ML" }, "code_information": [ { "code": "0121-4675-05", "type": "NDC" } ], "standard_charges": [ { "gross_charge": 10.43, "minimum": 8.34, "maximum": 8.87, "setting": "both", "payers_information": [ { "payer_name": "Aetna", "plan_name": "700700", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna", "plan_name": "700700_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Miscellaneous", "plan_name": "700720", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Miscellaneous", "plan_name": "700720_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Ppo Hmo", "plan_name": "701720", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Ppo Hmo", "plan_name": "701720_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Ms State Emplo", "plan_name": "401457", "standard_charge_percentage": 0.80, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Ms State Emplo", "plan_name": "401457_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Basic Pl", "plan_name": "400100", "standard_charge_percentage": 0.85, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Basic Pl", "plan_name": "400100_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Federal", "plan_name": "400110", "standard_charge_percentage": 0.85, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Federal", "plan_name": "400110_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." } ] } ] }, { "description": "Hydrocodone 7.5 mg-acetaminophen 325 mg/15 ml oral solution [37848]", "drug_information": { "unit": 5.00, "type": "ML" }, "code_information": [ { "code": "0121-4772-05", "type": "NDC" } ], "standard_charges": [ { "gross_charge": 85.42, "minimum": 68.34, "maximum": 72.61, "setting": "both", "payers_information": [ { "payer_name": "Aetna", "plan_name": "700700", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna", "plan_name": "700700_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Miscellaneous", "plan_name": "700720", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Miscellaneous", "plan_name": "700720_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Ppo Hmo", "plan_name": "701720", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Ppo Hmo", "plan_name": "701720_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Ms State Emplo", "plan_name": "401457", "standard_charge_percentage": 0.80, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Ms State Emplo", "plan_name": "401457_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Basic Pl", "plan_name": "400100", "standard_charge_percentage": 0.85, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Basic Pl", "plan_name": "400100_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Federal", "plan_name": "400110", "standard_charge_percentage": 0.85, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Federal", "plan_name": "400110_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." } ] } ] }, { "description": "Ferrous sulfate 300 mg (60 mg iron)/5 ml oral liquid [3071]", "drug_information": { "unit": 5.00, "type": "ML" }, "code_information": [ { "code": "0121053005", "type": "NDC" } ], "standard_charges": [ { "gross_charge": 20.14, "minimum": 16.11, "maximum": 17.12, "setting": "both", "payers_information": [ { "payer_name": "Aetna", "plan_name": "700700", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna", "plan_name": "700700_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Miscellaneous", "plan_name": "700720", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Miscellaneous", "plan_name": "700720_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Ppo Hmo", "plan_name": "701720", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Ppo Hmo", "plan_name": "701720_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Ms State Emplo", "plan_name": "401457", "standard_charge_percentage": 0.80, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Ms State Emplo", "plan_name": "401457_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Basic Pl", "plan_name": "400100", "standard_charge_percentage": 0.85, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Basic Pl", "plan_name": "400100_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Federal", "plan_name": "400110", "standard_charge_percentage": 0.85, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Federal", "plan_name": "400110_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." } ] } ] }, { "description": "Chlorhexidine gluconate 0.12 % mouthwash [9516]", "drug_information": { "unit": 473.00, "type": "ML" }, "code_information": [ { "code": "0126-0272-16", "type": "NDC" } ], "standard_charges": [ { "gross_charge": 40.44, "minimum": 32.35, "maximum": 34.37, "setting": "both", "payers_information": [ { "payer_name": "Aetna", "plan_name": "700700", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna", "plan_name": "700700_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Miscellaneous", "plan_name": "700720", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Miscellaneous", "plan_name": "700720_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Ppo Hmo", "plan_name": "701720", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Ppo Hmo", "plan_name": "701720_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Ms State Emplo", "plan_name": "401457", "standard_charge_percentage": 0.80, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Ms State Emplo", "plan_name": "401457_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Basic Pl", "plan_name": "400100", "standard_charge_percentage": 0.85, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Basic Pl", "plan_name": "400100_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Federal", "plan_name": "400110", "standard_charge_percentage": 0.85, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Federal", "plan_name": "400110_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." } ] } ] }, { "description": "Lacosamide 50 mg tablet [96968]", "drug_information": { "unit": 1.00, "type": "EA" }, "code_information": [ { "code": "0131-2477-60", "type": "NDC" } ], "standard_charges": [ { "gross_charge": 82.26, "minimum": 65.81, "maximum": 69.92, "setting": "both", "payers_information": [ { "payer_name": "Aetna", "plan_name": "700700", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna", "plan_name": "700700_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Miscellaneous", "plan_name": "700720", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Miscellaneous", "plan_name": "700720_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Ppo Hmo", "plan_name": "701720", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Ppo Hmo", "plan_name": "701720_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Ms State Emplo", "plan_name": "401457", "standard_charge_percentage": 0.80, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Ms State Emplo", "plan_name": "401457_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Basic Pl", "plan_name": "400100", "standard_charge_percentage": 0.85, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Basic Pl", "plan_name": "400100_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Federal", "plan_name": "400110", "standard_charge_percentage": 0.85, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Federal", "plan_name": "400110_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." } ] } ] }, { "description": "Lacosamide 200 mg tablet [96971]", "drug_information": { "unit": 1.00, "type": "EA" }, "code_information": [ { "code": "0131-2480-60", "type": "NDC" } ], "standard_charges": [ { "gross_charge": 52.48, "minimum": 41.98, "maximum": 44.61, "setting": "both", "payers_information": [ { "payer_name": "Aetna", "plan_name": "700700", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna", "plan_name": "700700_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Miscellaneous", "plan_name": "700720", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Miscellaneous", "plan_name": "700720_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Ppo Hmo", "plan_name": "701720", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Ppo Hmo", "plan_name": "701720_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Ms State Emplo", "plan_name": "401457", "standard_charge_percentage": 0.80, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Ms State Emplo", "plan_name": "401457_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Basic Pl", "plan_name": "400100", "standard_charge_percentage": 0.85, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Basic Pl", "plan_name": "400100_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Federal", "plan_name": "400110", "standard_charge_percentage": 0.85, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Federal", "plan_name": "400110_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." } ] } ] }, { "description": "Glycerin (adult) rectal suppository [15053]", "drug_information": { "unit": 1.00, "type": "EA" }, "code_information": [ { "code": "0132-0079-12", "type": "NDC" } ], "standard_charges": [ { "gross_charge": 1.00, "minimum": 0.80, "maximum": 0.85, "setting": "both", "payers_information": [ { "payer_name": "Aetna", "plan_name": "700700", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna", "plan_name": "700700_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Miscellaneous", "plan_name": "700720", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Miscellaneous", "plan_name": "700720_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Ppo Hmo", "plan_name": "701720", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Ppo Hmo", "plan_name": "701720_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Ms State Emplo", "plan_name": "401457", "standard_charge_percentage": 0.80, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Ms State Emplo", "plan_name": "401457_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Basic Pl", "plan_name": "400100", "standard_charge_percentage": 0.85, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Basic Pl", "plan_name": "400100_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Federal", "plan_name": "400110", "standard_charge_percentage": 0.85, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Federal", "plan_name": "400110_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." } ] } ] }, { "description": "Glycerin (adult) rectal suppository [15053]", "drug_information": { "unit": 12.00, "type": "EA" }, "code_information": [ { "code": "0132-0079-12", "type": "NDC" } ], "standard_charges": [ { "gross_charge": 3.96, "minimum": 3.17, "maximum": 3.37, "setting": "both", "payers_information": [ { "payer_name": "Aetna", "plan_name": "700700", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna", "plan_name": "700700_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Miscellaneous", "plan_name": "700720", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Miscellaneous", "plan_name": "700720_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Ppo Hmo", "plan_name": "701720", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Ppo Hmo", "plan_name": "701720_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Ms State Emplo", "plan_name": "401457", "standard_charge_percentage": 0.80, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Ms State Emplo", "plan_name": "401457_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Basic Pl", "plan_name": "400100", "standard_charge_percentage": 0.85, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Basic Pl", "plan_name": "400100_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Federal", "plan_name": "400110", "standard_charge_percentage": 0.85, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Federal", "plan_name": "400110_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." } ] } ] }, { "description": "Glycerin (child) 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"payer_name": "Aetna Miscellaneous", "plan_name": "700720_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Ppo Hmo", "plan_name": "701720", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Ppo Hmo", "plan_name": "701720_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Ms State Emplo", "plan_name": "401457", "standard_charge_percentage": 0.80, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Ms State Emplo", "plan_name": "401457_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Basic Pl", "plan_name": "400100", "standard_charge_percentage": 0.85, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Basic Pl", "plan_name": "400100_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Federal", "plan_name": "400110", "standard_charge_percentage": 0.85, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Federal", "plan_name": "400110_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." } ] } ] }, { "description": "Sodium phosphates 9.5 gram-3.5 gram/59 ml enema [116987]", "drug_information": { "unit": 66.00, "type": "ML" }, "code_information": [ { "code": "0132-0202-20", "type": "NDC" } ], "standard_charges": [ { "gross_charge": 4.46, "minimum": 3.57, "maximum": 3.79, "setting": "both", "payers_information": [ { "payer_name": "Aetna", "plan_name": "700700", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna", "plan_name": "700700_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Miscellaneous", "plan_name": "700720", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Miscellaneous", "plan_name": "700720_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Ppo Hmo", "plan_name": "701720", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Ppo Hmo", "plan_name": "701720_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Ms State Emplo", "plan_name": "401457", "standard_charge_percentage": 0.80, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Ms State Emplo", "plan_name": "401457_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Basic Pl", "plan_name": "400100", "standard_charge_percentage": 0.85, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Basic Pl", "plan_name": "400100_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Federal", "plan_name": "400110", "standard_charge_percentage": 0.85, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Federal", "plan_name": "400110_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." } ] } ] }, { "description": "Mineral oil enema [5087]", "drug_information": { "unit": 133.00, "type": "ML" }, "code_information": [ { "code": "0132-0301-40", "type": "NDC" } ], "standard_charges": [ { "gross_charge": 6.57, "minimum": 5.26, "maximum": 5.58, "setting": "both", "payers_information": [ { "payer_name": "Aetna", "plan_name": "700700", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna", "plan_name": "700700_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Miscellaneous", "plan_name": "700720", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Miscellaneous", "plan_name": "700720_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Ppo Hmo", "plan_name": "701720", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Ppo Hmo", "plan_name": "701720_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Ms State Emplo", "plan_name": "401457", "standard_charge_percentage": 0.80, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Ms State Emplo", "plan_name": "401457_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Basic Pl", "plan_name": "400100", "standard_charge_percentage": 0.85, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Basic Pl", "plan_name": "400100_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Federal", "plan_name": "400110", "standard_charge_percentage": 0.85, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Federal", "plan_name": "400110_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." } ] } ] }, { "description": "Sodium phosphates 9.5 gram-3.5 gram/59 ml enema [116987]", "drug_information": { "unit": 66.00, "type": "ML" }, "code_information": [ { "code": "0132020220", "type": "NDC" } ], "standard_charges": [ { "gross_charge": 3.26, "minimum": 2.61, "maximum": 2.77, "setting": "both", "payers_information": [ { "payer_name": "Aetna", "plan_name": "700700", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna", "plan_name": "700700_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Miscellaneous", "plan_name": "700720", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Miscellaneous", "plan_name": "700720_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Ppo Hmo", "plan_name": "701720", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Ppo Hmo", "plan_name": "701720_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Ms State Emplo", "plan_name": "401457", "standard_charge_percentage": 0.80, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Ms State Emplo", "plan_name": "401457_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Basic Pl", "plan_name": "400100", "standard_charge_percentage": 0.85, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Basic Pl", "plan_name": "400100_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Federal", "plan_name": "400110", "standard_charge_percentage": 0.85, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Federal", "plan_name": "400110_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." } ] } ] }, { "description": "Mineral oil enema [5087]", "drug_information": { "unit": 133.00, "type": "ML" }, "code_information": [ { "code": "0132030140", "type": "NDC" } ], "standard_charges": [ { "gross_charge": 4.84, "minimum": 3.87, "maximum": 4.11, "setting": "both", "payers_information": [ { "payer_name": "Aetna", "plan_name": "700700", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna", "plan_name": "700700_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Miscellaneous", "plan_name": "700720", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Miscellaneous", "plan_name": "700720_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Ppo Hmo", "plan_name": "701720", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Ppo Hmo", "plan_name": "701720_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Ms State Emplo", "plan_name": "401457", "standard_charge_percentage": 0.80, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Ms State Emplo", "plan_name": "401457_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Basic Pl", "plan_name": "400100", "standard_charge_percentage": 0.85, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Basic Pl", "plan_name": "400100_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Federal", "plan_name": "400110", "standard_charge_percentage": 0.85, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Federal", "plan_name": "400110_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." } ] } ] }, { "description": "Nicotine 14 mg/24 hr daily transdermal patch [27862]", "drug_information": { "unit": 1.00, "type": "EA" }, "code_information": [ { "code": "0135-0195-08", "type": "NDC" } ], "standard_charges": [ { "gross_charge": 3.71, "minimum": 2.97, "maximum": 3.15, "setting": "both", "payers_information": [ { "payer_name": "Aetna", "plan_name": "700700", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna", "plan_name": "700700_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Miscellaneous", "plan_name": "700720", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Miscellaneous", "plan_name": "700720_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Ppo Hmo", "plan_name": "701720", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Ppo Hmo", "plan_name": "701720_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Ms State Emplo", "plan_name": "401457", "standard_charge_percentage": 0.80, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Ms State Emplo", "plan_name": "401457_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Basic Pl", "plan_name": "400100", "standard_charge_percentage": 0.85, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Basic Pl", "plan_name": "400100_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Federal", "plan_name": "400110", "standard_charge_percentage": 0.85, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Federal", "plan_name": "400110_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." } ] } ] }, { "description": "Calcium 300 mg (as calcium carbonate 750 mg) chewable tablet [108629]", "drug_information": { "unit": 1.00, "type": "EA" }, "code_information": [ { "code": "0135-0246-05", "type": "NDC" } ], "standard_charges": [ { "gross_charge": 1.00, "minimum": 0.80, "maximum": 0.85, "setting": "both", "payers_information": [ { "payer_name": "Aetna", "plan_name": "700700", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna", "plan_name": "700700_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Miscellaneous", "plan_name": "700720", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Miscellaneous", "plan_name": "700720_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Ppo Hmo", "plan_name": "701720", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Ppo Hmo", "plan_name": "701720_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Ms State Emplo", "plan_name": "401457", "standard_charge_percentage": 0.80, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Ms State Emplo", "plan_name": "401457_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Basic Pl", "plan_name": "400100", "standard_charge_percentage": 0.85, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Basic Pl", "plan_name": "400100_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Federal", "plan_name": "400110", "standard_charge_percentage": 0.85, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Federal", "plan_name": "400110_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." } ] } ] }, { "description": "Phenobarbital 30 mg tablet (wrapped) [509000]", "drug_information": { "unit": 1.00, "type": "EA" }, "code_information": [ { "code": "0143-1500-01", "type": "NDC" } ], "standard_charges": [ { "gross_charge": 7.50, "minimum": 6.00, "maximum": 6.38, "setting": "both", "payers_information": [ { "payer_name": "Aetna", "plan_name": "700700", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna", "plan_name": "700700_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Miscellaneous", "plan_name": "700720", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Miscellaneous", "plan_name": "700720_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Ppo Hmo", "plan_name": "701720", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Ppo Hmo", "plan_name": "701720_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Ms State Emplo", "plan_name": "401457", "standard_charge_percentage": 0.80, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Ms State Emplo", "plan_name": "401457_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Basic Pl", "plan_name": "400100", "standard_charge_percentage": 0.85, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Basic Pl", "plan_name": "400100_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Federal", "plan_name": "400110", "standard_charge_percentage": 0.85, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Federal", "plan_name": "400110_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." } ] } ] }, { "description": "Isosorbide dinitrate 10 mg tablet [4064]", "drug_information": { "unit": 1.00, "type": "EA" }, "code_information": [ { "code": "0143-1771-01", "type": "NDC" } ], "standard_charges": [ { "gross_charge": 7.50, "minimum": 6.00, "maximum": 6.38, "setting": "both", "payers_information": [ { "payer_name": "Aetna", "plan_name": "700700", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna", "plan_name": "700700_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Miscellaneous", "plan_name": "700720", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Miscellaneous", "plan_name": "700720_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Ppo Hmo", "plan_name": "701720", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Ppo Hmo", "plan_name": "701720_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Ms State Emplo", "plan_name": "401457", "standard_charge_percentage": 0.80, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Ms State Emplo", "plan_name": "401457_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Basic Pl", "plan_name": "400100", "standard_charge_percentage": 0.85, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Basic Pl", "plan_name": "400100_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Federal", "plan_name": "400110", "standard_charge_percentage": 0.85, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Federal", "plan_name": "400110_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." } ] } ] }, { "description": "Promethazine 6.25 mg-codeine 10 mg/5 ml syrup [6627]", "drug_information": { "unit": 473.00, "type": "ML" }, "code_information": [ { "code": "0121-0928-16", "type": "NDC" } ], "standard_charges": [ { "gross_charge": 102.17, "minimum": 81.74, "maximum": 86.84, "setting": "both", "payers_information": [ { "payer_name": "Aetna", "plan_name": "700700", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna", "plan_name": "700700_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Miscellaneous", "plan_name": "700720", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Miscellaneous", "plan_name": "700720_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Ppo Hmo", "plan_name": "701720", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Ppo Hmo", "plan_name": "701720_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Ms State Emplo", "plan_name": "401457", "standard_charge_percentage": 0.80, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Ms State Emplo", "plan_name": "401457_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Basic Pl", "plan_name": "400100", "standard_charge_percentage": 0.85, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Basic Pl", "plan_name": "400100_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Federal", "plan_name": "400110", "standard_charge_percentage": 0.85, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Federal", "plan_name": "400110_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." } ] } ] }, { "description": "Docusate sodium 50 mg/5 ml oral liquid [36962]", "drug_information": { "unit": 5.00, "type": "ML" }, "code_information": [ { "code": "0121-0935-05", "type": "NDC" } ], "standard_charges": [ { "gross_charge": 4.58, "minimum": 3.66, "maximum": 3.89, "setting": "both", "payers_information": [ { "payer_name": "Aetna", "plan_name": "700700", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna", "plan_name": "700700_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Miscellaneous", "plan_name": "700720", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Miscellaneous", "plan_name": "700720_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Ppo Hmo", "plan_name": "701720", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Ppo Hmo", "plan_name": "701720_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Ms State Emplo", "plan_name": "401457", "standard_charge_percentage": 0.80, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Ms State Emplo", "plan_name": "401457_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Basic Pl", "plan_name": "400100", "standard_charge_percentage": 0.85, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Basic Pl", "plan_name": "400100_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Federal", "plan_name": "400110", "standard_charge_percentage": 0.85, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Federal", "plan_name": "400110_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." } ] } ] }, { "description": "Phenobarbital 20 mg/5 ml (4 mg/ml) oral elixir [6212]", "drug_information": { "unit": 473.00, "type": "ML" }, "code_information": [ { "code": "0121-0942-16", "type": "NDC" } ], "standard_charges": [ { "gross_charge": 482.11, "minimum": 385.69, "maximum": 409.79, "setting": "both", "payers_information": [ { "payer_name": "Aetna", "plan_name": "700700", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna", "plan_name": "700700_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Miscellaneous", "plan_name": "700720", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Miscellaneous", "plan_name": "700720_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Ppo Hmo", "plan_name": "701720", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Ppo Hmo", "plan_name": "701720_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Ms State Emplo", "plan_name": "401457", "standard_charge_percentage": 0.80, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Ms State Emplo", "plan_name": "401457_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Basic Pl", "plan_name": "400100", "standard_charge_percentage": 0.85, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Basic Pl", "plan_name": "400100_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Federal", "plan_name": "400110", "standard_charge_percentage": 0.85, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Federal", "plan_name": "400110_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." } ] } ] }, { "description": "Megestrol 400 mg/10 ml (10 ml) oral suspension [159205]", "drug_information": { "unit": 10.00, "type": "ML" }, "code_information": [ { "code": "0121-0945-10", "type": "NDC" } ], "standard_charges": [ { "gross_charge": 42.80, "minimum": 34.24, "maximum": 36.38, "setting": "both", "payers_information": [ { "payer_name": "Aetna", "plan_name": "700700", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna", "plan_name": "700700_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Miscellaneous", "plan_name": "700720", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Miscellaneous", "plan_name": "700720_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Ppo Hmo", "plan_name": "701720", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Ppo Hmo", "plan_name": "701720_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Ms State Emplo", "plan_name": "401457", "standard_charge_percentage": 0.80, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Ms State Emplo", "plan_name": "401457_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Basic Pl", "plan_name": "400100", "standard_charge_percentage": 0.85, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Basic Pl", "plan_name": "400100_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Federal", "plan_name": "400110", "standard_charge_percentage": 0.85, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Federal", "plan_name": "400110_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." } ] } ] }, { "description": "Vecuronium bromide 10 mg intravenous solution [11634]", "drug_information": { "unit": 1.00, "type": "EA" }, "code_information": [ { "code": "0143-9234-01", "type": "NDC" } ], "standard_charges": [ { "gross_charge": 62.26, "minimum": 49.81, "maximum": 52.92, "setting": "both", "payers_information": [ { "payer_name": "Aetna", "plan_name": "700700", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna", "plan_name": "700700_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Miscellaneous", "plan_name": "700720", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Miscellaneous", "plan_name": "700720_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Ppo Hmo", "plan_name": "701720", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Ppo Hmo", "plan_name": "701720_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Ms State Emplo", "plan_name": "401457", "standard_charge_percentage": 0.80, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Ms State Emplo", "plan_name": "401457_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Basic Pl", "plan_name": "400100", "standard_charge_percentage": 0.85, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Basic Pl", "plan_name": "400100_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Federal", "plan_name": "400110", "standard_charge_percentage": 0.85, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Federal", "plan_name": "400110_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." } ] } ] }, { "description": "Vecuronium bromide 10 mg intravenous 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"Aetna Miscellaneous", "plan_name": "700720_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Ppo Hmo", "plan_name": "701720", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Ppo Hmo", "plan_name": "701720_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Ms State Emplo", "plan_name": "401457", "standard_charge_percentage": 0.80, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Ms State Emplo", "plan_name": "401457_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Basic Pl", "plan_name": "400100", "standard_charge_percentage": 0.85, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Basic Pl", "plan_name": "400100_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Federal", "plan_name": "400110", "standard_charge_percentage": 0.85, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Federal", "plan_name": "400110_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." } ] } ] }, { "description": "Mitomycin hipec [40810631]", "drug_information": { "unit": 1.00, "type": "EA" }, "code_information": [ { "code": "0143-9280-01", "type": "NDC" } ], "standard_charges": [ { "gross_charge": 12472.07, "minimum": 9977.66, "maximum": 10601.26, "setting": "both", "payers_information": [ { "payer_name": "Aetna", "plan_name": "700700", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna", "plan_name": "700700_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { 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"Bc/Bs Ms State Emplo", "plan_name": "401457", "standard_charge_percentage": 0.80, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Ms State Emplo", "plan_name": "401457_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Basic Pl", "plan_name": "400100", "standard_charge_percentage": 0.85, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Basic Pl", "plan_name": "400100_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Federal", "plan_name": "400110", "standard_charge_percentage": 0.85, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Federal", "plan_name": "400110_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." } ] } ] }, { "description": "Norepinephrine bitartrate 1 mg/ml intravenous solution [10734]", "drug_information": { "unit": 4.00, "type": "ML" }, "code_information": [ { "code": "0143-9318-01", "type": "NDC" } ], "standard_charges": [ { "gross_charge": 112.38, "minimum": 89.90, "maximum": 95.52, "setting": "both", "payers_information": [ { "payer_name": "Aetna", "plan_name": "700700", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": 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"additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Ppo Hmo", "plan_name": "701720", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Ppo Hmo", "plan_name": "701720_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Ms State Emplo", "plan_name": "401457", "standard_charge_percentage": 0.80, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Ms State Emplo", "plan_name": "401457_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", 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"additional_payer_notes": "Insufficient remit data to calculate allowed amounts." } ] } ] }, { "description": "Etomidate 2 mg/ml intravenous solution [20472]", "drug_information": { "unit": 10.00, "type": "ML" }, "code_information": [ { "code": "0143-9506-10", "type": "NDC" } ], "standard_charges": [ { "gross_charge": 59.85, "minimum": 47.88, "maximum": 50.87, "setting": "both", "payers_information": [ { "payer_name": "Aetna", "plan_name": "700700", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna", "plan_name": "700700_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Miscellaneous", "plan_name": "700720", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Miscellaneous", "plan_name": "700720_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Ppo Hmo", "plan_name": "701720", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Ppo Hmo", "plan_name": "701720_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Ms State Emplo", "plan_name": "401457", "standard_charge_percentage": 0.80, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Ms State Emplo", "plan_name": "401457_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Basic Pl", "plan_name": "400100", "standard_charge_percentage": 0.85, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Basic Pl", "plan_name": "400100_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Federal", "plan_name": "400110", "standard_charge_percentage": 0.85, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Federal", "plan_name": "400110_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." } ] } ] }, { "description": "Ketamine 50 mg/ml injection solution [4238]", "drug_information": { "unit": 10.00, "type": "ML" }, "code_information": [ { "code": "0143-9508-01", "type": "NDC" } ], "standard_charges": [ { "gross_charge": 140.36, "minimum": 112.29, "maximum": 119.31, "setting": "both", "payers_information": [ { "payer_name": "Aetna", "plan_name": "700700", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna", "plan_name": "700700_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Miscellaneous", "plan_name": "700720", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Miscellaneous", "plan_name": "700720_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Ppo Hmo", "plan_name": "701720", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Ppo Hmo", "plan_name": "701720_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Ms State Emplo", "plan_name": "401457", "standard_charge_percentage": 0.80, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Ms State Emplo", "plan_name": "401457_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Basic Pl", "plan_name": "400100", "standard_charge_percentage": 0.85, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Basic Pl", "plan_name": "400100_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Federal", "plan_name": "400110", "standard_charge_percentage": 0.85, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Federal", "plan_name": "400110_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." } ] } ] }, { "description": "Ketamine 50 mg/ml injection solution [4238]", "drug_information": { "unit": 10.00, "type": "ML" }, "code_information": [ { "code": "0143-9508-10", "type": "NDC" } ], "standard_charges": [ { "gross_charge": 140.36, "minimum": 112.29, "maximum": 119.31, "setting": "both", "payers_information": [ { "payer_name": "Aetna", "plan_name": "700700", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna", "plan_name": "700700_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Miscellaneous", "plan_name": "700720", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Miscellaneous", "plan_name": "700720_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Ppo Hmo", "plan_name": "701720", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Ppo Hmo", "plan_name": "701720_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Ms State Emplo", "plan_name": "401457", "standard_charge_percentage": 0.80, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Ms State Emplo", "plan_name": "401457_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Basic Pl", "plan_name": "400100", "standard_charge_percentage": 0.85, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Basic Pl", "plan_name": "400100_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Federal", "plan_name": "400110", "standard_charge_percentage": 0.85, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Federal", "plan_name": "400110_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." } ] } ] }, { "description": "Lidocaine 20 mg/ml (2 %) nebulization solution [500805]", "drug_information": { "unit": 5.00, "type": "ML" }, "code_information": [ { "code": "0143-9594-01", "type": "NDC" } ], "standard_charges": [ { "gross_charge": 14.44, "minimum": 11.55, "maximum": 12.27, "setting": "both", "payers_information": [ { "payer_name": "Aetna", "plan_name": "700700", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna", "plan_name": "700700_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Miscellaneous", "plan_name": "700720", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data 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"payer_name": "Aetna Ppo Hmo", "plan_name": "701720_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Ms State Emplo", "plan_name": "401457", "standard_charge_percentage": 0.80, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Ms State Emplo", "plan_name": "401457_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Basic Pl", "plan_name": "400100", "standard_charge_percentage": 0.85, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Basic Pl", "plan_name": "400100_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Federal", "plan_name": "400110", "standard_charge_percentage": 0.85, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Federal", "plan_name": "400110_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." } ] } ] }, { "description": "Valproate sodium 500 mg/5 ml (100 mg/ml) intravenous solution [20887]", "drug_information": { "unit": 5.00, "type": "ML" }, "code_information": [ { "code": "0143-9785-01", "type": "NDC" } ], "standard_charges": [ { 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"Bc/Bs Of Ms Federal", "plan_name": "400110", "standard_charge_percentage": 0.85, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Federal", "plan_name": "400110_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." } ] } ] }, { "description": "Bismuth subsalicylate 262 mg chewable tablet [9285]", "drug_information": { "unit": 1.00, "type": "EA" }, "code_information": [ { "code": "0149032040", "type": "NDC" } ], "standard_charges": [ { "gross_charge": 1.00, "minimum": 0.80, "maximum": 0.85, "setting": "both", "payers_information": [ { "payer_name": "Aetna", "plan_name": "700700", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna", "plan_name": "700700_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Miscellaneous", "plan_name": "700720", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Miscellaneous", "plan_name": "700720_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Ppo Hmo", "plan_name": "701720", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Ppo Hmo", "plan_name": "701720_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Ms State Emplo", "plan_name": "401457", "standard_charge_percentage": 0.80, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Ms State Emplo", "plan_name": "401457_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Basic Pl", "plan_name": "400100", "standard_charge_percentage": 0.85, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Basic Pl", "plan_name": "400100_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Federal", "plan_name": "400110", "standard_charge_percentage": 0.85, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Federal", "plan_name": "400110_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." } ] } ] }, { "description": "Triamcinolone acetonide 0.1 % topical ointment [8118]", "drug_information": { "unit": 15.00, "type": "GR" }, "code_information": [ { "code": "0168-0006-15", "type": "NDC" } ], "standard_charges": [ { "gross_charge": 26.86, "minimum": 21.49, "maximum": 22.83, "setting": "both", "payers_information": [ { "payer_name": "Aetna", "plan_name": "700700", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna", "plan_name": "700700_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Miscellaneous", "plan_name": "700720", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Miscellaneous", "plan_name": "700720_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Ppo Hmo", "plan_name": "701720", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Ppo Hmo", "plan_name": "701720_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Ms State Emplo", "plan_name": "401457", "standard_charge_percentage": 0.80, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Ms State Emplo", "plan_name": "401457_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Basic Pl", "plan_name": "400100", "standard_charge_percentage": 0.85, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Basic Pl", "plan_name": "400100_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Federal", "plan_name": "400110", "standard_charge_percentage": 0.85, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Federal", "plan_name": "400110_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." } ] } ] }, { "description": "Triamcinolone acetonide 0.1 % topical ointment [8118]", "drug_information": { "unit": 80.00, "type": "GR" }, "code_information": [ { "code": "0168-0006-80", "type": "NDC" } ], "standard_charges": [ { "gross_charge": 67.26, "minimum": 53.81, "maximum": 57.17, "setting": "both", "payers_information": [ { "payer_name": "Aetna", "plan_name": "700700", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna", "plan_name": "700700_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Miscellaneous", "plan_name": "700720", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Miscellaneous", "plan_name": "700720_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Ppo Hmo", "plan_name": "701720", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Ppo Hmo", "plan_name": "701720_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Ms State Emplo", "plan_name": "401457", "standard_charge_percentage": 0.80, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Ms State Emplo", "plan_name": "401457_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Basic Pl", "plan_name": "400100", "standard_charge_percentage": 0.85, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Basic Pl", "plan_name": "400100_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Federal", "plan_name": "400110", "standard_charge_percentage": 0.85, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Federal", "plan_name": "400110_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." } ] } ] }, { "description": "Hydrocortisone 1 % topical cream [3726]", "drug_information": { "unit": 28.35, "type": "GR" }, "code_information": [ { "code": "0168-0015-31", "type": "NDC" } ], "standard_charges": [ { "gross_charge": 19.02, "minimum": 15.22, "maximum": 16.17, "setting": "both", "payers_information": [ { "payer_name": "Aetna", "plan_name": "700700", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna", "plan_name": "700700_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Miscellaneous", "plan_name": "700720", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Miscellaneous", "plan_name": "700720_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Ppo Hmo", "plan_name": "701720", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Ppo Hmo", "plan_name": "701720_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Ms State Emplo", "plan_name": "401457", "standard_charge_percentage": 0.80, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Ms State Emplo", "plan_name": "401457_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Basic Pl", "plan_name": "400100", "standard_charge_percentage": 0.85, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Basic Pl", "plan_name": "400100_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Federal", "plan_name": "400110", "standard_charge_percentage": 0.85, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Federal", "plan_name": "400110_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." } ] } ] }, { "description": "Betamethasone dipropionate 0.05 % topical cream [1027]", "drug_information": { "unit": 45.00, "type": "GR" }, "code_information": [ { "code": "0168-0055-46", "type": "NDC" } ], "standard_charges": [ { "gross_charge": 501.89, "minimum": 401.51, "maximum": 426.61, "setting": "both", "payers_information": [ { "payer_name": "Aetna", "plan_name": "700700", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna", "plan_name": "700700_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Miscellaneous", "plan_name": "700720", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Miscellaneous", "plan_name": "700720_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Ppo Hmo", "plan_name": "701720", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Ppo Hmo", "plan_name": "701720_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Ms State Emplo", "plan_name": "401457", "standard_charge_percentage": 0.80, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Ms State Emplo", "plan_name": "401457_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Basic Pl", "plan_name": "400100", "standard_charge_percentage": 0.85, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Basic Pl", "plan_name": "400100_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Federal", "plan_name": "400110", "standard_charge_percentage": 0.85, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Federal", "plan_name": "400110_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." } ] } ] }, { "description": "Hydrocortisone 2.5 % topical cream [3727]", "drug_information": { "unit": 30.00, "type": "GR" }, "code_information": [ { "code": "0168-0080-31", "type": "NDC" } ], "standard_charges": [ { "gross_charge": 23.66, "minimum": 18.93, "maximum": 20.11, "setting": "both", "payers_information": [ { "payer_name": "Aetna", "plan_name": "700700", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna", "plan_name": "700700_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Miscellaneous", "plan_name": "700720", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Miscellaneous", "plan_name": "700720_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Ppo Hmo", "plan_name": "701720", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Ppo Hmo", "plan_name": "701720_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Ms State Emplo", "plan_name": "401457", "standard_charge_percentage": 0.80, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Ms State Emplo", "plan_name": "401457_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Basic Pl", "plan_name": "400100", "standard_charge_percentage": 0.85, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Basic Pl", "plan_name": "400100_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Federal", "plan_name": "400110", "standard_charge_percentage": 0.85, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Federal", "plan_name": "400110_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." } ] } ] }, { "description": "Clotrimazole-betamethasone 1 %-0.05 % topical cream [29424]", "drug_information": { "unit": 15.00, "type": "GR" }, "code_information": [ { "code": "0168-0258-15", "type": "NDC" } ], "standard_charges": [ { "gross_charge": 97.68, "minimum": 78.14, "maximum": 83.03, "setting": "both", "payers_information": [ { "payer_name": "Aetna", "plan_name": "700700", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna", "plan_name": "700700_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Miscellaneous", "plan_name": "700720", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Miscellaneous", "plan_name": "700720_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Ppo Hmo", "plan_name": "701720", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Ppo Hmo", "plan_name": "701720_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Ms State Emplo", "plan_name": "401457", "standard_charge_percentage": 0.80, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Ms State Emplo", "plan_name": "401457_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Basic Pl", "plan_name": "400100", "standard_charge_percentage": 0.85, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Basic Pl", "plan_name": "400100_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Federal", "plan_name": "400110", "standard_charge_percentage": 0.85, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Federal", "plan_name": "400110_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." } ] } ] }, { "description": "Clotrimazole-betamethasone 1 %-0.05 % topical cream [29424]", "drug_information": { "unit": 45.00, "type": "GR" }, "code_information": [ { "code": "0168-0258-46", "type": "NDC" } ], "standard_charges": [ { "gross_charge": 210.33, "minimum": 168.26, "maximum": 178.78, "setting": "both", "payers_information": [ { "payer_name": "Aetna", "plan_name": "700700", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", 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"plan_name": "700700_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Miscellaneous", "plan_name": "700720", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Miscellaneous", "plan_name": "700720_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Ppo Hmo", "plan_name": "701720", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Ppo Hmo", "plan_name": "701720_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Ms State Emplo", "plan_name": "401457", "standard_charge_percentage": 0.80, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Ms State Emplo", "plan_name": "401457_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Basic Pl", "plan_name": "400100", "standard_charge_percentage": 0.85, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Basic Pl", "plan_name": "400100_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Federal", "plan_name": "400110", "standard_charge_percentage": 0.85, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Federal", "plan_name": "400110_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." } ] } ] }, { "description": "Magnesium carbonate 54 mg/5 ml oral liquid [160234]", "drug_information": { "unit": 355.00, "type": "ML" }, "code_information": [ { "code": "0187526701", "type": "NDC" } ], "standard_charges": [ { "gross_charge": 21.23, "minimum": 16.98, "maximum": 18.05, "setting": "both", "payers_information": [ { "payer_name": "Aetna", "plan_name": "700700", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna", "plan_name": "700700_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Miscellaneous", "plan_name": "700720", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Miscellaneous", "plan_name": "700720_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Ppo Hmo", "plan_name": "701720", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Ppo Hmo", "plan_name": "701720_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Ms State Emplo", "plan_name": "401457", "standard_charge_percentage": 0.80, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Ms State Emplo", "plan_name": "401457_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Basic Pl", "plan_name": "400100", "standard_charge_percentage": 0.85, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Basic Pl", "plan_name": "400100_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Federal", "plan_name": "400110", "standard_charge_percentage": 0.85, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Federal", "plan_name": "400110_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." } ] } ] }, { "description": "Sodium bicarbonate 650 mg tablet [7312]", "drug_information": { "unit": 1.00, "type": "EA" }, "code_information": [ { "code": "0223-1721-01", "type": "NDC" } ], "standard_charges": [ { "gross_charge": 7.50, "minimum": 6.00, "maximum": 6.38, "setting": "both", "payers_information": [ { "payer_name": "Aetna", "plan_name": "700700", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna", "plan_name": "700700_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Miscellaneous", "plan_name": "700720", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate 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}, { "payer_name": "Bc/Bs Ms State Emplo", "plan_name": "401457_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Basic Pl", "plan_name": "400100", "standard_charge_percentage": 0.85, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Basic Pl", "plan_name": "400100_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Federal", "plan_name": "400110", "standard_charge_percentage": 0.85, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Federal", "plan_name": "400110_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." } ] } ] }, { "description": "Sodium chloride 1000 mg soluble tablet [94158]", "drug_information": { "unit": 1.00, "type": "EA" }, "code_information": [ { "code": "0223-1760-01", "type": "NDC" } ], "standard_charges": [ { "gross_charge": 7.50, "minimum": 6.00, "maximum": 6.38, "setting": "both", "payers_information": [ { "payer_name": "Aetna", "plan_name": "700700", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna", "plan_name": "700700_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit 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"Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Ppo Hmo", "plan_name": "701720_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Ms State Emplo", "plan_name": "401457", "standard_charge_percentage": 0.80, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Ms State Emplo", "plan_name": "401457_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Basic Pl", "plan_name": "400100", "standard_charge_percentage": 0.85, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Basic Pl", "plan_name": "400100_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Federal", "plan_name": "400110", "standard_charge_percentage": 0.85, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Federal", "plan_name": "400110_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." } ] } ] }, { "description": "Phenylephrine 0.25 % nasal spray [6243]", "drug_information": { "unit": 15.00, "type": "ML" }, "code_information": [ { "code": "0225-0800-47", "type": "NDC" } ], "standard_charges": [ { "gross_charge": 10.80, "minimum": 8.64, "maximum": 9.18, "setting": "both", "payers_information": [ { "payer_name": "Aetna", "plan_name": "700700", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna", "plan_name": "700700_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Miscellaneous", "plan_name": "700720", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Miscellaneous", "plan_name": "700720_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed 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"additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Basic Pl", "plan_name": "400100", "standard_charge_percentage": 0.85, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Basic Pl", "plan_name": "400100_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Federal", "plan_name": "400110", "standard_charge_percentage": 0.85, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Federal", "plan_name": "400110_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." } ] } ] }, { "description": "Phenylephrine 0.5 % nasal spray [6244]", "drug_information": { "unit": 15.00, "type": "ML" }, "code_information": [ { "code": "0225-0805-47", "type": "NDC" } ], "standard_charges": [ { "gross_charge": 10.80, "minimum": 8.64, "maximum": 9.18, "setting": "both", "payers_information": [ { "payer_name": "Aetna", "plan_name": "700700", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna", "plan_name": "700700_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Miscellaneous", "plan_name": "700720", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent 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"methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Miscellaneous", "plan_name": "700720", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Miscellaneous", "plan_name": "700720_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Ppo Hmo", "plan_name": "701720", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Ppo Hmo", "plan_name": "701720_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Ms State Emplo", "plan_name": "401457", "standard_charge_percentage": 0.80, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Ms State Emplo", "plan_name": "401457_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Basic Pl", "plan_name": "400100", "standard_charge_percentage": 0.85, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Basic Pl", "plan_name": "400100_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Federal", "plan_name": "400110", "standard_charge_percentage": 0.85, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Federal", "plan_name": "400110_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." } ] } ] }, { "description": "Phenylephrine 1 % nasal spray [109137]", "drug_information": { "unit": 29.60, "type": "ML" }, "code_information": [ { "code": "0225-0810-47", "type": "NDC" } ], "standard_charges": [ { "gross_charge": 9.24, "minimum": 7.39, "maximum": 7.85, "setting": "both", "payers_information": [ { "payer_name": "Aetna", "plan_name": "700700", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna", "plan_name": "700700_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Miscellaneous", "plan_name": "700720", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Miscellaneous", "plan_name": "700720_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Ppo Hmo", "plan_name": "701720", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Ppo Hmo", "plan_name": "701720_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Ms State Emplo", "plan_name": "401457", "standard_charge_percentage": 0.80, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Ms State Emplo", "plan_name": "401457_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Basic Pl", "plan_name": "400100", "standard_charge_percentage": 0.85, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Basic Pl", "plan_name": "400100_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Federal", "plan_name": "400110", "standard_charge_percentage": 0.85, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Federal", "plan_name": "400110_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." } ] } ] }, { "description": "Sodium chloride 0.65 % nasal spray 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"plan_name": "401457_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Basic Pl", "plan_name": "400100", "standard_charge_percentage": 0.85, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Basic Pl", "plan_name": "400100_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Federal", "plan_name": "400110", "standard_charge_percentage": 0.85, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Federal", "plan_name": "400110_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." } ] } ] }, { "description": "Sodium chloride 0.65 % nasal drops [18225]", "drug_information": { "unit": 30.00, "type": "ML" }, "code_information": [ { "code": "0225055050", "type": "NDC" } ], "standard_charges": [ { "gross_charge": 6.86, "minimum": 5.49, "maximum": 5.83, "setting": "both", "payers_information": [ { "payer_name": "Aetna", "plan_name": "700700", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna", "plan_name": "700700_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Miscellaneous", "plan_name": "700720", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Miscellaneous", "plan_name": "700720_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Ppo Hmo", "plan_name": "701720", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Ppo Hmo", "plan_name": "701720_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Ms State Emplo", "plan_name": "401457", "standard_charge_percentage": 0.80, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Ms State Emplo", "plan_name": "401457_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Basic Pl", "plan_name": "400100", "standard_charge_percentage": 0.85, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Basic Pl", "plan_name": "400100_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Federal", "plan_name": "400110", "standard_charge_percentage": 0.85, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Federal", "plan_name": "400110_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." } ] } ] }, { "description": "Alprazolam 1 mg tablet [326]", "drug_information": { "unit": 1.00, "type": "EA" }, "code_information": [ { "code": "0228-2031-10", "type": "NDC" } ], "standard_charges": [ { "gross_charge": 7.50, "minimum": 6.00, "maximum": 6.38, "setting": "both", "payers_information": [ { "payer_name": "Aetna", "plan_name": "700700", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed 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"payer_name": "Aetna Ppo Hmo", "plan_name": "701720_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Ms State Emplo", "plan_name": "401457", "standard_charge_percentage": 0.80, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Ms State Emplo", "plan_name": "401457_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Basic Pl", "plan_name": "400100", "standard_charge_percentage": 0.85, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Basic Pl", "plan_name": "400100_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Federal", "plan_name": "400110", "standard_charge_percentage": 0.85, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Federal", "plan_name": "400110_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." } ] } ] }, { "description": "Temazepam 15 mg capsule [7753]", "drug_information": { "unit": 1.00, "type": "EA" }, "code_information": [ { "code": "0228-2076-10", "type": "NDC" } ], "standard_charges": [ { "gross_charge": 7.50, "minimum": 6.00, "maximum": 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allowed amounts." }, { "payer_name": "Aetna Ppo Hmo", "plan_name": "701720", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Ppo Hmo", "plan_name": "701720_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Ms State Emplo", "plan_name": "401457", "standard_charge_percentage": 0.80, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Ms State Emplo", "plan_name": "401457_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Basic Pl", "plan_name": "400100", "standard_charge_percentage": 0.85, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Basic Pl", "plan_name": "400100_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Federal", "plan_name": "400110", "standard_charge_percentage": 0.85, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Federal", "plan_name": "400110_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." } ] } ] }, { "description": "Clonidine hcl 0.1 mg tablet [1755]", "drug_information": { "unit": 1.00, "type": "EA" }, "code_information": [ { "code": "0228-2127-10", "type": "NDC" } ], "standard_charges": [ { "gross_charge": 7.50, "minimum": 6.00, "maximum": 6.38, "setting": "both", "payers_information": [ { "payer_name": "Aetna", "plan_name": "700700", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna", "plan_name": "700700_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Miscellaneous", "plan_name": "700720", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data 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allowed amounts." }, { "payer_name": "Bc/Bs Ms State Emplo", "plan_name": "401457_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Basic Pl", "plan_name": "400100", "standard_charge_percentage": 0.85, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Basic Pl", "plan_name": "400100_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Federal", "plan_name": "400110", "standard_charge_percentage": 0.85, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Federal", "plan_name": "400110_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." } ] } ] }, { "description": "Clonidine hcl 0.2 mg tablet [1756]", "drug_information": { "unit": 1.00, "type": "EA" }, "code_information": [ { "code": "0228-2128-10", "type": "NDC" } ], "standard_charges": [ { "gross_charge": 7.50, "minimum": 6.00, "maximum": 6.38, "setting": "both", "payers_information": [ { "payer_name": "Aetna", "plan_name": "700700", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna", "plan_name": "700700_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Miscellaneous", "plan_name": "700720", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Miscellaneous", "plan_name": "700720_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Ppo Hmo", "plan_name": "701720", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Ppo Hmo", "plan_name": "701720_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Ms State Emplo", "plan_name": "401457", "standard_charge_percentage": 0.80, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Ms State Emplo", "plan_name": "401457_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Basic Pl", "plan_name": "400100", "standard_charge_percentage": 0.85, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Basic Pl", "plan_name": "400100_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Federal", "plan_name": "400110", "standard_charge_percentage": 0.85, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Federal", "plan_name": "400110_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." } ] } ] }, { "description": "Clonidine hcl 0.3 mg tablet [1757]", "drug_information": { "unit": 1.00, "type": "EA" }, "code_information": [ { "code": "0228-2129-10", "type": "NDC" } ], "standard_charges": [ { "gross_charge": 7.50, "minimum": 6.00, "maximum": 6.38, "setting": "both", "payers_information": [ { "payer_name": "Aetna", "plan_name": "700700", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna", "plan_name": "700700_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Miscellaneous", "plan_name": "700720", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Miscellaneous", "plan_name": "700720_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Ppo Hmo", "plan_name": "701720", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Ppo Hmo", "plan_name": "701720_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Ms State Emplo", "plan_name": "401457", "standard_charge_percentage": 0.80, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Ms State Emplo", "plan_name": "401457_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Basic Pl", "plan_name": "400100", "standard_charge_percentage": 0.85, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Basic Pl", "plan_name": "400100_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Federal", "plan_name": "400110", "standard_charge_percentage": 0.85, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Federal", "plan_name": "400110_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." } ] } ] }, { "description": "Propylthiouracil 50 mg tablet [6662]", "drug_information": { "unit": 1.00, "type": "EA" }, "code_information": [ { "code": "0228-2348-10", "type": "NDC" } ], "standard_charges": [ { "gross_charge": 7.50, "minimum": 6.00, "maximum": 6.38, "setting": "both", "payers_information": [ { "payer_name": "Aetna", "plan_name": "700700", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna", "plan_name": "700700_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Miscellaneous", "plan_name": "700720", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Miscellaneous", "plan_name": "700720_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed 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"additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Basic Pl", "plan_name": "400100", "standard_charge_percentage": 0.85, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Basic Pl", "plan_name": "400100_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Federal", "plan_name": "400110", "standard_charge_percentage": 0.85, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Federal", "plan_name": "400110_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." } ] } ] }, { "description": "Nifedipine 10 mg capsule [5558]", "drug_information": { "unit": 1.00, "type": "EA" }, "code_information": [ { "code": "0228-2497-10", "type": "NDC" } ], "standard_charges": [ { "gross_charge": 7.50, "minimum": 6.00, "maximum": 6.38, "setting": "both", "payers_information": [ { "payer_name": "Aetna", "plan_name": "700700", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna", "plan_name": "700700_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Miscellaneous", "plan_name": "700720", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total 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"additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Ms State Emplo", "plan_name": "401457_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Basic Pl", "plan_name": "400100", "standard_charge_percentage": 0.85, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Basic Pl", "plan_name": "400100_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Federal", "plan_name": "400110", "standard_charge_percentage": 0.85, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Federal", "plan_name": "400110_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." } ] } ] }, { "description": "Carbidopa 25 mg-levodopa 100 mg tablet [9407]", "drug_information": { "unit": 1.00, "type": "EA" }, "code_information": [ { "code": "0228-2539-10", "type": "NDC" } ], "standard_charges": [ { "gross_charge": 7.50, "minimum": 6.00, "maximum": 6.38, "setting": "both", "payers_information": [ { "payer_name": "Aetna", "plan_name": "700700", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna", "plan_name": "700700_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Miscellaneous", "plan_name": "700720", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Miscellaneous", "plan_name": "700720_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Ppo Hmo", "plan_name": "701720", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Ppo Hmo", "plan_name": "701720_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total 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billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Federal", "plan_name": "400110", "standard_charge_percentage": 0.85, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Federal", "plan_name": "400110_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." } ] } ] }, { "description": "Diclofenac sodium 50 mg tabletdelayed release [15340]", "drug_information": { "unit": 1.00, "type": "EA" }, "code_information": [ { "code": "0228-2550-06", "type": "NDC" } ], "standard_charges": [ { "gross_charge": 7.50, "minimum": 6.00, "maximum": 6.38, "setting": "both", "payers_information": [ { "payer_name": "Aetna", "plan_name": "700700", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna", "plan_name": "700700_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Miscellaneous", "plan_name": "700720", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Miscellaneous", "plan_name": "700720_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Ppo Hmo", "plan_name": "701720", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Ppo Hmo", "plan_name": "701720_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Ms State Emplo", "plan_name": "401457", "standard_charge_percentage": 0.80, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Ms State Emplo", "plan_name": "401457_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Basic Pl", "plan_name": "400100", "standard_charge_percentage": 0.85, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Basic Pl", "plan_name": "400100_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Federal", "plan_name": "400110", "standard_charge_percentage": 0.85, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Federal", "plan_name": "400110_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." } ] } ] }, { "description": "Indapamide 1.25 mg tablet [10264]", "drug_information": { "unit": 1.00, "type": "EA" }, "code_information": [ { "code": "0228-2597-11", "type": "NDC" } ], "standard_charges": [ { "gross_charge": 7.50, "minimum": 6.00, "maximum": 6.38, "setting": "both", "payers_information": [ { "payer_name": "Aetna", "plan_name": "700700", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna", "plan_name": "700700_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Miscellaneous", "plan_name": "700720", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Miscellaneous", "plan_name": "700720_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Ppo Hmo", "plan_name": "701720", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Ppo Hmo", "plan_name": "701720_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Ms State Emplo", "plan_name": "401457", "standard_charge_percentage": 0.80, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Ms State Emplo", "plan_name": "401457_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Basic Pl", "plan_name": "400100", "standard_charge_percentage": 0.85, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Basic Pl", "plan_name": "400100_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Federal", "plan_name": "400110", "standard_charge_percentage": 0.85, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Federal", "plan_name": "400110_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." } ] } ] }, { "description": "Isosorbide mononitrate 20 mg tablet [10357]", "drug_information": { "unit": 1.00, "type": "EA" }, "code_information": [ { "code": "0228-2620-11", "type": "NDC" } ], "standard_charges": [ { "gross_charge": 7.50, "minimum": 6.00, "maximum": 6.38, "setting": "both", "payers_information": [ { "payer_name": "Aetna", "plan_name": "700700", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna", "plan_name": "700700_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Miscellaneous", "plan_name": "700720", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Miscellaneous", "plan_name": "700720_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Ppo Hmo", "plan_name": "701720", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Ppo Hmo", "plan_name": "701720_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Ms State Emplo", "plan_name": "401457", "standard_charge_percentage": 0.80, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Ms State Emplo", "plan_name": "401457_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Basic Pl", "plan_name": "400100", "standard_charge_percentage": 0.85, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Basic Pl", "plan_name": "400100_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Federal", "plan_name": "400110", "standard_charge_percentage": 0.85, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Federal", "plan_name": "400110_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." } ] } ] }, { "description": "Hydrochlorothiazide 12.5 mg tablet [76988]", "drug_information": { "unit": 1.00, "type": "EA" }, "code_information": [ { "code": "0228-2820-11", "type": "NDC" } ], "standard_charges": [ { "gross_charge": 7.50, "minimum": 6.00, "maximum": 6.38, "setting": "both", "payers_information": [ { "payer_name": "Aetna", "plan_name": "700700", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna", "plan_name": "700700_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Miscellaneous", "plan_name": "700720", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Miscellaneous", "plan_name": "700720_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Ppo Hmo", "plan_name": "701720", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Ppo Hmo", "plan_name": "701720_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Ms State Emplo", "plan_name": "401457", "standard_charge_percentage": 0.80, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Ms State Emplo", "plan_name": "401457_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Basic Pl", "plan_name": "400100", "standard_charge_percentage": 0.85, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Basic Pl", "plan_name": "400100_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Federal", "plan_name": "400110", "standard_charge_percentage": 0.85, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Federal", "plan_name": "400110_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." } ] } ] }, { "description": "Chlorhexidine gluconate 4 % topical liquid [28188]", "drug_information": { "unit": 118.00, "type": "ML" }, "code_information": [ { "code": "0234-0575-04", "type": "NDC" } ], "standard_charges": [ { "gross_charge": 24.66, "minimum": 19.73, "maximum": 20.96, "setting": "both", "payers_information": [ { "payer_name": "Aetna", "plan_name": "700700", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna", "plan_name": "700700_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Miscellaneous", "plan_name": "700720", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Miscellaneous", "plan_name": "700720_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed 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"0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Basic Pl", "plan_name": "400100", "standard_charge_percentage": 0.85, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Basic Pl", "plan_name": "400100_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Federal", "plan_name": "400110", "standard_charge_percentage": 0.85, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Federal", "plan_name": "400110_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." } ] } ] }, { "description": "Potassium chloride er 10 meq tabletextended release(part/cryst) [35942]", "drug_information": { "unit": 1.00, "type": "EA" }, "code_information": [ { "code": "0245-5317-89", "type": "NDC" } ], "standard_charges": [ { "gross_charge": 7.50, "minimum": 6.00, "maximum": 6.38, "setting": "both", "payers_information": [ { "payer_name": "Aetna", "plan_name": "700700", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna", "plan_name": "700700_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Miscellaneous", "plan_name": 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"payer_name": "Aetna Ppo Hmo", "plan_name": "701720_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Ms State Emplo", "plan_name": "401457", "standard_charge_percentage": 0.80, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Ms State Emplo", "plan_name": "401457_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Basic Pl", "plan_name": "400100", "standard_charge_percentage": 0.85, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Basic Pl", "plan_name": "400100_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Federal", "plan_name": "400110", "standard_charge_percentage": 0.85, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Federal", "plan_name": "400110_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." } ] } ] }, { "description": "Potassium chloride er 20 meq tabletextended release(part/cryst) [35943]", "drug_information": { "unit": 1.00, "type": "EA" }, "code_information": [ { "code": "0245-5319-89", "type": "NDC" } ], "standard_charges": [ { 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"additional_payer_notes": "Insufficient remit data to calculate allowed amounts." } ] } ] }, { "description": "Ferrous sulfate 325 mg (65 mg iron) tabletdelayed release [3077]", "drug_information": { "unit": 1.00, "type": "EA" }, "code_information": [ { "code": "0245010801", "type": "NDC" } ], "standard_charges": [ { "gross_charge": 1.00, "minimum": 0.80, "maximum": 0.85, "setting": "both", "payers_information": [ { "payer_name": "Aetna", "plan_name": "700700", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna", "plan_name": "700700_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Miscellaneous", "plan_name": "700720", "standard_charge_percentage": 80.0, "count": "0", 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"percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Ms State Emplo", "plan_name": "401457_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Basic Pl", "plan_name": "400100", "standard_charge_percentage": 0.85, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Basic Pl", "plan_name": "400100_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Federal", "plan_name": "400110", "standard_charge_percentage": 0.85, "count": "0", "methodology": 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"standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Miscellaneous", "plan_name": "700720", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Miscellaneous", "plan_name": "700720_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Ppo Hmo", "plan_name": "701720", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Ppo Hmo", "plan_name": "701720_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Ms State Emplo", "plan_name": "401457", "standard_charge_percentage": 0.80, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Ms State Emplo", "plan_name": "401457_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Basic Pl", "plan_name": "400100", "standard_charge_percentage": 0.85, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Basic Pl", "plan_name": "400100_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Federal", "plan_name": "400110", "standard_charge_percentage": 0.85, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Federal", "plan_name": "400110_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." } ] } ] }, { "description": "Lubiprostone 24 mcg capsule [70472]", "drug_information": { "unit": 1.00, "type": "EA" }, "code_information": [ { "code": "0254-3029-02", "type": "NDC" } ], "standard_charges": [ { "gross_charge": 12.89, "minimum": 10.31, "maximum": 10.96, "setting": "both", "payers_information": [ { 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"plan_name": "701720", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Ppo Hmo", "plan_name": "701720_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Ms State Emplo", "plan_name": "401457", "standard_charge_percentage": 0.80, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Ms State Emplo", "plan_name": "401457_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Basic Pl", "plan_name": "400100", "standard_charge_percentage": 0.85, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Basic Pl", "plan_name": "400100_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Federal", "plan_name": "400110", "standard_charge_percentage": 0.85, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Federal", "plan_name": "400110_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." } ] } ] }, { "description": "Dextrose 5 % in water (d5w) intravenous solution [2364]", "drug_information": { "unit": 50.00, "type": "ML" }, "code_information": [ { "code": "0264-1510-31", "type": "NDC" } ], "standard_charges": [ { "gross_charge": 81.81, "minimum": 65.45, "maximum": 69.54, "setting": "both", "payers_information": [ { "payer_name": "Aetna", "plan_name": "700700", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna", "plan_name": "700700_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Miscellaneous", "plan_name": "700720", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Miscellaneous", "plan_name": "700720_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Ppo Hmo", "plan_name": "701720", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Ppo Hmo", "plan_name": "701720_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Ms State Emplo", "plan_name": "401457", "standard_charge_percentage": 0.80, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Ms State Emplo", "plan_name": "401457_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Basic Pl", "plan_name": "400100", "standard_charge_percentage": 0.85, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Basic Pl", "plan_name": "400100_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Federal", "plan_name": "400110", "standard_charge_percentage": 0.85, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Federal", "plan_name": "400110_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." } ] } ] }, { "description": "Sodium chloride 0.9 % intravenous solution [27838]", "drug_information": { "unit": 50.00, "type": "ML" }, "code_information": [ { "code": "0264-1800-31", "type": "NDC" } ], "standard_charges": [ { "gross_charge": 81.81, "minimum": 65.45, "maximum": 69.54, "setting": "both", "payers_information": [ { "payer_name": "Aetna", "plan_name": "700700", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna", "plan_name": "700700_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient 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calculate allowed amounts." }, { "payer_name": "Bc/Bs Ms State Emplo", "plan_name": "401457", "standard_charge_percentage": 0.80, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Ms State Emplo", "plan_name": "401457_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Basic Pl", "plan_name": "400100", "standard_charge_percentage": 0.85, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Basic Pl", "plan_name": "400100_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Federal", "plan_name": "400110", "standard_charge_percentage": 0.85, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Federal", "plan_name": "400110_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." } ] } ] }, { "description": "Hetastarch 6 % in 0.9 % sodium chloride intravenous solution [25174]", "drug_information": { "unit": 500.00, "type": "ML" }, "code_information": [ { "code": "0264-1965-10", "type": "NDC" } ], "standard_charges": [ { "gross_charge": 207.69, "minimum": 166.15, "maximum": 176.54, "setting": "both", "payers_information": [ { "payer_name": "Aetna", "plan_name": "700700", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna", "plan_name": "700700_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Miscellaneous", "plan_name": "700720", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Miscellaneous", "plan_name": "700720_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Ppo Hmo", "plan_name": "701720", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Ppo Hmo", "plan_name": "701720_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Ms State Emplo", "plan_name": "401457", "standard_charge_percentage": 0.80, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Ms State Emplo", "plan_name": "401457_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Basic Pl", "plan_name": "400100", "standard_charge_percentage": 0.85, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Basic Pl", "plan_name": "400100_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Federal", "plan_name": "400110", "standard_charge_percentage": 0.85, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Federal", "plan_name": "400110_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." } ] } ] }, { "description": "Albuterol sulfate hfa 90 mcg/actuation aerosol inhaler [17837]", "drug_information": { "unit": 18.00, "type": "GR" }, "code_information": [ { "code": "0173-0682-20", "type": "NDC" } ], "standard_charges": [ { "gross_charge": 254.71, "minimum": 203.77, "maximum": 216.50, "setting": "both", "payers_information": [ { "payer_name": "Aetna", "plan_name": "700700", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna", "plan_name": "700700_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Miscellaneous", "plan_name": "700720", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Miscellaneous", "plan_name": "700720_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Ppo Hmo", "plan_name": "701720", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Ppo Hmo", "plan_name": "701720_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Ms State Emplo", "plan_name": "401457", "standard_charge_percentage": 0.80, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Ms State Emplo", "plan_name": "401457_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Basic Pl", "plan_name": "400100", "standard_charge_percentage": 0.85, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Basic Pl", "plan_name": "400100_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Federal", "plan_name": "400110", "standard_charge_percentage": 0.85, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Federal", "plan_name": "400110_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." } ] } ] }, { "description": "Albuterol sulfate hfa 90 mcg/actuation aerosol inhaler [17837]", "drug_information": { "unit": 8.00, "type": "GR" }, "code_information": [ { "code": "0173-0682-24", "type": "NDC" } ], "standard_charges": [ { "gross_charge": 101.50, "minimum": 81.20, "maximum": 86.28, "setting": "both", "payers_information": [ { "payer_name": "Aetna", "plan_name": "700700", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna", "plan_name": "700700_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Miscellaneous", "plan_name": 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}, { "payer_name": "Bc/Bs Of Ms Basic Pl", "plan_name": "400100_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Federal", "plan_name": "400110", "standard_charge_percentage": 0.85, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Federal", "plan_name": "400110_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." } ] } ] }, { "description": "Fluticasone 250 mcg-salmeterol 50 mcg/dose blistr powdr for inhalation [26538]", "drug_information": { "unit": 14.00, "type": "EA" }, "code_information": [ { "code": "0173-0696-04", "type": "NDC" } ], "standard_charges": [ { "gross_charge": 203.42, "minimum": 162.74, "maximum": 172.91, "setting": "both", "payers_information": [ { "payer_name": "Aetna", "plan_name": "700700", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna", "plan_name": "700700_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Miscellaneous", "plan_name": "700720", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Miscellaneous", "plan_name": "700720_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", 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"701720_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Ms State Emplo", "plan_name": "401457", "standard_charge_percentage": 0.80, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Ms State Emplo", "plan_name": "401457_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Basic Pl", "plan_name": "400100", "standard_charge_percentage": 0.85, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Basic Pl", "plan_name": "400100_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Federal", "plan_name": "400110", "standard_charge_percentage": 0.85, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Federal", "plan_name": "400110_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." } ] } ] }, { "description": "Diluent for epoprostenol (glycine) ph 11.7 - 12.3 intravenous solution [191175]", "drug_information": { "unit": 50.00, "type": "ML" }, "code_information": [ { "code": "0173-0857-01", "type": "NDC" } ], "standard_charges": [ { "gross_charge": 68.88, "minimum": 55.10, "maximum": 58.55, "setting": "both", "payers_information": [ { "payer_name": "Aetna", "plan_name": "700700", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna", "plan_name": "700700_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Miscellaneous", "plan_name": "700720", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Miscellaneous", "plan_name": "700720_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate 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amounts." }, { "payer_name": "Bc/Bs Of Ms Basic Pl", "plan_name": "400100", "standard_charge_percentage": 0.85, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Basic Pl", "plan_name": "400100_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Federal", "plan_name": "400110", "standard_charge_percentage": 0.85, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Federal", "plan_name": "400110_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." } ] } ] }, { "description": "Diluent for epoprostenol (glycine) ph 11.7 - 12.3 intravenous solution [191175]", "drug_information": { "unit": 50.00, "type": "ML" }, "code_information": [ { "code": "0173-0857-02", "type": "NDC" } ], "standard_charges": [ { "gross_charge": 68.88, "minimum": 55.10, "maximum": 58.55, "setting": "both", "payers_information": [ { "payer_name": "Aetna", "plan_name": "700700", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna", "plan_name": "700700_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Miscellaneous", "plan_name": "700720", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Miscellaneous", "plan_name": "700720_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Ppo Hmo", "plan_name": "701720", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Ppo Hmo", "plan_name": "701720_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Ms State Emplo", "plan_name": "401457", "standard_charge_percentage": 0.80, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Ms State Emplo", "plan_name": "401457_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Basic Pl", "plan_name": "400100", "standard_charge_percentage": 0.85, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Basic Pl", "plan_name": "400100_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Federal", "plan_name": "400110", "standard_charge_percentage": 0.85, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Federal", "plan_name": "400110_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." } ] } ] }, { "description": "Hydrochlorothiazide 25 mg tablet [3720]", "drug_information": { "unit": 1.00, "type": "EA" }, "code_information": [ { "code": "0172-2083-60", "type": "NDC" } ], "standard_charges": [ { "gross_charge": 7.50, "minimum": 6.00, "maximum": 6.38, "setting": "both", "payers_information": [ { "payer_name": "Aetna", "plan_name": "700700", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna", "plan_name": "700700_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": 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billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Basic Pl", "plan_name": "400100_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Federal", "plan_name": "400110", "standard_charge_percentage": 0.85, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Federal", "plan_name": "400110_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." } ] } ] }, { "description": "Diazepam 10 mg tablet [2403]", "drug_information": { "unit": 1.00, "type": "EA" }, "code_information": [ { "code": 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"400100_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Federal", "plan_name": "400110", "standard_charge_percentage": 0.85, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Federal", "plan_name": "400110_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." } ] } ] }, { "description": "Fluticasone fur. 100 mcg-umeclid 62.5 mcg-vilant 25 mcg inhalat.powder [183373]", "drug_information": { "unit": 28.00, "type": "EA" }, "code_information": [ { "code": "0173-0887-14", "type": "NDC" } ], "standard_charges": [ { "gross_charge": 1369.37, "minimum": 1095.50, "maximum": 1163.96, "setting": "both", "payers_information": [ { "payer_name": "Aetna", "plan_name": "700700", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna", "plan_name": "700700_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Miscellaneous", "plan_name": "700720", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Miscellaneous", "plan_name": "700720_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to 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allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Basic Pl", "plan_name": "400100", "standard_charge_percentage": 0.85, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Basic Pl", "plan_name": "400100_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Federal", "plan_name": "400110", "standard_charge_percentage": 0.85, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Federal", "plan_name": "400110_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." } ] } ] }, { "description": "Fluticasone fur. 200 mcg-umeclid 62.5 mcg-vilant 25 mcg inhalat.powder [191874]", "drug_information": { "unit": 1.00, "type": "EA" }, "code_information": [ { "code": "0173-0893-14", "type": "NDC" } ], "standard_charges": [ { "gross_charge": 48.91, "minimum": 39.13, "maximum": 41.57, "setting": "both", "payers_information": [ { "payer_name": "Aetna", "plan_name": "700700", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna", "plan_name": "700700_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Miscellaneous", "plan_name": "700720", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Miscellaneous", "plan_name": "700720_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Ppo Hmo", "plan_name": "701720", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Ppo Hmo", "plan_name": "701720_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Ms State Emplo", "plan_name": "401457", "standard_charge_percentage": 0.80, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Ms State Emplo", "plan_name": "401457_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Basic Pl", "plan_name": "400100", "standard_charge_percentage": 0.85, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Basic Pl", "plan_name": "400100_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Federal", "plan_name": "400110", "standard_charge_percentage": 0.85, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Federal", "plan_name": "400110_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." } ] } ] }, { "description": "Bupropion hcl sr 100 mg tablet12 hr sustained-release [18385]", "drug_information": { "unit": 1.00, "type": "EA" }, "code_information": [ { "code": "0173-0947-55", "type": "NDC" } ], "standard_charges": [ { "gross_charge": 32.82, "minimum": 26.26, "maximum": 27.90, "setting": "both", "payers_information": [ { "payer_name": "Aetna", "plan_name": "700700", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna", "plan_name": "700700_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Miscellaneous", "plan_name": "700720", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Miscellaneous", "plan_name": "700720_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Ppo Hmo", "plan_name": "701720", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Ppo Hmo", "plan_name": "701720_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Ms State Emplo", "plan_name": "401457", "standard_charge_percentage": 0.80, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Ms State Emplo", "plan_name": "401457_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Basic Pl", "plan_name": "400100", "standard_charge_percentage": 0.85, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Basic Pl", "plan_name": "400100_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Federal", "plan_name": "400110", "standard_charge_percentage": 0.85, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Federal", "plan_name": "400110_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." } ] } ] }, { "description": "Nabumetone 500 mg tablet [10676]", "drug_information": { "unit": 1.00, "type": "EA" }, "code_information": [ { "code": "0185-0145-01", "type": "NDC" } ], "standard_charges": [ { "gross_charge": 7.50, "minimum": 6.00, "maximum": 6.38, "setting": "both", "payers_information": [ { "payer_name": "Aetna", "plan_name": "700700", 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"standard_charge_percentage": 0.85, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Basic Pl", "plan_name": "400100_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Federal", "plan_name": "400110", "standard_charge_percentage": 0.85, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Federal", "plan_name": "400110_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." } ] } ] }, { "description": "Budesonide-formoterol hfa 160 mcg-4.5 mcg/actuation aerosol inhaler [81454]", "drug_information": { "unit": 6.00, "type": "GR" }, "code_information": [ { "code": "0186-0370-28", "type": "NDC" } ], "standard_charges": [ { "gross_charge": 711.28, "minimum": 569.02, "maximum": 604.59, "setting": "both", "payers_information": [ { "payer_name": "Aetna", "plan_name": "700700", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna", "plan_name": "700700_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Miscellaneous", "plan_name": "700720", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Miscellaneous", "plan_name": "700720_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Ppo Hmo", "plan_name": "701720", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Ppo Hmo", "plan_name": "701720_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Ms State Emplo", "plan_name": "401457", "standard_charge_percentage": 0.80, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Ms State Emplo", "plan_name": "401457_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Basic Pl", "plan_name": "400100", "standard_charge_percentage": 0.85, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Basic Pl", "plan_name": "400100_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Federal", "plan_name": "400110", "standard_charge_percentage": 0.85, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Federal", "plan_name": "400110_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." } ] } ] }, { "description": "Budesonide-formoterol hfa 80 mcg-4.5 mcg/actuation aerosol inhaler [81453]", "drug_information": { "unit": 6.90, "type": "GR" }, "code_information": [ { "code": "0186-0372-28", "type": "NDC" } ], "standard_charges": [ { "gross_charge": 618.37, "minimum": 494.70, "maximum": 525.61, "setting": "both", "payers_information": [ { "payer_name": "Aetna", "plan_name": "700700", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna", "plan_name": "700700_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Miscellaneous", "plan_name": "700720", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Miscellaneous", "plan_name": "700720_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Ppo Hmo", "plan_name": "701720", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Ppo Hmo", "plan_name": "701720_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Ms State Emplo", "plan_name": "401457", "standard_charge_percentage": 0.80, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Ms State Emplo", "plan_name": "401457_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Basic Pl", "plan_name": "400100", "standard_charge_percentage": 0.85, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Basic Pl", "plan_name": "400100_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Federal", "plan_name": "400110", "standard_charge_percentage": 0.85, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Federal", "plan_name": "400110_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." } ] } ] }, { "description": "Ticagrelor 90 mg tablet [151906]", "drug_information": { "unit": 1.00, "type": "EA" }, "code_information": [ { "code": "0186-0777-39", "type": "NDC" } ], "standard_charges": [ { "gross_charge": 33.60, "minimum": 26.88, "maximum": 28.56, "setting": "both", "payers_information": [ { "payer_name": "Aetna", "plan_name": "700700", "standard_charge_percentage": 80.0, "count": "0", "methodology": 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charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Ppo Hmo", "plan_name": "701720_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Ms State Emplo", "plan_name": "401457", "standard_charge_percentage": 0.80, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Ms State Emplo", "plan_name": "401457_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Basic Pl", "plan_name": "400100", "standard_charge_percentage": 0.85, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Basic Pl", "plan_name": "400100_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Federal", "plan_name": "400110", "standard_charge_percentage": 0.85, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Federal", "plan_name": "400110_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." } ] } ] }, { "description": "Ticagrelor 90 mg tablet [151906]", "drug_information": { "unit": 1.00, "type": "EA" }, "code_information": [ { "code": "0186-0777-60", "type": "NDC" } ], "standard_charges": [ { "gross_charge": 33.60, "minimum": 26.88, "maximum": 28.56, "setting": "both", "payers_information": [ { "payer_name": "Aetna", "plan_name": "700700", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna", "plan_name": "700700_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Miscellaneous", "plan_name": "700720", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Miscellaneous", "plan_name": "700720_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Ppo Hmo", "plan_name": "701720", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Ppo Hmo", "plan_name": "701720_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Ms State Emplo", "plan_name": "401457", "standard_charge_percentage": 0.80, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Ms State Emplo", "plan_name": "401457_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Basic Pl", "plan_name": "400100", "standard_charge_percentage": 0.85, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Basic Pl", "plan_name": "400100_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Federal", "plan_name": "400110", "standard_charge_percentage": 0.85, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Federal", "plan_name": "400110_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." } ] } ] }, { "description": "Budesonide 180 mcg/actuation breath activated powder inhaler [96977]", "drug_information": { "unit": 1.00, "type": "EA" }, "code_information": [ { "code": "0186-0916-12", "type": "NDC" } ], "standard_charges": [ { "gross_charge": 1256.85, "minimum": 1005.48, "maximum": 1068.32, "setting": "both", "payers_information": [ { "payer_name": "Aetna", "plan_name": "700700", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna", "plan_name": "700700_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Miscellaneous", "plan_name": "700720", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Miscellaneous", "plan_name": "700720_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Ppo Hmo", "plan_name": "701720", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Ppo Hmo", "plan_name": "701720_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Ms State Emplo", "plan_name": "401457", "standard_charge_percentage": 0.80, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Ms State Emplo", "plan_name": "401457_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Basic Pl", "plan_name": "400100", "standard_charge_percentage": 0.85, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Basic Pl", "plan_name": "400100_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Federal", "plan_name": "400110", "standard_charge_percentage": 0.85, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Federal", "plan_name": "400110_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." } ] } ] }, { "description": "Meropenem 1 gram/50 ml in 0.9% sodium chloride intravenous piggyback [171370]", "drug_information": { "unit": 1.00, "type": "EA" }, "code_information": [ { "code": "0264-3185-11", "type": "NDC" } ], "standard_charges": [ { "gross_charge": 215.44, "minimum": 172.35, "maximum": 183.12, "setting": "both", "payers_information": [ { "payer_name": "Aetna", "plan_name": "700700", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna", "plan_name": "700700_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Miscellaneous", "plan_name": "700720", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Miscellaneous", "plan_name": "700720_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Ppo Hmo", "plan_name": "701720", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Ppo Hmo", "plan_name": "701720_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Ms State Emplo", "plan_name": "401457", "standard_charge_percentage": 0.80, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Ms State Emplo", "plan_name": "401457_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Basic Pl", "plan_name": "400100", "standard_charge_percentage": 0.85, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Basic Pl", "plan_name": "400100_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Federal", "plan_name": "400110", "standard_charge_percentage": 0.85, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Federal", "plan_name": "400110_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." } ] } ] }, { "description": "Dextrose 5 % in water (d5w) intravenous solution [2364]", "drug_information": { "unit": 250.00, "type": "ML" }, "code_information": [ { "code": "0264-7510-20", "type": "NDC" } ], "standard_charges": [ { "gross_charge": 81.81, "minimum": 65.45, "maximum": 69.54, "setting": "both", "payers_information": [ { "payer_name": "Aetna", "plan_name": "700700", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna", "plan_name": "700700_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Miscellaneous", "plan_name": "700720", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Miscellaneous", "plan_name": "700720_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Ppo Hmo", "plan_name": "701720", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Ppo Hmo", "plan_name": "701720_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Ms State Emplo", "plan_name": "401457", "standard_charge_percentage": 0.80, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Ms State Emplo", "plan_name": "401457_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Basic Pl", "plan_name": "400100", "standard_charge_percentage": 0.85, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Basic Pl", "plan_name": "400100_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Federal", "plan_name": "400110", "standard_charge_percentage": 0.85, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Federal", "plan_name": "400110_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." } ] } ] }, { "description": "Dextrose 10 % in water (d10w) intravenous solution [2357]", "drug_information": { "unit": 1000.00, "type": "ML" }, "code_information": [ { "code": "0264-7520-00", "type": "NDC" } ], "standard_charges": [ { "gross_charge": 81.81, "minimum": 65.45, "maximum": 69.54, "setting": "both", "payers_information": [ { "payer_name": "Aetna", "plan_name": "700700", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna", "plan_name": "700700_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Miscellaneous", "plan_name": "700720", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Miscellaneous", "plan_name": "700720_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Ppo Hmo", "plan_name": "701720", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Ppo Hmo", "plan_name": "701720_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Ms State Emplo", "plan_name": "401457", "standard_charge_percentage": 0.80, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Ms State Emplo", "plan_name": "401457_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Basic Pl", "plan_name": "400100", "standard_charge_percentage": 0.85, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Basic Pl", "plan_name": "400100_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Federal", "plan_name": "400110", "standard_charge_percentage": 0.85, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Federal", "plan_name": "400110_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." } ] } ] }, { "description": "Mannitol 20 % intravenous solution [4749]", "drug_information": { "unit": 500.00, "type": "ML" }, "code_information": [ { "code": "0264-7578-10", "type": "NDC" } ], "standard_charges": [ { "gross_charge": 305.06, "minimum": 244.05, "maximum": 259.30, "setting": "both", "payers_information": [ { "payer_name": "Aetna", "plan_name": "700700", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna", "plan_name": "700700_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Miscellaneous", "plan_name": "700720", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Miscellaneous", "plan_name": "700720_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Ppo Hmo", "plan_name": "701720", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Ppo Hmo", "plan_name": "701720_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Ms State Emplo", "plan_name": "401457", "standard_charge_percentage": 0.80, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Ms State Emplo", "plan_name": "401457_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Basic Pl", "plan_name": "400100", "standard_charge_percentage": 0.85, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Basic Pl", "plan_name": "400100_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Federal", "plan_name": "400110", "standard_charge_percentage": 0.85, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Federal", "plan_name": "400110_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." } ] } ] }, { "description": "Dextrose 10 % and 0.45 % sodium chloride intravenous solution [9809]", "drug_information": { "unit": 1000.00, "type": "ML" }, "code_information": [ { "code": "0264-7622-00", "type": "NDC" } ], "standard_charges": [ { "gross_charge": 81.81, "minimum": 65.45, "maximum": 69.54, "setting": "both", "payers_information": [ { "payer_name": "Aetna", "plan_name": "700700", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna", "plan_name": "700700_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Miscellaneous", "plan_name": "700720", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Miscellaneous", "plan_name": "700720_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Ppo Hmo", "plan_name": "701720", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Ppo Hmo", "plan_name": "701720_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Ms State Emplo", "plan_name": "401457", "standard_charge_percentage": 0.80, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Ms State Emplo", "plan_name": "401457_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Basic Pl", "plan_name": "400100", "standard_charge_percentage": 0.85, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Basic Pl", "plan_name": "400100_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Federal", "plan_name": "400110", "standard_charge_percentage": 0.85, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Federal", "plan_name": "400110_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." } ] } ] }, { "description": "Fat emulsion 20 % intravenous [10014]", "drug_information": { "unit": 250.00, "type": "ML" }, "code_information": [ { "code": "0264-4460-30", "type": "NDC" } ], "standard_charges": [ { "gross_charge": 202.94, "minimum": 162.35, "maximum": 172.50, "setting": "both", "payers_information": [ { "payer_name": "Aetna", "plan_name": "700700", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna", "plan_name": "700700_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Miscellaneous", "plan_name": "700720", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Miscellaneous", "plan_name": "700720_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Ppo Hmo", "plan_name": "701720", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Ppo Hmo", "plan_name": "701720_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Ms State Emplo", "plan_name": "401457", "standard_charge_percentage": 0.80, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Ms State Emplo", "plan_name": "401457_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Basic Pl", "plan_name": "400100", "standard_charge_percentage": 0.85, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Basic Pl", "plan_name": "400100_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Federal", "plan_name": "400110", "standard_charge_percentage": 0.85, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Federal", "plan_name": "400110_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." } ] } ] }, { "description": "Water for injection sterile intravenous solution [28400]", "drug_information": { "unit": 1000.00, "type": "ML" }, "code_information": [ { "code": "0264-7850-00", "type": "NDC" } ], "standard_charges": [ { "gross_charge": 99.81, "minimum": 79.85, "maximum": 84.84, "setting": "both", "payers_information": [ { "payer_name": "Aetna", "plan_name": "700700", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna", "plan_name": "700700_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Miscellaneous", "plan_name": "700720", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Miscellaneous", "plan_name": "700720_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Ppo Hmo", "plan_name": "701720", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Ppo Hmo", "plan_name": "701720_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Ms State Emplo", "plan_name": "401457", "standard_charge_percentage": 0.80, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Ms State Emplo", "plan_name": "401457_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Basic Pl", "plan_name": "400100", "standard_charge_percentage": 0.85, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Basic Pl", "plan_name": "400100_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Federal", "plan_name": "400110", "standard_charge_percentage": 0.85, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Federal", "plan_name": "400110_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." } ] } ] }, { "description": "Nitroglycerin 2 % transdermal ointment [5606]", "drug_information": { "unit": 1.00, "type": "GR" }, "code_information": [ { "code": "0281-0326-08", "type": "NDC" } ], "standard_charges": [ { "gross_charge": 11.51, "minimum": 9.21, "maximum": 9.78, "setting": "both", "payers_information": [ { "payer_name": "Aetna", "plan_name": "700700", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna", "plan_name": "700700_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Miscellaneous", "plan_name": "700720", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Miscellaneous", "plan_name": "700720_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Ppo Hmo", "plan_name": "701720", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Ppo Hmo", "plan_name": "701720_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Ms State Emplo", "plan_name": "401457", "standard_charge_percentage": 0.80, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Ms State Emplo", "plan_name": "401457_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Basic Pl", "plan_name": "400100", "standard_charge_percentage": 0.85, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Basic Pl", "plan_name": "400100_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Federal", "plan_name": "400110", "standard_charge_percentage": 0.85, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Federal", "plan_name": "400110_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." } ] } ] }, { "description": "Benzocaine 20 % mucosal aerosol spray [19696]", "drug_information": { "unit": 57.00, "type": "GR" }, "code_information": [ { "code": "0283-0679-02", "type": "NDC" } ], "standard_charges": [ { "gross_charge": 181.13, "minimum": 144.90, "maximum": 153.96, "setting": "both", "payers_information": [ { "payer_name": "Aetna", "plan_name": "700700", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna", "plan_name": "700700_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Miscellaneous", "plan_name": "700720", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Miscellaneous", "plan_name": "700720_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Ppo Hmo", "plan_name": "701720", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Ppo Hmo", "plan_name": "701720_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Ms State Emplo", "plan_name": "401457", "standard_charge_percentage": 0.80, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Ms State Emplo", "plan_name": "401457_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient 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remit data to calculate allowed amounts." } ] } ] }, { "description": "Roflumilast 500 mcg tablet [151376]", "drug_information": { "unit": 1.00, "type": "EA" }, "code_information": [ { "code": "0310-0095-30", "type": "NDC" } ], "standard_charges": [ { "gross_charge": 66.10, "minimum": 52.88, "maximum": 56.19, "setting": "both", "payers_information": [ { "payer_name": "Aetna", "plan_name": "700700", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna", "plan_name": "700700_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Miscellaneous", "plan_name": "700720", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Miscellaneous", "plan_name": "700720_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Ppo Hmo", "plan_name": "701720", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Ppo Hmo", "plan_name": "701720_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Ms State Emplo", "plan_name": "401457", "standard_charge_percentage": 0.80, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Ms State Emplo", "plan_name": "401457_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Basic Pl", "plan_name": "400100", "standard_charge_percentage": 0.85, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Basic Pl", "plan_name": "400100_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Federal", "plan_name": "400110", "standard_charge_percentage": 0.85, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Federal", "plan_name": "400110_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." } ] } ] }, { "description": "Sodium zirconium cyclosilicate 5 gram oral powder packet [184833]", "drug_information": { "unit": 1.00, "type": "EA" }, "code_information": [ { "code": "0310-1105-01", "type": "NDC" } ], "standard_charges": [ { "gross_charge": 122.19, "minimum": 97.75, "maximum": 103.86, "setting": "both", "payers_information": [ { "payer_name": "Aetna", "plan_name": "700700", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna", "plan_name": "700700_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Miscellaneous", "plan_name": "700720", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Miscellaneous", "plan_name": "700720_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Ppo Hmo", "plan_name": "701720", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Ppo Hmo", "plan_name": "701720_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Ms State Emplo", "plan_name": "401457", "standard_charge_percentage": 0.80, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Ms State Emplo", "plan_name": "401457_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Basic Pl", "plan_name": "400100", "standard_charge_percentage": 0.85, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Basic Pl", "plan_name": "400100_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Federal", "plan_name": "400110", "standard_charge_percentage": 0.85, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Federal", "plan_name": "400110_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." } ] } ] }, { "description": "Sodium zirconium cyclosilicate 5 gram oral powder packet [184833]", "drug_information": { "unit": 1.00, "type": "EA" }, "code_information": [ { "code": "0310-1105-39", "type": "NDC" } ], "standard_charges": [ { "gross_charge": 122.19, "minimum": 97.75, "maximum": 103.86, "setting": "both", "payers_information": [ { "payer_name": "Aetna", 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"standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Ppo Hmo", "plan_name": "701720_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Ms State Emplo", "plan_name": "401457", "standard_charge_percentage": 0.80, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Ms State Emplo", "plan_name": "401457_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Basic Pl", "plan_name": "400100", 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oral powder packet [184834]", "drug_information": { "unit": 1.00, "type": "EA" }, "code_information": [ { "code": "0310-1110-01", "type": "NDC" } ], "standard_charges": [ { "gross_charge": 122.19, "minimum": 97.75, "maximum": 103.86, "setting": "both", "payers_information": [ { "payer_name": "Aetna", "plan_name": "700700", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna", "plan_name": "700700_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Miscellaneous", "plan_name": "700720", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Miscellaneous", "plan_name": "700720_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Ppo Hmo", "plan_name": "701720", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Ppo Hmo", "plan_name": "701720_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Ms State Emplo", "plan_name": "401457", "standard_charge_percentage": 0.80, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Ms State Emplo", "plan_name": "401457_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Basic Pl", "plan_name": "400100", "standard_charge_percentage": 0.85, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Basic Pl", "plan_name": "400100_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Federal", "plan_name": "400110", "standard_charge_percentage": 0.85, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Federal", "plan_name": "400110_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." } ] } ] }, { "description": "Sodium zirconium cyclosilicate 10 gram oral powder packet [184834]", "drug_information": { "unit": 1.00, "type": "EA" }, "code_information": [ { "code": "0310-1110-30", "type": "NDC" } ], "standard_charges": [ { "gross_charge": 122.19, "minimum": 97.75, "maximum": 103.86, "setting": "both", "payers_information": [ { "payer_name": "Aetna", "plan_name": "700700", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna", "plan_name": "700700_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Miscellaneous", "plan_name": "700720", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Miscellaneous", "plan_name": "700720_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Ppo Hmo", "plan_name": "701720", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Ppo Hmo", "plan_name": "701720_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Ms State Emplo", "plan_name": "401457", "standard_charge_percentage": 0.80, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Ms State Emplo", "plan_name": "401457_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Basic Pl", "plan_name": "400100", "standard_charge_percentage": 0.85, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Basic Pl", "plan_name": "400100_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Federal", "plan_name": "400110", "standard_charge_percentage": 0.85, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Federal", "plan_name": "400110_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." } ] } ] }, { "description": "Dapagliflozin propanediol 5 mg tablet [165132]", "drug_information": { "unit": 1.00, "type": "EA" }, "code_information": [ { "code": "0310-6205-30", "type": "NDC" } ], "standard_charges": [ { "gross_charge": 86.71, "minimum": 69.37, "maximum": 73.70, "setting": "both", "payers_information": [ { "payer_name": "Aetna", "plan_name": "700700", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna", "plan_name": "700700_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Miscellaneous", "plan_name": "700720", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Miscellaneous", "plan_name": "700720_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Ppo Hmo", "plan_name": "701720", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Ppo Hmo", "plan_name": "701720_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Ms State Emplo", "plan_name": "401457", "standard_charge_percentage": 0.80, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Ms State Emplo", "plan_name": "401457_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Basic Pl", "plan_name": "400100", "standard_charge_percentage": 0.85, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Basic Pl", "plan_name": "400100_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Federal", "plan_name": "400110", "standard_charge_percentage": 0.85, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Federal", "plan_name": "400110_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." } ] } ] }, { "description": "Camphor-menthol 0.5 %-0.5 % lotion [23063]", "drug_information": { "unit": 222.00, "type": "ML" }, "code_information": [ { "code": "0316-0229-75", "type": "NDC" } ], "standard_charges": [ { "gross_charge": 25.40, "minimum": 20.32, "maximum": 21.59, "setting": "both", "payers_information": [ { "payer_name": "Aetna", "plan_name": "700700", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna", "plan_name": "700700_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Miscellaneous", "plan_name": "700720", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Miscellaneous", "plan_name": "700720_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed 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"additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Basic Pl", "plan_name": "400100", "standard_charge_percentage": 0.85, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Basic Pl", "plan_name": "400100_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Federal", "plan_name": "400110", "standard_charge_percentage": 0.85, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Federal", "plan_name": "400110_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." } ] } ] }, { "description": "Pramoxine 1 % lotion [11099]", "drug_information": { "unit": 222.00, "type": "ML" }, "code_information": [ { "code": "0316-0230-75", "type": "NDC" } ], "standard_charges": [ { "gross_charge": 25.40, "minimum": 20.32, "maximum": 21.59, "setting": "both", "payers_information": [ { "payer_name": "Aetna", "plan_name": "700700", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna", "plan_name": "700700_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Miscellaneous", "plan_name": "700720", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of 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charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Federal", "plan_name": "400110_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." } ] } ] }, { "description": "Oxychlorosene sodium topical powder for solution [167418]", "drug_information": { "unit": 2.00, "type": "GR" }, "code_information": [ { "code": "0327-0001-10", "type": "NDC" } ], "standard_charges": [ { "gross_charge": 34.58, "minimum": 27.66, "maximum": 29.39, "setting": "both", "payers_information": [ { "payer_name": "Aetna", "plan_name": "700700", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna", "plan_name": "700700_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Miscellaneous", "plan_name": "700720", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Miscellaneous", "plan_name": "700720_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Ppo Hmo", "plan_name": "701720", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Ppo Hmo", "plan_name": "701720_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Ms State Emplo", "plan_name": "401457", "standard_charge_percentage": 0.80, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Ms State Emplo", "plan_name": "401457_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Basic Pl", "plan_name": "400100", "standard_charge_percentage": 0.85, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Basic Pl", "plan_name": "400100_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Federal", "plan_name": "400110", "standard_charge_percentage": 0.85, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Federal", "plan_name": "400110_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." } ] } ] }, { "description": "Water for irrigation sterile solution [7485]", "drug_information": { "unit": 1000.00, "type": "ML" }, "code_information": [ { "code": "0338-0003-44", "type": "NDC" } ], "standard_charges": [ { "gross_charge": 124.56, "minimum": 99.65, "maximum": 105.88, "setting": "both", "payers_information": [ { "payer_name": "Aetna", "plan_name": "700700", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna", "plan_name": "700700_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Miscellaneous", "plan_name": "700720", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Miscellaneous", "plan_name": "700720_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Ppo Hmo", "plan_name": "701720", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Ppo Hmo", "plan_name": "701720_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Ms State Emplo", "plan_name": "401457", "standard_charge_percentage": 0.80, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Ms State Emplo", "plan_name": "401457_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Basic Pl", "plan_name": "400100", "standard_charge_percentage": 0.85, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Basic Pl", "plan_name": "400100_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Federal", "plan_name": "400110", "standard_charge_percentage": 0.85, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Federal", "plan_name": "400110_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." } ] } ] }, { "description": "Water for irrigation sterile solution [7485]", "drug_information": { "unit": 3000.00, "type": "ML" }, "code_information": [ { "code": "0338-0003-47", "type": "NDC" } ], "standard_charges": [ { "gross_charge": 167.31, "minimum": 133.85, "maximum": 142.21, "setting": "both", "payers_information": [ { "payer_name": "Aetna", "plan_name": "700700", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna", "plan_name": "700700_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Miscellaneous", "plan_name": "700720", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Miscellaneous", "plan_name": "700720_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Ppo Hmo", "plan_name": "701720", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Ppo Hmo", "plan_name": "701720_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Ms State Emplo", "plan_name": "401457", "standard_charge_percentage": 0.80, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Ms State Emplo", "plan_name": "401457_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Basic Pl", "plan_name": "400100", "standard_charge_percentage": 0.85, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Basic Pl", "plan_name": "400100_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Federal", "plan_name": "400110", "standard_charge_percentage": 0.85, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Federal", "plan_name": "400110_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." } ] } ] }, { "description": "Water for irrigation sterile solution [7485]", "drug_information": { "unit": 1000.00, "type": "ML" }, "code_information": [ { "code": "0338-0004-04", "type": "NDC" } ], "standard_charges": [ { "gross_charge": 99.81, "minimum": 79.85, "maximum": 84.84, "setting": "both", "payers_information": [ { "payer_name": "Aetna", "plan_name": "700700", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna", "plan_name": "700700_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Miscellaneous", "plan_name": "700720", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Miscellaneous", "plan_name": "700720_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Ppo Hmo", "plan_name": "701720", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Ppo Hmo", "plan_name": "701720_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Ms State Emplo", "plan_name": "401457", "standard_charge_percentage": 0.80, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Ms State Emplo", "plan_name": "401457_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Basic Pl", "plan_name": "400100", "standard_charge_percentage": 0.85, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Basic Pl", "plan_name": "400100_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Federal", "plan_name": "400110", "standard_charge_percentage": 0.85, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Federal", "plan_name": "400110_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." } ] } ] }, { "description": "Water for injection sterile intravenous solution [28400]", "drug_information": { "unit": 1000.00, "type": "ML" }, "code_information": [ { "code": "0338-0013-04", "type": "NDC" } ], "standard_charges": [ { "gross_charge": 162.56, "minimum": 130.05, "maximum": 138.18, "setting": "both", "payers_information": [ { "payer_name": "Aetna", "plan_name": "700700", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna", "plan_name": "700700_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Miscellaneous", "plan_name": "700720", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Miscellaneous", "plan_name": "700720_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Ppo Hmo", "plan_name": "701720", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Ppo Hmo", "plan_name": "701720_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Ms State Emplo", "plan_name": "401457", "standard_charge_percentage": 0.80, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Ms State Emplo", "plan_name": "401457_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Basic Pl", "plan_name": "400100", "standard_charge_percentage": 0.85, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Basic Pl", "plan_name": "400100_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Federal", "plan_name": "400110", "standard_charge_percentage": 0.85, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Federal", "plan_name": "400110_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." } ] } ] }, { "description": "Dextrose 5 % in water (d5w) intravenous solution [2364]", "drug_information": { "unit": 250.00, "type": "ML" }, "code_information": [ { "code": "0338-0017-02", "type": "NDC" } ], "standard_charges": [ { "gross_charge": 81.81, "minimum": 65.45, "maximum": 69.54, "setting": "both", "payers_information": [ { "payer_name": "Aetna", "plan_name": "700700", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna", "plan_name": "700700_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Miscellaneous", "plan_name": "700720", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Miscellaneous", "plan_name": "700720_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Ppo Hmo", "plan_name": "701720", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Ppo Hmo", "plan_name": "701720_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Ms State Emplo", "plan_name": "401457", "standard_charge_percentage": 0.80, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Ms State Emplo", "plan_name": "401457_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Basic Pl", "plan_name": "400100", "standard_charge_percentage": 0.85, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Basic Pl", "plan_name": "400100_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Federal", "plan_name": "400110", "standard_charge_percentage": 0.85, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Federal", "plan_name": "400110_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", 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"methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Basic Pl", "plan_name": "400100_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Federal", "plan_name": "400110", "standard_charge_percentage": 0.85, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Federal", "plan_name": "400110_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." } ] } ] }, { "description": "Dextrose 10 % in water (d10w) intravenous solution [2357]", "drug_information": { "unit": 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"standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Ppo Hmo", "plan_name": "701720", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Ppo Hmo", "plan_name": "701720_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Ms State Emplo", "plan_name": "401457", "standard_charge_percentage": 0.80, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Ms State Emplo", "plan_name": "401457_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Basic Pl", "plan_name": "400100", "standard_charge_percentage": 0.85, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Basic Pl", "plan_name": "400100_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Federal", "plan_name": "400110", "standard_charge_percentage": 0.85, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Federal", "plan_name": "400110_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." } ] } ] }, { "description": "Sodium chloride 0.45 % intravenous solution [7318]", "drug_information": { "unit": 1000.00, "type": "ML" }, "code_information": [ { "code": "0338-0043-04", "type": "NDC" } ], "standard_charges": [ { "gross_charge": 81.81, "minimum": 65.45, "maximum": 69.54, "setting": "both", "payers_information": [ { "payer_name": "Aetna", "plan_name": "700700", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna", "plan_name": "700700_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": 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}, { "payer_name": "Bc/Bs Of Ms Basic Pl", "plan_name": "400100_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Federal", "plan_name": "400110", "standard_charge_percentage": 0.85, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Federal", "plan_name": "400110_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." } ] } ] }, { "description": "Sodium chloride 0.9 % irrigation solution [11403]", "drug_information": { "unit": 500.00, "type": "ML" }, "code_information": [ { "code": "0338-0048-03", "type": "NDC" } ], "standard_charges": [ { "gross_charge": 81.81, 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"methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Miscellaneous", "plan_name": "700720", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Miscellaneous", "plan_name": "700720_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Ppo Hmo", "plan_name": "701720", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Ppo Hmo", "plan_name": "701720_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Ms State Emplo", "plan_name": "401457", "standard_charge_percentage": 0.80, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Ms State Emplo", "plan_name": "401457_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Basic Pl", "plan_name": "400100", "standard_charge_percentage": 0.85, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Basic Pl", "plan_name": "400100_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Federal", "plan_name": "400110", "standard_charge_percentage": 0.85, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Federal", "plan_name": "400110_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." } ] } ] }, { "description": "Sodium chloride 0.9 % intravenous solution [27838]", "drug_information": { "unit": 500.00, "type": "ML" }, "code_information": [ { "code": "0338-0049-03", "type": "NDC" } ], "standard_charges": [ { "gross_charge": 81.81, "minimum": 65.45, "maximum": 69.54, "setting": "both", "payers_information": [ { "payer_name": "Aetna", "plan_name": "700700", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna", "plan_name": "700700_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Miscellaneous", "plan_name": "700720", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Miscellaneous", "plan_name": "700720_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Ppo Hmo", "plan_name": "701720", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Ppo Hmo", "plan_name": "701720_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Ms State Emplo", "plan_name": "401457", "standard_charge_percentage": 0.80, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Ms State Emplo", "plan_name": "401457_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Basic Pl", "plan_name": "400100", "standard_charge_percentage": 0.85, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Basic Pl", "plan_name": "400100_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Federal", "plan_name": "400110", "standard_charge_percentage": 0.85, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Federal", "plan_name": "400110_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." } ] } ] }, { "description": "Sodium chloride 0.9 % intravenous solution [27838]", "drug_information": { "unit": 25.00, "type": "ML" }, "code_information": [ { "code": "0338-0049-10", "type": "NDC" } ], "standard_charges": [ { "gross_charge": 81.81, "minimum": 65.45, "maximum": 69.54, "setting": "both", "payers_information": [ { "payer_name": "Aetna", "plan_name": "700700", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna", "plan_name": "700700_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Miscellaneous", "plan_name": "700720", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Miscellaneous", "plan_name": "700720_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Ppo Hmo", "plan_name": "701720", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Ppo Hmo", "plan_name": "701720_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Ms State Emplo", "plan_name": "401457", "standard_charge_percentage": 0.80, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Ms State Emplo", "plan_name": "401457_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Basic Pl", "plan_name": "400100", "standard_charge_percentage": 0.85, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Basic Pl", "plan_name": "400100_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Federal", "plan_name": "400110", "standard_charge_percentage": 0.85, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms 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{ "payer_name": "Bc/Bs Of Ms Federal", "plan_name": "400110", "standard_charge_percentage": 0.85, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Federal", "plan_name": "400110_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." } ] } ] }, { "description": "Sodium chloride 0.9 % intravenous solution [27838]", "drug_information": { "unit": 100.00, "type": "ML" }, "code_information": [ { "code": "0338-0049-18", "type": "NDC" } ], "standard_charges": [ { "gross_charge": 81.81, "minimum": 65.45, "maximum": 69.54, "setting": "both", "payers_information": [ { "payer_name": "Aetna", "plan_name": "700700", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": 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"standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Ms State Emplo", "plan_name": "401457", "standard_charge_percentage": 0.80, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Ms State Emplo", "plan_name": "401457_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Basic Pl", "plan_name": "400100", "standard_charge_percentage": 0.85, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Basic Pl", "plan_name": "400100_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Federal", "plan_name": "400110", "standard_charge_percentage": 0.85, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Federal", "plan_name": "400110_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." } ] } ] }, { "description": "Sodium chloride 0.9 % intravenous solution [27838]", "drug_information": { "unit": 100.00, "type": "ML" }, "code_information": [ { "code": "0338-0049-48", "type": "NDC" } ], "standard_charges": [ { "gross_charge": 81.81, "minimum": 65.45, "maximum": 69.54, "setting": "both", 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"payer_name": "Aetna Ppo Hmo", "plan_name": "701720", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Ppo Hmo", "plan_name": "701720_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Ms State Emplo", "plan_name": "401457", "standard_charge_percentage": 0.80, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Ms State Emplo", "plan_name": "401457_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Basic Pl", "plan_name": "400100", "standard_charge_percentage": 0.85, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Basic Pl", "plan_name": "400100_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Federal", "plan_name": "400110", "standard_charge_percentage": 0.85, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Federal", "plan_name": "400110_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." } ] } ] }, { "description": "Norepinephrine bitartrate 8 mg/250 ml (32 mcg/ml) in dextrose 5 % iv [119792]", "drug_information": { "unit": 250.00, "type": "ML" }, "code_information": [ { "code": "0338-0108-20", "type": "NDC" } ], "standard_charges": [ { "gross_charge": 238.56, "minimum": 190.85, "maximum": 202.78, "setting": "both", "payers_information": [ { "payer_name": "Aetna", "plan_name": "700700", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna", "plan_name": "700700_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Miscellaneous", "plan_name": "700720", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Miscellaneous", "plan_name": "700720_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Ppo Hmo", "plan_name": "701720", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Ppo Hmo", "plan_name": "701720_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Ms State Emplo", "plan_name": "401457", "standard_charge_percentage": 0.80, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Ms State Emplo", "plan_name": "401457_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Basic Pl", "plan_name": "400100", "standard_charge_percentage": 0.85, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Basic Pl", "plan_name": "400100_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Federal", "plan_name": "400110", "standard_charge_percentage": 0.85, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Federal", "plan_name": "400110_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." } ] } ] }, { "description": "Norepinephrine bitartrate 4 mg/250 ml (16 mcg/ml) in dextrose 5 % iv [118990]", "drug_information": { "unit": 250.00, "type": "ML" }, "code_information": [ { "code": "0338-0112-20", "type": "NDC" } ], "standard_charges": [ { "gross_charge": 193.44, "minimum": 154.75, "maximum": 164.42, "setting": "both", "payers_information": [ { "payer_name": "Aetna", "plan_name": "700700", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna", "plan_name": "700700_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Miscellaneous", "plan_name": "700720", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Miscellaneous", "plan_name": "700720_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Ppo Hmo", "plan_name": "701720", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Ppo Hmo", "plan_name": "701720_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Ms State Emplo", "plan_name": "401457", "standard_charge_percentage": 0.80, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Ms State Emplo", "plan_name": "401457_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Basic Pl", "plan_name": "400100", "standard_charge_percentage": 0.85, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Basic Pl", "plan_name": "400100_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Federal", "plan_name": "400110", "standard_charge_percentage": 0.85, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Federal", "plan_name": "400110_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." } ] } ] }, { "description": "Dextrose 5 % and 0.2 % sodium chloride intravenous solution [9812]", "drug_information": { "unit": 1000.00, "type": "ML" }, "code_information": [ { "code": "0338-0077-04", "type": "NDC" } ], "standard_charges": [ { "gross_charge": 81.81, "minimum": 65.45, "maximum": 69.54, "setting": "both", "payers_information": [ { "payer_name": "Aetna", "plan_name": "700700", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna", "plan_name": "700700_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Miscellaneous", "plan_name": "700720", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Miscellaneous", "plan_name": "700720_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Ppo Hmo", "plan_name": "701720", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Ppo Hmo", "plan_name": "701720_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Ms State Emplo", "plan_name": "401457", "standard_charge_percentage": 0.80, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Ms State Emplo", "plan_name": "401457_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Basic Pl", "plan_name": "400100", "standard_charge_percentage": 0.85, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Basic Pl", "plan_name": "400100_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Federal", "plan_name": "400110", "standard_charge_percentage": 0.85, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Federal", "plan_name": "400110_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." } ] } ] }, { "description": "Amino acid 8 % in dextrose 10% water intravenous solution [192094]", "drug_information": { "unit": 1000.00, "type": "ML" }, "code_information": [ { "code": "0338-0188-06", "type": "NDC" } ], "standard_charges": [ { "gross_charge": 333.56, "minimum": 266.85, "maximum": 283.53, "setting": "both", "payers_information": [ { "payer_name": "Aetna", "plan_name": "700700", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna", "plan_name": "700700_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Miscellaneous", "plan_name": "700720", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Miscellaneous", "plan_name": "700720_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Ppo Hmo", "plan_name": "701720", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Ppo Hmo", "plan_name": "701720_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Ms State Emplo", "plan_name": "401457", "standard_charge_percentage": 0.80, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Ms State Emplo", "plan_name": "401457_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Basic Pl", "plan_name": "400100", "standard_charge_percentage": 0.85, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Basic Pl", "plan_name": "400100_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Federal", "plan_name": "400110", "standard_charge_percentage": 0.85, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Federal", "plan_name": "400110_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." } ] } ] }, { "description": "Electrolyte-a intravenous solution [28113]", "drug_information": { "unit": 500.00, "type": "ML" }, "code_information": [ { "code": "0338-0221-03", "type": "NDC" } ], "standard_charges": [ { "gross_charge": 148.31, "minimum": 118.65, "maximum": 126.06, "setting": "both", "payers_information": [ { "payer_name": "Aetna", "plan_name": "700700", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna", "plan_name": "700700_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Miscellaneous", "plan_name": "700720", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Miscellaneous", "plan_name": "700720_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Ppo Hmo", "plan_name": "701720", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Ppo Hmo", "plan_name": "701720_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Ms State Emplo", "plan_name": "401457", "standard_charge_percentage": 0.80, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Ms State Emplo", "plan_name": "401457_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Basic Pl", "plan_name": "400100", "standard_charge_percentage": 0.85, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Basic Pl", "plan_name": "400100_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Federal", "plan_name": "400110", "standard_charge_percentage": 0.85, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Federal", "plan_name": "400110_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." } ] } ] }, { "description": "Electrolyte-a intravenous solution [28113]", "drug_information": { "unit": 1000.00, "type": "ML" }, "code_information": [ { "code": "0338-0221-04", "type": "NDC" } ], "standard_charges": [ { "gross_charge": 153.06, "minimum": 122.45, "maximum": 130.10, "setting": "both", "payers_information": [ { "payer_name": "Aetna", "plan_name": "700700", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna", "plan_name": "700700_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Miscellaneous", "plan_name": "700720", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Miscellaneous", "plan_name": "700720_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Ppo Hmo", "plan_name": "701720", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Ppo Hmo", "plan_name": "701720_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Ms State Emplo", "plan_name": "401457", "standard_charge_percentage": 0.80, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Ms State Emplo", "plan_name": "401457_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Basic Pl", "plan_name": "400100", "standard_charge_percentage": 0.85, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Basic Pl", "plan_name": "400100_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Federal", "plan_name": "400110", "standard_charge_percentage": 0.85, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Federal", "plan_name": "400110_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." } ] } ] }, { "description": "Glycine 1.5 % urologic solution for irrigation [3493]", "drug_information": { "unit": 3000.00, "type": "ML" }, "code_information": [ { "code": "0338-0289-47", "type": "NDC" } ], "standard_charges": [ { "gross_charge": 181.56, "minimum": 145.25, "maximum": 154.33, "setting": "both", "payers_information": [ { "payer_name": "Aetna", "plan_name": "700700", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna", "plan_name": "700700_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Miscellaneous", "plan_name": "700720", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Miscellaneous", "plan_name": "700720_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Ppo Hmo", "plan_name": "701720", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Ppo Hmo", "plan_name": "701720_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Ms State Emplo", "plan_name": "401457", "standard_charge_percentage": 0.80, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Ms State Emplo", "plan_name": "401457_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Basic Pl", "plan_name": "400100", "standard_charge_percentage": 0.85, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Basic Pl", "plan_name": "400100_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Federal", "plan_name": "400110", "standard_charge_percentage": 0.85, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Federal", "plan_name": "400110_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." } ] } ] }, { "description": "Thrombin (recombinant) 5000 unit topical solution [89570]", "drug_information": { "unit": 1.00, "type": "EA" }, "code_information": [ { "code": "0338-0322-01", "type": "NDC" } ], "standard_charges": [ { "gross_charge": 384.23, "minimum": 307.38, "maximum": 326.60, "setting": "both", "payers_information": [ { "payer_name": "Aetna", "plan_name": "700700", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna", "plan_name": "700700_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Miscellaneous", "plan_name": "700720", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Miscellaneous", "plan_name": "700720_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Ppo Hmo", "plan_name": "701720", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Ppo Hmo", "plan_name": "701720_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Ms State Emplo", "plan_name": "401457", "standard_charge_percentage": 0.80, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Ms State Emplo", "plan_name": "401457_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Basic Pl", "plan_name": "400100", "standard_charge_percentage": 0.85, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Basic Pl", "plan_name": "400100_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Federal", "plan_name": "400110", "standard_charge_percentage": 0.85, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Federal", "plan_name": "400110_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." } ] } ] }, { "description": "Thrombin (recombinant) 5000 unit topical solution [89570]", "drug_information": { "unit": 1.00, "type": "EA" }, "code_information": [ { "code": "0338-0324-01", "type": "NDC" } ], "standard_charges": [ { "gross_charge": 384.23, "minimum": 307.38, "maximum": 326.60, "setting": "both", "payers_information": [ { "payer_name": "Aetna", "plan_name": "700700", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna", "plan_name": "700700_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Miscellaneous", "plan_name": "700720", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Miscellaneous", "plan_name": "700720_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Ppo Hmo", "plan_name": "701720", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Ppo Hmo", "plan_name": "701720_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Ms State Emplo", "plan_name": "401457", "standard_charge_percentage": 0.80, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Ms State Emplo", "plan_name": "401457_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Basic Pl", "plan_name": "400100", "standard_charge_percentage": 0.85, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Basic Pl", "plan_name": "400100_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Federal", "plan_name": "400110", "standard_charge_percentage": 0.85, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Federal", "plan_name": "400110_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." } ] } ] }, { "description": "Sodium chloride 0.9 % intravenous piggyback [116170]", "drug_information": { "unit": 50.00, "type": "ML" }, "code_information": [ { "code": "0338-0553-11", "type": "NDC" } ], "standard_charges": [ { "gross_charge": 81.81, "minimum": 65.45, "maximum": 69.54, "setting": "both", "payers_information": [ { "payer_name": "Aetna", "plan_name": "700700", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna", "plan_name": "700700_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Miscellaneous", "plan_name": "700720", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Miscellaneous", "plan_name": "700720_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Ppo Hmo", "plan_name": "701720", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Ppo Hmo", "plan_name": "701720_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Ms State Emplo", "plan_name": "401457", "standard_charge_percentage": 0.80, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Ms State Emplo", "plan_name": "401457_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Basic Pl", "plan_name": "400100", "standard_charge_percentage": 0.85, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Basic Pl", "plan_name": "400100_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Federal", "plan_name": "400110", "standard_charge_percentage": 0.85, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Federal", "plan_name": "400110_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." } ] } ] }, { "description": "Sodium chloride 0.9 % intravenous piggyback [116170]", "drug_information": { "unit": 100.00, "type": "ML" }, "code_information": [ { "code": "0338-0553-18", "type": "NDC" } ], "standard_charges": [ { "gross_charge": 81.81, "minimum": 65.45, "maximum": 69.54, "setting": "both", "payers_information": [ { "payer_name": "Aetna", "plan_name": "700700", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna", "plan_name": "700700_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Miscellaneous", "plan_name": "700720", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Miscellaneous", "plan_name": "700720_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Ppo Hmo", "plan_name": "701720", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Ppo Hmo", "plan_name": "701720_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Ms State Emplo", "plan_name": "401457", "standard_charge_percentage": 0.80, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Ms State Emplo", "plan_name": "401457_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Basic Pl", "plan_name": "400100", "standard_charge_percentage": 0.85, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Basic Pl", "plan_name": "400100_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Federal", "plan_name": "400110", "standard_charge_percentage": 0.85, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Federal", "plan_name": "400110_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." } ] } ] }, { "description": "Acetic acid 0.25 % irrigation solution [8963]", "drug_information": { "unit": 1000.00, "type": "ML" }, "code_information": [ { "code": "0338-0656-04", "type": "NDC" } ], "standard_charges": [ { "gross_charge": 38.00, "minimum": 30.40, "maximum": 32.30, "setting": "both", "payers_information": [ { "payer_name": "Aetna", "plan_name": "700700", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna", "plan_name": "700700_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Miscellaneous", "plan_name": "700720", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Miscellaneous", "plan_name": "700720_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Ppo Hmo", "plan_name": "701720", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Ppo Hmo", "plan_name": "701720_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Ms State Emplo", "plan_name": "401457", "standard_charge_percentage": 0.80, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Ms State Emplo", "plan_name": "401457_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Basic Pl", "plan_name": "400100", "standard_charge_percentage": 0.85, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Basic Pl", "plan_name": "400100_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Federal", "plan_name": "400110", "standard_charge_percentage": 0.85, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Federal", "plan_name": "400110_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." } ] } ] }, { "description": "Gentamicin 80 mg/50 ml in sodium chloride(iso) intravenous piggyback [15911]", "drug_information": { "unit": 50.00, "type": "ML" }, "code_information": [ { "code": "0338-0509-41", "type": "NDC" } ], "standard_charges": [ { "gross_charge": 120.52, "minimum": 96.42, "maximum": 102.44, "setting": "both", "payers_information": [ { "payer_name": "Aetna", "plan_name": "700700", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna", "plan_name": "700700_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Miscellaneous", "plan_name": "700720", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Miscellaneous", "plan_name": "700720_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Ppo Hmo", "plan_name": "701720", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Ppo Hmo", "plan_name": "701720_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Ms State Emplo", "plan_name": "401457", "standard_charge_percentage": 0.80, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Ms State Emplo", "plan_name": "401457_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Basic Pl", "plan_name": "400100", "standard_charge_percentage": 0.85, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Basic Pl", "plan_name": "400100_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Federal", "plan_name": "400110", "standard_charge_percentage": 0.85, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Federal", "plan_name": "400110_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." } ] } ] }, { "description": "Fat emulsion 20 % intravenous [10014]", "drug_information": { "unit": 500.00, "type": "ML" }, "code_information": [ { "code": "0338-0519-13", "type": "NDC" } ], "standard_charges": [ { "gross_charge": 278.94, "minimum": 223.15, "maximum": 237.10, "setting": "both", "payers_information": [ { "payer_name": "Aetna", "plan_name": "700700", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna", "plan_name": "700700_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Miscellaneous", "plan_name": "700720", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Miscellaneous", "plan_name": "700720_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Ppo Hmo", "plan_name": "701720", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Ppo Hmo", "plan_name": "701720_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Ms State Emplo", "plan_name": "401457", "standard_charge_percentage": 0.80, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Ms State Emplo", "plan_name": "401457_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Basic Pl", "plan_name": "400100", "standard_charge_percentage": 0.85, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Basic Pl", "plan_name": "400100_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Federal", "plan_name": "400110", "standard_charge_percentage": 0.85, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Federal", "plan_name": "400110_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." } ] } ] }, { "description": "Nitroglycerin 25 mg/250 ml (100 mcg/ml) in 5 % dextrose intravenous [15858]", "drug_information": { "unit": 250.00, "type": "ML" }, "code_information": [ { "code": "0338-1047-02", "type": "NDC" } ], "standard_charges": [ { "gross_charge": 173.25, "minimum": 138.60, "maximum": 147.26, "setting": "both", "payers_information": [ { "payer_name": "Aetna", "plan_name": "700700", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna", "plan_name": "700700_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Miscellaneous", "plan_name": "700720", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Miscellaneous", "plan_name": "700720_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Ppo Hmo", "plan_name": "701720", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Ppo Hmo", "plan_name": "701720_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Ms State Emplo", "plan_name": "401457", "standard_charge_percentage": 0.80, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Ms State Emplo", "plan_name": "401457_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Basic Pl", "plan_name": "400100", "standard_charge_percentage": 0.85, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Basic Pl", "plan_name": "400100_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Federal", "plan_name": "400110", "standard_charge_percentage": 0.85, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Federal", "plan_name": "400110_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." } ] } ] }, { "description": "Amino acid 5 % in 20 % dextrose intravenous solution [27933]", "drug_information": { "unit": 2000.00, "type": "ML" }, "code_information": [ { "code": "0338-1101-04", "type": "NDC" } ], "standard_charges": [ { "gross_charge": 471.31, "minimum": 377.05, "maximum": 400.61, "setting": "both", "payers_information": [ { "payer_name": "Aetna", "plan_name": "700700", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna", "plan_name": "700700_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Miscellaneous", "plan_name": "700720", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Miscellaneous", "plan_name": "700720_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Ppo Hmo", "plan_name": "701720", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Ppo Hmo", "plan_name": "701720_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Ms State Emplo", "plan_name": "401457", "standard_charge_percentage": 0.80, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Ms State Emplo", "plan_name": "401457_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Basic Pl", "plan_name": "400100", "standard_charge_percentage": 0.85, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Basic Pl", "plan_name": "400100_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Federal", "plan_name": "400110", "standard_charge_percentage": 0.85, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Federal", "plan_name": "400110_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." } ] } ] }, { "description": "Amino acid 4.25 % in dextrose 5 % intravenous solution [27927]", "drug_information": { "unit": 1000.00, "type": "ML" }, "code_information": [ { "code": "0338-1133-03", "type": "NDC" } ], "standard_charges": [ { "gross_charge": 267.06, "minimum": 213.65, "maximum": 227.00, "setting": "both", "payers_information": [ { "payer_name": "Aetna", "plan_name": "700700", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna", "plan_name": "700700_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Miscellaneous", "plan_name": "700720", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Miscellaneous", "plan_name": "700720_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Ppo Hmo", "plan_name": "701720", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Ppo Hmo", "plan_name": "701720_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Ms State Emplo", "plan_name": "401457", "standard_charge_percentage": 0.80, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Ms State Emplo", "plan_name": "401457_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Basic Pl", "plan_name": "400100", "standard_charge_percentage": 0.85, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Basic Pl", "plan_name": "400100_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Federal", "plan_name": "400110", "standard_charge_percentage": 0.85, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Federal", "plan_name": "400110_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." } ] } ] }, { "description": "Amino acid 4.25 % in 10 % dextrose intravenous solution [27928]", "drug_information": { "unit": 1000.00, "type": "ML" }, "code_information": [ { "code": "0338-1134-03", "type": "NDC" } ], "standard_charges": [ { "gross_charge": 267.06, "minimum": 213.65, "maximum": 227.00, "setting": "both", "payers_information": [ { "payer_name": "Aetna", "plan_name": "700700", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna", "plan_name": "700700_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Miscellaneous", "plan_name": "700720", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Miscellaneous", "plan_name": "700720_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Ppo Hmo", "plan_name": "701720", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Ppo Hmo", "plan_name": "701720_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Ms State Emplo", "plan_name": "401457", "standard_charge_percentage": 0.80, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Ms State Emplo", "plan_name": "401457_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Basic Pl", "plan_name": "400100", "standard_charge_percentage": 0.85, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Basic Pl", "plan_name": "400100_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Federal", "plan_name": "400110", "standard_charge_percentage": 0.85, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Federal", "plan_name": "400110_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." } ] } ] }, { "description": "Amino acid 5 % in 20 % dextrose intravenous solution [27933]", "drug_information": { "unit": 1000.00, "type": "ML" }, "code_information": [ { "code": "0338-1138-03", "type": "NDC" } ], "standard_charges": [ { "gross_charge": 295.56, "minimum": 236.45, "maximum": 251.23, "setting": "both", "payers_information": [ { "payer_name": "Aetna", "plan_name": "700700", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna", "plan_name": "700700_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Miscellaneous", "plan_name": "700720", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Miscellaneous", "plan_name": "700720_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Ppo Hmo", "plan_name": "701720", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Ppo Hmo", "plan_name": "701720_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Ms State Emplo", "plan_name": "401457", "standard_charge_percentage": 0.80, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Ms State Emplo", "plan_name": "401457_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Basic Pl", "plan_name": "400100", "standard_charge_percentage": 0.85, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Basic Pl", "plan_name": "400100_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Federal", "plan_name": "400110", "standard_charge_percentage": 0.85, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Federal", "plan_name": "400110_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." } ] } ] }, { "description": "Psyllium husk (aspartame) 3.4 gram/5.8 gram oral powder [118530]", "drug_information": { "unit": 662.00, "type": "GR" }, "code_information": [ { "code": "0363-0515-11", "type": "NDC" } ], "standard_charges": [ { "gross_charge": 49.92, "minimum": 39.94, "maximum": 42.43, "setting": "both", "payers_information": [ { "payer_name": "Aetna", "plan_name": "700700", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna", "plan_name": "700700_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Miscellaneous", "plan_name": "700720", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Miscellaneous", "plan_name": "700720_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Ppo Hmo", "plan_name": "701720", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Ppo Hmo", "plan_name": "701720_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Ms State Emplo", "plan_name": "401457", "standard_charge_percentage": 0.80, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Ms State Emplo", "plan_name": "401457_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Basic Pl", "plan_name": "400100", "standard_charge_percentage": 0.85, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Basic Pl", "plan_name": "400100_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Federal", "plan_name": "400110", "standard_charge_percentage": 0.85, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Federal", "plan_name": "400110_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." } ] } ] }, { "description": "Indapamide 1.25 mg tablet [10264]", "drug_information": { "unit": 1.00, "type": "EA" }, "code_information": [ { "code": "0378-0069-01", "type": "NDC" } ], "standard_charges": [ { "gross_charge": 7.50, "minimum": 6.00, "maximum": 6.38, "setting": "both", "payers_information": [ { "payer_name": "Aetna", "plan_name": "700700", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna", "plan_name": "700700_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Miscellaneous", "plan_name": "700720", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Miscellaneous", "plan_name": "700720_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Ppo Hmo", "plan_name": "701720", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Ppo Hmo", "plan_name": "701720_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Ms State Emplo", "plan_name": "401457", "standard_charge_percentage": 0.80, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Ms State Emplo", "plan_name": "401457_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Basic Pl", "plan_name": "400100", "standard_charge_percentage": 0.85, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Basic Pl", "plan_name": "400100_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Federal", "plan_name": "400110", "standard_charge_percentage": 0.85, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Federal", "plan_name": "400110_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." } ] } ] }, { "description": "Pindolol 10 mg tablet [6296]", "drug_information": { "unit": 1.00, "type": "EA" }, "code_information": [ { "code": "0378-0127-01", "type": "NDC" } ], "standard_charges": [ { "gross_charge": 7.50, "minimum": 6.00, "maximum": 6.38, "setting": "both", "payers_information": [ { "payer_name": "Aetna", "plan_name": "700700", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna", "plan_name": "700700_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Miscellaneous", "plan_name": "700720", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Miscellaneous", "plan_name": "700720_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Ppo Hmo", "plan_name": "701720", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Ppo Hmo", "plan_name": "701720_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Ms State Emplo", "plan_name": "401457", "standard_charge_percentage": 0.80, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Ms State Emplo", "plan_name": "401457_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Basic Pl", "plan_name": "400100", "standard_charge_percentage": 0.85, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Basic Pl", "plan_name": "400100_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Federal", "plan_name": "400110", "standard_charge_percentage": 0.85, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Federal", "plan_name": "400110_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." } ] } ] }, { "description": "Amitriptyline-chlordiazepoxide 12.5 mg-5 mg tablet [14977]", "drug_information": { "unit": 1.00, "type": "EA" }, "code_information": [ { "code": "0378-0211-01", "type": "NDC" } ], "standard_charges": [ { "gross_charge": 12.95, "minimum": 10.36, "maximum": 11.01, "setting": "both", "payers_information": [ { "payer_name": "Aetna", "plan_name": "700700", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna", "plan_name": "700700_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Miscellaneous", "plan_name": "700720", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Miscellaneous", "plan_name": "700720_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Ppo Hmo", "plan_name": "701720", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Ppo Hmo", "plan_name": "701720_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Ms State Emplo", "plan_name": "401457", "standard_charge_percentage": 0.80, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Ms State Emplo", "plan_name": "401457_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Basic Pl", "plan_name": "400100", "standard_charge_percentage": 0.85, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Basic Pl", "plan_name": "400100_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Federal", "plan_name": "400110", "standard_charge_percentage": 0.85, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Federal", "plan_name": "400110_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." } ] } ] }, { "description": "Cimetidine 400 mg tablet [9606]", "drug_information": { "unit": 1.00, "type": "EA" }, "code_information": [ { "code": "0378-0372-01", "type": "NDC" } ], "standard_charges": [ { "gross_charge": 7.50, "minimum": 6.00, "maximum": 6.38, "setting": "both", "payers_information": [ { "payer_name": "Aetna", "plan_name": "700700", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna", "plan_name": "700700_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Miscellaneous", "plan_name": "700720", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Miscellaneous", "plan_name": "700720_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Ppo Hmo", "plan_name": "701720", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Ppo Hmo", "plan_name": "701720_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Ms State Emplo", "plan_name": "401457", "standard_charge_percentage": 0.80, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Ms State Emplo", "plan_name": "401457_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Basic Pl", "plan_name": "400100", "standard_charge_percentage": 0.85, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Basic Pl", "plan_name": "400100_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Federal", "plan_name": "400110", "standard_charge_percentage": 0.85, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Federal", "plan_name": "400110_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." } ] } ] }, { "description": "Hydroxychloroquine 200 mg tablet [10235]", "drug_information": { "unit": 1.00, "type": "EA" }, "code_information": [ { "code": "0378-0373-01", "type": "NDC" } ], "standard_charges": [ { "gross_charge": 7.50, "minimum": 6.00, "maximum": 6.38, "setting": "both", "payers_information": [ { "payer_name": "Aetna", "plan_name": "700700", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna", "plan_name": "700700_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Miscellaneous", "plan_name": "700720", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Miscellaneous", "plan_name": "700720_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Ppo Hmo", "plan_name": "701720", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Ppo Hmo", "plan_name": "701720_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Ms State Emplo", "plan_name": "401457", "standard_charge_percentage": 0.80, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Ms State Emplo", "plan_name": "401457_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Basic Pl", "plan_name": "400100", "standard_charge_percentage": 0.85, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Basic Pl", "plan_name": "400100_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Federal", "plan_name": "400110", "standard_charge_percentage": 0.85, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Federal", "plan_name": "400110_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." } ] } ] }, { "description": "Diphenoxylate-atropine 2.5 mg-0.025 mg tablet [2516]", "drug_information": { "unit": 1.00, "type": "EA" }, "code_information": [ { "code": "0378-0415-01", "type": "NDC" } ], "standard_charges": [ { "gross_charge": 7.50, "minimum": 6.00, "maximum": 6.38, "setting": "both", "payers_information": [ { "payer_name": "Aetna", "plan_name": "700700", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna", "plan_name": "700700_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Miscellaneous", "plan_name": "700720", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Miscellaneous", "plan_name": "700720_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Ppo Hmo", "plan_name": "701720", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Ppo Hmo", "plan_name": "701720_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Ms State Emplo", "plan_name": "401457", "standard_charge_percentage": 0.80, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Ms State Emplo", "plan_name": "401457_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Basic Pl", "plan_name": "400100", "standard_charge_percentage": 0.85, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Basic Pl", "plan_name": "400100_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Federal", "plan_name": "400110", "standard_charge_percentage": 0.85, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Federal", "plan_name": "400110_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." } ] } ] }, { "description": "Thioridazine 25 mg tablet [7899]", "drug_information": { "unit": 1.00, "type": "EA" }, "code_information": [ { "code": "0378-0614-01", "type": "NDC" } ], "standard_charges": [ { "gross_charge": 7.50, "minimum": 6.00, "maximum": 6.38, "setting": "both", "payers_information": [ { "payer_name": "Aetna", "plan_name": "700700", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna", "plan_name": "700700_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Miscellaneous", "plan_name": "700720", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Miscellaneous", "plan_name": "700720_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Ppo Hmo", "plan_name": "701720", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Ppo Hmo", "plan_name": "701720_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Ms State Emplo", "plan_name": "401457", "standard_charge_percentage": 0.80, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Ms State Emplo", "plan_name": "401457_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Basic Pl", "plan_name": "400100", "standard_charge_percentage": 0.85, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Basic Pl", "plan_name": "400100_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Federal", "plan_name": "400110", "standard_charge_percentage": 0.85, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Federal", "plan_name": "400110_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." } ] } ] }, { "description": "Doxepin 25 mg capsule [2611]", "drug_information": { "unit": 1.00, "type": "EA" }, "code_information": [ { "code": "0378-3125-01", "type": "NDC" } ], "standard_charges": [ { "gross_charge": 7.50, "minimum": 6.00, "maximum": 6.38, "setting": "both", "payers_information": [ { "payer_name": "Aetna", "plan_name": "700700", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna", "plan_name": "700700_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Miscellaneous", "plan_name": "700720", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Miscellaneous", "plan_name": "700720_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Ppo Hmo", "plan_name": "701720", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Ppo Hmo", "plan_name": "701720_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Ms State Emplo", "plan_name": "401457", "standard_charge_percentage": 0.80, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Ms State Emplo", "plan_name": "401457_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Basic Pl", "plan_name": "400100", "standard_charge_percentage": 0.85, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Basic Pl", "plan_name": "400100_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Federal", "plan_name": "400110", "standard_charge_percentage": 0.85, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Federal", "plan_name": "400110_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." } ] } ] }, { "description": "Ropinirole 0.5 mg tablet [21800]", "drug_information": { "unit": 1.00, "type": "EA" }, "code_information": [ { "code": "0378-5550-01", "type": "NDC" } ], "standard_charges": [ { "gross_charge": 7.50, "minimum": 6.00, "maximum": 6.38, "setting": "both", "payers_information": [ { "payer_name": "Aetna", "plan_name": "700700", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna", "plan_name": "700700_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Miscellaneous", "plan_name": "700720", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Miscellaneous", "plan_name": "700720_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Ppo Hmo", "plan_name": "701720", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Ppo Hmo", "plan_name": "701720_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Ms State Emplo", "plan_name": "401457", "standard_charge_percentage": 0.80, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Ms State Emplo", "plan_name": "401457_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Basic Pl", "plan_name": "400100", "standard_charge_percentage": 0.85, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Basic Pl", "plan_name": "400100_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Federal", "plan_name": "400110", "standard_charge_percentage": 0.85, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Federal", "plan_name": "400110_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." } ] } ] }, { "description": "Sumatriptan 50 mg tablet [15328]", "drug_information": { "unit": 1.00, "type": "EA" }, "code_information": [ { "code": "0378-5631-59", "type": "NDC" } ], "standard_charges": [ { "gross_charge": 7.50, "minimum": 6.00, "maximum": 6.38, "setting": "both", "payers_information": [ { "payer_name": "Aetna", "plan_name": "700700", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna", "plan_name": "700700_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Miscellaneous", "plan_name": "700720", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Miscellaneous", "plan_name": "700720_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Ppo Hmo", "plan_name": "701720", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Ppo Hmo", "plan_name": "701720_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Ms State Emplo", "plan_name": "401457", "standard_charge_percentage": 0.80, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Ms State Emplo", "plan_name": "401457_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Basic Pl", "plan_name": "400100", "standard_charge_percentage": 0.85, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Basic Pl", "plan_name": "400100_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Federal", "plan_name": "400110", "standard_charge_percentage": 0.85, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Federal", "plan_name": "400110_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." } ] } ] }, { "description": "Scopolamine 1 mg over 3 days transdermal patch [27696]", "drug_information": { "unit": 1.00, "type": "EA" }, "code_information": [ { "code": "0378-6470-16", "type": "NDC" } ], "standard_charges": [ { "gross_charge": 101.16, "minimum": 80.93, "maximum": 85.99, "setting": "both", "payers_information": [ { "payer_name": "Aetna", "plan_name": "700700", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna", "plan_name": "700700_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Miscellaneous", "plan_name": "700720", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Miscellaneous", "plan_name": "700720_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Ppo Hmo", "plan_name": "701720", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Ppo Hmo", "plan_name": "701720_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Ms State Emplo", "plan_name": "401457", "standard_charge_percentage": 0.80, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Ms State Emplo", "plan_name": "401457_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Basic Pl", "plan_name": "400100", "standard_charge_percentage": 0.85, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Basic Pl", "plan_name": "400100_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Federal", "plan_name": "400110", "standard_charge_percentage": 0.85, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Federal", "plan_name": "400110_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." } ] } ] }, { "description": "Scopolamine 1 mg over 3 days transdermal patch [27696]", "drug_information": { "unit": 1.00, "type": "EA" }, "code_information": [ { "code": "0378-6470-97", "type": "NDC" } ], "standard_charges": [ { "gross_charge": 101.16, "minimum": 80.93, "maximum": 85.99, "setting": "both", "payers_information": [ { "payer_name": "Aetna", "plan_name": "700700", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna", "plan_name": "700700_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Miscellaneous", "plan_name": "700720", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Miscellaneous", "plan_name": "700720_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Ppo Hmo", "plan_name": "701720", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Ppo Hmo", "plan_name": "701720_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Ms State Emplo", "plan_name": "401457", "standard_charge_percentage": 0.80, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Ms State Emplo", "plan_name": "401457_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Basic Pl", "plan_name": "400100", "standard_charge_percentage": 0.85, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Basic Pl", "plan_name": "400100_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Federal", "plan_name": "400110", "standard_charge_percentage": 0.85, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Federal", "plan_name": "400110_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." } ] } ] }, { "description": "Scopolamine 1 mg over 3 days transdermal patch [27696]", "drug_information": { "unit": 1.00, "type": "EA" }, "code_information": [ { "code": "0378-6470-99", "type": "NDC" } ], "standard_charges": [ { "gross_charge": 93.64, "minimum": 74.91, "maximum": 79.59, "setting": "both", "payers_information": [ { "payer_name": "Aetna", "plan_name": "700700", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna", "plan_name": "700700_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Miscellaneous", "plan_name": "700720", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Miscellaneous", "plan_name": "700720_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Ppo Hmo", "plan_name": "701720", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Ppo Hmo", "plan_name": "701720_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Ms State Emplo", "plan_name": "401457", "standard_charge_percentage": 0.80, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Ms State Emplo", "plan_name": "401457_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Basic Pl", "plan_name": "400100", "standard_charge_percentage": 0.85, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Basic Pl", "plan_name": "400100_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Federal", "plan_name": "400110", "standard_charge_percentage": 0.85, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Federal", "plan_name": "400110_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." } ] } ] }, { "description": "Sodium chloride 0.9 % for nebulization [7325]", "drug_information": { "unit": 5.00, "type": "ML" }, "code_information": [ { "code": "0378-6986-01", "type": "NDC" } ], "standard_charges": [ { "gross_charge": 7.50, "minimum": 6.00, "maximum": 6.38, "setting": "both", "payers_information": [ { "payer_name": "Aetna", "plan_name": "700700", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna", "plan_name": "700700_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Miscellaneous", "plan_name": "700720", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Miscellaneous", "plan_name": "700720_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Ppo Hmo", "plan_name": "701720", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Ppo Hmo", "plan_name": "701720_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Ms State Emplo", "plan_name": "401457", "standard_charge_percentage": 0.80, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Ms State Emplo", "plan_name": "401457_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Basic Pl", "plan_name": "400100", "standard_charge_percentage": 0.85, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Basic Pl", "plan_name": "400100_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Federal", "plan_name": "400110", "standard_charge_percentage": 0.85, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Federal", "plan_name": "400110_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." } ] } ] }, { "description": "Paroxetine 10 mg tablet [16632]", "drug_information": { "unit": 1.00, "type": "EA" }, "code_information": [ { "code": "0378-7001-93", "type": "NDC" } ], "standard_charges": [ { "gross_charge": 7.50, "minimum": 6.00, "maximum": 6.38, "setting": "both", "payers_information": [ { "payer_name": "Aetna", "plan_name": "700700", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna", "plan_name": "700700_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Miscellaneous", "plan_name": "700720", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Miscellaneous", "plan_name": "700720_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Ppo Hmo", "plan_name": "701720", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Ppo Hmo", "plan_name": "701720_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Ms State Emplo", "plan_name": "401457", "standard_charge_percentage": 0.80, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Ms State Emplo", "plan_name": "401457_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Basic Pl", "plan_name": "400100", "standard_charge_percentage": 0.85, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Basic Pl", "plan_name": "400100_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Federal", "plan_name": "400110", "standard_charge_percentage": 0.85, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Federal", "plan_name": "400110_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." } ] } ] }, { "description": "Sodium chloride 3 % for nebulization [7327]", "drug_information": { "unit": 15.00, "type": "ML" }, "code_information": [ { "code": "0378699789", "type": "NDC" } ], "standard_charges": [ { "gross_charge": 11.33, "minimum": 9.06, "maximum": 9.63, "setting": "both", "payers_information": [ { "payer_name": "Aetna", "plan_name": "700700", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna", "plan_name": "700700_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Miscellaneous", "plan_name": "700720", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Miscellaneous", "plan_name": "700720_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Ppo Hmo", "plan_name": "701720", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Ppo Hmo", "plan_name": "701720_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Ms State Emplo", "plan_name": "401457", "standard_charge_percentage": 0.80, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Ms State Emplo", "plan_name": "401457_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Basic Pl", "plan_name": "400100", "standard_charge_percentage": 0.85, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Basic Pl", "plan_name": "400100_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Federal", "plan_name": "400110", "standard_charge_percentage": 0.85, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Federal", "plan_name": "400110_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." } ] } ] }, { "description": "Ethyl chloride 100 % topical spray [2951]", "drug_information": { "unit": 116.00, "type": "ML" }, "code_information": [ { "code": "0386000102", "type": "NDC" } ], "standard_charges": [ { "gross_charge": 139.95, "minimum": 111.96, "maximum": 118.96, "setting": "both", "payers_information": [ { "payer_name": "Aetna", "plan_name": "700700", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna", "plan_name": "700700_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Miscellaneous", "plan_name": "700720", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Miscellaneous", "plan_name": "700720_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Ppo Hmo", "plan_name": "701720", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Ppo Hmo", "plan_name": "701720_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Ms State Emplo", "plan_name": "401457", "standard_charge_percentage": 0.80, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Ms State Emplo", "plan_name": "401457_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Basic Pl", "plan_name": "400100", "standard_charge_percentage": 0.85, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Basic Pl", "plan_name": "400100_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Federal", "plan_name": "400110", "standard_charge_percentage": 0.85, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Federal", "plan_name": "400110_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." } ] } ] }, { "description": "Ethyl chloride 100 % topical spray [2951]", "drug_information": { "unit": 116.00, "type": "ML" }, "code_information": [ { "code": "0386000103", "type": "NDC" } ], "standard_charges": [ { "gross_charge": 153.73, "minimum": 122.98, "maximum": 130.67, "setting": "both", "payers_information": [ { "payer_name": "Aetna", "plan_name": "700700", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna", "plan_name": "700700_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Miscellaneous", "plan_name": "700720", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Miscellaneous", "plan_name": "700720_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Ppo Hmo", "plan_name": "701720", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Ppo Hmo", "plan_name": "701720_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Ms State Emplo", "plan_name": "401457", "standard_charge_percentage": 0.80, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Ms State Emplo", "plan_name": "401457_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Basic Pl", "plan_name": "400100", "standard_charge_percentage": 0.85, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Basic Pl", "plan_name": "400100_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Federal", "plan_name": "400110", "standard_charge_percentage": 0.85, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Federal", "plan_name": "400110_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." } ] } ] }, { "description": "Ammonia aromatic inhalation spirits [27850]", "drug_information": { "unit": 59.00, "type": "ML" }, "code_information": [ { "code": "0395-0073-92", "type": "NDC" } ], "standard_charges": [ { "gross_charge": 19.06, "minimum": 15.25, "maximum": 16.20, "setting": "both", "payers_information": [ { "payer_name": "Aetna", "plan_name": "700700", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna", "plan_name": "700700_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Miscellaneous", "plan_name": "700720", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Miscellaneous", "plan_name": "700720_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Ppo Hmo", "plan_name": "701720", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Ppo Hmo", "plan_name": "701720_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Ms State Emplo", "plan_name": "401457", "standard_charge_percentage": 0.80, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Ms State Emplo", "plan_name": "401457_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Basic Pl", "plan_name": "400100", "standard_charge_percentage": 0.85, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Basic Pl", "plan_name": "400100_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Federal", "plan_name": "400110", "standard_charge_percentage": 0.85, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Federal", "plan_name": "400110_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." } ] } ] }, { "description": "Benzoin-aloe vera-storax-tolu balsam 10 %-2 %-8 %-4 % topical tincture [117132]", "drug_information": { "unit": 59.00, "type": "ML" }, "code_information": [ { "code": "0395-0243-92", "type": "NDC" } ], "standard_charges": [ { "gross_charge": 21.02, "minimum": 16.82, "maximum": 17.87, "setting": "both", "payers_information": [ { "payer_name": "Aetna", "plan_name": "700700", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna", "plan_name": "700700_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Miscellaneous", "plan_name": "700720", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Miscellaneous", "plan_name": "700720_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Ppo Hmo", "plan_name": "701720", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Ppo Hmo", "plan_name": "701720_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Ms State Emplo", "plan_name": "401457", "standard_charge_percentage": 0.80, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Ms State Emplo", "plan_name": "401457_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Basic Pl", "plan_name": "400100", "standard_charge_percentage": 0.85, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Basic Pl", "plan_name": "400100_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Federal", "plan_name": "400110", "standard_charge_percentage": 0.85, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Federal", "plan_name": "400110_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." } ] } ] }, { "description": "Benzoin (bulk) topical tincture [161159]", "drug_information": { "unit": 59.00, "type": "ML" }, "code_information": [ { "code": "0395-0247-92", "type": "NDC" } ], "standard_charges": [ { "gross_charge": 57.17, "minimum": 45.74, "maximum": 48.59, "setting": "both", "payers_information": [ { "payer_name": "Aetna", "plan_name": "700700", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna", "plan_name": "700700_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Miscellaneous", "plan_name": "700720", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Miscellaneous", "plan_name": "700720_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Ppo Hmo", "plan_name": "701720", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Ppo Hmo", "plan_name": "701720_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Ms State Emplo", "plan_name": "401457", "standard_charge_percentage": 0.80, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Ms State Emplo", "plan_name": "401457_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Basic Pl", "plan_name": "400100", "standard_charge_percentage": 0.85, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Basic Pl", "plan_name": "400100_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Federal", "plan_name": "400110", "standard_charge_percentage": 0.85, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Federal", "plan_name": "400110_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." } ] } ] }, { "description": "Gentian violet 1 % topical solution [3430]", "drug_information": { "unit": 59.00, "type": "ML" }, "code_information": [ { "code": "0395-1003-92", "type": "NDC" } ], "standard_charges": [ { "gross_charge": 37.83, "minimum": 30.26, "maximum": 32.16, "setting": "both", "payers_information": [ { "payer_name": "Aetna", "plan_name": "700700", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna", "plan_name": "700700_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Miscellaneous", "plan_name": "700720", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Miscellaneous", "plan_name": "700720_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Ppo Hmo", "plan_name": "701720", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Ppo Hmo", "plan_name": "701720_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Ms State Emplo", "plan_name": "401457", "standard_charge_percentage": 0.80, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Ms State Emplo", "plan_name": "401457_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Basic Pl", "plan_name": "400100", "standard_charge_percentage": 0.85, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Basic Pl", "plan_name": "400100_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Federal", "plan_name": "400110", "standard_charge_percentage": 0.85, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Federal", "plan_name": "400110_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." } ] } ] }, { "description": "Glycerin 99.5 % topical solution [116359]", "drug_information": { "unit": 473.00, "type": "ML" }, "code_information": [ { "code": "0395-1031-16", "type": "NDC" } ], "standard_charges": [ { "gross_charge": 114.59, "minimum": 91.67, "maximum": 97.40, "setting": "both", "payers_information": [ { "payer_name": "Aetna", "plan_name": "700700", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna", "plan_name": "700700_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Miscellaneous", "plan_name": "700720", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Miscellaneous", "plan_name": "700720_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Ppo Hmo", "plan_name": "701720", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Ppo Hmo", "plan_name": "701720_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Ms State Emplo", "plan_name": "401457", "standard_charge_percentage": 0.80, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Ms State Emplo", "plan_name": "401457_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Basic Pl", "plan_name": "400100", "standard_charge_percentage": 0.85, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Basic Pl", "plan_name": "400100_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Federal", "plan_name": "400110", "standard_charge_percentage": 0.85, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Federal", "plan_name": "400110_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." } ] } ] }, { "description": "Iodine-sodium iodide 2 % topical tincture [19490]", "drug_information": { "unit": 30.00, "type": "ML" }, "code_information": [ { "code": "0395-1213-91", "type": "NDC" } ], "standard_charges": [ { "gross_charge": 9.13, "minimum": 7.30, "maximum": 7.76, "setting": "both", "payers_information": [ { "payer_name": "Aetna", "plan_name": "700700", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna", "plan_name": "700700_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Miscellaneous", "plan_name": "700720", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Miscellaneous", "plan_name": "700720_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Ppo Hmo", "plan_name": "701720", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Ppo Hmo", "plan_name": "701720_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Ms State Emplo", "plan_name": "401457", "standard_charge_percentage": 0.80, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Ms State Emplo", "plan_name": "401457_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Basic Pl", "plan_name": "400100", "standard_charge_percentage": 0.85, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Basic Pl", "plan_name": "400100_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Federal", "plan_name": "400110", "standard_charge_percentage": 0.85, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Federal", "plan_name": "400110_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." } ] } ] }, { "description": "Iodine strong (lugols) 5 % oral solution [108150]", "drug_information": { "unit": 473.00, "type": "ML" }, "code_information": [ { "code": "0395-2775-16", "type": "NDC" } ], "standard_charges": [ { "gross_charge": 339.26, "minimum": 271.41, "maximum": 288.37, "setting": "both", "payers_information": [ { "payer_name": "Aetna", "plan_name": "700700", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna", "plan_name": "700700_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Miscellaneous", "plan_name": "700720", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Miscellaneous", "plan_name": "700720_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Ppo Hmo", "plan_name": "701720", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Ppo Hmo", "plan_name": "701720_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Ms State Emplo", "plan_name": "401457", "standard_charge_percentage": 0.80, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Ms State Emplo", "plan_name": "401457_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Basic Pl", "plan_name": "400100", "standard_charge_percentage": 0.85, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Basic Pl", "plan_name": "400100_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Federal", "plan_name": "400110", "standard_charge_percentage": 0.85, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Federal", "plan_name": "400110_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." } ] } ] }, { "description": "Boric acid (bulk) powder [1131]", "drug_information": { "unit": 170.00, "type": "GR" }, "code_information": [ { "code": "0395030396", "type": "NDC" } ], "standard_charges": [ { "gross_charge": 36.34, "minimum": 29.07, "maximum": 30.89, "setting": "both", "payers_information": [ { "payer_name": "Aetna", "plan_name": "700700", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna", "plan_name": "700700_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Miscellaneous", "plan_name": "700720", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Miscellaneous", "plan_name": "700720_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Ppo Hmo", "plan_name": "701720", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Ppo Hmo", "plan_name": "701720_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Ms State Emplo", "plan_name": "401457", "standard_charge_percentage": 0.80, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Ms State Emplo", "plan_name": "401457_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Basic Pl", "plan_name": "400100", "standard_charge_percentage": 0.85, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Basic Pl", "plan_name": "400100_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Federal", "plan_name": "400110", "standard_charge_percentage": 0.85, "count": "0", "methodology": "percent of total billed 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"payer_name": "Aetna", "plan_name": "700700_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Miscellaneous", "plan_name": "700720", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Miscellaneous", "plan_name": "700720_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Ppo Hmo", "plan_name": "701720", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Ppo 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"payer_name": "Bc/Bs Of Ms Basic Pl", "plan_name": "400100", "standard_charge_percentage": 0.85, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Basic Pl", "plan_name": "400100_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Federal", "plan_name": "400110", "standard_charge_percentage": 0.85, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Federal", "plan_name": "400110_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." } ] } ] }, { "description": "Hydrocodone 7.5 mg-acetaminophen 325 mg tablet [34544]", "drug_information": { "unit": 1.00, "type": "EA" }, "code_information": [ { "code": "0406-0124-23", "type": "NDC" } ], "standard_charges": [ { "gross_charge": 7.50, "minimum": 6.00, "maximum": 6.38, "setting": "both", "payers_information": [ { "payer_name": "Aetna", "plan_name": "700700", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna", "plan_name": "700700_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Miscellaneous", "plan_name": "700720", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Miscellaneous", "plan_name": "700720_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Ppo Hmo", "plan_name": "701720", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Ppo Hmo", "plan_name": "701720_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Ms State Emplo", "plan_name": "401457", "standard_charge_percentage": 0.80, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Ms State Emplo", "plan_name": "401457_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Basic Pl", "plan_name": "400100", "standard_charge_percentage": 0.85, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Basic Pl", "plan_name": "400100_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Federal", "plan_name": "400110", "standard_charge_percentage": 0.85, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate 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"additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Ms State Emplo", "plan_name": "401457", "standard_charge_percentage": 0.80, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Ms State Emplo", "plan_name": "401457_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Basic Pl", "plan_name": "400100", "standard_charge_percentage": 0.85, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Basic Pl", "plan_name": "400100_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Federal", "plan_name": "400110", "standard_charge_percentage": 0.85, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Federal", "plan_name": "400110_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." } ] } ] }, { "description": "Hydrocodone 10 mg-acetaminophen 325 mg tablet [28384]", "drug_information": { "unit": 1.00, "type": "EA" }, "code_information": [ { "code": "0406-0125-23", "type": "NDC" } ], "standard_charges": [ { "gross_charge": 7.91, "minimum": 6.33, "maximum": 6.72, "setting": "both", "payers_information": [ { "payer_name": "Aetna", "plan_name": "700700", "standard_charge_percentage": 80.0, "count": 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100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Ppo Hmo", "plan_name": "701720", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Ppo Hmo", "plan_name": "701720_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Ms State Emplo", "plan_name": "401457", "standard_charge_percentage": 0.80, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Ms State Emplo", "plan_name": "401457_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Basic Pl", "plan_name": "400100", "standard_charge_percentage": 0.85, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Basic Pl", "plan_name": "400100_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Federal", "plan_name": "400110", "standard_charge_percentage": 0.85, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Federal", "plan_name": "400110_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." } ] } ] }, { "description": "Acetaminophen 300 mg-codeine 30 mg tablet [14087]", "drug_information": { "unit": 1.00, "type": "EA" }, "code_information": [ { "code": "0406-0484-23", "type": "NDC" } ], "standard_charges": [ { "gross_charge": 7.50, "minimum": 6.00, "maximum": 6.38, "setting": "both", "payers_information": [ { "payer_name": "Aetna", "plan_name": "700700", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna", "plan_name": "700700_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Miscellaneous", "plan_name": "700720", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Miscellaneous", "plan_name": "700720_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Ppo Hmo", "plan_name": "701720", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Ppo Hmo", "plan_name": "701720_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Ms State Emplo", "plan_name": "401457", "standard_charge_percentage": 0.80, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Ms State Emplo", "plan_name": "401457_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Basic Pl", "plan_name": "400100", "standard_charge_percentage": 0.85, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Basic Pl", "plan_name": "400100_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Federal", "plan_name": "400110", "standard_charge_percentage": 0.85, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Federal", "plan_name": "400110_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." } ] } ] }, { "description": "Acetaminophen 300 mg-codeine 30 mg tablet [14087]", "drug_information": { "unit": 1.00, "type": "EA" }, "code_information": [ { "code": "0406-0484-62", "type": "NDC" } ], "standard_charges": [ { "gross_charge": 7.50, "minimum": 6.00, "maximum": 6.38, "setting": "both", "payers_information": [ { "payer_name": "Aetna", "plan_name": "700700", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna", "plan_name": "700700_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Miscellaneous", "plan_name": "700720", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Miscellaneous", "plan_name": "700720_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Ppo Hmo", "plan_name": "701720", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Ppo 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Pl", "plan_name": "400100_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Federal", "plan_name": "400110", "standard_charge_percentage": 0.85, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Federal", "plan_name": "400110_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." } ] } ] }, { "description": "Oxycodone-acetaminophen 5 mg-325 mg tablet [5940]", "drug_information": { "unit": 1.00, "type": "EA" }, "code_information": [ { "code": "0406-0512-01", "type": "NDC" } ], "standard_charges": [ { "gross_charge": 7.50, "minimum": 6.00, "maximum": 6.38, "setting": "both", "payers_information": [ { "payer_name": "Aetna", "plan_name": "700700", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna", "plan_name": "700700_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Miscellaneous", "plan_name": "700720", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Miscellaneous", "plan_name": "700720_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Ppo Hmo", "plan_name": "701720", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Ppo Hmo", "plan_name": "701720_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Ms State Emplo", "plan_name": "401457", "standard_charge_percentage": 0.80, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Ms State Emplo", "plan_name": "401457_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Basic Pl", "plan_name": "400100", "standard_charge_percentage": 0.85, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Basic Pl", "plan_name": "400100_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Federal", "plan_name": "400110", "standard_charge_percentage": 0.85, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Federal", "plan_name": "400110_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." } ] } ] }, { "description": "Oxycodone-acetaminophen 5 mg-325 mg tablet [5940]", "drug_information": { "unit": 1.00, "type": "EA" }, "code_information": [ { "code": "0406-0512-23", "type": "NDC" } ], "standard_charges": [ { "gross_charge": 7.50, "minimum": 6.00, "maximum": 6.38, "setting": "both", "payers_information": [ { "payer_name": "Aetna", "plan_name": "700700", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna", "plan_name": "700700_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Miscellaneous", "plan_name": "700720", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Miscellaneous", "plan_name": "700720_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Ppo Hmo", "plan_name": "701720", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Ppo Hmo", "plan_name": "701720_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Ms State Emplo", "plan_name": "401457", "standard_charge_percentage": 0.80, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Ms State Emplo", "plan_name": "401457_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Basic Pl", "plan_name": "400100", "standard_charge_percentage": 0.85, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Basic Pl", "plan_name": "400100_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Federal", "plan_name": "400110", "standard_charge_percentage": 0.85, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed 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"payer_name": "Aetna", "plan_name": "700700_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Miscellaneous", "plan_name": "700720", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Miscellaneous", "plan_name": "700720_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Ppo Hmo", "plan_name": "701720", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Ppo 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Pl", "plan_name": "400100_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Federal", "plan_name": "400110", "standard_charge_percentage": 0.85, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Federal", "plan_name": "400110_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." } ] } ] }, { "description": "Oxycodone 5 mg tablet [10814]", "drug_information": { "unit": 1.00, "type": "EA" }, "code_information": [ { "code": "0406-0552-23", "type": "NDC" } ], "standard_charges": [ { "gross_charge": 7.50, "minimum": 6.00, "maximum": 6.38, "setting": "both", 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"payer_name": "Aetna Ppo Hmo", "plan_name": "701720", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Ppo Hmo", "plan_name": "701720_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Ms State Emplo", "plan_name": "401457", "standard_charge_percentage": 0.80, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Ms State Emplo", "plan_name": "401457_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Basic Pl", "plan_name": "400100", "standard_charge_percentage": 0.85, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Basic Pl", "plan_name": "400100_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Federal", "plan_name": "400110", "standard_charge_percentage": 0.85, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Federal", "plan_name": "400110_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." } ] } ] }, { "description": "Oxycodone 5 mg tablet [10814]", "drug_information": { "unit": 1.00, "type": "EA" }, "code_information": [ { "code": "0406-0552-62", "type": "NDC" } ], "standard_charges": [ { "gross_charge": 7.50, "minimum": 6.00, "maximum": 6.38, "setting": "both", "payers_information": [ { "payer_name": "Aetna", "plan_name": "700700", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna", "plan_name": "700700_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Miscellaneous", "plan_name": "700720", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed 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"payer_name": "Bc/Bs Ms State Emplo", "plan_name": "401457_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Basic Pl", "plan_name": "400100", "standard_charge_percentage": 0.85, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Basic Pl", "plan_name": "400100_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Federal", "plan_name": "400110", "standard_charge_percentage": 0.85, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Federal", "plan_name": "400110_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." } ] } ] }, { "description": "Methylphenidate 5 mg tablet [4988]", "drug_information": { "unit": 1.00, "type": "EA" }, "code_information": [ { "code": "0406-1142-01", "type": "NDC" } ], "standard_charges": [ { "gross_charge": 7.50, "minimum": 6.00, "maximum": 6.38, "setting": "both", "payers_information": [ { "payer_name": "Aetna", "plan_name": "700700", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna", "plan_name": "700700_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Miscellaneous", "plan_name": "700720", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Miscellaneous", "plan_name": "700720_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Ppo Hmo", "plan_name": "701720", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Ppo Hmo", "plan_name": "701720_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Ms State Emplo", "plan_name": "401457", "standard_charge_percentage": 0.80, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Ms State Emplo", "plan_name": "401457_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Basic Pl", "plan_name": "400100", "standard_charge_percentage": 0.85, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Basic Pl", "plan_name": "400100_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Federal", "plan_name": "400110", "standard_charge_percentage": 0.85, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Federal", "plan_name": "400110_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." } ] } ] }, { "description": "Naltrexone 50 mg tablet [10685]", "drug_information": { "unit": 1.00, "type": "EA" }, "code_information": [ { "code": "0406-1170-03", "type": "NDC" } ], "standard_charges": [ { "gross_charge": 10.50, "minimum": 8.40, "maximum": 8.93, "setting": "both", "payers_information": [ { "payer_name": "Aetna", "plan_name": "700700", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna", "plan_name": "700700_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Miscellaneous", "plan_name": "700720", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Miscellaneous", "plan_name": "700720_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Ppo Hmo", "plan_name": "701720", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Ppo Hmo", "plan_name": "701720_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Ms State Emplo", "plan_name": "401457", "standard_charge_percentage": 0.80, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Ms State Emplo", "plan_name": "401457_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Basic Pl", "plan_name": "400100", "standard_charge_percentage": 0.85, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Basic Pl", "plan_name": "400100_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Federal", "plan_name": "400110", "standard_charge_percentage": 0.85, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Federal", "plan_name": "400110_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." } ] } ] }, { "description": "Diphenoxylate-atropine 2.5 mg-0.025 mg tablet [2516]", "drug_information": { "unit": 1.00, "type": "EA" }, "code_information": [ { "code": "0406-1236-01", "type": "NDC" } ], "standard_charges": [ { "gross_charge": 7.50, "minimum": 6.00, "maximum": 6.38, "setting": "both", "payers_information": [ { "payer_name": "Aetna", "plan_name": "700700", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna", "plan_name": "700700_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Miscellaneous", "plan_name": "700720", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Miscellaneous", "plan_name": "700720_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Ppo Hmo", "plan_name": "701720", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Ppo Hmo", "plan_name": "701720_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Ms State Emplo", "plan_name": "401457", "standard_charge_percentage": 0.80, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Ms State Emplo", "plan_name": "401457_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Basic Pl", "plan_name": "400100", "standard_charge_percentage": 0.85, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Basic Pl", "plan_name": "400100_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Federal", "plan_name": "400110", "standard_charge_percentage": 0.85, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Federal", "plan_name": "400110_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." } ] } ] }, { "description": "Cocaine (bulk) 100 % crystals [22776]", "drug_information": { "unit": 5.00, "type": "GR" }, "code_information": [ { "code": "0406-1520-53", "type": "NDC" } ], "standard_charges": [ { "gross_charge": 2578.50, "minimum": 2062.80, "maximum": 2191.73, "setting": "both", "payers_information": [ { "payer_name": "Aetna", "plan_name": "700700", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna", "plan_name": "700700_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Miscellaneous", "plan_name": "700720", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Miscellaneous", "plan_name": "700720_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Ppo Hmo", "plan_name": "701720", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Ppo Hmo", "plan_name": "701720_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Ms State Emplo", "plan_name": "401457", "standard_charge_percentage": 0.80, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Ms State Emplo", "plan_name": "401457_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Basic Pl", "plan_name": "400100", "standard_charge_percentage": 0.85, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Basic Pl", "plan_name": "400100_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Federal", "plan_name": "400110", "standard_charge_percentage": 0.85, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Federal", "plan_name": "400110_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." } ] } ] }, { "description": "Methadone 5 mg tablet [4954]", "drug_information": { "unit": 1.00, "type": "EA" }, "code_information": [ { "code": "0406-5755-23", "type": "NDC" } ], "standard_charges": [ { "gross_charge": 7.50, "minimum": 6.00, "maximum": 6.38, "setting": "both", "payers_information": [ { "payer_name": "Aetna", "plan_name": "700700", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna", "plan_name": "700700_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Miscellaneous", "plan_name": "700720", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Miscellaneous", "plan_name": "700720_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Ppo Hmo", "plan_name": "701720", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Ppo Hmo", "plan_name": "701720_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Ms State Emplo", "plan_name": "401457", "standard_charge_percentage": 0.80, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Ms State Emplo", "plan_name": "401457_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Basic Pl", "plan_name": "400100", "standard_charge_percentage": 0.85, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Basic Pl", "plan_name": "400100_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Federal", "plan_name": "400110", "standard_charge_percentage": 0.85, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Federal", "plan_name": "400110_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." } ] } ] }, { "description": "Methadone 5 mg tablet [4954]", "drug_information": { "unit": 1.00, "type": "EA" }, "code_information": [ { "code": "0406-5755-62", "type": "NDC" } ], "standard_charges": [ { "gross_charge": 7.50, "minimum": 6.00, "maximum": 6.38, "setting": "both", "payers_information": [ { "payer_name": "Aetna", "plan_name": "700700", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna", "plan_name": "700700_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Miscellaneous", "plan_name": "700720", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Miscellaneous", "plan_name": "700720_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Ppo Hmo", "plan_name": "701720", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Ppo Hmo", "plan_name": "701720_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Ms State Emplo", "plan_name": "401457", "standard_charge_percentage": 0.80, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Ms State Emplo", "plan_name": "401457_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Basic Pl", "plan_name": "400100", "standard_charge_percentage": 0.85, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Basic Pl", "plan_name": "400100_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Federal", "plan_name": "400110", "standard_charge_percentage": 0.85, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Federal", "plan_name": "400110_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." } ] } ] }, { "description": "Methadone 10 mg tablet [4953]", "drug_information": { "unit": 1.00, "type": "EA" }, "code_information": [ { "code": "0406-5771-23", "type": "NDC" } ], "standard_charges": [ { "gross_charge": 7.50, "minimum": 6.00, "maximum": 6.38, "setting": "both", "payers_information": [ { "payer_name": "Aetna", "plan_name": "700700", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna", "plan_name": "700700_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Miscellaneous", "plan_name": "700720", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Miscellaneous", "plan_name": "700720_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Ppo Hmo", "plan_name": "701720", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Ppo Hmo", "plan_name": "701720_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Ms State Emplo", "plan_name": "401457", "standard_charge_percentage": 0.80, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Ms State Emplo", "plan_name": "401457_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Basic Pl", "plan_name": "400100", "standard_charge_percentage": 0.85, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Basic Pl", "plan_name": "400100_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Federal", "plan_name": "400110", "standard_charge_percentage": 0.85, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Federal", "plan_name": "400110_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." } ] } ] }, { "description": "Methadone 10 mg tablet [4953]", "drug_information": { "unit": 1.00, "type": "EA" }, "code_information": [ { "code": "0406-5771-62", "type": "NDC" } ], "standard_charges": [ { "gross_charge": 7.50, "minimum": 6.00, "maximum": 6.38, "setting": "both", "payers_information": [ { "payer_name": "Aetna", "plan_name": "700700", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna", "plan_name": "700700_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Miscellaneous", "plan_name": "700720", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total 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"additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Miscellaneous", "plan_name": "700720_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Ppo Hmo", "plan_name": "701720", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Ppo Hmo", "plan_name": "701720_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Ms State Emplo", "plan_name": "401457", "standard_charge_percentage": 0.80, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Ms State Emplo", "plan_name": "401457_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Basic Pl", "plan_name": "400100", "standard_charge_percentage": 0.85, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Basic Pl", "plan_name": "400100_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Federal", "plan_name": "400110", "standard_charge_percentage": 0.85, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Federal", "plan_name": "400110_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." } ] } ] }, { "description": "Fentanyl 25 mcg/hr transdermal patch [27905]", "drug_information": { "unit": 1.00, "type": "EA" }, "code_information": [ { "code": "0406-9125-76", "type": "NDC" } ], "standard_charges": [ { "gross_charge": 59.10, "minimum": 47.28, "maximum": 50.24, "setting": "both", "payers_information": [ { "payer_name": "Aetna", "plan_name": "700700", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna", "plan_name": "700700_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Miscellaneous", "plan_name": "700720", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Miscellaneous", "plan_name": "700720_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Ppo Hmo", "plan_name": "701720", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Ppo Hmo", "plan_name": "701720_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Ms State Emplo", "plan_name": "401457", "standard_charge_percentage": 0.80, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Ms State Emplo", "plan_name": "401457_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Basic Pl", "plan_name": "400100", "standard_charge_percentage": 0.85, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Basic Pl", "plan_name": "400100_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Federal", "plan_name": "400110", "standard_charge_percentage": 0.85, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Federal", "plan_name": "400110_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." } ] } ] }, { "description": "Fentanyl 50 mcg/hr transdermal patch [27906]", "drug_information": { "unit": 1.00, "type": "EA" }, "code_information": [ { "code": "0406-9150-76", "type": "NDC" } ], "standard_charges": [ { "gross_charge": 104.29, "minimum": 83.43, "maximum": 88.65, "setting": "both", "payers_information": [ { "payer_name": "Aetna", "plan_name": "700700", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna", "plan_name": "700700_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Miscellaneous", "plan_name": "700720", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Miscellaneous", "plan_name": "700720_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Ppo Hmo", "plan_name": "701720", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Ppo Hmo", "plan_name": "701720_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Ms State Emplo", "plan_name": "401457", "standard_charge_percentage": 0.80, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Ms State Emplo", "plan_name": "401457_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Basic Pl", "plan_name": "400100", "standard_charge_percentage": 0.85, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Basic Pl", "plan_name": "400100_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Federal", "plan_name": "400110", "standard_charge_percentage": 0.85, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Federal", "plan_name": "400110_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." } ] } ] }, { "description": "Fentanyl 75 mcg/hr transdermal patch [27907]", "drug_information": { "unit": 1.00, "type": "EA" }, "code_information": [ { "code": "0406-9175-76", "type": "NDC" } ], "standard_charges": [ { "gross_charge": 164.85, "minimum": 131.88, "maximum": 140.12, "setting": "both", "payers_information": [ { "payer_name": "Aetna", "plan_name": "700700", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna", "plan_name": "700700_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Miscellaneous", "plan_name": "700720", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Miscellaneous", "plan_name": "700720_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Ppo Hmo", "plan_name": "701720", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Ppo Hmo", "plan_name": "701720_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Ms State Emplo", "plan_name": "401457", "standard_charge_percentage": 0.80, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Ms State Emplo", "plan_name": "401457_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Basic Pl", "plan_name": "400100", "standard_charge_percentage": 0.85, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Basic Pl", "plan_name": "400100_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Federal", "plan_name": "400110", "standard_charge_percentage": 0.85, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Federal", "plan_name": "400110_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." } ] } ] }, { "description": "Nitroglycerin 0.1 mg/hr transdermal 24 hour patch [27471]", "drug_information": { "unit": 1.00, "type": "EA" }, "code_information": [ { "code": "0378-9102-16", "type": "NDC" } ], "standard_charges": [ { "gross_charge": 7.50, "minimum": 6.00, "maximum": 6.38, "setting": "both", "payers_information": [ { "payer_name": "Aetna", "plan_name": "700700", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna", "plan_name": "700700_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Miscellaneous", "plan_name": "700720", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Miscellaneous", "plan_name": "700720_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Ppo Hmo", "plan_name": "701720", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Ppo Hmo", "plan_name": "701720_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Ms State Emplo", "plan_name": "401457", "standard_charge_percentage": 0.80, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Ms State Emplo", "plan_name": "401457_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Basic Pl", "plan_name": "400100", "standard_charge_percentage": 0.85, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Basic Pl", "plan_name": "400100_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Federal", "plan_name": "400110", "standard_charge_percentage": 0.85, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Federal", "plan_name": "400110_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." } ] } ] }, { "description": "Nitroglycerin 0.1 mg/hr transdermal 24 hour patch [27471]", "drug_information": { "unit": 1.00, "type": "EA" }, "code_information": [ { "code": "0378-9102-93", "type": "NDC" } ], "standard_charges": [ { "gross_charge": 7.50, "minimum": 6.00, "maximum": 6.38, "setting": "both", "payers_information": [ { "payer_name": "Aetna", "plan_name": "700700", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna", "plan_name": "700700_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Miscellaneous", "plan_name": "700720", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Miscellaneous", "plan_name": "700720_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Ppo Hmo", "plan_name": "701720", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Ppo Hmo", "plan_name": "701720_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Ms State Emplo", "plan_name": "401457", "standard_charge_percentage": 0.80, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Ms State Emplo", "plan_name": "401457_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Basic Pl", "plan_name": "400100", "standard_charge_percentage": 0.85, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Basic Pl", "plan_name": "400100_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Federal", "plan_name": "400110", "standard_charge_percentage": 0.85, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Federal", "plan_name": "400110_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." } ] } ] }, { "description": "Nitroglycerin 0.2 mg/hr transdermal 24 hour patch [27472]", "drug_information": { "unit": 1.00, "type": "EA" }, "code_information": [ { "code": "0378-9104-16", "type": "NDC" } ], "standard_charges": [ { "gross_charge": 7.50, "minimum": 6.00, "maximum": 6.38, "setting": "both", "payers_information": [ { "payer_name": "Aetna", "plan_name": "700700", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna", "plan_name": "700700_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Miscellaneous", "plan_name": "700720", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Miscellaneous", "plan_name": "700720_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Ppo Hmo", "plan_name": "701720", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Ppo Hmo", "plan_name": "701720_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Ms State Emplo", "plan_name": "401457", "standard_charge_percentage": 0.80, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Ms State Emplo", "plan_name": "401457_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Basic Pl", "plan_name": "400100", "standard_charge_percentage": 0.85, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Basic Pl", "plan_name": "400100_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Federal", "plan_name": "400110", "standard_charge_percentage": 0.85, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Federal", "plan_name": "400110_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." } ] } ] }, { "description": "Nitroglycerin 0.2 mg/hr transdermal 24 hour patch [27472]", "drug_information": { "unit": 1.00, "type": "EA" }, "code_information": [ { "code": "0378-9104-93", "type": "NDC" } ], "standard_charges": [ { "gross_charge": 7.50, "minimum": 6.00, "maximum": 6.38, "setting": "both", "payers_information": [ { "payer_name": "Aetna", "plan_name": "700700", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna", "plan_name": "700700_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Miscellaneous", "plan_name": "700720", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Miscellaneous", "plan_name": "700720_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Ppo Hmo", "plan_name": "701720", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Ppo Hmo", "plan_name": "701720_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Ms State Emplo", "plan_name": "401457", "standard_charge_percentage": 0.80, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Ms State Emplo", "plan_name": "401457_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Basic Pl", "plan_name": "400100", "standard_charge_percentage": 0.85, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Basic Pl", "plan_name": "400100_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Federal", "plan_name": "400110", "standard_charge_percentage": 0.85, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Federal", "plan_name": "400110_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." } ] } ] }, { "description": "Nitroglycerin 0.4 mg/hr transdermal 24 hour patch [27474]", "drug_information": { "unit": 1.00, "type": "EA" }, "code_information": [ { "code": "0378-9112-16", "type": "NDC" } ], "standard_charges": [ { "gross_charge": 7.50, "minimum": 6.00, "maximum": 6.38, "setting": "both", "payers_information": [ { "payer_name": "Aetna", "plan_name": "700700", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna", "plan_name": "700700_1", 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"standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Federal", "plan_name": "400110", "standard_charge_percentage": 0.85, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Federal", "plan_name": "400110_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." } ] } ] }, { "description": "Nitroglycerin 0.4 mg/hr transdermal 24 hour patch [27474]", "drug_information": { "unit": 1.00, "type": "EA" }, "code_information": [ { "code": "0378-9112-93", "type": "NDC" } ], "standard_charges": [ { "gross_charge": 7.50, "minimum": 6.00, "maximum": 6.38, "setting": "both", 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"payer_name": "Aetna Ppo Hmo", "plan_name": "701720", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Ppo Hmo", "plan_name": "701720_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Ms State Emplo", "plan_name": "401457", "standard_charge_percentage": 0.80, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Ms State Emplo", "plan_name": "401457_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Basic Pl", "plan_name": "400100", "standard_charge_percentage": 0.85, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Basic Pl", "plan_name": "400100_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Federal", "plan_name": "400110", "standard_charge_percentage": 0.85, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Federal", "plan_name": "400110_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." } ] } ] }, { "description": "Nitroglycerin 0.6 mg/hr transdermal 24 hour patch [27475]", "drug_information": { "unit": 1.00, "type": "EA" }, "code_information": [ { "code": "0378-9116-16", "type": "NDC" } ], "standard_charges": [ { "gross_charge": 7.87, "minimum": 6.30, "maximum": 6.69, "setting": "both", "payers_information": [ { "payer_name": "Aetna", "plan_name": "700700", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna", "plan_name": "700700_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Miscellaneous", "plan_name": "700720", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data 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allowed amounts." }, { "payer_name": "Bc/Bs Ms State Emplo", "plan_name": "401457_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Basic Pl", "plan_name": "400100", "standard_charge_percentage": 0.85, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Basic Pl", "plan_name": "400100_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Federal", "plan_name": "400110", "standard_charge_percentage": 0.85, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate 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"additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Miscellaneous", "plan_name": "700720", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Miscellaneous", "plan_name": "700720_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Ppo Hmo", "plan_name": "701720", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Ppo Hmo", "plan_name": "701720_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Ms State Emplo", "plan_name": "401457", "standard_charge_percentage": 0.80, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Ms State Emplo", "plan_name": "401457_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Basic Pl", "plan_name": "400100", "standard_charge_percentage": 0.85, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Basic Pl", "plan_name": "400100_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Federal", "plan_name": "400110", "standard_charge_percentage": 0.85, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Federal", "plan_name": "400110_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." } ] } ] }, { "description": "Fentanyl 12 mcg/hr transdermal patch [41382]", "drug_information": { "unit": 1.00, "type": "EA" }, "code_information": [ { "code": "0378-9119-16", "type": "NDC" } ], "standard_charges": [ { "gross_charge": 137.03, "minimum": 109.62, "maximum": 116.48, "setting": "both", "payers_information": [ { "payer_name": "Aetna", "plan_name": "700700", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna", "plan_name": "700700_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Miscellaneous", "plan_name": "700720", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Miscellaneous", "plan_name": "700720_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Ppo Hmo", "plan_name": "701720", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Ppo Hmo", "plan_name": "701720_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Ms State Emplo", "plan_name": "401457", "standard_charge_percentage": 0.80, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Ms State Emplo", "plan_name": "401457_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Basic Pl", "plan_name": "400100", "standard_charge_percentage": 0.85, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Basic Pl", "plan_name": "400100_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Federal", "plan_name": "400110", "standard_charge_percentage": 0.85, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Federal", "plan_name": "400110_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." } ] } ] }, { "description": "Fentanyl 12 mcg/hr transdermal patch [41382]", "drug_information": { "unit": 1.00, "type": "EA" }, "code_information": [ { "code": "0378-9119-98", "type": "NDC" } ], "standard_charges": [ { "gross_charge": 137.03, "minimum": 109.62, "maximum": 116.48, "setting": "both", "payers_information": [ { "payer_name": "Aetna", "plan_name": "700700", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna", "plan_name": "700700_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Miscellaneous", "plan_name": "700720", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Miscellaneous", "plan_name": "700720_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Ppo Hmo", "plan_name": "701720", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Ppo Hmo", "plan_name": "701720_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Ms State Emplo", "plan_name": "401457", "standard_charge_percentage": 0.80, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Ms State Emplo", "plan_name": "401457_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Basic Pl", "plan_name": "400100", "standard_charge_percentage": 0.85, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Basic Pl", "plan_name": "400100_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Federal", "plan_name": "400110", "standard_charge_percentage": 0.85, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Federal", "plan_name": "400110_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." } ] } ] }, { "description": "Fentanyl 25 mcg/hr transdermal patch [27905]", "drug_information": { "unit": 1.00, "type": "EA" }, "code_information": [ { "code": "0378-9121-16", "type": "NDC" } ], "standard_charges": [ { "gross_charge": 74.17, "minimum": 59.34, "maximum": 63.04, "setting": "both", "payers_information": [ { "payer_name": "Aetna", "plan_name": "700700", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna", "plan_name": "700700_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Miscellaneous", "plan_name": "700720", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Miscellaneous", "plan_name": "700720_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Ppo Hmo", "plan_name": "701720", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Ppo Hmo", "plan_name": "701720_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Ms State Emplo", "plan_name": "401457", "standard_charge_percentage": 0.80, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Ms State Emplo", "plan_name": "401457_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Basic Pl", "plan_name": "400100", "standard_charge_percentage": 0.85, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Basic Pl", "plan_name": "400100_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Federal", "plan_name": "400110", "standard_charge_percentage": 0.85, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Federal", "plan_name": "400110_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." } ] } ] }, { "description": "Fentanyl 25 mcg/hr transdermal patch [27905]", "drug_information": { "unit": 1.00, "type": "EA" }, "code_information": [ { "code": "0378-9121-98", "type": "NDC" } ], "standard_charges": [ { "gross_charge": 74.17, "minimum": 59.34, "maximum": 63.04, "setting": "both", "payers_information": [ { "payer_name": "Aetna", "plan_name": "700700", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna", "plan_name": "700700_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Miscellaneous", "plan_name": "700720", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Miscellaneous", "plan_name": "700720_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Ppo Hmo", "plan_name": "701720", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Ppo Hmo", "plan_name": "701720_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Ms State Emplo", "plan_name": "401457", "standard_charge_percentage": 0.80, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Ms State Emplo", "plan_name": "401457_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Basic Pl", "plan_name": "400100", "standard_charge_percentage": 0.85, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Basic Pl", "plan_name": "400100_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Federal", "plan_name": "400110", "standard_charge_percentage": 0.85, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Federal", "plan_name": "400110_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." } ] } ] }, { "description": "Fentanyl 50 mcg/hr transdermal patch [27906]", "drug_information": { "unit": 1.00, "type": "EA" }, "code_information": [ { "code": "0378-9122-16", "type": "NDC" } ], "standard_charges": [ { "gross_charge": 126.02, "minimum": 100.82, "maximum": 107.12, "setting": "both", "payers_information": [ { "payer_name": "Aetna", "plan_name": "700700", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna", "plan_name": "700700_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Miscellaneous", "plan_name": "700720", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Miscellaneous", "plan_name": "700720_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Ppo Hmo", "plan_name": "701720", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Ppo Hmo", "plan_name": "701720_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Ms State Emplo", "plan_name": "401457", "standard_charge_percentage": 0.80, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Ms State Emplo", "plan_name": "401457_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Basic Pl", "plan_name": "400100", "standard_charge_percentage": 0.85, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Basic Pl", "plan_name": "400100_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Federal", "plan_name": "400110", "standard_charge_percentage": 0.85, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Federal", "plan_name": "400110_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." } ] } ] }, { "description": "Fentanyl 50 mcg/hr transdermal patch [27906]", "drug_information": { "unit": 1.00, "type": "EA" }, "code_information": [ { "code": "0378-9122-98", "type": "NDC" } ], "standard_charges": [ { "gross_charge": 126.02, "minimum": 100.82, "maximum": 107.12, "setting": "both", "payers_information": [ { "payer_name": "Aetna", "plan_name": "700700", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna", "plan_name": "700700_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Miscellaneous", "plan_name": "700720", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Miscellaneous", "plan_name": "700720_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Ppo Hmo", "plan_name": "701720", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Ppo Hmo", "plan_name": "701720_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Ms State Emplo", "plan_name": "401457", "standard_charge_percentage": 0.80, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Ms State Emplo", "plan_name": "401457_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Basic Pl", "plan_name": "400100", "standard_charge_percentage": 0.85, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Basic Pl", "plan_name": "400100_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Federal", "plan_name": "400110", "standard_charge_percentage": 0.85, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Federal", "plan_name": "400110_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." } ] } ] }, { "description": "Thrombin(human)-fibrinogen-aprotinin synthetc-calcium 2 ml topical kit [180198]", "drug_information": { "unit": 1.00, "type": "EA" }, "code_information": [ { "code": "0338-4210-02", "type": "NDC" } ], "standard_charges": [ { "gross_charge": 825.06, "minimum": 660.05, "maximum": 701.30, "setting": "both", "payers_information": [ { "payer_name": "Aetna", "plan_name": "700700", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna", "plan_name": "700700_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed 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"additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Ms State Emplo", "plan_name": "401457", "standard_charge_percentage": 0.80, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Ms State Emplo", "plan_name": "401457_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Basic Pl", "plan_name": "400100", "standard_charge_percentage": 0.85, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Basic Pl", "plan_name": "400100_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Federal", "plan_name": "400110", "standard_charge_percentage": 0.85, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Federal", "plan_name": "400110_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." } ] } ] }, { "description": "Thrombin(human)-fibrinogen-aprotinin synthetc-calcium 2 ml topical kit [180198]", "drug_information": { "unit": 1.00, "type": "EA" }, "code_information": [ { "code": "0338-4301-02", "type": "NDC" } ], "standard_charges": [ { "gross_charge": 856.43, "minimum": 685.14, "maximum": 727.97, "setting": "both", "payers_information": [ { "payer_name": "Aetna", "plan_name": "700700", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna", "plan_name": "700700_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Miscellaneous", "plan_name": "700720", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Miscellaneous", "plan_name": "700720_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Ppo Hmo", "plan_name": "701720", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Ppo Hmo", "plan_name": "701720_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Ms State Emplo", "plan_name": "401457", "standard_charge_percentage": 0.80, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Ms State Emplo", "plan_name": "401457_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Basic Pl", "plan_name": "400100", "standard_charge_percentage": 0.85, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Basic Pl", "plan_name": "400100_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Federal", "plan_name": "400110", "standard_charge_percentage": 0.85, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Federal", "plan_name": "400110_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." } ] } ] }, { "description": "Sodium chloride 0.9 % intravenous piggyback [116170]", "drug_information": { "unit": 100.00, "type": "ML" }, "code_information": [ { "code": "0338-9159-30", "type": "NDC" } ], "standard_charges": [ { "gross_charge": 81.81, "minimum": 65.45, "maximum": 69.54, "setting": "both", "payers_information": [ { "payer_name": "Aetna", "plan_name": "700700", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna", "plan_name": "700700_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Miscellaneous", "plan_name": "700720", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Miscellaneous", "plan_name": "700720_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Ppo Hmo", "plan_name": "701720", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Ppo Hmo", "plan_name": "701720_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Ms State Emplo", "plan_name": "401457", "standard_charge_percentage": 0.80, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Ms State Emplo", "plan_name": "401457_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Basic Pl", "plan_name": "400100", "standard_charge_percentage": 0.85, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Basic Pl", "plan_name": "400100_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Federal", "plan_name": "400110", "standard_charge_percentage": 0.85, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Federal", "plan_name": "400110_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." } ] } ] }, { "description": "Iohexol 9 mg iodine/ml oral solution [186187]", "drug_information": { "unit": 500.00, "type": "ML" }, "code_information": [ { "code": "0407-1415-09", "type": "NDC" } ], "standard_charges": [ { "gross_charge": 45.13, "minimum": 36.10, "maximum": 38.36, "setting": "both", "payers_information": [ { "payer_name": "Aetna", "plan_name": "700700", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna", "plan_name": "700700_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Miscellaneous", "plan_name": "700720", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Miscellaneous", "plan_name": "700720_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Ppo Hmo", "plan_name": "701720", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Ppo Hmo", "plan_name": "701720_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Ms State Emplo", "plan_name": "401457", "standard_charge_percentage": 0.80, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Ms State Emplo", "plan_name": "401457_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Basic Pl", "plan_name": "400100", "standard_charge_percentage": 0.85, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Basic Pl", "plan_name": "400100_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Federal", "plan_name": "400110", "standard_charge_percentage": 0.85, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Federal", "plan_name": "400110_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." } ] } ] }, { "description": "Iohexol 12 mg iodine/ml oral solution [185333]", "drug_information": { "unit": 500.00, "type": "ML" }, "code_information": [ { "code": "0407-1416-12", "type": "NDC" } ], "standard_charges": [ { "gross_charge": 47.50, "minimum": 38.00, "maximum": 40.38, "setting": "both", "payers_information": [ { "payer_name": "Aetna", "plan_name": "700700", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna", "plan_name": "700700_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Miscellaneous", "plan_name": "700720", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Miscellaneous", "plan_name": "700720_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Ppo Hmo", "plan_name": "701720", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Ppo Hmo", "plan_name": "701720_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Ms State Emplo", "plan_name": "401457", "standard_charge_percentage": 0.80, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Ms State Emplo", "plan_name": "401457_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Basic Pl", "plan_name": "400100", "standard_charge_percentage": 0.85, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Basic Pl", "plan_name": "400100_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Federal", "plan_name": "400110", "standard_charge_percentage": 0.85, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Federal", "plan_name": "400110_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." } ] } ] }, { "description": "Atracurium 10 mg/ml intravenous solution [9168]", "drug_information": { "unit": 10.00, "type": "ML" }, "code_information": [ { "code": "0409-1105-02", "type": "NDC" } ], "standard_charges": [ { "gross_charge": 140.40, "minimum": 112.32, "maximum": 119.34, "setting": "both", "payers_information": [ { "payer_name": "Aetna", "plan_name": "700700", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna", "plan_name": "700700_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Miscellaneous", "plan_name": "700720", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Miscellaneous", "plan_name": "700720_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Ppo Hmo", "plan_name": "701720", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Ppo Hmo", "plan_name": "701720_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Ms State Emplo", "plan_name": "401457", "standard_charge_percentage": 0.80, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Ms State Emplo", "plan_name": "401457_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Basic Pl", "plan_name": "400100", "standard_charge_percentage": 0.85, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Basic Pl", "plan_name": "400100_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Federal", "plan_name": "400110", "standard_charge_percentage": 0.85, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Federal", "plan_name": "400110_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." } ] } ] }, { "description": "Atracurium 10 mg/ml intravenous solution [9168]", "drug_information": { "unit": 10.00, "type": "ML" }, "code_information": [ { "code": "0409-1105-22", "type": "NDC" } ], "standard_charges": [ { "gross_charge": 140.40, "minimum": 112.32, "maximum": 119.34, "setting": "both", "payers_information": [ { "payer_name": "Aetna", "plan_name": "700700", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna", "plan_name": "700700_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Miscellaneous", "plan_name": "700720", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Miscellaneous", "plan_name": "700720_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Ppo Hmo", "plan_name": "701720", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Ppo Hmo", "plan_name": "701720_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Ms State Emplo", "plan_name": "401457", "standard_charge_percentage": 0.80, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Ms State Emplo", "plan_name": "401457_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Basic Pl", "plan_name": "400100", "standard_charge_percentage": 0.85, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Basic Pl", "plan_name": "400100_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Federal", "plan_name": "400110", "standard_charge_percentage": 0.85, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Federal", "plan_name": "400110_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." } ] } ] }, { "description": "Atracurium 10 mg/ml intravenous solution [9168]", "drug_information": { "unit": 5.00, "type": "ML" }, "code_information": [ { "code": "0409-1109-01", "type": "NDC" } ], "standard_charges": [ { "gross_charge": 69.40, "minimum": 55.52, "maximum": 58.99, "setting": "both", "payers_information": [ { "payer_name": "Aetna", "plan_name": "700700", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna", "plan_name": "700700_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Miscellaneous", "plan_name": "700720", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Miscellaneous", "plan_name": "700720_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Ppo Hmo", "plan_name": "701720", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Ppo Hmo", "plan_name": "701720_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Ms State Emplo", "plan_name": "401457", "standard_charge_percentage": 0.80, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Ms State Emplo", "plan_name": "401457_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Basic Pl", "plan_name": "400100", "standard_charge_percentage": 0.85, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Basic Pl", "plan_name": "400100_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Federal", "plan_name": "400110", "standard_charge_percentage": 0.85, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Federal", "plan_name": "400110_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." } ] } ] }, { "description": "Atracurium 10 mg/ml intravenous solution [9168]", "drug_information": { "unit": 5.00, "type": "ML" }, "code_information": [ { "code": "0409-1109-11", "type": "NDC" } ], "standard_charges": [ { "gross_charge": 69.40, "minimum": 55.52, "maximum": 58.99, "setting": "both", "payers_information": [ { "payer_name": "Aetna", "plan_name": "700700", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna", "plan_name": "700700_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Miscellaneous", "plan_name": "700720", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Miscellaneous", "plan_name": "700720_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Ppo Hmo", "plan_name": "701720", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Ppo Hmo", "plan_name": "701720_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Ms State Emplo", "plan_name": "401457", "standard_charge_percentage": 0.80, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Ms State Emplo", "plan_name": "401457_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Basic Pl", "plan_name": "400100", "standard_charge_percentage": 0.85, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Basic Pl", "plan_name": "400100_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Federal", "plan_name": "400110", "standard_charge_percentage": 0.85, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Federal", "plan_name": "400110_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." } ] } ] }, { "description": "Verapamil 2.5 mg/ml intravenous solution [8527]", "drug_information": { "unit": 2.00, "type": "ML" }, "code_information": [ { "code": "0409-1144-05", "type": "NDC" } ], "standard_charges": [ { "gross_charge": 311.66, "minimum": 249.33, "maximum": 264.91, "setting": "both", "payers_information": [ { "payer_name": "Aetna", "plan_name": "700700", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna", "plan_name": "700700_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Miscellaneous", "plan_name": "700720", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Miscellaneous", "plan_name": "700720_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Ppo Hmo", "plan_name": "701720", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Ppo Hmo", "plan_name": "701720_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Ms State Emplo", "plan_name": "401457", "standard_charge_percentage": 0.80, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Ms State Emplo", "plan_name": "401457_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Basic Pl", "plan_name": "400100", "standard_charge_percentage": 0.85, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Basic Pl", "plan_name": "400100_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Federal", "plan_name": "400110", "standard_charge_percentage": 0.85, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Federal", "plan_name": "400110_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." } ] } ] }, { "description": "Verapamil 2.5 mg/ml intravenous solution [8527]", "drug_information": { "unit": 2.00, "type": "ML" }, "code_information": [ { "code": "0409-1144-65", "type": "NDC" } ], "standard_charges": [ { "gross_charge": 311.66, "minimum": 249.33, "maximum": 264.91, "setting": "both", "payers_information": [ { "payer_name": "Aetna", "plan_name": "700700", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna", "plan_name": "700700_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Miscellaneous", "plan_name": "700720", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Miscellaneous", "plan_name": "700720_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Ppo Hmo", "plan_name": "701720", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Ppo Hmo", "plan_name": "701720_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Ms State Emplo", "plan_name": "401457", "standard_charge_percentage": 0.80, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Ms State Emplo", "plan_name": "401457_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Basic Pl", "plan_name": "400100", "standard_charge_percentage": 0.85, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Basic Pl", "plan_name": "400100_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Federal", "plan_name": "400110", "standard_charge_percentage": 0.85, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Federal", "plan_name": "400110_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." } ] } ] }, { "description": "Nitroglycerin 50 mg/250 ml (200 mcg/ml) in 5 % dextrose intravenous [15859]", "drug_information": { "unit": 250.00, "type": "ML" }, "code_information": [ { "code": "0409-1482-02", "type": "NDC" } ], "standard_charges": [ { "gross_charge": 111.50, "minimum": 89.20, "maximum": 94.78, "setting": "both", "payers_information": [ { "payer_name": "Aetna", "plan_name": "700700", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna", "plan_name": "700700_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Miscellaneous", "plan_name": "700720", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Miscellaneous", "plan_name": "700720_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Ppo Hmo", "plan_name": "701720", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Ppo Hmo", "plan_name": "701720_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Ms State Emplo", "plan_name": "401457", "standard_charge_percentage": 0.80, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Ms State Emplo", "plan_name": "401457_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Basic Pl", "plan_name": "400100", "standard_charge_percentage": 0.85, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Basic Pl", "plan_name": "400100_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Federal", "plan_name": "400110", "standard_charge_percentage": 0.85, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Federal", "plan_name": "400110_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." } ] } ] }, { "description": "Nitroglycerin 25 mg/250 ml (100 mcg/ml) in 5 % dextrose intravenous [15858]", "drug_information": { "unit": 250.00, "type": 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"standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Ppo Hmo", "plan_name": "701720", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Ppo Hmo", "plan_name": "701720_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Ms State Emplo", "plan_name": "401457", "standard_charge_percentage": 0.80, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Ms State Emplo", "plan_name": "401457_1", 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"standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." } ] } ] }, { "description": "Dextrose 25 % in water (d25w) intravenous syringe [2361]", "drug_information": { "unit": 10.00, "type": "ML" }, "code_information": [ { "code": "0409-1775-40", "type": "NDC" } ], "standard_charges": [ { "gross_charge": 72.75, "minimum": 58.20, "maximum": 61.84, "setting": "both", "payers_information": [ { "payer_name": "Aetna", "plan_name": "700700", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna", "plan_name": "700700_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Miscellaneous", "plan_name": "700720", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Miscellaneous", "plan_name": "700720_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Ppo Hmo", "plan_name": "701720", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Ppo Hmo", "plan_name": "701720_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Ms State Emplo", "plan_name": "401457", "standard_charge_percentage": 0.80, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Ms State Emplo", "plan_name": "401457_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Basic Pl", "plan_name": "400100", "standard_charge_percentage": 0.85, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Basic Pl", "plan_name": "400100_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Federal", "plan_name": "400110", "standard_charge_percentage": 0.85, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Federal", "plan_name": "400110_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." } ] } ] }, { "description": "Metoprolol tartrate 5 mg/5 ml intravenous solution [5007]", "drug_information": { "unit": 5.00, "type": "ML" }, "code_information": [ { "code": "0409-1778-05", "type": "NDC" } ], "standard_charges": [ { "gross_charge": 12.10, "minimum": 9.68, "maximum": 10.29, "setting": "both", "payers_information": [ { "payer_name": "Aetna", "plan_name": "700700", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient 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"gross_charge": 12.10, "minimum": 9.68, "maximum": 10.29, "setting": "both", "payers_information": [ { "payer_name": "Aetna", "plan_name": "700700", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna", "plan_name": "700700_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Miscellaneous", "plan_name": "700720", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Miscellaneous", "plan_name": "700720_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Ppo Hmo", "plan_name": "701720", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Ppo Hmo", "plan_name": "701720_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Ms State Emplo", "plan_name": "401457", "standard_charge_percentage": 0.80, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Ms State Emplo", "plan_name": "401457_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Basic Pl", "plan_name": "400100", "standard_charge_percentage": 0.85, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Basic Pl", "plan_name": "400100_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Federal", "plan_name": "400110", "standard_charge_percentage": 0.85, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Federal", "plan_name": "400110_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." } ] } ] }, { "description": "Calcium chloride 100 mg/ml (10 %) intravenous syringe [1306]", "drug_information": { "unit": 10.00, "type": "ML" }, "code_information": [ { "code": "0409-1631-10", "type": "NDC" } ], "standard_charges": [ { "gross_charge": 53.95, "minimum": 43.16, "maximum": 45.86, "setting": "both", "payers_information": [ { "payer_name": "Aetna", "plan_name": "700700", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna", "plan_name": "700700_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Miscellaneous", "plan_name": "700720", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Miscellaneous", "plan_name": "700720_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Ppo Hmo", "plan_name": "701720", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Ppo Hmo", "plan_name": "701720_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Ms State Emplo", "plan_name": "401457", "standard_charge_percentage": 0.80, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Ms State Emplo", "plan_name": "401457_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Basic Pl", "plan_name": "400100", "standard_charge_percentage": 0.85, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Basic Pl", "plan_name": "400100_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Federal", "plan_name": "400110", "standard_charge_percentage": 0.85, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Federal", "plan_name": "400110_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." } ] } ] }, { "description": "Calcium chloride 100 mg/ml (10 %) intravenous syringe [1306]", "drug_information": { "unit": 10.00, "type": "ML" }, "code_information": [ { "code": "0409-1631-40", "type": "NDC" } ], "standard_charges": [ { "gross_charge": 53.95, "minimum": 43.16, "maximum": 45.86, "setting": "both", "payers_information": [ { "payer_name": "Aetna", "plan_name": "700700", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna", "plan_name": "700700_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Miscellaneous", "plan_name": "700720", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Miscellaneous", "plan_name": "700720_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Ppo Hmo", "plan_name": "701720", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Ppo Hmo", "plan_name": "701720_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Ms State Emplo", "plan_name": "401457", "standard_charge_percentage": 0.80, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Ms State Emplo", "plan_name": "401457_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Basic Pl", "plan_name": "400100", "standard_charge_percentage": 0.85, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Basic Pl", "plan_name": "400100_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Federal", "plan_name": "400110", "standard_charge_percentage": 0.85, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Federal", "plan_name": "400110_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." } ] } ] }, { "description": "Vecuronium bromide 10 mg intravenous solution [11634]", "drug_information": { "unit": 1.00, "type": "EA" }, "code_information": [ { "code": "0409-1632-21", "type": "NDC" } ], "standard_charges": [ { "gross_charge": 62.26, "minimum": 49.81, "maximum": 52.92, "setting": "both", "payers_information": [ { "payer_name": "Aetna", "plan_name": "700700", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna", "plan_name": "700700_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Miscellaneous", "plan_name": "700720", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Miscellaneous", "plan_name": "700720_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Ppo Hmo", "plan_name": "701720", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Ppo Hmo", "plan_name": "701720_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Ms State Emplo", "plan_name": "401457", "standard_charge_percentage": 0.80, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Ms State Emplo", "plan_name": "401457_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": 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"standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Federal", "plan_name": "400110", "standard_charge_percentage": 0.85, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Federal", "plan_name": "400110_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." } ] } ] }, { "description": "Water for injection bacteriostatic injection solution [864]", "drug_information": { "unit": 30.00, "type": "ML" }, "code_information": [ { "code": "0409-3977-03", "type": "NDC" } ], "standard_charges": [ { "gross_charge": 18.15, "minimum": 14.52, "maximum": 15.43, "setting": "both", 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"payer_name": "Aetna Ppo Hmo", "plan_name": "701720", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Ppo Hmo", "plan_name": "701720_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Ms State Emplo", "plan_name": "401457", "standard_charge_percentage": 0.80, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Ms State Emplo", "plan_name": "401457_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": 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remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Ms State Emplo", "plan_name": "401457", "standard_charge_percentage": 0.80, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Ms State Emplo", "plan_name": "401457_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Basic Pl", "plan_name": "400100", "standard_charge_percentage": 0.85, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Basic Pl", "plan_name": "400100_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Federal", "plan_name": "400110", "standard_charge_percentage": 0.85, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Federal", "plan_name": "400110_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." } ] } ] }, { "description": "Water for injection sterile injection solution [11671]", "drug_information": { "unit": 10.00, "type": "ML" }, "code_information": [ { "code": "0409-4887-10", "type": "NDC" } ], "standard_charges": [ { "gross_charge": 21.95, "minimum": 17.56, "maximum": 18.66, "setting": "both", "payers_information": [ { "payer_name": "Aetna", "plan_name": "700700", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna", "plan_name": "700700_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Miscellaneous", "plan_name": "700720", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Miscellaneous", "plan_name": "700720_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Ppo Hmo", "plan_name": "701720", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Ppo Hmo", "plan_name": "701720_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Ms State Emplo", "plan_name": "401457", "standard_charge_percentage": 0.80, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Ms State Emplo", "plan_name": "401457_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Basic Pl", "plan_name": "400100", "standard_charge_percentage": 0.85, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Basic Pl", "plan_name": "400100_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Federal", "plan_name": "400110", "standard_charge_percentage": 0.85, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Federal", "plan_name": "400110_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." } ] } ] }, { "description": "Water for injection sterile injection solution [11671]", "drug_information": { "unit": 10.00, "type": "ML" }, "code_information": [ { "code": "0409-4887-17", "type": "NDC" } ], "standard_charges": [ { "gross_charge": 21.95, "minimum": 17.56, "maximum": 18.66, "setting": "both", "payers_information": [ { "payer_name": "Aetna", "plan_name": "700700", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna", "plan_name": "700700_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Miscellaneous", "plan_name": "700720", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Miscellaneous", "plan_name": "700720_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Ppo Hmo", "plan_name": "701720", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Ppo Hmo", "plan_name": "701720_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Ms State Emplo", "plan_name": "401457", "standard_charge_percentage": 0.80, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Ms State Emplo", "plan_name": "401457_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Basic Pl", "plan_name": "400100", "standard_charge_percentage": 0.85, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Basic Pl", "plan_name": "400100_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Federal", "plan_name": "400110", "standard_charge_percentage": 0.85, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Federal", "plan_name": "400110_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." } ] } ] }, { "description": "Water for injection sterile injection solution [11671]", "drug_information": { "unit": 20.00, "type": "ML" }, "code_information": [ { "code": "0409-4887-20", "type": "NDC" } ], "standard_charges": [ { "gross_charge": 28.60, "minimum": 22.88, "maximum": 24.31, "setting": "both", "payers_information": [ { "payer_name": "Aetna", "plan_name": "700700", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna", "plan_name": "700700_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Miscellaneous", "plan_name": "700720", 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"payer_name": "Bc/Bs Of Ms Federal", "plan_name": "400110_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." } ] } ] }, { "description": "Diltiazem 100 mg intravenous solution [22156]", "drug_information": { "unit": 1.00, "type": "EA" }, "code_information": [ { "code": "0409-4350-03", "type": "NDC" } ], "standard_charges": [ { "gross_charge": 57.06, "minimum": 45.65, "maximum": 48.50, "setting": "both", "payers_information": [ { "payer_name": "Aetna", "plan_name": "700700", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna", "plan_name": "700700_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit 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"methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Ms State Emplo", "plan_name": "401457_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Basic Pl", "plan_name": "400100", "standard_charge_percentage": 0.85, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Basic Pl", "plan_name": "400100_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Federal", "plan_name": "400110", "standard_charge_percentage": 0.85, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Federal", "plan_name": "400110_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." } ] } ] }, { "description": "Sodium bicarbonate 1 meq/ml (8.4 %) intravenous solution [108819]", "drug_information": { "unit": 50.00, "type": "ML" }, "code_information": [ { "code": "0409-6625-22", "type": "NDC" } ], "standard_charges": [ { "gross_charge": 111.00, "minimum": 88.80, "maximum": 94.35, "setting": "both", "payers_information": [ { "payer_name": "Aetna", "plan_name": "700700", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna", "plan_name": "700700_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Miscellaneous", "plan_name": "700720", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Miscellaneous", "plan_name": "700720_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Ppo Hmo", "plan_name": "701720", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Ppo Hmo", "plan_name": "701720_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Ms State Emplo", "plan_name": "401457", "standard_charge_percentage": 0.80, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Ms State Emplo", "plan_name": "401457_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Basic Pl", "plan_name": "400100", "standard_charge_percentage": 0.85, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Basic Pl", "plan_name": "400100_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Federal", "plan_name": "400110", "standard_charge_percentage": 0.85, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Federal", "plan_name": "400110_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." } ] } ] }, { "description": "Sodium bicarbonate 1 meq/ml (8.4 %) intravenous solution [108819]", "drug_information": { "unit": 50.00, "type": "ML" }, "code_information": [ { "code": "0409-6625-30", "type": "NDC" } ], "standard_charges": [ { "gross_charge": 45.75, "minimum": 36.60, "maximum": 38.89, "setting": "both", 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}, { "payer_name": "Bc/Bs Of Ms Basic Pl", "plan_name": "400100_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Federal", "plan_name": "400110", "standard_charge_percentage": 0.85, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Federal", "plan_name": "400110_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." } ] } ] }, { "description": "Sodium chloride 0.9 % intravenous piggyback [116170]", "drug_information": { "unit": 250.00, "type": "ML" }, "code_information": [ { "code": "0409-7101-02", "type": "NDC" } ], "standard_charges": [ { "gross_charge": 81.81, 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calculate allowed amounts." } ] } ] }, { "description": "Sodium chloride 0.9 % intravenous piggyback [116170]", "drug_information": { "unit": 250.00, "type": "ML" }, "code_information": [ { "code": "0409-7101-04", "type": "NDC" } ], "standard_charges": [ { "gross_charge": 81.81, "minimum": 65.45, "maximum": 69.54, "setting": "both", "payers_information": [ { "payer_name": "Aetna", "plan_name": "700700", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna", "plan_name": "700700_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Miscellaneous", "plan_name": "700720", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Miscellaneous", "plan_name": "700720_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Ppo Hmo", "plan_name": "701720", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Ppo Hmo", "plan_name": "701720_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Ms State Emplo", "plan_name": "401457", "standard_charge_percentage": 0.80, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Ms State Emplo", "plan_name": "401457_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Basic Pl", "plan_name": "400100", "standard_charge_percentage": 0.85, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Basic Pl", "plan_name": "400100_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Federal", "plan_name": "400110", "standard_charge_percentage": 0.85, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Federal", "plan_name": "400110_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." } ] } ] }, { "description": "Sodium chloride 0.9 % intravenous piggyback [116170]", "drug_information": { "unit": 50.00, "type": "ML" }, "code_information": [ { "code": "0409-7101-66", "type": "NDC" } ], "standard_charges": [ { "gross_charge": 81.81, "minimum": 65.45, "maximum": 69.54, "setting": "both", "payers_information": [ { "payer_name": "Aetna", "plan_name": "700700", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna", "plan_name": "700700_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Miscellaneous", "plan_name": "700720", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Miscellaneous", "plan_name": "700720_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Ppo Hmo", "plan_name": "701720", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Ppo Hmo", "plan_name": "701720_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Ms State Emplo", "plan_name": "401457", "standard_charge_percentage": 0.80, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Ms State Emplo", "plan_name": "401457_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Basic Pl", "plan_name": "400100", "standard_charge_percentage": 0.85, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Basic Pl", "plan_name": "400100_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Federal", "plan_name": "400110", "standard_charge_percentage": 0.85, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Federal", "plan_name": "400110_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." } ] } ] }, { "description": "Sodium chloride 0.9 % intravenous piggyback [116170]", "drug_information": { "unit": 100.00, "type": "ML" }, "code_information": [ { "code": "0409-7101-67", "type": "NDC" } ], "standard_charges": [ { "gross_charge": 81.81, "minimum": 65.45, "maximum": 69.54, "setting": "both", "payers_information": [ { "payer_name": "Aetna", "plan_name": "700700", 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"standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Ppo Hmo", "plan_name": "701720_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Ms State Emplo", "plan_name": "401457", "standard_charge_percentage": 0.80, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Ms State Emplo", "plan_name": "401457_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Basic Pl", "plan_name": "400100", "standard_charge_percentage": 0.85, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Basic Pl", "plan_name": "400100_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Federal", "plan_name": "400110", "standard_charge_percentage": 0.85, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Federal", "plan_name": "400110_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." } ] } ] }, { "description": "Sodium chloride 0.9 % intravenous 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"Aetna Miscellaneous", "plan_name": "700720_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Ppo Hmo", "plan_name": "701720", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Ppo Hmo", "plan_name": "701720_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Ms State Emplo", "plan_name": "401457", "standard_charge_percentage": 0.80, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Ms State Emplo", "plan_name": "401457_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Basic Pl", "plan_name": "400100", "standard_charge_percentage": 0.85, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Basic Pl", "plan_name": "400100_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Federal", "plan_name": "400110", "standard_charge_percentage": 0.85, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Federal", "plan_name": "400110_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." } ] } ] }, { "description": "Sodium chloride 0.9 % intravenous piggyback [116170]", "drug_information": { "unit": 100.00, "type": "ML" }, "code_information": [ { "code": "0409-7101-69", "type": "NDC" } ], "standard_charges": [ { "gross_charge": 81.81, "minimum": 65.45, "maximum": 69.54, "setting": "both", "payers_information": [ { "payer_name": "Aetna", "plan_name": "700700", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna", "plan_name": "700700_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Miscellaneous", "plan_name": "700720", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Miscellaneous", "plan_name": "700720_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Ppo Hmo", "plan_name": "701720", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Ppo Hmo", "plan_name": "701720_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Ms State Emplo", "plan_name": "401457", "standard_charge_percentage": 0.80, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Ms State Emplo", "plan_name": "401457_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Basic Pl", "plan_name": "400100", "standard_charge_percentage": 0.85, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Basic Pl", "plan_name": "400100_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Federal", "plan_name": "400110", "standard_charge_percentage": 0.85, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Federal", "plan_name": "400110_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." } ] } ] }, { "description": "Sodium acetate 2 meq/ml intravenous solution [7301]", "drug_information": { "unit": 20.00, "type": "ML" }, "code_information": [ { "code": "0409-7299-73", "type": "NDC" } ], "standard_charges": [ { "gross_charge": 16.00, "minimum": 12.80, "maximum": 13.60, "setting": "both", "payers_information": [ { "payer_name": "Aetna", "plan_name": "700700", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna", "plan_name": "700700_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Miscellaneous", "plan_name": "700720", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Miscellaneous", "plan_name": "700720_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Ppo Hmo", "plan_name": "701720", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Ppo Hmo", "plan_name": "701720_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Ms State Emplo", "plan_name": "401457", "standard_charge_percentage": 0.80, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Ms State Emplo", "plan_name": "401457_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Basic Pl", "plan_name": "400100", "standard_charge_percentage": 0.85, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Basic Pl", "plan_name": "400100_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Federal", "plan_name": "400110", "standard_charge_percentage": 0.85, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Federal", "plan_name": "400110_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." } ] } ] }, { "description": "Sodium acetate 2 meq/ml oral solution (neo/ped) [507303]", "drug_information": { "unit": 20.00, "type": "ML" }, "code_information": [ { "code": "0409-7299-73", "type": "NDC" } ], "standard_charges": [ { "gross_charge": 16.00, "minimum": 12.80, "maximum": 13.60, "setting": "both", "payers_information": [ { "payer_name": "Aetna", "plan_name": "700700", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna", "plan_name": "700700_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Miscellaneous", "plan_name": "700720", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Miscellaneous", "plan_name": "700720_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Ppo Hmo", "plan_name": "701720", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Ppo Hmo", "plan_name": "701720_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Ms State Emplo", "plan_name": "401457", "standard_charge_percentage": 0.80, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Ms State Emplo", "plan_name": "401457_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Basic Pl", "plan_name": "400100", "standard_charge_percentage": 0.85, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Basic Pl", "plan_name": "400100_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Federal", "plan_name": "400110", "standard_charge_percentage": 0.85, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Federal", "plan_name": "400110_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." } ] } ] }, { "description": "Sodium acetate 2 meq/ml intravenous solution [7301]", "drug_information": { "unit": 20.00, "type": "ML" }, "code_information": [ { "code": "0409-7299-83", "type": "NDC" } ], "standard_charges": [ { "gross_charge": 16.00, "minimum": 12.80, "maximum": 13.60, "setting": "both", "payers_information": [ { "payer_name": "Aetna", "plan_name": "700700", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna", "plan_name": "700700_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Miscellaneous", "plan_name": "700720", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Miscellaneous", "plan_name": "700720_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Ppo Hmo", "plan_name": "701720", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Ppo Hmo", "plan_name": "701720_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Ms State Emplo", "plan_name": "401457", "standard_charge_percentage": 0.80, "count": "0", "methodology": 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"standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Ms State Emplo", "plan_name": "401457", "standard_charge_percentage": 0.80, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Ms State Emplo", "plan_name": "401457_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Basic Pl", "plan_name": "400100", "standard_charge_percentage": 0.85, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Basic Pl", "plan_name": "400100_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Federal", "plan_name": "400110", "standard_charge_percentage": 0.85, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Federal", "plan_name": "400110_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." } ] } ] }, { "description": "Sodium phosphate 3 mmol/ml intravenous solution [7351]", "drug_information": { "unit": 15.00, "type": "ML" }, "code_information": [ { "code": "0409-7391-82", "type": "NDC" } ], "standard_charges": [ { "gross_charge": 182.78, "minimum": 146.22, "maximum": 155.36, "setting": "both", 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"payer_name": "Aetna Ppo Hmo", "plan_name": "701720", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Ppo Hmo", "plan_name": "701720_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Ms State Emplo", "plan_name": "401457", "standard_charge_percentage": 0.80, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Ms State Emplo", "plan_name": "401457_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Basic Pl", "plan_name": "400100", "standard_charge_percentage": 0.85, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Basic Pl", "plan_name": "400100_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Federal", "plan_name": "400110", "standard_charge_percentage": 0.85, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Federal", "plan_name": "400110_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." } ] } ] }, { "description": "Sodium phosphate 3 mmol/ml oral solution (nicu) [507302]", "drug_information": { "unit": 15.00, "type": "ML" }, "code_information": [ { "code": "0409-7391-82", "type": "NDC" } ], "standard_charges": [ { "gross_charge": 182.78, "minimum": 146.22, "maximum": 155.36, "setting": "both", "payers_information": [ { "payer_name": "Aetna", "plan_name": "700700", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna", "plan_name": "700700_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Miscellaneous", "plan_name": "700720", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Miscellaneous", "plan_name": "700720_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Ppo Hmo", "plan_name": "701720", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Ppo Hmo", "plan_name": "701720_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Ms State Emplo", "plan_name": "401457", "standard_charge_percentage": 0.80, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate 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"additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Miscellaneous", "plan_name": "700720", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Miscellaneous", "plan_name": "700720_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Ppo Hmo", "plan_name": "701720", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Ppo Hmo", "plan_name": "701720_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Ms State Emplo", "plan_name": "401457", "standard_charge_percentage": 0.80, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Ms State Emplo", "plan_name": "401457_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Basic Pl", "plan_name": "400100", "standard_charge_percentage": 0.85, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Basic Pl", "plan_name": "400100_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Federal", "plan_name": "400110", "standard_charge_percentage": 0.85, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Federal", "plan_name": "400110_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." } ] } ] }, { "description": "Rocuronium 10 mg/ml intravenous solution [12734]", "drug_information": { "unit": 5.00, "type": "ML" }, "code_information": [ { "code": "0409-9558-05", "type": "NDC" } ], "standard_charges": [ { "gross_charge": 37.68, "minimum": 30.14, "maximum": 32.03, "setting": "both", "payers_information": [ { "payer_name": "Aetna", "plan_name": "700700", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna", "plan_name": "700700_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Miscellaneous", "plan_name": "700720", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Miscellaneous", "plan_name": "700720_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Ppo Hmo", "plan_name": "701720", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Ppo Hmo", "plan_name": "701720_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Ms State Emplo", "plan_name": "401457", "standard_charge_percentage": 0.80, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Ms State Emplo", "plan_name": "401457_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Basic Pl", "plan_name": "400100", "standard_charge_percentage": 0.85, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Basic Pl", "plan_name": "400100_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Federal", "plan_name": "400110", "standard_charge_percentage": 0.85, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Federal", "plan_name": "400110_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." } ] } ] }, { "description": "Rocuronium 10 mg/ml intravenous solution [12734]", "drug_information": { "unit": 5.00, "type": "ML" }, "code_information": [ { "code": "0409-9558-11", "type": "NDC" } ], "standard_charges": [ { "gross_charge": 37.68, "minimum": 30.14, "maximum": 32.03, "setting": "both", "payers_information": [ { "payer_name": "Aetna", "plan_name": "700700", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna", "plan_name": "700700_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Miscellaneous", "plan_name": "700720", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Miscellaneous", "plan_name": "700720_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Ppo Hmo", "plan_name": "701720", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Ppo Hmo", "plan_name": "701720_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Ms State Emplo", "plan_name": "401457", "standard_charge_percentage": 0.80, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Ms State Emplo", "plan_name": "401457_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Basic Pl", "plan_name": "400100", "standard_charge_percentage": 0.85, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Basic Pl", "plan_name": "400100_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Federal", "plan_name": "400110", "standard_charge_percentage": 0.85, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Federal", "plan_name": "400110_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." } ] } ] }, { "description": "Saccharomyces boulardii 250 mg capsule [37343]", "drug_information": { "unit": 1.00, "type": "EA" }, "code_information": [ { "code": "0414200024", "type": "NDC" } ], "standard_charges": [ { "gross_charge": 7.50, "minimum": 6.00, "maximum": 6.38, "setting": "both", "payers_information": [ { "payer_name": "Aetna", "plan_name": "700700", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna", "plan_name": "700700_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna 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"standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Ms State Emplo", "plan_name": "401457", "standard_charge_percentage": 0.80, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Ms State Emplo", "plan_name": "401457_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Basic Pl", "plan_name": "400100", "standard_charge_percentage": 0.85, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Basic Pl", "plan_name": "400100_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Federal", "plan_name": "400110", "standard_charge_percentage": 0.85, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Federal", "plan_name": "400110_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." } ] } ] }, { "description": "Betamethasone dipropionate 0.05 % topical cream [1027]", "drug_information": { "unit": 15.00, "type": "GR" }, "code_information": [ { "code": "0472-0380-15", "type": "NDC" } ], "standard_charges": [ { "gross_charge": 197.58, "minimum": 158.06, "maximum": 167.94, "setting": "both", 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"payer_name": "Aetna Ppo Hmo", "plan_name": "701720", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Ppo Hmo", "plan_name": "701720_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Ms State Emplo", "plan_name": "401457", "standard_charge_percentage": 0.80, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Ms State Emplo", "plan_name": "401457_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Basic Pl", "plan_name": "400100", "standard_charge_percentage": 0.85, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Basic Pl", "plan_name": "400100_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Federal", "plan_name": "400110", "standard_charge_percentage": 0.85, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Federal", "plan_name": "400110_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." } ] } ] }, { "description": "Albuterol sulfate 2 mg/5 ml oral syrup [252]", "drug_information": { "unit": 473.00, "type": "ML" }, "code_information": [ { "code": "0472-0825-16", "type": "NDC" } ], "standard_charges": [ { "gross_charge": 229.17, "minimum": 183.34, "maximum": 194.79, "setting": "both", "payers_information": [ { "payer_name": "Aetna", "plan_name": "700700", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna", "plan_name": "700700_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Miscellaneous", "plan_name": "700720", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to 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"additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Miscellaneous", "plan_name": "700720", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Miscellaneous", "plan_name": "700720_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Ppo Hmo", "plan_name": "701720", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Ppo Hmo", "plan_name": "701720_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Ms State Emplo", "plan_name": "401457", "standard_charge_percentage": 0.80, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Ms State Emplo", "plan_name": "401457_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Basic Pl", "plan_name": "400100", "standard_charge_percentage": 0.85, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Basic Pl", "plan_name": "400100_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Federal", "plan_name": "400110", "standard_charge_percentage": 0.85, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Federal", "plan_name": "400110_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." } ] } ] }, { "description": "Methenamine 81.6 mg-sod phos 40.8 mg-methylene blue 0.12mg-hyos tablet [119920]", "drug_information": { "unit": 1.00, "type": "EA" }, "code_information": [ { "code": "0485-0151-01", "type": "NDC" } ], "standard_charges": [ { "gross_charge": 21.00, "minimum": 16.80, "maximum": 17.85, "setting": "both", "payers_information": [ { "payer_name": "Aetna", "plan_name": "700700", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna", "plan_name": "700700_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Miscellaneous", "plan_name": "700720", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Miscellaneous", "plan_name": "700720_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Ppo Hmo", "plan_name": "701720", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Ppo Hmo", "plan_name": "701720_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Ms State Emplo", "plan_name": "401457", "standard_charge_percentage": 0.80, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Ms State Emplo", "plan_name": "401457_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Basic Pl", "plan_name": "400100", "standard_charge_percentage": 0.85, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Basic Pl", "plan_name": "400100_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Federal", "plan_name": "400110", "standard_charge_percentage": 0.85, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Federal", "plan_name": "400110_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." } ] } ] }, { "description": "Methenamine 81.6 mg-sod phos 40.8 mg-methylene blue 0.12mg-hyos tablet [119920]", "drug_information": { "unit": 1.00, "type": "EA" }, "code_information": [ { "code": "0485-0151-30", "type": "NDC" } ], "standard_charges": [ { "gross_charge": 22.06, "minimum": 17.65, "maximum": 18.75, "setting": "both", "payers_information": [ { "payer_name": "Aetna", "plan_name": "700700", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna", "plan_name": "700700_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Miscellaneous", "plan_name": "700720", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Miscellaneous", "plan_name": "700720_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Ppo Hmo", "plan_name": "701720", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Ppo Hmo", "plan_name": "701720_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Ms State Emplo", "plan_name": "401457", "standard_charge_percentage": 0.80, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Ms State Emplo", "plan_name": "401457_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Basic Pl", "plan_name": "400100", "standard_charge_percentage": 0.85, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Basic Pl", "plan_name": "400100_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Federal", "plan_name": "400110", "standard_charge_percentage": 0.85, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Federal", "plan_name": "400110_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." } ] } ] }, { "description": "Chlorpheniramine-phenylephrine 4 mg-10 mg/5 ml oral liquid [28164]", "drug_information": { "unit": 473.00, "type": "ML" }, "code_information": [ { "code": "0485-0155-16", "type": "NDC" } ], "standard_charges": [ { "gross_charge": 121.33, "minimum": 97.06, "maximum": 103.13, "setting": "both", "payers_information": [ { "payer_name": "Aetna", "plan_name": "700700", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna", "plan_name": "700700_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Miscellaneous", "plan_name": "700720", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Miscellaneous", "plan_name": "700720_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Ppo Hmo", "plan_name": "701720", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Ppo Hmo", "plan_name": "701720_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Ms State Emplo", "plan_name": "401457", "standard_charge_percentage": 0.80, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Ms State Emplo", "plan_name": "401457_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Basic Pl", "plan_name": "400100", "standard_charge_percentage": 0.85, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Basic Pl", "plan_name": "400100_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Federal", "plan_name": "400110", "standard_charge_percentage": 0.85, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Federal", "plan_name": "400110_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." } ] } ] }, { "description": "Chlorpheniramine 4 mg-phenylephrine 10 mg tablet [43444]", "drug_information": { "unit": 1.00, "type": "EA" }, "code_information": [ { "code": "0485-0254-01", "type": "NDC" } ], "standard_charges": [ { "gross_charge": 7.50, "minimum": 6.00, "maximum": 6.38, "setting": "both", "payers_information": [ { "payer_name": "Aetna", "plan_name": "700700", "standard_charge_percentage": 80.0, 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"methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Basic Pl", "plan_name": "400100_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Federal", "plan_name": "400110", "standard_charge_percentage": 0.85, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Federal", "plan_name": "400110_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." } ] } ] }, { "description": "Coenzyme q10 100 mg capsule [24678]", "drug_information": { "unit": 1.00, "type": "EA" }, 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100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Ppo Hmo", "plan_name": "701720", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Ppo Hmo", "plan_name": "701720_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Ms State Emplo", "plan_name": "401457", "standard_charge_percentage": 0.80, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Ms State Emplo", "plan_name": "401457_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Basic Pl", "plan_name": "400100", "standard_charge_percentage": 0.85, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Basic Pl", "plan_name": "400100_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Federal", "plan_name": "400110", "standard_charge_percentage": 0.85, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Federal", "plan_name": "400110_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." } ] } ] }, { "description": "Mirabegron er 25 mg tabletextended release 24 hr [158794]", "drug_information": { "unit": 1.00, "type": "EA" }, "code_information": [ { "code": "0469-2601-30", "type": "NDC" } ], "standard_charges": [ { "gross_charge": 68.55, "minimum": 54.84, "maximum": 58.27, "setting": "both", "payers_information": [ { "payer_name": "Aetna", "plan_name": "700700", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna", "plan_name": "700700_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Miscellaneous", "plan_name": "700720", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Miscellaneous", "plan_name": "700720_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Ppo Hmo", "plan_name": "701720", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Ppo Hmo", "plan_name": "701720_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Ms State Emplo", "plan_name": "401457", "standard_charge_percentage": 0.80, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Ms State Emplo", "plan_name": "401457_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Basic Pl", "plan_name": "400100", "standard_charge_percentage": 0.85, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Basic Pl", "plan_name": "400100_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Federal", "plan_name": "400110", "standard_charge_percentage": 0.85, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Federal", "plan_name": "400110_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." } ] } ] }, { "description": "Thyroid (pork) 30 mg tablet [119104]", "drug_information": { "unit": 1.00, "type": "EA" }, "code_information": [ { "code": "0456-0458-01", "type": "NDC" } ], "standard_charges": [ { "gross_charge": 7.50, "minimum": 6.00, "maximum": 6.38, "setting": "both", "payers_information": [ { "payer_name": "Aetna", "plan_name": "700700", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna", "plan_name": "700700_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Miscellaneous", "plan_name": "700720", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Miscellaneous", "plan_name": "700720_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Ppo Hmo", "plan_name": "701720", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Ppo Hmo", "plan_name": "701720_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Ms State Emplo", "plan_name": "401457", "standard_charge_percentage": 0.80, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Ms State Emplo", "plan_name": "401457_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Basic Pl", "plan_name": "400100", "standard_charge_percentage": 0.85, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Basic Pl", "plan_name": "400100_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Federal", "plan_name": "400110", "standard_charge_percentage": 0.85, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Federal", "plan_name": "400110_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." } ] } ] }, { "description": "Racepinephrine 2.25 % solution for nebulization [2851]", "drug_information": { "unit": 1.00, "type": "EA" }, "code_information": [ { "code": "0487-5901-99", "type": "NDC" } ], "standard_charges": [ { "gross_charge": 7.50, "minimum": 6.00, "maximum": 6.38, "setting": "both", 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"payer_name": "Aetna Ppo Hmo", "plan_name": "701720", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Ppo Hmo", "plan_name": "701720_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Ms State Emplo", "plan_name": "401457", "standard_charge_percentage": 0.80, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Ms State Emplo", "plan_name": "401457_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Basic Pl", "plan_name": "400100", "standard_charge_percentage": 0.85, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Basic Pl", "plan_name": "400100_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Federal", "plan_name": "400110", "standard_charge_percentage": 0.85, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Federal", "plan_name": "400110_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." } ] } ] }, { "description": "Sodium chloride 0.9 % for nebulization [7325]", "drug_information": { "unit": 3.00, "type": "ML" }, "code_information": [ { "code": "0487-9301-33", "type": "NDC" } ], "standard_charges": [ { "gross_charge": 28.50, "minimum": 22.80, "maximum": 24.23, "setting": "both", "payers_information": [ { "payer_name": "Aetna", "plan_name": "700700", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna", "plan_name": "700700_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Miscellaneous", "plan_name": "700720", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Miscellaneous", "plan_name": "700720_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Ppo Hmo", "plan_name": "701720", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Ppo Hmo", "plan_name": "701720_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Ms State Emplo", "plan_name": "401457", "standard_charge_percentage": 0.80, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Ms State Emplo", "plan_name": "401457_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Basic Pl", "plan_name": "400100", "standard_charge_percentage": 0.85, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Basic Pl", "plan_name": "400100_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Federal", "plan_name": "400110", "standard_charge_percentage": 0.85, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Federal", "plan_name": "400110_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." } ] } ] }, { "description": "Sodium chloride 3 % for nebulization [7327]", "drug_information": { "unit": 4.00, "type": "ML" }, "code_information": [ { "code": "0487900360", "type": "NDC" } ], "standard_charges": [ { "gross_charge": 7.50, "minimum": 6.00, "maximum": 6.38, "setting": "both", "payers_information": [ { "payer_name": "Aetna", "plan_name": "700700", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna", "plan_name": "700700_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Miscellaneous", "plan_name": "700720", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Miscellaneous", "plan_name": "700720_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Ppo Hmo", "plan_name": "701720", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Ppo Hmo", "plan_name": "701720_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Ms State Emplo", "plan_name": "401457", "standard_charge_percentage": 0.80, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Ms State Emplo", "plan_name": "401457_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Basic Pl", "plan_name": "400100", "standard_charge_percentage": 0.85, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Basic Pl", "plan_name": "400100_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to 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"payer_name": "Bc/Bs Of Ms Basic Pl", "plan_name": "400100", "standard_charge_percentage": 0.85, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Basic Pl", "plan_name": "400100_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Federal", "plan_name": "400110", "standard_charge_percentage": 0.85, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Federal", "plan_name": "400110_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." } ] } ] }, { "description": "Chlorpheniramine 4 mg tablet [1645]", "drug_information": { "unit": 1.00, "type": "EA" }, "code_information": [ { "code": "0536-1006-01", "type": "NDC" } ], "standard_charges": [ { "gross_charge": 1.00, "minimum": 0.80, "maximum": 0.85, "setting": "both", "payers_information": [ { "payer_name": "Aetna", "plan_name": "700700", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna", "plan_name": "700700_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Miscellaneous", "plan_name": "700720", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate 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}, { "payer_name": "Bc/Bs Ms State Emplo", "plan_name": "401457_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Basic Pl", "plan_name": "400100", "standard_charge_percentage": 0.85, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Basic Pl", "plan_name": "400100_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Federal", "plan_name": "400110", "standard_charge_percentage": 0.85, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Federal", "plan_name": "400110_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." } ] } ] }, { "description": "Docusate sodium 100 mg capsule [2566]", "drug_information": { "unit": 1.00, "type": "EA" }, "code_information": [ { "code": "0536-1062-29", "type": "NDC" } ], "standard_charges": [ { "gross_charge": 1.00, "minimum": 0.80, "maximum": 0.85, "setting": "both", "payers_information": [ { "payer_name": "Aetna", "plan_name": "700700", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna", "plan_name": "700700_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to 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"additional_payer_notes": "Insufficient remit data to calculate allowed amounts." } ] } ] }, { "description": "Dibucaine 1 % topical ointment [2412]", "drug_information": { "unit": 28.00, "type": "GR" }, "code_information": [ { "code": "0536-1211-95", "type": "NDC" } ], "standard_charges": [ { "gross_charge": 29.66, "minimum": 23.73, "maximum": 25.21, "setting": "both", "payers_information": [ { "payer_name": "Aetna", "plan_name": "700700", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna", "plan_name": "700700_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Miscellaneous", "plan_name": "700720", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Miscellaneous", "plan_name": "700720_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Ppo Hmo", "plan_name": "701720", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Ppo Hmo", "plan_name": "701720_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Ms State Emplo", "plan_name": "401457", "standard_charge_percentage": 0.80, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Ms State Emplo", "plan_name": "401457_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Basic Pl", "plan_name": "400100", "standard_charge_percentage": 0.85, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Basic Pl", "plan_name": "400100_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Federal", "plan_name": "400110", "standard_charge_percentage": 0.85, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Federal", "plan_name": "400110_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." } ] } ] }, { "description": "Phenol 1.4 % mucosal aerosol spray [27889]", "drug_information": { "unit": 177.00, "type": "ML" }, "code_information": [ { "code": "0536-1228-58", "type": "NDC" } ], "standard_charges": [ { "gross_charge": 9.20, "minimum": 7.36, "maximum": 7.82, "setting": "both", "payers_information": [ { "payer_name": "Aetna", "plan_name": "700700", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna", "plan_name": "700700_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Miscellaneous", "plan_name": "700720", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Miscellaneous", "plan_name": "700720_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Ppo Hmo", "plan_name": "701720", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Ppo Hmo", "plan_name": "701720_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Ms State Emplo", "plan_name": "401457", "standard_charge_percentage": 0.80, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Ms State Emplo", "plan_name": "401457_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Basic Pl", "plan_name": "400100", "standard_charge_percentage": 0.85, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Basic Pl", "plan_name": "400100_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Federal", "plan_name": "400110", "standard_charge_percentage": 0.85, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Federal", "plan_name": "400110_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." } ] } ] }, { "description": "Aspirin 325 mg tabletdelayed release [685]", "drug_information": { "unit": 1.00, "type": "EA" }, "code_information": [ { "code": "0536-1232-01", "type": "NDC" } ], "standard_charges": [ { "gross_charge": 1.00, "minimum": 0.80, "maximum": 0.85, "setting": "both", "payers_information": [ { "payer_name": "Aetna", "plan_name": "700700", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna", "plan_name": "700700_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Miscellaneous", "plan_name": "700720", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Miscellaneous", "plan_name": "700720_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Ppo Hmo", "plan_name": "701720", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Ppo Hmo", "plan_name": "701720_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Ms State Emplo", "plan_name": "401457", "standard_charge_percentage": 0.80, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Ms State Emplo", "plan_name": "401457_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Basic Pl", "plan_name": "400100", "standard_charge_percentage": 0.85, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Basic Pl", "plan_name": "400100_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Federal", "plan_name": "400110", "standard_charge_percentage": 0.85, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Federal", "plan_name": "400110_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." } ] } ] }, { "description": "Aspirin 81 mg tabletdelayed release [688]", "drug_information": { "unit": 1.00, "type": "EA" }, "code_information": [ { "code": "0536-1234-41", "type": "NDC" } ], "standard_charges": [ { "gross_charge": 1.00, "minimum": 0.80, "maximum": 0.85, "setting": "both", "payers_information": [ { "payer_name": "Aetna", "plan_name": "700700", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna", "plan_name": "700700_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Miscellaneous", "plan_name": "700720", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna 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"plan_name": "400110_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." } ] } ] }, { "description": "Sodium chloride 5 % eye drops [7332]", "drug_information": { "unit": 15.00, "type": "ML" }, "code_information": [ { "code": "0536-1254-94", "type": "NDC" } ], "standard_charges": [ { "gross_charge": 26.43, "minimum": 21.14, "maximum": 22.47, "setting": "both", "payers_information": [ { "payer_name": "Aetna", "plan_name": "700700", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna", "plan_name": "700700_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Miscellaneous", "plan_name": "700720", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Miscellaneous", "plan_name": "700720_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Ppo Hmo", "plan_name": "701720", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Ppo Hmo", "plan_name": "701720_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Ms State Emplo", "plan_name": "401457", "standard_charge_percentage": 0.80, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Ms State Emplo", "plan_name": "401457_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Basic Pl", "plan_name": "400100", "standard_charge_percentage": 0.85, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Basic Pl", "plan_name": "400100_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Federal", "plan_name": "400110", "standard_charge_percentage": 0.85, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Federal", "plan_name": "400110_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." } ] } ] }, { "description": "Clotrimazole 1 % topical cream [1767]", "drug_information": { "unit": 28.00, "type": "GR" }, "code_information": [ { "code": "0536-1265-95", "type": "NDC" } ], "standard_charges": [ { "gross_charge": 5.24, "minimum": 4.19, "maximum": 4.45, "setting": "both", "payers_information": [ { "payer_name": "Aetna", "plan_name": "700700", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to 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}, { "payer_name": "Bc/Bs Of Ms Basic Pl", "plan_name": "400100_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Federal", "plan_name": "400110", "standard_charge_percentage": 0.85, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Federal", "plan_name": "400110_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." } ] } ] }, { "description": "Clotrimazole 1 % topical cream [1767]", "drug_information": { "unit": 28.00, "type": "GR" }, "code_information": [ { "code": "0536-1272-22", "type": "NDC" } ], "standard_charges": [ { "gross_charge": 6.63, "minimum": 5.30, "maximum": 5.64, "setting": "both", "payers_information": [ { "payer_name": "Aetna", "plan_name": "700700", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna", "plan_name": "700700_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Miscellaneous", "plan_name": "700720", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Miscellaneous", "plan_name": "700720_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to 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allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Basic Pl", "plan_name": "400100", "standard_charge_percentage": 0.85, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Basic Pl", "plan_name": "400100_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Federal", "plan_name": "400110", "standard_charge_percentage": 0.85, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Federal", "plan_name": "400110_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." } ] } ] }, { "description": "Simethicone 40 mg/0.6 ml oral dropssuspension [7228]", "drug_information": { "unit": 30.00, "type": "ML" }, "code_information": [ { "code": "0536-1303-75", "type": "NDC" } ], "standard_charges": [ { "gross_charge": 7.18, "minimum": 5.74, "maximum": 6.10, "setting": "both", "payers_information": [ { "payer_name": "Aetna", "plan_name": "700700", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna", "plan_name": "700700_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Miscellaneous", "plan_name": "700720", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Miscellaneous", "plan_name": "700720_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Ppo Hmo", "plan_name": "701720", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Ppo Hmo", "plan_name": "701720_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Ms State Emplo", "plan_name": "401457", "standard_charge_percentage": 0.80, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Ms State Emplo", "plan_name": "401457_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Basic Pl", "plan_name": "400100", "standard_charge_percentage": 0.85, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Basic Pl", "plan_name": "400100_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Federal", "plan_name": "400110", "standard_charge_percentage": 0.85, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Federal", "plan_name": "400110_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." } ] } ] }, { "description": "Zinc oxide 20 % topical ointment [8874]", "drug_information": { "unit": 30.00, "type": "GR" }, "code_information": [ { "code": "0536-1316-28", "type": "NDC" } ], "standard_charges": [ { "gross_charge": 6.79, "minimum": 5.43, "maximum": 5.77, "setting": "both", "payers_information": [ { "payer_name": "Aetna", "plan_name": "700700", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna", "plan_name": "700700_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Miscellaneous", "plan_name": "700720", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Miscellaneous", "plan_name": "700720_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Ppo Hmo", "plan_name": "701720", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Ppo Hmo", "plan_name": "701720_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Ms State Emplo", "plan_name": "401457", "standard_charge_percentage": 0.80, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Ms State Emplo", "plan_name": "401457_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Basic Pl", "plan_name": "400100", "standard_charge_percentage": 0.85, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Basic Pl", "plan_name": "400100_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Federal", "plan_name": "400110", "standard_charge_percentage": 0.85, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Federal", "plan_name": "400110_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." } ] } ] }, { "description": "Capsaicin 0.025 % topical cream [1350]", "drug_information": { "unit": 60.00, "type": "GR" }, "code_information": [ { "code": "0536-2525-25", "type": "NDC" } ], "standard_charges": [ { "gross_charge": 26.36, "minimum": 21.09, "maximum": 22.41, "setting": "both", "payers_information": [ { "payer_name": "Aetna", "plan_name": "700700", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna", "plan_name": "700700_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Miscellaneous", "plan_name": "700720", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Miscellaneous", "plan_name": "700720_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Ppo Hmo", "plan_name": "701720", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Ppo Hmo", "plan_name": "701720_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Ms State Emplo", "plan_name": "401457", "standard_charge_percentage": 0.80, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Ms State Emplo", "plan_name": "401457_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Basic Pl", "plan_name": "400100", "standard_charge_percentage": 0.85, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Basic Pl", "plan_name": "400100_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Federal", "plan_name": "400110", "standard_charge_percentage": 0.85, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Federal", "plan_name": "400110_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." } ] } ] }, { "description": "Nicotine 21 mg/24 hr daily transdermal patch [27863]", "drug_information": { "unit": 1.00, "type": "EA" }, "code_information": [ { "code": "0536-5896-88", "type": "NDC" } ], "standard_charges": [ { "gross_charge": 5.66, "minimum": 4.53, "maximum": 4.81, "setting": "both", "payers_information": [ { "payer_name": "Aetna", "plan_name": "700700", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna", "plan_name": "700700_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Miscellaneous", "plan_name": "700720", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Miscellaneous", "plan_name": "700720_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Ppo Hmo", "plan_name": "701720", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Ppo Hmo", "plan_name": "701720_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Ms State Emplo", "plan_name": "401457", "standard_charge_percentage": 0.80, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Ms State Emplo", "plan_name": "401457_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Basic Pl", "plan_name": "400100", "standard_charge_percentage": 0.85, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Basic Pl", "plan_name": "400100_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Federal", "plan_name": "400110", "standard_charge_percentage": 0.85, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Federal", "plan_name": "400110_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." } ] } ] }, { "description": "Sodium phosphates 19 gram-7 gram/118 ml enema [11395]", "drug_information": { "unit": 133.00, "type": "ML" }, "code_information": [ { "code": "0536-7415-51", "type": "NDC" } ], "standard_charges": [ { "gross_charge": 4.84, "minimum": 3.87, "maximum": 4.11, "setting": "both", "payers_information": [ { "payer_name": "Aetna", "plan_name": "700700", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna", "plan_name": "700700_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Miscellaneous", "plan_name": "700720", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Miscellaneous", "plan_name": "700720_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Ppo Hmo", "plan_name": "701720", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Ppo Hmo", "plan_name": "701720_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Ms State Emplo", "plan_name": "401457", "standard_charge_percentage": 0.80, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Ms State Emplo", "plan_name": "401457_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Basic Pl", "plan_name": "400100", "standard_charge_percentage": 0.85, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Basic Pl", "plan_name": "400100_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Federal", "plan_name": "400110", "standard_charge_percentage": 0.85, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Federal", "plan_name": "400110_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." } ] } ] }, { "description": "Acidophilus 25 million cell-pectin citrus 100 mg tablet [134]", "drug_information": { "unit": 1.00, "type": "EA" }, "code_information": [ { "code": "0536142401", "type": "NDC" } ], "standard_charges": [ { "gross_charge": 7.50, "minimum": 6.00, "maximum": 6.38, "setting": "both", "payers_information": [ { "payer_name": "Aetna", "plan_name": "700700", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna", "plan_name": "700700_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Miscellaneous", "plan_name": "700720", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Miscellaneous", "plan_name": "700720_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Ppo Hmo", "plan_name": "701720", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Ppo Hmo", "plan_name": "701720_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Ms State Emplo", "plan_name": "401457", "standard_charge_percentage": 0.80, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Ms State Emplo", "plan_name": "401457_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Basic Pl", "plan_name": "400100", "standard_charge_percentage": 0.85, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Basic Pl", "plan_name": "400100_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Federal", "plan_name": "400110", "standard_charge_percentage": 0.85, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Federal", "plan_name": "400110_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." } ] } ] }, { "description": "Multivitamin-ferrous fumarate-folic acid 18 mg-400 mcg tablet [118668]", "drug_information": { "unit": 1.00, "type": "EA" }, "code_information": [ { "code": "0536344238", "type": "NDC" } ], "standard_charges": [ { "gross_charge": 1.00, "minimum": 0.80, "maximum": 0.85, "setting": "both", "payers_information": [ { "payer_name": "Aetna", "plan_name": "700700", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna", "plan_name": "700700_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Miscellaneous", "plan_name": "700720", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Miscellaneous", "plan_name": "700720_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Ppo Hmo", "plan_name": "701720", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Ppo Hmo", "plan_name": "701720_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Ms State Emplo", "plan_name": "401457", "standard_charge_percentage": 0.80, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Ms State Emplo", "plan_name": "401457_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Basic Pl", "plan_name": "400100", "standard_charge_percentage": 0.85, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Basic Pl", "plan_name": "400100_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Federal", "plan_name": "400110", "standard_charge_percentage": 0.85, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Federal", "plan_name": "400110_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." } ] } ] }, { "description": "Multivit-min-folic acid 0.4 mg-lycopene 300 mcg-lutein 250 mcg tablet [115775]", "drug_information": { "unit": 1.00, "type": "EA" }, "code_information": [ { "code": "0536344508", "type": "NDC" } ], "standard_charges": [ { "gross_charge": 7.50, "minimum": 6.00, "maximum": 6.38, "setting": "both", "payers_information": [ { "payer_name": "Aetna", "plan_name": "700700", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna", "plan_name": "700700_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Miscellaneous", "plan_name": "700720", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Miscellaneous", "plan_name": "700720_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Ppo Hmo", "plan_name": "701720", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Ppo Hmo", "plan_name": "701720_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Ms State Emplo", "plan_name": "401457", "standard_charge_percentage": 0.80, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Ms State Emplo", "plan_name": "401457_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Basic Pl", "plan_name": "400100", "standard_charge_percentage": 0.85, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Basic Pl", "plan_name": "400100_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Federal", "plan_name": "400110", "standard_charge_percentage": 0.85, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Federal", "plan_name": "400110_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." } ] } ] }, { "description": "Pyridoxine (vitamin b6) 25 mg tablet [6746]", "drug_information": { "unit": 1.00, "type": "EA" }, "code_information": [ { "code": "0536440601", "type": "NDC" } ], "standard_charges": [ { "gross_charge": 1.00, "minimum": 0.80, "maximum": 0.85, "setting": "both", "payers_information": [ { "payer_name": "Aetna", "plan_name": "700700", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna", "plan_name": "700700_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Miscellaneous", "plan_name": "700720", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Miscellaneous", "plan_name": "700720_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Ppo Hmo", "plan_name": "701720", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Ppo Hmo", "plan_name": "701720_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Ms State Emplo", "plan_name": "401457", "standard_charge_percentage": 0.80, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Ms State Emplo", "plan_name": "401457_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Basic Pl", "plan_name": "400100", "standard_charge_percentage": 0.85, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Basic Pl", "plan_name": "400100_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Federal", "plan_name": "400110", "standard_charge_percentage": 0.85, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Federal", "plan_name": "400110_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." } ] } ] }, { "description": "Vit a 300 mcg-c 200 mg-e 27 mg-lutein 2 mg and minerals tablet [116554]", "drug_information": { "unit": 1.00, "type": "EA" }, "code_information": [ { "code": "0536509008", "type": "NDC" } ], "standard_charges": [ { "gross_charge": 1.00, "minimum": 0.80, "maximum": 0.85, "setting": "both", "payers_information": [ { "payer_name": "Aetna", "plan_name": "700700", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna", "plan_name": "700700_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Miscellaneous", "plan_name": "700720", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Miscellaneous", "plan_name": "700720_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Ppo Hmo", "plan_name": "701720", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Ppo Hmo", "plan_name": "701720_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Ms State Emplo", "plan_name": "401457", "standard_charge_percentage": 0.80, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Ms State Emplo", "plan_name": "401457_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Basic Pl", "plan_name": "400100", "standard_charge_percentage": 0.85, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Basic Pl", "plan_name": "400100_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Federal", "plan_name": "400110", "standard_charge_percentage": 0.85, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Federal", "plan_name": "400110_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." } ] } ] }, { "description": "Calcium chloride 100 mg/ml (10 %) intravenous solution [108968]", "drug_information": { "unit": 10.00, "type": "ML" }, "code_information": [ { "code": "0517-6710-01", "type": "NDC" } ], "standard_charges": [ { "gross_charge": 202.20, "minimum": 161.76, "maximum": 171.87, "setting": "both", "payers_information": [ { "payer_name": "Aetna", "plan_name": "700700", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna", "plan_name": "700700_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Miscellaneous", "plan_name": "700720", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Miscellaneous", "plan_name": "700720_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Ppo Hmo", "plan_name": "701720", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Ppo Hmo", "plan_name": "701720_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Ms State Emplo", "plan_name": "401457", "standard_charge_percentage": 0.80, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Ms State Emplo", "plan_name": "401457_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Basic Pl", "plan_name": "400100", "standard_charge_percentage": 0.85, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Basic Pl", "plan_name": "400100_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Federal", "plan_name": "400110", "standard_charge_percentage": 0.85, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient 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"standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Ms State Emplo", "plan_name": "401457", "standard_charge_percentage": 0.80, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Ms State Emplo", "plan_name": "401457_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Basic Pl", "plan_name": "400100", "standard_charge_percentage": 0.85, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Basic Pl", "plan_name": "400100_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Federal", "plan_name": "400110", "standard_charge_percentage": 0.85, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Federal", "plan_name": "400110_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." } ] } ] }, { "description": "Megestrol 20 mg tablet [4870]", "drug_information": { "unit": 1.00, "type": "EA" }, "code_information": [ { "code": "0555-0606-02", "type": "NDC" } ], "standard_charges": [ { "gross_charge": 7.50, "minimum": 6.00, "maximum": 6.38, "setting": "both", "payers_information": [ { "payer_name": 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"701720", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Ppo Hmo", "plan_name": "701720_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Ms State Emplo", "plan_name": "401457", "standard_charge_percentage": 0.80, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Ms State Emplo", "plan_name": "401457_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Basic Pl", "plan_name": "400100", "standard_charge_percentage": 0.85, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Basic Pl", "plan_name": "400100_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Federal", "plan_name": "400110", "standard_charge_percentage": 0.85, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Federal", "plan_name": "400110_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." } ] } ] }, { "description": "Estradiol 1 mg tablet [9967]", "drug_information": { "unit": 1.00, "type": "EA" }, "code_information": [ { "code": "0555-0886-02", "type": "NDC" } ], "standard_charges": [ { "gross_charge": 7.50, "minimum": 6.00, "maximum": 6.38, "setting": "both", "payers_information": [ { "payer_name": "Aetna", "plan_name": "700700", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna", "plan_name": "700700_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Miscellaneous", "plan_name": "700720", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Miscellaneous", "plan_name": "700720_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Ppo Hmo", "plan_name": "701720", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Ppo Hmo", "plan_name": "701720_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Ms State Emplo", "plan_name": "401457", "standard_charge_percentage": 0.80, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Ms State Emplo", "plan_name": "401457_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Basic Pl", "plan_name": "400100", "standard_charge_percentage": 0.85, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Basic Pl", "plan_name": "400100_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Federal", "plan_name": "400110", "standard_charge_percentage": 0.85, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Federal", "plan_name": "400110_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." } ] } ] }, { "description": "Estradiol 0.5 mg tablet [12491]", "drug_information": { "unit": 1.00, "type": "EA" }, "code_information": [ { "code": "0555-0899-02", "type": "NDC" } ], "standard_charges": [ { "gross_charge": 7.50, "minimum": 6.00, "maximum": 6.38, "setting": "both", "payers_information": [ { "payer_name": "Aetna", "plan_name": "700700", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna", "plan_name": "700700_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna 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"payer_name": "Bc/Bs Of Ms Basic Pl", "plan_name": "400100_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Federal", "plan_name": "400110", "standard_charge_percentage": 0.85, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Federal", "plan_name": "400110_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." } ] } ] }, { "description": "Nystatin 100000 unit/gram topical powder [39136]", "drug_information": { "unit": 60.00, "type": "GR" }, "code_information": [ { "code": "0574-2008-02", "type": "NDC" } ], "standard_charges": [ { "gross_charge": 455.43, 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"methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Miscellaneous", "plan_name": "700720", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Miscellaneous", "plan_name": "700720_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Ppo Hmo", "plan_name": "701720", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Ppo Hmo", "plan_name": "701720_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Ms State Emplo", "plan_name": "401457", "standard_charge_percentage": 0.80, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Ms State Emplo", "plan_name": "401457_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Basic Pl", "plan_name": "400100", "standard_charge_percentage": 0.85, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Basic Pl", "plan_name": "400100_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Federal", "plan_name": "400110", "standard_charge_percentage": 0.85, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Federal", "plan_name": "400110_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." } ] } ] }, { "description": "Lidocaine-prilocaine 2.5 %-2.5 % topical cream [10434]", "drug_information": { "unit": 30.00, "type": "GR" }, "code_information": [ { "code": "0574-2042-30", "type": "NDC" } ], "standard_charges": [ { "gross_charge": 87.35, "minimum": 69.88, "maximum": 74.25, "setting": "both", "payers_information": [ { "payer_name": "Aetna", "plan_name": "700700", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna", "plan_name": "700700_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Miscellaneous", "plan_name": "700720", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Miscellaneous", "plan_name": "700720_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Ppo Hmo", "plan_name": "701720", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Ppo Hmo", "plan_name": "701720_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Ms State Emplo", "plan_name": "401457", "standard_charge_percentage": 0.80, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Ms State Emplo", "plan_name": "401457_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Basic Pl", "plan_name": "400100", "standard_charge_percentage": 0.85, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Basic Pl", "plan_name": "400100_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Federal", "plan_name": "400110", "standard_charge_percentage": 0.85, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Federal", "plan_name": "400110_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." } ] } ] }, { "description": "Erythromycin 5 mg/gram (0.5 %) eye 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"Aetna Miscellaneous", "plan_name": "700720_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Ppo Hmo", "plan_name": "701720", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Ppo Hmo", "plan_name": "701720_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Ms State Emplo", "plan_name": "401457", "standard_charge_percentage": 0.80, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Ms State Emplo", "plan_name": "401457_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Basic Pl", "plan_name": "400100", "standard_charge_percentage": 0.85, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Basic Pl", "plan_name": "400100_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Federal", "plan_name": "400110", "standard_charge_percentage": 0.85, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms 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"plan_name": "400100", "standard_charge_percentage": 0.85, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Basic Pl", "plan_name": "400100_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Federal", "plan_name": "400110", "standard_charge_percentage": 0.85, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Federal", "plan_name": "400110_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." } ] } ] }, { "description": "Hydrocortisone acetate 25 mg rectal suppository [3738]", "drug_information": { "unit": 1.00, "type": "EA" }, "code_information": [ { "code": "0574-7090-12", "type": "NDC" } ], "standard_charges": [ { "gross_charge": 68.51, "minimum": 54.81, "maximum": 58.23, "setting": "both", "payers_information": [ { "payer_name": "Aetna", "plan_name": "700700", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna", "plan_name": "700700_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Miscellaneous", "plan_name": "700720", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." 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"payer_name": "Bc/Bs Ms State Emplo", "plan_name": "401457_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Basic Pl", "plan_name": "400100", "standard_charge_percentage": 0.85, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Basic Pl", "plan_name": "400100_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Federal", "plan_name": "400110", "standard_charge_percentage": 0.85, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { 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"401457_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Basic Pl", "plan_name": "400100", "standard_charge_percentage": 0.85, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Basic Pl", "plan_name": "400100_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Federal", "plan_name": "400110", "standard_charge_percentage": 0.85, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Federal", "plan_name": 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"plan_name": "400110", "standard_charge_percentage": 0.85, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Federal", "plan_name": "400110_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." } ] } ] }, { "description": "Dicyclomine 10 mg capsule [2418]", "drug_information": { "unit": 1.00, "type": "EA" }, "code_information": [ { "code": "0591-0794-01", "type": "NDC" } ], "standard_charges": [ { "gross_charge": 7.50, "minimum": 6.00, "maximum": 6.38, "setting": "both", "payers_information": [ { "payer_name": "Aetna", "plan_name": "700700", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { 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"standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Ms State Emplo", "plan_name": "401457", "standard_charge_percentage": 0.80, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Ms State Emplo", "plan_name": "401457_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Basic Pl", "plan_name": "400100", "standard_charge_percentage": 0.85, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Basic Pl", "plan_name": "400100_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Federal", "plan_name": "400110", "standard_charge_percentage": 0.85, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Federal", "plan_name": "400110_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." } ] } ] }, { "description": "Memantine 5 mg tablet [37170]", "drug_information": { "unit": 1.00, "type": "EA" }, "code_information": [ { "code": "0591-3870-45", "type": "NDC" } ], "standard_charges": [ { "gross_charge": 7.50, "minimum": 6.00, "maximum": 6.38, "setting": "both", "payers_information": [ { "payer_name": "Aetna", "plan_name": "700700", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna", "plan_name": "700700_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Miscellaneous", "plan_name": "700720", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Miscellaneous", "plan_name": "700720_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Ppo Hmo", "plan_name": "701720", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Ppo Hmo", "plan_name": "701720_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Ms State Emplo", "plan_name": "401457", "standard_charge_percentage": 0.80, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Ms State Emplo", "plan_name": "401457_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Basic Pl", "plan_name": "400100", "standard_charge_percentage": 0.85, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Basic Pl", "plan_name": "400100_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Federal", "plan_name": "400110", "standard_charge_percentage": 0.85, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Federal", "plan_name": "400110_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." } ] } ] }, { "description": "Memantine 10 mg tablet [36966]", "drug_information": { "unit": 1.00, "type": "EA" }, "code_information": [ { "code": "0591-3875-44", "type": "NDC" } ], "standard_charges": [ { "gross_charge": 7.50, "minimum": 6.00, "maximum": 6.38, "setting": "both", "payers_information": [ { "payer_name": "Aetna", "plan_name": "700700", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna", "plan_name": "700700_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Miscellaneous", "plan_name": "700720", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Miscellaneous", "plan_name": "700720_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Ppo Hmo", "plan_name": "701720", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Ppo Hmo", "plan_name": "701720_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Ms State Emplo", "plan_name": "401457", "standard_charge_percentage": 0.80, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Ms State Emplo", "plan_name": "401457_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Basic Pl", "plan_name": "400100", "standard_charge_percentage": 0.85, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Basic Pl", "plan_name": "400100_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Federal", "plan_name": "400110", "standard_charge_percentage": 0.85, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Federal", "plan_name": "400110_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." } ] } ] }, { "description": "Memantine 10 mg tablet [36966]", "drug_information": { "unit": 1.00, "type": "EA" }, "code_information": [ { "code": "0591-3875-45", "type": "NDC" } ], "standard_charges": [ { "gross_charge": 7.50, "minimum": 6.00, "maximum": 6.38, "setting": "both", "payers_information": [ { "payer_name": "Aetna", "plan_name": "700700", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna", "plan_name": "700700_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna 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"plan_name": "401457", "standard_charge_percentage": 0.80, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Ms State Emplo", "plan_name": "401457_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Basic Pl", "plan_name": "400100", "standard_charge_percentage": 0.85, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Basic Pl", "plan_name": "400100_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Federal", "plan_name": "400110", "standard_charge_percentage": 0.85, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Federal", "plan_name": "400110_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." } ] } ] }, { "description": "Tiotropium bromide 18 mcg capsule with inhalation device [38315]", "drug_information": { "unit": 5.00, "type": "EA" }, "code_information": [ { "code": "0597-0075-75", "type": "NDC" } ], "standard_charges": [ { "gross_charge": 453.10, "minimum": 362.48, "maximum": 385.14, "setting": "both", "payers_information": [ { "payer_name": "Aetna", "plan_name": "700700", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna", "plan_name": "700700_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Miscellaneous", "plan_name": "700720", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Miscellaneous", "plan_name": "700720_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Ppo Hmo", "plan_name": "701720", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Ppo Hmo", "plan_name": "701720_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Ms State Emplo", "plan_name": "401457", "standard_charge_percentage": 0.80, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Ms State Emplo", "plan_name": "401457_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Basic Pl", "plan_name": "400100", "standard_charge_percentage": 0.85, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Basic Pl", "plan_name": "400100_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Federal", "plan_name": "400110", "standard_charge_percentage": 0.85, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Federal", "plan_name": "400110_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." } ] } ] }, { "description": "Tiotropium bromide 2.5 mcg/actuation mist for inhalation [167974]", "drug_information": { "unit": 4.00, "type": "GR" }, "code_information": [ { "code": "0597-0100-51", "type": "NDC" } ], "standard_charges": [ { "gross_charge": 335.12, "minimum": 268.10, "maximum": 284.85, "setting": "both", "payers_information": [ { "payer_name": "Aetna", "plan_name": "700700", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna", "plan_name": "700700_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Miscellaneous", "plan_name": "700720", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Miscellaneous", "plan_name": "700720_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Ppo Hmo", "plan_name": "701720", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Ppo Hmo", "plan_name": "701720_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Ms State Emplo", "plan_name": "401457", "standard_charge_percentage": 0.80, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Ms State Emplo", "plan_name": "401457_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Basic Pl", "plan_name": "400100", "standard_charge_percentage": 0.85, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Basic Pl", "plan_name": "400100_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Federal", "plan_name": "400110", "standard_charge_percentage": 0.85, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Federal", "plan_name": "400110_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." } ] } ] }, { "description": "Linagliptin 5 mg tablet [151385]", "drug_information": { "unit": 1.00, "type": "EA" }, "code_information": [ { "code": "0597-0140-30", "type": "NDC" } ], "standard_charges": [ { "gross_charge": 78.20, "minimum": 62.56, "maximum": 66.47, "setting": "both", "payers_information": [ { "payer_name": "Aetna", "plan_name": "700700", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna", "plan_name": "700700_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Miscellaneous", "plan_name": "700720", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Miscellaneous", "plan_name": "700720_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Ppo Hmo", "plan_name": "701720", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Ppo Hmo", "plan_name": "701720_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Ms State Emplo", "plan_name": "401457", "standard_charge_percentage": 0.80, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Ms State Emplo", "plan_name": "401457_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Basic Pl", "plan_name": "400100", "standard_charge_percentage": 0.85, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Basic Pl", "plan_name": "400100_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Federal", "plan_name": "400110", "standard_charge_percentage": 0.85, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Federal", "plan_name": "400110_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." } ] } ] }, { "description": "Empagliflozin 10 mg tablet [167189]", "drug_information": { "unit": 1.00, "type": "EA" }, "code_information": [ { "code": "0597-0152-30", "type": "NDC" } ], "standard_charges": [ { "gross_charge": 91.01, "minimum": 72.81, "maximum": 77.36, "setting": "both", "payers_information": [ { "payer_name": "Aetna", "plan_name": "700700", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna", "plan_name": "700700_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Miscellaneous", "plan_name": "700720", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Miscellaneous", "plan_name": "700720_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Ppo Hmo", "plan_name": "701720", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Ppo Hmo", "plan_name": "701720_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Ms State Emplo", "plan_name": "401457", "standard_charge_percentage": 0.80, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Ms State Emplo", "plan_name": "401457_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Basic Pl", "plan_name": "400100", "standard_charge_percentage": 0.85, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Basic Pl", "plan_name": "400100_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Federal", "plan_name": "400110", "standard_charge_percentage": 0.85, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Federal", "plan_name": "400110_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." } ] } ] }, { "description": "Empagliflozin 10 mg tablet [167189]", "drug_information": { "unit": 1.00, "type": "EA" }, "code_information": [ { "code": "0597-0152-37", "type": "NDC" } ], "standard_charges": [ { "gross_charge": 91.01, "minimum": 72.81, "maximum": 77.36, "setting": "both", "payers_information": [ { "payer_name": "Aetna", "plan_name": "700700", 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"plan_name": "400110", "standard_charge_percentage": 0.85, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Federal", "plan_name": "400110_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." } ] } ] }, { "description": "Dabigatran etexilate 75 mg capsule [106490]", "drug_information": { "unit": 1.00, "type": "EA" }, "code_information": [ { "code": "0597-0355-56", "type": "NDC" } ], "standard_charges": [ { "gross_charge": 14.77, "minimum": 11.82, "maximum": 12.55, "setting": "both", "payers_information": [ { "payer_name": "Aetna", "plan_name": "700700", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed 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"payer_name": "Bc/Bs Of Ms Basic Pl", "plan_name": "400100_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Federal", "plan_name": "400110", "standard_charge_percentage": 0.85, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Federal", "plan_name": "400110_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." } ] } ] }, { "description": "Dabigatran etexilate 150 mg capsule [106491]", "drug_information": { "unit": 1.00, "type": "EA" }, "code_information": [ { "code": "0597-0360-82", "type": "NDC" } ], "standard_charges": [ { "gross_charge": 14.77, "minimum": 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remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Federal", "plan_name": "400110", "standard_charge_percentage": 0.85, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Federal", "plan_name": "400110_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." } ] } ] }, { "description": "Lidocaine 5 % topical patch [28203]", "drug_information": { "unit": 1.00, "type": "EA" }, "code_information": [ { "code": "0603-1880-16", "type": "NDC" } ], "standard_charges": [ { "gross_charge": 17.36, "minimum": 13.89, "maximum": 14.76, "setting": "both", "payers_information": [ { "payer_name": "Aetna", "plan_name": "700700", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna", "plan_name": "700700_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Miscellaneous", "plan_name": "700720", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Miscellaneous", "plan_name": "700720_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Ppo Hmo", "plan_name": "701720", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Ppo Hmo", "plan_name": "701720_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Ms State Emplo", "plan_name": "401457", "standard_charge_percentage": 0.80, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Ms State Emplo", "plan_name": "401457_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Basic Pl", "plan_name": "400100", "standard_charge_percentage": 0.85, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Basic Pl", "plan_name": "400100_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Federal", "plan_name": "400110", "standard_charge_percentage": 0.85, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Federal", "plan_name": "400110_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." } ] } ] }, { "description": "Benztropine 0.5 mg tablet [998]", "drug_information": { "unit": 1.00, "type": "EA" }, "code_information": [ { "code": "0603-2437-21", "type": "NDC" } ], "standard_charges": [ { "gross_charge": 7.50, "minimum": 6.00, "maximum": 6.38, "setting": "both", "payers_information": [ { "payer_name": "Aetna", "plan_name": "700700", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna", "plan_name": "700700_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Miscellaneous", "plan_name": "700720", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Miscellaneous", "plan_name": "700720_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Ppo Hmo", "plan_name": "701720", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Ppo Hmo", "plan_name": "701720_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Ms State Emplo", "plan_name": "401457", "standard_charge_percentage": 0.80, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Ms State Emplo", "plan_name": "401457_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Basic Pl", "plan_name": "400100", "standard_charge_percentage": 0.85, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Basic Pl", "plan_name": "400100_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Federal", "plan_name": "400110", "standard_charge_percentage": 0.85, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Federal", "plan_name": "400110_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." } ] } ] }, { "description": "Propafenone 225 mg tablet [11147]", "drug_information": { "unit": 1.00, "type": "EA" }, "code_information": [ { "code": "0603-5449-21", "type": "NDC" } ], "standard_charges": [ { "gross_charge": 7.50, "minimum": 6.00, "maximum": 6.38, "setting": "both", "payers_information": [ { "payer_name": "Aetna", "plan_name": "700700", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna", "plan_name": "700700_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Miscellaneous", "plan_name": "700720", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Miscellaneous", "plan_name": "700720_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Ppo Hmo", "plan_name": "701720", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Ppo Hmo", "plan_name": "701720_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Ms State Emplo", "plan_name": "401457", "standard_charge_percentage": 0.80, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Ms State Emplo", "plan_name": "401457_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Basic Pl", "plan_name": "400100", "standard_charge_percentage": 0.85, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Basic Pl", "plan_name": "400100_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Federal", "plan_name": "400110", "standard_charge_percentage": 0.85, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Federal", "plan_name": "400110_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." } ] } ] }, { "description": "Propafenone 300 mg tablet [11148]", "drug_information": { "unit": 1.00, "type": "EA" }, "code_information": [ { "code": "0603-5450-21", "type": "NDC" } ], "standard_charges": [ { "gross_charge": 7.50, "minimum": 6.00, "maximum": 6.38, "setting": "both", "payers_information": [ { "payer_name": "Aetna", "plan_name": "700700", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna", "plan_name": "700700_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Miscellaneous", "plan_name": "700720", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Miscellaneous", "plan_name": "700720_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Ppo Hmo", "plan_name": "701720", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Ppo Hmo", "plan_name": "701720_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Ms State Emplo", "plan_name": "401457", "standard_charge_percentage": 0.80, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Ms State Emplo", "plan_name": "401457_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Basic Pl", "plan_name": "400100", "standard_charge_percentage": 0.85, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Basic Pl", "plan_name": "400100_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Federal", "plan_name": "400110", "standard_charge_percentage": 0.85, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Federal", "plan_name": "400110_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." } ] } ] }, { "description": "Witch hazel 50 % topical pads [119535]", "drug_information": { "unit": 1.00, "type": "EA" }, "code_information": [ { "code": "0573-0558-07", "type": "NDC" } ], "standard_charges": [ { "gross_charge": 1.11, "minimum": 0.89, "maximum": 0.94, "setting": "both", "payers_information": [ { "payer_name": "Aetna", "plan_name": "700700", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna", "plan_name": "700700_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Miscellaneous", "plan_name": "700720", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Miscellaneous", "plan_name": "700720_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Ppo Hmo", "plan_name": "701720", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Ppo Hmo", "plan_name": "701720_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Ms State Emplo", "plan_name": "401457", "standard_charge_percentage": 0.80, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Ms State Emplo", "plan_name": "401457_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Basic Pl", "plan_name": "400100", "standard_charge_percentage": 0.85, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Basic Pl", "plan_name": "400100_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Federal", "plan_name": "400110", "standard_charge_percentage": 0.85, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Federal", "plan_name": "400110_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." } ] } ] }, { "description": "Phenylephrine 0.25 %-mineral oil 14 %-petrolatm 74.9 % rectal ointment [163812]", "drug_information": { "unit": 28.00, "type": "GR" }, "code_information": [ { "code": "0573-2871-93", "type": "NDC" } ], "standard_charges": [ { "gross_charge": 22.86, "minimum": 18.29, "maximum": 19.43, "setting": "both", "payers_information": [ { "payer_name": "Aetna", "plan_name": "700700", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna", "plan_name": "700700_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Miscellaneous", "plan_name": "700720", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Miscellaneous", "plan_name": "700720_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Ppo Hmo", "plan_name": "701720", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Ppo Hmo", "plan_name": "701720_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Ms State Emplo", "plan_name": "401457", "standard_charge_percentage": 0.80, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Ms State Emplo", "plan_name": "401457_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Basic Pl", "plan_name": "400100", "standard_charge_percentage": 0.85, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Basic Pl", "plan_name": "400100_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Federal", "plan_name": "400110", "standard_charge_percentage": 0.85, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Federal", "plan_name": "400110_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." } ] } ] }, { "description": "Phenylephrine 0.25 %-cocoa butter 88.44 % rectal suppository [164880]", "drug_information": { "unit": 1.00, "type": "EA" }, "code_information": [ { "code": "0573-2883-11", "type": "NDC" } ], "standard_charges": [ { "gross_charge": 1.41, "minimum": 1.13, "maximum": 1.20, "setting": "both", "payers_information": [ { "payer_name": "Aetna", "plan_name": "700700", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna", "plan_name": "700700_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Miscellaneous", "plan_name": "700720", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Miscellaneous", "plan_name": "700720_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Ppo Hmo", "plan_name": "701720", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Ppo Hmo", "plan_name": "701720_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Ms State Emplo", "plan_name": "401457", "standard_charge_percentage": 0.80, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Ms State Emplo", "plan_name": "401457_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Basic Pl", "plan_name": "400100", "standard_charge_percentage": 0.85, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Basic Pl", "plan_name": "400100_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Federal", "plan_name": "400110", "standard_charge_percentage": 0.85, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Federal", "plan_name": "400110_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." } ] } ] }, { "description": "Multivitamin-ferrous fumarate-folic acid 18 mg-400 mcg tablet [118668]", "drug_information": { "unit": 1.00, "type": "EA" }, "code_information": [ { "code": "0573445174", "type": "NDC" } ], "standard_charges": [ { "gross_charge": 1.00, "minimum": 0.80, "maximum": 0.85, "setting": "both", "payers_information": [ { "payer_name": "Aetna", "plan_name": "700700", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna", "plan_name": "700700_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Miscellaneous", "plan_name": "700720", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Miscellaneous", "plan_name": "700720_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Ppo Hmo", "plan_name": "701720", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Ppo Hmo", "plan_name": "701720_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Ms State Emplo", "plan_name": "401457", "standard_charge_percentage": 0.80, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Ms State Emplo", "plan_name": "401457_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Basic Pl", "plan_name": "400100", "standard_charge_percentage": 0.85, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to 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"additional_payer_notes": "Insufficient remit data to calculate allowed amounts." } ] } ] }, { "description": "Potassium chloride er 10 meq tabletextended release [6436]", "drug_information": { "unit": 1.00, "type": "EA" }, "code_information": [ { "code": "0574-0275-01", "type": "NDC" } ], "standard_charges": [ { "gross_charge": 7.50, "minimum": 6.00, "maximum": 6.38, "setting": "both", "payers_information": [ { "payer_name": "Aetna", "plan_name": "700700", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna", "plan_name": "700700_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Miscellaneous", "plan_name": "700720", "standard_charge_percentage": 80.0, "count": "0", 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"standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Ms State Emplo", "plan_name": "401457", "standard_charge_percentage": 0.80, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Ms State Emplo", "plan_name": "401457_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Basic Pl", "plan_name": "400100", "standard_charge_percentage": 0.85, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Basic Pl", "plan_name": "400100_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Federal", "plan_name": "400110", "standard_charge_percentage": 0.85, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Federal", "plan_name": "400110_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." } ] } ] }, { "description": "Activated charcoal-sorbitol 50 gram/240 ml oral suspension [81428]", "drug_information": { "unit": 240.00, "type": "ML" }, "code_information": [ { "code": "0574-0520-76", "type": "NDC" } ], "standard_charges": [ { "gross_charge": 116.28, "minimum": 93.02, "maximum": 98.84, "setting": 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"payer_name": "Aetna Ppo Hmo", "plan_name": "701720", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Ppo Hmo", "plan_name": "701720_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Ms State Emplo", "plan_name": "401457", "standard_charge_percentage": 0.80, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Ms State Emplo", "plan_name": "401457_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Basic Pl", "plan_name": "400100", "standard_charge_percentage": 0.85, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Basic Pl", "plan_name": "400100_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Federal", "plan_name": "400110", "standard_charge_percentage": 0.85, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Federal", "plan_name": "400110_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." } ] } ] }, { "description": "Activated charcoal 25 gram/120 ml oral suspension [115332]", "drug_information": { "unit": 120.00, "type": "ML" }, "code_information": [ { "code": "0574-0521-74", "type": "NDC" } ], "standard_charges": [ { "gross_charge": 45.24, "minimum": 36.19, "maximum": 38.45, "setting": "both", "payers_information": [ { "payer_name": "Aetna", "plan_name": "700700", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna", "plan_name": "700700_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Miscellaneous", "plan_name": "700720", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit 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"additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Miscellaneous", "plan_name": "700720", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Miscellaneous", "plan_name": "700720_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Ppo Hmo", "plan_name": "701720", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Ppo Hmo", "plan_name": "701720_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Ms State Emplo", "plan_name": "401457", "standard_charge_percentage": 0.80, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Ms State Emplo", "plan_name": "401457_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Basic Pl", "plan_name": "400100", "standard_charge_percentage": 0.85, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Basic Pl", "plan_name": "400100_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Federal", "plan_name": "400110", "standard_charge_percentage": 0.85, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Federal", "plan_name": "400110_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." } ] } ] }, { "description": "Trihexyphenidyl 2 mg tablet [8166]", "drug_information": { "unit": 1.00, "type": "EA" }, "code_information": [ { "code": "0591-5335-01", "type": "NDC" } ], "standard_charges": [ { "gross_charge": 7.50, "minimum": 6.00, "maximum": 6.38, "setting": "both", "payers_information": [ { "payer_name": "Aetna", "plan_name": "700700", "standard_charge_percentage": 80.0, "count": "0", "methodology": 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charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Ppo Hmo", "plan_name": "701720_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Ms State Emplo", "plan_name": "401457", "standard_charge_percentage": 0.80, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Ms State Emplo", "plan_name": "401457_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Basic Pl", "plan_name": "400100", "standard_charge_percentage": 0.85, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Basic Pl", "plan_name": "400100_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Federal", "plan_name": "400110", "standard_charge_percentage": 0.85, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Federal", "plan_name": "400110_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." } ] } ] }, { "description": "Probenecid 500 mg tablet [6561]", "drug_information": { "unit": 1.00, "type": "EA" }, "code_information": [ { "code": "0591-5347-01", "type": "NDC" } ], "standard_charges": [ { "gross_charge": 10.63, "minimum": 8.50, "maximum": 9.04, "setting": "both", "payers_information": [ { "payer_name": "Aetna", "plan_name": "700700", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna", "plan_name": "700700_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Miscellaneous", "plan_name": "700720", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Miscellaneous", "plan_name": "700720_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total 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"additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Basic Pl", "plan_name": "400100", "standard_charge_percentage": 0.85, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Basic Pl", "plan_name": "400100_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Federal", "plan_name": "400110", "standard_charge_percentage": 0.85, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Federal", "plan_name": "400110_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." } ] } ] }, { "description": "Carbamide peroxide-sod chloride-sod bicarb 6.5 %-0.9 % otic comb pack [158647]", "drug_information": { "unit": 192.00, "type": "ML" }, "code_information": [ { "code": "0592860311", "type": "NDC" } ], "standard_charges": [ { "gross_charge": 23.96, "minimum": 19.17, "maximum": 20.37, "setting": "both", "payers_information": [ { "payer_name": "Aetna", "plan_name": "700700", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna", "plan_name": "700700_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Miscellaneous", "plan_name": "700720", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Miscellaneous", "plan_name": "700720_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Ppo Hmo", "plan_name": "701720", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Ppo Hmo", "plan_name": "701720_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Ms State Emplo", "plan_name": "401457", "standard_charge_percentage": 0.80, "count": 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"701720_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Ms State Emplo", "plan_name": "401457", "standard_charge_percentage": 0.80, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Ms State Emplo", "plan_name": "401457_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Basic Pl", "plan_name": "400100", "standard_charge_percentage": 0.85, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Basic Pl", "plan_name": "400100_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Federal", "plan_name": "400110", "standard_charge_percentage": 0.85, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Federal", "plan_name": "400110_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." } ] } ] }, { "description": "Ipratropium 20 mcg-albuterol 100 mcg/actuation mist for inhalation [167984]", "drug_information": { "unit": 4.00, "type": "GR" }, "code_information": [ { "code": "0597-0024-02", "type": "NDC" } ], "standard_charges": [ { "gross_charge": 2186.29, "minimum": 1749.03, "maximum": 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remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Federal", "plan_name": "400110_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." } ] } ] }, { "description": "Diltiazem 5 mg/ml intravenous solution [9869]", "drug_information": { "unit": 5.00, "type": "ML" }, "code_information": [ { "code": "0641-6013-10", "type": "NDC" } ], "standard_charges": [ { "gross_charge": 20.85, "minimum": 16.68, "maximum": 17.72, "setting": "both", "payers_information": [ { "payer_name": "Aetna", "plan_name": "700700", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna", "plan_name": "700700_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Miscellaneous", "plan_name": "700720", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Miscellaneous", "plan_name": "700720_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Ppo Hmo", "plan_name": "701720", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Ppo Hmo", "plan_name": "701720_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Ms State Emplo", "plan_name": "401457", "standard_charge_percentage": 0.80, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Ms State Emplo", "plan_name": "401457_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Basic Pl", "plan_name": "400100", "standard_charge_percentage": 0.85, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Basic Pl", "plan_name": "400100_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Federal", "plan_name": "400110", "standard_charge_percentage": 0.85, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Federal", "plan_name": "400110_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." } ] } ] }, { "description": "Diltiazem 5 mg/ml intravenous solution [9869]", "drug_information": { "unit": 10.00, "type": "ML" }, "code_information": [ { "code": "0641-6014-01", "type": "NDC" } ], "standard_charges": [ { "gross_charge": 38.00, "minimum": 30.40, "maximum": 32.30, "setting": "both", "payers_information": [ { "payer_name": "Aetna", "plan_name": "700700", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna", "plan_name": "700700_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Miscellaneous", "plan_name": "700720", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Miscellaneous", "plan_name": "700720_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Ppo Hmo", "plan_name": "701720", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Ppo Hmo", "plan_name": "701720_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Ms State Emplo", "plan_name": "401457", "standard_charge_percentage": 0.80, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Ms State Emplo", "plan_name": "401457_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Basic Pl", "plan_name": "400100", "standard_charge_percentage": 0.85, "count": "0", "methodology": "percent of total 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"standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Ppo Hmo", "plan_name": "701720_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Ms State Emplo", "plan_name": "401457", "standard_charge_percentage": 0.80, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Ms State Emplo", "plan_name": "401457_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Basic Pl", "plan_name": "400100", "standard_charge_percentage": 0.85, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Basic Pl", "plan_name": "400100_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Federal", "plan_name": "400110", "standard_charge_percentage": 0.85, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Federal", "plan_name": "400110_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." } ] } ] }, { "description": "Neomycin-bacitracn zn-polymyx 3.5 mg-400 unit-5000 unit/gram top oint [854]", "drug_information": { "unit": 28.40, "type": "GR" }, "code_information": [ { "code": "0713-0268-31", "type": "NDC" } ], "standard_charges": [ { "gross_charge": 8.57, "minimum": 6.86, "maximum": 7.28, "setting": "both", "payers_information": [ { "payer_name": "Aetna", "plan_name": "700700", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna", "plan_name": "700700_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Miscellaneous", "plan_name": "700720", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Miscellaneous", "plan_name": "700720_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Ppo Hmo", "plan_name": "701720", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Ppo Hmo", "plan_name": "701720_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Ms State Emplo", "plan_name": "401457", "standard_charge_percentage": 0.80, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": 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"methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Federal", "plan_name": "400110", "standard_charge_percentage": 0.85, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Federal", "plan_name": "400110_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." } ] } ] }, { "description": "Promethazine 12.5 mg rectal suppository [11143]", "drug_information": { "unit": 1.00, "type": "EA" }, "code_information": [ { "code": "0713-0536-12", "type": "NDC" } ], "standard_charges": [ { "gross_charge": 66.72, "minimum": 53.38, "maximum": 56.71, "setting": "both", "payers_information": [ { "payer_name": "Aetna", "plan_name": "700700", 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"standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Ppo Hmo", "plan_name": "701720_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Ms State Emplo", "plan_name": "401457", "standard_charge_percentage": 0.80, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Ms State Emplo", "plan_name": "401457_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Basic Pl", "plan_name": "400100", "standard_charge_percentage": 0.85, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Basic Pl", "plan_name": "400100_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Federal", "plan_name": "400110", "standard_charge_percentage": 0.85, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Federal", "plan_name": "400110_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." } ] } ] }, { "description": "Gentamicin 0.1 % topical cream [3423]", 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{ "payer_name": "Bc/Bs Of Ms Federal", "plan_name": "400110", "standard_charge_percentage": 0.85, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Federal", "plan_name": "400110_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." } ] } ] }, { "description": "Docosanol 10 % topical cream [29287]", "drug_information": { "unit": 2.00, "type": "GR" }, "code_information": [ { "code": "0766080155", "type": "NDC" } ], "standard_charges": [ { "gross_charge": 40.20, "minimum": 32.16, "maximum": 34.17, "setting": "both", "payers_information": [ { "payer_name": "Aetna", "plan_name": "700700", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit 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"methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Ms State Emplo", "plan_name": "401457", "standard_charge_percentage": 0.80, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Ms State Emplo", "plan_name": "401457_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Basic Pl", "plan_name": "400100", "standard_charge_percentage": 0.85, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Basic Pl", "plan_name": "400100_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Federal", "plan_name": "400110", "standard_charge_percentage": 0.85, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Federal", "plan_name": "400110_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." } ] } ] }, { "description": "Alprazolam 1 mg tablet [326]", "drug_information": { "unit": 1.00, "type": "EA" }, "code_information": [ { "code": "0781-1079-01", "type": "NDC" } ], "standard_charges": [ { "gross_charge": 7.50, "minimum": 6.00, "maximum": 6.38, "setting": "both", "payers_information": [ { "payer_name": "Aetna", "plan_name": "700700", 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"standard_charge_percentage": 0.85, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Basic Pl", "plan_name": "400100_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Federal", "plan_name": "400110", "standard_charge_percentage": 0.85, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Federal", "plan_name": "400110_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." } ] } ] }, { "description": "Amitriptyline 50 mg tablet [436]", 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80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna", "plan_name": "700700_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Miscellaneous", "plan_name": "700720", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Miscellaneous", "plan_name": "700720_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Ppo Hmo", "plan_name": "701720", "standard_charge_percentage": 80.0, "count": "0", 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"methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Basic Pl", "plan_name": "400100_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Federal", "plan_name": "400110", "standard_charge_percentage": 0.85, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Federal", "plan_name": "400110_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." } ] } ] }, { "description": "Vecuronium bromide 10 mg intravenous solution [11634]", "drug_information": { "unit": 1.00, 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"standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Ppo Hmo", "plan_name": "701720", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Ppo Hmo", "plan_name": "701720_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Ms State Emplo", "plan_name": "401457", "standard_charge_percentage": 0.80, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Ms State Emplo", "plan_name": "401457_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Basic Pl", "plan_name": "400100", "standard_charge_percentage": 0.85, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Basic Pl", "plan_name": "400100_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Federal", "plan_name": "400110", "standard_charge_percentage": 0.85, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Federal", "plan_name": "400110_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." } ] } ] }, { "description": "Oxybutynin chloride 5 mg tablet [5938]", "drug_information": { "unit": 1.00, "type": "EA" }, "code_information": [ { "code": "0832-0038-89", "type": "NDC" } ], "standard_charges": [ { "gross_charge": 7.50, "minimum": 6.00, "maximum": 6.38, "setting": "both", "payers_information": [ { "payer_name": "Aetna", "plan_name": "700700", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna", "plan_name": "700700_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna 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"plan_name": "401457", "standard_charge_percentage": 0.80, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Ms State Emplo", "plan_name": "401457_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Basic Pl", "plan_name": "400100", "standard_charge_percentage": 0.85, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Basic Pl", "plan_name": "400100_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Federal", "plan_name": "400110", "standard_charge_percentage": 0.85, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Federal", "plan_name": "400110_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." } ] } ] }, { "description": "Nystatin 100000 unit/gram topical powder [39136]", "drug_information": { "unit": 15.00, "type": "GR" }, "code_information": [ { "code": "0832-0465-15", "type": "NDC" } ], "standard_charges": [ { "gross_charge": 72.89, "minimum": 58.31, "maximum": 61.96, "setting": "both", "payers_information": [ { "payer_name": "Aetna", "plan_name": "700700", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna", "plan_name": "700700_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Miscellaneous", "plan_name": "700720", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Miscellaneous", "plan_name": "700720_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Ppo Hmo", "plan_name": "701720", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Ppo Hmo", "plan_name": "701720_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Ms State Emplo", "plan_name": "401457", "standard_charge_percentage": 0.80, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Ms State Emplo", "plan_name": "401457_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Basic Pl", "plan_name": "400100", "standard_charge_percentage": 0.85, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Basic Pl", "plan_name": "400100_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Federal", "plan_name": "400110", "standard_charge_percentage": 0.85, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Federal", "plan_name": "400110_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." } ] } ] }, { "description": "Nystatin 100000 unit/gram topical powder [39136]", "drug_information": { "unit": 60.00, "type": "GR" }, "code_information": [ { "code": "0832-0465-60", "type": "NDC" } ], "standard_charges": [ { "gross_charge": 254.22, "minimum": 203.38, "maximum": 216.09, "setting": "both", "payers_information": [ { "payer_name": "Aetna", "plan_name": "700700", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna", "plan_name": "700700_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Miscellaneous", "plan_name": "700720", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Miscellaneous", "plan_name": "700720_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Ppo Hmo", "plan_name": "701720", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Ppo Hmo", "plan_name": "701720_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Ms State Emplo", "plan_name": "401457", "standard_charge_percentage": 0.80, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Ms State Emplo", "plan_name": "401457_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Basic Pl", "plan_name": "400100", "standard_charge_percentage": 0.85, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Basic Pl", "plan_name": "400100_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Federal", "plan_name": "400110", "standard_charge_percentage": 0.85, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Federal", "plan_name": "400110_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." } ] } ] }, { "description": "Bethanechol chloride 25 mg tablet [1044]", "drug_information": { "unit": 1.00, "type": "EA" }, "code_information": [ { "code": "0832-0512-89", "type": "NDC" } ], "standard_charges": [ { "gross_charge": 7.50, "minimum": 6.00, "maximum": 6.38, "setting": "both", "payers_information": [ { "payer_name": "Aetna", "plan_name": "700700", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna", "plan_name": "700700_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Miscellaneous", "plan_name": "700720", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Miscellaneous", "plan_name": "700720_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Ppo Hmo", "plan_name": "701720", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Ppo Hmo", "plan_name": "701720_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Ms State Emplo", "plan_name": "401457", "standard_charge_percentage": 0.80, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Ms State Emplo", "plan_name": "401457_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Basic Pl", "plan_name": "400100", "standard_charge_percentage": 0.85, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Basic Pl", "plan_name": "400100_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Federal", "plan_name": "400110", "standard_charge_percentage": 0.85, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Federal", "plan_name": "400110_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." } ] } ] }, { "description": "Warfarin 1 mg tablet [11664]", "drug_information": { "unit": 1.00, "type": "EA" }, "code_information": [ { "code": "0832-1211-01", "type": "NDC" } ], "standard_charges": [ { "gross_charge": 7.50, "minimum": 6.00, "maximum": 6.38, "setting": "both", "payers_information": [ { "payer_name": "Aetna", "plan_name": "700700", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna", "plan_name": "700700_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Miscellaneous", "plan_name": "700720", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Miscellaneous", "plan_name": "700720_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Ppo Hmo", "plan_name": "701720", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Ppo Hmo", "plan_name": "701720_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Ms State Emplo", "plan_name": "401457", "standard_charge_percentage": 0.80, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Ms State Emplo", "plan_name": "401457_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Basic Pl", "plan_name": "400100", "standard_charge_percentage": 0.85, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Basic Pl", "plan_name": "400100_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Federal", "plan_name": "400110", "standard_charge_percentage": 0.85, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Federal", "plan_name": "400110_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." } ] } ] }, { "description": "Warfarin 1 mg tablet [11664]", "drug_information": { "unit": 1.00, "type": "EA" }, "code_information": [ { "code": "0832-1211-89", "type": "NDC" } ], "standard_charges": [ { "gross_charge": 7.50, "minimum": 6.00, "maximum": 6.38, "setting": "both", "payers_information": [ { "payer_name": "Aetna", "plan_name": "700700", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna", "plan_name": "700700_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Miscellaneous", "plan_name": "700720", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Miscellaneous", "plan_name": "700720_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Ppo Hmo", "plan_name": "701720", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Ppo Hmo", "plan_name": "701720_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Ms State Emplo", "plan_name": "401457", "standard_charge_percentage": 0.80, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Ms State Emplo", "plan_name": "401457_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Basic Pl", "plan_name": "400100", "standard_charge_percentage": 0.85, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Basic Pl", "plan_name": "400100_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Federal", "plan_name": "400110", "standard_charge_percentage": 0.85, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Federal", "plan_name": "400110_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." } ] } ] }, { "description": "Warfarin 3 mg tablet [19433]", "drug_information": { "unit": 1.00, "type": "EA" }, "code_information": [ { "code": "0832-1214-89", "type": "NDC" } ], "standard_charges": [ { "gross_charge": 7.50, "minimum": 6.00, "maximum": 6.38, "setting": "both", "payers_information": [ { "payer_name": "Aetna", "plan_name": "700700", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna", "plan_name": "700700_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Miscellaneous", "plan_name": "700720", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Miscellaneous", "plan_name": "700720_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Ppo Hmo", "plan_name": "701720", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Ppo Hmo", "plan_name": "701720_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Ms State Emplo", "plan_name": "401457", "standard_charge_percentage": 0.80, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Ms State Emplo", "plan_name": "401457_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Basic Pl", "plan_name": "400100", "standard_charge_percentage": 0.85, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Basic Pl", "plan_name": "400100_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Federal", "plan_name": "400110", "standard_charge_percentage": 0.85, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Federal", "plan_name": "400110_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." } ] } ] }, { "description": "Warfarin 5 mg tablet [8751]", "drug_information": { "unit": 1.00, "type": "EA" }, "code_information": [ { "code": "0832-1216-89", "type": "NDC" } ], "standard_charges": [ { "gross_charge": 7.50, "minimum": 6.00, "maximum": 6.38, "setting": "both", "payers_information": [ { "payer_name": "Aetna", "plan_name": "700700", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna", "plan_name": "700700_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Miscellaneous", "plan_name": "700720", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Miscellaneous", "plan_name": "700720_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Ppo Hmo", "plan_name": "701720", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Ppo Hmo", "plan_name": "701720_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Ms State Emplo", "plan_name": "401457", "standard_charge_percentage": 0.80, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Ms State Emplo", "plan_name": "401457_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Basic Pl", "plan_name": "400100", "standard_charge_percentage": 0.85, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Basic Pl", "plan_name": "400100_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Federal", "plan_name": "400110", "standard_charge_percentage": 0.85, "count": "0", "methodology": "percent of total billed charges", 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billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Federal", "plan_name": "400110", "standard_charge_percentage": 0.85, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Federal", "plan_name": "400110_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." } ] } ] }, { "description": "Brimonidine 0.2 %-timolol 0.5 % eye drops [87834]", "drug_information": { "unit": 5.00, "type": "ML" }, "code_information": [ { "code": "0832-1425-05", "type": "NDC" } ], "standard_charges": [ { "gross_charge": 879.89, "minimum": 703.91, "maximum": 747.91, "setting": "both", "payers_information": [ { "payer_name": "Aetna", "plan_name": "700700", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna", "plan_name": "700700_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Miscellaneous", "plan_name": "700720", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Miscellaneous", "plan_name": "700720_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Ppo Hmo", "plan_name": "701720", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Ppo Hmo", "plan_name": "701720_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Ms State Emplo", "plan_name": "401457", "standard_charge_percentage": 0.80, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Ms State Emplo", "plan_name": "401457_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Basic Pl", "plan_name": "400100", "standard_charge_percentage": 0.85, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Basic Pl", "plan_name": "400100_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Federal", "plan_name": "400110", "standard_charge_percentage": 0.85, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Federal", "plan_name": "400110_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." } ] } ] }, { "description": "Divalproex 250 mg tabletdelayed release [2552]", "drug_information": { "unit": 1.00, "type": "EA" }, "code_information": [ { "code": "0832-7123-89", "type": "NDC" } ], "standard_charges": [ { "gross_charge": 7.50, "minimum": 6.00, "maximum": 6.38, "setting": "both", "payers_information": [ { "payer_name": "Aetna", "plan_name": "700700", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna", "plan_name": "700700_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Miscellaneous", "plan_name": "700720", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna 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"plan_name": "401457_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Basic Pl", "plan_name": "400100", "standard_charge_percentage": 0.85, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Basic Pl", "plan_name": "400100_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Federal", "plan_name": "400110", "standard_charge_percentage": 0.85, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Federal", "plan_name": "400110_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." } ] } ] }, { "description": "Divalproex 500 mg tabletdelayed release [2553]", "drug_information": { "unit": 1.00, "type": "EA" }, "code_information": [ { "code": "0832-7124-01", "type": "NDC" } ], "standard_charges": [ { "gross_charge": 7.50, "minimum": 6.00, "maximum": 6.38, "setting": "both", "payers_information": [ { "payer_name": "Aetna", "plan_name": "700700", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna", "plan_name": "700700_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Miscellaneous", "plan_name": "700720", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Miscellaneous", "plan_name": "700720_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Ppo Hmo", "plan_name": "701720", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Ppo Hmo", "plan_name": "701720_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Ms State Emplo", "plan_name": "401457", "standard_charge_percentage": 0.80, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Ms State Emplo", "plan_name": "401457_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Basic Pl", "plan_name": "400100", "standard_charge_percentage": 0.85, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Basic Pl", "plan_name": "400100_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Federal", "plan_name": "400110", "standard_charge_percentage": 0.85, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Federal", "plan_name": "400110_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." } ] } ] }, { "description": "Amitriptyline 25 mg tablet [435]", "drug_information": { "unit": 1.00, "type": "EA" }, "code_information": [ { "code": "0904-0201-61", "type": "NDC" } ], "standard_charges": [ { "gross_charge": 7.50, "minimum": 6.00, "maximum": 6.38, "setting": "both", "payers_information": [ { "payer_name": "Aetna", "plan_name": "700700", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate 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"payer_name": "Aetna Ppo Hmo", "plan_name": "701720_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Ms State Emplo", "plan_name": "401457", "standard_charge_percentage": 0.80, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Ms State Emplo", "plan_name": "401457_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Basic Pl", "plan_name": "400100", "standard_charge_percentage": 0.85, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Basic Pl", "plan_name": "400100_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Federal", "plan_name": "400110", "standard_charge_percentage": 0.85, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Federal", "plan_name": "400110_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." } ] } ] }, { "description": "Amitriptyline 50 mg tablet [436]", "drug_information": { "unit": 1.00, "type": "EA" }, "code_information": [ { "code": "0904-0202-61", "type": "NDC" } ], "standard_charges": [ { "gross_charge": 7.50, "minimum": 6.00, "maximum": 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amounts." }, { "payer_name": "Bc/Bs Of Ms Basic Pl", "plan_name": "400100", "standard_charge_percentage": 0.85, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Basic Pl", "plan_name": "400100_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Federal", "plan_name": "400110", "standard_charge_percentage": 0.85, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Federal", "plan_name": "400110_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." } ] } ] }, { "description": "Doxycycline hyclate 100 mg capsule [2623]", "drug_information": { "unit": 1.00, "type": "EA" }, "code_information": [ { "code": "0904-0428-61", "type": "NDC" } ], "standard_charges": [ { "gross_charge": 7.50, "minimum": 6.00, "maximum": 6.38, "setting": "both", "payers_information": [ { "payer_name": "Aetna", "plan_name": "700700", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna", "plan_name": "700700_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Miscellaneous", "plan_name": "700720", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Miscellaneous", "plan_name": "700720_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Ppo Hmo", "plan_name": "701720", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Ppo Hmo", "plan_name": "701720_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Ms State Emplo", "plan_name": "401457", "standard_charge_percentage": 0.80, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Ms State Emplo", "plan_name": "401457_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Basic Pl", "plan_name": "400100", "standard_charge_percentage": 0.85, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Basic Pl", "plan_name": "400100_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Federal", "plan_name": "400110", "standard_charge_percentage": 0.85, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Federal", "plan_name": "400110_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." } ] } ] }, { "description": "Doxycycline hyclate 100 mg tablet [2625]", "drug_information": { "unit": 1.00, "type": "EA" }, "code_information": [ { "code": "0904-0430-04", "type": "NDC" } ], "standard_charges": [ { "gross_charge": 22.30, "minimum": 17.84, "maximum": 18.96, "setting": "both", "payers_information": [ { "payer_name": "Aetna", "plan_name": "700700", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna", "plan_name": "700700_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Miscellaneous", "plan_name": "700720", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Miscellaneous", "plan_name": "700720_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Ppo Hmo", "plan_name": "701720", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Ppo Hmo", "plan_name": "701720_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Ms State Emplo", "plan_name": "401457", "standard_charge_percentage": 0.80, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Ms State Emplo", "plan_name": "401457_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Basic Pl", "plan_name": "400100", "standard_charge_percentage": 0.85, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Basic Pl", "plan_name": "400100_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Federal", "plan_name": "400110", "standard_charge_percentage": 0.85, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Federal", "plan_name": "400110_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." } ] } ] }, { "description": "Magnesium hydroxide 400 mg/5 ml oral suspension [108978]", "drug_information": { "unit": 473.00, "type": "ML" }, "code_information": [ { "code": "0904-0788-16", "type": "NDC" } ], "standard_charges": [ { "gross_charge": 9.84, "minimum": 7.87, "maximum": 8.36, "setting": "both", "payers_information": [ { "payer_name": "Aetna", "plan_name": "700700", "standard_charge_percentage": 80.0, 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"methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Ppo Hmo", "plan_name": "701720_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Ms State Emplo", "plan_name": "401457", "standard_charge_percentage": 0.80, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Ms State Emplo", "plan_name": "401457_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Basic Pl", "plan_name": "400100", "standard_charge_percentage": 0.85, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Basic Pl", "plan_name": "400100_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Federal", "plan_name": "400110", "standard_charge_percentage": 0.85, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Federal", "plan_name": "400110_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." } ] } ] }, { "description": "Metronidazole 250 mg tablet [5015]", "drug_information": { "unit": 1.00, "type": "EA" }, 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100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Ppo Hmo", "plan_name": "701720", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Ppo Hmo", "plan_name": "701720_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Ms State Emplo", "plan_name": "401457", "standard_charge_percentage": 0.80, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Ms State Emplo", "plan_name": "401457_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Basic Pl", "plan_name": "400100", "standard_charge_percentage": 0.85, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Basic Pl", "plan_name": "400100_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Federal", "plan_name": "400110", "standard_charge_percentage": 0.85, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Federal", "plan_name": "400110_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." } ] } ] }, { "description": "Dimenhydrinate 50 mg tablet [2485]", "drug_information": { "unit": 1.00, "type": "EA" }, "code_information": [ { "code": "0904-2051-59", "type": "NDC" } ], "standard_charges": [ { "gross_charge": 1.00, "minimum": 0.80, "maximum": 0.85, "setting": "both", "payers_information": [ { "payer_name": "Aetna", "plan_name": "700700", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna", "plan_name": "700700_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Miscellaneous", "plan_name": "700720", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Miscellaneous", "plan_name": "700720_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Ppo Hmo", "plan_name": "701720", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Ppo Hmo", "plan_name": "701720_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Ms State Emplo", "plan_name": "401457", "standard_charge_percentage": 0.80, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Ms State Emplo", "plan_name": "401457_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Basic Pl", "plan_name": "400100", "standard_charge_percentage": 0.85, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Basic Pl", "plan_name": "400100_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Federal", "plan_name": "400110", "standard_charge_percentage": 0.85, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Federal", "plan_name": "400110_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." } ] } ] }, { "description": "Levofloxacin 250 mg tablet [18918]", "drug_information": { "unit": 1.00, "type": "EA" }, "code_information": [ { "code": "0781-5790-01", "type": "NDC" } ], "standard_charges": [ { "gross_charge": 7.50, "minimum": 6.00, "maximum": 6.38, "setting": "both", "payers_information": [ { "payer_name": "Aetna", "plan_name": "700700", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna", "plan_name": "700700_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Miscellaneous", "plan_name": "700720", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Miscellaneous", "plan_name": "700720_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Ppo Hmo", "plan_name": "701720", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Ppo Hmo", "plan_name": "701720_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Ms State Emplo", "plan_name": "401457", "standard_charge_percentage": 0.80, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Ms State Emplo", "plan_name": "401457_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Basic Pl", "plan_name": "400100", "standard_charge_percentage": 0.85, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Basic Pl", "plan_name": "400100_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Federal", "plan_name": "400110", "standard_charge_percentage": 0.85, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Federal", "plan_name": "400110_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." } ] } ] }, { "description": "Clarithromycin 250 mg/5 ml oral suspension [12886]", "drug_information": { "unit": 50.00, "type": "ML" }, "code_information": [ { "code": "0781-6023-52", "type": "NDC" } ], "standard_charges": [ { "gross_charge": 457.90, "minimum": 366.32, "maximum": 389.22, "setting": "both", 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"payer_name": "Aetna Ppo Hmo", "plan_name": "701720", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Ppo Hmo", "plan_name": "701720_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Ms State Emplo", "plan_name": "401457", "standard_charge_percentage": 0.80, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Ms State Emplo", "plan_name": "401457_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Basic Pl", "plan_name": "400100", "standard_charge_percentage": 0.85, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Basic Pl", "plan_name": "400100_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Federal", "plan_name": "400110", "standard_charge_percentage": 0.85, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Federal", "plan_name": "400110_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." } ] } ] }, { "description": "Ciprofloxacin 0.3 %-dexamethasone 0.1 % ear dropssuspension [36576]", "drug_information": { "unit": 7.50, "type": "ML" }, "code_information": [ { "code": "0781-6186-67", "type": "NDC" } ], "standard_charges": [ { "gross_charge": 1147.70, "minimum": 918.16, "maximum": 975.55, "setting": "both", "payers_information": [ { "payer_name": "Aetna", "plan_name": "700700", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna", "plan_name": "700700_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Miscellaneous", "plan_name": "700720", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": 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remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Ms State Emplo", "plan_name": "401457_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Basic Pl", "plan_name": "400100", "standard_charge_percentage": 0.85, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Basic Pl", "plan_name": "400100_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Federal", "plan_name": "400110", "standard_charge_percentage": 0.85, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Federal", "plan_name": "400110_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." } ] } ] }, { "description": "Estradiol 0.05 mg/24 hr weekly transdermal patch [108427]", "drug_information": { "unit": 1.00, "type": "EA" }, "code_information": [ { "code": "0781-7133-54", "type": "NDC" } ], "standard_charges": [ { "gross_charge": 90.61, "minimum": 72.49, "maximum": 77.02, "setting": "both", "payers_information": [ { "payer_name": "Aetna", "plan_name": "700700", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna", "plan_name": "700700_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Miscellaneous", "plan_name": "700720", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Miscellaneous", "plan_name": "700720_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Ppo Hmo", "plan_name": "701720", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Ppo Hmo", "plan_name": "701720_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Ms State Emplo", "plan_name": "401457", "standard_charge_percentage": 0.80, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Ms State Emplo", "plan_name": "401457_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Basic Pl", "plan_name": "400100", "standard_charge_percentage": 0.85, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Basic Pl", "plan_name": "400100_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Federal", "plan_name": "400110", "standard_charge_percentage": 0.85, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Federal", "plan_name": "400110_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." } ] } ] }, { "description": "Estradiol 0.05 mg/24 hr weekly transdermal patch [108427]", "drug_information": { "unit": 1.00, "type": "EA" }, "code_information": [ { "code": "0781-7133-58", "type": "NDC" } ], "standard_charges": [ { "gross_charge": 90.61, "minimum": 72.49, "maximum": 77.02, "setting": "both", "payers_information": [ { "payer_name": "Aetna", "plan_name": "700700", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna", "plan_name": "700700_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Miscellaneous", "plan_name": "700720", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Miscellaneous", "plan_name": "700720_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Ppo Hmo", "plan_name": "701720", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Ppo Hmo", "plan_name": "701720_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Ms State Emplo", "plan_name": "401457", "standard_charge_percentage": 0.80, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Ms State Emplo", "plan_name": "401457_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Basic Pl", "plan_name": "400100", "standard_charge_percentage": 0.85, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Basic Pl", "plan_name": "400100_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Federal", "plan_name": "400110", "standard_charge_percentage": 0.85, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Federal", "plan_name": "400110_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." } ] } ] }, { "description": "Calcium polycarbophil 625 mg tablet [11046]", "drug_information": { "unit": 1.00, "type": "EA" }, "code_information": [ { "code": "0904-2500-91", "type": "NDC" } ], "standard_charges": [ { "gross_charge": 1.00, "minimum": 0.80, "maximum": 0.85, "setting": "both", "payers_information": [ { "payer_name": "Aetna", "plan_name": "700700", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna", "plan_name": "700700_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Miscellaneous", "plan_name": "700720", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Miscellaneous", "plan_name": "700720_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Ppo Hmo", "plan_name": "701720", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Ppo Hmo", "plan_name": "701720_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Ms State Emplo", "plan_name": "401457", "standard_charge_percentage": 0.80, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Ms State Emplo", "plan_name": "401457_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Basic Pl", "plan_name": "400100", "standard_charge_percentage": 0.85, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Basic Pl", "plan_name": "400100_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Federal", "plan_name": "400110", "standard_charge_percentage": 0.85, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Federal", "plan_name": "400110_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." } ] } ] }, { "description": "Oxybutynin chloride 5 mg tablet [5938]", "drug_information": { "unit": 1.00, "type": "EA" }, "code_information": [ { "code": "0904-2821-61", "type": "NDC" } ], "standard_charges": [ { "gross_charge": 7.50, "minimum": 6.00, "maximum": 6.38, "setting": "both", "payers_information": [ { "payer_name": "Aetna", "plan_name": "700700", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna", "plan_name": "700700_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Miscellaneous", "plan_name": "700720", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Miscellaneous", "plan_name": "700720_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Ppo Hmo", "plan_name": "701720", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Ppo Hmo", "plan_name": "701720_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Ms State Emplo", "plan_name": "401457", "standard_charge_percentage": 0.80, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Ms State Emplo", "plan_name": "401457_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Basic Pl", "plan_name": "400100", "standard_charge_percentage": 0.85, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Basic Pl", "plan_name": "400100_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Federal", "plan_name": "400110", "standard_charge_percentage": 0.85, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Federal", "plan_name": "400110_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." } ] } ] }, { "description": "Sodium chloride 0.65 % nasal spray aerosol [29676]", "drug_information": { "unit": 44.00, "type": "ML" }, "code_information": [ { "code": "0904-3865-75", "type": "NDC" } ], "standard_charges": [ { "gross_charge": 3.09, "minimum": 2.47, "maximum": 2.63, "setting": "both", "payers_information": [ { "payer_name": "Aetna", "plan_name": "700700", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna", "plan_name": "700700_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Miscellaneous", "plan_name": "700720", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Miscellaneous", "plan_name": "700720_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Ppo Hmo", "plan_name": "701720", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Ppo Hmo", "plan_name": "701720_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Ms State Emplo", "plan_name": "401457", "standard_charge_percentage": 0.80, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Ms State Emplo", "plan_name": "401457_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Basic Pl", "plan_name": "400100", "standard_charge_percentage": 0.85, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Basic Pl", "plan_name": "400100_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Federal", "plan_name": "400110", "standard_charge_percentage": 0.85, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Federal", "plan_name": "400110_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." } ] } ] }, { "description": "Aspirin 81 mg chewable tablet [679]", "drug_information": { "unit": 1.00, "type": "EA" }, "code_information": [ { "code": "0904-4040-73", "type": "NDC" } ], "standard_charges": [ { "gross_charge": 1.00, "minimum": 0.80, "maximum": 0.85, "setting": "both", "payers_information": [ { "payer_name": "Aetna", "plan_name": "700700", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna", "plan_name": "700700_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Miscellaneous", "plan_name": "700720", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Miscellaneous", "plan_name": "700720_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Ppo Hmo", "plan_name": "701720", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Ppo Hmo", "plan_name": "701720_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Ms State Emplo", "plan_name": "401457", "standard_charge_percentage": 0.80, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Ms State Emplo", "plan_name": "401457_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Basic Pl", "plan_name": "400100", "standard_charge_percentage": 0.85, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Basic Pl", "plan_name": "400100_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Federal", "plan_name": "400110", "standard_charge_percentage": 0.85, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Federal", "plan_name": "400110_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." } ] } ] }, { "description": "Pseudoephedrine 30 mg tablet [6714]", "drug_information": { "unit": 1.00, "type": "EA" }, "code_information": [ { "code": "0904-5053-59", "type": "NDC" } ], "standard_charges": [ { "gross_charge": 7.50, "minimum": 6.00, "maximum": 6.38, "setting": "both", "payers_information": [ { "payer_name": "Aetna", "plan_name": "700700", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna", "plan_name": "700700_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Miscellaneous", "plan_name": "700720", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Miscellaneous", "plan_name": "700720_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Ppo Hmo", "plan_name": "701720", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Ppo Hmo", "plan_name": "701720_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Ms State Emplo", "plan_name": "401457", "standard_charge_percentage": 0.80, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Ms State Emplo", "plan_name": "401457_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Basic Pl", "plan_name": "400100", "standard_charge_percentage": 0.85, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Basic Pl", "plan_name": "400100_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Federal", "plan_name": "400110", "standard_charge_percentage": 0.85, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Federal", "plan_name": "400110_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." } ] } ] }, { "description": "Simethicone 80 mg chewable tablet [7227]", "drug_information": { "unit": 1.00, "type": "EA" }, "code_information": [ { "code": "0904-5068-60", "type": "NDC" } ], "standard_charges": [ { "gross_charge": 1.00, "minimum": 0.80, "maximum": 0.85, "setting": "both", "payers_information": [ { "payer_name": "Aetna", "plan_name": "700700", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna", "plan_name": "700700_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Miscellaneous", "plan_name": "700720", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Miscellaneous", "plan_name": "700720_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Ppo Hmo", "plan_name": "701720", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Ppo Hmo", "plan_name": "701720_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Ms State Emplo", "plan_name": "401457", "standard_charge_percentage": 0.80, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Ms State Emplo", "plan_name": "401457_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Basic Pl", "plan_name": "400100", "standard_charge_percentage": 0.85, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Basic Pl", "plan_name": "400100_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", 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"payer_name": "Aetna Miscellaneous", "plan_name": "700720_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Ppo Hmo", "plan_name": "701720", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Ppo Hmo", "plan_name": "701720_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Ms State Emplo", "plan_name": "401457", "standard_charge_percentage": 0.80, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": 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"payer_name": "Bc/Bs Ms State Emplo", "plan_name": "401457", "standard_charge_percentage": 0.80, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Ms State Emplo", "plan_name": "401457_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Basic Pl", "plan_name": "400100", "standard_charge_percentage": 0.85, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Basic Pl", "plan_name": "400100_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Federal", "plan_name": "400110", "standard_charge_percentage": 0.85, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Federal", "plan_name": "400110_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." } ] } ] }, { "description": "Enalapril maleate 20 mg tablet [9926]", "drug_information": { "unit": 1.00, "type": "EA" }, "code_information": [ { "code": "0904-5611-61", "type": "NDC" } ], "standard_charges": [ { "gross_charge": 7.50, "minimum": 6.00, "maximum": 6.38, "setting": "both", "payers_information": [ { "payer_name": "Aetna", "plan_name": "700700", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit 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}, { "payer_name": "Bc/Bs Of Ms Basic Pl", "plan_name": "400100_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Federal", "plan_name": "400110", "standard_charge_percentage": 0.85, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Federal", "plan_name": "400110_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." } ] } ] }, { "description": "Clonidine hcl 0.2 mg tablet [1756]", "drug_information": { "unit": 1.00, "type": "EA" }, "code_information": [ { "code": "0904-5657-61", "type": "NDC" } ], "standard_charges": [ { "gross_charge": 7.50, "minimum": 6.00, 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"percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." } ] } ] }, { "description": "Ibuprofen 400 mg tablet [3843]", "drug_information": { "unit": 1.00, "type": "EA" }, "code_information": [ { "code": "0904-5853-60", "type": "NDC" } ], "standard_charges": [ { "gross_charge": 7.50, "minimum": 6.00, "maximum": 6.38, "setting": "both", "payers_information": [ { "payer_name": "Aetna", "plan_name": "700700", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna", "plan_name": "700700_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Miscellaneous", "plan_name": "700720", "standard_charge_percentage": 80.0, "count": 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"methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Ms State Emplo", "plan_name": "401457_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Basic Pl", "plan_name": "400100", "standard_charge_percentage": 0.85, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Basic Pl", "plan_name": "400100_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Federal", "plan_name": "400110", "standard_charge_percentage": 0.85, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Federal", "plan_name": "400110_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." } ] } ] }, { "description": "Ibuprofen 400 mg tablet [3843]", "drug_information": { "unit": 1.00, "type": "EA" }, "code_information": [ { "code": "0904-5853-61", "type": "NDC" } ], "standard_charges": [ { "gross_charge": 7.50, "minimum": 6.00, "maximum": 6.38, "setting": "both", "payers_information": [ { "payer_name": "Aetna", "plan_name": "700700", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna", "plan_name": "700700_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Miscellaneous", "plan_name": "700720", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Miscellaneous", "plan_name": "700720_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Ppo Hmo", "plan_name": "701720", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Ppo Hmo", "plan_name": "701720_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Ms State Emplo", "plan_name": "401457", "standard_charge_percentage": 0.80, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Ms State Emplo", "plan_name": "401457_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Basic Pl", "plan_name": "400100", "standard_charge_percentage": 0.85, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Basic Pl", "plan_name": "400100_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Federal", "plan_name": "400110", "standard_charge_percentage": 0.85, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Federal", "plan_name": "400110_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." } ] } ] }, { "description": "Ibuprofen 600 mg tablet [3844]", "drug_information": { "unit": 1.00, "type": "EA" }, "code_information": [ { "code": "0904-5854-61", "type": "NDC" } ], "standard_charges": [ { "gross_charge": 7.50, "minimum": 6.00, "maximum": 6.38, "setting": "both", "payers_information": [ { "payer_name": "Aetna", "plan_name": "700700", 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"standard_charge_percentage": 0.85, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Basic Pl", "plan_name": "400100_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Federal", "plan_name": "400110", "standard_charge_percentage": 0.85, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Federal", "plan_name": "400110_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." } ] } ] }, { "description": "Ibuprofen 800 mg tablet [3845]", "drug_information": { "unit": 1.00, "type": "EA" }, "code_information": [ { "code": "0904-5855-61", "type": "NDC" } ], "standard_charges": [ { "gross_charge": 7.50, "minimum": 6.00, "maximum": 6.38, "setting": "both", "payers_information": [ { "payer_name": "Aetna", "plan_name": "700700", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna", "plan_name": "700700_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Miscellaneous", "plan_name": "700720", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Miscellaneous", "plan_name": "700720_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Ppo Hmo", "plan_name": "701720", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Ppo Hmo", "plan_name": "701720_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Ms State Emplo", "plan_name": "401457", "standard_charge_percentage": 0.80, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Ms State Emplo", "plan_name": "401457_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Basic Pl", "plan_name": "400100", "standard_charge_percentage": 0.85, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Basic Pl", "plan_name": "400100_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Federal", "plan_name": "400110", "standard_charge_percentage": 0.85, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Federal", "plan_name": "400110_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." } ] } ] }, { "description": "Digoxin 125 mcg (0.125 mg) tablet [2444]", "drug_information": { "unit": 1.00, "type": "EA" }, "code_information": [ { "code": "0904-5921-61", "type": "NDC" } ], "standard_charges": [ { "gross_charge": 9.09, "minimum": 7.27, "maximum": 7.73, "setting": "both", "payers_information": [ { "payer_name": "Aetna", "plan_name": "700700", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna", "plan_name": "700700_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna 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"plan_name": "401457", "standard_charge_percentage": 0.80, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Ms State Emplo", "plan_name": "401457_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Basic Pl", "plan_name": "400100", "standard_charge_percentage": 0.85, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Basic Pl", "plan_name": "400100_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Federal", "plan_name": "400110", "standard_charge_percentage": 0.85, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Federal", "plan_name": "400110_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." } ] } ] }, { "description": "Labetalol 100 mg tablet [10373]", "drug_information": { "unit": 1.00, "type": "EA" }, "code_information": [ { "code": "0904-5928-61", "type": "NDC" } ], "standard_charges": [ { "gross_charge": 7.50, "minimum": 6.00, "maximum": 6.38, "setting": "both", "payers_information": [ { "payer_name": "Aetna", "plan_name": "700700", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna", "plan_name": "700700_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Miscellaneous", "plan_name": "700720", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Miscellaneous", "plan_name": "700720_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Ppo Hmo", "plan_name": "701720", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Ppo 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Pl", "plan_name": "400100_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Federal", "plan_name": "400110", "standard_charge_percentage": 0.85, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Federal", "plan_name": "400110_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." } ] } ] }, { "description": "Clindamycin hcl 150 mg capsule [1740]", "drug_information": { "unit": 1.00, "type": "EA" }, "code_information": [ { "code": "0904-5959-61", "type": "NDC" } ], "standard_charges": [ { "gross_charge": 7.50, "minimum": 6.00, "maximum": 6.38, "setting": "both", "payers_information": [ { "payer_name": "Aetna", "plan_name": "700700", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna", "plan_name": "700700_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Miscellaneous", "plan_name": "700720", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Miscellaneous", "plan_name": "700720_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Ppo Hmo", "plan_name": "701720", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Ppo Hmo", "plan_name": "701720_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Ms State Emplo", "plan_name": "401457", "standard_charge_percentage": 0.80, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Ms State Emplo", "plan_name": "401457_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Basic Pl", "plan_name": "400100", "standard_charge_percentage": 0.85, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Basic Pl", "plan_name": "400100_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Federal", "plan_name": "400110", "standard_charge_percentage": 0.85, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Federal", "plan_name": "400110_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." } ] } ] }, { "description": "Citalopram 20 mg tablet [21062]", "drug_information": { "unit": 1.00, "type": "EA" }, "code_information": [ { "code": "0904-6085-61", "type": "NDC" } ], "standard_charges": [ { "gross_charge": 7.50, "minimum": 6.00, "maximum": 6.38, "setting": "both", "payers_information": [ { "payer_name": "Aetna", "plan_name": "700700", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna", "plan_name": "700700_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Miscellaneous", "plan_name": "700720", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed 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"payer_name": "Bc/Bs Ms State Emplo", "plan_name": "401457_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Basic Pl", "plan_name": "400100", "standard_charge_percentage": 0.85, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Basic Pl", "plan_name": "400100_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Federal", "plan_name": "400110", "standard_charge_percentage": 0.85, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Federal", "plan_name": "400110_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." } ] } ] }, { "description": "Carbamazepine 200 mg tablet [1357]", "drug_information": { "unit": 1.00, "type": "EA" }, "code_information": [ { "code": "0904-6172-61", "type": "NDC" } ], "standard_charges": [ { "gross_charge": 7.50, "minimum": 6.00, "maximum": 6.38, "setting": "both", "payers_information": [ { "payer_name": "Aetna", "plan_name": "700700", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna", "plan_name": "700700_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Miscellaneous", "plan_name": "700720", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Miscellaneous", "plan_name": "700720_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Ppo Hmo", "plan_name": "701720", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Ppo Hmo", "plan_name": "701720_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Ms State Emplo", "plan_name": "401457", "standard_charge_percentage": 0.80, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Ms State Emplo", "plan_name": "401457_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Basic Pl", "plan_name": "400100", "standard_charge_percentage": 0.85, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Basic Pl", "plan_name": "400100_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Federal", "plan_name": "400110", "standard_charge_percentage": 0.85, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Federal", "plan_name": "400110_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." } ] } ] }, { "description": "Benzocaine 15 mg-menthol 3.6 mg lozenges [152101]", "drug_information": { "unit": 18.00, "type": "EA" }, "code_information": [ { "code": "0904-6255-49", "type": "NDC" } ], "standard_charges": [ { "gross_charge": 9.45, "minimum": 7.56, "maximum": 8.03, "setting": "both", "payers_information": [ { "payer_name": "Aetna", "plan_name": "700700", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna", "plan_name": "700700_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Miscellaneous", "plan_name": "700720", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Miscellaneous", "plan_name": "700720_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Ppo Hmo", "plan_name": "701720", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Ppo Hmo", "plan_name": "701720_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Ms State Emplo", "plan_name": "401457", "standard_charge_percentage": 0.80, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Ms State Emplo", "plan_name": "401457_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Basic Pl", "plan_name": "400100", "standard_charge_percentage": 0.85, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Basic Pl", "plan_name": "400100_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Federal", "plan_name": "400110", "standard_charge_percentage": 0.85, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Federal", "plan_name": "400110_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." } ] } ] }, { "description": "Ziprasidone 20 mg capsule [29778]", "drug_information": { "unit": 1.00, "type": "EA" }, "code_information": [ { "code": "0904-6269-08", "type": "NDC" } ], "standard_charges": [ { "gross_charge": 36.86, "minimum": 29.49, "maximum": 31.33, "setting": "both", "payers_information": [ { "payer_name": "Aetna", "plan_name": "700700", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna", "plan_name": "700700_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Miscellaneous", "plan_name": "700720", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Miscellaneous", "plan_name": "700720_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Ppo Hmo", "plan_name": "701720", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Ppo Hmo", "plan_name": "701720_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Ms State Emplo", "plan_name": "401457", "standard_charge_percentage": 0.80, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Ms State Emplo", "plan_name": "401457_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Basic Pl", "plan_name": "400100", "standard_charge_percentage": 0.85, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Basic Pl", "plan_name": "400100_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Federal", "plan_name": "400110", "standard_charge_percentage": 0.85, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Federal", "plan_name": "400110_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." } ] } ] }, { "description": "Atorvastatin 10 mg tablet [19176]", "drug_information": { "unit": 1.00, "type": "EA" }, "code_information": [ { "code": "0904-6290-61", "type": "NDC" } ], "standard_charges": [ { "gross_charge": 7.50, "minimum": 6.00, "maximum": 6.38, "setting": "both", "payers_information": [ { "payer_name": "Aetna", "plan_name": "700700", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna", "plan_name": "700700_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Miscellaneous", "plan_name": "700720", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Miscellaneous", "plan_name": "700720_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Ppo Hmo", "plan_name": "701720", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Ppo Hmo", "plan_name": "701720_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Ms State Emplo", "plan_name": "401457", "standard_charge_percentage": 0.80, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Ms State Emplo", "plan_name": "401457_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Basic Pl", "plan_name": "400100", "standard_charge_percentage": 0.85, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Basic Pl", "plan_name": "400100_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Federal", "plan_name": "400110", "standard_charge_percentage": 0.85, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Federal", "plan_name": "400110_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." } ] } ] }, { "description": "Atorvastatin 20 mg tablet [19178]", "drug_information": { "unit": 1.00, "type": "EA" }, "code_information": [ { "code": "0904-6291-61", "type": "NDC" } ], "standard_charges": [ { "gross_charge": 7.50, "minimum": 6.00, "maximum": 6.38, "setting": "both", "payers_information": [ { "payer_name": "Aetna", "plan_name": "700700", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna", "plan_name": "700700_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Miscellaneous", "plan_name": "700720", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Miscellaneous", "plan_name": "700720_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Ppo Hmo", "plan_name": "701720", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Ppo Hmo", "plan_name": "701720_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Ms State Emplo", "plan_name": "401457", "standard_charge_percentage": 0.80, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Ms State Emplo", "plan_name": "401457_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Basic Pl", "plan_name": "400100", "standard_charge_percentage": 0.85, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Basic Pl", "plan_name": "400100_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Federal", "plan_name": "400110", "standard_charge_percentage": 0.85, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Federal", "plan_name": "400110_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." } ] } ] }, { "description": "Atorvastatin 40 mg tablet [19177]", "drug_information": { "unit": 1.00, "type": "EA" }, "code_information": [ { "code": "0904-6292-61", "type": "NDC" } ], "standard_charges": [ { "gross_charge": 7.50, "minimum": 6.00, "maximum": 6.38, "setting": "both", "payers_information": [ { "payer_name": "Aetna", "plan_name": "700700", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna", "plan_name": "700700_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Miscellaneous", "plan_name": "700720", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Miscellaneous", "plan_name": "700720_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Ppo Hmo", "plan_name": "701720", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Ppo Hmo", "plan_name": "701720_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Ms State Emplo", "plan_name": "401457", "standard_charge_percentage": 0.80, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Ms State Emplo", "plan_name": "401457_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Basic Pl", "plan_name": "400100", "standard_charge_percentage": 0.85, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Basic Pl", "plan_name": "400100_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Federal", "plan_name": "400110", "standard_charge_percentage": 0.85, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Federal", "plan_name": "400110_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." } ] } ] }, { "description": "Clopidogrel 75 mg tablet [22142]", "drug_information": { "unit": 1.00, "type": "EA" }, "code_information": [ { "code": "0904-6294-61", "type": "NDC" } ], "standard_charges": [ { "gross_charge": 7.50, "minimum": 6.00, "maximum": 6.38, "setting": "both", "payers_information": [ { "payer_name": "Aetna", "plan_name": "700700", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna", "plan_name": "700700_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Miscellaneous", "plan_name": "700720", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Miscellaneous", "plan_name": "700720_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Ppo Hmo", "plan_name": "701720", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Ppo Hmo", "plan_name": "701720_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Ms State Emplo", "plan_name": "401457", "standard_charge_percentage": 0.80, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Ms State Emplo", "plan_name": "401457_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Basic Pl", "plan_name": "400100", "standard_charge_percentage": 0.85, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Basic Pl", "plan_name": "400100_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Federal", "plan_name": "400110", "standard_charge_percentage": 0.85, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Federal", "plan_name": "400110_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." } ] } ] }, { "description": "Carvedilol 3.125 mg tablet [18551]", "drug_information": { "unit": 1.00, "type": "EA" }, "code_information": [ { "code": "0904-6300-61", "type": "NDC" } ], "standard_charges": [ { "gross_charge": 7.50, "minimum": 6.00, "maximum": 6.38, "setting": "both", "payers_information": [ { "payer_name": "Aetna", "plan_name": "700700", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna", "plan_name": "700700_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Miscellaneous", "plan_name": "700720", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Miscellaneous", "plan_name": "700720_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Ppo Hmo", "plan_name": "701720", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Ppo Hmo", "plan_name": "701720_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Ms State Emplo", "plan_name": "401457", "standard_charge_percentage": 0.80, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Ms State Emplo", "plan_name": "401457_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Basic Pl", "plan_name": "400100", "standard_charge_percentage": 0.85, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Basic Pl", "plan_name": "400100_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Federal", "plan_name": "400110", "standard_charge_percentage": 0.85, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Federal", "plan_name": "400110_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." } ] } ] }, { "description": "Carvedilol 6.25 mg tablet [15747]", "drug_information": { "unit": 1.00, "type": "EA" }, "code_information": [ { "code": "0904-6301-61", "type": "NDC" } ], "standard_charges": [ { "gross_charge": 7.50, "minimum": 6.00, "maximum": 6.38, "setting": "both", "payers_information": [ { "payer_name": "Aetna", "plan_name": "700700", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna", "plan_name": "700700_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Miscellaneous", "plan_name": "700720", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Miscellaneous", "plan_name": "700720_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Ppo Hmo", "plan_name": "701720", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Ppo Hmo", "plan_name": "701720_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Ms State Emplo", "plan_name": "401457", "standard_charge_percentage": 0.80, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Ms State Emplo", "plan_name": "401457_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Basic Pl", "plan_name": "400100", "standard_charge_percentage": 0.85, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Basic Pl", "plan_name": "400100_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Federal", "plan_name": "400110", "standard_charge_percentage": 0.85, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Federal", "plan_name": "400110_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." } ] } ] }, { "description": "Carvedilol 12.5 mg tablet [15749]", "drug_information": { "unit": 1.00, "type": "EA" }, "code_information": [ { "code": "0904-6302-61", "type": "NDC" } ], "standard_charges": [ { "gross_charge": 7.50, "minimum": 6.00, "maximum": 6.38, "setting": "both", "payers_information": [ { 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"plan_name": "701720", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Ppo Hmo", "plan_name": "701720_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Ms State Emplo", "plan_name": "401457", "standard_charge_percentage": 0.80, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Ms State Emplo", "plan_name": "401457_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Basic Pl", "plan_name": "400100", "standard_charge_percentage": 0.85, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Basic Pl", "plan_name": "400100_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Federal", "plan_name": "400110", "standard_charge_percentage": 0.85, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Federal", "plan_name": "400110_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." } ] } ] }, { "description": "Carvedilol 25 mg tablet [15748]", "drug_information": { "unit": 1.00, "type": "EA" }, "code_information": [ { "code": "0904-6303-61", "type": "NDC" } ], "standard_charges": [ { "gross_charge": 7.50, "minimum": 6.00, "maximum": 6.38, "setting": "both", "payers_information": [ { "payer_name": "Aetna", "plan_name": "700700", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna", "plan_name": "700700_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Miscellaneous", "plan_name": "700720", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna 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"plan_name": "401457_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Basic Pl", "plan_name": "400100", "standard_charge_percentage": 0.85, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Basic Pl", "plan_name": "400100_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Federal", "plan_name": "400110", "standard_charge_percentage": 0.85, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Federal", "plan_name": "400110_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." } ] } ] }, { "description": "Levofloxacin 250 mg tablet [18918]", "drug_information": { "unit": 1.00, "type": "EA" }, "code_information": [ { "code": "0904-6351-61", "type": "NDC" } ], "standard_charges": [ { "gross_charge": 7.50, "minimum": 6.00, "maximum": 6.38, "setting": "both", "payers_information": [ { "payer_name": "Aetna", "plan_name": "700700", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna", "plan_name": "700700_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Miscellaneous", "plan_name": "700720", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Miscellaneous", "plan_name": "700720_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Ppo Hmo", "plan_name": "701720", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Ppo Hmo", "plan_name": "701720_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Ms State Emplo", "plan_name": "401457", "standard_charge_percentage": 0.80, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Ms State Emplo", "plan_name": "401457_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Basic Pl", "plan_name": "400100", "standard_charge_percentage": 0.85, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Basic Pl", "plan_name": "400100_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Federal", "plan_name": "400110", "standard_charge_percentage": 0.85, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Federal", "plan_name": "400110_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." } ] } ] }, { "description": "Levofloxacin 500 mg tablet [18919]", "drug_information": { "unit": 1.00, "type": "EA" }, "code_information": [ { "code": "0904-6352-61", "type": "NDC" } ], "standard_charges": [ { "gross_charge": 7.50, "minimum": 6.00, "maximum": 6.38, "setting": "both", "payers_information": [ { "payer_name": "Aetna", "plan_name": "700700", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna", "plan_name": "700700_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Miscellaneous", "plan_name": "700720", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Miscellaneous", "plan_name": "700720_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Ppo Hmo", "plan_name": "701720", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Ppo Hmo", "plan_name": "701720_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Ms State Emplo", "plan_name": "401457", "standard_charge_percentage": 0.80, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Ms State Emplo", "plan_name": "401457_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Basic Pl", "plan_name": "400100", "standard_charge_percentage": 0.85, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Basic Pl", "plan_name": "400100_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Federal", "plan_name": "400110", "standard_charge_percentage": 0.85, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Federal", "plan_name": "400110_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." } ] } ] }, { "description": "Levofloxacin 750 mg tablet [28964]", "drug_information": { "unit": 1.00, "type": "EA" }, "code_information": [ { "code": "0904-6353-61", "type": "NDC" } ], "standard_charges": [ { "gross_charge": 7.50, "minimum": 6.00, "maximum": 6.38, "setting": "both", "payers_information": [ { "payer_name": "Aetna", "plan_name": "700700", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna", "plan_name": "700700_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Miscellaneous", "plan_name": "700720", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Miscellaneous", "plan_name": "700720_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Ppo Hmo", "plan_name": "701720", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Ppo Hmo", "plan_name": "701720_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Ms State Emplo", "plan_name": "401457", "standard_charge_percentage": 0.80, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Ms State Emplo", "plan_name": "401457_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Basic Pl", "plan_name": "400100", "standard_charge_percentage": 0.85, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Basic Pl", "plan_name": "400100_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Federal", "plan_name": "400110", "standard_charge_percentage": 0.85, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Federal", "plan_name": "400110_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." } ] } ] }, { "description": "Risperidone 0.25 mg tablet [25519]", "drug_information": { "unit": 1.00, "type": "EA" }, "code_information": [ { "code": "0904-6357-61", "type": "NDC" } ], "standard_charges": [ { "gross_charge": 7.50, "minimum": 6.00, "maximum": 6.38, "setting": "both", "payers_information": [ { "payer_name": "Aetna", "plan_name": "700700", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna", "plan_name": "700700_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Miscellaneous", "plan_name": "700720", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Miscellaneous", "plan_name": "700720_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Ppo Hmo", "plan_name": "701720", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Ppo Hmo", "plan_name": "701720_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Ms State Emplo", "plan_name": "401457", "standard_charge_percentage": 0.80, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Ms State Emplo", "plan_name": "401457_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Basic Pl", "plan_name": "400100", "standard_charge_percentage": 0.85, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Basic Pl", "plan_name": "400100_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Federal", "plan_name": "400110", "standard_charge_percentage": 0.85, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Federal", "plan_name": "400110_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." } ] } ] }, { "description": "Risperidone 0.5 mg tablet [25520]", "drug_information": { "unit": 1.00, "type": "EA" }, "code_information": [ { "code": "0904-6358-61", "type": "NDC" } ], "standard_charges": [ { "gross_charge": 7.50, "minimum": 6.00, "maximum": 6.38, "setting": "both", "payers_information": [ { "payer_name": "Aetna", "plan_name": "700700", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna", "plan_name": "700700_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Miscellaneous", "plan_name": "700720", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Miscellaneous", "plan_name": "700720_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Ppo Hmo", "plan_name": "701720", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Ppo Hmo", "plan_name": "701720_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Ms State Emplo", "plan_name": "401457", "standard_charge_percentage": 0.80, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Ms State Emplo", "plan_name": "401457_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Basic Pl", "plan_name": "400100", "standard_charge_percentage": 0.85, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Basic Pl", "plan_name": "400100_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Federal", "plan_name": "400110", "standard_charge_percentage": 0.85, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Federal", "plan_name": "400110_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." } ] } ] }, { "description": "Risperidone 1 mg tablet [18313]", "drug_information": { "unit": 1.00, "type": "EA" }, "code_information": [ { "code": "0904-6359-61", "type": "NDC" } ], "standard_charges": [ { "gross_charge": 7.50, "minimum": 6.00, "maximum": 6.38, "setting": "both", "payers_information": [ { "payer_name": "Aetna", "plan_name": "700700", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna", "plan_name": "700700_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Miscellaneous", "plan_name": "700720", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Miscellaneous", "plan_name": "700720_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Ppo Hmo", "plan_name": "701720", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Ppo Hmo", "plan_name": "701720_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Ms State Emplo", "plan_name": "401457", "standard_charge_percentage": 0.80, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Ms State Emplo", "plan_name": "401457_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Basic Pl", "plan_name": "400100", "standard_charge_percentage": 0.85, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Basic Pl", "plan_name": "400100_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Federal", "plan_name": "400110", "standard_charge_percentage": 0.85, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Federal", "plan_name": "400110_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." } ] } ] }, { "description": "Risperidone 2 mg tablet [18311]", "drug_information": { "unit": 1.00, "type": "EA" }, "code_information": [ { "code": "0904-6360-61", "type": "NDC" } ], 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charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Ppo Hmo", "plan_name": "701720", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Ppo Hmo", "plan_name": "701720_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Ms State Emplo", "plan_name": "401457", "standard_charge_percentage": 0.80, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Ms State Emplo", "plan_name": "401457_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Basic Pl", "plan_name": "400100", "standard_charge_percentage": 0.85, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Basic Pl", "plan_name": "400100_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Federal", "plan_name": "400110", "standard_charge_percentage": 0.85, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Federal", "plan_name": "400110_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." } ] } ] }, { "description": "Divalproex er 250 mg tabletextended release 24 hr [34418]", "drug_information": { "unit": 1.00, "type": "EA" }, "code_information": [ { "code": "0904-6363-45", "type": "NDC" } ], "standard_charges": [ { "gross_charge": 12.72, "minimum": 10.18, "maximum": 10.81, "setting": "both", "payers_information": [ { "payer_name": "Aetna", "plan_name": "700700", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna", "plan_name": "700700_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Miscellaneous", "plan_name": "700720", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Miscellaneous", "plan_name": "700720_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Ppo Hmo", "plan_name": "701720", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Ppo Hmo", "plan_name": "701720_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Ms State Emplo", "plan_name": "401457", "standard_charge_percentage": 0.80, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Ms State Emplo", "plan_name": "401457_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Basic Pl", "plan_name": "400100", "standard_charge_percentage": 0.85, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Basic Pl", "plan_name": "400100_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Federal", "plan_name": "400110", "standard_charge_percentage": 0.85, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Federal", "plan_name": "400110_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." } ] } ] }, { "description": "Amlodipine 2.5 mg tablet [9070]", "drug_information": { "unit": 1.00, "type": "EA" }, "code_information": [ { "code": "0904-6369-61", "type": "NDC" } ], "standard_charges": [ { "gross_charge": 7.50, "minimum": 6.00, "maximum": 6.38, "setting": "both", "payers_information": [ { "payer_name": "Aetna", "plan_name": "700700", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna", "plan_name": "700700_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Miscellaneous", "plan_name": "700720", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Miscellaneous", "plan_name": "700720_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Ppo Hmo", "plan_name": "701720", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Ppo Hmo", "plan_name": "701720_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Ms State Emplo", "plan_name": "401457", "standard_charge_percentage": 0.80, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Ms State Emplo", "plan_name": "401457_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Basic Pl", "plan_name": "400100", "standard_charge_percentage": 0.85, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Basic Pl", "plan_name": "400100_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Federal", "plan_name": "400110", "standard_charge_percentage": 0.85, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Federal", "plan_name": "400110_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." } ] } ] }, { "description": "Amlodipine 5 mg tablet [9071]", "drug_information": { "unit": 1.00, "type": "EA" }, "code_information": [ { "code": "0904-6370-61", "type": "NDC" } ], "standard_charges": [ { "gross_charge": 7.50, "minimum": 6.00, "maximum": 6.38, "setting": "both", "payers_information": [ { "payer_name": "Aetna", "plan_name": "700700", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna", "plan_name": "700700_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Miscellaneous", "plan_name": "700720", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Miscellaneous", "plan_name": "700720_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Ppo Hmo", "plan_name": "701720", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Ppo Hmo", "plan_name": "701720_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Ms State Emplo", "plan_name": "401457", "standard_charge_percentage": 0.80, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Ms State Emplo", "plan_name": "401457_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Basic Pl", "plan_name": "400100", "standard_charge_percentage": 0.85, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Basic Pl", "plan_name": "400100_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Federal", "plan_name": "400110", "standard_charge_percentage": 0.85, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Federal", "plan_name": "400110_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." } ] } ] }, { "description": "Amlodipine 10 mg tablet [9069]", "drug_information": { "unit": 1.00, "type": "EA" }, "code_information": [ { "code": "0904-6371-61", "type": "NDC" } ], "standard_charges": [ { "gross_charge": 7.50, "minimum": 6.00, "maximum": 6.38, "setting": "both", "payers_information": [ { "payer_name": "Aetna", "plan_name": "700700", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna", "plan_name": "700700_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Miscellaneous", "plan_name": "700720", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Miscellaneous", "plan_name": "700720_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Ppo Hmo", "plan_name": "701720", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Ppo Hmo", "plan_name": "701720_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Ms State Emplo", "plan_name": "401457", "standard_charge_percentage": 0.80, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Ms State Emplo", "plan_name": "401457_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Basic Pl", "plan_name": "400100", "standard_charge_percentage": 0.85, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Basic Pl", "plan_name": "400100_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Federal", "plan_name": "400110", "standard_charge_percentage": 0.85, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Federal", "plan_name": "400110_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." } ] } ] }, { "description": "Ropinirole 1 mg tablet [21689]", "drug_information": { "unit": 1.00, "type": "EA" }, "code_information": [ { "code": "0904-6374-61", "type": "NDC" } ], "standard_charges": [ { "gross_charge": 7.50, "minimum": 6.00, "maximum": 6.38, "setting": "both", "payers_information": [ { "payer_name": "Aetna", "plan_name": "700700", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna", "plan_name": "700700_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Miscellaneous", "plan_name": "700720", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Miscellaneous", "plan_name": "700720_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Ppo Hmo", "plan_name": "701720", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Ppo Hmo", "plan_name": "701720_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Ms State Emplo", "plan_name": "401457", "standard_charge_percentage": 0.80, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Ms State Emplo", "plan_name": "401457_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Basic Pl", "plan_name": "400100", "standard_charge_percentage": 0.85, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Basic Pl", "plan_name": "400100_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Federal", "plan_name": "400110", "standard_charge_percentage": 0.85, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Federal", "plan_name": "400110_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." } ] } ] }, { "description": "Tamsulosin 0.4 mg capsule [103890]", "drug_information": { "unit": 1.00, "type": "EA" }, "code_information": [ { "code": "0904-6401-61", "type": "NDC" } ], "standard_charges": [ { "gross_charge": 7.50, "minimum": 6.00, "maximum": 6.38, "setting": "both", "payers_information": [ { "payer_name": "Aetna", "plan_name": "700700", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna", "plan_name": "700700_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Miscellaneous", "plan_name": "700720", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Miscellaneous", "plan_name": "700720_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Ppo Hmo", "plan_name": "701720", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Ppo Hmo", "plan_name": "701720_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Ms State Emplo", "plan_name": "401457", "standard_charge_percentage": 0.80, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Ms State Emplo", "plan_name": "401457_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Basic Pl", "plan_name": "400100", "standard_charge_percentage": 0.85, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Basic Pl", "plan_name": "400100_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Federal", "plan_name": "400110", "standard_charge_percentage": 0.85, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Federal", "plan_name": "400110_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." } ] } ] }, { "description": "Bisacodyl 5 mg tabletdelayed release [1079]", "drug_information": { "unit": 1.00, "type": "EA" }, "code_information": [ { "code": "0904-6407-61", "type": "NDC" } ], "standard_charges": [ { "gross_charge": 1.00, "minimum": 0.80, "maximum": 0.85, "setting": "both", "payers_information": [ { "payer_name": "Aetna", "plan_name": "700700", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna", "plan_name": "700700_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Miscellaneous", "plan_name": "700720", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Miscellaneous", "plan_name": "700720_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Ppo Hmo", "plan_name": "701720", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Ppo Hmo", "plan_name": "701720_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Ms State Emplo", "plan_name": "401457", "standard_charge_percentage": 0.80, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Ms State Emplo", "plan_name": "401457_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Basic Pl", "plan_name": "400100", "standard_charge_percentage": 0.85, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Basic Pl", "plan_name": "400100_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Federal", "plan_name": "400110", "standard_charge_percentage": 0.85, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Federal", "plan_name": "400110_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." } ] } ] }, { "description": "Tizanidine 4 mg tablet [14793]", "drug_information": { "unit": 1.00, "type": "EA" }, "code_information": [ { "code": "0904-6418-61", "type": "NDC" } ], "standard_charges": [ { "gross_charge": 7.50, "minimum": 6.00, "maximum": 6.38, "setting": "both", "payers_information": [ { "payer_name": "Aetna", "plan_name": "700700", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna", "plan_name": "700700_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Miscellaneous", "plan_name": "700720", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Miscellaneous", "plan_name": "700720_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Ppo Hmo", "plan_name": "701720", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Ppo Hmo", "plan_name": "701720_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Ms State Emplo", "plan_name": "401457", "standard_charge_percentage": 0.80, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Ms State Emplo", "plan_name": "401457_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Basic Pl", "plan_name": "400100", "standard_charge_percentage": 0.85, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Basic Pl", "plan_name": "400100_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Federal", "plan_name": "400110", "standard_charge_percentage": 0.85, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Federal", "plan_name": "400110_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." } ] } ] }, { "description": "Escitalopram 10 mg tablet [33512]", "drug_information": { "unit": 1.00, "type": "EA" }, "code_information": [ { "code": "0904-6426-61", "type": "NDC" } ], "standard_charges": [ { "gross_charge": 7.50, "minimum": 6.00, "maximum": 6.38, "setting": "both", "payers_information": [ { "payer_name": "Aetna", "plan_name": "700700", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna", "plan_name": "700700_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate 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}, { "payer_name": "Bc/Bs Ms State Emplo", "plan_name": "401457", "standard_charge_percentage": 0.80, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Ms State Emplo", "plan_name": "401457_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Basic Pl", "plan_name": "400100", "standard_charge_percentage": 0.85, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Basic Pl", "plan_name": "400100_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Federal", "plan_name": "400110", "standard_charge_percentage": 0.85, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Federal", "plan_name": "400110_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." } ] } ] }, { "description": "Escitalopram 20 mg tablet [33513]", "drug_information": { "unit": 1.00, "type": "EA" }, "code_information": [ { "code": "0904-6427-61", "type": "NDC" } ], "standard_charges": [ { "gross_charge": 7.50, "minimum": 6.00, "maximum": 6.38, "setting": "both", "payers_information": [ { "payer_name": "Aetna", "plan_name": "700700", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data 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amounts." }, { "payer_name": "Aetna Ppo Hmo", "plan_name": "701720_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Ms State Emplo", "plan_name": "401457", "standard_charge_percentage": 0.80, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Ms State Emplo", "plan_name": "401457_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Basic Pl", "plan_name": "400100", "standard_charge_percentage": 0.85, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Basic Pl", "plan_name": "400100_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Federal", "plan_name": "400110", "standard_charge_percentage": 0.85, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Federal", "plan_name": "400110_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." } ] } ] }, { "description": "Hydralazine 25 mg tablet [3700]", "drug_information": { "unit": 1.00, "type": "EA" }, "code_information": [ { "code": "0904-6441-61", "type": "NDC" } ], "standard_charges": [ { "gross_charge": 7.50, "minimum": 6.00, "maximum": 6.38, "setting": "both", "payers_information": [ { "payer_name": "Aetna", "plan_name": "700700", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna", "plan_name": "700700_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Miscellaneous", "plan_name": "700720", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Miscellaneous", "plan_name": "700720_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Ppo Hmo", "plan_name": "701720", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Ppo Hmo", "plan_name": "701720_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Ms State Emplo", "plan_name": "401457", "standard_charge_percentage": 0.80, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Ms State Emplo", "plan_name": "401457_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Basic Pl", "plan_name": "400100", "standard_charge_percentage": 0.85, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Basic Pl", "plan_name": "400100_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Federal", "plan_name": "400110", "standard_charge_percentage": 0.85, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Federal", "plan_name": "400110_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." } ] } ] }, { "description": "Hydralazine 50 mg tablet [3701]", "drug_information": { "unit": 1.00, "type": "EA" }, "code_information": [ { "code": "0904-6442-61", "type": "NDC" } ], "standard_charges": [ { "gross_charge": 7.50, "minimum": 6.00, "maximum": 6.38, "setting": "both", "payers_information": [ { "payer_name": "Aetna", "plan_name": "700700", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna", "plan_name": "700700_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Miscellaneous", "plan_name": "700720", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Miscellaneous", "plan_name": "700720_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Ppo Hmo", "plan_name": "701720", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Ppo Hmo", "plan_name": "701720_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Ms State Emplo", "plan_name": "401457", "standard_charge_percentage": 0.80, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Ms State Emplo", "plan_name": "401457_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Basic Pl", "plan_name": "400100", "standard_charge_percentage": 0.85, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Basic Pl", "plan_name": "400100_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Federal", "plan_name": "400110", "standard_charge_percentage": 0.85, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Federal", "plan_name": "400110_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." } ] } ] }, { "description": "Isosorbide mononitrate er 30 mg tabletextended release 24 hr [24521]", "drug_information": { "unit": 1.00, "type": "EA" }, "code_information": [ { "code": "0904-6449-61", "type": "NDC" } ], "standard_charges": [ { "gross_charge": 7.50, "minimum": 6.00, "maximum": 6.38, "setting": "both", "payers_information": [ { "payer_name": "Aetna", "plan_name": "700700", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna", "plan_name": "700700_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", 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"methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." } ] } ] }, { "description": "Memantine 5 mg tablet [37170]", "drug_information": { "unit": 1.00, "type": "EA" }, "code_information": [ { "code": "0904-6505-61", "type": "NDC" } ], "standard_charges": [ { "gross_charge": 7.50, "minimum": 6.00, "maximum": 6.38, "setting": "both", "payers_information": [ { "payer_name": "Aetna", "plan_name": "700700", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna", "plan_name": "700700_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Miscellaneous", "plan_name": "700720", "standard_charge_percentage": 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"standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Federal", "plan_name": "400110", "standard_charge_percentage": 0.85, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Federal", "plan_name": "400110_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." } ] } ] }, { "description": "Meclizine 25 mg tablet [12025]", "drug_information": { "unit": 1.00, "type": "EA" }, "code_information": [ { "code": "0904-6517-61", "type": "NDC" } ], "standard_charges": [ { "gross_charge": 7.50, "minimum": 6.00, "maximum": 6.38, "setting": "both", "payers_information": [ { "payer_name": 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"standard_charge_percentage": 0.85, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Basic Pl", "plan_name": "400100_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Federal", "plan_name": "400110", "standard_charge_percentage": 0.85, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Federal", "plan_name": "400110_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." } ] } ] }, { "description": "Sennosides 8.6 mg tablet [11349]", 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"401457_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Basic Pl", "plan_name": "400100", "standard_charge_percentage": 0.85, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Basic Pl", "plan_name": "400100_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Federal", "plan_name": "400110", "standard_charge_percentage": 0.85, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Federal", "plan_name": "400110_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." } ] } ] }, { "description": "Quetiapine 50 mg tablet [70397]", "drug_information": { "unit": 1.00, "type": "EA" }, "code_information": [ { "code": "0904-6639-61", "type": "NDC" } ], "standard_charges": [ { "gross_charge": 7.50, "minimum": 6.00, "maximum": 6.38, "setting": "both", "payers_information": [ { "payer_name": "Aetna", "plan_name": "700700", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna", "plan_name": "700700_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna 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}, { "payer_name": "Bc/Bs Of Ms Basic Pl", "plan_name": "400100_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Federal", "plan_name": "400110", "standard_charge_percentage": 0.85, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Federal", "plan_name": "400110_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." } ] } ] }, { "description": "Lisinopril 20 mg tablet [4526]", "drug_information": { "unit": 1.00, "type": "EA" }, "code_information": [ { "code": "0904-6799-61", "type": "NDC" } ], "standard_charges": [ { "gross_charge": 7.50, "minimum": 6.00, 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data to calculate allowed amounts." }, { "payer_name": "Aetna Miscellaneous", "plan_name": "700720_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Ppo Hmo", "plan_name": "701720", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Ppo Hmo", "plan_name": "701720_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Ms State Emplo", "plan_name": "401457", "standard_charge_percentage": 0.80, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate 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"Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Miscellaneous", "plan_name": "700720", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Miscellaneous", "plan_name": "700720_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Ppo Hmo", "plan_name": "701720", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Ppo Hmo", "plan_name": "701720_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Ms State Emplo", "plan_name": "401457", "standard_charge_percentage": 0.80, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Ms State Emplo", "plan_name": "401457_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Basic Pl", "plan_name": "400100", "standard_charge_percentage": 0.85, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Basic Pl", "plan_name": "400100_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Federal", "plan_name": "400110", "standard_charge_percentage": 0.85, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Federal", "plan_name": "400110_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." } ] } ] }, { "description": "Docusate calcium 240 mg capsule [2565]", "drug_information": { "unit": 1.00, "type": "EA" }, "code_information": [ { "code": "0904-6997-40", "type": "NDC" } ], "standard_charges": [ { "gross_charge": 1.00, "minimum": 0.80, "maximum": 0.85, "setting": "both", "payers_information": [ { "payer_name": "Aetna", "plan_name": "700700", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", 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"Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Ppo Hmo", "plan_name": "701720_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Ms State Emplo", "plan_name": "401457", "standard_charge_percentage": 0.80, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Ms State Emplo", "plan_name": "401457_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Basic Pl", "plan_name": "400100", "standard_charge_percentage": 0.85, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Basic Pl", "plan_name": "400100_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Federal", "plan_name": "400110", "standard_charge_percentage": 0.85, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Federal", "plan_name": "400110_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." } ] } ] }, { "description": "Duloxetine 30 mg capsuledelayed release [39276]", "drug_information": { "unit": 1.00, "type": "EA" }, "code_information": [ { "code": "0904-7044-61", "type": "NDC" } ], "standard_charges": [ { "gross_charge": 13.51, "minimum": 10.81, "maximum": 11.48, "setting": "both", "payers_information": [ { "payer_name": "Aetna", "plan_name": "700700", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna", "plan_name": "700700_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Miscellaneous", "plan_name": "700720", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Miscellaneous", "plan_name": "700720_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed 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"additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Basic Pl", "plan_name": "400100", "standard_charge_percentage": 0.85, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Basic Pl", "plan_name": "400100_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Federal", "plan_name": "400110", "standard_charge_percentage": 0.85, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Federal", "plan_name": "400110_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." } ] } ] }, { "description": "Duloxetine 60 mg capsuledelayed release [39277]", "drug_information": { "unit": 1.00, "type": "EA" }, "code_information": [ { "code": "0904-7045-61", "type": "NDC" } ], "standard_charges": [ { "gross_charge": 13.51, "minimum": 10.81, "maximum": 11.48, "setting": "both", "payers_information": [ { "payer_name": "Aetna", "plan_name": "700700", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna", "plan_name": "700700_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Miscellaneous", "plan_name": "700720", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Miscellaneous", "plan_name": "700720_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Ppo Hmo", "plan_name": "701720", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Ppo Hmo", "plan_name": "701720_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Ms State Emplo", "plan_name": "401457", "standard_charge_percentage": 0.80, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Ms State Emplo", "plan_name": "401457_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Basic Pl", "plan_name": "400100", "standard_charge_percentage": 0.85, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Basic Pl", "plan_name": "400100_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Federal", "plan_name": "400110", "standard_charge_percentage": 0.85, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Federal", "plan_name": "400110_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." } ] } ] }, { "description": "Aspirin 25 mg-dipyridamole 200 mg capsuleext.release 12 hr multiphase [27644]", "drug_information": { "unit": 1.00, "type": "EA" }, "code_information": [ { "code": "0904-7056-99", "type": "NDC" } ], "standard_charges": [ { "gross_charge": 79.10, "minimum": 63.28, "maximum": 67.24, "setting": "both", "payers_information": [ { "payer_name": "Aetna", "plan_name": "700700", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna", "plan_name": "700700_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Miscellaneous", "plan_name": "700720", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Miscellaneous", "plan_name": "700720_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Ppo Hmo", "plan_name": "701720", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Ppo Hmo", "plan_name": "701720_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Ms State Emplo", "plan_name": "401457", "standard_charge_percentage": 0.80, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Ms State Emplo", "plan_name": "401457_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Basic Pl", "plan_name": "400100", "standard_charge_percentage": 0.85, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Basic Pl", "plan_name": "400100_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Federal", "plan_name": "400110", "standard_charge_percentage": 0.85, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Federal", "plan_name": "400110_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." } ] } ] }, { "description": "Ciprofloxacin 500 mg tablet [25119]", "drug_information": { "unit": 1.00, "type": "EA" }, "code_information": [ { "code": "0904-7083-61", "type": "NDC" } ], "standard_charges": [ { "gross_charge": 7.50, "minimum": 6.00, "maximum": 6.38, "setting": "both", "payers_information": [ { "payer_name": "Aetna", "plan_name": "700700", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna", "plan_name": "700700_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Miscellaneous", "plan_name": "700720", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Miscellaneous", "plan_name": "700720_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Ppo Hmo", "plan_name": "701720", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Ppo Hmo", "plan_name": "701720_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Ms State Emplo", "plan_name": "401457", "standard_charge_percentage": 0.80, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Ms State Emplo", "plan_name": "401457_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Basic Pl", "plan_name": "400100", "standard_charge_percentage": 0.85, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Basic Pl", "plan_name": "400100_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Federal", "plan_name": "400110", "standard_charge_percentage": 0.85, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Federal", "plan_name": "400110_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." } ] } ] }, { "description": "Levetiracetam 250 mg tablet [26816]", "drug_information": { "unit": 1.00, "type": "EA" }, "code_information": [ { "code": "0904-7123-61", "type": "NDC" } ], "standard_charges": [ { "gross_charge": 7.50, "minimum": 6.00, "maximum": 6.38, "setting": "both", "payers_information": [ { "payer_name": "Aetna", "plan_name": "700700", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna", "plan_name": "700700_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Miscellaneous", "plan_name": "700720", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Miscellaneous", "plan_name": "700720_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Ppo Hmo", "plan_name": "701720", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Ppo Hmo", "plan_name": "701720_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Ms State Emplo", "plan_name": "401457", "standard_charge_percentage": 0.80, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Ms State Emplo", "plan_name": "401457_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Basic Pl", "plan_name": "400100", "standard_charge_percentage": 0.85, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Basic Pl", "plan_name": "400100_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Federal", "plan_name": "400110", "standard_charge_percentage": 0.85, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Federal", "plan_name": "400110_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." } ] } ] }, { "description": "Levetiracetam 500 mg tablet [26817]", "drug_information": { "unit": 1.00, "type": "EA" }, "code_information": [ { "code": "0904-7124-61", "type": "NDC" } ], "standard_charges": [ { "gross_charge": 7.50, "minimum": 6.00, "maximum": 6.38, "setting": "both", "payers_information": [ { "payer_name": "Aetna", "plan_name": "700700", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna", "plan_name": "700700_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Miscellaneous", "plan_name": "700720", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Miscellaneous", "plan_name": "700720_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Ppo Hmo", "plan_name": "701720", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Ppo Hmo", "plan_name": "701720_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Ms State Emplo", "plan_name": "401457", "standard_charge_percentage": 0.80, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Ms State Emplo", "plan_name": "401457_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Basic Pl", "plan_name": "400100", "standard_charge_percentage": 0.85, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Basic Pl", "plan_name": "400100_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Federal", "plan_name": "400110", "standard_charge_percentage": 0.85, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Federal", "plan_name": "400110_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." } ] } ] }, { "description": "Dextromethorphan-guaifenesin 10 mg-100 mg/5 ml oral syrup [9774]", "drug_information": { "unit": 10.00, "type": "ML" }, "code_information": [ { "code": "0904-7135-72", "type": "NDC" } ], "standard_charges": [ { "gross_charge": 5.23, "minimum": 4.18, "maximum": 4.45, "setting": "both", "payers_information": [ { "payer_name": "Aetna", "plan_name": "700700", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna", "plan_name": "700700_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Miscellaneous", "plan_name": "700720", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Miscellaneous", "plan_name": "700720_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Ppo Hmo", "plan_name": "701720", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Ppo Hmo", "plan_name": "701720_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Ms State Emplo", "plan_name": "401457", "standard_charge_percentage": 0.80, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Ms State Emplo", "plan_name": "401457_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Basic Pl", "plan_name": "400100", "standard_charge_percentage": 0.85, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Basic Pl", "plan_name": "400100_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Federal", "plan_name": "400110", "standard_charge_percentage": 0.85, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Federal", "plan_name": "400110_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." } ] } ] }, { "description": "Guanfacine 1 mg tablet [10149]", "drug_information": { "unit": 1.00, "type": "EA" }, "code_information": [ { "code": "0904-7140-04", "type": "NDC" } ], "standard_charges": [ { "gross_charge": 24.18, "minimum": 19.34, "maximum": 20.55, "setting": "both", "payers_information": [ { "payer_name": "Aetna", "plan_name": "700700", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna", "plan_name": "700700_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Miscellaneous", "plan_name": "700720", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Miscellaneous", "plan_name": "700720_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Ppo Hmo", "plan_name": "701720", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Ppo Hmo", "plan_name": "701720_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Ms State Emplo", "plan_name": "401457", "standard_charge_percentage": 0.80, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Ms State Emplo", "plan_name": "401457_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Basic Pl", "plan_name": "400100", "standard_charge_percentage": 0.85, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Basic Pl", "plan_name": "400100_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Federal", "plan_name": "400110", "standard_charge_percentage": 0.85, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Federal", "plan_name": "400110_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." } ] } ] }, { "description": "Metformin 1000 mg tablet [24398]", "drug_information": { "unit": 1.00, "type": "EA" }, "code_information": [ { "code": "0904-7164-61", "type": "NDC" } ], "standard_charges": [ { "gross_charge": 7.50, "minimum": 6.00, "maximum": 6.38, "setting": "both", "payers_information": [ { "payer_name": "Aetna", "plan_name": "700700", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna", "plan_name": "700700_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Miscellaneous", "plan_name": "700720", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Miscellaneous", "plan_name": "700720_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Ppo Hmo", "plan_name": "701720", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Ppo Hmo", "plan_name": "701720_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Ms State Emplo", "plan_name": "401457", "standard_charge_percentage": 0.80, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Ms State Emplo", "plan_name": "401457_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Basic Pl", "plan_name": "400100", "standard_charge_percentage": 0.85, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Basic Pl", "plan_name": "400100_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Federal", "plan_name": "400110", "standard_charge_percentage": 0.85, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Federal", "plan_name": "400110_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." } ] } ] }, { "description": "Furosemide 20 mg tablet [3294]", "drug_information": { "unit": 1.00, "type": "EA" }, "code_information": [ { "code": "0904-7177-61", "type": "NDC" } ], "standard_charges": [ { "gross_charge": 7.50, "minimum": 6.00, "maximum": 6.38, "setting": "both", "payers_information": [ { "payer_name": "Aetna", "plan_name": "700700", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna", "plan_name": "700700_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Miscellaneous", "plan_name": "700720", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Miscellaneous", "plan_name": "700720_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Ppo Hmo", "plan_name": "701720", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Ppo Hmo", "plan_name": "701720_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Ms State Emplo", "plan_name": "401457", "standard_charge_percentage": 0.80, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Ms State Emplo", "plan_name": "401457_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Basic Pl", "plan_name": "400100", "standard_charge_percentage": 0.85, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Basic Pl", "plan_name": "400100_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Federal", "plan_name": "400110", "standard_charge_percentage": 0.85, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Federal", "plan_name": "400110_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." } ] } ] }, { "description": "Furosemide 40 mg tablet [3295]", "drug_information": { "unit": 1.00, "type": "EA" }, "code_information": [ { "code": "0904-7178-61", "type": "NDC" } ], "standard_charges": [ { "gross_charge": 7.50, "minimum": 6.00, "maximum": 6.38, "setting": "both", "payers_information": [ { "payer_name": "Aetna", "plan_name": "700700", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna", "plan_name": "700700_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Miscellaneous", "plan_name": "700720", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Miscellaneous", "plan_name": "700720_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Ppo Hmo", "plan_name": "701720", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Ppo Hmo", "plan_name": "701720_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Ms State Emplo", "plan_name": "401457", "standard_charge_percentage": 0.80, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Ms State Emplo", "plan_name": "401457_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Basic Pl", "plan_name": "400100", "standard_charge_percentage": 0.85, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Basic Pl", "plan_name": "400100_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Federal", "plan_name": "400110", "standard_charge_percentage": 0.85, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Federal", "plan_name": "400110_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." } ] } ] }, { "description": "Tramadol 50 mg tablet [14632]", "drug_information": { "unit": 1.00, "type": "EA" }, "code_information": [ { "code": "0904-7179-61", "type": "NDC" } ], "standard_charges": [ { "gross_charge": 7.50, "minimum": 6.00, "maximum": 6.38, "setting": "both", "payers_information": [ { "payer_name": "Aetna", "plan_name": "700700", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna", "plan_name": "700700_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Miscellaneous", "plan_name": "700720", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Miscellaneous", "plan_name": "700720_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Ppo Hmo", "plan_name": "701720", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Ppo Hmo", "plan_name": "701720_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Ms State Emplo", "plan_name": "401457", "standard_charge_percentage": 0.80, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Ms State Emplo", "plan_name": "401457_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Basic Pl", "plan_name": "400100", "standard_charge_percentage": 0.85, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Basic Pl", "plan_name": "400100_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Federal", "plan_name": "400110", "standard_charge_percentage": 0.85, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Federal", "plan_name": "400110_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." } ] } ] }, { "description": "Amitriptyline 25 mg tablet [435]", "drug_information": { "unit": 1.00, "type": "EA" }, "code_information": [ { "code": "0904-7184-61", "type": "NDC" } ], "standard_charges": [ { "gross_charge": 7.50, "minimum": 6.00, "maximum": 6.38, "setting": "both", "payers_information": [ { "payer_name": "Aetna", "plan_name": "700700", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna", "plan_name": "700700_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Miscellaneous", "plan_name": "700720", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Miscellaneous", "plan_name": "700720_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Ppo Hmo", "plan_name": "701720", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Ppo Hmo", "plan_name": "701720_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Ms State Emplo", "plan_name": "401457", "standard_charge_percentage": 0.80, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Ms State Emplo", "plan_name": "401457_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Basic Pl", "plan_name": "400100", "standard_charge_percentage": 0.85, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Basic Pl", "plan_name": "400100_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Federal", "plan_name": "400110", "standard_charge_percentage": 0.85, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Federal", "plan_name": "400110_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." } ] } ] }, { "description": "Famotidine 20 mg tablet [10011]", "drug_information": { "unit": 1.00, "type": "EA" }, "code_information": [ { "code": "0904-7193-61", "type": "NDC" } ], "standard_charges": [ { "gross_charge": 1.00, "minimum": 0.80, "maximum": 0.85, "setting": "both", "payers_information": [ { "payer_name": "Aetna", "plan_name": "700700", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna", "plan_name": "700700_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Miscellaneous", "plan_name": "700720", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Miscellaneous", "plan_name": "700720_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Ppo Hmo", "plan_name": "701720", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Ppo Hmo", "plan_name": "701720_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Ms State Emplo", "plan_name": "401457", "standard_charge_percentage": 0.80, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Ms State Emplo", "plan_name": "401457_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Basic Pl", "plan_name": "400100", "standard_charge_percentage": 0.85, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Basic Pl", "plan_name": "400100_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Federal", "plan_name": "400110", "standard_charge_percentage": 0.85, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Federal", "plan_name": "400110_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." } ] } ] }, { "description": "Lisinopril 40 mg tablet [10450]", "drug_information": { "unit": 1.00, "type": "EA" }, "code_information": [ { "code": "0904-7200-61", "type": "NDC" } ], "standard_charges": [ { "gross_charge": 1.00, "minimum": 0.80, "maximum": 0.85, "setting": "both", "payers_information": [ { "payer_name": "Aetna", "plan_name": "700700", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna", "plan_name": "700700_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Miscellaneous", "plan_name": "700720", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Miscellaneous", "plan_name": "700720_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Ppo Hmo", "plan_name": "701720", 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"standard_charge_percentage": 0.85, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Basic Pl", "plan_name": "400100_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Federal", "plan_name": "400110", "standard_charge_percentage": 0.85, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Federal", "plan_name": "400110_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." } ] } ] }, { "description": "Diltiazem cd 120 mg capsuleextended release 24 hr [27480]", "drug_information": { "unit": 1.00, "type": "EA" }, "code_information": [ { "code": "0904-7217-61", "type": "NDC" } ], "standard_charges": [ { "gross_charge": 7.50, "minimum": 6.00, "maximum": 6.38, "setting": "both", "payers_information": [ { "payer_name": "Aetna", "plan_name": "700700", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna", "plan_name": "700700_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Miscellaneous", "plan_name": "700720", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Miscellaneous", "plan_name": "700720_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Ppo Hmo", "plan_name": "701720", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Ppo Hmo", "plan_name": "701720_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Ms State Emplo", "plan_name": "401457", "standard_charge_percentage": 0.80, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Ms State Emplo", "plan_name": "401457_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Basic Pl", "plan_name": "400100", "standard_charge_percentage": 0.85, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Basic Pl", "plan_name": "400100_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Federal", "plan_name": "400110", "standard_charge_percentage": 0.85, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Federal", "plan_name": "400110_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." } ] } ] }, { "description": "Folic acid 1 mg tablet [3233]", "drug_information": { "unit": 1.00, "type": "EA" }, "code_information": [ { "code": "0904-7224-61", "type": "NDC" } ], "standard_charges": [ { "gross_charge": 7.50, "minimum": 6.00, "maximum": 6.38, "setting": "both", "payers_information": [ { "payer_name": "Aetna", "plan_name": "700700", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna", "plan_name": "700700_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Miscellaneous", "plan_name": "700720", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Miscellaneous", "plan_name": "700720_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Ppo Hmo", "plan_name": "701720", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Ppo Hmo", "plan_name": "701720_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Ms State Emplo", "plan_name": "401457", "standard_charge_percentage": 0.80, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Ms State Emplo", "plan_name": "401457_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Basic Pl", "plan_name": "400100", "standard_charge_percentage": 0.85, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Basic Pl", "plan_name": "400100_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Federal", "plan_name": "400110", "standard_charge_percentage": 0.85, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Federal", "plan_name": "400110_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." } ] } ] }, { "description": "Clonazepam 0.5 mg tablet [9637]", "drug_information": { "unit": 1.00, "type": "EA" }, "code_information": [ { "code": "0904-7227-61", "type": "NDC" } ], "standard_charges": [ { "gross_charge": 7.50, "minimum": 6.00, "maximum": 6.38, "setting": "both", "payers_information": [ { "payer_name": "Aetna", "plan_name": "700700", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate 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"payer_name": "Aetna Ppo Hmo", "plan_name": "701720_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Ms State Emplo", "plan_name": "401457", "standard_charge_percentage": 0.80, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Ms State Emplo", "plan_name": "401457_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Basic Pl", "plan_name": "400100", "standard_charge_percentage": 0.85, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Basic Pl", "plan_name": "400100_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Federal", "plan_name": "400110", "standard_charge_percentage": 0.85, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Federal", "plan_name": "400110_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." } ] } ] }, { "description": "Megestrol 40 mg tablet [4871]", "drug_information": { "unit": 1.00, "type": "EA" }, "code_information": [ { "code": "0904-7236-61", "type": "NDC" } ], "standard_charges": [ { "gross_charge": 7.50, "minimum": 6.00, "maximum": 6.38, "setting": "both", "payers_information": [ { "payer_name": "Aetna", "plan_name": "700700", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna", "plan_name": "700700_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Miscellaneous", "plan_name": "700720", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Miscellaneous", "plan_name": "700720_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Ppo Hmo", "plan_name": "701720", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Ppo Hmo", "plan_name": "701720_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Ms State Emplo", "plan_name": "401457", "standard_charge_percentage": 0.80, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Ms State Emplo", "plan_name": "401457_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Basic Pl", "plan_name": "400100", "standard_charge_percentage": 0.85, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Basic Pl", "plan_name": "400100_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Federal", "plan_name": "400110", "standard_charge_percentage": 0.85, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Federal", "plan_name": "400110_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." } ] } ] }, { "description": "Ciprofloxacin 500 mg tablet [25119]", "drug_information": { "unit": 1.00, "type": "EA" }, "code_information": [ { "code": "0904-7243-61", "type": "NDC" } ], "standard_charges": [ { "gross_charge": 7.50, "minimum": 6.00, "maximum": 6.38, "setting": "both", "payers_information": [ { "payer_name": "Aetna", "plan_name": "700700", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna", "plan_name": "700700_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Miscellaneous", "plan_name": "700720", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Miscellaneous", "plan_name": "700720_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Ppo Hmo", "plan_name": "701720", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Ppo Hmo", "plan_name": "701720_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Ms State Emplo", "plan_name": "401457", "standard_charge_percentage": 0.80, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate 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"Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Basic Pl", "plan_name": "400100_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Federal", "plan_name": "400110", "standard_charge_percentage": 0.85, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Federal", "plan_name": "400110_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." } ] } ] }, { "description": "Carvedilol 3.125 mg tablet [18551]", "drug_information": { "unit": 1.00, "type": "EA" }, "code_information": [ { "code": "0904-7305-61", "type": "NDC" } ], 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"additional_payer_notes": "Insufficient remit data to calculate allowed amounts." } ] } ] }, { "description": "Carvedilol 25 mg tablet [15748]", "drug_information": { "unit": 1.00, "type": "EA" }, "code_information": [ { "code": "0904-7308-61", "type": "NDC" } ], "standard_charges": [ { "gross_charge": 7.50, "minimum": 6.00, "maximum": 6.38, "setting": "both", "payers_information": [ { "payer_name": "Aetna", "plan_name": "700700", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna", "plan_name": "700700_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Miscellaneous", "plan_name": "700720", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total 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"additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Ms State Emplo", "plan_name": "401457_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Basic Pl", "plan_name": "400100", "standard_charge_percentage": 0.85, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Basic Pl", "plan_name": "400100_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Federal", "plan_name": "400110", "standard_charge_percentage": 0.85, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Federal", "plan_name": "400110_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." } ] } ] }, { "description": "Fluoxetine 20 mg capsule [10070]", "drug_information": { "unit": 1.00, "type": "EA" }, "code_information": [ { "code": "0904-7346-61", "type": "NDC" } ], "standard_charges": [ { "gross_charge": 7.50, "minimum": 6.00, "maximum": 6.38, "setting": "both", "payers_information": [ { "payer_name": "Aetna", "plan_name": "700700", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna", "plan_name": "700700_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of 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charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Federal", "plan_name": "400110", "standard_charge_percentage": 0.85, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Federal", "plan_name": "400110_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." } ] } ] }, { "description": "Cyclobenzaprine 10 mg tablet [2017]", "drug_information": { "unit": 1.00, "type": "EA" }, "code_information": [ { "code": "0904-7809-61", "type": "NDC" } ], "standard_charges": [ { "gross_charge": 7.50, "minimum": 6.00, "maximum": 6.38, "setting": "both", "payers_information": [ { "payer_name": "Aetna", "plan_name": "700700", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna", "plan_name": "700700_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Miscellaneous", "plan_name": "700720", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Miscellaneous", "plan_name": "700720_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Ppo Hmo", "plan_name": "701720", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of 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billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Basic Pl", "plan_name": "400100_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Federal", "plan_name": "400110", "standard_charge_percentage": 0.85, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Federal", "plan_name": "400110_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." } ] } ] }, { "description": "Ibuprofen 200 mg tablet [3841]", "drug_information": { "unit": 1.00, "type": "EA" }, "code_information": [ { "code": "0904-7914-61", "type": "NDC" } ], "standard_charges": [ { "gross_charge": 1.00, "minimum": 0.80, "maximum": 0.85, "setting": "both", "payers_information": [ { "payer_name": "Aetna", "plan_name": "700700", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna", "plan_name": "700700_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Miscellaneous", "plan_name": "700720", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Miscellaneous", "plan_name": "700720_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Ppo Hmo", "plan_name": "701720", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Ppo Hmo", "plan_name": "701720_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Ms State Emplo", "plan_name": "401457", "standard_charge_percentage": 0.80, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Ms State Emplo", "plan_name": "401457_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Basic Pl", "plan_name": "400100", "standard_charge_percentage": 0.85, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Basic Pl", "plan_name": "400100_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Federal", "plan_name": "400110", "standard_charge_percentage": 0.85, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Federal", "plan_name": "400110_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." } ] } ] }, { "description": "Vitamin e (dl acetate) 450 mg (1000 unit) capsule [151610]", "drug_information": { "unit": 1.00, "type": "EA" }, "code_information": [ { "code": "0904027760", "type": "NDC" } ], "standard_charges": [ { "gross_charge": 1.00, "minimum": 0.80, "maximum": 0.85, "setting": "both", "payers_information": [ { "payer_name": "Aetna", "plan_name": "700700", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna", "plan_name": "700700_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Miscellaneous", "plan_name": "700720", 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"plan_name": "400100_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Federal", "plan_name": "400110", "standard_charge_percentage": 0.85, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Federal", "plan_name": "400110_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." } ] } ] }, { "description": "Calcium 250 mg (as carbonate)-vitamin d3 3.125 mcg (125 unit) tablet [116161]", "drug_information": { "unit": 1.00, "type": "EA" }, "code_information": [ { "code": "0904188260", "type": "NDC" } ], "standard_charges": [ { "gross_charge": 1.00, "minimum": 0.80, 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80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna", "plan_name": "700700_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Miscellaneous", "plan_name": "700720", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Miscellaneous", "plan_name": "700720_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Ppo Hmo", "plan_name": "701720", "standard_charge_percentage": 80.0, "count": "0", 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100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Ppo Hmo", "plan_name": "701720", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Ppo Hmo", "plan_name": "701720_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Ms State Emplo", "plan_name": "401457", "standard_charge_percentage": 0.80, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Ms State Emplo", "plan_name": "401457_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Basic Pl", "plan_name": "400100", "standard_charge_percentage": 0.85, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Basic Pl", "plan_name": "400100_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Federal", "plan_name": "400110", "standard_charge_percentage": 0.85, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Federal", "plan_name": "400110_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." } ] } ] }, { "description": "Prenatal vitamin tablet (wrapped) [507182]", "drug_information": { "unit": 1.00, "type": "EA" }, "code_information": [ { "code": "0904531360", "type": "NDC" } ], "standard_charges": [ { "gross_charge": 1.00, "minimum": 0.80, "maximum": 0.85, "setting": "both", "payers_information": [ { "payer_name": "Aetna", "plan_name": "700700", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna", "plan_name": "700700_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Miscellaneous", "plan_name": "700720", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Miscellaneous", "plan_name": "700720_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Ppo Hmo", "plan_name": "701720", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Ppo Hmo", "plan_name": "701720_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Ms State Emplo", "plan_name": "401457", "standard_charge_percentage": 0.80, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Ms State Emplo", "plan_name": "401457_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Basic Pl", "plan_name": "400100", "standard_charge_percentage": 0.85, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Basic Pl", "plan_name": "400100_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Federal", "plan_name": "400110", "standard_charge_percentage": 0.85, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Federal", "plan_name": "400110_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." } ] } ] }, { "description": "Multivit-min-folic acid 0.4 mg-lycopene 300 mcg-lutein 250 mcg tablet [115775]", "drug_information": { "unit": 1.00, "type": "EA" }, "code_information": [ { "code": "0904548689", "type": "NDC" } ], "standard_charges": [ { "gross_charge": 7.50, "minimum": 6.00, "maximum": 6.38, "setting": "both", "payers_information": [ { "payer_name": "Aetna", "plan_name": "700700", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna", "plan_name": "700700_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Miscellaneous", "plan_name": "700720", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Miscellaneous", "plan_name": "700720_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Ppo Hmo", "plan_name": "701720", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Ppo Hmo", "plan_name": "701720_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Ms State Emplo", "plan_name": "401457", "standard_charge_percentage": 0.80, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Ms State Emplo", "plan_name": "401457_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Basic Pl", "plan_name": "400100", "standard_charge_percentage": 0.85, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Basic Pl", "plan_name": "400100_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Federal", "plan_name": "400110", "standard_charge_percentage": 0.85, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Federal", "plan_name": "400110_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." } ] } ] }, { "description": "Multivitamin-iron 9 mg-folic acid 400 mcg-calcium and minerals tablet [118929]", "drug_information": { "unit": 1.00, "type": "EA" }, "code_information": [ { "code": "0904549261", "type": "NDC" } ], "standard_charges": [ { "gross_charge": 1.00, "minimum": 0.80, "maximum": 0.85, "setting": "both", "payers_information": [ { "payer_name": "Aetna", "plan_name": "700700", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna", "plan_name": "700700_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Miscellaneous", "plan_name": "700720", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Miscellaneous", "plan_name": "700720_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Ppo Hmo", "plan_name": "701720", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Ppo Hmo", "plan_name": "701720_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Ms State Emplo", "plan_name": "401457", "standard_charge_percentage": 0.80, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Ms State Emplo", "plan_name": "401457_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Basic Pl", "plan_name": "400100", "standard_charge_percentage": 0.85, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Basic Pl", "plan_name": "400100_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Federal", "plan_name": "400110", "standard_charge_percentage": 0.85, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Federal", "plan_name": "400110_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." } ] } ] }, { "description": "Cholecalciferol (vitamin d3) 10 mcg (400 unit) tablet [109842]", "drug_information": { "unit": 1.00, "type": "EA" }, "code_information": [ { "code": "0904582360", "type": "NDC" } ], "standard_charges": [ { "gross_charge": 1.00, "minimum": 0.80, "maximum": 0.85, "setting": "both", "payers_information": [ { "payer_name": "Aetna", "plan_name": "700700", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna", "plan_name": "700700_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Miscellaneous", "plan_name": "700720", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Miscellaneous", "plan_name": "700720_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Ppo Hmo", "plan_name": "701720", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Ppo Hmo", "plan_name": "701720_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Ms State Emplo", "plan_name": "401457", "standard_charge_percentage": 0.80, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Ms State Emplo", "plan_name": "401457_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Basic Pl", "plan_name": "400100", "standard_charge_percentage": 0.85, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Basic Pl", "plan_name": "400100_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Federal", "plan_name": "400110", "standard_charge_percentage": 0.85, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Federal", "plan_name": "400110_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." } ] } ] }, { "description": "Lanolin alcohols-mineral oil-w.petrolatum-ceresin topical cream [118468]", "drug_information": { "unit": 454.00, "type": "GR" }, "code_information": [ { "code": "0904775127", "type": "NDC" } ], "standard_charges": [ { "gross_charge": 14.17, "minimum": 11.34, "maximum": 12.04, "setting": "both", "payers_information": [ { "payer_name": "Aetna", "plan_name": "700700", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna", "plan_name": "700700_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Miscellaneous", "plan_name": "700720", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Miscellaneous", "plan_name": "700720_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Ppo Hmo", "plan_name": "701720", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Ppo Hmo", "plan_name": "701720_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Ms State Emplo", "plan_name": "401457", "standard_charge_percentage": 0.80, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Ms State Emplo", "plan_name": "401457_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Basic Pl", "plan_name": "400100", "standard_charge_percentage": 0.85, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Basic Pl", "plan_name": "400100_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Federal", "plan_name": "400110", "standard_charge_percentage": 0.85, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Federal", "plan_name": "400110_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." } ] } ] }, { "description": "Mineral oil-isopropyl myristat lotion [111333]", "drug_information": { "unit": 473.00, "type": "ML" }, "code_information": [ { "code": "0904775216", "type": "NDC" } ], "standard_charges": [ { "gross_charge": 12.30, "minimum": 9.84, "maximum": 10.46, "setting": "both", "payers_information": [ { "payer_name": "Aetna", "plan_name": "700700", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna", "plan_name": "700700_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Miscellaneous", "plan_name": "700720", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Miscellaneous", "plan_name": "700720_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Ppo Hmo", "plan_name": "701720", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Ppo Hmo", "plan_name": "701720_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Ms State Emplo", "plan_name": "401457", "standard_charge_percentage": 0.80, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Ms State Emplo", "plan_name": "401457_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Basic Pl", "plan_name": "400100", "standard_charge_percentage": 0.85, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Basic Pl", "plan_name": "400100_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Federal", "plan_name": "400110", "standard_charge_percentage": 0.85, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Federal", "plan_name": "400110_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." } ] } ] }, { "description": "Thrombin (human plasma)-fibrinogen-aprotinin-calcium 2 ml topical kit [17434]", "drug_information": { "unit": 1.00, "type": "EA" }, "code_information": [ { "code": "0944-4201-03", "type": "NDC" } ], "standard_charges": [ { "gross_charge": 733.90, "minimum": 587.12, "maximum": 623.82, "setting": "both", "payers_information": [ { "payer_name": "Aetna", "plan_name": "700700", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna", "plan_name": "700700_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Miscellaneous", "plan_name": "700720", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Miscellaneous", "plan_name": "700720_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Ppo Hmo", "plan_name": "701720", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Ppo Hmo", "plan_name": "701720_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Ms State Emplo", "plan_name": "401457", "standard_charge_percentage": 0.80, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Ms State Emplo", "plan_name": "401457_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Basic Pl", "plan_name": "400100", "standard_charge_percentage": 0.85, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Basic Pl", "plan_name": "400100_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Federal", "plan_name": "400110", "standard_charge_percentage": 0.85, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Federal", "plan_name": "400110_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." } ] } ] }, { "description": "Leflunomide 20 mg tablet [23873]", "drug_information": { "unit": 1.00, "type": "EA" }, "code_information": [ { "code": "0955-1737-30", "type": "NDC" } ], "standard_charges": [ { "gross_charge": 23.75, "minimum": 19.00, "maximum": 20.19, "setting": "both", "payers_information": [ { "payer_name": "Aetna", "plan_name": "700700", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna", "plan_name": "700700_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Miscellaneous", "plan_name": "700720", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Miscellaneous", "plan_name": "700720_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Ppo Hmo", "plan_name": "701720", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Ppo Hmo", "plan_name": "701720_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Ms State Emplo", "plan_name": "401457", "standard_charge_percentage": 0.80, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Ms State Emplo", "plan_name": "401457_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Basic Pl", "plan_name": "400100", "standard_charge_percentage": 0.85, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Basic Pl", "plan_name": "400100_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Federal", "plan_name": "400110", "standard_charge_percentage": 0.85, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Federal", "plan_name": "400110_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." } ] } ] }, { "description": "Acetic acid 0.25 % irrigation solution [8963]", "drug_information": { "unit": 1000.00, "type": "ML" }, "code_information": [ { "code": "0990-6143-09", "type": "NDC" } ], "standard_charges": [ { "gross_charge": 28.50, "minimum": 22.80, "maximum": 24.23, "setting": "both", "payers_information": [ { "payer_name": "Aetna", "plan_name": "700700", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna", "plan_name": "700700_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Miscellaneous", "plan_name": "700720", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Miscellaneous", "plan_name": "700720_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Ppo Hmo", "plan_name": "701720", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Ppo Hmo", "plan_name": "701720_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Ms State Emplo", "plan_name": "401457", "standard_charge_percentage": 0.80, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Ms State Emplo", "plan_name": "401457_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Basic Pl", "plan_name": "400100", "standard_charge_percentage": 0.85, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Basic Pl", "plan_name": "400100_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Federal", "plan_name": "400110", "standard_charge_percentage": 0.85, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Federal", "plan_name": "400110_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." } ] } ] }, { "description": "Dextrose 70 % in water (d70w) intravenous solution [2367]", "drug_information": { "unit": 500.00, "type": "ML" }, "code_information": [ { "code": "0990-7918-19", "type": "NDC" } ], "standard_charges": [ { "gross_charge": 62.50, "minimum": 50.00, "maximum": 53.13, "setting": "both", "payers_information": [ { "payer_name": "Aetna", "plan_name": "700700", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna", "plan_name": "700700_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Miscellaneous", "plan_name": "700720", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Miscellaneous", "plan_name": "700720_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Ppo Hmo", "plan_name": "701720", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Ppo Hmo", "plan_name": "701720_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Ms State Emplo", "plan_name": "401457", "standard_charge_percentage": 0.80, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Ms State Emplo", "plan_name": "401457_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Basic Pl", "plan_name": "400100", "standard_charge_percentage": 0.85, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Basic Pl", "plan_name": "400100_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Federal", "plan_name": "400110", "standard_charge_percentage": 0.85, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Federal", "plan_name": "400110_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." } ] } ] }, { "description": "Dextrose 5 % in water (d5w) intravenous solution [2364]", "drug_information": { "unit": 250.00, "type": "ML" }, "code_information": [ { "code": "0990-7922-02", "type": "NDC" } ], "standard_charges": [ { "gross_charge": 81.81, "minimum": 65.45, "maximum": 69.54, "setting": "both", "payers_information": [ { "payer_name": "Aetna", "plan_name": "700700", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna", "plan_name": "700700_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Miscellaneous", "plan_name": "700720", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Miscellaneous", "plan_name": "700720_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Ppo Hmo", "plan_name": "701720", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Ppo Hmo", "plan_name": "701720_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Ms State Emplo", "plan_name": "401457", "standard_charge_percentage": 0.80, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Ms State Emplo", "plan_name": "401457_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Basic Pl", "plan_name": "400100", "standard_charge_percentage": 0.85, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Basic Pl", "plan_name": "400100_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Federal", "plan_name": "400110", "standard_charge_percentage": 0.85, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Federal", "plan_name": "400110_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." } ] } ] }, { "description": "Dextrose 5 % in water (d5w) intravenous solution [2364]", "drug_information": { "unit": 50.00, "type": "ML" }, "code_information": [ { "code": "0990-7923-36", "type": "NDC" } ], "standard_charges": [ { "gross_charge": 81.81, "minimum": 65.45, "maximum": 69.54, "setting": "both", "payers_information": [ { "payer_name": "Aetna", "plan_name": "700700", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna", "plan_name": "700700_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Miscellaneous", "plan_name": "700720", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Miscellaneous", "plan_name": "700720_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Ppo Hmo", "plan_name": "701720", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Ppo Hmo", "plan_name": "701720_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Ms State Emplo", "plan_name": "401457", "standard_charge_percentage": 0.80, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Ms State Emplo", "plan_name": "401457_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Basic Pl", "plan_name": "400100", "standard_charge_percentage": 0.85, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Basic Pl", "plan_name": "400100_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Federal", "plan_name": "400110", "standard_charge_percentage": 0.85, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Federal", "plan_name": "400110_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." } ] } ] }, { "description": "Dextrose 5 % in water (d5w) intravenous solution [2364]", "drug_information": { "unit": 100.00, "type": "ML" }, "code_information": [ { "code": "0990-7923-37", "type": "NDC" } ], "standard_charges": [ { "gross_charge": 81.81, "minimum": 65.45, "maximum": 69.54, "setting": "both", "payers_information": [ { "payer_name": "Aetna", "plan_name": "700700", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna", "plan_name": "700700_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Miscellaneous", "plan_name": "700720", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Miscellaneous", "plan_name": "700720_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Ppo Hmo", "plan_name": "701720", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Ppo Hmo", "plan_name": "701720_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Ms State Emplo", "plan_name": "401457", "standard_charge_percentage": 0.80, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Ms State Emplo", "plan_name": "401457_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Basic Pl", "plan_name": "400100", "standard_charge_percentage": 0.85, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Basic Pl", "plan_name": "400100_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Federal", "plan_name": "400110", "standard_charge_percentage": 0.85, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Federal", "plan_name": "400110_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." } ] } ] }, { "description": "Dextrose 5 % and 0.2 % sodium chloride intravenous solution [9812]", "drug_information": { "unit": 500.00, "type": "ML" }, "code_information": [ { "code": "0990-7924-03", "type": "NDC" } ], "standard_charges": [ { "gross_charge": 81.81, "minimum": 65.45, "maximum": 69.54, "setting": "both", "payers_information": [ { "payer_name": "Aetna", "plan_name": "700700", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna", "plan_name": "700700_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Miscellaneous", "plan_name": "700720", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Miscellaneous", "plan_name": "700720_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Ppo Hmo", "plan_name": "701720", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Ppo Hmo", "plan_name": "701720_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Ms State Emplo", "plan_name": "401457", "standard_charge_percentage": 0.80, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Ms State Emplo", "plan_name": "401457_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Basic Pl", "plan_name": "400100", "standard_charge_percentage": 0.85, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Basic Pl", "plan_name": "400100_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Federal", "plan_name": "400110", "standard_charge_percentage": 0.85, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Federal", "plan_name": "400110_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." } ] } ] }, { "description": "Honey 100 % topical paste [162265]", "drug_information": { "unit": 44.00, "type": "ML" }, "code_information": [ { "code": "0995803360", "type": "NDC" } ], "standard_charges": [ { "gross_charge": 76.29, "minimum": 61.03, "maximum": 64.85, "setting": "both", "payers_information": [ { "payer_name": "Aetna", "plan_name": "700700", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna", "plan_name": "700700_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Miscellaneous", "plan_name": "700720", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Miscellaneous", "plan_name": "700720_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Ppo Hmo", "plan_name": "701720", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Ppo Hmo", "plan_name": "701720_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Ms State Emplo", "plan_name": "401457", "standard_charge_percentage": 0.80, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Ms State Emplo", "plan_name": "401457_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Basic Pl", "plan_name": "400100", "standard_charge_percentage": 0.85, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Basic Pl", "plan_name": "400100_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Federal", "plan_name": "400110", "standard_charge_percentage": 0.85, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Federal", "plan_name": "400110_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." } ] } ] }, { "description": "Pilocarpine 1 % eye drops [6279]", "drug_information": { "unit": 15.00, "type": "ML" }, "code_information": [ { "code": "0998-0203-15", "type": "NDC" } ], "standard_charges": [ { "gross_charge": 441.96, "minimum": 353.57, "maximum": 375.67, "setting": "both", "payers_information": [ { "payer_name": "Aetna", "plan_name": "700700", "standard_charge_percentage": 80.0, "count": "0", 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"methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." } ] } ] }, { "description": "Magnesium oxide 400 mg (241.3 mg magnesium) tablet [10491]", "drug_information": { "unit": 1.00, "type": "EA" }, "code_information": [ { "code": "1000673038", "type": "NDC" } ], "standard_charges": [ { "gross_charge": 1.00, "minimum": 0.80, "maximum": 0.85, "setting": "both", "payers_information": [ { "payer_name": "Aetna", "plan_name": "700700", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna", "plan_name": "700700_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Miscellaneous", "plan_name": "700720", 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"standard_charge_percentage": 0.80, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Ms State Emplo", "plan_name": "401457_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Basic Pl", "plan_name": "400100", "standard_charge_percentage": 0.85, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Basic Pl", "plan_name": "400100_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Federal", "plan_name": "400110", 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"plan_name": "400100_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Federal", "plan_name": "400110", "standard_charge_percentage": 0.85, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Federal", "plan_name": "400110_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." } ] } ] }, { "description": "Scopolamine 1 mg over 3 days transdermal patch [27696]", "drug_information": { "unit": 1.00, "type": "EA" }, "code_information": [ { "code": "10019-553-90", "type": "NDC" } ], "standard_charges": [ { "gross_charge": 95.15, "minimum": 76.12, "maximum": 80.88, "setting": "both", "payers_information": [ { "payer_name": "Aetna", "plan_name": "700700", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna", "plan_name": "700700_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Miscellaneous", "plan_name": "700720", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Miscellaneous", "plan_name": "700720_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed 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"payer_name": "Bc/Bs Of Ms Basic Pl", "plan_name": "400100", "standard_charge_percentage": 0.85, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Basic Pl", "plan_name": "400100_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Federal", "plan_name": "400110", "standard_charge_percentage": 0.85, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Federal", "plan_name": "400110_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." } ] } ] }, { "description": "Sodium borate-boric acid-sodium chloride-water eye wash soln [161759]", "drug_information": { "unit": 118.00, "type": "ML" }, "code_information": [ { "code": "1011900252", "type": "NDC" } ], "standard_charges": [ { "gross_charge": 11.05, "minimum": 8.84, "maximum": 9.39, "setting": "both", "payers_information": [ { "payer_name": "Aetna", "plan_name": "700700", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna", "plan_name": "700700_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Miscellaneous", "plan_name": "700720", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Miscellaneous", "plan_name": "700720_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Ppo Hmo", "plan_name": "701720", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Ppo Hmo", "plan_name": "701720_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Ms State Emplo", "plan_name": "401457", "standard_charge_percentage": 0.80, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Ms State Emplo", "plan_name": "401457_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Basic Pl", "plan_name": "400100", "standard_charge_percentage": 0.85, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Basic Pl", "plan_name": "400100_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Federal", "plan_name": "400110", "standard_charge_percentage": 0.85, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient 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charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Ms State Emplo", "plan_name": "401457", "standard_charge_percentage": 0.80, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Ms State Emplo", "plan_name": "401457_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Basic Pl", "plan_name": "400100", "standard_charge_percentage": 0.85, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Basic Pl", "plan_name": "400100_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Federal", "plan_name": "400110", "standard_charge_percentage": 0.85, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Federal", "plan_name": "400110_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." } ] } ] }, { "description": "Thallous chloride tl-201 74 mbq/ml (2 mci/ml) intravenous solution [178574]", "drug_information": { "unit": 1.00, "type": "EA" }, "code_information": [ { "code": "11994-427-26", "type": "NDC" } ], "standard_charges": [ { "gross_charge": 965.25, "minimum": 772.20, "maximum": 820.46, "setting": "both", "payers_information": [ { "payer_name": "Aetna", "plan_name": "700700", 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"payer_name": "Bc/Bs Ms State Emplo", "plan_name": "401457", "standard_charge_percentage": 0.80, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Ms State Emplo", "plan_name": "401457_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Basic Pl", "plan_name": "400100", "standard_charge_percentage": 0.85, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Basic Pl", "plan_name": "400100_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Federal", "plan_name": "400110", "standard_charge_percentage": 0.85, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Federal", "plan_name": "400110_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." } ] } ] }, { "description": "Silver nitrate applicators 75 %-25 % topical stick [11359]", "drug_information": { "unit": 100.00, "type": "EA" }, "code_information": [ { "code": "12165-100-01", "type": "NDC" } ], "standard_charges": [ { "gross_charge": 106.40, "minimum": 85.12, "maximum": 90.44, "setting": "both", "payers_information": [ { "payer_name": "Aetna", "plan_name": "700700", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", 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charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Federal", "plan_name": "400110", "standard_charge_percentage": 0.85, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Federal", "plan_name": "400110_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." } ] } ] }, { "description": "Tetrahydrozoline 0.05 % eye drops [7800]", "drug_information": { "unit": 15.00, "type": "ML" }, "code_information": [ { "code": "1254749380", "type": "NDC" } ], "standard_charges": [ { "gross_charge": 11.58, "minimum": 9.26, "maximum": 9.84, "setting": "both", "payers_information": [ { "payer_name": "Aetna", "plan_name": "700700", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna", "plan_name": "700700_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Miscellaneous", "plan_name": "700720", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Miscellaneous", "plan_name": "700720_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Ppo Hmo", "plan_name": "701720", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of 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80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Miscellaneous", "plan_name": "700720_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Ppo Hmo", "plan_name": "701720", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Ppo Hmo", "plan_name": "701720_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Ms State Emplo", "plan_name": "401457", "standard_charge_percentage": 0.80, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Ms State Emplo", "plan_name": "401457_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Basic Pl", "plan_name": "400100", "standard_charge_percentage": 0.85, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Basic Pl", "plan_name": "400100_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Federal", "plan_name": "400110", "standard_charge_percentage": 0.85, "count": 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"standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Federal", "plan_name": "400110", "standard_charge_percentage": 0.85, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Federal", "plan_name": "400110_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." } ] } ] }, { "description": "Lorazepam 1 mg tablet [4573]", "drug_information": { "unit": 1.00, "type": "EA" }, "code_information": [ { "code": "13107-084-99", "type": "NDC" } ], "standard_charges": [ { "gross_charge": 7.50, "minimum": 6.00, "maximum": 6.38, "setting": "both", "payers_information": [ { "payer_name": 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"701720", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Ppo Hmo", "plan_name": "701720_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Ms State Emplo", "plan_name": "401457", "standard_charge_percentage": 0.80, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Ms State Emplo", "plan_name": "401457_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Basic Pl", "plan_name": "400100", "standard_charge_percentage": 0.85, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Basic Pl", "plan_name": "400100_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Federal", "plan_name": "400110", "standard_charge_percentage": 0.85, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Federal", "plan_name": "400110_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." } ] } ] }, { "description": "Clorazepate dipotassium 3.75 mg tablet [1759]", "drug_information": { "unit": 1.00, "type": "EA" }, "code_information": [ { "code": "13107-319-01", "type": "NDC" } ], "standard_charges": [ { "gross_charge": 7.50, "minimum": 6.00, "maximum": 6.38, "setting": "both", "payers_information": [ { "payer_name": "Aetna", "plan_name": "700700", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna", "plan_name": "700700_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Miscellaneous", "plan_name": "700720", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna 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"plan_name": "401457_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Basic Pl", "plan_name": "400100", "standard_charge_percentage": 0.85, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Basic Pl", "plan_name": "400100_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Federal", "plan_name": "400110", "standard_charge_percentage": 0.85, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Federal", "plan_name": "400110_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." } ] } ] }, { "description": "Itraconazole 100 mg capsule [10364]", "drug_information": { "unit": 1.00, "type": "EA" }, "code_information": [ { "code": "10147-1700-3", "type": "NDC" } ], "standard_charges": [ { "gross_charge": 43.01, "minimum": 34.41, "maximum": 36.56, "setting": "both", "payers_information": [ { "payer_name": "Aetna", "plan_name": "700700", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna", "plan_name": "700700_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Miscellaneous", "plan_name": "700720", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Miscellaneous", "plan_name": "700720_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Ppo Hmo", "plan_name": "701720", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Ppo Hmo", "plan_name": "701720_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Ms State Emplo", "plan_name": "401457", "standard_charge_percentage": 0.80, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Ms State Emplo", "plan_name": "401457_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Basic Pl", "plan_name": "400100", "standard_charge_percentage": 0.85, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Basic Pl", "plan_name": "400100_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Federal", "plan_name": "400110", "standard_charge_percentage": 0.85, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Federal", "plan_name": "400110_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." } ] } ] }, { "description": "Butamben-tetracaine-benzocaine 2 %-2 %-14 % (200 mg/sec) topical spray [9328]", "drug_information": { "unit": 20.00, "type": "GR" }, "code_information": [ { "code": "10223-0201-3", "type": "NDC" } ], "standard_charges": [ { "gross_charge": 531.72, "minimum": 425.38, "maximum": 451.96, "setting": "both", "payers_information": [ { "payer_name": "Aetna", "plan_name": "700700", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna", "plan_name": "700700_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Miscellaneous", "plan_name": "700720", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Miscellaneous", "plan_name": "700720_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Ppo Hmo", "plan_name": "701720", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Ppo Hmo", "plan_name": "701720_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Ms State Emplo", "plan_name": "401457", "standard_charge_percentage": 0.80, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Ms State Emplo", "plan_name": "401457_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Basic Pl", "plan_name": "400100", "standard_charge_percentage": 0.85, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Basic Pl", "plan_name": "400100_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Federal", "plan_name": "400110", "standard_charge_percentage": 0.85, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Federal", "plan_name": "400110_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." } ] } ] }, { "description": "Benzocaine 20 %-menthol 0.26 %-zinc chloride 0.15 % mucosal gel [194703]", "drug_information": { "unit": 11.90, "type": "GR" }, "code_information": [ { "code": 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"standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Ppo Hmo", "plan_name": "701720_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Ms State Emplo", "plan_name": "401457", "standard_charge_percentage": 0.80, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Ms State Emplo", "plan_name": "401457_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Basic Pl", "plan_name": "400100", "standard_charge_percentage": 0.85, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Basic Pl", "plan_name": "400100_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Federal", "plan_name": "400110", "standard_charge_percentage": 0.85, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Federal", "plan_name": "400110_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." } ] } ] }, { "description": "Polyethylene glycol 3350 17 gram oral 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"Aetna Miscellaneous", "plan_name": "700720_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Ppo Hmo", "plan_name": "701720", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Ppo Hmo", "plan_name": "701720_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Ms State Emplo", "plan_name": "401457", "standard_charge_percentage": 0.80, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Ms State Emplo", "plan_name": "401457_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Basic Pl", "plan_name": "400100", "standard_charge_percentage": 0.85, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Basic Pl", "plan_name": "400100_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Federal", "plan_name": "400110", "standard_charge_percentage": 0.85, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Federal", "plan_name": "400110_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." } ] } ] }, { "description": "Miconazole nitrate 2 % topical cream [5039]", "drug_information": { "unit": 142.00, "type": "GR" }, "code_information": [ { "code": "11701-045-14", "type": "NDC" } ], "standard_charges": [ { "gross_charge": 2.22, "minimum": 1.78, "maximum": 1.89, "setting": "both", "payers_information": [ { "payer_name": "Aetna", "plan_name": "700700", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna", "plan_name": "700700_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed 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"payer_name": "Bc/Bs Ms State Emplo", "plan_name": "401457", "standard_charge_percentage": 0.80, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Ms State Emplo", "plan_name": "401457_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Basic Pl", "plan_name": "400100", "standard_charge_percentage": 0.85, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Basic Pl", "plan_name": "400100_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Federal", "plan_name": "400110", "standard_charge_percentage": 0.85, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Federal", "plan_name": "400110_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." } ] } ] }, { "description": "Folic acid-vit b6-vit b12 0.8 mg-50 mg-100 mcg tablet [28251]", "drug_information": { "unit": 1.00, "type": "EA" }, "code_information": [ { "code": "1184512552", "type": "NDC" } ], "standard_charges": [ { "gross_charge": 7.50, "minimum": 6.00, "maximum": 6.38, "setting": "both", "payers_information": [ { "payer_name": "Aetna", "plan_name": "700700", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna", "plan_name": "700700_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Miscellaneous", "plan_name": "700720", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Miscellaneous", "plan_name": "700720_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Ppo Hmo", "plan_name": "701720", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data 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"additional_payer_notes": "Insufficient remit data to calculate allowed amounts." } ] } ] }, { "description": "Prednisolone acetate 1 % eye dropssuspension [6487]", "drug_information": { "unit": 5.00, "type": "ML" }, "code_information": [ { "code": "11980-180-05", "type": "NDC" } ], "standard_charges": [ { "gross_charge": 716.63, "minimum": 573.30, "maximum": 609.14, "setting": "both", "payers_information": [ { "payer_name": "Aetna", "plan_name": "700700", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna", "plan_name": "700700_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Miscellaneous", "plan_name": "700720", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Miscellaneous", "plan_name": "700720_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Ppo Hmo", "plan_name": "701720", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Ppo Hmo", "plan_name": "701720_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Ms State Emplo", "plan_name": "401457", "standard_charge_percentage": 0.80, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Ms State Emplo", "plan_name": "401457_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Basic Pl", "plan_name": "400100", "standard_charge_percentage": 0.85, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Basic Pl", "plan_name": "400100_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Federal", "plan_name": "400110", "standard_charge_percentage": 0.85, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Federal", "plan_name": "400110_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." } ] } ] }, { "description": "Sodium chloride 0.9 % intravenous solution [27838]", "drug_information": { "unit": 150.00, "type": "ML" }, "code_information": [ { "code": "0990-7983-61", "type": "NDC" } ], "standard_charges": [ { "gross_charge": 81.81, "minimum": 65.45, "maximum": 69.54, "setting": "both", "payers_information": [ { "payer_name": "Aetna", "plan_name": "700700", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna", "plan_name": "700700_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Miscellaneous", "plan_name": "700720", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Miscellaneous", "plan_name": "700720_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Ppo Hmo", "plan_name": "701720", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Ppo Hmo", "plan_name": "701720_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Ms State Emplo", "plan_name": "401457", "standard_charge_percentage": 0.80, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Ms State Emplo", "plan_name": "401457_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Basic Pl", "plan_name": "400100", "standard_charge_percentage": 0.85, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Basic Pl", "plan_name": "400100_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Federal", "plan_name": "400110", "standard_charge_percentage": 0.85, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Federal", "plan_name": "400110_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." } ] } ] }, { "description": "Sodium chloride 0.9 % intravenous solution [27838]", "drug_information": { "unit": 25.00, "type": "ML" }, "code_information": [ { "code": "0990-7984-20", "type": "NDC" } ], "standard_charges": [ { "gross_charge": 81.81, "minimum": 65.45, "maximum": 69.54, "setting": "both", "payers_information": [ { "payer_name": "Aetna", "plan_name": "700700", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna", "plan_name": "700700_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Miscellaneous", "plan_name": "700720", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Miscellaneous", "plan_name": "700720_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Ppo Hmo", "plan_name": "701720", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Ppo Hmo", "plan_name": "701720_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Ms State Emplo", "plan_name": "401457", "standard_charge_percentage": 0.80, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Ms State Emplo", "plan_name": "401457_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Basic Pl", "plan_name": "400100", "standard_charge_percentage": 0.85, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Basic Pl", "plan_name": "400100_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Federal", "plan_name": "400110", "standard_charge_percentage": 0.85, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Federal", "plan_name": "400110_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." } ] } ] }, { "description": "Sodium chloride 0.9 % intravenous solution [27838]", "drug_information": { "unit": 100.00, "type": "ML" }, "code_information": [ { "code": "0990-7984-37", "type": "NDC" } ], "standard_charges": [ { "gross_charge": 81.81, "minimum": 65.45, "maximum": 69.54, "setting": "both", "payers_information": [ { "payer_name": "Aetna", "plan_name": "700700", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna", "plan_name": "700700_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Miscellaneous", "plan_name": "700720", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Miscellaneous", "plan_name": "700720_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Ppo Hmo", "plan_name": "701720", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Ppo Hmo", "plan_name": "701720_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Ms State Emplo", "plan_name": "401457", "standard_charge_percentage": 0.80, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Ms State Emplo", "plan_name": "401457_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Basic Pl", "plan_name": "400100", "standard_charge_percentage": 0.85, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Basic Pl", "plan_name": "400100_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Federal", "plan_name": "400110", "standard_charge_percentage": 0.85, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Federal", "plan_name": "400110_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." } ] } ] }, { "description": "Zolpidem 10 mg tablet [11700]", "drug_information": { "unit": 1.00, "type": "EA" }, "code_information": [ { "code": "13668-008-01", "type": "NDC" } ], "standard_charges": [ { "gross_charge": 7.50, "minimum": 6.00, "maximum": 6.38, "setting": "both", "payers_information": [ { "payer_name": "Aetna", "plan_name": "700700", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna", "plan_name": "700700_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Miscellaneous", "plan_name": "700720", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Miscellaneous", "plan_name": "700720_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Ppo Hmo", "plan_name": "701720", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Ppo Hmo", "plan_name": "701720_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Ms State Emplo", "plan_name": "401457", "standard_charge_percentage": 0.80, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Ms State Emplo", "plan_name": "401457_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Basic Pl", "plan_name": "400100", "standard_charge_percentage": 0.85, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Basic Pl", "plan_name": "400100_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Federal", "plan_name": "400110", "standard_charge_percentage": 0.85, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Federal", "plan_name": "400110_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." } ] } ] }, { "description": "Citalopram 10 mg tablet [30264]", "drug_information": { "unit": 1.00, "type": "EA" }, "code_information": [ { "code": "13668-009-01", "type": "NDC" } ], "standard_charges": [ { "gross_charge": 7.50, "minimum": 6.00, "maximum": 6.38, "setting": "both", "payers_information": [ { "payer_name": "Aetna", "plan_name": "700700", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna", "plan_name": "700700_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Miscellaneous", "plan_name": "700720", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Miscellaneous", "plan_name": "700720_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Ppo Hmo", "plan_name": "701720", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Ppo Hmo", "plan_name": "701720_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Ms State Emplo", "plan_name": "401457", "standard_charge_percentage": 0.80, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Ms State Emplo", "plan_name": "401457_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Basic Pl", "plan_name": "400100", "standard_charge_percentage": 0.85, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Basic Pl", "plan_name": "400100_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Federal", "plan_name": "400110", "standard_charge_percentage": 0.85, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Federal", "plan_name": "400110_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." } ] } ] }, { "description": "Citalopram 20 mg tablet [21062]", "drug_information": { "unit": 1.00, "type": "EA" }, "code_information": [ { "code": "13668-010-01", "type": "NDC" } ], "standard_charges": [ { "gross_charge": 7.50, "minimum": 6.00, "maximum": 6.38, "setting": "both", "payers_information": [ { "payer_name": "Aetna", "plan_name": "700700", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna", "plan_name": "700700_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Miscellaneous", "plan_name": "700720", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Miscellaneous", "plan_name": "700720_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Ppo Hmo", "plan_name": "701720", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Ppo Hmo", "plan_name": "701720_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Ms State Emplo", "plan_name": "401457", "standard_charge_percentage": 0.80, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Ms State Emplo", "plan_name": "401457_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Basic Pl", "plan_name": "400100", "standard_charge_percentage": 0.85, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Basic Pl", "plan_name": "400100_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Federal", "plan_name": "400110", "standard_charge_percentage": 0.85, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Federal", "plan_name": "400110_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." } ] } ] }, { "description": "Pramipexole 0.125 mg tablet [21287]", "drug_information": { "unit": 1.00, "type": "EA" }, "code_information": [ { "code": "13668-091-90", "type": "NDC" } ], "standard_charges": [ { "gross_charge": 7.50, "minimum": 6.00, "maximum": 6.38, "setting": "both", "payers_information": [ { "payer_name": "Aetna", "plan_name": "700700", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna", "plan_name": "700700_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Miscellaneous", "plan_name": "700720", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Miscellaneous", "plan_name": "700720_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Ppo Hmo", "plan_name": "701720", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Ppo Hmo", "plan_name": "701720_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Ms State Emplo", "plan_name": "401457", "standard_charge_percentage": 0.80, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Ms State Emplo", "plan_name": "401457_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Basic Pl", "plan_name": "400100", "standard_charge_percentage": 0.85, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Basic Pl", "plan_name": "400100_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Federal", "plan_name": "400110", "standard_charge_percentage": 0.85, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Federal", "plan_name": "400110_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." } ] } ] }, { "description": "Pramipexole 0.5 mg tablet [22719]", "drug_information": { "unit": 1.00, "type": "EA" }, "code_information": [ { "code": "13668-093-90", "type": "NDC" } ], "standard_charges": [ { "gross_charge": 1.00, "minimum": 0.80, "maximum": 0.85, "setting": "both", "payers_information": [ { "payer_name": "Aetna", "plan_name": "700700", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna", "plan_name": "700700_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Miscellaneous", "plan_name": "700720", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Miscellaneous", "plan_name": "700720_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Ppo Hmo", "plan_name": "701720", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Ppo Hmo", "plan_name": "701720_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Ms State Emplo", "plan_name": "401457", "standard_charge_percentage": 0.80, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Ms State Emplo", "plan_name": "401457_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Basic Pl", "plan_name": "400100", "standard_charge_percentage": 0.85, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Basic Pl", "plan_name": "400100_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Federal", "plan_name": "400110", "standard_charge_percentage": 0.85, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Federal", "plan_name": "400110_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." } ] } ] }, { "description": "Isosorbide mononitrate er 60 mg tabletextended release 24 hr [24268]", "drug_information": { "unit": 1.00, "type": "EA" }, "code_information": [ { "code": "13668-105-01", "type": "NDC" } ], "standard_charges": [ { "gross_charge": 7.50, "minimum": 6.00, "maximum": 6.38, "setting": "both", "payers_information": [ { "payer_name": "Aetna", "plan_name": "700700", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna", "plan_name": "700700_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Miscellaneous", "plan_name": "700720", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Miscellaneous", "plan_name": "700720_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Ppo Hmo", "plan_name": "701720", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Ppo Hmo", "plan_name": "701720_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Ms State Emplo", "plan_name": "401457", "standard_charge_percentage": 0.80, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Ms State Emplo", "plan_name": "401457_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Basic Pl", "plan_name": "400100", "standard_charge_percentage": 0.85, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Basic Pl", "plan_name": "400100_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Federal", "plan_name": "400110", "standard_charge_percentage": 0.85, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Federal", "plan_name": "400110_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." } ] } ] }, { "description": "Felodipine er 2.5 mg tabletextended release 24 hr [27489]", "drug_information": { "unit": 1.00, "type": "EA" }, "code_information": [ { "code": "13668-132-01", "type": "NDC" } ], "standard_charges": [ { "gross_charge": 7.50, "minimum": 6.00, "maximum": 6.38, "setting": "both", "payers_information": [ { "payer_name": "Aetna", "plan_name": "700700", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna", "plan_name": "700700_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Miscellaneous", "plan_name": "700720", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Miscellaneous", "plan_name": "700720_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Ppo Hmo", "plan_name": "701720", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Ppo Hmo", "plan_name": "701720_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Ms State Emplo", "plan_name": "401457", "standard_charge_percentage": 0.80, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Ms State Emplo", "plan_name": "401457_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Basic Pl", "plan_name": "400100", "standard_charge_percentage": 0.85, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Basic Pl", "plan_name": "400100_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Federal", "plan_name": "400110", "standard_charge_percentage": 0.85, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Federal", "plan_name": "400110_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." } ] } ] }, { "description": "Aripiprazole 5 mg tablet [36438]", "drug_information": { "unit": 1.00, "type": "EA" }, "code_information": [ { "code": "13668-217-30", "type": "NDC" } ], "standard_charges": [ { "gross_charge": 7.50, "minimum": 6.00, "maximum": 6.38, "setting": "both", "payers_information": [ { "payer_name": "Aetna", "plan_name": "700700", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna", "plan_name": "700700_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Miscellaneous", "plan_name": "700720", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Miscellaneous", "plan_name": "700720_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Ppo Hmo", "plan_name": "701720", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Ppo Hmo", "plan_name": "701720_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Ms State Emplo", "plan_name": "401457", "standard_charge_percentage": 0.80, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Ms State Emplo", "plan_name": "401457_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Basic Pl", "plan_name": "400100", "standard_charge_percentage": 0.85, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Basic Pl", "plan_name": "400100_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Federal", "plan_name": "400110", "standard_charge_percentage": 0.85, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Federal", "plan_name": "400110_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." } ] } ] }, { "description": "Aripiprazole 10 mg tablet [34369]", "drug_information": { "unit": 1.00, "type": "EA" }, "code_information": [ { "code": "13668-218-30", "type": "NDC" } ], "standard_charges": [ { "gross_charge": 7.50, "minimum": 6.00, "maximum": 6.38, "setting": "both", "payers_information": [ { "payer_name": "Aetna", "plan_name": "700700", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna", "plan_name": "700700_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Miscellaneous", "plan_name": "700720", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Miscellaneous", "plan_name": "700720_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Ppo Hmo", "plan_name": "701720", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Ppo Hmo", "plan_name": "701720_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Ms State Emplo", "plan_name": "401457", "standard_charge_percentage": 0.80, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Ms State Emplo", "plan_name": "401457_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Basic Pl", "plan_name": "400100", "standard_charge_percentage": 0.85, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Basic Pl", "plan_name": "400100_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Federal", "plan_name": "400110", "standard_charge_percentage": 0.85, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Federal", "plan_name": "400110_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." } ] } ] }, { "description": "Trazodone 50 mg tablet [8085]", "drug_information": { "unit": 1.00, "type": "EA" }, "code_information": [ { "code": "13668-330-01", "type": "NDC" } ], "standard_charges": [ { "gross_charge": 7.50, "minimum": 6.00, "maximum": 6.38, "setting": "both", "payers_information": [ { "payer_name": "Aetna", "plan_name": "700700", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna", "plan_name": "700700_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Miscellaneous", "plan_name": "700720", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Miscellaneous", "plan_name": "700720_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Ppo Hmo", "plan_name": "701720", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Ppo Hmo", "plan_name": "701720_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Ms State Emplo", "plan_name": "401457", "standard_charge_percentage": 0.80, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Ms State Emplo", "plan_name": "401457_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Basic Pl", "plan_name": "400100", "standard_charge_percentage": 0.85, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Basic Pl", "plan_name": "400100_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Federal", "plan_name": "400110", "standard_charge_percentage": 0.85, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Federal", "plan_name": "400110_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." } ] } ] }, { "description": "Acyclovir 5 % topical ointment [8968]", "drug_information": { "unit": 15.00, "type": "GR" }, "code_information": [ { "code": "13668-515-01", "type": "NDC" } ], "standard_charges": [ { "gross_charge": 202.78, "minimum": 162.22, "maximum": 172.36, "setting": "both", "payers_information": [ { "payer_name": "Aetna", "plan_name": "700700", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna", "plan_name": "700700_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Miscellaneous", "plan_name": "700720", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Miscellaneous", "plan_name": "700720_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Ppo Hmo", "plan_name": "701720", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Ppo Hmo", "plan_name": "701720_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Ms State Emplo", "plan_name": "401457", "standard_charge_percentage": 0.80, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Ms State Emplo", "plan_name": "401457_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Basic Pl", "plan_name": "400100", "standard_charge_percentage": 0.85, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Basic Pl", "plan_name": "400100_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Federal", "plan_name": "400110", "standard_charge_percentage": 0.85, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Federal", "plan_name": "400110_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." } ] } ] }, { "description": "Nystatin 100000 unit/gram topical cream [5749]", "drug_information": { "unit": 15.00, "type": "GR" }, "code_information": [ { "code": "13668-595-01", "type": "NDC" } ], "standard_charges": [ { "gross_charge": 50.52, "minimum": 40.42, "maximum": 42.94, "setting": "both", "payers_information": [ { "payer_name": "Aetna", "plan_name": "700700", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna", "plan_name": "700700_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Miscellaneous", "plan_name": "700720", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Miscellaneous", "plan_name": "700720_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Ppo Hmo", "plan_name": "701720", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Ppo Hmo", "plan_name": "701720_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Ms State Emplo", "plan_name": "401457", "standard_charge_percentage": 0.80, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Ms State Emplo", "plan_name": "401457_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Basic Pl", "plan_name": "400100", "standard_charge_percentage": 0.85, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Basic Pl", "plan_name": "400100_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Federal", "plan_name": "400110", "standard_charge_percentage": 0.85, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Federal", "plan_name": "400110_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." } ] } ] }, { "description": "Nystatin 100000 unit/gram topical cream [5749]", "drug_information": { "unit": 30.00, "type": "GR" }, "code_information": [ { "code": "13668-595-02", "type": "NDC" } ], "standard_charges": [ { "gross_charge": 75.67, "minimum": 60.54, "maximum": 64.32, "setting": "both", "payers_information": [ { "payer_name": "Aetna", "plan_name": "700700", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna", "plan_name": "700700_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Miscellaneous", "plan_name": "700720", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Miscellaneous", "plan_name": "700720_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Ppo Hmo", "plan_name": "701720", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Ppo Hmo", "plan_name": "701720_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Ms State Emplo", "plan_name": "401457", "standard_charge_percentage": 0.80, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Ms State Emplo", "plan_name": "401457_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Basic Pl", "plan_name": "400100", "standard_charge_percentage": 0.85, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Basic Pl", "plan_name": "400100_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Federal", "plan_name": "400110", "standard_charge_percentage": 0.85, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Federal", "plan_name": "400110_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." } ] } ] }, { "description": "Carbamide peroxide-sod chloride-sod bicarb 6.5 %-0.9 % otic comb pack [158647]", "drug_information": { "unit": 90.00, "type": "ML" }, "code_information": [ { "code": "13709-230-10", "type": "NDC" } ], "standard_charges": [ { "gross_charge": 108.34, "minimum": 86.67, "maximum": 92.09, "setting": "both", "payers_information": [ { "payer_name": "Aetna", "plan_name": "700700", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna", "plan_name": "700700_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Miscellaneous", "plan_name": "700720", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Miscellaneous", "plan_name": "700720_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Ppo Hmo", "plan_name": "701720", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Ppo Hmo", "plan_name": "701720_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Ms State Emplo", "plan_name": "401457", "standard_charge_percentage": 0.80, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Ms State Emplo", "plan_name": "401457_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Basic Pl", "plan_name": "400100", "standard_charge_percentage": 0.85, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Basic Pl", "plan_name": "400100_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Federal", "plan_name": "400110", "standard_charge_percentage": 0.85, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Federal", "plan_name": "400110_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." } ] } ] }, { "description": "Calcium er 600 mg (as carbcit)-d3 12.5 mcg (500 unit) tablet ext.rel [154218]", "drug_information": { "unit": 1.00, "type": "EA" }, "code_information": [ { "code": "1650054099", "type": "NDC" } ], "standard_charges": [ { "gross_charge": 1.00, "minimum": 0.80, "maximum": 0.85, "setting": "both", "payers_information": [ { "payer_name": "Aetna", "plan_name": "700700", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna", "plan_name": "700700_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Miscellaneous", "plan_name": "700720", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Miscellaneous", "plan_name": "700720_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Ppo Hmo", "plan_name": "701720", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Ppo Hmo", "plan_name": "701720_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Ms State Emplo", "plan_name": "401457", "standard_charge_percentage": 0.80, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Ms State Emplo", "plan_name": "401457_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Basic Pl", "plan_name": "400100", "standard_charge_percentage": 0.85, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Basic Pl", "plan_name": "400100_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Federal", "plan_name": "400110", "standard_charge_percentage": 0.85, "count": "0", 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100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Miscellaneous", "plan_name": "700720", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Miscellaneous", "plan_name": "700720_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Ppo Hmo", "plan_name": "701720", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Ppo Hmo", "plan_name": "701720_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Ms State Emplo", "plan_name": "401457", "standard_charge_percentage": 0.80, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Ms State Emplo", "plan_name": "401457_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Basic Pl", "plan_name": "400100", "standard_charge_percentage": 0.85, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Basic Pl", "plan_name": "400100_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Federal", "plan_name": "400110", "standard_charge_percentage": 0.85, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Federal", "plan_name": "400110_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." } ] } ] }, { "description": "Cetirizine 5 mg tablet [15349]", "drug_information": { "unit": 1.00, "type": "EA" }, "code_information": [ { "code": "16571-401-10", "type": "NDC" } ], "standard_charges": [ { "gross_charge": 1.00, "minimum": 0.80, "maximum": 0.85, "setting": "both", "payers_information": [ { "payer_name": "Aetna", "plan_name": "700700", 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release12 hr [27635]", "drug_information": { "unit": 1.00, "type": "EA" }, "code_information": [ { "code": "16571-681-01", "type": "NDC" } ], "standard_charges": [ { "gross_charge": 7.50, "minimum": 6.00, "maximum": 6.38, "setting": "both", "payers_information": [ { "payer_name": "Aetna", "plan_name": "700700", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna", "plan_name": "700700_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Miscellaneous", "plan_name": "700720", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Miscellaneous", "plan_name": "700720_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Ppo Hmo", "plan_name": "701720", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Ppo Hmo", "plan_name": "701720_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Ms State Emplo", "plan_name": "401457", "standard_charge_percentage": 0.80, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Ms State Emplo", "plan_name": "401457_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Basic Pl", "plan_name": "400100", "standard_charge_percentage": 0.85, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Basic Pl", "plan_name": "400100_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Federal", "plan_name": "400110", "standard_charge_percentage": 0.85, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Federal", "plan_name": "400110_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." } ] } ] }, { "description": "Diltiazem er (xr/xt) 180 mg capsuleextended release 24 hr controlled [29347]", "drug_information": { "unit": 1.00, "type": "EA" }, "code_information": [ { "code": "16714-524-01", "type": "NDC" } ], "standard_charges": [ { "gross_charge": 7.50, "minimum": 6.00, "maximum": 6.38, "setting": "both", "payers_information": [ { "payer_name": "Aetna", "plan_name": "700700", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna", "plan_name": "700700_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit 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allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Federal", "plan_name": "400110", "standard_charge_percentage": 0.85, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Federal", "plan_name": "400110_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." } ] } ] }, { "description": "Glimepiride 1 mg tablet [16355]", "drug_information": { "unit": 1.00, "type": "EA" }, "code_information": [ { "code": "16729-001-01", "type": "NDC" } ], "standard_charges": [ { "gross_charge": 7.50, "minimum": 6.00, "maximum": 6.38, "setting": "both", "payers_information": [ { "payer_name": "Aetna", "plan_name": "700700", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna", "plan_name": "700700_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Miscellaneous", "plan_name": "700720", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Miscellaneous", "plan_name": "700720_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Ppo Hmo", "plan_name": "701720", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data 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calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Basic Pl", "plan_name": "400100_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Federal", "plan_name": "400110", "standard_charge_percentage": 0.85, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Federal", "plan_name": "400110_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." } ] } ] }, { "description": "Glimepiride 2 mg tablet [16356]", "drug_information": { "unit": 1.00, "type": "EA" }, "code_information": [ { "code": "16729-002-01", "type": "NDC" } ], "standard_charges": [ { "gross_charge": 7.50, "minimum": 6.00, "maximum": 6.38, "setting": "both", "payers_information": [ { "payer_name": "Aetna", "plan_name": "700700", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna", "plan_name": "700700_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Miscellaneous", "plan_name": "700720", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Miscellaneous", "plan_name": "700720_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": 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remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Basic Pl", "plan_name": "400100", "standard_charge_percentage": 0.85, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Basic Pl", "plan_name": "400100_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Federal", "plan_name": "400110", "standard_charge_percentage": 0.85, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Federal", "plan_name": "400110_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." } ] } ] }, { "description": "Glimepiride 4 mg tablet [16357]", "drug_information": { "unit": 1.00, "type": "EA" }, "code_information": [ { "code": "16729-003-01", "type": "NDC" } ], "standard_charges": [ { "gross_charge": 7.50, "minimum": 6.00, "maximum": 6.38, "setting": "both", "payers_information": [ { "payer_name": "Aetna", "plan_name": "700700", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna", "plan_name": "700700_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Miscellaneous", "plan_name": "700720", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Miscellaneous", "plan_name": "700720_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Ppo Hmo", "plan_name": "701720", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Ppo Hmo", "plan_name": "701720_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Ms State Emplo", "plan_name": "401457", "standard_charge_percentage": 0.80, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Ms State Emplo", "plan_name": "401457_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Basic Pl", "plan_name": "400100", "standard_charge_percentage": 0.85, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Basic Pl", "plan_name": "400100_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Federal", "plan_name": "400110", "standard_charge_percentage": 0.85, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Federal", "plan_name": "400110_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." } ] } ] }, { "description": "Bicalutamide 50 mg tablet [15746]", "drug_information": { "unit": 1.00, "type": "EA" }, "code_information": [ { "code": "16729-023-10", "type": "NDC" } ], "standard_charges": [ { "gross_charge": 7.50, "minimum": 6.00, "maximum": 6.38, "setting": "both", "payers_information": [ { "payer_name": "Aetna", "plan_name": "700700", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna", "plan_name": "700700_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Miscellaneous", "plan_name": "700720", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Miscellaneous", "plan_name": "700720_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Ppo Hmo", "plan_name": "701720", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Ppo Hmo", "plan_name": "701720_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Ms State Emplo", "plan_name": "401457", "standard_charge_percentage": 0.80, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Ms State Emplo", "plan_name": "401457_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Basic Pl", "plan_name": "400100", "standard_charge_percentage": 0.85, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Basic Pl", "plan_name": "400100_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Federal", "plan_name": "400110", "standard_charge_percentage": 0.85, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Federal", "plan_name": "400110_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." } ] } ] }, { "description": "Letrozole 2.5 mg tablet [21509]", "drug_information": { "unit": 1.00, "type": "EA" }, "code_information": [ { "code": "16729-034-10", "type": "NDC" } ], "standard_charges": [ { "gross_charge": 7.50, "minimum": 6.00, "maximum": 6.38, "setting": "both", "payers_information": [ { "payer_name": "Aetna", "plan_name": "700700", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna", "plan_name": "700700_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Miscellaneous", "plan_name": "700720", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Miscellaneous", "plan_name": "700720_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Ppo Hmo", "plan_name": "701720", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Ppo Hmo", "plan_name": "701720_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Ms State Emplo", "plan_name": "401457", "standard_charge_percentage": 0.80, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Ms State Emplo", "plan_name": "401457_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Basic Pl", "plan_name": "400100", "standard_charge_percentage": 0.85, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Basic Pl", "plan_name": "400100_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Federal", "plan_name": "400110", "standard_charge_percentage": 0.85, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Federal", "plan_name": "400110_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." } ] } ] }, { "description": "Clonazepam 0.5 mg tablet [9637]", "drug_information": { "unit": 1.00, "type": "EA" }, "code_information": [ { "code": "16729-136-00", "type": "NDC" } ], "standard_charges": [ { "gross_charge": 7.50, "minimum": 6.00, "maximum": 6.38, "setting": "both", "payers_information": [ { "payer_name": "Aetna", "plan_name": "700700", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna", "plan_name": "700700_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Miscellaneous", "plan_name": "700720", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Miscellaneous", "plan_name": "700720_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Ppo Hmo", "plan_name": "701720", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Ppo Hmo", "plan_name": "701720_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Ms State Emplo", "plan_name": "401457", "standard_charge_percentage": 0.80, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Ms State Emplo", "plan_name": "401457_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Basic Pl", "plan_name": "400100", "standard_charge_percentage": 0.85, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Basic Pl", "plan_name": "400100_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Federal", "plan_name": "400110", "standard_charge_percentage": 0.85, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Federal", "plan_name": "400110_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." } ] } ] }, { "description": "Clonazepam 1 mg tablet [9638]", "drug_information": { "unit": 1.00, "type": "EA" }, "code_information": [ { "code": "16729-137-00", "type": "NDC" } ], "standard_charges": [ { "gross_charge": 7.50, "minimum": 6.00, "maximum": 6.38, "setting": "both", "payers_information": [ { "payer_name": "Aetna", "plan_name": "700700", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna", "plan_name": "700700_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Miscellaneous", "plan_name": "700720", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Miscellaneous", "plan_name": "700720_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Ppo Hmo", "plan_name": "701720", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Ppo Hmo", "plan_name": "701720_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Ms State Emplo", "plan_name": "401457", "standard_charge_percentage": 0.80, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Ms State Emplo", "plan_name": "401457_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Basic Pl", "plan_name": "400100", "standard_charge_percentage": 0.85, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Basic Pl", "plan_name": "400100_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Federal", "plan_name": "400110", "standard_charge_percentage": 0.85, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Federal", "plan_name": "400110_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." } ] } ] }, { "description": "Escitalopram 5 mg tablet [37635]", "drug_information": { "unit": 1.00, "type": "EA" }, "code_information": [ { "code": "16729-168-01", "type": "NDC" } ], "standard_charges": [ { "gross_charge": 7.50, "minimum": 6.00, "maximum": 6.38, "setting": "both", "payers_information": [ { "payer_name": "Aetna", "plan_name": "700700", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna", "plan_name": "700700_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Miscellaneous", "plan_name": "700720", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Miscellaneous", "plan_name": "700720_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Ppo Hmo", "plan_name": "701720", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Ppo Hmo", "plan_name": "701720_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Ms State Emplo", "plan_name": "401457", "standard_charge_percentage": 0.80, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Ms State Emplo", "plan_name": "401457_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Basic Pl", "plan_name": "400100", "standard_charge_percentage": 0.85, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Basic Pl", "plan_name": "400100_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Federal", "plan_name": "400110", "standard_charge_percentage": 0.85, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Federal", "plan_name": "400110_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." } ] } ] }, { "description": "Amitriptyline 10 mg tablet [432]", "drug_information": { "unit": 1.00, "type": "EA" }, "code_information": [ { "code": "16729-171-01", "type": "NDC" } ], "standard_charges": [ { "gross_charge": 7.50, "minimum": 6.00, "maximum": 6.38, "setting": "both", "payers_information": [ { "payer_name": "Aetna", "plan_name": "700700", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna", "plan_name": "700700_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Miscellaneous", "plan_name": "700720", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Miscellaneous", "plan_name": "700720_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Ppo Hmo", "plan_name": "701720", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Ppo Hmo", "plan_name": "701720_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Ms State Emplo", "plan_name": "401457", "standard_charge_percentage": 0.80, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Ms State Emplo", "plan_name": "401457_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Basic Pl", "plan_name": "400100", "standard_charge_percentage": 0.85, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Basic Pl", "plan_name": "400100_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Federal", "plan_name": "400110", "standard_charge_percentage": 0.85, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Federal", "plan_name": "400110_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." } ] } ] }, { "description": "Buspirone 15 mg tablet [17464]", "drug_information": { "unit": 1.00, "type": "EA" }, "code_information": [ { "code": "16729-203-01", "type": "NDC" } ], "standard_charges": [ { "gross_charge": 7.50, "minimum": 6.00, "maximum": 6.38, "setting": "both", "payers_information": [ { "payer_name": "Aetna", "plan_name": "700700", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna", "plan_name": "700700_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Miscellaneous", "plan_name": "700720", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Miscellaneous", "plan_name": "700720_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Ppo Hmo", "plan_name": "701720", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Ppo Hmo", "plan_name": "701720_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Ms State Emplo", "plan_name": "401457", "standard_charge_percentage": 0.80, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Ms State Emplo", "plan_name": "401457_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Basic Pl", "plan_name": "400100", "standard_charge_percentage": 0.85, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Basic Pl", "plan_name": "400100_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Federal", "plan_name": "400110", "standard_charge_percentage": 0.85, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Federal", "plan_name": "400110_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." } ] } ] }, { "description": "Buspirone 15 mg tablet [17464]", "drug_information": { "unit": 1.00, "type": "EA" }, "code_information": [ { "code": "16729-203-12", "type": "NDC" } ], "standard_charges": [ { "gross_charge": 7.50, "minimum": 6.00, "maximum": 6.38, "setting": "both", "payers_information": [ { "payer_name": "Aetna", "plan_name": "700700", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna", "plan_name": "700700_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Miscellaneous", "plan_name": "700720", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Miscellaneous", "plan_name": "700720_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Ppo Hmo", "plan_name": "701720", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Ppo Hmo", "plan_name": "701720_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Ms State Emplo", "plan_name": "401457", "standard_charge_percentage": 0.80, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Ms State Emplo", "plan_name": "401457_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Basic Pl", "plan_name": "400100", "standard_charge_percentage": 0.85, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Basic Pl", "plan_name": "400100_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Federal", "plan_name": "400110", "standard_charge_percentage": 0.85, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Federal", "plan_name": "400110_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." } ] } ] }, { "description": "Doxazosin 1 mg tablet [9894]", "drug_information": { "unit": 1.00, "type": "EA" }, "code_information": [ { "code": "16729-211-01", "type": "NDC" } ], "standard_charges": [ { "gross_charge": 7.50, "minimum": 6.00, "maximum": 6.38, "setting": "both", "payers_information": [ { "payer_name": "Aetna", "plan_name": "700700", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna", "plan_name": "700700_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Miscellaneous", "plan_name": "700720", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Miscellaneous", "plan_name": "700720_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Ppo Hmo", "plan_name": "701720", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Ppo Hmo", "plan_name": "701720_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Ms State Emplo", "plan_name": "401457", "standard_charge_percentage": 0.80, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Ms State Emplo", "plan_name": "401457_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Basic Pl", "plan_name": "400100", "standard_charge_percentage": 0.85, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Basic Pl", "plan_name": "400100_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Federal", "plan_name": "400110", "standard_charge_percentage": 0.85, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Federal", "plan_name": "400110_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." } ] } ] }, { "description": "Doxazosin 4 mg tablet [9896]", "drug_information": { "unit": 1.00, "type": "EA" }, "code_information": [ { "code": "16729-213-01", "type": "NDC" } ], "standard_charges": [ { "gross_charge": 7.50, "minimum": 6.00, "maximum": 6.38, "setting": "both", "payers_information": [ { "payer_name": "Aetna", "plan_name": "700700", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna", "plan_name": "700700_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Miscellaneous", "plan_name": "700720", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Miscellaneous", "plan_name": "700720_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Ppo Hmo", "plan_name": "701720", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Ppo Hmo", "plan_name": "701720_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Ms State Emplo", "plan_name": "401457", "standard_charge_percentage": 0.80, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Ms State Emplo", "plan_name": "401457_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Basic Pl", "plan_name": "400100", "standard_charge_percentage": 0.85, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Basic Pl", "plan_name": "400100_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Federal", "plan_name": "400110", "standard_charge_percentage": 0.85, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Federal", "plan_name": "400110_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." } ] } ] }, { "description": "Ropinirole 0.25 mg tablet [21688]", "drug_information": { "unit": 1.00, "type": "EA" }, "code_information": [ { "code": "16729-232-01", "type": "NDC" } ], "standard_charges": [ { "gross_charge": 7.50, "minimum": 6.00, "maximum": 6.38, "setting": "both", "payers_information": [ { "payer_name": "Aetna", "plan_name": "700700", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna", "plan_name": "700700_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Miscellaneous", "plan_name": "700720", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Miscellaneous", "plan_name": "700720_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Ppo Hmo", "plan_name": "701720", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Ppo Hmo", "plan_name": "701720_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Ms State Emplo", "plan_name": "401457", "standard_charge_percentage": 0.80, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Ms State Emplo", "plan_name": "401457_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Basic Pl", "plan_name": "400100", "standard_charge_percentage": 0.85, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Basic Pl", "plan_name": "400100_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Federal", "plan_name": "400110", "standard_charge_percentage": 0.85, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Federal", "plan_name": "400110_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." } ] } ] }, { "description": "Ropinirole 0.5 mg tablet [21800]", "drug_information": { "unit": 1.00, "type": "EA" }, "code_information": [ { "code": "16729-233-01", "type": "NDC" } ], "standard_charges": [ { "gross_charge": 7.50, "minimum": 6.00, "maximum": 6.38, "setting": "both", "payers_information": [ { "payer_name": "Aetna", "plan_name": "700700", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna", "plan_name": "700700_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Miscellaneous", "plan_name": "700720", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Miscellaneous", "plan_name": "700720_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Ppo Hmo", "plan_name": "701720", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Ppo Hmo", "plan_name": "701720_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Ms State Emplo", "plan_name": "401457", "standard_charge_percentage": 0.80, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Ms State Emplo", "plan_name": "401457_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Basic Pl", "plan_name": "400100", "standard_charge_percentage": 0.85, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Basic Pl", "plan_name": "400100_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Federal", "plan_name": "400110", "standard_charge_percentage": 0.85, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Federal", "plan_name": "400110_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." } ] } ] }, { "description": "Prasugrel 10 mg tablet [98373]", "drug_information": { "unit": 1.00, "type": "EA" }, "code_information": [ { "code": "16729-273-10", "type": "NDC" } ], "standard_charges": [ { "gross_charge": 7.50, "minimum": 6.00, "maximum": 6.38, "setting": "both", "payers_information": [ { "payer_name": "Aetna", "plan_name": "700700", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna", "plan_name": "700700_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Miscellaneous", "plan_name": "700720", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Miscellaneous", "plan_name": "700720_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Ppo Hmo", "plan_name": "701720", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Ppo Hmo", "plan_name": "701720_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Ms State Emplo", "plan_name": "401457", "standard_charge_percentage": 0.80, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Ms State Emplo", "plan_name": "401457_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Basic Pl", "plan_name": "400100", "standard_charge_percentage": 0.85, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Basic Pl", "plan_name": "400100_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Federal", "plan_name": "400110", "standard_charge_percentage": 0.85, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Federal", "plan_name": "400110_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." } ] } ] }, { "description": "Levothyroxine 125 mcg tablet [4424]", "drug_information": { "unit": 1.00, "type": "EA" }, "code_information": [ { "code": "16729-453-15", "type": "NDC" } ], "standard_charges": [ { "gross_charge": 7.50, "minimum": 6.00, "maximum": 6.38, "setting": "both", "payers_information": [ { "payer_name": "Aetna", "plan_name": "700700", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna", "plan_name": "700700_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Miscellaneous", "plan_name": "700720", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Miscellaneous", "plan_name": "700720_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Ppo Hmo", "plan_name": "701720", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Ppo Hmo", "plan_name": "701720_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Ms State Emplo", "plan_name": "401457", "standard_charge_percentage": 0.80, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Ms State Emplo", "plan_name": "401457_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Basic Pl", "plan_name": "400100", "standard_charge_percentage": 0.85, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Basic Pl", "plan_name": "400100_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Federal", "plan_name": "400110", "standard_charge_percentage": 0.85, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Federal", "plan_name": "400110_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." } ] } ] }, { "description": "Benzocaine 20 %-menthol 0.5 % topical aerosol [28048]", "drug_information": { "unit": 85.00, "type": "GR" }, "code_information": [ { "code": "16864-680-03", "type": "NDC" } ], "standard_charges": [ { "gross_charge": 19.01, "minimum": 15.21, "maximum": 16.16, "setting": "both", "payers_information": [ { "payer_name": "Aetna", "plan_name": "700700", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna", "plan_name": "700700_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Miscellaneous", "plan_name": "700720", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", 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"0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Federal", "plan_name": "400110", "standard_charge_percentage": 0.85, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Federal", "plan_name": "400110_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." } ] } ] }, { "description": "Cyclopentolate 2 % eye drops [9700]", "drug_information": { "unit": 5.00, "type": "ML" }, "code_information": [ { "code": "17478-097-10", "type": "NDC" } ], "standard_charges": [ { "gross_charge": 185.44, "minimum": 148.35, "maximum": 157.62, "setting": "both", "payers_information": [ { "payer_name": "Aetna", "plan_name": "700700", 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"401457_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Basic Pl", "plan_name": "400100", "standard_charge_percentage": 0.85, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Basic Pl", "plan_name": "400100_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Federal", "plan_name": "400110", "standard_charge_percentage": 0.85, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Federal", "plan_name": "400110_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." } ] } ] }, { "description": "Cyclopentolate 1 % eye drops [2025]", "drug_information": { "unit": 15.00, "type": "ML" }, "code_information": [ { "code": "17478-100-12", "type": "NDC" } ], "standard_charges": [ { "gross_charge": 132.81, "minimum": 106.25, "maximum": 112.89, "setting": "both", "payers_information": [ { "payer_name": "Aetna", "plan_name": "700700", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna", "plan_name": "700700_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Miscellaneous", "plan_name": "700720", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Miscellaneous", "plan_name": "700720_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Ppo Hmo", "plan_name": "701720", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Ppo Hmo", "plan_name": "701720_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Ms State 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Federal", "plan_name": "400110", "standard_charge_percentage": 0.85, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Federal", "plan_name": "400110_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." } ] } ] }, { "description": "Tropicamide 1 % eye drops [8250]", "drug_information": { "unit": 15.00, "type": "ML" }, "code_information": [ { "code": "17478-102-12", "type": "NDC" } ], "standard_charges": [ { "gross_charge": 40.40, "minimum": 32.32, "maximum": 34.34, "setting": "both", "payers_information": [ { "payer_name": "Aetna", "plan_name": "700700", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna", "plan_name": "700700_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Miscellaneous", "plan_name": "700720", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Miscellaneous", "plan_name": "700720_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Ppo Hmo", "plan_name": "701720", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Ppo Hmo", "plan_name": "701720_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Ms State Emplo", "plan_name": "401457", "standard_charge_percentage": 0.80, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Ms State Emplo", "plan_name": "401457_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Basic Pl", "plan_name": "400100", "standard_charge_percentage": 0.85, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Basic Pl", "plan_name": "400100_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Federal", "plan_name": "400110", "standard_charge_percentage": 0.85, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Federal", "plan_name": "400110_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." } ] } ] }, { "description": "Fluorescein 1 mg eye strips [27663]", "drug_information": { "unit": 1.00, "type": "EA" }, "code_information": [ { "code": "17238-900-30", "type": "NDC" } ], "standard_charges": [ { "gross_charge": 7.50, "minimum": 6.00, "maximum": 6.38, "setting": "both", "payers_information": [ { "payer_name": "Aetna", "plan_name": "700700", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna", "plan_name": "700700_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Miscellaneous", "plan_name": "700720", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Miscellaneous", "plan_name": "700720_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Ppo Hmo", "plan_name": "701720", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Ppo Hmo", "plan_name": "701720_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Ms State Emplo", "plan_name": "401457", "standard_charge_percentage": 0.80, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Ms State Emplo", "plan_name": "401457_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Basic Pl", "plan_name": "400100", "standard_charge_percentage": 0.85, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Basic Pl", "plan_name": "400100_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Federal", "plan_name": "400110", "standard_charge_percentage": 0.85, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Federal", "plan_name": "400110_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." } ] } ] }, { "description": "Fluorescein 1 mg eye strips [27663]", "drug_information": { "unit": 1.00, "type": "EA" }, "code_information": [ { "code": "17238-900-99", "type": "NDC" } ], "standard_charges": [ { "gross_charge": 7.50, "minimum": 6.00, "maximum": 6.38, "setting": "both", "payers_information": [ { "payer_name": "Aetna", "plan_name": "700700", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna", "plan_name": "700700_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Miscellaneous", "plan_name": "700720", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Miscellaneous", "plan_name": "700720_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Ppo Hmo", "plan_name": "701720", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Ppo Hmo", "plan_name": "701720_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Ms State Emplo", "plan_name": "401457", "standard_charge_percentage": 0.80, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Ms State Emplo", "plan_name": "401457_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Basic Pl", "plan_name": "400100", "standard_charge_percentage": 0.85, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Basic Pl", "plan_name": "400100_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Federal", "plan_name": "400110", "standard_charge_percentage": 0.85, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Federal", "plan_name": "400110_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." } ] } ] }, { "description": "Tetracaine hcl (pf) 1 % (10 mg/ml) injection solution [11517]", "drug_information": { "unit": 2.00, "type": "ML" }, "code_information": [ { "code": "17478-045-32", "type": "NDC" } ], "standard_charges": [ { "gross_charge": 379.71, "minimum": 303.77, "maximum": 322.75, "setting": "both", "payers_information": [ { "payer_name": "Aetna", "plan_name": "700700", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna", "plan_name": "700700_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Miscellaneous", "plan_name": "700720", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Miscellaneous", "plan_name": "700720_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Ppo Hmo", "plan_name": "701720", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Ppo Hmo", "plan_name": "701720_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Ms State Emplo", "plan_name": "401457", "standard_charge_percentage": 0.80, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Ms State Emplo", "plan_name": "401457_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Basic Pl", "plan_name": "400100", "standard_charge_percentage": 0.85, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Basic Pl", "plan_name": "400100_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Federal", "plan_name": "400110", "standard_charge_percentage": 0.85, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Federal", "plan_name": "400110_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." } ] } ] }, { "description": "White petrolatum-mineral oil 83 %-15 % eye ointment [117765]", "drug_information": { "unit": 3.50, "type": "GR" }, "code_information": [ { "code": "17478-062-35", "type": "NDC" } ], "standard_charges": [ { "gross_charge": 18.17, "minimum": 14.54, "maximum": 15.44, "setting": "both", "payers_information": [ { "payer_name": "Aetna", "plan_name": "700700", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna", "plan_name": "700700_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Miscellaneous", "plan_name": "700720", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Miscellaneous", "plan_name": "700720_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Ppo Hmo", "plan_name": "701720", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Ppo Hmo", "plan_name": "701720_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Ms State Emplo", "plan_name": "401457", "standard_charge_percentage": 0.80, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Ms State Emplo", "plan_name": "401457_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Basic Pl", "plan_name": "400100", "standard_charge_percentage": 0.85, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Basic Pl", "plan_name": "400100_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Federal", "plan_name": "400110", "standard_charge_percentage": 0.85, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Federal", "plan_name": "400110_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." } ] } ] }, { "description": "Phenylephrine 2.5 % eye drops [6246]", "drug_information": { "unit": 15.00, "type": "ML" }, "code_information": [ { "code": "17478-201-15", "type": "NDC" } ], "standard_charges": [ { "gross_charge": 427.50, "minimum": 342.00, "maximum": 363.38, "setting": "both", "payers_information": [ { "payer_name": "Aetna", "plan_name": "700700", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna", "plan_name": "700700_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Miscellaneous", "plan_name": "700720", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Miscellaneous", "plan_name": "700720_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Ppo Hmo", "plan_name": "701720", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Ppo Hmo", "plan_name": "701720_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Ms State Emplo", "plan_name": "401457", "standard_charge_percentage": 0.80, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Ms State Emplo", "plan_name": "401457_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Basic Pl", "plan_name": "400100", "standard_charge_percentage": 0.85, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Basic Pl", "plan_name": "400100_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Federal", "plan_name": "400110", "standard_charge_percentage": 0.85, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Federal", "plan_name": "400110_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." } ] } ] }, { "description": "Phenylephrine 10 % eye drops [19636]", "drug_information": { "unit": 5.00, "type": "ML" }, "code_information": [ { "code": "17478-206-05", "type": "NDC" } ], "standard_charges": [ { "gross_charge": 190.00, "minimum": 152.00, "maximum": 161.50, "setting": "both", "payers_information": [ { "payer_name": "Aetna", "plan_name": "700700", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna", "plan_name": "700700_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Miscellaneous", "plan_name": "700720", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Miscellaneous", "plan_name": "700720_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Ppo Hmo", "plan_name": "701720", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Ppo Hmo", "plan_name": "701720_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Ms State Emplo", "plan_name": "401457", "standard_charge_percentage": 0.80, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Ms State Emplo", "plan_name": "401457_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Basic Pl", "plan_name": "400100", "standard_charge_percentage": 0.85, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Basic Pl", "plan_name": "400100_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Federal", "plan_name": "400110", "standard_charge_percentage": 0.85, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Federal", "plan_name": "400110_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." } ] } ] }, { "description": "Atropine 1 % eye drops [736]", "drug_information": { "unit": 5.00, "type": "ML" }, "code_information": [ { "code": "17478-215-05", "type": "NDC" } ], "standard_charges": [ { "gross_charge": 243.77, "minimum": 195.02, "maximum": 207.20, "setting": "both", "payers_information": [ { "payer_name": "Aetna", "plan_name": "700700", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna", "plan_name": "700700_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Miscellaneous", "plan_name": "700720", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Miscellaneous", "plan_name": "700720_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Ppo Hmo", "plan_name": "701720", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Ppo Hmo", "plan_name": "701720_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Ms State Emplo", "plan_name": "401457", "standard_charge_percentage": 0.80, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Ms State Emplo", "plan_name": "401457_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Basic Pl", "plan_name": "400100", "standard_charge_percentage": 0.85, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Basic Pl", "plan_name": "400100_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Federal", "plan_name": "400110", "standard_charge_percentage": 0.85, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Federal", "plan_name": "400110_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." } ] } ] }, { "description": "Fluorescein 1 mg eye strips [27663]", "drug_information": { "unit": 1.00, "type": "EA" }, "code_information": [ { "code": "17478-404-01", "type": "NDC" } ], "standard_charges": [ { "gross_charge": 7.50, "minimum": 6.00, "maximum": 6.38, "setting": "both", "payers_information": [ { "payer_name": "Aetna", "plan_name": "700700", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna", "plan_name": "700700_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Miscellaneous", "plan_name": "700720", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Miscellaneous", "plan_name": "700720_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Ppo Hmo", "plan_name": "701720", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Ppo Hmo", "plan_name": "701720_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Ms State Emplo", "plan_name": "401457", "standard_charge_percentage": 0.80, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Ms State Emplo", "plan_name": "401457_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Basic Pl", "plan_name": "400100", "standard_charge_percentage": 0.85, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Basic Pl", "plan_name": "400100_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Federal", "plan_name": "400110", "standard_charge_percentage": 0.85, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Federal", "plan_name": "400110_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." } ] } ] }, { "description": "Dorzolamide 22.3 mg-timolol 6.8 mg/ml eye drops [22982]", "drug_information": { "unit": 10.00, "type": "ML" }, "code_information": [ { "code": "17478-605-10", "type": "NDC" } ], "standard_charges": [ { "gross_charge": 995.65, "minimum": 796.52, "maximum": 846.30, "setting": "both", "payers_information": [ { "payer_name": "Aetna", "plan_name": "700700", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna", "plan_name": "700700_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Miscellaneous", "plan_name": "700720", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Miscellaneous", "plan_name": "700720_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Ppo Hmo", "plan_name": "701720", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Ppo Hmo", "plan_name": "701720_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Ms State Emplo", "plan_name": "401457", "standard_charge_percentage": 0.80, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Ms State Emplo", "plan_name": "401457_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Basic Pl", "plan_name": "400100", "standard_charge_percentage": 0.85, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Basic Pl", "plan_name": "400100_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Federal", "plan_name": "400110", "standard_charge_percentage": 0.85, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate 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"percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Basic Pl", "plan_name": "400100", "standard_charge_percentage": 0.85, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Basic Pl", "plan_name": "400100_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Federal", "plan_name": "400110", "standard_charge_percentage": 0.85, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Federal", "plan_name": "400110_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": 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"standard_charge_percentage": 0.80, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Ms State Emplo", "plan_name": "401457_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Basic Pl", "plan_name": "400100", "standard_charge_percentage": 0.85, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Basic Pl", "plan_name": "400100_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Federal", "plan_name": "400110", "standard_charge_percentage": 0.85, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Federal", "plan_name": "400110_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." } ] } ] }, { "description": "Ofloxacin 0.3 % eye drops [19746]", "drug_information": { "unit": 5.00, "type": "ML" }, "code_information": [ { "code": "17478-713-10", "type": "NDC" } ], "standard_charges": [ { "gross_charge": 79.56, "minimum": 63.65, "maximum": 67.63, "setting": "both", "payers_information": [ { "payer_name": "Aetna", "plan_name": "700700", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna", 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"701720_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Ms State Emplo", "plan_name": "401457", "standard_charge_percentage": 0.80, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Ms State Emplo", "plan_name": "401457_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Basic Pl", "plan_name": "400100", "standard_charge_percentage": 0.85, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Basic Pl", "plan_name": "400100_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Federal", "plan_name": "400110", "standard_charge_percentage": 0.85, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Federal", "plan_name": "400110_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." } ] } ] }, { "description": "Ofloxacin 0.3 % eye drops [19746]", "drug_information": { "unit": 10.00, "type": "ML" }, "code_information": [ { "code": "17478-713-11", "type": "NDC" } ], "standard_charges": [ { "gross_charge": 153.43, "minimum": 122.74, "maximum": 130.42, "setting": "both", "payers_information": [ { "payer_name": "Aetna", "plan_name": "700700", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna", "plan_name": "700700_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Miscellaneous", "plan_name": "700720", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Miscellaneous", "plan_name": "700720_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Ppo Hmo", "plan_name": "701720", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Ppo Hmo", "plan_name": "701720_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Ms State Emplo", "plan_name": "401457", "standard_charge_percentage": 0.80, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Ms State Emplo", "plan_name": "401457_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Basic Pl", "plan_name": "400100", "standard_charge_percentage": 0.85, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Basic Pl", "plan_name": "400100_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Federal", "plan_name": "400110", "standard_charge_percentage": 0.85, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Federal", "plan_name": "400110_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." } ] } ] }, { "description": "Ketotifen 0.025 % (0.035 %) eye drops [25471]", "drug_information": { "unit": 5.00, "type": "ML" }, "code_information": [ { "code": "17478-717-10", "type": "NDC" } ], "standard_charges": [ { "gross_charge": 43.42, "minimum": 34.74, "maximum": 36.91, "setting": "both", "payers_information": [ { "payer_name": "Aetna", "plan_name": "700700", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna", "plan_name": "700700_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Miscellaneous", "plan_name": "700720", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Miscellaneous", "plan_name": "700720_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Ppo Hmo", "plan_name": "701720", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Ppo Hmo", "plan_name": "701720_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Ms State Emplo", "plan_name": "401457", "standard_charge_percentage": 0.80, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Ms State Emplo", "plan_name": "401457_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Basic Pl", "plan_name": "400100", "standard_charge_percentage": 0.85, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Basic Pl", "plan_name": "400100_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Federal", "plan_name": "400110", "standard_charge_percentage": 0.85, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Federal", "plan_name": "400110_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." } ] } ] }, { "description": "Ferrous gluconate 324 mg (37.5 mg iron) tablet [152027]", "drug_information": { "unit": 1.00, "type": "EA" }, "code_information": [ { "code": "2055501900", "type": "NDC" } ], "standard_charges": [ { "gross_charge": 7.50, "minimum": 6.00, "maximum": 6.38, "setting": "both", "payers_information": [ { "payer_name": "Aetna", "plan_name": "700700", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna", "plan_name": "700700_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Miscellaneous", "plan_name": "700720", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Miscellaneous", "plan_name": "700720_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Ppo Hmo", "plan_name": "701720", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Ppo Hmo", "plan_name": "701720_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Ms State Emplo", "plan_name": "401457", "standard_charge_percentage": 0.80, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Ms State Emplo", "plan_name": "401457_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Basic Pl", "plan_name": "400100", "standard_charge_percentage": 0.85, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Basic Pl", "plan_name": "400100_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Federal", "plan_name": "400110", "standard_charge_percentage": 0.85, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Federal", "plan_name": "400110_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." } ] } ] }, { "description": "Cholecalciferol (vitamin d3) 25 mcg (1000 unit) tablet [82639]", "drug_information": { "unit": 1.00, "type": "EA" }, "code_information": [ { "code": "2055503300", "type": "NDC" } ], "standard_charges": [ { "gross_charge": 1.00, "minimum": 0.80, "maximum": 0.85, "setting": "both", "payers_information": [ { "payer_name": "Aetna", "plan_name": "700700", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna", "plan_name": "700700_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Miscellaneous", "plan_name": "700720", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Miscellaneous", "plan_name": "700720_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Ppo Hmo", "plan_name": "701720", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Ppo Hmo", "plan_name": "701720_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Ms State Emplo", "plan_name": "401457", "standard_charge_percentage": 0.80, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Ms State Emplo", "plan_name": "401457_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Basic Pl", "plan_name": "400100", "standard_charge_percentage": 0.85, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Basic Pl", "plan_name": "400100_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Federal", "plan_name": "400110", "standard_charge_percentage": 0.85, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Federal", "plan_name": "400110_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." } ] } ] }, { "description": "Melatonin 3 mg tablet [16830]", "drug_information": { "unit": 1.00, "type": "EA" }, "code_information": [ { "code": "2055503601", "type": "NDC" } ], "standard_charges": [ { "gross_charge": 1.00, "minimum": 0.80, "maximum": 0.85, "setting": "both", "payers_information": [ { "payer_name": "Aetna", "plan_name": "700700", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna", "plan_name": "700700_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Miscellaneous", "plan_name": "700720", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Miscellaneous", "plan_name": "700720_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Ppo Hmo", "plan_name": "701720", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Ppo Hmo", "plan_name": "701720_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Ms State Emplo", "plan_name": "401457", "standard_charge_percentage": 0.80, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Ms State Emplo", "plan_name": "401457_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Basic Pl", "plan_name": "400100", "standard_charge_percentage": 0.85, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Basic Pl", "plan_name": "400100_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Federal", "plan_name": "400110", "standard_charge_percentage": 0.85, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Federal", "plan_name": "400110_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." } ] } ] }, { "description": "Glucose 4 gram chewable tablet [16050]", "drug_information": { "unit": 1.00, "type": "EA" }, "code_information": [ { "code": "2129200431", "type": "NDC" } ], "standard_charges": [ { "gross_charge": 1.00, "minimum": 0.80, "maximum": 0.85, "setting": "both", "payers_information": [ { "payer_name": "Aetna", "plan_name": "700700", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna", "plan_name": "700700_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Miscellaneous", "plan_name": "700720", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Miscellaneous", "plan_name": "700720_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Ppo Hmo", "plan_name": "701720", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Ppo Hmo", "plan_name": "701720_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Ms State Emplo", "plan_name": "401457", "standard_charge_percentage": 0.80, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Ms State Emplo", "plan_name": "401457_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Basic Pl", "plan_name": "400100", "standard_charge_percentage": 0.85, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Basic Pl", "plan_name": "400100_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Federal", "plan_name": "400110", "standard_charge_percentage": 0.85, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Federal", "plan_name": "400110_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." } ] } ] }, { "description": "Clobetasol 0.05 % topical ointment [9631]", "drug_information": { "unit": 30.00, "type": "GR" }, "code_information": [ { "code": "21922-017-05", "type": "NDC" } ], "standard_charges": [ { "gross_charge": 76.95, "minimum": 61.56, "maximum": 65.41, "setting": "both", "payers_information": [ { "payer_name": "Aetna", "plan_name": "700700", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna", "plan_name": "700700_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Miscellaneous", "plan_name": "700720", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Miscellaneous", "plan_name": "700720_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Ppo Hmo", "plan_name": "701720", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Ppo Hmo", "plan_name": "701720_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Ms State Emplo", "plan_name": "401457", "standard_charge_percentage": 0.80, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Ms State Emplo", "plan_name": "401457_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Basic Pl", "plan_name": "400100", "standard_charge_percentage": 0.85, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Basic Pl", "plan_name": "400100_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Federal", "plan_name": "400110", "standard_charge_percentage": 0.85, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Federal", "plan_name": "400110_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." } ] } ] }, { "description": "Permethrin 5 % topical cream [10917]", "drug_information": { "unit": 60.00, "type": "GR" }, "code_information": [ { "code": "21922-021-07", "type": "NDC" } ], "standard_charges": [ { "gross_charge": 209.48, "minimum": 167.58, "maximum": 178.06, "setting": "both", "payers_information": [ { "payer_name": "Aetna", "plan_name": "700700", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna", "plan_name": "700700_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Miscellaneous", "plan_name": "700720", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Miscellaneous", "plan_name": "700720_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Ppo Hmo", "plan_name": "701720", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Ppo Hmo", "plan_name": "701720_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Ms State Emplo", "plan_name": "401457", "standard_charge_percentage": 0.80, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Ms State Emplo", "plan_name": "401457_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Basic Pl", "plan_name": "400100", "standard_charge_percentage": 0.85, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Basic Pl", "plan_name": "400100_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Federal", "plan_name": "400110", "standard_charge_percentage": 0.85, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Federal", "plan_name": "400110_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." } ] } ] }, { "description": "Ketoconazole 2 % topical cream [10368]", "drug_information": { "unit": 30.00, "type": "GR" }, "code_information": [ { "code": "21922-025-05", "type": "NDC" } ], "standard_charges": [ { "gross_charge": 144.78, "minimum": 115.82, "maximum": 123.06, "setting": "both", "payers_information": [ { "payer_name": "Aetna", "plan_name": "700700", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna", "plan_name": "700700_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Miscellaneous", "plan_name": "700720", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Miscellaneous", "plan_name": "700720_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Ppo Hmo", "plan_name": "701720", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Ppo Hmo", "plan_name": "701720_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Ms State Emplo", "plan_name": "401457", "standard_charge_percentage": 0.80, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Ms State Emplo", "plan_name": "401457_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Basic Pl", "plan_name": "400100", "standard_charge_percentage": 0.85, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Basic Pl", "plan_name": "400100_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Federal", "plan_name": "400110", "standard_charge_percentage": 0.85, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Federal", "plan_name": "400110_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." } ] } ] }, { "description": "Triamcinolone acetonide 0.1 % topical cream [8113]", "drug_information": { "unit": 80.00, "type": "GR" }, "code_information": [ { "code": "21922-062-15", "type": "NDC" } ], "standard_charges": [ { "gross_charge": 28.12, "minimum": 22.50, "maximum": 23.90, "setting": "both", "payers_information": [ { "payer_name": "Aetna", "plan_name": "700700", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna", "plan_name": "700700_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Miscellaneous", "plan_name": "700720", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Miscellaneous", "plan_name": "700720_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Ppo Hmo", "plan_name": "701720", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Ppo Hmo", "plan_name": "701720_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Ms State Emplo", "plan_name": "401457", "standard_charge_percentage": 0.80, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Ms State Emplo", "plan_name": "401457_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Basic Pl", "plan_name": "400100", "standard_charge_percentage": 0.85, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Basic Pl", "plan_name": "400100_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Federal", "plan_name": "400110", "standard_charge_percentage": 0.85, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Federal", "plan_name": "400110_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." } ] } ] }, { "description": "Verapamil 80 mg tablet [8530]", "drug_information": { "unit": 1.00, "type": "EA" }, "code_information": [ { "code": "23155-026-01", "type": "NDC" } ], "standard_charges": [ { "gross_charge": 7.50, "minimum": 6.00, "maximum": 6.38, "setting": "both", "payers_information": [ { "payer_name": "Aetna", "plan_name": "700700", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna", "plan_name": "700700_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Miscellaneous", "plan_name": "700720", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Miscellaneous", "plan_name": "700720_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Ppo Hmo", "plan_name": "701720", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Ppo Hmo", "plan_name": "701720_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Ms State Emplo", "plan_name": "401457", "standard_charge_percentage": 0.80, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Ms State Emplo", "plan_name": "401457_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Basic Pl", "plan_name": "400100", "standard_charge_percentage": 0.85, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Basic Pl", "plan_name": "400100_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Federal", "plan_name": "400110", "standard_charge_percentage": 0.85, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Federal", "plan_name": "400110_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." } ] } ] }, { "description": "Fluoxetine 10 mg capsule [10069]", "drug_information": { "unit": 1.00, "type": "EA" }, "code_information": [ { "code": "23155-028-01", "type": "NDC" } ], "standard_charges": [ { "gross_charge": 7.50, "minimum": 6.00, "maximum": 6.38, "setting": "both", "payers_information": [ { "payer_name": "Aetna", "plan_name": "700700", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna", "plan_name": "700700_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Miscellaneous", "plan_name": "700720", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Miscellaneous", "plan_name": "700720_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Ppo Hmo", "plan_name": "701720", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Ppo Hmo", "plan_name": "701720_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Ms State Emplo", "plan_name": "401457", "standard_charge_percentage": 0.80, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Ms State Emplo", "plan_name": "401457_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Basic Pl", "plan_name": "400100", "standard_charge_percentage": 0.85, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Basic Pl", "plan_name": "400100_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Federal", "plan_name": "400110", "standard_charge_percentage": 0.85, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Federal", "plan_name": "400110_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." } ] } ] }, { "description": "Diltiazem 5 mg/ml intravenous solution [9869]", "drug_information": { "unit": 10.00, "type": "ML" }, "code_information": [ { "code": "17478-937-10", "type": "NDC" } ], "standard_charges": [ { "gross_charge": 14.60, "minimum": 11.68, "maximum": 12.41, "setting": "both", "payers_information": [ { "payer_name": "Aetna", "plan_name": "700700", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna", "plan_name": "700700_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Miscellaneous", "plan_name": "700720", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Miscellaneous", "plan_name": "700720_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Ppo Hmo", "plan_name": "701720", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Ppo Hmo", "plan_name": "701720_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Ms State Emplo", "plan_name": "401457", "standard_charge_percentage": 0.80, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Ms State Emplo", "plan_name": "401457_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Basic Pl", "plan_name": "400100", "standard_charge_percentage": 0.85, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Basic Pl", "plan_name": "400100_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Federal", "plan_name": "400110", "standard_charge_percentage": 0.85, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Federal", "plan_name": "400110_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." } ] } ] }, { "description": "Benzocaine 15 mg-menthol 2.6 mg lozenges [152102]", "drug_information": { "unit": 1.00, "type": "EA" }, "code_information": [ { "code": "17856-0732-1", "type": "NDC" } ], "standard_charges": [ { "gross_charge": 1.98, "minimum": 1.58, "maximum": 1.68, "setting": "both", "payers_information": [ { "payer_name": "Aetna", "plan_name": "700700", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna", "plan_name": "700700_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Miscellaneous", "plan_name": "700720", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Miscellaneous", "plan_name": "700720_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Ppo Hmo", "plan_name": "701720", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Ppo Hmo", "plan_name": "701720_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Ms State Emplo", "plan_name": "401457", "standard_charge_percentage": 0.80, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Ms State Emplo", "plan_name": "401457_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Basic Pl", "plan_name": "400100", "standard_charge_percentage": 0.85, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Basic Pl", "plan_name": "400100_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Federal", "plan_name": "400110", "standard_charge_percentage": 0.85, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Federal", "plan_name": "400110_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." } ] } ] }, { "description": "Sodium chloride 5 % eye drops [7332]", "drug_information": { "unit": 15.00, "type": "ML" }, "code_information": [ { "code": "24208-277-15", "type": "NDC" } ], "standard_charges": [ { "gross_charge": 103.60, "minimum": 82.88, "maximum": 88.06, "setting": "both", "payers_information": [ { "payer_name": "Aetna", "plan_name": "700700", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna", "plan_name": "700700_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Miscellaneous", "plan_name": "700720", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Miscellaneous", "plan_name": "700720_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Ppo Hmo", "plan_name": "701720", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Ppo Hmo", "plan_name": "701720_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Ms State Emplo", "plan_name": "401457", "standard_charge_percentage": 0.80, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Ms State Emplo", "plan_name": "401457_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Basic Pl", "plan_name": "400100", "standard_charge_percentage": 0.85, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Basic Pl", "plan_name": "400100_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Federal", "plan_name": "400110", "standard_charge_percentage": 0.85, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Federal", "plan_name": "400110_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." } ] } ] }, { "description": "Tobramycin 0.3 % eye drops [7995]", "drug_information": { "unit": 5.00, "type": "ML" }, "code_information": [ { "code": "24208-290-05", "type": "NDC" } ], "standard_charges": [ { "gross_charge": 71.82, "minimum": 57.46, "maximum": 61.05, "setting": "both", "payers_information": [ { "payer_name": "Aetna", "plan_name": "700700", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna", "plan_name": "700700_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Miscellaneous", "plan_name": "700720", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Miscellaneous", "plan_name": "700720_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Ppo Hmo", "plan_name": "701720", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Ppo Hmo", "plan_name": "701720_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Ms State Emplo", "plan_name": "401457", "standard_charge_percentage": 0.80, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Ms State Emplo", "plan_name": "401457_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Basic Pl", "plan_name": "400100", "standard_charge_percentage": 0.85, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Basic Pl", "plan_name": "400100_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Federal", "plan_name": "400110", "standard_charge_percentage": 0.85, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Federal", "plan_name": "400110_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." } ] } ] }, { "description": "Polymyxin b sulfate 10000 unit-trimethoprim 1 mg/ml eye drops [109275]", "drug_information": { "unit": 10.00, "type": "ML" }, "code_information": [ { "code": "24208-315-10", "type": "NDC" } ], "standard_charges": [ { "gross_charge": 63.79, "minimum": 51.03, "maximum": 54.22, "setting": "both", "payers_information": [ { "payer_name": "Aetna", "plan_name": "700700", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna", "plan_name": "700700_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Miscellaneous", "plan_name": "700720", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Miscellaneous", "plan_name": "700720_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Ppo Hmo", "plan_name": "701720", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Ppo Hmo", "plan_name": "701720_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Ms State Emplo", "plan_name": "401457", "standard_charge_percentage": 0.80, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Ms State Emplo", "plan_name": "401457_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Basic Pl", "plan_name": "400100", "standard_charge_percentage": 0.85, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Basic Pl", "plan_name": "400100_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Federal", "plan_name": "400110", "standard_charge_percentage": 0.85, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Federal", "plan_name": "400110_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." } ] } ] }, { "description": "Desmopressin 10 mcg/spray (0.1 ml) nasal spray [27770]", "drug_information": { "unit": 5.00, "type": "ML" }, "code_information": [ { "code": "24208-342-05", "type": "NDC" } ], "standard_charges": [ { "gross_charge": 1145.99, "minimum": 916.79, "maximum": 974.09, "setting": "both", "payers_information": [ { "payer_name": "Aetna", "plan_name": "700700", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna", "plan_name": "700700_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Miscellaneous", "plan_name": "700720", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Miscellaneous", "plan_name": "700720_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Ppo Hmo", "plan_name": "701720", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Ppo Hmo", "plan_name": "701720_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Ms State Emplo", "plan_name": "401457", "standard_charge_percentage": 0.80, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Ms State Emplo", "plan_name": "401457_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Basic Pl", "plan_name": "400100", "standard_charge_percentage": 0.85, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Basic Pl", "plan_name": "400100_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Federal", "plan_name": "400110", "standard_charge_percentage": 0.85, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Federal", "plan_name": "400110_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." } ] } ] }, { "description": "Ipratropium bromide 21 mcg (0.03 %) nasal spray [16070]", "drug_information": { "unit": 30.00, "type": "ML" }, "code_information": [ { "code": "24208-398-30", "type": "NDC" } ], "standard_charges": [ { "gross_charge": 216.74, "minimum": 173.39, "maximum": 184.23, "setting": "both", "payers_information": [ { "payer_name": "Aetna", "plan_name": "700700", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna", "plan_name": "700700_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Miscellaneous", "plan_name": "700720", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Miscellaneous", "plan_name": "700720_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Ppo Hmo", "plan_name": "701720", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Ppo Hmo", "plan_name": "701720_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Ms State Emplo", "plan_name": "401457", "standard_charge_percentage": 0.80, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Ms State Emplo", "plan_name": "401457_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Basic Pl", "plan_name": "400100", "standard_charge_percentage": 0.85, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Basic Pl", "plan_name": "400100_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Federal", "plan_name": "400110", "standard_charge_percentage": 0.85, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Federal", "plan_name": "400110_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." } ] } ] }, { "description": "Ipratropium bromide 42 mcg (0.06 %) nasal spray [16071]", "drug_information": { "unit": 15.00, "type": "ML" }, "code_information": [ { "code": "24208-399-15", "type": "NDC" } ], "standard_charges": [ { "gross_charge": 216.67, "minimum": 173.34, "maximum": 184.17, "setting": "both", "payers_information": [ { "payer_name": "Aetna", "plan_name": "700700", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna", "plan_name": "700700_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Miscellaneous", "plan_name": "700720", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Miscellaneous", "plan_name": "700720_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Ppo Hmo", "plan_name": "701720", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Ppo Hmo", "plan_name": "701720_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Ms State Emplo", "plan_name": "401457", "standard_charge_percentage": 0.80, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Ms State Emplo", "plan_name": "401457_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Basic Pl", "plan_name": "400100", "standard_charge_percentage": 0.85, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Basic Pl", "plan_name": "400100_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Federal", "plan_name": "400110", "standard_charge_percentage": 0.85, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Federal", "plan_name": "400110_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." } ] } ] }, { "description": "Brimonidine 0.2 % eye drops [17881]", "drug_information": { "unit": 5.00, "type": "ML" }, "code_information": [ { "code": "24208-411-05", "type": "NDC" } ], "standard_charges": [ { "gross_charge": 86.07, "minimum": 68.86, "maximum": 73.16, "setting": "both", "payers_information": [ { "payer_name": "Aetna", "plan_name": "700700", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna", "plan_name": "700700_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Miscellaneous", "plan_name": "700720", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Miscellaneous", "plan_name": "700720_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Ppo Hmo", "plan_name": "701720", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Ppo Hmo", "plan_name": "701720_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Ms State Emplo", "plan_name": "401457", "standard_charge_percentage": 0.80, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Ms State Emplo", "plan_name": "401457_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Basic Pl", "plan_name": "400100", "standard_charge_percentage": 0.85, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Basic Pl", "plan_name": "400100_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Federal", "plan_name": "400110", "standard_charge_percentage": 0.85, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Federal", "plan_name": "400110_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." } ] } ] }, { "description": "Latanoprost 0.005 % eye drops [18621]", "drug_information": { "unit": 2.50, "type": "ML" }, "code_information": [ { "code": "24208-463-25", "type": "NDC" } ], "standard_charges": [ { "gross_charge": 115.76, "minimum": 92.61, "maximum": 98.40, "setting": "both", "payers_information": [ { "payer_name": "Aetna", "plan_name": "700700", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna", "plan_name": "700700_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Miscellaneous", "plan_name": "700720", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Miscellaneous", "plan_name": "700720_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Ppo Hmo", "plan_name": "701720", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Ppo Hmo", "plan_name": "701720_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Ms State Emplo", "plan_name": "401457", "standard_charge_percentage": 0.80, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Ms State Emplo", "plan_name": "401457_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Basic Pl", "plan_name": "400100", "standard_charge_percentage": 0.85, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Basic Pl", "plan_name": "400100_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Federal", "plan_name": "400110", "standard_charge_percentage": 0.85, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Federal", "plan_name": "400110_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." } ] } ] }, { "description": "Dorzolamide 2 % eye drops [14471]", "drug_information": { "unit": 10.00, "type": "ML" }, "code_information": [ { "code": "24208-485-10", "type": "NDC" } ], "standard_charges": [ { "gross_charge": 217.93, "minimum": 174.34, "maximum": 185.24, "setting": "both", "payers_information": [ { "payer_name": "Aetna", "plan_name": "700700", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna", "plan_name": "700700_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Miscellaneous", "plan_name": "700720", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Miscellaneous", "plan_name": "700720_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Ppo Hmo", "plan_name": "701720", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Ppo Hmo", "plan_name": "701720_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Ms State Emplo", "plan_name": "401457", "standard_charge_percentage": 0.80, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Ms State Emplo", "plan_name": "401457_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Basic Pl", "plan_name": "400100", "standard_charge_percentage": 0.85, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Basic Pl", "plan_name": "400100_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Federal", "plan_name": "400110", "standard_charge_percentage": 0.85, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Federal", "plan_name": "400110_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." } ] } ] }, { "description": "Dorzolamide 22.3 mg-timolol 6.8 mg/ml eye drops [22982]", "drug_information": { "unit": 10.00, "type": "ML" }, "code_information": [ { "code": "24208-486-10", "type": "NDC" } ], "standard_charges": [ { "gross_charge": 320.53, "minimum": 256.42, "maximum": 272.45, "setting": "both", "payers_information": [ { "payer_name": "Aetna", "plan_name": "700700", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna", "plan_name": "700700_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Miscellaneous", "plan_name": "700720", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Miscellaneous", "plan_name": "700720_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Ppo Hmo", "plan_name": "701720", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Ppo Hmo", "plan_name": "701720_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Ms State Emplo", "plan_name": "401457", "standard_charge_percentage": 0.80, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Ms State Emplo", "plan_name": "401457_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Basic Pl", "plan_name": "400100", "standard_charge_percentage": 0.85, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Basic Pl", "plan_name": "400100_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Federal", "plan_name": "400110", "standard_charge_percentage": 0.85, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Federal", "plan_name": "400110_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." } ] } ] }, { "description": "Acetylcholine chloride 1 % (10 mg/ml) intraocular kit [32559]", "drug_information": { "unit": 1.00, "type": "EA" }, "code_information": [ { "code": "24208-539-20", "type": "NDC" } ], "standard_charges": [ { "gross_charge": 605.00, "minimum": 484.00, "maximum": 514.25, "setting": "both", "payers_information": [ { "payer_name": "Aetna", "plan_name": "700700", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna", "plan_name": "700700_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Miscellaneous", "plan_name": "700720", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Miscellaneous", "plan_name": "700720_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Ppo Hmo", "plan_name": "701720", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Ppo Hmo", "plan_name": "701720_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Ms State Emplo", "plan_name": "401457", "standard_charge_percentage": 0.80, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Ms State Emplo", "plan_name": "401457_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Basic Pl", "plan_name": "400100", "standard_charge_percentage": 0.85, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Basic Pl", "plan_name": "400100_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Federal", "plan_name": "400110", "standard_charge_percentage": 0.85, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Federal", "plan_name": "400110_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." } ] } ] }, { "description": "Gentamicin 0.3 % eye drops [3428]", "drug_information": { "unit": 5.00, "type": "ML" }, "code_information": [ { "code": "24208-580-60", "type": "NDC" } ], "standard_charges": [ { "gross_charge": 206.91, "minimum": 165.53, "maximum": 175.87, "setting": "both", "payers_information": [ { "payer_name": "Aetna", "plan_name": "700700", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna", "plan_name": "700700_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Miscellaneous", "plan_name": "700720", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Miscellaneous", "plan_name": "700720_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Ppo Hmo", "plan_name": "701720", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Ppo Hmo", "plan_name": "701720_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Ms State Emplo", "plan_name": "401457", "standard_charge_percentage": 0.80, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Ms State Emplo", "plan_name": "401457_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Basic Pl", "plan_name": "400100", "standard_charge_percentage": 0.85, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Basic Pl", "plan_name": "400100_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Federal", "plan_name": "400110", "standard_charge_percentage": 0.85, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Federal", "plan_name": "400110_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." } ] } ] }, { "description": "Tropicamide 1 % eye drops [8250]", "drug_information": { "unit": 15.00, "type": "ML" }, "code_information": [ { "code": "24208-585-64", "type": "NDC" } ], "standard_charges": [ { "gross_charge": 142.50, "minimum": 114.00, "maximum": 121.13, "setting": "both", "payers_information": [ { "payer_name": "Aetna", "plan_name": "700700", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna", "plan_name": "700700_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Miscellaneous", "plan_name": "700720", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Miscellaneous", "plan_name": "700720_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Ppo Hmo", "plan_name": "701720", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Ppo Hmo", "plan_name": "701720_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Ms State Emplo", "plan_name": "401457", "standard_charge_percentage": 0.80, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Ms State Emplo", "plan_name": "401457_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Basic Pl", "plan_name": "400100", "standard_charge_percentage": 0.85, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Basic Pl", "plan_name": "400100_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Federal", "plan_name": "400110", "standard_charge_percentage": 0.85, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Federal", "plan_name": "400110_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." } ] } ] }, { "description": "Neomycin-polymyxin-hydrocort 3.5 mg/ml-10000 unit/ml-1 % ear solution [34814]", "drug_information": { "unit": 10.00, "type": "ML" }, "code_information": [ { "code": "24208-631-10", "type": "NDC" } ], "standard_charges": [ { "gross_charge": 486.16, "minimum": 388.93, "maximum": 413.24, "setting": "both", "payers_information": [ { "payer_name": "Aetna", "plan_name": "700700", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna", "plan_name": "700700_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Miscellaneous", "plan_name": "700720", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Miscellaneous", "plan_name": "700720_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Ppo Hmo", "plan_name": "701720", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Ppo Hmo", "plan_name": "701720_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Ms State Emplo", "plan_name": "401457", "standard_charge_percentage": 0.80, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Ms State Emplo", "plan_name": "401457_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Basic Pl", "plan_name": "400100", "standard_charge_percentage": 0.85, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Basic Pl", "plan_name": "400100_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Federal", "plan_name": "400110", "standard_charge_percentage": 0.85, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Federal", "plan_name": "400110_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." } ] } ] }, { "description": "Neomycin-polymyxin-hydrocort 3.5 mg-10000 unit/ml-1 % ear dropssusp [28810]", "drug_information": { "unit": 10.00, "type": "ML" }, "code_information": [ { "code": "24208-635-62", "type": "NDC" } ], "standard_charges": [ { "gross_charge": 486.16, "minimum": 388.93, "maximum": 413.24, "setting": "both", "payers_information": [ { "payer_name": "Aetna", "plan_name": "700700", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna", "plan_name": "700700_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Miscellaneous", "plan_name": "700720", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Miscellaneous", "plan_name": "700720_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Ppo Hmo", "plan_name": "701720", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Ppo Hmo", "plan_name": "701720_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Ms State Emplo", "plan_name": "401457", "standard_charge_percentage": 0.80, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Ms State Emplo", "plan_name": "401457_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Basic Pl", "plan_name": "400100", "standard_charge_percentage": 0.85, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Basic Pl", "plan_name": "400100_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Federal", "plan_name": "400110", "standard_charge_percentage": 0.85, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Federal", "plan_name": "400110_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." } ] } ] }, { "description": "Dexamethasone sodium phosphate 0.1 % eye drops [2335]", "drug_information": { "unit": 5.00, "type": "ML" }, "code_information": [ { "code": "24208-720-02", "type": "NDC" } ], "standard_charges": [ { "gross_charge": 285.95, "minimum": 228.76, "maximum": 243.06, "setting": "both", "payers_information": [ { "payer_name": "Aetna", "plan_name": "700700", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna", "plan_name": "700700_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Miscellaneous", "plan_name": "700720", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Miscellaneous", "plan_name": "700720_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Ppo Hmo", "plan_name": "701720", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Ppo Hmo", "plan_name": "701720_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Ms State Emplo", "plan_name": "401457", "standard_charge_percentage": 0.80, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Ms State Emplo", "plan_name": "401457_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Basic Pl", "plan_name": "400100", "standard_charge_percentage": 0.85, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Basic Pl", "plan_name": "400100_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Federal", "plan_name": "400110", "standard_charge_percentage": 0.85, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Federal", "plan_name": "400110_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." } ] } ] }, { "description": "Proparacaine 0.5 % eye drops [6644]", "drug_information": { "unit": 15.00, "type": "ML" }, "code_information": [ { "code": "24208-730-06", "type": "NDC" } ], "standard_charges": [ { "gross_charge": 209.97, "minimum": 167.98, "maximum": 178.47, "setting": "both", "payers_information": [ { "payer_name": "Aetna", "plan_name": "700700", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna", "plan_name": "700700_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Miscellaneous", "plan_name": "700720", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Miscellaneous", "plan_name": "700720_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Ppo Hmo", "plan_name": "701720", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Ppo Hmo", "plan_name": "701720_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Ms State Emplo", "plan_name": "401457", "standard_charge_percentage": 0.80, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Ms State Emplo", "plan_name": "401457_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Basic Pl", "plan_name": "400100", "standard_charge_percentage": 0.85, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Basic Pl", "plan_name": "400100_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Federal", "plan_name": "400110", "standard_charge_percentage": 0.85, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Federal", "plan_name": "400110_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." } ] } ] }, { "description": "Cyclopentolate 1 % eye drops [2025]", "drug_information": { "unit": 2.00, "type": "ML" }, "code_information": [ { "code": "24208-735-01", "type": "NDC" } ], "standard_charges": [ { "gross_charge": 70.06, "minimum": 56.05, "maximum": 59.55, "setting": "both", "payers_information": [ { "payer_name": "Aetna", "plan_name": "700700", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna", "plan_name": "700700_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Miscellaneous", "plan_name": "700720", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Miscellaneous", "plan_name": "700720_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Ppo Hmo", "plan_name": "701720", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Ppo Hmo", "plan_name": "701720_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Ms State Emplo", "plan_name": "401457", "standard_charge_percentage": 0.80, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Ms State Emplo", "plan_name": "401457_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Basic Pl", "plan_name": "400100", "standard_charge_percentage": 0.85, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Basic Pl", "plan_name": "400100_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Federal", "plan_name": "400110", "standard_charge_percentage": 0.85, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Federal", "plan_name": "400110_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." } ] } ] }, { "description": "Cyclopentolate 1 % eye drops [2025]", "drug_information": { "unit": 15.00, "type": "ML" }, "code_information": [ { "code": "24208-735-06", "type": "NDC" } ], "standard_charges": [ { "gross_charge": 164.23, "minimum": 131.38, "maximum": 139.60, "setting": "both", "payers_information": [ { "payer_name": "Aetna", "plan_name": "700700", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna", "plan_name": "700700_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Miscellaneous", "plan_name": "700720", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Miscellaneous", "plan_name": "700720_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Ppo Hmo", "plan_name": "701720", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Ppo Hmo", "plan_name": "701720_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Ms State Emplo", "plan_name": "401457", "standard_charge_percentage": 0.80, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Ms State Emplo", "plan_name": "401457_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Basic Pl", "plan_name": "400100", "standard_charge_percentage": 0.85, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Basic Pl", "plan_name": "400100_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Federal", "plan_name": "400110", "standard_charge_percentage": 0.85, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Federal", "plan_name": "400110_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." } ] } ] }, { "description": "Neomycin-bacitracin-polymyxn 3.5 mg-400 unit-10000 unit/gram eye oint [38701]", "drug_information": { "unit": 3.50, "type": "GR" }, "code_information": [ { "code": "24208-780-55", "type": "NDC" } ], "standard_charges": [ { "gross_charge": 270.47, "minimum": 216.38, "maximum": 229.90, "setting": "both", "payers_information": [ { "payer_name": "Aetna", "plan_name": "700700", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna", "plan_name": "700700_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Miscellaneous", "plan_name": "700720", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Miscellaneous", "plan_name": "700720_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Ppo Hmo", "plan_name": "701720", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Ppo Hmo", "plan_name": "701720_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Ms State Emplo", "plan_name": "401457", "standard_charge_percentage": 0.80, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Ms State Emplo", "plan_name": "401457_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Basic Pl", "plan_name": "400100", "standard_charge_percentage": 0.85, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Basic Pl", "plan_name": "400100_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Federal", "plan_name": "400110", "standard_charge_percentage": 0.85, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Federal", "plan_name": "400110_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." } ] } ] }, { "description": "Neomycin 1.75 mg-polymyxin 10000 unit-gramicidin 0.025mg/ml eye drops [5474]", "drug_information": { "unit": 10.00, "type": "ML" }, "code_information": [ { "code": "24208-790-62", "type": "NDC" } ], "standard_charges": [ { "gross_charge": 319.39, "minimum": 255.51, "maximum": 271.48, "setting": "both", "payers_information": [ { "payer_name": "Aetna", "plan_name": "700700", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna", "plan_name": "700700_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Miscellaneous", "plan_name": "700720", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Miscellaneous", "plan_name": "700720_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Ppo Hmo", "plan_name": "701720", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Ppo Hmo", "plan_name": "701720_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Ms State Emplo", "plan_name": "401457", "standard_charge_percentage": 0.80, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Ms State Emplo", "plan_name": "401457_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Basic Pl", "plan_name": "400100", "standard_charge_percentage": 0.85, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Basic Pl", "plan_name": "400100_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Federal", "plan_name": "400110", "standard_charge_percentage": 0.85, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Federal", "plan_name": "400110_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." } ] } ] }, { "description": "Neomycin 3.5 mg/g-polymyxin b 10000 unit/g-dexameth 0.1 % eye oint [19495]", "drug_information": { "unit": 3.50, "type": "GR" }, "code_information": [ { "code": "24208-795-35", "type": "NDC" } ], "standard_charges": [ { "gross_charge": 127.02, "minimum": 101.62, "maximum": 107.97, "setting": "both", "payers_information": [ { "payer_name": "Aetna", "plan_name": "700700", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna", "plan_name": "700700_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Miscellaneous", "plan_name": "700720", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Miscellaneous", "plan_name": "700720_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Ppo Hmo", "plan_name": "701720", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Ppo Hmo", "plan_name": "701720_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Ms State Emplo", "plan_name": "401457", "standard_charge_percentage": 0.80, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Ms State Emplo", "plan_name": "401457_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Basic Pl", "plan_name": "400100", "standard_charge_percentage": 0.85, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Basic Pl", "plan_name": "400100_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Federal", "plan_name": "400110", "standard_charge_percentage": 0.85, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Federal", "plan_name": "400110_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." } ] } ] }, { "description": "Neomycin-polymyxin-dexameth 3.5 mg/ml-10000 unit/ml-0.1% eye drops [10708]", "drug_information": { "unit": 5.00, "type": "ML" }, "code_information": [ { "code": "24208-830-60", "type": "NDC" } ], "standard_charges": [ { "gross_charge": 115.43, "minimum": 92.34, "maximum": 98.12, "setting": "both", "payers_information": [ { "payer_name": "Aetna", "plan_name": "700700", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna", "plan_name": "700700_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Miscellaneous", "plan_name": "700720", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Miscellaneous", "plan_name": "700720_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Ppo Hmo", "plan_name": "701720", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Ppo Hmo", "plan_name": "701720_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Ms State Emplo", "plan_name": "401457", "standard_charge_percentage": 0.80, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Ms State Emplo", "plan_name": "401457_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Basic Pl", "plan_name": "400100", "standard_charge_percentage": 0.85, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Basic Pl", "plan_name": "400100_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Federal", "plan_name": "400110", "standard_charge_percentage": 0.85, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Federal", "plan_name": "400110_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." } ] } ] }, { "description": "Erythromycin 5 mg/gram (0.5 %) eye ointment [2888]", "drug_information": { "unit": 1.00, "type": "GR" }, "code_information": [ { "code": "24208-910-19", "type": "NDC" } ], "standard_charges": [ { "gross_charge": 175.74, "minimum": 140.59, "maximum": 149.38, "setting": "both", "payers_information": [ { "payer_name": "Aetna", "plan_name": "700700", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna", "plan_name": "700700_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Miscellaneous", "plan_name": "700720", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Miscellaneous", "plan_name": "700720_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Ppo Hmo", "plan_name": "701720", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Ppo Hmo", "plan_name": "701720_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Ms State Emplo", "plan_name": "401457", "standard_charge_percentage": 0.80, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Ms State Emplo", "plan_name": "401457_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Basic Pl", "plan_name": "400100", "standard_charge_percentage": 0.85, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Basic Pl", "plan_name": "400100_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Federal", "plan_name": "400110", "standard_charge_percentage": 0.85, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Federal", "plan_name": "400110_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." } ] } ] }, { "description": "Erythromycin 5 mg/gram (0.5 %) eye ointment [2888]", "drug_information": { "unit": 3.50, "type": "GR" }, "code_information": [ { "code": "24208-910-55", "type": "NDC" } ], "standard_charges": [ { "gross_charge": 90.21, "minimum": 72.17, "maximum": 76.68, "setting": "both", 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"payer_name": "Bc/Bs Of Ms Basic Pl", "plan_name": "400100", "standard_charge_percentage": 0.85, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Basic Pl", "plan_name": "400100_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Federal", "plan_name": "400110", "standard_charge_percentage": 0.85, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Federal", "plan_name": "400110_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." } ] } ] }, { "description": "Camphor-eucalyptus oil-menthol 4.8 %-1.2 %-2.6 % topical ointment [76967]", "drug_information": { "unit": 50.00, "type": "GR" }, "code_information": [ { "code": "2390000361", "type": "NDC" } ], "standard_charges": [ { "gross_charge": 9.88, "minimum": 7.90, "maximum": 8.40, "setting": "both", "payers_information": [ { "payer_name": "Aetna", "plan_name": "700700", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna", "plan_name": "700700_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Miscellaneous", "plan_name": "700720", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": 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remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Federal", "plan_name": "400110_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." } ] } ] }, { "description": "Eucalyptus oil-aloe extr-lavenderrosemary oil-petrolatum top ointment [9125]", "drug_information": { "unit": 50.00, "type": "GR" }, "code_information": [ { "code": "2390000617", "type": "NDC" } ], "standard_charges": [ { "gross_charge": 14.69, "minimum": 11.75, "maximum": 12.49, "setting": "both", "payers_information": [ { "payer_name": "Aetna", "plan_name": "700700", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna", "plan_name": "700700_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": 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"percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Ppo Hmo", "plan_name": "701720_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Ms State Emplo", "plan_name": "401457", "standard_charge_percentage": 0.80, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Ms State Emplo", "plan_name": "401457_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Basic Pl", "plan_name": "400100", "standard_charge_percentage": 0.85, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Basic Pl", "plan_name": "400100_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Federal", "plan_name": "400110", "standard_charge_percentage": 0.85, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Federal", "plan_name": "400110_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." } ] } ] }, { "description": "Duloxetine 20 mg capsuledelayed release [39275]", "drug_information": { "unit": 1.00, "type": "EA" }, "code_information": [ { "code": "27241-097-06", "type": "NDC" } ], "standard_charges": [ { "gross_charge": 7.50, "minimum": 6.00, "maximum": 6.38, "setting": "both", "payers_information": [ { "payer_name": "Aetna", "plan_name": "700700", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna", "plan_name": "700700_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Miscellaneous", "plan_name": "700720", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Miscellaneous", "plan_name": "700720_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Ppo Hmo", "plan_name": "701720", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Ppo Hmo", "plan_name": "701720_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Ms State Emplo", "plan_name": "401457", "standard_charge_percentage": 0.80, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Ms State Emplo", "plan_name": "401457_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Basic Pl", "plan_name": "400100", "standard_charge_percentage": 0.85, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Basic Pl", "plan_name": "400100_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Federal", "plan_name": "400110", "standard_charge_percentage": 0.85, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Federal", "plan_name": "400110_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." } ] } ] }, { "description": "Duloxetine 30 mg capsuledelayed release [39276]", "drug_information": { "unit": 1.00, "type": "EA" }, "code_information": [ { "code": "27241-098-03", "type": "NDC" } ], "standard_charges": [ { "gross_charge": 7.50, "minimum": 6.00, "maximum": 6.38, "setting": "both", "payers_information": [ { "payer_name": "Aetna", "plan_name": "700700", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna", "plan_name": "700700_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Miscellaneous", "plan_name": "700720", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Miscellaneous", "plan_name": "700720_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Ppo Hmo", "plan_name": "701720", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Ppo Hmo", "plan_name": "701720_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Ms State Emplo", "plan_name": "401457", "standard_charge_percentage": 0.80, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Ms State Emplo", "plan_name": "401457_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Basic Pl", "plan_name": "400100", "standard_charge_percentage": 0.85, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Basic Pl", "plan_name": "400100_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Federal", "plan_name": "400110", "standard_charge_percentage": 0.85, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Federal", "plan_name": "400110_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." } ] } ] }, { "description": "Fenofibrate micronized 67 mg capsule [22976]", "drug_information": { "unit": 1.00, "type": "EA" }, "code_information": [ { "code": "27241-118-04", "type": "NDC" } ], "standard_charges": [ { "gross_charge": 7.50, "minimum": 6.00, "maximum": 6.38, "setting": "both", "payers_information": [ { "payer_name": "Aetna", "plan_name": "700700", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna", "plan_name": "700700_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Miscellaneous", "plan_name": "700720", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Miscellaneous", "plan_name": "700720_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Ppo Hmo", "plan_name": "701720", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Ppo Hmo", "plan_name": "701720_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Ms State Emplo", "plan_name": "401457", "standard_charge_percentage": 0.80, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Ms State Emplo", "plan_name": "401457_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Basic Pl", "plan_name": "400100", "standard_charge_percentage": 0.85, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Basic Pl", "plan_name": "400100_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Federal", "plan_name": "400110", "standard_charge_percentage": 0.85, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Federal", "plan_name": "400110_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." } ] } ] }, { "description": "Ranolazine er 500 mg tabletextended release12 hr [70434]", "drug_information": { "unit": 1.00, "type": "EA" }, "code_information": [ { "code": "27241-125-02", "type": "NDC" } ], "standard_charges": [ { "gross_charge": 7.50, "minimum": 6.00, "maximum": 6.38, "setting": "both", "payers_information": [ { "payer_name": "Aetna", "plan_name": "700700", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna", "plan_name": "700700_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Miscellaneous", "plan_name": "700720", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Miscellaneous", "plan_name": "700720_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Ppo Hmo", "plan_name": "701720", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Ppo Hmo", "plan_name": "701720_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Ms State Emplo", "plan_name": "401457", "standard_charge_percentage": 0.80, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Ms State Emplo", "plan_name": "401457_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Basic Pl", "plan_name": "400100", "standard_charge_percentage": 0.85, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Basic Pl", "plan_name": "400100_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Federal", "plan_name": "400110", "standard_charge_percentage": 0.85, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Federal", "plan_name": "400110_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." } ] } ] }, { "description": "Pantoprazole dr 40 mg granules delayed-release for susp in packet [89791]", "drug_information": { "unit": 1.00, "type": "EA" }, "code_information": [ { "code": "27241-256-11", "type": "NDC" } ], "standard_charges": [ { "gross_charge": 68.44, "minimum": 54.75, "maximum": 58.17, "setting": "both", "payers_information": [ { "payer_name": "Aetna", "plan_name": "700700", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna", "plan_name": "700700_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Miscellaneous", "plan_name": "700720", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": 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charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Federal", "plan_name": "400110", "standard_charge_percentage": 0.85, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Federal", "plan_name": "400110_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." } ] } ] }, { "description": "Methylergonovine 0.2 mg tablet [10572]", "drug_information": { "unit": 1.00, "type": "EA" }, "code_information": [ { "code": "27437-050-57", "type": "NDC" } ], "standard_charges": [ { "gross_charge": 295.69, "minimum": 236.55, "maximum": 251.34, "setting": "both", "payers_information": [ { "payer_name": "Aetna", "plan_name": "700700", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna", "plan_name": "700700_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Miscellaneous", "plan_name": "700720", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Miscellaneous", "plan_name": "700720_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Ppo Hmo", "plan_name": "701720", "standard_charge_percentage": 80.0, "count": "0", "methodology": 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"standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Basic Pl", "plan_name": "400100", "standard_charge_percentage": 0.85, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Basic Pl", "plan_name": "400100_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Federal", "plan_name": "400110", "standard_charge_percentage": 0.85, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Federal", "plan_name": "400110_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." } ] } ] }, { "description": "Colesevelam 625 mg tablet [28372]", "drug_information": { "unit": 1.00, "type": "EA" }, "code_information": [ { "code": "27808-190-01", "type": "NDC" } ], "standard_charges": [ { "gross_charge": 7.50, "minimum": 6.00, "maximum": 6.38, "setting": "both", "payers_information": [ { "payer_name": "Aetna", "plan_name": "700700", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna", "plan_name": "700700_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Miscellaneous", "plan_name": "700720", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Miscellaneous", "plan_name": "700720_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Ppo Hmo", "plan_name": "701720", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Ppo Hmo", "plan_name": "701720_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Ms State Emplo", "plan_name": "401457", "standard_charge_percentage": 0.80, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Ms State Emplo", "plan_name": "401457_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Basic Pl", "plan_name": "400100", "standard_charge_percentage": 0.85, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Basic Pl", "plan_name": "400100_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Federal", "plan_name": "400110", "standard_charge_percentage": 0.85, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Federal", "plan_name": "400110_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." } ] } ] }, { "description": "Nitroglycerin 400 mcg/spray translingual [27096]", "drug_information": { "unit": 4.90, "type": "GR" }, "code_information": [ { "code": "28595-550-49", "type": "NDC" } ], "standard_charges": [ { "gross_charge": 1229.11, "minimum": 983.29, "maximum": 1044.74, "setting": "both", "payers_information": [ { "payer_name": "Aetna", "plan_name": "700700", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed 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"payer_name": "Aetna Ppo Hmo", "plan_name": "701720_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Ms State Emplo", "plan_name": "401457", "standard_charge_percentage": 0.80, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Ms State Emplo", "plan_name": "401457_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Basic Pl", "plan_name": "400100", "standard_charge_percentage": 0.85, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Basic Pl", "plan_name": "400100_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Federal", "plan_name": "400110", "standard_charge_percentage": 0.85, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Federal", "plan_name": "400110_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." } ] } ] }, { "description": "Calcium acetate(phosphate binders) 667 mg capsule [30961]", "drug_information": { "unit": 1.00, "type": "EA" }, "code_information": [ { "code": "29033-026-02", "type": "NDC" } ], "standard_charges": [ { "gross_charge": 7.50, "minimum": 6.00, "maximum": 6.38, "setting": "both", "payers_information": [ { "payer_name": "Aetna", "plan_name": "700700", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna", "plan_name": "700700_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Miscellaneous", "plan_name": "700720", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Miscellaneous", "plan_name": "700720_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Ppo Hmo", "plan_name": "701720", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Ppo Hmo", "plan_name": "701720_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Ms State Emplo", "plan_name": "401457", "standard_charge_percentage": 0.80, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Ms State Emplo", "plan_name": "401457_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Basic Pl", "plan_name": "400100", "standard_charge_percentage": 0.85, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Basic Pl", "plan_name": "400100_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Federal", "plan_name": "400110", "standard_charge_percentage": 0.85, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Federal", "plan_name": "400110_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." } ] } ] }, { "description": "Lamotrigine 25 mg tablet [13981]", "drug_information": { "unit": 1.00, "type": "EA" }, "code_information": [ { "code": "29300-111-01", "type": "NDC" } ], "standard_charges": [ { "gross_charge": 7.50, "minimum": 6.00, "maximum": 6.38, "setting": "both", "payers_information": [ { "payer_name": "Aetna", "plan_name": "700700", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna", "plan_name": "700700_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Miscellaneous", "plan_name": "700720", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Miscellaneous", "plan_name": "700720_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Ppo Hmo", "plan_name": "701720", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Ppo Hmo", "plan_name": "701720_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Ms State Emplo", "plan_name": "401457", "standard_charge_percentage": 0.80, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Ms State Emplo", "plan_name": "401457_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Basic Pl", "plan_name": "400100", "standard_charge_percentage": 0.85, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Basic Pl", "plan_name": "400100_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Federal", "plan_name": "400110", "standard_charge_percentage": 0.85, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Federal", "plan_name": "400110_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." } ] } ] }, { "description": "Meloxicam 7.5 mg tablet [20566]", "drug_information": { "unit": 1.00, "type": "EA" }, "code_information": [ { "code": "29300-124-01", "type": "NDC" } ], "standard_charges": [ { "gross_charge": 7.50, "minimum": 6.00, "maximum": 6.38, "setting": "both", "payers_information": [ { "payer_name": "Aetna", "plan_name": "700700", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna", "plan_name": "700700_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Miscellaneous", "plan_name": "700720", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Miscellaneous", "plan_name": "700720_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Ppo Hmo", "plan_name": "701720", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Ppo Hmo", "plan_name": "701720_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Ms State Emplo", "plan_name": "401457", "standard_charge_percentage": 0.80, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Ms State Emplo", "plan_name": "401457_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Basic Pl", "plan_name": "400100", "standard_charge_percentage": 0.85, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Basic Pl", "plan_name": "400100_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Federal", "plan_name": "400110", "standard_charge_percentage": 0.85, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Federal", "plan_name": "400110_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." } ] } ] }, { "description": "Bisoprolol fumarate 5 mg tablet [18288]", "drug_information": { "unit": 1.00, "type": "EA" }, "code_information": [ { "code": "29300-126-01", "type": "NDC" } ], "standard_charges": [ { "gross_charge": 7.50, "minimum": 6.00, "maximum": 6.38, "setting": "both", "payers_information": [ { "payer_name": "Aetna", "plan_name": "700700", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna", "plan_name": "700700_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Miscellaneous", "plan_name": "700720", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Miscellaneous", "plan_name": "700720_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Ppo Hmo", "plan_name": "701720", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Ppo Hmo", "plan_name": "701720_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Ms State Emplo", "plan_name": "401457", "standard_charge_percentage": 0.80, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Ms State Emplo", "plan_name": "401457_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Basic Pl", "plan_name": "400100", "standard_charge_percentage": 0.85, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Basic Pl", "plan_name": "400100_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Federal", "plan_name": "400110", "standard_charge_percentage": 0.85, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Federal", "plan_name": "400110_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." } ] } ] }, { "description": "Bisoprolol fumarate 5 mg tablet [18288]", "drug_information": { "unit": 1.00, "type": "EA" }, "code_information": [ { "code": "29300-126-13", "type": "NDC" } ], "standard_charges": [ { "gross_charge": 7.50, "minimum": 6.00, "maximum": 6.38, "setting": "both", "payers_information": [ { "payer_name": "Aetna", "plan_name": "700700", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna", "plan_name": "700700_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Miscellaneous", "plan_name": "700720", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Miscellaneous", "plan_name": "700720_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Ppo Hmo", "plan_name": "701720", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Ppo Hmo", "plan_name": "701720_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Ms State Emplo", "plan_name": "401457", "standard_charge_percentage": 0.80, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Ms State Emplo", "plan_name": "401457_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Basic Pl", "plan_name": "400100", "standard_charge_percentage": 0.85, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Basic Pl", "plan_name": "400100_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Federal", "plan_name": "400110", "standard_charge_percentage": 0.85, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Federal", "plan_name": "400110_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." } ] } ] }, { "description": "Hydrochlorothiazide 25 mg tablet [3720]", "drug_information": { "unit": 1.00, "type": "EA" }, "code_information": [ { "code": "29300-128-01", "type": "NDC" } ], "standard_charges": [ { "gross_charge": 7.50, "minimum": 6.00, "maximum": 6.38, "setting": "both", "payers_information": [ { "payer_name": "Aetna", "plan_name": "700700", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna", "plan_name": "700700_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Miscellaneous", "plan_name": "700720", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Miscellaneous", "plan_name": "700720_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Ppo Hmo", "plan_name": "701720", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Ppo Hmo", "plan_name": "701720_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Ms State Emplo", "plan_name": "401457", "standard_charge_percentage": 0.80, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Ms State Emplo", "plan_name": "401457_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Basic Pl", "plan_name": "400100", "standard_charge_percentage": 0.85, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Basic Pl", "plan_name": "400100_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Federal", "plan_name": "400110", "standard_charge_percentage": 0.85, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Federal", "plan_name": "400110_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." } ] } ] }, { "description": "Hydrochlorothiazide 12.5 mg capsule [19146]", "drug_information": { "unit": 1.00, "type": "EA" }, "code_information": [ { "code": "29300-130-01", "type": "NDC" } ], "standard_charges": [ { "gross_charge": 7.50, "minimum": 6.00, "maximum": 6.38, "setting": "both", "payers_information": [ { "payer_name": "Aetna", "plan_name": "700700", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna", "plan_name": "700700_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Miscellaneous", "plan_name": "700720", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Miscellaneous", "plan_name": "700720_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Ppo Hmo", "plan_name": "701720", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Ppo Hmo", "plan_name": "701720_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Ms State Emplo", "plan_name": "401457", "standard_charge_percentage": 0.80, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Ms State Emplo", "plan_name": "401457_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Basic Pl", "plan_name": "400100", "standard_charge_percentage": 0.85, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Basic Pl", "plan_name": "400100_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Federal", "plan_name": "400110", "standard_charge_percentage": 0.85, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Federal", "plan_name": "400110_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." } ] } ] }, { "description": "Divalproex 500 mg tabletdelayed release [2553]", "drug_information": { "unit": 1.00, "type": "EA" }, "code_information": [ { "code": "29300-140-01", "type": "NDC" } ], "standard_charges": [ { "gross_charge": 7.50, "minimum": 6.00, "maximum": 6.38, "setting": "both", "payers_information": [ { "payer_name": "Aetna", "plan_name": "700700", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna", "plan_name": "700700_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Miscellaneous", "plan_name": "700720", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Miscellaneous", "plan_name": "700720_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Ppo Hmo", "plan_name": "701720", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Ppo Hmo", "plan_name": "701720_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Ms State Emplo", "plan_name": "401457", "standard_charge_percentage": 0.80, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Ms State Emplo", "plan_name": "401457_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Basic Pl", "plan_name": "400100", "standard_charge_percentage": 0.85, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Basic Pl", "plan_name": "400100_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Federal", "plan_name": "400110", "standard_charge_percentage": 0.85, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Federal", "plan_name": "400110_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." } ] } ] }, { "description": "Alfuzosin er 10 mg tabletextended release 24 hr [36982]", "drug_information": { "unit": 1.00, "type": "EA" }, "code_information": [ { "code": "29300-155-01", "type": "NDC" } ], "standard_charges": [ { "gross_charge": 7.50, "minimum": 6.00, "maximum": 6.38, "setting": "both", "payers_information": [ { "payer_name": "Aetna", "plan_name": "700700", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna", "plan_name": "700700_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Miscellaneous", "plan_name": "700720", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Miscellaneous", "plan_name": "700720_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Ppo Hmo", "plan_name": "701720", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Ppo Hmo", "plan_name": "701720_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Ms State Emplo", "plan_name": "401457", "standard_charge_percentage": 0.80, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Ms State Emplo", "plan_name": "401457_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Basic Pl", "plan_name": "400100", "standard_charge_percentage": 0.85, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Basic Pl", "plan_name": "400100_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Federal", "plan_name": "400110", "standard_charge_percentage": 0.85, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Federal", "plan_name": "400110_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." } ] } ] }, { "description": "Tizanidine 2 mg tablet [14792]", "drug_information": { "unit": 1.00, "type": "EA" }, "code_information": [ { "code": "29300-168-15", "type": "NDC" } ], "standard_charges": [ { "gross_charge": 7.50, "minimum": 6.00, "maximum": 6.38, "setting": "both", "payers_information": [ { "payer_name": "Aetna", "plan_name": "700700", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna", "plan_name": "700700_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Miscellaneous", "plan_name": "700720", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Miscellaneous", "plan_name": "700720_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Ppo Hmo", "plan_name": "701720", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Ppo Hmo", "plan_name": "701720_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Ms State Emplo", "plan_name": "401457", "standard_charge_percentage": 0.80, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Ms State Emplo", "plan_name": "401457_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Basic Pl", "plan_name": "400100", "standard_charge_percentage": 0.85, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Basic Pl", "plan_name": "400100_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Federal", "plan_name": "400110", "standard_charge_percentage": 0.85, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Federal", "plan_name": "400110_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." } ] } ] }, { "description": "Bisoprolol 5 mg-hydrochlorothiazide 6.25 mg tablet [18290]", "drug_information": { "unit": 1.00, "type": "EA" }, "code_information": [ { "code": "29300-188-01", "type": "NDC" } ], "standard_charges": [ { "gross_charge": 7.50, "minimum": 6.00, "maximum": 6.38, "setting": "both", "payers_information": [ { "payer_name": "Aetna", "plan_name": "700700", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna", "plan_name": "700700_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Miscellaneous", "plan_name": "700720", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Miscellaneous", "plan_name": "700720_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Ppo Hmo", "plan_name": "701720", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Ppo Hmo", "plan_name": "701720_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Ms State Emplo", "plan_name": "401457", "standard_charge_percentage": 0.80, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Ms State Emplo", "plan_name": "401457_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Basic Pl", "plan_name": "400100", "standard_charge_percentage": 0.85, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Basic Pl", "plan_name": "400100_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Federal", "plan_name": "400110", "standard_charge_percentage": 0.85, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Federal", "plan_name": "400110_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." } ] } ] }, { "description": "Solifenacin 5 mg tablet [40392]", "drug_information": { "unit": 1.00, "type": "EA" }, "code_information": [ { "code": "29300-328-13", "type": "NDC" } ], "standard_charges": [ { "gross_charge": 1.56, "minimum": 1.25, "maximum": 1.33, "setting": "both", "payers_information": [ { "payer_name": "Aetna", "plan_name": "700700", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna", "plan_name": "700700_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Miscellaneous", "plan_name": "700720", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Miscellaneous", "plan_name": "700720_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Ppo Hmo", "plan_name": "701720", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Ppo Hmo", "plan_name": "701720_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Ms State Emplo", "plan_name": "401457", "standard_charge_percentage": 0.80, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Ms State Emplo", "plan_name": "401457_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Basic Pl", "plan_name": "400100", "standard_charge_percentage": 0.85, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Basic Pl", "plan_name": "400100_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Federal", "plan_name": "400110", "standard_charge_percentage": 0.85, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Federal", "plan_name": "400110_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." } ] } ] }, { "description": "Solifenacin 5 mg tablet [40392]", "drug_information": { "unit": 1.00, "type": "EA" }, "code_information": [ { "code": "29300-328-19", "type": "NDC" } ], "standard_charges": [ { "gross_charge": 1.55, "minimum": 1.24, "maximum": 1.32, "setting": "both", "payers_information": [ { "payer_name": "Aetna", "plan_name": "700700", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna", "plan_name": "700700_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Miscellaneous", "plan_name": "700720", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Miscellaneous", "plan_name": "700720_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Ppo Hmo", "plan_name": "701720", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Ppo Hmo", "plan_name": "701720_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Ms State Emplo", "plan_name": "401457", "standard_charge_percentage": 0.80, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Ms State Emplo", "plan_name": "401457_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Basic Pl", "plan_name": "400100", "standard_charge_percentage": 0.85, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Basic Pl", "plan_name": "400100_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Federal", "plan_name": "400110", "standard_charge_percentage": 0.85, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Federal", "plan_name": "400110_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." } ] } ] }, { "description": "Guanfacine 1 mg tablet [10149]", "drug_information": { "unit": 1.00, "type": "EA" }, "code_information": [ { "code": "29300-458-01", "type": "NDC" } ], "standard_charges": [ { "gross_charge": 7.50, "minimum": 6.00, "maximum": 6.38, "setting": "both", "payers_information": [ { "payer_name": "Aetna", "plan_name": "700700", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna", "plan_name": "700700_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Miscellaneous", "plan_name": "700720", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Miscellaneous", "plan_name": "700720_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Ppo Hmo", "plan_name": "701720", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Ppo Hmo", "plan_name": "701720_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Ms State Emplo", "plan_name": "401457", "standard_charge_percentage": 0.80, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Ms State Emplo", "plan_name": "401457_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Basic Pl", "plan_name": "400100", "standard_charge_percentage": 0.85, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Basic Pl", "plan_name": "400100_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Federal", "plan_name": "400110", "standard_charge_percentage": 0.85, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Federal", "plan_name": "400110_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." } ] } ] }, { "description": "Buspirone 15 mg tablet [17464]", "drug_information": { "unit": 1.00, "type": "EA" }, "code_information": [ { "code": "29300-477-01", "type": "NDC" } ], "standard_charges": [ { "gross_charge": 7.50, "minimum": 6.00, "maximum": 6.38, "setting": "both", "payers_information": [ { "payer_name": "Aetna", "plan_name": "700700", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna", "plan_name": "700700_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Miscellaneous", "plan_name": "700720", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Miscellaneous", "plan_name": "700720_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Ppo Hmo", "plan_name": "701720", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Ppo Hmo", "plan_name": "701720_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Ms State Emplo", "plan_name": "401457", "standard_charge_percentage": 0.80, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Ms State Emplo", "plan_name": "401457_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Basic Pl", "plan_name": "400100", "standard_charge_percentage": 0.85, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Basic Pl", "plan_name": "400100_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Federal", "plan_name": "400110", "standard_charge_percentage": 0.85, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Federal", "plan_name": "400110_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." } ] } ] }, { "description": "Levocarnitine 500 mg tablet [109203]", "drug_information": { "unit": 1.00, "type": "EA" }, "code_information": [ { "code": "3076803741", "type": "NDC" } ], "standard_charges": [ { "gross_charge": 7.50, "minimum": 6.00, "maximum": 6.38, "setting": "both", "payers_information": [ { "payer_name": "Aetna", "plan_name": "700700", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna", "plan_name": "700700_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Miscellaneous", "plan_name": "700720", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Miscellaneous", "plan_name": "700720_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Ppo Hmo", "plan_name": "701720", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Ppo Hmo", "plan_name": "701720_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Ms State Emplo", "plan_name": "401457", "standard_charge_percentage": 0.80, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Ms State Emplo", "plan_name": "401457_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Basic Pl", "plan_name": "400100", "standard_charge_percentage": 0.85, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Basic Pl", "plan_name": "400100_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Federal", "plan_name": "400110", "standard_charge_percentage": 0.85, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Federal", "plan_name": "400110_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." } ] } ] }, { "description": "Folic acid 400 mcg tablet [3234]", "drug_information": { "unit": 1.00, "type": "EA" }, "code_information": [ { "code": "3076804069", "type": "NDC" } ], "standard_charges": [ { "gross_charge": 1.00, "minimum": 0.80, "maximum": 0.85, "setting": "both", "payers_information": [ { "payer_name": "Aetna", "plan_name": "700700", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna", "plan_name": "700700_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Miscellaneous", "plan_name": "700720", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Miscellaneous", "plan_name": "700720_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Ppo Hmo", "plan_name": "701720", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Ppo Hmo", "plan_name": "701720_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Ms State Emplo", "plan_name": "401457", "standard_charge_percentage": 0.80, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Ms State Emplo", "plan_name": "401457_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Basic Pl", "plan_name": "400100", "standard_charge_percentage": 0.85, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Basic Pl", "plan_name": "400100_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Federal", "plan_name": "400110", "standard_charge_percentage": 0.85, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Federal", "plan_name": "400110_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." } ] } ] }, { "description": "Dimenhydrinate 50 mg tablet [2485]", "drug_information": { "unit": 1.00, "type": "EA" }, "code_information": [ { "code": "3124800197", "type": "NDC" } ], "standard_charges": [ { "gross_charge": 1.09, "minimum": 0.87, "maximum": 0.93, "setting": "both", "payers_information": [ { "payer_name": "Aetna", "plan_name": "700700", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna", "plan_name": "700700_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Miscellaneous", "plan_name": "700720", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Miscellaneous", "plan_name": "700720_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Ppo Hmo", "plan_name": "701720", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Ppo Hmo", "plan_name": "701720_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Ms State Emplo", "plan_name": "401457", "standard_charge_percentage": 0.80, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Ms State Emplo", "plan_name": "401457_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Basic Pl", "plan_name": "400100", "standard_charge_percentage": 0.85, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Basic Pl", "plan_name": "400100_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Federal", "plan_name": "400110", "standard_charge_percentage": 0.85, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Federal", "plan_name": "400110_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." } ] } ] }, { "description": "Famotidine 20 mg tablet [10011]", "drug_information": { "unit": 1.00, "type": "EA" }, "code_information": [ { "code": "31722-017-01", "type": "NDC" } ], "standard_charges": [ { "gross_charge": 1.00, "minimum": 0.80, "maximum": 0.85, "setting": "both", "payers_information": [ { "payer_name": "Aetna", "plan_name": "700700", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna", "plan_name": "700700_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Miscellaneous", "plan_name": "700720", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Miscellaneous", "plan_name": "700720_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Ppo Hmo", "plan_name": "701720", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Ppo Hmo", "plan_name": "701720_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Ms State Emplo", "plan_name": "401457", "standard_charge_percentage": 0.80, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Ms State Emplo", "plan_name": "401457_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Basic Pl", "plan_name": "400100", "standard_charge_percentage": 0.85, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Basic Pl", "plan_name": "400100_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Federal", "plan_name": "400110", "standard_charge_percentage": 0.85, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Federal", "plan_name": "400110_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." } ] } ] }, { "description": "Famotidine 40 mg tablet [10012]", "drug_information": { "unit": 1.00, "type": "EA" }, "code_information": [ { "code": "31722-018-01", "type": "NDC" } ], "standard_charges": [ { "gross_charge": 7.50, "minimum": 6.00, "maximum": 6.38, "setting": "both", "payers_information": [ { "payer_name": "Aetna", "plan_name": "700700", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna", "plan_name": "700700_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Miscellaneous", "plan_name": "700720", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Miscellaneous", "plan_name": "700720_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Ppo Hmo", "plan_name": "701720", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Ppo Hmo", "plan_name": "701720_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Ms State Emplo", "plan_name": "401457", "standard_charge_percentage": 0.80, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Ms State Emplo", "plan_name": "401457_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Basic Pl", "plan_name": "400100", "standard_charge_percentage": 0.85, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Basic Pl", "plan_name": "400100_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Federal", "plan_name": "400110", "standard_charge_percentage": 0.85, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Federal", "plan_name": "400110_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." } ] } ] }, { "description": "Oxcarbazepine 300 mg tablet [21061]", "drug_information": { "unit": 1.00, "type": "EA" }, "code_information": [ { "code": "31722-024-01", "type": "NDC" } ], "standard_charges": [ { "gross_charge": 7.50, "minimum": 6.00, "maximum": 6.38, "setting": "both", "payers_information": [ { "payer_name": "Aetna", "plan_name": "700700", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna", "plan_name": "700700_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Miscellaneous", "plan_name": "700720", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Miscellaneous", "plan_name": "700720_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Ppo Hmo", "plan_name": "701720", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Ppo Hmo", "plan_name": "701720_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Ms State Emplo", "plan_name": "401457", "standard_charge_percentage": 0.80, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Ms State Emplo", "plan_name": "401457_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Basic Pl", "plan_name": "400100", "standard_charge_percentage": 0.85, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Basic Pl", "plan_name": "400100_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Federal", "plan_name": "400110", "standard_charge_percentage": 0.85, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Federal", "plan_name": "400110_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." } ] } ] }, { "description": "Solifenacin 5 mg tablet [40392]", "drug_information": { "unit": 1.00, "type": "EA" }, "code_information": [ { "code": "31722-027-30", "type": "NDC" } ], "standard_charges": [ { "gross_charge": 1.56, "minimum": 1.25, "maximum": 1.33, "setting": "both", "payers_information": [ { "payer_name": "Aetna", "plan_name": "700700", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna", "plan_name": "700700_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Miscellaneous", "plan_name": "700720", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Miscellaneous", "plan_name": "700720_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Ppo Hmo", "plan_name": "701720", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Ppo Hmo", "plan_name": "701720_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Ms State Emplo", "plan_name": "401457", "standard_charge_percentage": 0.80, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Ms State Emplo", "plan_name": "401457_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Basic Pl", "plan_name": "400100", "standard_charge_percentage": 0.85, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Basic Pl", "plan_name": "400100_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Federal", "plan_name": "400110", "standard_charge_percentage": 0.85, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Federal", "plan_name": "400110_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." } ] } ] }, { "description": "Bupropion hcl sr 100 mg tablet12 hr sustained-release [18385]", "drug_information": { "unit": 1.00, "type": "EA" }, "code_information": [ { "code": "31722-066-60", "type": "NDC" } ], "standard_charges": [ { "gross_charge": 7.50, "minimum": 6.00, "maximum": 6.38, "setting": "both", "payers_information": [ { "payer_name": "Aetna", "plan_name": "700700", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna", "plan_name": "700700_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Miscellaneous", "plan_name": "700720", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Miscellaneous", "plan_name": "700720_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Ppo Hmo", "plan_name": "701720", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Ppo Hmo", "plan_name": "701720_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Ms State Emplo", "plan_name": "401457", "standard_charge_percentage": 0.80, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Ms State Emplo", "plan_name": "401457_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Basic Pl", "plan_name": "400100", "standard_charge_percentage": 0.85, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Basic Pl", "plan_name": "400100_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Federal", "plan_name": "400110", "standard_charge_percentage": 0.85, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Federal", "plan_name": "400110_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." } ] } ] }, { "description": "Rocuronium 10 mg/ml intravenous solution [12734]", "drug_information": { "unit": 5.00, "type": "ML" }, "code_information": [ { "code": "25021-662-05", "type": "NDC" } ], "standard_charges": [ { "gross_charge": 37.68, "minimum": 30.14, "maximum": 32.03, "setting": "both", "payers_information": [ { "payer_name": "Aetna", "plan_name": "700700", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna", "plan_name": "700700_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Miscellaneous", "plan_name": "700720", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Miscellaneous", "plan_name": "700720_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Ppo Hmo", "plan_name": "701720", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Ppo Hmo", "plan_name": "701720_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Ms State Emplo", "plan_name": "401457", "standard_charge_percentage": 0.80, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Ms State Emplo", "plan_name": "401457_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Basic Pl", "plan_name": "400100", "standard_charge_percentage": 0.85, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Basic Pl", "plan_name": "400100_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Federal", "plan_name": "400110", "standard_charge_percentage": 0.85, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Federal", "plan_name": "400110_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." } ] } ] }, { "description": "Dutasteride 0.5 mg capsule [34089]", "drug_information": { "unit": 1.00, "type": "EA" }, "code_information": [ { "code": "31722-131-30", "type": "NDC" } ], "standard_charges": [ { "gross_charge": 7.50, "minimum": 6.00, "maximum": 6.38, "setting": "both", "payers_information": [ { "payer_name": "Aetna", "plan_name": "700700", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna", "plan_name": "700700_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Miscellaneous", "plan_name": "700720", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Miscellaneous", "plan_name": "700720_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Ppo Hmo", "plan_name": "701720", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Ppo Hmo", "plan_name": "701720_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Ms State Emplo", "plan_name": "401457", "standard_charge_percentage": 0.80, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Ms State Emplo", "plan_name": "401457_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Basic Pl", "plan_name": "400100", "standard_charge_percentage": 0.85, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Basic Pl", "plan_name": "400100_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Federal", "plan_name": "400110", "standard_charge_percentage": 0.85, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Federal", "plan_name": "400110_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." } ] } ] }, { "description": "Lamivudine 150 mg-zidovudine 300 mg tablet [21810]", "drug_information": { "unit": 1.00, "type": "EA" }, "code_information": [ { "code": "31722-506-60", "type": "NDC" } ], "standard_charges": [ { "gross_charge": 14.89, "minimum": 11.91, "maximum": 12.66, "setting": "both", "payers_information": [ { "payer_name": "Aetna", "plan_name": "700700", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna", "plan_name": "700700_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Miscellaneous", "plan_name": "700720", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Miscellaneous", "plan_name": "700720_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Ppo Hmo", "plan_name": "701720", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Ppo Hmo", "plan_name": "701720_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Ms State Emplo", "plan_name": "401457", "standard_charge_percentage": 0.80, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Ms State Emplo", "plan_name": "401457_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Basic Pl", "plan_name": "400100", "standard_charge_percentage": 0.85, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Basic Pl", "plan_name": "400100_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Federal", "plan_name": "400110", "standard_charge_percentage": 0.85, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Federal", "plan_name": "400110_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." } ] } ] }, { "description": "Finasteride 5 mg tablet [10037]", "drug_information": { "unit": 1.00, "type": "EA" }, "code_information": [ { "code": "31722-525-90", "type": "NDC" } ], "standard_charges": [ { "gross_charge": 7.50, "minimum": 6.00, "maximum": 6.38, "setting": "both", "payers_information": [ { "payer_name": "Aetna", "plan_name": "700700", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna", "plan_name": "700700_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Miscellaneous", "plan_name": "700720", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Miscellaneous", "plan_name": "700720_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Ppo Hmo", "plan_name": "701720", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Ppo Hmo", "plan_name": "701720_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Ms State Emplo", "plan_name": "401457", "standard_charge_percentage": 0.80, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Ms State Emplo", "plan_name": "401457_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Basic Pl", "plan_name": "400100", "standard_charge_percentage": 0.85, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Basic Pl", "plan_name": "400100_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Federal", "plan_name": "400110", "standard_charge_percentage": 0.85, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Federal", "plan_name": "400110_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." } ] } ] }, { "description": "Torsemide 10 mg tablet [18292]", "drug_information": { "unit": 1.00, "type": "EA" }, "code_information": [ { "code": "31722-530-01", "type": "NDC" } ], "standard_charges": [ { "gross_charge": 7.50, "minimum": 6.00, "maximum": 6.38, "setting": "both", "payers_information": [ { "payer_name": "Aetna", "plan_name": "700700", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna", "plan_name": "700700_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Miscellaneous", "plan_name": "700720", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Miscellaneous", "plan_name": "700720_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Ppo Hmo", "plan_name": "701720", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Ppo Hmo", "plan_name": "701720_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Ms State Emplo", "plan_name": "401457", "standard_charge_percentage": 0.80, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Ms State Emplo", "plan_name": "401457_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Basic Pl", "plan_name": "400100", "standard_charge_percentage": 0.85, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Basic Pl", "plan_name": "400100_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Federal", "plan_name": "400110", "standard_charge_percentage": 0.85, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Federal", "plan_name": "400110_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." } ] } ] }, { "description": "Torsemide 20 mg tablet [18293]", "drug_information": { "unit": 1.00, "type": "EA" }, "code_information": [ { "code": "31722-531-01", "type": "NDC" } ], "standard_charges": [ { "gross_charge": 7.50, "minimum": 6.00, "maximum": 6.38, "setting": "both", "payers_information": [ { "payer_name": "Aetna", "plan_name": "700700", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna", "plan_name": "700700_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Miscellaneous", "plan_name": "700720", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Miscellaneous", "plan_name": "700720_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Ppo Hmo", "plan_name": "701720", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Ppo Hmo", "plan_name": "701720_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Ms State Emplo", "plan_name": "401457", "standard_charge_percentage": 0.80, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Ms State Emplo", "plan_name": "401457_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Basic Pl", "plan_name": "400100", "standard_charge_percentage": 0.85, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Basic Pl", "plan_name": "400100_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Federal", "plan_name": "400110", "standard_charge_percentage": 0.85, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Federal", "plan_name": "400110_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." } ] } ] }, { "description": "Indomethacin 50 mg capsule [3898]", "drug_information": { "unit": 1.00, "type": "EA" }, "code_information": [ { "code": "31722-543-01", "type": "NDC" } ], "standard_charges": [ { "gross_charge": 7.50, "minimum": 6.00, "maximum": 6.38, "setting": "both", "payers_information": [ { "payer_name": "Aetna", "plan_name": "700700", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna", "plan_name": "700700_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Miscellaneous", "plan_name": "700720", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Miscellaneous", "plan_name": "700720_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Ppo Hmo", "plan_name": "701720", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Ppo Hmo", "plan_name": "701720_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Ms State Emplo", "plan_name": "401457", "standard_charge_percentage": 0.80, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Ms State Emplo", "plan_name": "401457_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Basic Pl", "plan_name": "400100", "standard_charge_percentage": 0.85, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Basic Pl", "plan_name": "400100_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Federal", "plan_name": "400110", "standard_charge_percentage": 0.85, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Federal", "plan_name": "400110_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." } ] } ] }, { "description": "Levetiracetam 100 mg/ml oral solution [36590]", "drug_information": { "unit": 473.00, "type": "ML" }, "code_information": [ { "code": "31722-574-47", "type": "NDC" } ], "standard_charges": [ { "gross_charge": 301.07, "minimum": 240.86, "maximum": 255.91, "setting": "both", "payers_information": [ { "payer_name": "Aetna", "plan_name": "700700", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna", "plan_name": "700700_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Miscellaneous", "plan_name": "700720", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Miscellaneous", "plan_name": "700720_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Ppo Hmo", "plan_name": "701720", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Ppo Hmo", "plan_name": "701720_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Ms State Emplo", "plan_name": "401457", "standard_charge_percentage": 0.80, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Ms State Emplo", "plan_name": "401457_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Basic Pl", "plan_name": "400100", "standard_charge_percentage": 0.85, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Basic Pl", "plan_name": "400100_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Federal", "plan_name": "400110", "standard_charge_percentage": 0.85, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Federal", "plan_name": "400110_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." } ] } ] }, { "description": "Nebivolol 5 mg tablet [89284]", "drug_information": { "unit": 1.00, "type": "EA" }, "code_information": [ { "code": "31722-586-90", "type": "NDC" } ], "standard_charges": [ { "gross_charge": 7.50, "minimum": 6.00, "maximum": 6.38, "setting": "both", "payers_information": [ { "payer_name": "Aetna", "plan_name": "700700", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna", "plan_name": "700700_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Miscellaneous", "plan_name": "700720", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total 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charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Federal", "plan_name": "400110", "standard_charge_percentage": 0.85, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Federal", "plan_name": "400110_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." } ] } ] }, { "description": "Valacyclovir 500 mg tablet [13133]", "drug_information": { "unit": 1.00, "type": "EA" }, "code_information": [ { "code": "31722-704-30", "type": "NDC" } ], "standard_charges": [ { "gross_charge": 7.50, "minimum": 6.00, "maximum": 6.38, "setting": "both", "payers_information": [ { "payer_name": "Aetna", "plan_name": "700700", "standard_charge_percentage": 80.0, "count": "0", 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billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Basic Pl", "plan_name": "400100_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Federal", "plan_name": "400110", "standard_charge_percentage": 0.85, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Federal", "plan_name": "400110_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." } ] } ] }, { "description": "Levofloxacin 250 mg tablet [18918]", "drug_information": { "unit": 1.00, "type": "EA" }, "code_information": [ { "code": "31722-721-50", "type": "NDC" } ], "standard_charges": [ { "gross_charge": 7.50, "minimum": 6.00, "maximum": 6.38, "setting": "both", "payers_information": [ { "payer_name": "Aetna", "plan_name": "700700", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna", "plan_name": "700700_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Miscellaneous", "plan_name": "700720", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Miscellaneous", "plan_name": "700720_1", "standard_charge_percentage": 100.0, "count": "0", 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"percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Basic Pl", "plan_name": "400100", "standard_charge_percentage": 0.85, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Basic Pl", "plan_name": "400100_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Federal", "plan_name": "400110", "standard_charge_percentage": 0.85, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Federal", "plan_name": "400110_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." } ] } ] }, { "description": "Irbesartan 150 mg tablet [21848]", "drug_information": { "unit": 1.00, "type": "EA" }, "code_information": [ { "code": "31722-730-90", "type": "NDC" } ], "standard_charges": [ { "gross_charge": 7.50, "minimum": 6.00, "maximum": 6.38, "setting": "both", "payers_information": [ { "payer_name": "Aetna", "plan_name": "700700", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna", "plan_name": "700700_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Miscellaneous", "plan_name": "700720", "standard_charge_percentage": 80.0, "count": 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"methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Ms State Emplo", "plan_name": "401457_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Basic Pl", "plan_name": "400100", "standard_charge_percentage": 0.85, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Basic Pl", "plan_name": "400100_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Federal", "plan_name": "400110", "standard_charge_percentage": 0.85, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Federal", "plan_name": "400110_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." } ] } ] }, { "description": "Linezolid 600 mg tablet [28224]", "drug_information": { "unit": 1.00, "type": "EA" }, "code_information": [ { "code": "31722-749-20", "type": "NDC" } ], "standard_charges": [ { "gross_charge": 42.86, "minimum": 34.29, "maximum": 36.43, "setting": "both", "payers_information": [ { "payer_name": "Aetna", "plan_name": "700700", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna", "plan_name": "700700_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Miscellaneous", "plan_name": "700720", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Miscellaneous", "plan_name": "700720_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Ppo Hmo", "plan_name": "701720", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Ppo Hmo", "plan_name": "701720_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Ms State Emplo", "plan_name": "401457", "standard_charge_percentage": 0.80, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Ms State Emplo", "plan_name": "401457_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Basic Pl", "plan_name": "400100", "standard_charge_percentage": 0.85, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Basic Pl", "plan_name": "400100_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Federal", "plan_name": "400110", "standard_charge_percentage": 0.85, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Federal", "plan_name": "400110_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." } ] } ] }, { "description": "Barium sulfate 24 % oral suspension [91915]", "drug_information": { "unit": 600.00, "type": "ML" }, "code_information": [ { "code": "32909-146-06", "type": "NDC" } ], "standard_charges": [ { "gross_charge": 165.30, "minimum": 132.24, "maximum": 140.51, "setting": "both", 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"payer_name": "Aetna Ppo Hmo", "plan_name": "701720", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Ppo Hmo", "plan_name": "701720_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Ms State Emplo", "plan_name": "401457", "standard_charge_percentage": 0.80, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Ms State Emplo", "plan_name": "401457_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": 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"description": "Oseltamivir 30 mg capsule [88704]", "drug_information": { "unit": 1.00, "type": "EA" }, "code_information": [ { "code": "33342-256-66", "type": "NDC" } ], "standard_charges": [ { "gross_charge": 18.49, "minimum": 14.79, "maximum": 15.72, "setting": "both", "payers_information": [ { "payer_name": "Aetna", "plan_name": "700700", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna", "plan_name": "700700_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Miscellaneous", "plan_name": "700720", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed 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"payer_name": "Bc/Bs Ms State Emplo", "plan_name": "401457_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Basic Pl", "plan_name": "400100", "standard_charge_percentage": 0.85, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Basic Pl", "plan_name": "400100_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Federal", "plan_name": "400110", "standard_charge_percentage": 0.85, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { 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"standard_charge_percentage": 0.85, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Basic Pl", "plan_name": "400100_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Federal", "plan_name": "400110", "standard_charge_percentage": 0.85, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Federal", "plan_name": "400110_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." } ] } ] }, { "description": "Ketoconazole 200 mg tablet [10369]", 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1.52, "minimum": 1.22, "maximum": 1.29, "setting": "both", "payers_information": [ { "payer_name": "Aetna", "plan_name": "700700", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna", "plan_name": "700700_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Miscellaneous", "plan_name": "700720", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Miscellaneous", "plan_name": "700720_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": 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"percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Federal", "plan_name": "400110", "standard_charge_percentage": 0.85, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Federal", "plan_name": "400110_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." } ] } ] }, { "description": "Psyllium husk 0.4 gram capsule [176461]", "drug_information": { "unit": 1.00, "type": "EA" }, "code_information": [ { "code": "3700040514", "type": "NDC" } ], "standard_charges": [ { "gross_charge": 1.00, "minimum": 0.80, "maximum": 0.85, "setting": "both", "payers_information": [ { "payer_name": "Aetna", "plan_name": "700700", 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"standard_charge_percentage": 0.85, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Basic Pl", "plan_name": "400100_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Federal", "plan_name": "400110", "standard_charge_percentage": 0.85, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Federal", "plan_name": "400110_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." } ] } ] }, { "description": "Psyllium oral packet [11218]", "drug_information": { "unit": 1.00, "type": "EA" }, "code_information": [ { "code": "3848580857", "type": "NDC" } ], "standard_charges": [ { "gross_charge": 7.50, "minimum": 6.00, "maximum": 6.38, "setting": "both", "payers_information": [ { "payer_name": "Aetna", "plan_name": "700700", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna", "plan_name": "700700_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Miscellaneous", "plan_name": "700720", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Miscellaneous", "plan_name": "700720_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Ppo Hmo", "plan_name": "701720", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Ppo Hmo", "plan_name": "701720_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Ms State Emplo", "plan_name": "401457", "standard_charge_percentage": 0.80, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Ms State Emplo", "plan_name": "401457_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Basic Pl", "plan_name": "400100", "standard_charge_percentage": 0.85, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Basic Pl", "plan_name": "400100_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Federal", "plan_name": "400110", "standard_charge_percentage": 0.85, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Federal", "plan_name": "400110_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." } ] } ] }, { "description": "Flexible collodion (bulk) liquid [12683]", "drug_information": { "unit": 500.00, "type": "ML" }, "code_information": [ { "code": "3877906258", "type": "NDC" } ], "standard_charges": [ { "gross_charge": 171.00, "minimum": 136.80, "maximum": 145.35, "setting": "both", "payers_information": [ { "payer_name": "Aetna", "plan_name": "700700", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna", "plan_name": "700700_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": 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"payer_name": "Aetna Ppo Hmo", "plan_name": "701720_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Ms State Emplo", "plan_name": "401457", "standard_charge_percentage": 0.80, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Ms State Emplo", "plan_name": "401457_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Basic Pl", "plan_name": "400100", "standard_charge_percentage": 0.85, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Basic Pl", "plan_name": "400100_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Federal", "plan_name": "400110", "standard_charge_percentage": 0.85, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Federal", "plan_name": "400110_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." } ] } ] }, { "description": "Ferrous sulfate 15 mg iron (75 mg)/ml oral drops [95693]", "drug_information": { "unit": 50.00, "type": "ML" }, "code_information": [ { "code": "3932805750", "type": "NDC" } ], "standard_charges": [ { "gross_charge": 17.10, "minimum": 13.68, "maximum": 14.54, "setting": "both", "payers_information": [ { "payer_name": "Aetna", "plan_name": "700700", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna", "plan_name": "700700_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Miscellaneous", "plan_name": "700720", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Miscellaneous", "plan_name": "700720_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient 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"percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Ms State Emplo", "plan_name": "401457", "standard_charge_percentage": 0.80, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Ms State Emplo", "plan_name": "401457_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Basic Pl", "plan_name": "400100", "standard_charge_percentage": 0.85, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Basic Pl", "plan_name": "400100_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Federal", "plan_name": "400110", "standard_charge_percentage": 0.85, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Federal", "plan_name": "400110_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." } ] } ] }, { "description": "Tranexamic acid 1000 mg/10 ml (100 mg/ml) intravenous solution [154712]", "drug_information": { "unit": 10.00, "type": "ML" }, "code_information": [ { "code": "39822-1000-1", "type": "NDC" } ], "standard_charges": [ { "gross_charge": 100.00, "minimum": 80.00, "maximum": 85.00, "setting": "both", "payers_information": [ { "payer_name": "Aetna", "plan_name": "700700", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna", "plan_name": "700700_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Miscellaneous", "plan_name": "700720", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Miscellaneous", "plan_name": "700720_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Ppo Hmo", "plan_name": "701720", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Ppo Hmo", "plan_name": "701720_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Ms State Emplo", "plan_name": "401457", "standard_charge_percentage": 0.80, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Ms State Emplo", "plan_name": "401457_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Basic Pl", "plan_name": "400100", "standard_charge_percentage": 0.85, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Basic Pl", "plan_name": "400100_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Federal", "plan_name": "400110", "standard_charge_percentage": 0.85, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Federal", "plan_name": "400110_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." } ] } ] }, { "description": "Folic acid 5 mg/ml injection solution [3232]", "drug_information": { "unit": 10.00, "type": "ML" }, "code_information": [ { "code": "39822-1100-1", "type": "NDC" } ], "standard_charges": [ { "gross_charge": 213.45, "minimum": 170.76, "maximum": 181.43, "setting": "both", "payers_information": [ { "payer_name": "Aetna", "plan_name": "700700", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna", "plan_name": "700700_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Miscellaneous", "plan_name": "700720", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Miscellaneous", "plan_name": "700720_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Ppo Hmo", "plan_name": "701720", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Ppo Hmo", "plan_name": "701720_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Ms State Emplo", "plan_name": "401457", "standard_charge_percentage": 0.80, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Ms State Emplo", "plan_name": "401457_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Basic Pl", "plan_name": "400100", "standard_charge_percentage": 0.85, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Basic Pl", "plan_name": "400100_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Federal", "plan_name": "400110", "standard_charge_percentage": 0.85, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Federal", "plan_name": "400110_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." } ] } ] }, { "description": "Neomycin 40 mg-polymyxin b 200000 unit/ml gu irrigation solution [70678]", "drug_information": { "unit": 1.00, "type": "ML" }, "code_information": [ { "code": "39822-1201-2", "type": "NDC" } ], "standard_charges": [ { "gross_charge": 55.17, "minimum": 44.14, "maximum": 46.89, "setting": "both", "payers_information": [ { "payer_name": "Aetna", "plan_name": "700700", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna", "plan_name": "700700_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Miscellaneous", "plan_name": "700720", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Miscellaneous", "plan_name": "700720_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Ppo Hmo", "plan_name": "701720", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Ppo Hmo", "plan_name": "701720_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Ms State Emplo", "plan_name": "401457", "standard_charge_percentage": 0.80, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Ms State Emplo", "plan_name": "401457_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Basic Pl", "plan_name": "400100", "standard_charge_percentage": 0.85, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Basic Pl", "plan_name": "400100_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Federal", "plan_name": "400110", "standard_charge_percentage": 0.85, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Federal", "plan_name": "400110_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." } ] } ] }, { "description": "Nystatin 100000 unit/gram topical powder [39136]", "drug_information": { "unit": 60.00, "type": "GR" }, "code_information": [ { "code": "39822-3015-6", "type": "NDC" } ], "standard_charges": [ { "gross_charge": 289.85, "minimum": 231.88, "maximum": 246.37, "setting": "both", "payers_information": [ { "payer_name": "Aetna", "plan_name": "700700", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", 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"Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Basic Pl", "plan_name": "400100_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Federal", "plan_name": "400110", "standard_charge_percentage": 0.85, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Federal", "plan_name": "400110_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." } ] } ] }, { "description": "Peppermint oil [6116]", "drug_information": { "unit": 15.00, "type": "ML" }, "code_information": [ { "code": "40093-0101-00", "type": "NDC" } ], "standard_charges": [ { "gross_charge": 24.01, "minimum": 19.21, "maximum": 20.41, "setting": "both", "payers_information": [ { "payer_name": "Aetna", "plan_name": "700700", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna", "plan_name": "700700_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Miscellaneous", "plan_name": "700720", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Miscellaneous", "plan_name": "700720_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", 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"additional_payer_notes": "Insufficient remit data to calculate allowed amounts." } ] } ] }, { "description": "Oxymetazoline 0.05 % nasal mist [112974]", "drug_information": { "unit": 15.00, "type": "ML" }, "code_information": [ { "code": "4110001509", "type": "NDC" } ], "standard_charges": [ { "gross_charge": 36.69, "minimum": 29.35, "maximum": 31.19, "setting": "both", "payers_information": [ { "payer_name": "Aetna", "plan_name": "700700", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna", "plan_name": "700700_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Miscellaneous", "plan_name": "700720", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Miscellaneous", "plan_name": "700720_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Ppo Hmo", "plan_name": "701720", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Ppo Hmo", "plan_name": "701720_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Ms State Emplo", "plan_name": "401457", "standard_charge_percentage": 0.80, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Ms State Emplo", "plan_name": "401457_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Basic Pl", "plan_name": "400100", "standard_charge_percentage": 0.85, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Basic Pl", "plan_name": "400100_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Federal", "plan_name": "400110", "standard_charge_percentage": 0.85, "count": "0", "methodology": "percent of total 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"count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Miscellaneous", "plan_name": "700720", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Miscellaneous", "plan_name": "700720_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Ppo Hmo", "plan_name": "701720", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Ppo Hmo", "plan_name": "701720_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Ms State Emplo", "plan_name": "401457", "standard_charge_percentage": 0.80, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Ms State Emplo", "plan_name": "401457_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Basic Pl", "plan_name": "400100", "standard_charge_percentage": 0.85, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Basic Pl", "plan_name": "400100_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Federal", "plan_name": "400110", "standard_charge_percentage": 0.85, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Federal", "plan_name": "400110_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." } ] } ] }, { "description": "Vitamins a and d-white petrolatum-lanolin topical ointment [118725]", "drug_information": { "unit": 42.50, "type": "GR" }, "code_information": [ { "code": "4110081122", "type": "NDC" } ], "standard_charges": [ { "gross_charge": 5.75, "minimum": 4.60, "maximum": 4.89, "setting": "both", "payers_information": [ { "payer_name": "Aetna", "plan_name": "700700", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna", "plan_name": "700700_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Miscellaneous", "plan_name": "700720", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Miscellaneous", "plan_name": "700720_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Ppo Hmo", "plan_name": "701720", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Ppo Hmo", "plan_name": "701720_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Ms State Emplo", "plan_name": "401457", "standard_charge_percentage": 0.80, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Ms State Emplo", "plan_name": "401457_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Basic Pl", "plan_name": "400100", "standard_charge_percentage": 0.85, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Basic Pl", "plan_name": "400100_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Federal", "plan_name": "400110", "standard_charge_percentage": 0.85, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Federal", "plan_name": "400110_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." } ] } ] }, { "description": "Vitamins a and d-white petrolatum-lanolin topical ointment [118725]", "drug_information": { "unit": 113.00, "type": "GR" }, "code_information": [ { "code": "4110081124", "type": "NDC" } ], "standard_charges": [ { "gross_charge": 9.11, "minimum": 7.29, "maximum": 7.74, "setting": "both", "payers_information": [ { "payer_name": "Aetna", "plan_name": "700700", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna", "plan_name": "700700_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Miscellaneous", "plan_name": "700720", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Miscellaneous", "plan_name": "700720_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Ppo Hmo", "plan_name": "701720", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Ppo Hmo", "plan_name": "701720_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Ms State Emplo", "plan_name": "401457", "standard_charge_percentage": 0.80, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Ms State Emplo", "plan_name": "401457_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Basic Pl", "plan_name": "400100", "standard_charge_percentage": 0.85, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Basic Pl", "plan_name": "400100_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Federal", "plan_name": "400110", "standard_charge_percentage": 0.85, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Federal", "plan_name": "400110_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." } ] } ] }, { "description": "Doxylamine succinate 25 mg tablet [14847]", "drug_information": { "unit": 1.00, "type": "EA" }, "code_information": [ { "code": "4116700607", "type": "NDC" } ], "standard_charges": [ { "gross_charge": 7.50, "minimum": 6.00, "maximum": 6.38, "setting": "both", "payers_information": [ { "payer_name": "Aetna", "plan_name": "700700", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna", "plan_name": "700700_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Miscellaneous", "plan_name": "700720", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Miscellaneous", "plan_name": "700720_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Ppo Hmo", "plan_name": "701720", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Ppo Hmo", "plan_name": "701720_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Ms State Emplo", "plan_name": "401457", "standard_charge_percentage": 0.80, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Ms State Emplo", "plan_name": "401457_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Basic Pl", "plan_name": "400100", "standard_charge_percentage": 0.85, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Basic Pl", "plan_name": "400100_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Federal", "plan_name": "400110", "standard_charge_percentage": 0.85, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Federal", "plan_name": "400110_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." } ] } ] }, { "description": "Trolamine salicylate 10 % topical cream [27680]", "drug_information": { "unit": 141.70, "type": "GR" }, "code_information": [ { "code": "4116705705", "type": "NDC" } ], "standard_charges": [ { "gross_charge": 26.92, "minimum": 21.54, "maximum": 22.88, "setting": "both", "payers_information": [ { "payer_name": "Aetna", "plan_name": "700700", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna", "plan_name": "700700_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Miscellaneous", "plan_name": "700720", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Miscellaneous", "plan_name": "700720_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Ppo Hmo", "plan_name": "701720", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Ppo Hmo", "plan_name": "701720_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Ms State Emplo", "plan_name": "401457", "standard_charge_percentage": 0.80, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Ms State Emplo", "plan_name": "401457_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Basic Pl", "plan_name": "400100", "standard_charge_percentage": 0.85, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Basic Pl", "plan_name": "400100_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Federal", "plan_name": "400110", "standard_charge_percentage": 0.85, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Federal", "plan_name": "400110_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." } ] } ] }, { "description": "Methyl salicylate 15 %-menthol 10 % topical cream [76971]", "drug_information": { "unit": 85.00, "type": "GR" }, "code_information": [ { "code": "4116706003", "type": "NDC" } ], "standard_charges": [ { "gross_charge": 5.53, "minimum": 4.42, "maximum": 4.70, "setting": "both", "payers_information": [ { "payer_name": "Aetna", "plan_name": "700700", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna", "plan_name": "700700_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Miscellaneous", "plan_name": "700720", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Miscellaneous", "plan_name": "700720_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Ppo Hmo", "plan_name": "701720", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Ppo Hmo", "plan_name": "701720_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Ms State Emplo", "plan_name": "401457", "standard_charge_percentage": 0.80, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Ms State Emplo", "plan_name": "401457_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Basic Pl", "plan_name": "400100", "standard_charge_percentage": 0.85, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Basic Pl", "plan_name": "400100_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Federal", "plan_name": "400110", "standard_charge_percentage": 0.85, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Federal", "plan_name": "400110_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." } ] } ] }, { "description": "Bismuth subsalicylate 262 mg/15 ml oral suspension [1090]", "drug_information": { "unit": 236.00, "type": "ML" }, "code_information": [ { "code": "4116733303", "type": "NDC" } ], "standard_charges": [ { "gross_charge": 9.20, "minimum": 7.36, "maximum": 7.82, "setting": "both", "payers_information": [ { "payer_name": "Aetna", "plan_name": "700700", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna", "plan_name": "700700_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Miscellaneous", "plan_name": "700720", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Miscellaneous", "plan_name": "700720_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Ppo Hmo", "plan_name": "701720", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Ppo Hmo", "plan_name": "701720_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Ms State Emplo", "plan_name": "401457", "standard_charge_percentage": 0.80, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Ms State Emplo", "plan_name": "401457_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Basic Pl", "plan_name": "400100", "standard_charge_percentage": 0.85, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Basic Pl", "plan_name": "400100_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Federal", "plan_name": "400110", "standard_charge_percentage": 0.85, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Federal", "plan_name": "400110_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." } ] } ] }, { "description": "Lip protectant 0.6 %-0.5 %-1.1 %-0.5 % topical ointment [116317]", "drug_information": { "unit": 6.00, "type": "GR" }, "code_information": [ { "code": "4138821021", "type": "NDC" } ], "standard_charges": [ { "gross_charge": 5.57, "minimum": 4.46, "maximum": 4.73, "setting": "both", "payers_information": [ { "payer_name": "Aetna", "plan_name": "700700", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna", "plan_name": "700700_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Miscellaneous", "plan_name": "700720", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Miscellaneous", "plan_name": "700720_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Ppo Hmo", "plan_name": "701720", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Ppo Hmo", "plan_name": "701720_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Ms State Emplo", "plan_name": "401457", "standard_charge_percentage": 0.80, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Ms State Emplo", "plan_name": "401457_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Basic Pl", "plan_name": "400100", "standard_charge_percentage": 0.85, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Basic Pl", "plan_name": "400100_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Federal", "plan_name": "400110", "standard_charge_percentage": 0.85, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Federal", "plan_name": "400110_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." } ] } ] }, { "description": "Epinephrine 1 mg/ml nasal solution [19604]", "drug_information": { "unit": 30.00, "type": "ML" }, "code_information": [ { "code": "42023-103-01", "type": "NDC" } ], "standard_charges": [ { "gross_charge": 1119.48, "minimum": 895.58, "maximum": 951.56, "setting": "both", "payers_information": [ { "payer_name": "Aetna", "plan_name": "700700", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna", "plan_name": "700700_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Miscellaneous", "plan_name": "700720", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Miscellaneous", "plan_name": "700720_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Ppo Hmo", "plan_name": "701720", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Ppo Hmo", "plan_name": "701720_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Ms State Emplo", "plan_name": "401457", "standard_charge_percentage": 0.80, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Ms State Emplo", "plan_name": "401457_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Basic Pl", "plan_name": "400100", "standard_charge_percentage": 0.85, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Basic Pl", "plan_name": "400100_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Federal", "plan_name": "400110", "standard_charge_percentage": 0.85, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Federal", "plan_name": "400110_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." } ] } ] }, { "description": "Hyoscyamine 0.125 mg sublingual tablet [17023]", "drug_information": { "unit": 1.00, "type": "EA" }, "code_information": [ { "code": "42192-339-01", "type": "NDC" } ], "standard_charges": [ { "gross_charge": 7.50, "minimum": 6.00, "maximum": 6.38, "setting": "both", "payers_information": [ { "payer_name": "Aetna", "plan_name": "700700", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna", "plan_name": "700700_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Miscellaneous", "plan_name": "700720", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Miscellaneous", "plan_name": "700720_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Ppo Hmo", "plan_name": "701720", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Ppo Hmo", "plan_name": "701720_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Ms State Emplo", "plan_name": "401457", "standard_charge_percentage": 0.80, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Ms State Emplo", "plan_name": "401457_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Basic Pl", "plan_name": "400100", "standard_charge_percentage": 0.85, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Basic Pl", "plan_name": "400100_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Federal", "plan_name": "400110", "standard_charge_percentage": 0.85, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Federal", "plan_name": "400110_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." } ] } ] }, { "description": "Hyoscyamine sulfate 0.125 mg tablet [3783]", "drug_information": { "unit": 1.00, "type": "EA" }, "code_information": [ { "code": "42192-340-01", "type": "NDC" } ], "standard_charges": [ { "gross_charge": 7.50, "minimum": 6.00, "maximum": 6.38, "setting": "both", "payers_information": [ { "payer_name": "Aetna", "plan_name": "700700", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna", "plan_name": "700700_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Miscellaneous", "plan_name": "700720", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Miscellaneous", "plan_name": "700720_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Ppo Hmo", "plan_name": "701720", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Ppo Hmo", "plan_name": "701720_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Ms State Emplo", "plan_name": "401457", "standard_charge_percentage": 0.80, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Ms State Emplo", "plan_name": "401457_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Basic Pl", "plan_name": "400100", "standard_charge_percentage": 0.85, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Basic Pl", "plan_name": "400100_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Federal", "plan_name": "400110", "standard_charge_percentage": 0.85, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Federal", "plan_name": "400110_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." } ] } ] }, { "description": "Phenazopyridine 100 mg tablet [6193]", "drug_information": { "unit": 1.00, "type": "EA" }, "code_information": [ { "code": "42192-801-01", "type": "NDC" } ], "standard_charges": [ { "gross_charge": 7.50, "minimum": 6.00, "maximum": 6.38, "setting": "both", "payers_information": [ { "payer_name": "Aetna", "plan_name": "700700", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna", "plan_name": "700700_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Miscellaneous", "plan_name": "700720", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Miscellaneous", "plan_name": "700720_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Ppo Hmo", "plan_name": "701720", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Ppo Hmo", "plan_name": "701720_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Ms State Emplo", "plan_name": "401457", "standard_charge_percentage": 0.80, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Ms State Emplo", "plan_name": "401457_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Basic Pl", "plan_name": "400100", "standard_charge_percentage": 0.85, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Basic Pl", "plan_name": "400100_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Federal", "plan_name": "400110", "standard_charge_percentage": 0.85, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Federal", "plan_name": "400110_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." } ] } ] }, { "description": "Phenazopyridine 200 mg tablet [6194]", "drug_information": { "unit": 1.00, "type": "EA" }, "code_information": [ { "code": "42192-802-01", "type": "NDC" } ], 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"additional_payer_notes": "Insufficient remit data to calculate allowed amounts." } ] } ] }, { "description": "Levothyroxine 88 mcg tablet [10403]", "drug_information": { "unit": 1.00, "type": "EA" }, "code_information": [ { "code": "42292-038-01", "type": "NDC" } ], "standard_charges": [ { "gross_charge": 7.50, "minimum": 6.00, "maximum": 6.38, "setting": "both", "payers_information": [ { "payer_name": "Aetna", "plan_name": "700700", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna", "plan_name": "700700_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Miscellaneous", "plan_name": "700720", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of 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billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Federal", "plan_name": "400110", "standard_charge_percentage": 0.85, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Federal", "plan_name": "400110_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." } ] } ] }, { "description": "Levothyroxine 112 mcg tablet [10404]", "drug_information": { "unit": 1.00, "type": "EA" }, "code_information": [ { "code": "42292-039-20", "type": "NDC" } ], "standard_charges": [ { "gross_charge": 7.50, "minimum": 6.00, "maximum": 6.38, "setting": "both", "payers_information": [ { "payer_name": "Aetna", "plan_name": "700700", "standard_charge_percentage": 80.0, "count": 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"percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Ppo Hmo", "plan_name": "701720_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Ms State Emplo", "plan_name": "401457", "standard_charge_percentage": 0.80, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Ms State Emplo", "plan_name": "401457_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Basic Pl", "plan_name": "400100", "standard_charge_percentage": 0.85, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Basic Pl", "plan_name": "400100_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Federal", "plan_name": "400110", "standard_charge_percentage": 0.85, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Federal", "plan_name": "400110_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." } ] } ] }, { "description": "Colchicine 0.6 mg tablet [1821]", "drug_information": { "unit": 1.00, "type": "EA" }, "code_information": [ { "code": "42292-054-01", "type": "NDC" } ], "standard_charges": [ { "gross_charge": 53.85, "minimum": 43.08, "maximum": 45.77, "setting": "both", "payers_information": [ { "payer_name": "Aetna", "plan_name": "700700", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna", "plan_name": "700700_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Miscellaneous", "plan_name": "700720", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Miscellaneous", "plan_name": "700720_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Ppo Hmo", "plan_name": "701720", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Ppo Hmo", "plan_name": "701720_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Ms State Emplo", "plan_name": "401457", "standard_charge_percentage": 0.80, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Ms State Emplo", "plan_name": "401457_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Basic Pl", "plan_name": "400100", "standard_charge_percentage": 0.85, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Basic Pl", "plan_name": "400100_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Federal", "plan_name": "400110", "standard_charge_percentage": 0.85, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Federal", "plan_name": "400110_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." } ] } ] }, { "description": "Ketamine 50 mg/ml injection solution [4238]", "drug_information": { "unit": 10.00, "type": "ML" }, "code_information": [ { "code": "42023-114-10", "type": "NDC" } ], "standard_charges": [ { "gross_charge": 65.01, "minimum": 52.01, "maximum": 55.26, "setting": "both", "payers_information": [ { "payer_name": "Aetna", "plan_name": "700700", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna", "plan_name": "700700_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Miscellaneous", "plan_name": "700720", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Miscellaneous", "plan_name": "700720_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Ppo Hmo", "plan_name": "701720", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Ppo Hmo", "plan_name": "701720_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Ms State Emplo", "plan_name": "401457", "standard_charge_percentage": 0.80, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Ms State Emplo", "plan_name": "401457_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Basic Pl", "plan_name": "400100", "standard_charge_percentage": 0.85, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Basic Pl", "plan_name": "400100_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Federal", "plan_name": "400110", "standard_charge_percentage": 0.85, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Federal", "plan_name": "400110_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." } ] } ] }, { "description": "Dantrolene 250 mg intravenous suspension [167159]", "drug_information": { "unit": 1.00, "type": "EA" }, "code_information": [ { "code": "42367-540-32", "type": "NDC" } ], "standard_charges": [ { "gross_charge": 15633.75, "minimum": 12507.00, "maximum": 13288.69, "setting": "both", "payers_information": [ { "payer_name": "Aetna", "plan_name": "700700", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna", "plan_name": "700700_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Miscellaneous", "plan_name": "700720", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Miscellaneous", "plan_name": "700720_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Ppo Hmo", "plan_name": "701720", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Ppo Hmo", "plan_name": "701720_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Ms State Emplo", "plan_name": "401457", "standard_charge_percentage": 0.80, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Ms State Emplo", "plan_name": "401457_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Basic Pl", "plan_name": "400100", "standard_charge_percentage": 0.85, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Basic Pl", "plan_name": "400100_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Federal", "plan_name": "400110", "standard_charge_percentage": 0.85, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Federal", "plan_name": "400110_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." } ] } ] }, { "description": "Vancomycin 125 mg capsule [11628]", "drug_information": { "unit": 1.00, "type": "EA" }, "code_information": [ { "code": "42494-450-20", "type": "NDC" } ], "standard_charges": [ { "gross_charge": 9.50, "minimum": 7.60, "maximum": 8.08, "setting": "both", "payers_information": [ { 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"plan_name": "701720", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Ppo Hmo", "plan_name": "701720_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Ms State Emplo", "plan_name": "401457", "standard_charge_percentage": 0.80, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Ms State Emplo", "plan_name": "401457_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Basic Pl", "plan_name": "400100", "standard_charge_percentage": 0.85, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Basic Pl", "plan_name": "400100_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Federal", "plan_name": "400110", "standard_charge_percentage": 0.85, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Federal", "plan_name": "400110_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." } ] } ] }, { "description": "Travoprost 0.004 % eye drops [108556]", "drug_information": { "unit": 2.50, "type": "ML" }, "code_information": [ { "code": "42571-130-27", "type": "NDC" } ], "standard_charges": [ { "gross_charge": 798.90, "minimum": 639.12, "maximum": 679.07, "setting": "both", "payers_information": [ { "payer_name": "Aetna", "plan_name": "700700", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna", "plan_name": "700700_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Miscellaneous", "plan_name": "700720", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Miscellaneous", "plan_name": "700720_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Ppo Hmo", "plan_name": "701720", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Ppo Hmo", "plan_name": "701720_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Ms State Emplo", "plan_name": "401457", "standard_charge_percentage": 0.80, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Ms State Emplo", "plan_name": "401457_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Basic Pl", "plan_name": "400100", "standard_charge_percentage": 0.85, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Basic Pl", "plan_name": "400100_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Federal", "plan_name": "400110", "standard_charge_percentage": 0.85, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Federal", "plan_name": "400110_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." } ] } ] }, { "description": "Ketorolac 0.5 % eye drops [19733]", "drug_information": { "unit": 5.00, "type": "ML" }, "code_information": [ { "code": "42571-137-25", "type": "NDC" } ], "standard_charges": [ { "gross_charge": 173.80, "minimum": 139.04, "maximum": 147.73, "setting": "both", "payers_information": [ { "payer_name": "Aetna", "plan_name": "700700", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna", "plan_name": "700700_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Miscellaneous", "plan_name": "700720", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Miscellaneous", "plan_name": "700720_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Ppo Hmo", "plan_name": "701720", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Ppo Hmo", "plan_name": "701720_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Ms State Emplo", "plan_name": "401457", "standard_charge_percentage": 0.80, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Ms State Emplo", "plan_name": "401457_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Basic Pl", "plan_name": "400100", "standard_charge_percentage": 0.85, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Basic Pl", "plan_name": "400100_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Federal", "plan_name": "400110", "standard_charge_percentage": 0.85, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Federal", "plan_name": "400110_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." } ] } ] }, { "description": "Dorzolamide 2 % eye drops [14471]", "drug_information": { "unit": 10.00, "type": "ML" }, "code_information": [ { "code": "42571-141-26", "type": "NDC" } ], "standard_charges": [ { "gross_charge": 196.94, "minimum": 157.55, "maximum": 167.40, "setting": "both", "payers_information": [ { "payer_name": "Aetna", "plan_name": "700700", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna", "plan_name": "700700_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Miscellaneous", "plan_name": "700720", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Miscellaneous", "plan_name": "700720_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Ppo Hmo", "plan_name": "701720", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Ppo Hmo", "plan_name": "701720_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Ms State Emplo", "plan_name": "401457", "standard_charge_percentage": 0.80, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Ms State Emplo", "plan_name": "401457_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Basic Pl", "plan_name": "400100", "standard_charge_percentage": 0.85, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Basic Pl", "plan_name": "400100_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Federal", "plan_name": "400110", "standard_charge_percentage": 0.85, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Federal", "plan_name": "400110_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." } ] } ] }, { "description": "Dorzolamide 22.3 mg-timolol 6.8 mg/ml eye drops [22982]", "drug_information": { "unit": 10.00, "type": "ML" }, "code_information": [ { "code": "42571-147-26", "type": "NDC" } ], "standard_charges": [ { "gross_charge": 289.70, "minimum": 231.76, "maximum": 246.25, "setting": "both", "payers_information": [ { "payer_name": "Aetna", "plan_name": "700700", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna", "plan_name": "700700_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Miscellaneous", "plan_name": "700720", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Miscellaneous", "plan_name": "700720_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Ppo Hmo", "plan_name": "701720", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Ppo Hmo", "plan_name": "701720_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Ms State Emplo", "plan_name": "401457", "standard_charge_percentage": 0.80, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Ms State Emplo", "plan_name": "401457_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Basic Pl", "plan_name": "400100", "standard_charge_percentage": 0.85, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Basic Pl", "plan_name": "400100_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Federal", "plan_name": "400110", "standard_charge_percentage": 0.85, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Federal", "plan_name": "400110_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." } ] } ] }, { "description": "Amoxicillin 250 mg-potassium clavulanate 125 mg tablet [22992]", "drug_information": { "unit": 1.00, "type": "EA" }, "code_information": [ { "code": "42571-160-30", "type": "NDC" } ], "standard_charges": [ { "gross_charge": 19.65, "minimum": 15.72, "maximum": 16.70, "setting": "both", "payers_information": [ { "payer_name": "Aetna", "plan_name": "700700", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna", "plan_name": "700700_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Miscellaneous", "plan_name": "700720", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Miscellaneous", "plan_name": "700720_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Ppo Hmo", "plan_name": "701720", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Ppo Hmo", "plan_name": "701720_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Ms State Emplo", "plan_name": "401457", "standard_charge_percentage": 0.80, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Ms State Emplo", "plan_name": "401457_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Basic Pl", "plan_name": "400100", "standard_charge_percentage": 0.85, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Basic Pl", "plan_name": "400100_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Federal", "plan_name": "400110", "standard_charge_percentage": 0.85, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Federal", "plan_name": "400110_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." } ] } ] }, { "description": "Amoxicillin 500 mg-potassium clavulanate 125 mg tablet [33227]", "drug_information": { "unit": 1.00, "type": "EA" }, "code_information": [ { "code": "42571-161-01", "type": "NDC" } ], "standard_charges": [ { "gross_charge": 7.50, "minimum": 6.00, "maximum": 6.38, "setting": "both", "payers_information": [ { "payer_name": "Aetna", "plan_name": "700700", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna", "plan_name": "700700_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Miscellaneous", "plan_name": "700720", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Miscellaneous", "plan_name": "700720_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Ppo Hmo", "plan_name": "701720", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Ppo Hmo", "plan_name": "701720_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Ms State Emplo", "plan_name": "401457", "standard_charge_percentage": 0.80, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Ms State Emplo", "plan_name": "401457_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Basic Pl", "plan_name": "400100", "standard_charge_percentage": 0.85, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Basic Pl", "plan_name": "400100_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Federal", "plan_name": "400110", "standard_charge_percentage": 0.85, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Federal", "plan_name": "400110_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." } ] } ] }, { "description": "Amoxicillin 875 mg-potassium clavulanate 125 mg tablet [33228]", "drug_information": { "unit": 1.00, "type": "EA" }, "code_information": [ { "code": "42571-162-42", "type": "NDC" } ], "standard_charges": [ { "gross_charge": 7.50, "minimum": 6.00, "maximum": 6.38, "setting": "both", "payers_information": [ { "payer_name": "Aetna", "plan_name": "700700", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna", "plan_name": "700700_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Miscellaneous", "plan_name": "700720", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Miscellaneous", "plan_name": "700720_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Ppo Hmo", "plan_name": "701720", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Ppo Hmo", "plan_name": "701720_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Ms State Emplo", "plan_name": "401457", "standard_charge_percentage": 0.80, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Ms State Emplo", "plan_name": "401457_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Basic Pl", "plan_name": "400100", "standard_charge_percentage": 0.85, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Basic Pl", "plan_name": "400100_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Federal", "plan_name": "400110", "standard_charge_percentage": 0.85, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Federal", "plan_name": "400110_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." } ] } ] }, { "description": "Rasagiline 1 mg tablet [76481]", "drug_information": { "unit": 1.00, "type": "EA" }, "code_information": [ { "code": "42571-221-30", "type": "NDC" } ], "standard_charges": [ { "gross_charge": 46.12, "minimum": 36.90, "maximum": 39.20, "setting": "both", "payers_information": [ { "payer_name": "Aetna", "plan_name": "700700", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna", "plan_name": "700700_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Miscellaneous", "plan_name": "700720", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Miscellaneous", "plan_name": "700720_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Ppo Hmo", "plan_name": "701720", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Ppo Hmo", "plan_name": "701720_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Ms State Emplo", "plan_name": "401457", "standard_charge_percentage": 0.80, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Ms State Emplo", "plan_name": "401457_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Basic Pl", "plan_name": "400100", "standard_charge_percentage": 0.85, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Basic Pl", "plan_name": "400100_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Federal", "plan_name": "400110", "standard_charge_percentage": 0.85, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Federal", "plan_name": "400110_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." } ] } ] }, { "description": "Acetazolamide er 500 mg capsuleextended release [8962]", "drug_information": { "unit": 1.00, "type": "EA" }, "code_information": [ { "code": "42571-243-01", "type": "NDC" } ], "standard_charges": [ { "gross_charge": 7.50, "minimum": 6.00, "maximum": 6.38, "setting": "both", "payers_information": [ { "payer_name": "Aetna", "plan_name": "700700", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna", "plan_name": "700700_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Miscellaneous", "plan_name": "700720", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Miscellaneous", "plan_name": "700720_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Ppo Hmo", "plan_name": "701720", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Ppo Hmo", "plan_name": "701720_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Ms State Emplo", "plan_name": "401457", "standard_charge_percentage": 0.80, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Ms State Emplo", "plan_name": "401457_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Basic Pl", "plan_name": "400100", "standard_charge_percentage": 0.85, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Basic Pl", "plan_name": "400100_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Federal", "plan_name": "400110", "standard_charge_percentage": 0.85, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Federal", "plan_name": "400110_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." } ] } ] }, { "description": "Aspirin 25 mg-dipyridamole 200 mg capsuleext.release 12 hr multiphase [27644]", "drug_information": { "unit": 1.00, "type": "EA" }, "code_information": [ { "code": "42571-274-60", "type": "NDC" } ], "standard_charges": [ { "gross_charge": 7.50, "minimum": 6.00, "maximum": 6.38, "setting": "both", "payers_information": [ { "payer_name": "Aetna", "plan_name": "700700", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna", "plan_name": "700700_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Miscellaneous", "plan_name": "700720", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Miscellaneous", "plan_name": "700720_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Ppo Hmo", "plan_name": "701720", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Ppo Hmo", "plan_name": "701720_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Ms State Emplo", "plan_name": "401457", "standard_charge_percentage": 0.80, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Ms State Emplo", "plan_name": "401457_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Basic Pl", "plan_name": "400100", "standard_charge_percentage": 0.85, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Basic Pl", "plan_name": "400100_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Federal", "plan_name": "400110", "standard_charge_percentage": 0.85, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Federal", "plan_name": "400110_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." } ] } ] }, { "description": "Phenylephrine 2.5 % eye drops [6246]", "drug_information": { "unit": 10.00, "type": "ML" }, "code_information": [ { "code": "42702-102-10", "type": "NDC" } ], "standard_charges": [ { "gross_charge": 285.00, "minimum": 228.00, "maximum": 242.25, "setting": "both", "payers_information": [ { "payer_name": "Aetna", "plan_name": "700700", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna", "plan_name": "700700_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Miscellaneous", "plan_name": "700720", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Miscellaneous", "plan_name": "700720_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Ppo Hmo", "plan_name": "701720", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Ppo Hmo", "plan_name": "701720_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Ms State Emplo", "plan_name": "401457", "standard_charge_percentage": 0.80, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Ms State Emplo", "plan_name": "401457_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Basic Pl", "plan_name": "400100", "standard_charge_percentage": 0.85, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Basic Pl", "plan_name": "400100_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Federal", "plan_name": "400110", "standard_charge_percentage": 0.85, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Federal", "plan_name": "400110_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." } ] } ] }, { "description": "Phenylephrine 10 % eye drops [19636]", "drug_information": { "unit": 5.00, "type": "ML" }, "code_information": [ { "code": "42702-103-05", "type": "NDC" } ], "standard_charges": [ { "gross_charge": 190.00, "minimum": 152.00, "maximum": 161.50, "setting": "both", "payers_information": [ { "payer_name": "Aetna", "plan_name": "700700", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna", "plan_name": "700700_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Miscellaneous", "plan_name": "700720", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Miscellaneous", "plan_name": "700720_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Ppo Hmo", "plan_name": "701720", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Ppo Hmo", "plan_name": "701720_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Ms State Emplo", "plan_name": "401457", "standard_charge_percentage": 0.80, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Ms State Emplo", "plan_name": "401457_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Basic Pl", "plan_name": "400100", "standard_charge_percentage": 0.85, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Basic Pl", "plan_name": "400100_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Federal", "plan_name": "400110", "standard_charge_percentage": 0.85, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Federal", "plan_name": "400110_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." } ] } ] }, { "description": "Amiloride 5 mg tablet [391]", "drug_information": { "unit": 1.00, "type": "EA" }, "code_information": [ { "code": "42794-005-02", "type": "NDC" } ], "standard_charges": [ { "gross_charge": 7.50, "minimum": 6.00, "maximum": 6.38, "setting": "both", "payers_information": [ { "payer_name": "Aetna", "plan_name": "700700", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna", "plan_name": "700700_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Miscellaneous", "plan_name": "700720", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Miscellaneous", "plan_name": "700720_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Ppo Hmo", "plan_name": "701720", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Ppo Hmo", "plan_name": "701720_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total 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"additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Federal", "plan_name": "400110", "standard_charge_percentage": 0.85, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Federal", "plan_name": "400110_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." } ] } ] }, { "description": "Cholestyramine-aspartame 4 gram oral powder for susp in a packet [113348]", "drug_information": { "unit": 1.00, "type": "EA" }, "code_information": [ { "code": "42806-270-95", "type": "NDC" } ], "standard_charges": [ { "gross_charge": 9.12, "minimum": 7.30, "maximum": 7.75, "setting": "both", "payers_information": [ { "payer_name": "Aetna", "plan_name": "700700", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna", "plan_name": "700700_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Miscellaneous", "plan_name": "700720", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Miscellaneous", "plan_name": "700720_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Ppo Hmo", "plan_name": "701720", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Ppo Hmo", "plan_name": "701720_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Ms State Emplo", "plan_name": "401457", "standard_charge_percentage": 0.80, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Ms State Emplo", "plan_name": "401457_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Basic Pl", "plan_name": "400100", "standard_charge_percentage": 0.85, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Basic Pl", "plan_name": "400100_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Federal", "plan_name": "400110", "standard_charge_percentage": 0.85, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Federal", "plan_name": "400110_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." } ] } ] }, { "description": "Cholestyramine-aspartame 4 gram oral powder for susp in a packet [113348]", "drug_information": { "unit": 1.00, "type": "EA" }, "code_information": [ { "code": "42806-270-98", "type": "NDC" } ], "standard_charges": [ { "gross_charge": 9.12, "minimum": 7.30, "maximum": 7.75, "setting": "both", "payers_information": [ { "payer_name": "Aetna", "plan_name": "700700", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna", "plan_name": "700700_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Miscellaneous", "plan_name": "700720", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Miscellaneous", "plan_name": "700720_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Ppo Hmo", "plan_name": "701720", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Ppo Hmo", "plan_name": "701720_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Ms State Emplo", "plan_name": "401457", "standard_charge_percentage": 0.80, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Ms State Emplo", "plan_name": "401457_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Basic Pl", "plan_name": "400100", "standard_charge_percentage": 0.85, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Basic Pl", "plan_name": "400100_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Federal", "plan_name": "400110", "standard_charge_percentage": 0.85, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Federal", "plan_name": "400110_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." } ] } ] }, { "description": "Dextroamphetamine-amphetamine 5 mg tablet [109893]", "drug_information": { "unit": 1.00, "type": "EA" }, "code_information": [ { "code": "42806-339-01", "type": "NDC" } ], "standard_charges": [ { "gross_charge": 7.50, "minimum": 6.00, "maximum": 6.38, "setting": "both", "payers_information": [ { "payer_name": "Aetna", "plan_name": "700700", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna", "plan_name": "700700_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Miscellaneous", "plan_name": "700720", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Miscellaneous", "plan_name": "700720_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Ppo Hmo", "plan_name": "701720", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Ppo Hmo", "plan_name": "701720_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Ms State Emplo", "plan_name": "401457", "standard_charge_percentage": 0.80, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Ms State Emplo", "plan_name": "401457_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Basic Pl", "plan_name": "400100", "standard_charge_percentage": 0.85, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Basic Pl", "plan_name": "400100_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Federal", "plan_name": "400110", "standard_charge_percentage": 0.85, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Federal", "plan_name": "400110_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." } ] } ] }, { "description": "Flecainide 50 mg tablet [10043]", "drug_information": { "unit": 1.00, "type": "EA" }, "code_information": [ { "code": "42806-817-01", "type": "NDC" } ], "standard_charges": [ { "gross_charge": 7.50, "minimum": 6.00, "maximum": 6.38, "setting": "both", "payers_information": [ { "payer_name": "Aetna", "plan_name": "700700", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna", "plan_name": "700700_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Miscellaneous", "plan_name": "700720", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Miscellaneous", "plan_name": "700720_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Ppo Hmo", "plan_name": "701720", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Ppo Hmo", "plan_name": "701720_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Ms State Emplo", "plan_name": "401457", "standard_charge_percentage": 0.80, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Ms State Emplo", "plan_name": "401457_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Basic Pl", "plan_name": "400100", "standard_charge_percentage": 0.85, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Basic Pl", "plan_name": "400100_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Federal", "plan_name": "400110", "standard_charge_percentage": 0.85, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Federal", "plan_name": "400110_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." } ] } ] }, { "description": "Oxycodone 5 mg tablet [10814]", "drug_information": { "unit": 1.00, "type": "EA" }, "code_information": [ { "code": "42858-001-10", "type": "NDC" } ], "standard_charges": [ { "gross_charge": 7.50, "minimum": 6.00, "maximum": 6.38, "setting": "both", "payers_information": [ { "payer_name": "Aetna", "plan_name": "700700", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna", "plan_name": "700700_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Miscellaneous", "plan_name": "700720", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Miscellaneous", "plan_name": "700720_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Ppo Hmo", "plan_name": "701720", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Ppo Hmo", "plan_name": "701720_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Ms State Emplo", "plan_name": "401457", "standard_charge_percentage": 0.80, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Ms State Emplo", "plan_name": "401457_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Basic Pl", "plan_name": "400100", "standard_charge_percentage": 0.85, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Basic Pl", "plan_name": "400100_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Federal", "plan_name": "400110", "standard_charge_percentage": 0.85, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Federal", "plan_name": "400110_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." } ] } ] }, { "description": "Lidocaine 5 % topical patch [28203]", "drug_information": { "unit": 1.00, "type": "EA" }, "code_information": [ { "code": "42858-118-30", "type": "NDC" } ], "standard_charges": [ { "gross_charge": 10.29, "minimum": 8.23, "maximum": 8.75, "setting": "both", "payers_information": [ { "payer_name": "Aetna", "plan_name": "700700", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna", "plan_name": "700700_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Miscellaneous", "plan_name": "700720", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Miscellaneous", "plan_name": "700720_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Ppo Hmo", "plan_name": "701720", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Ppo Hmo", "plan_name": "701720_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Ms State Emplo", "plan_name": "401457", "standard_charge_percentage": 0.80, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Ms State Emplo", "plan_name": "401457_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Basic Pl", "plan_name": "400100", "standard_charge_percentage": 0.85, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Basic Pl", "plan_name": "400100_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Federal", "plan_name": "400110", "standard_charge_percentage": 0.85, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Federal", "plan_name": "400110_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." } ] } ] }, { "description": "Hydromorphone 2 mg tablet [3760]", "drug_information": { "unit": 1.00, "type": "EA" }, "code_information": [ { "code": "42858-301-25", "type": "NDC" } ], "standard_charges": [ { "gross_charge": 7.50, "minimum": 6.00, "maximum": 6.38, "setting": "both", "payers_information": [ { "payer_name": "Aetna", "plan_name": "700700", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna", "plan_name": "700700_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Miscellaneous", "plan_name": "700720", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Miscellaneous", "plan_name": "700720_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Ppo Hmo", "plan_name": "701720", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Ppo Hmo", "plan_name": "701720_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Ms State Emplo", "plan_name": "401457", "standard_charge_percentage": 0.80, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Ms State Emplo", "plan_name": "401457_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Basic Pl", "plan_name": "400100", "standard_charge_percentage": 0.85, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Basic Pl", "plan_name": "400100_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Federal", "plan_name": "400110", "standard_charge_percentage": 0.85, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Federal", "plan_name": "400110_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." } ] } ] }, { "description": "Norepinephrine bitartrate 1 mg/ml intravenous solution [10734]", "drug_information": { "unit": 4.00, "type": "ML" }, "code_information": [ { "code": "43066-997-01", "type": "NDC" } ], "standard_charges": [ { "gross_charge": 112.38, "minimum": 89.90, "maximum": 95.52, "setting": "both", "payers_information": [ { "payer_name": "Aetna", "plan_name": "700700", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna", "plan_name": "700700_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Miscellaneous", "plan_name": "700720", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Miscellaneous", "plan_name": "700720_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Ppo Hmo", "plan_name": "701720", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Ppo Hmo", "plan_name": "701720_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Ms State Emplo", "plan_name": "401457", "standard_charge_percentage": 0.80, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Ms State Emplo", "plan_name": "401457_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Basic Pl", "plan_name": "400100", "standard_charge_percentage": 0.85, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Basic Pl", "plan_name": "400100_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Federal", "plan_name": "400110", "standard_charge_percentage": 0.85, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Federal", "plan_name": "400110_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." } ] } ] }, { "description": "Hyoscyamine 0.125 mg sublingual tablet [17023]", "drug_information": { "unit": 1.00, "type": "EA" }, "code_information": [ { "code": "43199-011-01", "type": "NDC" } ], "standard_charges": [ { "gross_charge": 7.50, "minimum": 6.00, "maximum": 6.38, "setting": "both", "payers_information": [ { "payer_name": "Aetna", "plan_name": "700700", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna", "plan_name": "700700_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Miscellaneous", "plan_name": "700720", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Miscellaneous", "plan_name": "700720_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Ppo Hmo", "plan_name": "701720", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Ppo Hmo", "plan_name": "701720_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Ms State Emplo", "plan_name": "401457", "standard_charge_percentage": 0.80, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Ms State Emplo", "plan_name": "401457_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Basic Pl", "plan_name": "400100", "standard_charge_percentage": 0.85, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Basic Pl", "plan_name": "400100_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Federal", "plan_name": "400110", "standard_charge_percentage": 0.85, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Federal", "plan_name": "400110_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." } ] } ] }, { "description": "Hyoscyamine sulfate 0.125 mg tablet [3783]", "drug_information": { "unit": 1.00, "type": "EA" }, "code_information": [ { "code": "43199-013-01", "type": "NDC" } ], "standard_charges": [ { "gross_charge": 7.50, "minimum": 6.00, "maximum": 6.38, "setting": "both", "payers_information": [ { "payer_name": "Aetna", "plan_name": "700700", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna", "plan_name": "700700_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Miscellaneous", "plan_name": "700720", "standard_charge_percentage": 80.0, 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"methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Ms State Emplo", "plan_name": "401457_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Basic Pl", "plan_name": "400100", "standard_charge_percentage": 0.85, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Basic Pl", "plan_name": "400100_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Federal", "plan_name": "400110", "standard_charge_percentage": 0.85, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Federal", "plan_name": "400110_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." } ] } ] }, { "description": "Escitalopram 5 mg tablet [37635]", "drug_information": { "unit": 1.00, "type": "EA" }, "code_information": [ { "code": "43547-280-10", "type": "NDC" } ], "standard_charges": [ { "gross_charge": 7.50, "minimum": 6.00, "maximum": 6.38, "setting": "both", "payers_information": [ { "payer_name": "Aetna", "plan_name": "700700", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna", "plan_name": "700700_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Miscellaneous", "plan_name": "700720", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Miscellaneous", "plan_name": "700720_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Ppo Hmo", "plan_name": "701720", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Ppo Hmo", "plan_name": "701720_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Ms State Emplo", "plan_name": "401457", "standard_charge_percentage": 0.80, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Ms State Emplo", "plan_name": "401457_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Basic Pl", "plan_name": "400100", "standard_charge_percentage": 0.85, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Basic Pl", "plan_name": "400100_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Federal", "plan_name": "400110", "standard_charge_percentage": 0.85, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Federal", "plan_name": "400110_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." } ] } ] }, { "description": "Benazepril 10 mg tablet [9220]", "drug_information": { "unit": 1.00, "type": "EA" }, "code_information": [ { "code": "43547-336-10", "type": "NDC" } ], "standard_charges": [ { "gross_charge": 7.50, "minimum": 6.00, "maximum": 6.38, "setting": "both", "payers_information": [ { "payer_name": "Aetna", "plan_name": "700700", 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"standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Ppo Hmo", "plan_name": "701720_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Ms State Emplo", "plan_name": "401457", "standard_charge_percentage": 0.80, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Ms State Emplo", "plan_name": "401457_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Basic Pl", "plan_name": "400100", "standard_charge_percentage": 0.85, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Basic Pl", "plan_name": "400100_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Federal", "plan_name": "400110", "standard_charge_percentage": 0.85, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Federal", "plan_name": "400110_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." } ] } ] }, { "description": "Lisinopril 2.5 mg tablet [13089]", "drug_information": { "unit": 1.00, "type": "EA" }, "code_information": [ { "code": "43547-351-10", "type": "NDC" } ], "standard_charges": [ { "gross_charge": 7.50, "minimum": 6.00, "maximum": 6.38, "setting": "both", "payers_information": [ { "payer_name": "Aetna", "plan_name": "700700", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna", "plan_name": "700700_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Miscellaneous", "plan_name": "700720", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Miscellaneous", "plan_name": "700720_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Ppo Hmo", "plan_name": "701720", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Ppo Hmo", "plan_name": "701720_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Ms State Emplo", "plan_name": "401457", "standard_charge_percentage": 0.80, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Ms State Emplo", "plan_name": "401457_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Basic Pl", "plan_name": "400100", "standard_charge_percentage": 0.85, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Basic Pl", "plan_name": "400100_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Federal", "plan_name": "400110", "standard_charge_percentage": 0.85, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Federal", "plan_name": "400110_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." } ] } ] }, { "description": "Furosemide 40 mg tablet [3295]", "drug_information": { "unit": 1.00, "type": "EA" }, "code_information": [ { "code": "43547-402-10", "type": "NDC" } ], "standard_charges": [ { "gross_charge": 7.50, "minimum": 6.00, "maximum": 6.38, "setting": "both", "payers_information": [ { "payer_name": "Aetna", "plan_name": "700700", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna", "plan_name": "700700_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna 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"plan_name": "401457", "standard_charge_percentage": 0.80, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Ms State Emplo", "plan_name": "401457_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Basic Pl", "plan_name": "400100", "standard_charge_percentage": 0.85, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Basic Pl", "plan_name": "400100_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Federal", "plan_name": "400110", "standard_charge_percentage": 0.85, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Federal", "plan_name": "400110_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." } ] } ] }, { "description": "Furosemide 80 mg tablet [3296]", "drug_information": { "unit": 1.00, "type": "EA" }, "code_information": [ { "code": "43547-403-10", "type": "NDC" } ], "standard_charges": [ { "gross_charge": 7.50, "minimum": 6.00, "maximum": 6.38, "setting": "both", "payers_information": [ { "payer_name": "Aetna", "plan_name": "700700", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna", "plan_name": "700700_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Miscellaneous", "plan_name": "700720", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Miscellaneous", "plan_name": "700720_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Ppo Hmo", "plan_name": "701720", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Ppo Hmo", "plan_name": "701720_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Ms State Emplo", "plan_name": "401457", "standard_charge_percentage": 0.80, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Ms State Emplo", "plan_name": "401457_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Basic Pl", "plan_name": "400100", "standard_charge_percentage": 0.85, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Basic Pl", "plan_name": "400100_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Federal", "plan_name": "400110", "standard_charge_percentage": 0.85, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Federal", "plan_name": "400110_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." } ] } ] }, { "description": "Clonazepam 0.5 mg tablet [9637]", "drug_information": { "unit": 1.00, "type": "EA" }, "code_information": [ { "code": "43547-406-10", "type": "NDC" } ], "standard_charges": [ { "gross_charge": 7.50, "minimum": 6.00, "maximum": 6.38, "setting": "both", "payers_information": [ { "payer_name": "Aetna", "plan_name": "700700", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna", "plan_name": "700700_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Miscellaneous", "plan_name": "700720", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Miscellaneous", "plan_name": "700720_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Ppo Hmo", "plan_name": "701720", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Ppo Hmo", "plan_name": "701720_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Ms State Emplo", "plan_name": "401457", "standard_charge_percentage": 0.80, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Ms State Emplo", "plan_name": "401457_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Basic Pl", "plan_name": "400100", "standard_charge_percentage": 0.85, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Basic Pl", "plan_name": "400100_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Federal", "plan_name": "400110", "standard_charge_percentage": 0.85, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Federal", "plan_name": "400110_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." } ] } ] }, { "description": "Nebivolol 5 mg tablet [89284]", "drug_information": { "unit": 1.00, "type": "EA" }, "code_information": [ { "code": "43547-525-09", "type": "NDC" } ], "standard_charges": [ { "gross_charge": 7.50, "minimum": 6.00, "maximum": 6.38, "setting": "both", "payers_information": [ { "payer_name": "Aetna", "plan_name": "700700", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna", "plan_name": "700700_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Miscellaneous", "plan_name": "700720", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Miscellaneous", "plan_name": "700720_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Ppo Hmo", "plan_name": "701720", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Ppo Hmo", "plan_name": "701720_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Ms State Emplo", "plan_name": "401457", "standard_charge_percentage": 0.80, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Ms State Emplo", "plan_name": "401457_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Basic Pl", "plan_name": "400100", "standard_charge_percentage": 0.85, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Basic Pl", "plan_name": "400100_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Federal", "plan_name": "400110", "standard_charge_percentage": 0.85, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Federal", "plan_name": "400110_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." } ] } ] }, { "description": "Ciprofloxacin 250 mg tablet [25118]", "drug_information": { "unit": 1.00, "type": "EA" }, "code_information": [ { "code": "43547-688-10", "type": "NDC" } ], "standard_charges": [ { "gross_charge": 7.50, "minimum": 6.00, "maximum": 6.38, "setting": "both", "payers_information": [ { "payer_name": "Aetna", "plan_name": "700700", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna", "plan_name": "700700_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Miscellaneous", "plan_name": "700720", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Miscellaneous", "plan_name": "700720_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Ppo Hmo", "plan_name": "701720", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Ppo Hmo", "plan_name": "701720_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Ms State Emplo", "plan_name": "401457", "standard_charge_percentage": 0.80, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Ms State Emplo", "plan_name": "401457_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Basic Pl", "plan_name": "400100", "standard_charge_percentage": 0.85, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Basic Pl", "plan_name": "400100_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Federal", "plan_name": "400110", "standard_charge_percentage": 0.85, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Federal", "plan_name": "400110_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." } ] } ] }, { "description": "Ketorolac 10 mg tablet [10371]", "drug_information": { "unit": 1.00, "type": "EA" }, "code_information": [ { "code": "43598-139-01", "type": "NDC" } ], "standard_charges": [ { "gross_charge": 7.50, "minimum": 6.00, "maximum": 6.38, "setting": "both", "payers_information": [ { "payer_name": "Aetna", "plan_name": "700700", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna", "plan_name": "700700_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Miscellaneous", "plan_name": "700720", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Miscellaneous", "plan_name": "700720_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Ppo Hmo", "plan_name": "701720", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Ppo Hmo", "plan_name": "701720_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Ms State Emplo", "plan_name": "401457", "standard_charge_percentage": 0.80, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Ms State Emplo", "plan_name": "401457_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Basic Pl", "plan_name": "400100", "standard_charge_percentage": 0.85, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Basic Pl", "plan_name": "400100_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Federal", "plan_name": "400110", "standard_charge_percentage": 0.85, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Federal", "plan_name": "400110_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." } ] } ] }, { "description": "Silver sulfadiazine 1 % topical cream [7224]", "drug_information": { "unit": 400.00, "type": "GR" }, "code_information": [ { "code": "43598-210-40", "type": "NDC" } ], "standard_charges": [ { "gross_charge": 252.70, "minimum": 202.16, "maximum": 214.80, "setting": "both", "payers_information": [ { "payer_name": "Aetna", "plan_name": "700700", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna", "plan_name": "700700_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Miscellaneous", "plan_name": "700720", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Miscellaneous", "plan_name": "700720_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Ppo Hmo", "plan_name": "701720", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Ppo Hmo", "plan_name": "701720_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Ms State Emplo", "plan_name": "401457", "standard_charge_percentage": 0.80, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Ms State Emplo", "plan_name": "401457_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Basic Pl", "plan_name": "400100", "standard_charge_percentage": 0.85, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Basic Pl", "plan_name": "400100_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Federal", "plan_name": "400110", "standard_charge_percentage": 0.85, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Federal", "plan_name": "400110_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." } ] } ] }, { "description": "Nitroglycerin 0.4 mg sublingual tablet [5604]", "drug_information": { "unit": 25.00, "type": "EA" }, "code_information": [ { "code": "43598-436-11", "type": "NDC" } ], "standard_charges": [ { "gross_charge": 122.55, "minimum": 98.04, "maximum": 104.17, "setting": "both", "payers_information": [ { "payer_name": "Aetna", "plan_name": "700700", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna", "plan_name": "700700_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Miscellaneous", "plan_name": "700720", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Miscellaneous", "plan_name": "700720_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Ppo Hmo", "plan_name": "701720", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Ppo Hmo", "plan_name": "701720_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Ms State Emplo", "plan_name": "401457", "standard_charge_percentage": 0.80, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Ms State Emplo", "plan_name": "401457_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Basic Pl", "plan_name": "400100", "standard_charge_percentage": 0.85, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Basic Pl", "plan_name": "400100_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Federal", "plan_name": "400110", "standard_charge_percentage": 0.85, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Federal", "plan_name": "400110_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." } ] } ] }, { "description": "Nitroglycerin 0.4 mg sublingual tablet [5604]", "drug_information": { "unit": 1.00, "type": "EA" }, "code_information": [ { "code": "43598-436-35", "type": "NDC" } ], "standard_charges": [ { "gross_charge": 7.50, "minimum": 6.00, "maximum": 6.38, "setting": "both", "payers_information": [ { "payer_name": "Aetna", "plan_name": "700700", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna", "plan_name": "700700_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Miscellaneous", "plan_name": "700720", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Miscellaneous", "plan_name": "700720_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Ppo Hmo", "plan_name": "701720", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Ppo Hmo", "plan_name": "701720_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Ms State Emplo", "plan_name": "401457", "standard_charge_percentage": 0.80, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Ms State Emplo", "plan_name": "401457_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Basic Pl", "plan_name": "400100", "standard_charge_percentage": 0.85, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Basic Pl", "plan_name": "400100_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Federal", "plan_name": "400110", "standard_charge_percentage": 0.85, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Federal", "plan_name": "400110_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." } ] } ] }, { "description": "Nitroglycerin 0.4 mg sublingual tablet [5604]", "drug_information": { "unit": 25.00, "type": "EA" }, "code_information": [ { "code": "43598-436-35", "type": "NDC" } ], "standard_charges": [ { "gross_charge": 122.55, "minimum": 98.04, "maximum": 104.17, "setting": "both", "payers_information": [ { "payer_name": "Aetna", "plan_name": "700700", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna", "plan_name": "700700_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Miscellaneous", "plan_name": "700720", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Miscellaneous", "plan_name": "700720_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Ppo Hmo", "plan_name": "701720", "standard_charge_percentage": 80.0, "count": "0", 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"methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Basic Pl", "plan_name": "400100_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Federal", "plan_name": "400110", "standard_charge_percentage": 0.85, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Federal", "plan_name": "400110_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." } ] } ] }, { "description": "Nicotine 7 mg/24 hr daily transdermal patch [27860]", "drug_information": { "unit": 1.00, 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"standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Basic Pl", "plan_name": "400100", "standard_charge_percentage": 0.85, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Basic Pl", "plan_name": "400100_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Federal", "plan_name": "400110", "standard_charge_percentage": 0.85, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Federal", "plan_name": "400110_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." } ] } ] }, { "description": "Nicotine 14 mg/24 hr daily transdermal patch [27862]", "drug_information": { "unit": 1.00, "type": "EA" }, "code_information": [ { "code": "43598-447-71", "type": "NDC" } ], "standard_charges": [ { "gross_charge": 5.66, "minimum": 4.53, "maximum": 4.81, "setting": "both", "payers_information": [ { "payer_name": "Aetna", "plan_name": "700700", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna", "plan_name": "700700_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna 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"plan_name": "401457", "standard_charge_percentage": 0.80, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Ms State Emplo", "plan_name": "401457_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Basic Pl", "plan_name": "400100", "standard_charge_percentage": 0.85, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Basic Pl", "plan_name": "400100_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Federal", "plan_name": "400110", "standard_charge_percentage": 0.85, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Federal", "plan_name": "400110_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." } ] } ] }, { "description": "Nicotine 14 mg/24 hr daily transdermal patch [27862]", "drug_information": { "unit": 1.00, "type": "EA" }, "code_information": [ { "code": "43598-447-74", "type": "NDC" } ], "standard_charges": [ { "gross_charge": 5.87, "minimum": 4.70, "maximum": 4.99, "setting": "both", "payers_information": [ { "payer_name": "Aetna", "plan_name": "700700", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna", "plan_name": "700700_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Miscellaneous", "plan_name": "700720", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Miscellaneous", "plan_name": "700720_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Ppo Hmo", "plan_name": "701720", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Ppo Hmo", "plan_name": "701720_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Ms State Emplo", "plan_name": "401457", "standard_charge_percentage": 0.80, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Ms State Emplo", "plan_name": "401457_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Basic Pl", "plan_name": "400100", "standard_charge_percentage": 0.85, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Basic Pl", "plan_name": "400100_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Federal", "plan_name": "400110", "standard_charge_percentage": 0.85, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Federal", "plan_name": "400110_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." } ] } ] }, { "description": "Nicotine 21 mg/24 hr daily transdermal patch [27863]", "drug_information": { "unit": 1.00, "type": "EA" }, "code_information": [ { "code": "43598-448-71", "type": "NDC" } ], "standard_charges": [ { "gross_charge": 5.29, "minimum": 4.23, "maximum": 4.50, "setting": "both", "payers_information": [ { "payer_name": "Aetna", "plan_name": "700700", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna", "plan_name": "700700_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Miscellaneous", "plan_name": "700720", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Miscellaneous", "plan_name": "700720_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient 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calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Basic Pl", "plan_name": "400100", "standard_charge_percentage": 0.85, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Basic Pl", "plan_name": "400100_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Federal", "plan_name": "400110", "standard_charge_percentage": 0.85, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Federal", "plan_name": "400110_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." } ] } ] }, { "description": "Nicotine 21 mg/24 hr daily transdermal patch [27863]", "drug_information": { "unit": 1.00, "type": "EA" }, "code_information": [ { "code": "43598-448-74", "type": "NDC" } ], "standard_charges": [ { "gross_charge": 5.87, "minimum": 4.70, "maximum": 4.99, "setting": "both", "payers_information": [ { "payer_name": "Aetna", "plan_name": "700700", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna", "plan_name": "700700_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Miscellaneous", "plan_name": "700720", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Miscellaneous", "plan_name": "700720_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Ppo Hmo", "plan_name": "701720", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Ppo Hmo", "plan_name": "701720_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Ms State Emplo", "plan_name": "401457", "standard_charge_percentage": 0.80, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Ms State Emplo", "plan_name": "401457_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Basic Pl", "plan_name": "400100", "standard_charge_percentage": 0.85, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Basic Pl", "plan_name": "400100_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Federal", "plan_name": "400110", "standard_charge_percentage": 0.85, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Federal", "plan_name": "400110_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." } ] } ] }, { "description": "Naproxen sodium 550 mg tablet [5395]", "drug_information": { "unit": 1.00, "type": "EA" }, "code_information": [ { "code": "43598-495-05", "type": "NDC" } ], "standard_charges": [ { "gross_charge": 7.50, "minimum": 6.00, "maximum": 6.38, "setting": "both", "payers_information": [ { "payer_name": "Aetna", "plan_name": "700700", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna", "plan_name": "700700_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent 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charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Ms State Emplo", "plan_name": "401457", "standard_charge_percentage": 0.80, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Ms State Emplo", "plan_name": "401457_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Basic Pl", "plan_name": "400100", "standard_charge_percentage": 0.85, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Basic Pl", "plan_name": "400100_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Federal", "plan_name": "400110", "standard_charge_percentage": 0.85, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Federal", "plan_name": "400110_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." } ] } ] }, { "description": "Ciprofloxacin 0.3 %-dexamethasone 0.1 % ear dropssuspension [36576]", "drug_information": { "unit": 7.50, "type": "ML" }, "code_information": [ { "code": "43598-326-75", "type": "NDC" } ], "standard_charges": [ { "gross_charge": 1147.70, "minimum": 918.16, "maximum": 975.55, "setting": "both", "payers_information": [ { "payer_name": "Aetna", "plan_name": "700700", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna", "plan_name": "700700_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Miscellaneous", "plan_name": "700720", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Miscellaneous", "plan_name": "700720_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Ppo Hmo", "plan_name": "701720", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Ppo Hmo", "plan_name": "701720_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Ms State Emplo", "plan_name": "401457", "standard_charge_percentage": 0.80, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Ms State Emplo", "plan_name": "401457_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Basic Pl", "plan_name": "400100", "standard_charge_percentage": 0.85, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Basic Pl", "plan_name": "400100_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Federal", "plan_name": "400110", "standard_charge_percentage": 0.85, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Federal", "plan_name": "400110_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." } ] } ] }, { "description": "Sodium nitroprusside 25 mg/ml intravenous solution [18908]", "drug_information": { "unit": 2.00, "type": "ML" }, "code_information": [ { "code": "43598-587-23", "type": "NDC" } ], "standard_charges": [ { "gross_charge": 616.60, "minimum": 493.28, "maximum": 524.11, "setting": "both", "payers_information": [ { "payer_name": "Aetna", "plan_name": "700700", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna", "plan_name": "700700_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Miscellaneous", "plan_name": "700720", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Miscellaneous", "plan_name": "700720_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Ppo Hmo", "plan_name": "701720", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Ppo Hmo", "plan_name": "701720_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Ms State Emplo", "plan_name": "401457", "standard_charge_percentage": 0.80, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Ms State Emplo", "plan_name": "401457_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Basic Pl", "plan_name": "400100", "standard_charge_percentage": 0.85, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Basic Pl", "plan_name": "400100_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Federal", "plan_name": "400110", "standard_charge_percentage": 0.85, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Federal", "plan_name": "400110_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." } ] } ] }, { "description": "Sodium chloride 7 % for nebulization [82134]", "drug_information": { "unit": 4.00, "type": "ML" }, "code_information": [ { "code": "4422930760", "type": "NDC" } ], "standard_charges": [ { "gross_charge": 7.50, "minimum": 6.00, "maximum": 6.38, "setting": "both", "payers_information": [ { "payer_name": "Aetna", "plan_name": "700700", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna", "plan_name": "700700_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Miscellaneous", "plan_name": "700720", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Miscellaneous", "plan_name": "700720_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Ppo Hmo", "plan_name": "701720", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Ppo Hmo", "plan_name": "701720_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Ms State Emplo", "plan_name": "401457", "standard_charge_percentage": 0.80, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Ms State Emplo", "plan_name": "401457_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Basic Pl", "plan_name": "400100", "standard_charge_percentage": 0.85, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Basic Pl", "plan_name": "400100_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Federal", "plan_name": "400110", "standard_charge_percentage": 0.85, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Federal", "plan_name": "400110_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." } ] } ] }, { "description": "Selenium sulfide 2.5 % lotion [172522]", "drug_information": { "unit": 120.00, "type": "ML" }, "code_information": [ { "code": "45802-040-64", "type": "NDC" } ], "standard_charges": [ { "gross_charge": 62.70, "minimum": 50.16, "maximum": 53.30, "setting": "both", "payers_information": [ { "payer_name": "Aetna", "plan_name": "700700", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to 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}, { "payer_name": "Bc/Bs Of Ms Basic Pl", "plan_name": "400100_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Federal", "plan_name": "400110", "standard_charge_percentage": 0.85, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Federal", "plan_name": "400110_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." } ] } ] }, { "description": "Gentamicin 0.1 % topical ointment [3424]", "drug_information": { "unit": 15.00, "type": "GR" }, "code_information": [ { "code": "45802-046-35", "type": "NDC" } ], "standard_charges": [ { "gross_charge": 234.48, "minimum": 187.58, "maximum": 199.31, "setting": "both", "payers_information": [ { "payer_name": "Aetna", "plan_name": "700700", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna", "plan_name": "700700_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Miscellaneous", "plan_name": "700720", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Miscellaneous", "plan_name": "700720_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Ppo Hmo", "plan_name": "701720", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Ppo Hmo", "plan_name": "701720_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Ms State Emplo", "plan_name": "401457", "standard_charge_percentage": 0.80, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Ms State Emplo", "plan_name": "401457_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Basic Pl", "plan_name": "400100", "standard_charge_percentage": 0.85, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Basic Pl", "plan_name": "400100_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Federal", "plan_name": "400110", "standard_charge_percentage": 0.85, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Federal", "plan_name": "400110_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." } ] } ] }, { "description": "Triamcinolone acetonide 0.1 % topical ointment [8118]", "drug_information": { "unit": 454.00, "type": "GR" }, "code_information": [ { "code": "45802-055-05", "type": "NDC" } ], "standard_charges": [ { "gross_charge": 196.24, "minimum": 156.99, "maximum": 166.80, "setting": "both", "payers_information": [ { "payer_name": "Aetna", "plan_name": "700700", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna", "plan_name": "700700_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Miscellaneous", "plan_name": "700720", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Miscellaneous", "plan_name": "700720_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Ppo Hmo", "plan_name": "701720", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Ppo Hmo", "plan_name": "701720_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Ms State Emplo", "plan_name": "401457", "standard_charge_percentage": 0.80, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Ms State Emplo", "plan_name": "401457_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Basic Pl", "plan_name": "400100", "standard_charge_percentage": 0.85, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Basic Pl", "plan_name": "400100_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Federal", "plan_name": "400110", "standard_charge_percentage": 0.85, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Federal", "plan_name": "400110_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." } ] } ] }, { "description": "Triamcinolone acetonide 0.1 % topical ointment [8118]", "drug_information": { "unit": 80.00, "type": "GR" }, "code_information": [ { "code": "45802-055-36", "type": "NDC" } ], "standard_charges": [ { "gross_charge": 60.04, "minimum": 48.03, "maximum": 51.03, "setting": "both", "payers_information": [ { "payer_name": "Aetna", "plan_name": "700700", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna", "plan_name": "700700_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Miscellaneous", "plan_name": "700720", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Miscellaneous", "plan_name": "700720_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Ppo Hmo", "plan_name": "701720", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Ppo Hmo", "plan_name": "701720_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Ms State Emplo", "plan_name": "401457", "standard_charge_percentage": 0.80, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Ms State Emplo", "plan_name": "401457_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Basic Pl", "plan_name": "400100", "standard_charge_percentage": 0.85, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Basic Pl", "plan_name": "400100_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Federal", "plan_name": "400110", "standard_charge_percentage": 0.85, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Federal", "plan_name": "400110_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." } ] } ] }, { "description": "Nystatin 100000 unit/gram topical cream [5749]", "drug_information": { "unit": 30.00, "type": "GR" }, "code_information": [ { "code": "45802-059-11", "type": "NDC" } ], "standard_charges": [ { "gross_charge": 124.69, "minimum": 99.75, "maximum": 105.99, "setting": "both", "payers_information": [ { "payer_name": "Aetna", "plan_name": "700700", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna", "plan_name": "700700_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Miscellaneous", "plan_name": "700720", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Miscellaneous", "plan_name": "700720_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Ppo Hmo", "plan_name": "701720", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Ppo Hmo", "plan_name": "701720_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Ms State Emplo", "plan_name": "401457", "standard_charge_percentage": 0.80, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Ms State Emplo", "plan_name": "401457_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Basic Pl", "plan_name": "400100", "standard_charge_percentage": 0.85, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Basic Pl", "plan_name": "400100_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Federal", "plan_name": "400110", "standard_charge_percentage": 0.85, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Federal", "plan_name": "400110_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." } ] } ] }, { "description": "Nystatin 100000 unit/gram topical cream [5749]", "drug_information": { "unit": 15.00, "type": "GR" }, "code_information": [ { "code": "45802-059-35", "type": "NDC" } ], "standard_charges": [ { "gross_charge": 83.08, "minimum": 66.46, "maximum": 70.62, "setting": "both", "payers_information": [ { "payer_name": "Aetna", "plan_name": "700700", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna", "plan_name": "700700_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Miscellaneous", "plan_name": "700720", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Miscellaneous", "plan_name": "700720_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Ppo Hmo", "plan_name": "701720", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Ppo Hmo", "plan_name": "701720_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Ms State Emplo", "plan_name": "401457", "standard_charge_percentage": 0.80, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Ms State Emplo", "plan_name": "401457_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Basic Pl", "plan_name": "400100", "standard_charge_percentage": 0.85, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Basic Pl", "plan_name": "400100_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Federal", "plan_name": "400110", "standard_charge_percentage": 0.85, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Federal", "plan_name": "400110_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." } ] } ] }, { "description": "Bacitracin 500 unit/gram topical packet [113172]", "drug_information": { "unit": 1.00, "type": "EA" }, "code_information": [ { "code": "45802-060-00", "type": "NDC" } ], "standard_charges": [ { "gross_charge": 1.00, "minimum": 0.80, "maximum": 0.85, "setting": "both", "payers_information": [ { "payer_name": "Aetna", "plan_name": "700700", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna", "plan_name": "700700_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Miscellaneous", "plan_name": "700720", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Miscellaneous", "plan_name": "700720_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Ppo Hmo", "plan_name": "701720", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Ppo Hmo", "plan_name": "701720_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Ms State Emplo", "plan_name": "401457", "standard_charge_percentage": 0.80, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Ms State Emplo", "plan_name": "401457_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Basic Pl", "plan_name": "400100", "standard_charge_percentage": 0.85, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Basic Pl", "plan_name": "400100_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Federal", "plan_name": "400110", "standard_charge_percentage": 0.85, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Federal", "plan_name": "400110_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." } ] } ] }, { "description": "Bacitracin 500 unit/gram topical ointment [850]", "drug_information": { "unit": 14.00, "type": "GR" }, "code_information": [ { "code": "45802-060-01", "type": "NDC" } ], "standard_charges": [ { "gross_charge": 11.37, "minimum": 9.10, "maximum": 9.66, "setting": "both", "payers_information": [ { "payer_name": "Aetna", "plan_name": "700700", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna", "plan_name": "700700_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Miscellaneous", "plan_name": "700720", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Miscellaneous", "plan_name": "700720_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Ppo Hmo", "plan_name": "701720", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Ppo Hmo", "plan_name": "701720_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Ms State Emplo", "plan_name": "401457", "standard_charge_percentage": 0.80, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Ms State Emplo", "plan_name": "401457_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Basic Pl", "plan_name": "400100", "standard_charge_percentage": 0.85, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Basic Pl", "plan_name": "400100_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Federal", "plan_name": "400110", "standard_charge_percentage": 0.85, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Federal", "plan_name": "400110_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." } ] } ] }, { "description": "Bacitracin 500 unit/gram topical packet [113172]", "drug_information": { "unit": 1.00, "type": "EA" }, "code_information": [ { "code": "45802-060-70", "type": "NDC" } ], "standard_charges": [ { "gross_charge": 1.00, "minimum": 0.80, "maximum": 0.85, "setting": "both", "payers_information": [ { "payer_name": "Aetna", "plan_name": "700700", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna", "plan_name": "700700_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Miscellaneous", "plan_name": "700720", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Miscellaneous", "plan_name": "700720_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Ppo Hmo", "plan_name": "701720", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Ppo Hmo", "plan_name": "701720_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Ms State Emplo", "plan_name": "401457", "standard_charge_percentage": 0.80, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Ms State Emplo", "plan_name": "401457_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Basic Pl", "plan_name": "400100", "standard_charge_percentage": 0.85, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Basic Pl", "plan_name": "400100_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Federal", "plan_name": "400110", "standard_charge_percentage": 0.85, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Federal", "plan_name": "400110_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." } ] } ] }, { "description": "Triamcinolone acetonide 0.5 % topical cream [8114]", "drug_information": { "unit": 15.00, "type": "GR" }, "code_information": [ { "code": "45802-065-35", "type": "NDC" } ], "standard_charges": [ { "gross_charge": 47.95, "minimum": 38.36, "maximum": 40.76, "setting": "both", "payers_information": [ { "payer_name": "Aetna", "plan_name": "700700", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna", "plan_name": "700700_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Miscellaneous", "plan_name": "700720", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Miscellaneous", "plan_name": "700720_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Ppo Hmo", "plan_name": "701720", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Ppo Hmo", "plan_name": "701720_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Ms State Emplo", "plan_name": "401457", "standard_charge_percentage": 0.80, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Ms State Emplo", "plan_name": "401457_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Basic Pl", "plan_name": "400100", "standard_charge_percentage": 0.85, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Basic Pl", "plan_name": "400100_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Federal", "plan_name": "400110", "standard_charge_percentage": 0.85, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Federal", "plan_name": "400110_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." } ] } ] }, { "description": "Estradiol 0.01% (0.1 mg/gram) vaginal cream [9969]", "drug_information": { "unit": 42.50, "type": "GR" }, "code_information": [ { "code": "45802-097-35", "type": "NDC" } ], "standard_charges": [ { "gross_charge": 569.89, "minimum": 455.91, "maximum": 484.41, "setting": "both", "payers_information": [ { "payer_name": "Aetna", "plan_name": "700700", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna", "plan_name": "700700_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Miscellaneous", "plan_name": "700720", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Miscellaneous", "plan_name": "700720_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Ppo Hmo", "plan_name": "701720", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Ppo Hmo", "plan_name": "701720_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Ms State Emplo", "plan_name": "401457", "standard_charge_percentage": 0.80, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Ms State Emplo", "plan_name": "401457_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Basic Pl", "plan_name": "400100", "standard_charge_percentage": 0.85, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Basic Pl", "plan_name": "400100_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Federal", "plan_name": "400110", "standard_charge_percentage": 0.85, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Federal", "plan_name": "400110_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." } ] } ] }, { "description": "Mupirocin 2 % topical ointment [10674]", "drug_information": { "unit": 22.00, "type": "GR" }, "code_information": [ { "code": "45802-112-22", "type": "NDC" } ], "standard_charges": [ { "gross_charge": 53.40, "minimum": 42.72, "maximum": 45.39, "setting": "both", "payers_information": [ { "payer_name": "Aetna", "plan_name": "700700", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna", "plan_name": "700700_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Miscellaneous", "plan_name": "700720", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Miscellaneous", "plan_name": "700720_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Ppo Hmo", "plan_name": "701720", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Ppo Hmo", "plan_name": "701720_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Ms State Emplo", "plan_name": "401457", "standard_charge_percentage": 0.80, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Ms State Emplo", "plan_name": "401457_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Basic Pl", "plan_name": "400100", "standard_charge_percentage": 0.85, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Basic Pl", "plan_name": "400100_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Federal", "plan_name": "400110", "standard_charge_percentage": 0.85, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Federal", "plan_name": "400110_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." } ] } ] }, { "description": "Ciclopirox 0.77 % topical cream [9598]", "drug_information": { "unit": 30.00, "type": "GR" }, "code_information": [ { "code": "45802-138-11", "type": "NDC" } ], "standard_charges": [ { "gross_charge": 181.12, "minimum": 144.90, "maximum": 153.95, "setting": "both", "payers_information": [ { "payer_name": "Aetna", "plan_name": "700700", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna", "plan_name": "700700_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Miscellaneous", "plan_name": "700720", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna 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"plan_name": "400110_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." } ] } ] }, { "description": "Neomycin-bacitracn zn-polymyxn 3.5 mg-400 unit-5000 unit top oint pkt [116684]", "drug_information": { "unit": 1.00, "type": "EA" }, "code_information": [ { "code": "45802-143-00", "type": "NDC" } ], "standard_charges": [ { "gross_charge": 1.00, "minimum": 0.80, "maximum": 0.85, "setting": "both", "payers_information": [ { "payer_name": "Aetna", "plan_name": "700700", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna", "plan_name": "700700_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to 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"methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." } ] } ] }, { "description": "Methyl salicylate 15 %-menthol 10 % topical cream [76971]", "drug_information": { "unit": 85.00, "type": "GR" }, "code_information": [ { "code": "45802-174-53", "type": "NDC" } ], "standard_charges": [ { "gross_charge": 7.51, "minimum": 6.01, "maximum": 6.38, "setting": "both", "payers_information": [ { "payer_name": "Aetna", "plan_name": "700700", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna", "plan_name": "700700_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Miscellaneous", "plan_name": "700720", 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"payer_name": "Aetna", "plan_name": "700700_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Miscellaneous", "plan_name": "700720", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Miscellaneous", "plan_name": "700720_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Ppo Hmo", "plan_name": "701720", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Ppo 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"payer_name": "Bc/Bs Of Ms Basic Pl", "plan_name": "400100", "standard_charge_percentage": 0.85, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Basic Pl", "plan_name": "400100_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Federal", "plan_name": "400110", "standard_charge_percentage": 0.85, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Federal", "plan_name": "400110_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." } ] } ] }, { "description": "Nitroglycerin 400 mcg/spray translingual [27096]", "drug_information": { "unit": 4.90, "type": "GR" }, "code_information": [ { "code": "45802-210-01", "type": "NDC" } ], "standard_charges": [ { "gross_charge": 1066.14, "minimum": 852.91, "maximum": 906.22, "setting": "both", "payers_information": [ { "payer_name": "Aetna", "plan_name": "700700", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna", "plan_name": "700700_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Miscellaneous", "plan_name": "700720", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Miscellaneous", "plan_name": "700720_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Ppo Hmo", "plan_name": "701720", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Ppo Hmo", "plan_name": "701720_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Ms State Emplo", "plan_name": "401457", "standard_charge_percentage": 0.80, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Ms State Emplo", "plan_name": "401457_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Basic Pl", "plan_name": "400100", "standard_charge_percentage": 0.85, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Basic Pl", "plan_name": "400100_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Federal", "plan_name": "400110", "standard_charge_percentage": 0.85, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Federal", "plan_name": "400110_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." } ] } ] }, { "description": "Mometasone 0.1 % topical cream [10646]", "drug_information": { "unit": 45.00, "type": "GR" }, "code_information": [ { "code": "45802-257-42", "type": "NDC" } ], "standard_charges": [ { "gross_charge": 200.71, "minimum": 160.57, "maximum": 170.60, "setting": "both", "payers_information": [ { "payer_name": "Aetna", "plan_name": "700700", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna", "plan_name": "700700_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Miscellaneous", "plan_name": "700720", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Miscellaneous", "plan_name": "700720_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Ppo Hmo", "plan_name": "701720", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Ppo Hmo", "plan_name": "701720_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Ms State Emplo", "plan_name": "401457", "standard_charge_percentage": 0.80, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Ms State Emplo", "plan_name": "401457_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Basic Pl", "plan_name": "400100", "standard_charge_percentage": 0.85, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Basic Pl", "plan_name": "400100_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Federal", "plan_name": "400110", "standard_charge_percentage": 0.85, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Federal", "plan_name": "400110_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." } ] } ] }, { "description": "Permethrin 5 % topical cream [10917]", "drug_information": { "unit": 60.00, "type": "GR" }, "code_information": [ { "code": "45802-269-37", "type": "NDC" } ], "standard_charges": [ { "gross_charge": 564.30, "minimum": 451.44, "maximum": 479.66, "setting": "both", "payers_information": [ { "payer_name": "Aetna", "plan_name": "700700", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna", "plan_name": "700700_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Miscellaneous", "plan_name": "700720", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Miscellaneous", "plan_name": "700720_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Ppo Hmo", "plan_name": "701720", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Ppo Hmo", "plan_name": "701720_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Ms State Emplo", "plan_name": "401457", "standard_charge_percentage": 0.80, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Ms State Emplo", "plan_name": "401457_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Basic Pl", "plan_name": "400100", "standard_charge_percentage": 0.85, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Basic Pl", "plan_name": "400100_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Federal", "plan_name": "400110", "standard_charge_percentage": 0.85, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Federal", "plan_name": "400110_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." } ] } ] }, { "description": "Diphenhydramine-zinc acetate 2 %-0.1 % topical cream [16299]", "drug_information": { "unit": 28.00, "type": "GR" }, "code_information": [ { "code": "45802-358-03", "type": "NDC" } ], "standard_charges": [ { "gross_charge": 8.15, "minimum": 6.52, "maximum": 6.93, "setting": "both", "payers_information": [ { "payer_name": "Aetna", "plan_name": "700700", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna", "plan_name": "700700_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Miscellaneous", "plan_name": "700720", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Miscellaneous", "plan_name": "700720_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Ppo Hmo", "plan_name": "701720", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Ppo Hmo", "plan_name": "701720_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Ms State Emplo", "plan_name": "401457", "standard_charge_percentage": 0.80, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Ms State Emplo", "plan_name": "401457_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Basic Pl", "plan_name": "400100", "standard_charge_percentage": 0.85, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Basic Pl", "plan_name": "400100_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Federal", "plan_name": "400110", "standard_charge_percentage": 0.85, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Federal", "plan_name": "400110_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." } ] } ] }, { "description": "Ciclopirox 0.77 % topical suspension [38962]", "drug_information": { "unit": 60.00, "type": "ML" }, "code_information": [ { "code": "45802-400-46", "type": "NDC" } ], "standard_charges": [ { "gross_charge": 616.17, "minimum": 492.94, "maximum": 523.74, "setting": "both", "payers_information": [ { "payer_name": "Aetna", "plan_name": "700700", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna", "plan_name": "700700_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Miscellaneous", "plan_name": "700720", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Miscellaneous", "plan_name": "700720_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Ppo Hmo", "plan_name": "701720", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Ppo Hmo", "plan_name": "701720_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Ms State Emplo", "plan_name": "401457", "standard_charge_percentage": 0.80, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Ms State Emplo", "plan_name": "401457_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Basic Pl", "plan_name": "400100", "standard_charge_percentage": 0.85, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Basic Pl", "plan_name": "400100_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Federal", "plan_name": "400110", "standard_charge_percentage": 0.85, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Federal", "plan_name": "400110_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." } ] } ] }, { "description": "Hydrocortisone 1 % topical cream [3726]", "drug_information": { "unit": 28.00, "type": "GR" }, "code_information": [ { "code": "45802-438-03", "type": "NDC" } ], "standard_charges": [ { "gross_charge": 7.94, "minimum": 6.35, "maximum": 6.75, "setting": "both", "payers_information": [ { "payer_name": "Aetna", "plan_name": "700700", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna", "plan_name": "700700_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Miscellaneous", "plan_name": "700720", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Miscellaneous", "plan_name": "700720_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Ppo Hmo", "plan_name": "701720", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Ppo Hmo", "plan_name": "701720_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Ms State Emplo", "plan_name": "401457", "standard_charge_percentage": 0.80, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Ms State Emplo", "plan_name": "401457_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Basic Pl", "plan_name": "400100", "standard_charge_percentage": 0.85, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Basic Pl", "plan_name": "400100_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Federal", "plan_name": "400110", "standard_charge_percentage": 0.85, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Federal", "plan_name": "400110_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." } ] } ] }, { "description": "Ammonium lactate 12 % topical cream [17997]", "drug_information": { "unit": 385.00, "type": "GR" }, "code_information": [ { "code": "45802-493-26", "type": "NDC" } ], "standard_charges": [ { "gross_charge": 137.14, "minimum": 109.71, "maximum": 116.57, "setting": "both", "payers_information": [ { "payer_name": "Aetna", "plan_name": "700700", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna", "plan_name": "700700_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Miscellaneous", "plan_name": "700720", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Miscellaneous", "plan_name": "700720_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Ppo Hmo", "plan_name": "701720", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Ppo Hmo", "plan_name": "701720_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Ms State Emplo", "plan_name": "401457", "standard_charge_percentage": 0.80, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Ms State Emplo", "plan_name": "401457_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Basic Pl", "plan_name": "400100", "standard_charge_percentage": 0.85, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Basic Pl", "plan_name": "400100_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Federal", "plan_name": "400110", "standard_charge_percentage": 0.85, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Federal", "plan_name": "400110_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." } ] } ] }, { "description": "Scopolamine 1 mg over 3 days transdermal patch [27696]", "drug_information": { "unit": 1.00, "type": "EA" }, "code_information": [ { "code": "45802-580-01", "type": "NDC" } ], "standard_charges": [ { "gross_charge": 101.15, "minimum": 80.92, "maximum": 85.98, "setting": "both", "payers_information": [ { "payer_name": "Aetna", "plan_name": "700700", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna", "plan_name": "700700_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Miscellaneous", "plan_name": "700720", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Miscellaneous", "plan_name": "700720_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Ppo Hmo", "plan_name": "701720", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Ppo Hmo", "plan_name": "701720_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Ms State Emplo", "plan_name": "401457", "standard_charge_percentage": 0.80, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate 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}, { "payer_name": "Bc/Bs Ms State Emplo", "plan_name": "401457", "standard_charge_percentage": 0.80, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Ms State Emplo", "plan_name": "401457_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Basic Pl", "plan_name": "400100", "standard_charge_percentage": 0.85, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Basic Pl", "plan_name": "400100_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Federal", "plan_name": "400110", "standard_charge_percentage": 0.85, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Federal", "plan_name": "400110_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." } ] } ] }, { "description": "Ammonium lactate 12 % topical cream [17997]", "drug_information": { "unit": 140.00, "type": "GR" }, "code_information": [ { "code": "4580251377", "type": "NDC" } ], "standard_charges": [ { "gross_charge": 33.85, "minimum": 27.08, "maximum": 28.77, "setting": "both", "payers_information": [ { "payer_name": "Aetna", "plan_name": "700700", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna", "plan_name": "700700_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Miscellaneous", "plan_name": "700720", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Miscellaneous", "plan_name": "700720_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Ppo Hmo", "plan_name": "701720", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data 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calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Basic Pl", "plan_name": "400100_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Federal", "plan_name": "400110", "standard_charge_percentage": 0.85, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Federal", "plan_name": "400110_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." } ] } ] }, { "description": "Ammonium lactate 12 % lotion [10380]", "drug_information": { "unit": 227.00, "type": "GR" }, "code_information": [ { "code": "4580252555", "type": "NDC" } ], "standard_charges": [ { "gross_charge": 66.85, "minimum": 53.48, "maximum": 56.82, "setting": "both", "payers_information": [ { "payer_name": "Aetna", "plan_name": "700700", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna", "plan_name": "700700_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Miscellaneous", "plan_name": "700720", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Miscellaneous", "plan_name": "700720_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Ppo Hmo", "plan_name": "701720", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Ppo Hmo", "plan_name": "701720_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Ms State Emplo", "plan_name": "401457", "standard_charge_percentage": 0.80, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Ms State Emplo", "plan_name": "401457_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Basic Pl", "plan_name": "400100", "standard_charge_percentage": 0.85, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Basic Pl", "plan_name": "400100_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Federal", "plan_name": "400110", "standard_charge_percentage": 0.85, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Federal", "plan_name": "400110_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." } ] } ] }, { "description": "Dexmedetomidine 400 mcg/100 ml (4 mcg/ml) in dextrose 5 % iv solution [185895]", "drug_information": { "unit": 100.00, "type": "ML" }, "code_information": [ { "code": "44567-603-24", "type": "NDC" } ], "standard_charges": [ { "gross_charge": 242.84, "minimum": 194.27, "maximum": 206.41, "setting": "both", "payers_information": [ { "payer_name": "Aetna", "plan_name": "700700", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna", "plan_name": "700700_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Miscellaneous", "plan_name": "700720", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Miscellaneous", "plan_name": "700720_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Ppo Hmo", "plan_name": "701720", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Ppo Hmo", "plan_name": "701720_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Ms State Emplo", "plan_name": "401457", "standard_charge_percentage": 0.80, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Ms State Emplo", "plan_name": "401457_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Basic Pl", "plan_name": "400100", "standard_charge_percentage": 0.85, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Basic Pl", "plan_name": "400100_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Federal", "plan_name": "400110", "standard_charge_percentage": 0.85, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Federal", "plan_name": "400110_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." } ] } ] }, { "description": "Norepinephrine bitartrate 4 mg/250 ml (16 mcg/ml) in 0.9 % nacl iv [118989]", "drug_information": { "unit": 250.00, "type": "ML" }, "code_information": [ { "code": "44567-640-01", "type": "NDC" } ], "standard_charges": [ { "gross_charge": 246.87, "minimum": 197.50, "maximum": 209.84, "setting": "both", "payers_information": [ { "payer_name": "Aetna", "plan_name": "700700", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna", "plan_name": "700700_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Miscellaneous", "plan_name": "700720", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Miscellaneous", "plan_name": "700720_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Ppo Hmo", "plan_name": "701720", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Ppo Hmo", "plan_name": "701720_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Ms State Emplo", "plan_name": "401457", "standard_charge_percentage": 0.80, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Ms State Emplo", "plan_name": "401457_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Basic Pl", "plan_name": "400100", "standard_charge_percentage": 0.85, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Basic Pl", "plan_name": "400100_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Federal", "plan_name": "400110", "standard_charge_percentage": 0.85, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Federal", "plan_name": "400110_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." } ] } ] }, { "description": "Norepinephrine bitartrate 8 mg/250 ml (32 mcg/ml) in 0.9 % nacl iv [119763]", "drug_information": { "unit": 250.00, "type": "ML" }, "code_information": [ { "code": "44567-641-01", "type": "NDC" } ], "standard_charges": [ { "gross_charge": 300.31, "minimum": 240.25, "maximum": 255.26, "setting": "both", "payers_information": [ { "payer_name": "Aetna", "plan_name": "700700", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna", "plan_name": "700700_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Miscellaneous", "plan_name": "700720", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Miscellaneous", "plan_name": "700720_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Ppo Hmo", "plan_name": "701720", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Ppo Hmo", "plan_name": "701720_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Ms State Emplo", "plan_name": "401457", "standard_charge_percentage": 0.80, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Ms State Emplo", "plan_name": "401457_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Basic Pl", "plan_name": "400100", "standard_charge_percentage": 0.85, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Basic Pl", "plan_name": "400100_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Federal", "plan_name": "400110", "standard_charge_percentage": 0.85, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Federal", "plan_name": "400110_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." } ] } ] }, { "description": "Norepinephrine bitartrate 8 mg/250 ml (32 mcg/ml) in 0.9 % nacl iv [119763]", "drug_information": { "unit": 250.00, "type": "ML" }, "code_information": [ { "code": "44567-641-10", "type": "NDC" } ], "standard_charges": [ { "gross_charge": 300.31, "minimum": 240.25, "maximum": 255.26, "setting": "both", "payers_information": [ { "payer_name": "Aetna", "plan_name": "700700", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna", "plan_name": "700700_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Miscellaneous", "plan_name": "700720", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Miscellaneous", "plan_name": "700720_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Ppo Hmo", "plan_name": "701720", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Ppo Hmo", "plan_name": "701720_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Ms State Emplo", "plan_name": "401457", "standard_charge_percentage": 0.80, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Ms State Emplo", "plan_name": "401457_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Basic Pl", "plan_name": "400100", "standard_charge_percentage": 0.85, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Basic Pl", "plan_name": "400100_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Federal", "plan_name": "400110", "standard_charge_percentage": 0.85, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Federal", "plan_name": "400110_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." } ] } ] }, { "description": "Norepinephrine bitartrate 16 mg/250 ml (64 mcg/ml) in 0.9 % nacl iv [154492]", "drug_information": { "unit": 250.00, "type": "ML" }, "code_information": [ { "code": "44567-642-01", "type": "NDC" } ], "standard_charges": [ { "gross_charge": 434.50, "minimum": 347.60, "maximum": 369.33, "setting": "both", "payers_information": [ { "payer_name": "Aetna", "plan_name": "700700", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna", "plan_name": "700700_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Miscellaneous", "plan_name": "700720", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Miscellaneous", "plan_name": "700720_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Ppo Hmo", "plan_name": "701720", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Ppo Hmo", "plan_name": "701720_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Ms State Emplo", "plan_name": "401457", "standard_charge_percentage": 0.80, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Ms State Emplo", "plan_name": "401457_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Basic Pl", "plan_name": "400100", "standard_charge_percentage": 0.85, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Basic Pl", "plan_name": "400100_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Federal", "plan_name": "400110", "standard_charge_percentage": 0.85, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Federal", "plan_name": "400110_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." } ] } ] }, { "description": "Norepinephrine bitartrate 16 mg/250 ml (64 mcg/ml) in 0.9 % nacl iv [154492]", "drug_information": { "unit": 250.00, "type": "ML" }, "code_information": [ { "code": "44567-642-10", "type": "NDC" } ], "standard_charges": [ { "gross_charge": 434.50, "minimum": 347.60, "maximum": 369.33, "setting": "both", "payers_information": [ { "payer_name": "Aetna", "plan_name": "700700", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna", "plan_name": "700700_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Miscellaneous", "plan_name": "700720", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Miscellaneous", "plan_name": "700720_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to 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allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Basic Pl", "plan_name": "400100", "standard_charge_percentage": 0.85, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Basic Pl", "plan_name": "400100_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Federal", "plan_name": "400110", "standard_charge_percentage": 0.85, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Federal", "plan_name": "400110_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." } ] } ] }, { "description": "Mineral oil oral [5086]", "drug_information": { "unit": 473.00, "type": "ML" }, "code_information": [ { "code": "4603600168", "type": "NDC" } ], "standard_charges": [ { "gross_charge": 9.84, "minimum": 7.87, "maximum": 8.36, "setting": "both", "payers_information": [ { "payer_name": "Aetna", "plan_name": "700700", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna", "plan_name": "700700_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Miscellaneous", "plan_name": "700720", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Miscellaneous", "plan_name": "700720_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Ppo Hmo", "plan_name": "701720", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Ppo Hmo", "plan_name": "701720_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Ms State Emplo", "plan_name": "401457", "standard_charge_percentage": 0.80, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Ms State Emplo", "plan_name": "401457_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Basic Pl", "plan_name": "400100", "standard_charge_percentage": 0.85, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Basic Pl", "plan_name": "400100_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Federal", "plan_name": "400110", "standard_charge_percentage": 0.85, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Federal", "plan_name": "400110_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." } ] } ] }, { "description": "Aspirin 81 mg tabletdelayed release [688]", "drug_information": { "unit": 1.00, "type": "EA" }, "code_information": [ { "code": "4603600188", "type": "NDC" } ], "standard_charges": [ { "gross_charge": 1.00, "minimum": 0.80, "maximum": 0.85, "setting": "both", "payers_information": [ { "payer_name": "Aetna", "plan_name": "700700", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna", "plan_name": "700700_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Miscellaneous", "plan_name": "700720", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Miscellaneous", "plan_name": "700720_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Ppo Hmo", "plan_name": "701720", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Ppo Hmo", "plan_name": "701720_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to 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calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Federal", "plan_name": "400110", "standard_charge_percentage": 0.85, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Federal", "plan_name": "400110_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." } ] } ] }, { "description": "Phenol 1.4 % mucosal aerosol spray [27889]", "drug_information": { "unit": 177.00, "type": "ML" }, "code_information": [ { "code": "4603600582", "type": "NDC" } ], "standard_charges": [ { "gross_charge": 9.67, "minimum": 7.74, "maximum": 8.22, "setting": "both", "payers_information": [ { "payer_name": "Aetna", "plan_name": "700700", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna", "plan_name": "700700_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Miscellaneous", "plan_name": "700720", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Miscellaneous", "plan_name": "700720_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Ppo Hmo", "plan_name": "701720", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Ppo Hmo", "plan_name": "701720_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Ms State Emplo", "plan_name": "401457", "standard_charge_percentage": 0.80, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Ms State Emplo", "plan_name": "401457_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Basic Pl", "plan_name": "400100", "standard_charge_percentage": 0.85, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Basic Pl", "plan_name": "400100_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Federal", "plan_name": "400110", "standard_charge_percentage": 0.85, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Federal", "plan_name": "400110_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." } ] } ] }, { "description": "Phenol 1.4 % mucosal aerosol spray [27889]", "drug_information": { "unit": 177.00, "type": "ML" }, "code_information": [ { "code": "4603600607", "type": "NDC" } ], "standard_charges": [ { "gross_charge": 9.67, "minimum": 7.74, "maximum": 8.22, "setting": "both", "payers_information": [ { "payer_name": "Aetna", "plan_name": "700700", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna", "plan_name": "700700_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Miscellaneous", "plan_name": "700720", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Miscellaneous", "plan_name": "700720_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Ppo Hmo", "plan_name": "701720", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Ppo Hmo", "plan_name": "701720_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Ms State Emplo", "plan_name": "401457", "standard_charge_percentage": 0.80, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Ms State Emplo", "plan_name": "401457_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Basic Pl", "plan_name": "400100", "standard_charge_percentage": 0.85, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Basic Pl", "plan_name": "400100_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Federal", "plan_name": "400110", "standard_charge_percentage": 0.85, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Federal", "plan_name": "400110_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." } ] } ] }, { "description": "Calamine 8 %-zinc oxide 8 % lotion [78879]", "drug_information": { "unit": 177.00, "type": "ML" }, "code_information": [ { "code": "4603600662", "type": "NDC" } ], "standard_charges": [ { "gross_charge": 4.60, "minimum": 3.68, "maximum": 3.91, "setting": "both", "payers_information": [ { "payer_name": "Aetna", "plan_name": "700700", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna", "plan_name": "700700_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Miscellaneous", "plan_name": "700720", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Miscellaneous", "plan_name": "700720_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Ppo Hmo", "plan_name": "701720", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Ppo Hmo", "plan_name": "701720_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Ms State Emplo", "plan_name": "401457", "standard_charge_percentage": 0.80, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Ms State Emplo", "plan_name": "401457_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Basic Pl", "plan_name": "400100", "standard_charge_percentage": 0.85, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Basic Pl", "plan_name": "400100_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Federal", "plan_name": "400110", "standard_charge_percentage": 0.85, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Federal", "plan_name": "400110_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." } ] } ] }, { "description": "Sodium polystyrene sulfonate 15 gram-sorbitol 20 gram/60 ml oral susp [178533]", "drug_information": { "unit": 473.00, "type": "ML" }, "code_information": [ { "code": "46287-006-01", "type": "NDC" } ], "standard_charges": [ { "gross_charge": 997.56, "minimum": 798.05, "maximum": 847.93, "setting": "both", "payers_information": [ { "payer_name": "Aetna", "plan_name": "700700", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna", "plan_name": "700700_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Miscellaneous", "plan_name": "700720", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Miscellaneous", "plan_name": "700720_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Ppo Hmo", "plan_name": "701720", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Ppo Hmo", "plan_name": "701720_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Ms State Emplo", "plan_name": "401457", "standard_charge_percentage": 0.80, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Ms State Emplo", "plan_name": "401457_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Basic Pl", "plan_name": "400100", "standard_charge_percentage": 0.85, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Basic Pl", "plan_name": "400100_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Federal", "plan_name": "400110", "standard_charge_percentage": 0.85, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Federal", "plan_name": "400110_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." } ] } ] }, { "description": "Sodium polystyrene sulfonate 15 gram-sorbitol 20 gram/60 ml oral susp [178533]", "drug_information": { "unit": 60.00, "type": "ML" }, "code_information": [ { "code": "46287-006-60", "type": "NDC" } ], "standard_charges": [ { "gross_charge": 117.71, "minimum": 94.17, "maximum": 100.05, "setting": "both", "payers_information": [ { "payer_name": "Aetna", "plan_name": "700700", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna", "plan_name": "700700_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Miscellaneous", "plan_name": "700720", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Miscellaneous", "plan_name": "700720_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Ppo Hmo", "plan_name": "701720", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Ppo Hmo", "plan_name": "701720_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Ms State Emplo", "plan_name": "401457", "standard_charge_percentage": 0.80, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Ms State Emplo", "plan_name": "401457_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Basic Pl", "plan_name": "400100", "standard_charge_percentage": 0.85, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Basic Pl", "plan_name": "400100_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Federal", "plan_name": "400110", "standard_charge_percentage": 0.85, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Federal", "plan_name": "400110_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." } ] } ] }, { "description": "Sorbitol 70 % solution [7413]", "drug_information": { "unit": 473.00, "type": "ML" }, "code_information": [ { "code": "4628750001", "type": "NDC" } ], "standard_charges": [ { "gross_charge": 58.42, "minimum": 46.74, "maximum": 49.66, "setting": "both", "payers_information": [ { "payer_name": "Aetna", "plan_name": "700700", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna", "plan_name": "700700_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Miscellaneous", "plan_name": "700720", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Miscellaneous", "plan_name": "700720_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Ppo Hmo", "plan_name": "701720", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Ppo Hmo", "plan_name": "701720_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Ms State Emplo", "plan_name": "401457", "standard_charge_percentage": 0.80, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Ms State Emplo", "plan_name": "401457_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Basic Pl", "plan_name": "400100", "standard_charge_percentage": 0.85, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Basic Pl", "plan_name": "400100_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Federal", "plan_name": "400110", "standard_charge_percentage": 0.85, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Federal", "plan_name": "400110_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." } ] } ] }, { "description": "Menthol 0.44 %-zinc oxide 20.6 % topical ointment [91352]", "drug_information": { "unit": 71.00, "type": "GR" }, "code_information": [ { "code": "4687600025", "type": "NDC" } ], "standard_charges": [ { "gross_charge": 10.15, "minimum": 8.12, "maximum": 8.63, "setting": "both", "payers_information": [ { "payer_name": "Aetna", "plan_name": "700700", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna", "plan_name": "700700_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient 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calculate allowed amounts." }, { "payer_name": "Bc/Bs Ms State Emplo", "plan_name": "401457", "standard_charge_percentage": 0.80, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Ms State Emplo", "plan_name": "401457_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Basic Pl", "plan_name": "400100", "standard_charge_percentage": 0.85, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Basic Pl", "plan_name": "400100_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Federal", "plan_name": "400110", "standard_charge_percentage": 0.85, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Federal", "plan_name": "400110_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." } ] } ] }, { "description": "Menthol 0.44 %-zinc oxide 20.6 % topical ointment [91352]", "drug_information": { "unit": 113.00, "type": "GR" }, "code_information": [ { "code": "4687600040", "type": "NDC" } ], "standard_charges": [ { "gross_charge": 12.63, "minimum": 10.10, "maximum": 10.74, "setting": "both", "payers_information": [ { "payer_name": "Aetna", "plan_name": "700700", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna", "plan_name": "700700_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Miscellaneous", "plan_name": "700720", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Miscellaneous", "plan_name": "700720_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Ppo Hmo", "plan_name": "701720", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Ppo Hmo", "plan_name": "701720_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Ms State Emplo", "plan_name": "401457", "standard_charge_percentage": 0.80, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Ms State Emplo", "plan_name": "401457_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Basic Pl", "plan_name": "400100", "standard_charge_percentage": 0.85, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Basic Pl", "plan_name": "400100_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Federal", "plan_name": "400110", "standard_charge_percentage": 0.85, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Federal", "plan_name": "400110_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." } ] } ] }, { "description": "Vecuronium bromide 10 mg intravenous solution [11634]", "drug_information": { "unit": 1.00, "type": "EA" }, "code_information": [ { "code": "47335-931-40", "type": "NDC" } ], "standard_charges": [ { "gross_charge": 62.26, "minimum": 49.81, "maximum": 52.92, "setting": "both", "payers_information": [ { "payer_name": "Aetna", "plan_name": "700700", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna", "plan_name": "700700_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Miscellaneous", "plan_name": "700720", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Miscellaneous", "plan_name": "700720_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Ppo Hmo", "plan_name": "701720", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Ppo Hmo", "plan_name": "701720_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Ms State Emplo", "plan_name": "401457", "standard_charge_percentage": 0.80, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Ms State Emplo", "plan_name": "401457_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Basic Pl", "plan_name": "400100", "standard_charge_percentage": 0.85, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Basic Pl", "plan_name": "400100_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Federal", "plan_name": "400110", "standard_charge_percentage": 0.85, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Federal", "plan_name": "400110_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." } ] } ] }, { "description": "Neomycin-bacitracn zn-polymyxn 3.5 mg-400 unit-5000 unit top oint pkt [116684]", "drug_information": { "unit": 1.00, "type": "EA" }, "code_information": [ { "code": "47682-223-35", "type": "NDC" } ], "standard_charges": [ { "gross_charge": 1.00, "minimum": 0.80, "maximum": 0.85, "setting": "both", "payers_information": [ { "payer_name": "Aetna", "plan_name": "700700", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna", "plan_name": "700700_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Miscellaneous", "plan_name": "700720", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Miscellaneous", "plan_name": "700720_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Ppo Hmo", "plan_name": "701720", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Ppo Hmo", "plan_name": "701720_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Ms State Emplo", "plan_name": "401457", "standard_charge_percentage": 0.80, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Ms State Emplo", "plan_name": "401457_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Basic Pl", "plan_name": "400100", "standard_charge_percentage": 0.85, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Basic Pl", "plan_name": "400100_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Federal", "plan_name": "400110", "standard_charge_percentage": 0.85, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Federal", "plan_name": "400110_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." } ] } ] }, { "description": "Neomycin-bacitracn zn-polymyxn 3.5 mg-400 unit-5000 unit top oint pkt [116684]", "drug_information": { "unit": 1.00, "type": "EA" }, "code_information": [ { "code": "47682-223-99", "type": "NDC" } ], "standard_charges": [ { "gross_charge": 1.00, "minimum": 0.80, "maximum": 0.85, "setting": "both", "payers_information": [ { "payer_name": "Aetna", "plan_name": "700700", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna", "plan_name": "700700_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Miscellaneous", "plan_name": "700720", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Miscellaneous", "plan_name": "700720_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Ppo Hmo", "plan_name": "701720", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Ppo Hmo", "plan_name": "701720_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Ms State Emplo", "plan_name": "401457", "standard_charge_percentage": 0.80, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Ms State Emplo", "plan_name": "401457_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Basic Pl", "plan_name": "400100", "standard_charge_percentage": 0.85, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Basic Pl", "plan_name": "400100_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Federal", "plan_name": "400110", "standard_charge_percentage": 0.85, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Federal", "plan_name": "400110_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." } ] } ] }, { "description": "Phenylephrine 10 mg tablet [40368]", "drug_information": { "unit": 1.00, "type": "EA" }, "code_information": [ { "code": "47682-809-33", "type": "NDC" } ], "standard_charges": [ { "gross_charge": 7.50, "minimum": 6.00, "maximum": 6.38, "setting": "both", "payers_information": [ { "payer_name": "Aetna", "plan_name": "700700", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna", "plan_name": "700700_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Miscellaneous", "plan_name": "700720", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Miscellaneous", "plan_name": "700720_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Ppo Hmo", "plan_name": "701720", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Ppo Hmo", "plan_name": "701720_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Ms State Emplo", "plan_name": "401457", "standard_charge_percentage": 0.80, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Ms State Emplo", "plan_name": "401457_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Basic Pl", "plan_name": "400100", "standard_charge_percentage": 0.85, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Basic Pl", "plan_name": "400100_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Federal", "plan_name": "400110", "standard_charge_percentage": 0.85, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Federal", "plan_name": "400110_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." } ] } ] }, { "description": "Hyoscyamine 0.125 mg sublingual tablet [17023]", "drug_information": { "unit": 1.00, "type": "EA" }, "code_information": [ { "code": "47781-011-01", "type": "NDC" } ], "standard_charges": [ { "gross_charge": 7.50, "minimum": 6.00, "maximum": 6.38, "setting": "both", "payers_information": [ { "payer_name": "Aetna", "plan_name": "700700", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna", "plan_name": "700700_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Miscellaneous", "plan_name": "700720", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Miscellaneous", "plan_name": "700720_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Ppo Hmo", "plan_name": "701720", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Ppo Hmo", "plan_name": "701720_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Ms State Emplo", "plan_name": "401457", "standard_charge_percentage": 0.80, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Ms State Emplo", "plan_name": "401457_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Basic Pl", "plan_name": "400100", "standard_charge_percentage": 0.85, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Basic Pl", "plan_name": "400100_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Federal", "plan_name": "400110", "standard_charge_percentage": 0.85, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Federal", "plan_name": "400110_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." } ] } ] }, { "description": "Estradiol 0.01% (0.1 mg/gram) vaginal cream [9969]", "drug_information": { "unit": 42.50, "type": "GR" }, "code_information": [ { "code": "47781-104-44", "type": "NDC" } ], "standard_charges": [ { "gross_charge": 969.20, "minimum": 775.36, "maximum": 823.82, "setting": "both", "payers_information": [ { "payer_name": "Aetna", "plan_name": "700700", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna", "plan_name": "700700_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Miscellaneous", "plan_name": "700720", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Miscellaneous", "plan_name": "700720_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Ppo Hmo", "plan_name": "701720", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Ppo Hmo", "plan_name": "701720_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Ms State Emplo", "plan_name": "401457", "standard_charge_percentage": 0.80, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Ms State Emplo", "plan_name": "401457_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Basic Pl", "plan_name": "400100", "standard_charge_percentage": 0.85, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Basic Pl", "plan_name": "400100_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Federal", "plan_name": "400110", "standard_charge_percentage": 0.85, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Federal", "plan_name": "400110_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." } ] } ] }, { "description": "Nitrofurantoin monohydrate/macrocrystals 100 mg capsule [10724]", "drug_information": { "unit": 1.00, "type": "EA" }, "code_information": [ { "code": "47781-303-01", "type": "NDC" } ], "standard_charges": [ { "gross_charge": 9.07, "minimum": 7.26, "maximum": 7.71, "setting": "both", "payers_information": [ { "payer_name": "Aetna", "plan_name": "700700", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna", "plan_name": "700700_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Miscellaneous", "plan_name": "700720", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Miscellaneous", "plan_name": "700720_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Ppo Hmo", "plan_name": "701720", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Ppo Hmo", "plan_name": "701720_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Ms State Emplo", "plan_name": "401457", "standard_charge_percentage": 0.80, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Ms State Emplo", "plan_name": "401457_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Basic Pl", "plan_name": "400100", "standard_charge_percentage": 0.85, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Basic Pl", "plan_name": "400100_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Federal", "plan_name": "400110", "standard_charge_percentage": 0.85, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Federal", "plan_name": "400110_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." } ] } ] }, { "description": "Fentanyl 25 mcg/hr transdermal patch [27905]", "drug_information": { "unit": 1.00, "type": "EA" }, "code_information": [ { "code": "47781-424-11", "type": "NDC" } ], "standard_charges": [ { "gross_charge": 59.10, "minimum": 47.28, "maximum": 50.24, "setting": "both", "payers_information": [ { "payer_name": "Aetna", "plan_name": "700700", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna", "plan_name": "700700_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Miscellaneous", "plan_name": "700720", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Miscellaneous", "plan_name": "700720_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Ppo Hmo", "plan_name": "701720", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Ppo Hmo", "plan_name": "701720_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Ms State Emplo", "plan_name": "401457", "standard_charge_percentage": 0.80, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Ms State Emplo", "plan_name": "401457_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Basic Pl", "plan_name": "400100", "standard_charge_percentage": 0.85, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Basic Pl", "plan_name": "400100_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Federal", "plan_name": "400110", "standard_charge_percentage": 0.85, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Federal", "plan_name": "400110_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." } ] } ] }, { "description": "Fentanyl 25 mcg/hr transdermal patch [27905]", "drug_information": { "unit": 1.00, "type": "EA" }, "code_information": [ { "code": "47781-424-47", "type": "NDC" } ], "standard_charges": [ { "gross_charge": 59.10, "minimum": 47.28, "maximum": 50.24, "setting": "both", "payers_information": [ { "payer_name": "Aetna", "plan_name": "700700", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna", "plan_name": "700700_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Miscellaneous", "plan_name": "700720", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Miscellaneous", "plan_name": "700720_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Ppo Hmo", "plan_name": "701720", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Ppo Hmo", "plan_name": "701720_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Ms State Emplo", "plan_name": "401457", "standard_charge_percentage": 0.80, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Ms State Emplo", "plan_name": "401457_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Basic Pl", "plan_name": "400100", "standard_charge_percentage": 0.85, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Basic Pl", "plan_name": "400100_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Federal", "plan_name": "400110", "standard_charge_percentage": 0.85, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Federal", "plan_name": "400110_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." } ] } ] }, { "description": "Fentanyl 50 mcg/hr transdermal patch [27906]", "drug_information": { "unit": 1.00, "type": "EA" }, "code_information": [ { "code": "47781-426-11", "type": "NDC" } ], "standard_charges": [ { "gross_charge": 104.29, "minimum": 83.43, "maximum": 88.65, "setting": "both", "payers_information": [ { "payer_name": "Aetna", "plan_name": "700700", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna", "plan_name": "700700_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Miscellaneous", "plan_name": "700720", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Miscellaneous", "plan_name": "700720_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Ppo Hmo", "plan_name": "701720", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Ppo Hmo", "plan_name": "701720_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Ms State Emplo", "plan_name": "401457", "standard_charge_percentage": 0.80, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Ms State Emplo", "plan_name": "401457_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Basic Pl", "plan_name": "400100", "standard_charge_percentage": 0.85, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Basic Pl", "plan_name": "400100_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Federal", "plan_name": "400110", "standard_charge_percentage": 0.85, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Federal", "plan_name": "400110_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." } ] } ] }, { "description": "Fentanyl 50 mcg/hr transdermal patch [27906]", "drug_information": { "unit": 1.00, "type": "EA" }, "code_information": [ { "code": "47781-426-47", "type": "NDC" } ], "standard_charges": [ { "gross_charge": 104.29, "minimum": 83.43, "maximum": 88.65, "setting": "both", "payers_information": [ { "payer_name": "Aetna", "plan_name": "700700", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna", "plan_name": "700700_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Miscellaneous", "plan_name": "700720", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Miscellaneous", "plan_name": "700720_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data 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allowed amounts." } ] } ] }, { "description": "Fentanyl 75 mcg/hr transdermal patch [27907]", "drug_information": { "unit": 1.00, "type": "EA" }, "code_information": [ { "code": "47781-427-11", "type": "NDC" } ], "standard_charges": [ { "gross_charge": 164.85, "minimum": 131.88, "maximum": 140.12, "setting": "both", "payers_information": [ { "payer_name": "Aetna", "plan_name": "700700", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna", "plan_name": "700700_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Miscellaneous", "plan_name": "700720", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": 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remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Ms State Emplo", "plan_name": "401457_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Basic Pl", "plan_name": "400100", "standard_charge_percentage": 0.85, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Basic Pl", "plan_name": "400100_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Federal", "plan_name": "400110", "standard_charge_percentage": 0.85, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient 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billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Basic Pl", "plan_name": "400100_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Federal", "plan_name": "400110", "standard_charge_percentage": 0.85, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Federal", "plan_name": "400110_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." } ] } ] }, { "description": "Oseltamivir 75 mg capsule [26546]", "drug_information": { "unit": 1.00, "type": "EA" }, "code_information": [ { "code": 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"percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Basic Pl", "plan_name": "400100", "standard_charge_percentage": 0.85, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Basic Pl", "plan_name": "400100_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Federal", "plan_name": "400110", "standard_charge_percentage": 0.85, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Federal", "plan_name": "400110_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." } ] } ] }, { "description": "Methenamine hippurate 1 gram tablet [10549]", "drug_information": { "unit": 1.00, "type": "EA" }, "code_information": [ { "code": "47781-577-01", "type": "NDC" } ], "standard_charges": [ { "gross_charge": 9.93, "minimum": 7.94, "maximum": 8.44, "setting": "both", "payers_information": [ { "payer_name": "Aetna", "plan_name": "700700", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna", "plan_name": "700700_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Miscellaneous", "plan_name": "700720", "standard_charge_percentage": 80.0, 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"methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Ms State Emplo", "plan_name": "401457_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Basic Pl", "plan_name": "400100", "standard_charge_percentage": 0.85, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Basic Pl", "plan_name": "400100_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Federal", "plan_name": "400110", "standard_charge_percentage": 0.85, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Federal", "plan_name": "400110_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." } ] } ] }, { "description": "Aspirin 81 mg chewable tablet [679]", "drug_information": { "unit": 1.00, "type": "EA" }, "code_information": [ { "code": "48433-129-01", "type": "NDC" } ], "standard_charges": [ { "gross_charge": 1.00, "minimum": 0.80, "maximum": 0.85, "setting": "both", "payers_information": [ { "payer_name": "Aetna", "plan_name": "700700", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna", "plan_name": "700700_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Miscellaneous", "plan_name": "700720", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Miscellaneous", "plan_name": "700720_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Ppo Hmo", "plan_name": "701720", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Ppo Hmo", "plan_name": "701720_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Ms State Emplo", "plan_name": "401457", "standard_charge_percentage": 0.80, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Ms State Emplo", "plan_name": "401457_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Basic Pl", "plan_name": "400100", "standard_charge_percentage": 0.85, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Basic Pl", "plan_name": "400100_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Federal", "plan_name": "400110", "standard_charge_percentage": 0.85, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Federal", "plan_name": "400110_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." } ] } ] }, { "description": "Saliva stimulant combination no.3 oral mucosal spray [118454]", "drug_information": { "unit": 44.30, "type": "ML" }, "code_information": [ { "code": "4858200155", "type": "NDC" } ], "standard_charges": [ { "gross_charge": 18.54, "minimum": 14.83, "maximum": 15.76, "setting": "both", "payers_information": [ { "payer_name": "Aetna", "plan_name": "700700", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna", "plan_name": "700700_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Miscellaneous", "plan_name": "700720", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Miscellaneous", "plan_name": "700720_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Ppo Hmo", "plan_name": "701720", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Ppo Hmo", "plan_name": "701720_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Ms State Emplo", "plan_name": "401457", "standard_charge_percentage": 0.80, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Ms State Emplo", "plan_name": "401457_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Basic Pl", "plan_name": "400100", "standard_charge_percentage": 0.85, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Basic Pl", "plan_name": "400100_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Federal", "plan_name": "400110", "standard_charge_percentage": 0.85, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Federal", "plan_name": "400110_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." } ] } ] }, { "description": "Ferric subsulfate 0.2 gram to 0.22 gram/ml topical soln and applicator [163610]", "drug_information": { "unit": 8.00, "type": "ML" }, "code_information": [ { "code": "48783-112-08", "type": "NDC" } ], "standard_charges": [ { "gross_charge": 91.16, "minimum": 72.93, "maximum": 77.49, "setting": "both", "payers_information": [ { "payer_name": "Aetna", "plan_name": "700700", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna", "plan_name": "700700_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Miscellaneous", "plan_name": "700720", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Miscellaneous", "plan_name": "700720_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Ppo Hmo", "plan_name": "701720", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Ppo Hmo", "plan_name": "701720_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Ms State Emplo", "plan_name": "401457", "standard_charge_percentage": 0.80, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Ms State Emplo", "plan_name": "401457_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Basic Pl", "plan_name": "400100", "standard_charge_percentage": 0.85, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Basic Pl", "plan_name": "400100_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Federal", "plan_name": "400110", "standard_charge_percentage": 0.85, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Federal", "plan_name": "400110_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." } ] } ] }, { "description": "Nicotine 14 mg/24 hr daily transdermal patch [27862]", "drug_information": { "unit": 1.00, "type": "EA" }, "code_information": [ { "code": "4898500150", "type": "NDC" } ], "standard_charges": [ { "gross_charge": 4.62, "minimum": 3.70, "maximum": 3.93, "setting": "both", "payers_information": [ { "payer_name": "Aetna", "plan_name": "700700", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna", "plan_name": "700700_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Miscellaneous", "plan_name": "700720", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Miscellaneous", "plan_name": "700720_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Ppo Hmo", "plan_name": "701720", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Ppo Hmo", "plan_name": "701720_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Ms State Emplo", "plan_name": "401457", "standard_charge_percentage": 0.80, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Ms State Emplo", "plan_name": "401457_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Basic Pl", "plan_name": "400100", "standard_charge_percentage": 0.85, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Basic Pl", "plan_name": "400100_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Federal", "plan_name": "400110", "standard_charge_percentage": 0.85, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Federal", "plan_name": "400110_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." } ] } ] }, { "description": "Nicotine 21 mg/24 hr daily transdermal patch [27863]", "drug_information": { "unit": 1.00, "type": "EA" }, "code_information": [ { "code": "4898500152", "type": "NDC" } ], "standard_charges": [ { "gross_charge": 4.62, "minimum": 3.70, "maximum": 3.93, "setting": "both", "payers_information": [ { "payer_name": "Aetna", "plan_name": "700700", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna", "plan_name": "700700_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Miscellaneous", "plan_name": "700720", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Miscellaneous", "plan_name": "700720_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Ppo Hmo", "plan_name": "701720", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Ppo Hmo", "plan_name": "701720_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Ms State Emplo", "plan_name": "401457", "standard_charge_percentage": 0.80, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Ms State Emplo", "plan_name": "401457_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Basic Pl", "plan_name": "400100", "standard_charge_percentage": 0.85, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Basic Pl", "plan_name": "400100_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Federal", "plan_name": "400110", "standard_charge_percentage": 0.85, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Federal", "plan_name": "400110_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." } ] } ] }, { "description": "Isosorbide dinitrate 30 mg tablet [4066]", "drug_information": { "unit": 1.00, "type": "EA" }, "code_information": [ { "code": "49884-009-01", "type": "NDC" } ], "standard_charges": [ { "gross_charge": 7.50, "minimum": 6.00, "maximum": 6.38, "setting": "both", "payers_information": [ { "payer_name": "Aetna", "plan_name": "700700", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna", "plan_name": "700700_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Miscellaneous", "plan_name": "700720", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Miscellaneous", "plan_name": "700720_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Ppo Hmo", "plan_name": "701720", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Ppo Hmo", "plan_name": "701720_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Ms State Emplo", "plan_name": "401457", "standard_charge_percentage": 0.80, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Ms State Emplo", "plan_name": "401457_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Basic Pl", "plan_name": "400100", "standard_charge_percentage": 0.85, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Basic Pl", "plan_name": "400100_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Federal", "plan_name": "400110", "standard_charge_percentage": 0.85, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Federal", "plan_name": "400110_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." } ] } ] }, { "description": "Imipramine 10 mg tablet [3860]", "drug_information": { "unit": 1.00, "type": "EA" }, "code_information": [ { "code": "49884-054-01", "type": "NDC" } ], "standard_charges": [ { "gross_charge": 7.50, "minimum": 6.00, "maximum": 6.38, "setting": "both", "payers_information": [ { "payer_name": "Aetna", "plan_name": "700700", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna", "plan_name": "700700_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Miscellaneous", "plan_name": "700720", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Miscellaneous", "plan_name": "700720_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Ppo Hmo", "plan_name": "701720", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Ppo Hmo", "plan_name": "701720_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Ms State Emplo", "plan_name": "401457", "standard_charge_percentage": 0.80, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Ms State Emplo", "plan_name": "401457_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Basic Pl", "plan_name": "400100", "standard_charge_percentage": 0.85, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Basic Pl", "plan_name": "400100_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Federal", "plan_name": "400110", "standard_charge_percentage": 0.85, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Federal", "plan_name": "400110_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." } ] } ] }, { "description": "Calcitonin (salmon) 200 unit/actuation nasal spray [15738]", "drug_information": { "unit": 3.70, "type": "ML" }, "code_information": [ { "code": "49884-161-11", "type": "NDC" } ], "standard_charges": [ { "gross_charge": 355.63, "minimum": 284.50, "maximum": 302.29, "setting": "both", "payers_information": [ { "payer_name": "Aetna", "plan_name": "700700", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna", "plan_name": "700700_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Miscellaneous", "plan_name": "700720", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Miscellaneous", "plan_name": "700720_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Ppo Hmo", "plan_name": "701720", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Ppo Hmo", "plan_name": "701720_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Ms State Emplo", "plan_name": "401457", "standard_charge_percentage": 0.80, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Ms State Emplo", "plan_name": "401457_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Basic Pl", "plan_name": "400100", "standard_charge_percentage": 0.85, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Basic Pl", "plan_name": "400100_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Federal", "plan_name": "400110", "standard_charge_percentage": 0.85, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Federal", "plan_name": "400110_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." } ] } ] }, { "description": "Minoxidil 10 mg tablet [5114]", "drug_information": { "unit": 1.00, "type": "EA" }, "code_information": [ { "code": "49884-257-01", "type": "NDC" } ], "standard_charges": [ { "gross_charge": 7.50, "minimum": 6.00, "maximum": 6.38, "setting": "both", "payers_information": [ { "payer_name": "Aetna", "plan_name": "700700", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna", "plan_name": "700700_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Miscellaneous", "plan_name": "700720", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Miscellaneous", "plan_name": "700720_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Ppo Hmo", "plan_name": "701720", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Ppo Hmo", "plan_name": "701720_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Ms State Emplo", "plan_name": "401457", "standard_charge_percentage": 0.80, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Ms State Emplo", "plan_name": "401457_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Basic Pl", "plan_name": "400100", "standard_charge_percentage": 0.85, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Basic Pl", "plan_name": "400100_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Federal", "plan_name": "400110", "standard_charge_percentage": 0.85, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Federal", "plan_name": "400110_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." } ] } ] }, { "description": "Pimozide 1 mg tablet [15275]", "drug_information": { "unit": 1.00, "type": "EA" }, "code_information": [ { "code": "49884-347-01", "type": "NDC" } ], "standard_charges": [ { "gross_charge": 9.42, "minimum": 7.54, "maximum": 8.01, "setting": "both", "payers_information": [ { "payer_name": "Aetna", "plan_name": "700700", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna", "plan_name": "700700_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Miscellaneous", "plan_name": "700720", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Miscellaneous", "plan_name": "700720_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Ppo Hmo", "plan_name": "701720", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Ppo Hmo", "plan_name": "701720_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Ms State Emplo", "plan_name": "401457", "standard_charge_percentage": 0.80, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Ms State Emplo", "plan_name": "401457_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Basic Pl", "plan_name": "400100", "standard_charge_percentage": 0.85, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Basic Pl", "plan_name": "400100_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Federal", "plan_name": "400110", "standard_charge_percentage": 0.85, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Federal", "plan_name": "400110_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." } ] } ] }, { "description": "Cholestyramine-aspartame 4 gram oral powder for susp in a packet [113348]", "drug_information": { "unit": 1.00, "type": "EA" }, "code_information": [ { "code": "49884-466-63", "type": "NDC" } ], "standard_charges": [ { "gross_charge": 13.50, "minimum": 10.80, "maximum": 11.48, "setting": "both", "payers_information": [ { "payer_name": "Aetna", "plan_name": "700700", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna", "plan_name": "700700_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Miscellaneous", "plan_name": "700720", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Miscellaneous", "plan_name": "700720_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Ppo Hmo", "plan_name": "701720", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Ppo Hmo", "plan_name": "701720_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Ms State Emplo", "plan_name": "401457", "standard_charge_percentage": 0.80, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Ms State Emplo", "plan_name": "401457_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Basic Pl", "plan_name": "400100", "standard_charge_percentage": 0.85, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Basic Pl", "plan_name": "400100_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Federal", "plan_name": "400110", "standard_charge_percentage": 0.85, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Federal", "plan_name": "400110_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." } ] } ] }, { "description": "Cholestyramine-aspartame 4 gram oral powder for susp in a packet [113348]", "drug_information": { "unit": 1.00, "type": "EA" }, "code_information": [ { "code": "49884-466-65", "type": "NDC" } ], "standard_charges": [ { "gross_charge": 13.50, "minimum": 10.80, "maximum": 11.48, "setting": "both", "payers_information": [ { "payer_name": "Aetna", "plan_name": "700700", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", 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"Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Basic Pl", "plan_name": "400100_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Federal", "plan_name": "400110", "standard_charge_percentage": 0.85, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Federal", "plan_name": "400110_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." } ] } ] }, { "description": "Hydroxyurea 500 mg capsule [10236]", "drug_information": { "unit": 1.00, "type": "EA" }, "code_information": [ { "code": "49884-724-01", "type": "NDC" } ], 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charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Ppo Hmo", "plan_name": "701720", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Ppo Hmo", "plan_name": "701720_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Ms State Emplo", "plan_name": "401457", "standard_charge_percentage": 0.80, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Ms State Emplo", "plan_name": "401457_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Basic Pl", "plan_name": "400100", "standard_charge_percentage": 0.85, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Basic Pl", "plan_name": "400100_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Federal", "plan_name": "400110", "standard_charge_percentage": 0.85, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Federal", "plan_name": "400110_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." } ] } ] }, { "description": "Tolvaptan 15 mg tablet [97893]", "drug_information": { "unit": 1.00, "type": "EA" }, "code_information": [ { "code": "49884-768-54", "type": "NDC" } ], "standard_charges": [ { "gross_charge": 823.87, "minimum": 659.10, "maximum": 700.29, "setting": "both", "payers_information": [ { "payer_name": "Aetna", "plan_name": "700700", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna", "plan_name": "700700_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Miscellaneous", "plan_name": "700720", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of 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charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Ms State Emplo", "plan_name": "401457_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Basic Pl", "plan_name": "400100", "standard_charge_percentage": 0.85, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Basic Pl", "plan_name": "400100_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Federal", "plan_name": "400110", "standard_charge_percentage": 0.85, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Federal", "plan_name": "400110_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." } ] } ] }, { "description": "Midodrine 5 mg tablet [10610]", "drug_information": { "unit": 1.00, "type": "EA" }, "code_information": [ { "code": "49884-849-01", "type": "NDC" } ], "standard_charges": [ { "gross_charge": 8.07, "minimum": 6.46, "maximum": 6.86, "setting": "both", "payers_information": [ { "payer_name": "Aetna", "plan_name": "700700", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna", "plan_name": "700700_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Miscellaneous", "plan_name": "700720", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Miscellaneous", "plan_name": "700720_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Ppo Hmo", "plan_name": "701720", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Ppo Hmo", "plan_name": "701720_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Ms State Emplo", "plan_name": "401457", "standard_charge_percentage": 0.80, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Ms State Emplo", "plan_name": "401457_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Basic Pl", "plan_name": "400100", "standard_charge_percentage": 0.85, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Basic Pl", "plan_name": "400100_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Federal", "plan_name": "400110", "standard_charge_percentage": 0.85, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Federal", "plan_name": "400110_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." } ] } ] }, { "description": "Dapsone 100 mg tablet [2131]", "drug_information": { "unit": 1.00, "type": "EA" }, "code_information": [ { "code": "49938-101-30", "type": "NDC" } ], "standard_charges": [ { "gross_charge": 13.30, "minimum": 10.64, "maximum": 11.31, "setting": "both", "payers_information": [ { "payer_name": "Aetna", "plan_name": "700700", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna", "plan_name": "700700_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Miscellaneous", "plan_name": "700720", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Miscellaneous", "plan_name": "700720_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Ppo Hmo", "plan_name": "701720", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Ppo Hmo", "plan_name": "701720_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Ms State Emplo", "plan_name": "401457", "standard_charge_percentage": 0.80, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Ms State Emplo", "plan_name": "401457_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Basic Pl", "plan_name": "400100", "standard_charge_percentage": 0.85, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Basic Pl", "plan_name": "400100_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Federal", "plan_name": "400110", "standard_charge_percentage": 0.85, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Federal", "plan_name": "400110_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." } ] } ] }, { "description": "Aminocaproic acid 500 mg tablet [9063]", "drug_information": { "unit": 1.00, "type": "EA" }, "code_information": [ { "code": "49411-050-30", "type": "NDC" } ], "standard_charges": [ { "gross_charge": 102.03, "minimum": 81.62, "maximum": 86.73, "setting": "both", "payers_information": [ { "payer_name": "Aetna", "plan_name": "700700", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna", "plan_name": "700700_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Miscellaneous", "plan_name": "700720", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Miscellaneous", "plan_name": "700720_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Ppo Hmo", "plan_name": "701720", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Ppo Hmo", "plan_name": "701720_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Ms State Emplo", "plan_name": "401457", "standard_charge_percentage": 0.80, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Ms State Emplo", "plan_name": "401457_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Basic Pl", "plan_name": "400100", "standard_charge_percentage": 0.85, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Basic Pl", "plan_name": "400100_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Federal", "plan_name": "400110", "standard_charge_percentage": 0.85, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Federal", "plan_name": "400110_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." } ] } ] }, { "description": "Flexible collodion (bulk) liquid [12683]", "drug_information": { "unit": 500.00, "type": "ML" }, "code_information": [ { "code": "49452-2220-2", "type": "NDC" } ], "standard_charges": [ { "gross_charge": 370.74, "minimum": 296.59, "maximum": 315.13, "setting": "both", "payers_information": [ { "payer_name": "Aetna", "plan_name": "700700", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna", "plan_name": "700700_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Miscellaneous", "plan_name": "700720", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Miscellaneous", "plan_name": "700720_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Ppo Hmo", "plan_name": "701720", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Ppo Hmo", "plan_name": "701720_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Ms State Emplo", "plan_name": "401457", "standard_charge_percentage": 0.80, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Ms State Emplo", "plan_name": "401457_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Basic Pl", "plan_name": "400100", "standard_charge_percentage": 0.85, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Basic Pl", "plan_name": "400100_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Federal", "plan_name": "400110", "standard_charge_percentage": 0.85, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Federal", "plan_name": "400110_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." } ] } ] }, { "description": "Acetazolamide 250 mg tablet [113]", "drug_information": { "unit": 1.00, "type": "EA" }, "code_information": [ { "code": "50268-054-11", "type": "NDC" } ], "standard_charges": [ { "gross_charge": 19.89, "minimum": 15.91, "maximum": 16.91, "setting": "both", "payers_information": [ { "payer_name": "Aetna", "plan_name": "700700", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna", "plan_name": "700700_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Miscellaneous", "plan_name": "700720", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Miscellaneous", "plan_name": "700720_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Ppo Hmo", "plan_name": "701720", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Ppo Hmo", "plan_name": "701720_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Ms State Emplo", "plan_name": "401457", "standard_charge_percentage": 0.80, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Ms State Emplo", "plan_name": "401457_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Basic Pl", "plan_name": "400100", "standard_charge_percentage": 0.85, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Basic Pl", "plan_name": "400100_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Federal", "plan_name": "400110", "standard_charge_percentage": 0.85, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Federal", "plan_name": "400110_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." } ] } ] }, { "description": "Acyclovir 400 mg tablet [8971]", "drug_information": { "unit": 1.00, "type": "EA" }, "code_information": [ { "code": "50268-061-11", "type": "NDC" } ], "standard_charges": [ { "gross_charge": 7.50, "minimum": 6.00, "maximum": 6.38, "setting": "both", "payers_information": [ { "payer_name": "Aetna", "plan_name": "700700", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna", "plan_name": "700700_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Miscellaneous", "plan_name": "700720", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Miscellaneous", "plan_name": "700720_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Ppo Hmo", "plan_name": "701720", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Ppo Hmo", "plan_name": "701720_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Ms State Emplo", "plan_name": "401457", "standard_charge_percentage": 0.80, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Ms State Emplo", "plan_name": "401457_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Basic Pl", "plan_name": "400100", "standard_charge_percentage": 0.85, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Basic Pl", "plan_name": "400100_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Federal", "plan_name": "400110", "standard_charge_percentage": 0.85, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Federal", "plan_name": "400110_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." } ] } ] }, { "description": "Anastrozole 1 mg tablet [16205]", "drug_information": { "unit": 1.00, "type": "EA" }, "code_information": [ { "code": "50268-075-11", "type": "NDC" } ], "standard_charges": [ { "gross_charge": 7.52, "minimum": 6.02, "maximum": 6.39, "setting": "both", "payers_information": [ { "payer_name": "Aetna", "plan_name": "700700", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna", "plan_name": "700700_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Miscellaneous", "plan_name": "700720", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Miscellaneous", "plan_name": "700720_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Ppo Hmo", "plan_name": "701720", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Ppo Hmo", "plan_name": "701720_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Ms State Emplo", "plan_name": "401457", "standard_charge_percentage": 0.80, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Ms State Emplo", "plan_name": "401457_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Basic Pl", "plan_name": "400100", "standard_charge_percentage": 0.85, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Basic Pl", "plan_name": "400100_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Federal", "plan_name": "400110", "standard_charge_percentage": 0.85, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Federal", "plan_name": "400110_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." } ] } ] }, { "description": "Aripiprazole 2 mg tablet [70306]", "drug_information": { "unit": 1.00, "type": "EA" }, "code_information": [ { "code": "50268-087-11", "type": "NDC" } ], "standard_charges": [ { "gross_charge": 8.87, "minimum": 7.10, "maximum": 7.54, "setting": "both", "payers_information": [ { "payer_name": "Aetna", "plan_name": "700700", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna", "plan_name": "700700_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Miscellaneous", "plan_name": "700720", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Miscellaneous", "plan_name": "700720_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Ppo Hmo", "plan_name": "701720", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Ppo Hmo", "plan_name": "701720_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Ms State Emplo", "plan_name": "401457", "standard_charge_percentage": 0.80, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Ms State Emplo", "plan_name": "401457_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Basic Pl", "plan_name": "400100", "standard_charge_percentage": 0.85, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Basic Pl", "plan_name": "400100_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Federal", "plan_name": "400110", "standard_charge_percentage": 0.85, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Federal", "plan_name": "400110_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." } ] } ] }, { "description": "Baclofen 10 mg tablet [860]", "drug_information": { "unit": 1.00, "type": "EA" }, "code_information": [ { "code": "50268-106-11", "type": "NDC" } ], "standard_charges": [ { "gross_charge": 7.50, "minimum": 6.00, "maximum": 6.38, "setting": "both", "payers_information": [ { "payer_name": "Aetna", "plan_name": "700700", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna", "plan_name": "700700_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Miscellaneous", "plan_name": "700720", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Miscellaneous", "plan_name": "700720_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Ppo Hmo", "plan_name": "701720", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Ppo Hmo", "plan_name": "701720_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Ms State Emplo", "plan_name": "401457", "standard_charge_percentage": 0.80, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Ms State Emplo", "plan_name": "401457_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Basic Pl", "plan_name": "400100", "standard_charge_percentage": 0.85, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Basic Pl", "plan_name": "400100_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Federal", "plan_name": "400110", "standard_charge_percentage": 0.85, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Federal", "plan_name": "400110_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." } ] } ] }, { "description": "Bumetanide 1 mg tablet [9310]", "drug_information": { "unit": 1.00, "type": "EA" }, "code_information": [ { "code": "50268-131-11", "type": "NDC" } ], "standard_charges": [ { "gross_charge": 7.89, "minimum": 6.31, "maximum": 6.71, "setting": "both", "payers_information": [ { "payer_name": "Aetna", "plan_name": "700700", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna", "plan_name": "700700_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Miscellaneous", "plan_name": "700720", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Miscellaneous", "plan_name": "700720_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Ppo Hmo", "plan_name": "701720", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Ppo Hmo", "plan_name": "701720_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Ms State Emplo", "plan_name": "401457", "standard_charge_percentage": 0.80, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Ms State Emplo", "plan_name": "401457_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": 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"standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." } ] } ] }, { "description": "Clarithromycin 500 mg tablet [9617]", "drug_information": { "unit": 1.00, "type": "EA" }, "code_information": [ { "code": "50268-179-13", "type": "NDC" } ], "standard_charges": [ { "gross_charge": 22.68, "minimum": 18.14, "maximum": 19.28, "setting": "both", "payers_information": [ { "payer_name": "Aetna", "plan_name": "700700", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna", "plan_name": "700700_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna 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"payer_name": "Aetna", "plan_name": "700700_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Miscellaneous", "plan_name": "700720", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Miscellaneous", "plan_name": "700720_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Ppo Hmo", "plan_name": "701720", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Ppo 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"description": "Cyproheptadine 4 mg tablet [2033]", "drug_information": { "unit": 1.00, "type": "EA" }, "code_information": [ { "code": "50268-189-15", "type": "NDC" } ], "standard_charges": [ { "gross_charge": 7.50, "minimum": 6.00, "maximum": 6.38, "setting": "both", "payers_information": [ { "payer_name": "Aetna", "plan_name": "700700", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna", "plan_name": "700700_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Miscellaneous", "plan_name": "700720", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed 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"payer_name": "Bc/Bs Ms State Emplo", "plan_name": "401457_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Basic Pl", "plan_name": "400100", "standard_charge_percentage": 0.85, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Basic Pl", "plan_name": "400100_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Federal", "plan_name": "400110", "standard_charge_percentage": 0.85, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Federal", "plan_name": "400110_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." } ] } ] }, { "description": "Doxycycline hyclate 100 mg capsule [2623]", "drug_information": { "unit": 1.00, "type": "EA" }, "code_information": [ { "code": "50268-278-11", "type": "NDC" } ], "standard_charges": [ { "gross_charge": 14.31, "minimum": 11.45, "maximum": 12.16, "setting": "both", "payers_information": [ { "payer_name": "Aetna", "plan_name": "700700", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna", "plan_name": "700700_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to 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amounts." }, { "payer_name": "Bc/Bs Of Ms Federal", "plan_name": "400110", "standard_charge_percentage": 0.85, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Federal", "plan_name": "400110_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." } ] } ] }, { "description": "Doxycycline hyclate 100 mg capsule [2623]", "drug_information": { "unit": 1.00, "type": "EA" }, "code_information": [ { "code": "50268-278-15", "type": "NDC" } ], "standard_charges": [ { "gross_charge": 14.31, "minimum": 11.45, "maximum": 12.16, "setting": "both", "payers_information": [ { "payer_name": "Aetna", "plan_name": "700700", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": 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calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Basic Pl", "plan_name": "400100_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Federal", "plan_name": "400110", "standard_charge_percentage": 0.85, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Federal", "plan_name": "400110_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." } ] } ] }, { "description": "Fenofibrate 54 mg tablet [31336]", "drug_information": { "unit": 1.00, "type": "EA" }, "code_information": [ { "code": "50268-312-11", "type": "NDC" } ], "standard_charges": [ { "gross_charge": 11.26, "minimum": 9.01, "maximum": 9.57, "setting": "both", "payers_information": [ { "payer_name": "Aetna", "plan_name": "700700", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna", "plan_name": "700700_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Miscellaneous", "plan_name": "700720", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Miscellaneous", "plan_name": "700720_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Ppo Hmo", "plan_name": "701720", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Ppo Hmo", "plan_name": "701720_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Ms State Emplo", "plan_name": "401457", "standard_charge_percentage": 0.80, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Ms State Emplo", "plan_name": "401457_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Basic Pl", "plan_name": "400100", "standard_charge_percentage": 0.85, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Basic Pl", "plan_name": "400100_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Federal", "plan_name": "400110", "standard_charge_percentage": 0.85, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Federal", "plan_name": "400110_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." } ] } ] }, { "description": "Finasteride 5 mg tablet [10037]", "drug_information": { "unit": 1.00, "type": "EA" }, "code_information": [ { "code": "50268-314-11", "type": "NDC" } ], "standard_charges": [ { "gross_charge": 7.50, "minimum": 6.00, "maximum": 6.38, "setting": "both", "payers_information": [ { "payer_name": "Aetna", "plan_name": "700700", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna", "plan_name": "700700_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Miscellaneous", "plan_name": "700720", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Miscellaneous", "plan_name": "700720_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Ppo Hmo", "plan_name": "701720", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Ppo Hmo", "plan_name": "701720_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Ms State Emplo", "plan_name": "401457", "standard_charge_percentage": 0.80, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Ms State Emplo", "plan_name": "401457_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Basic Pl", "plan_name": "400100", "standard_charge_percentage": 0.85, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Basic Pl", "plan_name": "400100_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Federal", "plan_name": "400110", "standard_charge_percentage": 0.85, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Federal", "plan_name": "400110_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." } ] } ] }, { "description": "Finasteride 5 mg tablet [10037]", "drug_information": { "unit": 1.00, "type": "EA" }, "code_information": [ { "code": "50268-314-15", "type": "NDC" } ], "standard_charges": [ { "gross_charge": 7.50, "minimum": 6.00, "maximum": 6.38, "setting": "both", "payers_information": [ { "payer_name": "Aetna", "plan_name": "700700", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna", "plan_name": "700700_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Miscellaneous", "plan_name": "700720", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Miscellaneous", "plan_name": "700720_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Ppo Hmo", "plan_name": "701720", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Ppo Hmo", "plan_name": "701720_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Ms State Emplo", "plan_name": "401457", "standard_charge_percentage": 0.80, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Ms State Emplo", "plan_name": "401457_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Basic Pl", "plan_name": "400100", "standard_charge_percentage": 0.85, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Basic Pl", "plan_name": "400100_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Federal", "plan_name": "400110", "standard_charge_percentage": 0.85, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Federal", "plan_name": "400110_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." } ] } ] }, { "description": "Flavoxate 100 mg tablet [10039]", "drug_information": { "unit": 1.00, "type": "EA" }, "code_information": [ { "code": "50268-324-15", "type": "NDC" } ], "standard_charges": [ { "gross_charge": 7.50, "minimum": 6.00, "maximum": 6.38, "setting": "both", "payers_information": [ { "payer_name": "Aetna", "plan_name": "700700", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna", "plan_name": "700700_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Miscellaneous", "plan_name": "700720", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Miscellaneous", "plan_name": "700720_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Ppo Hmo", "plan_name": "701720", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Ppo Hmo", "plan_name": "701720_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Ms State Emplo", "plan_name": "401457", "standard_charge_percentage": 0.80, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Ms State Emplo", "plan_name": "401457_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Basic Pl", "plan_name": "400100", "standard_charge_percentage": 0.85, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Basic Pl", "plan_name": "400100_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Federal", "plan_name": "400110", "standard_charge_percentage": 0.85, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Federal", "plan_name": "400110_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." } ] } ] }, { "description": "Fludrocortisone 0.1 mg tablet [10054]", "drug_information": { "unit": 1.00, "type": "EA" }, "code_information": [ { "code": "50268-330-11", "type": "NDC" } ], "standard_charges": [ { "gross_charge": 7.50, "minimum": 6.00, "maximum": 6.38, "setting": "both", "payers_information": [ { "payer_name": "Aetna", "plan_name": "700700", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna", "plan_name": "700700_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Miscellaneous", "plan_name": "700720", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Miscellaneous", "plan_name": "700720_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Ppo Hmo", "plan_name": "701720", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Ppo Hmo", "plan_name": "701720_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Ms State Emplo", "plan_name": "401457", "standard_charge_percentage": 0.80, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Ms State Emplo", "plan_name": "401457_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Basic Pl", "plan_name": "400100", "standard_charge_percentage": 0.85, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Basic Pl", "plan_name": "400100_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Federal", "plan_name": "400110", "standard_charge_percentage": 0.85, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Federal", "plan_name": "400110_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." } ] } ] }, { "description": "Fludrocortisone 0.1 mg tablet [10054]", "drug_information": { "unit": 1.00, "type": "EA" }, "code_information": [ { "code": "50268-330-15", "type": "NDC" } ], "standard_charges": [ { "gross_charge": 7.50, "minimum": 6.00, "maximum": 6.38, "setting": "both", "payers_information": [ { "payer_name": "Aetna", "plan_name": "700700", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna", "plan_name": "700700_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Miscellaneous", "plan_name": "700720", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Miscellaneous", "plan_name": "700720_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Ppo Hmo", "plan_name": "701720", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Ppo Hmo", "plan_name": "701720_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Ms State Emplo", "plan_name": "401457", "standard_charge_percentage": 0.80, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Ms State Emplo", "plan_name": "401457_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Basic Pl", "plan_name": "400100", "standard_charge_percentage": 0.85, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Basic Pl", "plan_name": "400100_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Federal", "plan_name": "400110", "standard_charge_percentage": 0.85, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Federal", "plan_name": "400110_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." } ] } ] }, { "description": "Glipizide 5 mg tablet [10117]", "drug_information": { "unit": 1.00, "type": "EA" }, "code_information": [ { "code": "50268-361-11", "type": "NDC" } ], "standard_charges": [ { "gross_charge": 7.50, "minimum": 6.00, "maximum": 6.38, "setting": "both", "payers_information": [ { "payer_name": "Aetna", "plan_name": "700700", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna", "plan_name": "700700_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Miscellaneous", "plan_name": "700720", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Miscellaneous", "plan_name": "700720_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Ppo Hmo", "plan_name": "701720", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Ppo Hmo", "plan_name": "701720_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Ms State Emplo", "plan_name": "401457", "standard_charge_percentage": 0.80, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Ms State Emplo", "plan_name": "401457_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Basic Pl", "plan_name": "400100", "standard_charge_percentage": 0.85, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Basic Pl", "plan_name": "400100_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Federal", "plan_name": "400110", "standard_charge_percentage": 0.85, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Federal", "plan_name": "400110_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." } ] } ] }, { "description": "Glipizide 5 mg tablet [10117]", "drug_information": { "unit": 1.00, "type": "EA" }, "code_information": [ { "code": "50268-361-15", "type": "NDC" } ], "standard_charges": [ { "gross_charge": 7.50, "minimum": 6.00, "maximum": 6.38, "setting": "both", "payers_information": [ { "payer_name": "Aetna", "plan_name": "700700", 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"standard_charges": [ { "gross_charge": 7.50, "minimum": 6.00, "maximum": 6.38, "setting": "both", "payers_information": [ { "payer_name": "Aetna", "plan_name": "700700", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna", "plan_name": "700700_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Miscellaneous", "plan_name": "700720", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Miscellaneous", "plan_name": "700720_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Ppo Hmo", "plan_name": "701720", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Ppo Hmo", "plan_name": "701720_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Ms State Emplo", "plan_name": "401457", "standard_charge_percentage": 0.80, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Ms State Emplo", "plan_name": "401457_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Basic Pl", "plan_name": "400100", "standard_charge_percentage": 0.85, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Basic Pl", "plan_name": "400100_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Federal", "plan_name": "400110", "standard_charge_percentage": 0.85, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Federal", "plan_name": "400110_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." } ] } ] }, { "description": "Itraconazole 100 mg capsule [10364]", "drug_information": { "unit": 1.00, "type": "EA" }, "code_information": [ { "code": "50268-450-11", "type": "NDC" } ], "standard_charges": [ { "gross_charge": 22.89, "minimum": 18.31, "maximum": 19.46, "setting": "both", "payers_information": [ { "payer_name": "Aetna", "plan_name": "700700", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna", "plan_name": "700700_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Miscellaneous", "plan_name": "700720", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Miscellaneous", "plan_name": "700720_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Ppo Hmo", "plan_name": "701720", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Ppo Hmo", "plan_name": "701720_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Ms State Emplo", "plan_name": "401457", "standard_charge_percentage": 0.80, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Ms State Emplo", "plan_name": "401457_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Basic Pl", "plan_name": "400100", "standard_charge_percentage": 0.85, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Basic Pl", "plan_name": "400100_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Federal", "plan_name": "400110", "standard_charge_percentage": 0.85, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Federal", "plan_name": "400110_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." } ] } ] }, { "description": "Leflunomide 20 mg tablet [23873]", "drug_information": { "unit": 1.00, "type": "EA" }, "code_information": [ { "code": "50268-478-11", "type": "NDC" } ], "standard_charges": [ { "gross_charge": 16.06, "minimum": 12.85, "maximum": 13.65, "setting": "both", "payers_information": [ { "payer_name": "Aetna", "plan_name": "700700", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna", "plan_name": "700700_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Miscellaneous", "plan_name": "700720", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Miscellaneous", "plan_name": "700720_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Ppo Hmo", "plan_name": "701720", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Ppo Hmo", "plan_name": "701720_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Ms State Emplo", "plan_name": "401457", "standard_charge_percentage": 0.80, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Ms State Emplo", "plan_name": "401457_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Basic Pl", "plan_name": "400100", "standard_charge_percentage": 0.85, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Basic Pl", "plan_name": "400100_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Federal", "plan_name": "400110", "standard_charge_percentage": 0.85, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Federal", "plan_name": "400110_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." } ] } ] }, { "description": "Methocarbamol 500 mg tablet [4971]", "drug_information": { "unit": 1.00, "type": "EA" }, "code_information": [ { "code": "50268-520-11", "type": "NDC" } ], "standard_charges": [ { "gross_charge": 7.50, "minimum": 6.00, "maximum": 6.38, "setting": "both", "payers_information": [ { "payer_name": "Aetna", "plan_name": "700700", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna", "plan_name": "700700_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Miscellaneous", "plan_name": "700720", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Miscellaneous", "plan_name": "700720_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Ppo Hmo", "plan_name": "701720", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Ppo Hmo", "plan_name": "701720_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Ms State Emplo", "plan_name": "401457", "standard_charge_percentage": 0.80, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Ms State Emplo", "plan_name": "401457_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Basic Pl", "plan_name": "400100", "standard_charge_percentage": 0.85, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Basic Pl", "plan_name": "400100_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Federal", "plan_name": "400110", "standard_charge_percentage": 0.85, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Federal", "plan_name": "400110_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." } ] } ] }, { "description": "Meclizine 12.5 mg tablet [12024]", "drug_information": { "unit": 1.00, "type": "EA" }, "code_information": [ { "code": "50268-522-15", "type": "NDC" } ], "standard_charges": [ { "gross_charge": 1.82, "minimum": 1.46, "maximum": 1.55, "setting": "both", "payers_information": [ { "payer_name": "Aetna", "plan_name": "700700", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna", "plan_name": "700700_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Miscellaneous", "plan_name": "700720", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Miscellaneous", "plan_name": "700720_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Ppo Hmo", "plan_name": "701720", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Ppo Hmo", "plan_name": "701720_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Ms State Emplo", "plan_name": "401457", "standard_charge_percentage": 0.80, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Ms State Emplo", "plan_name": "401457_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Basic Pl", "plan_name": "400100", "standard_charge_percentage": 0.85, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Basic Pl", "plan_name": "400100_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Federal", "plan_name": "400110", "standard_charge_percentage": 0.85, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Federal", "plan_name": "400110_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." } ] } ] }, { "description": "Meloxicam 7.5 mg tablet [20566]", "drug_information": { "unit": 1.00, "type": "EA" }, "code_information": [ { "code": "50268-525-11", "type": "NDC" } ], "standard_charges": [ { "gross_charge": 7.50, "minimum": 6.00, "maximum": 6.38, "setting": "both", "payers_information": [ { "payer_name": "Aetna", "plan_name": "700700", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna", "plan_name": "700700_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Miscellaneous", "plan_name": "700720", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Miscellaneous", "plan_name": "700720_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Ppo Hmo", "plan_name": "701720", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Ppo Hmo", "plan_name": "701720_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Ms State Emplo", "plan_name": "401457", "standard_charge_percentage": 0.80, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Ms State Emplo", "plan_name": "401457_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Basic Pl", "plan_name": "400100", "standard_charge_percentage": 0.85, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Basic Pl", "plan_name": "400100_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Federal", "plan_name": "400110", "standard_charge_percentage": 0.85, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Federal", "plan_name": "400110_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." } ] } ] }, { "description": "Metronidazole 500 mg tablet [5016]", "drug_information": { "unit": 1.00, "type": "EA" }, "code_information": [ { "code": "50268-535-11", "type": "NDC" } ], "standard_charges": [ { "gross_charge": 7.50, "minimum": 6.00, "maximum": 6.38, "setting": "both", "payers_information": [ { "payer_name": "Aetna", "plan_name": "700700", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna", "plan_name": "700700_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Miscellaneous", "plan_name": "700720", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Miscellaneous", "plan_name": "700720_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Ppo Hmo", "plan_name": "701720", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Ppo Hmo", "plan_name": "701720_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Ms State Emplo", "plan_name": "401457", "standard_charge_percentage": 0.80, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Ms State Emplo", "plan_name": "401457_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Basic Pl", "plan_name": "400100", "standard_charge_percentage": 0.85, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Basic Pl", "plan_name": "400100_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Federal", "plan_name": "400110", "standard_charge_percentage": 0.85, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Federal", "plan_name": "400110_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." } ] } ] }, { "description": "Midodrine 5 mg tablet [10610]", "drug_information": { "unit": 1.00, "type": "EA" }, "code_information": [ { "code": "50268-562-11", "type": "NDC" } ], "standard_charges": [ { "gross_charge": 7.50, "minimum": 6.00, "maximum": 6.38, "setting": "both", "payers_information": [ { "payer_name": 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"standard_charge_percentage": 0.85, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Basic Pl", "plan_name": "400100_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Federal", "plan_name": "400110", "standard_charge_percentage": 0.85, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Federal", "plan_name": "400110_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." } ] } ] }, { "description": "Primidone 250 mg tablet [6544]", "drug_information": { "unit": 1.00, "type": "EA" }, "code_information": [ { "code": "50268-687-11", "type": "NDC" } ], "standard_charges": [ { "gross_charge": 7.50, "minimum": 6.00, "maximum": 6.38, "setting": "both", "payers_information": [ { "payer_name": "Aetna", "plan_name": "700700", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna", "plan_name": "700700_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Miscellaneous", "plan_name": "700720", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Miscellaneous", "plan_name": "700720_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Ppo Hmo", "plan_name": "701720", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Ppo Hmo", "plan_name": "701720_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Ms State Emplo", "plan_name": "401457", "standard_charge_percentage": 0.80, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Ms State Emplo", "plan_name": "401457_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Basic Pl", "plan_name": "400100", "standard_charge_percentage": 0.85, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Basic Pl", "plan_name": "400100_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Federal", "plan_name": "400110", "standard_charge_percentage": 0.85, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Federal", "plan_name": "400110_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." } ] } ] }, { "description": "Primidone 250 mg tablet [6544]", "drug_information": { "unit": 1.00, "type": "EA" }, "code_information": [ { "code": "50268-687-15", "type": "NDC" } ], "standard_charges": [ { "gross_charge": 7.50, "minimum": 6.00, "maximum": 6.38, "setting": "both", "payers_information": [ { "payer_name": "Aetna", "plan_name": "700700", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna", "plan_name": "700700_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna 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"plan_name": "401457", "standard_charge_percentage": 0.80, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Ms State Emplo", "plan_name": "401457_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Basic Pl", "plan_name": "400100", "standard_charge_percentage": 0.85, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Basic Pl", "plan_name": "400100_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Federal", "plan_name": "400110", "standard_charge_percentage": 0.85, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Federal", "plan_name": "400110_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." } ] } ] }, { "description": "Raloxifene 60 mg tablet [22143]", "drug_information": { "unit": 1.00, "type": "EA" }, "code_information": [ { "code": "50268-694-11", "type": "NDC" } ], "standard_charges": [ { "gross_charge": 26.57, "minimum": 21.26, "maximum": 22.58, "setting": "both", "payers_information": [ { "payer_name": "Aetna", "plan_name": "700700", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna", "plan_name": "700700_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Miscellaneous", "plan_name": "700720", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Miscellaneous", "plan_name": "700720_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Ppo Hmo", "plan_name": "701720", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Ppo Hmo", "plan_name": "701720_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Ms State Emplo", "plan_name": "401457", "standard_charge_percentage": 0.80, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Ms State Emplo", "plan_name": "401457_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Basic Pl", "plan_name": "400100", "standard_charge_percentage": 0.85, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Basic Pl", "plan_name": "400100_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Federal", "plan_name": "400110", "standard_charge_percentage": 0.85, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Federal", "plan_name": "400110_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." } ] } ] }, { "description": "Propranolol 20 mg tablet [6657]", "drug_information": { "unit": 1.00, "type": "EA" }, "code_information": [ { "code": "50268-701-11", "type": "NDC" } ], "standard_charges": [ { "gross_charge": 7.50, "minimum": 6.00, "maximum": 6.38, "setting": "both", "payers_information": [ { "payer_name": "Aetna", "plan_name": "700700", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna", "plan_name": "700700_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Miscellaneous", "plan_name": "700720", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Miscellaneous", "plan_name": "700720_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Ppo Hmo", "plan_name": "701720", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Ppo Hmo", "plan_name": "701720_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Ms State Emplo", "plan_name": "401457", "standard_charge_percentage": 0.80, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Ms State Emplo", "plan_name": "401457_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Basic Pl", "plan_name": "400100", "standard_charge_percentage": 0.85, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Basic Pl", "plan_name": "400100_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Federal", "plan_name": "400110", "standard_charge_percentage": 0.85, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Federal", "plan_name": "400110_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." } ] } ] }, { "description": "Rosuvastatin 20 mg tablet [35135]", "drug_information": { "unit": 1.00, "type": "EA" }, "code_information": [ { "code": "50268-710-11", "type": "NDC" } ], "standard_charges": [ { "gross_charge": 7.50, "minimum": 6.00, "maximum": 6.38, "setting": "both", "payers_information": [ { "payer_name": "Aetna", "plan_name": "700700", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna", "plan_name": "700700_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Miscellaneous", "plan_name": "700720", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Miscellaneous", "plan_name": "700720_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Ppo Hmo", "plan_name": "701720", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Ppo Hmo", "plan_name": "701720_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Ms State Emplo", "plan_name": "401457", "standard_charge_percentage": 0.80, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Ms State Emplo", "plan_name": "401457_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Basic Pl", "plan_name": "400100", "standard_charge_percentage": 0.85, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Basic Pl", "plan_name": "400100_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Federal", "plan_name": "400110", "standard_charge_percentage": 0.85, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Federal", "plan_name": "400110_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." } ] } ] }, { "description": "Rosuvastatin 20 mg tablet [35135]", "drug_information": { "unit": 1.00, "type": "EA" }, "code_information": [ { "code": "50268-710-15", "type": "NDC" } ], "standard_charges": [ { "gross_charge": 7.50, "minimum": 6.00, "maximum": 6.38, "setting": "both", "payers_information": [ { "payer_name": "Aetna", "plan_name": "700700", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna", "plan_name": "700700_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Miscellaneous", "plan_name": "700720", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Miscellaneous", "plan_name": "700720_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Ppo Hmo", "plan_name": "701720", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Ppo Hmo", "plan_name": "701720_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Ms State Emplo", "plan_name": "401457", "standard_charge_percentage": 0.80, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Ms State Emplo", "plan_name": "401457_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Basic Pl", "plan_name": "400100", "standard_charge_percentage": 0.85, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Basic Pl", "plan_name": "400100_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Federal", "plan_name": "400110", "standard_charge_percentage": 0.85, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Federal", "plan_name": "400110_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." } ] } ] }, { "description": "Sildenafil (pulmonary hypertension) 20 mg tablet [41832]", "drug_information": { "unit": 1.00, "type": "EA" }, "code_information": [ { "code": "50268-717-11", "type": "NDC" } ], "standard_charges": [ { "gross_charge": 7.50, "minimum": 6.00, "maximum": 6.38, "setting": "both", "payers_information": [ { "payer_name": "Aetna", "plan_name": "700700", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna", "plan_name": "700700_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Miscellaneous", "plan_name": "700720", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Miscellaneous", "plan_name": "700720_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Ppo Hmo", "plan_name": "701720", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Ppo Hmo", "plan_name": "701720_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Ms State Emplo", "plan_name": "401457", "standard_charge_percentage": 0.80, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Ms State Emplo", "plan_name": "401457_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Basic Pl", "plan_name": "400100", "standard_charge_percentage": 0.85, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Basic Pl", "plan_name": "400100_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Federal", "plan_name": "400110", "standard_charge_percentage": 0.85, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Federal", "plan_name": "400110_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." } ] } ] }, { "description": "Sildenafil (pulmonary hypertension) 20 mg tablet [41832]", "drug_information": { "unit": 1.00, "type": "EA" }, "code_information": [ { "code": "50268-717-15", "type": "NDC" } ], 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"additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Basic Pl", "plan_name": "400100", "standard_charge_percentage": 0.85, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Basic Pl", "plan_name": "400100_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Federal", "plan_name": "400110", "standard_charge_percentage": 0.85, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Federal", "plan_name": "400110_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." } ] } ] }, { "description": "Ranolazine er 500 mg tabletextended release12 hr [70434]", "drug_information": { "unit": 1.00, "type": "EA" }, "code_information": [ { "code": "50268-722-11", "type": "NDC" } ], "standard_charges": [ { "gross_charge": 10.31, "minimum": 8.25, "maximum": 8.76, "setting": "both", "payers_information": [ { "payer_name": "Aetna", "plan_name": "700700", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna", "plan_name": "700700_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Miscellaneous", "plan_name": "700720", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Miscellaneous", "plan_name": "700720_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Ppo Hmo", "plan_name": "701720", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Ppo Hmo", "plan_name": "701720_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Ms State Emplo", "plan_name": "401457", "standard_charge_percentage": 0.80, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Ms State Emplo", "plan_name": "401457_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Basic Pl", "plan_name": "400100", "standard_charge_percentage": 0.85, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Basic Pl", "plan_name": "400100_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Federal", "plan_name": "400110", "standard_charge_percentage": 0.85, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Federal", "plan_name": "400110_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." } ] } ] }, { "description": "Sulfamethoxazole 400 mg-trimethoprim 80 mg tablet [7557]", "drug_information": { "unit": 1.00, "type": "EA" }, "code_information": [ { "code": "50268-728-11", "type": "NDC" } ], "standard_charges": [ { "gross_charge": 7.50, "minimum": 6.00, "maximum": 6.38, "setting": "both", "payers_information": [ { "payer_name": "Aetna", "plan_name": "700700", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna", "plan_name": "700700_1", 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"standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Ms State Emplo", "plan_name": "401457", "standard_charge_percentage": 0.80, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Ms State Emplo", "plan_name": "401457_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Basic Pl", "plan_name": "400100", "standard_charge_percentage": 0.85, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Basic Pl", "plan_name": "400100_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Federal", "plan_name": "400110", "standard_charge_percentage": 0.85, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Federal", "plan_name": "400110_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." } ] } ] }, { "description": "Sulfamethoxazole 400 mg-trimethoprim 80 mg tablet [7557]", "drug_information": { "unit": 1.00, "type": "EA" }, "code_information": [ { "code": "50268-728-15", "type": "NDC" } ], "standard_charges": [ { "gross_charge": 7.50, "minimum": 6.00, "maximum": 6.38, "setting": "both", "payers_information": [ { "payer_name": "Aetna", "plan_name": "700700", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna", "plan_name": "700700_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Miscellaneous", "plan_name": "700720", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Miscellaneous", "plan_name": "700720_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Ppo Hmo", "plan_name": "701720", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Ppo Hmo", "plan_name": "701720_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Ms State Emplo", "plan_name": "401457", "standard_charge_percentage": 0.80, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Ms State Emplo", "plan_name": "401457_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Basic Pl", "plan_name": "400100", "standard_charge_percentage": 0.85, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Basic Pl", "plan_name": "400100_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Federal", "plan_name": "400110", "standard_charge_percentage": 0.85, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Federal", "plan_name": "400110_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." } ] } ] }, { "description": "Torsemide 20 mg tablet [18293]", "drug_information": { "unit": 1.00, "type": "EA" }, "code_information": [ { "code": "50268-756-11", "type": "NDC" } ], "standard_charges": [ { "gross_charge": 7.50, "minimum": 6.00, "maximum": 6.38, "setting": "both", "payers_information": [ { "payer_name": "Aetna", "plan_name": "700700", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna", "plan_name": "700700_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Miscellaneous", "plan_name": "700720", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed 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"payer_name": "Bc/Bs Ms State Emplo", "plan_name": "401457_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Basic Pl", "plan_name": "400100", "standard_charge_percentage": 0.85, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Basic Pl", "plan_name": "400100_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Federal", "plan_name": "400110", "standard_charge_percentage": 0.85, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Federal", "plan_name": "400110_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." } ] } ] }, { "description": "Torsemide 100 mg tablet [18294]", "drug_information": { "unit": 1.00, "type": "EA" }, "code_information": [ { "code": "50268-757-11", "type": "NDC" } ], "standard_charges": [ { "gross_charge": 7.50, "minimum": 6.00, "maximum": 6.38, "setting": "both", "payers_information": [ { "payer_name": "Aetna", "plan_name": "700700", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna", "plan_name": "700700_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate 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}, { "payer_name": "Bc/Bs Ms State Emplo", "plan_name": "401457", "standard_charge_percentage": 0.80, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Ms State Emplo", "plan_name": "401457_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Basic Pl", "plan_name": "400100", "standard_charge_percentage": 0.85, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Basic Pl", "plan_name": "400100_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Federal", "plan_name": "400110", "standard_charge_percentage": 0.85, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Federal", "plan_name": "400110_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." } ] } ] }, { "description": "Torsemide 100 mg tablet [18294]", "drug_information": { "unit": 1.00, "type": "EA" }, "code_information": [ { "code": "50268-757-15", "type": "NDC" } ], "standard_charges": [ { "gross_charge": 7.50, "minimum": 6.00, "maximum": 6.38, "setting": "both", "payers_information": [ { "payer_name": "Aetna", "plan_name": "700700", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to 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amounts." }, { "payer_name": "Aetna Ppo Hmo", "plan_name": "701720_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Ms State Emplo", "plan_name": "401457", "standard_charge_percentage": 0.80, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Ms State Emplo", "plan_name": "401457_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Basic Pl", "plan_name": "400100", "standard_charge_percentage": 0.85, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Basic Pl", "plan_name": "400100_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Federal", "plan_name": "400110", "standard_charge_percentage": 0.85, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Federal", "plan_name": "400110_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." } ] } ] }, { "description": "Terazosin 5 mg capsule [14553]", "drug_information": { "unit": 1.00, "type": "EA" }, "code_information": [ { "code": "50268-766-11", "type": "NDC" } ], "standard_charges": [ { "gross_charge": 7.50, "minimum": 6.00, 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"standard_charge_percentage": 0.85, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Basic Pl", "plan_name": "400100_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Federal", "plan_name": "400110", "standard_charge_percentage": 0.85, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Federal", "plan_name": "400110_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." } ] } ] }, { "description": "Cyanocobalamin (vit b-12) 100 mcg tablet 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"plan_name": "401457_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Basic Pl", "plan_name": "400100", "standard_charge_percentage": 0.85, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Basic Pl", "plan_name": "400100_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Federal", "plan_name": "400110", "standard_charge_percentage": 0.85, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Federal", "plan_name": "400110_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." } ] } ] }, { "description": "Cyanocobalamin (vit b-12) 250 mcg tablet [2010]", "drug_information": { "unit": 1.00, "type": "EA" }, "code_information": [ { "code": "5026885311", "type": "NDC" } ], "standard_charges": [ { "gross_charge": 1.00, "minimum": 0.80, "maximum": 0.85, "setting": "both", "payers_information": [ { "payer_name": "Aetna", "plan_name": "700700", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna", "plan_name": "700700_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Miscellaneous", "plan_name": "700720", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Miscellaneous", "plan_name": "700720_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Ppo Hmo", "plan_name": "701720", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Ppo Hmo", "plan_name": "701720_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Ms State Emplo", "plan_name": "401457", "standard_charge_percentage": 0.80, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Ms State Emplo", "plan_name": "401457_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Basic Pl", "plan_name": "400100", "standard_charge_percentage": 0.85, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Basic Pl", "plan_name": "400100_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Federal", "plan_name": "400110", "standard_charge_percentage": 0.85, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Federal", "plan_name": "400110_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." } ] } ] }, { "description": "Cyanocobalamin (vit b-12) 500 mcg tablet [2012]", "drug_information": { "unit": 1.00, "type": "EA" }, "code_information": [ { "code": "5026885411", "type": "NDC" } ], "standard_charges": [ { "gross_charge": 1.00, "minimum": 0.80, "maximum": 0.85, "setting": "both", "payers_information": [ { "payer_name": "Aetna", "plan_name": "700700", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to 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amounts." }, { "payer_name": "Aetna Ppo Hmo", "plan_name": "701720_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Ms State Emplo", "plan_name": "401457", "standard_charge_percentage": 0.80, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Ms State Emplo", "plan_name": "401457_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Basic Pl", "plan_name": "400100", "standard_charge_percentage": 0.85, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Basic Pl", "plan_name": "400100_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Federal", "plan_name": "400110", "standard_charge_percentage": 0.85, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Federal", "plan_name": "400110_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." } ] } ] }, { "description": "Pyridoxine (vitamin b6) 100 mg tablet [6745]", "drug_information": { "unit": 1.00, "type": "EA" }, "code_information": [ { "code": "5026885911", "type": "NDC" } ], "standard_charges": [ { "gross_charge": 7.50, "minimum": 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allowed amounts." } ] } ] }, { "description": "Vitamin e (dl acetate) 180 mg (400 unit) capsule [118622]", "drug_information": { "unit": 1.00, "type": "EA" }, "code_information": [ { "code": "5026887011", "type": "NDC" } ], "standard_charges": [ { "gross_charge": 1.71, "minimum": 1.37, "maximum": 1.45, "setting": "both", "payers_information": [ { "payer_name": "Aetna", "plan_name": "700700", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna", "plan_name": "700700_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Miscellaneous", "plan_name": "700720", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Miscellaneous", "plan_name": "700720_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Ppo Hmo", "plan_name": "701720", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Ppo Hmo", "plan_name": "701720_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Ms State Emplo", "plan_name": "401457", "standard_charge_percentage": 0.80, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Ms State Emplo", "plan_name": "401457_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Basic Pl", "plan_name": "400100", "standard_charge_percentage": 0.85, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Basic Pl", "plan_name": "400100_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Federal", "plan_name": "400110", "standard_charge_percentage": 0.85, "count": "0", "methodology": "percent of total billed charges", 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"0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Miscellaneous", "plan_name": "700720", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Miscellaneous", "plan_name": "700720_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Ppo Hmo", "plan_name": "701720", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Ppo Hmo", "plan_name": "701720_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Ms State Emplo", "plan_name": "401457", "standard_charge_percentage": 0.80, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Ms State Emplo", "plan_name": "401457_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Basic Pl", "plan_name": "400100", "standard_charge_percentage": 0.85, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Basic Pl", "plan_name": "400100_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Federal", "plan_name": "400110", "standard_charge_percentage": 0.85, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Federal", "plan_name": "400110_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." } ] } ] }, { "description": "Quetiapine 25 mg tablet [21823]", "drug_information": { "unit": 1.00, "type": "EA" }, "code_information": [ { "code": "50268-630-11", "type": "NDC" } ], "standard_charges": [ { "gross_charge": 7.50, "minimum": 6.00, "maximum": 6.38, "setting": "both", "payers_information": [ { "payer_name": "Aetna", "plan_name": "700700", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna", "plan_name": "700700_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Miscellaneous", "plan_name": "700720", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Miscellaneous", "plan_name": "700720_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Ppo Hmo", "plan_name": "701720", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Ppo Hmo", "plan_name": "701720_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Ms State Emplo", "plan_name": "401457", "standard_charge_percentage": 0.80, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Ms State Emplo", "plan_name": "401457_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Basic Pl", "plan_name": "400100", "standard_charge_percentage": 0.85, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Basic Pl", "plan_name": "400100_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Federal", "plan_name": "400110", "standard_charge_percentage": 0.85, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Federal", "plan_name": "400110_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." } ] } ] }, { "description": "Quetiapine 25 mg tablet [21823]", "drug_information": { "unit": 1.00, "type": "EA" }, "code_information": [ { "code": "50268-630-15", "type": "NDC" } ], "standard_charges": [ { "gross_charge": 7.50, "minimum": 6.00, "maximum": 6.38, "setting": "both", "payers_information": [ { "payer_name": "Aetna", "plan_name": "700700", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna", "plan_name": "700700_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Miscellaneous", "plan_name": "700720", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Miscellaneous", "plan_name": "700720_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Ppo Hmo", "plan_name": "701720", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Ppo Hmo", "plan_name": "701720_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Ms State Emplo", "plan_name": "401457", "standard_charge_percentage": 0.80, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Ms State Emplo", "plan_name": "401457_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Basic Pl", "plan_name": "400100", "standard_charge_percentage": 0.85, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Basic Pl", "plan_name": "400100_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Federal", "plan_name": "400110", "standard_charge_percentage": 0.85, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Federal", "plan_name": "400110_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." } ] } ] }, { "description": "Propranolol 40 mg tablet [6658]", "drug_information": { "unit": 1.00, "type": "EA" }, "code_information": [ { "code": "50268-664-15", "type": "NDC" } ], "standard_charges": [ { "gross_charge": 7.50, "minimum": 6.00, "maximum": 6.38, "setting": "both", "payers_information": [ { "payer_name": "Aetna", "plan_name": "700700", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna", "plan_name": "700700_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna 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"plan_name": "401457", "standard_charge_percentage": 0.80, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Ms State Emplo", "plan_name": "401457_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Basic Pl", "plan_name": "400100", "standard_charge_percentage": 0.85, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Basic Pl", "plan_name": "400100_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Federal", "plan_name": "400110", "standard_charge_percentage": 0.85, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Federal", "plan_name": "400110_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." } ] } ] }, { "description": "Acetaminophen 120 mg-codeine 12 mg/5 ml oral solution [108327]", "drug_information": { "unit": 473.00, "type": "ML" }, "code_information": [ { "code": "50383-079-16", "type": "NDC" } ], "standard_charges": [ { "gross_charge": 20.91, "minimum": 16.73, "maximum": 17.77, "setting": "both", "payers_information": [ { "payer_name": "Aetna", "plan_name": "700700", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to 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}, { "payer_name": "Bc/Bs Of Ms Basic Pl", "plan_name": "400100_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Federal", "plan_name": "400110", "standard_charge_percentage": 0.85, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Federal", "plan_name": "400110_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." } ] } ] }, { "description": "Levofloxacin 250 mg/10 ml oral solution [39970]", "drug_information": { "unit": 200.00, "type": "ML" }, "code_information": [ { "code": "50383-286-08", "type": "NDC" } ], "standard_charges": [ { "gross_charge": 1061.15, "minimum": 848.92, "maximum": 901.98, "setting": "both", "payers_information": [ { "payer_name": "Aetna", "plan_name": "700700", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna", "plan_name": "700700_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Miscellaneous", "plan_name": "700720", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Miscellaneous", "plan_name": "700720_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Ppo Hmo", "plan_name": "701720", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Ppo Hmo", "plan_name": "701720_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Ms State Emplo", "plan_name": "401457", "standard_charge_percentage": 0.80, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Ms State Emplo", "plan_name": "401457_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Basic Pl", "plan_name": "400100", "standard_charge_percentage": 0.85, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Basic Pl", "plan_name": "400100_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Federal", "plan_name": "400110", "standard_charge_percentage": 0.85, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Federal", "plan_name": "400110_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." } ] } ] }, { "description": "Lidocaine hcl 2 % mucosal solution [109454]", "drug_information": { "unit": 15.00, "type": "ML" }, "code_information": [ { "code": "50383-363-15", "type": "NDC" } ], "standard_charges": [ { "gross_charge": 7.50, "minimum": 6.00, "maximum": 6.38, "setting": "both", "payers_information": [ { "payer_name": "Aetna", "plan_name": "700700", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna", "plan_name": "700700_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Miscellaneous", "plan_name": "700720", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Miscellaneous", "plan_name": "700720_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Ppo Hmo", "plan_name": "701720", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Ppo Hmo", "plan_name": "701720_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Ms State Emplo", "plan_name": "401457", "standard_charge_percentage": 0.80, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Ms State Emplo", "plan_name": "401457_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Basic Pl", "plan_name": "400100", "standard_charge_percentage": 0.85, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Basic Pl", "plan_name": "400100_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Federal", "plan_name": "400110", "standard_charge_percentage": 0.85, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Federal", "plan_name": "400110_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." } ] } ] }, { "description": "Docusate sodium 50 mg/5 ml oral liquid [36962]", "drug_information": { "unit": 473.00, "type": "ML" }, "code_information": [ { "code": "50383-771-16", "type": "NDC" } ], "standard_charges": [ { "gross_charge": 8.61, "minimum": 6.89, "maximum": 7.32, "setting": "both", "payers_information": [ { "payer_name": "Aetna", "plan_name": "700700", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna", "plan_name": "700700_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Miscellaneous", "plan_name": "700720", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Miscellaneous", "plan_name": "700720_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Ppo Hmo", "plan_name": "701720", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Ppo Hmo", "plan_name": "701720_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Ms State Emplo", "plan_name": "401457", "standard_charge_percentage": 0.80, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Ms State Emplo", "plan_name": "401457_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Basic Pl", "plan_name": "400100", "standard_charge_percentage": 0.85, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Basic Pl", "plan_name": "400100_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Federal", "plan_name": "400110", "standard_charge_percentage": 0.85, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Federal", "plan_name": "400110_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." } ] } ] }, { "description": "Lidocaine hcl 2 % mucosal solution [109454]", "drug_information": { "unit": 100.00, "type": "ML" }, "code_information": [ { "code": "50383-775-04", "type": "NDC" } ], "standard_charges": [ { "gross_charge": 52.25, "minimum": 41.80, "maximum": 44.41, "setting": "both", "payers_information": [ { "payer_name": "Aetna", "plan_name": "700700", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna", "plan_name": "700700_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Miscellaneous", "plan_name": "700720", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Miscellaneous", "plan_name": "700720_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Ppo Hmo", "plan_name": "701720", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Ppo Hmo", "plan_name": "701720_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Ms State Emplo", "plan_name": "401457", "standard_charge_percentage": 0.80, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Ms State Emplo", "plan_name": "401457_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Basic Pl", "plan_name": "400100", "standard_charge_percentage": 0.85, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Basic Pl", "plan_name": "400100_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Federal", "plan_name": "400110", "standard_charge_percentage": 0.85, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Federal", "plan_name": "400110_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." } ] } ] }, { "description": "Estradiol 0.1 mg/24 hr weekly transdermal 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"payer_name": "Bc/Bs Of Ms Federal", "plan_name": "400110", "standard_charge_percentage": 0.85, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Federal", "plan_name": "400110_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." } ] } ] }, { "description": "Sodium hyaluronate 10 mg/ml intra-articular syringe [21353]", "drug_information": { "unit": 2.50, "type": "ML" }, "code_information": [ { "code": "50653-0006-04", "type": "NDC" } ], "standard_charges": [ { "gross_charge": 2254.35, "minimum": 1803.48, "maximum": 1916.20, "setting": "both", "payers_information": [ { "payer_name": "Aetna", "plan_name": "700700", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", 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"payer_name": "Aetna Ppo Hmo", "plan_name": "701720", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Ppo Hmo", "plan_name": "701720_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Ms State Emplo", "plan_name": "401457", "standard_charge_percentage": 0.80, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Ms State Emplo", "plan_name": "401457_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Basic Pl", "plan_name": "400100", "standard_charge_percentage": 0.85, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Basic Pl", "plan_name": "400100_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Federal", "plan_name": "400110", "standard_charge_percentage": 0.85, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Federal", "plan_name": "400110_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." } ] } ] }, { "description": "Sodium phosphates 19 gram-7 gram/118 ml enema [11395]", "drug_information": { "unit": 133.00, "type": "ML" }, "code_information": [ { "code": "50804-004-01", "type": "NDC" } ], "standard_charges": [ { "gross_charge": 2.42, "minimum": 1.94, "maximum": 2.06, "setting": "both", "payers_information": [ { "payer_name": "Aetna", "plan_name": "700700", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna", "plan_name": "700700_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Miscellaneous", "plan_name": "700720", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to 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amounts." }, { "payer_name": "Bc/Bs Ms State Emplo", "plan_name": "401457_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Basic Pl", "plan_name": "400100", "standard_charge_percentage": 0.85, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Basic Pl", "plan_name": "400100_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Federal", "plan_name": "400110", "standard_charge_percentage": 0.85, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Federal", "plan_name": "400110_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." } ] } ] }, { "description": "Magnesium citrate oral solution [4712]", "drug_information": { "unit": 296.00, "type": "ML" }, "code_information": [ { "code": "50804-166-38", "type": "NDC" } ], "standard_charges": [ { "gross_charge": 3.08, "minimum": 2.46, "maximum": 2.62, "setting": "both", "payers_information": [ { "payer_name": "Aetna", "plan_name": "700700", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna", "plan_name": "700700_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient 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calculate allowed amounts." }, { "payer_name": "Bc/Bs Ms State Emplo", "plan_name": "401457", "standard_charge_percentage": 0.80, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Ms State Emplo", "plan_name": "401457_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Basic Pl", "plan_name": "400100", "standard_charge_percentage": 0.85, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Basic Pl", "plan_name": "400100_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Federal", "plan_name": "400110", "standard_charge_percentage": 0.85, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Federal", "plan_name": "400110_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." } ] } ] }, { "description": "Magnesium sulfate (bulk) 100 % crystals [4722]", "drug_information": { "unit": 1810.00, "type": "GR" }, "code_information": [ { "code": "50804-395-04", "type": "NDC" } ], "standard_charges": [ { "gross_charge": 14.12, "minimum": 11.30, "maximum": 12.00, "setting": "both", "payers_information": [ { "payer_name": "Aetna", "plan_name": "700700", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna", "plan_name": "700700_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Miscellaneous", "plan_name": "700720", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Miscellaneous", "plan_name": "700720_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Ppo Hmo", "plan_name": "701720", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Ppo Hmo", "plan_name": "701720_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Ms State Emplo", "plan_name": "401457", "standard_charge_percentage": 0.80, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Ms State Emplo", "plan_name": "401457_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Basic Pl", "plan_name": "400100", "standard_charge_percentage": 0.85, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Basic Pl", "plan_name": "400100_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Federal", "plan_name": "400110", "standard_charge_percentage": 0.85, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Federal", "plan_name": "400110_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." } ] } ] }, { "description": "Aluminum-mag hydroxide-simethicone 400 mg-400 mg-40 mg/5 ml oral susp [9015]", "drug_information": { "unit": 355.00, "type": "ML" }, "code_information": [ { "code": "50804-619-12", "type": "NDC" } ], "standard_charges": [ { "gross_charge": 10.15, "minimum": 8.12, "maximum": 8.63, "setting": "both", "payers_information": [ { "payer_name": "Aetna", "plan_name": "700700", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna", "plan_name": "700700_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Miscellaneous", "plan_name": "700720", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Miscellaneous", "plan_name": "700720_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Ppo Hmo", "plan_name": "701720", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Ppo Hmo", "plan_name": "701720_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Ms State Emplo", "plan_name": "401457", "standard_charge_percentage": 0.80, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Ms State Emplo", "plan_name": "401457_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": 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"percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." } ] } ] }, { "description": "Sennosides 8.6 mg tablet [11349]", "drug_information": { "unit": 1.00, "type": "EA" }, "code_information": [ { "code": "50804-631-10", "type": "NDC" } ], "standard_charges": [ { "gross_charge": 1.00, "minimum": 0.80, "maximum": 0.85, "setting": "both", "payers_information": [ { "payer_name": "Aetna", "plan_name": "700700", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna", "plan_name": "700700_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Miscellaneous", "plan_name": "700720", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Miscellaneous", "plan_name": "700720_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Ppo Hmo", "plan_name": "701720", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Ppo Hmo", "plan_name": "701720_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Ms State Emplo", "plan_name": "401457", "standard_charge_percentage": 0.80, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Ms State Emplo", "plan_name": "401457_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Basic Pl", "plan_name": "400100", "standard_charge_percentage": 0.85, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Basic Pl", "plan_name": "400100_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Federal", "plan_name": "400110", "standard_charge_percentage": 0.85, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Federal", "plan_name": "400110_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." } ] } ] }, { "description": "Xylitol-yerba santa mucosal spray with pump [205743]", "drug_information": { "unit": 59.00, "type": "ML" }, "code_information": [ { "code": "5093009802", "type": "NDC" } ], "standard_charges": [ { "gross_charge": 15.80, "minimum": 12.64, "maximum": 13.43, "setting": "both", "payers_information": [ { "payer_name": "Aetna", "plan_name": "700700", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna", "plan_name": "700700_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Miscellaneous", "plan_name": "700720", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Miscellaneous", "plan_name": "700720_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Ppo Hmo", "plan_name": "701720", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Ppo Hmo", "plan_name": "701720_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Ms State Emplo", "plan_name": "401457", "standard_charge_percentage": 0.80, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Ms State Emplo", "plan_name": "401457_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Basic Pl", "plan_name": "400100", "standard_charge_percentage": 0.85, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Basic Pl", "plan_name": "400100_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Federal", "plan_name": "400110", "standard_charge_percentage": 0.85, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Federal", "plan_name": "400110_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." } ] } ] }, { "description": "Omeprazole 20 mg capsuledelayed release [27694]", "drug_information": { "unit": 1.00, "type": "EA" }, "code_information": [ { "code": "51079-007-20", "type": "NDC" } ], "standard_charges": [ { "gross_charge": 1.00, "minimum": 0.80, "maximum": 0.85, "setting": "both", "payers_information": [ { "payer_name": "Aetna", "plan_name": "700700", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna", "plan_name": "700700_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Miscellaneous", "plan_name": "700720", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Miscellaneous", "plan_name": "700720_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Ppo Hmo", "plan_name": "701720", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Ppo Hmo", "plan_name": "701720_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Ms State Emplo", "plan_name": "401457", "standard_charge_percentage": 0.80, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Ms State Emplo", "plan_name": "401457_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Basic Pl", "plan_name": "400100", "standard_charge_percentage": 0.85, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Basic Pl", "plan_name": "400100_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Federal", "plan_name": "400110", "standard_charge_percentage": 0.85, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Federal", "plan_name": "400110_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." } ] } ] }, { "description": "Metolazone 5 mg tablet [10588]", "drug_information": { "unit": 1.00, "type": "EA" }, "code_information": [ { "code": "51079-024-01", "type": "NDC" } ], "standard_charges": [ { "gross_charge": 21.80, "minimum": 17.44, "maximum": 18.53, "setting": "both", "payers_information": [ { "payer_name": "Aetna", "plan_name": "700700", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna", "plan_name": "700700_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Miscellaneous", "plan_name": "700720", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Miscellaneous", "plan_name": "700720_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Ppo Hmo", "plan_name": "701720", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Ppo Hmo", "plan_name": "701720_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Ms State Emplo", "plan_name": "401457", "standard_charge_percentage": 0.80, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Ms State Emplo", "plan_name": "401457_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Basic Pl", "plan_name": "400100", "standard_charge_percentage": 0.85, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Basic Pl", "plan_name": "400100_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Federal", "plan_name": "400110", "standard_charge_percentage": 0.85, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Federal", "plan_name": "400110_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." } ] } ] }, { "description": "Pantoprazole 40 mg tabletdelayed release [26225]", "drug_information": { "unit": 1.00, "type": "EA" }, "code_information": [ { "code": "51079-051-01", "type": "NDC" } ], "standard_charges": [ { "gross_charge": 7.50, "minimum": 6.00, "maximum": 6.38, "setting": "both", "payers_information": [ { "payer_name": "Aetna", "plan_name": "700700", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna", "plan_name": "700700_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Miscellaneous", "plan_name": "700720", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Miscellaneous", "plan_name": "700720_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Ppo Hmo", "plan_name": "701720", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Ppo Hmo", "plan_name": "701720_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Ms State Emplo", "plan_name": "401457", "standard_charge_percentage": 0.80, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Ms State Emplo", "plan_name": "401457_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Basic Pl", "plan_name": "400100", "standard_charge_percentage": 0.85, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Basic Pl", "plan_name": "400100_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Federal", "plan_name": "400110", "standard_charge_percentage": 0.85, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Federal", "plan_name": "400110_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." } ] } ] }, { "description": "Chlorthalidone 25 mg tablet [1661]", "drug_information": { "unit": 1.00, "type": "EA" }, "code_information": [ { "code": "51079-058-01", "type": "NDC" } ], "standard_charges": [ { "gross_charge": 15.75, "minimum": 12.60, "maximum": 13.39, "setting": "both", "payers_information": [ { "payer_name": "Aetna", "plan_name": "700700", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna", "plan_name": "700700_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Miscellaneous", "plan_name": "700720", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Miscellaneous", "plan_name": "700720_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Ppo Hmo", "plan_name": "701720", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Ppo Hmo", "plan_name": "701720_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Ms State Emplo", "plan_name": "401457", "standard_charge_percentage": 0.80, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Ms State Emplo", "plan_name": "401457_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Basic Pl", "plan_name": "400100", "standard_charge_percentage": 0.85, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Basic Pl", "plan_name": "400100_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Federal", "plan_name": "400110", "standard_charge_percentage": 0.85, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Federal", "plan_name": "400110_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." } ] } ] }, { "description": "Furosemide 20 mg tablet [3294]", "drug_information": { "unit": 1.00, "type": "EA" }, "code_information": [ { "code": "51079-072-01", "type": "NDC" } ], "standard_charges": [ { "gross_charge": 7.50, "minimum": 6.00, "maximum": 6.38, "setting": "both", "payers_information": [ { "payer_name": "Aetna", "plan_name": "700700", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna", "plan_name": "700700_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Miscellaneous", "plan_name": "700720", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Miscellaneous", "plan_name": "700720_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Ppo Hmo", "plan_name": "701720", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Ppo Hmo", "plan_name": "701720_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Ms State Emplo", "plan_name": "401457", "standard_charge_percentage": 0.80, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Ms State Emplo", "plan_name": "401457_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Basic Pl", "plan_name": "400100", "standard_charge_percentage": 0.85, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Basic Pl", "plan_name": "400100_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Federal", "plan_name": "400110", "standard_charge_percentage": 0.85, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Federal", "plan_name": "400110_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." } ] } ] }, { "description": "Hydralazine 10 mg tablet [3698]", "drug_information": { "unit": 1.00, "type": "EA" }, "code_information": [ { "code": "51079-074-01", "type": "NDC" } ], "standard_charges": [ { "gross_charge": 7.50, "minimum": 6.00, "maximum": 6.38, "setting": "both", "payers_information": [ { "payer_name": "Aetna", "plan_name": "700700", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna", "plan_name": "700700_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Miscellaneous", "plan_name": "700720", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Miscellaneous", "plan_name": "700720_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Ppo Hmo", "plan_name": "701720", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Ppo Hmo", "plan_name": "701720_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Ms State Emplo", "plan_name": "401457", "standard_charge_percentage": 0.80, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Ms State Emplo", "plan_name": "401457_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Basic Pl", "plan_name": "400100", "standard_charge_percentage": 0.85, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Basic Pl", "plan_name": "400100_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Federal", "plan_name": "400110", "standard_charge_percentage": 0.85, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Federal", "plan_name": "400110_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." } ] } ] }, { "description": "Hydralazine 10 mg tablet [3698]", "drug_information": { "unit": 1.00, "type": "EA" }, "code_information": [ { "code": "51079-074-20", "type": "NDC" } ], "standard_charges": [ { "gross_charge": 7.50, "minimum": 6.00, "maximum": 6.38, "setting": "both", "payers_information": [ { "payer_name": "Aetna", "plan_name": "700700", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna", "plan_name": "700700_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Miscellaneous", "plan_name": "700720", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Miscellaneous", "plan_name": "700720_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Ppo Hmo", "plan_name": "701720", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Ppo Hmo", "plan_name": "701720_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Ms State Emplo", "plan_name": "401457", "standard_charge_percentage": 0.80, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Ms State Emplo", "plan_name": "401457_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Basic Pl", "plan_name": "400100", "standard_charge_percentage": 0.85, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Basic Pl", "plan_name": "400100_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Federal", "plan_name": "400110", "standard_charge_percentage": 0.85, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Federal", "plan_name": "400110_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." } ] } ] }, { "description": "Hydralazine 50 mg tablet [3701]", "drug_information": { "unit": 1.00, "type": "EA" }, "code_information": [ { "code": "51079-076-01", "type": "NDC" } ], "standard_charges": [ { "gross_charge": 7.50, "minimum": 6.00, "maximum": 6.38, "setting": "both", "payers_information": [ { "payer_name": "Aetna", "plan_name": "700700", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna", "plan_name": "700700_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Miscellaneous", "plan_name": "700720", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Miscellaneous", "plan_name": "700720_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Ppo Hmo", "plan_name": "701720", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Ppo Hmo", "plan_name": "701720_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Ms State Emplo", "plan_name": "401457", "standard_charge_percentage": 0.80, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Ms State Emplo", "plan_name": "401457_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Basic Pl", "plan_name": "400100", "standard_charge_percentage": 0.85, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Basic Pl", "plan_name": "400100_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Federal", "plan_name": "400110", "standard_charge_percentage": 0.85, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Federal", "plan_name": "400110_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." } ] } ] }, { "description": "Valacyclovir 500 mg tablet [13133]", "drug_information": { "unit": 1.00, "type": "EA" }, "code_information": [ { "code": "51079-093-01", "type": "NDC" } ], "standard_charges": [ { "gross_charge": 14.50, "minimum": 11.60, "maximum": 12.33, "setting": "both", "payers_information": [ { "payer_name": "Aetna", "plan_name": "700700", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna", "plan_name": "700700_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Miscellaneous", "plan_name": "700720", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Miscellaneous", "plan_name": "700720_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Ppo Hmo", "plan_name": "701720", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Ppo Hmo", "plan_name": "701720_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Ms State Emplo", "plan_name": "401457", "standard_charge_percentage": 0.80, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Ms State Emplo", "plan_name": "401457_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Basic Pl", "plan_name": "400100", "standard_charge_percentage": 0.85, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Basic Pl", "plan_name": "400100_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Federal", "plan_name": "400110", "standard_charge_percentage": 0.85, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Federal", "plan_name": "400110_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." } ] } ] }, { "description": "Valacyclovir 500 mg tablet [13133]", "drug_information": { "unit": 1.00, "type": "EA" }, "code_information": [ { "code": "51079-093-03", "type": "NDC" } ], "standard_charges": [ { "gross_charge": 14.50, "minimum": 11.60, "maximum": 12.33, "setting": "both", "payers_information": [ { "payer_name": "Aetna", "plan_name": "700700", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna", "plan_name": "700700_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Miscellaneous", "plan_name": "700720", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Miscellaneous", "plan_name": "700720_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Ppo Hmo", "plan_name": "701720", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Ppo Hmo", "plan_name": "701720_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Ms State Emplo", "plan_name": "401457", "standard_charge_percentage": 0.80, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Ms State Emplo", "plan_name": "401457_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Basic Pl", "plan_name": "400100", "standard_charge_percentage": 0.85, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Basic Pl", "plan_name": "400100_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Federal", "plan_name": "400110", "standard_charge_percentage": 0.85, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Federal", "plan_name": "400110_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." } ] } ] }, { "description": "Spironolactone 25 mg tablet [7437]", "drug_information": { "unit": 1.00, "type": "EA" }, "code_information": [ { "code": "51079-103-01", "type": "NDC" } ], "standard_charges": [ { "gross_charge": 7.50, "minimum": 6.00, "maximum": 6.38, "setting": "both", "payers_information": [ { "payer_name": "Aetna", "plan_name": "700700", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna", "plan_name": "700700_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Miscellaneous", "plan_name": "700720", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Miscellaneous", "plan_name": "700720_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Ppo Hmo", "plan_name": "701720", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Ppo Hmo", "plan_name": "701720_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Ms State Emplo", "plan_name": "401457", "standard_charge_percentage": 0.80, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Ms State Emplo", "plan_name": "401457_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Basic Pl", "plan_name": "400100", "standard_charge_percentage": 0.85, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Basic Pl", "plan_name": "400100_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Federal", "plan_name": "400110", "standard_charge_percentage": 0.85, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Federal", "plan_name": "400110_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." } ] } ] }, { "description": "Lansoprazole 30 mg capsuledelayed release [27692]", "drug_information": { "unit": 1.00, "type": "EA" }, "code_information": [ { "code": "51079-121-01", "type": "NDC" } ], "standard_charges": [ { "gross_charge": 17.16, "minimum": 13.73, "maximum": 14.59, "setting": "both", "payers_information": [ { "payer_name": "Aetna", "plan_name": "700700", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna", "plan_name": "700700_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Miscellaneous", "plan_name": "700720", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Miscellaneous", "plan_name": "700720_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Ppo Hmo", "plan_name": "701720", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Ppo Hmo", "plan_name": "701720_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Ms State Emplo", "plan_name": "401457", "standard_charge_percentage": 0.80, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Ms State Emplo", "plan_name": "401457_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Basic Pl", "plan_name": "400100", "standard_charge_percentage": 0.85, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Basic Pl", "plan_name": "400100_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Federal", "plan_name": "400110", "standard_charge_percentage": 0.85, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Federal", "plan_name": "400110_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." } ] } ] }, { "description": "Amitriptyline 10 mg tablet [432]", "drug_information": { "unit": 1.00, "type": "EA" }, "code_information": [ { "code": "51079-131-20", "type": "NDC" } ], "standard_charges": [ { "gross_charge": 7.50, "minimum": 6.00, "maximum": 6.38, "setting": "both", "payers_information": [ { "payer_name": "Aetna", "plan_name": "700700", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna", "plan_name": "700700_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Miscellaneous", "plan_name": "700720", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Miscellaneous", "plan_name": "700720_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Ppo Hmo", "plan_name": "701720", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Ppo Hmo", "plan_name": "701720_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Ms State Emplo", "plan_name": "401457", "standard_charge_percentage": 0.80, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Ms State Emplo", "plan_name": "401457_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Basic Pl", "plan_name": "400100", "standard_charge_percentage": 0.85, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Basic Pl", "plan_name": "400100_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Federal", "plan_name": "400110", "standard_charge_percentage": 0.85, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Federal", "plan_name": "400110_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." } ] } ] }, { "description": "Chlordiazepoxide 25 mg capsule [1623]", "drug_information": { "unit": 1.00, "type": "EA" }, "code_information": [ { "code": "51079-141-01", "type": "NDC" } ], "standard_charges": [ { "gross_charge": 7.50, "minimum": 6.00, "maximum": 6.38, "setting": "both", "payers_information": [ { "payer_name": "Aetna", "plan_name": "700700", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna", "plan_name": "700700_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Miscellaneous", "plan_name": "700720", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Miscellaneous", "plan_name": "700720_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Ppo Hmo", "plan_name": "701720", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Ppo Hmo", "plan_name": "701720_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Ms State Emplo", "plan_name": "401457", "standard_charge_percentage": 0.80, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Ms State Emplo", "plan_name": "401457_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Basic Pl", "plan_name": "400100", "standard_charge_percentage": 0.85, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Basic Pl", "plan_name": "400100_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Federal", "plan_name": "400110", "standard_charge_percentage": 0.85, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Federal", "plan_name": "400110_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." } ] } ] }, { "description": "Chlordiazepoxide 25 mg capsule [1623]", "drug_information": { "unit": 1.00, "type": "EA" }, "code_information": [ { "code": "51079-141-20", "type": "NDC" } ], "standard_charges": [ { "gross_charge": 7.50, "minimum": 6.00, "maximum": 6.38, "setting": "both", "payers_information": [ { "payer_name": "Aetna", "plan_name": "700700", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna", "plan_name": "700700_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Miscellaneous", "plan_name": "700720", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Miscellaneous", "plan_name": "700720_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Ppo Hmo", "plan_name": "701720", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Ppo Hmo", "plan_name": "701720_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Ms State Emplo", "plan_name": "401457", "standard_charge_percentage": 0.80, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Ms State Emplo", "plan_name": "401457_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Basic Pl", "plan_name": "400100", "standard_charge_percentage": 0.85, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Basic Pl", "plan_name": "400100_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Federal", "plan_name": "400110", "standard_charge_percentage": 0.85, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Federal", "plan_name": "400110_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." } ] } ] }, { "description": "Metoprolol succinate er 50 mg tabletextended release 24 hr [30070]", "drug_information": { "unit": 1.00, "type": "EA" }, "code_information": [ { "code": "51079-170-01", "type": "NDC" } ], "standard_charges": [ { "gross_charge": 7.50, "minimum": 6.00, "maximum": 6.38, "setting": "both", "payers_information": [ { "payer_name": "Aetna", "plan_name": "700700", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna", "plan_name": "700700_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Miscellaneous", "plan_name": "700720", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Miscellaneous", "plan_name": "700720_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Ppo Hmo", "plan_name": "701720", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Ppo Hmo", "plan_name": "701720_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Ms State Emplo", "plan_name": "401457", "standard_charge_percentage": 0.80, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Ms State Emplo", "plan_name": "401457_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Basic Pl", "plan_name": "400100", "standard_charge_percentage": 0.85, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Basic Pl", "plan_name": "400100_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Federal", "plan_name": "400110", "standard_charge_percentage": 0.85, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Federal", "plan_name": "400110_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." } ] } ] }, { "description": "Allopurinol 100 mg tablet [310]", "drug_information": { "unit": 1.00, "type": "EA" }, "code_information": [ { "code": "51079-205-01", "type": "NDC" } ], "standard_charges": [ { "gross_charge": 7.50, "minimum": 6.00, "maximum": 6.38, "setting": "both", "payers_information": [ { "payer_name": "Aetna", "plan_name": "700700", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna", "plan_name": "700700_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Miscellaneous", "plan_name": "700720", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Miscellaneous", "plan_name": "700720_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Ppo Hmo", "plan_name": "701720", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Ppo Hmo", "plan_name": "701720_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Ms State Emplo", "plan_name": "401457", "standard_charge_percentage": 0.80, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Ms State Emplo", "plan_name": "401457_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Basic Pl", "plan_name": "400100", "standard_charge_percentage": 0.85, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Basic Pl", "plan_name": "400100_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Federal", "plan_name": "400110", "standard_charge_percentage": 0.85, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Federal", "plan_name": "400110_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." } ] } ] }, { "description": "Allopurinol 100 mg tablet [310]", "drug_information": { "unit": 1.00, "type": "EA" }, "code_information": [ { "code": "51079-205-20", "type": "NDC" } ], "standard_charges": [ { "gross_charge": 7.50, "minimum": 6.00, "maximum": 6.38, "setting": "both", "payers_information": [ { "payer_name": "Aetna", "plan_name": "700700", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna", "plan_name": "700700_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Miscellaneous", "plan_name": "700720", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Miscellaneous", "plan_name": "700720_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Ppo Hmo", "plan_name": "701720", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Ppo Hmo", "plan_name": "701720_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Ms State Emplo", "plan_name": "401457", "standard_charge_percentage": 0.80, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Ms State Emplo", "plan_name": "401457_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Basic Pl", "plan_name": "400100", "standard_charge_percentage": 0.85, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Basic Pl", "plan_name": "400100_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Federal", "plan_name": "400110", "standard_charge_percentage": 0.85, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Federal", "plan_name": "400110_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." } ] } ] }, { "description": "Allopurinol 300 mg tablet [311]", "drug_information": { "unit": 1.00, "type": "EA" }, "code_information": [ { "code": "51079-206-01", "type": "NDC" } ], "standard_charges": [ { "gross_charge": 7.50, "minimum": 6.00, "maximum": 6.38, "setting": "both", "payers_information": [ { "payer_name": "Aetna", "plan_name": "700700", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna", "plan_name": "700700_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Miscellaneous", "plan_name": "700720", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Miscellaneous", "plan_name": "700720_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Ppo Hmo", "plan_name": "701720", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Ppo Hmo", "plan_name": "701720_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Ms State Emplo", "plan_name": "401457", "standard_charge_percentage": 0.80, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Ms State Emplo", "plan_name": "401457_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Basic Pl", "plan_name": "400100", "standard_charge_percentage": 0.85, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Basic Pl", "plan_name": "400100_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Federal", "plan_name": "400110", "standard_charge_percentage": 0.85, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Federal", "plan_name": "400110_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." } ] } ] }, { "description": "Atorvastatin 20 mg tablet [19178]", "drug_information": { "unit": 1.00, "type": "EA" }, "code_information": [ { "code": "51079-209-01", "type": "NDC" } ], "standard_charges": [ { "gross_charge": 7.50, "minimum": 6.00, "maximum": 6.38, "setting": "both", "payers_information": [ { "payer_name": "Aetna", "plan_name": "700700", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna", "plan_name": "700700_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Miscellaneous", "plan_name": "700720", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Miscellaneous", "plan_name": "700720_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Ppo Hmo", "plan_name": "701720", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Ppo Hmo", "plan_name": "701720_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Ms State Emplo", "plan_name": "401457", "standard_charge_percentage": 0.80, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Ms State Emplo", "plan_name": "401457_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Basic Pl", "plan_name": "400100", "standard_charge_percentage": 0.85, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Basic Pl", "plan_name": "400100_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Federal", "plan_name": "400110", "standard_charge_percentage": 0.85, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Federal", "plan_name": "400110_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." } ] } ] }, { "description": "Atorvastatin 40 mg tablet [19177]", "drug_information": { "unit": 1.00, "type": "EA" }, "code_information": [ { "code": "51079-210-01", "type": "NDC" } ], "standard_charges": [ { "gross_charge": 7.50, "minimum": 6.00, "maximum": 6.38, "setting": "both", "payers_information": [ { "payer_name": "Aetna", "plan_name": "700700", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna", "plan_name": "700700_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Miscellaneous", "plan_name": "700720", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Miscellaneous", "plan_name": "700720_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Ppo Hmo", "plan_name": "701720", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Ppo Hmo", "plan_name": "701720_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Ms State Emplo", "plan_name": "401457", "standard_charge_percentage": 0.80, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Ms State Emplo", "plan_name": "401457_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Basic Pl", "plan_name": "400100", "standard_charge_percentage": 0.85, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Basic Pl", "plan_name": "400100_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Federal", "plan_name": "400110", "standard_charge_percentage": 0.85, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Federal", "plan_name": "400110_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." } ] } ] }, { "description": "Metoprolol tartrate 25 mg tablet [37637]", "drug_information": { "unit": 1.00, "type": "EA" }, "code_information": [ { "code": "51079-255-01", "type": "NDC" } ], "standard_charges": [ { "gross_charge": 7.50, "minimum": 6.00, "maximum": 6.38, "setting": "both", "payers_information": [ { "payer_name": "Aetna", "plan_name": "700700", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna", "plan_name": "700700_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Miscellaneous", "plan_name": "700720", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Miscellaneous", "plan_name": "700720_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Ppo Hmo", "plan_name": "701720", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Ppo Hmo", "plan_name": "701720_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Ms State Emplo", "plan_name": "401457", "standard_charge_percentage": 0.80, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Ms State Emplo", "plan_name": "401457_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Basic Pl", "plan_name": "400100", "standard_charge_percentage": 0.85, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Basic Pl", "plan_name": "400100_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Federal", "plan_name": "400110", "standard_charge_percentage": 0.85, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Federal", "plan_name": "400110_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." } ] } ] }, { "description": "Diazepam 2 mg tablet [2404]", "drug_information": { "unit": 1.00, "type": "EA" }, "code_information": [ { "code": "51079-284-01", "type": "NDC" } ], "standard_charges": [ { "gross_charge": 7.50, "minimum": 6.00, "maximum": 6.38, "setting": "both", "payers_information": [ { "payer_name": "Aetna", "plan_name": "700700", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna", "plan_name": "700700_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Miscellaneous", "plan_name": "700720", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Miscellaneous", "plan_name": "700720_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Ppo Hmo", "plan_name": "701720", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Ppo Hmo", "plan_name": "701720_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Ms State Emplo", "plan_name": "401457", "standard_charge_percentage": 0.80, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Ms State Emplo", "plan_name": "401457_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Basic Pl", "plan_name": "400100", "standard_charge_percentage": 0.85, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Basic Pl", "plan_name": "400100_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Federal", "plan_name": "400110", "standard_charge_percentage": 0.85, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Federal", "plan_name": "400110_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." } ] } ] }, { "description": "Diazepam 2 mg tablet [2404]", "drug_information": { "unit": 1.00, "type": "EA" }, "code_information": [ { "code": "51079-284-20", "type": "NDC" } ], "standard_charges": [ { "gross_charge": 7.50, "minimum": 6.00, "maximum": 6.38, "setting": "both", "payers_information": [ { "payer_name": "Aetna", "plan_name": "700700", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna", "plan_name": "700700_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Miscellaneous", "plan_name": "700720", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Miscellaneous", "plan_name": "700720_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Ppo Hmo", "plan_name": "701720", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Ppo Hmo", "plan_name": "701720_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Ms State Emplo", "plan_name": "401457", "standard_charge_percentage": 0.80, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Ms State Emplo", "plan_name": "401457_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Basic Pl", "plan_name": "400100", "standard_charge_percentage": 0.85, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Basic Pl", "plan_name": "400100_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Federal", "plan_name": "400110", "standard_charge_percentage": 0.85, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Federal", "plan_name": "400110_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." } ] } ] }, { "description": "Diazepam 5 mg tablet [2405]", "drug_information": { "unit": 1.00, "type": "EA" }, "code_information": [ { "code": "51079-285-01", "type": "NDC" } ], "standard_charges": [ { "gross_charge": 7.50, "minimum": 6.00, "maximum": 6.38, "setting": "both", "payers_information": [ { "payer_name": "Aetna", "plan_name": "700700", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna", "plan_name": "700700_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Miscellaneous", "plan_name": "700720", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total 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"additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Ms State Emplo", "plan_name": "401457_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Basic Pl", "plan_name": "400100", "standard_charge_percentage": 0.85, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Basic Pl", "plan_name": "400100_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Federal", "plan_name": "400110", "standard_charge_percentage": 0.85, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Federal", "plan_name": "400110_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." } ] } ] }, { "description": "Diazepam 5 mg tablet [2405]", "drug_information": { "unit": 1.00, "type": "EA" }, "code_information": [ { "code": "51079-285-20", "type": "NDC" } ], "standard_charges": [ { "gross_charge": 7.50, "minimum": 6.00, "maximum": 6.38, "setting": "both", "payers_information": [ { "payer_name": "Aetna", "plan_name": "700700", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna", "plan_name": "700700_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total 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"additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Ms State Emplo", "plan_name": "401457", "standard_charge_percentage": 0.80, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Ms State Emplo", "plan_name": "401457_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Basic Pl", "plan_name": "400100", "standard_charge_percentage": 0.85, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Basic Pl", "plan_name": "400100_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Federal", "plan_name": "400110", "standard_charge_percentage": 0.85, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Federal", "plan_name": "400110_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." } ] } ] }, { "description": "Diazepam 10 mg tablet [2403]", "drug_information": { "unit": 1.00, "type": "EA" }, "code_information": [ { "code": "51079-286-01", "type": "NDC" } ], "standard_charges": [ { "gross_charge": 7.50, "minimum": 6.00, "maximum": 6.38, "setting": "both", "payers_information": [ { "payer_name": "Aetna", "plan_name": "700700", "standard_charge_percentage": 80.0, "count": "0", "methodology": 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"additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Basic Pl", "plan_name": "400100_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Federal", "plan_name": "400110", "standard_charge_percentage": 0.85, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Federal", "plan_name": "400110_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." } ] } ] }, { "description": "Diazepam 10 mg tablet [2403]", "drug_information": { "unit": 1.00, "type": "EA" }, "code_information": [ { "code": "51079-286-20", "type": 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billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Ppo Hmo", "plan_name": "701720", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Ppo Hmo", "plan_name": "701720_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Ms State Emplo", "plan_name": "401457", "standard_charge_percentage": 0.80, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Ms State Emplo", "plan_name": "401457_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Basic Pl", "plan_name": "400100", "standard_charge_percentage": 0.85, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Basic Pl", "plan_name": "400100_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Federal", "plan_name": "400110", "standard_charge_percentage": 0.85, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Federal", "plan_name": "400110_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." } ] } ] }, { "description": "Clonidine hcl 0.1 mg tablet [1755]", "drug_information": { "unit": 1.00, "type": "EA" }, "code_information": [ { "code": "51079-299-20", "type": "NDC" } ], "standard_charges": [ { "gross_charge": 7.50, "minimum": 6.00, "maximum": 6.38, "setting": "both", "payers_information": [ { "payer_name": "Aetna", "plan_name": "700700", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna", "plan_name": "700700_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Miscellaneous", "plan_name": "700720", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Miscellaneous", "plan_name": "700720_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Ppo Hmo", "plan_name": "701720", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Ppo Hmo", "plan_name": "701720_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Ms State Emplo", "plan_name": "401457", "standard_charge_percentage": 0.80, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Ms State Emplo", "plan_name": "401457_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Basic Pl", "plan_name": "400100", "standard_charge_percentage": 0.85, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Basic Pl", "plan_name": "400100_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Federal", "plan_name": "400110", "standard_charge_percentage": 0.85, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Federal", "plan_name": "400110_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." } ] } ] }, { "description": "Polyethylene glycol 3350 17 gram oral powder packet [25424]", "drug_information": { "unit": 1.00, "type": "EA" }, "code_information": [ { "code": "51079-306-01", "type": "NDC" } ], "standard_charges": [ { "gross_charge": 5.09, "minimum": 4.07, "maximum": 4.33, "setting": "both", "payers_information": [ { "payer_name": "Aetna", "plan_name": "700700", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna", "plan_name": "700700_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Miscellaneous", "plan_name": "700720", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Miscellaneous", "plan_name": "700720_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Ppo Hmo", "plan_name": "701720", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Ppo Hmo", "plan_name": "701720_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Ms State Emplo", "plan_name": "401457", "standard_charge_percentage": 0.80, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Ms State Emplo", "plan_name": "401457_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Basic Pl", "plan_name": "400100", "standard_charge_percentage": 0.85, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Basic Pl", "plan_name": "400100_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Federal", "plan_name": "400110", "standard_charge_percentage": 0.85, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Federal", "plan_name": "400110_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." } ] } ] }, { "description": "Polyethylene glycol 3350 17 gram oral powder packet [25424]", "drug_information": { "unit": 1.00, "type": "EA" }, "code_information": [ { "code": "51079-306-30", "type": "NDC" } ], "standard_charges": [ { "gross_charge": 5.09, "minimum": 4.07, "maximum": 4.33, "setting": "both", "payers_information": [ { "payer_name": "Aetna", "plan_name": "700700", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna", "plan_name": "700700_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Miscellaneous", "plan_name": "700720", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Miscellaneous", "plan_name": "700720_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Ppo Hmo", "plan_name": "701720", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Ppo Hmo", "plan_name": "701720_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Ms State Emplo", "plan_name": "401457", "standard_charge_percentage": 0.80, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Ms State Emplo", "plan_name": "401457_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Basic Pl", "plan_name": "400100", "standard_charge_percentage": 0.85, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Basic Pl", "plan_name": "400100_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Federal", "plan_name": "400110", "standard_charge_percentage": 0.85, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Federal", "plan_name": "400110_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." } ] } ] }, { "description": "Megestrol 20 mg tablet [4870]", "drug_information": { "unit": 1.00, "type": "EA" }, "code_information": [ { "code": "51079-434-20", "type": "NDC" } ], "standard_charges": [ { "gross_charge": 7.50, "minimum": 6.00, "maximum": 6.38, "setting": "both", "payers_information": [ { "payer_name": "Aetna", "plan_name": "700700", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna", "plan_name": "700700_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Miscellaneous", "plan_name": "700720", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Miscellaneous", "plan_name": "700720_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Ppo Hmo", "plan_name": "701720", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Ppo Hmo", "plan_name": "701720_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Ms State Emplo", "plan_name": "401457", "standard_charge_percentage": 0.80, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Ms State Emplo", "plan_name": "401457_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Basic Pl", "plan_name": "400100", "standard_charge_percentage": 0.85, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Basic Pl", "plan_name": "400100_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Federal", "plan_name": "400110", "standard_charge_percentage": 0.85, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Federal", "plan_name": "400110_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." } ] } ] }, { "description": "Doxepin 25 mg capsule [2611]", "drug_information": { "unit": 1.00, "type": "EA" }, "code_information": [ { "code": "51079-437-01", "type": "NDC" } ], "standard_charges": [ { "gross_charge": 7.50, "minimum": 6.00, "maximum": 6.38, "setting": "both", "payers_information": [ { "payer_name": "Aetna", "plan_name": "700700", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna", "plan_name": "700700_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna 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"plan_name": "401457", "standard_charge_percentage": 0.80, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Ms State Emplo", "plan_name": "401457_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Basic Pl", "plan_name": "400100", "standard_charge_percentage": 0.85, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Basic Pl", "plan_name": "400100_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Federal", "plan_name": "400110", "standard_charge_percentage": 0.85, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Federal", "plan_name": "400110_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." } ] } ] }, { "description": "Doxepin 50 mg capsule [2612]", "drug_information": { "unit": 1.00, "type": "EA" }, "code_information": [ { "code": "51079-438-01", "type": "NDC" } ], "standard_charges": [ { "gross_charge": 8.09, "minimum": 6.47, "maximum": 6.88, "setting": "both", "payers_information": [ { "payer_name": "Aetna", "plan_name": "700700", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna", "plan_name": "700700_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Miscellaneous", "plan_name": "700720", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Miscellaneous", "plan_name": "700720_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Ppo Hmo", "plan_name": "701720", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Ppo Hmo", "plan_name": "701720_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Ms State Emplo", "plan_name": "401457", "standard_charge_percentage": 0.80, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Ms State Emplo", "plan_name": "401457_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Basic Pl", "plan_name": "400100", "standard_charge_percentage": 0.85, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Basic Pl", "plan_name": "400100_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Federal", "plan_name": "400110", "standard_charge_percentage": 0.85, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Federal", "plan_name": "400110_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." } ] } ] }, { "description": "Levothyroxine 50 mcg tablet [4421]", "drug_information": { "unit": 1.00, "type": "EA" }, "code_information": [ { "code": "51079-440-01", "type": "NDC" } ], "standard_charges": [ { "gross_charge": 7.50, "minimum": 6.00, "maximum": 6.38, "setting": "both", "payers_information": [ { "payer_name": "Aetna", "plan_name": "700700", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna", "plan_name": "700700_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Miscellaneous", "plan_name": "700720", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Miscellaneous", "plan_name": "700720_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Ppo Hmo", "plan_name": "701720", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Ppo Hmo", "plan_name": "701720_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Ms State Emplo", "plan_name": "401457", "standard_charge_percentage": 0.80, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Ms State Emplo", "plan_name": "401457_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Basic Pl", "plan_name": "400100", "standard_charge_percentage": 0.85, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Basic Pl", "plan_name": "400100_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Federal", "plan_name": "400110", "standard_charge_percentage": 0.85, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Federal", "plan_name": "400110_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." } ] } ] }, { "description": "Levothyroxine 75 mcg tablet [4422]", "drug_information": { "unit": 1.00, "type": "EA" }, "code_information": [ { "code": "51079-441-01", "type": "NDC" } ], "standard_charges": [ { "gross_charge": 7.50, "minimum": 6.00, "maximum": 6.38, "setting": "both", "payers_information": [ { "payer_name": "Aetna", "plan_name": "700700", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna", "plan_name": "700700_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Miscellaneous", "plan_name": "700720", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Miscellaneous", "plan_name": "700720_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Ppo Hmo", "plan_name": "701720", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Ppo Hmo", "plan_name": "701720_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Ms State Emplo", "plan_name": "401457", "standard_charge_percentage": 0.80, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Ms State Emplo", "plan_name": "401457_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Basic Pl", "plan_name": "400100", "standard_charge_percentage": 0.85, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Basic Pl", "plan_name": "400100_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Federal", "plan_name": "400110", "standard_charge_percentage": 0.85, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Federal", "plan_name": "400110_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." } ] } ] }, { "description": "Levothyroxine 100 mcg tablet [4423]", "drug_information": { "unit": 1.00, "type": "EA" }, "code_information": [ { "code": "51079-442-01", "type": "NDC" } ], "standard_charges": [ { "gross_charge": 7.50, "minimum": 6.00, "maximum": 6.38, "setting": "both", "payers_information": [ { "payer_name": "Aetna", "plan_name": "700700", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna", "plan_name": "700700_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Miscellaneous", "plan_name": "700720", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Miscellaneous", "plan_name": "700720_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Ppo Hmo", "plan_name": "701720", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Ppo Hmo", "plan_name": "701720_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Ms State Emplo", "plan_name": "401457", "standard_charge_percentage": 0.80, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Ms State Emplo", "plan_name": "401457_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Basic Pl", "plan_name": "400100", "standard_charge_percentage": 0.85, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Basic Pl", "plan_name": "400100_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Federal", "plan_name": "400110", "standard_charge_percentage": 0.85, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Federal", "plan_name": "400110_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." } ] } ] }, { "description": "Levothyroxine 125 mcg tablet [4424]", "drug_information": { "unit": 1.00, "type": "EA" }, "code_information": [ { "code": "51079-443-01", "type": "NDC" } ], "standard_charges": [ { "gross_charge": 7.50, "minimum": 6.00, "maximum": 6.38, "setting": "both", "payers_information": [ { "payer_name": "Aetna", "plan_name": "700700", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna", "plan_name": "700700_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Miscellaneous", "plan_name": "700720", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Miscellaneous", "plan_name": "700720_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Ppo Hmo", "plan_name": "701720", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Ppo Hmo", "plan_name": "701720_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Ms State Emplo", "plan_name": "401457", "standard_charge_percentage": 0.80, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Ms State Emplo", "plan_name": "401457_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Basic Pl", "plan_name": "400100", "standard_charge_percentage": 0.85, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Basic Pl", "plan_name": "400100_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Federal", "plan_name": "400110", "standard_charge_percentage": 0.85, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Federal", "plan_name": "400110_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." } ] } ] }, { "description": "Levothyroxine 25 mcg tablet [4420]", "drug_information": { "unit": 1.00, "type": "EA" }, "code_information": [ { "code": "51079-444-01", "type": "NDC" } ], "standard_charges": [ { "gross_charge": 7.50, "minimum": 6.00, "maximum": 6.38, "setting": "both", "payers_information": [ { "payer_name": "Aetna", "plan_name": "700700", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna", "plan_name": "700700_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Miscellaneous", "plan_name": "700720", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Miscellaneous", "plan_name": "700720_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Ppo Hmo", "plan_name": "701720", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Ppo Hmo", "plan_name": "701720_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Ms State Emplo", "plan_name": "401457", "standard_charge_percentage": 0.80, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Ms State Emplo", "plan_name": "401457_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient 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remit data to calculate allowed amounts." } ] } ] }, { "description": "Levothyroxine 150 mcg tablet [4425]", "drug_information": { "unit": 1.00, "type": "EA" }, "code_information": [ { "code": "51079-445-01", "type": "NDC" } ], "standard_charges": [ { "gross_charge": 7.50, "minimum": 6.00, "maximum": 6.38, "setting": "both", "payers_information": [ { "payer_name": "Aetna", "plan_name": "700700", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna", "plan_name": "700700_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Miscellaneous", "plan_name": "700720", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Miscellaneous", "plan_name": "700720_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Ppo Hmo", "plan_name": "701720", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Ppo Hmo", "plan_name": "701720_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Ms State Emplo", "plan_name": "401457", "standard_charge_percentage": 0.80, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Ms State Emplo", "plan_name": "401457_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Basic Pl", "plan_name": "400100", "standard_charge_percentage": 0.85, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Basic Pl", "plan_name": "400100_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Federal", "plan_name": "400110", "standard_charge_percentage": 0.85, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Federal", "plan_name": "400110_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." } ] } ] }, { "description": "Pravastatin 20 mg tablet [11111]", "drug_information": { "unit": 1.00, "type": "EA" }, "code_information": [ { "code": "51079-458-01", "type": "NDC" } ], "standard_charges": [ { "gross_charge": 7.50, "minimum": 6.00, "maximum": 6.38, "setting": "both", "payers_information": [ { "payer_name": "Aetna", "plan_name": "700700", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna", "plan_name": "700700_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of 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charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Federal", "plan_name": "400110", "standard_charge_percentage": 0.85, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Federal", "plan_name": "400110_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." } ] } ] }, { "description": "Diclofenac sodium 50 mg tabletdelayed release [15340]", "drug_information": { "unit": 1.00, "type": "EA" }, "code_information": [ { "code": "51079-466-20", "type": "NDC" } ], "standard_charges": [ { "gross_charge": 7.50, "minimum": 6.00, "maximum": 6.38, "setting": "both", "payers_information": [ { "payer_name": "Aetna", "plan_name": "700700", "standard_charge_percentage": 80.0, 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"methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Basic Pl", "plan_name": "400100_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Federal", "plan_name": "400110", "standard_charge_percentage": 0.85, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Federal", "plan_name": "400110_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." } ] } ] }, { "description": "Furosemide 80 mg tablet [3296]", "drug_information": { "unit": 1.00, "type": "EA" }, 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100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Ppo Hmo", "plan_name": "701720", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Ppo Hmo", "plan_name": "701720_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Ms State Emplo", "plan_name": "401457", "standard_charge_percentage": 0.80, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Ms State Emplo", "plan_name": "401457_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Basic Pl", "plan_name": "400100", "standard_charge_percentage": 0.85, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Basic Pl", "plan_name": "400100_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Federal", "plan_name": "400110", "standard_charge_percentage": 0.85, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Federal", "plan_name": "400110_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." } ] } ] }, { "description": "Furosemide 80 mg tablet [3296]", "drug_information": { "unit": 1.00, "type": "EA" }, "code_information": [ { "code": "51079-527-20", "type": "NDC" } ], "standard_charges": [ { "gross_charge": 7.50, "minimum": 6.00, "maximum": 6.38, "setting": "both", "payers_information": [ { "payer_name": "Aetna", "plan_name": "700700", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna", "plan_name": "700700_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Miscellaneous", "plan_name": "700720", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Miscellaneous", "plan_name": "700720_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Ppo Hmo", "plan_name": "701720", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Ppo Hmo", "plan_name": "701720_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Ms State Emplo", "plan_name": "401457", "standard_charge_percentage": 0.80, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Ms State Emplo", "plan_name": "401457_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Basic Pl", "plan_name": "400100", "standard_charge_percentage": 0.85, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Basic Pl", "plan_name": "400100_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Federal", "plan_name": "400110", "standard_charge_percentage": 0.85, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Federal", "plan_name": "400110_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." } ] } ] }, { "description": "Lipase 10500-protease 35500-amylase 61500 unit capsuledelayed rel [179585]", "drug_information": { "unit": 1.00, "type": "EA" }, "code_information": [ { "code": "50458-342-60", "type": "NDC" } ], "standard_charges": [ { "gross_charge": 14.27, "minimum": 11.42, "maximum": 12.13, "setting": "both", "payers_information": [ { "payer_name": "Aetna", "plan_name": "700700", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna", "plan_name": "700700_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Miscellaneous", "plan_name": "700720", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Miscellaneous", "plan_name": "700720_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Ppo Hmo", "plan_name": "701720", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Ppo Hmo", "plan_name": "701720_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Ms State Emplo", "plan_name": "401457", "standard_charge_percentage": 0.80, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Ms State Emplo", "plan_name": "401457_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Basic Pl", "plan_name": "400100", "standard_charge_percentage": 0.85, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Basic Pl", "plan_name": "400100_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Federal", "plan_name": "400110", "standard_charge_percentage": 0.85, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Federal", "plan_name": "400110_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." } ] } ] }, { "description": "Rivaroxaban 2.5 mg tablet [185293]", "drug_information": { "unit": 1.00, "type": "EA" }, "code_information": [ { "code": "50458-577-01", "type": "NDC" } ], "standard_charges": [ { "gross_charge": 42.41, "minimum": 33.93, "maximum": 36.05, "setting": "both", "payers_information": [ { "payer_name": "Aetna", "plan_name": "700700", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna", "plan_name": "700700_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Miscellaneous", "plan_name": "700720", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Miscellaneous", "plan_name": "700720_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Ppo Hmo", "plan_name": "701720", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Ppo Hmo", "plan_name": "701720_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Ms State Emplo", "plan_name": "401457", "standard_charge_percentage": 0.80, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Ms State Emplo", "plan_name": "401457_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Basic Pl", "plan_name": "400100", "standard_charge_percentage": 0.85, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Basic Pl", "plan_name": "400100_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Federal", "plan_name": "400110", "standard_charge_percentage": 0.85, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Federal", "plan_name": "400110_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." } ] } ] }, { "description": "Rivaroxaban 2.5 mg 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Emplo", "plan_name": "401457_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Basic Pl", "plan_name": "400100", "standard_charge_percentage": 0.85, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Basic Pl", "plan_name": "400100_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Federal", "plan_name": "400110", "standard_charge_percentage": 0.85, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Federal", "plan_name": "400110_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." } ] } ] }, { "description": "Rivaroxaban 15 mg tablet [154501]", "drug_information": { "unit": 1.00, "type": "EA" }, "code_information": [ { "code": "50458-578-01", "type": "NDC" } ], "standard_charges": [ { "gross_charge": 84.83, "minimum": 67.86, "maximum": 72.11, "setting": "both", "payers_information": [ { "payer_name": "Aetna", "plan_name": "700700", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna", "plan_name": "700700_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Miscellaneous", "plan_name": "700720", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Miscellaneous", "plan_name": "700720_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Ppo Hmo", "plan_name": "701720", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Ppo Hmo", "plan_name": "701720_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Ms State Emplo", "plan_name": "401457", "standard_charge_percentage": 0.80, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Ms State Emplo", "plan_name": "401457_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Basic Pl", "plan_name": "400100", "standard_charge_percentage": 0.85, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Basic Pl", "plan_name": "400100_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Federal", "plan_name": "400110", "standard_charge_percentage": 0.85, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Federal", "plan_name": "400110_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." } ] } ] }, { "description": "Rivaroxaban 15 mg tablet [154501]", "drug_information": { "unit": 1.00, "type": "EA" }, "code_information": [ { "code": "50458-578-10", "type": "NDC" } ], "standard_charges": [ { "gross_charge": 84.83, "minimum": 67.86, "maximum": 72.11, "setting": "both", "payers_information": [ { "payer_name": "Aetna", "plan_name": "700700", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate 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"payer_name": "Aetna Ppo Hmo", "plan_name": "701720_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Ms State Emplo", "plan_name": "401457", "standard_charge_percentage": 0.80, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Ms State Emplo", "plan_name": "401457_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Basic Pl", "plan_name": "400100", "standard_charge_percentage": 0.85, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Basic Pl", "plan_name": "400100_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Federal", "plan_name": "400110", "standard_charge_percentage": 0.85, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Federal", "plan_name": "400110_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." } ] } ] }, { "description": "Rivaroxaban 15 mg tablet [154501]", "drug_information": { "unit": 1.00, "type": "EA" }, "code_information": [ { "code": "50458-578-30", "type": "NDC" } ], "standard_charges": [ { "gross_charge": 84.83, "minimum": 67.86, 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allowed amounts." } ] } ] }, { "description": "Rivaroxaban 20 mg tablet [154502]", "drug_information": { "unit": 1.00, "type": "EA" }, "code_information": [ { "code": "50458-579-01", "type": "NDC" } ], "standard_charges": [ { "gross_charge": 84.83, "minimum": 67.86, "maximum": 72.11, "setting": "both", "payers_information": [ { "payer_name": "Aetna", "plan_name": "700700", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna", "plan_name": "700700_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Miscellaneous", "plan_name": "700720", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient 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calculate allowed amounts." }, { "payer_name": "Bc/Bs Ms State Emplo", "plan_name": "401457_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Basic Pl", "plan_name": "400100", "standard_charge_percentage": 0.85, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Basic Pl", "plan_name": "400100_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Federal", "plan_name": "400110", "standard_charge_percentage": 0.85, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Federal", "plan_name": "400110_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." } ] } ] }, { "description": "Rivaroxaban 10 mg tablet [151761]", "drug_information": { "unit": 1.00, "type": "EA" }, "code_information": [ { "code": "50458-580-01", "type": "NDC" } ], "standard_charges": [ { "gross_charge": 84.83, "minimum": 67.86, "maximum": 72.11, "setting": "both", "payers_information": [ { "payer_name": "Aetna", "plan_name": "700700", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna", "plan_name": "700700_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Miscellaneous", "plan_name": "700720", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Miscellaneous", "plan_name": "700720_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Ppo Hmo", "plan_name": "701720", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Ppo Hmo", "plan_name": "701720_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient 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remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Federal", "plan_name": "400110", "standard_charge_percentage": 0.85, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Federal", "plan_name": "400110_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." } ] } ] }, { "description": "Rivaroxaban 10 mg tablet [151761]", "drug_information": { "unit": 1.00, "type": "EA" }, "code_information": [ { "code": "50458-580-30", "type": "NDC" } ], "standard_charges": [ { "gross_charge": 84.83, "minimum": 67.86, "maximum": 72.11, "setting": "both", "payers_information": [ { "payer_name": "Aetna", "plan_name": "700700", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna", "plan_name": "700700_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Miscellaneous", "plan_name": "700720", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Miscellaneous", "plan_name": "700720_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Ppo Hmo", "plan_name": "701720", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Ppo Hmo", "plan_name": "701720_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Ms State Emplo", "plan_name": "401457", "standard_charge_percentage": 0.80, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Ms State Emplo", "plan_name": "401457_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Basic Pl", "plan_name": "400100", "standard_charge_percentage": 0.85, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Basic Pl", "plan_name": "400100_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Federal", "plan_name": "400110", "standard_charge_percentage": 0.85, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Federal", "plan_name": "400110_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." } ] } ] }, { "description": "Levofloxacin 250 mg tablet [18918]", "drug_information": { "unit": 1.00, "type": "EA" }, "code_information": [ { "code": "50458-920-10", "type": "NDC" } ], 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calculate allowed amounts." }, { "payer_name": "Aetna Ppo Hmo", "plan_name": "701720", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Ppo Hmo", "plan_name": "701720_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Ms State Emplo", "plan_name": "401457", "standard_charge_percentage": 0.80, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Ms State Emplo", "plan_name": "401457_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Basic Pl", "plan_name": "400100", "standard_charge_percentage": 0.85, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Basic Pl", "plan_name": "400100_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Federal", "plan_name": "400110", "standard_charge_percentage": 0.85, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Federal", "plan_name": "400110_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." } ] } ] }, { "description": "Cetirizine 10 mg tablet [9506]", "drug_information": { "unit": 1.00, "type": "EA" }, "code_information": [ { "code": "51079-597-20", "type": "NDC" } ], "standard_charges": [ { "gross_charge": 1.00, "minimum": 0.80, "maximum": 0.85, "setting": "both", "payers_information": [ { "payer_name": "Aetna", "plan_name": "700700", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna", "plan_name": "700700_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Miscellaneous", "plan_name": "700720", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Miscellaneous", "plan_name": "700720_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Ppo Hmo", "plan_name": "701720", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Ppo Hmo", "plan_name": "701720_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Ms State Emplo", "plan_name": "401457", "standard_charge_percentage": 0.80, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Ms State Emplo", "plan_name": "401457_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Basic Pl", "plan_name": "400100", "standard_charge_percentage": 0.85, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Basic Pl", "plan_name": "400100_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Federal", "plan_name": "400110", "standard_charge_percentage": 0.85, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Federal", "plan_name": "400110_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." } ] } ] }, { "description": "Fenofibrate nanocrystallized 145 mg tablet [40010]", "drug_information": { "unit": 1.00, "type": "EA" }, "code_information": [ { "code": "51079-608-01", "type": "NDC" } ], "standard_charges": [ { "gross_charge": 24.86, "minimum": 19.89, "maximum": 21.13, "setting": "both", "payers_information": [ { "payer_name": "Aetna", "plan_name": "700700", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna", "plan_name": "700700_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Miscellaneous", "plan_name": "700720", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Miscellaneous", "plan_name": "700720_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Ppo Hmo", "plan_name": "701720", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Ppo Hmo", "plan_name": "701720_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Ms State Emplo", "plan_name": "401457", "standard_charge_percentage": 0.80, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Ms State Emplo", "plan_name": "401457_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Basic Pl", "plan_name": "400100", "standard_charge_percentage": 0.85, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Basic Pl", "plan_name": "400100_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Federal", "plan_name": "400110", "standard_charge_percentage": 0.85, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Federal", "plan_name": "400110_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." } ] } ] }, { "description": "Atenolol 50 mg tablet [718]", "drug_information": { "unit": 1.00, "type": "EA" }, "code_information": [ { "code": "51079-684-01", "type": "NDC" } ], "standard_charges": [ { "gross_charge": 7.50, "minimum": 6.00, "maximum": 6.38, "setting": "both", "payers_information": [ { "payer_name": "Aetna", "plan_name": "700700", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna", "plan_name": "700700_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Miscellaneous", "plan_name": "700720", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Miscellaneous", "plan_name": "700720_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Ppo Hmo", "plan_name": "701720", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Ppo Hmo", "plan_name": "701720_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Ms State Emplo", "plan_name": "401457", "standard_charge_percentage": 0.80, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Ms State Emplo", "plan_name": "401457_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Basic Pl", "plan_name": "400100", "standard_charge_percentage": 0.85, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Basic Pl", "plan_name": "400100_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Federal", "plan_name": "400110", "standard_charge_percentage": 0.85, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Federal", "plan_name": "400110_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." } ] } ] }, { "description": "Atenolol 50 mg tablet [718]", "drug_information": { "unit": 1.00, "type": "EA" }, "code_information": [ { "code": "51079-684-20", "type": "NDC" } ], "standard_charges": [ { "gross_charge": 7.50, "minimum": 6.00, "maximum": 6.38, "setting": "both", "payers_information": [ { "payer_name": "Aetna", "plan_name": "700700", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna", "plan_name": "700700_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Miscellaneous", "plan_name": "700720", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Miscellaneous", "plan_name": "700720_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Ppo Hmo", "plan_name": "701720", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Ppo Hmo", "plan_name": "701720_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Ms State Emplo", "plan_name": "401457", "standard_charge_percentage": 0.80, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Ms State Emplo", "plan_name": "401457_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Basic Pl", "plan_name": "400100", "standard_charge_percentage": 0.85, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Basic Pl", "plan_name": "400100_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Federal", "plan_name": "400110", "standard_charge_percentage": 0.85, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Federal", "plan_name": "400110_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." } ] } ] }, { "description": "Loperamide 2 mg capsule [4560]", "drug_information": { "unit": 1.00, "type": "EA" }, "code_information": [ { "code": "51079-690-01", "type": "NDC" } ], "standard_charges": [ { "gross_charge": 4.36, "minimum": 3.49, "maximum": 3.71, "setting": "both", "payers_information": [ { "payer_name": "Aetna", "plan_name": "700700", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna", "plan_name": "700700_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Miscellaneous", "plan_name": "700720", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Miscellaneous", "plan_name": "700720_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Ppo Hmo", "plan_name": "701720", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Ppo Hmo", "plan_name": "701720_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Ms State Emplo", "plan_name": "401457", "standard_charge_percentage": 0.80, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Ms State Emplo", "plan_name": "401457_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Basic Pl", "plan_name": "400100", "standard_charge_percentage": 0.85, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Basic Pl", "plan_name": "400100_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Federal", "plan_name": "400110", "standard_charge_percentage": 0.85, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Federal", "plan_name": "400110_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." } ] } ] }, { "description": "Azithromycin 500 mg tablet [17482]", "drug_information": { "unit": 1.00, "type": "EA" }, "code_information": [ { "code": "51224-122-30", "type": "NDC" } ], "standard_charges": [ { "gross_charge": 22.68, "minimum": 18.14, "maximum": 19.28, "setting": "both", "payers_information": [ { "payer_name": "Aetna", "plan_name": "700700", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna", "plan_name": "700700_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Miscellaneous", "plan_name": "700720", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Miscellaneous", "plan_name": "700720_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Ppo Hmo", "plan_name": "701720", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Ppo Hmo", "plan_name": "701720_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Ms State Emplo", "plan_name": "401457", "standard_charge_percentage": 0.80, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Ms State Emplo", "plan_name": "401457_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Basic Pl", "plan_name": "400100", "standard_charge_percentage": 0.85, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Basic Pl", "plan_name": "400100_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Federal", "plan_name": "400110", "standard_charge_percentage": 0.85, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Federal", "plan_name": "400110_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." } ] } ] }, { "description": "Solifenacin 5 mg tablet [40392]", "drug_information": { "unit": 1.00, "type": "EA" }, "code_information": [ { "code": "51248-150-01", "type": "NDC" } ], "standard_charges": [ { "gross_charge": 31.43, "minimum": 25.14, "maximum": 26.72, "setting": "both", "payers_information": [ { "payer_name": "Aetna", "plan_name": "700700", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna", "plan_name": "700700_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Miscellaneous", "plan_name": "700720", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Miscellaneous", "plan_name": "700720_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Ppo Hmo", "plan_name": "701720", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Ppo Hmo", "plan_name": "701720_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Ms State Emplo", "plan_name": "401457", "standard_charge_percentage": 0.80, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Ms State Emplo", "plan_name": "401457_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Basic Pl", "plan_name": "400100", "standard_charge_percentage": 0.85, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Basic Pl", "plan_name": "400100_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Federal", "plan_name": "400110", "standard_charge_percentage": 0.85, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Federal", "plan_name": "400110_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." } ] } ] }, { "description": "Phenobarbital 97.2 mg tablet [6220]", "drug_information": { "unit": 1.00, "type": "EA" }, "code_information": [ { "code": "51293-628-01", "type": "NDC" } ], "standard_charges": [ { "gross_charge": 8.03, "minimum": 6.42, "maximum": 6.83, "setting": "both", "payers_information": [ { "payer_name": "Aetna", "plan_name": "700700", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna", "plan_name": "700700_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Miscellaneous", "plan_name": "700720", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Miscellaneous", "plan_name": "700720_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Ppo Hmo", "plan_name": "701720", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Ppo Hmo", "plan_name": "701720_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Ms State Emplo", "plan_name": "401457", "standard_charge_percentage": 0.80, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Ms State Emplo", "plan_name": "401457_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Basic Pl", "plan_name": "400100", "standard_charge_percentage": 0.85, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Basic Pl", "plan_name": "400100_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Federal", "plan_name": "400110", "standard_charge_percentage": 0.85, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Federal", "plan_name": "400110_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." } ] } ] }, { "description": "Phenazopyridine 100 mg tablet [6193]", "drug_information": { "unit": 1.00, "type": "EA" }, "code_information": [ { "code": "51293-810-01", "type": "NDC" } ], "standard_charges": [ { "gross_charge": 7.50, "minimum": 6.00, "maximum": 6.38, "setting": "both", "payers_information": [ { "payer_name": "Aetna", "plan_name": "700700", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna", "plan_name": "700700_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Miscellaneous", "plan_name": "700720", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Miscellaneous", "plan_name": "700720_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Ppo Hmo", "plan_name": "701720", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Ppo Hmo", "plan_name": "701720_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Ms State Emplo", "plan_name": "401457", "standard_charge_percentage": 0.80, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Ms State Emplo", "plan_name": "401457_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Basic Pl", "plan_name": "400100", "standard_charge_percentage": 0.85, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Basic Pl", "plan_name": "400100_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Federal", "plan_name": "400110", "standard_charge_percentage": 0.85, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Federal", "plan_name": "400110_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." } ] } ] }, { "description": "Benzethonium chloride 0.2 % topical film-forming liquid [163076]", "drug_information": { "unit": 30.00, "type": "ML" }, "code_information": [ { "code": "5140900701", "type": "NDC" } ], "standard_charges": [ { "gross_charge": 18.67, "minimum": 14.94, "maximum": 15.87, "setting": "both", "payers_information": [ { "payer_name": "Aetna", "plan_name": "700700", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna", "plan_name": "700700_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Miscellaneous", "plan_name": "700720", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Miscellaneous", "plan_name": "700720_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Ppo Hmo", "plan_name": "701720", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Ppo Hmo", "plan_name": "701720_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Ms State Emplo", "plan_name": "401457", "standard_charge_percentage": 0.80, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Ms State Emplo", "plan_name": "401457_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Basic Pl", "plan_name": "400100", "standard_charge_percentage": 0.85, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Basic Pl", "plan_name": "400100_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Federal", "plan_name": "400110", "standard_charge_percentage": 0.85, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Federal", "plan_name": "400110_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." } ] } ] }, { "description": "Acetic acid (bulk) 3 % liquid [15091]", "drug_information": { "unit": 500.00, "type": "ML" }, "code_information": [ { "code": "5155200516", "type": "NDC" } ], "standard_charges": [ { "gross_charge": 180.50, "minimum": 144.40, "maximum": 153.43, "setting": "both", "payers_information": [ { "payer_name": "Aetna", "plan_name": "700700", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna", "plan_name": "700700_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Miscellaneous", "plan_name": "700720", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Miscellaneous", "plan_name": "700720_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Ppo Hmo", "plan_name": "701720", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Ppo Hmo", "plan_name": "701720_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Ms State Emplo", "plan_name": "401457", "standard_charge_percentage": 0.80, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Ms State Emplo", "plan_name": "401457_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Basic Pl", "plan_name": "400100", "standard_charge_percentage": 0.85, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Basic Pl", "plan_name": "400100_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Federal", "plan_name": "400110", "standard_charge_percentage": 0.85, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Federal", "plan_name": "400110_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." } ] } ] }, { "description": "Acetic acid (bulk) 5 % liquid [14702]", "drug_information": { "unit": 500.00, "type": "ML" }, "code_information": [ { "code": "5155200556", "type": "NDC" } ], "standard_charges": [ { "gross_charge": 178.13, "minimum": 142.50, "maximum": 151.41, "setting": "both", "payers_information": [ { "payer_name": "Aetna", "plan_name": "700700", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna", "plan_name": "700700_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Miscellaneous", "plan_name": "700720", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Miscellaneous", "plan_name": "700720_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Ppo Hmo", "plan_name": "701720", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Ppo Hmo", "plan_name": "701720_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Ms State Emplo", "plan_name": "401457", "standard_charge_percentage": 0.80, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Ms State Emplo", "plan_name": "401457_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Basic Pl", "plan_name": "400100", "standard_charge_percentage": 0.85, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Basic Pl", "plan_name": "400100_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Federal", "plan_name": "400110", "standard_charge_percentage": 0.85, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Federal", "plan_name": "400110_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." } ] } ] }, { "description": "Magnesium oxide 400 mg (241.3 mg magnesium) tablet [10491]", "drug_information": { "unit": 1.00, "type": "EA" }, "code_information": [ { "code": "5164578508", "type": "NDC" } ], "standard_charges": [ { "gross_charge": 1.00, "minimum": 0.80, "maximum": 0.85, "setting": "both", "payers_information": [ { "payer_name": "Aetna", "plan_name": "700700", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna", "plan_name": "700700_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Miscellaneous", "plan_name": "700720", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Miscellaneous", "plan_name": "700720_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Ppo Hmo", "plan_name": "701720", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Ppo Hmo", "plan_name": "701720_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Ms State Emplo", "plan_name": "401457", "standard_charge_percentage": 0.80, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Ms State Emplo", "plan_name": "401457_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Basic Pl", "plan_name": "400100", "standard_charge_percentage": 0.85, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Basic Pl", "plan_name": "400100_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Federal", "plan_name": "400110", "standard_charge_percentage": 0.85, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Federal", "plan_name": "400110_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." } ] } ] }, { "description": "Calcium 500 mg (as calcium carbonate 1250 mg) tablet [1300]", "drug_information": { "unit": 1.00, "type": "EA" }, "code_information": [ { "code": "5164582799", "type": "NDC" } ], "standard_charges": [ { "gross_charge": 1.00, "minimum": 0.80, "maximum": 0.85, "setting": "both", "payers_information": [ { "payer_name": "Aetna", "plan_name": "700700", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna", "plan_name": "700700_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Miscellaneous", "plan_name": "700720", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Miscellaneous", "plan_name": "700720_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Ppo Hmo", "plan_name": "701720", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Ppo Hmo", "plan_name": "701720_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Ms State Emplo", "plan_name": "401457", "standard_charge_percentage": 0.80, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Ms State Emplo", "plan_name": "401457_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Basic Pl", "plan_name": "400100", "standard_charge_percentage": 0.85, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Basic Pl", "plan_name": "400100_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Federal", "plan_name": "400110", "standard_charge_percentage": 0.85, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Federal", "plan_name": "400110_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." } ] } ] }, { "description": "Zinc sulfate 50 mg zinc (220 mg) capsule [8880]", "drug_information": { "unit": 1.00, "type": "EA" }, "code_information": [ { "code": "5164599101", "type": "NDC" } ], "standard_charges": [ { "gross_charge": 7.50, "minimum": 6.00, "maximum": 6.38, "setting": "both", "payers_information": [ { "payer_name": "Aetna", "plan_name": "700700", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna", "plan_name": "700700_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Miscellaneous", "plan_name": "700720", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Miscellaneous", "plan_name": "700720_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Ppo Hmo", "plan_name": "701720", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Ppo Hmo", "plan_name": "701720_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Ms State Emplo", "plan_name": "401457", "standard_charge_percentage": 0.80, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Ms State Emplo", "plan_name": "401457_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", 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"additional_payer_notes": "Insufficient remit data to calculate allowed amounts." } ] } ] }, { "description": "Loratadine-pseudoephedrine er 10 mg-240 mg tabletextended release24hr [27521]", "drug_information": { "unit": 1.00, "type": "EA" }, "code_information": [ { "code": "51660-724-11", "type": "NDC" } ], "standard_charges": [ { "gross_charge": 1.58, "minimum": 1.26, "maximum": 1.34, "setting": "both", "payers_information": [ { "payer_name": "Aetna", "plan_name": "700700", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna", "plan_name": "700700_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Miscellaneous", "plan_name": "700720", "standard_charge_percentage": 80.0, 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"methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Ms State Emplo", "plan_name": "401457_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Basic Pl", "plan_name": "400100", "standard_charge_percentage": 0.85, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Basic Pl", "plan_name": "400100_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Federal", "plan_name": "400110", "standard_charge_percentage": 0.85, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Federal", "plan_name": "400110_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." } ] } ] }, { "description": "Nystatin-triamcinolone 100000 unit/g-0.1 % topical cream [5754]", "drug_information": { "unit": 15.00, "type": "GR" }, "code_information": [ { "code": "51672-1263-1", "type": "NDC" } ], "standard_charges": [ { "gross_charge": 137.94, "minimum": 110.35, "maximum": 117.25, "setting": "both", "payers_information": [ { "payer_name": "Aetna", "plan_name": "700700", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna", "plan_name": "700700_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Miscellaneous", "plan_name": "700720", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Miscellaneous", "plan_name": "700720_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Ppo Hmo", "plan_name": "701720", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Ppo Hmo", "plan_name": "701720_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Ms State Emplo", "plan_name": "401457", "standard_charge_percentage": 0.80, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Ms State Emplo", "plan_name": "401457_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Basic Pl", "plan_name": "400100", "standard_charge_percentage": 0.85, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Basic Pl", "plan_name": "400100_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Federal", "plan_name": "400110", "standard_charge_percentage": 0.85, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Federal", "plan_name": "400110_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." } ] } ] }, { "description": "Nystatin-triamcinolone 100000 unit/g-0.1 % topical cream [5754]", "drug_information": { "unit": 30.00, "type": "GR" }, "code_information": [ { "code": "51672-1263-2", "type": "NDC" } ], "standard_charges": [ { "gross_charge": 193.66, "minimum": 154.93, "maximum": 164.61, "setting": "both", 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"payer_name": "Aetna Ppo Hmo", "plan_name": "701720", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Ppo Hmo", "plan_name": "701720_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Ms State Emplo", "plan_name": "401457", "standard_charge_percentage": 0.80, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Ms State Emplo", "plan_name": "401457_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Basic Pl", "plan_name": "400100", "standard_charge_percentage": 0.85, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Basic Pl", "plan_name": "400100_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Federal", "plan_name": "400110", "standard_charge_percentage": 0.85, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Federal", "plan_name": "400110_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." } ] } ] }, { 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"additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Ms State Emplo", "plan_name": "401457", "standard_charge_percentage": 0.80, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Ms State Emplo", "plan_name": "401457_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Basic Pl", "plan_name": "400100", "standard_charge_percentage": 0.85, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Basic Pl", "plan_name": "400100_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Federal", "plan_name": "400110", "standard_charge_percentage": 0.85, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Federal", "plan_name": "400110_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." } ] } ] }, { "description": "Nystatin-triamcinolone 100000 unit/gram-0.1 % topical ointment [5755]", "drug_information": { "unit": 15.00, "type": "GR" }, "code_information": [ { "code": "51672-1272-1", "type": "NDC" } ], "standard_charges": [ { "gross_charge": 90.35, "minimum": 72.28, "maximum": 76.80, "setting": "both", "payers_information": [ { "payer_name": "Aetna", "plan_name": "700700", 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"standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Ppo Hmo", "plan_name": "701720_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Ms State Emplo", "plan_name": "401457", "standard_charge_percentage": 0.80, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Ms State Emplo", "plan_name": "401457_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Basic Pl", "plan_name": "400100", "standard_charge_percentage": 0.85, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Basic Pl", "plan_name": "400100_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Federal", "plan_name": "400110", "standard_charge_percentage": 0.85, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Federal", "plan_name": "400110_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." } ] } ] }, { "description": "Nystatin-triamcinolone 100000 unit/gram-0.1 % topical ointment [5755]", "drug_information": { "unit": 30.00, "type": "GR" }, "code_information": [ { "code": "51672-1272-2", "type": "NDC" } ], "standard_charges": [ { "gross_charge": 141.93, "minimum": 113.54, "maximum": 120.64, "setting": "both", "payers_information": [ { "payer_name": "Aetna", "plan_name": "700700", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna", "plan_name": "700700_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Miscellaneous", "plan_name": "700720", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Miscellaneous", "plan_name": "700720_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Ppo Hmo", "plan_name": "701720", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Ppo Hmo", "plan_name": "701720_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Ms State Emplo", "plan_name": "401457", "standard_charge_percentage": 0.80, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Ms State Emplo", "plan_name": "401457_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Basic Pl", "plan_name": "400100", "standard_charge_percentage": 0.85, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Basic Pl", "plan_name": "400100_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Federal", "plan_name": "400110", "standard_charge_percentage": 0.85, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Federal", "plan_name": "400110_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." } ] } ] }, { "description": "Clotrimazole 1 % topical cream [1767]", "drug_information": { "unit": 15.00, "type": "GR" }, "code_information": [ { "code": "51672-1275-1", "type": "NDC" } ], "standard_charges": [ { "gross_charge": 37.09, "minimum": 29.67, "maximum": 31.53, "setting": "both", "payers_information": [ { "payer_name": "Aetna", "plan_name": "700700", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna", "plan_name": "700700_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to 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amounts." }, { "payer_name": "Bc/Bs Of Ms Federal", "plan_name": "400110", "standard_charge_percentage": 0.85, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Federal", "plan_name": "400110_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." } ] } ] }, { "description": "Nystatin 100000 unit/gram topical cream [5749]", "drug_information": { "unit": 15.00, "type": "GR" }, "code_information": [ { "code": "51672-1289-1", "type": "NDC" } ], "standard_charges": [ { "gross_charge": 57.43, "minimum": 45.94, "maximum": 48.82, "setting": "both", "payers_information": [ { "payer_name": "Aetna", "plan_name": "700700", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna", "plan_name": "700700_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Miscellaneous", "plan_name": "700720", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Miscellaneous", "plan_name": "700720_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Ppo Hmo", "plan_name": "701720", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Ppo Hmo", "plan_name": "701720_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Ms State Emplo", "plan_name": "401457", "standard_charge_percentage": 0.80, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Ms State Emplo", "plan_name": "401457_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Basic Pl", "plan_name": "400100", "standard_charge_percentage": 0.85, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Basic Pl", "plan_name": "400100_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Federal", "plan_name": "400110", "standard_charge_percentage": 0.85, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Federal", "plan_name": "400110_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." } ] } ] }, { "description": "Nystatin 100000 unit/gram topical cream [5749]", "drug_information": { "unit": 30.00, "type": "GR" }, "code_information": [ { "code": "51672-1289-2", "type": "NDC" } 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"additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Basic Pl", "plan_name": "400100", "standard_charge_percentage": 0.85, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Basic Pl", "plan_name": "400100_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Federal", "plan_name": "400110", "standard_charge_percentage": 0.85, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Federal", "plan_name": "400110_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." } ] } ] }, { "description": "Terconazole 0.4 % vaginal cream [11510]", "drug_information": { "unit": 45.00, "type": "GR" }, "code_information": [ { "code": "51672-1304-6", "type": "NDC" } ], "standard_charges": [ { "gross_charge": 211.61, "minimum": 169.29, "maximum": 179.87, "setting": "both", "payers_information": [ { "payer_name": "Aetna", "plan_name": "700700", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna", "plan_name": "700700_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Miscellaneous", "plan_name": "700720", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Miscellaneous", "plan_name": "700720_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Ppo Hmo", "plan_name": "701720", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Ppo Hmo", "plan_name": "701720_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Ms State Emplo", "plan_name": "401457", "standard_charge_percentage": 0.80, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Ms State Emplo", "plan_name": "401457_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Basic Pl", "plan_name": "400100", "standard_charge_percentage": 0.85, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Basic Pl", "plan_name": "400100_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Federal", "plan_name": "400110", "standard_charge_percentage": 0.85, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Federal", "plan_name": "400110_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." } ] } ] }, { "description": "Mupirocin 2 % topical ointment [10674]", "drug_information": { "unit": 22.00, "type": "GR" }, "code_information": [ { "code": "51672-1312-0", "type": "NDC" } ], "standard_charges": [ { "gross_charge": 52.15, "minimum": 41.72, "maximum": 44.33, "setting": "both", "payers_information": [ { "payer_name": "Aetna", "plan_name": "700700", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna", "plan_name": "700700_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Miscellaneous", "plan_name": "700720", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Miscellaneous", "plan_name": "700720_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Ppo Hmo", "plan_name": "701720", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Ppo Hmo", "plan_name": "701720_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Ms State Emplo", "plan_name": "401457", "standard_charge_percentage": 0.80, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Ms State Emplo", "plan_name": "401457_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Basic Pl", "plan_name": "400100", "standard_charge_percentage": 0.85, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Basic Pl", "plan_name": "400100_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Federal", "plan_name": "400110", "standard_charge_percentage": 0.85, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Federal", "plan_name": "400110_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." } ] } ] }, { "description": "Acyclovir 5 % topical ointment [8968]", "drug_information": { "unit": 15.00, "type": "GR" }, "code_information": [ { "code": "51672-1360-1", "type": "NDC" } ], "standard_charges": [ { "gross_charge": 144.85, "minimum": 115.88, "maximum": 123.12, "setting": "both", "payers_information": [ { "payer_name": "Aetna", "plan_name": "700700", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna", "plan_name": "700700_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Miscellaneous", "plan_name": "700720", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Miscellaneous", "plan_name": "700720_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Ppo Hmo", "plan_name": "701720", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Ppo Hmo", "plan_name": "701720_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Ms State Emplo", "plan_name": "401457", "standard_charge_percentage": 0.80, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Ms State Emplo", "plan_name": "401457_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Basic Pl", "plan_name": "400100", "standard_charge_percentage": 0.85, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Basic Pl", "plan_name": "400100_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Federal", "plan_name": "400110", "standard_charge_percentage": 0.85, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Federal", "plan_name": "400110_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." } ] } ] }, { "description": "Lidocaine hcl 4 % (40 mg/ml) mucosal solution [4450]", "drug_information": { "unit": 50.00, "type": "ML" }, "code_information": [ { "code": "51672-1411-3", "type": "NDC" } ], "standard_charges": [ { "gross_charge": 219.45, "minimum": 175.56, "maximum": 186.53, "setting": "both", "payers_information": [ { "payer_name": "Aetna", "plan_name": "700700", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna", "plan_name": "700700_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Miscellaneous", "plan_name": "700720", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Miscellaneous", "plan_name": "700720_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Ppo Hmo", "plan_name": "701720", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Ppo Hmo", "plan_name": "701720_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Ms State Emplo", "plan_name": "401457", "standard_charge_percentage": 0.80, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Ms State Emplo", "plan_name": "401457_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Basic Pl", "plan_name": "400100", "standard_charge_percentage": 0.85, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Basic Pl", "plan_name": "400100_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Federal", "plan_name": "400110", "standard_charge_percentage": 0.85, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Federal", "plan_name": "400110_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." } ] } ] }, { "description": "Hydrocortisone 1 % topical ointment [3731]", "drug_information": { "unit": 28.40, "type": "GR" }, "code_information": [ { "code": "51672-2018-2", "type": "NDC" } ], "standard_charges": [ { "gross_charge": 14.77, "minimum": 11.82, "maximum": 12.55, "setting": "both", "payers_information": [ { "payer_name": "Aetna", "plan_name": "700700", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna", "plan_name": "700700_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed 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"methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Basic Pl", "plan_name": "400100_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Federal", "plan_name": "400110", "standard_charge_percentage": 0.85, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Federal", "plan_name": "400110_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." } ] } ] }, { "description": "Acetaminophen 325 mg rectal suppository [104]", "drug_information": { "unit": 1.00, "type": 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"standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Basic Pl", "plan_name": "400100", "standard_charge_percentage": 0.85, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Basic Pl", "plan_name": "400100_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Federal", "plan_name": "400110", "standard_charge_percentage": 0.85, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Federal", "plan_name": "400110_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." } ] } ] }, { "description": "Lidocaine 5 % topical ointment [156314]", "drug_information": { "unit": 35.44, "type": "GR" }, "code_information": [ { "code": "51672-3020-9", "type": "NDC" } ], "standard_charges": [ { "gross_charge": 144.77, "minimum": 115.82, "maximum": 123.05, "setting": "both", "payers_information": [ { "payer_name": "Aetna", "plan_name": "700700", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna", "plan_name": "700700_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna 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"additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Basic Pl", "plan_name": "400100_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Federal", "plan_name": "400110", "standard_charge_percentage": 0.85, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Federal", "plan_name": "400110_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." } ] } ] }, { "description": "Clotrimazole-betamethasone 1 %-0.05 % topical cream [29424]", "drug_information": { "unit": 45.00, "type": "GR" }, "code_information": [ { 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"payer_name": "Bc/Bs Of Ms Basic Pl", "plan_name": "400100_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Federal", "plan_name": "400110", "standard_charge_percentage": 0.85, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Federal", "plan_name": "400110_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." } ] } ] }, { "description": "Tranexamic acid 1000 mg/100 ml(10 mg/ml)in sod chloriso iv piggyback [187964]", "drug_information": { "unit": 100.00, "type": "ML" }, "code_information": [ { "code": "51754-0108-1", "type": "NDC" } ], "standard_charges": [ { 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"standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Federal", "plan_name": "400110", "standard_charge_percentage": 0.85, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Federal", "plan_name": "400110_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." } ] } ] }, { "description": "Caffeine citrate oral syringe 20 mg/ml [500740]", "drug_information": { "unit": 3.00, "type": "ML" }, "code_information": [ { "code": "51754-0501-3", "type": "NDC" } ], "standard_charges": [ { "gross_charge": 192.86, "minimum": 154.29, "maximum": 163.93, "setting": "both", 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"payer_name": "Aetna Ppo Hmo", "plan_name": "701720", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Ppo Hmo", "plan_name": "701720_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Ms State Emplo", "plan_name": "401457", "standard_charge_percentage": 0.80, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Ms State Emplo", "plan_name": "401457_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Basic Pl", "plan_name": "400100", "standard_charge_percentage": 0.85, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Basic Pl", "plan_name": "400100_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Federal", "plan_name": "400110", "standard_charge_percentage": 0.85, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Federal", "plan_name": "400110_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." } ] } ] }, { "description": "Sodium bicarbonate 1 meq/ml (8.4 %) intravenous solution [108819]", "drug_information": { "unit": 50.00, "type": "ML" }, "code_information": [ { "code": "51754-5001-1", "type": "NDC" } ], "standard_charges": [ { "gross_charge": 111.00, "minimum": 88.80, "maximum": 94.35, "setting": "both", "payers_information": [ { "payer_name": "Aetna", "plan_name": "700700", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna", "plan_name": "700700_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Miscellaneous", "plan_name": "700720", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": 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"payer_name": "Aetna Ppo Hmo", "plan_name": "701720_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Ms State Emplo", "plan_name": "401457", "standard_charge_percentage": 0.80, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Ms State Emplo", "plan_name": "401457_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Basic Pl", "plan_name": "400100", "standard_charge_percentage": 0.85, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Basic Pl", "plan_name": "400100_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Federal", "plan_name": "400110", "standard_charge_percentage": 0.85, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Federal", "plan_name": "400110_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." } ] } ] }, { "description": "Amiodarone 400 mg tablet [29481]", "drug_information": { "unit": 1.00, "type": "EA" }, "code_information": [ { "code": "51862-242-30", "type": "NDC" } ], "standard_charges": [ { "gross_charge": 24.37, "minimum": 19.50, "maximum": 20.71, "setting": "both", "payers_information": [ { "payer_name": "Aetna", "plan_name": "700700", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna", "plan_name": "700700_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Miscellaneous", "plan_name": "700720", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Miscellaneous", "plan_name": "700720_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Ppo Hmo", "plan_name": "701720", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Ppo Hmo", "plan_name": "701720_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Ms State Emplo", "plan_name": "401457", "standard_charge_percentage": 0.80, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Ms State Emplo", "plan_name": "401457_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Basic Pl", "plan_name": "400100", "standard_charge_percentage": 0.85, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Basic Pl", "plan_name": "400100_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Federal", "plan_name": "400110", "standard_charge_percentage": 0.85, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Federal", "plan_name": "400110_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." } ] } ] }, { "description": "Estradiol 0.5 mg tablet [12491]", "drug_information": { "unit": 1.00, "type": "EA" }, "code_information": [ { "code": "51862-332-01", "type": "NDC" } ], "standard_charges": [ { "gross_charge": 7.50, "minimum": 6.00, "maximum": 6.38, "setting": "both", "payers_information": [ { "payer_name": "Aetna", "plan_name": "700700", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna", "plan_name": "700700_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Miscellaneous", "plan_name": "700720", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Miscellaneous", "plan_name": "700720_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Ppo Hmo", "plan_name": "701720", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Ppo Hmo", "plan_name": "701720_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Ms State Emplo", "plan_name": "401457", "standard_charge_percentage": 0.80, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Ms State Emplo", "plan_name": "401457_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Basic Pl", "plan_name": "400100", "standard_charge_percentage": 0.85, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Basic Pl", "plan_name": "400100_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Federal", "plan_name": "400110", "standard_charge_percentage": 0.85, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Federal", "plan_name": "400110_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." } ] } ] }, { "description": "Estradiol 1 mg tablet [9967]", "drug_information": { "unit": 1.00, "type": "EA" }, "code_information": [ { "code": "51862-333-01", "type": "NDC" } ], "standard_charges": [ { "gross_charge": 7.50, "minimum": 6.00, "maximum": 6.38, "setting": "both", "payers_information": [ { "payer_name": "Aetna", "plan_name": "700700", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna", "plan_name": "700700_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Miscellaneous", "plan_name": "700720", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Miscellaneous", "plan_name": "700720_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Ppo Hmo", "plan_name": "701720", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Ppo Hmo", "plan_name": "701720_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Ms State Emplo", "plan_name": "401457", "standard_charge_percentage": 0.80, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Ms State Emplo", "plan_name": "401457_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Basic Pl", "plan_name": "400100", "standard_charge_percentage": 0.85, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Basic Pl", "plan_name": "400100_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Federal", "plan_name": "400110", "standard_charge_percentage": 0.85, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Federal", "plan_name": "400110_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." } ] } ] }, { "description": "Clonidine 0.1 mg/24 hr weekly transdermal patch [27505]", "drug_information": { "unit": 1.00, "type": "EA" }, "code_information": [ { "code": "51862-453-04", "type": "NDC" } ], "standard_charges": [ { "gross_charge": 120.10, "minimum": 96.08, "maximum": 102.09, "setting": "both", "payers_information": [ { "payer_name": "Aetna", "plan_name": "700700", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna", "plan_name": "700700_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Miscellaneous", "plan_name": "700720", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Miscellaneous", "plan_name": "700720_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Ppo Hmo", "plan_name": "701720", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Ppo Hmo", "plan_name": "701720_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Ms State Emplo", "plan_name": "401457", "standard_charge_percentage": 0.80, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Ms State Emplo", "plan_name": "401457_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Basic Pl", "plan_name": "400100", "standard_charge_percentage": 0.85, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Basic Pl", "plan_name": "400100_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Federal", "plan_name": "400110", "standard_charge_percentage": 0.85, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Federal", "plan_name": "400110_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." } ] } ] }, { "description": "Carbidopa 10 mg-levodopa 100 mg tablet [9406]", "drug_information": { "unit": 1.00, "type": "EA" }, "code_information": [ { "code": "51862-855-01", "type": "NDC" } ], "standard_charges": [ { "gross_charge": 7.50, "minimum": 6.00, "maximum": 6.38, "setting": "both", "payers_information": [ { "payer_name": "Aetna", "plan_name": "700700", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna", "plan_name": "700700_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Miscellaneous", "plan_name": "700720", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Miscellaneous", "plan_name": "700720_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Ppo Hmo", "plan_name": "701720", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Ppo Hmo", "plan_name": "701720_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Ms State Emplo", "plan_name": "401457", "standard_charge_percentage": 0.80, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Ms State Emplo", "plan_name": "401457_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Basic Pl", "plan_name": "400100", "standard_charge_percentage": 0.85, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Basic Pl", "plan_name": "400100_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Federal", "plan_name": "400110", "standard_charge_percentage": 0.85, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Federal", "plan_name": "400110_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." } ] } ] }, { "description": "Benzalkonium chloride (bulk) 50 % solution [9226]", "drug_information": { "unit": 1.00, "type": "ML" }, "code_information": [ { "code": "5192715680", "type": "NDC" } ], "standard_charges": [ { "gross_charge": 9.03, "minimum": 7.22, "maximum": 7.68, "setting": "both", "payers_information": [ { "payer_name": "Aetna", "plan_name": "700700", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna", "plan_name": "700700_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Miscellaneous", "plan_name": "700720", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Miscellaneous", "plan_name": "700720_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Ppo Hmo", "plan_name": "701720", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Ppo Hmo", "plan_name": "701720_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Ms State Emplo", "plan_name": "401457", "standard_charge_percentage": 0.80, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Ms State Emplo", "plan_name": "401457_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Basic Pl", "plan_name": "400100", "standard_charge_percentage": 0.85, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Basic Pl", "plan_name": "400100_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Federal", "plan_name": "400110", "standard_charge_percentage": 0.85, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Federal", "plan_name": "400110_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." } ] } ] }, { "description": "Letrozole 2.5 mg tablet [21509]", "drug_information": { "unit": 1.00, "type": "EA" }, "code_information": [ { "code": "51991-759-33", "type": "NDC" } ], "standard_charges": [ { "gross_charge": 7.50, "minimum": 6.00, "maximum": 6.38, "setting": "both", "payers_information": [ { "payer_name": "Aetna", "plan_name": "700700", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna", "plan_name": "700700_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Miscellaneous", "plan_name": "700720", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Miscellaneous", "plan_name": "700720_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Ppo Hmo", "plan_name": "701720", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Ppo Hmo", "plan_name": "701720_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Ms State Emplo", "plan_name": "401457", "standard_charge_percentage": 0.80, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Ms State Emplo", "plan_name": "401457_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Basic Pl", "plan_name": "400100", "standard_charge_percentage": 0.85, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Basic Pl", "plan_name": "400100_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Federal", "plan_name": "400110", "standard_charge_percentage": 0.85, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Federal", "plan_name": "400110_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." } ] } ] }, { "description": "Cyproheptadine 4 mg tablet [2033]", "drug_information": { "unit": 1.00, "type": "EA" }, "code_information": [ { "code": "51991-838-01", "type": "NDC" } ], "standard_charges": [ { "gross_charge": 7.50, "minimum": 6.00, "maximum": 6.38, "setting": "both", "payers_information": [ { "payer_name": "Aetna", "plan_name": "700700", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna", "plan_name": "700700_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Miscellaneous", "plan_name": "700720", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Miscellaneous", "plan_name": "700720_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Ppo Hmo", "plan_name": "701720", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Ppo Hmo", "plan_name": "701720_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Ms State Emplo", "plan_name": "401457", "standard_charge_percentage": 0.80, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Ms State Emplo", "plan_name": "401457_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Basic Pl", "plan_name": "400100", "standard_charge_percentage": 0.85, "count": "0", 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"Bc/Bs Of Ms Federal", "plan_name": "400110", "standard_charge_percentage": 0.85, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Federal", "plan_name": "400110_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." } ] } ] }, { "description": "Iron polysacch cplx 150 mg iron-vit b12 25 mcg-folic acid 1 mg capsule [28034]", "drug_information": { "unit": 1.00, "type": "EA" }, "code_information": [ { "code": "5199119899", "type": "NDC" } ], "standard_charges": [ { "gross_charge": 7.50, "minimum": 6.00, "maximum": 6.38, "setting": "both", "payers_information": [ { "payer_name": "Aetna", "plan_name": "700700", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", 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"standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Federal", "plan_name": "400110", "standard_charge_percentage": 0.85, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Federal", "plan_name": "400110_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." } ] } ] }, { "description": "Midodrine 5 mg tablet [10610]", "drug_information": { "unit": 1.00, "type": "EA" }, "code_information": [ { "code": "52817-324-10", "type": "NDC" } ], "standard_charges": [ { "gross_charge": 7.50, "minimum": 6.00, "maximum": 6.38, "setting": "both", "payers_information": [ { "payer_name": 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"standard_charge_percentage": 0.85, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Basic Pl", "plan_name": "400100_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Federal", "plan_name": "400110", "standard_charge_percentage": 0.85, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Federal", "plan_name": "400110_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." } ] } ] }, { "description": "Carbidopa 10 mg-levodopa 100 mg tablet [9406]", "drug_information": { "unit": 1.00, "type": "EA" }, "code_information": [ { "code": "52817-390-10", "type": "NDC" } ], "standard_charges": [ { "gross_charge": 7.50, "minimum": 6.00, "maximum": 6.38, "setting": "both", "payers_information": [ { "payer_name": "Aetna", "plan_name": "700700", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna", "plan_name": "700700_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Miscellaneous", "plan_name": "700720", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna 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"plan_name": "401457_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Basic Pl", "plan_name": "400100", "standard_charge_percentage": 0.85, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Basic Pl", "plan_name": "400100_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Federal", "plan_name": "400110", "standard_charge_percentage": 0.85, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Federal", "plan_name": "400110_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." } ] } ] }, { "description": "Sucralfate 100 mg/ml oral suspension [11441]", "drug_information": { "unit": 473.00, "type": "ML" }, "code_information": [ { "code": "52817-840-16", "type": "NDC" } ], "standard_charges": [ { "gross_charge": 471.82, "minimum": 377.46, "maximum": 401.05, "setting": "both", "payers_information": [ { "payer_name": "Aetna", "plan_name": "700700", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna", "plan_name": "700700_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." 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"Bc/Bs Ms State Emplo", "plan_name": "401457", "standard_charge_percentage": 0.80, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Ms State Emplo", "plan_name": "401457_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Basic Pl", "plan_name": "400100", "standard_charge_percentage": 0.85, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Basic Pl", "plan_name": "400100_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Federal", "plan_name": "400110", "standard_charge_percentage": 0.85, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Federal", "plan_name": "400110_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." } ] } ] }, { "description": "Vitamin a and d topical ointment [8723]", "drug_information": { "unit": 5.00, "type": "GR" }, "code_information": [ { "code": "53329-090-16", "type": "NDC" } ], "standard_charges": [ { "gross_charge": 1.00, "minimum": 0.80, "maximum": 0.85, "setting": "both", "payers_information": [ { "payer_name": "Aetna", "plan_name": "700700", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to 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amounts." }, { "payer_name": "Aetna Ppo Hmo", "plan_name": "701720_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Ms State Emplo", "plan_name": "401457", "standard_charge_percentage": 0.80, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Ms State Emplo", "plan_name": "401457_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Basic Pl", "plan_name": "400100", "standard_charge_percentage": 0.85, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Basic Pl", "plan_name": "400100_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Federal", "plan_name": "400110", "standard_charge_percentage": 0.85, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Federal", "plan_name": "400110_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." } ] } ] }, { "description": "Vitamin a and d topical ointment [8723]", "drug_information": { "unit": 5.00, "type": "GR" }, "code_information": [ { "code": "53329-090-96", "type": "NDC" } ], "standard_charges": [ { "gross_charge": 1.00, "minimum": 0.80, "maximum": 0.85, "setting": "both", "payers_information": [ { "payer_name": "Aetna", "plan_name": "700700", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna", "plan_name": "700700_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Miscellaneous", "plan_name": "700720", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Miscellaneous", "plan_name": "700720_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to 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allowed amounts." } ] } ] }, { "description": "Miconazole nitrate 2 % topical powder [10599]", "drug_information": { "unit": 85.00, "type": "GR" }, "code_information": [ { "code": "53329-170-79", "type": "NDC" } ], "standard_charges": [ { "gross_charge": 28.26, "minimum": 22.61, "maximum": 24.02, "setting": "both", "payers_information": [ { "payer_name": "Aetna", "plan_name": "700700", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna", "plan_name": "700700_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Miscellaneous", "plan_name": "700720", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Miscellaneous", "plan_name": "700720_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Ppo Hmo", "plan_name": "701720", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Ppo Hmo", "plan_name": "701720_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Ms State Emplo", "plan_name": "401457", "standard_charge_percentage": 0.80, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient 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remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Federal", "plan_name": "400110_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." } ] } ] }, { "description": "Povidone-iodine 10 % topical solution [6458]", "drug_information": { "unit": 118.00, "type": "ML" }, "code_information": [ { "code": "53329-939-04", "type": "NDC" } ], "standard_charges": [ { "gross_charge": 6.14, "minimum": 4.91, "maximum": 5.22, "setting": "both", "payers_information": [ { "payer_name": "Aetna", "plan_name": "700700", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna", "plan_name": "700700_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Miscellaneous", "plan_name": "700720", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Miscellaneous", "plan_name": "700720_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Ppo Hmo", "plan_name": "701720", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Ppo Hmo", "plan_name": "701720_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Ms State Emplo", "plan_name": "401457", "standard_charge_percentage": 0.80, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Ms State Emplo", "plan_name": "401457_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Basic Pl", "plan_name": "400100", "standard_charge_percentage": 0.85, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Basic Pl", "plan_name": "400100_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Federal", "plan_name": "400110", "standard_charge_percentage": 0.85, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Federal", "plan_name": "400110_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." } ] } ] }, { "description": "Naproxen sodium 550 mg tablet [5395]", "drug_information": { "unit": 1.00, "type": "EA" }, "code_information": [ { "code": "53746-194-01", "type": "NDC" } ], "standard_charges": [ { "gross_charge": 7.50, "minimum": 6.00, "maximum": 6.38, "setting": "both", "payers_information": [ { "payer_name": "Aetna", "plan_name": "700700", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna", "plan_name": "700700_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Miscellaneous", "plan_name": "700720", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Miscellaneous", "plan_name": "700720_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Ppo Hmo", "plan_name": "701720", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Ppo Hmo", "plan_name": "701720_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Ms State Emplo", "plan_name": "401457", "standard_charge_percentage": 0.80, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Ms State Emplo", "plan_name": "401457_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Basic Pl", "plan_name": "400100", "standard_charge_percentage": 0.85, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Basic Pl", "plan_name": "400100_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Federal", "plan_name": "400110", "standard_charge_percentage": 0.85, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Federal", "plan_name": "400110_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." } ] } ] }, { "description": "Naproxen sodium 550 mg tablet [5395]", "drug_information": { "unit": 1.00, "type": "EA" }, "code_information": [ { "code": "53746-194-05", "type": "NDC" } ], "standard_charges": [ { "gross_charge": 7.50, "minimum": 6.00, "maximum": 6.38, "setting": "both", "payers_information": [ { "payer_name": "Aetna", "plan_name": "700700", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna", "plan_name": "700700_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Miscellaneous", "plan_name": "700720", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Miscellaneous", "plan_name": "700720_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Ppo Hmo", "plan_name": "701720", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Ppo Hmo", "plan_name": "701720_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Ms State Emplo", "plan_name": "401457", "standard_charge_percentage": 0.80, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Ms State Emplo", "plan_name": "401457_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Basic Pl", "plan_name": "400100", "standard_charge_percentage": 0.85, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Basic Pl", "plan_name": "400100_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Federal", "plan_name": "400110", "standard_charge_percentage": 0.85, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Federal", "plan_name": "400110_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." } ] } ] }, { "description": "Demeclocycline 150 mg tablet [9726]", "drug_information": { "unit": 1.00, "type": "EA" }, "code_information": [ { "code": "53746-554-01", "type": "NDC" } ], "standard_charges": [ { "gross_charge": 36.83, "minimum": 29.46, "maximum": 31.31, "setting": "both", "payers_information": [ { "payer_name": "Aetna", "plan_name": "700700", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna", "plan_name": "700700_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Miscellaneous", "plan_name": "700720", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Miscellaneous", "plan_name": "700720_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Ppo Hmo", "plan_name": "701720", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Ppo Hmo", "plan_name": "701720_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Ms State Emplo", "plan_name": "401457", "standard_charge_percentage": 0.80, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Ms State Emplo", "plan_name": "401457_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Basic Pl", "plan_name": "400100", "standard_charge_percentage": 0.85, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Basic Pl", "plan_name": "400100_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Federal", "plan_name": "400110", "standard_charge_percentage": 0.85, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Federal", "plan_name": "400110_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." } ] } ] }, { "description": "Haloperidol 5 mg tablet [3583]", "drug_information": { "unit": 1.00, "type": "EA" }, "code_information": [ { "code": "51079-736-01", "type": "NDC" } ], "standard_charges": [ { "gross_charge": 7.50, "minimum": 6.00, "maximum": 6.38, "setting": "both", "payers_information": [ { "payer_name": "Aetna", "plan_name": "700700", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna", "plan_name": "700700_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Miscellaneous", "plan_name": "700720", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Miscellaneous", "plan_name": "700720_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Ppo Hmo", "plan_name": "701720", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Ppo Hmo", "plan_name": "701720_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Ms State Emplo", "plan_name": "401457", "standard_charge_percentage": 0.80, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Ms State Emplo", "plan_name": "401457_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Basic Pl", "plan_name": "400100", "standard_charge_percentage": 0.85, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Basic Pl", "plan_name": "400100_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Federal", "plan_name": "400110", "standard_charge_percentage": 0.85, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Federal", "plan_name": "400110_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." } ] } ] }, { "description": "Diltiazem 30 mg tablet [2475]", "drug_information": { "unit": 1.00, "type": "EA" }, "code_information": [ { "code": "51079-745-20", "type": "NDC" } ], "standard_charges": [ { "gross_charge": 7.50, "minimum": 6.00, "maximum": 6.38, "setting": "both", "payers_information": [ { "payer_name": "Aetna", "plan_name": "700700", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna", "plan_name": "700700_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Miscellaneous", "plan_name": "700720", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Miscellaneous", "plan_name": "700720_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Ppo Hmo", "plan_name": "701720", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Ppo Hmo", "plan_name": "701720_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Ms State Emplo", "plan_name": "401457", "standard_charge_percentage": 0.80, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Ms State Emplo", "plan_name": "401457_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Basic Pl", "plan_name": "400100", "standard_charge_percentage": 0.85, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Basic Pl", "plan_name": "400100_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Federal", "plan_name": "400110", "standard_charge_percentage": 0.85, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Federal", "plan_name": "400110_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." } ] } ] }, { "description": "Sucralfate 1 gram tablet [11442]", "drug_information": { "unit": 1.00, "type": "EA" }, "code_information": [ { "code": "51079-753-01", "type": "NDC" } ], "standard_charges": [ { "gross_charge": 7.50, "minimum": 6.00, "maximum": 6.38, "setting": "both", "payers_information": [ { "payer_name": "Aetna", "plan_name": "700700", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna", "plan_name": "700700_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Miscellaneous", "plan_name": "700720", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Miscellaneous", "plan_name": "700720_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Ppo Hmo", "plan_name": "701720", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Ppo Hmo", "plan_name": "701720_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Ms State Emplo", "plan_name": "401457", "standard_charge_percentage": 0.80, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Ms State Emplo", "plan_name": "401457_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Basic Pl", "plan_name": "400100", "standard_charge_percentage": 0.85, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Basic Pl", "plan_name": "400100_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Federal", "plan_name": "400110", "standard_charge_percentage": 0.85, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Federal", "plan_name": "400110_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." } ] } ] }, { "description": "Atenolol 25 mg tablet [717]", "drug_information": { "unit": 1.00, "type": "EA" }, "code_information": [ { "code": "51079-759-01", "type": "NDC" } ], "standard_charges": [ { "gross_charge": 7.50, "minimum": 6.00, "maximum": 6.38, "setting": "both", "payers_information": [ { "payer_name": "Aetna", "plan_name": "700700", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna", "plan_name": "700700_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Miscellaneous", "plan_name": "700720", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Miscellaneous", "plan_name": "700720_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Ppo Hmo", "plan_name": "701720", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Ppo Hmo", "plan_name": "701720_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Ms State Emplo", "plan_name": "401457", "standard_charge_percentage": 0.80, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Ms State Emplo", "plan_name": "401457_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Basic Pl", "plan_name": "400100", "standard_charge_percentage": 0.85, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Basic Pl", "plan_name": "400100_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Federal", "plan_name": "400110", "standard_charge_percentage": 0.85, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Federal", "plan_name": "400110_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." } ] } ] }, { "description": "Divalproex er 250 mg tabletextended release 24 hr [34418]", "drug_information": { "unit": 1.00, "type": "EA" }, "code_information": [ { "code": "51079-766-01", "type": "NDC" } ], "standard_charges": [ { "gross_charge": 7.50, "minimum": 6.00, "maximum": 6.38, "setting": "both", "payers_information": [ { "payer_name": "Aetna", "plan_name": "700700", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna", "plan_name": "700700_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Miscellaneous", "plan_name": "700720", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Miscellaneous", "plan_name": "700720_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Ppo Hmo", "plan_name": "701720", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Ppo Hmo", "plan_name": "701720_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Ms State Emplo", "plan_name": "401457", "standard_charge_percentage": 0.80, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Ms State Emplo", "plan_name": "401457_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Basic Pl", "plan_name": "400100", "standard_charge_percentage": 0.85, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Basic Pl", "plan_name": "400100_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Federal", "plan_name": "400110", "standard_charge_percentage": 0.85, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Federal", "plan_name": "400110_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." } ] } ] }, { "description": "Carvedilol 3.125 mg tablet [18551]", "drug_information": { "unit": 1.00, "type": "EA" }, "code_information": [ { "code": "51079-771-01", "type": "NDC" } ], "standard_charges": [ { "gross_charge": 7.50, "minimum": 6.00, "maximum": 6.38, "setting": "both", "payers_information": [ { "payer_name": "Aetna", "plan_name": "700700", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna", "plan_name": "700700_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Miscellaneous", "plan_name": "700720", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Miscellaneous", "plan_name": "700720_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Ppo Hmo", "plan_name": "701720", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Ppo Hmo", "plan_name": "701720_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Ms State Emplo", "plan_name": "401457", "standard_charge_percentage": 0.80, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Ms State Emplo", "plan_name": "401457_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Basic Pl", "plan_name": "400100", "standard_charge_percentage": 0.85, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Basic Pl", "plan_name": "400100_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Federal", "plan_name": "400110", "standard_charge_percentage": 0.85, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Federal", "plan_name": "400110_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." } ] } ] }, { "description": "Pravastatin 40 mg tablet [11112]", "drug_information": { "unit": 1.00, "type": "EA" }, "code_information": [ { "code": "51079-782-01", "type": "NDC" } ], "standard_charges": [ { "gross_charge": 7.50, "minimum": 6.00, "maximum": 6.38, "setting": "both", "payers_information": [ { "payer_name": "Aetna", "plan_name": "700700", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna", "plan_name": "700700_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Miscellaneous", "plan_name": "700720", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Miscellaneous", "plan_name": "700720_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Ppo Hmo", "plan_name": "701720", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Ppo Hmo", "plan_name": "701720_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Ms State Emplo", "plan_name": "401457", "standard_charge_percentage": 0.80, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Ms State Emplo", "plan_name": "401457_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Basic Pl", "plan_name": "400100", "standard_charge_percentage": 0.85, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Basic Pl", "plan_name": "400100_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Federal", "plan_name": "400110", "standard_charge_percentage": 0.85, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Federal", "plan_name": "400110_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." } ] } ] }, { "description": "Metoprolol tartrate 50 mg tablet [5009]", "drug_information": { "unit": 1.00, "type": "EA" }, "code_information": [ { "code": "51079-801-01", "type": "NDC" } ], "standard_charges": [ { "gross_charge": 7.50, "minimum": 6.00, "maximum": 6.38, "setting": "both", "payers_information": [ { "payer_name": "Aetna", "plan_name": "700700", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna", "plan_name": "700700_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Miscellaneous", "plan_name": "700720", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Miscellaneous", "plan_name": "700720_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Ppo Hmo", "plan_name": "701720", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Ppo Hmo", "plan_name": "701720_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Ms State Emplo", "plan_name": "401457", "standard_charge_percentage": 0.80, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Ms State Emplo", "plan_name": "401457_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Basic Pl", "plan_name": "400100", "standard_charge_percentage": 0.85, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Basic Pl", "plan_name": "400100_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Federal", "plan_name": "400110", "standard_charge_percentage": 0.85, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Federal", "plan_name": "400110_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." } ] } ] }, { "description": "Metoprolol tartrate 50 mg tablet [5009]", "drug_information": { "unit": 1.00, "type": "EA" }, "code_information": [ { "code": "51079-801-20", "type": "NDC" } ], "standard_charges": [ { "gross_charge": 7.50, "minimum": 6.00, "maximum": 6.38, "setting": "both", "payers_information": [ { "payer_name": "Aetna", "plan_name": "700700", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna", "plan_name": "700700_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Miscellaneous", "plan_name": "700720", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Miscellaneous", "plan_name": "700720_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Ppo Hmo", "plan_name": "701720", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Ppo Hmo", "plan_name": "701720_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Ms State Emplo", "plan_name": "401457", "standard_charge_percentage": 0.80, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Ms State Emplo", "plan_name": "401457_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Basic Pl", "plan_name": "400100", "standard_charge_percentage": 0.85, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Basic Pl", "plan_name": "400100_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Federal", "plan_name": "400110", "standard_charge_percentage": 0.85, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Federal", "plan_name": "400110_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." } ] } ] }, { "description": "Glipizide 5 mg tablet [10117]", "drug_information": { "unit": 1.00, "type": "EA" }, "code_information": [ { "code": "51079-810-20", "type": "NDC" } ], "standard_charges": [ { "gross_charge": 7.50, "minimum": 6.00, "maximum": 6.38, "setting": "both", "payers_information": [ { "payer_name": "Aetna", "plan_name": "700700", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna", "plan_name": "700700_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Miscellaneous", "plan_name": "700720", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Miscellaneous", "plan_name": "700720_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Ppo Hmo", "plan_name": "701720", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Ppo Hmo", "plan_name": "701720_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Ms State Emplo", "plan_name": "401457", "standard_charge_percentage": 0.80, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Ms State Emplo", "plan_name": "401457_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Basic Pl", "plan_name": "400100", "standard_charge_percentage": 0.85, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Basic Pl", "plan_name": "400100_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Federal", "plan_name": "400110", "standard_charge_percentage": 0.85, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Federal", "plan_name": "400110_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." } ] } ] }, { "description": "Nadolol 40 mg tablet [5331]", "drug_information": { "unit": 1.00, "type": "EA" }, "code_information": [ { "code": "51079-813-01", "type": "NDC" } ], "standard_charges": [ { "gross_charge": 28.61, "minimum": 22.89, "maximum": 24.32, "setting": "both", "payers_information": [ { "payer_name": "Aetna", "plan_name": "700700", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna", "plan_name": "700700_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Miscellaneous", "plan_name": "700720", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Miscellaneous", "plan_name": "700720_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Ppo Hmo", "plan_name": "701720", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Ppo Hmo", "plan_name": "701720_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Ms State Emplo", "plan_name": "401457", "standard_charge_percentage": 0.80, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Ms State Emplo", "plan_name": "401457_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Basic Pl", "plan_name": "400100", "standard_charge_percentage": 0.85, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Basic Pl", "plan_name": "400100_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Federal", "plan_name": "400110", "standard_charge_percentage": 0.85, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Federal", "plan_name": "400110_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." } ] } ] }, { "description": "Captopril 25 mg tablet [9402]", "drug_information": { "unit": 1.00, "type": "EA" }, "code_information": [ { "code": "51079-864-20", "type": "NDC" } ], "standard_charges": [ { "gross_charge": 7.50, "minimum": 6.00, "maximum": 6.38, "setting": "both", "payers_information": [ { "payer_name": "Aetna", "plan_name": "700700", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna", "plan_name": "700700_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Miscellaneous", "plan_name": "700720", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Miscellaneous", "plan_name": "700720_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Ppo Hmo", "plan_name": "701720", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Ppo Hmo", "plan_name": "701720_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Ms State Emplo", "plan_name": "401457", "standard_charge_percentage": 0.80, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Ms State Emplo", "plan_name": "401457_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Basic Pl", "plan_name": "400100", "standard_charge_percentage": 0.85, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Basic Pl", "plan_name": "400100_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Federal", "plan_name": "400110", "standard_charge_percentage": 0.85, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Federal", "plan_name": "400110_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." } ] } ] }, { "description": "Metoclopramide 5 mg tablet [5006]", "drug_information": { "unit": 1.00, "type": "EA" }, "code_information": [ { "code": "51079-886-01", "type": "NDC" } ], "standard_charges": [ { "gross_charge": 7.50, "minimum": 6.00, "maximum": 6.38, "setting": "both", "payers_information": [ { "payer_name": "Aetna", "plan_name": "700700", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna", "plan_name": "700700_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Miscellaneous", "plan_name": "700720", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Miscellaneous", "plan_name": "700720_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Ppo Hmo", "plan_name": "701720", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Ppo Hmo", "plan_name": "701720_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Ms State Emplo", "plan_name": "401457", "standard_charge_percentage": 0.80, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Ms State Emplo", "plan_name": "401457_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Basic Pl", "plan_name": "400100", "standard_charge_percentage": 0.85, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Basic Pl", "plan_name": "400100_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Federal", "plan_name": "400110", "standard_charge_percentage": 0.85, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Federal", "plan_name": "400110_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." } ] } ] }, { "description": "Metoclopramide 10 mg tablet [5005]", "drug_information": { "unit": 1.00, "type": "EA" }, "code_information": [ { "code": "51079-888-01", "type": "NDC" } ], "standard_charges": [ { "gross_charge": 7.50, "minimum": 6.00, "maximum": 6.38, "setting": "both", "payers_information": [ { "payer_name": "Aetna", "plan_name": "700700", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna", "plan_name": "700700_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Miscellaneous", "plan_name": "700720", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Miscellaneous", "plan_name": "700720_1", "standard_charge_percentage": 100.0, "count": "0", 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"percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." } ] } ] }, { "description": "Diltiazem er (xr/xt) 180 mg capsuleextended release 24 hr controlled [29347]", "drug_information": { "unit": 1.00, "type": "EA" }, "code_information": [ { "code": "51079-948-01", "type": "NDC" } ], "standard_charges": [ { "gross_charge": 7.50, "minimum": 6.00, "maximum": 6.38, "setting": "both", "payers_information": [ { "payer_name": "Aetna", "plan_name": "700700", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna", "plan_name": "700700_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Miscellaneous", "plan_name": "700720", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Miscellaneous", "plan_name": "700720_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Ppo Hmo", "plan_name": "701720", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Ppo Hmo", "plan_name": "701720_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Ms State Emplo", "plan_name": "401457", 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"standard_charge_percentage": 0.85, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Federal", "plan_name": "400110_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." } ] } ] }, { "description": "Buspirone 15 mg tablet [17464]", "drug_information": { "unit": 1.00, "type": "EA" }, "code_information": [ { "code": "51079-960-01", "type": "NDC" } ], "standard_charges": [ { "gross_charge": 7.50, "minimum": 6.00, "maximum": 6.38, "setting": "both", "payers_information": [ { "payer_name": "Aetna", "plan_name": "700700", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna", "plan_name": "700700_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Miscellaneous", "plan_name": "700720", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Miscellaneous", "plan_name": "700720_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Ppo Hmo", "plan_name": "701720", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Ppo Hmo", "plan_name": 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"400100_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Federal", "plan_name": "400110", "standard_charge_percentage": 0.85, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Federal", "plan_name": "400110_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." } ] } ] }, { "description": "Buspirone 15 mg tablet [17464]", "drug_information": { "unit": 1.00, "type": "EA" }, "code_information": [ { "code": "51079-960-20", "type": "NDC" } ], "standard_charges": [ { "gross_charge": 7.50, "minimum": 6.00, "maximum": 6.38, "setting": "both", "payers_information": [ { 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"plan_name": "701720", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Ppo Hmo", "plan_name": "701720_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Ms State Emplo", "plan_name": "401457", "standard_charge_percentage": 0.80, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Ms State Emplo", "plan_name": "401457_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Basic Pl", "plan_name": "400100", "standard_charge_percentage": 0.85, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Basic Pl", "plan_name": "400100_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Federal", "plan_name": "400110", "standard_charge_percentage": 0.85, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Federal", "plan_name": "400110_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." } ] } ] }, { "description": "Spironolactone 100 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"plan_name": "401457_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Basic Pl", "plan_name": "400100", "standard_charge_percentage": 0.85, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Basic Pl", "plan_name": "400100_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Federal", "plan_name": "400110", "standard_charge_percentage": 0.85, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Federal", "plan_name": "400110_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." } ] } ] }, { "description": "Buspirone 5 mg tablet [9324]", "drug_information": { "unit": 1.00, "type": "EA" }, "code_information": [ { "code": "51079-985-01", "type": "NDC" } ], "standard_charges": [ { "gross_charge": 7.50, "minimum": 6.00, "maximum": 6.38, "setting": "both", "payers_information": [ { "payer_name": "Aetna", "plan_name": "700700", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna", "plan_name": "700700_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Miscellaneous", "plan_name": "700720", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Miscellaneous", "plan_name": "700720_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Ppo Hmo", "plan_name": "701720", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Ppo Hmo", "plan_name": "701720_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Ms State Emplo", "plan_name": "401457", "standard_charge_percentage": 0.80, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Ms State Emplo", "plan_name": "401457_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Basic Pl", "plan_name": "400100", "standard_charge_percentage": 0.85, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Basic Pl", "plan_name": "400100_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Federal", "plan_name": "400110", "standard_charge_percentage": 0.85, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Federal", "plan_name": "400110_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." } ] } ] }, { "description": "Buspirone 5 mg tablet [9324]", "drug_information": { "unit": 1.00, "type": "EA" }, "code_information": [ { "code": "51079-985-20", "type": "NDC" } ], "standard_charges": [ { "gross_charge": 7.50, "minimum": 6.00, "maximum": 6.38, "setting": "both", "payers_information": [ { "payer_name": "Aetna", "plan_name": "700700", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna", "plan_name": "700700_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Miscellaneous", "plan_name": "700720", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Miscellaneous", "plan_name": "700720_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Ppo Hmo", "plan_name": "701720", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Ppo Hmo", "plan_name": "701720_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Ms State Emplo", "plan_name": "401457", "standard_charge_percentage": 0.80, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Ms State Emplo", "plan_name": "401457_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Basic Pl", "plan_name": "400100", "standard_charge_percentage": 0.85, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Basic Pl", "plan_name": "400100_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Federal", "plan_name": "400110", "standard_charge_percentage": 0.85, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Federal", "plan_name": "400110_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." } ] } ] }, { "description": "Buspirone 10 mg tablet [9323]", "drug_information": { "unit": 1.00, "type": "EA" }, "code_information": [ { "code": "51079-986-01", "type": "NDC" } ], "standard_charges": [ { "gross_charge": 7.50, "minimum": 6.00, "maximum": 6.38, "setting": "both", "payers_information": [ { "payer_name": "Aetna", "plan_name": "700700", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna", "plan_name": "700700_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Miscellaneous", "plan_name": "700720", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Miscellaneous", "plan_name": "700720_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Ppo Hmo", "plan_name": "701720", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Ppo Hmo", "plan_name": "701720_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Ms State Emplo", "plan_name": "401457", "standard_charge_percentage": 0.80, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Ms State Emplo", "plan_name": "401457_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Basic Pl", "plan_name": "400100", "standard_charge_percentage": 0.85, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Basic Pl", "plan_name": "400100_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Federal", "plan_name": "400110", "standard_charge_percentage": 0.85, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Federal", "plan_name": "400110_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." } ] } ] }, { "description": "Buspirone 10 mg tablet [9323]", "drug_information": { "unit": 1.00, "type": "EA" }, "code_information": [ { "code": "51079-986-20", "type": "NDC" } ], "standard_charges": [ { "gross_charge": 7.50, "minimum": 6.00, "maximum": 6.38, "setting": "both", "payers_information": [ { "payer_name": "Aetna", "plan_name": "700700", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna", "plan_name": "700700_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Miscellaneous", "plan_name": "700720", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Miscellaneous", "plan_name": "700720_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Ppo Hmo", "plan_name": "701720", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Ppo Hmo", "plan_name": "701720_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Ms State Emplo", "plan_name": "401457", "standard_charge_percentage": 0.80, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Ms State Emplo", "plan_name": "401457_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Basic Pl", "plan_name": "400100", "standard_charge_percentage": 0.85, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Basic Pl", "plan_name": "400100_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Federal", "plan_name": "400110", "standard_charge_percentage": 0.85, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Federal", "plan_name": "400110_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." } ] } ] }, { "description": "Cholecalciferol (vitamin d3) 25 mcg (1000 unit) tablet [82639]", "drug_information": { "unit": 1.00, "type": "EA" }, "code_information": [ { "code": "54629-0050-24", "type": "NDC" } ], "standard_charges": [ { "gross_charge": 1.00, "minimum": 0.80, "maximum": 0.85, "setting": "both", "payers_information": [ { "payer_name": "Aetna", "plan_name": "700700", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna", "plan_name": "700700_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Miscellaneous", "plan_name": "700720", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Miscellaneous", "plan_name": "700720_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Ppo Hmo", "plan_name": "701720", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Ppo Hmo", "plan_name": "701720_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Ms State Emplo", "plan_name": "401457", "standard_charge_percentage": 0.80, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Ms State Emplo", "plan_name": "401457_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Basic Pl", "plan_name": "400100", "standard_charge_percentage": 0.85, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Basic Pl", "plan_name": "400100_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Federal", "plan_name": "400110", "standard_charge_percentage": 0.85, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Federal", "plan_name": "400110_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." } ] } ] }, { "description": "Vitamin b complex-vitamin c-folic acid 0.8 mg tablet [29833]", "drug_information": { "unit": 1.00, "type": "EA" }, "code_information": [ { "code": "54629-0126-91", "type": "NDC" } ], "standard_charges": [ { "gross_charge": 1.00, "minimum": 0.80, "maximum": 0.85, "setting": "both", "payers_information": [ { "payer_name": "Aetna", "plan_name": "700700", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna", "plan_name": "700700_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Miscellaneous", "plan_name": "700720", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Miscellaneous", "plan_name": "700720_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Ppo Hmo", "plan_name": "701720", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Ppo Hmo", "plan_name": "701720_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Ms State Emplo", "plan_name": "401457", "standard_charge_percentage": 0.80, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Ms State Emplo", "plan_name": "401457_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Basic Pl", "plan_name": "400100", "standard_charge_percentage": 0.85, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Basic Pl", "plan_name": "400100_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Federal", "plan_name": "400110", "standard_charge_percentage": 0.85, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Federal", "plan_name": "400110_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." } ] } ] }, { "description": "Cyanocobalamin (vit b-12) 250 mcg tablet [2010]", "drug_information": { "unit": 1.00, "type": "EA" }, "code_information": [ { "code": "54629-0580-01", "type": "NDC" } ], "standard_charges": [ { "gross_charge": 1.00, "minimum": 0.80, "maximum": 0.85, "setting": "both", "payers_information": [ { "payer_name": "Aetna", "plan_name": "700700", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna", "plan_name": "700700_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Miscellaneous", "plan_name": "700720", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Miscellaneous", "plan_name": "700720_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Ppo Hmo", "plan_name": "701720", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Ppo Hmo", "plan_name": "701720_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Ms State Emplo", "plan_name": "401457", "standard_charge_percentage": 0.80, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Ms State Emplo", "plan_name": "401457_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Basic Pl", "plan_name": "400100", "standard_charge_percentage": 0.85, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Basic Pl", "plan_name": "400100_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Federal", "plan_name": "400110", "standard_charge_percentage": 0.85, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Federal", "plan_name": "400110_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." } ] } ] }, { "description": "Potassium gluconate 500 mg (83 mg) tablet [163814]", "drug_information": { "unit": 1.00, "type": "EA" }, "code_information": [ { "code": "54629-0850-01", "type": "NDC" } ], "standard_charges": [ { "gross_charge": 7.50, "minimum": 6.00, "maximum": 6.38, "setting": "both", "payers_information": [ { "payer_name": "Aetna", "plan_name": "700700", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna", "plan_name": "700700_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Miscellaneous", "plan_name": "700720", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Miscellaneous", "plan_name": "700720_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Ppo Hmo", "plan_name": "701720", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Ppo Hmo", "plan_name": "701720_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Ms State Emplo", "plan_name": "401457", "standard_charge_percentage": 0.80, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Ms State Emplo", "plan_name": "401457_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Basic Pl", "plan_name": "400100", "standard_charge_percentage": 0.85, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Basic Pl", "plan_name": "400100_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Federal", "plan_name": "400110", "standard_charge_percentage": 0.85, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Federal", "plan_name": "400110_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." } ] } ] }, { "description": "Cholecalciferol (vitamin d3) 125 mcg (5000 unit) tablet [118996]", "drug_information": { "unit": 1.00, "type": "EA" }, "code_information": [ { "code": "54629-7941-01", "type": "NDC" } ], "standard_charges": [ { "gross_charge": 7.50, "minimum": 6.00, "maximum": 6.38, "setting": "both", "payers_information": [ { "payer_name": "Aetna", "plan_name": "700700", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna", "plan_name": "700700_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Miscellaneous", "plan_name": "700720", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Miscellaneous", "plan_name": "700720_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Ppo Hmo", "plan_name": "701720", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Ppo Hmo", "plan_name": "701720_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Ms State Emplo", "plan_name": "401457", "standard_charge_percentage": 0.80, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Ms State Emplo", "plan_name": "401457_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Basic Pl", "plan_name": "400100", "standard_charge_percentage": 0.85, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Basic Pl", "plan_name": "400100_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Federal", "plan_name": "400110", "standard_charge_percentage": 0.85, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Federal", "plan_name": "400110_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." } ] } ] }, { "description": "Mviadult no.4 with vit k 3300 unit-150 mcg/10 ml intravenous solution [159234]", "drug_information": { "unit": 10.00, "type": "ML" }, "code_information": [ { "code": "54643-5649-1", "type": "NDC" } ], "standard_charges": [ { "gross_charge": 72.35, "minimum": 57.88, "maximum": 61.50, "setting": "both", "payers_information": [ { "payer_name": "Aetna", "plan_name": "700700", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna", "plan_name": "700700_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Miscellaneous", "plan_name": "700720", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Miscellaneous", "plan_name": "700720_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Ppo Hmo", "plan_name": "701720", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Ppo Hmo", "plan_name": "701720_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Ms State Emplo", "plan_name": "401457", "standard_charge_percentage": 0.80, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Ms State Emplo", "plan_name": "401457_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to 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"percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Federal", "plan_name": "400110", "standard_charge_percentage": 0.85, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Federal", "plan_name": "400110_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." } ] } ] }, { "description": "Hyoscyamine 0.125 mg/ml oral drops [3782]", "drug_information": { "unit": 15.00, "type": "ML" }, "code_information": [ { "code": "54838-506-15", "type": "NDC" } ], "standard_charges": [ { "gross_charge": 221.94, "minimum": 177.55, "maximum": 188.65, "setting": "both", "payers_information": [ { "payer_name": "Aetna", "plan_name": "700700", 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"standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Ppo Hmo", "plan_name": "701720_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Ms State Emplo", "plan_name": "401457", "standard_charge_percentage": 0.80, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Ms State Emplo", "plan_name": "401457_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Basic Pl", "plan_name": "400100", "standard_charge_percentage": 0.85, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Basic Pl", "plan_name": "400100_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Federal", "plan_name": "400110", "standard_charge_percentage": 0.85, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Federal", "plan_name": "400110_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." } ] } ] }, { "description": "Oxybutynin chloride 5 mg/5 ml oral syrup [10810]", "drug_information": { "unit": 473.00, "type": "ML" }, "code_information": [ { "code": "54838-510-80", "type": "NDC" } ], "standard_charges": [ { "gross_charge": 123.57, "minimum": 98.86, "maximum": 105.03, "setting": "both", "payers_information": [ { "payer_name": "Aetna", "plan_name": "700700", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna", "plan_name": "700700_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Miscellaneous", "plan_name": "700720", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna 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"plan_name": "401457_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Basic Pl", "plan_name": "400100", "standard_charge_percentage": 0.85, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Basic Pl", "plan_name": "400100_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Federal", "plan_name": "400110", "standard_charge_percentage": 0.85, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Federal", "plan_name": "400110_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." } ] } ] }, { "description": "Hyoscyamine 0.125 mg/5 ml oral elixir [3781]", "drug_information": { "unit": 473.00, "type": "ML" }, "code_information": [ { "code": "54838-511-80", "type": "NDC" } ], "standard_charges": [ { "gross_charge": 193.22, "minimum": 154.58, "maximum": 164.24, "setting": "both", "payers_information": [ { "payer_name": "Aetna", "plan_name": "700700", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna", "plan_name": "700700_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Miscellaneous", "plan_name": "700720", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Miscellaneous", "plan_name": "700720_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Ppo Hmo", "plan_name": "701720", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Ppo Hmo", "plan_name": "701720_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Ms State Emplo", "plan_name": "401457", "standard_charge_percentage": 0.80, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Ms State Emplo", "plan_name": "401457_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Basic Pl", "plan_name": "400100", "standard_charge_percentage": 0.85, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Basic Pl", "plan_name": "400100_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Federal", "plan_name": "400110", "standard_charge_percentage": 0.85, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Federal", "plan_name": "400110_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." } ] } ] }, { "description": "Levetiracetam 100 mg/ml oral solution [36590]", "drug_information": { "unit": 473.00, "type": "ML" }, "code_information": [ { "code": "54838-548-80", "type": "NDC" } ], "standard_charges": [ { "gross_charge": 285.34, "minimum": 228.27, "maximum": 242.54, "setting": "both", "payers_information": [ { "payer_name": "Aetna", "plan_name": "700700", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna", "plan_name": "700700_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Miscellaneous", "plan_name": "700720", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Miscellaneous", "plan_name": "700720_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Ppo Hmo", "plan_name": "701720", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed 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}, { "payer_name": "Bc/Bs Of Ms Basic Pl", "plan_name": "400100_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Federal", "plan_name": "400110", "standard_charge_percentage": 0.85, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Federal", "plan_name": "400110_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." } ] } ] }, { "description": "Ferrous sulfate 220 mg (44 mg iron)/5 ml oral elixir [177665]", "drug_information": { "unit": 473.00, "type": "ML" }, "code_information": [ { "code": "5483800180", "type": "NDC" } ], "standard_charges": [ { "gross_charge": 46.73, "minimum": 37.38, "maximum": 39.72, "setting": "both", "payers_information": [ { "payer_name": "Aetna", "plan_name": "700700", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna", "plan_name": "700700_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Miscellaneous", "plan_name": "700720", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Miscellaneous", "plan_name": "700720_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Ppo Hmo", "plan_name": "701720", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Ppo Hmo", "plan_name": "701720_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Ms State Emplo", "plan_name": "401457", "standard_charge_percentage": 0.80, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Ms State Emplo", "plan_name": "401457_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Basic Pl", "plan_name": "400100", "standard_charge_percentage": 0.85, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Basic Pl", "plan_name": "400100_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Federal", "plan_name": "400110", "standard_charge_percentage": 0.85, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Federal", "plan_name": "400110_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." } ] } ] }, { "description": "Phenobarbital 20 mg/5 ml (4 mg/ml) oral elixir [6212]", "drug_information": { "unit": 473.00, "type": "ML" }, "code_information": [ { "code": "54932-501-81", "type": "NDC" } ], "standard_charges": [ { "gross_charge": 526.80, "minimum": 421.44, "maximum": 447.78, "setting": "both", "payers_information": [ { "payer_name": "Aetna", "plan_name": "700700", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna", "plan_name": "700700_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Miscellaneous", "plan_name": "700720", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Miscellaneous", "plan_name": "700720_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Ppo Hmo", "plan_name": "701720", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Ppo Hmo", "plan_name": "701720_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Ms State Emplo", "plan_name": "401457", "standard_charge_percentage": 0.80, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Ms State Emplo", "plan_name": "401457_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Basic Pl", "plan_name": "400100", "standard_charge_percentage": 0.85, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Basic Pl", "plan_name": "400100_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Federal", "plan_name": "400110", "standard_charge_percentage": 0.85, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Federal", "plan_name": "400110_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." } ] } ] }, { "description": "Famotidine 20 mg tablet [10011]", "drug_information": { "unit": 1.00, "type": "EA" }, "code_information": [ { "code": "55111-119-01", "type": "NDC" } ], "standard_charges": [ { "gross_charge": 1.00, "minimum": 0.80, "maximum": 0.85, "setting": "both", "payers_information": [ { "payer_name": "Aetna", "plan_name": "700700", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna", "plan_name": "700700_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Miscellaneous", "plan_name": "700720", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Miscellaneous", "plan_name": "700720_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Ppo Hmo", "plan_name": "701720", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Ppo Hmo", "plan_name": "701720_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Ms State Emplo", "plan_name": "401457", "standard_charge_percentage": 0.80, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Ms State Emplo", "plan_name": "401457_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Basic Pl", "plan_name": "400100", "standard_charge_percentage": 0.85, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Basic Pl", "plan_name": "400100_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Federal", "plan_name": "400110", "standard_charge_percentage": 0.85, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Federal", "plan_name": "400110_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." } ] } ] }, { "description": "Ciprofloxacin 250 mg tablet [25118]", "drug_information": { "unit": 1.00, "type": "EA" }, "code_information": [ { "code": "55111-126-01", "type": "NDC" } ], "standard_charges": [ { "gross_charge": 7.50, "minimum": 6.00, "maximum": 6.38, "setting": "both", "payers_information": [ { "payer_name": "Aetna", "plan_name": "700700", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna", "plan_name": "700700_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Miscellaneous", "plan_name": "700720", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Miscellaneous", "plan_name": "700720_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Ppo Hmo", "plan_name": "701720", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Ppo Hmo", "plan_name": "701720_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Ms State Emplo", "plan_name": "401457", "standard_charge_percentage": 0.80, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Ms State Emplo", "plan_name": "401457_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Basic Pl", "plan_name": "400100", "standard_charge_percentage": 0.85, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Basic Pl", "plan_name": "400100_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Federal", "plan_name": "400110", "standard_charge_percentage": 0.85, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Federal", "plan_name": "400110_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." } ] } ] }, { "description": "Ciprofloxacin 500 mg tablet [25119]", "drug_information": { "unit": 1.00, "type": "EA" }, "code_information": [ { "code": "55111-127-01", "type": "NDC" } ], "standard_charges": [ { "gross_charge": 7.50, "minimum": 6.00, "maximum": 6.38, "setting": "both", "payers_information": [ { "payer_name": "Aetna", "plan_name": "700700", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna", "plan_name": "700700_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Miscellaneous", "plan_name": "700720", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Miscellaneous", "plan_name": "700720_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Ppo Hmo", "plan_name": "701720", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Ppo Hmo", "plan_name": "701720_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Ms State Emplo", "plan_name": "401457", "standard_charge_percentage": 0.80, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Ms State Emplo", "plan_name": "401457_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Basic Pl", "plan_name": "400100", "standard_charge_percentage": 0.85, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Basic Pl", "plan_name": "400100_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Federal", "plan_name": "400110", "standard_charge_percentage": 0.85, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Federal", "plan_name": "400110_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." } ] } ] }, { "description": "Omeprazole 20 mg capsuledelayed release [27694]", "drug_information": { "unit": 1.00, "type": "EA" }, "code_information": [ { "code": "55111-158-01", "type": "NDC" } ], "standard_charges": [ { "gross_charge": 1.00, "minimum": 0.80, "maximum": 0.85, "setting": "both", "payers_information": [ { "payer_name": "Aetna", "plan_name": "700700", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna", "plan_name": "700700_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Miscellaneous", "plan_name": "700720", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Miscellaneous", "plan_name": "700720_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Ppo Hmo", "plan_name": "701720", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Ppo Hmo", "plan_name": "701720_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Ms State Emplo", "plan_name": "401457", "standard_charge_percentage": 0.80, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Ms State Emplo", "plan_name": "401457_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Basic Pl", "plan_name": "400100", "standard_charge_percentage": 0.85, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Basic Pl", "plan_name": "400100_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Federal", "plan_name": "400110", "standard_charge_percentage": 0.85, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Federal", "plan_name": "400110_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." } ] } ] }, { "description": "Omeprazole 20 mg capsuledelayed release [27694]", "drug_information": { "unit": 1.00, "type": "EA" }, "code_information": [ { "code": "55111-158-30", "type": "NDC" } ], "standard_charges": [ { "gross_charge": 1.00, "minimum": 0.80, "maximum": 0.85, "setting": "both", "payers_information": [ { "payer_name": "Aetna", "plan_name": "700700", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna", "plan_name": "700700_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Miscellaneous", "plan_name": "700720", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Miscellaneous", "plan_name": "700720_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Ppo Hmo", "plan_name": "701720", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Ppo Hmo", "plan_name": "701720_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Ms State Emplo", "plan_name": "401457", "standard_charge_percentage": 0.80, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Ms State Emplo", "plan_name": "401457_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Basic Pl", "plan_name": "400100", "standard_charge_percentage": 0.85, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Basic Pl", "plan_name": "400100_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Federal", "plan_name": "400110", "standard_charge_percentage": 0.85, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Federal", "plan_name": "400110_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." } ] } ] }, { "description": "Tizanidine 2 mg tablet [14792]", "drug_information": { "unit": 1.00, "type": "EA" }, "code_information": [ { "code": "55111-179-15", "type": "NDC" } ], "standard_charges": [ { "gross_charge": 7.50, "minimum": 6.00, "maximum": 6.38, "setting": "both", "payers_information": [ { "payer_name": "Aetna", "plan_name": "700700", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna", "plan_name": "700700_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Miscellaneous", "plan_name": "700720", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Miscellaneous", "plan_name": "700720_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Ppo Hmo", "plan_name": "701720", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Ppo Hmo", "plan_name": "701720_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Ms State Emplo", "plan_name": "401457", "standard_charge_percentage": 0.80, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Ms State Emplo", "plan_name": "401457_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Basic Pl", "plan_name": "400100", "standard_charge_percentage": 0.85, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Basic Pl", "plan_name": "400100_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Federal", "plan_name": "400110", "standard_charge_percentage": 0.85, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Federal", "plan_name": "400110_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." } ] } ] }, { "description": "Ziprasidone 20 mg capsule [29778]", "drug_information": { "unit": 1.00, "type": "EA" }, "code_information": [ { "code": "55111-256-60", "type": "NDC" } ], "standard_charges": [ { "gross_charge": 7.50, "minimum": 6.00, "maximum": 6.38, "setting": "both", "payers_information": [ { "payer_name": "Aetna", "plan_name": "700700", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna", "plan_name": "700700_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Miscellaneous", "plan_name": "700720", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Miscellaneous", "plan_name": "700720_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Ppo Hmo", "plan_name": "701720", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Ppo Hmo", "plan_name": "701720_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Ms State Emplo", "plan_name": "401457", "standard_charge_percentage": 0.80, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Ms State Emplo", "plan_name": "401457_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Basic Pl", "plan_name": "400100", "standard_charge_percentage": 0.85, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Basic Pl", "plan_name": "400100_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Federal", "plan_name": "400110", "standard_charge_percentage": 0.85, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Federal", "plan_name": "400110_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." } ] } ] }, { "description": "Levofloxacin 500 mg tablet [18919]", "drug_information": { "unit": 1.00, "type": "EA" }, "code_information": [ { "code": "55111-280-50", "type": "NDC" } ], "standard_charges": [ { "gross_charge": 7.50, "minimum": 6.00, "maximum": 6.38, "setting": "both", "payers_information": [ { "payer_name": "Aetna", "plan_name": "700700", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna", "plan_name": "700700_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna 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"plan_name": "401457", "standard_charge_percentage": 0.80, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Ms State Emplo", "plan_name": "401457_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Basic Pl", "plan_name": "400100", "standard_charge_percentage": 0.85, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Basic Pl", "plan_name": "400100_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Federal", "plan_name": "400110", "standard_charge_percentage": 0.85, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Federal", "plan_name": "400110_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." } ] } ] }, { "description": "Glimepiride 1 mg tablet [16355]", "drug_information": { "unit": 1.00, "type": "EA" }, "code_information": [ { "code": "55111-320-01", "type": "NDC" } ], "standard_charges": [ { "gross_charge": 7.50, "minimum": 6.00, "maximum": 6.38, "setting": "both", "payers_information": [ { "payer_name": "Aetna", "plan_name": "700700", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna", "plan_name": "700700_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Miscellaneous", "plan_name": "700720", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Miscellaneous", "plan_name": "700720_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Ppo Hmo", "plan_name": "701720", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Ppo Hmo", "plan_name": "701720_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Ms State Emplo", "plan_name": "401457", "standard_charge_percentage": 0.80, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Ms State Emplo", "plan_name": "401457_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Basic Pl", "plan_name": "400100", "standard_charge_percentage": 0.85, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Basic Pl", "plan_name": "400100_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Federal", "plan_name": "400110", "standard_charge_percentage": 0.85, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Federal", "plan_name": "400110_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." } ] } ] }, { "description": "Glimepiride 2 mg tablet [16356]", "drug_information": { "unit": 1.00, "type": "EA" }, "code_information": [ { "code": "55111-321-01", "type": "NDC" } ], "standard_charges": [ { "gross_charge": 7.50, "minimum": 6.00, "maximum": 6.38, "setting": "both", "payers_information": [ { "payer_name": "Aetna", "plan_name": "700700", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna", "plan_name": "700700_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Miscellaneous", "plan_name": "700720", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Miscellaneous", "plan_name": "700720_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Ppo Hmo", "plan_name": "701720", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Ppo Hmo", "plan_name": "701720_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Ms State Emplo", "plan_name": "401457", "standard_charge_percentage": 0.80, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Ms State Emplo", "plan_name": "401457_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Basic Pl", "plan_name": "400100", "standard_charge_percentage": 0.85, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Basic Pl", "plan_name": "400100_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Federal", "plan_name": "400110", "standard_charge_percentage": 0.85, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Federal", "plan_name": "400110_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." } ] } ] }, { "description": "Glimepiride 4 mg tablet [16357]", "drug_information": { "unit": 1.00, "type": "EA" }, "code_information": [ { "code": "55111-322-01", "type": "NDC" } ], "standard_charges": [ { "gross_charge": 7.50, "minimum": 6.00, "maximum": 6.38, "setting": "both", "payers_information": [ { "payer_name": "Aetna", "plan_name": "700700", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna", "plan_name": "700700_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Miscellaneous", "plan_name": "700720", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Miscellaneous", "plan_name": "700720_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Ppo Hmo", "plan_name": "701720", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Ppo Hmo", "plan_name": "701720_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Ms State Emplo", "plan_name": "401457", "standard_charge_percentage": 0.80, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Ms State Emplo", "plan_name": "401457_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Basic Pl", "plan_name": "400100", "standard_charge_percentage": 0.85, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Basic Pl", "plan_name": "400100_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Federal", "plan_name": "400110", "standard_charge_percentage": 0.85, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Federal", "plan_name": "400110_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." } ] } ] }, { "description": "Rivastigmine 1.5 mg capsule [28278]", "drug_information": { "unit": 1.00, "type": "EA" }, "code_information": [ { "code": "55111-352-60", "type": "NDC" } ], "standard_charges": [ { "gross_charge": 7.50, "minimum": 6.00, "maximum": 6.38, "setting": "both", "payers_information": [ { "payer_name": "Aetna", "plan_name": "700700", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna", "plan_name": "700700_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Miscellaneous", "plan_name": "700720", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Miscellaneous", "plan_name": "700720_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Ppo Hmo", "plan_name": "701720", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Ppo Hmo", "plan_name": "701720_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Ms State Emplo", "plan_name": "401457", "standard_charge_percentage": 0.80, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Ms State Emplo", "plan_name": "401457_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Basic Pl", "plan_name": "400100", "standard_charge_percentage": 0.85, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Basic Pl", "plan_name": "400100_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Federal", "plan_name": "400110", "standard_charge_percentage": 0.85, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Federal", "plan_name": "400110_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." } ] } ] }, { "description": "Ibandronate 150 mg tablet [41063]", "drug_information": { "unit": 1.00, "type": "EA" }, "code_information": [ { "code": "55111-575-11", "type": "NDC" } ], "standard_charges": [ { "gross_charge": 67.29, "minimum": 53.83, "maximum": 57.20, "setting": "both", "payers_information": [ { "payer_name": "Aetna", "plan_name": "700700", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna", "plan_name": "700700_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Miscellaneous", "plan_name": "700720", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Miscellaneous", "plan_name": "700720_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Ppo Hmo", "plan_name": "701720", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Ppo Hmo", "plan_name": "701720_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Ms State Emplo", "plan_name": "401457", "standard_charge_percentage": 0.80, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Ms State Emplo", "plan_name": "401457_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Basic Pl", "plan_name": "400100", "standard_charge_percentage": 0.85, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Basic Pl", "plan_name": "400100_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Federal", "plan_name": "400110", "standard_charge_percentage": 0.85, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Federal", "plan_name": "400110_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." } ] } ] }, { "description": "Ibandronate 150 mg tablet [41063]", "drug_information": { "unit": 1.00, "type": "EA" }, "code_information": [ { "code": "55111-575-43", "type": "NDC" } ], "standard_charges": [ { "gross_charge": 82.08, "minimum": 65.66, "maximum": 69.77, "setting": "both", "payers_information": [ { "payer_name": "Aetna", "plan_name": "700700", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna", "plan_name": "700700_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Miscellaneous", "plan_name": "700720", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Miscellaneous", "plan_name": "700720_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Ppo Hmo", "plan_name": "701720", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Ppo Hmo", "plan_name": "701720_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Ms State Emplo", "plan_name": "401457", "standard_charge_percentage": 0.80, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Ms State Emplo", "plan_name": "401457_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Basic Pl", "plan_name": "400100", "standard_charge_percentage": 0.85, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Basic Pl", "plan_name": "400100_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Federal", "plan_name": "400110", "standard_charge_percentage": 0.85, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Federal", "plan_name": "400110_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." } ] } ] }, { "description": "Lanthanum 500 mg chewable tablet [39975]", "drug_information": { "unit": 1.00, "type": "EA" }, "code_information": [ { "code": "54092-252-45", "type": "NDC" } ], "standard_charges": [ { "gross_charge": 57.03, "minimum": 45.62, "maximum": 48.48, "setting": "both", "payers_information": [ { "payer_name": "Aetna", "plan_name": "700700", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna", "plan_name": "700700_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Miscellaneous", "plan_name": "700720", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Miscellaneous", "plan_name": "700720_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Ppo Hmo", "plan_name": "701720", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Ppo Hmo", "plan_name": "701720_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Ms State Emplo", "plan_name": "401457", "standard_charge_percentage": 0.80, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Ms State Emplo", "plan_name": "401457_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Basic Pl", "plan_name": "400100", "standard_charge_percentage": 0.85, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Basic Pl", "plan_name": "400100_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Federal", "plan_name": "400110", "standard_charge_percentage": 0.85, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Federal", "plan_name": "400110_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." } ] } ] }, { "description": "Dexmedetomidine 100 mcg/ml intravenous solution [27103]", "drug_information": { "unit": 2.00, "type": "ML" }, "code_information": [ { "code": "55150-209-02", "type": "NDC" } ], "standard_charges": [ { "gross_charge": 36.00, "minimum": 28.80, "maximum": 30.60, "setting": "both", "payers_information": [ { "payer_name": "Aetna", "plan_name": "700700", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna", "plan_name": "700700_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Miscellaneous", "plan_name": "700720", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Miscellaneous", "plan_name": "700720_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Ppo Hmo", "plan_name": "701720", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Ppo Hmo", "plan_name": "701720_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Ms State Emplo", "plan_name": "401457", "standard_charge_percentage": 0.80, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Ms State Emplo", "plan_name": "401457_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Basic Pl", "plan_name": "400100", "standard_charge_percentage": 0.85, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Basic Pl", "plan_name": "400100_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Federal", "plan_name": "400110", "standard_charge_percentage": 0.85, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Federal", "plan_name": "400110_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." } ] } ] }, { "description": "Etomidate 2 mg/ml intravenous solution [20472]", "drug_information": { "unit": 10.00, "type": "ML" }, "code_information": [ { "code": "55150-221-10", "type": "NDC" } ], "standard_charges": [ { "gross_charge": 59.85, "minimum": 47.88, "maximum": 50.87, "setting": "both", "payers_information": [ { "payer_name": "Aetna", "plan_name": "700700", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna", "plan_name": "700700_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Miscellaneous", "plan_name": "700720", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Miscellaneous", "plan_name": "700720_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Ppo Hmo", "plan_name": "701720", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Ppo Hmo", "plan_name": "701720_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Ms State Emplo", "plan_name": "401457", "standard_charge_percentage": 0.80, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Ms State Emplo", "plan_name": "401457_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Basic Pl", "plan_name": "400100", "standard_charge_percentage": 0.85, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Basic Pl", "plan_name": "400100_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Federal", "plan_name": "400110", "standard_charge_percentage": 0.85, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Federal", "plan_name": "400110_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." } ] } ] }, { "description": "Vecuronium bromide 10 mg intravenous solution [11634]", "drug_information": { "unit": 1.00, "type": "EA" }, "code_information": [ { "code": "55150-235-02", "type": "NDC" } ], "standard_charges": [ { "gross_charge": 19.80, "minimum": 15.84, "maximum": 16.83, "setting": "both", "payers_information": [ { "payer_name": "Aetna", "plan_name": "700700", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna", "plan_name": "700700_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Miscellaneous", "plan_name": "700720", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Miscellaneous", "plan_name": "700720_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Ppo Hmo", "plan_name": "701720", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Ppo Hmo", "plan_name": "701720_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Ms State Emplo", "plan_name": "401457", "standard_charge_percentage": 0.80, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Ms State Emplo", "plan_name": "401457_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Basic Pl", "plan_name": "400100", "standard_charge_percentage": 0.85, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Basic Pl", "plan_name": "400100_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Federal", "plan_name": "400110", "standard_charge_percentage": 0.85, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Federal", "plan_name": "400110_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." } ] } ] }, { "description": "Vecuronium bromide 10 mg intravenous solution [11634]", "drug_information": { "unit": 1.00, "type": "EA" }, "code_information": [ { "code": "55150-235-10", "type": "NDC" } ], "standard_charges": [ { "gross_charge": 62.26, "minimum": 49.81, "maximum": 52.92, "setting": "both", "payers_information": [ { "payer_name": "Aetna", "plan_name": "700700", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna", "plan_name": "700700_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Miscellaneous", "plan_name": "700720", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Miscellaneous", "plan_name": "700720_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Ppo Hmo", "plan_name": "701720", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Ppo Hmo", "plan_name": "701720_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Ms State Emplo", "plan_name": "401457", "standard_charge_percentage": 0.80, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Ms State Emplo", "plan_name": "401457_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Basic Pl", "plan_name": "400100", "standard_charge_percentage": 0.85, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Basic Pl", "plan_name": "400100_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Federal", "plan_name": "400110", "standard_charge_percentage": 0.85, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Federal", "plan_name": "400110_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." } ] } ] }, { "description": "Dexmedetomidine 400 mcg/100 ml (4 mcg/ml) in 0.9 % sodium chloride iv [162240]", "drug_information": { "unit": 100.00, "type": "ML" }, "code_information": [ { "code": "55150-297-01", "type": "NDC" } ], "standard_charges": [ { "gross_charge": 629.96, "minimum": 503.97, "maximum": 535.47, "setting": "both", "payers_information": [ { "payer_name": "Aetna", "plan_name": "700700", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna", "plan_name": "700700_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Miscellaneous", "plan_name": "700720", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Miscellaneous", "plan_name": "700720_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Ppo Hmo", "plan_name": "701720", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Ppo Hmo", "plan_name": "701720_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Ms State Emplo", "plan_name": "401457", "standard_charge_percentage": 0.80, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Ms State Emplo", "plan_name": "401457_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Basic Pl", "plan_name": "400100", "standard_charge_percentage": 0.85, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Basic Pl", "plan_name": "400100_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Federal", "plan_name": "400110", "standard_charge_percentage": 0.85, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Federal", "plan_name": "400110_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." } ] } ] }, { "description": "Diltiazem 5 mg/ml intravenous solution [9869]", "drug_information": { "unit": 5.00, "type": "ML" }, "code_information": [ { "code": "55150-425-01", "type": "NDC" } ], "standard_charges": [ { "gross_charge": 23.18, "minimum": 18.54, "maximum": 19.70, "setting": "both", "payers_information": [ { "payer_name": "Aetna", "plan_name": "700700", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna", "plan_name": "700700_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Miscellaneous", "plan_name": "700720", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Miscellaneous", "plan_name": "700720_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Ppo Hmo", "plan_name": "701720", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Ppo Hmo", "plan_name": "701720_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Ms State Emplo", "plan_name": "401457", "standard_charge_percentage": 0.80, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Ms State Emplo", "plan_name": "401457_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Basic Pl", "plan_name": "400100", "standard_charge_percentage": 0.85, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Basic Pl", "plan_name": "400100_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Federal", "plan_name": "400110", "standard_charge_percentage": 0.85, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Federal", "plan_name": "400110_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." } ] } ] }, { "description": "Simethicone 40 mg/0.6 ml oral dropssuspension [7228]", "drug_information": { "unit": 30.00, "type": "ML" }, "code_information": [ { "code": "5618412041", "type": "NDC" } ], "standard_charges": [ { "gross_charge": 17.16, "minimum": 13.73, "maximum": 14.59, "setting": "both", "payers_information": [ { "payer_name": "Aetna", "plan_name": "700700", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna", "plan_name": "700700_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Miscellaneous", "plan_name": "700720", 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"standard_charge_percentage": 0.85, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Federal", "plan_name": "400110_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." } ] } ] }, { "description": "Phenylephrine 0.125 % nasal drops [36952]", "drug_information": { "unit": 15.00, "type": "ML" }, "code_information": [ { "code": "5618412105", "type": "NDC" } ], "standard_charges": [ { "gross_charge": 8.31, "minimum": 6.65, "maximum": 7.06, "setting": "both", "payers_information": [ { "payer_name": "Aetna", "plan_name": "700700", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna", "plan_name": "700700_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Miscellaneous", "plan_name": "700720", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Miscellaneous", "plan_name": "700720_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Ppo Hmo", "plan_name": "701720", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Ppo Hmo", "plan_name": "701720_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Ms State Emplo", "plan_name": "401457", "standard_charge_percentage": 0.80, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Ms State Emplo", "plan_name": "401457_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Basic Pl", "plan_name": "400100", "standard_charge_percentage": 0.85, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Basic Pl", "plan_name": "400100_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Federal", "plan_name": "400110", "standard_charge_percentage": 0.85, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Federal", "plan_name": "400110_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." } ] } ] }, { "description": "Cefprozil 250 mg/5 ml oral suspension [9471]", "drug_information": { "unit": 50.00, "type": "ML" }, "code_information": [ { "code": "57237-035-50", "type": "NDC" } ], "standard_charges": [ { "gross_charge": 185.73, "minimum": 148.58, "maximum": 157.87, "setting": 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"payer_name": "Aetna Ppo Hmo", "plan_name": "701720", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Ppo Hmo", "plan_name": "701720_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Ms State Emplo", "plan_name": "401457", "standard_charge_percentage": 0.80, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Ms State Emplo", "plan_name": "401457_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Basic Pl", "plan_name": "400100", "standard_charge_percentage": 0.85, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Basic Pl", "plan_name": "400100_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Federal", "plan_name": "400110", "standard_charge_percentage": 0.85, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Federal", "plan_name": "400110_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." } ] } ] }, { "description": "Divalproex 500 mg tabletdelayed release [2553]", "drug_information": { "unit": 1.00, "type": "EA" }, "code_information": [ { "code": "57237-048-01", "type": "NDC" } ], "standard_charges": [ { "gross_charge": 7.50, "minimum": 6.00, "maximum": 6.38, "setting": "both", "payers_information": [ { "payer_name": "Aetna", "plan_name": "700700", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna", "plan_name": "700700_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Miscellaneous", "plan_name": "700720", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to 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"additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna", "plan_name": "700700_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Miscellaneous", "plan_name": "700720", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Miscellaneous", "plan_name": "700720_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Ppo Hmo", "plan_name": "701720", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": 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"Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Basic Pl", "plan_name": "400100_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Federal", "plan_name": "400110", "standard_charge_percentage": 0.85, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Federal", "plan_name": "400110_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." } ] } ] }, { "description": "Warfarin 1 mg tablet [11664]", "drug_information": { "unit": 1.00, "type": "EA" }, "code_information": [ { "code": "57237-119-01", "type": "NDC" } ], 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"additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Basic Pl", "plan_name": "400100", "standard_charge_percentage": 0.85, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Basic Pl", "plan_name": "400100_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Federal", "plan_name": "400110", "standard_charge_percentage": 0.85, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Federal", "plan_name": "400110_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." } ] } ] }, { "description": "Warfarin 3 mg tablet [19433]", "drug_information": { "unit": 1.00, "type": "EA" }, "code_information": [ { "code": "57237-122-01", "type": "NDC" } ], "standard_charges": [ { "gross_charge": 7.50, "minimum": 6.00, "maximum": 6.38, "setting": "both", "payers_information": [ { "payer_name": "Aetna", "plan_name": "700700", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna", "plan_name": "700700_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Miscellaneous", "plan_name": "700720", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total 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"additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Ms State Emplo", "plan_name": "401457_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Basic Pl", "plan_name": "400100", "standard_charge_percentage": 0.85, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Basic Pl", "plan_name": "400100_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Federal", "plan_name": "400110", "standard_charge_percentage": 0.85, "count": "0", "methodology": "percent of total billed charges", 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charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Federal", "plan_name": "400110", "standard_charge_percentage": 0.85, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Federal", "plan_name": "400110_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." } ] } ] }, { "description": "Pioglitazone 15 mg tablet [25528]", "drug_information": { "unit": 1.00, "type": "EA" }, "code_information": [ { "code": "57237-219-30", "type": "NDC" } ], "standard_charges": [ { "gross_charge": 7.50, "minimum": 6.00, "maximum": 6.38, "setting": "both", "payers_information": [ { "payer_name": "Aetna", "plan_name": "700700", "standard_charge_percentage": 80.0, "count": "0", 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billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Basic Pl", "plan_name": "400100_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Federal", "plan_name": "400110", "standard_charge_percentage": 0.85, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Federal", "plan_name": "400110_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." } ] } ] }, { "description": "Pioglitazone 30 mg tablet [25529]", "drug_information": { "unit": 1.00, "type": "EA" }, "code_information": [ { "code": "57237-220-30", "type": "NDC" } ], "standard_charges": [ { "gross_charge": 7.50, "minimum": 6.00, "maximum": 6.38, "setting": "both", "payers_information": [ { "payer_name": "Aetna", "plan_name": "700700", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna", "plan_name": "700700_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Miscellaneous", "plan_name": "700720", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Miscellaneous", "plan_name": "700720_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Ppo Hmo", "plan_name": "701720", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Ppo Hmo", "plan_name": "701720_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Ms State Emplo", "plan_name": "401457", "standard_charge_percentage": 0.80, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Ms State Emplo", "plan_name": "401457_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Basic Pl", "plan_name": "400100", "standard_charge_percentage": 0.85, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Basic Pl", "plan_name": "400100_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Federal", "plan_name": "400110", "standard_charge_percentage": 0.85, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Federal", "plan_name": "400110_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." } ] } ] }, { "description": "Pioglitazone 45 mg tablet [25530]", "drug_information": { "unit": 1.00, "type": "EA" }, "code_information": [ { "code": "57237-221-30", "type": "NDC" } ], "standard_charges": [ { "gross_charge": 7.50, "minimum": 6.00, "maximum": 6.38, "setting": "both", "payers_information": [ { "payer_name": "Aetna", "plan_name": "700700", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna", "plan_name": "700700_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Miscellaneous", "plan_name": "700720", "standard_charge_percentage": 80.0, "count": 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"methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Ms State Emplo", "plan_name": "401457_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Basic Pl", "plan_name": "400100", "standard_charge_percentage": 0.85, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Basic Pl", "plan_name": "400100_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Federal", "plan_name": "400110", "standard_charge_percentage": 0.85, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Federal", "plan_name": "400110_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." } ] } ] }, { "description": "Venlafaxine 75 mg tablet [12206]", "drug_information": { "unit": 1.00, "type": "EA" }, "code_information": [ { "code": "57664-395-88", "type": "NDC" } ], "standard_charges": [ { "gross_charge": 7.50, "minimum": 6.00, "maximum": 6.38, "setting": "both", "payers_information": [ { "payer_name": "Aetna", "plan_name": "700700", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna", "plan_name": "700700_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Miscellaneous", "plan_name": "700720", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Miscellaneous", "plan_name": "700720_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Ppo Hmo", "plan_name": "701720", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Ppo Hmo", "plan_name": "701720_1", "standard_charge_percentage": 100.0, "count": 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"0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Federal", "plan_name": "400110", "standard_charge_percentage": 0.85, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Federal", "plan_name": "400110_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." } ] } ] }, { "description": "Digoxin 125 mcg (0.125 mg) tablet [2444]", "drug_information": { "unit": 1.00, "type": "EA" }, "code_information": [ { "code": "57664-437-88", "type": "NDC" } ], "standard_charges": [ { "gross_charge": 7.50, "minimum": 6.00, "maximum": 6.38, "setting": "both", "payers_information": [ { "payer_name": "Aetna", "plan_name": "700700", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna", "plan_name": "700700_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Miscellaneous", "plan_name": "700720", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Miscellaneous", "plan_name": "700720_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Ppo Hmo", "plan_name": "701720", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Ppo Hmo", "plan_name": "701720_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Ms State Emplo", "plan_name": "401457", "standard_charge_percentage": 0.80, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Ms State Emplo", "plan_name": "401457_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Basic Pl", "plan_name": "400100", "standard_charge_percentage": 0.85, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Basic Pl", "plan_name": "400100_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Federal", "plan_name": "400110", "standard_charge_percentage": 0.85, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Federal", "plan_name": "400110_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." } ] } ] }, { "description": "Sodium hyaluronate 12 mg/ml intraocular syringe [28924]", "drug_information": { "unit": 0.80, "type": "ML" }, "code_information": [ { "code": "5777049565", "type": "NDC" } ], "standard_charges": [ { "gross_charge": 667.80, "minimum": 534.24, "maximum": 567.63, "setting": "both", "payers_information": [ { "payer_name": "Aetna", "plan_name": "700700", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna", "plan_name": "700700_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Miscellaneous", "plan_name": "700720", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": 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"plan_name": "400110_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." } ] } ] }, { "description": "Dextromethorphan-guaifenesin 10 mg-100 mg/5 ml oral syrup [9774]", "drug_information": { "unit": 473.00, "type": "ML" }, "code_information": [ { "code": "57896-660-16", "type": "NDC" } ], "standard_charges": [ { "gross_charge": 7.38, "minimum": 5.90, "maximum": 6.27, "setting": "both", "payers_information": [ { "payer_name": "Aetna", "plan_name": "700700", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna", "plan_name": "700700_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate 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}, { "payer_name": "Bc/Bs Ms State Emplo", "plan_name": "401457", "standard_charge_percentage": 0.80, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Ms State Emplo", "plan_name": "401457_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Basic Pl", "plan_name": "400100", "standard_charge_percentage": 0.85, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Basic Pl", "plan_name": "400100_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Federal", "plan_name": "400110", "standard_charge_percentage": 0.85, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Federal", "plan_name": "400110_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." } ] } ] }, { "description": "Dextromethorphan-guaifenesin 10 mg-100 mg/5 ml oral liquid [108397]", "drug_information": { "unit": 118.00, "type": "ML" }, "code_information": [ { "code": "57896-756-04", "type": "NDC" } ], "standard_charges": [ { "gross_charge": 5.22, "minimum": 4.18, "maximum": 4.44, "setting": "both", "payers_information": [ { "payer_name": "Aetna", "plan_name": "700700", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", 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"Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Basic Pl", "plan_name": "400100_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Federal", "plan_name": "400110", "standard_charge_percentage": 0.85, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Federal", "plan_name": "400110_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." } ] } ] }, { "description": "Simethicone 80 mg chewable tablet [7227]", "drug_information": { "unit": 1.00, "type": "EA" }, "code_information": [ { "code": "57896-791-01", "type": "NDC" } ], 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"additional_payer_notes": "Insufficient remit data to calculate allowed amounts." } ] } ] }, { "description": "Guaifenesin 100 mg/5 ml oral liquid [3542]", "drug_information": { "unit": 473.00, "type": "ML" }, "code_information": [ { "code": "57896-793-16", "type": "NDC" } ], "standard_charges": [ { "gross_charge": 7.38, "minimum": 5.90, "maximum": 6.27, "setting": "both", "payers_information": [ { "payer_name": "Aetna", "plan_name": "700700", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna", "plan_name": "700700_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Miscellaneous", "plan_name": "700720", "standard_charge_percentage": 80.0, "count": "0", "methodology": 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"count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Miscellaneous", "plan_name": "700720", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Miscellaneous", "plan_name": "700720_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Ppo Hmo", "plan_name": "701720", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Ppo Hmo", "plan_name": "701720_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Ms State Emplo", "plan_name": "401457", "standard_charge_percentage": 0.80, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Ms State Emplo", "plan_name": "401457_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Basic Pl", "plan_name": "400100", "standard_charge_percentage": 0.85, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Basic Pl", "plan_name": "400100_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Federal", "plan_name": "400110", "standard_charge_percentage": 0.85, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Federal", "plan_name": "400110_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." } ] } ] }, { "description": "Aspirin 325 mg tablet [681]", "drug_information": { "unit": 1.00, "type": "EA" }, "code_information": [ { "code": "57896-901-01", "type": "NDC" } ], "standard_charges": [ { "gross_charge": 1.00, "minimum": 0.80, "maximum": 0.85, "setting": "both", "payers_information": [ { "payer_name": "Aetna", "plan_name": "700700", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna", "plan_name": "700700_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Miscellaneous", "plan_name": "700720", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Miscellaneous", "plan_name": "700720_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Ppo Hmo", "plan_name": "701720", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Ppo Hmo", "plan_name": "701720_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Ms State Emplo", "plan_name": "401457", "standard_charge_percentage": 0.80, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Ms State Emplo", "plan_name": "401457_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Basic Pl", "plan_name": "400100", "standard_charge_percentage": 0.85, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Basic Pl", "plan_name": "400100_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Federal", "plan_name": "400110", "standard_charge_percentage": 0.85, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Federal", "plan_name": "400110_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." } ] } ] }, { "description": "Therapeutic multivitamin tablet [7857]", "drug_information": { "unit": 1.00, "type": "EA" }, "code_information": [ { "code": "5789660101", "type": "NDC" } ], "standard_charges": [ { "gross_charge": 1.00, "minimum": 0.80, "maximum": 0.85, "setting": "both", "payers_information": [ { "payer_name": "Aetna", "plan_name": "700700", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna", "plan_name": "700700_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Miscellaneous", "plan_name": "700720", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Miscellaneous", "plan_name": "700720_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Ppo Hmo", "plan_name": "701720", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Ppo Hmo", "plan_name": "701720_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Ms State Emplo", "plan_name": "401457", "standard_charge_percentage": 0.80, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Ms State Emplo", "plan_name": "401457_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Basic Pl", "plan_name": "400100", "standard_charge_percentage": 0.85, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Basic Pl", "plan_name": "400100_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Federal", "plan_name": "400110", "standard_charge_percentage": 0.85, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Federal", "plan_name": 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amounts." }, { "payer_name": "Bc/Bs Of Ms Federal", "plan_name": "400110", "standard_charge_percentage": 0.85, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Federal", "plan_name": "400110_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." } ] } ] }, { "description": "Sevelamer carbonate 0.8 gram oral powder packet [99694]", "drug_information": { "unit": 1.00, "type": "EA" }, "code_information": [ { "code": "58468-0132-1", "type": "NDC" } ], "standard_charges": [ { "gross_charge": 79.74, "minimum": 63.79, "maximum": 67.78, "setting": "both", "payers_information": [ { "payer_name": "Aetna", "plan_name": "700700", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna", "plan_name": "700700_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Miscellaneous", "plan_name": "700720", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Miscellaneous", "plan_name": "700720_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Ppo Hmo", "plan_name": "701720", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Ppo Hmo", "plan_name": "701720_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Ms State Emplo", "plan_name": "401457", "standard_charge_percentage": 0.80, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Ms State Emplo", "plan_name": "401457_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Basic Pl", "plan_name": "400100", "standard_charge_percentage": 0.85, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Basic Pl", "plan_name": "400100_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Federal", "plan_name": "400110", "standard_charge_percentage": 0.85, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Federal", "plan_name": "400110_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." } ] } ] }, { "description": "Hyoscyamine 0.125 mg/5 ml oral elixir [3781]", "drug_information": { "unit": 473.00, "type": "ML" }, "code_information": [ { "code": "58657-427-16", "type": "NDC" } ], 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charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Ppo Hmo", "plan_name": "701720", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Ppo Hmo", "plan_name": "701720_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Ms State Emplo", "plan_name": "401457", "standard_charge_percentage": 0.80, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Ms State Emplo", "plan_name": "401457_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Basic Pl", "plan_name": "400100", "standard_charge_percentage": 0.85, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Basic Pl", "plan_name": "400100_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Federal", "plan_name": "400110", "standard_charge_percentage": 0.85, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Federal", "plan_name": "400110_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." } ] } ] }, { "description": "Methenamine 81.6 mg-sod phos 40.8 mg-methylene blue 0.12mg-hyos tablet [119920]", "drug_information": { "unit": 1.00, "type": "EA" }, "code_information": [ { "code": "58657-454-01", "type": "NDC" } ], "standard_charges": [ { "gross_charge": 22.32, "minimum": 17.86, "maximum": 18.97, "setting": "both", "payers_information": [ { "payer_name": "Aetna", "plan_name": "700700", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna", "plan_name": "700700_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Miscellaneous", "plan_name": "700720", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Miscellaneous", "plan_name": "700720_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Ppo Hmo", "plan_name": "701720", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Ppo Hmo", "plan_name": "701720_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Ms State Emplo", "plan_name": "401457", "standard_charge_percentage": 0.80, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Ms State Emplo", "plan_name": "401457_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Basic Pl", "plan_name": "400100", "standard_charge_percentage": 0.85, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Basic Pl", "plan_name": "400100_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Federal", "plan_name": "400110", "standard_charge_percentage": 0.85, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Federal", "plan_name": "400110_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." } ] } ] }, { "description": "Sucralfate 100 mg/ml oral suspension [11441]", "drug_information": { "unit": 420.00, "type": "ML" }, "code_information": [ { "code": "58914-170-14", "type": "NDC" } ], "standard_charges": [ { "gross_charge": 1193.01, "minimum": 954.41, "maximum": 1014.06, "setting": "both", "payers_information": [ { "payer_name": "Aetna", "plan_name": "700700", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna", "plan_name": "700700_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Miscellaneous", "plan_name": "700720", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Miscellaneous", "plan_name": "700720_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Ppo Hmo", "plan_name": "701720", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Ppo Hmo", "plan_name": "701720_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Ms State Emplo", "plan_name": "401457", "standard_charge_percentage": 0.80, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Ms State Emplo", "plan_name": "401457_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Basic Pl", "plan_name": "400100", "standard_charge_percentage": 0.85, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Basic Pl", "plan_name": "400100_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Federal", "plan_name": "400110", "standard_charge_percentage": 0.85, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Federal", "plan_name": "400110_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." } ] } ] }, { "description": "Bacitracin zinc 500 unit/gram topical ointment [13818]", "drug_information": { "unit": 28.35, "type": "GR" }, "code_information": [ { "code": "58980-011-10", "type": "NDC" } ], "standard_charges": [ { "gross_charge": 13.27, "minimum": 10.62, "maximum": 11.28, "setting": "both", "payers_information": [ { "payer_name": "Aetna", "plan_name": "700700", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna", "plan_name": "700700_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Miscellaneous", "plan_name": "700720", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Miscellaneous", "plan_name": "700720_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Ppo Hmo", "plan_name": "701720", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Ppo Hmo", "plan_name": "701720_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Ms State Emplo", "plan_name": "401457", "standard_charge_percentage": 0.80, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Ms State Emplo", "plan_name": "401457_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Basic Pl", "plan_name": "400100", "standard_charge_percentage": 0.85, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Basic Pl", "plan_name": "400100_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Federal", "plan_name": "400110", "standard_charge_percentage": 0.85, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Federal", "plan_name": "400110_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." } ] } ] }, { "description": "Glycerin (child) rectal suppository [3492]", "drug_information": { "unit": 12.00, "type": "EA" }, "code_information": [ { "code": "58980-409-12", "type": "NDC" } ], "standard_charges": [ { "gross_charge": 22.56, "minimum": 18.05, "maximum": 19.18, "setting": "both", "payers_information": [ { "payer_name": "Aetna", "plan_name": "700700", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna", "plan_name": "700700_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Miscellaneous", "plan_name": "700720", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Miscellaneous", "plan_name": "700720_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Ppo Hmo", "plan_name": "701720", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Ppo Hmo", "plan_name": "701720_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Ms State Emplo", "plan_name": "401457", "standard_charge_percentage": 0.80, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Ms State Emplo", "plan_name": "401457_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Basic Pl", "plan_name": "400100", "standard_charge_percentage": 0.85, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Basic Pl", "plan_name": "400100_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Federal", "plan_name": "400110", "standard_charge_percentage": 0.85, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Federal", "plan_name": "400110_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." } ] } ] }, { "description": "Glycerin (child) rectal suppository [3492]", "drug_information": { "unit": 25.00, "type": "EA" }, "code_information": [ { "code": "58980-409-25", "type": "NDC" } ], "standard_charges": [ { "gross_charge": 33.93, "minimum": 27.14, "maximum": 28.84, "setting": "both", "payers_information": [ { "payer_name": "Aetna", "plan_name": "700700", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna", "plan_name": "700700_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Miscellaneous", "plan_name": "700720", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Miscellaneous", "plan_name": "700720_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Ppo Hmo", "plan_name": "701720", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Ppo Hmo", "plan_name": "701720_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient 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"code": "59651-499-01", "type": "NDC" } ], "standard_charges": [ { "gross_charge": 7.50, "minimum": 6.00, "maximum": 6.38, "setting": "both", "payers_information": [ { "payer_name": "Aetna", "plan_name": "700700", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna", "plan_name": "700700_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Miscellaneous", "plan_name": "700720", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Miscellaneous", "plan_name": "700720_1", "standard_charge_percentage": 100.0, "count": "0", 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"percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." } ] } ] }, { "description": "Nitroglycerin 0.4 mg sublingual tablet [5604]", "drug_information": { "unit": 1.00, "type": "EA" }, "code_information": [ { "code": "59651-658-25", "type": "NDC" } ], "standard_charges": [ { "gross_charge": 7.50, "minimum": 6.00, "maximum": 6.38, "setting": "both", "payers_information": [ { "payer_name": "Aetna", "plan_name": "700700", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna", "plan_name": "700700_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Miscellaneous", "plan_name": "700720", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Miscellaneous", "plan_name": "700720_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Ppo Hmo", "plan_name": "701720", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Ppo Hmo", "plan_name": "701720_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Ms State Emplo", "plan_name": "401457", "standard_charge_percentage": 0.80, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Ms State Emplo", "plan_name": "401457_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Basic Pl", "plan_name": "400100", "standard_charge_percentage": 0.85, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Basic Pl", "plan_name": "400100_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Federal", "plan_name": "400110", "standard_charge_percentage": 0.85, "count": 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"standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Federal", "plan_name": "400110", "standard_charge_percentage": 0.85, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Federal", "plan_name": "400110_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." } ] } ] }, { "description": "Glipizide er 2.5 mg tablet extended release 24 hr [37648]", "drug_information": { "unit": 1.00, "type": "EA" }, "code_information": [ { "code": "59651-780-30", "type": "NDC" } ], "standard_charges": [ { "gross_charge": 7.50, "minimum": 6.00, "maximum": 6.38, "setting": "both", 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"payer_name": "Aetna Ppo Hmo", "plan_name": "701720", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Ppo Hmo", "plan_name": "701720_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Ms State Emplo", "plan_name": "401457", "standard_charge_percentage": 0.80, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Ms State Emplo", "plan_name": "401457_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Basic Pl", "plan_name": "400100", "standard_charge_percentage": 0.85, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Basic Pl", "plan_name": "400100_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Federal", "plan_name": "400110", "standard_charge_percentage": 0.85, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Federal", "plan_name": "400110_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." } ] } ] }, { "description": "Sodium nitrite-sodium thiosulfate 300 mg/10 ml-12.5 gram/50 ml iv soln [151109]", "drug_information": { "unit": 60.00, "type": "ML" }, "code_information": [ { "code": "60267-812-00", "type": "NDC" } ], "standard_charges": [ { "gross_charge": 950.10, "minimum": 760.08, "maximum": 807.59, "setting": "both", "payers_information": [ { "payer_name": "Aetna", "plan_name": "700700", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna", "plan_name": "700700_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Miscellaneous", "plan_name": "700720", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Miscellaneous", "plan_name": "700720_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Ppo Hmo", "plan_name": "701720", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Ppo Hmo", "plan_name": "701720_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Ms State Emplo", "plan_name": "401457", "standard_charge_percentage": 0.80, "count": "0", "methodology": "percent of total billed charges", 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"standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Miscellaneous", "plan_name": "700720", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Miscellaneous", "plan_name": "700720_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Ppo Hmo", "plan_name": "701720", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Ppo Hmo", "plan_name": "701720_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Ms State Emplo", "plan_name": "401457", "standard_charge_percentage": 0.80, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Ms State Emplo", "plan_name": "401457_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Basic Pl", "plan_name": "400100", "standard_charge_percentage": 0.85, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Basic Pl", "plan_name": "400100_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Federal", "plan_name": "400110", "standard_charge_percentage": 0.85, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Federal", "plan_name": "400110_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." } ] } ] }, { "description": "Amoxicillin 250 mg-potassium clavulanate 62.5 mg/5 ml oral suspension [9080]", "drug_information": { "unit": 75.00, "type": "ML" }, "code_information": [ { "code": "60432-065-75", "type": "NDC" } ], "standard_charges": [ { "gross_charge": 307.44, "minimum": 245.95, "maximum": 261.32, "setting": "both", "payers_information": [ { "payer_name": "Aetna", "plan_name": "700700", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna", "plan_name": "700700_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Miscellaneous", "plan_name": "700720", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Miscellaneous", "plan_name": "700720_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed 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"payer_name": "Bc/Bs Of Ms Basic Pl", "plan_name": "400100", "standard_charge_percentage": 0.85, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Basic Pl", "plan_name": "400100_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Federal", "plan_name": "400110", "standard_charge_percentage": 0.85, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Federal", "plan_name": "400110_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." } ] } ] }, { "description": "Carbamazepine 100 mg/5 ml oral suspension [109663]", "drug_information": { "unit": 450.00, "type": "ML" }, "code_information": [ { "code": "60432-129-16", "type": "NDC" } ], "standard_charges": [ { "gross_charge": 284.29, "minimum": 227.43, "maximum": 241.65, "setting": "both", "payers_information": [ { "payer_name": "Aetna", "plan_name": "700700", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna", "plan_name": "700700_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Miscellaneous", "plan_name": "700720", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit 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"methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Basic Pl", "plan_name": "400100_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Federal", "plan_name": "400110", "standard_charge_percentage": 0.85, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Federal", "plan_name": "400110_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." } ] } ] }, { "description": "Pentoxifylline er 400 mg tabletextended release [10911]", "drug_information": { "unit": 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"standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." } ] } ] }, { "description": "Doxazosin 1 mg tablet [9894]", "drug_information": { "unit": 1.00, "type": "EA" }, "code_information": [ { "code": "60505-0093-0", "type": "NDC" } ], "standard_charges": [ { "gross_charge": 7.50, "minimum": 6.00, "maximum": 6.38, "setting": "both", "payers_information": [ { "payer_name": "Aetna", "plan_name": "700700", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna", "plan_name": "700700_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Miscellaneous", "plan_name": "700720", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Miscellaneous", "plan_name": "700720_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Ppo Hmo", "plan_name": "701720", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Ppo Hmo", "plan_name": "701720_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Ms State Emplo", "plan_name": "401457", "standard_charge_percentage": 0.80, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Ms State Emplo", "plan_name": "401457_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Basic Pl", "plan_name": "400100", "standard_charge_percentage": 0.85, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Basic Pl", "plan_name": "400100_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Federal", "plan_name": "400110", "standard_charge_percentage": 0.85, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Federal", "plan_name": "400110_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." } ] } ] }, { "description": "Doxazosin 4 mg tablet [9896]", "drug_information": { "unit": 1.00, "type": "EA" }, "code_information": [ { "code": "60505-0095-0", "type": "NDC" } ], "standard_charges": [ { "gross_charge": 7.50, "minimum": 6.00, "maximum": 6.38, "setting": "both", "payers_information": [ { "payer_name": "Aetna", "plan_name": "700700", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna", "plan_name": "700700_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Miscellaneous", "plan_name": "700720", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Miscellaneous", "plan_name": "700720_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Ppo Hmo", "plan_name": "701720", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Ppo Hmo", "plan_name": "701720_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Ms State Emplo", "plan_name": "401457", "standard_charge_percentage": 0.80, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Ms State Emplo", "plan_name": "401457_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Basic Pl", "plan_name": "400100", "standard_charge_percentage": 0.85, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Basic Pl", "plan_name": "400100_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Federal", "plan_name": "400110", "standard_charge_percentage": 0.85, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Federal", "plan_name": "400110_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." } ] } ] }, { "description": "Glipizide 5 mg tablet [10117]", "drug_information": { "unit": 1.00, "type": "EA" }, "code_information": [ { "code": "60505-0141-0", "type": "NDC" } ], "standard_charges": [ { "gross_charge": 7.50, "minimum": 6.00, "maximum": 6.38, "setting": "both", 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"payer_name": "Aetna Ppo Hmo", "plan_name": "701720", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Ppo Hmo", "plan_name": "701720_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Ms State Emplo", "plan_name": "401457", "standard_charge_percentage": 0.80, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Ms State Emplo", "plan_name": "401457_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Basic Pl", "plan_name": "400100", "standard_charge_percentage": 0.85, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Basic Pl", "plan_name": "400100_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Federal", "plan_name": "400110", "standard_charge_percentage": 0.85, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Federal", "plan_name": "400110_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." } ] } ] }, { "description": "Bupropion hcl 100 mg tablet [9321]", "drug_information": { "unit": 1.00, "type": "EA" }, "code_information": [ { "code": "60505-0157-1", "type": "NDC" } ], "standard_charges": [ { "gross_charge": 7.50, "minimum": 6.00, "maximum": 6.38, "setting": "both", "payers_information": [ { "payer_name": "Aetna", "plan_name": "700700", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna", "plan_name": "700700_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Miscellaneous", "plan_name": "700720", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Miscellaneous", "plan_name": "700720_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Ppo Hmo", "plan_name": "701720", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Ppo Hmo", "plan_name": "701720_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Ms State Emplo", "plan_name": "401457", "standard_charge_percentage": 0.80, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Ms State Emplo", "plan_name": "401457_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Basic Pl", "plan_name": "400100", "standard_charge_percentage": 0.85, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Basic Pl", "plan_name": "400100_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Federal", "plan_name": "400110", "standard_charge_percentage": 0.85, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Federal", "plan_name": "400110_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." } ] } ] }, { "description": "Sotalol 120 mg tablet [15723]", "drug_information": { "unit": 1.00, "type": "EA" }, "code_information": [ { "code": "60505-0159-0", "type": "NDC" } ], "standard_charges": [ { "gross_charge": 7.50, "minimum": 6.00, "maximum": 6.38, "setting": "both", "payers_information": [ { "payer_name": "Aetna", "plan_name": "700700", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna", "plan_name": "700700_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Miscellaneous", "plan_name": "700720", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Miscellaneous", "plan_name": "700720_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Ppo Hmo", "plan_name": "701720", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Ppo Hmo", "plan_name": "701720_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Ms State Emplo", "plan_name": "401457", "standard_charge_percentage": 0.80, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Ms State Emplo", "plan_name": "401457_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Basic Pl", "plan_name": "400100", "standard_charge_percentage": 0.85, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Basic Pl", "plan_name": "400100_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Federal", "plan_name": "400110", "standard_charge_percentage": 0.85, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Federal", "plan_name": "400110_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." } ] } ] }, { "description": "Fluvoxamine 50 mg tablet [10085]", "drug_information": { "unit": 1.00, "type": "EA" }, "code_information": [ { "code": "60505-0165-1", "type": "NDC" } ], "standard_charges": [ { "gross_charge": 7.50, "minimum": 6.00, "maximum": 6.38, "setting": "both", "payers_information": [ { "payer_name": "Aetna", "plan_name": "700700", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna", "plan_name": "700700_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Miscellaneous", "plan_name": "700720", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Miscellaneous", "plan_name": "700720_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Ppo Hmo", "plan_name": "701720", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Ppo Hmo", "plan_name": "701720_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Ms State Emplo", "plan_name": "401457", "standard_charge_percentage": 0.80, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Ms State Emplo", "plan_name": "401457_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Basic Pl", "plan_name": "400100", "standard_charge_percentage": 0.85, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Basic Pl", "plan_name": "400100_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Federal", "plan_name": "400110", "standard_charge_percentage": 0.85, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Federal", "plan_name": "400110_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." } ] } ] }, { "description": "Carbamazepine 200 mg tablet [1357]", "drug_information": { "unit": 1.00, "type": "EA" }, "code_information": [ { "code": "60505-0183-0", "type": "NDC" } ], "standard_charges": [ { "gross_charge": 7.50, "minimum": 6.00, "maximum": 6.38, "setting": "both", "payers_information": [ { "payer_name": "Aetna", "plan_name": "700700", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna", "plan_name": "700700_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Miscellaneous", "plan_name": "700720", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Miscellaneous", "plan_name": "700720_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Ppo Hmo", "plan_name": "701720", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Ppo Hmo", "plan_name": "701720_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Ms State Emplo", "plan_name": "401457", "standard_charge_percentage": 0.80, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Ms State Emplo", "plan_name": "401457_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Basic Pl", "plan_name": "400100", "standard_charge_percentage": 0.85, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Basic Pl", "plan_name": "400100_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Federal", "plan_name": "400110", "standard_charge_percentage": 0.85, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Federal", "plan_name": "400110_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." } ] } ] }, { "description": "Ofloxacin 0.3 % ear drops [22257]", "drug_information": { "unit": 5.00, "type": "ML" }, "code_information": [ { "code": "60505-0363-1", "type": "NDC" } ], "standard_charges": [ { "gross_charge": 455.10, "minimum": 364.08, "maximum": 386.84, "setting": "both", "payers_information": [ { "payer_name": "Aetna", "plan_name": "700700", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna", "plan_name": "700700_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Miscellaneous", "plan_name": "700720", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Miscellaneous", "plan_name": "700720_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Ppo Hmo", "plan_name": "701720", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Ppo Hmo", "plan_name": "701720_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Ms State Emplo", "plan_name": "401457", "standard_charge_percentage": 0.80, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Ms State Emplo", "plan_name": "401457_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Basic Pl", "plan_name": "400100", "standard_charge_percentage": 0.85, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Basic Pl", "plan_name": "400100_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Federal", "plan_name": "400110", "standard_charge_percentage": 0.85, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Federal", "plan_name": "400110_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." } ] } ] }, { "description": "Ofloxacin 0.3 % ear drops [22257]", "drug_information": { "unit": 10.00, "type": "ML" }, "code_information": [ { "code": "60505-0363-2", "type": "NDC" } ], "standard_charges": [ { "gross_charge": 910.20, "minimum": 728.16, "maximum": 773.67, "setting": "both", "payers_information": [ { "payer_name": "Aetna", "plan_name": "700700", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna", "plan_name": "700700_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Miscellaneous", "plan_name": "700720", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Miscellaneous", "plan_name": "700720_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Ppo Hmo", "plan_name": "701720", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Ppo Hmo", "plan_name": "701720_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Ms State Emplo", "plan_name": "401457", "standard_charge_percentage": 0.80, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Ms State Emplo", "plan_name": "401457_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Basic Pl", "plan_name": "400100", "standard_charge_percentage": 0.85, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Basic Pl", "plan_name": "400100_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Federal", "plan_name": "400110", "standard_charge_percentage": 0.85, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Federal", "plan_name": "400110_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." } ] } ] }, { "description": "Ofloxacin 0.3 % eye drops [19746]", "drug_information": { "unit": 10.00, "type": "ML" }, "code_information": [ { "code": "60505-0560-1", "type": "NDC" } ], "standard_charges": [ { "gross_charge": 191.76, "minimum": 153.41, "maximum": 163.00, "setting": "both", "payers_information": [ { "payer_name": "Aetna", "plan_name": "700700", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna", "plan_name": "700700_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Miscellaneous", "plan_name": "700720", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Miscellaneous", "plan_name": "700720_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Ppo Hmo", "plan_name": "701720", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Ppo Hmo", "plan_name": "701720_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Ms State Emplo", "plan_name": "401457", "standard_charge_percentage": 0.80, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Ms State Emplo", "plan_name": "401457_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Basic Pl", "plan_name": "400100", "standard_charge_percentage": 0.85, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Basic Pl", "plan_name": "400100_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Federal", "plan_name": "400110", "standard_charge_percentage": 0.85, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Federal", "plan_name": "400110_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." } ] } ] }, { "description": "Brimonidine 0.2 %-timolol 0.5 % eye drops [87834]", "drug_information": { "unit": 5.00, "type": "ML" }, "code_information": [ { "code": "60505-0589-1", "type": "NDC" } ], "standard_charges": [ { "gross_charge": 969.62, "minimum": 775.70, "maximum": 824.18, "setting": "both", "payers_information": [ { "payer_name": "Aetna", "plan_name": "700700", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna", "plan_name": "700700_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Miscellaneous", "plan_name": "700720", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Miscellaneous", "plan_name": "700720_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Ppo Hmo", "plan_name": "701720", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Ppo Hmo", "plan_name": "701720_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Ms State Emplo", "plan_name": "401457", "standard_charge_percentage": 0.80, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Ms State Emplo", "plan_name": "401457_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Basic Pl", "plan_name": "400100", "standard_charge_percentage": 0.85, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Basic Pl", "plan_name": "400100_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Federal", "plan_name": "400110", "standard_charge_percentage": 0.85, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Federal", "plan_name": "400110_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." } ] } ] }, { "description": "Calcitonin (salmon) 200 unit/actuation nasal spray [15738]", "drug_information": { "unit": 3.70, "type": "ML" }, "code_information": [ { "code": "60505-0823-6", "type": "NDC" } ], "standard_charges": [ { "gross_charge": 524.21, "minimum": 419.37, "maximum": 445.58, "setting": "both", "payers_information": [ { "payer_name": "Aetna", "plan_name": "700700", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna", "plan_name": "700700_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Miscellaneous", "plan_name": "700720", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Miscellaneous", "plan_name": "700720_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Ppo Hmo", "plan_name": "701720", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Ppo Hmo", "plan_name": "701720_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Ms State Emplo", "plan_name": "401457", "standard_charge_percentage": 0.80, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Ms State Emplo", "plan_name": "401457_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Basic Pl", "plan_name": "400100", "standard_charge_percentage": 0.85, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Basic Pl", "plan_name": "400100_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Federal", "plan_name": "400110", "standard_charge_percentage": 0.85, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Federal", "plan_name": "400110_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." } ] } ] }, { "description": "Fluticasone propionate 50 mcg/actuation nasal spraysuspension [70536]", "drug_information": { "unit": 16.00, "type": "GR" }, "code_information": [ { "code": "60505-0829-1", "type": "NDC" } ], "standard_charges": [ { "gross_charge": 126.01, "minimum": 100.81, "maximum": 107.11, "setting": "both", "payers_information": [ { "payer_name": "Aetna", "plan_name": "700700", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna", "plan_name": "700700_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Miscellaneous", "plan_name": "700720", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Miscellaneous", "plan_name": "700720_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Ppo Hmo", "plan_name": "701720", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Ppo Hmo", "plan_name": "701720_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Ms State Emplo", "plan_name": "401457", "standard_charge_percentage": 0.80, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Ms State Emplo", "plan_name": "401457_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Basic Pl", "plan_name": "400100", "standard_charge_percentage": 0.85, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Basic Pl", "plan_name": "400100_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Federal", "plan_name": "400110", "standard_charge_percentage": 0.85, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Federal", "plan_name": "400110_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." } ] } ] }, { "description": "Mometasone 50 mcg/actuation nasal spray [21905]", "drug_information": { "unit": 17.00, "type": "GR" }, "code_information": [ { "code": "60505-0830-1", "type": "NDC" } ], "standard_charges": [ { "gross_charge": 840.20, "minimum": 672.16, "maximum": 714.17, "setting": "both", "payers_information": [ { "payer_name": "Aetna", "plan_name": "700700", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna", "plan_name": "700700_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Miscellaneous", "plan_name": "700720", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Miscellaneous", "plan_name": "700720_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Ppo Hmo", "plan_name": "701720", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Ppo Hmo", "plan_name": "701720_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Ms State Emplo", "plan_name": "401457", "standard_charge_percentage": 0.80, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Ms State Emplo", "plan_name": "401457_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Basic Pl", "plan_name": "400100", "standard_charge_percentage": 0.85, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Basic Pl", "plan_name": "400100_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Federal", "plan_name": "400110", "standard_charge_percentage": 0.85, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Federal", "plan_name": "400110_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." } ] } ] }, { "description": "Azelastine 137 mcg (0.1 %) nasal spray [19179]", "drug_information": { "unit": 30.00, "type": "ML" }, "code_information": [ { "code": "60505-0833-5", "type": "NDC" } ], "standard_charges": [ { "gross_charge": 152.33, "minimum": 121.86, "maximum": 129.48, "setting": "both", "payers_information": [ { "payer_name": "Aetna", "plan_name": "700700", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna", "plan_name": "700700_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Miscellaneous", "plan_name": "700720", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Miscellaneous", "plan_name": "700720_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Ppo Hmo", "plan_name": "701720", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Ppo Hmo", "plan_name": "701720_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Ms State Emplo", "plan_name": "401457", "standard_charge_percentage": 0.80, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Ms State Emplo", "plan_name": "401457_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Basic Pl", "plan_name": "400100", "standard_charge_percentage": 0.85, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Basic Pl", "plan_name": "400100_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Federal", "plan_name": "400110", "standard_charge_percentage": 0.85, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Federal", "plan_name": "400110_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." } ] } ] }, { "description": "Ketorolac 0.5 % eye drops [19733]", "drug_information": { "unit": 5.00, "type": "ML" }, "code_information": [ { "code": "60505-1003-1", "type": "NDC" } ], "standard_charges": [ { "gross_charge": 224.49, "minimum": 179.59, "maximum": 190.82, "setting": "both", "payers_information": [ { "payer_name": "Aetna", "plan_name": "700700", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna", "plan_name": "700700_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Miscellaneous", "plan_name": "700720", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Miscellaneous", "plan_name": "700720_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Ppo Hmo", "plan_name": "701720", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Ppo Hmo", "plan_name": "701720_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Ms State Emplo", "plan_name": "401457", "standard_charge_percentage": 0.80, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Ms State Emplo", "plan_name": "401457_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Basic Pl", "plan_name": "400100", "standard_charge_percentage": 0.85, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Basic Pl", "plan_name": "400100_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Federal", "plan_name": "400110", "standard_charge_percentage": 0.85, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Federal", "plan_name": "400110_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." } ] } ] }, { "description": "Midodrine 5 mg tablet [10610]", "drug_information": { "unit": 1.00, "type": "EA" }, "code_information": [ { "code": "60505-1321-1", "type": "NDC" } ], "standard_charges": [ { "gross_charge": 7.50, "minimum": 6.00, "maximum": 6.38, "setting": "both", "payers_information": [ { "payer_name": "Aetna", "plan_name": "700700", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna", "plan_name": "700700_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Miscellaneous", "plan_name": "700720", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Miscellaneous", "plan_name": "700720_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Ppo Hmo", "plan_name": "701720", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Ppo Hmo", "plan_name": "701720_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Ms State Emplo", "plan_name": "401457", "standard_charge_percentage": 0.80, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Ms State Emplo", "plan_name": "401457_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Basic Pl", "plan_name": "400100", "standard_charge_percentage": 0.85, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Basic Pl", "plan_name": "400100_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Federal", "plan_name": "400110", "standard_charge_percentage": 0.85, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Federal", "plan_name": "400110_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." } ] } ] }, { "description": "Triamterene 37.5 mg-hydrochlorothiazide 25 mg tablet [8132]", "drug_information": { "unit": 1.00, "type": "EA" }, "code_information": [ { "code": "60505-2656-1", "type": "NDC" } ], "standard_charges": [ { "gross_charge": 7.50, "minimum": 6.00, "maximum": 6.38, "setting": "both", "payers_information": [ { "payer_name": "Aetna", "plan_name": "700700", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna", "plan_name": "700700_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Miscellaneous", "plan_name": "700720", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Miscellaneous", "plan_name": "700720_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Ppo Hmo", "plan_name": "701720", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Ppo Hmo", "plan_name": "701720_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Ms State Emplo", "plan_name": "401457", "standard_charge_percentage": 0.80, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Ms State Emplo", "plan_name": "401457_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Basic Pl", "plan_name": "400100", "standard_charge_percentage": 0.85, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Basic Pl", "plan_name": "400100_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Federal", "plan_name": "400110", "standard_charge_percentage": 0.85, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Federal", "plan_name": "400110_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." } ] } ] }, { "description": "Triamterene 75 mg-hydrochlorothiazide 50 mg tablet [8134]", "drug_information": { "unit": 1.00, "type": "EA" }, "code_information": [ { "code": "60505-2657-1", "type": "NDC" } ], "standard_charges": [ { "gross_charge": 7.50, "minimum": 6.00, "maximum": 6.38, "setting": "both", "payers_information": [ { "payer_name": "Aetna", "plan_name": "700700", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna", "plan_name": "700700_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Miscellaneous", "plan_name": "700720", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Miscellaneous", "plan_name": "700720_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Ppo Hmo", "plan_name": "701720", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Ppo Hmo", "plan_name": "701720_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Ms State Emplo", "plan_name": "401457", "standard_charge_percentage": 0.80, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Ms State Emplo", "plan_name": "401457_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Basic Pl", "plan_name": "400100", "standard_charge_percentage": 0.85, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Basic Pl", "plan_name": "400100_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Federal", "plan_name": "400110", "standard_charge_percentage": 0.85, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Federal", "plan_name": "400110_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." } ] } ] }, { "description": "Olanzapine 5 mg tablet [17936]", "drug_information": { "unit": 1.00, "type": "EA" }, "code_information": [ { "code": "60505-3111-0", "type": "NDC" } ], "standard_charges": [ { "gross_charge": 7.50, "minimum": 6.00, "maximum": 6.38, "setting": "both", "payers_information": [ { "payer_name": "Aetna", "plan_name": "700700", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna", "plan_name": "700700_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Miscellaneous", "plan_name": "700720", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Miscellaneous", "plan_name": "700720_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Ppo Hmo", "plan_name": "701720", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Ppo Hmo", "plan_name": "701720_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Ms State Emplo", "plan_name": "401457", "standard_charge_percentage": 0.80, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Ms State Emplo", "plan_name": "401457_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Basic Pl", "plan_name": "400100", "standard_charge_percentage": 0.85, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Basic Pl", "plan_name": "400100_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Federal", "plan_name": "400110", "standard_charge_percentage": 0.85, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Federal", "plan_name": "400110_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." } ] } ] }, { "description": "Tolvaptan 15 mg tablet [97893]", "drug_information": { "unit": 1.00, "type": "EA" }, "code_information": [ { "code": "60505-4317-0", "type": "NDC" } ], "standard_charges": [ { "gross_charge": 1180.63, "minimum": 944.50, "maximum": 1003.54, "setting": "both", "payers_information": [ { "payer_name": "Aetna", "plan_name": "700700", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna", "plan_name": "700700_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Miscellaneous", "plan_name": "700720", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Miscellaneous", "plan_name": "700720_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Ppo Hmo", "plan_name": "701720", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Ppo Hmo", "plan_name": "701720_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Ms State Emplo", "plan_name": "401457", "standard_charge_percentage": 0.80, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Ms State Emplo", "plan_name": "401457_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Basic Pl", "plan_name": "400100", "standard_charge_percentage": 0.85, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Basic Pl", "plan_name": "400100_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Federal", "plan_name": "400110", "standard_charge_percentage": 0.85, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Federal", "plan_name": "400110_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." } ] } ] }, { "description": "Iodine-potassium iodide 5 %-10 % topical solution [3961]", "drug_information": { "unit": 8.00, "type": "ML" }, "code_information": [ { "code": "59365-6064-0", "type": "NDC" } ], "standard_charges": [ { "gross_charge": 37.39, "minimum": 29.91, "maximum": 31.78, "setting": "both", "payers_information": [ { "payer_name": "Aetna", "plan_name": "700700", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna", "plan_name": "700700_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Miscellaneous", "plan_name": "700720", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Miscellaneous", "plan_name": "700720_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Ppo Hmo", "plan_name": "701720", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Ppo Hmo", "plan_name": "701720_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Ms State Emplo", "plan_name": "401457", "standard_charge_percentage": 0.80, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Ms State Emplo", "plan_name": "401457_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Basic Pl", "plan_name": "400100", "standard_charge_percentage": 0.85, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Basic Pl", "plan_name": "400100_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Federal", "plan_name": "400110", "standard_charge_percentage": 0.85, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Federal", "plan_name": "400110_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." } ] } ] }, { "description": "Terazosin 1 mg capsule [14550]", "drug_information": { "unit": 1.00, "type": "EA" }, "code_information": [ { "code": "59746-383-06", "type": "NDC" } ], "standard_charges": [ { "gross_charge": 7.50, "minimum": 6.00, "maximum": 6.38, "setting": "both", "payers_information": [ { "payer_name": "Aetna", "plan_name": "700700", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna", "plan_name": "700700_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Miscellaneous", "plan_name": "700720", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Miscellaneous", "plan_name": "700720_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Ppo Hmo", "plan_name": "701720", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Ppo Hmo", "plan_name": "701720_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Ms State Emplo", "plan_name": "401457", "standard_charge_percentage": 0.80, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Ms State Emplo", "plan_name": "401457_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Basic Pl", "plan_name": "400100", "standard_charge_percentage": 0.85, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Basic Pl", "plan_name": "400100_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Federal", "plan_name": "400110", "standard_charge_percentage": 0.85, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Federal", "plan_name": "400110_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." } ] } ] }, { "description": "Medroxyprogesterone 10 mg tablet [4854]", "drug_information": { "unit": 1.00, "type": "EA" }, "code_information": [ { "code": "59762-0056-1", "type": "NDC" } ], "standard_charges": [ { "gross_charge": 7.50, "minimum": 6.00, "maximum": 6.38, "setting": "both", "payers_information": [ { "payer_name": "Aetna", "plan_name": "700700", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna", "plan_name": "700700_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Miscellaneous", "plan_name": "700720", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Miscellaneous", "plan_name": "700720_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Ppo Hmo", "plan_name": "701720", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Ppo Hmo", "plan_name": "701720_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Ms State Emplo", "plan_name": "401457", "standard_charge_percentage": 0.80, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Ms State Emplo", "plan_name": "401457_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Basic Pl", "plan_name": "400100", "standard_charge_percentage": 0.85, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Basic Pl", "plan_name": "400100_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Federal", "plan_name": "400110", "standard_charge_percentage": 0.85, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Federal", "plan_name": "400110_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." } ] } ] }, { "description": "Hydrocortisone 20 mg tablet [3734]", "drug_information": { "unit": 1.00, "type": "EA" }, "code_information": [ { "code": "59762-0075-1", "type": "NDC" } ], "standard_charges": [ { "gross_charge": 7.50, "minimum": 6.00, "maximum": 6.38, "setting": "both", "payers_information": [ { "payer_name": "Aetna", "plan_name": "700700", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna", "plan_name": "700700_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Miscellaneous", "plan_name": "700720", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Miscellaneous", "plan_name": "700720_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Ppo Hmo", "plan_name": "701720", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Ppo Hmo", "plan_name": "701720_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Ms State Emplo", "plan_name": "401457", "standard_charge_percentage": 0.80, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Ms State Emplo", "plan_name": "401457_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Basic Pl", "plan_name": "400100", "standard_charge_percentage": 0.85, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Basic Pl", "plan_name": "400100_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Federal", "plan_name": "400110", "standard_charge_percentage": 0.85, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Federal", "plan_name": "400110_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." } ] } ] }, { "description": "Latanoprost 0.005 % eye drops [18621]", "drug_information": { "unit": 2.50, "type": "ML" }, "code_information": [ { "code": "59762-0333-2", "type": "NDC" } ], "standard_charges": [ { "gross_charge": 72.72, "minimum": 58.18, "maximum": 61.81, "setting": "both", "payers_information": [ { "payer_name": "Aetna", "plan_name": "700700", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna", "plan_name": "700700_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Miscellaneous", "plan_name": "700720", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent 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charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Ms State Emplo", "plan_name": "401457_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Basic Pl", "plan_name": "400100", "standard_charge_percentage": 0.85, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Basic Pl", "plan_name": "400100_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Federal", "plan_name": "400110", "standard_charge_percentage": 0.85, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Federal", "plan_name": "400110_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." } ] } ] }, { "description": "Sucralfate 1 gram tablet [11442]", "drug_information": { "unit": 1.00, "type": "EA" }, "code_information": [ { "code": "59762-0401-1", "type": "NDC" } ], "standard_charges": [ { "gross_charge": 7.50, "minimum": 6.00, "maximum": 6.38, "setting": "both", "payers_information": [ { "payer_name": "Aetna", "plan_name": "700700", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna", "plan_name": "700700_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Miscellaneous", "plan_name": "700720", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Miscellaneous", "plan_name": "700720_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Ppo Hmo", "plan_name": "701720", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Ppo Hmo", "plan_name": "701720_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Ms State Emplo", "plan_name": "401457", "standard_charge_percentage": 0.80, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Ms State Emplo", "plan_name": "401457_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Basic Pl", "plan_name": "400100", "standard_charge_percentage": 0.85, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Basic Pl", "plan_name": "400100_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Federal", "plan_name": "400110", "standard_charge_percentage": 0.85, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Federal", "plan_name": "400110_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." } ] } ] }, { "description": "Alprazolam 0.25 mg tablet [324]", "drug_information": { "unit": 1.00, "type": "EA" }, "code_information": [ { "code": "59762-3719-1", "type": "NDC" } ], "standard_charges": [ { "gross_charge": 7.50, "minimum": 6.00, "maximum": 6.38, "setting": "both", "payers_information": [ { "payer_name": "Aetna", "plan_name": "700700", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna", "plan_name": "700700_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Miscellaneous", "plan_name": "700720", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Miscellaneous", "plan_name": "700720_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Ppo Hmo", "plan_name": "701720", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Ppo Hmo", "plan_name": "701720_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Ms State Emplo", "plan_name": "401457", "standard_charge_percentage": 0.80, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Ms State Emplo", "plan_name": "401457_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Basic Pl", "plan_name": "400100", "standard_charge_percentage": 0.85, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Basic Pl", "plan_name": "400100_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Federal", "plan_name": "400110", "standard_charge_percentage": 0.85, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Federal", "plan_name": "400110_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." } ] } ] }, { "description": "Alprazolam 0.5 mg tablet [325]", "drug_information": { "unit": 1.00, "type": "EA" }, "code_information": [ { "code": "59762-3720-1", "type": "NDC" } ], "standard_charges": [ { "gross_charge": 7.50, "minimum": 6.00, "maximum": 6.38, "setting": "both", "payers_information": [ { "payer_name": "Aetna", "plan_name": "700700", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna", "plan_name": "700700_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Miscellaneous", "plan_name": "700720", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Miscellaneous", "plan_name": "700720_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Ppo Hmo", "plan_name": "701720", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Ppo Hmo", "plan_name": "701720_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Ms State Emplo", "plan_name": "401457", "standard_charge_percentage": 0.80, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Ms State Emplo", "plan_name": "401457_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Basic Pl", "plan_name": "400100", "standard_charge_percentage": 0.85, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Basic Pl", "plan_name": "400100_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Federal", "plan_name": "400110", "standard_charge_percentage": 0.85, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Federal", "plan_name": "400110_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." } ] } ] }, { "description": "Alprazolam 1 mg tablet [326]", "drug_information": { "unit": 1.00, "type": "EA" }, "code_information": [ { "code": "59762-3721-1", "type": "NDC" } ], "standard_charges": [ { "gross_charge": 7.50, "minimum": 6.00, "maximum": 6.38, "setting": "both", "payers_information": [ { "payer_name": "Aetna", "plan_name": "700700", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna", "plan_name": "700700_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Miscellaneous", "plan_name": "700720", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Miscellaneous", "plan_name": "700720_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Ppo Hmo", "plan_name": "701720", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Ppo Hmo", "plan_name": "701720_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Ms State Emplo", "plan_name": "401457", "standard_charge_percentage": 0.80, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Ms State Emplo", "plan_name": "401457_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Basic Pl", "plan_name": "400100", "standard_charge_percentage": 0.85, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Basic Pl", "plan_name": "400100_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Federal", "plan_name": "400110", "standard_charge_percentage": 0.85, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Federal", "plan_name": "400110_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." } ] } ] }, { "description": "Fluconazole 10 mg/ml oral suspension [14232]", "drug_information": { "unit": 35.00, "type": "ML" }, "code_information": [ { "code": "59762-5029-1", "type": "NDC" } ], "standard_charges": [ { "gross_charge": 113.38, "minimum": 90.70, "maximum": 96.37, "setting": "both", "payers_information": [ { "payer_name": "Aetna", "plan_name": "700700", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna", "plan_name": "700700_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Miscellaneous", "plan_name": "700720", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Miscellaneous", "plan_name": "700720_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Ppo Hmo", "plan_name": "701720", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Ppo Hmo", "plan_name": "701720_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Ms State Emplo", "plan_name": "401457", "standard_charge_percentage": 0.80, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Ms State Emplo", "plan_name": "401457_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Basic Pl", "plan_name": "400100", "standard_charge_percentage": 0.85, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Basic Pl", "plan_name": "400100_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Federal", "plan_name": "400110", "standard_charge_percentage": 0.85, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Federal", "plan_name": "400110_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." } ] } ] }, { "description": "Fluconazole 40 mg/ml oral suspension [14233]", "drug_information": { "unit": 35.00, "type": "ML" }, "code_information": [ { "code": "59762-5030-1", "type": "NDC" } ], "standard_charges": [ { "gross_charge": 279.63, "minimum": 223.70, "maximum": 237.69, "setting": "both", "payers_information": [ { "payer_name": "Aetna", "plan_name": "700700", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna", "plan_name": "700700_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Miscellaneous", "plan_name": "700720", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Miscellaneous", "plan_name": "700720_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Ppo Hmo", "plan_name": "701720", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Ppo Hmo", "plan_name": "701720_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Ms State Emplo", "plan_name": "401457", "standard_charge_percentage": 0.80, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Ms State Emplo", "plan_name": "401457_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Basic Pl", "plan_name": "400100", "standard_charge_percentage": 0.85, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Basic Pl", "plan_name": "400100_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Federal", "plan_name": "400110", "standard_charge_percentage": 0.85, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Federal", "plan_name": "400110_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." } ] } ] }, { "description": "Atropine 1 % eye drops [736]", "drug_information": { "unit": 5.00, "type": "ML" }, "code_information": [ { "code": "60219-1749-3", "type": "NDC" } ], "standard_charges": [ { "gross_charge": 273.46, "minimum": 218.77, "maximum": 232.44, "setting": "both", "payers_information": [ { "payer_name": "Aetna", "plan_name": "700700", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna", "plan_name": "700700_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Miscellaneous", "plan_name": "700720", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Miscellaneous", "plan_name": "700720_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Ppo Hmo", "plan_name": "701720", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Ppo Hmo", "plan_name": "701720_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Ms State Emplo", "plan_name": "401457", "standard_charge_percentage": 0.80, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Ms State Emplo", "plan_name": "401457_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Basic Pl", "plan_name": "400100", "standard_charge_percentage": 0.85, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Basic Pl", "plan_name": "400100_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Federal", "plan_name": "400110", "standard_charge_percentage": 0.85, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Federal", "plan_name": "400110_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." } ] } ] }, { "description": "Fenofibrate 160 mg tablet [28252]", "drug_information": { "unit": 1.00, "type": "EA" }, "code_information": [ { "code": "60219-5522-9", "type": "NDC" } ], "standard_charges": [ { "gross_charge": 7.50, "minimum": 6.00, "maximum": 6.38, "setting": "both", "payers_information": [ { "payer_name": "Aetna", "plan_name": "700700", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna", "plan_name": "700700_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate 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}, { "payer_name": "Bc/Bs Ms State Emplo", "plan_name": "401457", "standard_charge_percentage": 0.80, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Ms State Emplo", "plan_name": "401457_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Basic Pl", "plan_name": "400100", "standard_charge_percentage": 0.85, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Basic Pl", "plan_name": "400100_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Federal", "plan_name": "400110", "standard_charge_percentage": 0.85, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Federal", "plan_name": "400110_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." } ] } ] }, { "description": "Iron-vit c-vit b12-folic acid 100 mg-250 mg-25 mcg-1 mg tablet [28040]", "drug_information": { "unit": 1.00, "type": "EA" }, "code_information": [ { "code": "6025810101", "type": "NDC" } ], "standard_charges": [ { "gross_charge": 1.00, "minimum": 0.80, "maximum": 0.85, "setting": "both", "payers_information": [ { "payer_name": "Aetna", "plan_name": "700700", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna", "plan_name": "700700_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Miscellaneous", "plan_name": "700720", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Miscellaneous", "plan_name": "700720_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Ppo Hmo", "plan_name": "701720", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Ppo Hmo", "plan_name": "701720_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Ms State Emplo", "plan_name": "401457", "standard_charge_percentage": 0.80, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Ms State Emplo", "plan_name": "401457_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Basic Pl", "plan_name": "400100", "standard_charge_percentage": 0.85, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Basic Pl", "plan_name": "400100_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Federal", "plan_name": "400110", "standard_charge_percentage": 0.85, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Federal", "plan_name": "400110_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." } ] } ] }, { "description": "Meclizine 12.5 mg tablet [12024]", "drug_information": { "unit": 1.00, "type": "EA" }, "code_information": [ { "code": "59746-122-06", "type": "NDC" } ], "standard_charges": [ { "gross_charge": 1.00, "minimum": 0.80, "maximum": 0.85, "setting": "both", "payers_information": [ { "payer_name": "Aetna", "plan_name": "700700", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna", "plan_name": "700700_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Miscellaneous", "plan_name": "700720", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Miscellaneous", "plan_name": "700720_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Ppo Hmo", "plan_name": "701720", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Ppo Hmo", "plan_name": "701720_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Ms State Emplo", "plan_name": "401457", "standard_charge_percentage": 0.80, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Ms State Emplo", "plan_name": "401457_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Basic Pl", "plan_name": "400100", "standard_charge_percentage": 0.85, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Basic Pl", "plan_name": "400100_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Federal", "plan_name": "400110", "standard_charge_percentage": 0.85, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Federal", "plan_name": "400110_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." } ] } ] }, { "description": "Atropine 1 % eye drops [736]", "drug_information": { "unit": 5.00, "type": "ML" }, "code_information": [ { "code": "60505-6226-1", "type": "NDC" } ], "standard_charges": [ { "gross_charge": 210.76, "minimum": 168.61, "maximum": 179.15, "setting": "both", "payers_information": [ { "payer_name": "Aetna", "plan_name": "700700", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna", "plan_name": "700700_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Miscellaneous", "plan_name": "700720", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Miscellaneous", "plan_name": "700720_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Ppo Hmo", "plan_name": "701720", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Ppo Hmo", "plan_name": "701720_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Ms State Emplo", "plan_name": "401457", "standard_charge_percentage": 0.80, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Ms State Emplo", "plan_name": "401457_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Basic Pl", "plan_name": "400100", "standard_charge_percentage": 0.85, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Basic Pl", "plan_name": "400100_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Federal", "plan_name": "400110", "standard_charge_percentage": 0.85, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Federal", "plan_name": "400110_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." } ] } ] }, { "description": "Metformin 500 mg tablet [10544]", "drug_information": { "unit": 1.00, "type": "EA" }, "code_information": [ { "code": "60687-155-11", "type": "NDC" } ], "standard_charges": [ { "gross_charge": 7.50, "minimum": 6.00, "maximum": 6.38, "setting": "both", "payers_information": [ { "payer_name": "Aetna", "plan_name": "700700", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna", "plan_name": "700700_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Miscellaneous", "plan_name": "700720", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Miscellaneous", "plan_name": "700720_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Ppo Hmo", "plan_name": "701720", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Ppo Hmo", "plan_name": "701720_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Ms State Emplo", "plan_name": "401457", "standard_charge_percentage": 0.80, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Ms State Emplo", "plan_name": "401457_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Basic Pl", "plan_name": "400100", "standard_charge_percentage": 0.85, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Basic Pl", "plan_name": "400100_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Federal", "plan_name": "400110", "standard_charge_percentage": 0.85, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Federal", "plan_name": "400110_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." } ] } ] }, { "description": "Phenytoin 50 mg chewable tablet [11018]", "drug_information": { "unit": 1.00, "type": "EA" }, "code_information": [ { "code": "60687-156-25", "type": "NDC" } ], "standard_charges": [ { "gross_charge": 7.50, "minimum": 6.00, "maximum": 6.38, "setting": "both", "payers_information": [ { "payer_name": "Aetna", "plan_name": "700700", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna", "plan_name": "700700_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Miscellaneous", "plan_name": "700720", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Miscellaneous", "plan_name": "700720_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Ppo Hmo", "plan_name": "701720", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Ppo Hmo", "plan_name": "701720_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Ms State Emplo", "plan_name": "401457", "standard_charge_percentage": 0.80, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Ms State Emplo", "plan_name": "401457_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Basic Pl", "plan_name": "400100", "standard_charge_percentage": 0.85, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Basic Pl", "plan_name": "400100_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Federal", "plan_name": "400110", "standard_charge_percentage": 0.85, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Federal", "plan_name": "400110_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." } ] } ] }, { "description": "Phenytoin 50 mg chewable tablet [11018]", "drug_information": { "unit": 1.00, "type": "EA" }, "code_information": [ { "code": "60687-156-95", "type": "NDC" } ], "standard_charges": [ { "gross_charge": 7.50, "minimum": 6.00, "maximum": 6.38, "setting": "both", "payers_information": [ { "payer_name": "Aetna", "plan_name": "700700", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna", "plan_name": "700700_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Miscellaneous", "plan_name": "700720", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Miscellaneous", "plan_name": "700720_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Ppo Hmo", "plan_name": "701720", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Ppo Hmo", "plan_name": "701720_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Ms State Emplo", "plan_name": "401457", "standard_charge_percentage": 0.80, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Ms State Emplo", "plan_name": "401457_1", 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"plan_name": "400100_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Federal", "plan_name": "400110", "standard_charge_percentage": 0.85, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Federal", "plan_name": "400110_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." } ] } ] }, { "description": "Cephalexin 500 mg capsule [9500]", "drug_information": { "unit": 1.00, "type": "EA" }, "code_information": [ { "code": "60687-163-11", "type": "NDC" } ], "standard_charges": [ { "gross_charge": 7.50, "minimum": 6.00, "maximum": 6.38, "setting": "both", 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"plan_name": "400100", "standard_charge_percentage": 0.85, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Basic Pl", "plan_name": "400100_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Federal", "plan_name": "400110", "standard_charge_percentage": 0.85, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Federal", "plan_name": "400110_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." } ] } ] }, { "description": "Raloxifene 60 mg 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"payer_name": "Bc/Bs Ms State Emplo", "plan_name": "401457_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Basic Pl", "plan_name": "400100", "standard_charge_percentage": 0.85, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Basic Pl", "plan_name": "400100_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Federal", "plan_name": "400110", "standard_charge_percentage": 0.85, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { 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}, { "payer_name": "Bc/Bs Ms State Emplo", "plan_name": "401457", "standard_charge_percentage": 0.80, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Ms State Emplo", "plan_name": "401457_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Basic Pl", "plan_name": "400100", "standard_charge_percentage": 0.85, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Basic Pl", "plan_name": "400100_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Federal", "plan_name": "400110", "standard_charge_percentage": 0.85, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Federal", "plan_name": "400110_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." } ] } ] }, { "description": "Propranolol 20 mg tablet [6657]", "drug_information": { "unit": 1.00, "type": "EA" }, "code_information": [ { "code": "60687-306-11", "type": "NDC" } ], "standard_charges": [ { "gross_charge": 7.50, "minimum": 6.00, "maximum": 6.38, "setting": "both", "payers_information": [ { "payer_name": "Aetna", "plan_name": "700700", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to 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}, { "payer_name": "Bc/Bs Of Ms Basic Pl", "plan_name": "400100_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Federal", "plan_name": "400110", "standard_charge_percentage": 0.85, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Federal", "plan_name": "400110_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." } ] } ] }, { "description": "Linezolid 600 mg tablet [28224]", "drug_information": { "unit": 1.00, "type": "EA" }, "code_information": [ { "code": "60687-309-11", "type": "NDC" } ], "standard_charges": [ { "gross_charge": 29.85, "minimum": 23.88, 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allowed amounts." } ] } ] }, { "description": "Linezolid 600 mg tablet [28224]", "drug_information": { "unit": 1.00, "type": "EA" }, "code_information": [ { "code": "60687-309-21", "type": "NDC" } ], "standard_charges": [ { "gross_charge": 29.85, "minimum": 23.88, "maximum": 25.37, "setting": "both", "payers_information": [ { "payer_name": "Aetna", "plan_name": "700700", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna", "plan_name": "700700_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Miscellaneous", "plan_name": "700720", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient 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"additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Miscellaneous", "plan_name": "700720", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Miscellaneous", "plan_name": "700720_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Ppo Hmo", "plan_name": "701720", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Ppo Hmo", "plan_name": "701720_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Ms State Emplo", "plan_name": "401457", "standard_charge_percentage": 0.80, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Ms State Emplo", "plan_name": "401457_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Basic Pl", "plan_name": "400100", "standard_charge_percentage": 0.85, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Basic Pl", "plan_name": "400100_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", 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"payer_name": "Aetna Ppo Hmo", "plan_name": "701720", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Ppo Hmo", "plan_name": "701720_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Ms State Emplo", "plan_name": "401457", "standard_charge_percentage": 0.80, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Ms State Emplo", "plan_name": "401457_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Basic Pl", "plan_name": "400100", "standard_charge_percentage": 0.85, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Basic Pl", "plan_name": "400100_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Federal", "plan_name": "400110", "standard_charge_percentage": 0.85, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Federal", "plan_name": "400110_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." } ] } ] }, { "description": "Ezetimibe 10 mg tablet [34153]", "drug_information": { "unit": 1.00, "type": "EA" }, "code_information": [ { "code": "60687-373-11", "type": "NDC" } ], "standard_charges": [ { "gross_charge": 49.07, "minimum": 39.26, "maximum": 41.71, "setting": "both", "payers_information": [ { "payer_name": "Aetna", "plan_name": "700700", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna", "plan_name": "700700_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Miscellaneous", "plan_name": "700720", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed 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"payer_name": "Bc/Bs Ms State Emplo", "plan_name": "401457_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Basic Pl", "plan_name": "400100", "standard_charge_percentage": 0.85, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Basic Pl", "plan_name": "400100_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Federal", "plan_name": "400110", "standard_charge_percentage": 0.85, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Federal", "plan_name": "400110_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." } ] } ] }, { "description": "Nabumetone 500 mg tablet [10676]", "drug_information": { "unit": 1.00, "type": "EA" }, "code_information": [ { "code": "60687-374-01", "type": "NDC" } ], "standard_charges": [ { "gross_charge": 7.50, "minimum": 6.00, "maximum": 6.38, "setting": "both", "payers_information": [ { "payer_name": "Aetna", "plan_name": "700700", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna", "plan_name": "700700_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Miscellaneous", "plan_name": "700720", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Miscellaneous", "plan_name": "700720_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Ppo Hmo", "plan_name": "701720", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Ppo Hmo", "plan_name": "701720_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Ms State Emplo", "plan_name": "401457", "standard_charge_percentage": 0.80, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Ms State Emplo", "plan_name": "401457_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Basic Pl", "plan_name": "400100", "standard_charge_percentage": 0.85, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Basic Pl", "plan_name": "400100_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Federal", "plan_name": "400110", "standard_charge_percentage": 0.85, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Federal", "plan_name": "400110_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." } ] } ] }, { "description": "Ursodiol 250 mg tablet [22660]", "drug_information": { "unit": 1.00, "type": "EA" }, "code_information": [ { "code": "60687-527-11", "type": "NDC" } ], "standard_charges": [ { "gross_charge": 22.80, "minimum": 18.24, "maximum": 19.38, "setting": "both", "payers_information": [ { "payer_name": "Aetna", "plan_name": "700700", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data 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amounts." }, { "payer_name": "Aetna Ppo Hmo", "plan_name": "701720_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Ms State Emplo", "plan_name": "401457", "standard_charge_percentage": 0.80, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Ms State Emplo", "plan_name": "401457_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Basic Pl", "plan_name": "400100", "standard_charge_percentage": 0.85, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Basic Pl", "plan_name": "400100_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Federal", "plan_name": "400110", "standard_charge_percentage": 0.85, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Federal", "plan_name": "400110_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." } ] } ] }, { "description": "Ursodiol 250 mg tablet [22660]", "drug_information": { "unit": 1.00, "type": "EA" }, "code_information": [ { "code": "60687-527-21", "type": "NDC" } ], "standard_charges": [ { "gross_charge": 22.80, "minimum": 18.24, "maximum": 19.38, "setting": "both", "payers_information": [ { "payer_name": "Aetna", "plan_name": "700700", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna", "plan_name": "700700_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Miscellaneous", "plan_name": "700720", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Miscellaneous", "plan_name": "700720_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Ppo Hmo", "plan_name": "701720", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Ppo Hmo", "plan_name": "701720_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Ms State Emplo", "plan_name": "401457", "standard_charge_percentage": 0.80, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Ms State Emplo", "plan_name": "401457_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Basic Pl", "plan_name": "400100", "standard_charge_percentage": 0.85, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Basic Pl", "plan_name": "400100_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Federal", "plan_name": "400110", "standard_charge_percentage": 0.85, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Federal", "plan_name": "400110_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." } ] } ] }, { "description": "Metolazone 2.5 mg tablet [10587]", "drug_information": { "unit": 1.00, "type": "EA" }, "code_information": [ { "code": "60687-536-11", "type": "NDC" } ], "standard_charges": [ { "gross_charge": 13.06, "minimum": 10.45, "maximum": 11.10, "setting": "both", "payers_information": [ { "payer_name": "Aetna", "plan_name": "700700", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna", "plan_name": "700700_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Miscellaneous", "plan_name": "700720", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Miscellaneous", "plan_name": "700720_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Ppo Hmo", "plan_name": "701720", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Ppo Hmo", "plan_name": "701720_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Ms State Emplo", "plan_name": "401457", "standard_charge_percentage": 0.80, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Ms State Emplo", "plan_name": "401457_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Basic Pl", "plan_name": "400100", "standard_charge_percentage": 0.85, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Basic Pl", "plan_name": "400100_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Federal", "plan_name": "400110", "standard_charge_percentage": 0.85, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Federal", "plan_name": "400110_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." } ] } ] }, { "description": "Propafenone 150 mg tablet [11146]", "drug_information": { "unit": 1.00, "type": "EA" }, "code_information": [ { "code": "60687-537-11", "type": "NDC" } ], "standard_charges": [ { "gross_charge": 7.50, "minimum": 6.00, "maximum": 6.38, "setting": "both", "payers_information": [ { "payer_name": "Aetna", "plan_name": "700700", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna", "plan_name": "700700_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Miscellaneous", "plan_name": "700720", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Miscellaneous", "plan_name": "700720_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Ppo Hmo", "plan_name": "701720", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Ppo Hmo", "plan_name": "701720_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Ms State Emplo", "plan_name": "401457", "standard_charge_percentage": 0.80, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Ms State Emplo", "plan_name": "401457_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Basic Pl", "plan_name": "400100", "standard_charge_percentage": 0.85, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Basic Pl", "plan_name": "400100_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Federal", "plan_name": "400110", "standard_charge_percentage": 0.85, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Federal", "plan_name": "400110_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." } ] } ] }, { "description": "Clonazepam 0.5 mg tablet [9637]", "drug_information": { "unit": 1.00, "type": "EA" }, "code_information": [ { "code": "60687-544-01", "type": "NDC" } ], "standard_charges": [ { "gross_charge": 7.50, "minimum": 6.00, "maximum": 6.38, "setting": "both", "payers_information": [ { "payer_name": "Aetna", "plan_name": "700700", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna", "plan_name": "700700_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Miscellaneous", "plan_name": "700720", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Miscellaneous", "plan_name": "700720_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Ppo Hmo", "plan_name": "701720", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": 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"400110_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." } ] } ] }, { "description": "Metolazone 2.5 mg tablet [10587]", "drug_information": { "unit": 1.00, "type": "EA" }, "code_information": [ { "code": "60687-624-11", "type": "NDC" } ], "standard_charges": [ { "gross_charge": 22.72, "minimum": 18.18, "maximum": 19.31, "setting": "both", "payers_information": [ { "payer_name": "Aetna", "plan_name": "700700", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna", "plan_name": "700700_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna 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"plan_name": "401457", "standard_charge_percentage": 0.80, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Ms State Emplo", "plan_name": "401457_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Basic Pl", "plan_name": "400100", "standard_charge_percentage": 0.85, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Basic Pl", "plan_name": "400100_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Federal", "plan_name": "400110", "standard_charge_percentage": 0.85, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Federal", "plan_name": "400110_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." } ] } ] }, { "description": "Lorazepam 0.5 mg tablet [4572]", "drug_information": { "unit": 1.00, "type": "EA" }, "code_information": [ { "code": "60687-627-01", "type": "NDC" } ], "standard_charges": [ { "gross_charge": 7.50, "minimum": 6.00, "maximum": 6.38, "setting": "both", "payers_information": [ { "payer_name": "Aetna", "plan_name": "700700", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna", "plan_name": "700700_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Miscellaneous", "plan_name": "700720", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Miscellaneous", "plan_name": "700720_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Ppo Hmo", "plan_name": "701720", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Ppo 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"description": "Fenofibrate nanocrystallized 145 mg tablet [40010]", "drug_information": { "unit": 1.00, "type": "EA" }, "code_information": [ { "code": "60687-629-11", "type": "NDC" } ], "standard_charges": [ { "gross_charge": 24.86, "minimum": 19.89, "maximum": 21.13, "setting": "both", "payers_information": [ { "payer_name": "Aetna", "plan_name": "700700", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna", "plan_name": "700700_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Miscellaneous", "plan_name": "700720", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to 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billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Ms State Emplo", "plan_name": "401457_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Basic Pl", "plan_name": "400100", "standard_charge_percentage": 0.85, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Basic Pl", "plan_name": "400100_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Federal", "plan_name": "400110", "standard_charge_percentage": 0.85, "count": "0", "methodology": "percent of total 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"percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Ms State Emplo", "plan_name": "401457", "standard_charge_percentage": 0.80, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Ms State Emplo", "plan_name": "401457_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Basic Pl", "plan_name": "400100", "standard_charge_percentage": 0.85, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Basic Pl", "plan_name": "400100_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": 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"401457_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Basic Pl", "plan_name": "400100", "standard_charge_percentage": 0.85, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Basic Pl", "plan_name": "400100_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Federal", "plan_name": "400110", "standard_charge_percentage": 0.85, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Federal", "plan_name": 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"payer_name": "Aetna Ppo Hmo", "plan_name": "701720", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Ppo Hmo", "plan_name": "701720_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Ms State Emplo", "plan_name": "401457", "standard_charge_percentage": 0.80, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Ms State Emplo", "plan_name": "401457_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": 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"description": "Glipizide 5 mg tablet [10117]", "drug_information": { "unit": 1.00, "type": "EA" }, "code_information": [ { "code": "60687-690-11", "type": "NDC" } ], "standard_charges": [ { "gross_charge": 7.50, "minimum": 6.00, "maximum": 6.38, "setting": "both", "payers_information": [ { "payer_name": "Aetna", "plan_name": "700700", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna", "plan_name": "700700_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Miscellaneous", "plan_name": "700720", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed 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"payer_name": "Bc/Bs Ms State Emplo", "plan_name": "401457_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Basic Pl", "plan_name": "400100", "standard_charge_percentage": 0.85, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Basic Pl", "plan_name": "400100_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Federal", "plan_name": "400110", "standard_charge_percentage": 0.85, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Federal", "plan_name": "400110_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." } ] } ] }, { "description": "Hydrocodone 7.5 mg-acetaminophen 325 mg tablet [34544]", "drug_information": { "unit": 1.00, "type": "EA" }, "code_information": [ { "code": "60687-407-01", "type": "NDC" } ], "standard_charges": [ { "gross_charge": 7.50, "minimum": 6.00, "maximum": 6.38, "setting": "both", "payers_information": [ { "payer_name": "Aetna", "plan_name": "700700", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna", "plan_name": "700700_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient 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calculate allowed amounts." }, { "payer_name": "Bc/Bs Ms State Emplo", "plan_name": "401457", "standard_charge_percentage": 0.80, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Ms State Emplo", "plan_name": "401457_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Basic Pl", "plan_name": "400100", "standard_charge_percentage": 0.85, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Basic Pl", "plan_name": "400100_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Federal", "plan_name": "400110", "standard_charge_percentage": 0.85, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Federal", "plan_name": "400110_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." } ] } ] }, { "description": "Mesalamine 800 mg tabletdelayed release [96949]", "drug_information": { "unit": 1.00, "type": "EA" }, "code_information": [ { "code": "60687-408-25", "type": "NDC" } ], "standard_charges": [ { "gross_charge": 125.59, "minimum": 100.47, "maximum": 106.75, "setting": "both", "payers_information": [ { "payer_name": "Aetna", "plan_name": "700700", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", 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}, { "payer_name": "Bc/Bs Ms State Emplo", "plan_name": "401457", "standard_charge_percentage": 0.80, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Ms State Emplo", "plan_name": "401457_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Basic Pl", "plan_name": "400100", "standard_charge_percentage": 0.85, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Basic Pl", "plan_name": "400100_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Federal", "plan_name": "400110", "standard_charge_percentage": 0.85, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Federal", "plan_name": "400110_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." } ] } ] }, { "description": "Trazodone 100 mg tablet [8083]", "drug_information": { "unit": 1.00, "type": "EA" }, "code_information": [ { "code": "60687-454-11", "type": "NDC" } ], "standard_charges": [ { "gross_charge": 7.50, "minimum": 6.00, "maximum": 6.38, "setting": "both", "payers_information": [ { "payer_name": "Aetna", "plan_name": "700700", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to 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}, { "payer_name": "Bc/Bs Of Ms Basic Pl", "plan_name": "400100_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Federal", "plan_name": "400110", "standard_charge_percentage": 0.85, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Federal", "plan_name": "400110_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." } ] } ] }, { "description": "Ibuprofen 600 mg tablet [3844]", "drug_information": { "unit": 1.00, "type": "EA" }, "code_information": [ { "code": "60687-457-01", "type": "NDC" } ], "standard_charges": [ { "gross_charge": 7.50, "minimum": 6.00, "maximum": 6.38, "setting": "both", "payers_information": [ { "payer_name": "Aetna", "plan_name": "700700", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna", "plan_name": "700700_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Miscellaneous", "plan_name": "700720", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Miscellaneous", "plan_name": "700720_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to 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allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Basic Pl", "plan_name": "400100", "standard_charge_percentage": 0.85, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Basic Pl", "plan_name": "400100_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Federal", "plan_name": "400110", "standard_charge_percentage": 0.85, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Federal", "plan_name": "400110_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." } ] } ] }, { "description": "Ibuprofen 600 mg tablet [3844]", "drug_information": { "unit": 1.00, "type": "EA" }, "code_information": [ { "code": "60687-457-11", "type": "NDC" } ], "standard_charges": [ { "gross_charge": 7.50, "minimum": 6.00, "maximum": 6.38, "setting": "both", "payers_information": [ { "payer_name": "Aetna", "plan_name": "700700", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna", "plan_name": "700700_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Miscellaneous", "plan_name": "700720", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit 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allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Federal", "plan_name": "400110_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." } ] } ] }, { "description": "Labetalol 300 mg tablet [10375]", "drug_information": { "unit": 1.00, "type": "EA" }, "code_information": [ { "code": "60687-461-11", "type": "NDC" } ], "standard_charges": [ { "gross_charge": 7.50, "minimum": 6.00, "maximum": 6.38, "setting": "both", "payers_information": [ { "payer_name": "Aetna", "plan_name": "700700", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna", "plan_name": "700700_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient 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calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Federal", "plan_name": "400110", "standard_charge_percentage": 0.85, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Federal", "plan_name": "400110_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." } ] } ] }, { "description": "Spironolactone 25 mg tablet [7437]", "drug_information": { "unit": 1.00, "type": "EA" }, "code_information": [ { "code": "60687-465-11", "type": "NDC" } ], "standard_charges": [ { "gross_charge": 7.50, "minimum": 6.00, "maximum": 6.38, "setting": "both", "payers_information": [ { "payer_name": "Aetna", "plan_name": "700700", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", 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"Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Basic Pl", "plan_name": "400100_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Federal", "plan_name": "400110", "standard_charge_percentage": 0.85, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Federal", "plan_name": "400110_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." } ] } ] }, { "description": "Ibuprofen 800 mg tablet [3845]", "drug_information": { "unit": 1.00, "type": "EA" }, "code_information": [ { "code": "60687-468-11", "type": "NDC" } ], 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"additional_payer_notes": "Insufficient remit data to calculate allowed amounts." } ] } ] }, { "description": "Nitrofurantoin macrocrystal 50 mg capsule [5595]", "drug_information": { "unit": 1.00, "type": "EA" }, "code_information": [ { "code": "60687-472-11", "type": "NDC" } ], "standard_charges": [ { "gross_charge": 18.39, "minimum": 14.71, "maximum": 15.63, "setting": "both", "payers_information": [ { "payer_name": "Aetna", "plan_name": "700700", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna", "plan_name": "700700_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Miscellaneous", "plan_name": "700720", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Miscellaneous", "plan_name": "700720_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Ppo Hmo", "plan_name": "701720", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Ppo Hmo", "plan_name": "701720_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Ms State Emplo", "plan_name": "401457", "standard_charge_percentage": 0.80, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Ms State Emplo", "plan_name": "401457_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Basic Pl", "plan_name": "400100", "standard_charge_percentage": 0.85, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Basic Pl", "plan_name": "400100_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Federal", "plan_name": "400110", "standard_charge_percentage": 0.85, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Federal", "plan_name": "400110_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." } ] } ] }, { "description": "Pregabalin 25 mg capsule [42162]", "drug_information": { "unit": 1.00, "type": "EA" }, "code_information": [ { "code": "60687-473-11", "type": "NDC" } ], "standard_charges": [ { "gross_charge": 11.10, "minimum": 8.88, "maximum": 9.44, "setting": "both", "payers_information": [ { "payer_name": "Aetna", "plan_name": "700700", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna", "plan_name": "700700_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Miscellaneous", "plan_name": "700720", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Miscellaneous", "plan_name": "700720_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Ppo Hmo", "plan_name": "701720", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Ppo Hmo", "plan_name": "701720_1", "standard_charge_percentage": 100.0, "count": "0", 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"description": "Oxcarbazepine 300 mg tablet [21061]", "drug_information": { "unit": 1.00, "type": "EA" }, "code_information": [ { "code": "60687-722-11", "type": "NDC" } ], "standard_charges": [ { "gross_charge": 7.50, "minimum": 6.00, "maximum": 6.38, "setting": "both", "payers_information": [ { "payer_name": "Aetna", "plan_name": "700700", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna", "plan_name": "700700_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Miscellaneous", "plan_name": "700720", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed 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"payer_name": "Bc/Bs Ms State Emplo", "plan_name": "401457_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Basic Pl", "plan_name": "400100", "standard_charge_percentage": 0.85, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Basic Pl", "plan_name": "400100_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Federal", "plan_name": "400110", "standard_charge_percentage": 0.85, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { 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"additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Federal", "plan_name": "400110", "standard_charge_percentage": 0.85, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Federal", "plan_name": "400110_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." } ] } ] }, { "description": "Gentamicin 0.3 % eye drops [3428]", "drug_information": { "unit": 5.00, "type": "ML" }, "code_information": [ { "code": "60758-188-05", "type": "NDC" } ], "standard_charges": [ { "gross_charge": 20.71, "minimum": 16.57, "maximum": 17.60, "setting": "both", "payers_information": [ { "payer_name": "Aetna", "plan_name": "700700", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna", "plan_name": "700700_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Miscellaneous", "plan_name": "700720", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Miscellaneous", "plan_name": "700720_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Ppo Hmo", "plan_name": "701720", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Ppo Hmo", "plan_name": "701720_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Ms State Emplo", "plan_name": "401457", "standard_charge_percentage": 0.80, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Ms State Emplo", "plan_name": "401457_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Basic Pl", "plan_name": "400100", "standard_charge_percentage": 0.85, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Basic Pl", "plan_name": "400100_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Federal", "plan_name": "400110", "standard_charge_percentage": 0.85, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Federal", "plan_name": "400110_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." } ] } ] }, { "description": "Ketorolac 0.4 % eye drops [36631]", "drug_information": { "unit": 5.00, "type": "ML" }, "code_information": [ { "code": "60758-773-05", "type": "NDC" } ], "standard_charges": [ { "gross_charge": 189.54, "minimum": 151.63, "maximum": 161.11, "setting": "both", "payers_information": [ { "payer_name": "Aetna", "plan_name": "700700", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna", "plan_name": "700700_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Miscellaneous", "plan_name": "700720", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Miscellaneous", "plan_name": "700720_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Ppo Hmo", "plan_name": "701720", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Ppo Hmo", "plan_name": "701720_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Ms State Emplo", "plan_name": "401457", "standard_charge_percentage": 0.80, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Ms State Emplo", "plan_name": "401457_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Basic Pl", "plan_name": "400100", "standard_charge_percentage": 0.85, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Basic Pl", "plan_name": "400100_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Federal", "plan_name": "400110", "standard_charge_percentage": 0.85, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Federal", "plan_name": "400110_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." } ] } ] }, { "description": "Timolol maleate 0.5 % eye drops [11562]", "drug_information": { "unit": 5.00, "type": "ML" }, "code_information": [ { "code": "60758-801-05", "type": "NDC" } ], "standard_charges": [ { "gross_charge": 56.05, "minimum": 44.84, "maximum": 47.64, "setting": "both", "payers_information": [ { "payer_name": "Aetna", "plan_name": "700700", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna", "plan_name": "700700_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Miscellaneous", "plan_name": "700720", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Miscellaneous", "plan_name": "700720_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Ppo Hmo", "plan_name": "701720", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Ppo Hmo", "plan_name": "701720_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Ms State Emplo", "plan_name": "401457", "standard_charge_percentage": 0.80, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Ms State Emplo", "plan_name": "401457_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Basic Pl", "plan_name": "400100", "standard_charge_percentage": 0.85, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Basic Pl", "plan_name": "400100_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Federal", "plan_name": "400110", "standard_charge_percentage": 0.85, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Federal", "plan_name": "400110_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." } ] } ] }, { "description": "Timolol maleate 0.25 % eye drops [11561]", "drug_information": { "unit": 5.00, "type": "ML" }, "code_information": [ { "code": "60758-802-05", "type": "NDC" } ], "standard_charges": [ { "gross_charge": 27.79, "minimum": 22.23, "maximum": 23.62, "setting": "both", "payers_information": [ { "payer_name": "Aetna", "plan_name": "700700", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna", "plan_name": "700700_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Miscellaneous", "plan_name": "700720", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Miscellaneous", "plan_name": "700720_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Ppo Hmo", "plan_name": "701720", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Ppo Hmo", "plan_name": "701720_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Ms State Emplo", "plan_name": "401457", "standard_charge_percentage": 0.80, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Ms State Emplo", "plan_name": "401457_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Basic Pl", "plan_name": "400100", "standard_charge_percentage": 0.85, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Basic Pl", "plan_name": "400100_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Federal", "plan_name": "400110", "standard_charge_percentage": 0.85, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Federal", "plan_name": "400110_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." } ] } ] }, { "description": "Fluorometholone 0.1 % eye dropssuspension [3208]", "drug_information": { "unit": 5.00, "type": "ML" }, "code_information": [ { "code": "60758-880-05", "type": "NDC" } ], "standard_charges": [ { "gross_charge": 677.45, "minimum": 541.96, "maximum": 575.83, "setting": "both", "payers_information": [ { "payer_name": "Aetna", "plan_name": "700700", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna", "plan_name": "700700_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Miscellaneous", "plan_name": "700720", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Miscellaneous", "plan_name": "700720_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Ppo Hmo", "plan_name": "701720", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Ppo Hmo", "plan_name": "701720_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Ms State Emplo", "plan_name": "401457", "standard_charge_percentage": 0.80, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Ms State Emplo", "plan_name": "401457_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Basic Pl", "plan_name": "400100", "standard_charge_percentage": 0.85, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Basic Pl", "plan_name": "400100_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Federal", "plan_name": "400110", "standard_charge_percentage": 0.85, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Federal", "plan_name": "400110_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." } ] } ] }, { "description": "Polymyxin b sulfate 10000 unit-trimethoprim 1 mg/ml eye drops [109275]", "drug_information": { "unit": 10.00, "type": "ML" }, "code_information": [ { "code": "60758-908-10", "type": "NDC" } ], "standard_charges": [ { "gross_charge": 51.73, "minimum": 41.38, "maximum": 43.97, "setting": "both", "payers_information": [ { "payer_name": "Aetna", "plan_name": "700700", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna", "plan_name": "700700_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Miscellaneous", "plan_name": "700720", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Miscellaneous", "plan_name": "700720_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Ppo Hmo", "plan_name": "701720", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Ppo Hmo", "plan_name": "701720_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Ms State Emplo", "plan_name": "401457", "standard_charge_percentage": 0.80, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Ms State Emplo", "plan_name": "401457_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Basic Pl", "plan_name": "400100", "standard_charge_percentage": 0.85, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Basic Pl", "plan_name": "400100_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Federal", "plan_name": "400110", "standard_charge_percentage": 0.85, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Federal", "plan_name": "400110_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." } ] } ] }, { "description": "Thrombin (bovine) 5000 unit topical solution [117741]", "drug_information": { "unit": 1.00, "type": "EA" }, "code_information": [ { "code": "60793-215-05", "type": "NDC" } ], "standard_charges": [ { "gross_charge": 322.29, "minimum": 257.83, "maximum": 273.95, "setting": "both", "payers_information": [ { "payer_name": "Aetna", "plan_name": "700700", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna", "plan_name": "700700_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Miscellaneous", "plan_name": "700720", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Miscellaneous", "plan_name": "700720_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Ppo Hmo", "plan_name": "701720", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Ppo Hmo", "plan_name": "701720_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Ms State Emplo", "plan_name": "401457", "standard_charge_percentage": 0.80, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Ms State Emplo", "plan_name": "401457_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Basic Pl", "plan_name": "400100", "standard_charge_percentage": 0.85, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Basic Pl", "plan_name": "400100_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Federal", "plan_name": "400110", "standard_charge_percentage": 0.85, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Federal", "plan_name": "400110_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." } ] } ] }, { "description": "Sodium chloride 0.9 % topical solution [19758]", "drug_information": { "unit": 5.00, "type": "ML" }, "code_information": [ { "code": "60793-218-09", "type": "NDC" } ], "standard_charges": [ { "gross_charge": 302.34, "minimum": 241.87, "maximum": 256.99, "setting": "both", "payers_information": [ { "payer_name": "Aetna", "plan_name": "700700", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna", "plan_name": "700700_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Miscellaneous", "plan_name": "700720", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Miscellaneous", "plan_name": "700720_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Ppo Hmo", "plan_name": "701720", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Ppo Hmo", "plan_name": "701720_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Ms State Emplo", "plan_name": "401457", "standard_charge_percentage": 0.80, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Ms State Emplo", "plan_name": "401457_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Basic Pl", "plan_name": "400100", "standard_charge_percentage": 0.85, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Basic Pl", "plan_name": "400100_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Federal", "plan_name": "400110", "standard_charge_percentage": 0.85, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Federal", "plan_name": "400110_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." } ] } ] }, { "description": "Thrombin (bovine) 5000 unit topical solution [117741]", "drug_information": { "unit": 1.00, "type": "EA" }, "code_information": [ { "code": "60793-315-01", "type": "NDC" } ], "standard_charges": [ { "gross_charge": 322.29, "minimum": 257.83, "maximum": 273.95, "setting": "both", "payers_information": [ { "payer_name": "Aetna", "plan_name": "700700", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna", "plan_name": "700700_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Miscellaneous", "plan_name": "700720", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Miscellaneous", "plan_name": "700720_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Ppo Hmo", "plan_name": "701720", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Ppo Hmo", "plan_name": "701720_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Ms State Emplo", "plan_name": "401457", "standard_charge_percentage": 0.80, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Ms State Emplo", "plan_name": "401457_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Basic Pl", "plan_name": "400100", "standard_charge_percentage": 0.85, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Basic Pl", "plan_name": "400100_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Federal", "plan_name": "400110", "standard_charge_percentage": 0.85, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Federal", "plan_name": "400110_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." } ] } ] }, { "description": "Nicotine 21 mg/24 hr daily transdermal patch [27863]", "drug_information": { "unit": 1.00, "type": "EA" }, "code_information": [ { "code": "60505-7063-0", "type": "NDC" } ], "standard_charges": [ { "gross_charge": 5.25, "minimum": 4.20, "maximum": 4.46, "setting": "both", "payers_information": [ { "payer_name": "Aetna", "plan_name": "700700", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna", "plan_name": "700700_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Miscellaneous", "plan_name": "700720", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Miscellaneous", "plan_name": "700720_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Ppo Hmo", "plan_name": "701720", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Ppo Hmo", "plan_name": "701720_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Ms State Emplo", "plan_name": "401457", "standard_charge_percentage": 0.80, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Ms State Emplo", "plan_name": "401457_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Basic Pl", "plan_name": "400100", "standard_charge_percentage": 0.85, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Basic Pl", "plan_name": "400100_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Federal", "plan_name": "400110", "standard_charge_percentage": 0.85, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Federal", "plan_name": "400110_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." } ] } ] }, { "description": "Dextromethorphan-guaifenesin 10 mg-100 mg/5 ml oral liquid [108397]", "drug_information": { "unit": 118.00, "type": "ML" }, "code_information": [ { "code": "6056906204", "type": "NDC" } ], "standard_charges": [ { "gross_charge": 11.66, "minimum": 9.33, "maximum": 9.91, "setting": "both", "payers_information": [ { "payer_name": "Aetna", "plan_name": "700700", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna", "plan_name": "700700_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Miscellaneous", "plan_name": "700720", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Miscellaneous", "plan_name": "700720_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Ppo Hmo", "plan_name": "701720", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Ppo Hmo", "plan_name": "701720_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Ms State Emplo", "plan_name": "401457", "standard_charge_percentage": 0.80, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Ms State Emplo", "plan_name": "401457_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Basic Pl", "plan_name": "400100", "standard_charge_percentage": 0.85, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Basic Pl", "plan_name": "400100_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Federal", "plan_name": "400110", "standard_charge_percentage": 0.85, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Federal", "plan_name": "400110_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." } ] } ] }, { "description": "Guaifenesin 100 mg/5 ml oral liquid [3542]", "drug_information": { "unit": 118.00, "type": "ML" }, "code_information": [ { "code": "6056906304", "type": "NDC" } ], "standard_charges": [ { "gross_charge": 11.66, "minimum": 9.33, "maximum": 9.91, "setting": "both", "payers_information": [ { "payer_name": "Aetna", "plan_name": "700700", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna", "plan_name": "700700_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Miscellaneous", "plan_name": "700720", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Miscellaneous", "plan_name": "700720_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Ppo Hmo", "plan_name": "701720", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Ppo Hmo", "plan_name": "701720_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Ms State Emplo", "plan_name": "401457", "standard_charge_percentage": 0.80, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Ms State Emplo", "plan_name": "401457_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Basic Pl", "plan_name": "400100", "standard_charge_percentage": 0.85, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Basic Pl", "plan_name": "400100_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Federal", "plan_name": "400110", "standard_charge_percentage": 0.85, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Federal", "plan_name": "400110_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." } ] } ] }, { "description": "Magnesium oxide 400 mg (241.3 mg magnesium) tablet [10491]", "drug_information": { "unit": 1.00, "type": "EA" }, "code_information": [ { "code": "6056949460", "type": "NDC" } ], "standard_charges": [ { "gross_charge": 1.00, "minimum": 0.80, "maximum": 0.85, "setting": "both", "payers_information": [ { "payer_name": "Aetna", "plan_name": "700700", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna", "plan_name": "700700_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Miscellaneous", "plan_name": "700720", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Miscellaneous", "plan_name": "700720_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Ppo Hmo", "plan_name": "701720", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Ppo Hmo", "plan_name": "701720_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Ms State Emplo", "plan_name": "401457", "standard_charge_percentage": 0.80, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Ms State Emplo", "plan_name": "401457_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Basic Pl", "plan_name": "400100", "standard_charge_percentage": 0.85, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Basic Pl", "plan_name": "400100_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Federal", "plan_name": "400110", "standard_charge_percentage": 0.85, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Federal", "plan_name": "400110_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." } ] } ] }, { "description": "Ursodiol 300 mg capsule [11624]", "drug_information": { "unit": 1.00, "type": "EA" }, "code_information": [ { "code": "60687-100-11", "type": "NDC" } ], "standard_charges": [ { "gross_charge": 28.28, "minimum": 22.62, "maximum": 24.04, "setting": "both", "payers_information": [ { "payer_name": "Aetna", "plan_name": "700700", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna", "plan_name": "700700_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Miscellaneous", "plan_name": "700720", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Miscellaneous", "plan_name": "700720_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Ppo Hmo", "plan_name": "701720", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Ppo Hmo", "plan_name": "701720_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Ms State Emplo", "plan_name": "401457", "standard_charge_percentage": 0.80, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Ms State Emplo", "plan_name": "401457_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Basic Pl", "plan_name": "400100", "standard_charge_percentage": 0.85, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Basic Pl", "plan_name": "400100_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Federal", "plan_name": "400110", "standard_charge_percentage": 0.85, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Federal", "plan_name": "400110_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." } ] } ] }, { "description": "Ketorolac 10 mg tablet [10371]", "drug_information": { "unit": 1.00, "type": "EA" }, "code_information": [ { "code": "60687-104-11", "type": "NDC" } ], "standard_charges": [ { "gross_charge": 52.14, "minimum": 41.71, "maximum": 44.32, "setting": "both", "payers_information": [ { "payer_name": "Aetna", "plan_name": "700700", "standard_charge_percentage": 80.0, "count": "0", 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"Bc/Bs Of Ms Federal", "plan_name": "400110", "standard_charge_percentage": 0.85, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Federal", "plan_name": "400110_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." } ] } ] }, { "description": "Metformin 850 mg tablet [14719]", "drug_information": { "unit": 1.00, "type": "EA" }, "code_information": [ { "code": "60687-143-01", "type": "NDC" } ], "standard_charges": [ { "gross_charge": 7.50, "minimum": 6.00, "maximum": 6.38, "setting": "both", "payers_information": [ { "payer_name": "Aetna", "plan_name": "700700", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate 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"payer_name": "Bc/Bs Ms State Emplo", "plan_name": "401457", "standard_charge_percentage": 0.80, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Ms State Emplo", "plan_name": "401457_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Basic Pl", "plan_name": "400100", "standard_charge_percentage": 0.85, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Basic Pl", "plan_name": "400100_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Federal", "plan_name": "400110", "standard_charge_percentage": 0.85, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Federal", "plan_name": "400110_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." } ] } ] }, { "description": "Diclofenac 0.1 % eye drops [19714]", "drug_information": { "unit": 5.00, "type": "ML" }, "code_information": [ { "code": "61314-014-05", "type": "NDC" } ], "standard_charges": [ { "gross_charge": 98.04, "minimum": 78.43, "maximum": 83.33, "setting": "both", "payers_information": [ { "payer_name": "Aetna", "plan_name": "700700", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna", "plan_name": "700700_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Miscellaneous", "plan_name": "700720", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Miscellaneous", "plan_name": "700720_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Ppo Hmo", "plan_name": "701720", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Ppo Hmo", "plan_name": "701720_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Ms State Emplo", "plan_name": "401457", "standard_charge_percentage": 0.80, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Ms State Emplo", "plan_name": "401457_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Basic Pl", "plan_name": "400100", "standard_charge_percentage": 0.85, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Basic Pl", "plan_name": "400100_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Federal", "plan_name": "400110", "standard_charge_percentage": 0.85, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Federal", "plan_name": "400110_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." } ] } ] }, { "description": "Dorzolamide 22.3 mg-timolol 6.8 mg/ml eye drops [22982]", "drug_information": { "unit": 10.00, "type": "ML" }, "code_information": [ { "code": "61314-030-02", "type": "NDC" } ], "standard_charges": [ { "gross_charge": 140.03, "minimum": 112.02, "maximum": 119.03, "setting": "both", "payers_information": [ { "payer_name": "Aetna", "plan_name": "700700", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna", "plan_name": "700700_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Miscellaneous", "plan_name": "700720", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Miscellaneous", "plan_name": "700720_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Ppo Hmo", "plan_name": "701720", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Ppo Hmo", "plan_name": "701720_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Ms State Emplo", "plan_name": "401457", "standard_charge_percentage": 0.80, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Ms State Emplo", "plan_name": "401457_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Basic Pl", "plan_name": "400100", "standard_charge_percentage": 0.85, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Basic Pl", "plan_name": "400100_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Federal", "plan_name": "400110", "standard_charge_percentage": 0.85, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Federal", "plan_name": "400110_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." } ] } ] }, { "description": "Brimonidine 0.2 % eye drops [17881]", "drug_information": { "unit": 5.00, "type": "ML" }, "code_information": [ { "code": "61314-143-05", "type": "NDC" } ], "standard_charges": [ { "gross_charge": 70.02, "minimum": 56.02, "maximum": 59.52, "setting": "both", "payers_information": [ { "payer_name": "Aetna", "plan_name": "700700", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna", "plan_name": "700700_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Miscellaneous", "plan_name": "700720", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Miscellaneous", "plan_name": "700720_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Ppo Hmo", "plan_name": "701720", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Ppo Hmo", "plan_name": "701720_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Ms State Emplo", "plan_name": "401457", "standard_charge_percentage": 0.80, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Ms State Emplo", "plan_name": "401457_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Basic Pl", "plan_name": "400100", "standard_charge_percentage": 0.85, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Basic Pl", "plan_name": "400100_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Federal", "plan_name": "400110", "standard_charge_percentage": 0.85, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Federal", "plan_name": "400110_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." } ] } ] }, { "description": "Brimonidine 0.15 % eye drops [31158]", "drug_information": { "unit": 5.00, "type": "ML" }, "code_information": [ { "code": "61314-144-05", "type": "NDC" } ], "standard_charges": [ { "gross_charge": 984.58, "minimum": 787.66, "maximum": 836.89, "setting": "both", "payers_information": [ { "payer_name": "Aetna", "plan_name": "700700", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna", "plan_name": "700700_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Miscellaneous", "plan_name": "700720", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Miscellaneous", "plan_name": "700720_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Ppo Hmo", "plan_name": "701720", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Ppo Hmo", "plan_name": "701720_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Ms State Emplo", "plan_name": "401457", "standard_charge_percentage": 0.80, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Ms State Emplo", "plan_name": "401457_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Basic Pl", "plan_name": "400100", "standard_charge_percentage": 0.85, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Basic Pl", "plan_name": "400100_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Federal", "plan_name": "400110", "standard_charge_percentage": 0.85, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Federal", "plan_name": "400110_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." } ] } ] }, { "description": "Timolol maleate 0.25 % eye drops [11561]", "drug_information": { "unit": 5.00, "type": "ML" }, "code_information": [ { "code": "61314-226-05", "type": "NDC" } ], "standard_charges": [ { "gross_charge": 36.20, "minimum": 28.96, "maximum": 30.77, "setting": "both", "payers_information": [ { "payer_name": "Aetna", "plan_name": "700700", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna", "plan_name": "700700_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Miscellaneous", "plan_name": "700720", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Miscellaneous", "plan_name": "700720_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Ppo Hmo", "plan_name": "701720", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Ppo Hmo", "plan_name": "701720_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Ms State Emplo", "plan_name": "401457", "standard_charge_percentage": 0.80, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Ms State Emplo", "plan_name": "401457_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Basic Pl", "plan_name": "400100", "standard_charge_percentage": 0.85, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Basic Pl", "plan_name": "400100_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Federal", "plan_name": "400110", "standard_charge_percentage": 0.85, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Federal", "plan_name": "400110_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." } ] } ] }, { "description": "Timolol maleate 0.5 % eye drops [11562]", "drug_information": { "unit": 5.00, "type": "ML" }, "code_information": [ { "code": "61314-227-05", "type": "NDC" } ], "standard_charges": [ { "gross_charge": 67.55, "minimum": 54.04, "maximum": 57.42, "setting": "both", "payers_information": [ { "payer_name": "Aetna", "plan_name": "700700", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna", "plan_name": "700700_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Miscellaneous", "plan_name": "700720", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Miscellaneous", "plan_name": "700720_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Ppo Hmo", "plan_name": "701720", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Ppo Hmo", "plan_name": "701720_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Ms State Emplo", "plan_name": "401457", "standard_charge_percentage": 0.80, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Ms State Emplo", "plan_name": "401457_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Basic Pl", "plan_name": "400100", "standard_charge_percentage": 0.85, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Basic Pl", "plan_name": "400100_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Federal", "plan_name": "400110", "standard_charge_percentage": 0.85, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Federal", "plan_name": "400110_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." } ] } ] }, { "description": "Carteolol 1 % eye drops [9417]", "drug_information": { "unit": 5.00, "type": "ML" }, "code_information": [ { "code": "61314-238-05", "type": "NDC" } ], "standard_charges": [ { "gross_charge": 72.87, "minimum": 58.30, "maximum": 61.94, "setting": "both", "payers_information": [ { "payer_name": "Aetna", "plan_name": "700700", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna", "plan_name": "700700_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Miscellaneous", "plan_name": "700720", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Miscellaneous", "plan_name": "700720_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Ppo Hmo", "plan_name": "701720", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Ppo Hmo", "plan_name": "701720_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Ms State Emplo", "plan_name": "401457", "standard_charge_percentage": 0.80, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Ms State Emplo", "plan_name": "401457_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Basic Pl", "plan_name": "400100", "standard_charge_percentage": 0.85, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Basic Pl", "plan_name": "400100_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Federal", "plan_name": "400110", "standard_charge_percentage": 0.85, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Federal", "plan_name": "400110_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." } ] } ] }, { "description": "Tropicamide 1 % eye drops [8250]", "drug_information": { "unit": 3.00, "type": "ML" }, "code_information": [ { "code": "61314-355-01", "type": "NDC" } ], "standard_charges": [ { "gross_charge": 79.80, "minimum": 63.84, "maximum": 67.83, "setting": "both", "payers_information": [ { "payer_name": "Aetna", "plan_name": "700700", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna", "plan_name": "700700_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Miscellaneous", "plan_name": "700720", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Miscellaneous", "plan_name": "700720_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Ppo Hmo", "plan_name": "701720", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Ppo Hmo", "plan_name": "701720_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Ms State Emplo", "plan_name": "401457", "standard_charge_percentage": 0.80, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Ms State Emplo", "plan_name": "401457_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Basic Pl", "plan_name": "400100", "standard_charge_percentage": 0.85, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Basic Pl", 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"description": "Neomycin-polymyxin-dexameth 3.5 mg/ml-10000 unit/ml-0.1% eye drops [10708]", "drug_information": { "unit": 5.00, "type": "ML" }, "code_information": [ { "code": "61314-630-06", "type": "NDC" } ], "standard_charges": [ { "gross_charge": 126.02, "minimum": 100.82, "maximum": 107.12, "setting": "both", "payers_information": [ { "payer_name": "Aetna", "plan_name": "700700", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna", "plan_name": "700700_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Miscellaneous", "plan_name": "700720", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": 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"payer_name": "Bc/Bs Ms State Emplo", "plan_name": "401457", "standard_charge_percentage": 0.80, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Ms State Emplo", "plan_name": "401457_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Basic Pl", "plan_name": "400100", "standard_charge_percentage": 0.85, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Basic Pl", "plan_name": "400100_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Federal", "plan_name": "400110", "standard_charge_percentage": 0.85, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Federal", "plan_name": "400110_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." } ] } ] }, { "description": "Tobramycin 0.3 %-dexamethasone 0.1 % eye dropssuspension [11567]", "drug_information": { "unit": 2.50, "type": "ML" }, "code_information": [ { "code": "61314-647-25", "type": "NDC" } ], "standard_charges": [ { "gross_charge": 287.99, "minimum": 230.39, "maximum": 244.79, "setting": "both", "payers_information": [ { "payer_name": "Aetna", "plan_name": "700700", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna", "plan_name": "700700_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Miscellaneous", "plan_name": "700720", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Miscellaneous", "plan_name": "700720_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Ppo Hmo", "plan_name": "701720", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": 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"400110_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." } ] } ] }, { "description": "Rifampin 300 mg capsule [11293]", "drug_information": { "unit": 1.00, "type": "EA" }, "code_information": [ { "code": "61748-018-01", "type": "NDC" } ], "standard_charges": [ { "gross_charge": 7.50, "minimum": 6.00, "maximum": 6.38, "setting": "both", "payers_information": [ { "payer_name": "Aetna", "plan_name": "700700", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna", "plan_name": "700700_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna 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"plan_name": "401457", "standard_charge_percentage": 0.80, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Ms State Emplo", "plan_name": "401457_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Basic Pl", "plan_name": "400100", "standard_charge_percentage": 0.85, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Basic Pl", "plan_name": "400100_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Federal", "plan_name": "400110", "standard_charge_percentage": 0.85, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Federal", "plan_name": "400110_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." } ] } ] }, { "description": "Zinc oxide 16 % topical ointment [28827]", "drug_information": { "unit": 57.00, "type": "GR" }, "code_information": [ { "code": "6210333302", "type": "NDC" } ], "standard_charges": [ { "gross_charge": 10.82, "minimum": 8.66, "maximum": 9.20, "setting": "both", "payers_information": [ { "payer_name": "Aetna", "plan_name": "700700", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna", "plan_name": "700700_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Miscellaneous", "plan_name": "700720", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Miscellaneous", "plan_name": "700720_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Ppo Hmo", "plan_name": "701720", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna 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"payer_name": "Aetna Ppo Hmo", "plan_name": "701720", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Ppo Hmo", "plan_name": "701720_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Ms State Emplo", "plan_name": "401457", "standard_charge_percentage": 0.80, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Ms State Emplo", "plan_name": "401457_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": 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"description": "Lipase 10500-protease 35500-amylase 61500 unit capsuledelayed rel [179585]", "drug_information": { "unit": 1.00, "type": "EA" }, "code_information": [ { "code": "62541-403-10", "type": "NDC" } ], "standard_charges": [ { "gross_charge": 14.09, "minimum": 11.27, "maximum": 11.98, "setting": "both", "payers_information": [ { "payer_name": "Aetna", "plan_name": "700700", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna", "plan_name": "700700_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Miscellaneous", "plan_name": "700720", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": 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billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Federal", "plan_name": "400110", "standard_charge_percentage": 0.85, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Federal", "plan_name": "400110_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." } ] } ] }, { "description": "Propafenone 225 mg tablet [11147]", "drug_information": { "unit": 1.00, "type": "EA" }, "code_information": [ { "code": "62559-231-01", "type": "NDC" } ], "standard_charges": [ { "gross_charge": 7.50, "minimum": 6.00, "maximum": 6.38, "setting": "both", "payers_information": [ { "payer_name": "Aetna", "plan_name": "700700", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna", "plan_name": "700700_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Miscellaneous", "plan_name": "700720", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Miscellaneous", "plan_name": "700720_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Ppo Hmo", "plan_name": "701720", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of 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billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Basic Pl", "plan_name": "400100_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Federal", "plan_name": "400110", "standard_charge_percentage": 0.85, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Federal", "plan_name": "400110_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." } ] } ] }, { "description": "Propafenone 300 mg tablet [11148]", "drug_information": { "unit": 1.00, "type": "EA" }, "code_information": [ { "code": 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remit data to calculate allowed amounts." } ] } ] }, { "description": "Demeclocycline 150 mg tablet [9726]", "drug_information": { "unit": 1.00, "type": "EA" }, "code_information": [ { "code": "62584-159-11", "type": "NDC" } ], "standard_charges": [ { "gross_charge": 32.94, "minimum": 26.35, "maximum": 28.00, "setting": "both", "payers_information": [ { "payer_name": "Aetna", "plan_name": "700700", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna", "plan_name": "700700_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Miscellaneous", "plan_name": "700720", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Miscellaneous", "plan_name": "700720_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Ppo Hmo", "plan_name": "701720", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Ppo Hmo", "plan_name": "701720_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Ms State Emplo", "plan_name": "401457", "standard_charge_percentage": 0.80, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Ms State Emplo", "plan_name": "401457_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Basic Pl", "plan_name": "400100", "standard_charge_percentage": 0.85, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Basic Pl", "plan_name": "400100_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Federal", "plan_name": "400110", "standard_charge_percentage": 0.85, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Federal", "plan_name": "400110_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." } ] } ] }, { "description": "Metoprolol tartrate 100 mg tablet [5008]", "drug_information": { "unit": 1.00, "type": "EA" }, "code_information": [ { "code": "62584-267-11", "type": "NDC" } ], "standard_charges": [ { "gross_charge": 7.50, "minimum": 6.00, "maximum": 6.38, "setting": "both", "payers_information": [ { "payer_name": "Aetna", "plan_name": "700700", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna", "plan_name": "700700_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Miscellaneous", "plan_name": "700720", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Miscellaneous", "plan_name": "700720_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Ppo Hmo", "plan_name": "701720", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Ppo Hmo", "plan_name": "701720_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Ms State Emplo", "plan_name": "401457", "standard_charge_percentage": 0.80, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Ms State Emplo", "plan_name": "401457_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Basic Pl", "plan_name": "400100", "standard_charge_percentage": 0.85, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Basic Pl", "plan_name": "400100_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Federal", "plan_name": "400110", "standard_charge_percentage": 0.85, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Federal", "plan_name": "400110_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." } ] } ] }, { "description": "Hydralazine 25 mg tablet [3700]", "drug_information": { "unit": 1.00, "type": "EA" }, "code_information": [ { "code": "62584-733-11", "type": "NDC" } ], "standard_charges": [ { "gross_charge": 7.50, "minimum": 6.00, "maximum": 6.38, "setting": "both", "payers_information": [ { "payer_name": "Aetna", "plan_name": "700700", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna", "plan_name": "700700_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Miscellaneous", "plan_name": "700720", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Miscellaneous", "plan_name": "700720_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Ppo Hmo", "plan_name": "701720", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Ppo Hmo", "plan_name": "701720_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Ms State Emplo", "plan_name": "401457", "standard_charge_percentage": 0.80, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Ms State Emplo", "plan_name": "401457_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Basic Pl", "plan_name": "400100", "standard_charge_percentage": 0.85, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Basic Pl", "plan_name": "400100_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Federal", "plan_name": "400110", "standard_charge_percentage": 0.85, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Federal", "plan_name": "400110_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." } ] } ] }, { "description": "Hydralazine 50 mg tablet [3701]", "drug_information": { "unit": 1.00, "type": "EA" }, "code_information": [ { "code": "62584-734-01", "type": "NDC" } ], "standard_charges": [ { "gross_charge": 7.50, "minimum": 6.00, "maximum": 6.38, "setting": "both", "payers_information": [ { "payer_name": "Aetna", "plan_name": "700700", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna", "plan_name": "700700_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Miscellaneous", "plan_name": "700720", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Miscellaneous", "plan_name": "700720_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Ppo Hmo", "plan_name": "701720", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Ppo Hmo", "plan_name": "701720_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Ms State Emplo", "plan_name": "401457", "standard_charge_percentage": 0.80, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Ms State Emplo", "plan_name": "401457_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Basic Pl", "plan_name": "400100", "standard_charge_percentage": 0.85, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Basic Pl", "plan_name": "400100_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Federal", "plan_name": "400110", "standard_charge_percentage": 0.85, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Federal", "plan_name": "400110_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." } ] } ] }, { "description": "Hydralazine 50 mg tablet [3701]", "drug_information": { "unit": 1.00, "type": "EA" }, "code_information": [ { "code": "62584-734-11", "type": "NDC" } ], "standard_charges": [ { "gross_charge": 7.50, "minimum": 6.00, "maximum": 6.38, "setting": "both", "payers_information": [ { "payer_name": "Aetna", "plan_name": "700700", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna", "plan_name": "700700_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Miscellaneous", "plan_name": "700720", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Miscellaneous", "plan_name": "700720_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Ppo Hmo", "plan_name": "701720", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Ppo Hmo", "plan_name": "701720_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Ms State Emplo", "plan_name": "401457", "standard_charge_percentage": 0.80, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Ms State Emplo", "plan_name": "401457_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Basic Pl", "plan_name": "400100", "standard_charge_percentage": 0.85, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Basic Pl", "plan_name": "400100_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Federal", "plan_name": "400110", "standard_charge_percentage": 0.85, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Federal", "plan_name": "400110_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." } ] } ] }, { "description": "Folic acid 1 mg tablet [3233]", "drug_information": { "unit": 1.00, "type": "EA" }, "code_information": [ { "code": "62584-897-11", "type": "NDC" } ], "standard_charges": [ { "gross_charge": 7.50, "minimum": 6.00, "maximum": 6.38, "setting": "both", "payers_information": [ { "payer_name": "Aetna", "plan_name": "700700", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna", "plan_name": "700700_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Miscellaneous", "plan_name": "700720", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Miscellaneous", "plan_name": "700720_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Ppo Hmo", "plan_name": "701720", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Ppo Hmo", "plan_name": "701720_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Ms State Emplo", "plan_name": "401457", "standard_charge_percentage": 0.80, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Ms State Emplo", "plan_name": "401457_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Basic Pl", "plan_name": "400100", "standard_charge_percentage": 0.85, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Basic Pl", "plan_name": "400100_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Federal", "plan_name": "400110", "standard_charge_percentage": 0.85, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Federal", "plan_name": "400110_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." } ] } ] }, { "description": "Warfarin 2 mg tablet [8749]", "drug_information": { "unit": 1.00, "type": "EA" }, "code_information": [ { "code": "62584-984-11", "type": "NDC" } ], "standard_charges": [ { "gross_charge": 7.50, "minimum": 6.00, "maximum": 6.38, "setting": "both", "payers_information": [ { "payer_name": "Aetna", "plan_name": "700700", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna", "plan_name": "700700_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Miscellaneous", "plan_name": "700720", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Miscellaneous", "plan_name": "700720_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Ppo Hmo", "plan_name": "701720", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Ppo Hmo", "plan_name": "701720_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Ms State Emplo", "plan_name": "401457", "standard_charge_percentage": 0.80, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Ms State Emplo", "plan_name": "401457_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Basic Pl", "plan_name": "400100", "standard_charge_percentage": 0.85, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Basic Pl", "plan_name": "400100_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Federal", "plan_name": "400110", "standard_charge_percentage": 0.85, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Federal", "plan_name": "400110_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." } ] } ] }, { "description": "Warfarin 5 mg tablet [8751]", 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"plan_name": "400100", "standard_charge_percentage": 0.85, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Basic Pl", "plan_name": "400100_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Federal", "plan_name": "400110", "standard_charge_percentage": 0.85, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Federal", "plan_name": "400110_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." } ] } ] }, { "description": "Hydroxyzine hcl 10 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{ "payer_name": "Aetna Miscellaneous", "plan_name": "700720_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Ppo Hmo", "plan_name": "701720", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Ppo Hmo", "plan_name": "701720_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Ms State Emplo", "plan_name": "401457", "standard_charge_percentage": 0.80, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Ms State Emplo", "plan_name": "401457_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Basic Pl", "plan_name": "400100", "standard_charge_percentage": 0.85, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Basic Pl", "plan_name": "400100_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Federal", "plan_name": "400110", "standard_charge_percentage": 0.85, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Federal", "plan_name": "400110_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." } ] } ] }, { "description": "Doxycycline hyclate 100 mg tablet [2625]", "drug_information": { "unit": 1.00, "type": "EA" }, "code_information": [ { "code": "62135-626-50", "type": "NDC" } ], "standard_charges": [ { "gross_charge": 7.50, "minimum": 6.00, "maximum": 6.38, "setting": "both", "payers_information": [ { "payer_name": "Aetna", "plan_name": "700700", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna", "plan_name": "700700_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed 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"payer_name": "Bc/Bs Ms State Emplo", "plan_name": "401457", "standard_charge_percentage": 0.80, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Ms State Emplo", "plan_name": "401457_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Basic Pl", "plan_name": "400100", "standard_charge_percentage": 0.85, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Basic Pl", "plan_name": "400100_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Federal", "plan_name": "400110", "standard_charge_percentage": 0.85, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Federal", "plan_name": "400110_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." } ] } ] }, { "description": "Doxycycline hyclate 100 mg capsule [2623]", "drug_information": { "unit": 1.00, "type": "EA" }, "code_information": [ { "code": "62135-985-50", "type": "NDC" } ], "standard_charges": [ { "gross_charge": 7.50, "minimum": 6.00, "maximum": 6.38, "setting": "both", "payers_information": [ { "payer_name": "Aetna", "plan_name": "700700", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit 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}, { "payer_name": "Bc/Bs Of Ms Basic Pl", "plan_name": "400100_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Federal", "plan_name": "400110", "standard_charge_percentage": 0.85, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Federal", "plan_name": "400110_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." } ] } ] }, { "description": "Isosorbide mononitrate 20 mg tablet [10357]", "drug_information": { "unit": 1.00, "type": "EA" }, "code_information": [ { "code": "62175-107-01", "type": "NDC" } ], "standard_charges": [ { "gross_charge": 7.50, "minimum": 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allowed amounts." } ] } ] }, { "description": "Lidocaine hcl (bulk) 100 % powder [118597]", "drug_information": { "unit": 100.00, "type": "GR" }, "code_information": [ { "code": "62991-1095-2", "type": "NDC" } ], "standard_charges": [ { "gross_charge": 1816.88, "minimum": 1453.50, "maximum": 1544.35, "setting": "both", "payers_information": [ { "payer_name": "Aetna", "plan_name": "700700", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna", "plan_name": "700700_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Miscellaneous", "plan_name": "700720", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Miscellaneous", "plan_name": "700720_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Ppo Hmo", "plan_name": "701720", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Ppo Hmo", "plan_name": "701720_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Ms State Emplo", "plan_name": "401457", "standard_charge_percentage": 0.80, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Ms State Emplo", "plan_name": "401457_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Basic Pl", "plan_name": "400100", "standard_charge_percentage": 0.85, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Basic Pl", "plan_name": "400100_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Federal", "plan_name": "400110", "standard_charge_percentage": 0.85, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Federal", "plan_name": "400110_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." } ] } ] }, { "description": "Phenylephrine hcl (bulk) 100 % powder [6247]", "drug_information": { "unit": 25.00, "type": "GR" }, "code_information": [ { "code": "62991-2046-2", "type": "NDC" } ], "standard_charges": [ { "gross_charge": 519.09, "minimum": 415.27, "maximum": 441.23, "setting": "both", "payers_information": [ { "payer_name": "Aetna", "plan_name": "700700", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna", "plan_name": "700700_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Miscellaneous", "plan_name": "700720", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Miscellaneous", "plan_name": "700720_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Ppo Hmo", "plan_name": "701720", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Ppo Hmo", "plan_name": "701720_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Ms State Emplo", "plan_name": "401457", "standard_charge_percentage": 0.80, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Ms State Emplo", "plan_name": "401457_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Basic Pl", "plan_name": "400100", "standard_charge_percentage": 0.85, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Basic Pl", "plan_name": "400100_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Federal", "plan_name": "400110", "standard_charge_percentage": 0.85, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Federal", "plan_name": "400110_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." } ] } ] }, { "description": "Hydrocortisone (bulk) powder [3735]", "drug_information": { "unit": 25.00, "type": "GR" }, "code_information": [ { "code": "62991-3057-1", "type": "NDC" } ], "standard_charges": [ { "gross_charge": 1962.11, "minimum": 1569.69, "maximum": 1667.79, "setting": "both", "payers_information": [ { "payer_name": "Aetna", "plan_name": "700700", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna", "plan_name": "700700_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Miscellaneous", "plan_name": "700720", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Miscellaneous", "plan_name": "700720_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Ppo Hmo", "plan_name": "701720", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Ppo Hmo", "plan_name": "701720_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Ms State Emplo", "plan_name": "401457", "standard_charge_percentage": 0.80, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Ms State Emplo", "plan_name": "401457_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Basic Pl", "plan_name": "400100", "standard_charge_percentage": 0.85, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Basic Pl", "plan_name": "400100_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Federal", "plan_name": "400110", "standard_charge_percentage": 0.85, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Federal", "plan_name": "400110_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." } ] } ] }, { "description": "Ranolazine er 500 mg tabletextended release12 hr [70434]", "drug_information": { "unit": 1.00, "type": "EA" }, "code_information": [ { "code": "63304-017-60", "type": "NDC" } ], "standard_charges": [ { "gross_charge": 7.50, "minimum": 6.00, "maximum": 6.38, "setting": "both", "payers_information": [ { "payer_name": "Aetna", "plan_name": "700700", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna", "plan_name": "700700_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Miscellaneous", "plan_name": "700720", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Miscellaneous", "plan_name": "700720_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Ppo Hmo", "plan_name": "701720", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Ppo Hmo", "plan_name": "701720_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Ms State Emplo", "plan_name": "401457", "standard_charge_percentage": 0.80, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Ms State 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"standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." } ] } ] }, { "description": "Folic acid 5 mg/ml injection solution [3232]", "drug_information": { "unit": 10.00, "type": "ML" }, "code_information": [ { "code": "63323-184-10", "type": "NDC" } ], "standard_charges": [ { "gross_charge": 341.95, "minimum": 273.56, "maximum": 290.66, "setting": "both", "payers_information": [ { "payer_name": "Aetna", "plan_name": "700700", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna", "plan_name": "700700_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna 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"plan_name": "401457", "standard_charge_percentage": 0.80, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Ms State Emplo", "plan_name": "401457_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Basic Pl", "plan_name": "400100", "standard_charge_percentage": 0.85, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Basic Pl", "plan_name": "400100_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Federal", "plan_name": "400110", "standard_charge_percentage": 0.85, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Federal", "plan_name": "400110_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." } ] } ] }, { "description": "Water for injection sterile injection solution [11671]", "drug_information": { "unit": 5.00, "type": "ML" }, "code_information": [ { "code": "63323-185-04", "type": "NDC" } ], "standard_charges": [ { "gross_charge": 18.00, "minimum": 14.40, "maximum": 15.30, "setting": "both", "payers_information": [ { "payer_name": "Aetna", "plan_name": "700700", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate 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"payer_name": "Aetna Ppo Hmo", "plan_name": "701720_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Ms State Emplo", "plan_name": "401457", "standard_charge_percentage": 0.80, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Ms State Emplo", "plan_name": "401457_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Basic Pl", "plan_name": "400100", "standard_charge_percentage": 0.85, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Basic Pl", "plan_name": "400100_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Federal", "plan_name": "400110", "standard_charge_percentage": 0.85, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Federal", "plan_name": "400110_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." } ] } ] }, { "description": "Water for injection sterile injection solution [11671]", "drug_information": { "unit": 10.00, "type": "ML" }, "code_information": [ { "code": "63323-185-07", "type": "NDC" } ], "standard_charges": [ { "gross_charge": 26.80, 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"additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Miscellaneous", "plan_name": "700720_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Ppo Hmo", "plan_name": "701720", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Ppo Hmo", "plan_name": "701720_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Ms State Emplo", "plan_name": "401457", "standard_charge_percentage": 0.80, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Ms State Emplo", "plan_name": "401457_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Basic Pl", "plan_name": "400100", "standard_charge_percentage": 0.85, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Basic Pl", "plan_name": "400100_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Federal", "plan_name": "400110", "standard_charge_percentage": 0.85, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Federal", "plan_name": "400110_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." } ] } ] }, { "description": "Sodium chloride 0.9 % injection solution [41463]", "drug_information": { "unit": 10.00, "type": "ML" }, "code_information": [ { "code": "63323-186-01", "type": "NDC" } ], "standard_charges": [ { "gross_charge": 18.80, "minimum": 15.04, "maximum": 15.98, "setting": "both", "payers_information": [ { "payer_name": "Aetna", "plan_name": "700700", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna", "plan_name": "700700_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Miscellaneous", "plan_name": "700720", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Miscellaneous", "plan_name": "700720_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Ppo Hmo", "plan_name": "701720", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Ppo Hmo", "plan_name": "701720_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Ms State Emplo", "plan_name": "401457", "standard_charge_percentage": 0.80, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Ms State Emplo", "plan_name": "401457_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Basic Pl", "plan_name": "400100", "standard_charge_percentage": 0.85, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Basic Pl", "plan_name": "400100_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Federal", "plan_name": "400110", "standard_charge_percentage": 0.85, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Federal", "plan_name": "400110_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." } ] } ] }, { "description": "Sodium chloride 0.9 % injection solution [41463]", "drug_information": { "unit": 10.00, "type": "ML" }, "code_information": [ { "code": "63323-186-10", "type": "NDC" } ], "standard_charges": [ { "gross_charge": 18.80, "minimum": 15.04, "maximum": 15.98, "setting": "both", "payers_information": [ { "payer_name": "Aetna", "plan_name": "700700", 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"standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Ppo Hmo", "plan_name": "701720_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Ms State Emplo", "plan_name": "401457", "standard_charge_percentage": 0.80, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Ms State Emplo", "plan_name": "401457_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Basic Pl", "plan_name": "400100", "standard_charge_percentage": 0.85, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Basic Pl", "plan_name": "400100_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Federal", "plan_name": "400110", "standard_charge_percentage": 0.85, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Federal", "plan_name": "400110_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." } ] } ] }, { "description": "Rifampin 600 mg intravenous solution [11291]", "drug_information": { "unit": 1.00, "type": "EA" }, "code_information": [ { "code": "63323-351-20", "type": "NDC" } ], "standard_charges": [ { "gross_charge": 772.65, "minimum": 618.12, "maximum": 656.75, "setting": "both", "payers_information": [ { "payer_name": "Aetna", "plan_name": "700700", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna", "plan_name": "700700_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Miscellaneous", "plan_name": "700720", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna 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"plan_name": "401457_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Basic Pl", "plan_name": "400100", "standard_charge_percentage": 0.85, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Basic Pl", "plan_name": "400100_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Federal", "plan_name": "400110", "standard_charge_percentage": 0.85, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Federal", "plan_name": "400110_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." } ] } ] }, { "description": "Bupivacaine-epinephrine (pf) 0.5 %-1:200000 injection solution [105634]", "drug_information": { "unit": 30.00, "type": "ML" }, "code_information": [ { "code": "63323-462-37", "type": "NDC" } ], "standard_charges": [ { "gross_charge": 64.05, "minimum": 51.24, "maximum": 54.44, "setting": "both", "payers_information": [ { "payer_name": "Aetna", "plan_name": "700700", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna", "plan_name": "700700_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to 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amounts." }, { "payer_name": "Bc/Bs Of Ms Federal", "plan_name": "400110", "standard_charge_percentage": 0.85, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Federal", "plan_name": "400110_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." } ] } ] }, { "description": "Bupivacaine-epinephrine (pf) 0.25 %-1:200000 injection solution [105633]", "drug_information": { "unit": 10.00, "type": "ML" }, "code_information": [ { "code": "63323-468-01", "type": "NDC" } ], "standard_charges": [ { "gross_charge": 31.10, "minimum": 24.88, "maximum": 26.44, "setting": "both", "payers_information": [ { "payer_name": "Aetna", "plan_name": "700700", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed 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"additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Ppo Hmo", "plan_name": "701720_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Ms State Emplo", "plan_name": "401457", "standard_charge_percentage": 0.80, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Ms State Emplo", "plan_name": "401457_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Basic Pl", "plan_name": "400100", "standard_charge_percentage": 0.85, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Basic Pl", "plan_name": "400100_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Federal", "plan_name": "400110", "standard_charge_percentage": 0.85, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Federal", "plan_name": "400110_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." } ] } ] }, { "description": "Bupivacaine-epinephrine (pf) 0.25 %-1:200000 injection solution [105633]", "drug_information": { "unit": 30.00, "type": "ML" }, 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"standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Ppo Hmo", "plan_name": "701720", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Ppo Hmo", "plan_name": "701720_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Ms State Emplo", "plan_name": "401457", "standard_charge_percentage": 0.80, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Ms State Emplo", "plan_name": "401457_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Basic Pl", "plan_name": "400100", "standard_charge_percentage": 0.85, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Basic Pl", "plan_name": "400100_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Federal", "plan_name": "400110", "standard_charge_percentage": 0.85, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Federal", "plan_name": "400110_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." } ] } ] }, { "description": "Bupivacaine-epinephrine (pf) 0.25 %-1:200000 injection solution [105633]", "drug_information": { "unit": 10.00, "type": "ML" }, "code_information": [ { "code": "63323-468-17", "type": "NDC" } ], "standard_charges": [ { "gross_charge": 31.10, "minimum": 24.88, "maximum": 26.44, "setting": "both", "payers_information": [ { "payer_name": "Aetna", "plan_name": "700700", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna", "plan_name": "700700_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Miscellaneous", "plan_name": "700720", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Miscellaneous", "plan_name": "700720_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Ppo Hmo", "plan_name": "701720", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Ppo Hmo", "plan_name": "701720_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Ms State Emplo", "plan_name": "401457", "standard_charge_percentage": 0.80, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Ms State Emplo", "plan_name": "401457_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Basic Pl", "plan_name": "400100", "standard_charge_percentage": 0.85, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Basic Pl", "plan_name": "400100_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Federal", "plan_name": "400110", "standard_charge_percentage": 0.85, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Federal", "plan_name": "400110_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." } ] } ] }, { "description": "Caffeine citrate 60 mg/3 ml (20 mg/ml) intravenous solution [77412]", "drug_information": { "unit": 3.00, "type": "ML" }, "code_information": [ { "code": "63323-407-03", "type": "NDC" } ], "standard_charges": [ { "gross_charge": 155.66, "minimum": 124.53, "maximum": 132.31, "setting": "both", "payers_information": [ { "payer_name": "Aetna", "plan_name": "700700", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna", "plan_name": "700700_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Miscellaneous", "plan_name": "700720", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Miscellaneous", "plan_name": "700720_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Ppo Hmo", "plan_name": "701720", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Ppo Hmo", "plan_name": "701720_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Ms State Emplo", "plan_name": "401457", "standard_charge_percentage": 0.80, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Ms State Emplo", "plan_name": "401457_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Basic Pl", "plan_name": "400100", "standard_charge_percentage": 0.85, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Basic Pl", "plan_name": "400100_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Federal", "plan_name": "400110", "standard_charge_percentage": 0.85, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Federal", "plan_name": "400110_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." } ] } ] }, { "description": "Flumazenil 0.1 mg/ml intravenous solution [10055]", "drug_information": { "unit": 5.00, "type": "ML" }, "code_information": [ { "code": "63323-424-05", "type": "NDC" } ], "standard_charges": [ { "gross_charge": 68.88, "minimum": 55.10, "maximum": 58.55, "setting": "both", "payers_information": [ { "payer_name": "Aetna", "plan_name": "700700", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna", "plan_name": "700700_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Miscellaneous", "plan_name": "700720", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Miscellaneous", "plan_name": "700720_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Ppo Hmo", "plan_name": "701720", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Ppo Hmo", "plan_name": "701720_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Ms State Emplo", "plan_name": "401457", "standard_charge_percentage": 0.80, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Ms State Emplo", "plan_name": "401457_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Basic Pl", "plan_name": "400100", "standard_charge_percentage": 0.85, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Basic Pl", "plan_name": "400100_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Federal", "plan_name": "400110", "standard_charge_percentage": 0.85, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Federal", "plan_name": "400110_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." } ] } ] }, { "description": "Lidocaine 20 mg/ml (2 %) nebulization solution [500805]", "drug_information": { "unit": 5.00, "type": "ML" }, "code_information": [ { "code": "63323-495-04", "type": "NDC" } ], "standard_charges": [ { "gross_charge": 16.03, "minimum": 12.82, "maximum": 13.63, "setting": "both", "payers_information": [ { "payer_name": "Aetna", "plan_name": "700700", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna", "plan_name": "700700_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Miscellaneous", "plan_name": "700720", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Miscellaneous", "plan_name": "700720_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Ppo Hmo", "plan_name": "701720", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Ppo Hmo", "plan_name": "701720_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Ms State Emplo", "plan_name": "401457", "standard_charge_percentage": 0.80, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Ms State Emplo", "plan_name": "401457_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Basic Pl", "plan_name": "400100", "standard_charge_percentage": 0.85, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Basic Pl", "plan_name": "400100_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Federal", "plan_name": "400110", "standard_charge_percentage": 0.85, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Federal", "plan_name": "400110_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." } ] } ] }, { "description": "Lidocaine 20 mg/ml (2 %) nebulization solution [500805]", "drug_information": { "unit": 5.00, "type": "ML" }, "code_information": [ { "code": "63323-495-07", "type": "NDC" } ], "standard_charges": [ { "gross_charge": 16.03, "minimum": 12.82, "maximum": 13.63, "setting": "both", "payers_information": [ { "payer_name": "Aetna", "plan_name": "700700", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna", "plan_name": "700700_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Miscellaneous", "plan_name": "700720", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Miscellaneous", "plan_name": "700720_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Ppo Hmo", "plan_name": "701720", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Ppo Hmo", "plan_name": "701720_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Ms State Emplo", "plan_name": "401457", "standard_charge_percentage": 0.80, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Ms State Emplo", "plan_name": "401457_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Basic Pl", "plan_name": "400100", "standard_charge_percentage": 0.85, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Basic Pl", "plan_name": "400100_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Federal", "plan_name": "400110", "standard_charge_percentage": 0.85, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Federal", "plan_name": "400110_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." } ] } ] }, { "description": "Sodium chloride 0.9 % intravenous solution [27838]", "drug_information": { "unit": 100.00, "type": "ML" }, "code_information": [ { "code": "63323-623-61", "type": "NDC" } ], "standard_charges": [ { "gross_charge": 81.81, "minimum": 65.45, "maximum": 69.54, "setting": "both", "payers_information": [ { "payer_name": "Aetna", "plan_name": "700700", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna", "plan_name": "700700_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Miscellaneous", "plan_name": "700720", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Miscellaneous", "plan_name": "700720_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Ppo Hmo", "plan_name": "701720", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Ppo Hmo", "plan_name": "701720_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Ms State Emplo", "plan_name": "401457", "standard_charge_percentage": 0.80, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Ms State Emplo", "plan_name": "401457_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Basic Pl", "plan_name": "400100", "standard_charge_percentage": 0.85, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Basic Pl", "plan_name": "400100_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Federal", "plan_name": "400110", "standard_charge_percentage": 0.85, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Federal", "plan_name": "400110_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." } ] } ] }, { "description": "Dextrose 5 % in water (d5w) intravenous solution [2364]", "drug_information": { "unit": 50.00, "type": "ML" }, "code_information": [ { "code": "63323-624-50", "type": "NDC" } ], "standard_charges": [ { "gross_charge": 81.81, "minimum": 65.45, "maximum": 69.54, "setting": "both", "payers_information": [ { "payer_name": "Aetna", "plan_name": "700700", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna", "plan_name": "700700_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Miscellaneous", "plan_name": "700720", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Miscellaneous", "plan_name": "700720_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Ppo Hmo", "plan_name": "701720", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Ppo Hmo", "plan_name": "701720_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Ms State Emplo", "plan_name": "401457", "standard_charge_percentage": 0.80, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Ms State Emplo", "plan_name": "401457_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Basic Pl", "plan_name": "400100", "standard_charge_percentage": 0.85, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Basic Pl", "plan_name": "400100_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Federal", "plan_name": "400110", "standard_charge_percentage": 0.85, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Federal", "plan_name": "400110_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." } ] } ] }, { "description": "Dextrose 5 % in water (d5w) intravenous solution [2364]", "drug_information": { "unit": 100.00, "type": "ML" }, "code_information": [ { "code": "63323-624-61", "type": "NDC" } ], "standard_charges": [ { "gross_charge": 81.81, "minimum": 65.45, "maximum": 69.54, "setting": "both", "payers_information": [ { "payer_name": "Aetna", "plan_name": "700700", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna", "plan_name": "700700_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Miscellaneous", "plan_name": "700720", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Miscellaneous", "plan_name": "700720_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Ppo Hmo", "plan_name": "701720", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Ppo Hmo", "plan_name": "701720_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Ms State Emplo", "plan_name": "401457", "standard_charge_percentage": 0.80, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Ms State Emplo", "plan_name": "401457_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Basic Pl", "plan_name": "400100", "standard_charge_percentage": 0.85, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Basic Pl", "plan_name": "400100_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Federal", "plan_name": "400110", "standard_charge_percentage": 0.85, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Federal", "plan_name": "400110_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." } ] } ] }, { "description": "Dextrose 5 % in water (d5w) intravenous solution [2364]", "drug_information": { "unit": 250.00, "type": "ML" }, "code_information": [ { "code": "63323-624-74", "type": "NDC" } ], "standard_charges": [ { "gross_charge": 81.81, "minimum": 65.45, "maximum": 69.54, "setting": "both", "payers_information": [ { "payer_name": "Aetna", "plan_name": "700700", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna", "plan_name": "700700_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Miscellaneous", "plan_name": "700720", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Miscellaneous", "plan_name": "700720_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Ppo Hmo", "plan_name": "701720", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Ppo Hmo", "plan_name": "701720_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Ms State Emplo", "plan_name": "401457", "standard_charge_percentage": 0.80, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Ms State Emplo", "plan_name": "401457_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Basic Pl", "plan_name": "400100", "standard_charge_percentage": 0.85, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Basic Pl", "plan_name": "400100_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Federal", "plan_name": "400110", "standard_charge_percentage": 0.85, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Federal", "plan_name": "400110_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." } ] } ] }, { "description": "Dextrose 5 % in water (d5w) intravenous solution [2364]", "drug_information": { "unit": 250.00, "type": "ML" }, "code_information": [ { "code": "63323-624-04", "type": "NDC" } ], "standard_charges": [ { "gross_charge": 81.81, "minimum": 65.45, "maximum": 69.54, "setting": "both", "payers_information": [ { "payer_name": "Aetna", "plan_name": "700700", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna", "plan_name": "700700_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Miscellaneous", "plan_name": "700720", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Miscellaneous", "plan_name": "700720_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Ppo Hmo", "plan_name": "701720", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Ppo Hmo", "plan_name": "701720_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Ms State Emplo", "plan_name": "401457", "standard_charge_percentage": 0.80, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Ms State Emplo", "plan_name": "401457_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Basic Pl", "plan_name": "400100", "standard_charge_percentage": 0.85, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Basic Pl", "plan_name": "400100_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Federal", "plan_name": "400110", "standard_charge_percentage": 0.85, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Federal", "plan_name": "400110_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." } ] } ] }, { "description": "Dextrose 5 % in water (d5w) intravenous solution [2364]", "drug_information": { "unit": 100.00, "type": "ML" }, "code_information": [ { "code": "63323-624-06", "type": "NDC" } ], "standard_charges": [ { "gross_charge": 81.81, "minimum": 65.45, "maximum": 69.54, "setting": "both", "payers_information": [ { "payer_name": "Aetna", "plan_name": "700700", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna", "plan_name": "700700_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Miscellaneous", "plan_name": "700720", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Miscellaneous", "plan_name": "700720_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Ppo Hmo", "plan_name": "701720", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Ppo Hmo", "plan_name": "701720_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Ms State Emplo", "plan_name": "401457", "standard_charge_percentage": 0.80, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Ms State Emplo", "plan_name": "401457_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Basic Pl", "plan_name": "400100", "standard_charge_percentage": 0.85, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Basic Pl", "plan_name": "400100_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Federal", "plan_name": "400110", "standard_charge_percentage": 0.85, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Federal", "plan_name": "400110_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." } ] } ] }, { "description": "Lidocaine 5 % topical patch [28203]", "drug_information": { "unit": 1.00, "type": "EA" }, "code_information": [ { "code": "63481-687-01", "type": "NDC" } ], "standard_charges": [ { "gross_charge": 125.91, "minimum": 100.73, "maximum": 107.02, "setting": "both", "payers_information": [ { "payer_name": "Aetna", "plan_name": "700700", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna", "plan_name": "700700_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Miscellaneous", "plan_name": "700720", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Miscellaneous", "plan_name": "700720_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Ppo Hmo", "plan_name": "701720", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Ppo Hmo", "plan_name": "701720_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Ms State Emplo", "plan_name": "401457", "standard_charge_percentage": 0.80, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Ms State Emplo", "plan_name": "401457_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Basic Pl", "plan_name": "400100", "standard_charge_percentage": 0.85, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Basic Pl", "plan_name": "400100_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Federal", "plan_name": "400110", "standard_charge_percentage": 0.85, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Federal", "plan_name": "400110_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." } ] } ] }, { "description": "Lidocaine 5 % topical patch [28203]", "drug_information": { "unit": 1.00, "type": "EA" }, "code_information": [ { "code": "63481-687-06", "type": "NDC" } ], "standard_charges": [ { "gross_charge": 125.91, "minimum": 100.73, "maximum": 107.02, "setting": "both", "payers_information": [ { "payer_name": "Aetna", "plan_name": "700700", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna", "plan_name": "700700_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Miscellaneous", "plan_name": "700720", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Miscellaneous", "plan_name": "700720_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Ppo Hmo", "plan_name": "701720", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Ppo Hmo", "plan_name": "701720_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Ms State Emplo", "plan_name": "401457", "standard_charge_percentage": 0.80, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Ms State Emplo", "plan_name": "401457_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Basic Pl", "plan_name": "400100", "standard_charge_percentage": 0.85, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Basic Pl", "plan_name": "400100_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Federal", "plan_name": "400110", "standard_charge_percentage": 0.85, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Federal", "plan_name": "400110_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." } ] } ] }, { "description": "Ketoconazole 2 % shampoo [14132]", "drug_information": { "unit": 120.00, "type": "ML" }, "code_information": [ { "code": "63646-010-04", "type": "NDC" } ], "standard_charges": [ { "gross_charge": 114.00, "minimum": 91.20, "maximum": 96.90, "setting": "both", "payers_information": [ { "payer_name": "Aetna", "plan_name": "700700", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna", "plan_name": "700700_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Miscellaneous", "plan_name": "700720", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Miscellaneous", "plan_name": "700720_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Ppo Hmo", "plan_name": "701720", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Ppo Hmo", "plan_name": "701720_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Ms State Emplo", "plan_name": "401457", "standard_charge_percentage": 0.80, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Ms State Emplo", "plan_name": "401457_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Basic Pl", "plan_name": "400100", "standard_charge_percentage": 0.85, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Basic Pl", "plan_name": "400100_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Federal", "plan_name": "400110", "standard_charge_percentage": 0.85, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Federal", "plan_name": "400110_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." } ] } ] }, { "description": "Gelatin spongeabsorbable-porcine skin 12 mm-7 mm topical sponge [28018]", "drug_information": { "unit": 1.00, "type": "EA" }, "code_information": [ { "code": "6371301972", "type": "NDC" } ], "standard_charges": [ { "gross_charge": 26.68, "minimum": 21.34, "maximum": 22.68, "setting": "both", "payers_information": [ { "payer_name": "Aetna", "plan_name": "700700", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna", "plan_name": "700700_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Miscellaneous", "plan_name": "700720", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Miscellaneous", "plan_name": "700720_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Ppo Hmo", "plan_name": "701720", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Ppo Hmo", "plan_name": "701720_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Ms State Emplo", "plan_name": "401457", "standard_charge_percentage": 0.80, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Ms State Emplo", "plan_name": "401457_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Basic Pl", "plan_name": "400100", "standard_charge_percentage": 0.85, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Basic Pl", "plan_name": "400100_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Federal", "plan_name": "400110", "standard_charge_percentage": 0.85, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Federal", "plan_name": "400110_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." } ] } ] }, { "description": "Iron-vit c-vit b12-folic acid 100 mg-250 mg-25 mcg-1 mg tablet [28040]", "drug_information": { "unit": 1.00, "type": "EA" }, "code_information": [ { "code": "6371710001", "type": "NDC" } ], "standard_charges": [ { "gross_charge": 3.50, "minimum": 2.80, "maximum": 2.98, "setting": "both", "payers_information": [ { "payer_name": "Aetna", "plan_name": "700700", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna", "plan_name": "700700_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Miscellaneous", "plan_name": "700720", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Miscellaneous", "plan_name": "700720_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Ppo Hmo", "plan_name": "701720", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Ppo Hmo", "plan_name": "701720_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Ms State Emplo", "plan_name": "401457", "standard_charge_percentage": 0.80, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Ms State Emplo", "plan_name": "401457_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Basic Pl", "plan_name": "400100", "standard_charge_percentage": 0.85, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Basic Pl", "plan_name": "400100_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Federal", "plan_name": "400110", "standard_charge_percentage": 0.85, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Federal", "plan_name": "400110_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." } ] } ] }, { "description": "White petrolatum 57.7 %-mineral oil 31.9 % eye ointment [171564]", "drug_information": { "unit": 3.50, "type": "GR" }, "code_information": [ { "code": "6373614308", "type": "NDC" } ], "standard_charges": [ { "gross_charge": 18.30, "minimum": 14.64, "maximum": 15.56, "setting": "both", "payers_information": [ { "payer_name": "Aetna", "plan_name": "700700", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna", "plan_name": "700700_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Miscellaneous", "plan_name": "700720", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Miscellaneous", "plan_name": "700720_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Ppo Hmo", "plan_name": "701720", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Ppo Hmo", "plan_name": "701720_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Ms State Emplo", "plan_name": "401457", "standard_charge_percentage": 0.80, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Ms State Emplo", "plan_name": "401457_1", 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"standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." } ] } ] }, { "description": "Miconazole nitrate 2 % vaginal cream [5040]", "drug_information": { "unit": 45.00, "type": "GR" }, "code_information": [ { "code": "6373644263", "type": "NDC" } ], "standard_charges": [ { "gross_charge": 23.17, "minimum": 18.54, "maximum": 19.69, "setting": "both", "payers_information": [ { "payer_name": "Aetna", "plan_name": "700700", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna", "plan_name": "700700_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna 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"plan_name": "400110", "standard_charge_percentage": 0.85, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Federal", "plan_name": "400110_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." } ] } ] }, { "description": "Ziprasidone 40 mg capsule [29779]", "drug_information": { "unit": 1.00, "type": "EA" }, "code_information": [ { "code": "63739-005-32", "type": "NDC" } ], "standard_charges": [ { "gross_charge": 26.16, "minimum": 20.93, "maximum": 22.24, "setting": "both", "payers_information": [ { "payer_name": "Aetna", "plan_name": "700700", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna", "plan_name": "700700_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Miscellaneous", "plan_name": "700720", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Miscellaneous", "plan_name": "700720_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Ppo Hmo", "plan_name": "701720", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Ppo 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"payer_name": "Aetna Ppo Hmo", "plan_name": "701720", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Ppo Hmo", "plan_name": "701720_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Ms State Emplo", "plan_name": "401457", "standard_charge_percentage": 0.80, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Ms State Emplo", "plan_name": "401457_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": 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"description": "Amiodarone 200 mg tablet [9066]", "drug_information": { "unit": 1.00, "type": "EA" }, "code_information": [ { "code": "63739-051-10", "type": "NDC" } ], "standard_charges": [ { "gross_charge": 7.50, "minimum": 6.00, "maximum": 6.38, "setting": "both", "payers_information": [ { "payer_name": "Aetna", "plan_name": "700700", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna", "plan_name": "700700_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Miscellaneous", "plan_name": "700720", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed 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"payer_name": "Bc/Bs Ms State Emplo", "plan_name": "401457_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Basic Pl", "plan_name": "400100", "standard_charge_percentage": 0.85, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Basic Pl", "plan_name": "400100_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Federal", "plan_name": "400110", "standard_charge_percentage": 0.85, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Federal", "plan_name": "400110_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." } ] } ] }, { "description": "Diltiazem 60 mg tablet [2476]", "drug_information": { "unit": 1.00, "type": "EA" }, "code_information": [ { "code": "63739-080-10", "type": "NDC" } ], "standard_charges": [ { "gross_charge": 7.50, "minimum": 6.00, "maximum": 6.38, "setting": "both", "payers_information": [ { "payer_name": "Aetna", "plan_name": "700700", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna", "plan_name": "700700_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate 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}, { "payer_name": "Bc/Bs Ms State Emplo", "plan_name": "401457", "standard_charge_percentage": 0.80, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Ms State Emplo", "plan_name": "401457_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Basic Pl", "plan_name": "400100", "standard_charge_percentage": 0.85, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Basic Pl", "plan_name": "400100_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Federal", "plan_name": "400110", "standard_charge_percentage": 0.85, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Federal", "plan_name": "400110_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." } ] } ] }, { "description": "Tamoxifen 10 mg tablet [7711]", "drug_information": { "unit": 1.00, "type": "EA" }, "code_information": [ { "code": "63739-143-10", "type": "NDC" } ], "standard_charges": [ { "gross_charge": 7.50, "minimum": 6.00, "maximum": 6.38, "setting": "both", "payers_information": [ { "payer_name": "Aetna", "plan_name": "700700", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to 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}, { "payer_name": "Bc/Bs Of Ms Basic Pl", "plan_name": "400100_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Federal", "plan_name": "400110", "standard_charge_percentage": 0.85, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Federal", "plan_name": "400110_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." } ] } ] }, { "description": "Aspirin 81 mg tabletdelayed release [688]", "drug_information": { "unit": 1.00, "type": "EA" }, "code_information": [ { "code": "63739-212-02", "type": "NDC" } ], "standard_charges": [ { "gross_charge": 1.00, "minimum": 0.80, "maximum": 0.85, "setting": "both", "payers_information": [ { "payer_name": "Aetna", "plan_name": "700700", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna", "plan_name": "700700_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Miscellaneous", "plan_name": "700720", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Miscellaneous", "plan_name": "700720_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Ppo Hmo", "plan_name": "701720", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Ppo Hmo", "plan_name": "701720_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Ms State Emplo", "plan_name": "401457", "standard_charge_percentage": 0.80, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Ms State Emplo", "plan_name": "401457_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Basic Pl", "plan_name": "400100", "standard_charge_percentage": 0.85, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Basic Pl", "plan_name": "400100_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Federal", "plan_name": "400110", "standard_charge_percentage": 0.85, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Federal", "plan_name": "400110_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." } ] } ] }, { "description": "Simethicone 80 mg chewable tablet [7227]", "drug_information": { "unit": 1.00, "type": "EA" }, "code_information": [ { "code": "63739-225-10", "type": "NDC" } ], "standard_charges": [ { "gross_charge": 1.00, "minimum": 0.80, "maximum": 0.85, "setting": "both", "payers_information": [ { "payer_name": "Aetna", "plan_name": "700700", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna", "plan_name": "700700_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Miscellaneous", "plan_name": "700720", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Miscellaneous", "plan_name": "700720_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Ppo Hmo", "plan_name": "701720", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Ppo Hmo", "plan_name": "701720_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Ms State Emplo", "plan_name": "401457", "standard_charge_percentage": 0.80, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Ms State Emplo", "plan_name": "401457_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Basic Pl", "plan_name": "400100", "standard_charge_percentage": 0.85, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Basic Pl", "plan_name": "400100_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Federal", "plan_name": "400110", "standard_charge_percentage": 0.85, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Federal", "plan_name": "400110_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." } ] } ] }, { "description": "Hydralazine 25 mg tablet [3700]", "drug_information": { "unit": 1.00, "type": "EA" }, "code_information": [ { "code": "63739-327-10", "type": "NDC" } ], "standard_charges": [ { "gross_charge": 7.50, "minimum": 6.00, "maximum": 6.38, "setting": "both", "payers_information": [ { "payer_name": "Aetna", "plan_name": "700700", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna", "plan_name": "700700_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Miscellaneous", "plan_name": "700720", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Miscellaneous", "plan_name": "700720_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Ppo Hmo", "plan_name": "701720", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Ppo Hmo", "plan_name": "701720_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Ms State Emplo", "plan_name": "401457", "standard_charge_percentage": 0.80, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Ms State Emplo", "plan_name": "401457_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Basic Pl", "plan_name": "400100", "standard_charge_percentage": 0.85, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Basic Pl", "plan_name": "400100_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Federal", "plan_name": "400110", "standard_charge_percentage": 0.85, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Federal", "plan_name": "400110_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." } ] } ] }, { "description": "Hydralazine 50 mg tablet [3701]", "drug_information": { "unit": 1.00, "type": "EA" }, "code_information": [ { "code": "63739-328-10", "type": "NDC" } ], "standard_charges": [ { "gross_charge": 7.50, "minimum": 6.00, "maximum": 6.38, "setting": "both", "payers_information": [ { "payer_name": "Aetna", "plan_name": "700700", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna", "plan_name": "700700_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Miscellaneous", "plan_name": "700720", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Miscellaneous", "plan_name": "700720_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Ppo Hmo", "plan_name": "701720", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Ppo Hmo", "plan_name": "701720_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Ms State Emplo", "plan_name": "401457", "standard_charge_percentage": 0.80, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Ms State Emplo", "plan_name": "401457_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Basic Pl", "plan_name": "400100", "standard_charge_percentage": 0.85, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Basic Pl", "plan_name": "400100_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Federal", "plan_name": "400110", "standard_charge_percentage": 0.85, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Federal", "plan_name": "400110_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." } ] } ] }, { "description": "Isosorbide dinitrate 20 mg tablet [4065]", "drug_information": { "unit": 1.00, "type": "EA" }, "code_information": [ { "code": "63739-367-10", "type": "NDC" } ], "standard_charges": [ { "gross_charge": 7.50, "minimum": 6.00, "maximum": 6.38, "setting": "both", "payers_information": [ { "payer_name": "Aetna", "plan_name": "700700", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna", "plan_name": "700700_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Miscellaneous", "plan_name": "700720", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Miscellaneous", "plan_name": "700720_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Ppo Hmo", "plan_name": "701720", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Ppo Hmo", "plan_name": "701720_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Ms State Emplo", "plan_name": "401457", "standard_charge_percentage": 0.80, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Ms State Emplo", "plan_name": "401457_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Basic Pl", "plan_name": "400100", "standard_charge_percentage": 0.85, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Basic Pl", "plan_name": "400100_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Federal", "plan_name": "400110", "standard_charge_percentage": 0.85, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Federal", "plan_name": "400110_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." } ] } ] }, { "description": "Allopurinol 100 mg tablet [310]", "drug_information": { "unit": 1.00, "type": "EA" }, "code_information": [ { "code": "63739-410-10", "type": "NDC" } ], "standard_charges": [ { "gross_charge": 7.50, "minimum": 6.00, "maximum": 6.38, "setting": "both", "payers_information": [ { "payer_name": "Aetna", "plan_name": "700700", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna", "plan_name": "700700_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Miscellaneous", "plan_name": "700720", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Miscellaneous", "plan_name": "700720_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Ppo Hmo", "plan_name": "701720", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Ppo Hmo", "plan_name": "701720_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Ms State Emplo", "plan_name": "401457", "standard_charge_percentage": 0.80, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Ms State Emplo", "plan_name": "401457_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Basic Pl", "plan_name": "400100", "standard_charge_percentage": 0.85, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Basic Pl", "plan_name": "400100_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Federal", "plan_name": "400110", "standard_charge_percentage": 0.85, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Federal", "plan_name": "400110_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." } ] } ] }, { "description": "Aspirin 81 mg chewable tablet [679]", "drug_information": { "unit": 1.00, "type": "EA" }, "code_information": [ { "code": "63739-434-02", "type": "NDC" } ], "standard_charges": [ { "gross_charge": 1.00, "minimum": 0.80, "maximum": 0.85, "setting": "both", "payers_information": [ { "payer_name": "Aetna", "plan_name": "700700", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna", "plan_name": "700700_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Miscellaneous", "plan_name": "700720", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Miscellaneous", "plan_name": "700720_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Ppo Hmo", "plan_name": "701720", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Ppo Hmo", "plan_name": "701720_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Ms State Emplo", "plan_name": "401457", "standard_charge_percentage": 0.80, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Ms State Emplo", "plan_name": "401457_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Basic Pl", "plan_name": "400100", "standard_charge_percentage": 0.85, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Basic Pl", "plan_name": "400100_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Federal", "plan_name": "400110", "standard_charge_percentage": 0.85, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Federal", "plan_name": "400110_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." } ] } ] }, { "description": "Docusate sodium 100 mg capsule [2566]", "drug_information": { "unit": 1.00, "type": "EA" }, "code_information": [ { "code": "63739-478-02", "type": "NDC" } ], "standard_charges": [ { "gross_charge": 1.00, "minimum": 0.80, "maximum": 0.85, "setting": "both", "payers_information": [ { "payer_name": "Aetna", "plan_name": "700700", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna", "plan_name": "700700_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Miscellaneous", "plan_name": "700720", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Miscellaneous", "plan_name": "700720_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Ppo Hmo", "plan_name": "701720", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Ppo Hmo", "plan_name": "701720_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Ms State Emplo", "plan_name": "401457", "standard_charge_percentage": 0.80, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Ms State Emplo", "plan_name": "401457_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Basic Pl", "plan_name": "400100", "standard_charge_percentage": 0.85, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Basic Pl", "plan_name": "400100_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Federal", "plan_name": "400110", "standard_charge_percentage": 0.85, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Federal", "plan_name": "400110_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." } ] } ] }, { "description": "Baclofen 10 mg tablet [860]", "drug_information": { "unit": 1.00, "type": "EA" }, "code_information": [ { "code": "63739-479-10", "type": "NDC" } ], "standard_charges": [ { "gross_charge": 7.50, "minimum": 6.00, "maximum": 6.38, "setting": "both", "payers_information": [ { "payer_name": "Aetna", "plan_name": "700700", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna", "plan_name": "700700_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Miscellaneous", "plan_name": "700720", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna 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"plan_name": "401457_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Basic Pl", "plan_name": "400100", "standard_charge_percentage": 0.85, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Basic Pl", "plan_name": "400100_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Federal", "plan_name": "400110", "standard_charge_percentage": 0.85, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Federal", "plan_name": "400110_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." } ] } ] }, { "description": "Baclofen 20 mg tablet [861]", "drug_information": { "unit": 1.00, "type": "EA" }, "code_information": [ { "code": "63739-480-10", "type": "NDC" } ], "standard_charges": [ { "gross_charge": 7.50, "minimum": 6.00, "maximum": 6.38, "setting": "both", "payers_information": [ { "payer_name": "Aetna", "plan_name": "700700", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna", "plan_name": "700700_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna 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"plan_name": "401457", "standard_charge_percentage": 0.80, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Ms State Emplo", "plan_name": "401457_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Basic Pl", "plan_name": "400100", "standard_charge_percentage": 0.85, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Basic Pl", "plan_name": "400100_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Federal", "plan_name": "400110", "standard_charge_percentage": 0.85, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Federal", "plan_name": "400110_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." } ] } ] }, { "description": "Hydroxyzine hcl 25 mg tablet [3774]", "drug_information": { "unit": 1.00, "type": "EA" }, "code_information": [ { "code": "63739-486-10", "type": "NDC" } ], "standard_charges": [ { "gross_charge": 7.50, "minimum": 6.00, "maximum": 6.38, "setting": "both", "payers_information": [ { "payer_name": "Aetna", "plan_name": "700700", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna", "plan_name": "700700_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Miscellaneous", "plan_name": "700720", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Miscellaneous", "plan_name": "700720_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Ppo Hmo", "plan_name": "701720", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Ppo Hmo", "plan_name": "701720_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Ms State Emplo", "plan_name": "401457", "standard_charge_percentage": 0.80, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Ms State Emplo", "plan_name": "401457_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Basic Pl", "plan_name": "400100", "standard_charge_percentage": 0.85, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Basic Pl", "plan_name": "400100_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Federal", "plan_name": "400110", "standard_charge_percentage": 0.85, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Federal", "plan_name": "400110_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." } ] } ] }, { "description": "Valacyclovir 500 mg tablet [13133]", "drug_information": { "unit": 1.00, "type": "EA" }, "code_information": [ { "code": "63739-525-10", "type": "NDC" } ], "standard_charges": [ { "gross_charge": 18.35, "minimum": 14.68, "maximum": 15.60, "setting": "both", "payers_information": [ { "payer_name": "Aetna", "plan_name": "700700", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna", "plan_name": "700700_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Miscellaneous", "plan_name": "700720", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Miscellaneous", "plan_name": "700720_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Ppo Hmo", "plan_name": "701720", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Ppo Hmo", "plan_name": "701720_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Ms State Emplo", "plan_name": "401457", "standard_charge_percentage": 0.80, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Ms State Emplo", "plan_name": "401457_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Basic Pl", "plan_name": "400100", "standard_charge_percentage": 0.85, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Basic Pl", "plan_name": "400100_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Federal", "plan_name": "400110", "standard_charge_percentage": 0.85, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Federal", "plan_name": "400110_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." } ] } ] }, { "description": "Spironolactone 25 mg tablet [7437]", "drug_information": { "unit": 1.00, "type": "EA" }, "code_information": [ { "code": "63739-544-10", "type": "NDC" } ], "standard_charges": [ { "gross_charge": 7.50, "minimum": 6.00, "maximum": 6.38, "setting": "both", "payers_information": [ { "payer_name": "Aetna", "plan_name": "700700", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna", "plan_name": "700700_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Miscellaneous", "plan_name": "700720", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed 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"payer_name": "Bc/Bs Ms State Emplo", "plan_name": "401457_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Basic Pl", "plan_name": "400100", "standard_charge_percentage": 0.85, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Basic Pl", "plan_name": "400100_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Federal", "plan_name": "400110", "standard_charge_percentage": 0.85, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Federal", "plan_name": "400110_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." } ] } ] }, { "description": "Spironolactone 50 mg tablet [11426]", "drug_information": { "unit": 1.00, "type": "EA" }, "code_information": [ { "code": "63739-545-10", "type": "NDC" } ], "standard_charges": [ { "gross_charge": 7.50, "minimum": 6.00, "maximum": 6.38, "setting": "both", "payers_information": [ { "payer_name": "Aetna", "plan_name": "700700", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna", "plan_name": "700700_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Miscellaneous", "plan_name": "700720", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Miscellaneous", "plan_name": "700720_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Ppo Hmo", "plan_name": "701720", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Ppo Hmo", "plan_name": "701720_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Ms State Emplo", "plan_name": "401457", "standard_charge_percentage": 0.80, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Ms State Emplo", "plan_name": "401457_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Basic Pl", "plan_name": "400100", "standard_charge_percentage": 0.85, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Basic Pl", "plan_name": "400100_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Federal", "plan_name": "400110", "standard_charge_percentage": 0.85, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Federal", "plan_name": "400110_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." } ] } ] }, { "description": "Ciprofloxacin 500 mg tablet [25119]", "drug_information": { "unit": 1.00, "type": "EA" }, "code_information": [ { "code": "63739-559-10", "type": "NDC" } ], "standard_charges": [ { "gross_charge": 7.50, "minimum": 6.00, "maximum": 6.38, "setting": "both", "payers_information": [ { "payer_name": "Aetna", "plan_name": "700700", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna", "plan_name": "700700_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Miscellaneous", "plan_name": "700720", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Miscellaneous", "plan_name": "700720_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Ppo Hmo", "plan_name": "701720", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Ppo Hmo", "plan_name": "701720_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Ms State Emplo", "plan_name": "401457", "standard_charge_percentage": 0.80, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Ms State Emplo", "plan_name": "401457_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Basic Pl", "plan_name": "400100", "standard_charge_percentage": 0.85, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Basic Pl", "plan_name": "400100_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Federal", "plan_name": "400110", "standard_charge_percentage": 0.85, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Federal", "plan_name": "400110_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." } ] } ] }, { "description": "Tamsulosin 0.4 mg capsule [103890]", "drug_information": { "unit": 1.00, "type": "EA" }, "code_information": [ { "code": "63739-567-10", "type": "NDC" } ], "standard_charges": [ { "gross_charge": 7.50, "minimum": 6.00, "maximum": 6.38, "setting": "both", "payers_information": [ { "payer_name": "Aetna", "plan_name": "700700", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna", "plan_name": "700700_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Miscellaneous", "plan_name": "700720", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Miscellaneous", "plan_name": "700720_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Ppo Hmo", "plan_name": "701720", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Ppo Hmo", "plan_name": "701720_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Ms State Emplo", "plan_name": "401457", "standard_charge_percentage": 0.80, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Ms State Emplo", "plan_name": "401457_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Basic Pl", "plan_name": "400100", "standard_charge_percentage": 0.85, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Basic Pl", "plan_name": "400100_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Federal", "plan_name": "400110", "standard_charge_percentage": 0.85, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Federal", "plan_name": "400110_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." } ] } ] }, { "description": "Simvastatin 10 mg tablet [11364]", "drug_information": { "unit": 1.00, "type": "EA" }, "code_information": [ { "code": "63739-571-10", "type": "NDC" } ], "standard_charges": [ { "gross_charge": 7.50, "minimum": 6.00, "maximum": 6.38, "setting": "both", "payers_information": [ { "payer_name": "Aetna", "plan_name": "700700", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna", "plan_name": "700700_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Miscellaneous", "plan_name": "700720", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Miscellaneous", "plan_name": "700720_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Ppo Hmo", "plan_name": "701720", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Ppo Hmo", "plan_name": "701720_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Ms State Emplo", "plan_name": "401457", "standard_charge_percentage": 0.80, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Ms State Emplo", "plan_name": "401457_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Basic Pl", "plan_name": "400100", "standard_charge_percentage": 0.85, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Basic Pl", "plan_name": "400100_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Federal", "plan_name": "400110", "standard_charge_percentage": 0.85, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Federal", "plan_name": "400110_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." } ] } ] }, { "description": "Simvastatin 20 mg tablet [11365]", "drug_information": { "unit": 1.00, "type": "EA" }, "code_information": [ { "code": "63739-572-10", "type": "NDC" } ], "standard_charges": [ { "gross_charge": 7.50, "minimum": 6.00, "maximum": 6.38, "setting": "both", "payers_information": [ { "payer_name": "Aetna", "plan_name": "700700", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna", "plan_name": "700700_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Miscellaneous", "plan_name": "700720", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Miscellaneous", "plan_name": "700720_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Ppo Hmo", "plan_name": "701720", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Ppo Hmo", "plan_name": "701720_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Ms State Emplo", "plan_name": "401457", "standard_charge_percentage": 0.80, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Ms State Emplo", "plan_name": "401457_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Basic Pl", "plan_name": "400100", "standard_charge_percentage": 0.85, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Basic Pl", "plan_name": "400100_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Federal", "plan_name": "400110", "standard_charge_percentage": 0.85, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Federal", "plan_name": "400110_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." } ] } ] }, { "description": "Famotidine 20 mg tablet [10011]", "drug_information": { "unit": 1.00, "type": "EA" }, "code_information": [ { "code": "63739-645-10", "type": "NDC" } ], "standard_charges": [ { "gross_charge": 1.00, "minimum": 0.80, "maximum": 0.85, "setting": "both", "payers_information": [ { "payer_name": "Aetna", "plan_name": "700700", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna", "plan_name": "700700_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Miscellaneous", "plan_name": "700720", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Miscellaneous", "plan_name": "700720_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Ppo Hmo", "plan_name": "701720", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of 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billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Basic Pl", "plan_name": "400100_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Federal", "plan_name": "400110", "standard_charge_percentage": 0.85, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Federal", "plan_name": "400110_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." } ] } ] }, { "description": "Losartan 50 mg tablet [14824]", "drug_information": { "unit": 1.00, "type": "EA" }, "code_information": [ { "code": "63739-686-10", "type": "NDC" } ], "standard_charges": [ { "gross_charge": 7.50, "minimum": 6.00, "maximum": 6.38, "setting": "both", "payers_information": [ { "payer_name": "Aetna", "plan_name": "700700", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna", "plan_name": "700700_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Miscellaneous", "plan_name": "700720", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Miscellaneous", "plan_name": "700720_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Ppo Hmo", "plan_name": "701720", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Ppo Hmo", "plan_name": "701720_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Ms State Emplo", "plan_name": "401457", "standard_charge_percentage": 0.80, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Ms State Emplo", "plan_name": "401457_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Basic Pl", "plan_name": "400100", "standard_charge_percentage": 0.85, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Basic Pl", "plan_name": "400100_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Federal", "plan_name": "400110", "standard_charge_percentage": 0.85, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Federal", "plan_name": "400110_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." } ] } ] }, { "description": "Losartan 100 mg tablet [22588]", "drug_information": { "unit": 1.00, "type": "EA" }, "code_information": [ { "code": "63739-698-10", "type": "NDC" } ], "standard_charges": [ { "gross_charge": 7.50, "minimum": 6.00, "maximum": 6.38, "setting": "both", "payers_information": [ { "payer_name": "Aetna", "plan_name": "700700", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna", "plan_name": "700700_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Miscellaneous", "plan_name": "700720", "standard_charge_percentage": 80.0, "count": 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"methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Ms State Emplo", "plan_name": "401457_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Basic Pl", "plan_name": "400100", "standard_charge_percentage": 0.85, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Basic Pl", "plan_name": "400100_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Federal", "plan_name": "400110", "standard_charge_percentage": 0.85, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Federal", "plan_name": "400110_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." } ] } ] }, { "description": "Levetiracetam 250 mg tablet [26816]", "drug_information": { "unit": 1.00, "type": "EA" }, "code_information": [ { "code": "63739-795-10", "type": "NDC" } ], "standard_charges": [ { "gross_charge": 7.50, "minimum": 6.00, "maximum": 6.38, "setting": "both", "payers_information": [ { "payer_name": "Aetna", "plan_name": "700700", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna", "plan_name": "700700_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Miscellaneous", "plan_name": "700720", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Miscellaneous", "plan_name": "700720_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Ppo Hmo", "plan_name": "701720", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Ppo Hmo", "plan_name": "701720_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Ms State Emplo", "plan_name": "401457", "standard_charge_percentage": 0.80, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Ms State Emplo", "plan_name": "401457_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Basic Pl", "plan_name": "400100", "standard_charge_percentage": 0.85, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Basic Pl", "plan_name": "400100_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Federal", "plan_name": "400110", "standard_charge_percentage": 0.85, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Federal", "plan_name": "400110_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." } ] } ] }, { "description": "Allopurinol 300 mg tablet [311]", "drug_information": { "unit": 1.00, "type": "EA" }, "code_information": [ { "code": "63739-796-10", "type": "NDC" } ], "standard_charges": [ { "gross_charge": 7.50, "minimum": 6.00, "maximum": 6.38, "setting": "both", "payers_information": [ { "payer_name": 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"standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Federal", "plan_name": "400110", "standard_charge_percentage": 0.85, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Federal", "plan_name": "400110_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." } ] } ] }, { "description": "Potassium chloride er 10 meq tabletextended release(part/cryst) [35942]", "drug_information": { "unit": 1.00, "type": "EA" }, "code_information": [ { "code": "63739-972-10", "type": "NDC" } ], "standard_charges": [ { "gross_charge": 7.50, "minimum": 6.00, "maximum": 6.38, "setting": "both", 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"payer_name": "Aetna Ppo Hmo", "plan_name": "701720", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Ppo Hmo", "plan_name": "701720_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Ms State Emplo", "plan_name": "401457", "standard_charge_percentage": 0.80, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Ms State Emplo", "plan_name": "401457_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Basic Pl", "plan_name": "400100", "standard_charge_percentage": 0.85, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Basic Pl", "plan_name": "400100_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Federal", "plan_name": "400110", "standard_charge_percentage": 0.85, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Federal", "plan_name": "400110_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." } ] } ] }, { "description": "Potassium chloride er 20 meq tabletextended release(part/cryst) [35943]", "drug_information": { "unit": 1.00, "type": "EA" }, "code_information": [ { "code": "63739-973-10", "type": "NDC" } ], "standard_charges": [ { "gross_charge": 7.50, "minimum": 6.00, "maximum": 6.38, "setting": "both", "payers_information": [ { "payer_name": "Aetna", "plan_name": "700700", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna", "plan_name": "700700_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Miscellaneous", "plan_name": "700720", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Miscellaneous", "plan_name": "700720_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Ppo Hmo", "plan_name": "701720", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Ppo Hmo", "plan_name": "701720_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Ms State Emplo", "plan_name": "401457", "standard_charge_percentage": 0.80, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Ms State Emplo", "plan_name": "401457_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Basic Pl", "plan_name": "400100", "standard_charge_percentage": 0.85, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Basic Pl", "plan_name": "400100_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Federal", "plan_name": "400110", "standard_charge_percentage": 0.85, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Federal", "plan_name": "400110_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." } ] } ] }, { "description": "Dextromethorphan-guaifenesin 5 mg-100 mg/5 ml oral liquid [9781]", "drug_information": { "unit": 180.00, "type": "ML" }, "code_information": [ { "code": "6382401866", "type": "NDC" } ], "standard_charges": [ { "gross_charge": 21.53, "minimum": 17.22, "maximum": 18.30, "setting": "both", "payers_information": [ { "payer_name": "Aetna", "plan_name": "700700", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna", "plan_name": "700700_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Miscellaneous", "plan_name": "700720", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Miscellaneous", "plan_name": "700720_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Ppo Hmo", "plan_name": "701720", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Ppo Hmo", "plan_name": "701720_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Ms State Emplo", "plan_name": "401457", "standard_charge_percentage": 0.80, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Ms State Emplo", "plan_name": "401457_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Basic Pl", "plan_name": "400100", "standard_charge_percentage": 0.85, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Basic Pl", "plan_name": "400100_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Federal", "plan_name": "400110", "standard_charge_percentage": 0.85, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Federal", "plan_name": "400110_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." } ] } ] }, { "description": "Dextromethorphan-guaifenesin 30 mg-600 mg tablet extended release12 hr [27543]", "drug_information": { "unit": 1.00, "type": "EA" }, "code_information": [ { "code": "6382405640", "type": "NDC" } ], "standard_charges": [ { "gross_charge": 1.23, "minimum": 0.98, "maximum": 1.05, "setting": "both", "payers_information": [ { "payer_name": "Aetna", "plan_name": "700700", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna", "plan_name": "700700_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Miscellaneous", "plan_name": "700720", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Miscellaneous", "plan_name": "700720_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Ppo Hmo", "plan_name": "701720", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Ppo Hmo", "plan_name": "701720_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Ms State Emplo", "plan_name": "401457", "standard_charge_percentage": 0.80, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Ms State Emplo", "plan_name": "401457_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Basic Pl", "plan_name": "400100", "standard_charge_percentage": 0.85, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Basic Pl", "plan_name": "400100_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Federal", "plan_name": "400110", "standard_charge_percentage": 0.85, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Federal", "plan_name": "400110_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." } ] } ] }, { "description": "Benzocaine 15 mg-menthol 2.6 mg lozenges [152102]", "drug_information": { "unit": 1.00, "type": "EA" }, "code_information": [ { "code": "6382473016", "type": "NDC" } ], "standard_charges": [ { "gross_charge": 1.00, "minimum": 0.80, "maximum": 0.85, "setting": "both", "payers_information": [ { "payer_name": "Aetna", "plan_name": "700700", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna", "plan_name": "700700_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Miscellaneous", "plan_name": "700720", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Miscellaneous", "plan_name": "700720_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Ppo Hmo", "plan_name": "701720", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Ppo Hmo", "plan_name": "701720_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Ms State Emplo", "plan_name": "401457", "standard_charge_percentage": 0.80, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Ms State Emplo", "plan_name": "401457_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Basic Pl", "plan_name": "400100", "standard_charge_percentage": 0.85, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Basic Pl", "plan_name": "400100_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Federal", "plan_name": "400110", "standard_charge_percentage": 0.85, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Federal", "plan_name": "400110_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." } ] } ] }, { "description": "Water for injection sterile injection solution [11671]", "drug_information": { "unit": 20.00, "type": "ML" }, "code_information": [ { "code": "63833-761-20", "type": "NDC" } ], "standard_charges": [ { "gross_charge": 11.00, "minimum": 8.80, "maximum": 9.35, "setting": "both", "payers_information": [ { "payer_name": "Aetna", "plan_name": "700700", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna", "plan_name": "700700_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Miscellaneous", "plan_name": "700720", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Miscellaneous", "plan_name": "700720_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Ppo Hmo", "plan_name": "701720", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Ppo Hmo", "plan_name": "701720_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Ms State Emplo", "plan_name": "401457", "standard_charge_percentage": 0.80, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Ms State Emplo", "plan_name": "401457_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Basic Pl", "plan_name": "400100", "standard_charge_percentage": 0.85, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Basic Pl", "plan_name": "400100_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Federal", "plan_name": "400110", "standard_charge_percentage": 0.85, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Federal", "plan_name": "400110_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." } ] } ] }, { "description": "Water for injection sterile injection solution [11671]", "drug_information": { "unit": 40.00, "type": "ML" }, "code_information": [ { "code": "63833-761-40", "type": "NDC" } ], "standard_charges": [ { "gross_charge": 11.00, "minimum": 8.80, "maximum": 9.35, "setting": "both", "payers_information": [ { "payer_name": "Aetna", "plan_name": "700700", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna", "plan_name": "700700_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Miscellaneous", "plan_name": "700720", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Miscellaneous", "plan_name": "700720_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Ppo Hmo", "plan_name": "701720", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Ppo Hmo", "plan_name": "701720_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Ms State Emplo", "plan_name": "401457", "standard_charge_percentage": 0.80, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Ms State Emplo", "plan_name": "401457_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Basic Pl", "plan_name": "400100", "standard_charge_percentage": 0.85, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Basic Pl", "plan_name": "400100_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Federal", "plan_name": "400110", "standard_charge_percentage": 0.85, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Federal", "plan_name": "400110_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." } ] } ] }, { "description": "Megestrol 20 mg tablet [4870]", "drug_information": { "unit": 1.00, "type": "EA" }, "code_information": [ { "code": "64380-158-01", "type": "NDC" } ], "standard_charges": [ { "gross_charge": 7.50, "minimum": 6.00, "maximum": 6.38, "setting": "both", "payers_information": [ { "payer_name": "Aetna", "plan_name": "700700", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna", "plan_name": "700700_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Miscellaneous", "plan_name": "700720", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Miscellaneous", "plan_name": "700720_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Ppo Hmo", "plan_name": "701720", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Ppo Hmo", "plan_name": "701720_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Ms State Emplo", "plan_name": "401457", "standard_charge_percentage": 0.80, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Ms State Emplo", "plan_name": "401457_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Basic Pl", "plan_name": "400100", "standard_charge_percentage": 0.85, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Basic Pl", "plan_name": "400100_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Federal", "plan_name": "400110", "standard_charge_percentage": 0.85, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Federal", "plan_name": "400110_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." } ] } ] }, { "description": "Acarbose 50 mg tablet [15895]", "drug_information": { "unit": 1.00, "type": "EA" }, "code_information": [ { "code": "64380-759-06", "type": "NDC" } ], "standard_charges": [ { "gross_charge": 7.50, "minimum": 6.00, "maximum": 6.38, "setting": "both", "payers_information": [ { "payer_name": "Aetna", "plan_name": "700700", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna", "plan_name": "700700_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Miscellaneous", "plan_name": "700720", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Miscellaneous", "plan_name": "700720_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Ppo Hmo", "plan_name": "701720", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Ppo Hmo", "plan_name": "701720_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Ms State Emplo", "plan_name": "401457", "standard_charge_percentage": 0.80, "count": "0", "methodology": "percent of total billed charges", 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"standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Basic Pl", "plan_name": "400100", "standard_charge_percentage": 0.85, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Basic Pl", "plan_name": "400100_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Federal", "plan_name": "400110", "standard_charge_percentage": 0.85, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Federal", "plan_name": "400110_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." } ] } ] }, { "description": "Lubiprostone 24 mcg capsule [70472]", "drug_information": { "unit": 1.00, "type": "EA" }, "code_information": [ { "code": "64764-240-60", "type": "NDC" } ], "standard_charges": [ { "gross_charge": 29.38, "minimum": 23.50, "maximum": 24.97, "setting": "both", "payers_information": [ { "payer_name": "Aetna", "plan_name": "700700", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna", "plan_name": "700700_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna 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"plan_name": "400110", "standard_charge_percentage": 0.85, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Federal", "plan_name": "400110_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." } ] } ] }, { "description": "Febuxostat 40 mg tablet [97133]", "drug_information": { "unit": 1.00, "type": "EA" }, "code_information": [ { "code": "64764-918-30", "type": "NDC" } ], "standard_charges": [ { "gross_charge": 49.15, "minimum": 39.32, "maximum": 41.78, "setting": "both", "payers_information": [ { "payer_name": "Aetna", "plan_name": "700700", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna", "plan_name": "700700_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Miscellaneous", "plan_name": "700720", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Miscellaneous", "plan_name": "700720_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Ppo Hmo", "plan_name": "701720", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Ppo 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Pl", "plan_name": "400100_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Federal", "plan_name": "400110", "standard_charge_percentage": 0.85, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Federal", "plan_name": "400110_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." } ] } ] }, { "description": "Hydrocodone 7.5 mg-acetaminophen 325 mg/15 ml oral solution [37848]", "drug_information": { "unit": 473.00, "type": "ML" }, "code_information": [ { "code": "64950-373-16", "type": "NDC" } ], "standard_charges": [ { "gross_charge": 2078.48, "minimum": 1662.78, 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allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Basic Pl", "plan_name": "400100", "standard_charge_percentage": 0.85, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Basic Pl", "plan_name": "400100_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Federal", "plan_name": "400110", "standard_charge_percentage": 0.85, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Federal", "plan_name": "400110_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." } ] } ] }, { "description": "Glipizide er 2.5 mg tablet extended release 24 hr [37648]", "drug_information": { "unit": 1.00, "type": "EA" }, "code_information": [ { "code": "64980-279-03", "type": "NDC" } ], "standard_charges": [ { "gross_charge": 7.50, "minimum": 6.00, "maximum": 6.38, "setting": "both", "payers_information": [ { "payer_name": "Aetna", "plan_name": "700700", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna", "plan_name": "700700_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Miscellaneous", "plan_name": "700720", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Miscellaneous", "plan_name": "700720_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Ppo Hmo", "plan_name": "701720", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Ppo Hmo", "plan_name": "701720_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Ms State Emplo", "plan_name": "401457", "standard_charge_percentage": 0.80, "count": "0", "methodology": "percent of total billed charges", 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"percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Federal", "plan_name": "400110", "standard_charge_percentage": 0.85, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Federal", "plan_name": "400110_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." } ] } ] }, { "description": "Hydrocortisone 2.5 % topical cream with perineal applicator [28824]", "drug_information": { "unit": 30.00, "type": "GR" }, "code_information": [ { "code": "64980-324-30", "type": "NDC" } ], "standard_charges": [ { "gross_charge": 132.95, "minimum": 106.36, "maximum": 113.01, "setting": "both", "payers_information": [ { "payer_name": "Aetna", "plan_name": "700700", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna", "plan_name": "700700_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Miscellaneous", "plan_name": "700720", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Miscellaneous", "plan_name": "700720_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Ppo Hmo", "plan_name": "701720", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Ppo Hmo", "plan_name": "701720_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Ms State Emplo", "plan_name": "401457", "standard_charge_percentage": 0.80, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Ms State Emplo", "plan_name": "401457_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Basic Pl", "plan_name": "400100", "standard_charge_percentage": 0.85, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Basic Pl", "plan_name": "400100_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Federal", "plan_name": "400110", "standard_charge_percentage": 0.85, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Federal", "plan_name": "400110_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." } ] } ] }, { "description": "Alendronate 35 mg tablet [29072]", 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"401457_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Basic Pl", "plan_name": "400100", "standard_charge_percentage": 0.85, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Basic Pl", "plan_name": "400100_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Federal", "plan_name": "400110", "standard_charge_percentage": 0.85, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Federal", "plan_name": "400110_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." } ] } ] }, { "description": "Alendronate 70 mg tablet [29048]", "drug_information": { "unit": 1.00, "type": "EA" }, "code_information": [ { "code": "64980-342-14", "type": "NDC" } ], "standard_charges": [ { "gross_charge": 7.50, "minimum": 6.00, "maximum": 6.38, "setting": "both", "payers_information": [ { "payer_name": "Aetna", "plan_name": "700700", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna", "plan_name": "700700_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna 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"plan_name": "401457", "standard_charge_percentage": 0.80, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Ms State Emplo", "plan_name": "401457_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Basic Pl", "plan_name": "400100", "standard_charge_percentage": 0.85, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Basic Pl", "plan_name": "400100_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Federal", "plan_name": "400110", "standard_charge_percentage": 0.85, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Federal", "plan_name": "400110_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." } ] } ] }, { "description": "Efavirenz 200 mg capsule [23900]", "drug_information": { "unit": 1.00, "type": "EA" }, "code_information": [ { "code": "64980-407-09", "type": "NDC" } ], "standard_charges": [ { "gross_charge": 44.72, "minimum": 35.78, "maximum": 38.01, "setting": "both", "payers_information": [ { "payer_name": "Aetna", "plan_name": "700700", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna", "plan_name": "700700_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Miscellaneous", "plan_name": "700720", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Miscellaneous", "plan_name": "700720_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Ppo Hmo", "plan_name": "701720", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Ppo Hmo", "plan_name": "701720_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Ms State Emplo", "plan_name": "401457", "standard_charge_percentage": 0.80, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Ms State Emplo", "plan_name": "401457_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Basic Pl", "plan_name": "400100", "standard_charge_percentage": 0.85, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Basic Pl", "plan_name": "400100_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Federal", "plan_name": "400110", "standard_charge_percentage": 0.85, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Federal", "plan_name": "400110_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." } ] } ] }, { "description": "Clindamycin 75 mg/5 ml oral solution [37642]", "drug_information": { "unit": 100.00, "type": "ML" }, "code_information": [ { "code": "64980-511-10", "type": "NDC" } ], "standard_charges": [ { "gross_charge": 186.68, "minimum": 149.34, "maximum": 158.68, "setting": "both", "payers_information": [ { "payer_name": "Aetna", "plan_name": "700700", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna", "plan_name": "700700_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Miscellaneous", "plan_name": "700720", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Miscellaneous", "plan_name": "700720_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed 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"payer_name": "Bc/Bs Of Ms Basic Pl", "plan_name": "400100", "standard_charge_percentage": 0.85, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Basic Pl", "plan_name": "400100_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Federal", "plan_name": "400110", "standard_charge_percentage": 0.85, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Federal", "plan_name": "400110_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." } ] } ] }, { "description": "Latanoprost 0.005 % eye drops [18621]", "drug_information": { "unit": 2.50, "type": "ML" }, "code_information": [ { "code": "64980-516-25", "type": "NDC" } ], "standard_charges": [ { "gross_charge": 61.94, "minimum": 49.55, "maximum": 52.65, "setting": "both", "payers_information": [ { "payer_name": "Aetna", "plan_name": "700700", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna", "plan_name": "700700_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Miscellaneous", "plan_name": "700720", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Miscellaneous", "plan_name": "700720_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Ppo Hmo", "plan_name": "701720", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Ppo Hmo", "plan_name": "701720_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Ms State Emplo", "plan_name": "401457", "standard_charge_percentage": 0.80, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Ms State Emplo", "plan_name": "401457_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Basic Pl", "plan_name": "400100", "standard_charge_percentage": 0.85, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Basic Pl", "plan_name": "400100_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Federal", "plan_name": "400110", "standard_charge_percentage": 0.85, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Federal", "plan_name": "400110_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." } ] } ] }, { "description": "Nitazoxanide 500 mg tablet [39254]", "drug_information": { "unit": 1.00, "type": "EA" }, "code_information": [ { "code": "64980-526-60", "type": "NDC" } ], "standard_charges": [ { "gross_charge": 924.43, "minimum": 739.54, "maximum": 785.77, "setting": "both", "payers_information": [ { "payer_name": "Aetna", "plan_name": "700700", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna", "plan_name": "700700_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Miscellaneous", "plan_name": "700720", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Miscellaneous", "plan_name": "700720_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Ppo Hmo", "plan_name": "701720", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Ppo Hmo", "plan_name": "701720_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Ms State Emplo", "plan_name": "401457", "standard_charge_percentage": 0.80, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Ms State Emplo", "plan_name": "401457_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Basic Pl", "plan_name": "400100", "standard_charge_percentage": 0.85, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Basic Pl", "plan_name": "400100_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Federal", "plan_name": "400110", "standard_charge_percentage": 0.85, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Federal", "plan_name": "400110_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." } ] } ] }, { "description": "Furosemide 80 mg tablet [3296]", "drug_information": { "unit": 1.00, "type": "EA" }, "code_information": [ { "code": "64980-564-01", "type": "NDC" } ], "standard_charges": [ { "gross_charge": 7.50, "minimum": 6.00, "maximum": 6.38, "setting": "both", "payers_information": [ { "payer_name": "Aetna", "plan_name": "700700", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna", "plan_name": "700700_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Miscellaneous", "plan_name": "700720", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Miscellaneous", "plan_name": "700720_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Ppo Hmo", "plan_name": "701720", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Ppo Hmo", "plan_name": "701720_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Ms State Emplo", "plan_name": "401457", "standard_charge_percentage": 0.80, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Ms State Emplo", "plan_name": "401457_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Basic Pl", "plan_name": "400100", "standard_charge_percentage": 0.85, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Basic Pl", "plan_name": "400100_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Federal", "plan_name": "400110", "standard_charge_percentage": 0.85, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Federal", "plan_name": "400110_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." } ] } ] }, { "description": "L.acidophilus-l.bulgar-b.bifid-s.thermoph 1 billion cell-250 mg tablet [119376]", "drug_information": { "unit": 1.00, "type": "EA" }, "code_information": [ { "code": "6498016401", "type": "NDC" } ], "standard_charges": [ { "gross_charge": 7.50, "minimum": 6.00, "maximum": 6.38, "setting": "both", "payers_information": [ { "payer_name": "Aetna", "plan_name": "700700", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna", "plan_name": "700700_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Miscellaneous", "plan_name": "700720", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Miscellaneous", "plan_name": "700720_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Ppo Hmo", "plan_name": "701720", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Ppo Hmo", "plan_name": "701720_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Ms State Emplo", "plan_name": "401457", "standard_charge_percentage": 0.80, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Ms State Emplo", "plan_name": "401457_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Basic Pl", "plan_name": "400100", "standard_charge_percentage": 0.85, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Basic Pl", "plan_name": "400100_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Federal", "plan_name": "400110", "standard_charge_percentage": 0.85, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Federal", "plan_name": "400110_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." } ] } ] }, { "description": "Prasugrel 10 mg tablet [98373]", "drug_information": { "unit": 1.00, "type": "EA" }, "code_information": [ { "code": "65162-002-03", "type": "NDC" } ], "standard_charges": [ { "gross_charge": 7.50, "minimum": 6.00, "maximum": 6.38, "setting": "both", "payers_information": [ { "payer_name": "Aetna", "plan_name": "700700", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna", "plan_name": "700700_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Miscellaneous", "plan_name": "700720", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Miscellaneous", "plan_name": "700720_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Ppo Hmo", "plan_name": "701720", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Ppo Hmo", "plan_name": "701720_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Ms State Emplo", "plan_name": "401457", "standard_charge_percentage": 0.80, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Ms State Emplo", "plan_name": "401457_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Basic Pl", "plan_name": "400100", "standard_charge_percentage": 0.85, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Basic Pl", "plan_name": "400100_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Federal", "plan_name": "400110", "standard_charge_percentage": 0.85, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Federal", "plan_name": "400110_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." } ] } ] }, { "description": "Sevelamer carbonate 800 mg tablet [89201]", "drug_information": { "unit": 1.00, "type": "EA" }, "code_information": [ { "code": "65162-058-27", "type": "NDC" } ], "standard_charges": [ { "gross_charge": 7.50, "minimum": 6.00, "maximum": 6.38, "setting": "both", "payers_information": [ { "payer_name": "Aetna", "plan_name": "700700", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna", "plan_name": "700700_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Miscellaneous", "plan_name": "700720", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Miscellaneous", "plan_name": "700720_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Ppo Hmo", "plan_name": "701720", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Ppo Hmo", "plan_name": "701720_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Ms State Emplo", "plan_name": "401457", "standard_charge_percentage": 0.80, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Ms State Emplo", "plan_name": "401457_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Basic Pl", "plan_name": "400100", "standard_charge_percentage": 0.85, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Basic Pl", "plan_name": "400100_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Federal", "plan_name": "400110", "standard_charge_percentage": 0.85, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Federal", "plan_name": "400110_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." } ] } ] }, { "description": "Sucralfate 100 mg/ml oral suspension [11441]", "drug_information": { "unit": 420.00, "type": "ML" }, "code_information": [ { "code": "65162-062-05", "type": "NDC" } ], "standard_charges": [ { "gross_charge": 1105.23, "minimum": 884.18, "maximum": 939.45, "setting": "both", "payers_information": [ { "payer_name": "Aetna", "plan_name": "700700", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna", "plan_name": "700700_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Miscellaneous", "plan_name": "700720", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Miscellaneous", "plan_name": "700720_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Ppo Hmo", "plan_name": "701720", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Ppo Hmo", "plan_name": "701720_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Ms State Emplo", "plan_name": "401457", "standard_charge_percentage": 0.80, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Ms State Emplo", "plan_name": "401457_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Basic Pl", "plan_name": "400100", "standard_charge_percentage": 0.85, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Basic Pl", "plan_name": "400100_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Federal", "plan_name": "400110", "standard_charge_percentage": 0.85, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Federal", "plan_name": "400110_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." } ] } ] }, { "description": "Norethindrone acetate 5 mg tablet [10747]", "drug_information": { "unit": 1.00, "type": "EA" }, "code_information": [ { "code": "65162-475-05", "type": "NDC" } ], "standard_charges": [ { "gross_charge": 11.89, "minimum": 9.51, "maximum": 10.11, "setting": "both", "payers_information": [ { "payer_name": "Aetna", "plan_name": "700700", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna", "plan_name": "700700_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Miscellaneous", "plan_name": "700720", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Miscellaneous", "plan_name": "700720_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Ppo Hmo", "plan_name": "701720", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Ppo Hmo", "plan_name": "701720_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Ms State Emplo", "plan_name": "401457", "standard_charge_percentage": 0.80, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Ms State Emplo", "plan_name": "401457_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Basic Pl", "plan_name": "400100", "standard_charge_percentage": 0.85, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Basic Pl", "plan_name": "400100_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Federal", "plan_name": "400110", "standard_charge_percentage": 0.85, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Federal", "plan_name": "400110_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." } ] } ] }, { "description": "Phenazopyridine 100 mg tablet [6193]", "drug_information": { "unit": 1.00, "type": "EA" }, "code_information": [ { "code": "65162-681-10", "type": "NDC" } ], "standard_charges": [ { "gross_charge": 7.50, "minimum": 6.00, "maximum": 6.38, "setting": "both", "payers_information": [ { "payer_name": "Aetna", "plan_name": "700700", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna", "plan_name": "700700_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Miscellaneous", "plan_name": "700720", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Miscellaneous", "plan_name": "700720_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Ppo Hmo", "plan_name": "701720", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Ppo Hmo", "plan_name": "701720_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Ms State Emplo", "plan_name": 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"description": "Mometasone 50 mcg/actuation nasal spray [21905]", "drug_information": { "unit": 17.00, "type": "GR" }, "code_information": [ { "code": "65162-891-29", "type": "NDC" } ], "standard_charges": [ { "gross_charge": 771.24, "minimum": 616.99, "maximum": 655.55, "setting": "both", "payers_information": [ { "payer_name": "Aetna", "plan_name": "700700", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna", "plan_name": "700700_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Miscellaneous", "plan_name": "700720", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to 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"standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Ppo Hmo", "plan_name": "701720", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Ppo Hmo", "plan_name": "701720_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Ms State Emplo", "plan_name": "401457", "standard_charge_percentage": 0.80, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Ms State Emplo", "plan_name": "401457_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Basic Pl", "plan_name": "400100", "standard_charge_percentage": 0.85, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Basic Pl", "plan_name": "400100_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Federal", "plan_name": "400110", "standard_charge_percentage": 0.85, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Federal", "plan_name": "400110_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." } ] } ] }, { "description": "Kit for preparation of tc-99m-medronate sodium 25 mg iv solution [150725]", "drug_information": { "unit": 1.00, "type": "EA" }, "code_information": [ { "code": "65174-660-30", "type": "NDC" } ], "standard_charges": [ { "gross_charge": 65.00, "minimum": 52.00, "maximum": 55.25, "setting": "both", "payers_information": [ { "payer_name": "Aetna", "plan_name": "700700", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna", "plan_name": "700700_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Miscellaneous", "plan_name": "700720", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Miscellaneous", "plan_name": "700720_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Ppo Hmo", "plan_name": "701720", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Ppo Hmo", "plan_name": "701720_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Ms State Emplo", "plan_name": "401457", "standard_charge_percentage": 0.80, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Ms State Emplo", "plan_name": "401457_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Basic Pl", "plan_name": "400100", "standard_charge_percentage": 0.85, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Basic Pl", "plan_name": "400100_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Federal", "plan_name": "400110", "standard_charge_percentage": 0.85, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Federal", "plan_name": "400110_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." } ] } ] }, { "description": "Miconazole nitrate 2 % topical cream [5039]", "drug_information": { "unit": 14.00, "type": "GR" }, "code_information": [ { "code": "65197-103-05", "type": "NDC" } ], "standard_charges": [ { "gross_charge": 10.96, "minimum": 8.77, "maximum": 9.32, "setting": "both", "payers_information": [ { "payer_name": "Aetna", "plan_name": "700700", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna", "plan_name": "700700_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Miscellaneous", "plan_name": "700720", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Miscellaneous", "plan_name": "700720_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Ppo Hmo", "plan_name": "701720", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Ppo Hmo", "plan_name": "701720_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Ms State Emplo", "plan_name": "401457", "standard_charge_percentage": 0.80, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Ms State Emplo", "plan_name": "401457_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Basic Pl", "plan_name": "400100", "standard_charge_percentage": 0.85, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Basic Pl", "plan_name": "400100_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Federal", "plan_name": "400110", "standard_charge_percentage": 0.85, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Federal", "plan_name": "400110_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." } ] } ] }, { "description": "Vitamins a and d-white petrolatum-lanolin topical ointment [118725]", "drug_information": { "unit": 42.50, "type": "GR" }, "code_information": [ { "code": "65197-400-10", "type": "NDC" } ], "standard_charges": [ { "gross_charge": 8.84, "minimum": 7.07, "maximum": 7.51, "setting": "both", "payers_information": [ { "payer_name": "Aetna", "plan_name": "700700", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna", "plan_name": "700700_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Miscellaneous", "plan_name": "700720", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Miscellaneous", "plan_name": "700720_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Ppo Hmo", "plan_name": "701720", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Ppo Hmo", "plan_name": "701720_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Ms State Emplo", "plan_name": "401457", "standard_charge_percentage": 0.80, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Ms State Emplo", "plan_name": "401457_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Basic Pl", "plan_name": "400100", "standard_charge_percentage": 0.85, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Basic Pl", "plan_name": "400100_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Federal", "plan_name": "400110", "standard_charge_percentage": 0.85, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Federal", "plan_name": "400110_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." } ] } ] }, { "description": "Potassium phosphates-mbasic and dibasic 3 mmol/ml intravenous solution [6451]", "drug_information": { "unit": 5.00, "type": "ML" }, "code_information": [ { "code": "65219-052-09", "type": "NDC" } ], "standard_charges": [ { "gross_charge": 119.90, "minimum": 95.92, "maximum": 101.92, "setting": "both", "payers_information": [ { "payer_name": "Aetna", "plan_name": "700700", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna", "plan_name": "700700_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Miscellaneous", "plan_name": "700720", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Miscellaneous", "plan_name": "700720_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Ppo Hmo", "plan_name": "701720", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Ppo Hmo", "plan_name": "701720_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Ms State Emplo", "plan_name": "401457", "standard_charge_percentage": 0.80, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Ms State Emplo", "plan_name": "401457_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Basic Pl", "plan_name": "400100", "standard_charge_percentage": 0.85, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Basic Pl", "plan_name": "400100_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Federal", "plan_name": "400110", "standard_charge_percentage": 0.85, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Federal", "plan_name": "400110_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." } ] } ] }, { "description": "Potassium phosphates-mbasic and dibasic 3 mmol/ml intravenous solution [6451]", "drug_information": { "unit": 5.00, "type": "ML" }, "code_information": [ { "code": "65219-052-29", "type": "NDC" } ], "standard_charges": [ { "gross_charge": 119.90, "minimum": 95.92, "maximum": 101.92, "setting": "both", "payers_information": [ { "payer_name": "Aetna", "plan_name": "700700", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna", "plan_name": "700700_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Miscellaneous", "plan_name": "700720", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Miscellaneous", "plan_name": "700720_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Ppo Hmo", "plan_name": "701720", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Ppo Hmo", "plan_name": "701720_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Ms State Emplo", "plan_name": "401457", "standard_charge_percentage": 0.80, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Ms State Emplo", "plan_name": "401457_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Basic Pl", "plan_name": "400100", "standard_charge_percentage": 0.85, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Basic Pl", "plan_name": "400100_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Federal", "plan_name": "400110", "standard_charge_percentage": 0.85, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Federal", "plan_name": "400110_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." } ] } ] }, { "description": "Etomidate 2 mg/ml intravenous solution [20472]", "drug_information": { "unit": 10.00, "type": "ML" }, "code_information": [ { "code": "65219-445-01", "type": "NDC" } ], "standard_charges": [ { "gross_charge": 59.85, "minimum": 47.88, "maximum": 50.87, "setting": "both", "payers_information": [ { "payer_name": "Aetna", "plan_name": "700700", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna", "plan_name": "700700_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Miscellaneous", "plan_name": "700720", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Miscellaneous", "plan_name": "700720_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Ppo Hmo", "plan_name": "701720", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Ppo Hmo", "plan_name": "701720_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Ms State Emplo", "plan_name": "401457", "standard_charge_percentage": 0.80, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Ms State Emplo", "plan_name": "401457_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Basic Pl", "plan_name": "400100", "standard_charge_percentage": 0.85, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Basic Pl", "plan_name": "400100_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Federal", "plan_name": "400110", "standard_charge_percentage": 0.85, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Federal", "plan_name": "400110_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." } ] } ] }, { "description": "Etomidate 2 mg/ml intravenous solution [20472]", "drug_information": { "unit": 10.00, "type": "ML" }, "code_information": [ { "code": "65219-445-10", "type": "NDC" } ], "standard_charges": [ { "gross_charge": 59.85, "minimum": 47.88, "maximum": 50.87, "setting": "both", "payers_information": [ { "payer_name": "Aetna", "plan_name": "700700", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna", "plan_name": "700700_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Miscellaneous", "plan_name": "700720", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Miscellaneous", "plan_name": "700720_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Ppo Hmo", "plan_name": "701720", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Ppo Hmo", "plan_name": "701720_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Ms State Emplo", "plan_name": "401457", "standard_charge_percentage": 0.80, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Ms State Emplo", "plan_name": "401457_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Basic Pl", "plan_name": "400100", "standard_charge_percentage": 0.85, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Basic Pl", "plan_name": "400100_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Federal", "plan_name": "400110", "standard_charge_percentage": 0.85, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Federal", "plan_name": "400110_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." } ] } ] }, { "description": "Colesevelam 625 mg tablet [28372]", "drug_information": { "unit": 1.00, "type": "EA" }, "code_information": [ { "code": "65597-701-18", "type": "NDC" } ], "standard_charges": [ { "gross_charge": 17.67, "minimum": 14.14, "maximum": 15.02, "setting": "both", "payers_information": [ { "payer_name": "Aetna", "plan_name": "700700", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna", "plan_name": "700700_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Miscellaneous", "plan_name": "700720", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Miscellaneous", "plan_name": "700720_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Ppo Hmo", "plan_name": "701720", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Ppo Hmo", "plan_name": "701720_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate 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"standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Federal", "plan_name": "400110", "standard_charge_percentage": 0.85, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Federal", "plan_name": "400110_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." } ] } ] }, { "description": "Cefuroxime axetil 250 mg tablet [9495]", "drug_information": { "unit": 1.00, "type": "EA" }, "code_information": [ { "code": "65862-699-60", "type": "NDC" } ], "standard_charges": [ { "gross_charge": 7.50, "minimum": 6.00, "maximum": 6.38, "setting": "both", "payers_information": [ { 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"plan_name": "701720", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Ppo Hmo", "plan_name": "701720_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Ms State Emplo", "plan_name": "401457", "standard_charge_percentage": 0.80, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Ms State Emplo", "plan_name": "401457_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Basic Pl", "plan_name": "400100", "standard_charge_percentage": 0.85, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Basic Pl", "plan_name": "400100_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Federal", "plan_name": "400110", "standard_charge_percentage": 0.85, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Federal", "plan_name": "400110_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." } ] } ] }, { "description": "Amoxicillin 250 mg/5 ml oral suspension [454]", "drug_information": { "unit": 100.00, "type": "ML" }, "code_information": [ { "code": "65862-707-01", "type": "NDC" } ], "standard_charges": [ { "gross_charge": 25.18, "minimum": 20.14, "maximum": 21.40, "setting": "both", "payers_information": [ { "payer_name": "Aetna", "plan_name": "700700", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna", "plan_name": "700700_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Miscellaneous", "plan_name": "700720", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Miscellaneous", "plan_name": "700720_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Ppo Hmo", "plan_name": "701720", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Ppo Hmo", "plan_name": "701720_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Ms State Emplo", "plan_name": "401457", "standard_charge_percentage": 0.80, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Ms State Emplo", "plan_name": "401457_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Basic Pl", "plan_name": "400100", "standard_charge_percentage": 0.85, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Basic Pl", "plan_name": "400100_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Federal", "plan_name": "400110", "standard_charge_percentage": 0.85, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Federal", "plan_name": "400110_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." } ] } ] }, { "description": "Pregabalin 150 mg capsule [42166]", "drug_information": { "unit": 1.00, "type": "EA" }, "code_information": [ { "code": "65862-762-90", "type": "NDC" } ], "standard_charges": [ { "gross_charge": 7.50, "minimum": 6.00, "maximum": 6.38, "setting": "both", "payers_information": [ { "payer_name": "Aetna", "plan_name": "700700", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna", "plan_name": "700700_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed 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"payer_name": "Bc/Bs Ms State Emplo", "plan_name": "401457", "standard_charge_percentage": 0.80, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Ms State Emplo", "plan_name": "401457_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Basic Pl", "plan_name": "400100", "standard_charge_percentage": 0.85, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Basic Pl", "plan_name": "400100_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Federal", "plan_name": "400110", "standard_charge_percentage": 0.85, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Federal", "plan_name": "400110_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." } ] } ] }, { "description": "Prasugrel 10 mg tablet [98373]", "drug_information": { "unit": 1.00, "type": "EA" }, "code_information": [ { "code": "65862-830-30", "type": "NDC" } ], "standard_charges": [ { "gross_charge": 7.50, "minimum": 6.00, "maximum": 6.38, "setting": "both", "payers_information": [ { "payer_name": "Aetna", "plan_name": "700700", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to 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amounts." }, { "payer_name": "Aetna Ppo Hmo", "plan_name": "701720_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Ms State Emplo", "plan_name": "401457", "standard_charge_percentage": 0.80, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Ms State Emplo", "plan_name": "401457_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Basic Pl", "plan_name": "400100", "standard_charge_percentage": 0.85, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Basic Pl", "plan_name": "400100_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Federal", "plan_name": "400110", "standard_charge_percentage": 0.85, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Federal", "plan_name": "400110_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." } ] } ] }, { "description": "Moxifloxacin 0.5 % eye drops [35699]", "drug_information": { "unit": 3.00, "type": "ML" }, "code_information": [ { "code": "65862-840-03", "type": "NDC" } ], "standard_charges": [ { "gross_charge": 229.10, "minimum": 183.28, "maximum": 194.74, "setting": "both", "payers_information": [ { "payer_name": "Aetna", "plan_name": "700700", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna", "plan_name": "700700_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Miscellaneous", "plan_name": "700720", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Miscellaneous", "plan_name": "700720_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Ppo Hmo", "plan_name": "701720", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Ppo Hmo", "plan_name": "701720_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Ms State Emplo", "plan_name": "401457", "standard_charge_percentage": 0.80, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Ms State Emplo", "plan_name": "401457_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Basic Pl", "plan_name": "400100", "standard_charge_percentage": 0.85, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Basic Pl", "plan_name": "400100_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Federal", "plan_name": "400110", "standard_charge_percentage": 0.85, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Federal", "plan_name": "400110_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." } ] } ] }, { "description": "Aspirin 325 mg tablet [681]", "drug_information": { "unit": 1.00, "type": "EA" }, "code_information": [ { "code": "66553-001-01", "type": "NDC" } ], "standard_charges": [ { "gross_charge": 1.00, "minimum": 0.80, "maximum": 0.85, "setting": "both", "payers_information": [ { "payer_name": "Aetna", "plan_name": "700700", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna", "plan_name": "700700_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Miscellaneous", "plan_name": "700720", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Miscellaneous", "plan_name": "700720_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Ppo Hmo", "plan_name": "701720", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Ppo Hmo", "plan_name": "701720_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Ms State Emplo", "plan_name": "401457", "standard_charge_percentage": 0.80, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Ms State Emplo", "plan_name": "401457_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Basic Pl", "plan_name": "400100", "standard_charge_percentage": 0.85, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Basic Pl", "plan_name": "400100_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Federal", "plan_name": "400110", "standard_charge_percentage": 0.85, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Federal", "plan_name": "400110_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." } ] } ] }, { "description": "Aspirin 81 mg chewable tablet [679]", "drug_information": { "unit": 1.00, "type": "EA" }, "code_information": [ { "code": "66553-002-01", "type": "NDC" } ], "standard_charges": [ { "gross_charge": 1.00, "minimum": 0.80, "maximum": 0.85, "setting": "both", "payers_information": [ { "payer_name": "Aetna", "plan_name": "700700", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna", "plan_name": "700700_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Miscellaneous", "plan_name": "700720", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Miscellaneous", "plan_name": "700720_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Ppo Hmo", "plan_name": "701720", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Ppo Hmo", "plan_name": "701720_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient 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"payer_name": "Aetna Ppo Hmo", "plan_name": "701720", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Ppo Hmo", "plan_name": "701720_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Ms State Emplo", "plan_name": "401457", "standard_charge_percentage": 0.80, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Ms State Emplo", "plan_name": "401457_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Basic Pl", "plan_name": "400100", "standard_charge_percentage": 0.85, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Basic Pl", "plan_name": "400100_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Federal", "plan_name": "400110", "standard_charge_percentage": 0.85, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Federal", "plan_name": "400110_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." } ] } ] }, { "description": "Hydrocodone 7.5 mg-acetaminophen 325 mg/15 ml oral solution [37848]", "drug_information": { "unit": 15.00, "type": "ML" }, "code_information": [ { "code": "66689-023-01", "type": "NDC" } ], "standard_charges": [ { "gross_charge": 28.65, "minimum": 22.92, "maximum": 24.35, "setting": "both", "payers_information": [ { "payer_name": "Aetna", "plan_name": "700700", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna", "plan_name": "700700_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Miscellaneous", "plan_name": "700720", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": 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"methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Basic Pl", "plan_name": "400100_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Federal", "plan_name": "400110", "standard_charge_percentage": 0.85, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Federal", "plan_name": "400110_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." } ] } ] }, { "description": "Phenytoin 100 mg/4 ml oral suspension [118124]", "drug_information": { "unit": 4.00, 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"standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Ppo Hmo", "plan_name": "701720", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Ppo Hmo", "plan_name": "701720_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Ms State Emplo", "plan_name": "401457", "standard_charge_percentage": 0.80, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Ms State Emplo", "plan_name": "401457_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Basic Pl", "plan_name": "400100", "standard_charge_percentage": 0.85, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Basic Pl", "plan_name": "400100_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Federal", "plan_name": "400110", "standard_charge_percentage": 0.85, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Federal", "plan_name": "400110_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." } ] } ] }, { "description": "Nystatin 100000 unit/ml oral suspension [5751]", "drug_information": { "unit": 5.00, "type": "ML" }, "code_information": [ { "code": "66689-037-01", "type": "NDC" } ], "standard_charges": [ { "gross_charge": 7.50, "minimum": 6.00, "maximum": 6.38, "setting": "both", "payers_information": [ { "payer_name": "Aetna", "plan_name": "700700", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna", "plan_name": "700700_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna 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"plan_name": "401457", "standard_charge_percentage": 0.80, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Ms State Emplo", "plan_name": "401457_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Basic Pl", "plan_name": "400100", "standard_charge_percentage": 0.85, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Basic Pl", "plan_name": "400100_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Federal", "plan_name": "400110", "standard_charge_percentage": 0.85, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Federal", "plan_name": "400110_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." } ] } ] }, { "description": "Lactulose 20 gram/30 ml oral solution [154863]", "drug_information": { "unit": 30.00, "type": "ML" }, "code_information": [ { "code": "66689-038-01", "type": "NDC" } ], "standard_charges": [ { "gross_charge": 7.50, "minimum": 6.00, "maximum": 6.38, "setting": "both", "payers_information": [ { "payer_name": "Aetna", "plan_name": "700700", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed 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"payer_name": "Aetna Ppo Hmo", "plan_name": "701720_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Ms State Emplo", "plan_name": "401457", "standard_charge_percentage": 0.80, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Ms State Emplo", "plan_name": "401457_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Basic Pl", "plan_name": "400100", "standard_charge_percentage": 0.85, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Basic Pl", "plan_name": "400100_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Federal", "plan_name": "400110", "standard_charge_percentage": 0.85, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Federal", "plan_name": "400110_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." } ] } ] }, { "description": "Lactulose 10 gram/15 ml (15 ml) oral solution [150549]", "drug_information": { "unit": 15.00, "type": "ML" }, "code_information": [ { "code": "66689-039-01", "type": "NDC" } ], "standard_charges": [ { "gross_charge": 7.50, 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"additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Basic Pl", "plan_name": "400100", "standard_charge_percentage": 0.85, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Basic Pl", "plan_name": "400100_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Federal", "plan_name": "400110", "standard_charge_percentage": 0.85, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Federal", "plan_name": "400110_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." } ] } ] }, { "description": "Gent violet-brlnt grn-proflav 2.29 mg-2.29 mg-1.14 mg/ml topical swab [115833]", "drug_information": { "unit": 1.00, "type": "EA" }, "code_information": [ { "code": "66689-710-06", "type": "NDC" } ], "standard_charges": [ { "gross_charge": 28.17, "minimum": 22.54, "maximum": 23.94, "setting": "both", "payers_information": [ { "payer_name": "Aetna", "plan_name": "700700", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna", "plan_name": "700700_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Miscellaneous", "plan_name": "700720", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Miscellaneous", "plan_name": "700720_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Ppo Hmo", "plan_name": "701720", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Ppo Hmo", "plan_name": "701720_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Ms State Emplo", "plan_name": "401457", "standard_charge_percentage": 0.80, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Ms State Emplo", "plan_name": "401457_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Basic Pl", "plan_name": "400100", "standard_charge_percentage": 0.85, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Basic Pl", "plan_name": "400100_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Federal", "plan_name": "400110", "standard_charge_percentage": 0.85, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Federal", "plan_name": "400110_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." } ] } ] }, { "description": "Sertraline 100 mg tablet [11350]", "drug_information": { "unit": 1.00, "type": "EA" }, "code_information": [ { "code": "65862-013-01", "type": "NDC" } ], "standard_charges": [ { "gross_charge": 7.50, "minimum": 6.00, "maximum": 6.38, "setting": "both", "payers_information": [ { "payer_name": "Aetna", "plan_name": "700700", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna", "plan_name": "700700_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Miscellaneous", "plan_name": "700720", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Miscellaneous", "plan_name": "700720_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Ppo Hmo", "plan_name": "701720", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Ppo Hmo", "plan_name": "701720_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Ms State Emplo", "plan_name": "401457", "standard_charge_percentage": 0.80, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Ms State Emplo", "plan_name": "401457_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Basic Pl", "plan_name": "400100", "standard_charge_percentage": 0.85, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Basic Pl", "plan_name": "400100_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Federal", "plan_name": "400110", "standard_charge_percentage": 0.85, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Federal", "plan_name": "400110_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." } ] } ] }, { "description": "Amoxicillin 250 mg capsule [450]", "drug_information": { "unit": 1.00, "type": "EA" }, "code_information": [ { "code": "65862-016-01", "type": "NDC" } ], "standard_charges": [ { "gross_charge": 7.50, "minimum": 6.00, "maximum": 6.38, "setting": "both", "payers_information": [ { "payer_name": "Aetna", "plan_name": "700700", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna", "plan_name": "700700_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Miscellaneous", "plan_name": "700720", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Miscellaneous", "plan_name": "700720_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Ppo Hmo", "plan_name": "701720", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Ppo Hmo", "plan_name": "701720_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Ms State Emplo", "plan_name": "401457", "standard_charge_percentage": 0.80, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Ms State Emplo", "plan_name": "401457_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Basic Pl", "plan_name": "400100", "standard_charge_percentage": 0.85, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Basic Pl", "plan_name": "400100_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Federal", "plan_name": "400110", "standard_charge_percentage": 0.85, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Federal", "plan_name": "400110_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." } ] } ] }, { "description": "Terbinafine hcl 250 mg tablet [12724]", "drug_information": { "unit": 1.00, "type": "EA" }, "code_information": [ { "code": "65862-079-30", "type": "NDC" } ], "standard_charges": [ { "gross_charge": 7.50, "minimum": 6.00, "maximum": 6.38, "setting": "both", "payers_information": [ { "payer_name": "Aetna", "plan_name": "700700", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna", "plan_name": "700700_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Miscellaneous", "plan_name": "700720", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Miscellaneous", "plan_name": "700720_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Ppo Hmo", "plan_name": "701720", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Ppo Hmo", "plan_name": "701720_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Ms State Emplo", "plan_name": "401457", "standard_charge_percentage": 0.80, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Ms State Emplo", "plan_name": "401457_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Basic Pl", "plan_name": "400100", "standard_charge_percentage": 0.85, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Basic Pl", "plan_name": "400100_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Federal", "plan_name": "400110", "standard_charge_percentage": 0.85, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Federal", "plan_name": "400110_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." } ] } ] }, { "description": "Sumatriptan 25 mg tablet [15327]", "drug_information": { "unit": 1.00, "type": "EA" }, "code_information": [ { "code": "65862-146-36", "type": "NDC" } ], "standard_charges": [ { "gross_charge": 7.50, "minimum": 6.00, "maximum": 6.38, "setting": "both", "payers_information": [ { "payer_name": "Aetna", "plan_name": "700700", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna", "plan_name": "700700_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Miscellaneous", "plan_name": "700720", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Miscellaneous", "plan_name": "700720_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Ppo Hmo", "plan_name": "701720", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Ppo Hmo", "plan_name": "701720_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Ms State Emplo", "plan_name": "401457", "standard_charge_percentage": 0.80, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Ms State Emplo", "plan_name": "401457_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Basic Pl", "plan_name": "400100", "standard_charge_percentage": 0.85, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Basic Pl", "plan_name": "400100_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Federal", "plan_name": "400110", "standard_charge_percentage": 0.85, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Federal", "plan_name": "400110_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." } ] } ] }, { "description": "Sumatriptan 100 mg tablet [13369]", "drug_information": { "unit": 1.00, "type": "EA" }, "code_information": [ { "code": "65862-148-36", "type": "NDC" } ], "standard_charges": [ { "gross_charge": 7.50, "minimum": 6.00, "maximum": 6.38, "setting": "both", "payers_information": [ { "payer_name": "Aetna", "plan_name": "700700", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna", "plan_name": "700700_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Miscellaneous", "plan_name": "700720", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Miscellaneous", "plan_name": "700720_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Ppo Hmo", "plan_name": "701720", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Ppo Hmo", "plan_name": "701720_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Ms State Emplo", "plan_name": "401457", "standard_charge_percentage": 0.80, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Ms State Emplo", "plan_name": "401457_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Basic Pl", "plan_name": "400100", "standard_charge_percentage": 0.85, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Basic Pl", "plan_name": "400100_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Federal", "plan_name": "400110", "standard_charge_percentage": 0.85, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Federal", "plan_name": "400110_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." } ] } ] }, { "description": "Penicillin v potassium 500 mg tablet [6093]", "drug_information": { "unit": 1.00, "type": "EA" }, "code_information": [ { "code": "65862-176-01", "type": "NDC" } ], "standard_charges": [ { "gross_charge": 7.50, "minimum": 6.00, "maximum": 6.38, "setting": "both", "payers_information": [ { "payer_name": "Aetna", "plan_name": "700700", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna", "plan_name": "700700_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Miscellaneous", "plan_name": "700720", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Miscellaneous", "plan_name": "700720_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Ppo Hmo", "plan_name": "701720", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Ppo Hmo", "plan_name": "701720_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Ms State Emplo", "plan_name": "401457", "standard_charge_percentage": 0.80, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Ms State Emplo", "plan_name": "401457_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate 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allowed amounts." } ] } ] }, { "description": "Cefdinir 250 mg/5 ml oral suspension [39522]", "drug_information": { "unit": 100.00, "type": "ML" }, "code_information": [ { "code": "65862-219-01", "type": "NDC" } ], "standard_charges": [ { "gross_charge": 171.00, "minimum": 136.80, "maximum": 145.35, "setting": "both", "payers_information": [ { "payer_name": "Aetna", "plan_name": "700700", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna", "plan_name": "700700_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Miscellaneous", "plan_name": "700720", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": 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"standard_charge_percentage": 0.85, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Federal", "plan_name": "400110_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." } ] } ] }, { "description": "Sulfamethoxazole 200 mg-trimethoprim 40 mg/5 ml oral suspension [22560]", "drug_information": { "unit": 473.00, "type": "ML" }, "code_information": [ { "code": "66993-727-57", "type": "NDC" } ], "standard_charges": [ { "gross_charge": 204.46, "minimum": 163.57, "maximum": 173.79, "setting": "both", "payers_information": [ { "payer_name": "Aetna", "plan_name": "700700", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate 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"payer_name": "Aetna Ppo Hmo", "plan_name": "701720_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Ms State Emplo", "plan_name": "401457", "standard_charge_percentage": 0.80, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Ms State Emplo", "plan_name": "401457_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Basic Pl", "plan_name": "400100", "standard_charge_percentage": 0.85, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Basic Pl", "plan_name": "400100_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Federal", "plan_name": "400110", "standard_charge_percentage": 0.85, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Federal", "plan_name": "400110_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." } ] } ] }, { "description": "Ascorbic acid (vitamin c) 500 mg/ml intravenous solution [182148]", "drug_information": { "unit": 50.00, "type": "ML" }, "code_information": [ { "code": "67157-101-50", "type": "NDC" } ], "standard_charges": [ { "gross_charge": 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remit data to calculate allowed amounts." } ] } ] }, { "description": "Ascorbic acid (vitamin c) 500 mg/ml intravenous solution [182148]", "drug_information": { "unit": 50.00, "type": "ML" }, "code_information": [ { "code": "67157-101-51", "type": "NDC" } ], "standard_charges": [ { "gross_charge": 1257.00, "minimum": 1005.60, "maximum": 1068.45, "setting": "both", "payers_information": [ { "payer_name": "Aetna", "plan_name": "700700", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna", "plan_name": "700700_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Miscellaneous", "plan_name": "700720", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of 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"0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Federal", "plan_name": "400110", "standard_charge_percentage": 0.85, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Federal", "plan_name": "400110_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." } ] } ] }, { "description": "Rocuronium 10 mg/ml intravenous solution [12734]", "drug_information": { "unit": 5.00, "type": "ML" }, "code_information": [ { "code": "67457-228-00", "type": "NDC" } ], "standard_charges": [ { "gross_charge": 37.68, "minimum": 30.14, "maximum": 32.03, "setting": "both", "payers_information": [ { "payer_name": "Aetna", "plan_name": 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"standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Ppo Hmo", "plan_name": "701720_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Ms State Emplo", "plan_name": "401457", "standard_charge_percentage": 0.80, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Ms State Emplo", "plan_name": "401457_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Basic Pl", "plan_name": "400100", 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"plan_name": "400110_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." } ] } ] }, { "description": "Doxycycline hyclate 100 mg intravenous powder for solution [2622]", "drug_information": { "unit": 1.00, "type": "EA" }, "code_information": [ { "code": "67457-437-00", "type": "NDC" } ], "standard_charges": [ { "gross_charge": 208.49, "minimum": 166.79, "maximum": 177.22, "setting": "both", "payers_information": [ { "payer_name": "Aetna", "plan_name": "700700", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna", "plan_name": "700700_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate 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}, { "payer_name": "Bc/Bs Ms State Emplo", "plan_name": "401457", "standard_charge_percentage": 0.80, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Ms State Emplo", "plan_name": "401457_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Basic Pl", "plan_name": "400100", "standard_charge_percentage": 0.85, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Basic Pl", "plan_name": "400100_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Federal", "plan_name": "400110", "standard_charge_percentage": 0.85, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Federal", "plan_name": "400110_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." } ] } ] }, { "description": "Doxycycline hyclate 100 mg intravenous powder for solution [2622]", "drug_information": { "unit": 1.00, "type": "EA" }, "code_information": [ { "code": "67457-437-10", "type": "NDC" } ], "standard_charges": [ { "gross_charge": 208.49, "minimum": 166.79, "maximum": 177.22, "setting": "both", "payers_information": [ { "payer_name": "Aetna", "plan_name": "700700", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", 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"Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Basic Pl", "plan_name": "400100_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Federal", "plan_name": "400110", "standard_charge_percentage": 0.85, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Federal", "plan_name": "400110_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." } ] } ] }, { "description": "Norepinephrine bitartrate 1 mg/ml intravenous solution [10734]", "drug_information": { "unit": 4.00, "type": "ML" }, "code_information": [ { "code": "67457-852-00", 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charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." } ] } ] }, { "description": "Norepinephrine bitartrate 1 mg/ml intravenous solution [10734]", "drug_information": { "unit": 4.00, "type": "ML" }, "code_information": [ { "code": "67457-852-04", "type": "NDC" } ], "standard_charges": [ { "gross_charge": 112.38, "minimum": 89.90, "maximum": 95.52, "setting": "both", "payers_information": [ { "payer_name": "Aetna", "plan_name": "700700", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna", "plan_name": "700700_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Miscellaneous", "plan_name": "700720", "standard_charge_percentage": 80.0, 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"additional_payer_notes": "Insufficient remit data to calculate allowed amounts." } ] } ] }, { "description": "Gadoterate meglumine 0.5 mmol/ml intravenous syringe [163967]", "drug_information": { "unit": 15.00, "type": "ML" }, "code_information": [ { "code": "67684-3001-2", "type": "NDC" } ], "standard_charges": [ { "gross_charge": 211.65, "minimum": 169.32, "maximum": 179.90, "setting": "both", "payers_information": [ { "payer_name": "Aetna", "plan_name": "700700", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna", "plan_name": "700700_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Miscellaneous", "plan_name": "700720", "standard_charge_percentage": 80.0, "count": 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"additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Ms State Emplo", "plan_name": "401457_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Basic Pl", "plan_name": "400100", "standard_charge_percentage": 0.85, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Basic Pl", "plan_name": "400100_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Federal", "plan_name": "400110", "standard_charge_percentage": 0.85, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Federal", "plan_name": "400110_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." } ] } ] }, { "description": "Triamcinolone acetonide 0.1 % topical cream [8113]", "drug_information": { "unit": 80.00, "type": "GR" }, "code_information": [ { "code": "67877-251-80", "type": "NDC" } ], "standard_charges": [ { "gross_charge": 58.14, "minimum": 46.51, "maximum": 49.42, "setting": "both", "payers_information": [ { "payer_name": "Aetna", "plan_name": "700700", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna", "plan_name": "700700_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Miscellaneous", "plan_name": "700720", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Miscellaneous", "plan_name": "700720_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Ppo Hmo", "plan_name": "701720", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Ppo Hmo", "plan_name": "701720_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Ms State Emplo", "plan_name": "401457", "standard_charge_percentage": 0.80, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Ms State Emplo", "plan_name": "401457_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Basic Pl", "plan_name": "400100", "standard_charge_percentage": 0.85, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Basic Pl", "plan_name": "400100_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Federal", "plan_name": "400110", "standard_charge_percentage": 0.85, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Federal", "plan_name": "400110_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." } ] } ] }, { "description": "Rizatriptan 10 mg tablet [23377]", "drug_information": { "unit": 1.00, "type": "EA" }, "code_information": [ { "code": "67877-262-06", "type": "NDC" } ], "standard_charges": [ { "gross_charge": 8.00, "minimum": 6.40, "maximum": 6.80, "setting": "both", "payers_information": [ { "payer_name": "Aetna", "plan_name": "700700", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna", "plan_name": "700700_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Miscellaneous", "plan_name": "700720", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Miscellaneous", "plan_name": "700720_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Ppo Hmo", "plan_name": "701720", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Ppo Hmo", "plan_name": "701720_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Ms State Emplo", "plan_name": "401457", "standard_charge_percentage": 0.80, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Ms State Emplo", "plan_name": "401457_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Basic Pl", "plan_name": "400100", "standard_charge_percentage": 0.85, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Basic Pl", "plan_name": "400100_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Federal", "plan_name": "400110", "standard_charge_percentage": 0.85, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Federal", "plan_name": "400110_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." } ] } ] }, { "description": "Rizatriptan 10 mg tablet [23377]", "drug_information": { "unit": 1.00, "type": "EA" }, "code_information": [ { "code": "67877-262-18", "type": "NDC" } ], "standard_charges": [ { "gross_charge": 8.00, "minimum": 6.40, "maximum": 6.80, "setting": "both", "payers_information": [ { "payer_name": "Aetna", "plan_name": "700700", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna", "plan_name": "700700_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Miscellaneous", "plan_name": "700720", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Miscellaneous", "plan_name": "700720_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Ppo Hmo", "plan_name": "701720", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Ppo Hmo", "plan_name": "701720_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Ms State Emplo", "plan_name": "401457", "standard_charge_percentage": 0.80, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Ms State Emplo", "plan_name": "401457_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Basic Pl", "plan_name": "400100", "standard_charge_percentage": 0.85, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Basic Pl", "plan_name": "400100_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Federal", "plan_name": "400110", "standard_charge_percentage": 0.85, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Federal", "plan_name": "400110_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." } ] } ] }, { "description": "Etomidate 2 mg/ml intravenous solution [20472]", "drug_information": { "unit": 20.00, "type": "ML" }, "code_information": [ { "code": "67457-903-00", "type": "NDC" } ], "standard_charges": [ { "gross_charge": 66.50, "minimum": 53.20, "maximum": 56.53, "setting": "both", "payers_information": [ { "payer_name": "Aetna", "plan_name": "700700", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna", "plan_name": "700700_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Miscellaneous", "plan_name": "700720", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Miscellaneous", "plan_name": "700720_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Ppo Hmo", "plan_name": "701720", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Ppo Hmo", "plan_name": "701720_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Ms State Emplo", "plan_name": "401457", "standard_charge_percentage": 0.80, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Ms State Emplo", "plan_name": "401457_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Basic Pl", "plan_name": "400100", "standard_charge_percentage": 0.85, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Basic Pl", "plan_name": "400100_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Federal", "plan_name": "400110", "standard_charge_percentage": 0.85, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Federal", "plan_name": "400110_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." } ] } ] }, { "description": "Etomidate 2 mg/ml intravenous solution [20472]", "drug_information": { "unit": 20.00, "type": "ML" }, "code_information": [ { "code": "67457-903-20", "type": "NDC" } ], "standard_charges": [ { "gross_charge": 66.50, "minimum": 53.20, "maximum": 56.53, "setting": "both", "payers_information": [ { "payer_name": "Aetna", "plan_name": "700700", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna", "plan_name": "700700_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Miscellaneous", "plan_name": "700720", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Miscellaneous", "plan_name": "700720_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Ppo Hmo", "plan_name": "701720", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Ppo Hmo", "plan_name": "701720_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Ms State Emplo", "plan_name": "401457", "standard_charge_percentage": 0.80, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Ms State Emplo", "plan_name": "401457_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Basic Pl", "plan_name": "400100", "standard_charge_percentage": 0.85, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Basic Pl", "plan_name": "400100_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Federal", "plan_name": "400110", "standard_charge_percentage": 0.85, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Federal", "plan_name": "400110_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." } ] } ] }, { "description": "Gabapentin 600 mg tablet [25855]", "drug_information": { "unit": 1.00, "type": "EA" }, "code_information": [ { "code": "67877-428-01", "type": "NDC" } ], "standard_charges": [ { "gross_charge": 7.50, "minimum": 6.00, "maximum": 6.38, "setting": "both", "payers_information": [ { "payer_name": "Aetna", "plan_name": "700700", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna", "plan_name": "700700_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Miscellaneous", "plan_name": "700720", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Miscellaneous", "plan_name": "700720_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Ppo Hmo", "plan_name": "701720", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Ppo Hmo", "plan_name": "701720_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Ms State Emplo", "plan_name": "401457", "standard_charge_percentage": 0.80, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Ms State Emplo", "plan_name": "401457_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Basic Pl", "plan_name": "400100", "standard_charge_percentage": 0.85, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Basic Pl", "plan_name": "400100_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Federal", "plan_name": "400110", "standard_charge_percentage": 0.85, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Federal", "plan_name": "400110_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." } ] } ] }, { "description": "Aripiprazole 5 mg tablet [36438]", "drug_information": { "unit": 1.00, "type": "EA" }, "code_information": [ { "code": "67877-431-03", "type": "NDC" } ], "standard_charges": [ { "gross_charge": 7.50, "minimum": 6.00, "maximum": 6.38, "setting": "both", "payers_information": [ { "payer_name": "Aetna", "plan_name": "700700", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna", "plan_name": "700700_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Miscellaneous", "plan_name": "700720", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Miscellaneous", "plan_name": "700720_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Ppo Hmo", "plan_name": "701720", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Ppo Hmo", "plan_name": "701720_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Ms State Emplo", "plan_name": "401457", "standard_charge_percentage": 0.80, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Ms State Emplo", "plan_name": "401457_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Basic Pl", "plan_name": "400100", "standard_charge_percentage": 0.85, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Basic Pl", "plan_name": "400100_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Federal", "plan_name": "400110", "standard_charge_percentage": 0.85, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Federal", "plan_name": "400110_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." } ] } ] }, { "description": "Aripiprazole 10 mg tablet [34369]", "drug_information": { "unit": 1.00, "type": "EA" }, "code_information": [ { "code": "67877-432-03", "type": "NDC" } ], "standard_charges": [ { "gross_charge": 7.50, "minimum": 6.00, "maximum": 6.38, "setting": "both", "payers_information": [ { "payer_name": "Aetna", "plan_name": "700700", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna", "plan_name": "700700_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Miscellaneous", "plan_name": "700720", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Miscellaneous", "plan_name": "700720_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Ppo Hmo", "plan_name": "701720", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Ppo Hmo", "plan_name": "701720_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Ms State Emplo", "plan_name": "401457", "standard_charge_percentage": 0.80, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Ms State Emplo", "plan_name": "401457_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Basic Pl", "plan_name": "400100", "standard_charge_percentage": 0.85, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Basic Pl", "plan_name": "400100_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Federal", "plan_name": "400110", "standard_charge_percentage": 0.85, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Federal", "plan_name": "400110_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." } ] } ] }, { "description": "Lidocaine 5 % topical ointment [156314]", "drug_information": { "unit": 35.44, "type": "GR" }, "code_information": [ { "code": "67877-473-79", "type": "NDC" } ], "standard_charges": [ { "gross_charge": 57.07, "minimum": 45.66, "maximum": 48.51, "setting": "both", "payers_information": [ { "payer_name": "Aetna", "plan_name": "700700", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient 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allowed amounts." }, { "payer_name": "Aetna Ppo Hmo", "plan_name": "701720_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Ms State Emplo", "plan_name": "401457", "standard_charge_percentage": 0.80, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Ms State Emplo", "plan_name": "401457_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Basic Pl", "plan_name": "400100", "standard_charge_percentage": 0.85, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Basic Pl", "plan_name": "400100_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Federal", "plan_name": "400110", "standard_charge_percentage": 0.85, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Federal", "plan_name": "400110_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." } ] } ] }, { "description": "Telmisartan 40 mg tablet [24335]", "drug_information": { "unit": 1.00, "type": "EA" }, "code_information": [ { "code": "67877-483-30", "type": "NDC" } ], "standard_charges": [ { "gross_charge": 7.50, "minimum": 6.00, "maximum": 6.38, "setting": "both", "payers_information": [ { "payer_name": "Aetna", "plan_name": "700700", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna", "plan_name": "700700_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Miscellaneous", "plan_name": "700720", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Miscellaneous", "plan_name": "700720_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Ppo Hmo", "plan_name": "701720", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Ppo Hmo", "plan_name": "701720_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Ms State Emplo", "plan_name": "401457", "standard_charge_percentage": 0.80, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Ms State Emplo", "plan_name": "401457_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Basic Pl", "plan_name": "400100", "standard_charge_percentage": 0.85, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Basic Pl", "plan_name": "400100_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Federal", "plan_name": "400110", "standard_charge_percentage": 0.85, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Federal", "plan_name": "400110_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." } ] } ] }, { "description": "Warfarin 2.5 mg tablet [8750]", "drug_information": { "unit": 1.00, "type": "EA" }, "code_information": [ { "code": "68084-027-01", "type": "NDC" } ], "standard_charges": [ { "gross_charge": 7.50, "minimum": 6.00, "maximum": 6.38, "setting": "both", "payers_information": [ { "payer_name": "Aetna", "plan_name": "700700", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna", "plan_name": "700700_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Miscellaneous", "plan_name": "700720", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Miscellaneous", "plan_name": "700720_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Ppo Hmo", "plan_name": "701720", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Ppo Hmo", "plan_name": "701720_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Ms State Emplo", "plan_name": "401457", "standard_charge_percentage": 0.80, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Ms State Emplo", "plan_name": "401457_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Basic Pl", "plan_name": "400100", "standard_charge_percentage": 0.85, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Basic Pl", "plan_name": "400100_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Federal", "plan_name": "400110", "standard_charge_percentage": 0.85, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Federal", "plan_name": "400110_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." } ] } ] }, { "description": "Warfarin 2.5 mg tablet [8750]", "drug_information": { "unit": 1.00, "type": "EA" }, "code_information": [ { "code": "68084-027-11", "type": "NDC" } ], "standard_charges": [ { "gross_charge": 7.50, "minimum": 6.00, "maximum": 6.38, "setting": "both", "payers_information": [ { "payer_name": "Aetna", "plan_name": "700700", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna", "plan_name": "700700_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Miscellaneous", "plan_name": "700720", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Miscellaneous", "plan_name": "700720_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Ppo Hmo", "plan_name": "701720", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Ppo Hmo", "plan_name": "701720_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Ms State Emplo", "plan_name": "401457", "standard_charge_percentage": 0.80, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Ms State Emplo", "plan_name": "401457_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Basic Pl", "plan_name": "400100", "standard_charge_percentage": 0.85, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Basic Pl", "plan_name": "400100_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Federal", "plan_name": "400110", "standard_charge_percentage": 0.85, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Federal", "plan_name": "400110_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." } ] } ] }, { "description": "Misoprostol 100 mcg tablet [10628]", "drug_information": { "unit": 1.00, "type": "EA" }, "code_information": [ { "code": "68084-040-11", "type": "NDC" } ], "standard_charges": [ { "gross_charge": 9.81, "minimum": 7.85, "maximum": 8.34, "setting": "both", "payers_information": [ { "payer_name": "Aetna", "plan_name": "700700", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna", "plan_name": "700700_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Miscellaneous", "plan_name": "700720", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Miscellaneous", "plan_name": "700720_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Ppo Hmo", "plan_name": "701720", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Ppo Hmo", "plan_name": "701720_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Ms State Emplo", "plan_name": "401457", "standard_charge_percentage": 0.80, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Ms State Emplo", "plan_name": "401457_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Basic Pl", "plan_name": "400100", "standard_charge_percentage": 0.85, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Basic Pl", "plan_name": "400100_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Federal", "plan_name": "400110", "standard_charge_percentage": 0.85, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Federal", "plan_name": "400110_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." } ] } ] }, { "description": "Misoprostol 200 mcg tablet [10629]", "drug_information": { "unit": 1.00, "type": "EA" }, "code_information": [ { "code": "68084-041-01", "type": "NDC" } ], "standard_charges": [ { "gross_charge": 10.79, "minimum": 8.63, "maximum": 9.17, "setting": "both", "payers_information": [ { "payer_name": "Aetna", "plan_name": "700700", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna", "plan_name": "700700_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Miscellaneous", "plan_name": "700720", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Miscellaneous", "plan_name": "700720_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Ppo Hmo", "plan_name": "701720", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Ppo Hmo", "plan_name": "701720_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Ms State Emplo", "plan_name": "401457", "standard_charge_percentage": 0.80, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Ms State Emplo", "plan_name": "401457_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Basic Pl", "plan_name": "400100", "standard_charge_percentage": 0.85, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Basic Pl", "plan_name": "400100_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Federal", "plan_name": "400110", "standard_charge_percentage": 0.85, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Federal", "plan_name": "400110_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." } ] } ] }, { "description": "Misoprostol 200 mcg tablet [10629]", "drug_information": { "unit": 1.00, "type": "EA" }, "code_information": [ { "code": "68084-041-11", "type": "NDC" } ], "standard_charges": [ { "gross_charge": 10.79, "minimum": 8.63, "maximum": 9.17, "setting": "both", "payers_information": [ { "payer_name": "Aetna", "plan_name": "700700", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna", "plan_name": "700700_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Miscellaneous", "plan_name": "700720", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Miscellaneous", "plan_name": "700720_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Ppo Hmo", "plan_name": "701720", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Ppo Hmo", "plan_name": "701720_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Ms State Emplo", "plan_name": "401457", "standard_charge_percentage": 0.80, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Ms State Emplo", "plan_name": "401457_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Basic Pl", "plan_name": "400100", "standard_charge_percentage": 0.85, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Basic Pl", "plan_name": "400100_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Federal", "plan_name": "400110", "standard_charge_percentage": 0.85, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Federal", "plan_name": "400110_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." } ] } ] }, { "description": "Paroxetine 20 mg tablet [10855]", "drug_information": { "unit": 1.00, "type": "EA" }, "code_information": [ { "code": "68084-045-11", "type": "NDC" } ], "standard_charges": [ { "gross_charge": 7.50, "minimum": 6.00, "maximum": 6.38, "setting": "both", "payers_information": [ { "payer_name": "Aetna", "plan_name": "700700", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna", "plan_name": "700700_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of 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charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Ms State Emplo", "plan_name": "401457", "standard_charge_percentage": 0.80, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Ms State Emplo", "plan_name": "401457_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Basic Pl", "plan_name": "400100", "standard_charge_percentage": 0.85, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Basic Pl", "plan_name": "400100_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Federal", "plan_name": "400110", "standard_charge_percentage": 0.85, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Federal", "plan_name": "400110_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." } ] } ] }, { "description": "Ciprofloxacin 500 mg tablet [25119]", "drug_information": { "unit": 1.00, "type": "EA" }, "code_information": [ { "code": "68084-070-01", "type": "NDC" } ], "standard_charges": [ { "gross_charge": 7.50, "minimum": 6.00, "maximum": 6.38, "setting": "both", "payers_information": [ { "payer_name": "Aetna", "plan_name": "700700", "standard_charge_percentage": 80.0, "count": "0", 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billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Basic Pl", "plan_name": "400100_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Federal", "plan_name": "400110", "standard_charge_percentage": 0.85, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Federal", "plan_name": "400110_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." } ] } ] }, { "description": "Ciprofloxacin 500 mg tablet [25119]", "drug_information": { "unit": 1.00, "type": "EA" }, "code_information": [ { "code": "68084-070-11", "type": "NDC" } ], "standard_charges": [ { "gross_charge": 7.50, "minimum": 6.00, "maximum": 6.38, "setting": "both", "payers_information": [ { "payer_name": "Aetna", "plan_name": "700700", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna", "plan_name": "700700_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Miscellaneous", "plan_name": "700720", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Miscellaneous", "plan_name": "700720_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Ppo Hmo", "plan_name": "701720", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Ppo Hmo", "plan_name": "701720_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Ms State Emplo", "plan_name": "401457", "standard_charge_percentage": 0.80, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Ms State Emplo", "plan_name": "401457_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Basic Pl", "plan_name": "400100", "standard_charge_percentage": 0.85, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Basic Pl", "plan_name": "400100_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Federal", "plan_name": "400110", "standard_charge_percentage": 0.85, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Federal", "plan_name": "400110_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." } ] } ] }, { "description": "Isosorbide dinitrate 20 mg tablet [4065]", "drug_information": { "unit": 1.00, "type": "EA" }, "code_information": [ { "code": "68084-083-11", "type": "NDC" } ], "standard_charges": [ { "gross_charge": 7.50, "minimum": 6.00, "maximum": 6.38, "setting": "both", "payers_information": [ { "payer_name": "Aetna", "plan_name": "700700", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna", "plan_name": "700700_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Miscellaneous", "plan_name": "700720", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Miscellaneous", "plan_name": "700720_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Ppo Hmo", "plan_name": "701720", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Ppo Hmo", "plan_name": "701720_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Ms State Emplo", "plan_name": "401457", "standard_charge_percentage": 0.80, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Ms State Emplo", "plan_name": "401457_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Basic Pl", "plan_name": "400100", "standard_charge_percentage": 0.85, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Basic Pl", "plan_name": "400100_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Federal", "plan_name": "400110", "standard_charge_percentage": 0.85, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Federal", "plan_name": "400110_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." } ] } ] }, { "description": "Carbidopa 25 mg-levodopa 100 mg tablet [9407]", "drug_information": { "unit": 1.00, "type": "EA" }, "code_information": [ { "code": "68084-093-11", "type": "NDC" } ], "standard_charges": [ { "gross_charge": 7.50, "minimum": 6.00, "maximum": 6.38, "setting": "both", "payers_information": [ { "payer_name": "Aetna", "plan_name": "700700", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna", "plan_name": "700700_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Miscellaneous", "plan_name": "700720", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Miscellaneous", "plan_name": "700720_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Ppo Hmo", "plan_name": "701720", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Ppo Hmo", "plan_name": "701720_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Ms State Emplo", "plan_name": "401457", "standard_charge_percentage": 0.80, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Ms State Emplo", "plan_name": "401457_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Basic Pl", "plan_name": "400100", "standard_charge_percentage": 0.85, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Basic Pl", "plan_name": "400100_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Federal", "plan_name": "400110", "standard_charge_percentage": 0.85, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Federal", "plan_name": "400110_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." } ] } ] }, { "description": "Carbidopa 25 mg-levodopa 250 mg tablet [9408]", "drug_information": { "unit": 1.00, "type": "EA" }, "code_information": [ { "code": "68084-094-11", "type": "NDC" } ], "standard_charges": [ { "gross_charge": 7.50, "minimum": 6.00, "maximum": 6.38, "setting": "both", "payers_information": [ { "payer_name": "Aetna", "plan_name": "700700", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna", "plan_name": "700700_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Miscellaneous", "plan_name": "700720", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Miscellaneous", "plan_name": "700720_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Ppo Hmo", "plan_name": "701720", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Ppo Hmo", "plan_name": "701720_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Ms State Emplo", "plan_name": "401457", "standard_charge_percentage": 0.80, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Ms State Emplo", "plan_name": "401457_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Basic Pl", "plan_name": "400100", "standard_charge_percentage": 0.85, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Basic Pl", "plan_name": "400100_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Federal", "plan_name": "400110", "standard_charge_percentage": 0.85, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Federal", "plan_name": "400110_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." } ] } ] }, { "description": "Atorvastatin 10 mg tablet [19176]", "drug_information": { "unit": 1.00, "type": "EA" }, "code_information": [ { "code": "68084-097-11", "type": "NDC" } ], "standard_charges": [ { "gross_charge": 7.50, "minimum": 6.00, "maximum": 6.38, "setting": "both", "payers_information": [ { "payer_name": "Aetna", "plan_name": "700700", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna", "plan_name": "700700_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Miscellaneous", "plan_name": "700720", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Miscellaneous", "plan_name": "700720_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Ppo Hmo", "plan_name": "701720", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Ppo Hmo", "plan_name": "701720_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Ms State Emplo", "plan_name": "401457", "standard_charge_percentage": 0.80, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Ms State Emplo", "plan_name": "401457_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Basic Pl", "plan_name": "400100", "standard_charge_percentage": 0.85, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Basic Pl", "plan_name": "400100_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Federal", "plan_name": "400110", "standard_charge_percentage": 0.85, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Federal", "plan_name": "400110_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." } ] } ] }, { "description": "Atorvastatin 20 mg tablet [19178]", "drug_information": { "unit": 1.00, "type": "EA" }, "code_information": [ { "code": "68084-098-01", "type": "NDC" } ], "standard_charges": [ { "gross_charge": 7.50, "minimum": 6.00, "maximum": 6.38, "setting": "both", "payers_information": [ { "payer_name": "Aetna", "plan_name": "700700", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna", "plan_name": "700700_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Miscellaneous", "plan_name": "700720", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Miscellaneous", "plan_name": "700720_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Ppo Hmo", "plan_name": "701720", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Ppo Hmo", "plan_name": "701720_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Ms State Emplo", "plan_name": "401457", "standard_charge_percentage": 0.80, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Ms State Emplo", "plan_name": "401457_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Basic Pl", "plan_name": "400100", "standard_charge_percentage": 0.85, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Basic Pl", "plan_name": "400100_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Federal", "plan_name": "400110", "standard_charge_percentage": 0.85, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Federal", "plan_name": "400110_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." } ] } ] }, { "description": "Atorvastatin 20 mg tablet [19178]", "drug_information": { "unit": 1.00, "type": "EA" }, "code_information": [ { "code": "68084-098-11", "type": "NDC" } ], "standard_charges": [ { "gross_charge": 7.50, "minimum": 6.00, "maximum": 6.38, "setting": "both", "payers_information": [ { "payer_name": "Aetna", "plan_name": "700700", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna", "plan_name": "700700_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Miscellaneous", "plan_name": "700720", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Miscellaneous", "plan_name": "700720_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Ppo Hmo", "plan_name": "701720", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Ppo Hmo", "plan_name": "701720_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Ms State Emplo", "plan_name": "401457", "standard_charge_percentage": 0.80, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Ms State Emplo", "plan_name": "401457_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Basic Pl", "plan_name": "400100", "standard_charge_percentage": 0.85, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Basic Pl", "plan_name": "400100_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Federal", "plan_name": "400110", "standard_charge_percentage": 0.85, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Federal", "plan_name": "400110_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." } ] } ] }, { "description": "Ziprasidone 40 mg capsule [29779]", "drug_information": { "unit": 1.00, "type": "EA" }, "code_information": [ { "code": "68084-104-11", "type": "NDC" } ], "standard_charges": [ { "gross_charge": 25.95, "minimum": 20.76, "maximum": 22.06, "setting": "both", "payers_information": [ { "payer_name": "Aetna", "plan_name": "700700", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna", "plan_name": "700700_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Miscellaneous", "plan_name": "700720", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Miscellaneous", "plan_name": "700720_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Ppo Hmo", "plan_name": "701720", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Ppo Hmo", "plan_name": "701720_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Ms State Emplo", "plan_name": "401457", "standard_charge_percentage": 0.80, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Ms State Emplo", "plan_name": "401457_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Basic Pl", "plan_name": "400100", "standard_charge_percentage": 0.85, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Basic Pl", "plan_name": "400100_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Federal", "plan_name": "400110", "standard_charge_percentage": 0.85, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Federal", "plan_name": "400110_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." } ] } ] }, { "description": "Acyclovir 800 mg tablet [8972]", "drug_information": { "unit": 1.00, "type": "EA" }, "code_information": [ { "code": "68084-109-11", "type": "NDC" } ], "standard_charges": [ { "gross_charge": 7.50, "minimum": 6.00, "maximum": 6.38, "setting": "both", "payers_information": [ { "payer_name": "Aetna", "plan_name": "700700", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna", "plan_name": "700700_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Miscellaneous", "plan_name": "700720", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Miscellaneous", "plan_name": "700720_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Ppo Hmo", "plan_name": "701720", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Ppo Hmo", "plan_name": "701720_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Ms State Emplo", "plan_name": "401457", "standard_charge_percentage": 0.80, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Ms State Emplo", "plan_name": "401457_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Basic Pl", "plan_name": "400100", "standard_charge_percentage": 0.85, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Basic Pl", "plan_name": "400100_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Federal", "plan_name": "400110", "standard_charge_percentage": 0.85, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Federal", "plan_name": "400110_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." } ] } ] }, { "description": "Mirtazapine 15 mg tablet [17466]", "drug_information": { "unit": 1.00, "type": "EA" }, "code_information": [ { "code": "68084-119-11", "type": "NDC" } ], "standard_charges": [ { "gross_charge": 7.50, "minimum": 6.00, "maximum": 6.38, "setting": "both", "payers_information": [ { "payer_name": "Aetna", "plan_name": "700700", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna", "plan_name": "700700_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Miscellaneous", "plan_name": "700720", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Miscellaneous", "plan_name": "700720_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Ppo Hmo", "plan_name": "701720", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Ppo Hmo", "plan_name": "701720_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Ms State Emplo", "plan_name": "401457", "standard_charge_percentage": 0.80, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Ms State Emplo", "plan_name": "401457_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Basic Pl", "plan_name": "400100", "standard_charge_percentage": 0.85, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Basic Pl", "plan_name": "400100_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Federal", "plan_name": "400110", "standard_charge_percentage": 0.85, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Federal", "plan_name": "400110_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." } ] } ] }, { "description": "Mirtazapine 30 mg tablet [17465]", "drug_information": { "unit": 1.00, "type": "EA" }, "code_information": [ { "code": "68084-120-11", "type": "NDC" } ], "standard_charges": [ { "gross_charge": 7.50, "minimum": 6.00, "maximum": 6.38, "setting": "both", "payers_information": [ { "payer_name": "Aetna", "plan_name": "700700", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna", "plan_name": "700700_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Miscellaneous", "plan_name": "700720", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Miscellaneous", "plan_name": "700720_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Ppo Hmo", "plan_name": "701720", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Ppo Hmo", "plan_name": "701720_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Ms State Emplo", "plan_name": "401457", "standard_charge_percentage": 0.80, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Ms State Emplo", "plan_name": "401457_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Basic Pl", "plan_name": "400100", "standard_charge_percentage": 0.85, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Basic Pl", "plan_name": "400100_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Federal", "plan_name": "400110", "standard_charge_percentage": 0.85, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Federal", "plan_name": "400110_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." } ] } ] }, { "description": "Omeprazole 20 mg capsuledelayed release [27694]", "drug_information": { "unit": 1.00, "type": "EA" }, "code_information": [ { "code": "68084-128-11", "type": "NDC" } ], "standard_charges": [ { "gross_charge": 1.57, "minimum": 1.26, "maximum": 1.33, "setting": "both", "payers_information": [ { "payer_name": "Aetna", "plan_name": "700700", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna", "plan_name": "700700_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Miscellaneous", "plan_name": "700720", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Miscellaneous", "plan_name": "700720_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Ppo Hmo", "plan_name": "701720", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Ppo Hmo", "plan_name": "701720_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Ms State Emplo", "plan_name": "401457", "standard_charge_percentage": 0.80, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Ms State Emplo", "plan_name": "401457_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Basic Pl", "plan_name": "400100", "standard_charge_percentage": 0.85, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Basic Pl", "plan_name": "400100_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Federal", "plan_name": "400110", "standard_charge_percentage": 0.85, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Federal", "plan_name": "400110_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." } ] } ] }, { "description": "Cephalexin 250 mg/5 ml oral suspension [9502]", "drug_information": { "unit": 200.00, "type": "ML" }, "code_information": [ { "code": "67877-545-68", "type": "NDC" } ], "standard_charges": [ { "gross_charge": 220.40, "minimum": 176.32, "maximum": 187.34, "setting": "both", "payers_information": [ { "payer_name": "Aetna", "plan_name": "700700", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna", "plan_name": "700700_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Miscellaneous", "plan_name": "700720", "standard_charge_percentage": 80.0, "count": "0", 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"additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Ms State Emplo", "plan_name": "401457_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Basic Pl", "plan_name": "400100", "standard_charge_percentage": 0.85, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Basic Pl", "plan_name": "400100_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Federal", "plan_name": "400110", "standard_charge_percentage": 0.85, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Federal", "plan_name": "400110_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." } ] } ] }, { "description": "Zolpidem 5 mg tablet [11701]", "drug_information": { "unit": 1.00, "type": "EA" }, "code_information": [ { "code": "68084-189-01", "type": "NDC" } ], "standard_charges": [ { "gross_charge": 7.50, "minimum": 6.00, "maximum": 6.38, "setting": "both", "payers_information": [ { "payer_name": "Aetna", "plan_name": "700700", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna", "plan_name": "700700_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total 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"additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Ms State Emplo", "plan_name": "401457", "standard_charge_percentage": 0.80, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Ms State Emplo", "plan_name": "401457_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Basic Pl", "plan_name": "400100", "standard_charge_percentage": 0.85, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Basic Pl", "plan_name": "400100_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Federal", "plan_name": "400110", "standard_charge_percentage": 0.85, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Federal", "plan_name": "400110_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." } ] } ] }, { "description": "Zolpidem 5 mg tablet [11701]", "drug_information": { "unit": 1.00, "type": "EA" }, "code_information": [ { "code": "68084-189-11", "type": "NDC" } ], "standard_charges": [ { "gross_charge": 7.50, "minimum": 6.00, "maximum": 6.38, "setting": "both", "payers_information": [ { "payer_name": "Aetna", "plan_name": "700700", "standard_charge_percentage": 80.0, "count": "0", "methodology": 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charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Ppo Hmo", "plan_name": "701720_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Ms State Emplo", "plan_name": "401457", "standard_charge_percentage": 0.80, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Ms State Emplo", "plan_name": "401457_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Basic Pl", "plan_name": "400100", "standard_charge_percentage": 0.85, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Basic Pl", "plan_name": "400100_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Federal", "plan_name": "400110", "standard_charge_percentage": 0.85, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Federal", "plan_name": "400110_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." } ] } ] }, { "description": "Lisinopril 5 mg tablet [10451]", "drug_information": { "unit": 1.00, "type": "EA" }, "code_information": [ { "code": "68084-196-11", "type": "NDC" } ], "standard_charges": [ { "gross_charge": 7.50, "minimum": 6.00, "maximum": 6.38, "setting": "both", "payers_information": [ { "payer_name": "Aetna", "plan_name": "700700", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna", "plan_name": "700700_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Miscellaneous", "plan_name": "700720", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Miscellaneous", "plan_name": "700720_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Ppo Hmo", "plan_name": "701720", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Ppo Hmo", "plan_name": "701720_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Ms State Emplo", "plan_name": "401457", "standard_charge_percentage": 0.80, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Ms State Emplo", "plan_name": "401457_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Basic Pl", "plan_name": "400100", "standard_charge_percentage": 0.85, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Basic Pl", "plan_name": "400100_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Federal", "plan_name": "400110", "standard_charge_percentage": 0.85, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Federal", "plan_name": "400110_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." } ] } ] }, { "description": "Lisinopril 40 mg tablet [10450]", "drug_information": { "unit": 1.00, "type": "EA" }, "code_information": [ { "code": "68084-199-11", "type": "NDC" } ], "standard_charges": [ { "gross_charge": 1.00, "minimum": 0.80, "maximum": 0.85, "setting": "both", "payers_information": [ { "payer_name": "Aetna", "plan_name": "700700", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna", "plan_name": "700700_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Miscellaneous", "plan_name": "700720", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total 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"additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Ms State Emplo", "plan_name": "401457_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Basic Pl", "plan_name": "400100", "standard_charge_percentage": 0.85, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Basic Pl", "plan_name": "400100_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Federal", "plan_name": "400110", "standard_charge_percentage": 0.85, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Federal", "plan_name": "400110_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." } ] } ] }, { "description": "Primidone 50 mg tablet [11129]", "drug_information": { "unit": 1.00, "type": "EA" }, "code_information": [ { "code": "68084-202-11", "type": "NDC" } ], "standard_charges": [ { "gross_charge": 7.50, "minimum": 6.00, "maximum": 6.38, "setting": "both", "payers_information": [ { "payer_name": "Aetna", "plan_name": "700700", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna", "plan_name": "700700_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Miscellaneous", "plan_name": "700720", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Miscellaneous", "plan_name": "700720_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Ppo Hmo", "plan_name": "701720", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Ppo Hmo", "plan_name": "701720_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Ms State Emplo", "plan_name": "401457", "standard_charge_percentage": 0.80, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Ms State Emplo", "plan_name": "401457_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Basic Pl", "plan_name": "400100", "standard_charge_percentage": 0.85, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Basic Pl", "plan_name": "400100_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Federal", "plan_name": "400110", "standard_charge_percentage": 0.85, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Federal", "plan_name": "400110_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." } ] } ] }, { "description": "Minoxidil 2.5 mg tablet [5115]", "drug_information": { "unit": 1.00, "type": "EA" }, "code_information": [ { "code": "68084-204-11", "type": "NDC" } ], "standard_charges": [ { "gross_charge": 7.50, "minimum": 6.00, "maximum": 6.38, "setting": "both", "payers_information": [ { "payer_name": "Aetna", "plan_name": "700700", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna", "plan_name": "700700_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Miscellaneous", "plan_name": "700720", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Miscellaneous", "plan_name": "700720_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Ppo Hmo", "plan_name": "701720", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Ppo Hmo", "plan_name": "701720_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Ms State Emplo", "plan_name": "401457", "standard_charge_percentage": 0.80, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Ms State Emplo", "plan_name": "401457_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Basic Pl", "plan_name": "400100", "standard_charge_percentage": 0.85, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Basic Pl", "plan_name": "400100_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Federal", "plan_name": "400110", "standard_charge_percentage": 0.85, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Federal", "plan_name": "400110_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." } ] } ] }, { "description": "Minoxidil 10 mg tablet [5114]", "drug_information": { "unit": 1.00, "type": "EA" }, "code_information": [ { "code": "68084-205-11", "type": "NDC" } ], "standard_charges": [ { "gross_charge": 7.50, "minimum": 6.00, "maximum": 6.38, "setting": "both", "payers_information": [ { "payer_name": "Aetna", "plan_name": "700700", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna", "plan_name": "700700_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Miscellaneous", "plan_name": "700720", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Miscellaneous", "plan_name": "700720_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Ppo Hmo", "plan_name": "701720", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Ppo Hmo", "plan_name": "701720_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Ms State Emplo", "plan_name": "401457", "standard_charge_percentage": 0.80, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Ms State Emplo", "plan_name": "401457_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Basic Pl", "plan_name": "400100", "standard_charge_percentage": 0.85, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Basic Pl", "plan_name": "400100_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Federal", "plan_name": "400110", "standard_charge_percentage": 0.85, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Federal", "plan_name": "400110_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." } ] } ] }, { "description": "Benzonatate 100 mg capsule [988]", "drug_information": { "unit": 1.00, "type": "EA" }, "code_information": [ { "code": "68084-214-01", "type": "NDC" } ], "standard_charges": [ { "gross_charge": 7.50, "minimum": 6.00, "maximum": 6.38, "setting": "both", "payers_information": [ { "payer_name": "Aetna", "plan_name": "700700", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna", "plan_name": "700700_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Miscellaneous", "plan_name": "700720", "standard_charge_percentage": 80.0, "count": 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"payer_name": "Aetna Ppo Hmo", "plan_name": "701720_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Ms State Emplo", "plan_name": "401457", "standard_charge_percentage": 0.80, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Ms State Emplo", "plan_name": "401457_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Basic Pl", "plan_name": "400100", "standard_charge_percentage": 0.85, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Basic Pl", "plan_name": "400100_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Federal", "plan_name": "400110", "standard_charge_percentage": 0.85, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Federal", "plan_name": "400110_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." } ] } ] }, { "description": "Risperidone 0.25 mg tablet [25519]", "drug_information": { "unit": 1.00, "type": "EA" }, "code_information": [ { "code": "68084-270-01", "type": "NDC" } ], "standard_charges": [ { "gross_charge": 7.50, "minimum": 6.00, 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allowed amounts." } ] } ] }, { "description": "Risperidone 0.25 mg tablet [25519]", "drug_information": { "unit": 1.00, "type": "EA" }, "code_information": [ { "code": "68084-270-11", "type": "NDC" } ], "standard_charges": [ { "gross_charge": 7.50, "minimum": 6.00, "maximum": 6.38, "setting": "both", "payers_information": [ { "payer_name": "Aetna", "plan_name": "700700", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna", "plan_name": "700700_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Miscellaneous", "plan_name": "700720", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient 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"standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Federal", "plan_name": "400110", "standard_charge_percentage": 0.85, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Federal", "plan_name": "400110_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." } ] } ] }, { "description": "Tamsulosin 0.4 mg capsule [103890]", "drug_information": { "unit": 1.00, "type": "EA" }, "code_information": [ { "code": "68084-299-11", "type": "NDC" } ], "standard_charges": [ { "gross_charge": 7.50, "minimum": 6.00, "maximum": 6.38, "setting": "both", "payers_information": [ { 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"plan_name": "400100", "standard_charge_percentage": 0.85, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Basic Pl", "plan_name": "400100_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Federal", "plan_name": "400110", "standard_charge_percentage": 0.85, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Federal", "plan_name": "400110_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." } ] } ] }, { "description": "Divalproex er 250 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{ "payer_name": "Aetna Miscellaneous", "plan_name": "700720_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Ppo Hmo", "plan_name": "701720", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Ppo Hmo", "plan_name": "701720_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Ms State Emplo", "plan_name": "401457", "standard_charge_percentage": 0.80, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Ms State Emplo", "plan_name": "401457_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Basic Pl", "plan_name": "400100", "standard_charge_percentage": 0.85, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Basic Pl", "plan_name": "400100_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Federal", "plan_name": "400110", "standard_charge_percentage": 0.85, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Federal", "plan_name": "400110_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." } ] } ] }, { "description": "Divalproex 125 mg capsuledelayed release sprinkle [27631]", "drug_information": { "unit": 1.00, "type": "EA" }, "code_information": [ { "code": "68084-313-11", "type": "NDC" } ], "standard_charges": [ { "gross_charge": 7.50, "minimum": 6.00, "maximum": 6.38, "setting": "both", "payers_information": [ { "payer_name": "Aetna", "plan_name": "700700", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna", "plan_name": "700700_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Miscellaneous", "plan_name": "700720", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Miscellaneous", "plan_name": "700720_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Ppo Hmo", "plan_name": "701720", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Ppo Hmo", "plan_name": "701720_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Ms State Emplo", "plan_name": "401457", "standard_charge_percentage": 0.80, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Ms State Emplo", "plan_name": "401457_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Basic Pl", "plan_name": "400100", "standard_charge_percentage": 0.85, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Basic Pl", "plan_name": "400100_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Federal", "plan_name": "400110", "standard_charge_percentage": 0.85, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Federal", "plan_name": "400110_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." } ] } ] }, { "description": "Lamotrigine 25 mg tablet [13981]", "drug_information": { "unit": 1.00, "type": "EA" }, "code_information": [ { "code": "68084-318-01", "type": "NDC" } ], "standard_charges": [ { "gross_charge": 7.50, "minimum": 6.00, "maximum": 6.38, "setting": "both", "payers_information": [ { "payer_name": "Aetna", "plan_name": "700700", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient 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allowed amounts." }, { "payer_name": "Aetna Ppo Hmo", "plan_name": "701720_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Ms State Emplo", "plan_name": "401457", "standard_charge_percentage": 0.80, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Ms State Emplo", "plan_name": "401457_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Basic Pl", "plan_name": "400100", "standard_charge_percentage": 0.85, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Basic Pl", "plan_name": "400100_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Federal", "plan_name": "400110", "standard_charge_percentage": 0.85, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Federal", "plan_name": "400110_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." } ] } ] }, { "description": "Lamotrigine 100 mg tablet [13982]", "drug_information": { "unit": 1.00, "type": "EA" }, "code_information": [ { "code": "68084-319-11", "type": "NDC" } ], "standard_charges": [ { "gross_charge": 7.50, "minimum": 6.00, "maximum": 6.38, "setting": "both", "payers_information": [ { "payer_name": "Aetna", "plan_name": "700700", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna", "plan_name": "700700_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Miscellaneous", "plan_name": "700720", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Miscellaneous", "plan_name": "700720_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Ppo Hmo", "plan_name": "701720", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Ppo Hmo", "plan_name": "701720_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Ms State Emplo", "plan_name": "401457", "standard_charge_percentage": 0.80, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Ms State Emplo", "plan_name": "401457_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Basic Pl", "plan_name": "400100", "standard_charge_percentage": 0.85, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Basic Pl", "plan_name": "400100_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Federal", "plan_name": "400110", "standard_charge_percentage": 0.85, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Federal", "plan_name": "400110_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." } ] } ] }, { "description": "Glimepiride 4 mg tablet [16357]", "drug_information": { "unit": 1.00, "type": "EA" }, "code_information": [ { "code": "68084-327-11", "type": "NDC" } ], "standard_charges": [ { "gross_charge": 7.50, "minimum": 6.00, "maximum": 6.38, "setting": "both", "payers_information": [ { "payer_name": "Aetna", "plan_name": "700700", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna", "plan_name": "700700_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Miscellaneous", "plan_name": "700720", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit 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allowed amounts." }, { "payer_name": "Bc/Bs Ms State Emplo", "plan_name": "401457_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Basic Pl", "plan_name": "400100", "standard_charge_percentage": 0.85, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Basic Pl", "plan_name": "400100_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Federal", "plan_name": "400110", "standard_charge_percentage": 0.85, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Federal", "plan_name": "400110_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." } ] } ] }, { "description": "Fenofibrate 160 mg tablet [28252]", "drug_information": { "unit": 1.00, "type": "EA" }, "code_information": [ { "code": "68084-328-11", "type": "NDC" } ], "standard_charges": [ { "gross_charge": 13.89, "minimum": 11.11, "maximum": 11.81, "setting": "both", "payers_information": [ { "payer_name": "Aetna", "plan_name": "700700", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna", "plan_name": "700700_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Miscellaneous", "plan_name": "700720", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Miscellaneous", "plan_name": "700720_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Ppo Hmo", "plan_name": "701720", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Ppo Hmo", "plan_name": "701720_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Ms State Emplo", "plan_name": "401457", "standard_charge_percentage": 0.80, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Ms State Emplo", "plan_name": "401457_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Basic Pl", "plan_name": "400100", "standard_charge_percentage": 0.85, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Basic Pl", "plan_name": "400100_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Federal", "plan_name": "400110", "standard_charge_percentage": 0.85, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Federal", "plan_name": "400110_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." } ] } ] }, { "description": "Fenofibrate 160 mg tablet [28252]", "drug_information": { "unit": 1.00, "type": "EA" }, "code_information": [ { "code": "68084-328-21", "type": "NDC" } ], "standard_charges": [ { "gross_charge": 13.89, "minimum": 11.11, "maximum": 11.81, "setting": "both", "payers_information": [ { "payer_name": "Aetna", "plan_name": "700700", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna", "plan_name": "700700_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Miscellaneous", "plan_name": "700720", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Miscellaneous", "plan_name": "700720_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Ppo Hmo", "plan_name": "701720", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Ppo Hmo", "plan_name": "701720_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Ms State Emplo", "plan_name": "401457", "standard_charge_percentage": 0.80, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Ms State Emplo", "plan_name": "401457_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Basic Pl", "plan_name": "400100", "standard_charge_percentage": 0.85, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Basic Pl", "plan_name": "400100_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Federal", "plan_name": "400110", "standard_charge_percentage": 0.85, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Federal", "plan_name": "400110_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." } ] } ] }, { "description": "Diclofenac sodium 75 mg tabletdelayed release [15341]", "drug_information": { "unit": 1.00, "type": "EA" }, "code_information": [ { "code": "68084-333-01", "type": "NDC" } ], "standard_charges": [ { "gross_charge": 7.50, "minimum": 6.00, "maximum": 6.38, "setting": "both", "payers_information": [ { "payer_name": "Aetna", "plan_name": "700700", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna", "plan_name": "700700_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Miscellaneous", "plan_name": "700720", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Miscellaneous", "plan_name": "700720_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Ppo Hmo", "plan_name": "701720", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Ppo Hmo", "plan_name": "701720_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Ms State Emplo", "plan_name": "401457", "standard_charge_percentage": 0.80, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Ms State Emplo", "plan_name": "401457_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Basic Pl", "plan_name": "400100", "standard_charge_percentage": 0.85, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Basic Pl", "plan_name": "400100_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Federal", "plan_name": "400110", "standard_charge_percentage": 0.85, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Federal", "plan_name": "400110_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." } ] } ] }, { "description": "Diclofenac sodium 75 mg tabletdelayed release [15341]", "drug_information": { "unit": 1.00, "type": "EA" }, "code_information": [ { "code": "68084-333-11", "type": "NDC" } ], "standard_charges": [ { "gross_charge": 7.50, "minimum": 6.00, "maximum": 6.38, "setting": "both", "payers_information": [ { "payer_name": "Aetna", "plan_name": "700700", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna", "plan_name": "700700_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Miscellaneous", "plan_name": "700720", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Miscellaneous", "plan_name": "700720_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Ppo Hmo", "plan_name": "701720", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Ppo Hmo", "plan_name": "701720_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Ms State Emplo", "plan_name": "401457", "standard_charge_percentage": 0.80, "count": "0", "methodology": 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"methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Federal", "plan_name": "400110", "standard_charge_percentage": 0.85, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Federal", "plan_name": "400110_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." } ] } ] }, { "description": "Topiramate 50 mg tablet [37616]", "drug_information": { "unit": 1.00, "type": "EA" }, "code_information": [ { "code": "68084-343-11", "type": "NDC" } ], "standard_charges": [ { "gross_charge": 7.50, "minimum": 6.00, "maximum": 6.38, "setting": "both", "payers_information": [ { "payer_name": "Aetna", "plan_name": "700700", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna", "plan_name": "700700_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Miscellaneous", "plan_name": "700720", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Miscellaneous", "plan_name": "700720_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Ppo Hmo", "plan_name": "701720", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Ppo Hmo", "plan_name": "701720_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Ms State Emplo", "plan_name": "401457", "standard_charge_percentage": 0.80, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Ms State Emplo", "plan_name": "401457_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Basic Pl", "plan_name": "400100", "standard_charge_percentage": 0.85, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Basic Pl", "plan_name": "400100_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Federal", "plan_name": "400110", "standard_charge_percentage": 0.85, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Federal", "plan_name": "400110_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." } ] } ] }, { "description": "Topiramate 100 mg tablet [18922]", "drug_information": { "unit": 1.00, "type": "EA" }, "code_information": [ { "code": "68084-344-11", "type": "NDC" } ], "standard_charges": [ { "gross_charge": 7.50, "minimum": 6.00, "maximum": 6.38, "setting": "both", "payers_information": [ { "payer_name": "Aetna", "plan_name": "700700", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna", "plan_name": "700700_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Miscellaneous", "plan_name": "700720", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Miscellaneous", "plan_name": "700720_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Ppo Hmo", "plan_name": "701720", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Ppo Hmo", "plan_name": "701720_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Ms State Emplo", "plan_name": "401457", "standard_charge_percentage": 0.80, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Ms State Emplo", "plan_name": "401457_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Basic Pl", "plan_name": "400100", "standard_charge_percentage": 0.85, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Basic Pl", "plan_name": "400100_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Federal", "plan_name": "400110", "standard_charge_percentage": 0.85, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Federal", "plan_name": "400110_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." } ] } ] }, { "description": "Losartan 25 mg tablet [14823]", "drug_information": { "unit": 1.00, "type": "EA" }, "code_information": [ { "code": "68084-346-11", "type": "NDC" } ], "standard_charges": [ { "gross_charge": 7.50, "minimum": 6.00, "maximum": 6.38, "setting": "both", "payers_information": [ { "payer_name": "Aetna", "plan_name": "700700", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna", "plan_name": "700700_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna 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"plan_name": "401457", "standard_charge_percentage": 0.80, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Ms State Emplo", "plan_name": "401457_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Basic Pl", "plan_name": "400100", "standard_charge_percentage": 0.85, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Basic Pl", "plan_name": "400100_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Federal", "plan_name": "400110", "standard_charge_percentage": 0.85, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Federal", "plan_name": "400110_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." } ] } ] }, { "description": "Losartan 50 mg tablet [14824]", "drug_information": { "unit": 1.00, "type": "EA" }, "code_information": [ { "code": "68084-347-01", "type": "NDC" } ], "standard_charges": [ { "gross_charge": 7.50, "minimum": 6.00, "maximum": 6.38, "setting": "both", "payers_information": [ { "payer_name": "Aetna", "plan_name": "700700", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna", "plan_name": "700700_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Miscellaneous", "plan_name": "700720", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Miscellaneous", "plan_name": "700720_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Ppo Hmo", "plan_name": "701720", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Ppo Hmo", "plan_name": "701720_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Ms State Emplo", "plan_name": "401457", "standard_charge_percentage": 0.80, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Ms State Emplo", "plan_name": "401457_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Basic Pl", "plan_name": "400100", "standard_charge_percentage": 0.85, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Basic Pl", "plan_name": "400100_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Federal", "plan_name": "400110", "standard_charge_percentage": 0.85, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Federal", "plan_name": "400110_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." } ] } ] }, { "description": "Losartan 50 mg tablet [14824]", "drug_information": { "unit": 1.00, "type": "EA" }, "code_information": [ { "code": "68084-347-11", "type": "NDC" } ], "standard_charges": [ { "gross_charge": 7.50, "minimum": 6.00, "maximum": 6.38, "setting": "both", 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"payer_name": "Aetna Ppo Hmo", "plan_name": "701720", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Ppo Hmo", "plan_name": "701720_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Ms State Emplo", "plan_name": "401457", "standard_charge_percentage": 0.80, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Ms State Emplo", "plan_name": "401457_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Basic Pl", "plan_name": "400100", "standard_charge_percentage": 0.85, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Basic Pl", "plan_name": "400100_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Federal", "plan_name": "400110", "standard_charge_percentage": 0.85, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Federal", "plan_name": "400110_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." } ] } ] }, { "description": "Losartan 100 mg tablet [22588]", "drug_information": { "unit": 1.00, "type": "EA" }, "code_information": [ { "code": "68084-348-01", "type": "NDC" } ], "standard_charges": [ { "gross_charge": 7.50, "minimum": 6.00, "maximum": 6.38, "setting": "both", "payers_information": [ { "payer_name": "Aetna", "plan_name": "700700", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna", "plan_name": "700700_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Miscellaneous", "plan_name": "700720", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed 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"payer_name": "Bc/Bs Ms State Emplo", "plan_name": "401457_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Basic Pl", "plan_name": "400100", "standard_charge_percentage": 0.85, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Basic Pl", "plan_name": "400100_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Federal", "plan_name": "400110", "standard_charge_percentage": 0.85, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { 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{ "payer_name": "Bc/Bs Of Ms Federal", "plan_name": "400110", "standard_charge_percentage": 0.85, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Federal", "plan_name": "400110_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." } ] } ] }, { "description": "Oxycodone 5 mg tablet [10814]", "drug_information": { "unit": 1.00, "type": "EA" }, "code_information": [ { "code": "68084-354-01", "type": "NDC" } ], "standard_charges": [ { "gross_charge": 7.50, "minimum": 6.00, "maximum": 6.38, "setting": "both", "payers_information": [ { "payer_name": "Aetna", "plan_name": "700700", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to 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"percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Federal", "plan_name": "400110", "standard_charge_percentage": 0.85, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Federal", "plan_name": "400110_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." } ] } ] }, { "description": "Benztropine 1 mg tablet [999]", "drug_information": { "unit": 1.00, "type": "EA" }, "code_information": [ { "code": "68084-388-01", "type": "NDC" } ], "standard_charges": [ { "gross_charge": 7.50, "minimum": 6.00, "maximum": 6.38, "setting": "both", "payers_information": [ { "payer_name": "Aetna", "plan_name": "700700", "standard_charge_percentage": 80.0, 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"methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Basic Pl", "plan_name": "400100_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Federal", "plan_name": "400110", "standard_charge_percentage": 0.85, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Federal", "plan_name": "400110_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." } ] } ] }, { "description": "Benztropine 1 mg tablet [999]", "drug_information": { "unit": 1.00, "type": "EA" }, 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100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Ppo Hmo", "plan_name": "701720", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Ppo Hmo", "plan_name": "701720_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Ms State Emplo", "plan_name": "401457", "standard_charge_percentage": 0.80, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Ms State Emplo", "plan_name": "401457_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Basic Pl", "plan_name": "400100", "standard_charge_percentage": 0.85, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Basic Pl", "plan_name": "400100_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Federal", "plan_name": "400110", "standard_charge_percentage": 0.85, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Federal", "plan_name": "400110_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." } ] } ] }, { "description": "Butalbital-acetaminophen-caffeine 50 mg-325 mg-40 mg tablet [8958]", "drug_information": { "unit": 1.00, "type": "EA" }, "code_information": [ { "code": "68084-396-11", "type": "NDC" } ], "standard_charges": [ { "gross_charge": 10.98, "minimum": 8.78, "maximum": 9.33, "setting": "both", "payers_information": [ { "payer_name": "Aetna", "plan_name": "700700", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna", "plan_name": "700700_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Miscellaneous", "plan_name": 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"payer_name": "Bc/Bs Of Ms Basic Pl", "plan_name": "400100_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Federal", "plan_name": "400110", "standard_charge_percentage": 0.85, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Federal", "plan_name": "400110_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." } ] } ] }, { "description": "Oxybutynin chloride 5 mg tablet [5938]", "drug_information": { "unit": 1.00, "type": "EA" }, "code_information": [ { "code": "68084-400-01", "type": "NDC" } ], "standard_charges": [ { "gross_charge": 7.50, "minimum": 6.00, 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"additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Ms State Emplo", "plan_name": "401457", "standard_charge_percentage": 0.80, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Ms State Emplo", "plan_name": "401457_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Basic Pl", "plan_name": "400100", "standard_charge_percentage": 0.85, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Basic Pl", "plan_name": "400100_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", 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"additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Basic Pl", "plan_name": "400100_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Federal", "plan_name": "400110", "standard_charge_percentage": 0.85, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Federal", "plan_name": "400110_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." } ] } ] }, { "description": "Nitrofurantoin monohydrate/macrocrystals 100 mg capsule [10724]", "drug_information": { "unit": 1.00, "type": "EA" }, "code_information": [ { 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"methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Ppo Hmo", "plan_name": "701720", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Ppo Hmo", "plan_name": "701720_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Ms State Emplo", "plan_name": "401457", "standard_charge_percentage": 0.80, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Ms State Emplo", "plan_name": "401457_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Basic Pl", "plan_name": "400100", "standard_charge_percentage": 0.85, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Basic Pl", "plan_name": "400100_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Federal", "plan_name": "400110", "standard_charge_percentage": 0.85, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Federal", "plan_name": "400110_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." } ] } ] }, { "description": "Nitrofurantoin monohydrate/macrocrystals 100 mg capsule [10724]", "drug_information": { "unit": 1.00, "type": "EA" }, "code_information": [ { "code": "68084-446-11", "type": "NDC" } ], "standard_charges": [ { "gross_charge": 13.97, "minimum": 11.18, "maximum": 11.87, "setting": "both", "payers_information": [ { "payer_name": "Aetna", "plan_name": "700700", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna", "plan_name": "700700_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Miscellaneous", "plan_name": "700720", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Miscellaneous", "plan_name": "700720_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Ppo Hmo", "plan_name": "701720", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Ppo Hmo", "plan_name": "701720_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Ms State Emplo", "plan_name": "401457", "standard_charge_percentage": 0.80, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Ms State Emplo", "plan_name": "401457_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Basic Pl", "plan_name": "400100", "standard_charge_percentage": 0.85, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Basic Pl", "plan_name": "400100_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Federal", "plan_name": "400110", "standard_charge_percentage": 0.85, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Federal", "plan_name": "400110_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." } ] } ] }, { "description": "Hydralazine 10 mg tablet [3698]", "drug_information": { "unit": 1.00, "type": "EA" }, "code_information": [ { "code": "68084-447-01", "type": "NDC" } ], "standard_charges": [ { "gross_charge": 7.50, "minimum": 6.00, "maximum": 6.38, "setting": "both", "payers_information": [ { "payer_name": "Aetna", "plan_name": "700700", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna", "plan_name": "700700_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Miscellaneous", "plan_name": "700720", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Miscellaneous", "plan_name": "700720_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Ppo Hmo", "plan_name": "701720", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Ppo Hmo", "plan_name": "701720_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Ms State Emplo", "plan_name": "401457", "standard_charge_percentage": 0.80, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Ms State Emplo", "plan_name": "401457_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Basic Pl", "plan_name": "400100", "standard_charge_percentage": 0.85, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Basic Pl", "plan_name": "400100_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Federal", "plan_name": "400110", "standard_charge_percentage": 0.85, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Federal", "plan_name": "400110_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." } ] } ] }, { "description": "Hydralazine 10 mg tablet [3698]", "drug_information": { "unit": 1.00, "type": "EA" }, "code_information": [ { "code": "68084-447-11", "type": "NDC" } ], "standard_charges": [ { "gross_charge": 7.50, "minimum": 6.00, "maximum": 6.38, "setting": "both", "payers_information": [ { "payer_name": "Aetna", "plan_name": "700700", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna", "plan_name": "700700_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Miscellaneous", "plan_name": "700720", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Miscellaneous", "plan_name": "700720_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Ppo Hmo", "plan_name": "701720", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Ppo Hmo", "plan_name": "701720_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Ms State Emplo", "plan_name": "401457", "standard_charge_percentage": 0.80, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Ms State Emplo", "plan_name": "401457_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Basic Pl", "plan_name": "400100", "standard_charge_percentage": 0.85, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Basic Pl", "plan_name": "400100_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Federal", "plan_name": "400110", "standard_charge_percentage": 0.85, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Federal", "plan_name": "400110_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." } ] } ] }, { "description": "Nateglinide 60 mg tablet [29437]", "drug_information": { "unit": 1.00, "type": "EA" }, "code_information": [ { "code": "68084-458-11", "type": "NDC" } ], "standard_charges": [ { "gross_charge": 8.98, "minimum": 7.18, "maximum": 7.63, "setting": "both", "payers_information": [ { "payer_name": "Aetna", "plan_name": "700700", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna", "plan_name": "700700_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Miscellaneous", "plan_name": "700720", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Miscellaneous", "plan_name": "700720_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Ppo Hmo", "plan_name": "701720", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Ppo Hmo", "plan_name": "701720_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Ms State Emplo", "plan_name": "401457", "standard_charge_percentage": 0.80, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Ms State Emplo", "plan_name": "401457_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Basic Pl", "plan_name": "400100", "standard_charge_percentage": 0.85, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Basic Pl", "plan_name": "400100_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Federal", "plan_name": "400110", "standard_charge_percentage": 0.85, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Federal", "plan_name": "400110_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." } ] } ] }, { "description": "Oxybutynin chloride er 5 mg tabletextended release 24 hr [24470]", "drug_information": { "unit": 1.00, "type": "EA" }, "code_information": [ { "code": "68084-480-11", "type": "NDC" } ], "standard_charges": [ { "gross_charge": 14.29, "minimum": 11.43, "maximum": 12.15, "setting": "both", "payers_information": [ { "payer_name": "Aetna", "plan_name": "700700", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna", "plan_name": "700700_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Miscellaneous", "plan_name": "700720", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Miscellaneous", "plan_name": "700720_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Ppo Hmo", "plan_name": "701720", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Ppo Hmo", "plan_name": "701720_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Ms State Emplo", "plan_name": "401457", "standard_charge_percentage": 0.80, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Ms State Emplo", "plan_name": "401457_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Basic Pl", "plan_name": "400100", "standard_charge_percentage": 0.85, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Basic Pl", "plan_name": "400100_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Federal", "plan_name": "400110", "standard_charge_percentage": 0.85, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Federal", "plan_name": "400110_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." } ] } ] }, { "description": "Meclizine 12.5 mg tablet [12024]", "drug_information": { "unit": 1.00, "type": "EA" }, "code_information": [ { "code": "68084-490-11", "type": "NDC" } ], "standard_charges": [ { "gross_charge": 1.29, "minimum": 1.03, "maximum": 1.10, "setting": "both", "payers_information": [ { "payer_name": "Aetna", "plan_name": "700700", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna", "plan_name": "700700_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Miscellaneous", "plan_name": "700720", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Miscellaneous", "plan_name": "700720_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Ppo Hmo", "plan_name": "701720", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Ppo Hmo", "plan_name": "701720_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Ms State Emplo", "plan_name": "401457", "standard_charge_percentage": 0.80, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Ms State Emplo", "plan_name": "401457_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Basic Pl", "plan_name": "400100", "standard_charge_percentage": 0.85, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Basic Pl", "plan_name": "400100_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Federal", "plan_name": "400110", "standard_charge_percentage": 0.85, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Federal", "plan_name": "400110_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." } ] } ] }, { "description": "Meclizine 25 mg tablet [12025]", "drug_information": { "unit": 1.00, "type": "EA" }, "code_information": [ { "code": "68084-491-11", "type": "NDC" } ], "standard_charges": [ { "gross_charge": 7.50, "minimum": 6.00, "maximum": 6.38, "setting": "both", "payers_information": [ { "payer_name": "Aetna", "plan_name": "700700", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna", "plan_name": "700700_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Miscellaneous", "plan_name": "700720", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Miscellaneous", "plan_name": "700720_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Ppo Hmo", "plan_name": "701720", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Ppo Hmo", "plan_name": "701720_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Ms State Emplo", "plan_name": "401457", "standard_charge_percentage": 0.80, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Ms State Emplo", "plan_name": "401457_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Basic Pl", "plan_name": "400100", "standard_charge_percentage": 0.85, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Basic Pl", "plan_name": "400100_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Federal", "plan_name": "400110", "standard_charge_percentage": 0.85, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Federal", "plan_name": "400110_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." } ] } ] }, { "description": "Clopidogrel 75 mg tablet [22142]", "drug_information": { "unit": 1.00, "type": "EA" }, "code_information": [ { "code": "68084-536-01", "type": "NDC" } ], "standard_charges": [ { "gross_charge": 7.50, "minimum": 6.00, "maximum": 6.38, "setting": "both", "payers_information": [ { "payer_name": "Aetna", "plan_name": "700700", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna", "plan_name": "700700_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Miscellaneous", "plan_name": "700720", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Miscellaneous", "plan_name": "700720_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Ppo Hmo", "plan_name": "701720", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Ppo Hmo", "plan_name": "701720_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Ms State Emplo", "plan_name": "401457", "standard_charge_percentage": 0.80, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate 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tabletextended release 24 hr [24268]", "drug_information": { "unit": 1.00, "type": "EA" }, "code_information": [ { "code": "68084-592-11", "type": "NDC" } ], "standard_charges": [ { "gross_charge": 7.50, "minimum": 6.00, "maximum": 6.38, "setting": "both", "payers_information": [ { "payer_name": "Aetna", "plan_name": "700700", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna", "plan_name": "700700_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Miscellaneous", "plan_name": "700720", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { 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80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna", "plan_name": "700700_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Miscellaneous", "plan_name": "700720", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Miscellaneous", "plan_name": "700720_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Ppo Hmo", "plan_name": "701720", "standard_charge_percentage": 80.0, "count": "0", 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"standard_charge_percentage": 0.85, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Federal", "plan_name": "400110_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." } ] } ] }, { "description": "Galantamine 4 mg tablet [29806]", "drug_information": { "unit": 1.00, "type": "EA" }, "code_information": [ { "code": "68084-729-11", "type": "NDC" } ], "standard_charges": [ { "gross_charge": 30.49, "minimum": 24.39, "maximum": 25.92, "setting": "both", "payers_information": [ { "payer_name": "Aetna", "plan_name": "700700", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna", 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"400100_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Federal", "plan_name": "400110", "standard_charge_percentage": 0.85, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Federal", "plan_name": "400110_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." } ] } ] }, { "description": "Fluconazole 200 mg tablet [10045]", "drug_information": { "unit": 1.00, "type": "EA" }, "code_information": [ { "code": "68084-735-11", "type": "NDC" } ], "standard_charges": [ { "gross_charge": 20.77, "minimum": 16.62, "maximum": 17.65, "setting": "both", "payers_information": 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"plan_name": "701720", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Ppo Hmo", "plan_name": "701720_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Ms State Emplo", "plan_name": "401457", "standard_charge_percentage": 0.80, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Ms State Emplo", "plan_name": "401457_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Basic Pl", "plan_name": "400100", "standard_charge_percentage": 0.85, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Basic Pl", "plan_name": "400100_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Federal", "plan_name": "400110", "standard_charge_percentage": 0.85, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Federal", "plan_name": "400110_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." } ] } ] }, { "description": "Guanfacine 1 mg 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"plan_name": "401457_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Basic Pl", "plan_name": "400100", "standard_charge_percentage": 0.85, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Basic Pl", "plan_name": "400100_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Federal", "plan_name": "400110", "standard_charge_percentage": 0.85, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Federal", "plan_name": "400110_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." } ] } ] }, { "description": "Triamterene 37.5 mg-hydrochlorothiazide 25 mg tablet [8132]", "drug_information": { "unit": 1.00, "type": "EA" }, "code_information": [ { "code": "68084-750-95", "type": "NDC" } ], "standard_charges": [ { "gross_charge": 7.50, "minimum": 6.00, "maximum": 6.38, "setting": "both", "payers_information": [ { "payer_name": "Aetna", "plan_name": "700700", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna", "plan_name": "700700_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Miscellaneous", "plan_name": "700720", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Miscellaneous", "plan_name": "700720_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Ppo Hmo", "plan_name": "701720", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Ppo Hmo", "plan_name": "701720_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Ms State Emplo", "plan_name": "401457", "standard_charge_percentage": 0.80, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Ms State Emplo", "plan_name": "401457_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Basic Pl", "plan_name": "400100", "standard_charge_percentage": 0.85, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Basic Pl", "plan_name": "400100_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Federal", "plan_name": "400110", "standard_charge_percentage": 0.85, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Federal", "plan_name": "400110_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." } ] } ] }, { "description": "Cyclobenzaprine 5 mg tablet [35184]", "drug_information": { "unit": 1.00, "type": "EA" }, "code_information": [ { "code": "68084-753-25", "type": "NDC" } ], "standard_charges": [ { "gross_charge": 7.50, "minimum": 6.00, "maximum": 6.38, "setting": "both", "payers_information": [ { "payer_name": "Aetna", "plan_name": "700700", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data 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amounts." }, { "payer_name": "Aetna Ppo Hmo", "plan_name": "701720_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Ms State Emplo", "plan_name": "401457", "standard_charge_percentage": 0.80, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Ms State Emplo", "plan_name": "401457_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Basic Pl", "plan_name": "400100", "standard_charge_percentage": 0.85, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Basic Pl", "plan_name": "400100_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Federal", "plan_name": "400110", "standard_charge_percentage": 0.85, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Federal", "plan_name": "400110_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." } ] } ] }, { "description": "Cyclobenzaprine 5 mg tablet [35184]", "drug_information": { "unit": 1.00, "type": "EA" }, "code_information": [ { "code": "68084-753-95", "type": "NDC" } ], "standard_charges": [ { "gross_charge": 7.50, "minimum": 6.00, "maximum": 6.38, "setting": "both", "payers_information": [ { "payer_name": "Aetna", "plan_name": "700700", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna", "plan_name": "700700_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Miscellaneous", "plan_name": "700720", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Miscellaneous", "plan_name": "700720_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Ppo Hmo", "plan_name": "701720", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Ppo Hmo", "plan_name": "701720_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Ms State Emplo", "plan_name": "401457", "standard_charge_percentage": 0.80, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Ms State Emplo", "plan_name": "401457_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Basic Pl", "plan_name": "400100", "standard_charge_percentage": 0.85, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Basic Pl", "plan_name": "400100_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Federal", "plan_name": "400110", "standard_charge_percentage": 0.85, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Federal", "plan_name": "400110_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." } ] } ] }, { "description": "Tramadol 50 mg tablet [14632]", "drug_information": { "unit": 1.00, "type": "EA" }, "code_information": [ { "code": "68084-808-01", "type": "NDC" } ], "standard_charges": [ { "gross_charge": 7.50, "minimum": 6.00, "maximum": 6.38, "setting": "both", "payers_information": [ { "payer_name": "Aetna", "plan_name": "700700", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna", "plan_name": "700700_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Miscellaneous", "plan_name": "700720", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Miscellaneous", "plan_name": "700720_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Ppo Hmo", "plan_name": "701720", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Ppo Hmo", "plan_name": "701720_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Ms State Emplo", "plan_name": "401457", "standard_charge_percentage": 0.80, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Ms State Emplo", "plan_name": "401457_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Basic Pl", "plan_name": "400100", "standard_charge_percentage": 0.85, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Basic Pl", "plan_name": "400100_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Federal", "plan_name": "400110", "standard_charge_percentage": 0.85, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Federal", "plan_name": "400110_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." } ] } ] }, { "description": "Tramadol 50 mg tablet [14632]", "drug_information": { "unit": 1.00, "type": "EA" }, "code_information": [ { "code": "68084-808-11", "type": "NDC" } ], "standard_charges": [ { "gross_charge": 7.50, "minimum": 6.00, "maximum": 6.38, "setting": "both", "payers_information": [ { "payer_name": "Aetna", "plan_name": "700700", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna", "plan_name": "700700_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Miscellaneous", "plan_name": "700720", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Miscellaneous", "plan_name": "700720_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Ppo Hmo", "plan_name": "701720", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Ppo Hmo", "plan_name": "701720_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Ms State Emplo", "plan_name": "401457", "standard_charge_percentage": 0.80, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Ms State Emplo", "plan_name": "401457_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Basic Pl", "plan_name": "400100", "standard_charge_percentage": 0.85, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Basic Pl", "plan_name": "400100_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Federal", "plan_name": "400110", "standard_charge_percentage": 0.85, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Federal", "plan_name": "400110_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." } ] } ] }, { "description": "Oxcarbazepine 150 mg tablet [27049]", "drug_information": { "unit": 1.00, "type": "EA" }, "code_information": [ { "code": "68084-845-11", "type": "NDC" } ], "standard_charges": [ { "gross_charge": 7.50, "minimum": 6.00, "maximum": 6.38, "setting": "both", "payers_information": [ { "payer_name": "Aetna", "plan_name": "700700", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna", "plan_name": "700700_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Miscellaneous", "plan_name": "700720", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Miscellaneous", "plan_name": "700720_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Ppo Hmo", "plan_name": "701720", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Ppo Hmo", "plan_name": "701720_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Ms State Emplo", "plan_name": "401457", "standard_charge_percentage": 0.80, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Ms State Emplo", "plan_name": "401457_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Basic Pl", "plan_name": "400100", "standard_charge_percentage": 0.85, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Basic Pl", "plan_name": "400100_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Federal", "plan_name": "400110", "standard_charge_percentage": 0.85, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Federal", "plan_name": "400110_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." } ] } ] }, { "description": "Potassium citrate er 10 meq (1080 mg) tabletextended release [11083]", "drug_information": { "unit": 1.00, "type": "EA" }, "code_information": [ { "code": "68084-850-33", "type": "NDC" } ], "standard_charges": [ { "gross_charge": 20.63, "minimum": 16.50, "maximum": 17.54, "setting": "both", "payers_information": [ { "payer_name": "Aetna", "plan_name": "700700", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna", "plan_name": "700700_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Miscellaneous", "plan_name": "700720", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Miscellaneous", "plan_name": "700720_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Ppo Hmo", "plan_name": "701720", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Ppo Hmo", "plan_name": "701720_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Ms State Emplo", "plan_name": "401457", "standard_charge_percentage": 0.80, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Ms State Emplo", "plan_name": "401457_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Basic Pl", "plan_name": "400100", "standard_charge_percentage": 0.85, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Basic Pl", "plan_name": "400100_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Federal", "plan_name": "400110", "standard_charge_percentage": 0.85, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Federal", "plan_name": "400110_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." } ] } ] }, { "description": "Doxazosin 2 mg tablet [9895]", "drug_information": { "unit": 1.00, "type": "EA" }, "code_information": [ { "code": "68084-851-11", "type": "NDC" } ], "standard_charges": [ { "gross_charge": 7.50, "minimum": 6.00, "maximum": 6.38, "setting": "both", "payers_information": [ { "payer_name": "Aetna", "plan_name": "700700", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna", "plan_name": "700700_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Miscellaneous", "plan_name": "700720", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Miscellaneous", "plan_name": "700720_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Ppo Hmo", "plan_name": "701720", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Ppo Hmo", "plan_name": "701720_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Ms State Emplo", "plan_name": "401457", "standard_charge_percentage": 0.80, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Ms State Emplo", "plan_name": "401457_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Basic Pl", "plan_name": "400100", "standard_charge_percentage": 0.85, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Basic Pl", "plan_name": "400100_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Federal", "plan_name": "400110", "standard_charge_percentage": 0.85, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Federal", "plan_name": "400110_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." } ] } ] }, { "description": "Doxazosin 2 mg tablet [9895]", "drug_information": { "unit": 1.00, "type": "EA" }, "code_information": [ { "code": "68084-851-95", "type": "NDC" } ], "standard_charges": [ { "gross_charge": 7.50, "minimum": 6.00, "maximum": 6.38, "setting": "both", "payers_information": [ { "payer_name": "Aetna", "plan_name": "700700", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna", "plan_name": "700700_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total 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"additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Ms State Emplo", "plan_name": "401457", "standard_charge_percentage": 0.80, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Ms State Emplo", "plan_name": "401457_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Basic Pl", "plan_name": "400100", "standard_charge_percentage": 0.85, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Basic Pl", "plan_name": "400100_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Federal", "plan_name": "400110", "standard_charge_percentage": 0.85, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Federal", "plan_name": "400110_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." } ] } ] }, { "description": "Oxcarbazepine 300 mg tablet [21061]", "drug_information": { "unit": 1.00, "type": "EA" }, "code_information": [ { "code": "68084-853-11", "type": "NDC" } ], "standard_charges": [ { "gross_charge": 7.50, "minimum": 6.00, "maximum": 6.38, "setting": "both", "payers_information": [ { "payer_name": "Aetna", "plan_name": "700700", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna", "plan_name": "700700_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Miscellaneous", "plan_name": "700720", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Miscellaneous", "plan_name": "700720_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Ppo Hmo", "plan_name": "701720", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Ppo Hmo", "plan_name": "701720_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Ms State Emplo", "plan_name": "401457", "standard_charge_percentage": 0.80, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Ms State Emplo", "plan_name": "401457_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Basic Pl", "plan_name": "400100", "standard_charge_percentage": 0.85, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Basic Pl", "plan_name": "400100_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Federal", "plan_name": "400110", "standard_charge_percentage": 0.85, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Federal", "plan_name": "400110_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." } ] } ] }, { "description": "Baclofen 10 mg tablet [860]", "drug_information": { "unit": 1.00, "type": "EA" }, "code_information": [ { "code": "68084-855-11", "type": 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billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Ppo Hmo", "plan_name": "701720", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Ppo Hmo", "plan_name": "701720_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Ms State Emplo", "plan_name": "401457", "standard_charge_percentage": 0.80, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Ms State Emplo", "plan_name": "401457_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Basic Pl", "plan_name": "400100", "standard_charge_percentage": 0.85, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Basic Pl", "plan_name": "400100_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Federal", "plan_name": "400110", "standard_charge_percentage": 0.85, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Federal", "plan_name": "400110_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." } ] } ] }, { "description": "Doxazosin 4 mg tablet [9896]", "drug_information": { "unit": 1.00, "type": "EA" }, "code_information": [ { "code": "68084-862-11", "type": "NDC" } ], "standard_charges": [ { "gross_charge": 7.50, "minimum": 6.00, "maximum": 6.38, "setting": "both", "payers_information": [ { "payer_name": "Aetna", "plan_name": "700700", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna", "plan_name": "700700_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Miscellaneous", "plan_name": "700720", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total 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"additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Ms State Emplo", "plan_name": "401457_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Basic Pl", "plan_name": "400100", "standard_charge_percentage": 0.85, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Basic Pl", "plan_name": "400100_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Federal", "plan_name": "400110", "standard_charge_percentage": 0.85, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Federal", "plan_name": "400110_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." } ] } ] }, { "description": "Baclofen 20 mg tablet [861]", "drug_information": { "unit": 1.00, "type": "EA" }, "code_information": [ { "code": "68084-868-11", "type": "NDC" } ], "standard_charges": [ { "gross_charge": 7.50, "minimum": 6.00, "maximum": 6.38, "setting": "both", "payers_information": [ { "payer_name": "Aetna", "plan_name": "700700", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna", "plan_name": "700700_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Miscellaneous", "plan_name": "700720", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Miscellaneous", "plan_name": "700720_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Ppo Hmo", "plan_name": "701720", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Ppo Hmo", "plan_name": "701720_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Ms State Emplo", "plan_name": "401457", "standard_charge_percentage": 0.80, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Ms State Emplo", "plan_name": "401457_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Basic Pl", "plan_name": "400100", "standard_charge_percentage": 0.85, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Basic Pl", "plan_name": "400100_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Federal", "plan_name": "400110", "standard_charge_percentage": 0.85, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Federal", "plan_name": "400110_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." } ] } ] }, { "description": "Levetiracetam 500 mg tablet [26817]", "drug_information": { "unit": 1.00, "type": "EA" }, "code_information": [ { "code": "68084-870-11", "type": "NDC" } ], "standard_charges": [ { "gross_charge": 7.50, "minimum": 6.00, "maximum": 6.38, "setting": "both", "payers_information": [ { "payer_name": "Aetna", "plan_name": "700700", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna", "plan_name": "700700_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Miscellaneous", "plan_name": "700720", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Miscellaneous", "plan_name": "700720_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Ppo Hmo", "plan_name": "701720", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Ppo Hmo", "plan_name": "701720_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Ms State Emplo", "plan_name": "401457", "standard_charge_percentage": 0.80, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Ms State Emplo", "plan_name": "401457_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Basic Pl", "plan_name": "400100", "standard_charge_percentage": 0.85, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Basic Pl", "plan_name": "400100_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Federal", "plan_name": "400110", "standard_charge_percentage": 0.85, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Federal", "plan_name": "400110_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." } ] } ] }, { "description": "Montelukast 10 mg tablet [22509]", "drug_information": { "unit": 1.00, "type": "EA" }, "code_information": [ { "code": "68084-875-11", "type": "NDC" } ], "standard_charges": [ { "gross_charge": 7.50, "minimum": 6.00, "maximum": 6.38, "setting": "both", "payers_information": [ { "payer_name": "Aetna", "plan_name": "700700", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna", "plan_name": "700700_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Miscellaneous", "plan_name": "700720", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Miscellaneous", "plan_name": "700720_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Ppo Hmo", "plan_name": "701720", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Ppo Hmo", "plan_name": "701720_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Ms State Emplo", "plan_name": "401457", "standard_charge_percentage": 0.80, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Ms State Emplo", "plan_name": "401457_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Basic Pl", "plan_name": "400100", "standard_charge_percentage": 0.85, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Basic Pl", "plan_name": "400100_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Federal", "plan_name": "400110", "standard_charge_percentage": 0.85, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Federal", "plan_name": "400110_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." } ] } ] }, { "description": "Pilocarpine 5 mg tablet [12803]", "drug_information": { "unit": 1.00, "type": "EA" }, "code_information": [ { "code": "68084-928-95", "type": "NDC" } ], "standard_charges": [ { "gross_charge": 20.03, "minimum": 16.02, "maximum": 17.03, "setting": "both", "payers_information": [ { "payer_name": "Aetna", "plan_name": "700700", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna", "plan_name": "700700_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Miscellaneous", "plan_name": "700720", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Miscellaneous", "plan_name": "700720_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Ppo Hmo", "plan_name": "701720", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Ppo Hmo", "plan_name": "701720_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Ms State Emplo", "plan_name": "401457", "standard_charge_percentage": 0.80, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Ms State Emplo", "plan_name": "401457_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Basic Pl", "plan_name": "400100", "standard_charge_percentage": 0.85, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Basic Pl", "plan_name": "400100_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Federal", "plan_name": "400110", "standard_charge_percentage": 0.85, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Federal", "plan_name": "400110_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." } ] } ] }, { "description": "Oxycodone 15 mg tablet [28899]", "drug_information": { "unit": 1.00, "type": "EA" }, "code_information": [ { "code": "68084-975-01", "type": "NDC" } ], "standard_charges": [ { "gross_charge": 13.82, "minimum": 11.06, "maximum": 11.75, "setting": "both", "payers_information": [ { "payer_name": "Aetna", "plan_name": "700700", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna", "plan_name": "700700_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Miscellaneous", "plan_name": "700720", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Miscellaneous", "plan_name": "700720_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Ppo Hmo", "plan_name": "701720", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Ppo Hmo", "plan_name": "701720_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Ms State Emplo", "plan_name": "401457", "standard_charge_percentage": 0.80, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Ms State Emplo", "plan_name": "401457_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Basic Pl", "plan_name": "400100", "standard_charge_percentage": 0.85, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Basic Pl", "plan_name": "400100_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Federal", "plan_name": "400110", "standard_charge_percentage": 0.85, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Federal", "plan_name": "400110_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." } ] } ] }, { "description": "Oxycodone 15 mg tablet [28899]", "drug_information": { "unit": 1.00, "type": "EA" }, "code_information": [ { "code": "68084-975-11", "type": "NDC" } ], "standard_charges": [ { "gross_charge": 13.82, "minimum": 11.06, "maximum": 11.75, "setting": "both", "payers_information": [ { "payer_name": "Aetna", "plan_name": "700700", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna", "plan_name": "700700_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Miscellaneous", "plan_name": "700720", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Miscellaneous", "plan_name": "700720_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Ppo Hmo", "plan_name": "701720", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Ppo Hmo", "plan_name": "701720_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Ms State Emplo", "plan_name": "401457", "standard_charge_percentage": 0.80, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Ms State Emplo", "plan_name": "401457_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Basic Pl", "plan_name": "400100", "standard_charge_percentage": 0.85, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Basic Pl", "plan_name": "400100_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Federal", "plan_name": "400110", "standard_charge_percentage": 0.85, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Federal", "plan_name": "400110_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." } ] } ] }, { "description": "Calcium 200 mg (as calcium carbonate 500 mg) chewable tablet [9385]", "drug_information": { "unit": 1.00, "type": "EA" }, "code_information": [ { "code": "68084-988-32", "type": "NDC" } ], "standard_charges": [ { "gross_charge": 2.43, "minimum": 1.94, "maximum": 2.07, "setting": "both", "payers_information": [ { "payer_name": "Aetna", "plan_name": "700700", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna", "plan_name": "700700_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Miscellaneous", "plan_name": "700720", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Miscellaneous", "plan_name": "700720_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Ppo Hmo", "plan_name": "701720", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Ppo Hmo", "plan_name": "701720_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Ms State Emplo", "plan_name": "401457", "standard_charge_percentage": 0.80, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Ms State Emplo", "plan_name": "401457_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Basic Pl", "plan_name": "400100", "standard_charge_percentage": 0.85, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Basic Pl", "plan_name": "400100_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Federal", "plan_name": "400110", "standard_charge_percentage": 0.85, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Federal", "plan_name": "400110_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." } ] } ] }, { "description": "Calcium 200 mg (as calcium carbonate 500 mg) chewable tablet [9385]", "drug_information": { "unit": 1.00, "type": "EA" }, "code_information": [ { "code": "68084-988-33", "type": "NDC" } ], "standard_charges": [ { "gross_charge": 2.43, "minimum": 1.94, "maximum": 2.07, "setting": "both", "payers_information": [ { "payer_name": "Aetna", "plan_name": "700700", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna", "plan_name": "700700_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Miscellaneous", "plan_name": "700720", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Miscellaneous", "plan_name": "700720_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Ppo Hmo", "plan_name": "701720", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Ppo Hmo", "plan_name": "701720_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Ms State Emplo", "plan_name": "401457", "standard_charge_percentage": 0.80, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Ms State Emplo", "plan_name": "401457_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Basic Pl", "plan_name": "400100", "standard_charge_percentage": 0.85, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Basic Pl", "plan_name": "400100_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Federal", "plan_name": "400110", "standard_charge_percentage": 0.85, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Federal", "plan_name": "400110_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." } ] } ] }, { "description": "Cetirizine 5 mg/5 ml oral solution [97141]", "drug_information": { "unit": 5.00, "type": "ML" }, "code_information": [ { "code": "68094-004-59", "type": "NDC" } ], "standard_charges": [ { "gross_charge": 7.77, "minimum": 6.22, "maximum": 6.60, "setting": "both", "payers_information": [ { "payer_name": "Aetna", "plan_name": "700700", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna", "plan_name": "700700_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Miscellaneous", "plan_name": "700720", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Miscellaneous", "plan_name": "700720_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Ppo Hmo", "plan_name": "701720", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Ppo Hmo", "plan_name": "701720_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Ms State Emplo", "plan_name": "401457", "standard_charge_percentage": 0.80, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Ms State Emplo", "plan_name": "401457_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Basic Pl", "plan_name": "400100", "standard_charge_percentage": 0.85, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Basic Pl", "plan_name": "400100_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Federal", "plan_name": "400110", "standard_charge_percentage": 0.85, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Federal", "plan_name": "400110_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." } ] } ] }, { "description": "Diphenhydramine 25 mg tablet [2505]", "drug_information": { "unit": 1.00, "type": "EA" }, "code_information": [ { "code": "68094-018-59", "type": "NDC" } ], "standard_charges": [ { "gross_charge": 1.00, "minimum": 0.80, "maximum": 0.85, "setting": "both", "payers_information": [ { "payer_name": "Aetna", "plan_name": "700700", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna", "plan_name": "700700_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Miscellaneous", "plan_name": "700720", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Miscellaneous", "plan_name": "700720_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Ppo Hmo", "plan_name": "701720", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Ppo Hmo", "plan_name": "701720_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Ms State Emplo", "plan_name": "401457", "standard_charge_percentage": 0.80, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Ms State Emplo", "plan_name": "401457_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate 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150 mg 24 hr tablet extended release [36775]", "drug_information": { "unit": 1.00, "type": "EA" }, "code_information": [ { "code": "68180-319-06", "type": "NDC" } ], "standard_charges": [ { "gross_charge": 7.50, "minimum": 6.00, "maximum": 6.38, "setting": "both", "payers_information": [ { "payer_name": "Aetna", "plan_name": "700700", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna", "plan_name": "700700_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Miscellaneous", "plan_name": "700720", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed 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"percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." } ] } ] }, { "description": "Ramipril 5 mg capsule [11261]", "drug_information": { "unit": 1.00, "type": "EA" }, "code_information": [ { "code": "68180-590-01", "type": "NDC" } ], "standard_charges": [ { "gross_charge": 7.50, "minimum": 6.00, "maximum": 6.38, "setting": "both", "payers_information": [ { "payer_name": "Aetna", "plan_name": "700700", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna", "plan_name": "700700_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Miscellaneous", "plan_name": "700720", "standard_charge_percentage": 80.0, "count": "0", 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amounts." } ] } ] }, { "description": "Carvedilol 12.5 mg tablet [15749]", "drug_information": { "unit": 1.00, "type": "EA" }, "code_information": [ { "code": "68382-094-01", "type": "NDC" } ], "standard_charges": [ { "gross_charge": 7.50, "minimum": 6.00, "maximum": 6.38, "setting": "both", "payers_information": [ { "payer_name": "Aetna", "plan_name": "700700", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna", "plan_name": "700700_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Miscellaneous", "plan_name": "700720", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Miscellaneous", "plan_name": "700720_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Ppo Hmo", "plan_name": "701720", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Ppo Hmo", "plan_name": "701720_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Ms State Emplo", "plan_name": "401457", "standard_charge_percentage": 0.80, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Ms State Emplo", "plan_name": "401457_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Basic Pl", "plan_name": "400100", "standard_charge_percentage": 0.85, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Basic Pl", "plan_name": "400100_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Federal", "plan_name": "400110", "standard_charge_percentage": 0.85, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Federal", "plan_name": "400110_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." } ] } ] }, { "description": "Dipyridamole 25 mg tablet [2528]", "drug_information": { "unit": 1.00, "type": "EA" }, "code_information": [ { "code": "68382-187-01", "type": "NDC" } ], "standard_charges": [ { "gross_charge": 7.50, "minimum": 6.00, "maximum": 6.38, "setting": "both", "payers_information": [ { "payer_name": "Aetna", "plan_name": "700700", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna", "plan_name": "700700_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Miscellaneous", "plan_name": "700720", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Miscellaneous", "plan_name": "700720_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Ppo Hmo", "plan_name": "701720", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Ppo Hmo", "plan_name": "701720_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Ms State Emplo", "plan_name": "401457", "standard_charge_percentage": 0.80, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Ms State Emplo", "plan_name": "401457_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Basic Pl", "plan_name": "400100", "standard_charge_percentage": 0.85, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Basic Pl", "plan_name": "400100_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Federal", "plan_name": "400110", "standard_charge_percentage": 0.85, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Federal", "plan_name": "400110_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." } ] } ] }, { "description": "Dipyridamole 75 mg tablet [2530]", "drug_information": { "unit": 1.00, "type": "EA" }, "code_information": [ { "code": "68382-189-01", "type": "NDC" } ], "standard_charges": [ { "gross_charge": 7.95, "minimum": 6.36, "maximum": 6.76, "setting": "both", "payers_information": [ { "payer_name": "Aetna", "plan_name": "700700", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna", "plan_name": "700700_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Miscellaneous", "plan_name": "700720", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Miscellaneous", "plan_name": "700720_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Ppo Hmo", "plan_name": "701720", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Ppo Hmo", "plan_name": "701720_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Ms State Emplo", "plan_name": "401457", "standard_charge_percentage": 0.80, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Ms State Emplo", "plan_name": "401457_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Basic Pl", "plan_name": "400100", "standard_charge_percentage": 0.85, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Basic Pl", "plan_name": "400100_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Federal", "plan_name": "400110", "standard_charge_percentage": 0.85, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Federal", "plan_name": "400110_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." } ] } ] }, { "description": "Gabapentin 600 mg tablet [25855]", "drug_information": { "unit": 1.00, "type": "EA" }, "code_information": [ { "code": "68382-204-01", "type": "NDC" } ], "standard_charges": [ { "gross_charge": 7.50, "minimum": 6.00, "maximum": 6.38, "setting": "both", "payers_information": [ { "payer_name": "Aetna", "plan_name": "700700", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna", "plan_name": "700700_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Miscellaneous", "plan_name": "700720", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Miscellaneous", "plan_name": "700720_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Ppo Hmo", "plan_name": "701720", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Ppo Hmo", "plan_name": "701720_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Ms State Emplo", "plan_name": "401457", "standard_charge_percentage": 0.80, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Ms State Emplo", "plan_name": "401457_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Basic Pl", "plan_name": "400100", "standard_charge_percentage": 0.85, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Basic Pl", "plan_name": "400100_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Federal", "plan_name": "400110", "standard_charge_percentage": 0.85, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Federal", "plan_name": "400110_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." } ] } ] }, { "description": "Gabapentin 800 mg tablet [25856]", "drug_information": { "unit": 1.00, "type": "EA" }, "code_information": [ { "code": "68382-205-01", "type": "NDC" } ], "standard_charges": [ { "gross_charge": 7.50, "minimum": 6.00, "maximum": 6.38, "setting": "both", "payers_information": [ { "payer_name": "Aetna", "plan_name": "700700", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna", "plan_name": "700700_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Miscellaneous", "plan_name": "700720", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Miscellaneous", "plan_name": "700720_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Ppo Hmo", "plan_name": "701720", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Ppo Hmo", "plan_name": "701720_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Ms State Emplo", "plan_name": "401457", "standard_charge_percentage": 0.80, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Ms State Emplo", "plan_name": "401457_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Basic Pl", "plan_name": "400100", "standard_charge_percentage": 0.85, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Basic Pl", "plan_name": "400100_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Federal", "plan_name": "400110", "standard_charge_percentage": 0.85, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Federal", "plan_name": "400110_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." } ] } ] }, { "description": "Mesalamine 800 mg tabletdelayed release [96949]", "drug_information": { "unit": 1.00, "type": "EA" }, "code_information": [ { "code": "68382-435-28", "type": "NDC" } ], "standard_charges": [ { "gross_charge": 44.67, "minimum": 35.74, "maximum": 37.97, "setting": "both", "payers_information": [ { "payer_name": "Aetna", "plan_name": "700700", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna", "plan_name": "700700_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Miscellaneous", "plan_name": "700720", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Miscellaneous", "plan_name": "700720_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Ppo Hmo", "plan_name": "701720", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Ppo Hmo", "plan_name": "701720_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Ms State Emplo", "plan_name": "401457", "standard_charge_percentage": 0.80, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Ms State Emplo", "plan_name": "401457_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Basic Pl", "plan_name": "400100", "standard_charge_percentage": 0.85, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Basic Pl", "plan_name": "400100_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Federal", "plan_name": "400110", "standard_charge_percentage": 0.85, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Federal", "plan_name": "400110_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." } ] } ] }, { "description": "Potassium citrate er 10 meq (1080 mg) tabletextended release [11083]", "drug_information": { "unit": 1.00, "type": "EA" }, "code_information": [ { "code": "68382-537-01", "type": "NDC" } ], "standard_charges": [ { "gross_charge": 7.50, "minimum": 6.00, "maximum": 6.38, "setting": "both", "payers_information": [ { "payer_name": "Aetna", "plan_name": "700700", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna", "plan_name": "700700_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Miscellaneous", "plan_name": "700720", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Miscellaneous", "plan_name": "700720_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Ppo Hmo", "plan_name": "701720", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Ppo Hmo", "plan_name": "701720_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Ms State Emplo", "plan_name": "401457", "standard_charge_percentage": 0.80, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Ms State Emplo", "plan_name": "401457_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Basic Pl", "plan_name": "400100", "standard_charge_percentage": 0.85, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Basic Pl", "plan_name": "400100_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Federal", "plan_name": "400110", "standard_charge_percentage": 0.85, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Federal", "plan_name": "400110_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." } ] } ] }, { "description": "Liothyronine 5 mcg tablet [10443]", "drug_information": { "unit": 1.00, "type": "EA" }, "code_information": [ { "code": "68382-582-01", "type": "NDC" } ], "standard_charges": [ { "gross_charge": 7.50, "minimum": 6.00, "maximum": 6.38, "setting": "both", "payers_information": [ { "payer_name": "Aetna", "plan_name": "700700", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna", "plan_name": "700700_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Miscellaneous", "plan_name": "700720", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Miscellaneous", "plan_name": "700720_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Ppo Hmo", "plan_name": "701720", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Ppo Hmo", "plan_name": "701720_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Ms State Emplo", "plan_name": "401457", "standard_charge_percentage": 0.80, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Ms State Emplo", "plan_name": "401457_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Basic Pl", "plan_name": "400100", "standard_charge_percentage": 0.85, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Basic Pl", "plan_name": "400100_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Federal", "plan_name": "400110", "standard_charge_percentage": 0.85, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Federal", "plan_name": "400110_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." } ] } ] }, { "description": "Liothyronine 25 mcg tablet [4504]", "drug_information": { "unit": 1.00, "type": "EA" }, "code_information": [ { "code": "68382-583-01", "type": "NDC" } ], "standard_charges": [ { "gross_charge": 7.50, "minimum": 6.00, "maximum": 6.38, "setting": "both", "payers_information": [ { "payer_name": "Aetna", "plan_name": "700700", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna", "plan_name": "700700_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Miscellaneous", "plan_name": "700720", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Miscellaneous", "plan_name": "700720_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Ppo Hmo", "plan_name": "701720", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Ppo Hmo", "plan_name": "701720_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Ms State Emplo", "plan_name": "401457", "standard_charge_percentage": 0.80, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Ms State Emplo", "plan_name": "401457_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Basic Pl", "plan_name": "400100", "standard_charge_percentage": 0.85, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Basic Pl", "plan_name": "400100_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Federal", "plan_name": "400110", "standard_charge_percentage": 0.85, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Federal", "plan_name": "400110_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." } ] } ] }, { "description": "Pyridostigmine bromide 60 mg tablet [11239]", "drug_information": { "unit": 1.00, "type": "EA" }, "code_information": [ { "code": "68382-659-06", "type": "NDC" } ], "standard_charges": [ { "gross_charge": 7.50, "minimum": 6.00, "maximum": 6.38, "setting": "both", "payers_information": [ { "payer_name": "Aetna", "plan_name": "700700", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna", "plan_name": "700700_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Miscellaneous", "plan_name": "700720", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Miscellaneous", "plan_name": "700720_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Ppo Hmo", "plan_name": "701720", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Ppo Hmo", "plan_name": "701720_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Ms State Emplo", "plan_name": "401457", "standard_charge_percentage": 0.80, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Ms State Emplo", "plan_name": "401457_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Basic Pl", "plan_name": "400100", "standard_charge_percentage": 0.85, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Basic Pl", "plan_name": "400100_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Federal", "plan_name": "400110", "standard_charge_percentage": 0.85, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Federal", "plan_name": "400110_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." } ] } ] }, { "description": "Metformin 500 mg tablet [10544]", "drug_information": { "unit": 1.00, "type": "EA" }, "code_information": [ { "code": "68382-758-01", "type": "NDC" } ], "standard_charges": [ { "gross_charge": 7.50, "minimum": 6.00, "maximum": 6.38, "setting": "both", "payers_information": [ { "payer_name": "Aetna", "plan_name": "700700", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna", "plan_name": "700700_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Miscellaneous", "plan_name": "700720", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Miscellaneous", "plan_name": "700720_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Ppo Hmo", "plan_name": "701720", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Ppo Hmo", "plan_name": "701720_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Ms State Emplo", "plan_name": "401457", "standard_charge_percentage": 0.80, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Ms State Emplo", "plan_name": "401457_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Basic Pl", "plan_name": "400100", "standard_charge_percentage": 0.85, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Basic Pl", "plan_name": "400100_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Federal", "plan_name": "400110", "standard_charge_percentage": 0.85, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Federal", "plan_name": "400110_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." } ] } ] }, { "description": "Labetalol 100 mg tablet [10373]", "drug_information": { "unit": 1.00, "type": "EA" }, "code_information": [ { "code": "68382-798-01", "type": "NDC" } ], "standard_charges": [ { "gross_charge": 7.50, "minimum": 6.00, "maximum": 6.38, "setting": "both", "payers_information": [ { "payer_name": "Aetna", "plan_name": "700700", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna", "plan_name": "700700_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Miscellaneous", "plan_name": "700720", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Miscellaneous", "plan_name": "700720_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Ppo Hmo", "plan_name": "701720", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Ppo Hmo", "plan_name": "701720_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Ms State Emplo", "plan_name": "401457", "standard_charge_percentage": 0.80, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Ms State Emplo", "plan_name": "401457_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Basic Pl", "plan_name": "400100", "standard_charge_percentage": 0.85, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Basic Pl", "plan_name": "400100_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Federal", "plan_name": "400110", "standard_charge_percentage": 0.85, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Federal", "plan_name": "400110_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." } ] } ] }, { "description": "Labetalol 200 mg tablet [10374]", "drug_information": { "unit": 1.00, "type": "EA" }, "code_information": [ { "code": "68382-799-01", "type": "NDC" } ], "standard_charges": [ { "gross_charge": 7.50, "minimum": 6.00, "maximum": 6.38, "setting": "both", "payers_information": [ { "payer_name": "Aetna", "plan_name": "700700", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna", "plan_name": "700700_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Miscellaneous", "plan_name": "700720", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Miscellaneous", "plan_name": "700720_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Ppo Hmo", "plan_name": "701720", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Ppo Hmo", "plan_name": "701720_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Ms State Emplo", "plan_name": "401457", "standard_charge_percentage": 0.80, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Ms State Emplo", "plan_name": "401457_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Basic Pl", "plan_name": "400100", "standard_charge_percentage": 0.85, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Basic Pl", "plan_name": "400100_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Federal", "plan_name": "400110", "standard_charge_percentage": 0.85, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Federal", "plan_name": "400110_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." } ] } ] }, { "description": "Doxycycline hyclate 100 mg intravenous powder for solution [2622]", "drug_information": { "unit": 1.00, "type": "EA" }, "code_information": [ { "code": "68382-910-01", "type": "NDC" } ], "standard_charges": [ { "gross_charge": 208.50, "minimum": 166.80, "maximum": 177.23, "setting": "both", "payers_information": [ { "payer_name": "Aetna", "plan_name": "700700", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna", "plan_name": "700700_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Miscellaneous", "plan_name": "700720", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Miscellaneous", "plan_name": "700720_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Ppo Hmo", "plan_name": "701720", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Ppo Hmo", "plan_name": "701720_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Ms State Emplo", "plan_name": "401457", "standard_charge_percentage": 0.80, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Ms State Emplo", "plan_name": "401457_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Basic Pl", "plan_name": "400100", "standard_charge_percentage": 0.85, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Basic Pl", "plan_name": "400100_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Federal", "plan_name": "400110", "standard_charge_percentage": 0.85, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Federal", "plan_name": "400110_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." } ] } ] }, { "description": "Doxycycline hyclate 100 mg intravenous powder for solution [2622]", "drug_information": { "unit": 1.00, "type": "EA" }, "code_information": [ { "code": "68382-910-10", "type": "NDC" } ], "standard_charges": [ { "gross_charge": 208.50, "minimum": 166.80, "maximum": 177.23, "setting": "both", "payers_information": [ { "payer_name": "Aetna", "plan_name": "700700", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna", "plan_name": "700700_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Miscellaneous", "plan_name": "700720", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Miscellaneous", "plan_name": "700720_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Ppo Hmo", "plan_name": "701720", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Ppo Hmo", "plan_name": "701720_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Ms State Emplo", "plan_name": "401457", "standard_charge_percentage": 0.80, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Ms State Emplo", "plan_name": "401457_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Basic Pl", "plan_name": "400100", "standard_charge_percentage": 0.85, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Basic Pl", "plan_name": "400100_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Federal", "plan_name": "400110", "standard_charge_percentage": 0.85, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Federal", "plan_name": "400110_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." } ] } ] }, { "description": "Zinc oxide 3 x 10 yard bandage [113037]", "drug_information": { "unit": 1.00, "type": "EA" }, "code_information": [ { "code": "6845510763", "type": "NDC" } ], "standard_charges": [ { "gross_charge": 31.85, "minimum": 25.48, "maximum": 27.07, "setting": "both", "payers_information": [ { "payer_name": "Aetna", "plan_name": "700700", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna", "plan_name": "700700_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Miscellaneous", "plan_name": "700720", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Miscellaneous", "plan_name": "700720_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Ppo Hmo", "plan_name": "701720", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Ppo Hmo", "plan_name": "701720_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Ms State Emplo", "plan_name": "401457", "standard_charge_percentage": 0.80, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Ms State Emplo", "plan_name": "401457_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Basic Pl", "plan_name": "400100", "standard_charge_percentage": 0.85, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Basic Pl", "plan_name": "400100_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Federal", "plan_name": "400110", "standard_charge_percentage": 0.85, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Federal", "plan_name": "400110_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." } ] } ] }, { "description": "Mupirocin 2 % topical ointment [10674]", "drug_information": { "unit": 22.00, "type": "GR" }, "code_information": [ { "code": "68462-180-22", "type": "NDC" } ], "standard_charges": [ { "gross_charge": 52.56, "minimum": 42.05, "maximum": 44.68, "setting": "both", "payers_information": [ { "payer_name": "Aetna", "plan_name": "700700", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna", "plan_name": "700700_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Miscellaneous", "plan_name": "700720", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Miscellaneous", "plan_name": "700720_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Ppo Hmo", "plan_name": "701720", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Ppo Hmo", "plan_name": "701720_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Ms State Emplo", "plan_name": "401457", "standard_charge_percentage": 0.80, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Ms State Emplo", "plan_name": "401457_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Basic Pl", "plan_name": "400100", "standard_charge_percentage": 0.85, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Basic Pl", "plan_name": "400100_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Federal", "plan_name": "400110", "standard_charge_percentage": 0.85, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Federal", "plan_name": "400110_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." } ] } ] }, { "description": "Indomethacin 25 mg capsule [3897]", "drug_information": { "unit": 1.00, "type": "EA" }, "code_information": [ { "code": "68462-406-01", "type": "NDC" } ], "standard_charges": [ { "gross_charge": 7.50, "minimum": 6.00, "maximum": 6.38, "setting": "both", "payers_information": [ { "payer_name": "Aetna", "plan_name": "700700", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna", "plan_name": "700700_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Miscellaneous", "plan_name": "700720", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Miscellaneous", "plan_name": "700720_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Ppo Hmo", "plan_name": "701720", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Ppo Hmo", "plan_name": "701720_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Ms State Emplo", "plan_name": "401457", "standard_charge_percentage": 0.80, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Ms State Emplo", "plan_name": "401457_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Basic Pl", "plan_name": "400100", "standard_charge_percentage": 0.85, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Basic Pl", "plan_name": "400100_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Federal", "plan_name": "400110", "standard_charge_percentage": 0.85, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Federal", "plan_name": "400110_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." } ] } ] }, { "description": "Olmesartan 20 mg tablet [32762]", "drug_information": { "unit": 1.00, "type": "EA" }, "code_information": [ { "code": "68462-437-30", "type": "NDC" } ], "standard_charges": [ { "gross_charge": 7.50, "minimum": 6.00, "maximum": 6.38, "setting": "both", "payers_information": [ { "payer_name": "Aetna", "plan_name": "700700", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna", "plan_name": "700700_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Miscellaneous", "plan_name": "700720", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Miscellaneous", "plan_name": "700720_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Ppo Hmo", "plan_name": "701720", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Ppo Hmo", "plan_name": "701720_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Ms State Emplo", "plan_name": "401457", "standard_charge_percentage": 0.80, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Ms State Emplo", "plan_name": "401457_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Basic Pl", "plan_name": "400100", "standard_charge_percentage": 0.85, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Basic Pl", "plan_name": "400100_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Federal", "plan_name": "400110", "standard_charge_percentage": 0.85, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Federal", "plan_name": "400110_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." } ] } ] }, { "description": "Trospium 20 mg tablet [38977]", "drug_information": { "unit": 1.00, "type": "EA" }, "code_information": [ { "code": "68462-461-60", "type": "NDC" } ], "standard_charges": [ { "gross_charge": 7.50, "minimum": 6.00, "maximum": 6.38, "setting": "both", "payers_information": [ { "payer_name": "Aetna", "plan_name": "700700", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna", "plan_name": "700700_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Miscellaneous", "plan_name": "700720", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Miscellaneous", "plan_name": "700720_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Ppo Hmo", "plan_name": "701720", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Ppo Hmo", "plan_name": "701720_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Ms State Emplo", "plan_name": "401457", "standard_charge_percentage": 0.80, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Ms State Emplo", "plan_name": "401457_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Basic Pl", "plan_name": "400100", "standard_charge_percentage": 0.85, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Basic Pl", "plan_name": "400100_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Federal", "plan_name": "400110", "standard_charge_percentage": 0.85, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Federal", "plan_name": "400110_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." } ] } ] }, { "description": "Albumin human 5 % intravenous solution [8982]", "drug_information": { "unit": 50.00, "type": "ML" }, "code_information": [ { "code": "68516-5214-5", "type": "NDC" } ], "standard_charges": [ { "gross_charge": 237.61, "minimum": 190.09, "maximum": 201.97, "setting": "both", "payers_information": [ { "payer_name": "Aetna", "plan_name": "700700", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna", "plan_name": "700700_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Miscellaneous", "plan_name": "700720", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Miscellaneous", "plan_name": "700720_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Ppo Hmo", "plan_name": "701720", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Ppo Hmo", "plan_name": "701720_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Ms State Emplo", "plan_name": "401457", "standard_charge_percentage": 0.80, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Ms State Emplo", "plan_name": "401457_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Basic Pl", "plan_name": "400100", "standard_charge_percentage": 0.85, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Basic Pl", "plan_name": "400100_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Federal", "plan_name": "400110", "standard_charge_percentage": 0.85, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Federal", "plan_name": "400110_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." } ] } ] }, { "description": "Albumin human 5 % intravenous solution [8982]", "drug_information": { "unit": 50.00, "type": "ML" }, "code_information": [ { "code": "68516-5214-6", "type": "NDC" } ], "standard_charges": [ { "gross_charge": 237.61, "minimum": 190.09, "maximum": 201.97, "setting": "both", "payers_information": [ { "payer_name": "Aetna", "plan_name": "700700", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna", "plan_name": "700700_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Miscellaneous", "plan_name": "700720", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Miscellaneous", "plan_name": "700720_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Ppo Hmo", "plan_name": "701720", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Ppo Hmo", "plan_name": "701720_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Ms State Emplo", "plan_name": "401457", "standard_charge_percentage": 0.80, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Ms State Emplo", "plan_name": "401457_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Basic Pl", "plan_name": "400100", "standard_charge_percentage": 0.85, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Basic Pl", "plan_name": "400100_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Federal", "plan_name": "400110", "standard_charge_percentage": 0.85, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Federal", "plan_name": "400110_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." } ] } ] }, { "description": "Pentoxifylline er 400 mg tabletextended release [10911]", "drug_information": { "unit": 1.00, "type": "EA" }, "code_information": [ { "code": "68682-101-10", "type": "NDC" } ], "standard_charges": [ { "gross_charge": 7.50, "minimum": 6.00, "maximum": 6.38, "setting": "both", "payers_information": [ { "payer_name": "Aetna", "plan_name": "700700", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna", "plan_name": "700700_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Miscellaneous", "plan_name": "700720", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Miscellaneous", "plan_name": "700720_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Ppo Hmo", "plan_name": "701720", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Ppo Hmo", "plan_name": "701720_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Ms State Emplo", "plan_name": "401457", "standard_charge_percentage": 0.80, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Ms State Emplo", "plan_name": "401457_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Basic Pl", "plan_name": "400100", "standard_charge_percentage": 0.85, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Basic Pl", "plan_name": "400100_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Federal", "plan_name": "400110", "standard_charge_percentage": 0.85, "count": "0", "methodology": 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"plan_name": "400110_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." } ] } ] }, { "description": "Cyclobenzaprine 10 mg tablet [2017]", "drug_information": { "unit": 1.00, "type": "EA" }, "code_information": [ { "code": "69097-846-07", "type": "NDC" } ], "standard_charges": [ { "gross_charge": 7.50, "minimum": 6.00, "maximum": 6.38, "setting": "both", "payers_information": [ { "payer_name": "Aetna", "plan_name": "700700", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna", "plan_name": "700700_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { 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"Bc/Bs Ms State Emplo", "plan_name": "401457", "standard_charge_percentage": 0.80, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Ms State Emplo", "plan_name": "401457_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Basic Pl", "plan_name": "400100", "standard_charge_percentage": 0.85, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Basic Pl", "plan_name": "400100_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Federal", "plan_name": "400110", "standard_charge_percentage": 0.85, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Federal", "plan_name": "400110_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." } ] } ] }, { "description": "Potassium chloride er 20 meq tabletextended release(part/cryst) [35943]", "drug_information": { "unit": 1.00, "type": "EA" }, "code_information": [ { "code": "69238-1069-1", "type": "NDC" } ], "standard_charges": [ { "gross_charge": 7.50, "minimum": 6.00, "maximum": 6.38, "setting": "both", "payers_information": [ { "payer_name": "Aetna", "plan_name": "700700", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": 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calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Basic Pl", "plan_name": "400100_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Federal", "plan_name": "400110", "standard_charge_percentage": 0.85, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Federal", "plan_name": "400110_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." } ] } ] }, { "description": "Pilocarpine 1 % eye drops [6279]", "drug_information": { "unit": 15.00, "type": "ML" }, "code_information": [ { "code": "69238-1745-8", "type": "NDC" } ], "standard_charges": [ { "gross_charge": 365.37, "minimum": 292.30, "maximum": 310.56, "setting": "both", "payers_information": [ { "payer_name": "Aetna", "plan_name": "700700", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna", "plan_name": "700700_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Miscellaneous", "plan_name": "700720", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Miscellaneous", "plan_name": "700720_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Ppo Hmo", "plan_name": "701720", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Ppo Hmo", "plan_name": "701720_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Ms State Emplo", "plan_name": "401457", "standard_charge_percentage": 0.80, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Ms State Emplo", "plan_name": "401457_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient 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remit data to calculate allowed amounts." } ] } ] }, { "description": "Pilocarpine 2 % eye drops [6280]", "drug_information": { "unit": 15.00, "type": "ML" }, "code_information": [ { "code": "69238-1746-8", "type": "NDC" } ], "standard_charges": [ { "gross_charge": 373.71, "minimum": 298.97, "maximum": 317.65, "setting": "both", "payers_information": [ { "payer_name": "Aetna", "plan_name": "700700", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna", "plan_name": "700700_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Miscellaneous", "plan_name": "700720", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Miscellaneous", "plan_name": "700720_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Ppo Hmo", "plan_name": "701720", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Ppo Hmo", "plan_name": "701720_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Ms State Emplo", "plan_name": "401457", "standard_charge_percentage": 0.80, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Ms State Emplo", "plan_name": "401457_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Basic Pl", "plan_name": "400100", "standard_charge_percentage": 0.85, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Basic Pl", "plan_name": "400100_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Federal", "plan_name": "400110", "standard_charge_percentage": 0.85, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Federal", "plan_name": "400110_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." } ] } ] }, { "description": "Levothyroxine 112 mcg tablet [10404]", "drug_information": { "unit": 1.00, "type": "EA" }, "code_information": [ { "code": "69238-1835-1", "type": "NDC" } ], "standard_charges": [ { "gross_charge": 7.50, "minimum": 6.00, "maximum": 6.38, "setting": "both", "payers_information": [ { "payer_name": "Aetna", "plan_name": "700700", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna", "plan_name": "700700_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent 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charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Federal", "plan_name": "400110", "standard_charge_percentage": 0.85, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Federal", "plan_name": "400110_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." } ] } ] }, { "description": "Captopril 12.5 mg tablet [9401]", "drug_information": { "unit": 1.00, "type": "EA" }, "code_information": [ { "code": "69292-522-01", "type": "NDC" } ], "standard_charges": [ { "gross_charge": 7.50, "minimum": 6.00, "maximum": 6.38, "setting": "both", "payers_information": [ { "payer_name": "Aetna", "plan_name": "700700", "standard_charge_percentage": 80.0, "count": "0", 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billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Basic Pl", "plan_name": "400100_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Federal", "plan_name": "400110", "standard_charge_percentage": 0.85, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Federal", "plan_name": "400110_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." } ] } ] }, { "description": "Captopril 25 mg tablet [9402]", "drug_information": { "unit": 1.00, "type": "EA" }, "code_information": [ { "code": "69292-524-01", "type": "NDC" } ], "standard_charges": [ { "gross_charge": 7.50, "minimum": 6.00, "maximum": 6.38, "setting": "both", "payers_information": [ { "payer_name": "Aetna", "plan_name": "700700", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna", "plan_name": "700700_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Miscellaneous", "plan_name": "700720", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Miscellaneous", "plan_name": "700720_1", "standard_charge_percentage": 100.0, "count": "0", 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"percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." } ] } ] }, { "description": "Furosemide 40 mg tablet [3295]", "drug_information": { "unit": 1.00, "type": "EA" }, "code_information": [ { "code": "69315-117-01", "type": "NDC" } ], "standard_charges": [ { "gross_charge": 7.50, "minimum": 6.00, "maximum": 6.38, "setting": "both", "payers_information": [ { "payer_name": "Aetna", "plan_name": "700700", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna", "plan_name": "700700_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Miscellaneous", "plan_name": "700720", "standard_charge_percentage": 80.0, "count": 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"methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Federal", "plan_name": "400110_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." } ] } ] }, { "description": "Imipramine 10 mg tablet [3860]", "drug_information": { "unit": 1.00, "type": "EA" }, "code_information": [ { "code": "69315-133-01", "type": "NDC" } ], "standard_charges": [ { "gross_charge": 7.50, "minimum": 6.00, "maximum": 6.38, "setting": "both", "payers_information": [ { "payer_name": "Aetna", "plan_name": "700700", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna", "plan_name": "700700_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Miscellaneous", "plan_name": "700720", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Miscellaneous", "plan_name": "700720_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Ppo Hmo", "plan_name": "701720", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Ppo Hmo", "plan_name": "701720_1", "standard_charge_percentage": 100.0, "count": 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"0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Federal", "plan_name": "400110", "standard_charge_percentage": 0.85, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Federal", "plan_name": "400110_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." } ] } ] }, { "description": "Imipramine 25 mg tablet [3861]", "drug_information": { "unit": 1.00, "type": "EA" }, "code_information": [ { "code": "69315-134-01", "type": "NDC" } ], "standard_charges": [ { "gross_charge": 7.50, "minimum": 6.00, "maximum": 6.38, "setting": "both", "payers_information": [ { "payer_name": "Aetna", "plan_name": "700700", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna", "plan_name": "700700_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Miscellaneous", "plan_name": "700720", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Miscellaneous", "plan_name": "700720_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Ppo Hmo", "plan_name": "701720", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Ppo Hmo", "plan_name": "701720_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Ms State Emplo", "plan_name": "401457", "standard_charge_percentage": 0.80, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Ms State Emplo", "plan_name": "401457_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Basic Pl", "plan_name": "400100", "standard_charge_percentage": 0.85, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Basic Pl", "plan_name": "400100_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Federal", "plan_name": "400110", "standard_charge_percentage": 0.85, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Federal", "plan_name": "400110_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." } ] } ] }, { "description": "Nifedipine 10 mg capsule [5558]", 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"plan_name": "700720_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Ppo Hmo", "plan_name": "701720", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Ppo Hmo", "plan_name": "701720_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Ms State Emplo", "plan_name": "401457", "standard_charge_percentage": 0.80, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Ms State Emplo", "plan_name": "401457_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Basic Pl", "plan_name": "400100", "standard_charge_percentage": 0.85, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Basic Pl", "plan_name": "400100_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Federal", "plan_name": "400110", "standard_charge_percentage": 0.85, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Federal", "plan_name": "400110_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." } ] } ] }, { "description": "Ciprofloxacin 0.3 % eye drops [9610]", "drug_information": { "unit": 2.50, "type": "ML" }, "code_information": [ { "code": "69315-308-02", "type": "NDC" } ], "standard_charges": [ { "gross_charge": 78.90, "minimum": 63.12, "maximum": 67.07, "setting": "both", "payers_information": [ { "payer_name": "Aetna", "plan_name": "700700", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna", "plan_name": "700700_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna 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"plan_name": "401457", "standard_charge_percentage": 0.80, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Ms State Emplo", "plan_name": "401457_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Basic Pl", "plan_name": "400100", "standard_charge_percentage": 0.85, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Basic Pl", "plan_name": "400100_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Federal", "plan_name": "400110", "standard_charge_percentage": 0.85, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Federal", "plan_name": "400110_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." } ] } ] }, { "description": "Ciprofloxacin 0.3 % eye drops [9610]", "drug_information": { "unit": 5.00, "type": "ML" }, "code_information": [ { "code": "69315-308-05", "type": "NDC" } ], "standard_charges": [ { "gross_charge": 81.08, "minimum": 64.86, "maximum": 68.92, "setting": "both", "payers_information": [ { "payer_name": "Aetna", "plan_name": "700700", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna", "plan_name": "700700_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Miscellaneous", "plan_name": "700720", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Miscellaneous", "plan_name": "700720_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Ppo Hmo", "plan_name": "701720", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Ppo Hmo", "plan_name": "701720_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Ms State Emplo", "plan_name": "401457", "standard_charge_percentage": 0.80, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Ms State Emplo", "plan_name": "401457_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Basic Pl", "plan_name": "400100", "standard_charge_percentage": 0.85, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Basic Pl", "plan_name": "400100_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Federal", "plan_name": "400110", "standard_charge_percentage": 0.85, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Federal", "plan_name": "400110_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." } ] } ] }, { "description": "Ofloxacin 0.3 % ear drops [22257]", "drug_information": { "unit": 5.00, "type": "ML" }, "code_information": [ { "code": "69315-320-05", "type": "NDC" } ], "standard_charges": [ { "gross_charge": 287.14, "minimum": 229.71, "maximum": 244.07, "setting": "both", "payers_information": [ { "payer_name": "Aetna", "plan_name": "700700", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna", "plan_name": "700700_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Miscellaneous", "plan_name": "700720", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Miscellaneous", "plan_name": "700720_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Ppo Hmo", "plan_name": "701720", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Ppo Hmo", "plan_name": "701720_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Ms State Emplo", "plan_name": "401457", "standard_charge_percentage": 0.80, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Ms State Emplo", "plan_name": "401457_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Basic Pl", "plan_name": "400100", "standard_charge_percentage": 0.85, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Basic Pl", "plan_name": "400100_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Federal", "plan_name": "400110", "standard_charge_percentage": 0.85, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Federal", "plan_name": "400110_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." } ] } ] }, { "description": "Phenylephrine 2.5 % eye drops [6246]", "drug_information": { "unit": 2.00, "type": "ML" }, "code_information": [ { "code": "69315-323-08", "type": "NDC" } ], "standard_charges": [ { "gross_charge": 162.26, "minimum": 129.81, "maximum": 137.92, "setting": "both", "payers_information": [ { "payer_name": "Aetna", "plan_name": "700700", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna", "plan_name": "700700_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Miscellaneous", "plan_name": "700720", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Miscellaneous", "plan_name": "700720_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Ppo Hmo", "plan_name": "701720", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Ppo Hmo", "plan_name": "701720_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Ms State Emplo", "plan_name": "401457", "standard_charge_percentage": 0.80, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Ms State Emplo", "plan_name": "401457_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Basic Pl", "plan_name": "400100", "standard_charge_percentage": 0.85, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Basic Pl", "plan_name": "400100_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Federal", "plan_name": "400110", "standard_charge_percentage": 0.85, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Federal", "plan_name": "400110_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." } ] } ] }, { "description": "Lorazepam 0.5 mg tablet [4572]", "drug_information": { "unit": 1.00, "type": "EA" }, "code_information": [ { "code": "69315-904-01", "type": "NDC" } ], "standard_charges": [ { "gross_charge": 7.50, "minimum": 6.00, "maximum": 6.38, "setting": "both", "payers_information": [ { "payer_name": "Aetna", "plan_name": "700700", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna", "plan_name": "700700_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Miscellaneous", "plan_name": "700720", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Miscellaneous", "plan_name": "700720_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Ppo Hmo", "plan_name": "701720", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Ppo Hmo", "plan_name": "701720_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Ms State Emplo", "plan_name": "401457", "standard_charge_percentage": 0.80, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Ms State Emplo", "plan_name": "401457_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Basic Pl", "plan_name": "400100", "standard_charge_percentage": 0.85, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Basic Pl", "plan_name": "400100_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Federal", "plan_name": "400110", "standard_charge_percentage": 0.85, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Federal", "plan_name": "400110_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." } ] } ] }, { "description": "Lorazepam 1 mg tablet [4573]", "drug_information": { "unit": 1.00, "type": "EA" }, "code_information": [ { "code": "69315-905-01", "type": "NDC" } ], "standard_charges": [ { "gross_charge": 7.50, "minimum": 6.00, "maximum": 6.38, "setting": "both", "payers_information": [ { "payer_name": "Aetna", "plan_name": "700700", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna", "plan_name": "700700_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Miscellaneous", "plan_name": "700720", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Miscellaneous", "plan_name": "700720_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Ppo Hmo", "plan_name": "701720", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Ppo Hmo", "plan_name": "701720_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Ms State Emplo", "plan_name": "401457", "standard_charge_percentage": 0.80, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Ms State Emplo", "plan_name": "401457_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Basic Pl", "plan_name": "400100", "standard_charge_percentage": 0.85, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Basic Pl", "plan_name": "400100_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Federal", "plan_name": "400110", "standard_charge_percentage": 0.85, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Federal", "plan_name": "400110_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." } ] } ] }, { "description": "Magnesium hydroxide 400 mg/5 ml oral suspension [108978]", "drug_information": { "unit": 30.00, "type": "ML" }, "code_information": [ { "code": "69339-153-01", "type": "NDC" } ], "standard_charges": [ { "gross_charge": 7.41, "minimum": 5.93, "maximum": 6.30, "setting": "both", "payers_information": [ { "payer_name": "Aetna", "plan_name": "700700", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna", "plan_name": "700700_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Miscellaneous", "plan_name": "700720", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Miscellaneous", "plan_name": "700720_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Ppo Hmo", "plan_name": "701720", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Ppo Hmo", "plan_name": "701720_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Ms State Emplo", "plan_name": "401457", "standard_charge_percentage": 0.80, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Ms State Emplo", "plan_name": "401457_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Basic Pl", "plan_name": "400100", "standard_charge_percentage": 0.85, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Basic Pl", "plan_name": "400100_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Federal", "plan_name": "400110", "standard_charge_percentage": 0.85, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Federal", "plan_name": "400110_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." } ] } ] }, { "description": "Phenobarbital 30 mg tablet (wrapped) [509000]", "drug_information": { "unit": 1.00, "type": "EA" }, "code_information": [ { "code": "69367-212-01", "type": "NDC" } ], "standard_charges": [ { "gross_charge": 7.50, "minimum": 6.00, "maximum": 6.38, "setting": "both", "payers_information": [ { "payer_name": "Aetna", "plan_name": "700700", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna", "plan_name": "700700_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Miscellaneous", "plan_name": "700720", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Miscellaneous", "plan_name": "700720_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Ppo Hmo", "plan_name": "701720", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Ppo Hmo", "plan_name": "701720_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Ms State Emplo", "plan_name": "401457", "standard_charge_percentage": 0.80, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Ms State Emplo", "plan_name": "401457_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Basic Pl", "plan_name": "400100", "standard_charge_percentage": 0.85, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Basic Pl", "plan_name": "400100_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Federal", "plan_name": "400110", "standard_charge_percentage": 0.85, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Federal", "plan_name": "400110_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." } ] } ] }, { "description": "Phenobarbital 32.4 mg tablet [6217]", "drug_information": { "unit": 1.00, "type": "EA" }, "code_information": [ { "code": "69367-212-01", "type": "NDC" } ], "standard_charges": [ { "gross_charge": 7.50, "minimum": 6.00, "maximum": 6.38, "setting": "both", "payers_information": [ { "payer_name": "Aetna", "plan_name": "700700", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna", "plan_name": "700700_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent 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charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Federal", "plan_name": "400110", "standard_charge_percentage": 0.85, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Federal", "plan_name": "400110_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." } ] } ] }, { "description": "Hydrochlorothiazide 12.5 mg capsule [19146]", "drug_information": { "unit": 1.00, "type": "EA" }, "code_information": [ { "code": "69367-219-01", "type": "NDC" } ], "standard_charges": [ { "gross_charge": 7.50, "minimum": 6.00, "maximum": 6.38, "setting": "both", "payers_information": [ { "payer_name": "Aetna", "plan_name": "700700", "standard_charge_percentage": 80.0, "count": 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"code": "69367-242-01", "type": "NDC" } ], "standard_charges": [ { "gross_charge": 7.50, "minimum": 6.00, "maximum": 6.38, "setting": "both", "payers_information": [ { "payer_name": "Aetna", "plan_name": "700700", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna", "plan_name": "700700_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Miscellaneous", "plan_name": "700720", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Miscellaneous", "plan_name": "700720_1", "standard_charge_percentage": 100.0, "count": "0", 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"standard_charge_percentage": 0.80, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Ms State Emplo", "plan_name": "401457_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Basic Pl", "plan_name": "400100", "standard_charge_percentage": 0.85, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Basic Pl", "plan_name": "400100_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Federal", "plan_name": "400110", "standard_charge_percentage": 0.85, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Federal", "plan_name": "400110_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." } ] } ] }, { "description": "Cyproheptadine 4 mg tablet [2033]", "drug_information": { "unit": 1.00, "type": "EA" }, "code_information": [ { "code": "69367-246-01", "type": "NDC" } ], "standard_charges": [ { "gross_charge": 7.50, "minimum": 6.00, "maximum": 6.38, "setting": "both", "payers_information": [ { "payer_name": "Aetna", "plan_name": "700700", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna", 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"701720_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Ms State Emplo", "plan_name": "401457", "standard_charge_percentage": 0.80, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Ms State Emplo", "plan_name": "401457_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Basic Pl", "plan_name": "400100", "standard_charge_percentage": 0.85, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Basic Pl", "plan_name": "400100_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Federal", "plan_name": "400110", "standard_charge_percentage": 0.85, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Federal", "plan_name": "400110_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." } ] } ] }, { "description": "Sodium bicarbonate 8.4 % (1 meq/ml) intravenous syringe [7309]", "drug_information": { "unit": 50.00, "type": "ML" }, "code_information": [ { "code": "69374-214-50", "type": "NDC" } ], "standard_charges": [ { "gross_charge": 55.00, "minimum": 44.00, "maximum": 46.75, "setting": 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"payer_name": "Aetna Ppo Hmo", "plan_name": "701720", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Ppo Hmo", "plan_name": "701720_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Ms State Emplo", "plan_name": "401457", "standard_charge_percentage": 0.80, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Ms State Emplo", "plan_name": "401457_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Basic Pl", "plan_name": "400100", "standard_charge_percentage": 0.85, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Basic Pl", "plan_name": "400100_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Federal", "plan_name": "400110", "standard_charge_percentage": 0.85, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Federal", "plan_name": "400110_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." } ] } ] }, { "description": "Lidocaine 20 mg/ml (2 %) nebulization solution [500805]", "drug_information": { "unit": 5.00, "type": "ML" }, "code_information": [ { "code": "69374-949-35", "type": "NDC" } ], "standard_charges": [ { "gross_charge": 23.75, "minimum": 19.00, "maximum": 20.19, "setting": "both", "payers_information": [ { "payer_name": "Aetna", "plan_name": "700700", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna", "plan_name": "700700_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Miscellaneous", "plan_name": "700720", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data 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allowed amounts." }, { "payer_name": "Bc/Bs Ms State Emplo", "plan_name": "401457_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Basic Pl", "plan_name": "400100", "standard_charge_percentage": 0.85, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Basic Pl", "plan_name": "400100_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Federal", "plan_name": "400110", "standard_charge_percentage": 0.85, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate 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80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna", "plan_name": "700700_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Miscellaneous", "plan_name": "700720", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Miscellaneous", "plan_name": "700720_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Ppo Hmo", "plan_name": "701720", "standard_charge_percentage": 80.0, "count": "0", 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"standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Basic Pl", "plan_name": "400100", "standard_charge_percentage": 0.85, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Basic Pl", "plan_name": "400100_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Federal", "plan_name": "400110", "standard_charge_percentage": 0.85, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Federal", "plan_name": "400110_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." } ] } ] }, { "description": "Ropinirole 0.25 mg tablet [21688]", "drug_information": { "unit": 1.00, "type": "EA" }, "code_information": [ { "code": "69452-356-20", "type": "NDC" } ], "standard_charges": [ { "gross_charge": 7.50, "minimum": 6.00, "maximum": 6.38, "setting": "both", "payers_information": [ { "payer_name": "Aetna", "plan_name": "700700", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna", "plan_name": "700700_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Miscellaneous", "plan_name": "700720", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Miscellaneous", "plan_name": "700720_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Ppo Hmo", "plan_name": "701720", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Ppo Hmo", "plan_name": "701720_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Ms State Emplo", "plan_name": "401457", "standard_charge_percentage": 0.80, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Ms State Emplo", "plan_name": "401457_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Basic Pl", "plan_name": "400100", "standard_charge_percentage": 0.85, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Basic Pl", "plan_name": "400100_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Federal", "plan_name": "400110", "standard_charge_percentage": 0.85, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Federal", "plan_name": "400110_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." } ] } ] }, { "description": "Ropinirole 0.5 mg tablet [21800]", "drug_information": { "unit": 1.00, "type": "EA" }, "code_information": [ { "code": "69452-357-20", "type": "NDC" } ], "standard_charges": [ { "gross_charge": 7.50, "minimum": 6.00, "maximum": 6.38, "setting": "both", "payers_information": [ { "payer_name": "Aetna", "plan_name": "700700", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna", "plan_name": "700700_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Miscellaneous", "plan_name": "700720", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Miscellaneous", "plan_name": "700720_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Ppo Hmo", "plan_name": "701720", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Ppo Hmo", "plan_name": "701720_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Ms State Emplo", "plan_name": "401457", "standard_charge_percentage": 0.80, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Ms State Emplo", "plan_name": "401457_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Basic Pl", "plan_name": "400100", "standard_charge_percentage": 0.85, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Basic Pl", "plan_name": "400100_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Federal", "plan_name": "400110", "standard_charge_percentage": 0.85, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Federal", "plan_name": "400110_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." } ] } ] }, { "description": "Ibandronate 150 mg tablet [41063]", "drug_information": { "unit": 1.00, "type": "EA" }, "code_information": [ { "code": "69452-378-74", "type": "NDC" } ], "standard_charges": [ { "gross_charge": 45.03, "minimum": 36.02, "maximum": 38.28, "setting": "both", "payers_information": [ { "payer_name": "Aetna", "plan_name": "700700", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna", "plan_name": "700700_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Miscellaneous", "plan_name": "700720", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Miscellaneous", "plan_name": "700720_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Ppo Hmo", "plan_name": "701720", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Ppo Hmo", "plan_name": "701720_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Ms State Emplo", "plan_name": "401457", "standard_charge_percentage": 0.80, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Ms State Emplo", "plan_name": "401457_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Basic Pl", "plan_name": "400100", "standard_charge_percentage": 0.85, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Basic Pl", "plan_name": "400100_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Federal", "plan_name": "400110", "standard_charge_percentage": 0.85, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Federal", "plan_name": "400110_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." } ] } ] }, { "description": "Olanzapine 5 mg tablet [17936]", "drug_information": { "unit": 1.00, "type": "EA" }, "code_information": [ { "code": "69543-381-30", "type": "NDC" } ], "standard_charges": [ { "gross_charge": 7.50, "minimum": 6.00, "maximum": 6.38, "setting": "both", "payers_information": [ { "payer_name": "Aetna", "plan_name": "700700", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna", "plan_name": "700700_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Miscellaneous", "plan_name": "700720", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Miscellaneous", "plan_name": "700720_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Ppo Hmo", "plan_name": "701720", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Ppo Hmo", "plan_name": "701720_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Ms State Emplo", "plan_name": "401457", "standard_charge_percentage": 0.80, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Ms State Emplo", "plan_name": "401457_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Basic Pl", "plan_name": "400100", "standard_charge_percentage": 0.85, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Basic Pl", "plan_name": "400100_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Federal", "plan_name": "400110", "standard_charge_percentage": 0.85, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Federal", "plan_name": "400110_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." } ] } ] }, { "description": "Buspirone 15 mg tablet [17464]", "drug_information": { "unit": 1.00, "type": "EA" }, "code_information": [ { "code": "69584-093-10", "type": "NDC" } ], "standard_charges": [ { "gross_charge": 7.50, "minimum": 6.00, "maximum": 6.38, "setting": "both", "payers_information": [ { "payer_name": "Aetna", "plan_name": "700700", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna", "plan_name": "700700_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Miscellaneous", "plan_name": "700720", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Miscellaneous", "plan_name": "700720_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Ppo Hmo", "plan_name": "701720", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Ppo Hmo", "plan_name": "701720_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Ms State Emplo", "plan_name": "401457", "standard_charge_percentage": 0.80, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Ms State Emplo", "plan_name": "401457_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Basic Pl", "plan_name": "400100", "standard_charge_percentage": 0.85, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Basic Pl", "plan_name": "400100_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Federal", "plan_name": "400110", "standard_charge_percentage": 0.85, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Federal", "plan_name": "400110_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." } ] } ] }, { "description": "Carisoprodol 350 mg tablet [1395]", "drug_information": { "unit": 1.00, "type": "EA" }, "code_information": [ { "code": "69584-111-10", "type": "NDC" } ], "standard_charges": [ { "gross_charge": 7.50, "minimum": 6.00, "maximum": 6.38, "setting": "both", "payers_information": [ { "payer_name": "Aetna", "plan_name": "700700", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna", "plan_name": "700700_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Miscellaneous", "plan_name": "700720", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Miscellaneous", "plan_name": "700720_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Ppo Hmo", "plan_name": "701720", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Ppo Hmo", "plan_name": "701720_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Ms State Emplo", "plan_name": "401457", "standard_charge_percentage": 0.80, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Ms State Emplo", "plan_name": "401457_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Basic Pl", "plan_name": "400100", "standard_charge_percentage": 0.85, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Basic Pl", "plan_name": "400100_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Federal", "plan_name": "400110", "standard_charge_percentage": 0.85, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Federal", "plan_name": "400110_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." } ] } ] }, { "description": "Methocarbamol 500 mg tablet [4971]", "drug_information": { "unit": 1.00, "type": "EA" }, "code_information": [ { "code": "69584-611-10", "type": "NDC" } ], "standard_charges": [ { "gross_charge": 7.50, "minimum": 6.00, "maximum": 6.38, "setting": "both", "payers_information": [ { "payer_name": "Aetna", "plan_name": "700700", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna", "plan_name": "700700_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Miscellaneous", "plan_name": "700720", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Miscellaneous", "plan_name": "700720_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Ppo Hmo", "plan_name": "701720", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Ppo Hmo", "plan_name": "701720_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Ms State Emplo", "plan_name": "401457", "standard_charge_percentage": 0.80, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Ms State Emplo", "plan_name": "401457_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Basic Pl", "plan_name": "400100", "standard_charge_percentage": 0.85, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Basic Pl", "plan_name": "400100_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Federal", "plan_name": "400110", "standard_charge_percentage": 0.85, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Federal", "plan_name": "400110_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." } ] } ] }, { "description": "Meclizine 12.5 mg tablet [12024]", "drug_information": { "unit": 1.00, "type": "EA" }, "code_information": [ { "code": "69618-027-01", "type": "NDC" } ], "standard_charges": [ { "gross_charge": 1.00, "minimum": 0.80, "maximum": 0.85, "setting": "both", "payers_information": [ { "payer_name": "Aetna", "plan_name": "700700", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna", "plan_name": "700700_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Miscellaneous", "plan_name": "700720", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Miscellaneous", "plan_name": "700720_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Ppo Hmo", "plan_name": "701720", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Ppo Hmo", "plan_name": "701720_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Ms State Emplo", "plan_name": "401457", "standard_charge_percentage": 0.80, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Ms State Emplo", "plan_name": "401457_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Basic Pl", "plan_name": "400100", "standard_charge_percentage": 0.85, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Basic Pl", "plan_name": "400100_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Federal", "plan_name": "400110", "standard_charge_percentage": 0.85, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Federal", "plan_name": "400110_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." } ] } ] }, { "description": "Simethicone 125 mg chewable tablet [7226]", "drug_information": { "unit": 1.00, "type": "EA" }, "code_information": [ { "code": "69618-032-06", "type": "NDC" } ], "standard_charges": [ { "gross_charge": 1.00, "minimum": 0.80, "maximum": 0.85, "setting": "both", "payers_information": [ { "payer_name": "Aetna", "plan_name": "700700", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna", "plan_name": "700700_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Miscellaneous", "plan_name": "700720", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Miscellaneous", "plan_name": "700720_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Ppo Hmo", "plan_name": "701720", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Ppo Hmo", "plan_name": "701720_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Ms State Emplo", "plan_name": "401457", "standard_charge_percentage": 0.80, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Ms State Emplo", "plan_name": "401457_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Basic Pl", "plan_name": "400100", "standard_charge_percentage": 0.85, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Basic Pl", "plan_name": "400100_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Federal", "plan_name": "400110", "standard_charge_percentage": 0.85, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Federal", "plan_name": "400110_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." } ] } ] }, { "description": "Simethicone 80 mg chewable tablet [7227]", "drug_information": { "unit": 1.00, "type": "EA" }, "code_information": [ { "code": "69618-033-01", "type": "NDC" } ], "standard_charges": [ { "gross_charge": 1.00, "minimum": 0.80, "maximum": 0.85, "setting": "both", "payers_information": [ { "payer_name": "Aetna", "plan_name": "700700", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna", "plan_name": "700700_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Miscellaneous", "plan_name": "700720", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Miscellaneous", "plan_name": "700720_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Ppo Hmo", "plan_name": "701720", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Ppo Hmo", "plan_name": "701720_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Ms State Emplo", "plan_name": "401457", "standard_charge_percentage": 0.80, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Ms State Emplo", "plan_name": "401457_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Basic Pl", "plan_name": "400100", "standard_charge_percentage": 0.85, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Basic Pl", "plan_name": "400100_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Federal", "plan_name": "400110", "standard_charge_percentage": 0.85, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Federal", "plan_name": "400110_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." } ] } ] }, { "description": "Sennosides 8.6 mg tablet [11349]", "drug_information": { "unit": 1.00, "type": "EA" }, "code_information": [ { "code": "69618-048-01", "type": "NDC" } ], 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"additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Basic Pl", "plan_name": "400100", "standard_charge_percentage": 0.85, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Basic Pl", "plan_name": "400100_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Federal", "plan_name": "400110", "standard_charge_percentage": 0.85, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Federal", "plan_name": "400110_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." } ] } ] }, { "description": "Sennosides 8.6 mg tablet [11349]", "drug_information": { "unit": 1.00, "type": "EA" }, "code_information": [ { "code": "69618-064-01", "type": "NDC" } ], "standard_charges": [ { "gross_charge": 1.00, "minimum": 0.80, "maximum": 0.85, "setting": "both", "payers_information": [ { "payer_name": "Aetna", "plan_name": "700700", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna", "plan_name": "700700_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Miscellaneous", "plan_name": "700720", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Miscellaneous", "plan_name": "700720_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Ppo Hmo", "plan_name": "701720", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Ppo Hmo", "plan_name": "701720_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Ms State Emplo", "plan_name": "401457", "standard_charge_percentage": 0.80, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Ms State Emplo", "plan_name": "401457_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Basic Pl", "plan_name": "400100", "standard_charge_percentage": 0.85, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Basic Pl", "plan_name": "400100_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Federal", "plan_name": "400110", "standard_charge_percentage": 0.85, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Federal", "plan_name": "400110_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." } ] } ] }, { "description": "Sennosides 8.6 mg-docusate sodium 50 mg tablet [24216]", "drug_information": { "unit": 1.00, "type": "EA" }, "code_information": [ { "code": "69618-065-01", "type": "NDC" } ], "standard_charges": [ { "gross_charge": 1.00, "minimum": 0.80, "maximum": 0.85, "setting": "both", "payers_information": [ { "payer_name": "Aetna", "plan_name": "700700", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna", "plan_name": "700700_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Miscellaneous", "plan_name": "700720", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Miscellaneous", "plan_name": "700720_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Ppo Hmo", "plan_name": "701720", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Ppo Hmo", "plan_name": "701720_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Ms State Emplo", "plan_name": "401457", "standard_charge_percentage": 0.80, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Ms State Emplo", "plan_name": "401457_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Basic Pl", "plan_name": "400100", "standard_charge_percentage": 0.85, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Basic Pl", "plan_name": "400100_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Federal", "plan_name": "400110", "standard_charge_percentage": 0.85, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Federal", "plan_name": "400110_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." } ] } ] }, { "description": "Aspirin 81 mg tabletdelayed release [688]", "drug_information": { "unit": 1.00, "type": "EA" }, "code_information": [ { "code": "69618-066-02", "type": "NDC" } ], "standard_charges": [ { "gross_charge": 1.00, "minimum": 0.80, "maximum": 0.85, "setting": "both", "payers_information": [ { "payer_name": "Aetna", "plan_name": "700700", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna", "plan_name": "700700_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Miscellaneous", "plan_name": "700720", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Miscellaneous", "plan_name": "700720_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Ppo Hmo", "plan_name": "701720", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Ppo Hmo", "plan_name": "701720_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Ms State Emplo", "plan_name": "401457", "standard_charge_percentage": 0.80, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Ms State Emplo", "plan_name": "401457_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Basic Pl", "plan_name": "400100", "standard_charge_percentage": 0.85, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Basic Pl", "plan_name": "400100_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Federal", "plan_name": "400110", "standard_charge_percentage": 0.85, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Federal", "plan_name": "400110_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." } ] } ] }, { "description": "Guaifenesin 100 mg/5 ml oral liquid [3542]", "drug_information": { "unit": 118.00, "type": "ML" }, "code_information": [ { "code": "69618-068-54", "type": "NDC" } ], "standard_charges": [ { "gross_charge": 7.06, "minimum": 5.65, "maximum": 6.00, "setting": "both", "payers_information": [ { "payer_name": "Aetna", "plan_name": "700700", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna", "plan_name": "700700_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Miscellaneous", "plan_name": "700720", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Miscellaneous", "plan_name": "700720_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Ppo Hmo", "plan_name": "701720", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Ppo Hmo", "plan_name": "701720_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Ms State Emplo", "plan_name": "401457", "standard_charge_percentage": 0.80, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Ms State Emplo", "plan_name": "401457_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Basic Pl", "plan_name": "400100", "standard_charge_percentage": 0.85, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Basic Pl", "plan_name": "400100_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Federal", "plan_name": "400110", "standard_charge_percentage": 0.85, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Federal", "plan_name": "400110_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." } ] } ] }, { "description": "Multivit and minerals-ferrous gluconate 9 mg iron/15 ml oral liquid [119617]", "drug_information": { "unit": 236.00, "type": "ML" }, "code_information": [ { "code": "6961800858", "type": "NDC" } ], "standard_charges": [ { "gross_charge": 21.30, "minimum": 17.04, "maximum": 18.11, "setting": "both", "payers_information": [ { "payer_name": "Aetna", "plan_name": "700700", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna", "plan_name": "700700_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to 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"payer_name": "Aetna Ppo Hmo", "plan_name": "701720", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Ppo Hmo", "plan_name": "701720_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Ms State Emplo", "plan_name": "401457", "standard_charge_percentage": 0.80, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Ms State Emplo", "plan_name": "401457_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Basic Pl", "plan_name": "400100", "standard_charge_percentage": 0.85, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Basic Pl", "plan_name": "400100_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Federal", "plan_name": "400110", "standard_charge_percentage": 0.85, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Federal", "plan_name": "400110_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." } ] } ] }, { "description": "Oxymetazoline 0.05 % nasal spray [5943]", "drug_information": { "unit": 30.00, "type": "ML" }, "code_information": [ { "code": "7003013360", "type": "NDC" } ], "standard_charges": [ { "gross_charge": 30.64, "minimum": 24.51, "maximum": 26.04, "setting": "both", "payers_information": [ { "payer_name": "Aetna", "plan_name": "700700", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna", "plan_name": "700700_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Miscellaneous", "plan_name": "700720", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate 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}, { "payer_name": "Bc/Bs Ms State Emplo", "plan_name": "401457_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Basic Pl", "plan_name": "400100", "standard_charge_percentage": 0.85, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Basic Pl", "plan_name": "400100_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Federal", "plan_name": "400110", "standard_charge_percentage": 0.85, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Federal", "plan_name": "400110_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." } ] } ] }, { "description": "Miconazole nitrate 2 % vaginal cream [5040]", "drug_information": { "unit": 45.00, "type": "GR" }, "code_information": [ { "code": "7003013422", "type": "NDC" } ], "standard_charges": [ { "gross_charge": 12.99, "minimum": 10.39, "maximum": 11.04, "setting": "both", "payers_information": [ { "payer_name": "Aetna", "plan_name": "700700", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna", "plan_name": "700700_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data 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allowed amounts." }, { "payer_name": "Bc/Bs Ms State Emplo", "plan_name": "401457", "standard_charge_percentage": 0.80, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Ms State Emplo", "plan_name": "401457_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Basic Pl", "plan_name": "400100", "standard_charge_percentage": 0.85, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Basic Pl", "plan_name": "400100_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Federal", "plan_name": "400110", "standard_charge_percentage": 0.85, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Federal", "plan_name": "400110_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." } ] } ] }, { "description": "Oxymetazoline 0.05 % nasal spray [5943]", "drug_information": { "unit": 30.00, "type": "ML" }, "code_information": [ { "code": "7003013995", "type": "NDC" } ], "standard_charges": [ { "gross_charge": 7.50, "minimum": 6.00, "maximum": 6.38, "setting": "both", "payers_information": [ { "payer_name": "Aetna", "plan_name": "700700", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna", "plan_name": "700700_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Miscellaneous", "plan_name": "700720", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Miscellaneous", "plan_name": "700720_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Ppo Hmo", "plan_name": "701720", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data 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calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Basic Pl", "plan_name": "400100_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Federal", "plan_name": "400110", "standard_charge_percentage": 0.85, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Federal", "plan_name": "400110_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." } ] } ] }, { "description": "Phenylephrine 10 mg tablet [40368]", "drug_information": { "unit": 1.00, "type": "EA" }, "code_information": [ { "code": "7003014739", "type": "NDC" } ], "standard_charges": [ { "gross_charge": 7.50, "minimum": 6.00, "maximum": 6.38, "setting": "both", "payers_information": [ { "payer_name": "Aetna", "plan_name": "700700", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna", "plan_name": "700700_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Miscellaneous", "plan_name": "700720", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Miscellaneous", "plan_name": "700720_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Ppo Hmo", "plan_name": "701720", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Ppo Hmo", "plan_name": "701720_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Ms State Emplo", "plan_name": "401457", "standard_charge_percentage": 0.80, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Ms State Emplo", "plan_name": "401457_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Basic Pl", "plan_name": "400100", "standard_charge_percentage": 0.85, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Basic Pl", "plan_name": "400100_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Federal", "plan_name": "400110", "standard_charge_percentage": 0.85, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Federal", "plan_name": "400110_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." } ] } ] }, { "description": "Famotidine 20 mg tablet [10011]", "drug_information": { "unit": 1.00, "type": "EA" }, "code_information": [ { "code": "7003014828", "type": "NDC" } ], "standard_charges": [ { "gross_charge": 1.00, "minimum": 0.80, "maximum": 0.85, "setting": "both", "payers_information": [ { "payer_name": "Aetna", "plan_name": "700700", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna", "plan_name": "700700_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Miscellaneous", "plan_name": "700720", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Miscellaneous", "plan_name": "700720_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Ppo Hmo", "plan_name": "701720", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Ppo Hmo", "plan_name": "701720_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Ms State Emplo", "plan_name": "401457", "standard_charge_percentage": 0.80, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Ms State Emplo", "plan_name": "401457_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Basic Pl", "plan_name": "400100", "standard_charge_percentage": 0.85, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Basic Pl", "plan_name": "400100_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Federal", "plan_name": "400110", "standard_charge_percentage": 0.85, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Federal", "plan_name": "400110_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." } ] } ] }, { "description": "Pyrethrins 0.33 %-piperonyl butoxide 4 % shampoo [11236]", "drug_information": { "unit": 118.00, "type": "ML" }, "code_information": [ { "code": "7003014843", "type": "NDC" } ], "standard_charges": [ { "gross_charge": 22.98, "minimum": 18.38, "maximum": 19.53, "setting": "both", "payers_information": [ { "payer_name": "Aetna", "plan_name": "700700", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna", "plan_name": "700700_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Miscellaneous", "plan_name": "700720", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Miscellaneous", "plan_name": "700720_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Ppo Hmo", "plan_name": "701720", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Ppo Hmo", "plan_name": "701720_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Ms State Emplo", "plan_name": "401457", "standard_charge_percentage": 0.80, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Ms State Emplo", "plan_name": "401457_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Basic Pl", "plan_name": "400100", "standard_charge_percentage": 0.85, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Basic Pl", "plan_name": "400100_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": 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"standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Ms State Emplo", "plan_name": "401457", "standard_charge_percentage": 0.80, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Ms State Emplo", "plan_name": "401457_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Basic Pl", "plan_name": "400100", "standard_charge_percentage": 0.85, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Basic Pl", "plan_name": "400100_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Federal", "plan_name": "400110", "standard_charge_percentage": 0.85, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Federal", "plan_name": "400110_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." } ] } ] }, { "description": "Hyoscyamine sulfate 0.125 mg tablet [3783]", "drug_information": { "unit": 1.00, "type": "EA" }, "code_information": [ { "code": "70156-104-01", "type": "NDC" } ], "standard_charges": [ { "gross_charge": 7.50, "minimum": 6.00, "maximum": 6.38, "setting": "both", "payers_information": [ { 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"plan_name": "701720", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Ppo Hmo", "plan_name": "701720_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Ms State Emplo", "plan_name": "401457", "standard_charge_percentage": 0.80, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Ms State Emplo", "plan_name": "401457_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Basic Pl", 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100 mg tablet12 hr sustained-release [18385]", "drug_information": { "unit": 1.00, "type": "EA" }, "code_information": [ { "code": "70436-058-01", "type": "NDC" } ], "standard_charges": [ { "gross_charge": 7.50, "minimum": 6.00, "maximum": 6.38, "setting": "both", "payers_information": [ { "payer_name": "Aetna", "plan_name": "700700", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna", "plan_name": "700700_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Miscellaneous", "plan_name": "700720", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed 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"payer_name": "Bc/Bs Ms State Emplo", "plan_name": "401457_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Basic Pl", "plan_name": "400100", "standard_charge_percentage": 0.85, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Basic Pl", "plan_name": "400100_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Federal", "plan_name": "400110", "standard_charge_percentage": 0.85, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Federal", "plan_name": "400110_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." } ] } ] }, { "description": "Tolterodine er 2 mg capsuleextended release 24 hr [29434]", "drug_information": { "unit": 1.00, "type": "EA" }, "code_information": [ { "code": "70436-160-04", "type": "NDC" } ], "standard_charges": [ { "gross_charge": 7.50, "minimum": 6.00, "maximum": 6.38, "setting": "both", "payers_information": [ { "payer_name": "Aetna", "plan_name": "700700", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna", "plan_name": "700700_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient 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calculate allowed amounts." }, { "payer_name": "Bc/Bs Ms State Emplo", "plan_name": "401457", "standard_charge_percentage": 0.80, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Ms State Emplo", "plan_name": "401457_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Basic Pl", "plan_name": "400100", "standard_charge_percentage": 0.85, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Basic Pl", "plan_name": "400100_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Federal", "plan_name": "400110", "standard_charge_percentage": 0.85, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Federal", "plan_name": "400110_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." } ] } ] }, { "description": "Oseltamivir 6 mg/ml oral suspension [151808]", "drug_information": { "unit": 60.00, "type": "ML" }, "code_information": [ { "code": "70710-1165-6", "type": "NDC" } ], "standard_charges": [ { "gross_charge": 461.99, "minimum": 369.59, "maximum": 392.69, "setting": "both", "payers_information": [ { "payer_name": "Aetna", "plan_name": "700700", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna", "plan_name": "700700_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Miscellaneous", "plan_name": "700720", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Miscellaneous", "plan_name": "700720_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Ppo Hmo", "plan_name": "701720", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Ppo Hmo", "plan_name": "701720_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Ms State Emplo", "plan_name": "401457", "standard_charge_percentage": 0.80, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Ms State Emplo", "plan_name": "401457_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Basic Pl", "plan_name": "400100", "standard_charge_percentage": 0.85, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Basic Pl", "plan_name": "400100_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Federal", "plan_name": "400110", "standard_charge_percentage": 0.85, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Federal", "plan_name": "400110_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." } ] } ] }, { "description": "Clobetasol 0.05 % topical ointment [9631]", "drug_information": { "unit": 30.00, "type": "GR" }, "code_information": [ { "code": "70710-1401-2", "type": "NDC" } ], "standard_charges": [ { "gross_charge": 266.05, "minimum": 212.84, "maximum": 226.14, "setting": "both", "payers_information": [ { "payer_name": "Aetna", "plan_name": "700700", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna", "plan_name": "700700_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Miscellaneous", "plan_name": "700720", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Miscellaneous", "plan_name": "700720_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Ppo Hmo", "plan_name": "701720", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Ppo Hmo", "plan_name": "701720_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Ms State Emplo", "plan_name": "401457", "standard_charge_percentage": 0.80, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Ms State Emplo", "plan_name": "401457_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Basic Pl", "plan_name": "400100", "standard_charge_percentage": 0.85, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Basic Pl", "plan_name": "400100_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Federal", "plan_name": "400110", "standard_charge_percentage": 0.85, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Federal", "plan_name": "400110_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." } ] } ] }, { "description": "Verapamil 2.5 mg/ml intravenous solution [8527]", "drug_information": { "unit": 2.00, "type": "ML" }, "code_information": [ { "code": "70710-1643-1", "type": "NDC" } ], "standard_charges": [ { "gross_charge": 87.23, "minimum": 69.78, "maximum": 74.15, "setting": "both", "payers_information": [ { "payer_name": "Aetna", "plan_name": "700700", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna", "plan_name": "700700_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Miscellaneous", "plan_name": "700720", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Miscellaneous", "plan_name": "700720_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Ppo Hmo", "plan_name": "701720", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Ppo Hmo", "plan_name": "701720_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Ms State Emplo", "plan_name": "401457", "standard_charge_percentage": 0.80, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Ms State Emplo", "plan_name": "401457_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Basic Pl", "plan_name": "400100", "standard_charge_percentage": 0.85, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Basic Pl", "plan_name": "400100_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Federal", "plan_name": "400110", "standard_charge_percentage": 0.85, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Federal", "plan_name": "400110_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." } ] } ] }, { "description": "Verapamil 2.5 mg/ml intravenous solution [8527]", "drug_information": { "unit": 2.00, "type": "ML" }, "code_information": [ { "code": "70710-1643-7", "type": "NDC" } ], "standard_charges": [ { "gross_charge": 311.66, "minimum": 249.33, "maximum": 264.91, "setting": "both", "payers_information": [ { "payer_name": "Aetna", "plan_name": "700700", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna", "plan_name": "700700_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Miscellaneous", "plan_name": "700720", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Miscellaneous", "plan_name": "700720_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Ppo Hmo", "plan_name": "701720", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Ppo Hmo", "plan_name": "701720_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Ms State Emplo", "plan_name": "401457", "standard_charge_percentage": 0.80, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Ms State Emplo", "plan_name": "401457_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Basic Pl", "plan_name": "400100", "standard_charge_percentage": 0.85, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Basic Pl", "plan_name": "400100_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Federal", "plan_name": "400110", "standard_charge_percentage": 0.85, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Federal", "plan_name": "400110_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." } ] } ] }, { "description": "Phenylephrine 10 % eye drops [19636]", "drug_information": { "unit": 5.00, "type": "ML" }, "code_information": [ { "code": "70756-614-30", "type": "NDC" } ], "standard_charges": [ { "gross_charge": 190.05, "minimum": 152.04, "maximum": 161.54, "setting": "both", "payers_information": [ { "payer_name": "Aetna", "plan_name": "700700", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna", "plan_name": "700700_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Miscellaneous", "plan_name": "700720", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Miscellaneous", "plan_name": "700720_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Ppo Hmo", "plan_name": "701720", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Ppo Hmo", "plan_name": "701720_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Ms State Emplo", "plan_name": "401457", "standard_charge_percentage": 0.80, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Ms State Emplo", "plan_name": "401457_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Basic Pl", "plan_name": "400100", "standard_charge_percentage": 0.85, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Basic Pl", "plan_name": "400100_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Federal", "plan_name": "400110", "standard_charge_percentage": 0.85, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Federal", "plan_name": "400110_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." } ] } ] }, { "description": "Phenylephrine 2.5 % eye drops [6246]", "drug_information": { "unit": 15.00, "type": "ML" }, "code_information": [ { "code": "70756-649-35", "type": "NDC" } ], "standard_charges": [ { "gross_charge": 798.07, "minimum": 638.46, "maximum": 678.36, "setting": "both", "payers_information": [ { "payer_name": "Aetna", "plan_name": "700700", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna", "plan_name": "700700_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Miscellaneous", "plan_name": "700720", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Miscellaneous", "plan_name": "700720_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Ppo Hmo", "plan_name": "701720", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Ppo Hmo", "plan_name": "701720_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Ms State Emplo", "plan_name": "401457", "standard_charge_percentage": 0.80, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Ms State Emplo", "plan_name": "401457_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Basic Pl", "plan_name": "400100", "standard_charge_percentage": 0.85, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Basic Pl", "plan_name": "400100_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Federal", "plan_name": "400110", "standard_charge_percentage": 0.85, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Federal", "plan_name": "400110_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." } ] } ] }, { "description": "Diltiazem 5 mg/ml intravenous solution [9869]", "drug_information": { "unit": 10.00, "type": "ML" }, "code_information": [ { "code": "70860-301-10", "type": "NDC" } ], "standard_charges": [ { "gross_charge": 23.80, "minimum": 19.04, "maximum": 20.23, "setting": "both", "payers_information": [ { "payer_name": "Aetna", "plan_name": "700700", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna", "plan_name": "700700_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Miscellaneous", "plan_name": "700720", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Miscellaneous", "plan_name": "700720_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Ppo Hmo", "plan_name": "701720", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Ppo Hmo", "plan_name": "701720_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Ms State Emplo", "plan_name": "401457", "standard_charge_percentage": 0.80, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Ms State Emplo", "plan_name": "401457_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Basic Pl", "plan_name": "400100", "standard_charge_percentage": 0.85, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Basic Pl", "plan_name": "400100_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Federal", "plan_name": "400110", "standard_charge_percentage": 0.85, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Federal", "plan_name": "400110_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." } ] } ] }, { "description": "Diltiazem 5 mg/ml intravenous solution [9869]", "drug_information": { "unit": 10.00, "type": "ML" }, "code_information": [ { "code": "70860-301-42", "type": "NDC" } ], "standard_charges": [ { "gross_charge": 23.80, "minimum": 19.04, "maximum": 20.23, "setting": "both", "payers_information": [ { "payer_name": "Aetna", "plan_name": "700700", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna", "plan_name": "700700_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Miscellaneous", "plan_name": "700720", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Miscellaneous", "plan_name": "700720_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Ppo Hmo", "plan_name": "701720", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Ppo Hmo", "plan_name": "701720_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Ms State Emplo", "plan_name": "401457", "standard_charge_percentage": 0.80, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Ms State Emplo", "plan_name": "401457_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Basic Pl", "plan_name": "400100", "standard_charge_percentage": 0.85, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Basic Pl", "plan_name": "400100_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Federal", "plan_name": "400110", "standard_charge_percentage": 0.85, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Federal", "plan_name": "400110_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." } ] } ] }, { "description": "Dexmedetomidine 100 mcg/ml intravenous solution [27103]", "drug_information": { "unit": 2.00, "type": "ML" }, "code_information": [ { "code": "70860-605-03", "type": "NDC" } ], "standard_charges": [ { "gross_charge": 30.00, "minimum": 24.00, "maximum": 25.50, "setting": "both", "payers_information": [ { "payer_name": "Aetna", "plan_name": "700700", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna", "plan_name": "700700_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Miscellaneous", "plan_name": "700720", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Miscellaneous", "plan_name": "700720_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Ppo Hmo", "plan_name": "701720", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Ppo Hmo", "plan_name": "701720_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Ms State Emplo", "plan_name": "401457", "standard_charge_percentage": 0.80, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Ms State Emplo", "plan_name": "401457_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Basic Pl", "plan_name": "400100", "standard_charge_percentage": 0.85, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Basic Pl", "plan_name": "400100_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Federal", "plan_name": "400110", "standard_charge_percentage": 0.85, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Federal", "plan_name": "400110_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." } ] } ] }, { "description": "Dexmedetomidine 100 mcg/ml intravenous solution [27103]", "drug_information": { "unit": 2.00, "type": "ML" }, "code_information": [ { "code": "70860-605-41", "type": "NDC" } ], "standard_charges": [ { "gross_charge": 30.00, "minimum": 24.00, "maximum": 25.50, "setting": "both", "payers_information": [ { "payer_name": "Aetna", "plan_name": "700700", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna", "plan_name": "700700_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Miscellaneous", "plan_name": "700720", "standard_charge_percentage": 80.0, "count": "0", 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"payer_name": "Bc/Bs Of Ms Federal", "plan_name": "400110", "standard_charge_percentage": 0.85, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Federal", "plan_name": "400110_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." } ] } ] }, { "description": "Lidocaine 1 %-phenylephrine 1.5 % in sterile water intraocular soln [183219]", "drug_information": { "unit": 1.00, "type": "ML" }, "code_information": [ { "code": "71449-090-42", "type": "NDC" } ], "standard_charges": [ { "gross_charge": 115.00, "minimum": 92.00, "maximum": 97.75, "setting": "both", "payers_information": [ { "payer_name": "Aetna", "plan_name": "700700", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna", "plan_name": "700700_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Miscellaneous", "plan_name": "700720", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Miscellaneous", "plan_name": "700720_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Ppo Hmo", "plan_name": "701720", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Ppo Hmo", "plan_name": "701720_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Ms State Emplo", "plan_name": "401457", "standard_charge_percentage": 0.80, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Ms State Emplo", "plan_name": "401457_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Basic Pl", "plan_name": "400100", "standard_charge_percentage": 0.85, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Basic Pl", "plan_name": "400100_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Federal", "plan_name": "400110", "standard_charge_percentage": 0.85, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Federal", "plan_name": "400110_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." } ] } ] }, { "description": "Cyclopentolate 1 %-tropicam 1 %-phenylephrine 2.5 % in water eye drops [179727]", "drug_information": { "unit": 5.00, "type": "ML" }, "code_information": [ { "code": "71449-092-46", "type": "NDC" } ], "standard_charges": [ { "gross_charge": 270.75, "minimum": 216.60, "maximum": 230.14, "setting": "both", "payers_information": [ { "payer_name": "Aetna", "plan_name": "700700", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna", "plan_name": "700700_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Miscellaneous", "plan_name": "700720", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Miscellaneous", "plan_name": "700720_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Ppo Hmo", "plan_name": "701720", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Ppo Hmo", "plan_name": "701720_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Ms State Emplo", "plan_name": "401457", "standard_charge_percentage": 0.80, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Ms State Emplo", "plan_name": "401457_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Basic Pl", "plan_name": "400100", "standard_charge_percentage": 0.85, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Basic Pl", "plan_name": "400100_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Federal", "plan_name": "400110", "standard_charge_percentage": 0.85, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Federal", "plan_name": "400110_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." } ] } ] }, { "description": "Potassium iodide 1 gram/ml oral solution [6445]", "drug_information": { "unit": 30.00, "type": "ML" }, "code_information": [ { "code": "71740-112-30", "type": "NDC" } ], "standard_charges": [ { "gross_charge": 2042.45, "minimum": 1633.96, "maximum": 1736.08, "setting": "both", "payers_information": [ { "payer_name": "Aetna", "plan_name": "700700", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna", "plan_name": "700700_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Miscellaneous", "plan_name": "700720", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Miscellaneous", "plan_name": "700720_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Ppo Hmo", "plan_name": "701720", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Ppo Hmo", "plan_name": "701720_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Ms State Emplo", "plan_name": "401457", "standard_charge_percentage": 0.80, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Ms State Emplo", "plan_name": "401457_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Basic Pl", "plan_name": "400100", "standard_charge_percentage": 0.85, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Basic Pl", "plan_name": "400100_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Federal", "plan_name": "400110", "standard_charge_percentage": 0.85, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Federal", "plan_name": "400110_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." } ] } ] }, { "description": "Brimonidine 0.2 % eye drops [17881]", "drug_information": { "unit": 5.00, "type": "ML" }, "code_information": [ { "code": "71921-185-05", "type": "NDC" } ], "standard_charges": [ { "gross_charge": 47.50, "minimum": 38.00, "maximum": 40.38, "setting": "both", "payers_information": [ { "payer_name": "Aetna", "plan_name": "700700", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna", "plan_name": "700700_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Miscellaneous", "plan_name": "700720", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Miscellaneous", "plan_name": "700720_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Ppo Hmo", "plan_name": "701720", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Ppo Hmo", "plan_name": "701720_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Ms State Emplo", "plan_name": "401457", "standard_charge_percentage": 0.80, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Ms State Emplo", "plan_name": "401457_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Basic Pl", "plan_name": "400100", "standard_charge_percentage": 0.85, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Basic Pl", "plan_name": "400100_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Federal", "plan_name": "400110", "standard_charge_percentage": 0.85, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Federal", "plan_name": "400110_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." } ] } ] }, { "description": "Hydrocodone 7.5 mg-acetaminophen 325 mg/15 ml oral solution [37848]", "drug_information": { "unit": 473.00, "type": "ML" }, "code_information": [ { "code": "71930-027-43", "type": "NDC" } ], "standard_charges": [ { "gross_charge": 2078.48, "minimum": 1662.78, "maximum": 1766.71, "setting": "both", "payers_information": [ { "payer_name": "Aetna", "plan_name": "700700", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna", "plan_name": "700700_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Miscellaneous", "plan_name": "700720", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Miscellaneous", "plan_name": "700720_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Ppo Hmo", "plan_name": "701720", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Ppo Hmo", "plan_name": "701720_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Ms State Emplo", "plan_name": "401457", "standard_charge_percentage": 0.80, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Ms State Emplo", "plan_name": "401457_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Basic Pl", "plan_name": "400100", "standard_charge_percentage": 0.85, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Basic Pl", "plan_name": "400100_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Federal", "plan_name": "400110", "standard_charge_percentage": 0.85, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Federal", "plan_name": "400110_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." } ] } ] }, { "description": "Norepinephrine bitartrate 1 mg/ml intravenous solution [10734]", "drug_information": { "unit": 4.00, "type": "ML" }, "code_information": [ { "code": "72078-002-00", "type": "NDC" } ], "standard_charges": [ { "gross_charge": 87.30, "minimum": 69.84, "maximum": 74.21, "setting": "both", "payers_information": [ { "payer_name": "Aetna", "plan_name": "700700", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna", "plan_name": "700700_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Miscellaneous", "plan_name": "700720", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Miscellaneous", "plan_name": "700720_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Ppo Hmo", "plan_name": "701720", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Ppo Hmo", "plan_name": "701720_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Ms State Emplo", "plan_name": "401457", "standard_charge_percentage": 0.80, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Ms State Emplo", "plan_name": "401457_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Basic Pl", "plan_name": "400100", "standard_charge_percentage": 0.85, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Basic Pl", "plan_name": "400100_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Federal", "plan_name": "400110", "standard_charge_percentage": 0.85, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Federal", "plan_name": "400110_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." } ] } ] }, { "description": "Lanolin alcohols-mineral oil-w.petrolatum-ceresin topical cream [118468]", "drug_information": { "unit": 113.00, "type": "GR" }, "code_information": [ { "code": "7214000022", "type": "NDC" } ], "standard_charges": [ { "gross_charge": 19.10, "minimum": 15.28, "maximum": 16.24, "setting": "both", "payers_information": [ { "payer_name": "Aetna", "plan_name": "700700", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna", "plan_name": "700700_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Miscellaneous", "plan_name": "700720", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Miscellaneous", "plan_name": "700720_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Ppo Hmo", "plan_name": "701720", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Ppo Hmo", "plan_name": "701720_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Ms State Emplo", "plan_name": "401457", "standard_charge_percentage": 0.80, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Ms State Emplo", "plan_name": "401457_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Basic Pl", "plan_name": "400100", "standard_charge_percentage": 0.85, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Basic Pl", "plan_name": "400100_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Federal", "plan_name": "400110", "standard_charge_percentage": 0.85, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Federal", "plan_name": "400110_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." } ] } ] }, { "description": "White petrolatum 41 % topical ointment [113619]", "drug_information": { "unit": 99.00, "type": "GR" }, "code_information": [ { "code": "7214003263", "type": "NDC" } ], "standard_charges": [ { "gross_charge": 19.31, "minimum": 15.45, "maximum": 16.41, "setting": "both", "payers_information": [ { "payer_name": "Aetna", "plan_name": "700700", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna", "plan_name": "700700_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Miscellaneous", "plan_name": "700720", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Miscellaneous", "plan_name": "700720_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Ppo Hmo", "plan_name": "701720", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Ppo Hmo", "plan_name": "701720_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Ms State Emplo", "plan_name": "401457", "standard_charge_percentage": 0.80, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Ms State Emplo", "plan_name": "401457_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Basic Pl", "plan_name": "400100", "standard_charge_percentage": 0.85, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Basic Pl", "plan_name": "400100_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Federal", "plan_name": "400110", "standard_charge_percentage": 0.85, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Federal", "plan_name": "400110_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." } ] } ] }, { "description": "Lanolin-mineral oil lotion [2787]", 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"plan_name": "700720_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Ppo Hmo", "plan_name": "701720", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Ppo Hmo", "plan_name": "701720_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Ms State Emplo", "plan_name": "401457", "standard_charge_percentage": 0.80, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Ms State Emplo", "plan_name": "401457_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Basic Pl", "plan_name": "400100", "standard_charge_percentage": 0.85, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Basic Pl", "plan_name": "400100_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Federal", "plan_name": "400110", "standard_charge_percentage": 0.85, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Federal", "plan_name": "400110_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." } ] } ] }, { "description": "White petrolatum 41 % topical ointment [113619]", "drug_information": { "unit": 50.00, "type": "GR" }, "code_information": [ { "code": "7214045231", "type": "NDC" } ], "standard_charges": [ { "gross_charge": 16.25, "minimum": 13.00, "maximum": 13.81, "setting": "both", "payers_information": [ { "payer_name": "Aetna", "plan_name": "700700", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna", "plan_name": "700700_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Miscellaneous", "plan_name": "700720", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Miscellaneous", "plan_name": "700720_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Ppo Hmo", "plan_name": "701720", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Ppo Hmo", "plan_name": "701720_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Ms State Emplo", "plan_name": "401457", "standard_charge_percentage": 0.80, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Ms State Emplo", "plan_name": "401457_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Basic Pl", "plan_name": "400100", "standard_charge_percentage": 0.85, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Basic Pl", "plan_name": "400100_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Federal", "plan_name": "400110", "standard_charge_percentage": 0.85, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Federal", "plan_name": "400110_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." } ] } ] }, { "description": "Dofetilide 250 mcg capsule [26966]", "drug_information": { "unit": 1.00, "type": "EA" }, "code_information": [ { "code": "72205-040-60", "type": "NDC" } ], "standard_charges": [ { "gross_charge": 7.50, "minimum": 6.00, "maximum": 6.38, "setting": "both", "payers_information": [ { "payer_name": "Aetna", "plan_name": "700700", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna", "plan_name": "700700_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Miscellaneous", "plan_name": "700720", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Miscellaneous", "plan_name": "700720_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Ppo Hmo", "plan_name": "701720", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Ppo Hmo", "plan_name": "701720_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Ms State Emplo", "plan_name": "401457", "standard_charge_percentage": 0.80, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Ms State Emplo", "plan_name": "401457_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Basic Pl", "plan_name": "400100", "standard_charge_percentage": 0.85, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Basic Pl", "plan_name": "400100_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Federal", "plan_name": "400110", "standard_charge_percentage": 0.85, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Federal", "plan_name": "400110_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." } ] } ] }, { "description": "Atracurium 10 mg/ml intravenous solution [9168]", "drug_information": { "unit": 5.00, "type": "ML" }, "code_information": [ { "code": "71288-701-05", "type": "NDC" } ], "standard_charges": [ { "gross_charge": 69.40, "minimum": 55.52, "maximum": 58.99, "setting": "both", "payers_information": [ { "payer_name": "Aetna", "plan_name": "700700", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna", "plan_name": "700700_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Miscellaneous", "plan_name": "700720", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Miscellaneous", "plan_name": "700720_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Ppo Hmo", "plan_name": "701720", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Ppo Hmo", "plan_name": "701720_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Ms State Emplo", "plan_name": "401457", "standard_charge_percentage": 0.80, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Ms State Emplo", "plan_name": "401457_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Basic Pl", "plan_name": "400100", "standard_charge_percentage": 0.85, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Basic Pl", "plan_name": "400100_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Federal", "plan_name": "400110", "standard_charge_percentage": 0.85, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Federal", "plan_name": "400110_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." } ] } ] }, { "description": "Sodium nitroprusside 25 mg/ml intravenous solution [18908]", "drug_information": { "unit": 2.00, "type": "ML" }, "code_information": [ { "code": "72485-105-01", "type": "NDC" } ], "standard_charges": [ { "gross_charge": 616.60, "minimum": 493.28, "maximum": 524.11, "setting": "both", "payers_information": [ { "payer_name": "Aetna", "plan_name": "700700", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna", "plan_name": "700700_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Miscellaneous", "plan_name": "700720", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Miscellaneous", "plan_name": "700720_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Ppo Hmo", "plan_name": "701720", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Ppo Hmo", "plan_name": "701720_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Ms State Emplo", "plan_name": "401457", "standard_charge_percentage": 0.80, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Ms State Emplo", "plan_name": "401457_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Basic Pl", "plan_name": "400100", "standard_charge_percentage": 0.85, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Basic Pl", "plan_name": "400100_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Federal", "plan_name": "400110", "standard_charge_percentage": 0.85, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Federal", "plan_name": "400110_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." } ] } ] }, { "description": "Zonisamide 100 mg capsule [27780]", "drug_information": { "unit": 1.00, "type": "EA" }, "code_information": [ { "code": "72578-042-01", "type": "NDC" } ], "standard_charges": [ { "gross_charge": 7.50, "minimum": 6.00, "maximum": 6.38, "setting": "both", "payers_information": [ { "payer_name": "Aetna", "plan_name": "700700", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna", "plan_name": "700700_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Miscellaneous", "plan_name": "700720", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Miscellaneous", "plan_name": "700720_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Ppo Hmo", "plan_name": "701720", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Ppo Hmo", "plan_name": "701720_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Ms State Emplo", "plan_name": "401457", "standard_charge_percentage": 0.80, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Ms State Emplo", "plan_name": "401457_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Basic Pl", "plan_name": "400100", "standard_charge_percentage": 0.85, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Basic Pl", "plan_name": "400100_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Federal", "plan_name": "400110", "standard_charge_percentage": 0.85, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Federal", "plan_name": "400110_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." } ] } ] }, { "description": "Nystatin-triamcinolone 100000 unit/gram-0.1 % topical ointment [5755]", "drug_information": { "unit": 30.00, "type": "GR" }, "code_information": [ { "code": "72578-088-04", "type": "NDC" } ], "standard_charges": [ { "gross_charge": 168.58, "minimum": 134.86, "maximum": 143.29, "setting": "both", "payers_information": [ { "payer_name": "Aetna", "plan_name": "700700", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna", "plan_name": "700700_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Miscellaneous", "plan_name": "700720", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Miscellaneous", "plan_name": "700720_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Ppo Hmo", "plan_name": "701720", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Ppo Hmo", "plan_name": "701720_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Ms State Emplo", "plan_name": "401457", "standard_charge_percentage": 0.80, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Ms State Emplo", "plan_name": "401457_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Basic Pl", "plan_name": "400100", "standard_charge_percentage": 0.85, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Basic Pl", "plan_name": "400100_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Federal", "plan_name": "400110", "standard_charge_percentage": 0.85, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Federal", "plan_name": "400110_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." } ] } ] }, { "description": "Nystatin 100000 unit/gram topical 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"Aetna Miscellaneous", "plan_name": "700720_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Ppo Hmo", "plan_name": "701720", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Ppo Hmo", "plan_name": "701720_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Ms State Emplo", "plan_name": "401457", "standard_charge_percentage": 0.80, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Ms State Emplo", "plan_name": "401457_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Basic Pl", "plan_name": "400100", "standard_charge_percentage": 0.85, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Basic Pl", "plan_name": "400100_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Federal", "plan_name": "400110", "standard_charge_percentage": 0.85, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Federal", "plan_name": "400110_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." } ] } ] }, { "description": "Bisoprolol fumarate 5 mg tablet [18288]", "drug_information": { "unit": 1.00, "type": "EA" }, "code_information": [ { "code": "72578-111-01", "type": "NDC" } ], "standard_charges": [ { "gross_charge": 7.50, "minimum": 6.00, "maximum": 6.38, "setting": "both", "payers_information": [ { "payer_name": "Aetna", "plan_name": "700700", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna", "plan_name": "700700_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Miscellaneous", "plan_name": "700720", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Miscellaneous", "plan_name": "700720_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Ppo Hmo", "plan_name": "701720", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Ppo Hmo", "plan_name": "701720_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Ms State Emplo", "plan_name": "401457", "standard_charge_percentage": 0.80, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Ms State Emplo", "plan_name": "401457_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Basic Pl", "plan_name": "400100", "standard_charge_percentage": 0.85, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Basic Pl", "plan_name": "400100_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Federal", "plan_name": "400110", "standard_charge_percentage": 0.85, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Federal", "plan_name": "400110_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." } ] } ] }, { "description": "Bisoprolol fumarate 5 mg tablet [18288]", "drug_information": { "unit": 1.00, "type": "EA" }, "code_information": [ { "code": "72578-111-06", "type": "NDC" } ], "standard_charges": [ { "gross_charge": 7.50, "minimum": 6.00, "maximum": 6.38, "setting": "both", "payers_information": [ { "payer_name": "Aetna", "plan_name": "700700", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna", "plan_name": "700700_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Miscellaneous", "plan_name": "700720", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Miscellaneous", "plan_name": "700720_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Ppo Hmo", "plan_name": "701720", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Ppo Hmo", "plan_name": "701720_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Ms State Emplo", "plan_name": "401457", "standard_charge_percentage": 0.80, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Ms State Emplo", "plan_name": "401457_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Basic Pl", "plan_name": "400100", "standard_charge_percentage": 0.85, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Basic Pl", "plan_name": "400100_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Federal", "plan_name": "400110", "standard_charge_percentage": 0.85, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Federal", "plan_name": "400110_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." } ] } ] }, { "description": "Hydroxyzine hcl 10 mg/5 ml oral solution [3771]", "drug_information": { "unit": 5.00, "type": "ML" }, "code_information": [ { "code": "99999-8000-15", "type": "NDC" } ], "standard_charges": [ { "gross_charge": 7.50, "minimum": 6.00, "maximum": 6.38, "setting": "both", "payers_information": [ { "payer_name": "Aetna", "plan_name": "700700", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna", "plan_name": "700700_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Miscellaneous", "plan_name": "700720", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Miscellaneous", "plan_name": "700720_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Ppo Hmo", "plan_name": "701720", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Ppo Hmo", "plan_name": "701720_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Ms State Emplo", "plan_name": "401457", "standard_charge_percentage": 0.80, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Ms State Emplo", "plan_name": "401457_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Basic Pl", "plan_name": "400100", "standard_charge_percentage": 0.85, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Basic Pl", "plan_name": "400100_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Federal", "plan_name": "400110", "standard_charge_percentage": 0.85, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Federal", "plan_name": "400110_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." } ] } ] }, { "description": "Amiodarone 400 mg tablet [29481]", "drug_information": { "unit": 1.00, "type": "EA" }, "code_information": [ { "code": "72888-061-30", "type": "NDC" } ], "standard_charges": [ { "gross_charge": 24.37, "minimum": 19.50, "maximum": 20.71, "setting": "both", "payers_information": [ { "payer_name": "Aetna", "plan_name": "700700", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna", "plan_name": "700700_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Miscellaneous", "plan_name": "700720", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Miscellaneous", "plan_name": "700720_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Ppo Hmo", "plan_name": "701720", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Ppo Hmo", "plan_name": "701720_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Ms State Emplo", "plan_name": "401457", "standard_charge_percentage": 0.80, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Ms State Emplo", "plan_name": "401457_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Basic Pl", "plan_name": "400100", "standard_charge_percentage": 0.85, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Basic Pl", "plan_name": "400100_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Federal", "plan_name": "400110", "standard_charge_percentage": 0.85, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Federal", "plan_name": "400110_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." } ] } ] }, { "description": "Lidocaine hcl 2 % mucosal solution [109454]", "drug_information": { "unit": 100.00, "type": "ML" }, "code_information": [ { "code": "72888-125-26", "type": "NDC" } ], "standard_charges": [ { "gross_charge": 63.65, "minimum": 50.92, "maximum": 54.10, "setting": "both", "payers_information": [ { "payer_name": "Aetna", "plan_name": "700700", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna", "plan_name": "700700_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Miscellaneous", "plan_name": "700720", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Miscellaneous", "plan_name": "700720_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Ppo Hmo", "plan_name": "701720", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Ppo Hmo", "plan_name": "701720_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Ms State Emplo", "plan_name": "401457", "standard_charge_percentage": 0.80, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Ms State Emplo", "plan_name": "401457_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Basic Pl", "plan_name": "400100", "standard_charge_percentage": 0.85, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Basic Pl", "plan_name": "400100_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Federal", "plan_name": "400110", "standard_charge_percentage": 0.85, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Federal", "plan_name": "400110_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." } ] } ] }, { "description": "Metronidazole 0.75 % (37.5 mg/5 gram) vaginal gel [10592]", "drug_information": { "unit": 70.00, "type": "GR" }, "code_information": [ { "code": "73473-303-70", "type": "NDC" } ], "standard_charges": [ { "gross_charge": 521.36, "minimum": 417.09, "maximum": 443.16, "setting": "both", "payers_information": [ { "payer_name": "Aetna", "plan_name": "700700", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna", "plan_name": "700700_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Miscellaneous", "plan_name": "700720", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Miscellaneous", "plan_name": "700720_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Ppo Hmo", "plan_name": "701720", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Ppo Hmo", "plan_name": "701720_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Ms State Emplo", "plan_name": "401457", "standard_charge_percentage": 0.80, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Ms State Emplo", "plan_name": "401457_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Basic Pl", "plan_name": "400100", "standard_charge_percentage": 0.85, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Basic Pl", "plan_name": "400100_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Federal", "plan_name": "400110", "standard_charge_percentage": 0.85, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Federal", "plan_name": "400110_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." } ] } ] }, { "description": "Zinc oxide-cod liver oil 40 % topical paste [119503]", "drug_information": { "unit": 57.00, "type": "GR" }, "code_information": [ { "code": "7430000070", "type": "NDC" } ], "standard_charges": [ { "gross_charge": 13.78, "minimum": 11.02, "maximum": 11.71, "setting": "both", "payers_information": [ { "payer_name": "Aetna", "plan_name": "700700", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna", "plan_name": "700700_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Miscellaneous", "plan_name": "700720", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Miscellaneous", "plan_name": "700720_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Ppo Hmo", "plan_name": "701720", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Ppo Hmo", "plan_name": "701720_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Ms State Emplo", "plan_name": "401457", "standard_charge_percentage": 0.80, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Ms State Emplo", "plan_name": "401457_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Basic Pl", "plan_name": "400100", "standard_charge_percentage": 0.85, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Basic Pl", "plan_name": "400100_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Federal", "plan_name": "400110", "standard_charge_percentage": 0.85, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Federal", "plan_name": "400110_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." } ] } ] }, { "description": "Permethrin 0.5 % spray [10919]", "drug_information": { "unit": 141.80, "type": "GR" }, "code_information": [ { "code": "7430000421", "type": "NDC" } ], "standard_charges": [ { "gross_charge": 11.06, "minimum": 8.85, "maximum": 9.40, "setting": "both", "payers_information": [ { "payer_name": "Aetna", "plan_name": "700700", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna", "plan_name": "700700_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Miscellaneous", "plan_name": "700720", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Miscellaneous", "plan_name": "700720_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Ppo Hmo", "plan_name": "701720", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Ppo Hmo", "plan_name": "701720_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Ms State Emplo", "plan_name": "401457", "standard_charge_percentage": 0.80, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Ms State Emplo", "plan_name": "401457_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Basic Pl", "plan_name": "400100", "standard_charge_percentage": 0.85, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Basic Pl", "plan_name": "400100_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Federal", "plan_name": "400110", "standard_charge_percentage": 0.85, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Federal", "plan_name": "400110_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." } ] } ] }, { "description": "Polyethylene glycol 400 1 % eye drops [195072]", "drug_information": { "unit": 15.00, "type": "ML" }, "code_information": [ { "code": "7430001067", "type": "NDC" } ], "standard_charges": [ { "gross_charge": 20.09, "minimum": 16.07, "maximum": 17.08, "setting": "both", "payers_information": [ { "payer_name": "Aetna", "plan_name": "700700", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna", "plan_name": "700700_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Miscellaneous", "plan_name": "700720", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Miscellaneous", "plan_name": "700720_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Ppo Hmo", "plan_name": "701720", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Ppo Hmo", "plan_name": "701720_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Ms State Emplo", "plan_name": "401457", "standard_charge_percentage": 0.80, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Ms State Emplo", "plan_name": "401457_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Basic Pl", "plan_name": "400100", "standard_charge_percentage": 0.85, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Basic Pl", "plan_name": "400100_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Federal", "plan_name": "400110", "standard_charge_percentage": 0.85, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Federal", "plan_name": "400110_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." } ] } ] }, { "description": "Levocarnitine 500 mg tablet [109203]", "drug_information": { "unit": 1.00, "type": "EA" }, "code_information": [ { "code": "7431201683", "type": "NDC" } ], "standard_charges": [ { "gross_charge": 7.50, "minimum": 6.00, "maximum": 6.38, "setting": "both", 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"payer_name": "Aetna Ppo Hmo", "plan_name": "701720", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Ppo Hmo", "plan_name": "701720_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Ms State Emplo", "plan_name": "401457", "standard_charge_percentage": 0.80, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Ms State Emplo", "plan_name": "401457_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Basic Pl", "plan_name": "400100", "standard_charge_percentage": 0.85, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Basic Pl", "plan_name": "400100_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Federal", "plan_name": "400110", "standard_charge_percentage": 0.85, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Federal", "plan_name": "400110_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." } ] } ] }, { "description": "Lutein 20 mg capsule [81458]", "drug_information": { "unit": 1.00, "type": "EA" }, "code_information": [ { "code": "7431204902", "type": "NDC" } ], "standard_charges": [ { "gross_charge": 1.00, "minimum": 0.80, "maximum": 0.85, "setting": "both", "payers_information": [ { "payer_name": "Aetna", "plan_name": "700700", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna", "plan_name": "700700_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Miscellaneous", "plan_name": "700720", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Miscellaneous", "plan_name": "700720_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Ppo Hmo", "plan_name": "701720", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Ppo Hmo", "plan_name": "701720_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Ms State Emplo", "plan_name": "401457", "standard_charge_percentage": 0.80, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Ms State Emplo", "plan_name": "401457_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Basic Pl", "plan_name": "400100", "standard_charge_percentage": 0.85, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Basic Pl", "plan_name": "400100_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Federal", "plan_name": "400110", "standard_charge_percentage": 0.85, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Federal", "plan_name": "400110_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." } ] } ] }, { "description": "Melatonin 10 mg capsule [160803]", "drug_information": { "unit": 1.00, "type": "EA" }, "code_information": [ { "code": "7431219491", "type": "NDC" } ], "standard_charges": [ { "gross_charge": 1.00, "minimum": 0.80, "maximum": 0.85, "setting": "both", "payers_information": [ { "payer_name": "Aetna", "plan_name": "700700", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna", "plan_name": "700700_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Miscellaneous", "plan_name": "700720", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Miscellaneous", "plan_name": "700720_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Ppo Hmo", "plan_name": "701720", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Ppo Hmo", "plan_name": "701720_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Ms State Emplo", "plan_name": "401457", "standard_charge_percentage": 0.80, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Ms State Emplo", "plan_name": "401457_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Basic Pl", "plan_name": "400100", "standard_charge_percentage": 0.85, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Basic Pl", "plan_name": "400100_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Federal", "plan_name": "400110", "standard_charge_percentage": 0.85, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Federal", "plan_name": "400110_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." } ] } ] }, { "description": "Verapamil er (sr) 180 mg tabletextended release [11640]", "drug_information": { "unit": 1.00, "type": "EA" }, "code_information": [ { "code": "75834-158-01", "type": "NDC" } ], "standard_charges": [ { "gross_charge": 7.50, "minimum": 6.00, "maximum": 6.38, "setting": "both", "payers_information": [ { "payer_name": "Aetna", "plan_name": "700700", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna", "plan_name": "700700_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Miscellaneous", "plan_name": "700720", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Miscellaneous", "plan_name": "700720_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Ppo Hmo", "plan_name": "701720", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Ppo Hmo", "plan_name": "701720_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Ms State Emplo", "plan_name": "401457", "standard_charge_percentage": 0.80, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Ms State Emplo", "plan_name": "401457_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Basic Pl", "plan_name": "400100", "standard_charge_percentage": 0.85, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Basic Pl", "plan_name": "400100_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Federal", "plan_name": "400110", "standard_charge_percentage": 0.85, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Federal", "plan_name": "400110_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." } ] } ] }, { "description": "Verapamil er (sr) 240 mg tabletextended release [8531]", "drug_information": { "unit": 1.00, "type": "EA" }, "code_information": [ { "code": "75834-159-01", "type": "NDC" } ], "standard_charges": [ { "gross_charge": 7.50, "minimum": 6.00, "maximum": 6.38, "setting": "both", "payers_information": [ { "payer_name": "Aetna", "plan_name": "700700", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna", "plan_name": "700700_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Miscellaneous", "plan_name": "700720", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Miscellaneous", "plan_name": "700720_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", 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"payer_name": "Aetna Miscellaneous", "plan_name": "700720", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Miscellaneous", "plan_name": "700720_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Ppo Hmo", "plan_name": "701720", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Ppo Hmo", "plan_name": "701720_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": 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"Bc/Bs Of Ms Federal", "plan_name": "400110", "standard_charge_percentage": 0.85, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Federal", "plan_name": "400110_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." } ] } ] }, { "description": "Lactobacillus acidophilus 500 million cell capsule [180435]", "drug_information": { "unit": 1.00, "type": "EA" }, "code_information": [ { "code": "7733300415", "type": "NDC" } ], "standard_charges": [ { "gross_charge": 7.50, "minimum": 6.00, "maximum": 6.38, "setting": "both", "payers_information": [ { "payer_name": "Aetna", "plan_name": "700700", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient 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{ "payer_name": "Bc/Bs Of Ms Federal", "plan_name": "400110", "standard_charge_percentage": 0.85, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Federal", "plan_name": "400110_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." } ] } ] }, { "description": "Melatonin 5 mg tablet [91665]", "drug_information": { "unit": 1.00, "type": "EA" }, "code_information": [ { "code": "7733352025", "type": "NDC" } ], "standard_charges": [ { "gross_charge": 1.00, "minimum": 0.80, "maximum": 0.85, "setting": "both", "payers_information": [ { "payer_name": "Aetna", "plan_name": "700700", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to 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}, { "payer_name": "Bc/Bs Of Ms Basic Pl", "plan_name": "400100_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Federal", "plan_name": "400110", "standard_charge_percentage": 0.85, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Federal", "plan_name": "400110_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." } ] } ] }, { "description": "Thiamine mononitrate (vitamin b1) 100 mg tablet [119871]", "drug_information": { "unit": 1.00, "type": "EA" }, "code_information": [ { "code": "7733393410", "type": "NDC" } ], "standard_charges": [ { "gross_charge": 1.00, 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"payer_name": "Bc/Bs Of Ms Basic Pl", "plan_name": "400100_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Federal", "plan_name": "400110", "standard_charge_percentage": 0.85, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Federal", "plan_name": "400110_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." } ] } ] }, { "description": "Phenol 1.4 % mucosal aerosol spray [27889]", "drug_information": { "unit": 177.00, "type": "ML" }, "code_information": [ { "code": "7811201103", "type": "NDC" } ], "standard_charges": [ { "gross_charge": 14.73, "minimum": 11.78, 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calculate allowed amounts." }, { "payer_name": "Aetna Ppo Hmo", "plan_name": "701720", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Ppo Hmo", "plan_name": "701720_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Ms State Emplo", "plan_name": "401457", "standard_charge_percentage": 0.80, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Ms State Emplo", "plan_name": "401457_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Basic Pl", "plan_name": "400100", "standard_charge_percentage": 0.85, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Basic Pl", "plan_name": "400100_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Federal", "plan_name": "400110", "standard_charge_percentage": 0.85, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Federal", "plan_name": "400110_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." } ] } ] }, { "description": "Phenol 1.4 % mucosal aerosol spray [27889]", "drug_information": { "unit": 177.00, "type": "ML" }, "code_information": [ { "code": "7811201104", "type": "NDC" } ], "standard_charges": [ { "gross_charge": 14.73, "minimum": 11.78, "maximum": 12.52, "setting": "both", "payers_information": [ { "payer_name": "Aetna", "plan_name": "700700", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna", "plan_name": "700700_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Miscellaneous", "plan_name": "700720", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Miscellaneous", "plan_name": "700720_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Ppo Hmo", "plan_name": "701720", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Ppo Hmo", "plan_name": "701720_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Ms State Emplo", "plan_name": "401457", "standard_charge_percentage": 0.80, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Ms State Emplo", "plan_name": "401457_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Basic Pl", "plan_name": "400100", "standard_charge_percentage": 0.85, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Basic Pl", "plan_name": "400100_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Federal", "plan_name": "400110", "standard_charge_percentage": 0.85, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Federal", "plan_name": "400110_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." } ] } ] }, { "description": "Benzocaine 6 mg-menthol 10 mg lozenges [41085]", "drug_information": { "unit": 18.00, "type": "EA" }, "code_information": [ { "code": "7811201106", "type": "NDC" } ], "standard_charges": [ { "gross_charge": 7.91, "minimum": 6.33, "maximum": 6.72, "setting": "both", "payers_information": [ { "payer_name": "Aetna", "plan_name": "700700", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna", "plan_name": "700700_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Miscellaneous", "plan_name": "700720", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Miscellaneous", "plan_name": "700720_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Ppo Hmo", "plan_name": "701720", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Ppo Hmo", "plan_name": "701720_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Ms State Emplo", "plan_name": "401457", "standard_charge_percentage": 0.80, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Ms State Emplo", "plan_name": "401457_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Basic Pl", "plan_name": "400100", "standard_charge_percentage": 0.85, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Basic Pl", "plan_name": "400100_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Federal", "plan_name": "400110", "standard_charge_percentage": 0.85, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Federal", "plan_name": "400110_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." } ] } ] }, { "description": "Polyvinyl alcohol-povidone 0.5 %-0.6 % eye drops [70255]", "drug_information": { "unit": 15.00, "type": "ML" }, "code_information": [ { "code": "7811273645", "type": "NDC" } ], "standard_charges": [ { "gross_charge": 12.71, "minimum": 10.17, "maximum": 10.80, "setting": "both", "payers_information": [ { "payer_name": "Aetna", "plan_name": "700700", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna", "plan_name": "700700_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Miscellaneous", "plan_name": "700720", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Miscellaneous", "plan_name": "700720_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Ppo Hmo", "plan_name": "701720", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Ppo Hmo", "plan_name": "701720_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Ms State Emplo", "plan_name": "401457", "standard_charge_percentage": 0.80, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Ms State Emplo", "plan_name": "401457_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Basic Pl", "plan_name": "400100", "standard_charge_percentage": 0.85, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Basic Pl", "plan_name": "400100_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Federal", "plan_name": "400110", "standard_charge_percentage": 0.85, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Federal", "plan_name": "400110_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." } ] } ] }, { "description": "Dextromethorphan 5 mg-benzocaine 6 mg-menthol 10 mg lozenges [169019]", "drug_information": { "unit": 1.00, "type": "EA" }, "code_information": [ { "code": "7811280122", "type": "NDC" } ], "standard_charges": [ { "gross_charge": 1.00, "minimum": 0.80, "maximum": 0.85, "setting": "both", "payers_information": [ { "payer_name": "Aetna", "plan_name": "700700", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna", "plan_name": "700700_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Miscellaneous", "plan_name": "700720", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Miscellaneous", "plan_name": "700720_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Ppo Hmo", "plan_name": "701720", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Ppo Hmo", "plan_name": "701720_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Ms State Emplo", "plan_name": "401457", "standard_charge_percentage": 0.80, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Ms State Emplo", "plan_name": "401457_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Basic Pl", "plan_name": "400100", "standard_charge_percentage": 0.85, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Basic Pl", "plan_name": "400100_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Federal", "plan_name": "400110", "standard_charge_percentage": 0.85, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Federal", "plan_name": "400110_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." } ] } ] }, { "description": "Ezetimibe 10 mg tablet [34153]", "drug_information": { "unit": 1.00, "type": "EA" }, "code_information": [ { "code": "78206-178-01", "type": "NDC" } ], "standard_charges": [ { "gross_charge": 59.06, "minimum": 47.25, "maximum": 50.20, "setting": "both", "payers_information": [ { "payer_name": "Aetna", "plan_name": "700700", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna", "plan_name": "700700_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Miscellaneous", "plan_name": "700720", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Miscellaneous", "plan_name": "700720_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Ppo Hmo", "plan_name": "701720", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Ppo Hmo", "plan_name": "701720_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Ms State Emplo", "plan_name": "401457", "standard_charge_percentage": 0.80, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Ms State Emplo", "plan_name": "401457_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Basic Pl", "plan_name": "400100", "standard_charge_percentage": 0.85, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Basic Pl", "plan_name": "400100_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Federal", "plan_name": "400110", "standard_charge_percentage": 0.85, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Federal", "plan_name": "400110_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." } ] } ] }, { "description": "Vitamin b complex-vitamin c-folic acid 0.8 mg tablet [29833]", "drug_information": { "unit": 1.00, "type": "EA" }, "code_information": [ { "code": "7985401269", "type": "NDC" } ], "standard_charges": [ { "gross_charge": 1.00, "minimum": 0.80, "maximum": 0.85, "setting": "both", "payers_information": [ { "payer_name": "Aetna", "plan_name": "700700", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna", "plan_name": "700700_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Miscellaneous", "plan_name": "700720", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Miscellaneous", "plan_name": "700720_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Ppo Hmo", "plan_name": "701720", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Ppo Hmo", "plan_name": "701720_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Ms State Emplo", "plan_name": "401457", "standard_charge_percentage": 0.80, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Ms State Emplo", "plan_name": "401457_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Basic Pl", "plan_name": "400100", "standard_charge_percentage": 0.85, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Basic Pl", "plan_name": "400100_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Federal", "plan_name": "400110", "standard_charge_percentage": 0.85, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Federal", "plan_name": "400110_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." } ] } ] }, { "description": "Cholecalciferol (vitamin d3) 25 mcg (1000 unit) tablet [82639]", "drug_information": { "unit": 1.00, "type": "EA" }, "code_information": [ { "code": "7985405024", "type": "NDC" } ], "standard_charges": [ { "gross_charge": 1.00, "minimum": 0.80, "maximum": 0.85, "setting": "both", "payers_information": [ { "payer_name": "Aetna", "plan_name": "700700", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna", "plan_name": "700700_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Miscellaneous", "plan_name": "700720", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Miscellaneous", "plan_name": "700720_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Ppo Hmo", "plan_name": "701720", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Ppo Hmo", "plan_name": "701720_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Ms State Emplo", "plan_name": "401457", "standard_charge_percentage": 0.80, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Ms State Emplo", "plan_name": "401457_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Basic Pl", "plan_name": "400100", "standard_charge_percentage": 0.85, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Basic Pl", "plan_name": "400100_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Federal", "plan_name": "400110", "standard_charge_percentage": 0.85, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Federal", "plan_name": "400110_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." } ] } ] }, { "description": "Cholecalciferol (vitamin d3) 125 mcg (5000 unit) tablet [118996]", "drug_information": { "unit": 1.00, "type": "EA" }, "code_information": [ { "code": "7985407941", "type": "NDC" } ], "standard_charges": [ { "gross_charge": 7.50, "minimum": 6.00, "maximum": 6.38, "setting": "both", "payers_information": [ { "payer_name": "Aetna", "plan_name": "700700", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna", "plan_name": "700700_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Miscellaneous", "plan_name": "700720", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Miscellaneous", "plan_name": "700720_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Ppo Hmo", "plan_name": "701720", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Ppo Hmo", "plan_name": "701720_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Ms State Emplo", "plan_name": "401457", "standard_charge_percentage": 0.80, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Ms State Emplo", "plan_name": "401457_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Basic Pl", "plan_name": "400100", "standard_charge_percentage": 0.85, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Basic Pl", "plan_name": "400100_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Federal", "plan_name": "400110", "standard_charge_percentage": 0.85, "count": "0", "methodology": "percent of total billed charges", 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"methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Miscellaneous", "plan_name": "700720", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Miscellaneous", "plan_name": "700720_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Ppo Hmo", "plan_name": "701720", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Ppo Hmo", "plan_name": "701720_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Ms State Emplo", "plan_name": "401457", "standard_charge_percentage": 0.80, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Ms State Emplo", "plan_name": "401457_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Basic Pl", "plan_name": "400100", "standard_charge_percentage": 0.85, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Basic Pl", "plan_name": "400100_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Federal", "plan_name": "400110", "standard_charge_percentage": 0.85, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Federal", "plan_name": "400110_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." } ] } ] }, { "description": "Cyanocobalamin (vit b-12) 3000 mcg/ml sublingual drops [177257]", "drug_information": { "unit": 52.00, "type": "ML" }, "code_information": [ { "code": "7985408980", "type": "NDC" } ], "standard_charges": [ { "gross_charge": 20.42, "minimum": 16.34, "maximum": 17.36, "setting": "both", "payers_information": [ { "payer_name": "Aetna", "plan_name": "700700", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna", "plan_name": "700700_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Miscellaneous", "plan_name": "700720", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Miscellaneous", "plan_name": "700720_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Ppo Hmo", "plan_name": "701720", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Ppo Hmo", "plan_name": "701720_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Ms State Emplo", "plan_name": "401457", "standard_charge_percentage": 0.80, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Ms State Emplo", "plan_name": "401457_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Basic Pl", "plan_name": "400100", "standard_charge_percentage": 0.85, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Basic Pl", "plan_name": "400100_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Federal", "plan_name": "400110", "standard_charge_percentage": 0.85, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Federal", "plan_name": "400110_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." } ] } ] }, { "description": "Niacin er 500 mg tabletextended release [151047]", "drug_information": { "unit": 1.00, "type": "EA" }, "code_information": [ { "code": "7985410078", "type": "NDC" } ], "standard_charges": [ { "gross_charge": 7.50, "minimum": 6.00, "maximum": 6.38, "setting": "both", "payers_information": [ { "payer_name": "Aetna", "plan_name": "700700", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna", "plan_name": "700700_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Miscellaneous", "plan_name": "700720", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna 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"plan_name": "401457_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Basic Pl", "plan_name": "400100", "standard_charge_percentage": 0.85, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Basic Pl", "plan_name": "400100_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Federal", "plan_name": "400110", "standard_charge_percentage": 0.85, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Federal", "plan_name": "400110_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." } ] } ] }, { "description": "Pyridoxine (vitamin b6) 100 mg tablet [6745]", "drug_information": { "unit": 1.00, "type": "EA" }, "code_information": [ { "code": "7985420035", "type": "NDC" } ], "standard_charges": [ { "gross_charge": 7.50, "minimum": 6.00, "maximum": 6.38, "setting": "both", "payers_information": [ { "payer_name": "Aetna", "plan_name": "700700", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna", "plan_name": "700700_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Miscellaneous", "plan_name": "700720", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Miscellaneous", "plan_name": "700720_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Ppo Hmo", "plan_name": "701720", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Ppo Hmo", "plan_name": "701720_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Ms State Emplo", "plan_name": "401457", "standard_charge_percentage": 0.80, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Ms State Emplo", "plan_name": "401457_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Basic Pl", "plan_name": "400100", "standard_charge_percentage": 0.85, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Basic Pl", "plan_name": "400100_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Federal", "plan_name": "400110", "standard_charge_percentage": 0.85, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Federal", "plan_name": "400110_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." } ] } ] }, { "description": "Vitamin b complex capsule [804]", "drug_information": { "unit": 1.00, "type": "EA" }, "code_information": [ { "code": "7985420080", "type": "NDC" } ], "standard_charges": [ { "gross_charge": 1.00, "minimum": 0.80, "maximum": 0.85, "setting": "both", "payers_information": [ { "payer_name": "Aetna", "plan_name": "700700", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna", "plan_name": "700700_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Miscellaneous", "plan_name": "700720", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Miscellaneous", "plan_name": "700720_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Ppo Hmo", "plan_name": "701720", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Ppo Hmo", "plan_name": "701720_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Ms State Emplo", "plan_name": "401457", "standard_charge_percentage": 0.80, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Ms State Emplo", "plan_name": "401457_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Basic Pl", "plan_name": "400100", "standard_charge_percentage": 0.85, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Basic Pl", "plan_name": "400100_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Federal", "plan_name": "400110", "standard_charge_percentage": 0.85, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Federal", "plan_name": "400110_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." } ] } ] }, { "description": "Calcium 600 mg (as calcium carbonate 1500 mg) tablet [1302]", "drug_information": { "unit": 1.00, "type": "EA" }, "code_information": [ { "code": "7985450022", "type": "NDC" } ], "standard_charges": [ { "gross_charge": 1.00, "minimum": 0.80, "maximum": 0.85, "setting": "both", "payers_information": [ { "payer_name": "Aetna", "plan_name": "700700", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna", "plan_name": "700700_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Miscellaneous", "plan_name": "700720", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Miscellaneous", "plan_name": "700720_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Ppo Hmo", "plan_name": "701720", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Ppo Hmo", "plan_name": "701720_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Ms State Emplo", "plan_name": "401457", "standard_charge_percentage": 0.80, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Ms State Emplo", "plan_name": "401457_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Basic Pl", "plan_name": "400100", "standard_charge_percentage": 0.85, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Basic Pl", "plan_name": "400100_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Federal", "plan_name": "400110", "standard_charge_percentage": 0.85, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Federal", "plan_name": "400110_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." } ] } ] }, { "description": "Vitamin e (dl acetate) 180 mg (400 unit) capsule [118622]", "drug_information": { "unit": 1.00, "type": "EA" }, "code_information": [ { "code": "7985490020", "type": "NDC" } ], "standard_charges": [ { "gross_charge": 1.00, "minimum": 0.80, "maximum": 0.85, "setting": "both", "payers_information": [ { "payer_name": "Aetna", "plan_name": "700700", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna", "plan_name": "700700_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Miscellaneous", "plan_name": "700720", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Miscellaneous", "plan_name": "700720_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Ppo Hmo", "plan_name": "701720", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Ppo Hmo", "plan_name": "701720_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Ms State Emplo", "plan_name": "401457", "standard_charge_percentage": 0.80, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Ms State Emplo", "plan_name": "401457_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Basic Pl", "plan_name": "400100", "standard_charge_percentage": 0.85, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Basic Pl", "plan_name": "400100_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Federal", "plan_name": "400110", "standard_charge_percentage": 0.85, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Federal", "plan_name": "400110_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." } ] } ] }, { "description": "Vitamin e (dl acetate) 450 mg (1000 unit) capsule [151610]", "drug_information": { "unit": 1.00, "type": "EA" }, "code_information": [ { "code": "7985490040", "type": "NDC" } ], "standard_charges": [ { "gross_charge": 1.00, "minimum": 0.80, "maximum": 0.85, "setting": "both", "payers_information": [ { "payer_name": "Aetna", "plan_name": "700700", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna", "plan_name": "700700_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Miscellaneous", "plan_name": "700720", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Miscellaneous", "plan_name": "700720_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Ppo Hmo", "plan_name": "701720", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Ppo Hmo", "plan_name": "701720_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Ms State Emplo", "plan_name": "401457", "standard_charge_percentage": 0.80, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Ms State Emplo", "plan_name": "401457_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Basic Pl", "plan_name": "400100", "standard_charge_percentage": 0.85, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Basic Pl", "plan_name": "400100_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Federal", "plan_name": "400110", "standard_charge_percentage": 0.85, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Federal", "plan_name": "400110_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." } ] } ] }, { "description": "Miconazole nitrate 2 % topical powder [10599]", "drug_information": { "unit": 85.00, "type": "GR" }, "code_information": [ { "code": "8019652856", "type": "NDC" } ], "standard_charges": [ { "gross_charge": 20.59, "minimum": 16.47, "maximum": 17.50, "setting": "both", "payers_information": [ { "payer_name": "Aetna", "plan_name": "700700", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna", "plan_name": "700700_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Miscellaneous", "plan_name": "700720", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Miscellaneous", "plan_name": "700720_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Ppo Hmo", "plan_name": "701720", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Ppo Hmo", "plan_name": "701720_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Ms State Emplo", "plan_name": "401457", "standard_charge_percentage": 0.80, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Ms State Emplo", "plan_name": "401457_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Basic Pl", "plan_name": "400100", "standard_charge_percentage": 0.85, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Basic Pl", "plan_name": "400100_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Federal", "plan_name": "400110", "standard_charge_percentage": 0.85, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Federal", "plan_name": "400110_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." } ] } ] }, { "description": "Polyvinyl alcohol-povidone 0.5 %-0.6 % eye drops [70255]", "drug_information": { "unit": 15.00, "type": "ML" }, "code_information": [ { "code": "8041000016", "type": "NDC" } ], "standard_charges": [ { "gross_charge": 2.65, "minimum": 2.12, "maximum": 2.25, "setting": "both", "payers_information": [ { "payer_name": "Aetna", "plan_name": "700700", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna", "plan_name": "700700_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Miscellaneous", "plan_name": "700720", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Miscellaneous", "plan_name": "700720_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Ppo Hmo", "plan_name": "701720", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Ppo Hmo", "plan_name": "701720_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Ms State Emplo", "plan_name": "401457", "standard_charge_percentage": 0.80, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Ms State Emplo", "plan_name": "401457_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Basic Pl", "plan_name": "400100", "standard_charge_percentage": 0.85, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Basic Pl", "plan_name": "400100_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Federal", "plan_name": "400110", "standard_charge_percentage": 0.85, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Federal", "plan_name": "400110_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." } ] } ] }, { "description": "Chondroitin-sod hyaluron 4 %-3 %(0.5 ml)1 %(0.85 ml)intraocular syring [202399]", "drug_information": { "unit": 1.35, "type": "ML" }, "code_information": [ { "code": "8065199907", "type": "NDC" } ], "standard_charges": [ { "gross_charge": 1577.45, "minimum": 1261.96, "maximum": 1340.83, "setting": "both", "payers_information": [ { "payer_name": "Aetna", "plan_name": "700700", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna", "plan_name": "700700_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Miscellaneous", "plan_name": "700720", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Miscellaneous", "plan_name": "700720_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Ppo Hmo", "plan_name": "701720", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Ppo Hmo", "plan_name": "701720_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Ms State Emplo", "plan_name": "401457", "standard_charge_percentage": 0.80, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Ms State Emplo", "plan_name": "401457_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Basic Pl", "plan_name": "400100", "standard_charge_percentage": 0.85, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Basic Pl", "plan_name": "400100_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Federal", "plan_name": "400110", "standard_charge_percentage": 0.85, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Federal", "plan_name": "400110_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." } ] } ] }, { "description": "Zinc gluconate 50 mg tablet [8872]", "drug_information": { "unit": 1.00, "type": "EA" }, "code_information": [ { "code": "8068100200", "type": "NDC" } ], "standard_charges": [ { "gross_charge": 1.00, "minimum": 0.80, "maximum": 0.85, "setting": "both", "payers_information": [ { "payer_name": "Aetna", "plan_name": "700700", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna", "plan_name": "700700_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Miscellaneous", "plan_name": "700720", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Miscellaneous", "plan_name": "700720_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Ppo Hmo", "plan_name": "701720", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Ppo Hmo", "plan_name": "701720_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Ms State Emplo", "plan_name": "401457", "standard_charge_percentage": 0.80, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Ms State Emplo", "plan_name": "401457_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Basic Pl", "plan_name": "400100", "standard_charge_percentage": 0.85, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Basic Pl", "plan_name": "400100_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Federal", "plan_name": "400110", "standard_charge_percentage": 0.85, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Federal", "plan_name": "400110_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." } ] } ] }, { "description": "Acidophilus 25 million cell-pectin citrus 100 mg tablet [134]", "drug_information": { "unit": 1.00, "type": "EA" }, "code_information": [ { "code": "8068102600", "type": "NDC" } ], "standard_charges": [ { "gross_charge": 7.50, "minimum": 6.00, "maximum": 6.38, "setting": "both", "payers_information": [ { "payer_name": "Aetna", "plan_name": "700700", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna", "plan_name": "700700_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Miscellaneous", "plan_name": "700720", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Miscellaneous", "plan_name": "700720_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Ppo Hmo", "plan_name": "701720", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Ppo Hmo", "plan_name": "701720_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Ms State Emplo", "plan_name": "401457", "standard_charge_percentage": 0.80, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Ms State Emplo", "plan_name": "401457_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Basic Pl", "plan_name": "400100", "standard_charge_percentage": 0.85, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Basic Pl", "plan_name": "400100_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Federal", "plan_name": "400110", "standard_charge_percentage": 0.85, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Federal", "plan_name": "400110_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." } ] } ] }, { "description": "Cyanocobalamin (vit b-12) 100 mcg tablet [2008]", "drug_information": { "unit": 1.00, "type": "EA" }, "code_information": [ { "code": "8068107100", "type": "NDC" } ], "standard_charges": [ { "gross_charge": 1.00, "minimum": 0.80, "maximum": 0.85, "setting": "both", "payers_information": [ { "payer_name": "Aetna", "plan_name": "700700", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna", "plan_name": "700700_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Miscellaneous", "plan_name": "700720", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Miscellaneous", "plan_name": "700720_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Ppo Hmo", "plan_name": "701720", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Ppo Hmo", "plan_name": "701720_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Ms State Emplo", "plan_name": "401457", "standard_charge_percentage": 0.80, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Ms State Emplo", "plan_name": "401457_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Basic Pl", "plan_name": "400100", "standard_charge_percentage": 0.85, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Basic Pl", "plan_name": "400100_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Federal", "plan_name": "400110", "standard_charge_percentage": 0.85, "count": "0", "methodology": "percent of total 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"methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Ms State Emplo", "plan_name": "401457", "standard_charge_percentage": 0.80, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Ms State Emplo", "plan_name": "401457_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Basic Pl", "plan_name": "400100", "standard_charge_percentage": 0.85, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Basic Pl", "plan_name": "400100_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Federal", "plan_name": "400110", "standard_charge_percentage": 0.85, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Federal", "plan_name": "400110_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." } ] } ] }, { "description": "Multivit-min-folic acid 0.4 mg-lycopene 300 mcg-lutein 250 mcg tablet [115775]", "drug_information": { "unit": 1.00, "type": "EA" }, "code_information": [ { "code": "8068114101", "type": "NDC" } ], "standard_charges": [ { "gross_charge": 7.50, "minimum": 6.00, "maximum": 6.38, "setting": "both", "payers_information": [ { "payer_name": 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"701720", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Ppo Hmo", "plan_name": "701720_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Ms State Emplo", "plan_name": "401457", "standard_charge_percentage": 0.80, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Ms State Emplo", "plan_name": "401457_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Basic Pl", "plan_name": "400100", "standard_charge_percentage": 0.85, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Basic Pl", "plan_name": "400100_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Federal", "plan_name": "400110", "standard_charge_percentage": 0.85, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Federal", "plan_name": "400110_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." } ] } ] }, { "description": "Multivitamin-ferrous fumarate-folic acid 18 mg-400 mcg tablet [118668]", "drug_information": { "unit": 1.00, "type": "EA" }, "code_information": [ { "code": "8068114202", "type": "NDC" } ], "standard_charges": [ { "gross_charge": 1.00, "minimum": 0.80, "maximum": 0.85, "setting": "both", "payers_information": [ { "payer_name": "Aetna", "plan_name": "700700", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna", "plan_name": "700700_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Miscellaneous", "plan_name": "700720", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Miscellaneous", "plan_name": "700720_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Ppo Hmo", "plan_name": "701720", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Ppo Hmo", "plan_name": "701720_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Ms State Emplo", "plan_name": "401457", "standard_charge_percentage": 0.80, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Ms State Emplo", "plan_name": "401457_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Basic Pl", "plan_name": "400100", "standard_charge_percentage": 0.85, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Basic Pl", "plan_name": "400100_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Federal", "plan_name": "400110", "standard_charge_percentage": 0.85, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Federal", "plan_name": "400110_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." } ] } ] }, { "description": "B-complex with vitamin c tablet [807]", "drug_information": { "unit": 1.00, "type": "EA" }, "code_information": [ { "code": "8068115400", "type": "NDC" } ], "standard_charges": [ { "gross_charge": 1.00, "minimum": 0.80, "maximum": 0.85, "setting": "both", "payers_information": [ { "payer_name": "Aetna", "plan_name": "700700", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna", "plan_name": "700700_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed 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"payer_name": "Bc/Bs Ms State Emplo", "plan_name": "401457", "standard_charge_percentage": 0.80, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Ms State Emplo", "plan_name": "401457_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Basic Pl", "plan_name": "400100", "standard_charge_percentage": 0.85, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Basic Pl", "plan_name": "400100_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Federal", "plan_name": "400110", "standard_charge_percentage": 0.85, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Federal", "plan_name": "400110_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." } ] } ] }, { "description": "Multivitamin-iron 9 mg-folic acid 400 mcg-calcium and minerals tablet [118929]", "drug_information": { "unit": 1.00, "type": "EA" }, "code_information": [ { "code": "8068116000", "type": "NDC" } ], "standard_charges": [ { "gross_charge": 1.00, "minimum": 0.80, "maximum": 0.85, "setting": "both", "payers_information": [ { "payer_name": "Aetna", "plan_name": "700700", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna", "plan_name": "700700_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Miscellaneous", "plan_name": "700720", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Miscellaneous", "plan_name": "700720_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Ppo Hmo", "plan_name": "701720", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Ppo Hmo", "plan_name": "701720_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Ms State Emplo", "plan_name": "401457", "standard_charge_percentage": 0.80, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Ms State Emplo", "plan_name": "401457_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Basic Pl", "plan_name": "400100", "standard_charge_percentage": 0.85, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Basic Pl", "plan_name": "400100_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Federal", "plan_name": "400110", "standard_charge_percentage": 0.85, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Federal", "plan_name": "400110_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." } ] } ] }, { "description": "Cholecalciferol (vitamin d3) 25 mcg (1000 unit) tablet [82639]", "drug_information": { "unit": 1.00, "type": "EA" }, "code_information": [ { "code": "8068116900", "type": "NDC" } ], "standard_charges": [ { "gross_charge": 1.00, "minimum": 0.80, "maximum": 0.85, "setting": "both", "payers_information": [ { "payer_name": "Aetna", "plan_name": "700700", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna", "plan_name": "700700_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Miscellaneous", "plan_name": "700720", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Miscellaneous", "plan_name": "700720_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of 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charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." } ] } ] }, { "description": "Mineral oil topical [9921]", "drug_information": { "unit": 120.00, "type": "ML" }, "code_information": [ { "code": "8137003307", "type": "NDC" } ], "standard_charges": [ { "gross_charge": 3.43, "minimum": 2.74, "maximum": 2.92, "setting": "both", "payers_information": [ { "payer_name": "Aetna", "plan_name": "700700", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna", "plan_name": "700700_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Miscellaneous", "plan_name": "700720", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Miscellaneous", "plan_name": "700720_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Ppo Hmo", "plan_name": "701720", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Ppo Hmo", "plan_name": "701720_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Ms State Emplo", "plan_name": "401457", "standard_charge_percentage": 0.80, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Ms State Emplo", "plan_name": "401457_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Basic Pl", "plan_name": "400100", "standard_charge_percentage": 0.85, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Basic Pl", "plan_name": "400100_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Federal", "plan_name": "400110", "standard_charge_percentage": 0.85, "count": "0", "methodology": "percent of total billed 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"gross_charge": 580.00, "minimum": 464.00, "maximum": 493.00, "setting": "both", "payers_information": [ { "payer_name": "Aetna", "plan_name": "700700", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna", "plan_name": "700700_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Miscellaneous", "plan_name": "700720", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Miscellaneous", "plan_name": "700720_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", 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"percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Federal", "plan_name": "400110_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." } ] } ] }, { "description": "Acetaminophen 120 mg-codeine 12 mg/5 ml oral solution [108327]", "drug_information": { "unit": 5.00, "type": "ML" }, "code_information": [ { "code": "9999-0005-95", "type": "NDC" } ], "standard_charges": [ { "gross_charge": 1.00, "minimum": 0.80, "maximum": 0.85, "setting": "both", "payers_information": [ { "payer_name": "Aetna", "plan_name": "700700", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna", "plan_name": "700700_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Miscellaneous", "plan_name": "700720", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Miscellaneous", "plan_name": "700720_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Ppo Hmo", "plan_name": "701720", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Ppo Hmo", "plan_name": "701720_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Ms State Emplo", "plan_name": "401457", "standard_charge_percentage": 0.80, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Ms State Emplo", "plan_name": "401457_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Basic Pl", "plan_name": "400100", "standard_charge_percentage": 0.85, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Basic Pl", "plan_name": "400100_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Federal", "plan_name": "400110", "standard_charge_percentage": 0.85, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Federal", "plan_name": "400110_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." } ] } ] }, { "description": "Phenobarbital 20 mg/5 ml (4 mg/ml) oral elixir [6212]", "drug_information": { "unit": 7.50, "type": "ML" }, "code_information": [ { "code": "9999-0005-96", "type": "NDC" } ], "standard_charges": [ { "gross_charge": 7.50, "minimum": 6.00, "maximum": 6.38, "setting": "both", "payers_information": [ { "payer_name": "Aetna", "plan_name": "700700", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna", "plan_name": "700700_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Miscellaneous", "plan_name": "700720", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Miscellaneous", "plan_name": "700720_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Ppo Hmo", "plan_name": "701720", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Ppo Hmo", "plan_name": "701720_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Ms State Emplo", "plan_name": "401457", "standard_charge_percentage": 0.80, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Ms State Emplo", "plan_name": "401457_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Basic Pl", "plan_name": "400100", "standard_charge_percentage": 0.85, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Basic Pl", "plan_name": "400100_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Federal", "plan_name": "400110", "standard_charge_percentage": 0.85, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Federal", "plan_name": "400110_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." } ] } ] }, { "description": "Codeine 10 mg-guaifenesin 100 mg/5 ml oral liquid [78003]", "drug_information": { "unit": 5.00, "type": "ML" }, "code_information": [ { "code": "9999-0005-97", "type": "NDC" } ], "standard_charges": [ { "gross_charge": 7.50, "minimum": 6.00, "maximum": 6.38, "setting": "both", "payers_information": [ { "payer_name": "Aetna", "plan_name": "700700", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna", "plan_name": "700700_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Miscellaneous", "plan_name": "700720", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Miscellaneous", "plan_name": "700720_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Ppo Hmo", "plan_name": "701720", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Ppo Hmo", "plan_name": "701720_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Ms State Emplo", "plan_name": "401457", "standard_charge_percentage": 0.80, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Ms State Emplo", "plan_name": "401457_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Basic Pl", "plan_name": "400100", "standard_charge_percentage": 0.85, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Basic Pl", "plan_name": "400100_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Federal", "plan_name": "400110", "standard_charge_percentage": 0.85, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Federal", "plan_name": "400110_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." } ] } ] }, { "description": "Loperamide 1 mg/7.5 ml oral liquid [42219]", "drug_information": { "unit": 15.00, "type": "ML" }, "code_information": [ { "code": "9999-0005-98", "type": "NDC" } ], "standard_charges": [ { "gross_charge": 1.00, "minimum": 0.80, "maximum": 0.85, "setting": "both", "payers_information": [ { "payer_name": "Aetna", "plan_name": "700700", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna", "plan_name": "700700_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Miscellaneous", "plan_name": "700720", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Miscellaneous", "plan_name": "700720_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Ppo Hmo", "plan_name": "701720", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Ppo Hmo", "plan_name": "701720_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Ms State Emplo", "plan_name": "401457", "standard_charge_percentage": 0.80, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Ms State Emplo", "plan_name": "401457_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Basic Pl", "plan_name": "400100", "standard_charge_percentage": 0.85, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Basic Pl", "plan_name": "400100_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Federal", "plan_name": "400110", "standard_charge_percentage": 0.85, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Federal", "plan_name": "400110_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." } ] } ] }, { "description": "Chlorhexidine gluconate 0.12 % mouthwash [9516]", "drug_information": { "unit": 15.00, "type": "ML" }, "code_information": [ { "code": "9999-0005-99", "type": "NDC" } ], "standard_charges": [ { "gross_charge": 7.50, "minimum": 6.00, "maximum": 6.38, "setting": "both", "payers_information": [ { "payer_name": "Aetna", "plan_name": "700700", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna", "plan_name": "700700_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Miscellaneous", "plan_name": "700720", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Miscellaneous", "plan_name": "700720_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Ppo Hmo", "plan_name": "701720", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Ppo Hmo", "plan_name": "701720_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Ms State Emplo", "plan_name": "401457", "standard_charge_percentage": 0.80, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Ms State Emplo", "plan_name": "401457_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Basic Pl", "plan_name": "400100", "standard_charge_percentage": 0.85, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Basic Pl", "plan_name": "400100_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Federal", "plan_name": "400110", "standard_charge_percentage": 0.85, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Federal", "plan_name": "400110_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." } ] } ] }, { "description": "Cetirizine 1 mg/ml oral solution [70838]", "drug_information": { "unit": 5.00, "type": "ML" }, "code_information": [ { "code": "9999-0006-00", "type": "NDC" } ], "standard_charges": [ { "gross_charge": 1.00, "minimum": 0.80, "maximum": 0.85, "setting": "both", "payers_information": [ { "payer_name": "Aetna", "plan_name": "700700", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna", "plan_name": "700700_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Miscellaneous", "plan_name": "700720", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Miscellaneous", "plan_name": "700720_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Ppo Hmo", "plan_name": "701720", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Ppo Hmo", "plan_name": "701720_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Ms State Emplo", "plan_name": "401457", "standard_charge_percentage": 0.80, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Ms State Emplo", "plan_name": "401457_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Basic Pl", "plan_name": "400100", "standard_charge_percentage": 0.85, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Basic Pl", "plan_name": "400100_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Federal", "plan_name": "400110", "standard_charge_percentage": 0.85, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Federal", "plan_name": "400110_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." } ] } ] }, { "description": "Ferrous sulfate 220 mg (44 mg iron)/5 ml oral elixir [177665]", "drug_information": { "unit": 5.00, "type": "ML" }, "code_information": [ { "code": "9999-0006-01", "type": "NDC" } ], "standard_charges": [ { "gross_charge": 1.00, "minimum": 0.80, "maximum": 0.85, "setting": "both", "payers_information": [ { "payer_name": "Aetna", "plan_name": "700700", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna", "plan_name": "700700_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Miscellaneous", "plan_name": "700720", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Miscellaneous", "plan_name": "700720_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Ppo Hmo", "plan_name": "701720", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Ppo Hmo", "plan_name": "701720_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Ms State Emplo", "plan_name": "401457", "standard_charge_percentage": 0.80, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Ms State Emplo", "plan_name": "401457_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Basic Pl", "plan_name": "400100", "standard_charge_percentage": 0.85, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Basic Pl", "plan_name": "400100_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Federal", "plan_name": "400110", "standard_charge_percentage": 0.85, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Federal", "plan_name": "400110_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." } ] } ] }, { "description": "Hydrocodone 7.5 mg-acetaminophen 325 mg/15 ml oral solution [37848]", "drug_information": { "unit": 10.00, "type": "ML" }, "code_information": [ { "code": "9999-0006-02", "type": "NDC" } ], "standard_charges": [ { "gross_charge": 7.50, "minimum": 6.00, "maximum": 6.38, "setting": "both", "payers_information": [ { "payer_name": "Aetna", "plan_name": "700700", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna", "plan_name": "700700_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Miscellaneous", "plan_name": "700720", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Miscellaneous", "plan_name": "700720_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Ppo Hmo", "plan_name": "701720", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Ppo Hmo", "plan_name": "701720_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Ms State Emplo", "plan_name": "401457", "standard_charge_percentage": 0.80, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Ms State Emplo", "plan_name": "401457_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Basic Pl", "plan_name": "400100", "standard_charge_percentage": 0.85, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { 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"Bc/Bs Of Ms Federal", "plan_name": "400110", "standard_charge_percentage": 0.85, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Federal", "plan_name": "400110_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." } ] } ] }, { "description": "Bismuth subsalicylate 262 mg/15 ml oral suspension [1090]", "drug_information": { "unit": 15.00, "type": "ML" }, "code_information": [ { "code": "9999-0006-10", "type": "NDC" } ], "standard_charges": [ { "gross_charge": 1.00, "minimum": 0.80, "maximum": 0.85, "setting": "both", "payers_information": [ { "payer_name": "Aetna", "plan_name": "700700", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient 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allowed amounts." }, { "payer_name": "Aetna Ppo Hmo", "plan_name": "701720_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Ms State Emplo", "plan_name": "401457", "standard_charge_percentage": 0.80, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Ms State Emplo", "plan_name": "401457_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Basic Pl", "plan_name": "400100", "standard_charge_percentage": 0.85, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Basic Pl", "plan_name": "400100_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Federal", "plan_name": "400110", "standard_charge_percentage": 0.85, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Federal", "plan_name": "400110_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." } ] } ] }, { "description": "Calcium 500 mg/5 ml (as calcium carb 1250 mg/5 ml) oral suspension [1299]", "drug_information": { "unit": 5.00, "type": "ML" }, "code_information": [ { "code": "9999-0006-11", "type": "NDC" } ], "standard_charges": [ { "gross_charge": 7.50, "minimum": 6.00, "maximum": 6.38, "setting": "both", "payers_information": [ { "payer_name": "Aetna", "plan_name": "700700", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna", "plan_name": "700700_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Miscellaneous", "plan_name": "700720", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Miscellaneous", "plan_name": "700720_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Ppo Hmo", "plan_name": "701720", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Ppo Hmo", "plan_name": "701720_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Ms State Emplo", "plan_name": "401457", "standard_charge_percentage": 0.80, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Ms State Emplo", "plan_name": "401457_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Basic Pl", "plan_name": "400100", "standard_charge_percentage": 0.85, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Basic Pl", "plan_name": "400100_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Federal", "plan_name": "400110", "standard_charge_percentage": 0.85, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Federal", "plan_name": "400110_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." } ] } ] }, { "description": "Hyoscyamine 0.125 mg/5 ml oral elixir [3781]", "drug_information": { "unit": 5.00, "type": "ML" }, "code_information": [ { "code": "9999-0006-12", "type": "NDC" } ], "standard_charges": [ { "gross_charge": 7.50, "minimum": 6.00, "maximum": 6.38, "setting": "both", "payers_information": [ { "payer_name": "Aetna", "plan_name": "700700", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna", "plan_name": "700700_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Miscellaneous", "plan_name": "700720", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Miscellaneous", "plan_name": "700720_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Ppo Hmo", "plan_name": "701720", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Ppo Hmo", "plan_name": "701720_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Ms State Emplo", "plan_name": "401457", "standard_charge_percentage": 0.80, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Ms State Emplo", "plan_name": "401457_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Basic Pl", "plan_name": "400100", "standard_charge_percentage": 0.85, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Basic Pl", "plan_name": "400100_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Federal", "plan_name": "400110", "standard_charge_percentage": 0.85, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Federal", "plan_name": "400110_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." } ] } ] }, { "description": "Theophylline 80 mg/15 ml oral solution [7821]", "drug_information": { "unit": 5.00, "type": "ML" }, "code_information": [ { "code": "9999-0006-13", "type": "NDC" } ], "standard_charges": [ { "gross_charge": 7.50, "minimum": 6.00, "maximum": 6.38, "setting": "both", "payers_information": [ { "payer_name": "Aetna", "plan_name": "700700", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna", "plan_name": "700700_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Miscellaneous", "plan_name": "700720", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Miscellaneous", "plan_name": "700720_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Ppo Hmo", "plan_name": "701720", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Ppo Hmo", "plan_name": "701720_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Ms State Emplo", "plan_name": "401457", "standard_charge_percentage": 0.80, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Ms State Emplo", "plan_name": "401457_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Basic Pl", "plan_name": "400100", "standard_charge_percentage": 0.85, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Basic Pl", "plan_name": "400100_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Federal", "plan_name": "400110", "standard_charge_percentage": 0.85, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Federal", "plan_name": "400110_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." } ] } ] }, { "description": "Pseudoephedrine 15 mg/5 ml oral liquid [108834]", "drug_information": { "unit": 5.00, "type": "ML" }, "code_information": [ { "code": "9999-0006-14", "type": "NDC" } ], "standard_charges": [ { "gross_charge": 7.50, "minimum": 6.00, "maximum": 6.38, "setting": "both", "payers_information": [ { "payer_name": "Aetna", "plan_name": "700700", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna", "plan_name": "700700_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Miscellaneous", "plan_name": "700720", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Miscellaneous", "plan_name": "700720_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Ppo Hmo", "plan_name": "701720", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Ppo Hmo", "plan_name": "701720_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Ms State Emplo", "plan_name": "401457", "standard_charge_percentage": 0.80, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Ms State Emplo", "plan_name": "401457_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Basic Pl", "plan_name": "400100", "standard_charge_percentage": 0.85, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Basic Pl", "plan_name": "400100_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Federal", "plan_name": "400110", "standard_charge_percentage": 0.85, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Federal", "plan_name": "400110_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." } ] } ] }, { "description": "Carbamazepine 100 mg/5 ml oral suspension [109663]", "drug_information": { "unit": 5.00, "type": "ML" }, "code_information": [ { "code": "9999-0006-15", "type": "NDC" } ], "standard_charges": [ { "gross_charge": 7.50, "minimum": 6.00, "maximum": 6.38, "setting": "both", "payers_information": [ { "payer_name": "Aetna", "plan_name": "700700", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna", "plan_name": "700700_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Miscellaneous", "plan_name": "700720", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Miscellaneous", "plan_name": "700720_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Ppo Hmo", "plan_name": "701720", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Ppo Hmo", "plan_name": "701720_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Ms State Emplo", "plan_name": "401457", "standard_charge_percentage": 0.80, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Ms State Emplo", "plan_name": "401457_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Basic Pl", "plan_name": "400100", "standard_charge_percentage": 0.85, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Basic Pl", "plan_name": "400100_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Federal", "plan_name": "400110", "standard_charge_percentage": 0.85, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Federal", "plan_name": "400110_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." } ] } ] }, { "description": "Sulfamethoxazole 200 mg-trimethoprim 40 mg/5 ml oral suspension [22560]", "drug_information": { "unit": 10.00, "type": "ML" }, "code_information": [ { "code": "9999-0006-16", "type": "NDC" } ], "standard_charges": [ { "gross_charge": 8.98, "minimum": 7.18, "maximum": 7.63, "setting": "both", "payers_information": [ { "payer_name": "Aetna", "plan_name": "700700", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna", "plan_name": "700700_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Miscellaneous", "plan_name": "700720", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Miscellaneous", "plan_name": "700720_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Ppo Hmo", "plan_name": "701720", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Ppo Hmo", "plan_name": "701720_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Ms State Emplo", "plan_name": "401457", "standard_charge_percentage": 0.80, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Ms State Emplo", "plan_name": "401457_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Basic Pl", "plan_name": "400100", "standard_charge_percentage": 0.85, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Basic Pl", "plan_name": "400100_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Federal", "plan_name": "400110", "standard_charge_percentage": 0.85, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Federal", "plan_name": "400110_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." } ] } ] }, { "description": "Dextromethorphan-guaifenesin 10 mg-100 mg/5 ml oral syrup [9774]", "drug_information": { "unit": 10.00, "type": "ML" }, "code_information": [ { "code": "9999-0006-17", "type": "NDC" } ], "standard_charges": [ { "gross_charge": 1.00, "minimum": 0.80, "maximum": 0.85, "setting": "both", "payers_information": [ { "payer_name": "Aetna", "plan_name": "700700", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna", "plan_name": "700700_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Miscellaneous", "plan_name": "700720", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Miscellaneous", "plan_name": "700720_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Ppo Hmo", "plan_name": "701720", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Ppo Hmo", "plan_name": "701720_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Ms State Emplo", "plan_name": "401457", "standard_charge_percentage": 0.80, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Ms State Emplo", "plan_name": "401457_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Basic Pl", "plan_name": "400100", "standard_charge_percentage": 0.85, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Basic Pl", "plan_name": "400100_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Federal", "plan_name": "400110", "standard_charge_percentage": 0.85, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Federal", "plan_name": "400110_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." } ] } ] }, { "description": "Promethazine 6.25 mg-codeine 10 mg/5 ml syrup [6627]", "drug_information": { "unit": 5.00, "type": "ML" }, "code_information": [ { "code": "9999-0006-18", "type": "NDC" } ], "standard_charges": [ { "gross_charge": 7.50, "minimum": 6.00, "maximum": 6.38, "setting": "both", "payers_information": [ { "payer_name": "Aetna", "plan_name": "700700", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna", "plan_name": "700700_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Miscellaneous", "plan_name": "700720", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Miscellaneous", "plan_name": "700720_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Ppo Hmo", "plan_name": "701720", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Ppo Hmo", "plan_name": "701720_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Ms State Emplo", "plan_name": "401457", "standard_charge_percentage": 0.80, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Ms State Emplo", "plan_name": "401457_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Basic Pl", "plan_name": "400100", "standard_charge_percentage": 0.85, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Basic Pl", "plan_name": "400100_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Federal", "plan_name": "400110", "standard_charge_percentage": 0.85, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Federal", "plan_name": "400110_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." } ] } ] }, { "description": "Midazolam 2 mg/ml oral syrup [24176]", "drug_information": { "unit": 60.00, "type": "ML" }, "code_information": [ { "code": "9999-0006-19", "type": "NDC" } ], "standard_charges": [ { "gross_charge": 446.31, "minimum": 357.05, "maximum": 379.36, "setting": "both", "payers_information": [ { "payer_name": "Aetna", "plan_name": "700700", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna", "plan_name": "700700_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Miscellaneous", "plan_name": "700720", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Miscellaneous", "plan_name": "700720_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Ppo Hmo", "plan_name": "701720", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Ppo Hmo", "plan_name": "701720_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Ms State Emplo", "plan_name": "401457", "standard_charge_percentage": 0.80, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Ms State Emplo", "plan_name": "401457_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Basic Pl", "plan_name": "400100", "standard_charge_percentage": 0.85, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Basic Pl", "plan_name": "400100_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Federal", "plan_name": "400110", "standard_charge_percentage": 0.85, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Federal", "plan_name": "400110_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." } ] } ] }, { "description": "Hydrocodone-homatropine 5 mg-1.5 mg/5 ml oral syrup [3724]", "drug_information": { "unit": 5.00, "type": "ML" }, "code_information": [ { "code": "9999-0006-20", "type": "NDC" } ], "standard_charges": [ { "gross_charge": 7.50, "minimum": 6.00, "maximum": 6.38, "setting": "both", "payers_information": [ { "payer_name": "Aetna", "plan_name": "700700", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna", "plan_name": "700700_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Miscellaneous", "plan_name": "700720", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Miscellaneous", "plan_name": "700720_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Ppo Hmo", "plan_name": "701720", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Ppo Hmo", "plan_name": "701720_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Ms State Emplo", "plan_name": "401457", "standard_charge_percentage": 0.80, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Ms State Emplo", "plan_name": "401457_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Basic Pl", "plan_name": "400100", "standard_charge_percentage": 0.85, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Basic Pl", "plan_name": "400100_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Federal", "plan_name": "400110", "standard_charge_percentage": 0.85, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Federal", "plan_name": "400110_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." } ] } ] }, { "description": "Albuterol sulfate 2 mg/5 ml oral syrup [252]", "drug_information": { "unit": 5.00, "type": "ML" }, "code_information": [ { "code": "9999-0006-21", "type": "NDC" } ], "standard_charges": [ { "gross_charge": 7.50, "minimum": 6.00, "maximum": 6.38, "setting": "both", "payers_information": [ { "payer_name": "Aetna", "plan_name": "700700", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna", "plan_name": "700700_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Miscellaneous", "plan_name": "700720", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Miscellaneous", "plan_name": "700720_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Ppo Hmo", "plan_name": "701720", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Ppo Hmo", "plan_name": "701720_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Ms State Emplo", "plan_name": "401457", "standard_charge_percentage": 0.80, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Ms State Emplo", "plan_name": "401457_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Basic Pl", "plan_name": "400100", "standard_charge_percentage": 0.85, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Basic Pl", "plan_name": "400100_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Federal", "plan_name": "400110", "standard_charge_percentage": 0.85, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Federal", "plan_name": "400110_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." } ] } ] }, { "description": "Ascorbic acid (vitamin c) 500 mg/5 ml oral liquid [189786]", "drug_information": { "unit": 5.00, "type": "ML" }, "code_information": [ { "code": "9999-0006-22", "type": "NDC" } ], "standard_charges": [ { "gross_charge": 7.50, "minimum": 6.00, "maximum": 6.38, "setting": "both", "payers_information": [ { "payer_name": "Aetna", "plan_name": "700700", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna", "plan_name": "700700_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Miscellaneous", "plan_name": "700720", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Miscellaneous", "plan_name": "700720_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Ppo Hmo", "plan_name": "701720", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Ppo Hmo", "plan_name": "701720_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Ms State Emplo", "plan_name": "401457", "standard_charge_percentage": 0.80, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Ms State Emplo", "plan_name": "401457_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Basic Pl", "plan_name": "400100", "standard_charge_percentage": 0.85, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Basic Pl", "plan_name": "400100_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Federal", "plan_name": "400110", "standard_charge_percentage": 0.85, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Federal", "plan_name": "400110_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." } ] } ] }, { "description": "Hydroxyzine hcl 10 mg/5 ml oral solution [3771]", "drug_information": { "unit": 5.00, "type": "ML" }, "code_information": [ { "code": "9999-0006-23", "type": "NDC" } ], "standard_charges": [ { "gross_charge": 7.50, "minimum": 6.00, "maximum": 6.38, "setting": "both", "payers_information": [ { "payer_name": "Aetna", "plan_name": "700700", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna", "plan_name": "700700_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Miscellaneous", "plan_name": "700720", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Miscellaneous", "plan_name": "700720_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Ppo Hmo", "plan_name": "701720", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Ppo Hmo", "plan_name": "701720_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Ms State Emplo", "plan_name": "401457", "standard_charge_percentage": 0.80, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Ms State Emplo", "plan_name": "401457_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Basic Pl", "plan_name": "400100", "standard_charge_percentage": 0.85, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Basic Pl", "plan_name": "400100_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Federal", "plan_name": "400110", "standard_charge_percentage": 0.85, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Federal", "plan_name": "400110_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." } ] } ] }, { "description": "Sucralfate 100 mg/ml oral suspension [11441]", "drug_information": { "unit": 10.00, "type": "ML" }, "code_information": [ { "code": "9999-0006-24", "type": "NDC" } ], "standard_charges": [ { "gross_charge": 20.19, "minimum": 16.15, "maximum": 17.16, "setting": "both", "payers_information": [ { "payer_name": "Aetna", "plan_name": "700700", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna", "plan_name": "700700_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Miscellaneous", "plan_name": "700720", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Miscellaneous", "plan_name": "700720_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Ppo Hmo", "plan_name": "701720", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Ppo Hmo", "plan_name": "701720_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Ms State Emplo", "plan_name": "401457", "standard_charge_percentage": 0.80, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Ms State Emplo", "plan_name": "401457_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Basic Pl", "plan_name": "400100", "standard_charge_percentage": 0.85, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Basic Pl", "plan_name": "400100_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Federal", "plan_name": "400110", "standard_charge_percentage": 0.85, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Federal", "plan_name": "400110_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." } ] } ] }, { "description": "Oxybutynin chloride 5 mg/5 ml oral syrup [10810]", "drug_information": { "unit": 5.00, "type": "ML" }, "code_information": [ { "code": "9999-0006-25", "type": "NDC" } ], "standard_charges": [ { "gross_charge": 7.50, "minimum": 6.00, "maximum": 6.38, "setting": "both", "payers_information": [ { "payer_name": "Aetna", "plan_name": "700700", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna", "plan_name": "700700_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Miscellaneous", "plan_name": "700720", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Miscellaneous", "plan_name": "700720_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Ppo Hmo", "plan_name": "701720", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Ppo Hmo", "plan_name": "701720_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Ms State Emplo", "plan_name": "401457", "standard_charge_percentage": 0.80, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Ms State Emplo", "plan_name": "401457_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Basic Pl", "plan_name": "400100", "standard_charge_percentage": 0.85, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Basic Pl", "plan_name": "400100_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Federal", "plan_name": "400110", "standard_charge_percentage": 0.85, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Federal", "plan_name": "400110_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." } ] } ] }, { "description": "Lidocaine hcl 2 % mucosal solution [109454]", "drug_information": { "unit": 15.00, "type": "ML" }, "code_information": [ { "code": "9999-0006-26", "type": "NDC" } ], "standard_charges": [ { "gross_charge": 7.84, "minimum": 6.27, "maximum": 6.66, "setting": "both", "payers_information": [ { "payer_name": "Aetna", "plan_name": "700700", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna", "plan_name": "700700_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Miscellaneous", "plan_name": "700720", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Miscellaneous", "plan_name": "700720_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Ppo Hmo", "plan_name": "701720", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Ppo Hmo", "plan_name": "701720_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Ms State Emplo", "plan_name": "401457", "standard_charge_percentage": 0.80, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Ms State Emplo", "plan_name": "401457_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Basic Pl", "plan_name": "400100", "standard_charge_percentage": 0.85, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Basic Pl", "plan_name": "400100_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Federal", "plan_name": "400110", "standard_charge_percentage": 0.85, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Federal", "plan_name": "400110_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." } ] } ] }, { "description": "Hutchinson topical solution [50075]", "drug_information": { "unit": 5.00, "type": "ML" }, "code_information": [ { "code": "9999-0006-40", "type": "NDC" } ], "standard_charges": [ { "gross_charge": 234.56, "minimum": 187.65, "maximum": 199.38, "setting": "both", "payers_information": [ { "payer_name": "Aetna", "plan_name": "700700", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna", "plan_name": "700700_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Miscellaneous", "plan_name": "700720", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Miscellaneous", "plan_name": "700720_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Ppo Hmo", "plan_name": "701720", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Ppo Hmo", "plan_name": "701720_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Ms State Emplo", "plan_name": "401457", "standard_charge_percentage": 0.80, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Ms State Emplo", "plan_name": "401457_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Basic Pl", "plan_name": "400100", "standard_charge_percentage": 0.85, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Basic Pl", "plan_name": "400100_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Federal", "plan_name": "400110", "standard_charge_percentage": 0.85, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Federal", "plan_name": "400110_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." } ] } ] }, { "description": "Austin's topical solution [50077]", "drug_information": { "unit": 30.00, "type": "ML" }, "code_information": [ { "code": "9999-0006-41", "type": "NDC" } ], "standard_charges": [ { "gross_charge": 33.92, "minimum": 27.14, "maximum": 28.83, "setting": "both", "payers_information": [ { "payer_name": "Aetna", "plan_name": "700700", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna", "plan_name": "700700_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Miscellaneous", "plan_name": "700720", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Miscellaneous", "plan_name": "700720_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Ppo Hmo", "plan_name": "701720", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Ppo Hmo", "plan_name": "701720_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Ms State Emplo", "plan_name": "401457", "standard_charge_percentage": 0.80, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Ms State Emplo", "plan_name": "401457_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Basic Pl", "plan_name": "400100", "standard_charge_percentage": 0.85, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Basic Pl", "plan_name": "400100_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Federal", "plan_name": "400110", "standard_charge_percentage": 0.85, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Federal", "plan_name": "400110_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." } ] } ] }, { "description": "Prismasate bk 0/3.5 dialysis solution [5000708]", "drug_information": { "unit": 5000.00, "type": "ML" }, "code_information": [ { "code": "9999-0006-44", "type": "NDC" } ], "standard_charges": [ { "gross_charge": 224.31, "minimum": 179.45, "maximum": 190.66, "setting": "both", "payers_information": [ { "payer_name": "Aetna", "plan_name": "700700", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna", "plan_name": "700700_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Miscellaneous", "plan_name": "700720", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Miscellaneous", "plan_name": "700720_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Ppo Hmo", "plan_name": "701720", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Ppo Hmo", "plan_name": "701720_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Ms State Emplo", "plan_name": "401457", "standard_charge_percentage": 0.80, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Ms State Emplo", "plan_name": "401457_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Basic Pl", "plan_name": "400100", "standard_charge_percentage": 0.85, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Basic Pl", "plan_name": "400100_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Federal", "plan_name": "400110", "standard_charge_percentage": 0.85, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Federal", "plan_name": "400110_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." } ] } ] }, { "description": "Gi cocktail oral suspension 30ml swmc [5000801]", "drug_information": { "unit": 30.00, "type": "ML" }, "code_information": [ { "code": "9999-0006-45", "type": "NDC" } ], "standard_charges": [ { "gross_charge": 9.98, "minimum": 7.98, "maximum": 8.48, "setting": "both", "payers_information": [ { "payer_name": "Aetna", "plan_name": "700700", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna", "plan_name": "700700_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Miscellaneous", "plan_name": "700720", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Miscellaneous", "plan_name": "700720_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Ppo Hmo", "plan_name": "701720", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Ppo Hmo", "plan_name": "701720_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Ms State Emplo", "plan_name": "401457", "standard_charge_percentage": 0.80, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Ms State Emplo", "plan_name": "401457_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Basic Pl", "plan_name": "400100", "standard_charge_percentage": 0.85, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Basic Pl", "plan_name": "400100_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Federal", "plan_name": "400110", "standard_charge_percentage": 0.85, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Federal", "plan_name": "400110_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." } ] } ] }, { "description": "Gi cocktail with anti-spasmotic 55ml swmc [5000712]", "drug_information": { "unit": 55.00, "type": "ML" }, "code_information": [ { "code": "9999-0006-46", "type": "NDC" } ], "standard_charges": [ { "gross_charge": 25.08, "minimum": 20.06, "maximum": 21.32, "setting": "both", "payers_information": [ { "payer_name": "Aetna", "plan_name": "700700", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna", "plan_name": "700700_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Miscellaneous", "plan_name": "700720", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Miscellaneous", "plan_name": "700720_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Ppo Hmo", "plan_name": "701720", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Ppo Hmo", "plan_name": "701720_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Ms State Emplo", "plan_name": "401457", "standard_charge_percentage": 0.80, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Ms State Emplo", "plan_name": "401457_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Basic Pl", "plan_name": "400100", "standard_charge_percentage": 0.85, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Basic Pl", "plan_name": "400100_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Federal", "plan_name": "400110", "standard_charge_percentage": 0.85, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Federal", "plan_name": "400110_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." } ] } ] }, { "description": "Nitroglycerin for cvt/cvl 200 mcg/ml injection [555009]", "drug_information": { "unit": 10.00, "type": "ML" }, "code_information": [ { "code": "9999-0006-47", "type": "NDC" } ], "standard_charges": [ { "gross_charge": 11.00, "minimum": 8.80, "maximum": 9.35, "setting": "both", "payers_information": [ { "payer_name": "Aetna", "plan_name": "700700", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna", "plan_name": "700700_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Miscellaneous", "plan_name": "700720", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Miscellaneous", "plan_name": "700720_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Ppo Hmo", "plan_name": "701720", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Ppo Hmo", "plan_name": "701720_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Ms State Emplo", "plan_name": "401457", "standard_charge_percentage": 0.80, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Ms State Emplo", "plan_name": "401457_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Basic Pl", "plan_name": "400100", "standard_charge_percentage": 0.85, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Basic Pl", "plan_name": "400100_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Federal", "plan_name": "400110", "standard_charge_percentage": 0.85, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Federal", "plan_name": "400110_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." } ] } ] }, { "description": "Vancomycin oral syringe 25 mg/ml [195935]", "drug_information": { "unit": 5.00, "type": "ML" }, "code_information": [ { "code": "9999-0006-48", "type": "NDC" } ], "standard_charges": [ { "gross_charge": 35.91, "minimum": 28.73, "maximum": 30.52, "setting": "both", "payers_information": [ { "payer_name": "Aetna", "plan_name": "700700", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna", "plan_name": "700700_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Miscellaneous", "plan_name": "700720", "standard_charge_percentage": 80.0, "count": "0", "methodology": 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"plan_name": "400110_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." } ] } ] }, { "description": "Guaifenesin 100 mg/5 ml oral liquid [3542]", "drug_information": { "unit": 10.00, "type": "ML" }, "code_information": [ { "code": "9999-0006-52", "type": "NDC" } ], "standard_charges": [ { "gross_charge": 1.00, "minimum": 0.80, "maximum": 0.85, "setting": "both", "payers_information": [ { "payer_name": "Aetna", "plan_name": "700700", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna", "plan_name": "700700_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { 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"Bc/Bs Of Ms Federal", "plan_name": "400110", "standard_charge_percentage": 0.85, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Federal", "plan_name": "400110_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." } ] } ] }, { "description": "Guaifenesin 100 mg/5 ml oral liquid [3542]", "drug_information": { "unit": 15.00, "type": "ML" }, "code_information": [ { "code": "9999-0006-53", "type": "NDC" } ], "standard_charges": [ { "gross_charge": 1.00, "minimum": 0.80, "maximum": 0.85, "setting": "both", "payers_information": [ { "payer_name": "Aetna", "plan_name": "700700", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to 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}, { "payer_name": "Bc/Bs Of Ms Basic Pl", "plan_name": "400100_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Federal", "plan_name": "400110", "standard_charge_percentage": 0.85, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Federal", "plan_name": "400110_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." } ] } ] }, { "description": "Multivit and minerals-ferrous gluconate 9 mg iron/15 ml oral liquid [119617]", "drug_information": { "unit": 15.00, "type": "ML" }, "code_information": [ { "code": "9999-0006-54", "type": "NDC" } ], "standard_charges": [ { "gross_charge": 7.50, "minimum": 6.00, "maximum": 6.38, "setting": "both", "payers_information": [ { "payer_name": "Aetna", "plan_name": "700700", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna", "plan_name": "700700_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Miscellaneous", "plan_name": "700720", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Miscellaneous", "plan_name": "700720_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Ppo Hmo", "plan_name": "701720", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Ppo Hmo", "plan_name": "701720_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Ms State Emplo", "plan_name": "401457", "standard_charge_percentage": 0.80, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Ms State Emplo", "plan_name": "401457_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Basic Pl", "plan_name": "400100", "standard_charge_percentage": 0.85, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Basic Pl", "plan_name": "400100_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Federal", "plan_name": "400110", "standard_charge_percentage": 0.85, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Federal", "plan_name": "400110_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." } ] } ] }, { "description": "Vancomycin oral syringe 25 mg/ml [195935]", "drug_information": { "unit": 10.00, "type": "ML" }, "code_information": [ { "code": "9999-0006-56", "type": "NDC" } ], "standard_charges": [ { "gross_charge": 71.82, "minimum": 57.46, "maximum": 61.05, "setting": "both", "payers_information": [ { "payer_name": "Aetna", "plan_name": "700700", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna", "plan_name": "700700_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Miscellaneous", "plan_name": "700720", "standard_charge_percentage": 80.0, "count": "0", "methodology": 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"methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Federal", "plan_name": "400110", "standard_charge_percentage": 0.85, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Federal", "plan_name": "400110_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." } ] } ] }, { "description": "Vancomycin oral syringe 25 mg/ml [195935]", "drug_information": { "unit": 20.00, "type": "ML" }, "code_information": [ { "code": "9999-0006-58", "type": "NDC" } ], "standard_charges": [ { "gross_charge": 143.64, "minimum": 114.91, "maximum": 122.09, "setting": "both", "payers_information": [ { "payer_name": "Aetna", "plan_name": "700700", 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"plan_name": "400110_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." } ] } ] }, { "description": "Phytonadione 1 mg/ml oral syrup [50081]", "drug_information": { "unit": 30.00, "type": "ML" }, "code_information": [ { "code": "9999-0006-60", "type": "NDC" } ], "standard_charges": [ { "gross_charge": 550.91, "minimum": 440.73, "maximum": 468.27, "setting": "both", "payers_information": [ { "payer_name": "Aetna", "plan_name": "700700", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna", "plan_name": "700700_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { 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"Bc/Bs Of Ms Federal", "plan_name": "400110", "standard_charge_percentage": 0.85, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Federal", "plan_name": "400110_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." } ] } ] }, { "description": "Yergaw's magic mouthwash [5000714]", "drug_information": { "unit": 240.00, "type": "ML" }, "code_information": [ { "code": "9999-0006-61", "type": "NDC" } ], "standard_charges": [ { "gross_charge": 731.88, "minimum": 585.50, "maximum": 622.10, "setting": "both", "payers_information": [ { "payer_name": "Aetna", "plan_name": "700700", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to 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}, { "payer_name": "Bc/Bs Of Ms Basic Pl", "plan_name": "400100_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Federal", "plan_name": "400110", "standard_charge_percentage": 0.85, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Federal", "plan_name": "400110_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." } ] } ] }, { "description": "Sodium polystyrene sulfonate 15 gram-sorbitol 20 gram/60 ml oral susp [178533]", "drug_information": { "unit": 60.00, "type": "ML" }, "code_information": [ { "code": "9999-0006-62", "type": "NDC" } ], "standard_charges": [ { "gross_charge": 115.43, "minimum": 92.34, "maximum": 98.12, "setting": "both", "payers_information": [ { "payer_name": "Aetna", "plan_name": "700700", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna", "plan_name": "700700_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Miscellaneous", "plan_name": "700720", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Miscellaneous", "plan_name": "700720_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Ppo Hmo", "plan_name": "701720", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Ppo Hmo", "plan_name": "701720_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Ms State Emplo", "plan_name": "401457", "standard_charge_percentage": 0.80, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Ms State Emplo", "plan_name": "401457_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Basic Pl", "plan_name": "400100", "standard_charge_percentage": 0.85, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Basic Pl", "plan_name": "400100_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Federal", "plan_name": "400110", "standard_charge_percentage": 0.85, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Federal", "plan_name": "400110_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." } ] } ] }, { "description": "Lidocaine 2 % mucosal jelly in applicator [118460]", "drug_information": { "unit": 5.00, "type": "ML" }, "code_information": [ { "code": "76329-3011-5", "type": "NDC" } ], "standard_charges": [ { "gross_charge": 34.77, "minimum": 27.82, "maximum": 29.55, "setting": "both", "payers_information": [ { "payer_name": "Aetna", "plan_name": "700700", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna", "plan_name": "700700_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Miscellaneous", "plan_name": "700720", "standard_charge_percentage": 80.0, "count": "0", 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"standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Federal", "plan_name": "400110", "standard_charge_percentage": 0.85, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Federal", "plan_name": "400110_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." } ] } ] }, { "description": "Calcium chloride 100 mg/ml (10 %) intravenous syringe [1306]", "drug_information": { "unit": 10.00, "type": "ML" }, "code_information": [ { "code": "76329-3304-1", "type": "NDC" } ], "standard_charges": [ { "gross_charge": 57.35, "minimum": 45.88, "maximum": 48.75, "setting": "both", 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"payer_name": "Aetna Ppo Hmo", "plan_name": "701720", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Ppo Hmo", "plan_name": "701720_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Ms State Emplo", "plan_name": "401457", "standard_charge_percentage": 0.80, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Ms State Emplo", "plan_name": "401457_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": 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"description": "Indigotindisulfonate sodium 8 mg/ml (0.8 %) intravenous solution [198007]", "drug_information": { "unit": 5.00, "type": "ML" }, "code_information": [ { "code": "81284-315-00", "type": "NDC" } ], "standard_charges": [ { "gross_charge": 1881.20, "minimum": 1504.96, "maximum": 1599.02, "setting": "both", "payers_information": [ { "payer_name": "Aetna", "plan_name": "700700", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna", "plan_name": "700700_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Miscellaneous", "plan_name": "700720", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": 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"standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna", "plan_name": "700700_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Miscellaneous", "plan_name": "700720", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Miscellaneous", "plan_name": "700720_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Ppo Hmo", "plan_name": "701720", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Ppo Hmo", "plan_name": "701720_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Ms State Emplo", "plan_name": "401457", "standard_charge_percentage": 0.80, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Ms State Emplo", "plan_name": "401457_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Basic Pl", "plan_name": "400100", "standard_charge_percentage": 0.85, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Basic Pl", "plan_name": "400100_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Federal", "plan_name": "400110", "standard_charge_percentage": 0.85, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Federal", "plan_name": "400110_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." } ] } ] }, { "description": "Nitroglycerin 0.125% topical ointment [50083]", "drug_information": { "unit": 2.00, "type": "GR" }, "code_information": [ { "code": "9999-0006-64", "type": "NDC" } ], "standard_charges": [ { "gross_charge": 7.50, "minimum": 6.00, "maximum": 6.38, "setting": "both", "payers_information": [ { "payer_name": "Aetna", "plan_name": "700700", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna", "plan_name": "700700_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Miscellaneous", "plan_name": "700720", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna 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"plan_name": "401457_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Basic Pl", "plan_name": "400100", "standard_charge_percentage": 0.85, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Basic Pl", "plan_name": "400100_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Federal", "plan_name": "400110", "standard_charge_percentage": 0.85, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Federal", "plan_name": "400110_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." } ] } ] }, { "description": "Meropenem 1 gram/50 ml in 0.9% sodium chloride intravenous piggyback [171370]", "drug_information": { "unit": 50.00, "type": "ML" }, "code_information": [ { "code": "9999-0006-65", "type": "NDC" } ], "standard_charges": [ { "gross_charge": 123.37, "minimum": 98.70, "maximum": 104.86, "setting": "both", "payers_information": [ { "payer_name": "Aetna", "plan_name": "700700", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna", "plan_name": "700700_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Miscellaneous", "plan_name": "700720", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Miscellaneous", "plan_name": "700720_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Ppo Hmo", "plan_name": "701720", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Ppo Hmo", "plan_name": "701720_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Ms State Emplo", "plan_name": "401457", "standard_charge_percentage": 0.80, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Ms State Emplo", "plan_name": "401457_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Basic Pl", "plan_name": "400100", "standard_charge_percentage": 0.85, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Basic Pl", "plan_name": "400100_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Federal", "plan_name": "400110", "standard_charge_percentage": 0.85, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Federal", "plan_name": "400110_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." } ] } ] }, { "description": "Midazolam 2 mg/ml oral syrup [24176]", "drug_information": { "unit": 118.00, "type": "ML" }, "code_information": [ { "code": "9999-0006-66", "type": "NDC" } ], "standard_charges": [ { "gross_charge": 877.74, "minimum": 702.19, "maximum": 746.08, "setting": "both", "payers_information": [ { "payer_name": "Aetna", "plan_name": "700700", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna", "plan_name": "700700_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Miscellaneous", "plan_name": "700720", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Miscellaneous", "plan_name": "700720_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Ppo Hmo", "plan_name": "701720", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Ppo Hmo", "plan_name": "701720_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Ms State Emplo", "plan_name": "401457", "standard_charge_percentage": 0.80, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Ms State Emplo", "plan_name": "401457_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Basic Pl", "plan_name": "400100", "standard_charge_percentage": 0.85, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Basic Pl", "plan_name": "400100_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Federal", "plan_name": "400110", "standard_charge_percentage": 0.85, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Federal", "plan_name": "400110_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." } ] } ] }, { "description": "Lidocaine hcl 4 % (40 mg/ml) mucosal solution [4450]", "drug_information": { "unit": 5.00, "type": "ML" }, "code_information": [ { "code": "9999-0006-72", "type": "NDC" } ], "standard_charges": [ { "gross_charge": 19.00, "minimum": 15.20, "maximum": 16.15, "setting": "both", "payers_information": [ { "payer_name": "Aetna", "plan_name": "700700", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna", "plan_name": "700700_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Miscellaneous", "plan_name": "700720", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Miscellaneous", "plan_name": "700720_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Ppo Hmo", "plan_name": "701720", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Ppo Hmo", "plan_name": "701720_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Ms State Emplo", "plan_name": "401457", "standard_charge_percentage": 0.80, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Ms State Emplo", "plan_name": "401457_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Basic Pl", "plan_name": "400100", "standard_charge_percentage": 0.85, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Basic Pl", "plan_name": "400100_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Federal", "plan_name": "400110", "standard_charge_percentage": 0.85, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Federal", "plan_name": "400110_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." } ] } ] }, { "description": "Magic mouthwash lch [50091]", "drug_information": { "unit": 300.00, "type": "ML" }, "code_information": [ { "code": "9999-0006-78", "type": "NDC" } ], "standard_charges": [ { "gross_charge": 65.55, "minimum": 52.44, "maximum": 55.72, "setting": "both", "payers_information": [ { "payer_name": "Aetna", "plan_name": "700700", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna", "plan_name": "700700_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Miscellaneous", "plan_name": "700720", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Miscellaneous", "plan_name": "700720_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Ppo Hmo", "plan_name": "701720", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Ppo Hmo", "plan_name": "701720_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Ms State Emplo", "plan_name": "401457", "standard_charge_percentage": 0.80, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Ms State Emplo", "plan_name": "401457_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Basic Pl", "plan_name": "400100", "standard_charge_percentage": 0.85, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Basic Pl", "plan_name": "400100_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Federal", "plan_name": "400110", "standard_charge_percentage": 0.85, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Federal", "plan_name": "400110_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." } ] } ] }, { "description": "Ertapenem iv syringe 20 mg/ml (pediatric) [5175627]", "drug_information": { "unit": 1.00, "type": "ML" }, "code_information": [ { "code": "9999-0006-80", "type": "NDC" } ], "standard_charges": [ { "gross_charge": 20.79, "minimum": 16.63, "maximum": 17.67, "setting": "both", "payers_information": [ { "payer_name": "Aetna", "plan_name": "700700", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna", "plan_name": "700700_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Miscellaneous", "plan_name": "700720", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Miscellaneous", "plan_name": "700720_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Ppo Hmo", "plan_name": "701720", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Ppo Hmo", "plan_name": "701720_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Ms State Emplo", "plan_name": "401457", "standard_charge_percentage": 0.80, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Ms State Emplo", "plan_name": "401457_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Basic Pl", "plan_name": "400100", "standard_charge_percentage": 0.85, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Basic Pl", "plan_name": "400100_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Federal", "plan_name": "400110", "standard_charge_percentage": 0.85, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Federal", "plan_name": "400110_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." } ] } ] }, { "description": "Hydrocodone 7.5 mg-acetaminophen 325 mg/15 ml oral solution [37848]", "drug_information": { "unit": 5.00, "type": "ML" }, "code_information": [ { "code": "9999-9000-07", "type": "NDC" } ], "standard_charges": [ { "gross_charge": 7.50, "minimum": 6.00, "maximum": 6.38, "setting": "both", "payers_information": [ { "payer_name": "Aetna", "plan_name": "700700", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna", "plan_name": "700700_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Miscellaneous", "plan_name": "700720", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Miscellaneous", "plan_name": "700720_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Ppo Hmo", "plan_name": "701720", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Ppo Hmo", "plan_name": "701720_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Ms State Emplo", "plan_name": "401457", "standard_charge_percentage": 0.80, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Ms State Emplo", "plan_name": "401457_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Basic Pl", "plan_name": "400100", "standard_charge_percentage": 0.85, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Basic Pl", "plan_name": "400100_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Federal", "plan_name": "400110", "standard_charge_percentage": 0.85, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Federal", "plan_name": "400110_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." } ] } ] }, { "description": "Alcohol of choice 120 ml [500682]", "drug_information": { "unit": 120.00, "type": "ML" }, "code_information": [ { "code": "99999-0002-77", "type": "NDC" } ], "standard_charges": [ { "gross_charge": 40.50, "minimum": 32.40, "maximum": 34.43, "setting": "both", "payers_information": [ { "payer_name": "Aetna", "plan_name": "700700", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna", "plan_name": "700700_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Miscellaneous", "plan_name": "700720", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna 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"plan_name": "401457_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Basic Pl", "plan_name": "400100", "standard_charge_percentage": 0.85, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Basic Pl", "plan_name": "400100_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Federal", "plan_name": "400110", "standard_charge_percentage": 0.85, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Federal", "plan_name": "400110_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." } ] } ] }, { "description": "Cefepime iv syringe 40 mg/ml (neo/ped) [500489]", "drug_information": { "unit": 1.00, "type": "ML" }, "code_information": [ { "code": "99999-0003-05", "type": "NDC" } ], "standard_charges": [ { "gross_charge": 11.00, "minimum": 8.80, "maximum": 9.35, "setting": "both", "payers_information": [ { "payer_name": "Aetna", "plan_name": "700700", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna", "plan_name": "700700_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Miscellaneous", "plan_name": "700720", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Miscellaneous", "plan_name": "700720_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Ppo Hmo", "plan_name": "701720", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Ppo Hmo", "plan_name": "701720_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Ms State Emplo", "plan_name": "401457", "standard_charge_percentage": 0.80, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Ms State Emplo", "plan_name": "401457_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Basic Pl", "plan_name": "400100", "standard_charge_percentage": 0.85, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Basic Pl", "plan_name": "400100_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Federal", "plan_name": "400110", "standard_charge_percentage": 0.85, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Federal", "plan_name": "400110_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." } ] } ] }, { "description": "Hc m-protein isotype maldi ms s (mmpts)rfx", "code_information": [ { "code": "0077U", "type": "CPT" } ], "standard_charges": [ { "gross_charge": 252.78, "minimum": 202.22, "maximum": 214.86, "setting": "both", "payers_information": [ { "payer_name": "Aetna", "plan_name": "700700", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna", "plan_name": "700700_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Miscellaneous", "plan_name": "700720", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Miscellaneous", "plan_name": "700720_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Ppo Hmo", "plan_name": "701720", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Ppo Hmo", "plan_name": "701720_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Ms State Emplo", "plan_name": "401457", "standard_charge_percentage": 0.80, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Ms State Emplo", "plan_name": "401457_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Basic Pl", "plan_name": "400100", "standard_charge_percentage": 0.85, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Basic Pl", "plan_name": "400100_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Federal", "plan_name": "400110", "standard_charge_percentage": 0.85, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Federal", "plan_name": "400110_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." } ] } ] }, { "description": "Ig paraprotein qual bld/ur", "code_information": [ { "code": "0077U", "type": "CPT" } ], "standard_charges": [ { "gross_charge": 252.78, "minimum": 202.22, "maximum": 214.86, "setting": "both", "payers_information": [ { "payer_name": "Aetna", "plan_name": "700700", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna", "plan_name": "700700_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Miscellaneous", "plan_name": "700720", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Miscellaneous", "plan_name": "700720_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Ppo Hmo", "plan_name": "701720", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Ppo Hmo", "plan_name": "701720_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Ms State Emplo", "plan_name": "401457", "standard_charge_percentage": 0.80, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Ms State Emplo", "plan_name": "401457_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Basic Pl", "plan_name": "400100", "standard_charge_percentage": 0.85, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Basic Pl", "plan_name": "400100_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Federal", "plan_name": "400110", "standard_charge_percentage": 0.85, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Federal", "plan_name": "400110_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." } ] } ] }, { "description": "Hc respiratory pathogens pcr 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"methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Miscellaneous", "plan_name": "700720", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Miscellaneous", "plan_name": "700720_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Ppo Hmo", "plan_name": "701720", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Ppo Hmo", "plan_name": "701720_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Ambetter 68069", "plan_name": "500516", "standard_charge_dollar": 416.78, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Ms State Emplo", "plan_name": "401457", "standard_charge_percentage": 0.80, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Ms State Emplo", "plan_name": "401457_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Basic Pl", "plan_name": "400100", "standard_charge_percentage": 0.85, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Basic Pl", "plan_name": "400100_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Federal", "plan_name": "400110", "standard_charge_percentage": 0.85, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Federal", "plan_name": "400110_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Cigna Healthsprings Ffs", "plan_name": "500064", "standard_charge_dollar": 416.78, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Conseco", "plan_name": "500302", "standard_charge_dollar": 416.78, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Humana Ffs 61101", "plan_name": "500006", "standard_charge_dollar": 416.78, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Medicare A", "plan_name": "100100", "standard_charge_dollar": 416.78, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Medicare A", "plan_name": "100500", "standard_charge_dollar": 416.78, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Medicare Part B Only", "plan_name": "100300", "standard_charge_dollar": 416.78, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Medicare Railroad", "plan_name": "100103", "standard_charge_dollar": 416.78, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Ms Physicians Care N", "plan_name": "714210", "standard_charge_dollar": 520.98, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Peoples Hlth Ffs 72126", "plan_name": "500019", "standard_charge_dollar": 416.78, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Uhc/Secure Horizons", "plan_name": "500449", "standard_charge_dollar": 416.78, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "United Health Care/", "plan_name": "500292", "standard_charge_dollar": 470.96, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "United Healthcare", "plan_name": "750104", "standard_charge_dollar": 470.96, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "United Healthcare Ba", "plan_name": "750090", "standard_charge_dollar": 470.96, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "United Healthcare Me", "plan_name": "501310", "standard_charge_dollar": 416.78, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Windsor Mcare Extra", "plan_name": "500778", "standard_charge_dollar": 416.78, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." } ] } ] }, { "description": "Nfct ds 22 trgt sars-cov-2", "code_information": [ { "code": "0202U", "type": "CPT" } ], "standard_charges": [ { "gross_charge": 1041.95, "minimum": 416.78, "maximum": 885.66, "setting": "both", "payers_information": [ { "payer_name": "Aarp", "plan_name": "500102", "standard_charge_dollar": 416.78, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna", "plan_name": "700700", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna", "plan_name": "700700_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Mcare Ffs 6005", "plan_name": "700703", "standard_charge_dollar": 416.78, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Miscellaneous", "plan_name": "700720", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Miscellaneous", "plan_name": "700720_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Ppo Hmo", "plan_name": "701720", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Ppo Hmo", "plan_name": "701720_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Ambetter 68069", "plan_name": "500516", "standard_charge_dollar": 416.78, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Ms State Emplo", "plan_name": "401457", "standard_charge_percentage": 0.80, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Ms State Emplo", "plan_name": "401457_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Basic Pl", "plan_name": "400100", "standard_charge_percentage": 0.85, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Basic Pl", "plan_name": "400100_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Federal", "plan_name": "400110", "standard_charge_percentage": 0.85, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Federal", "plan_name": "400110_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Cigna Healthsprings Ffs", "plan_name": "500064", "standard_charge_dollar": 416.78, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Conseco", "plan_name": "500302", "standard_charge_dollar": 416.78, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Humana Ffs 61101", "plan_name": "500006", "standard_charge_dollar": 416.78, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Medicare A", "plan_name": "100100", "standard_charge_dollar": 416.78, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Medicare A", "plan_name": "100500", "standard_charge_dollar": 416.78, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Medicare Part B Only", "plan_name": "100300", "standard_charge_dollar": 416.78, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Medicare Railroad", "plan_name": "100103", "standard_charge_dollar": 416.78, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Ms Physicians Care N", "plan_name": "714210", "standard_charge_dollar": 520.98, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Peoples Hlth Ffs 72126", "plan_name": "500019", "standard_charge_dollar": 416.78, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Uhc/Secure Horizons", "plan_name": "500449", "standard_charge_dollar": 416.78, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "United Health Care/", "plan_name": "500292", "standard_charge_dollar": 470.96, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "United Healthcare", "plan_name": "750104", "standard_charge_dollar": 470.96, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "United Healthcare Ba", "plan_name": "750090", "standard_charge_dollar": 470.96, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "United Healthcare Me", "plan_name": "501310", "standard_charge_dollar": 416.78, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Windsor Mcare Extra", "plan_name": "500778", "standard_charge_dollar": 416.78, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." } ] } ] }, { "description": "Hc respiratory pathogens pcr nasopharyngeal", "code_information": [ { "code": "0202U", "type": "CPT" } ], "standard_charges": [ { "gross_charge": 1041.95, "minimum": 833.56, "maximum": 885.66, "setting": "both", "payers_information": [ { "payer_name": "Aetna", "plan_name": "700700", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "modifiers": "QW", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna", "plan_name": "700700_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Miscellaneous", "plan_name": "700720", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Miscellaneous", "plan_name": "700720_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Ppo Hmo", "plan_name": "701720", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Ppo Hmo", "plan_name": "701720_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Ms State Emplo", "plan_name": "401457", "standard_charge_percentage": 0.80, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Ms State Emplo", "plan_name": "401457_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Basic Pl", "plan_name": "400100", "standard_charge_percentage": 0.85, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Basic Pl", "plan_name": "400100_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Federal", "plan_name": "400110", "standard_charge_percentage": 0.85, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Federal", "plan_name": "400110_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." } ] } ] }, { "description": "Hc monocyte distribution width whole blood", "code_information": [ { "code": "0427U", "type": "CPT" } ], "standard_charges": [ { "gross_charge": 0.01, "minimum": 0.01, "maximum": 0.01, "setting": "both", "payers_information": [ { "payer_name": "Aetna", "plan_name": "700700", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna", "plan_name": "700700_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Miscellaneous", "plan_name": "700720", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Miscellaneous", "plan_name": "700720_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Ppo Hmo", "plan_name": "701720", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Ppo Hmo", "plan_name": "701720_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Ms State Emplo", "plan_name": "401457", "standard_charge_percentage": 0.80, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Ms State Emplo", "plan_name": "401457_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Basic Pl", "plan_name": "400100", "standard_charge_percentage": 0.85, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Basic Pl", "plan_name": "400100_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Federal", "plan_name": "400110", "standard_charge_percentage": 0.85, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Federal", "plan_name": "400110_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." } ] } ] }, { "description": "Monocyte dstrbj wdth whl bld", "code_information": [ { "code": "0427U", "type": "CPT" } ], "standard_charges": [ { "gross_charge": 0.01, "minimum": 0.01, "maximum": 0.01, "setting": "both", "payers_information": [ { "payer_name": "Aetna", "plan_name": "700700", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna", "plan_name": "700700_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Miscellaneous", "plan_name": "700720", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Miscellaneous", "plan_name": "700720_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Ppo Hmo", "plan_name": "701720", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Ppo Hmo", "plan_name": "701720_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Ms State Emplo", "plan_name": "401457", "standard_charge_percentage": 0.80, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Ms State Emplo", "plan_name": "401457_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Basic Pl", "plan_name": "400100", "standard_charge_percentage": 0.85, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Basic Pl", "plan_name": "400100_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Federal", "plan_name": "400110", "standard_charge_percentage": 0.85, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Federal", "plan_name": "400110_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." } ] } ] }, { "description": "Acne surgery", "code_information": [ { "code": "10040", "type": "CPT" } ], "standard_charges": [ { "gross_charge": 21868.55, "minimum": 182.02, "maximum": 229.58, "setting": "inpatient", "payers_information": [ { "payer_name": "Aarp", "plan_name": "500102", "standard_charge_dollar": 182.02, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna", "plan_name": "700700", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna", "plan_name": "700700_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Mcare Ffs 6005", "plan_name": "700703", "standard_charge_dollar": 182.02, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Miscellaneous", "plan_name": "700720", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Miscellaneous", "plan_name": "700720_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Ppo Hmo", "plan_name": "701720", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Ppo Hmo", "plan_name": "701720_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Ambetter 68069", "plan_name": "500516", "standard_charge_dollar": 182.02, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Ms State Emplo", "plan_name": "401457", "standard_charge_dollar": 229.58, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Ms State Emplo", "plan_name": "401457_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Basic Pl", "plan_name": "400100", "standard_charge_dollar": 229.58, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Basic Pl", "plan_name": "400100_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Federal", "plan_name": "400110", "standard_charge_dollar": 229.58, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Federal", "plan_name": "400110_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Cigna Healthsprings Ffs", "plan_name": "500064", "standard_charge_dollar": 182.02, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Conseco", "plan_name": "500302", "standard_charge_dollar": 182.02, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Humana Ffs 61101", "plan_name": "500006", "standard_charge_dollar": 182.02, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Medicare A", "plan_name": "100100", "standard_charge_dollar": 182.02, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Medicare A", "plan_name": "100500", "standard_charge_dollar": 182.02, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Medicare Part B Only", "plan_name": "100300", "standard_charge_dollar": 182.02, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Medicare Railroad", "plan_name": "100103", "standard_charge_dollar": 182.02, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Ms Physicians Care N", "plan_name": "714210", "standard_charge_dollar": 227.53, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Peoples Hlth Ffs 72126", "plan_name": "500019", "standard_charge_dollar": 182.02, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Uhc/Secure Horizons", "plan_name": "500449", "standard_charge_dollar": 182.02, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "United Health Care/", "plan_name": "500292", "standard_charge_dollar": 205.69, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "United Healthcare", "plan_name": "750104", "standard_charge_dollar": 205.69, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "United Healthcare Ba", "plan_name": "750090", "standard_charge_dollar": 205.69, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "United Healthcare Me", "plan_name": "501310", "standard_charge_dollar": 182.02, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Windsor Mcare Extra", "plan_name": "500778", "standard_charge_dollar": 182.02, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." } ] } ] }, { "description": "Drainage of skin abscess", "code_information": [ { "code": "10060", "type": "CPT" } ], "standard_charges": [ { "gross_charge": 22561.16, "minimum": 182.02, "maximum": 19176.99, "setting": "inpatient", "payers_information": [ { "payer_name": "Aarp", "plan_name": "500102", "standard_charge_dollar": 182.02, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna", "plan_name": "700700", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna", "plan_name": "700700_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Mcare Ffs 6005", "plan_name": "700703", "standard_charge_dollar": 182.02, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Miscellaneous", "plan_name": "700720", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Miscellaneous", "plan_name": "700720_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Ppo Hmo", "plan_name": "701720", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Ppo Hmo", "plan_name": "701720_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Ambetter 68069", "plan_name": "500516", "standard_charge_dollar": 182.02, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Ms State Emplo", "plan_name": "401457", "standard_charge_percentage": 0.80, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Ms State Emplo", "plan_name": "401457_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Basic Pl", "plan_name": "400100", "standard_charge_percentage": 0.85, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Basic Pl", "plan_name": "400100_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Federal", "plan_name": "400110", "standard_charge_percentage": 0.85, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Federal", "plan_name": "400110_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Cigna Healthsprings Ffs", "plan_name": "500064", "standard_charge_dollar": 182.02, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Conseco", "plan_name": "500302", "standard_charge_dollar": 182.02, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Humana Ffs 61101", "plan_name": "500006", "standard_charge_dollar": 182.02, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Medicare A", "plan_name": "100100", "standard_charge_dollar": 182.02, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Medicare A", "plan_name": "100500", "standard_charge_dollar": 182.02, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Medicare Part B Only", "plan_name": "100300", "standard_charge_dollar": 182.02, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Medicare Railroad", "plan_name": "100103", "standard_charge_dollar": 182.02, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Ms Physicians Care N", "plan_name": "714210", "standard_charge_dollar": 227.53, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Peoples Hlth Ffs 72126", "plan_name": "500019", "standard_charge_dollar": 182.02, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Uhc/Secure Horizons", "plan_name": "500449", "standard_charge_dollar": 182.02, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "United Health Care/", "plan_name": "500292", "standard_charge_dollar": 205.69, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "United Healthcare", "plan_name": "750104", "standard_charge_dollar": 205.69, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "United Healthcare Ba", "plan_name": "750090", "standard_charge_dollar": 205.69, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "United Healthcare Me", "plan_name": "501310", "standard_charge_dollar": 182.02, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Windsor Mcare Extra", "plan_name": "500778", "standard_charge_dollar": 182.02, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." } ] } ] }, { "description": "Drainage of skin abscess", "code_information": [ { "code": "10060", "type": "CPT" } ], "standard_charges": [ { "gross_charge": 486.00, "minimum": 182.02, "maximum": 413.10, "setting": "outpatient", "payers_information": [ { "payer_name": "Aarp", "plan_name": "500102", "standard_charge_dollar": 182.02, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna", "plan_name": "700700", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna", "plan_name": "700700_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Mcare Ffs 6005", "plan_name": "700703", "standard_charge_dollar": 182.02, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Miscellaneous", "plan_name": "700720", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Miscellaneous", "plan_name": "700720_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Ppo Hmo", "plan_name": "701720", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Ppo Hmo", "plan_name": "701720_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Ambetter 68069", "plan_name": "500516", "standard_charge_dollar": 182.02, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Ms State Emplo", "plan_name": "401457", "standard_charge_percentage": 0.80, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Ms State Emplo", "plan_name": "401457_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Basic Pl", "plan_name": "400100", "standard_charge_percentage": 0.85, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Basic Pl", "plan_name": "400100_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Federal", "plan_name": "400110", "standard_charge_percentage": 0.85, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Federal", "plan_name": "400110_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Cigna Healthsprings Ffs", "plan_name": "500064", "standard_charge_dollar": 182.02, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Conseco", "plan_name": "500302", "standard_charge_dollar": 182.02, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Humana Ffs 61101", "plan_name": "500006", "standard_charge_dollar": 182.02, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Medicare A", "plan_name": "100100", "standard_charge_dollar": 182.02, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Medicare A", "plan_name": "100500", "standard_charge_dollar": 182.02, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Medicare Part B Only", "plan_name": "100300", "standard_charge_dollar": 182.02, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Medicare Railroad", "plan_name": "100103", "standard_charge_dollar": 182.02, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Ms Physicians Care N", "plan_name": "714210", "standard_charge_dollar": 227.53, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Peoples Hlth Ffs 72126", "plan_name": "500019", "standard_charge_dollar": 182.02, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Uhc/Secure Horizons", "plan_name": "500449", "standard_charge_dollar": 182.02, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "United Health Care/", "plan_name": "500292", "standard_charge_dollar": 205.69, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "United Healthcare", "plan_name": "750104", "standard_charge_dollar": 205.69, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "United Healthcare Ba", "plan_name": "750090", "standard_charge_dollar": 205.69, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "United Healthcare Me", "plan_name": "501310", "standard_charge_dollar": 182.02, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Windsor Mcare Extra", "plan_name": "500778", "standard_charge_dollar": 182.02, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." } ] } ] }, { "description": "Hc i&d abscess simple", "code_information": [ { "code": "10060", "type": "CPT" } ], "standard_charges": [ { "gross_charge": 486.00, "minimum": 182.02, "maximum": 413.10, "setting": "both", "payers_information": [ { "payer_name": "Aarp", "plan_name": "500102", "standard_charge_dollar": 182.02, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna", "plan_name": "700700", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna", "plan_name": "700700_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Mcare Ffs 6005", "plan_name": "700703", "standard_charge_dollar": 182.02, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Miscellaneous", "plan_name": "700720", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Miscellaneous", "plan_name": "700720_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Ppo Hmo", "plan_name": "701720", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Ppo Hmo", "plan_name": "701720_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Ambetter 68069", "plan_name": "500516", "standard_charge_dollar": 182.02, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Ms State Emplo", "plan_name": "401457", "standard_charge_percentage": 0.80, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Ms State Emplo", "plan_name": "401457_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Basic Pl", "plan_name": "400100", "standard_charge_percentage": 0.85, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Basic Pl", "plan_name": "400100_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Federal", "plan_name": "400110", "standard_charge_percentage": 0.85, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Federal", "plan_name": "400110_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Cigna Healthsprings Ffs", "plan_name": "500064", "standard_charge_dollar": 182.02, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Conseco", "plan_name": "500302", "standard_charge_dollar": 182.02, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Humana Ffs 61101", "plan_name": "500006", "standard_charge_dollar": 182.02, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Medicare A", "plan_name": "100100", "standard_charge_dollar": 182.02, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Medicare A", "plan_name": "100500", "standard_charge_dollar": 182.02, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Medicare Part B Only", "plan_name": "100300", "standard_charge_dollar": 182.02, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Medicare Railroad", "plan_name": "100103", "standard_charge_dollar": 182.02, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Ms Physicians Care N", "plan_name": "714210", "standard_charge_dollar": 227.53, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Peoples Hlth Ffs 72126", "plan_name": "500019", "standard_charge_dollar": 182.02, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Uhc/Secure Horizons", "plan_name": "500449", "standard_charge_dollar": 182.02, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "United Health Care/", "plan_name": "500292", "standard_charge_dollar": 205.69, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "United Healthcare", "plan_name": "750104", "standard_charge_dollar": 205.69, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "United Healthcare Ba", "plan_name": "750090", "standard_charge_dollar": 205.69, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "United Healthcare Me", "plan_name": "501310", "standard_charge_dollar": 182.02, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Windsor Mcare Extra", "plan_name": "500778", "standard_charge_dollar": 182.02, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." } ] } ] }, { "description": "Drainage of skin abscess", "code_information": [ { "code": "10061", "type": "CPT" } ], "standard_charges": [ { "gross_charge": 22561.16, "minimum": 366.00, "maximum": 19176.99, "setting": "inpatient", "payers_information": [ { "payer_name": "Aarp", "plan_name": "500102", "standard_charge_dollar": 366.00, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna", "plan_name": "700700", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna", "plan_name": "700700_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Mcare Ffs 6005", "plan_name": "700703", "standard_charge_dollar": 366.00, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Miscellaneous", "plan_name": "700720", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Miscellaneous", "plan_name": "700720_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Ppo Hmo", "plan_name": "701720", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Ppo Hmo", "plan_name": "701720_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Ambetter 68069", "plan_name": "500516", "standard_charge_dollar": 366.00, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Ms State Emplo", "plan_name": "401457", "standard_charge_percentage": 0.80, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Ms State Emplo", "plan_name": "401457_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Basic Pl", "plan_name": "400100", "standard_charge_percentage": 0.85, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Basic Pl", "plan_name": "400100_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Federal", "plan_name": "400110", "standard_charge_percentage": 0.85, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Federal", "plan_name": "400110_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Cigna Healthsprings Ffs", "plan_name": "500064", "standard_charge_dollar": 366.00, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Conseco", "plan_name": "500302", "standard_charge_dollar": 366.00, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Humana Ffs 61101", "plan_name": "500006", "standard_charge_dollar": 366.00, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Medicare A", "plan_name": "100100", "standard_charge_dollar": 366.00, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Medicare A", "plan_name": "100500", "standard_charge_dollar": 366.00, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Medicare Part B Only", "plan_name": "100300", "standard_charge_dollar": 366.00, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Medicare Railroad", "plan_name": "100103", "standard_charge_dollar": 366.00, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Ms Physicians Care N", "plan_name": "714210", "standard_charge_dollar": 457.50, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Peoples Hlth Ffs 72126", "plan_name": "500019", "standard_charge_dollar": 366.00, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Uhc/Secure Horizons", "plan_name": "500449", "standard_charge_dollar": 366.00, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "United Health Care/", "plan_name": "500292", "standard_charge_dollar": 413.58, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "United Healthcare", "plan_name": "750104", "standard_charge_dollar": 413.58, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "United Healthcare Ba", "plan_name": "750090", "standard_charge_dollar": 413.58, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "United Healthcare Me", "plan_name": "501310", "standard_charge_dollar": 366.00, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Windsor Mcare Extra", "plan_name": "500778", "standard_charge_dollar": 366.00, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." } ] } ] }, { "description": "Drainage of skin abscess", "code_information": [ { "code": "10061", "type": "CPT" } ], "standard_charges": [ { "gross_charge": 597.00, "minimum": 366.00, "maximum": 507.45, "setting": "outpatient", "payers_information": [ { "payer_name": "Aarp", "plan_name": "500102", "standard_charge_dollar": 366.00, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna", "plan_name": "700700", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna", "plan_name": "700700_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Mcare Ffs 6005", "plan_name": "700703", "standard_charge_dollar": 366.00, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Miscellaneous", "plan_name": "700720", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Miscellaneous", "plan_name": "700720_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Ppo Hmo", "plan_name": "701720", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Ppo Hmo", "plan_name": "701720_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Ambetter 68069", "plan_name": "500516", "standard_charge_dollar": 366.00, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Ms State Emplo", "plan_name": "401457", "standard_charge_percentage": 0.80, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Ms State Emplo", "plan_name": "401457_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Basic Pl", "plan_name": "400100", "standard_charge_percentage": 0.85, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Basic Pl", "plan_name": "400100_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Federal", "plan_name": "400110", "standard_charge_percentage": 0.85, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Federal", "plan_name": "400110_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Cigna Healthsprings Ffs", "plan_name": "500064", "standard_charge_dollar": 366.00, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Conseco", "plan_name": "500302", "standard_charge_dollar": 366.00, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Humana Ffs 61101", "plan_name": "500006", "standard_charge_dollar": 366.00, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Medicare A", "plan_name": "100100", "standard_charge_dollar": 366.00, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Medicare A", "plan_name": "100500", "standard_charge_dollar": 366.00, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Medicare Part B Only", "plan_name": "100300", "standard_charge_dollar": 366.00, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Medicare Railroad", "plan_name": "100103", "standard_charge_dollar": 366.00, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Ms Physicians Care N", "plan_name": "714210", "standard_charge_dollar": 457.50, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Peoples Hlth Ffs 72126", "plan_name": "500019", "standard_charge_dollar": 366.00, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Uhc/Secure Horizons", "plan_name": "500449", "standard_charge_dollar": 366.00, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "United Health Care/", "plan_name": "500292", "standard_charge_dollar": 413.58, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "United Healthcare", "plan_name": "750104", "standard_charge_dollar": 413.58, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "United Healthcare Ba", "plan_name": "750090", "standard_charge_dollar": 413.58, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "United Healthcare Me", "plan_name": "501310", "standard_charge_dollar": 366.00, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Windsor Mcare Extra", "plan_name": "500778", "standard_charge_dollar": 366.00, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." } ] } ] }, { "description": "Hc i&d abscess complicated", "code_information": [ { "code": "10061", "type": "CPT" } ], "standard_charges": [ { "gross_charge": 597.00, "minimum": 366.00, "maximum": 507.45, "setting": "both", "payers_information": [ { "payer_name": "Aarp", "plan_name": "500102", "standard_charge_dollar": 366.00, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna", "plan_name": "700700", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna", "plan_name": "700700_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Mcare Ffs 6005", "plan_name": "700703", "standard_charge_dollar": 366.00, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Miscellaneous", "plan_name": "700720", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Miscellaneous", "plan_name": "700720_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Ppo Hmo", "plan_name": "701720", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Ppo Hmo", "plan_name": "701720_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Ambetter 68069", "plan_name": "500516", "standard_charge_dollar": 366.00, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Ms State Emplo", "plan_name": "401457", "standard_charge_percentage": 0.80, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Ms State Emplo", "plan_name": "401457_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Basic Pl", "plan_name": "400100", "standard_charge_percentage": 0.85, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Basic Pl", "plan_name": "400100_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Federal", "plan_name": "400110", "standard_charge_percentage": 0.85, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Federal", "plan_name": "400110_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Cigna Healthsprings Ffs", "plan_name": "500064", "standard_charge_dollar": 366.00, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Conseco", "plan_name": "500302", "standard_charge_dollar": 366.00, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Humana Ffs 61101", "plan_name": "500006", "standard_charge_dollar": 366.00, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Medicare A", "plan_name": "100100", "standard_charge_dollar": 366.00, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Medicare A", "plan_name": "100500", "standard_charge_dollar": 366.00, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Medicare Part B Only", "plan_name": "100300", "standard_charge_dollar": 366.00, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Medicare Railroad", "plan_name": "100103", "standard_charge_dollar": 366.00, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Ms Physicians Care N", "plan_name": "714210", "standard_charge_dollar": 457.50, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Peoples Hlth Ffs 72126", "plan_name": "500019", "standard_charge_dollar": 366.00, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Uhc/Secure Horizons", "plan_name": "500449", "standard_charge_dollar": 366.00, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "United Health Care/", "plan_name": "500292", "standard_charge_dollar": 413.58, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "United Healthcare", "plan_name": "750104", "standard_charge_dollar": 413.58, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "United Healthcare Ba", "plan_name": "750090", "standard_charge_dollar": 413.58, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "United Healthcare Me", "plan_name": "501310", "standard_charge_dollar": 366.00, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Windsor Mcare Extra", "plan_name": "500778", "standard_charge_dollar": 366.00, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." } ] } ] }, { "description": "Hc i&d abscess complicated", "code_information": [ { "code": "10061", "type": "CPT" } ], "standard_charges": [ { "gross_charge": 2388.00, "minimum": 366.00, "maximum": 2029.80, "setting": "both", "payers_information": [ { "payer_name": "Aarp", "plan_name": "500102", "standard_charge_dollar": 366.00, "count": "0", "methodology": "fee schedule", "modifiers": "50", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna", "plan_name": "700700", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna", "plan_name": "700700_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Mcare Ffs 6005", "plan_name": "700703", "standard_charge_dollar": 366.00, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Miscellaneous", "plan_name": "700720", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Miscellaneous", "plan_name": "700720_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Ppo Hmo", "plan_name": "701720", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Ppo Hmo", "plan_name": "701720_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Ambetter 68069", "plan_name": "500516", "standard_charge_dollar": 366.00, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Ms State Emplo", "plan_name": "401457", "standard_charge_percentage": 0.80, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Ms State Emplo", "plan_name": "401457_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Basic Pl", "plan_name": "400100", "standard_charge_percentage": 0.85, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Basic Pl", "plan_name": "400100_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Federal", "plan_name": "400110", "standard_charge_percentage": 0.85, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Federal", "plan_name": "400110_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Cigna Healthsprings Ffs", "plan_name": "500064", "standard_charge_dollar": 366.00, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Conseco", "plan_name": "500302", "standard_charge_dollar": 366.00, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Humana Ffs 61101", "plan_name": "500006", "standard_charge_dollar": 366.00, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Medicare A", "plan_name": "100100", "standard_charge_dollar": 366.00, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Medicare A", "plan_name": "100500", "standard_charge_dollar": 366.00, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Medicare Part B Only", "plan_name": "100300", "standard_charge_dollar": 366.00, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Medicare Railroad", "plan_name": "100103", "standard_charge_dollar": 366.00, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Ms Physicians Care N", "plan_name": "714210", "standard_charge_dollar": 457.50, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Peoples Hlth Ffs 72126", "plan_name": "500019", "standard_charge_dollar": 366.00, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Uhc/Secure Horizons", "plan_name": "500449", "standard_charge_dollar": 366.00, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "United Health Care/", "plan_name": "500292", "standard_charge_dollar": 413.58, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "United Healthcare", "plan_name": "750104", "standard_charge_dollar": 413.58, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "United Healthcare Ba", "plan_name": "750090", "standard_charge_dollar": 413.58, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "United Healthcare Me", "plan_name": "501310", "standard_charge_dollar": 366.00, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Windsor Mcare Extra", "plan_name": "500778", "standard_charge_dollar": 366.00, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." } ] } ] }, { "description": "Drainage of pilonidal cyst", "code_information": [ { "code": "10080", "type": "CPT" } ], "standard_charges": [ { "gross_charge": 18415.72, "minimum": 644.54, "maximum": 15653.36, "setting": "inpatient", "payers_information": [ { "payer_name": "Aarp", "plan_name": "500102", "standard_charge_dollar": 644.54, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna", "plan_name": "700700", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna", "plan_name": "700700_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Mcare Ffs 6005", "plan_name": "700703", "standard_charge_dollar": 644.54, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Miscellaneous", "plan_name": "700720", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Miscellaneous", "plan_name": "700720_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Ppo Hmo", "plan_name": "701720", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Ppo Hmo", "plan_name": "701720_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Ambetter 68069", "plan_name": "500516", "standard_charge_dollar": 644.54, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Ms State Emplo", "plan_name": "401457", "standard_charge_percentage": 0.80, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Ms State Emplo", "plan_name": "401457_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Basic Pl", "plan_name": "400100", "standard_charge_percentage": 0.85, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Basic Pl", "plan_name": "400100_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Federal", "plan_name": "400110", "standard_charge_percentage": 0.85, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Federal", "plan_name": "400110_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Cigna Healthsprings Ffs", "plan_name": "500064", "standard_charge_dollar": 644.54, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Conseco", "plan_name": "500302", "standard_charge_dollar": 644.54, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Humana Ffs 61101", "plan_name": "500006", "standard_charge_dollar": 644.54, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Medicare A", "plan_name": "100100", "standard_charge_dollar": 644.54, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Medicare A", "plan_name": "100500", "standard_charge_dollar": 644.54, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Medicare Part B Only", "plan_name": "100300", "standard_charge_dollar": 644.54, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Medicare Railroad", "plan_name": "100103", "standard_charge_dollar": 644.54, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Ms Physicians Care N", "plan_name": "714210", "standard_charge_dollar": 805.67, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Peoples Hlth Ffs 72126", "plan_name": "500019", "standard_charge_dollar": 644.54, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Uhc/Secure Horizons", "plan_name": "500449", "standard_charge_dollar": 644.54, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "United Health Care/", "plan_name": "500292", "standard_charge_dollar": 728.33, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "United Healthcare", "plan_name": "750104", "standard_charge_dollar": 728.33, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "United Healthcare Ba", "plan_name": "750090", "standard_charge_dollar": 728.33, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "United Healthcare Me", "plan_name": "501310", "standard_charge_dollar": 644.54, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Windsor Mcare Extra", "plan_name": "500778", "standard_charge_dollar": 644.54, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." } ] } ] }, { "description": "Drainage of pilonidal cyst", "code_information": [ { "code": "10080", "type": "CPT" } ], "standard_charges": [ { "gross_charge": 1038.00, "minimum": 644.54, "maximum": 882.30, "setting": "outpatient", "payers_information": [ { "payer_name": "Aarp", "plan_name": "500102", "standard_charge_dollar": 644.54, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna", "plan_name": "700700", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna", "plan_name": "700700_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Mcare Ffs 6005", "plan_name": "700703", "standard_charge_dollar": 644.54, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Miscellaneous", "plan_name": "700720", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Miscellaneous", "plan_name": "700720_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Ppo Hmo", "plan_name": "701720", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Ppo Hmo", "plan_name": "701720_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Ambetter 68069", "plan_name": "500516", "standard_charge_dollar": 644.54, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Ms State Emplo", "plan_name": "401457", "standard_charge_percentage": 0.80, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Ms State Emplo", "plan_name": "401457_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Basic Pl", "plan_name": "400100", "standard_charge_percentage": 0.85, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Basic Pl", "plan_name": "400100_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Federal", "plan_name": "400110", "standard_charge_percentage": 0.85, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Federal", "plan_name": "400110_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Cigna Healthsprings Ffs", "plan_name": "500064", "standard_charge_dollar": 644.54, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Conseco", "plan_name": "500302", "standard_charge_dollar": 644.54, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Humana Ffs 61101", "plan_name": "500006", "standard_charge_dollar": 644.54, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Medicare A", "plan_name": "100100", "standard_charge_dollar": 644.54, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Medicare A", "plan_name": "100500", "standard_charge_dollar": 644.54, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Medicare Part B Only", "plan_name": "100300", "standard_charge_dollar": 644.54, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Medicare Railroad", "plan_name": "100103", "standard_charge_dollar": 644.54, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Ms Physicians Care N", "plan_name": "714210", "standard_charge_dollar": 805.67, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Peoples Hlth Ffs 72126", "plan_name": "500019", "standard_charge_dollar": 644.54, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Uhc/Secure Horizons", "plan_name": "500449", "standard_charge_dollar": 644.54, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "United Health Care/", "plan_name": "500292", "standard_charge_dollar": 728.33, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "United Healthcare", "plan_name": "750104", "standard_charge_dollar": 728.33, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "United Healthcare Ba", "plan_name": "750090", "standard_charge_dollar": 728.33, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "United Healthcare Me", "plan_name": "501310", "standard_charge_dollar": 644.54, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Windsor Mcare Extra", "plan_name": "500778", "standard_charge_dollar": 644.54, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." } ] } ] }, { "description": "Hc i & d pilonidal cyst simple", "code_information": [ { "code": "10080", "type": "CPT" } ], "standard_charges": [ { "gross_charge": 1038.00, "minimum": 644.54, "maximum": 882.30, "setting": "both", "payers_information": [ { "payer_name": "Aarp", "plan_name": "500102", "standard_charge_dollar": 644.54, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna", "plan_name": "700700", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna", "plan_name": "700700_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Mcare Ffs 6005", "plan_name": "700703", "standard_charge_dollar": 644.54, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Miscellaneous", "plan_name": "700720", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Miscellaneous", "plan_name": "700720_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Ppo Hmo", "plan_name": "701720", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Ppo Hmo", "plan_name": "701720_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Ambetter 68069", "plan_name": "500516", "standard_charge_dollar": 644.54, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Ms State Emplo", "plan_name": "401457", "standard_charge_percentage": 0.80, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Ms State Emplo", "plan_name": "401457_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Basic Pl", "plan_name": "400100", "standard_charge_percentage": 0.85, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Basic Pl", "plan_name": "400100_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Federal", "plan_name": "400110", "standard_charge_percentage": 0.85, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Federal", "plan_name": "400110_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Cigna Healthsprings Ffs", "plan_name": "500064", "standard_charge_dollar": 644.54, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Conseco", "plan_name": "500302", "standard_charge_dollar": 644.54, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Humana Ffs 61101", "plan_name": "500006", "standard_charge_dollar": 644.54, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Medicare A", "plan_name": "100100", "standard_charge_dollar": 644.54, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Medicare A", "plan_name": "100500", "standard_charge_dollar": 644.54, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Medicare Part B Only", "plan_name": "100300", "standard_charge_dollar": 644.54, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Medicare Railroad", "plan_name": "100103", "standard_charge_dollar": 644.54, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Ms Physicians Care N", "plan_name": "714210", "standard_charge_dollar": 805.67, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Peoples Hlth Ffs 72126", "plan_name": "500019", "standard_charge_dollar": 644.54, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Uhc/Secure Horizons", "plan_name": "500449", "standard_charge_dollar": 644.54, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "United Health Care/", "plan_name": "500292", "standard_charge_dollar": 728.33, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "United Healthcare", "plan_name": "750104", "standard_charge_dollar": 728.33, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "United Healthcare Ba", "plan_name": "750090", "standard_charge_dollar": 728.33, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "United Healthcare Me", "plan_name": "501310", "standard_charge_dollar": 644.54, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Windsor Mcare Extra", "plan_name": "500778", "standard_charge_dollar": 644.54, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." } ] } ] }, { "description": "Drainage of pilonidal cyst", "code_information": [ { "code": "10081", "type": "CPT" } ], "standard_charges": [ { "gross_charge": 18415.72, "minimum": 644.54, "maximum": 15653.36, "setting": "inpatient", "payers_information": [ { "payer_name": "Aarp", "plan_name": "500102", "standard_charge_dollar": 644.54, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna", "plan_name": "700700", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna", "plan_name": "700700_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Mcare Ffs 6005", "plan_name": "700703", "standard_charge_dollar": 644.54, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Miscellaneous", "plan_name": "700720", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Miscellaneous", "plan_name": "700720_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Ppo Hmo", "plan_name": "701720", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Ppo Hmo", "plan_name": "701720_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Ambetter 68069", "plan_name": "500516", "standard_charge_dollar": 644.54, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Ms State Emplo", "plan_name": "401457", "standard_charge_percentage": 0.80, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Ms State Emplo", "plan_name": "401457_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Basic Pl", "plan_name": "400100", "standard_charge_percentage": 0.85, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Basic Pl", "plan_name": "400100_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Federal", "plan_name": "400110", "standard_charge_percentage": 0.85, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Federal", "plan_name": "400110_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Cigna Healthsprings Ffs", "plan_name": "500064", "standard_charge_dollar": 644.54, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Conseco", "plan_name": "500302", "standard_charge_dollar": 644.54, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Humana Ffs 61101", "plan_name": "500006", "standard_charge_dollar": 644.54, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Medicare A", "plan_name": "100100", "standard_charge_dollar": 644.54, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Medicare A", "plan_name": "100500", "standard_charge_dollar": 644.54, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Medicare Part B Only", "plan_name": "100300", "standard_charge_dollar": 644.54, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Medicare Railroad", "plan_name": "100103", "standard_charge_dollar": 644.54, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Ms Physicians Care N", "plan_name": "714210", "standard_charge_dollar": 805.67, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Peoples Hlth Ffs 72126", "plan_name": "500019", "standard_charge_dollar": 644.54, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Uhc/Secure Horizons", "plan_name": "500449", "standard_charge_dollar": 644.54, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "United Health Care/", "plan_name": "500292", "standard_charge_dollar": 728.33, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "United Healthcare", "plan_name": "750104", "standard_charge_dollar": 728.33, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "United Healthcare Ba", "plan_name": "750090", "standard_charge_dollar": 728.33, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "United Healthcare Me", "plan_name": "501310", "standard_charge_dollar": 644.54, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Windsor Mcare Extra", "plan_name": "500778", "standard_charge_dollar": 644.54, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." } ] } ] }, { "description": "Hc removal foreign body simple", "code_information": [ { "code": "10120", "type": "CPT" } ], "standard_charges": [ { "gross_charge": 597.00, "minimum": 366.00, "maximum": 507.45, "setting": "both", "payers_information": [ { "payer_name": "Aarp", "plan_name": "500102", "standard_charge_dollar": 366.00, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna", "plan_name": "700700", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna", "plan_name": "700700_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Mcare Ffs 6005", "plan_name": "700703", "standard_charge_dollar": 366.00, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Miscellaneous", "plan_name": "700720", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Miscellaneous", "plan_name": "700720_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Ppo Hmo", "plan_name": "701720", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Ppo Hmo", "plan_name": "701720_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Ambetter 68069", "plan_name": "500516", "standard_charge_dollar": 366.00, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Ms State Emplo", "plan_name": "401457", "standard_charge_percentage": 0.80, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Ms State Emplo", "plan_name": "401457_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Basic Pl", "plan_name": "400100", "standard_charge_percentage": 0.85, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Basic Pl", "plan_name": "400100_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Federal", "plan_name": "400110", "standard_charge_percentage": 0.85, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Federal", "plan_name": "400110_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Cigna Healthsprings Ffs", "plan_name": "500064", "standard_charge_dollar": 366.00, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Conseco", "plan_name": "500302", "standard_charge_dollar": 366.00, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Humana Ffs 61101", "plan_name": "500006", "standard_charge_dollar": 366.00, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Medicare A", "plan_name": "100100", "standard_charge_dollar": 366.00, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Medicare A", "plan_name": "100500", "standard_charge_dollar": 366.00, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Medicare Part B Only", "plan_name": "100300", "standard_charge_dollar": 366.00, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Medicare Railroad", "plan_name": "100103", "standard_charge_dollar": 366.00, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Ms Physicians Care N", "plan_name": "714210", "standard_charge_dollar": 457.50, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Peoples Hlth Ffs 72126", "plan_name": "500019", "standard_charge_dollar": 366.00, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Uhc/Secure Horizons", "plan_name": "500449", "standard_charge_dollar": 366.00, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "United Health Care/", "plan_name": "500292", "standard_charge_dollar": 413.58, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "United Healthcare", "plan_name": "750104", "standard_charge_dollar": 413.58, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "United Healthcare Ba", "plan_name": "750090", "standard_charge_dollar": 413.58, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "United Healthcare Me", "plan_name": "501310", "standard_charge_dollar": 366.00, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Windsor Mcare Extra", "plan_name": "500778", "standard_charge_dollar": 366.00, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." } ] } ] }, { "description": "Remove foreign body", "code_information": [ { "code": "10120", "type": "CPT" } ], "standard_charges": [ { "gross_charge": 30733.15, "minimum": 366.00, "maximum": 26123.18, "setting": "inpatient", "payers_information": [ { "payer_name": "Aarp", "plan_name": "500102", "standard_charge_dollar": 366.00, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna", "plan_name": "700700", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna", "plan_name": "700700_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Mcare Ffs 6005", "plan_name": "700703", "standard_charge_dollar": 366.00, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Miscellaneous", "plan_name": "700720", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Miscellaneous", "plan_name": "700720_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Ppo Hmo", "plan_name": "701720", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Ppo Hmo", "plan_name": "701720_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Ambetter 68069", "plan_name": "500516", "standard_charge_dollar": 366.00, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Ms State Emplo", "plan_name": "401457", "standard_charge_percentage": 0.80, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Ms State Emplo", "plan_name": "401457_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Basic Pl", "plan_name": "400100", "standard_charge_percentage": 0.85, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Basic Pl", "plan_name": "400100_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Federal", "plan_name": "400110", "standard_charge_percentage": 0.85, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Federal", "plan_name": "400110_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Cigna Healthsprings Ffs", "plan_name": "500064", "standard_charge_dollar": 366.00, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Conseco", "plan_name": "500302", "standard_charge_dollar": 366.00, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Humana Ffs 61101", "plan_name": "500006", "standard_charge_dollar": 366.00, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Medicare A", "plan_name": "100100", "standard_charge_dollar": 366.00, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Medicare A", "plan_name": "100500", "standard_charge_dollar": 366.00, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Medicare Part B Only", "plan_name": "100300", "standard_charge_dollar": 366.00, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Medicare Railroad", "plan_name": "100103", "standard_charge_dollar": 366.00, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Ms Physicians Care N", "plan_name": "714210", "standard_charge_dollar": 457.50, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Peoples Hlth Ffs 72126", "plan_name": "500019", "standard_charge_dollar": 366.00, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Uhc/Secure Horizons", "plan_name": "500449", "standard_charge_dollar": 366.00, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "United Health Care/", "plan_name": "500292", "standard_charge_dollar": 413.58, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "United Healthcare", "plan_name": "750104", "standard_charge_dollar": 413.58, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "United Healthcare Ba", "plan_name": "750090", "standard_charge_dollar": 413.58, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "United Healthcare Me", "plan_name": "501310", "standard_charge_dollar": 366.00, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Windsor Mcare Extra", "plan_name": "500778", "standard_charge_dollar": 366.00, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." } ] } ] }, { "description": "Remove foreign body", "code_information": [ { "code": "10120", "type": "CPT" } ], "standard_charges": [ { "gross_charge": 597.00, "minimum": 366.00, "maximum": 507.45, "setting": "outpatient", "payers_information": [ { "payer_name": "Aarp", "plan_name": "500102", "standard_charge_dollar": 366.00, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna", "plan_name": "700700", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna", "plan_name": "700700_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Mcare Ffs 6005", "plan_name": "700703", "standard_charge_dollar": 366.00, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Miscellaneous", "plan_name": "700720", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Miscellaneous", "plan_name": "700720_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Ppo Hmo", "plan_name": "701720", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Ppo Hmo", "plan_name": "701720_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Ambetter 68069", "plan_name": "500516", "standard_charge_dollar": 366.00, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Ms State Emplo", "plan_name": "401457", "standard_charge_percentage": 0.80, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Ms State Emplo", "plan_name": "401457_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Basic Pl", "plan_name": "400100", "standard_charge_percentage": 0.85, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Basic Pl", "plan_name": "400100_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Federal", "plan_name": "400110", "standard_charge_percentage": 0.85, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Federal", "plan_name": "400110_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Cigna Healthsprings Ffs", "plan_name": "500064", "standard_charge_dollar": 366.00, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Conseco", "plan_name": "500302", "standard_charge_dollar": 366.00, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Humana Ffs 61101", "plan_name": "500006", "standard_charge_dollar": 366.00, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Medicare A", "plan_name": "100100", "standard_charge_dollar": 366.00, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Medicare A", "plan_name": "100500", "standard_charge_dollar": 366.00, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Medicare Part B Only", "plan_name": "100300", "standard_charge_dollar": 366.00, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Medicare Railroad", "plan_name": "100103", "standard_charge_dollar": 366.00, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Ms Physicians Care N", "plan_name": "714210", "standard_charge_dollar": 457.50, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Peoples Hlth Ffs 72126", "plan_name": "500019", "standard_charge_dollar": 366.00, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Uhc/Secure Horizons", "plan_name": "500449", "standard_charge_dollar": 366.00, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "United Health Care/", "plan_name": "500292", "standard_charge_dollar": 413.58, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "United Healthcare", "plan_name": "750104", "standard_charge_dollar": 413.58, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "United Healthcare Ba", "plan_name": "750090", "standard_charge_dollar": 413.58, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "United Healthcare Me", "plan_name": "501310", "standard_charge_dollar": 366.00, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Windsor Mcare Extra", "plan_name": "500778", "standard_charge_dollar": 366.00, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." } ] } ] }, { "description": "Hc incision and removal of foreign body", "code_information": [ { "code": "10121", "type": "CPT" } ], "standard_charges": [ { "gross_charge": 3192.00, "minimum": 1484.25, "maximum": 2713.20, "setting": "both", "payers_information": [ { "payer_name": "Aarp", "plan_name": "500102", "standard_charge_dollar": 1484.25, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna", "plan_name": "700700", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna", "plan_name": "700700_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Mcare Ffs 6005", "plan_name": "700703", "standard_charge_dollar": 1484.25, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Miscellaneous", "plan_name": "700720", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Miscellaneous", "plan_name": "700720_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Ppo Hmo", "plan_name": "701720", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Ppo Hmo", "plan_name": "701720_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Ambetter 68069", "plan_name": "500516", "standard_charge_dollar": 1484.25, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Ms State Emplo", "plan_name": "401457", "standard_charge_percentage": 0.80, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Ms State Emplo", "plan_name": "401457_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Basic Pl", "plan_name": "400100", "standard_charge_percentage": 0.85, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Basic Pl", "plan_name": "400100_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Federal", "plan_name": "400110", "standard_charge_percentage": 0.85, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Federal", "plan_name": "400110_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Cigna Healthsprings Ffs", "plan_name": "500064", "standard_charge_dollar": 1484.25, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Conseco", "plan_name": "500302", "standard_charge_dollar": 1484.25, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Humana Ffs 61101", "plan_name": "500006", "standard_charge_dollar": 1484.25, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Medicare A", "plan_name": "100100", "standard_charge_dollar": 1484.25, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Medicare A", "plan_name": "100500", "standard_charge_dollar": 1484.25, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Medicare Part B Only", "plan_name": "100300", "standard_charge_dollar": 1484.25, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Medicare Railroad", "plan_name": "100103", "standard_charge_dollar": 1484.25, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Ms Physicians Care N", "plan_name": "714210", "standard_charge_dollar": 1855.31, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Peoples Hlth Ffs 72126", "plan_name": "500019", "standard_charge_dollar": 1484.25, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Uhc/Secure Horizons", "plan_name": "500449", "standard_charge_dollar": 1484.25, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "United Health Care/", "plan_name": "500292", "standard_charge_dollar": 1677.20, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "United Healthcare", "plan_name": "750104", "standard_charge_dollar": 1677.20, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "United Healthcare Ba", "plan_name": "750090", "standard_charge_dollar": 1677.20, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "United Healthcare Me", "plan_name": "501310", "standard_charge_dollar": 1484.25, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Windsor Mcare Extra", "plan_name": "500778", "standard_charge_dollar": 1484.25, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." } ] } ] }, { "description": "Remove foreign body", "code_information": [ { "code": "10121", "type": "CPT" } ], "standard_charges": [ { "gross_charge": 31759.48, "minimum": 1484.25, "maximum": 26995.56, "setting": "inpatient", "payers_information": [ { "payer_name": "Aarp", "plan_name": "500102", "standard_charge_dollar": 1484.25, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna", "plan_name": "700700", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna", "plan_name": "700700_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Mcare Ffs 6005", "plan_name": "700703", "standard_charge_dollar": 1484.25, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Miscellaneous", "plan_name": "700720", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Miscellaneous", "plan_name": "700720_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Ppo Hmo", "plan_name": "701720", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Ppo Hmo", "plan_name": "701720_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Ambetter 68069", "plan_name": "500516", "standard_charge_dollar": 1484.25, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Ms State Emplo", "plan_name": "401457", "standard_charge_percentage": 0.80, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Ms State Emplo", "plan_name": "401457_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Basic Pl", "plan_name": "400100", "standard_charge_percentage": 0.85, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Basic Pl", "plan_name": "400100_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Federal", "plan_name": "400110", "standard_charge_percentage": 0.85, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Federal", "plan_name": "400110_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Cigna Healthsprings Ffs", "plan_name": "500064", "standard_charge_dollar": 1484.25, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Conseco", "plan_name": "500302", "standard_charge_dollar": 1484.25, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Humana Ffs 61101", "plan_name": "500006", "standard_charge_dollar": 1484.25, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Medicare A", "plan_name": "100100", "standard_charge_dollar": 1484.25, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Medicare A", "plan_name": "100500", "standard_charge_dollar": 1484.25, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Medicare Part B Only", "plan_name": "100300", "standard_charge_dollar": 1484.25, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Medicare Railroad", "plan_name": "100103", "standard_charge_dollar": 1484.25, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Ms Physicians Care N", "plan_name": "714210", "standard_charge_dollar": 1855.31, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Peoples Hlth Ffs 72126", "plan_name": "500019", "standard_charge_dollar": 1484.25, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Uhc/Secure Horizons", "plan_name": "500449", "standard_charge_dollar": 1484.25, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "United Health Care/", "plan_name": "500292", "standard_charge_dollar": 1677.20, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "United Healthcare", "plan_name": "750104", "standard_charge_dollar": 1677.20, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "United Healthcare Ba", "plan_name": "750090", "standard_charge_dollar": 1677.20, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "United Healthcare Me", "plan_name": "501310", "standard_charge_dollar": 1484.25, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Windsor Mcare Extra", "plan_name": "500778", "standard_charge_dollar": 1484.25, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." } ] } ] }, { "description": "Remove foreign body", "code_information": [ { "code": "10121", "type": "CPT" } ], "standard_charges": [ { "gross_charge": 3192.00, "minimum": 1484.25, "maximum": 2713.20, "setting": "outpatient", "payers_information": [ { "payer_name": "Aarp", "plan_name": "500102", "standard_charge_dollar": 1484.25, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna", "plan_name": "700700", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna", "plan_name": "700700_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Mcare Ffs 6005", "plan_name": "700703", "standard_charge_dollar": 1484.25, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Miscellaneous", "plan_name": "700720", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Miscellaneous", "plan_name": "700720_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Ppo Hmo", "plan_name": "701720", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Ppo Hmo", "plan_name": "701720_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Ambetter 68069", "plan_name": "500516", "standard_charge_dollar": 1484.25, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Ms State Emplo", "plan_name": "401457", "standard_charge_percentage": 0.80, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Ms State Emplo", "plan_name": "401457_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Basic Pl", "plan_name": "400100", "standard_charge_percentage": 0.85, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Basic Pl", "plan_name": "400100_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Federal", "plan_name": "400110", "standard_charge_percentage": 0.85, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Federal", "plan_name": "400110_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Cigna Healthsprings Ffs", "plan_name": "500064", "standard_charge_dollar": 1484.25, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Conseco", "plan_name": "500302", "standard_charge_dollar": 1484.25, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Humana Ffs 61101", "plan_name": "500006", "standard_charge_dollar": 1484.25, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Medicare A", "plan_name": "100100", "standard_charge_dollar": 1484.25, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Medicare A", "plan_name": "100500", "standard_charge_dollar": 1484.25, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Medicare Part B Only", "plan_name": "100300", "standard_charge_dollar": 1484.25, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Medicare Railroad", "plan_name": "100103", "standard_charge_dollar": 1484.25, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Ms Physicians Care N", "plan_name": "714210", "standard_charge_dollar": 1855.31, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Peoples Hlth Ffs 72126", "plan_name": "500019", "standard_charge_dollar": 1484.25, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Uhc/Secure Horizons", "plan_name": "500449", "standard_charge_dollar": 1484.25, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "United Health Care/", "plan_name": "500292", "standard_charge_dollar": 1677.20, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "United Healthcare", "plan_name": "750104", "standard_charge_dollar": 1677.20, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "United Healthcare Ba", "plan_name": "750090", "standard_charge_dollar": 1677.20, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "United Healthcare Me", "plan_name": "501310", "standard_charge_dollar": 1484.25, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Windsor Mcare Extra", "plan_name": "500778", "standard_charge_dollar": 1484.25, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." } ] } ] }, { "description": "Drainage of hematoma/fluid", "code_information": [ { "code": "10140", "type": "CPT" } ], "standard_charges": [ { "gross_charge": 23570.39, "minimum": 1484.25, "maximum": 20034.83, "setting": "inpatient", "payers_information": [ { "payer_name": "Aarp", "plan_name": "500102", "standard_charge_dollar": 1484.25, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna", "plan_name": "700700", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna", "plan_name": "700700_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Mcare Ffs 6005", "plan_name": "700703", "standard_charge_dollar": 1484.25, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Miscellaneous", "plan_name": "700720", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Miscellaneous", "plan_name": "700720_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Ppo Hmo", "plan_name": "701720", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Ppo Hmo", "plan_name": "701720_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Ambetter 68069", "plan_name": "500516", "standard_charge_dollar": 1484.25, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Ms State Emplo", "plan_name": "401457", "standard_charge_percentage": 0.80, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Ms State Emplo", "plan_name": "401457_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Basic Pl", "plan_name": "400100", "standard_charge_percentage": 0.85, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Basic Pl", "plan_name": "400100_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Federal", "plan_name": "400110", "standard_charge_percentage": 0.85, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Federal", "plan_name": "400110_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Cigna Healthsprings Ffs", "plan_name": "500064", "standard_charge_dollar": 1484.25, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Conseco", "plan_name": "500302", "standard_charge_dollar": 1484.25, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Humana Ffs 61101", "plan_name": "500006", "standard_charge_dollar": 1484.25, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Medicare A", "plan_name": "100100", "standard_charge_dollar": 1484.25, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Medicare A", "plan_name": "100500", "standard_charge_dollar": 1484.25, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Medicare Part B Only", "plan_name": "100300", "standard_charge_dollar": 1484.25, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Medicare Railroad", "plan_name": "100103", "standard_charge_dollar": 1484.25, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Ms Physicians Care N", "plan_name": "714210", "standard_charge_dollar": 1855.31, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Peoples Hlth Ffs 72126", "plan_name": "500019", "standard_charge_dollar": 1484.25, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Uhc/Secure Horizons", "plan_name": "500449", "standard_charge_dollar": 1484.25, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "United Health Care/", "plan_name": "500292", "standard_charge_dollar": 1677.20, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "United Healthcare", "plan_name": "750104", "standard_charge_dollar": 1677.20, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "United Healthcare Ba", "plan_name": "750090", "standard_charge_dollar": 1677.20, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "United Healthcare Me", "plan_name": "501310", "standard_charge_dollar": 1484.25, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Windsor Mcare Extra", "plan_name": "500778", "standard_charge_dollar": 1484.25, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." } ] } ] }, { "description": "Drainage of hematoma/fluid", "code_information": [ { "code": "10140", "type": "CPT" } ], "standard_charges": [ { "gross_charge": 2003.00, "minimum": 1484.25, "maximum": 1855.31, "setting": "outpatient", "payers_information": [ { "payer_name": "Aarp", "plan_name": "500102", "standard_charge_dollar": 1484.25, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna", "plan_name": "700700", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna", "plan_name": "700700_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Mcare Ffs 6005", "plan_name": "700703", "standard_charge_dollar": 1484.25, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Miscellaneous", "plan_name": "700720", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Miscellaneous", "plan_name": "700720_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Ppo Hmo", "plan_name": "701720", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Ppo Hmo", "plan_name": "701720_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Ambetter 68069", "plan_name": "500516", "standard_charge_dollar": 1484.25, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Ms State Emplo", "plan_name": "401457", "standard_charge_percentage": 0.80, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Ms State Emplo", "plan_name": "401457_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Basic Pl", "plan_name": "400100", "standard_charge_percentage": 0.85, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Basic Pl", "plan_name": "400100_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Federal", "plan_name": "400110", "standard_charge_percentage": 0.85, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Federal", "plan_name": "400110_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Cigna Healthsprings Ffs", "plan_name": "500064", "standard_charge_dollar": 1484.25, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Conseco", "plan_name": "500302", "standard_charge_dollar": 1484.25, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Humana Ffs 61101", "plan_name": "500006", "standard_charge_dollar": 1484.25, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Medicare A", "plan_name": "100100", "standard_charge_dollar": 1484.25, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Medicare A", "plan_name": "100500", "standard_charge_dollar": 1484.25, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Medicare Part B Only", "plan_name": "100300", "standard_charge_dollar": 1484.25, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Medicare Railroad", "plan_name": "100103", "standard_charge_dollar": 1484.25, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Ms Physicians Care N", "plan_name": "714210", "standard_charge_dollar": 1855.31, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Peoples Hlth Ffs 72126", "plan_name": "500019", "standard_charge_dollar": 1484.25, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Uhc/Secure Horizons", "plan_name": "500449", "standard_charge_dollar": 1484.25, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "United Health Care/", "plan_name": "500292", "standard_charge_dollar": 1677.20, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "United Healthcare", "plan_name": "750104", "standard_charge_dollar": 1677.20, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "United Healthcare Ba", "plan_name": "750090", "standard_charge_dollar": 1677.20, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "United Healthcare Me", "plan_name": "501310", "standard_charge_dollar": 1484.25, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Windsor Mcare Extra", "plan_name": "500778", "standard_charge_dollar": 1484.25, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." } ] } ] }, { "description": "Hc i&d hematoma seroma fluid", "code_information": [ { "code": "10140", "type": "CPT" } ], "standard_charges": [ { "gross_charge": 2003.00, "minimum": 1484.25, "maximum": 1855.31, "setting": "both", "payers_information": [ { "payer_name": "Aarp", "plan_name": "500102", "standard_charge_dollar": 1484.25, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna", "plan_name": "700700", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna", "plan_name": "700700_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Mcare Ffs 6005", "plan_name": "700703", "standard_charge_dollar": 1484.25, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Miscellaneous", "plan_name": "700720", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Miscellaneous", "plan_name": "700720_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Ppo Hmo", "plan_name": "701720", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Ppo Hmo", "plan_name": "701720_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Ambetter 68069", "plan_name": "500516", "standard_charge_dollar": 1484.25, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Ms State Emplo", "plan_name": "401457", "standard_charge_percentage": 0.80, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Ms State Emplo", "plan_name": "401457_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Basic Pl", "plan_name": "400100", "standard_charge_percentage": 0.85, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Basic Pl", "plan_name": "400100_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Federal", "plan_name": "400110", "standard_charge_percentage": 0.85, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Federal", "plan_name": "400110_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Cigna Healthsprings Ffs", "plan_name": "500064", "standard_charge_dollar": 1484.25, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Conseco", "plan_name": "500302", "standard_charge_dollar": 1484.25, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Humana Ffs 61101", "plan_name": "500006", "standard_charge_dollar": 1484.25, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Medicare A", "plan_name": "100100", "standard_charge_dollar": 1484.25, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Medicare A", "plan_name": "100500", "standard_charge_dollar": 1484.25, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Medicare Part B Only", "plan_name": "100300", "standard_charge_dollar": 1484.25, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Medicare Railroad", "plan_name": "100103", "standard_charge_dollar": 1484.25, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Ms Physicians Care N", "plan_name": "714210", "standard_charge_dollar": 1855.31, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Peoples Hlth Ffs 72126", "plan_name": "500019", "standard_charge_dollar": 1484.25, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Uhc/Secure Horizons", "plan_name": "500449", "standard_charge_dollar": 1484.25, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "United Health Care/", "plan_name": "500292", "standard_charge_dollar": 1677.20, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "United Healthcare", "plan_name": "750104", "standard_charge_dollar": 1677.20, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "United Healthcare Ba", "plan_name": "750090", "standard_charge_dollar": 1677.20, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "United Healthcare Me", "plan_name": "501310", "standard_charge_dollar": 1484.25, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Windsor Mcare Extra", "plan_name": "500778", "standard_charge_dollar": 1484.25, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." } ] } ] }, { "description": "Hc puncture drainage of lesion", "code_information": [ { "code": "10160", "type": "CPT" } ], "standard_charges": [ { "gross_charge": 597.00, "minimum": 366.00, "maximum": 507.45, "setting": "both", "payers_information": [ { "payer_name": "Aarp", "plan_name": "500102", "standard_charge_dollar": 366.00, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna", "plan_name": "700700", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna", "plan_name": "700700_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Mcare Ffs 6005", "plan_name": "700703", "standard_charge_dollar": 366.00, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Miscellaneous", "plan_name": "700720", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Miscellaneous", "plan_name": "700720_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Ppo Hmo", "plan_name": "701720", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Ppo Hmo", "plan_name": "701720_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Ambetter 68069", "plan_name": "500516", "standard_charge_dollar": 366.00, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Ms State Emplo", "plan_name": "401457", "standard_charge_percentage": 0.80, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Ms State Emplo", "plan_name": "401457_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Basic Pl", "plan_name": "400100", "standard_charge_percentage": 0.85, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Basic Pl", "plan_name": "400100_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Federal", "plan_name": "400110", "standard_charge_percentage": 0.85, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Federal", "plan_name": "400110_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Cigna Healthsprings Ffs", "plan_name": "500064", "standard_charge_dollar": 366.00, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Conseco", "plan_name": "500302", "standard_charge_dollar": 366.00, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Humana Ffs 61101", "plan_name": "500006", "standard_charge_dollar": 366.00, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Medicare A", "plan_name": "100100", "standard_charge_dollar": 366.00, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Medicare A", "plan_name": "100500", "standard_charge_dollar": 366.00, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Medicare Part B Only", "plan_name": "100300", "standard_charge_dollar": 366.00, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Medicare Railroad", "plan_name": "100103", "standard_charge_dollar": 366.00, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Ms Physicians Care N", "plan_name": "714210", "standard_charge_dollar": 457.50, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Peoples Hlth Ffs 72126", "plan_name": "500019", "standard_charge_dollar": 366.00, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Uhc/Secure Horizons", "plan_name": "500449", "standard_charge_dollar": 366.00, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "United Health Care/", "plan_name": "500292", "standard_charge_dollar": 413.58, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "United Healthcare", "plan_name": "750104", "standard_charge_dollar": 413.58, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "United Healthcare Ba", "plan_name": "750090", "standard_charge_dollar": 413.58, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "United Healthcare Me", "plan_name": "501310", "standard_charge_dollar": 366.00, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Windsor Mcare Extra", "plan_name": "500778", "standard_charge_dollar": 366.00, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." } ] } ] }, { "description": "Puncture drainage of lesion", "code_information": [ { "code": "10160", "type": "CPT" } ], "standard_charges": [ { "gross_charge": 15652.48, "minimum": 366.00, "maximum": 13304.61, "setting": "inpatient", "payers_information": [ { "payer_name": "Aarp", "plan_name": "500102", "standard_charge_dollar": 366.00, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna", "plan_name": "700700", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna", "plan_name": "700700_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Mcare Ffs 6005", "plan_name": "700703", "standard_charge_dollar": 366.00, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Miscellaneous", "plan_name": "700720", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Miscellaneous", "plan_name": "700720_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Ppo Hmo", "plan_name": "701720", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Ppo Hmo", "plan_name": "701720_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Ambetter 68069", "plan_name": "500516", "standard_charge_dollar": 366.00, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Ms State Emplo", "plan_name": "401457", "standard_charge_percentage": 0.80, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Ms State Emplo", "plan_name": "401457_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Basic Pl", "plan_name": "400100", "standard_charge_percentage": 0.85, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Basic Pl", "plan_name": "400100_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Federal", "plan_name": "400110", "standard_charge_percentage": 0.85, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Federal", "plan_name": "400110_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Cigna Healthsprings Ffs", "plan_name": "500064", "standard_charge_dollar": 366.00, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Conseco", "plan_name": "500302", "standard_charge_dollar": 366.00, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Humana Ffs 61101", "plan_name": "500006", "standard_charge_dollar": 366.00, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Medicare A", "plan_name": "100100", "standard_charge_dollar": 366.00, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Medicare A", "plan_name": "100500", "standard_charge_dollar": 366.00, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Medicare Part B Only", "plan_name": "100300", "standard_charge_dollar": 366.00, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Medicare Railroad", "plan_name": "100103", "standard_charge_dollar": 366.00, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Ms Physicians Care N", "plan_name": "714210", "standard_charge_dollar": 457.50, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Peoples Hlth Ffs 72126", "plan_name": "500019", "standard_charge_dollar": 366.00, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Uhc/Secure Horizons", "plan_name": "500449", "standard_charge_dollar": 366.00, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "United Health Care/", "plan_name": "500292", "standard_charge_dollar": 413.58, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "United Healthcare", "plan_name": "750104", "standard_charge_dollar": 413.58, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "United Healthcare Ba", "plan_name": "750090", "standard_charge_dollar": 413.58, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "United Healthcare Me", "plan_name": "501310", "standard_charge_dollar": 366.00, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Windsor Mcare Extra", "plan_name": "500778", "standard_charge_dollar": 366.00, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." } ] } ] }, { "description": "Puncture drainage of lesion", "code_information": [ { "code": "10160", "type": "CPT" } ], "standard_charges": [ { "gross_charge": 597.00, "minimum": 366.00, "maximum": 507.45, "setting": "outpatient", "payers_information": [ { "payer_name": "Aarp", "plan_name": "500102", "standard_charge_dollar": 366.00, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna", "plan_name": "700700", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna", "plan_name": "700700_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Mcare Ffs 6005", "plan_name": "700703", "standard_charge_dollar": 366.00, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Miscellaneous", "plan_name": "700720", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Miscellaneous", "plan_name": "700720_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Ppo Hmo", "plan_name": "701720", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Ppo Hmo", "plan_name": "701720_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Ambetter 68069", "plan_name": "500516", "standard_charge_dollar": 366.00, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Ms State Emplo", "plan_name": "401457", "standard_charge_percentage": 0.80, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Ms State Emplo", "plan_name": "401457_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Basic Pl", "plan_name": "400100", "standard_charge_percentage": 0.85, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Basic Pl", "plan_name": "400100_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Federal", "plan_name": "400110", "standard_charge_percentage": 0.85, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Federal", "plan_name": "400110_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Cigna Healthsprings Ffs", "plan_name": "500064", "standard_charge_dollar": 366.00, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Conseco", "plan_name": "500302", "standard_charge_dollar": 366.00, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Humana Ffs 61101", "plan_name": "500006", "standard_charge_dollar": 366.00, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Medicare A", "plan_name": "100100", "standard_charge_dollar": 366.00, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Medicare A", "plan_name": "100500", "standard_charge_dollar": 366.00, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Medicare Part B Only", "plan_name": "100300", "standard_charge_dollar": 366.00, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Medicare Railroad", "plan_name": "100103", "standard_charge_dollar": 366.00, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Ms Physicians Care N", "plan_name": "714210", "standard_charge_dollar": 457.50, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Peoples Hlth Ffs 72126", "plan_name": "500019", "standard_charge_dollar": 366.00, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Uhc/Secure Horizons", "plan_name": "500449", "standard_charge_dollar": 366.00, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "United Health Care/", "plan_name": "500292", "standard_charge_dollar": 413.58, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "United Healthcare", "plan_name": "750104", "standard_charge_dollar": 413.58, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "United Healthcare Ba", "plan_name": "750090", "standard_charge_dollar": 413.58, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "United Healthcare Me", "plan_name": "501310", "standard_charge_dollar": 366.00, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Windsor Mcare Extra", "plan_name": "500778", "standard_charge_dollar": 366.00, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." } ] } ] }, { "description": "Complex drainage wound", "code_information": [ { "code": "10180", "type": "CPT" } ], "standard_charges": [ { "gross_charge": 23072.47, "minimum": 2621.84, "maximum": 19611.60, "setting": "inpatient", "payers_information": [ { "payer_name": "Aarp", "plan_name": "500102", "standard_charge_dollar": 2621.84, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna", "plan_name": "700700", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna", "plan_name": "700700_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Mcare Ffs 6005", "plan_name": "700703", "standard_charge_dollar": 2621.84, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Miscellaneous", "plan_name": "700720", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Miscellaneous", "plan_name": "700720_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Ppo Hmo", "plan_name": "701720", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Ppo Hmo", "plan_name": "701720_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Ambetter 68069", "plan_name": "500516", "standard_charge_dollar": 2621.84, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Ms State Emplo", "plan_name": "401457", "standard_charge_percentage": 0.80, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Ms State Emplo", "plan_name": "401457_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Basic Pl", "plan_name": "400100", "standard_charge_percentage": 0.85, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Basic Pl", "plan_name": "400100_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Federal", "plan_name": "400110", "standard_charge_percentage": 0.85, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Federal", "plan_name": "400110_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Cigna Healthsprings Ffs", "plan_name": "500064", "standard_charge_dollar": 2621.84, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Conseco", "plan_name": "500302", "standard_charge_dollar": 2621.84, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Humana Ffs 61101", "plan_name": "500006", "standard_charge_dollar": 2621.84, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Medicare A", "plan_name": "100100", "standard_charge_dollar": 2621.84, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Medicare A", "plan_name": "100500", "standard_charge_dollar": 2621.84, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Medicare Part B Only", "plan_name": "100300", "standard_charge_dollar": 2621.84, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Medicare Railroad", "plan_name": "100103", "standard_charge_dollar": 2621.84, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Ms Physicians Care N", "plan_name": "714210", "standard_charge_dollar": 3277.29, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Peoples Hlth Ffs 72126", "plan_name": "500019", "standard_charge_dollar": 2621.84, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Uhc/Secure Horizons", "plan_name": "500449", "standard_charge_dollar": 2621.84, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "United Health Care/", "plan_name": "500292", "standard_charge_dollar": 2962.67, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "United Healthcare", "plan_name": "750104", "standard_charge_dollar": 2962.67, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "United Healthcare Ba", "plan_name": "750090", "standard_charge_dollar": 2962.67, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "United Healthcare Me", "plan_name": "501310", "standard_charge_dollar": 2621.84, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Windsor Mcare Extra", "plan_name": "500778", "standard_charge_dollar": 2621.84, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." } ] } ] }, { "description": "Complex drainage wound", "code_information": [ { "code": "10180", "type": "CPT" } ], "standard_charges": [ { "gross_charge": 4133.00, "minimum": 2621.84, "maximum": 3513.05, "setting": "outpatient", "payers_information": [ { "payer_name": "Aarp", "plan_name": "500102", "standard_charge_dollar": 2621.84, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna", "plan_name": "700700", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna", "plan_name": "700700_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Mcare Ffs 6005", "plan_name": "700703", "standard_charge_dollar": 2621.84, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Miscellaneous", "plan_name": "700720", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Miscellaneous", "plan_name": "700720_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Ppo Hmo", "plan_name": "701720", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Ppo Hmo", "plan_name": "701720_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Ambetter 68069", "plan_name": "500516", "standard_charge_dollar": 2621.84, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Ms State Emplo", "plan_name": "401457", "standard_charge_percentage": 0.80, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Ms State Emplo", "plan_name": "401457_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Basic Pl", "plan_name": "400100", "standard_charge_percentage": 0.85, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Basic Pl", "plan_name": "400100_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Federal", "plan_name": "400110", "standard_charge_percentage": 0.85, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Federal", "plan_name": "400110_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Cigna Healthsprings Ffs", "plan_name": "500064", "standard_charge_dollar": 2621.84, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Conseco", "plan_name": "500302", "standard_charge_dollar": 2621.84, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Humana Ffs 61101", "plan_name": "500006", "standard_charge_dollar": 2621.84, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Medicare A", "plan_name": "100100", "standard_charge_dollar": 2621.84, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Medicare A", "plan_name": "100500", "standard_charge_dollar": 2621.84, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Medicare Part B Only", "plan_name": "100300", "standard_charge_dollar": 2621.84, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Medicare Railroad", "plan_name": "100103", "standard_charge_dollar": 2621.84, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Ms Physicians Care N", "plan_name": "714210", "standard_charge_dollar": 3277.29, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Peoples Hlth Ffs 72126", "plan_name": "500019", "standard_charge_dollar": 2621.84, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Uhc/Secure Horizons", "plan_name": "500449", "standard_charge_dollar": 2621.84, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "United Health Care/", "plan_name": "500292", "standard_charge_dollar": 2962.67, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "United Healthcare", "plan_name": "750104", "standard_charge_dollar": 2962.67, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "United Healthcare Ba", "plan_name": "750090", "standard_charge_dollar": 2962.67, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "United Healthcare Me", "plan_name": "501310", "standard_charge_dollar": 2621.84, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Windsor Mcare Extra", "plan_name": "500778", "standard_charge_dollar": 2621.84, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." } ] } ] }, { "description": "Hc i&d complex postop wnd infectn", "code_information": [ { "code": "10180", "type": "CPT" } ], "standard_charges": [ { "gross_charge": 4133.00, "minimum": 2621.84, "maximum": 3513.05, "setting": "both", "payers_information": [ { "payer_name": "Aarp", "plan_name": "500102", "standard_charge_dollar": 2621.84, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna", "plan_name": "700700", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna", "plan_name": "700700_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Mcare Ffs 6005", "plan_name": "700703", "standard_charge_dollar": 2621.84, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Miscellaneous", "plan_name": "700720", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Miscellaneous", "plan_name": "700720_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Ppo Hmo", "plan_name": "701720", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Ppo Hmo", "plan_name": "701720_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Ambetter 68069", "plan_name": "500516", "standard_charge_dollar": 2621.84, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Ms State Emplo", "plan_name": "401457", "standard_charge_percentage": 0.80, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Ms State Emplo", "plan_name": "401457_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Basic Pl", "plan_name": "400100", "standard_charge_percentage": 0.85, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Basic Pl", "plan_name": "400100_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Federal", "plan_name": "400110", "standard_charge_percentage": 0.85, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Federal", "plan_name": "400110_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Cigna Healthsprings Ffs", "plan_name": "500064", "standard_charge_dollar": 2621.84, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Conseco", "plan_name": "500302", "standard_charge_dollar": 2621.84, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Humana Ffs 61101", "plan_name": "500006", "standard_charge_dollar": 2621.84, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Medicare A", "plan_name": "100100", "standard_charge_dollar": 2621.84, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Medicare A", "plan_name": "100500", "standard_charge_dollar": 2621.84, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Medicare Part B Only", "plan_name": "100300", "standard_charge_dollar": 2621.84, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Medicare Railroad", "plan_name": "100103", "standard_charge_dollar": 2621.84, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Ms Physicians Care N", "plan_name": "714210", "standard_charge_dollar": 3277.29, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Peoples Hlth Ffs 72126", "plan_name": "500019", "standard_charge_dollar": 2621.84, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Uhc/Secure Horizons", "plan_name": "500449", "standard_charge_dollar": 2621.84, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "United Health Care/", "plan_name": "500292", "standard_charge_dollar": 2962.67, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "United Healthcare", "plan_name": "750104", "standard_charge_dollar": 2962.67, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "United Healthcare Ba", "plan_name": "750090", "standard_charge_dollar": 2962.67, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "United Healthcare Me", "plan_name": "501310", "standard_charge_dollar": 2621.84, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Windsor Mcare Extra", "plan_name": "500778", "standard_charge_dollar": 2621.84, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." } ] } ] }, { "description": "Debride infected skin", "code_information": [ { "code": "11000", "type": "CPT" } ], "standard_charges": [ { "gross_charge": 26535.50, "minimum": 560.75, "maximum": 22555.18, "setting": "inpatient", "payers_information": [ { "payer_name": "Aarp", "plan_name": "500102", "standard_charge_dollar": 560.75, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna", "plan_name": "700700", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna", "plan_name": "700700_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Mcare Ffs 6005", "plan_name": "700703", "standard_charge_dollar": 560.75, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Miscellaneous", "plan_name": "700720", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Miscellaneous", "plan_name": "700720_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Ppo Hmo", "plan_name": "701720", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Ppo Hmo", "plan_name": "701720_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Ambetter 68069", "plan_name": "500516", "standard_charge_dollar": 560.75, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Ms State Emplo", "plan_name": "401457", "standard_charge_percentage": 0.80, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Ms State Emplo", "plan_name": "401457_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Basic Pl", "plan_name": "400100", "standard_charge_percentage": 0.85, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Basic Pl", "plan_name": "400100_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Federal", "plan_name": "400110", "standard_charge_percentage": 0.85, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Federal", "plan_name": "400110_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Cigna Healthsprings Ffs", "plan_name": "500064", "standard_charge_dollar": 560.75, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Conseco", "plan_name": "500302", "standard_charge_dollar": 560.75, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Humana Ffs 61101", "plan_name": "500006", "standard_charge_dollar": 560.75, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Medicare A", "plan_name": "100100", "standard_charge_dollar": 560.75, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Medicare A", "plan_name": "100500", "standard_charge_dollar": 560.75, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Medicare Part B Only", "plan_name": "100300", "standard_charge_dollar": 560.75, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Medicare Railroad", "plan_name": "100103", "standard_charge_dollar": 560.75, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Ms Physicians Care N", "plan_name": "714210", "standard_charge_dollar": 700.94, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Peoples Hlth Ffs 72126", "plan_name": "500019", "standard_charge_dollar": 560.75, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Uhc/Secure Horizons", "plan_name": "500449", "standard_charge_dollar": 560.75, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "United Health Care/", "plan_name": "500292", "standard_charge_dollar": 633.65, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "United Healthcare", "plan_name": "750104", "standard_charge_dollar": 633.65, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "United Healthcare Ba", "plan_name": "750090", "standard_charge_dollar": 633.65, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "United Healthcare Me", "plan_name": "501310", "standard_charge_dollar": 560.75, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Windsor Mcare Extra", "plan_name": "500778", "standard_charge_dollar": 560.75, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." } ] } ] }, { "description": "Debride infected skin add-on", "code_information": [ { "code": "11001", "type": "CPT" } ], "standard_charges": [ { "gross_charge": 26535.50, "minimum": 21228.40, "maximum": 22555.18, "setting": "inpatient", "payers_information": [ { "payer_name": "Aetna", "plan_name": "700700", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna", "plan_name": "700700_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Miscellaneous", "plan_name": "700720", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Miscellaneous", "plan_name": "700720_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Ppo Hmo", "plan_name": "701720", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Ppo Hmo", "plan_name": "701720_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Ms State Emplo", "plan_name": "401457", "standard_charge_percentage": 0.80, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Ms State Emplo", "plan_name": "401457_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Basic Pl", "plan_name": "400100", "standard_charge_percentage": 0.85, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Basic Pl", "plan_name": "400100_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Federal", "plan_name": "400110", "standard_charge_percentage": 0.85, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Federal", "plan_name": "400110_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." } ] } ] }, { "description": "Debride genitalia & perineum", "code_information": [ { "code": "11004", "type": "CPT" } ], "standard_charges": [ { "gross_charge": 50344.22, "minimum": 40275.38, "maximum": 42792.59, "setting": "inpatient", "payers_information": [ { "payer_name": "Aetna", "plan_name": "700700", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna", "plan_name": "700700_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Miscellaneous", "plan_name": "700720", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Miscellaneous", "plan_name": "700720_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Ppo Hmo", "plan_name": "701720", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Ppo Hmo", "plan_name": "701720_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Ms State Emplo", "plan_name": "401457", "standard_charge_percentage": 0.80, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Ms State Emplo", "plan_name": "401457_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Basic Pl", "plan_name": "400100", "standard_charge_percentage": 0.85, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Basic Pl", "plan_name": "400100_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Federal", "plan_name": "400110", "standard_charge_percentage": 0.85, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Federal", "plan_name": "400110_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." } ] } ] }, { "description": "Debride genit/per/abdom wall", "code_information": [ { "code": "11006", "type": "CPT" } ], "standard_charges": [ { "gross_charge": 50344.22, "minimum": 40275.38, "maximum": 42792.59, "setting": "inpatient", "payers_information": [ { "payer_name": "Aetna", "plan_name": "700700", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna", "plan_name": "700700_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Miscellaneous", "plan_name": "700720", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Miscellaneous", "plan_name": "700720_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Ppo Hmo", "plan_name": "701720", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Ppo Hmo", "plan_name": "701720_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Ms State Emplo", "plan_name": "401457", "standard_charge_percentage": 0.80, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Ms State Emplo", "plan_name": "401457_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Basic Pl", "plan_name": "400100", "standard_charge_percentage": 0.85, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Basic Pl", "plan_name": "400100_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Federal", "plan_name": "400110", "standard_charge_percentage": 0.85, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Federal", "plan_name": "400110_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." } ] } ] }, { "description": "Debride skin at fx site", "code_information": [ { "code": "11010", "type": "CPT" } ], "standard_charges": [ { "gross_charge": 35824.34, "minimum": 644.54, "maximum": 30450.69, "setting": "inpatient", "payers_information": [ { "payer_name": "Aarp", "plan_name": "500102", "standard_charge_dollar": 644.54, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna", "plan_name": "700700", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna", "plan_name": "700700_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Mcare Ffs 6005", "plan_name": "700703", "standard_charge_dollar": 644.54, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Miscellaneous", "plan_name": "700720", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Miscellaneous", "plan_name": "700720_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Ppo Hmo", "plan_name": "701720", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Ppo Hmo", "plan_name": "701720_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Ambetter 68069", "plan_name": "500516", "standard_charge_dollar": 644.54, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Ms State Emplo", "plan_name": "401457", "standard_charge_percentage": 0.80, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Ms State Emplo", "plan_name": "401457_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Basic Pl", "plan_name": "400100", "standard_charge_percentage": 0.85, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Basic Pl", "plan_name": "400100_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Federal", "plan_name": "400110", "standard_charge_percentage": 0.85, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Federal", "plan_name": "400110_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Cigna Healthsprings Ffs", "plan_name": "500064", "standard_charge_dollar": 644.54, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Conseco", "plan_name": "500302", "standard_charge_dollar": 644.54, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Humana Ffs 61101", "plan_name": "500006", "standard_charge_dollar": 644.54, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Medicare A", "plan_name": "100100", "standard_charge_dollar": 644.54, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Medicare A", "plan_name": "100500", "standard_charge_dollar": 644.54, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Medicare Part B Only", "plan_name": "100300", "standard_charge_dollar": 644.54, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Medicare Railroad", "plan_name": "100103", "standard_charge_dollar": 644.54, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Ms Physicians Care N", "plan_name": "714210", "standard_charge_dollar": 805.67, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Peoples Hlth Ffs 72126", "plan_name": "500019", "standard_charge_dollar": 644.54, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Uhc/Secure Horizons", "plan_name": "500449", "standard_charge_dollar": 644.54, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "United Health Care/", "plan_name": "500292", "standard_charge_dollar": 728.33, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "United Healthcare", "plan_name": "750104", "standard_charge_dollar": 728.33, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "United Healthcare Ba", "plan_name": "750090", "standard_charge_dollar": 728.33, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "United Healthcare Me", "plan_name": "501310", "standard_charge_dollar": 644.54, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Windsor Mcare Extra", "plan_name": "500778", "standard_charge_dollar": 644.54, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." } ] } ] }, { "description": "Debride skin musc at fx site", "code_information": [ { "code": "11011", "type": "CPT" } ], "standard_charges": [ { "gross_charge": 33034.90, "minimum": 644.54, "maximum": 28079.67, "setting": "inpatient", "payers_information": [ { "payer_name": "Aarp", "plan_name": "500102", "standard_charge_dollar": 644.54, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna", "plan_name": "700700", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna", "plan_name": "700700_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Mcare Ffs 6005", "plan_name": "700703", "standard_charge_dollar": 644.54, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Miscellaneous", "plan_name": "700720", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Miscellaneous", "plan_name": "700720_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Ppo Hmo", "plan_name": "701720", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Ppo Hmo", "plan_name": "701720_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Ambetter 68069", "plan_name": "500516", "standard_charge_dollar": 644.54, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Ms State Emplo", "plan_name": "401457", "standard_charge_percentage": 0.80, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Ms State Emplo", "plan_name": "401457_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Basic Pl", "plan_name": "400100", "standard_charge_percentage": 0.85, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Basic Pl", "plan_name": "400100_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Federal", "plan_name": "400110", "standard_charge_percentage": 0.85, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Federal", "plan_name": "400110_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Cigna Healthsprings Ffs", "plan_name": "500064", "standard_charge_dollar": 644.54, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Conseco", "plan_name": "500302", "standard_charge_dollar": 644.54, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Humana Ffs 61101", "plan_name": "500006", "standard_charge_dollar": 644.54, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Medicare A", "plan_name": "100100", "standard_charge_dollar": 644.54, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Medicare A", "plan_name": "100500", "standard_charge_dollar": 644.54, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Medicare Part B Only", "plan_name": "100300", "standard_charge_dollar": 644.54, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Medicare Railroad", "plan_name": "100103", "standard_charge_dollar": 644.54, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Ms Physicians Care N", "plan_name": "714210", "standard_charge_dollar": 805.67, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Peoples Hlth Ffs 72126", "plan_name": "500019", "standard_charge_dollar": 644.54, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Uhc/Secure Horizons", "plan_name": "500449", "standard_charge_dollar": 644.54, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "United Health Care/", "plan_name": "500292", "standard_charge_dollar": 728.33, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "United Healthcare", "plan_name": "750104", "standard_charge_dollar": 728.33, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "United Healthcare Ba", "plan_name": "750090", "standard_charge_dollar": 728.33, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "United Healthcare Me", "plan_name": "501310", "standard_charge_dollar": 644.54, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Windsor Mcare Extra", "plan_name": "500778", "standard_charge_dollar": 644.54, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." } ] } ] }, { "description": "Deb subq tissue 20 sq cm/<", "code_information": [ { "code": "11042", "type": "CPT" } ], "standard_charges": [ { "gross_charge": 35824.34, "minimum": 366.00, "maximum": 30450.69, "setting": "inpatient", "payers_information": [ { "payer_name": "Aarp", "plan_name": "500102", "standard_charge_dollar": 366.00, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna", "plan_name": "700700", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna", "plan_name": "700700_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Mcare Ffs 6005", "plan_name": "700703", "standard_charge_dollar": 366.00, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Miscellaneous", "plan_name": "700720", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Miscellaneous", "plan_name": "700720_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Ppo Hmo", "plan_name": "701720", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Ppo Hmo", "plan_name": "701720_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Ambetter 68069", "plan_name": "500516", "standard_charge_dollar": 366.00, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Ms State Emplo", "plan_name": "401457", "standard_charge_percentage": 0.80, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Ms State Emplo", "plan_name": "401457_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Basic Pl", "plan_name": "400100", "standard_charge_percentage": 0.85, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Basic Pl", "plan_name": "400100_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Federal", "plan_name": "400110", "standard_charge_percentage": 0.85, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Federal", "plan_name": "400110_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Cigna Healthsprings Ffs", "plan_name": "500064", "standard_charge_dollar": 366.00, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Conseco", "plan_name": "500302", "standard_charge_dollar": 366.00, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Humana Ffs 61101", "plan_name": "500006", "standard_charge_dollar": 366.00, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Medicare A", "plan_name": "100100", "standard_charge_dollar": 366.00, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Medicare A", "plan_name": "100500", "standard_charge_dollar": 366.00, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Medicare Part B Only", "plan_name": "100300", "standard_charge_dollar": 366.00, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Medicare Railroad", "plan_name": "100103", "standard_charge_dollar": 366.00, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Ms Physicians Care N", "plan_name": "714210", "standard_charge_dollar": 457.50, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Peoples Hlth Ffs 72126", "plan_name": "500019", "standard_charge_dollar": 366.00, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Uhc/Secure Horizons", "plan_name": "500449", "standard_charge_dollar": 366.00, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "United Health Care/", "plan_name": "500292", "standard_charge_dollar": 413.58, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "United Healthcare", "plan_name": "750104", "standard_charge_dollar": 413.58, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "United Healthcare Ba", "plan_name": "750090", "standard_charge_dollar": 413.58, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "United Healthcare Me", "plan_name": "501310", "standard_charge_dollar": 366.00, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Windsor Mcare Extra", "plan_name": "500778", "standard_charge_dollar": 366.00, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." } ] } ] }, { "description": "Deb subq tissue 20 sq cm/<", "code_information": [ { "code": "11042", "type": "CPT" } ], "standard_charges": [ { "gross_charge": 746.00, "minimum": 366.00, "maximum": 634.10, "setting": "outpatient", "payers_information": [ { "payer_name": "Aarp", "plan_name": "500102", "standard_charge_dollar": 366.00, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna", "plan_name": "700700", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna", "plan_name": "700700_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Mcare Ffs 6005", "plan_name": "700703", "standard_charge_dollar": 366.00, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Miscellaneous", "plan_name": "700720", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Miscellaneous", "plan_name": "700720_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Ppo Hmo", "plan_name": "701720", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Ppo Hmo", "plan_name": "701720_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Ambetter 68069", "plan_name": "500516", "standard_charge_dollar": 366.00, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Ms State Emplo", "plan_name": "401457", "standard_charge_percentage": 0.80, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Ms State Emplo", "plan_name": "401457_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Basic Pl", "plan_name": "400100", "standard_charge_percentage": 0.85, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Basic Pl", "plan_name": "400100_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Federal", "plan_name": "400110", "standard_charge_percentage": 0.85, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Federal", "plan_name": "400110_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Cigna Healthsprings Ffs", "plan_name": "500064", "standard_charge_dollar": 366.00, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Conseco", "plan_name": "500302", "standard_charge_dollar": 366.00, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Humana Ffs 61101", "plan_name": "500006", "standard_charge_dollar": 366.00, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Medicare A", "plan_name": "100100", "standard_charge_dollar": 366.00, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Medicare A", "plan_name": "100500", "standard_charge_dollar": 366.00, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Medicare Part B Only", "plan_name": "100300", "standard_charge_dollar": 366.00, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Medicare Railroad", "plan_name": "100103", "standard_charge_dollar": 366.00, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Ms Physicians Care N", "plan_name": "714210", "standard_charge_dollar": 457.50, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Peoples Hlth Ffs 72126", "plan_name": "500019", "standard_charge_dollar": 366.00, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Uhc/Secure Horizons", "plan_name": "500449", "standard_charge_dollar": 366.00, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "United Health Care/", "plan_name": "500292", "standard_charge_dollar": 413.58, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "United Healthcare", "plan_name": "750104", "standard_charge_dollar": 413.58, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "United Healthcare Ba", "plan_name": "750090", "standard_charge_dollar": 413.58, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "United Healthcare Me", "plan_name": "501310", "standard_charge_dollar": 366.00, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Windsor Mcare Extra", "plan_name": "500778", "standard_charge_dollar": 366.00, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." } ] } ] }, { "description": "Hc debridement skin & s/q tissue", "code_information": [ { "code": "11042", "type": "CPT" } ], "standard_charges": [ { "gross_charge": 746.00, "minimum": 366.00, "maximum": 634.10, "setting": "both", "payers_information": [ { "payer_name": "Aarp", "plan_name": "500102", "standard_charge_dollar": 366.00, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna", "plan_name": "700700", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna", "plan_name": "700700_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Mcare Ffs 6005", "plan_name": "700703", "standard_charge_dollar": 366.00, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Miscellaneous", "plan_name": "700720", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Miscellaneous", "plan_name": "700720_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Ppo Hmo", "plan_name": "701720", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Ppo Hmo", "plan_name": "701720_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Ambetter 68069", "plan_name": "500516", "standard_charge_dollar": 366.00, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Ms State Emplo", "plan_name": "401457", "standard_charge_percentage": 0.80, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Ms State Emplo", "plan_name": "401457_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Basic Pl", "plan_name": "400100", "standard_charge_percentage": 0.85, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Basic Pl", "plan_name": "400100_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Federal", "plan_name": "400110", "standard_charge_percentage": 0.85, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Federal", "plan_name": "400110_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Cigna Healthsprings Ffs", "plan_name": "500064", "standard_charge_dollar": 366.00, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Conseco", "plan_name": "500302", "standard_charge_dollar": 366.00, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Humana Ffs 61101", "plan_name": "500006", "standard_charge_dollar": 366.00, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Medicare A", "plan_name": "100100", "standard_charge_dollar": 366.00, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Medicare A", "plan_name": "100500", "standard_charge_dollar": 366.00, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Medicare Part B Only", "plan_name": "100300", "standard_charge_dollar": 366.00, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Medicare Railroad", "plan_name": "100103", "standard_charge_dollar": 366.00, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Ms Physicians Care N", "plan_name": "714210", "standard_charge_dollar": 457.50, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Peoples Hlth Ffs 72126", "plan_name": "500019", "standard_charge_dollar": 366.00, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Uhc/Secure Horizons", "plan_name": "500449", "standard_charge_dollar": 366.00, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "United Health Care/", "plan_name": "500292", "standard_charge_dollar": 413.58, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "United Healthcare", "plan_name": "750104", "standard_charge_dollar": 413.58, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "United Healthcare Ba", "plan_name": "750090", "standard_charge_dollar": 413.58, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "United Healthcare Me", "plan_name": "501310", "standard_charge_dollar": 366.00, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Windsor Mcare Extra", "plan_name": "500778", "standard_charge_dollar": 366.00, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." } ] } ] }, { "description": "Hc debridement skin & s/q tissue", "code_information": [ { "code": "11042", "type": "CPT" } ], "standard_charges": [ { "gross_charge": 2984.00, "minimum": 366.00, "maximum": 2536.40, "setting": "both", "payers_information": [ { "payer_name": "Aarp", "plan_name": "500102", "standard_charge_dollar": 366.00, "count": "0", "methodology": "fee schedule", "modifiers": "50", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna", "plan_name": "700700", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna", "plan_name": "700700_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Mcare Ffs 6005", "plan_name": "700703", "standard_charge_dollar": 366.00, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Miscellaneous", "plan_name": "700720", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Miscellaneous", "plan_name": "700720_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Ppo Hmo", "plan_name": "701720", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Ppo Hmo", "plan_name": "701720_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Ambetter 68069", "plan_name": "500516", "standard_charge_dollar": 366.00, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Ms State Emplo", "plan_name": "401457", "standard_charge_percentage": 0.80, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Ms State Emplo", "plan_name": "401457_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Basic Pl", "plan_name": "400100", "standard_charge_percentage": 0.85, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Basic Pl", "plan_name": "400100_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Federal", "plan_name": "400110", "standard_charge_percentage": 0.85, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Federal", "plan_name": "400110_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Cigna Healthsprings Ffs", "plan_name": "500064", "standard_charge_dollar": 366.00, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Conseco", "plan_name": "500302", "standard_charge_dollar": 366.00, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Humana Ffs 61101", "plan_name": "500006", "standard_charge_dollar": 366.00, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Medicare A", "plan_name": "100100", "standard_charge_dollar": 366.00, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Medicare A", "plan_name": "100500", "standard_charge_dollar": 366.00, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Medicare Part B Only", "plan_name": "100300", "standard_charge_dollar": 366.00, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Medicare Railroad", "plan_name": "100103", "standard_charge_dollar": 366.00, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Ms Physicians Care N", "plan_name": "714210", "standard_charge_dollar": 457.50, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Peoples Hlth Ffs 72126", "plan_name": "500019", "standard_charge_dollar": 366.00, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Uhc/Secure Horizons", "plan_name": "500449", "standard_charge_dollar": 366.00, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "United Health Care/", "plan_name": "500292", "standard_charge_dollar": 413.58, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "United Healthcare", "plan_name": "750104", "standard_charge_dollar": 413.58, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "United Healthcare Ba", "plan_name": "750090", "standard_charge_dollar": 413.58, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "United Healthcare Me", "plan_name": "501310", "standard_charge_dollar": 366.00, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Windsor Mcare Extra", "plan_name": "500778", "standard_charge_dollar": 366.00, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." } ] } ] }, { "description": "Deb musc/fascia 20 sq cm/<", "code_information": [ { "code": "11043", "type": "CPT" } ], "standard_charges": [ { "gross_charge": 35824.34, "minimum": 560.75, "maximum": 30450.69, "setting": "inpatient", "payers_information": [ { "payer_name": "Aarp", "plan_name": "500102", "standard_charge_dollar": 560.75, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna", "plan_name": "700700", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna", "plan_name": "700700_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Mcare Ffs 6005", "plan_name": "700703", "standard_charge_dollar": 560.75, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Miscellaneous", "plan_name": "700720", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Miscellaneous", "plan_name": "700720_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Ppo Hmo", "plan_name": "701720", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Ppo Hmo", "plan_name": "701720_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Ambetter 68069", "plan_name": "500516", "standard_charge_dollar": 560.75, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Ms State Emplo", "plan_name": "401457", "standard_charge_percentage": 0.80, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Ms State Emplo", "plan_name": "401457_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Basic Pl", "plan_name": "400100", "standard_charge_percentage": 0.85, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Basic Pl", "plan_name": "400100_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Federal", "plan_name": "400110", "standard_charge_percentage": 0.85, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Federal", "plan_name": "400110_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Cigna Healthsprings Ffs", "plan_name": "500064", "standard_charge_dollar": 560.75, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Conseco", "plan_name": "500302", "standard_charge_dollar": 560.75, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Humana Ffs 61101", "plan_name": "500006", "standard_charge_dollar": 560.75, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Medicare A", "plan_name": "100100", "standard_charge_dollar": 560.75, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Medicare A", "plan_name": "100500", "standard_charge_dollar": 560.75, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Medicare Part B Only", "plan_name": "100300", "standard_charge_dollar": 560.75, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Medicare Railroad", "plan_name": "100103", "standard_charge_dollar": 560.75, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Ms Physicians Care N", "plan_name": "714210", "standard_charge_dollar": 700.94, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Peoples Hlth Ffs 72126", "plan_name": "500019", "standard_charge_dollar": 560.75, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Uhc/Secure Horizons", "plan_name": "500449", "standard_charge_dollar": 560.75, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "United Health Care/", "plan_name": "500292", "standard_charge_dollar": 633.65, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "United Healthcare", "plan_name": "750104", "standard_charge_dollar": 633.65, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "United Healthcare Ba", "plan_name": "750090", "standard_charge_dollar": 633.65, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "United Healthcare Me", "plan_name": "501310", "standard_charge_dollar": 560.75, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Windsor Mcare Extra", "plan_name": "500778", "standard_charge_dollar": 560.75, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." } ] } ] }, { "description": "Deb musc/fascia 20 sq cm/<", "code_information": [ { "code": "11043", "type": "CPT" } ], "standard_charges": [ { "gross_charge": 746.00, "minimum": 560.75, "maximum": 700.94, "setting": "outpatient", "payers_information": [ { "payer_name": "Aarp", "plan_name": "500102", "standard_charge_dollar": 560.75, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna", "plan_name": "700700", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna", "plan_name": "700700_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Mcare Ffs 6005", "plan_name": "700703", "standard_charge_dollar": 560.75, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Miscellaneous", "plan_name": "700720", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Miscellaneous", "plan_name": "700720_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Ppo Hmo", "plan_name": "701720", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Ppo Hmo", "plan_name": "701720_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Ambetter 68069", "plan_name": "500516", "standard_charge_dollar": 560.75, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Ms State Emplo", "plan_name": "401457", "standard_charge_percentage": 0.80, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Ms State Emplo", "plan_name": "401457_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Basic Pl", "plan_name": "400100", "standard_charge_percentage": 0.85, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Basic Pl", "plan_name": "400100_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Federal", "plan_name": "400110", "standard_charge_percentage": 0.85, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Federal", "plan_name": "400110_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Cigna Healthsprings Ffs", "plan_name": "500064", "standard_charge_dollar": 560.75, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Conseco", "plan_name": "500302", "standard_charge_dollar": 560.75, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Humana Ffs 61101", "plan_name": "500006", "standard_charge_dollar": 560.75, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Medicare A", "plan_name": "100100", "standard_charge_dollar": 560.75, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Medicare A", "plan_name": "100500", "standard_charge_dollar": 560.75, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Medicare Part B Only", "plan_name": "100300", "standard_charge_dollar": 560.75, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Medicare Railroad", "plan_name": "100103", "standard_charge_dollar": 560.75, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Ms Physicians Care N", "plan_name": "714210", "standard_charge_dollar": 700.94, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Peoples Hlth Ffs 72126", "plan_name": "500019", "standard_charge_dollar": 560.75, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Uhc/Secure Horizons", "plan_name": "500449", "standard_charge_dollar": 560.75, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "United Health Care/", "plan_name": "500292", "standard_charge_dollar": 633.65, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "United Healthcare", "plan_name": "750104", "standard_charge_dollar": 633.65, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "United Healthcare Ba", "plan_name": "750090", "standard_charge_dollar": 633.65, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "United Healthcare Me", "plan_name": "501310", "standard_charge_dollar": 560.75, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Windsor Mcare Extra", "plan_name": "500778", "standard_charge_dollar": 560.75, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." } ] } ] }, { "description": "Hc debride skin s/q tiss & muscle", "code_information": [ { "code": "11043", "type": "CPT" } ], "standard_charges": [ { "gross_charge": 746.00, "minimum": 560.75, "maximum": 700.94, "setting": "both", "payers_information": [ { "payer_name": "Aarp", "plan_name": "500102", "standard_charge_dollar": 560.75, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna", "plan_name": "700700", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna", "plan_name": "700700_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Mcare Ffs 6005", "plan_name": "700703", "standard_charge_dollar": 560.75, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Miscellaneous", "plan_name": "700720", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Miscellaneous", "plan_name": "700720_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Ppo Hmo", "plan_name": "701720", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Ppo Hmo", "plan_name": "701720_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Ambetter 68069", "plan_name": "500516", "standard_charge_dollar": 560.75, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Ms State Emplo", "plan_name": "401457", "standard_charge_percentage": 0.80, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Ms State Emplo", "plan_name": "401457_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Basic Pl", "plan_name": "400100", "standard_charge_percentage": 0.85, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Basic Pl", "plan_name": "400100_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Federal", "plan_name": "400110", "standard_charge_percentage": 0.85, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Federal", "plan_name": "400110_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Cigna Healthsprings Ffs", "plan_name": "500064", "standard_charge_dollar": 560.75, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Conseco", "plan_name": "500302", "standard_charge_dollar": 560.75, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Humana Ffs 61101", "plan_name": "500006", "standard_charge_dollar": 560.75, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Medicare A", "plan_name": "100100", "standard_charge_dollar": 560.75, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Medicare A", "plan_name": "100500", "standard_charge_dollar": 560.75, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Medicare Part B Only", "plan_name": "100300", "standard_charge_dollar": 560.75, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Medicare Railroad", "plan_name": "100103", "standard_charge_dollar": 560.75, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Ms Physicians Care N", "plan_name": "714210", "standard_charge_dollar": 700.94, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Peoples Hlth Ffs 72126", "plan_name": "500019", "standard_charge_dollar": 560.75, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Uhc/Secure Horizons", "plan_name": "500449", "standard_charge_dollar": 560.75, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "United Health Care/", "plan_name": "500292", "standard_charge_dollar": 633.65, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "United Healthcare", "plan_name": "750104", "standard_charge_dollar": 633.65, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "United Healthcare Ba", "plan_name": "750090", "standard_charge_dollar": 633.65, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "United Healthcare Me", "plan_name": "501310", "standard_charge_dollar": 560.75, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Windsor Mcare Extra", "plan_name": "500778", "standard_charge_dollar": 560.75, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." } ] } ] }, { "description": "Hc debride skin s/q tiss & muscle", "code_information": [ { "code": "11043", "type": "CPT" } ], "standard_charges": [ { "gross_charge": 2984.00, "minimum": 560.75, "maximum": 2536.40, "setting": "both", "payers_information": [ { "payer_name": "Aarp", "plan_name": "500102", "standard_charge_dollar": 560.75, "count": "0", "methodology": "fee schedule", "modifiers": "50", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna", "plan_name": "700700", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna", "plan_name": "700700_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Mcare Ffs 6005", "plan_name": "700703", "standard_charge_dollar": 560.75, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Miscellaneous", "plan_name": "700720", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Miscellaneous", "plan_name": "700720_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Ppo Hmo", "plan_name": "701720", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Ppo Hmo", "plan_name": "701720_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Ambetter 68069", "plan_name": "500516", "standard_charge_dollar": 560.75, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Ms State Emplo", "plan_name": "401457", "standard_charge_percentage": 0.80, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Ms State Emplo", "plan_name": "401457_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Basic Pl", "plan_name": "400100", "standard_charge_percentage": 0.85, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Basic Pl", "plan_name": "400100_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Federal", "plan_name": "400110", "standard_charge_percentage": 0.85, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Federal", "plan_name": "400110_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Cigna Healthsprings Ffs", "plan_name": "500064", "standard_charge_dollar": 560.75, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Conseco", "plan_name": "500302", "standard_charge_dollar": 560.75, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Humana Ffs 61101", "plan_name": "500006", "standard_charge_dollar": 560.75, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Medicare A", "plan_name": "100100", "standard_charge_dollar": 560.75, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Medicare A", "plan_name": "100500", "standard_charge_dollar": 560.75, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Medicare Part B Only", "plan_name": "100300", "standard_charge_dollar": 560.75, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Medicare Railroad", "plan_name": "100103", "standard_charge_dollar": 560.75, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Ms Physicians Care N", "plan_name": "714210", "standard_charge_dollar": 700.94, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Peoples Hlth Ffs 72126", "plan_name": "500019", "standard_charge_dollar": 560.75, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Uhc/Secure Horizons", "plan_name": "500449", "standard_charge_dollar": 560.75, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "United Health Care/", "plan_name": "500292", "standard_charge_dollar": 633.65, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "United Healthcare", "plan_name": "750104", "standard_charge_dollar": 633.65, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "United Healthcare Ba", "plan_name": "750090", "standard_charge_dollar": 633.65, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "United Healthcare Me", "plan_name": "501310", "standard_charge_dollar": 560.75, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Windsor Mcare Extra", "plan_name": "500778", "standard_charge_dollar": 560.75, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." } ] } ] }, { "description": "Deb bone 20 sq cm/<", "code_information": [ { "code": "11044", "type": "CPT" } ], "standard_charges": [ { "gross_charge": 25756.12, "minimum": 1484.25, "maximum": 21892.70, "setting": "inpatient", "payers_information": [ { "payer_name": "Aarp", "plan_name": "500102", "standard_charge_dollar": 1484.25, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna", "plan_name": "700700", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna", "plan_name": "700700_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Mcare Ffs 6005", "plan_name": "700703", "standard_charge_dollar": 1484.25, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Miscellaneous", "plan_name": "700720", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Miscellaneous", "plan_name": "700720_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Ppo Hmo", "plan_name": "701720", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Ppo Hmo", "plan_name": "701720_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Ambetter 68069", "plan_name": "500516", "standard_charge_dollar": 1484.25, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Ms State Emplo", "plan_name": "401457", "standard_charge_percentage": 0.80, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Ms State Emplo", "plan_name": "401457_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Basic Pl", "plan_name": "400100", "standard_charge_percentage": 0.85, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Basic Pl", "plan_name": "400100_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Federal", "plan_name": "400110", "standard_charge_percentage": 0.85, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Federal", "plan_name": "400110_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Cigna Healthsprings Ffs", "plan_name": "500064", "standard_charge_dollar": 1484.25, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Conseco", "plan_name": "500302", "standard_charge_dollar": 1484.25, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Humana Ffs 61101", "plan_name": "500006", "standard_charge_dollar": 1484.25, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Medicare A", "plan_name": "100100", "standard_charge_dollar": 1484.25, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Medicare A", "plan_name": "100500", "standard_charge_dollar": 1484.25, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Medicare Part B Only", "plan_name": "100300", "standard_charge_dollar": 1484.25, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Medicare Railroad", "plan_name": "100103", "standard_charge_dollar": 1484.25, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Ms Physicians Care N", "plan_name": "714210", "standard_charge_dollar": 1855.31, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Peoples Hlth Ffs 72126", "plan_name": "500019", "standard_charge_dollar": 1484.25, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Uhc/Secure Horizons", "plan_name": "500449", "standard_charge_dollar": 1484.25, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "United Health Care/", "plan_name": "500292", "standard_charge_dollar": 1677.20, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "United Healthcare", "plan_name": "750104", "standard_charge_dollar": 1677.20, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "United Healthcare Ba", "plan_name": "750090", "standard_charge_dollar": 1677.20, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "United Healthcare Me", "plan_name": "501310", "standard_charge_dollar": 1484.25, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Windsor Mcare Extra", "plan_name": "500778", "standard_charge_dollar": 1484.25, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." } ] } ] }, { "description": "Deb bone 20 sq cm/<", "code_information": [ { "code": "11044", "type": "CPT" } ], "standard_charges": [ { "gross_charge": 2003.00, "minimum": 1484.25, "maximum": 1855.31, "setting": "outpatient", "payers_information": [ { "payer_name": "Aarp", "plan_name": "500102", "standard_charge_dollar": 1484.25, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna", "plan_name": "700700", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna", "plan_name": "700700_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Mcare Ffs 6005", "plan_name": "700703", "standard_charge_dollar": 1484.25, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Miscellaneous", "plan_name": "700720", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Miscellaneous", "plan_name": "700720_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Ppo Hmo", "plan_name": "701720", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Ppo Hmo", "plan_name": "701720_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Ambetter 68069", "plan_name": "500516", "standard_charge_dollar": 1484.25, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Ms State Emplo", "plan_name": "401457", "standard_charge_percentage": 0.80, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Ms State Emplo", "plan_name": "401457_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Basic Pl", "plan_name": "400100", "standard_charge_percentage": 0.85, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Basic Pl", "plan_name": "400100_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Federal", "plan_name": "400110", "standard_charge_percentage": 0.85, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Federal", "plan_name": "400110_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Cigna Healthsprings Ffs", "plan_name": "500064", "standard_charge_dollar": 1484.25, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Conseco", "plan_name": "500302", "standard_charge_dollar": 1484.25, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Humana Ffs 61101", "plan_name": "500006", "standard_charge_dollar": 1484.25, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Medicare A", "plan_name": "100100", "standard_charge_dollar": 1484.25, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Medicare A", "plan_name": "100500", "standard_charge_dollar": 1484.25, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Medicare Part B Only", "plan_name": "100300", "standard_charge_dollar": 1484.25, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Medicare Railroad", "plan_name": "100103", "standard_charge_dollar": 1484.25, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Ms Physicians Care N", "plan_name": "714210", "standard_charge_dollar": 1855.31, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Peoples Hlth Ffs 72126", "plan_name": "500019", "standard_charge_dollar": 1484.25, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Uhc/Secure Horizons", "plan_name": "500449", "standard_charge_dollar": 1484.25, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "United Health Care/", "plan_name": "500292", "standard_charge_dollar": 1677.20, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "United Healthcare", "plan_name": "750104", "standard_charge_dollar": 1677.20, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "United Healthcare Ba", "plan_name": "750090", "standard_charge_dollar": 1677.20, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "United Healthcare Me", "plan_name": "501310", "standard_charge_dollar": 1484.25, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Windsor Mcare Extra", "plan_name": "500778", "standard_charge_dollar": 1484.25, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." } ] } ] }, { "description": "Hc debride bone 20 cm or less", "code_information": [ { "code": "11044", "type": "CPT" } ], "standard_charges": [ { "gross_charge": 2003.00, "minimum": 1484.25, "maximum": 1855.31, "setting": "both", "payers_information": [ { "payer_name": "Aarp", "plan_name": "500102", "standard_charge_dollar": 1484.25, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna", "plan_name": "700700", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna", "plan_name": "700700_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Mcare Ffs 6005", "plan_name": "700703", "standard_charge_dollar": 1484.25, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Miscellaneous", "plan_name": "700720", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Miscellaneous", "plan_name": "700720_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Ppo Hmo", "plan_name": "701720", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Ppo Hmo", "plan_name": "701720_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Ambetter 68069", "plan_name": "500516", "standard_charge_dollar": 1484.25, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Ms State Emplo", "plan_name": "401457", "standard_charge_percentage": 0.80, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Ms State Emplo", "plan_name": "401457_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Basic Pl", "plan_name": "400100", "standard_charge_percentage": 0.85, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Basic Pl", "plan_name": "400100_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Federal", "plan_name": "400110", "standard_charge_percentage": 0.85, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Federal", "plan_name": "400110_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Cigna Healthsprings Ffs", "plan_name": "500064", "standard_charge_dollar": 1484.25, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Conseco", "plan_name": "500302", "standard_charge_dollar": 1484.25, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Humana Ffs 61101", "plan_name": "500006", "standard_charge_dollar": 1484.25, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Medicare A", "plan_name": "100100", "standard_charge_dollar": 1484.25, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Medicare A", "plan_name": "100500", "standard_charge_dollar": 1484.25, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Medicare Part B Only", "plan_name": "100300", "standard_charge_dollar": 1484.25, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Medicare Railroad", "plan_name": "100103", "standard_charge_dollar": 1484.25, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Ms Physicians Care N", "plan_name": "714210", "standard_charge_dollar": 1855.31, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Peoples Hlth Ffs 72126", "plan_name": "500019", "standard_charge_dollar": 1484.25, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Uhc/Secure Horizons", "plan_name": "500449", "standard_charge_dollar": 1484.25, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "United Health Care/", "plan_name": "500292", "standard_charge_dollar": 1677.20, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "United Healthcare", "plan_name": "750104", "standard_charge_dollar": 1677.20, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "United Healthcare Ba", "plan_name": "750090", "standard_charge_dollar": 1677.20, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "United Healthcare Me", "plan_name": "501310", "standard_charge_dollar": 1484.25, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Windsor Mcare Extra", "plan_name": "500778", "standard_charge_dollar": 1484.25, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." } ] } ] }, { "description": "Deb subq tissue add-on", "code_information": [ { "code": "11045", "type": "CPT" } ], "standard_charges": [ { "gross_charge": 35824.34, "minimum": 28659.47, "maximum": 30450.69, "setting": "inpatient", "payers_information": [ { "payer_name": "Aetna", "plan_name": "700700", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna", "plan_name": "700700_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Miscellaneous", "plan_name": "700720", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Miscellaneous", "plan_name": "700720_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Ppo Hmo", "plan_name": "701720", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Ppo Hmo", "plan_name": "701720_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Ms State Emplo", "plan_name": "401457", "standard_charge_percentage": 0.80, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Ms State Emplo", "plan_name": "401457_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Basic Pl", "plan_name": "400100", "standard_charge_percentage": 0.85, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Basic Pl", "plan_name": "400100_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Federal", "plan_name": "400110", "standard_charge_percentage": 0.85, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Federal", "plan_name": "400110_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." } ] } ] }, { "description": "Deb subq tissue add-on", "code_information": [ { "code": "11045", "type": "CPT" } ], "standard_charges": [ { "gross_charge": 746.00, "minimum": 596.80, "maximum": 634.10, "setting": "outpatient", "payers_information": [ { "payer_name": "Aetna", "plan_name": "700700", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna", "plan_name": "700700_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Miscellaneous", "plan_name": "700720", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Miscellaneous", "plan_name": "700720_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Ppo Hmo", "plan_name": "701720", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Ppo Hmo", "plan_name": "701720_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Ms State Emplo", "plan_name": "401457", "standard_charge_percentage": 0.80, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Ms State Emplo", "plan_name": "401457_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Basic Pl", "plan_name": "400100", "standard_charge_percentage": 0.85, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Basic Pl", "plan_name": "400100_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Federal", "plan_name": "400110", "standard_charge_percentage": 0.85, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Federal", "plan_name": "400110_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." } ] } ] }, { "description": "Hc debride skin sq ea addl 20 cm", "code_information": [ { "code": "11045", "type": "CPT" } ], "standard_charges": [ { "gross_charge": 746.00, "minimum": 596.80, "maximum": 634.10, "setting": "both", "payers_information": [ { "payer_name": "Aetna", "plan_name": "700700", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna", "plan_name": "700700_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Miscellaneous", "plan_name": "700720", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Miscellaneous", "plan_name": "700720_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Ppo Hmo", "plan_name": "701720", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Ppo Hmo", "plan_name": "701720_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Ms State Emplo", "plan_name": "401457", "standard_charge_percentage": 0.80, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Ms State Emplo", "plan_name": "401457_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Basic Pl", "plan_name": "400100", "standard_charge_percentage": 0.85, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Basic Pl", "plan_name": "400100_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Federal", "plan_name": "400110", "standard_charge_percentage": 0.85, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Federal", "plan_name": "400110_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." } ] } ] }, { "description": "Hc debride skin sq ea addl 20 cm", "code_information": [ { "code": "11045", "type": "CPT" } ], "standard_charges": [ { "gross_charge": 2984.00, "minimum": 2387.20, "maximum": 2536.40, "setting": "both", "payers_information": [ { "payer_name": "Aetna", "plan_name": "700700", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "modifiers": "50", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna", "plan_name": "700700_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Miscellaneous", "plan_name": "700720", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Miscellaneous", "plan_name": "700720_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Ppo Hmo", "plan_name": "701720", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Ppo Hmo", "plan_name": "701720_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Ms State Emplo", "plan_name": "401457", "standard_charge_percentage": 0.80, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Ms State Emplo", "plan_name": "401457_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Basic Pl", "plan_name": "400100", "standard_charge_percentage": 0.85, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Basic Pl", "plan_name": "400100_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Federal", "plan_name": "400110", "standard_charge_percentage": 0.85, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Federal", "plan_name": "400110_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." } ] } ] }, { "description": "Deb musc/fascia add-on", "code_information": [ { "code": "11046", "type": "CPT" } ], "standard_charges": [ { "gross_charge": 33034.90, "minimum": 26427.92, "maximum": 28079.67, "setting": "inpatient", "payers_information": [ { "payer_name": "Aetna", "plan_name": "700700", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna", "plan_name": "700700_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Miscellaneous", "plan_name": "700720", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Miscellaneous", "plan_name": "700720_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Ppo Hmo", "plan_name": "701720", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Ppo Hmo", "plan_name": "701720_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Ms State Emplo", "plan_name": "401457", "standard_charge_percentage": 0.80, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Ms State Emplo", "plan_name": "401457_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Basic Pl", "plan_name": "400100", "standard_charge_percentage": 0.85, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Basic Pl", "plan_name": "400100_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Federal", "plan_name": "400110", "standard_charge_percentage": 0.85, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Federal", "plan_name": "400110_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." } ] } ] }, { "description": "Deb musc/fascia add-on", "code_information": [ { "code": "11046", "type": "CPT" } ], "standard_charges": [ { "gross_charge": 746.00, "minimum": 596.80, "maximum": 634.10, "setting": "outpatient", "payers_information": [ { "payer_name": "Aetna", "plan_name": "700700", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna", "plan_name": "700700_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Miscellaneous", "plan_name": "700720", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Miscellaneous", "plan_name": "700720_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Ppo Hmo", "plan_name": "701720", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Ppo Hmo", "plan_name": "701720_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Ms State Emplo", "plan_name": "401457", "standard_charge_percentage": 0.80, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Ms State Emplo", "plan_name": "401457_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Basic Pl", "plan_name": "400100", "standard_charge_percentage": 0.85, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Basic Pl", "plan_name": "400100_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Federal", "plan_name": "400110", "standard_charge_percentage": 0.85, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Federal", "plan_name": "400110_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." } ] } ] }, { "description": "Hc debride muscle/fas ea addl 20 cm", "code_information": [ { "code": "11046", "type": "CPT" } ], "standard_charges": [ { "gross_charge": 746.00, "minimum": 596.80, "maximum": 634.10, "setting": "both", "payers_information": [ { "payer_name": "Aetna", "plan_name": "700700", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna", "plan_name": "700700_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Miscellaneous", "plan_name": "700720", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Miscellaneous", "plan_name": "700720_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Ppo Hmo", "plan_name": "701720", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Ppo Hmo", "plan_name": "701720_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Ms State Emplo", "plan_name": "401457", "standard_charge_percentage": 0.80, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Ms State Emplo", "plan_name": "401457_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Basic Pl", "plan_name": "400100", "standard_charge_percentage": 0.85, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Basic Pl", "plan_name": "400100_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Federal", "plan_name": "400110", "standard_charge_percentage": 0.85, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Federal", "plan_name": "400110_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." } ] } ] }, { "description": "Deb bone add-on", "code_information": [ { "code": "11047", "type": "CPT" } ], "standard_charges": [ { "gross_charge": 25756.12, "minimum": 20604.90, "maximum": 21892.70, "setting": "inpatient", "payers_information": [ { "payer_name": "Aetna", "plan_name": "700700", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna", "plan_name": "700700_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Miscellaneous", "plan_name": "700720", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Miscellaneous", "plan_name": "700720_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Ppo Hmo", "plan_name": "701720", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Ppo Hmo", "plan_name": "701720_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Ms State Emplo", "plan_name": "401457", "standard_charge_percentage": 0.80, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Ms State Emplo", "plan_name": "401457_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Basic Pl", "plan_name": "400100", "standard_charge_percentage": 0.85, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Basic Pl", "plan_name": "400100_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Federal", "plan_name": "400110", "standard_charge_percentage": 0.85, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Federal", "plan_name": "400110_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." } ] } ] }, { "description": "Deb bone add-on", "code_information": [ { "code": "11047", "type": "CPT" } ], "standard_charges": [ { "gross_charge": 746.00, "minimum": 596.80, "maximum": 634.10, "setting": "outpatient", "payers_information": [ { "payer_name": "Aetna", "plan_name": "700700", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna", "plan_name": "700700_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Miscellaneous", "plan_name": "700720", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Miscellaneous", "plan_name": "700720_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Ppo Hmo", "plan_name": "701720", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Ppo Hmo", "plan_name": "701720_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Ms State Emplo", "plan_name": "401457", "standard_charge_percentage": 0.80, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Ms State Emplo", "plan_name": "401457_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Basic Pl", "plan_name": "400100", "standard_charge_percentage": 0.85, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Basic Pl", "plan_name": "400100_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Federal", "plan_name": "400110", "standard_charge_percentage": 0.85, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Federal", "plan_name": "400110_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." } ] } ] }, { "description": "Hc debride bone ea addl 20 cm", "code_information": [ { "code": "11047", "type": "CPT" } ], "standard_charges": [ { "gross_charge": 746.00, "minimum": 596.80, "maximum": 634.10, "setting": "both", "payers_information": [ { "payer_name": "Aetna", "plan_name": "700700", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna", "plan_name": "700700_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Miscellaneous", "plan_name": "700720", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Miscellaneous", "plan_name": "700720_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Ppo Hmo", "plan_name": "701720", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Ppo Hmo", "plan_name": "701720_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Ms State Emplo", "plan_name": "401457", "standard_charge_percentage": 0.80, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Ms State Emplo", "plan_name": "401457_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Basic Pl", "plan_name": "400100", "standard_charge_percentage": 0.85, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Basic Pl", "plan_name": "400100_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Federal", "plan_name": "400110", "standard_charge_percentage": 0.85, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Federal", "plan_name": "400110_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." } ] } ] }, { "description": "Hc trim skin lesion", "code_information": [ { "code": "11055", "type": "CPT" } ], "standard_charges": [ { "gross_charge": 250.00, "minimum": 182.02, "maximum": 229.58, "setting": "both", "payers_information": [ { "payer_name": "Aarp", "plan_name": "500102", "standard_charge_dollar": 182.02, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna", "plan_name": "700700", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna", "plan_name": "700700_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Mcare Ffs 6005", "plan_name": "700703", "standard_charge_dollar": 182.02, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Miscellaneous", "plan_name": "700720", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Miscellaneous", "plan_name": "700720_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Ppo Hmo", "plan_name": "701720", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Ppo Hmo", "plan_name": "701720_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Ambetter 68069", "plan_name": "500516", "standard_charge_dollar": 182.02, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Ms State Emplo", "plan_name": "401457", "standard_charge_dollar": 229.58, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Ms State Emplo", "plan_name": "401457_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Basic Pl", "plan_name": "400100", "standard_charge_dollar": 229.58, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Basic Pl", "plan_name": "400100_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Federal", "plan_name": "400110", "standard_charge_dollar": 229.58, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Federal", "plan_name": "400110_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Cigna Healthsprings Ffs", "plan_name": "500064", "standard_charge_dollar": 182.02, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Conseco", "plan_name": "500302", "standard_charge_dollar": 182.02, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Humana Ffs 61101", "plan_name": "500006", "standard_charge_dollar": 182.02, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Medicare A", "plan_name": "100100", "standard_charge_dollar": 182.02, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Medicare A", "plan_name": "100500", "standard_charge_dollar": 182.02, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Medicare Part B Only", "plan_name": "100300", "standard_charge_dollar": 182.02, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Medicare Railroad", "plan_name": "100103", "standard_charge_dollar": 182.02, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Ms Physicians Care N", "plan_name": "714210", "standard_charge_dollar": 227.53, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Peoples Hlth Ffs 72126", "plan_name": "500019", "standard_charge_dollar": 182.02, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Uhc/Secure Horizons", "plan_name": "500449", "standard_charge_dollar": 182.02, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "United Health Care/", "plan_name": "500292", "standard_charge_dollar": 205.69, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "United Healthcare", "plan_name": "750104", "standard_charge_dollar": 205.69, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "United Healthcare Ba", "plan_name": "750090", "standard_charge_dollar": 205.69, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "United Healthcare Me", "plan_name": "501310", "standard_charge_dollar": 182.02, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Windsor Mcare Extra", "plan_name": "500778", "standard_charge_dollar": 182.02, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." } ] } ] }, { "description": "Trim skin lesion", "code_information": [ { "code": "11055", "type": "CPT" } ], "standard_charges": [ { "gross_charge": 26535.50, "minimum": 182.02, "maximum": 229.58, "setting": "inpatient", "payers_information": [ { "payer_name": "Aarp", "plan_name": "500102", "standard_charge_dollar": 182.02, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna", "plan_name": "700700", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna", "plan_name": "700700_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Mcare Ffs 6005", "plan_name": "700703", "standard_charge_dollar": 182.02, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Miscellaneous", "plan_name": "700720", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Miscellaneous", "plan_name": "700720_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Ppo Hmo", "plan_name": "701720", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Ppo Hmo", "plan_name": "701720_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Ambetter 68069", "plan_name": "500516", "standard_charge_dollar": 182.02, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Ms State Emplo", "plan_name": "401457", "standard_charge_dollar": 229.58, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Ms State Emplo", "plan_name": "401457_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Basic Pl", "plan_name": "400100", "standard_charge_dollar": 229.58, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Basic Pl", "plan_name": "400100_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Federal", "plan_name": "400110", "standard_charge_dollar": 229.58, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Federal", "plan_name": "400110_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Cigna Healthsprings Ffs", "plan_name": "500064", "standard_charge_dollar": 182.02, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Conseco", "plan_name": "500302", "standard_charge_dollar": 182.02, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Humana Ffs 61101", "plan_name": "500006", "standard_charge_dollar": 182.02, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Medicare A", "plan_name": "100100", "standard_charge_dollar": 182.02, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Medicare A", "plan_name": "100500", "standard_charge_dollar": 182.02, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Medicare Part B Only", "plan_name": "100300", "standard_charge_dollar": 182.02, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Medicare Railroad", "plan_name": "100103", "standard_charge_dollar": 182.02, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Ms Physicians Care N", "plan_name": "714210", "standard_charge_dollar": 227.53, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Peoples Hlth Ffs 72126", "plan_name": "500019", "standard_charge_dollar": 182.02, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Uhc/Secure Horizons", "plan_name": "500449", "standard_charge_dollar": 182.02, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "United Health Care/", "plan_name": "500292", "standard_charge_dollar": 205.69, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "United Healthcare", "plan_name": "750104", "standard_charge_dollar": 205.69, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "United Healthcare Ba", "plan_name": "750090", "standard_charge_dollar": 205.69, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "United Healthcare Me", "plan_name": "501310", "standard_charge_dollar": 182.02, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Windsor Mcare Extra", "plan_name": "500778", "standard_charge_dollar": 182.02, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." } ] } ] }, { "description": "Trim skin lesion", "code_information": [ { "code": "11055", "type": "CPT" } ], "standard_charges": [ { "gross_charge": 250.00, "minimum": 182.02, "maximum": 229.58, "setting": "outpatient", "payers_information": [ { "payer_name": "Aarp", "plan_name": "500102", "standard_charge_dollar": 182.02, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna", "plan_name": "700700", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna", "plan_name": "700700_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Mcare Ffs 6005", "plan_name": "700703", "standard_charge_dollar": 182.02, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Miscellaneous", "plan_name": "700720", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Miscellaneous", "plan_name": "700720_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Ppo Hmo", "plan_name": "701720", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Ppo Hmo", "plan_name": "701720_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Ambetter 68069", "plan_name": "500516", "standard_charge_dollar": 182.02, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Ms State Emplo", "plan_name": "401457", "standard_charge_dollar": 229.58, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Ms State Emplo", "plan_name": "401457_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Basic Pl", "plan_name": "400100", "standard_charge_dollar": 229.58, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Basic Pl", "plan_name": "400100_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Federal", "plan_name": "400110", "standard_charge_dollar": 229.58, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Federal", "plan_name": "400110_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Cigna Healthsprings Ffs", "plan_name": "500064", "standard_charge_dollar": 182.02, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Conseco", "plan_name": "500302", "standard_charge_dollar": 182.02, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Humana Ffs 61101", "plan_name": "500006", "standard_charge_dollar": 182.02, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Medicare A", "plan_name": "100100", "standard_charge_dollar": 182.02, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Medicare A", "plan_name": "100500", "standard_charge_dollar": 182.02, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Medicare Part B Only", "plan_name": "100300", "standard_charge_dollar": 182.02, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Medicare Railroad", "plan_name": "100103", "standard_charge_dollar": 182.02, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Ms Physicians Care N", "plan_name": "714210", "standard_charge_dollar": 227.53, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Peoples Hlth Ffs 72126", "plan_name": "500019", "standard_charge_dollar": 182.02, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Uhc/Secure Horizons", "plan_name": "500449", "standard_charge_dollar": 182.02, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "United Health Care/", "plan_name": "500292", "standard_charge_dollar": 205.69, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "United Healthcare", "plan_name": "750104", "standard_charge_dollar": 205.69, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "United Healthcare Ba", "plan_name": "750090", "standard_charge_dollar": 205.69, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "United Healthcare Me", "plan_name": "501310", "standard_charge_dollar": 182.02, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Windsor Mcare Extra", "plan_name": "500778", "standard_charge_dollar": 182.02, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." } ] } ] }, { "description": "Hc trim skin lesion 2 - 4", "code_information": [ { "code": "11056", "type": "CPT" } ], "standard_charges": [ { "gross_charge": 300.00, "minimum": 182.02, "maximum": 229.58, "setting": "both", "payers_information": [ { "payer_name": "Aarp", "plan_name": "500102", "standard_charge_dollar": 182.02, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna", "plan_name": "700700", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna", "plan_name": "700700_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Mcare Ffs 6005", "plan_name": "700703", "standard_charge_dollar": 182.02, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Miscellaneous", "plan_name": "700720", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Miscellaneous", "plan_name": "700720_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Ppo Hmo", "plan_name": "701720", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Ppo Hmo", "plan_name": "701720_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Ambetter 68069", "plan_name": "500516", "standard_charge_dollar": 182.02, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Ms State Emplo", "plan_name": "401457", "standard_charge_dollar": 229.58, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Ms State Emplo", "plan_name": "401457_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Basic Pl", "plan_name": "400100", "standard_charge_dollar": 229.58, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Basic Pl", "plan_name": "400100_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Federal", "plan_name": "400110", "standard_charge_dollar": 229.58, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Federal", "plan_name": "400110_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Cigna Healthsprings Ffs", "plan_name": "500064", "standard_charge_dollar": 182.02, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Conseco", "plan_name": "500302", "standard_charge_dollar": 182.02, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Humana Ffs 61101", "plan_name": "500006", "standard_charge_dollar": 182.02, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Medicare A", "plan_name": "100100", "standard_charge_dollar": 182.02, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Medicare A", "plan_name": "100500", "standard_charge_dollar": 182.02, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Medicare Part B Only", "plan_name": "100300", "standard_charge_dollar": 182.02, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Medicare Railroad", "plan_name": "100103", "standard_charge_dollar": 182.02, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Ms Physicians Care N", "plan_name": "714210", "standard_charge_dollar": 227.53, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Peoples Hlth Ffs 72126", "plan_name": "500019", "standard_charge_dollar": 182.02, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Uhc/Secure Horizons", "plan_name": "500449", "standard_charge_dollar": 182.02, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "United Health Care/", "plan_name": "500292", "standard_charge_dollar": 205.69, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "United Healthcare", "plan_name": "750104", "standard_charge_dollar": 205.69, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "United Healthcare Ba", "plan_name": "750090", "standard_charge_dollar": 205.69, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "United Healthcare Me", "plan_name": "501310", "standard_charge_dollar": 182.02, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Windsor Mcare Extra", "plan_name": "500778", "standard_charge_dollar": 182.02, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." } ] } ] }, { "description": "Trim skin lesions 2 to 4", "code_information": [ { "code": "11056", "type": "CPT" } ], "standard_charges": [ { "gross_charge": 26535.50, "minimum": 182.02, "maximum": 229.58, "setting": "inpatient", "payers_information": [ { "payer_name": "Aarp", "plan_name": "500102", "standard_charge_dollar": 182.02, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna", "plan_name": "700700", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna", "plan_name": "700700_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Mcare Ffs 6005", "plan_name": "700703", "standard_charge_dollar": 182.02, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Miscellaneous", "plan_name": "700720", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Miscellaneous", "plan_name": "700720_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Ppo Hmo", "plan_name": "701720", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Ppo Hmo", "plan_name": "701720_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Ambetter 68069", "plan_name": "500516", "standard_charge_dollar": 182.02, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Ms State Emplo", "plan_name": "401457", "standard_charge_dollar": 229.58, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Ms State Emplo", "plan_name": "401457_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Basic Pl", "plan_name": "400100", "standard_charge_dollar": 229.58, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Basic Pl", "plan_name": "400100_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Federal", "plan_name": "400110", "standard_charge_dollar": 229.58, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Federal", "plan_name": "400110_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Cigna Healthsprings Ffs", "plan_name": "500064", "standard_charge_dollar": 182.02, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Conseco", "plan_name": "500302", "standard_charge_dollar": 182.02, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Humana Ffs 61101", "plan_name": "500006", "standard_charge_dollar": 182.02, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Medicare A", "plan_name": "100100", "standard_charge_dollar": 182.02, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Medicare A", "plan_name": "100500", "standard_charge_dollar": 182.02, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Medicare Part B Only", "plan_name": "100300", "standard_charge_dollar": 182.02, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Medicare Railroad", "plan_name": "100103", "standard_charge_dollar": 182.02, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Ms Physicians Care N", "plan_name": "714210", "standard_charge_dollar": 227.53, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Peoples Hlth Ffs 72126", "plan_name": "500019", "standard_charge_dollar": 182.02, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Uhc/Secure Horizons", "plan_name": "500449", "standard_charge_dollar": 182.02, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "United Health Care/", "plan_name": "500292", "standard_charge_dollar": 205.69, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "United Healthcare", "plan_name": "750104", "standard_charge_dollar": 205.69, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "United Healthcare Ba", "plan_name": "750090", "standard_charge_dollar": 205.69, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "United Healthcare Me", "plan_name": "501310", "standard_charge_dollar": 182.02, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Windsor Mcare Extra", "plan_name": "500778", "standard_charge_dollar": 182.02, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." } ] } ] }, { "description": "Trim skin lesions 2 to 4", "code_information": [ { "code": "11056", "type": "CPT" } ], "standard_charges": [ { "gross_charge": 300.00, "minimum": 182.02, "maximum": 229.58, "setting": "outpatient", "payers_information": [ { "payer_name": "Aarp", "plan_name": "500102", "standard_charge_dollar": 182.02, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna", "plan_name": "700700", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna", "plan_name": "700700_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Mcare Ffs 6005", "plan_name": "700703", "standard_charge_dollar": 182.02, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Miscellaneous", "plan_name": "700720", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Miscellaneous", "plan_name": "700720_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Ppo Hmo", "plan_name": "701720", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Ppo Hmo", "plan_name": "701720_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Ambetter 68069", "plan_name": "500516", "standard_charge_dollar": 182.02, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Ms State Emplo", "plan_name": "401457", "standard_charge_dollar": 229.58, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Ms State Emplo", "plan_name": "401457_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Basic Pl", "plan_name": "400100", "standard_charge_dollar": 229.58, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Basic Pl", "plan_name": "400100_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Federal", "plan_name": "400110", "standard_charge_dollar": 229.58, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Federal", "plan_name": "400110_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Cigna Healthsprings Ffs", "plan_name": "500064", "standard_charge_dollar": 182.02, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Conseco", "plan_name": "500302", "standard_charge_dollar": 182.02, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Humana Ffs 61101", "plan_name": "500006", "standard_charge_dollar": 182.02, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Medicare A", "plan_name": "100100", "standard_charge_dollar": 182.02, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Medicare A", "plan_name": "100500", "standard_charge_dollar": 182.02, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Medicare Part B Only", "plan_name": "100300", "standard_charge_dollar": 182.02, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Medicare Railroad", "plan_name": "100103", "standard_charge_dollar": 182.02, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Ms Physicians Care N", "plan_name": "714210", "standard_charge_dollar": 227.53, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Peoples Hlth Ffs 72126", "plan_name": "500019", "standard_charge_dollar": 182.02, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Uhc/Secure Horizons", "plan_name": "500449", "standard_charge_dollar": 182.02, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "United Health Care/", "plan_name": "500292", "standard_charge_dollar": 205.69, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "United Healthcare", "plan_name": "750104", "standard_charge_dollar": 205.69, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "United Healthcare Ba", "plan_name": "750090", "standard_charge_dollar": 205.69, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "United Healthcare Me", "plan_name": "501310", "standard_charge_dollar": 182.02, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Windsor Mcare Extra", "plan_name": "500778", "standard_charge_dollar": 182.02, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." } ] } ] }, { "description": "Hc paring or cutting >4 lesions", "code_information": [ { "code": "11057", "type": "CPT" } ], "standard_charges": [ { "gross_charge": 350.00, "minimum": 182.02, "maximum": 297.50, "setting": "both", "payers_information": [ { "payer_name": "Aarp", "plan_name": "500102", "standard_charge_dollar": 182.02, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna", "plan_name": "700700", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna", "plan_name": "700700_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Mcare Ffs 6005", "plan_name": "700703", "standard_charge_dollar": 182.02, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Miscellaneous", "plan_name": "700720", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Miscellaneous", "plan_name": "700720_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Ppo Hmo", "plan_name": "701720", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Ppo Hmo", "plan_name": "701720_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Ambetter 68069", "plan_name": "500516", "standard_charge_dollar": 182.02, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Ms State Emplo", "plan_name": "401457", "standard_charge_percentage": 0.80, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Ms State Emplo", "plan_name": "401457_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Basic Pl", "plan_name": "400100", "standard_charge_percentage": 0.85, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Basic Pl", "plan_name": "400100_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Federal", "plan_name": "400110", "standard_charge_percentage": 0.85, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Federal", "plan_name": "400110_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Cigna Healthsprings Ffs", "plan_name": "500064", "standard_charge_dollar": 182.02, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Conseco", "plan_name": "500302", "standard_charge_dollar": 182.02, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Humana Ffs 61101", "plan_name": "500006", "standard_charge_dollar": 182.02, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Medicare A", "plan_name": "100100", "standard_charge_dollar": 182.02, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Medicare A", "plan_name": "100500", "standard_charge_dollar": 182.02, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Medicare Part B Only", "plan_name": "100300", "standard_charge_dollar": 182.02, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Medicare Railroad", "plan_name": "100103", "standard_charge_dollar": 182.02, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Ms Physicians Care N", "plan_name": "714210", "standard_charge_dollar": 227.53, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Peoples Hlth Ffs 72126", "plan_name": "500019", "standard_charge_dollar": 182.02, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Uhc/Secure Horizons", "plan_name": "500449", "standard_charge_dollar": 182.02, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "United Health Care/", "plan_name": "500292", "standard_charge_dollar": 205.69, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "United Healthcare", "plan_name": "750104", "standard_charge_dollar": 205.69, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "United Healthcare Ba", "plan_name": "750090", "standard_charge_dollar": 205.69, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "United Healthcare Me", "plan_name": "501310", "standard_charge_dollar": 182.02, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Windsor Mcare Extra", "plan_name": "500778", "standard_charge_dollar": 182.02, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." } ] } ] }, { "description": "Trim skin lesions over 4", "code_information": [ { "code": "11057", "type": "CPT" } ], "standard_charges": [ { "gross_charge": 26535.50, "minimum": 182.02, "maximum": 22555.18, "setting": "inpatient", "payers_information": [ { "payer_name": "Aarp", "plan_name": "500102", "standard_charge_dollar": 182.02, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna", "plan_name": "700700", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna", "plan_name": "700700_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Mcare Ffs 6005", "plan_name": "700703", "standard_charge_dollar": 182.02, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Miscellaneous", "plan_name": "700720", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Miscellaneous", "plan_name": "700720_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Ppo Hmo", "plan_name": "701720", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Ppo Hmo", "plan_name": "701720_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Ambetter 68069", "plan_name": "500516", "standard_charge_dollar": 182.02, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Ms State Emplo", "plan_name": "401457", "standard_charge_percentage": 0.80, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Ms State Emplo", "plan_name": "401457_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Basic Pl", "plan_name": "400100", "standard_charge_percentage": 0.85, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Basic Pl", "plan_name": "400100_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Federal", "plan_name": "400110", "standard_charge_percentage": 0.85, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Federal", "plan_name": "400110_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Cigna Healthsprings Ffs", "plan_name": "500064", "standard_charge_dollar": 182.02, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Conseco", "plan_name": "500302", "standard_charge_dollar": 182.02, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Humana Ffs 61101", "plan_name": "500006", "standard_charge_dollar": 182.02, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Medicare A", "plan_name": "100100", "standard_charge_dollar": 182.02, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Medicare A", "plan_name": "100500", "standard_charge_dollar": 182.02, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Medicare Part B Only", "plan_name": "100300", "standard_charge_dollar": 182.02, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Medicare Railroad", "plan_name": "100103", "standard_charge_dollar": 182.02, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Ms Physicians Care N", "plan_name": "714210", "standard_charge_dollar": 227.53, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Peoples Hlth Ffs 72126", "plan_name": "500019", "standard_charge_dollar": 182.02, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Uhc/Secure Horizons", "plan_name": "500449", "standard_charge_dollar": 182.02, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "United Health Care/", "plan_name": "500292", "standard_charge_dollar": 205.69, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "United Healthcare", "plan_name": "750104", "standard_charge_dollar": 205.69, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "United Healthcare Ba", "plan_name": "750090", "standard_charge_dollar": 205.69, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "United Healthcare Me", "plan_name": "501310", "standard_charge_dollar": 182.02, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Windsor Mcare Extra", "plan_name": "500778", "standard_charge_dollar": 182.02, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." } ] } ] }, { "description": "Trim skin lesions over 4", "code_information": [ { "code": "11057", "type": "CPT" } ], "standard_charges": [ { "gross_charge": 350.00, "minimum": 182.02, "maximum": 297.50, "setting": "outpatient", "payers_information": [ { "payer_name": "Aarp", "plan_name": "500102", "standard_charge_dollar": 182.02, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna", "plan_name": "700700", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna", "plan_name": "700700_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Mcare Ffs 6005", "plan_name": "700703", "standard_charge_dollar": 182.02, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Miscellaneous", "plan_name": "700720", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Miscellaneous", "plan_name": "700720_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Ppo Hmo", "plan_name": "701720", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Ppo Hmo", "plan_name": "701720_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Ambetter 68069", "plan_name": "500516", "standard_charge_dollar": 182.02, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Ms State Emplo", "plan_name": "401457", "standard_charge_percentage": 0.80, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Ms State Emplo", "plan_name": "401457_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Basic Pl", "plan_name": "400100", "standard_charge_percentage": 0.85, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Basic Pl", "plan_name": "400100_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Federal", "plan_name": "400110", "standard_charge_percentage": 0.85, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Federal", "plan_name": "400110_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Cigna Healthsprings Ffs", "plan_name": "500064", "standard_charge_dollar": 182.02, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Conseco", "plan_name": "500302", "standard_charge_dollar": 182.02, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Humana Ffs 61101", "plan_name": "500006", "standard_charge_dollar": 182.02, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Medicare A", "plan_name": "100100", "standard_charge_dollar": 182.02, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Medicare A", "plan_name": "100500", "standard_charge_dollar": 182.02, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Medicare Part B Only", "plan_name": "100300", "standard_charge_dollar": 182.02, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Medicare Railroad", "plan_name": "100103", "standard_charge_dollar": 182.02, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Ms Physicians Care N", "plan_name": "714210", "standard_charge_dollar": 227.53, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Peoples Hlth Ffs 72126", "plan_name": "500019", "standard_charge_dollar": 182.02, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Uhc/Secure Horizons", "plan_name": "500449", "standard_charge_dollar": 182.02, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "United Health Care/", "plan_name": "500292", "standard_charge_dollar": 205.69, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "United Healthcare", "plan_name": "750104", "standard_charge_dollar": 205.69, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "United Healthcare Ba", "plan_name": "750090", "standard_charge_dollar": 205.69, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "United Healthcare Me", "plan_name": "501310", "standard_charge_dollar": 182.02, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Windsor Mcare Extra", "plan_name": "500778", "standard_charge_dollar": 182.02, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." } ] } ] }, { "description": "Hc tangential bx skin sing les", "code_information": [ { "code": "11102", "type": "CPT" } ], "standard_charges": [ { "gross_charge": 400.00, "minimum": 182.02, "maximum": 340.00, "setting": "both", "payers_information": [ { "payer_name": "Aarp", "plan_name": "500102", "standard_charge_dollar": 182.02, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna", "plan_name": "700700", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna", "plan_name": "700700_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Mcare Ffs 6005", "plan_name": "700703", "standard_charge_dollar": 182.02, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Miscellaneous", "plan_name": "700720", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Miscellaneous", "plan_name": "700720_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Ppo Hmo", "plan_name": "701720", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Ppo Hmo", "plan_name": "701720_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Ambetter 68069", "plan_name": "500516", "standard_charge_dollar": 182.02, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Ms State Emplo", "plan_name": "401457", "standard_charge_percentage": 0.80, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Ms State Emplo", "plan_name": "401457_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Basic Pl", "plan_name": "400100", "standard_charge_percentage": 0.85, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Basic Pl", "plan_name": "400100_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Federal", "plan_name": "400110", "standard_charge_percentage": 0.85, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Federal", "plan_name": "400110_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Cigna Healthsprings Ffs", "plan_name": "500064", "standard_charge_dollar": 182.02, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Conseco", "plan_name": "500302", "standard_charge_dollar": 182.02, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Humana Ffs 61101", "plan_name": "500006", "standard_charge_dollar": 182.02, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Medicare A", "plan_name": "100100", "standard_charge_dollar": 182.02, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Medicare A", "plan_name": "100500", "standard_charge_dollar": 182.02, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Medicare Part B Only", "plan_name": "100300", "standard_charge_dollar": 182.02, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Medicare Railroad", "plan_name": "100103", "standard_charge_dollar": 182.02, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Ms Physicians Care N", "plan_name": "714210", "standard_charge_dollar": 227.53, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Peoples Hlth Ffs 72126", "plan_name": "500019", "standard_charge_dollar": 182.02, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Uhc/Secure Horizons", "plan_name": "500449", "standard_charge_dollar": 182.02, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "United Health Care/", "plan_name": "500292", "standard_charge_dollar": 205.69, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "United Healthcare", "plan_name": "750104", "standard_charge_dollar": 205.69, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "United Healthcare Ba", "plan_name": "750090", "standard_charge_dollar": 205.69, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "United Healthcare Me", "plan_name": "501310", "standard_charge_dollar": 182.02, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Windsor Mcare Extra", "plan_name": "500778", "standard_charge_dollar": 182.02, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." } ] } ] }, { "description": "Tangntl bx skin single les", "code_information": [ { "code": "11102", "type": "CPT" } ], "standard_charges": [ { "gross_charge": 26061.70, "minimum": 182.02, "maximum": 22152.45, "setting": "inpatient", "payers_information": [ { "payer_name": "Aarp", "plan_name": "500102", "standard_charge_dollar": 182.02, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna", "plan_name": "700700", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna", "plan_name": "700700_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Mcare Ffs 6005", "plan_name": "700703", "standard_charge_dollar": 182.02, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Miscellaneous", "plan_name": "700720", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Miscellaneous", "plan_name": "700720_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Ppo Hmo", "plan_name": "701720", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Ppo Hmo", "plan_name": "701720_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Ambetter 68069", "plan_name": "500516", "standard_charge_dollar": 182.02, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Ms State Emplo", "plan_name": "401457", "standard_charge_percentage": 0.80, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Ms State Emplo", "plan_name": "401457_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Basic Pl", "plan_name": "400100", "standard_charge_percentage": 0.85, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Basic Pl", "plan_name": "400100_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Federal", "plan_name": "400110", "standard_charge_percentage": 0.85, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Federal", "plan_name": "400110_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Cigna Healthsprings Ffs", "plan_name": "500064", "standard_charge_dollar": 182.02, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Conseco", "plan_name": "500302", "standard_charge_dollar": 182.02, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Humana Ffs 61101", "plan_name": "500006", "standard_charge_dollar": 182.02, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Medicare A", "plan_name": "100100", "standard_charge_dollar": 182.02, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Medicare A", "plan_name": "100500", "standard_charge_dollar": 182.02, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Medicare Part B Only", "plan_name": "100300", "standard_charge_dollar": 182.02, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Medicare Railroad", "plan_name": "100103", "standard_charge_dollar": 182.02, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Ms Physicians Care N", "plan_name": "714210", "standard_charge_dollar": 227.53, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Peoples Hlth Ffs 72126", "plan_name": "500019", "standard_charge_dollar": 182.02, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Uhc/Secure Horizons", "plan_name": "500449", "standard_charge_dollar": 182.02, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "United Health Care/", "plan_name": "500292", "standard_charge_dollar": 205.69, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "United Healthcare", "plan_name": "750104", "standard_charge_dollar": 205.69, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "United Healthcare Ba", "plan_name": "750090", "standard_charge_dollar": 205.69, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "United Healthcare Me", "plan_name": "501310", "standard_charge_dollar": 182.02, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Windsor Mcare Extra", "plan_name": "500778", "standard_charge_dollar": 182.02, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." } ] } ] }, { "description": "Tangntl bx skin single les", "code_information": [ { "code": "11102", "type": "CPT" } ], "standard_charges": [ { "gross_charge": 400.00, "minimum": 182.02, "maximum": 340.00, "setting": "outpatient", "payers_information": [ { "payer_name": "Aarp", "plan_name": "500102", "standard_charge_dollar": 182.02, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna", "plan_name": "700700", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna", "plan_name": "700700_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Mcare Ffs 6005", "plan_name": "700703", "standard_charge_dollar": 182.02, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Miscellaneous", "plan_name": "700720", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Miscellaneous", "plan_name": "700720_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Ppo Hmo", "plan_name": "701720", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Ppo Hmo", "plan_name": "701720_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Ambetter 68069", "plan_name": "500516", "standard_charge_dollar": 182.02, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Ms State Emplo", "plan_name": "401457", "standard_charge_percentage": 0.80, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Ms State Emplo", "plan_name": "401457_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Basic Pl", "plan_name": "400100", "standard_charge_percentage": 0.85, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Basic Pl", "plan_name": "400100_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Federal", "plan_name": "400110", "standard_charge_percentage": 0.85, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Federal", "plan_name": "400110_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Cigna Healthsprings Ffs", "plan_name": "500064", "standard_charge_dollar": 182.02, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Conseco", "plan_name": "500302", "standard_charge_dollar": 182.02, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Humana Ffs 61101", "plan_name": "500006", "standard_charge_dollar": 182.02, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Medicare A", "plan_name": "100100", "standard_charge_dollar": 182.02, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Medicare A", "plan_name": "100500", "standard_charge_dollar": 182.02, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Medicare Part B Only", "plan_name": "100300", "standard_charge_dollar": 182.02, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Medicare Railroad", "plan_name": "100103", "standard_charge_dollar": 182.02, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Ms Physicians Care N", "plan_name": "714210", "standard_charge_dollar": 227.53, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Peoples Hlth Ffs 72126", "plan_name": "500019", "standard_charge_dollar": 182.02, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Uhc/Secure Horizons", "plan_name": "500449", "standard_charge_dollar": 182.02, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "United Health Care/", "plan_name": "500292", "standard_charge_dollar": 205.69, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "United Healthcare", "plan_name": "750104", "standard_charge_dollar": 205.69, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "United Healthcare Ba", "plan_name": "750090", "standard_charge_dollar": 205.69, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "United Healthcare Me", "plan_name": "501310", "standard_charge_dollar": 182.02, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Windsor Mcare Extra", "plan_name": "500778", "standard_charge_dollar": 182.02, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." } ] } ] }, { "description": "Hc tangential bx skin ea addl les", "code_information": [ { "code": "11103", "type": "CPT" } ], "standard_charges": [ { "gross_charge": 400.00, "minimum": 320.00, "maximum": 340.00, "setting": "both", "payers_information": [ { "payer_name": "Aetna", "plan_name": "700700", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna", "plan_name": "700700_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Miscellaneous", "plan_name": "700720", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Miscellaneous", "plan_name": "700720_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Ppo Hmo", "plan_name": "701720", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Ppo Hmo", "plan_name": "701720_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Ms State Emplo", "plan_name": "401457", "standard_charge_percentage": 0.80, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Ms State Emplo", "plan_name": "401457_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Basic Pl", "plan_name": "400100", "standard_charge_percentage": 0.85, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Basic Pl", "plan_name": "400100_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Federal", "plan_name": "400110", "standard_charge_percentage": 0.85, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Federal", "plan_name": "400110_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." } ] } ] }, { "description": "Tangntl bx skin ea sep/addl", "code_information": [ { "code": "11103", "type": "CPT" } ], "standard_charges": [ { "gross_charge": 26061.70, "minimum": 20849.36, "maximum": 22152.45, "setting": "inpatient", "payers_information": [ { "payer_name": "Aetna", "plan_name": "700700", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna", "plan_name": "700700_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Miscellaneous", "plan_name": "700720", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Miscellaneous", "plan_name": "700720_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Ppo Hmo", "plan_name": "701720", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Ppo Hmo", "plan_name": "701720_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Ms State Emplo", "plan_name": "401457", "standard_charge_percentage": 0.80, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Ms State Emplo", "plan_name": "401457_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Basic Pl", "plan_name": "400100", "standard_charge_percentage": 0.85, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Basic Pl", "plan_name": "400100_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Federal", "plan_name": "400110", "standard_charge_percentage": 0.85, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Federal", "plan_name": "400110_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." } ] } ] }, { "description": "Tangntl bx skin ea sep/addl", "code_information": [ { "code": "11103", "type": "CPT" } ], "standard_charges": [ { "gross_charge": 400.00, "minimum": 320.00, "maximum": 340.00, "setting": "outpatient", "payers_information": [ { "payer_name": "Aetna", "plan_name": "700700", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna", "plan_name": "700700_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Miscellaneous", "plan_name": "700720", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Miscellaneous", "plan_name": "700720_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Ppo Hmo", "plan_name": "701720", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Ppo Hmo", "plan_name": "701720_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Ms State Emplo", "plan_name": "401457", "standard_charge_percentage": 0.80, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Ms State Emplo", "plan_name": "401457_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Basic Pl", "plan_name": "400100", "standard_charge_percentage": 0.85, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Basic Pl", "plan_name": "400100_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Federal", "plan_name": "400110", "standard_charge_percentage": 0.85, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Federal", "plan_name": "400110_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." } ] } ] }, { "description": "Hc punch bx skin sing les", "code_information": [ { "code": "11104", "type": "CPT" } ], "standard_charges": [ { "gross_charge": 400.00, "minimum": 320.00, "maximum": 457.50, "setting": "both", "payers_information": [ { "payer_name": "Aarp", "plan_name": "500102", "standard_charge_dollar": 366.00, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna", "plan_name": "700700", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna", "plan_name": "700700_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Mcare Ffs 6005", "plan_name": "700703", "standard_charge_dollar": 366.00, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Miscellaneous", "plan_name": "700720", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Miscellaneous", "plan_name": "700720_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Ppo Hmo", "plan_name": "701720", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Ppo Hmo", "plan_name": "701720_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Ambetter 68069", "plan_name": "500516", "standard_charge_dollar": 366.00, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Ms State Emplo", "plan_name": "401457", "standard_charge_percentage": 0.80, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Ms State Emplo", "plan_name": "401457_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Basic Pl", "plan_name": "400100", "standard_charge_percentage": 0.85, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Basic Pl", "plan_name": "400100_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Federal", "plan_name": "400110", "standard_charge_percentage": 0.85, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Federal", "plan_name": "400110_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Cigna Healthsprings Ffs", "plan_name": "500064", "standard_charge_dollar": 366.00, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Conseco", "plan_name": "500302", "standard_charge_dollar": 366.00, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Humana Ffs 61101", "plan_name": "500006", "standard_charge_dollar": 366.00, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Medicare A", "plan_name": "100100", "standard_charge_dollar": 366.00, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Medicare A", "plan_name": "100500", "standard_charge_dollar": 366.00, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Medicare Part B Only", "plan_name": "100300", "standard_charge_dollar": 366.00, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Medicare Railroad", "plan_name": "100103", "standard_charge_dollar": 366.00, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Ms Physicians Care N", "plan_name": "714210", "standard_charge_dollar": 457.50, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Peoples Hlth Ffs 72126", "plan_name": "500019", "standard_charge_dollar": 366.00, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Uhc/Secure Horizons", "plan_name": "500449", "standard_charge_dollar": 366.00, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "United Health Care/", "plan_name": "500292", "standard_charge_dollar": 413.58, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "United Healthcare", "plan_name": "750104", "standard_charge_dollar": 413.58, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "United Healthcare Ba", "plan_name": "750090", "standard_charge_dollar": 413.58, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "United Healthcare Me", "plan_name": "501310", "standard_charge_dollar": 366.00, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Windsor Mcare Extra", "plan_name": "500778", "standard_charge_dollar": 366.00, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." } ] } ] }, { "description": "Punch bx skin single lesion", "code_information": [ { "code": "11104", "type": "CPT" } ], "standard_charges": [ { "gross_charge": 26061.70, "minimum": 366.00, "maximum": 22152.45, "setting": "inpatient", "payers_information": [ { "payer_name": "Aarp", "plan_name": "500102", "standard_charge_dollar": 366.00, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna", "plan_name": "700700", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna", "plan_name": "700700_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Mcare Ffs 6005", "plan_name": "700703", "standard_charge_dollar": 366.00, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Miscellaneous", "plan_name": "700720", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Miscellaneous", "plan_name": "700720_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Ppo Hmo", "plan_name": "701720", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Ppo Hmo", "plan_name": "701720_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Ambetter 68069", "plan_name": "500516", "standard_charge_dollar": 366.00, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Ms State Emplo", "plan_name": "401457", "standard_charge_percentage": 0.80, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Ms State Emplo", "plan_name": "401457_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Basic Pl", "plan_name": "400100", "standard_charge_percentage": 0.85, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Basic Pl", "plan_name": "400100_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Federal", "plan_name": "400110", "standard_charge_percentage": 0.85, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Federal", "plan_name": "400110_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Cigna Healthsprings Ffs", "plan_name": "500064", "standard_charge_dollar": 366.00, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Conseco", "plan_name": "500302", "standard_charge_dollar": 366.00, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Humana Ffs 61101", "plan_name": "500006", "standard_charge_dollar": 366.00, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Medicare A", "plan_name": "100100", "standard_charge_dollar": 366.00, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Medicare A", "plan_name": "100500", "standard_charge_dollar": 366.00, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Medicare Part B Only", "plan_name": "100300", "standard_charge_dollar": 366.00, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Medicare Railroad", "plan_name": "100103", "standard_charge_dollar": 366.00, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Ms Physicians Care N", "plan_name": "714210", "standard_charge_dollar": 457.50, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Peoples Hlth Ffs 72126", "plan_name": "500019", "standard_charge_dollar": 366.00, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Uhc/Secure Horizons", "plan_name": "500449", "standard_charge_dollar": 366.00, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "United Health Care/", "plan_name": "500292", "standard_charge_dollar": 413.58, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "United Healthcare", "plan_name": "750104", "standard_charge_dollar": 413.58, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "United Healthcare Ba", "plan_name": "750090", "standard_charge_dollar": 413.58, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "United Healthcare Me", "plan_name": "501310", "standard_charge_dollar": 366.00, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Windsor Mcare Extra", "plan_name": "500778", "standard_charge_dollar": 366.00, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." } ] } ] }, { "description": "Punch bx skin single lesion", "code_information": [ { "code": "11104", "type": "CPT" } ], "standard_charges": [ { "gross_charge": 400.00, "minimum": 320.00, "maximum": 457.50, "setting": "outpatient", "payers_information": [ { "payer_name": "Aarp", "plan_name": "500102", "standard_charge_dollar": 366.00, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna", "plan_name": "700700", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna", "plan_name": "700700_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Mcare Ffs 6005", "plan_name": "700703", "standard_charge_dollar": 366.00, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Miscellaneous", "plan_name": "700720", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Miscellaneous", "plan_name": "700720_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Ppo Hmo", "plan_name": "701720", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Ppo Hmo", "plan_name": "701720_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Ambetter 68069", "plan_name": "500516", "standard_charge_dollar": 366.00, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Ms State Emplo", "plan_name": "401457", "standard_charge_percentage": 0.80, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Ms State Emplo", "plan_name": "401457_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Basic Pl", "plan_name": "400100", "standard_charge_percentage": 0.85, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Basic Pl", "plan_name": "400100_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Federal", "plan_name": "400110", "standard_charge_percentage": 0.85, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Federal", "plan_name": "400110_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Cigna Healthsprings Ffs", "plan_name": "500064", "standard_charge_dollar": 366.00, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Conseco", "plan_name": "500302", "standard_charge_dollar": 366.00, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Humana Ffs 61101", "plan_name": "500006", "standard_charge_dollar": 366.00, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Medicare A", "plan_name": "100100", "standard_charge_dollar": 366.00, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Medicare A", "plan_name": "100500", "standard_charge_dollar": 366.00, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Medicare Part B Only", "plan_name": "100300", "standard_charge_dollar": 366.00, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Medicare Railroad", "plan_name": "100103", "standard_charge_dollar": 366.00, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Ms Physicians Care N", "plan_name": "714210", "standard_charge_dollar": 457.50, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Peoples Hlth Ffs 72126", "plan_name": "500019", "standard_charge_dollar": 366.00, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Uhc/Secure Horizons", "plan_name": "500449", "standard_charge_dollar": 366.00, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "United Health Care/", "plan_name": "500292", "standard_charge_dollar": 413.58, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "United Healthcare", "plan_name": "750104", "standard_charge_dollar": 413.58, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "United Healthcare Ba", "plan_name": "750090", "standard_charge_dollar": 413.58, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "United Healthcare Me", "plan_name": "501310", "standard_charge_dollar": 366.00, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Windsor Mcare Extra", "plan_name": "500778", "standard_charge_dollar": 366.00, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." } ] } ] }, { "description": "Hc punch bx skin ea sep/addl les", "code_information": [ { "code": "11105", "type": "CPT" } ], "standard_charges": [ { "gross_charge": 400.00, "minimum": 320.00, "maximum": 340.00, "setting": "both", "payers_information": [ { "payer_name": "Aetna", "plan_name": "700700", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna", "plan_name": "700700_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Miscellaneous", "plan_name": "700720", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Miscellaneous", "plan_name": "700720_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Ppo Hmo", "plan_name": "701720", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Ppo Hmo", "plan_name": "701720_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Ms State Emplo", "plan_name": "401457", "standard_charge_percentage": 0.80, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Ms State Emplo", "plan_name": "401457_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Basic Pl", "plan_name": "400100", "standard_charge_percentage": 0.85, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Basic Pl", "plan_name": "400100_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Federal", "plan_name": "400110", "standard_charge_percentage": 0.85, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Federal", "plan_name": "400110_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." } ] } ] }, { "description": "Punch bx skin ea sep/addl", "code_information": [ { "code": "11105", "type": "CPT" } ], "standard_charges": [ { "gross_charge": 26061.70, "minimum": 20849.36, "maximum": 22152.45, "setting": "inpatient", "payers_information": [ { "payer_name": "Aetna", "plan_name": "700700", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna", "plan_name": "700700_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Miscellaneous", "plan_name": "700720", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Miscellaneous", "plan_name": "700720_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Ppo Hmo", "plan_name": "701720", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Ppo Hmo", "plan_name": "701720_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Ms State Emplo", "plan_name": "401457", "standard_charge_percentage": 0.80, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Ms State Emplo", "plan_name": "401457_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Basic Pl", "plan_name": "400100", "standard_charge_percentage": 0.85, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Basic Pl", "plan_name": "400100_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Federal", "plan_name": "400110", "standard_charge_percentage": 0.85, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Federal", "plan_name": "400110_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." } ] } ] }, { "description": "Punch bx skin ea sep/addl", "code_information": [ { "code": "11105", "type": "CPT" } ], "standard_charges": [ { "gross_charge": 400.00, "minimum": 320.00, "maximum": 340.00, "setting": "outpatient", "payers_information": [ { "payer_name": "Aetna", "plan_name": "700700", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna", "plan_name": "700700_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Miscellaneous", "plan_name": "700720", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Miscellaneous", "plan_name": "700720_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Ppo Hmo", "plan_name": "701720", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Ppo Hmo", "plan_name": "701720_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Ms State Emplo", "plan_name": "401457", "standard_charge_percentage": 0.80, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Ms State Emplo", "plan_name": "401457_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Basic Pl", "plan_name": "400100", "standard_charge_percentage": 0.85, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Basic Pl", "plan_name": "400100_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Federal", "plan_name": "400110", "standard_charge_percentage": 0.85, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Federal", "plan_name": "400110_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." } ] } ] }, { "description": "Hc incisional bx skin sing les", "code_information": [ { "code": "11106", "type": "CPT" } ], "standard_charges": [ { "gross_charge": 400.00, "minimum": 320.00, "maximum": 700.94, "setting": "both", "payers_information": [ { "payer_name": "Aarp", "plan_name": "500102", "standard_charge_dollar": 560.75, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna", "plan_name": "700700", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna", "plan_name": "700700_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Mcare Ffs 6005", "plan_name": "700703", "standard_charge_dollar": 560.75, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Miscellaneous", "plan_name": "700720", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Miscellaneous", "plan_name": "700720_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Ppo Hmo", "plan_name": "701720", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Ppo Hmo", "plan_name": "701720_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Ambetter 68069", "plan_name": "500516", "standard_charge_dollar": 560.75, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Ms State Emplo", "plan_name": "401457", "standard_charge_percentage": 0.80, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Ms State Emplo", "plan_name": "401457_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Basic Pl", "plan_name": "400100", "standard_charge_percentage": 0.85, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Basic Pl", "plan_name": "400100_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Federal", "plan_name": "400110", "standard_charge_percentage": 0.85, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Federal", "plan_name": "400110_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Cigna Healthsprings Ffs", "plan_name": "500064", "standard_charge_dollar": 560.75, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Conseco", "plan_name": "500302", "standard_charge_dollar": 560.75, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Humana Ffs 61101", "plan_name": "500006", "standard_charge_dollar": 560.75, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Medicare A", "plan_name": "100100", "standard_charge_dollar": 560.75, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Medicare A", "plan_name": "100500", "standard_charge_dollar": 560.75, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Medicare Part B Only", "plan_name": "100300", "standard_charge_dollar": 560.75, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Medicare Railroad", "plan_name": "100103", "standard_charge_dollar": 560.75, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Ms Physicians Care N", "plan_name": "714210", "standard_charge_dollar": 700.94, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Peoples Hlth Ffs 72126", "plan_name": "500019", "standard_charge_dollar": 560.75, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Uhc/Secure Horizons", "plan_name": "500449", "standard_charge_dollar": 560.75, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "United Health Care/", "plan_name": "500292", "standard_charge_dollar": 633.65, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "United Healthcare", "plan_name": "750104", "standard_charge_dollar": 633.65, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "United Healthcare Ba", "plan_name": "750090", "standard_charge_dollar": 633.65, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "United Healthcare Me", "plan_name": "501310", "standard_charge_dollar": 560.75, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Windsor Mcare Extra", "plan_name": "500778", "standard_charge_dollar": 560.75, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." } ] } ] }, { "description": "Incal bx skn single les", "code_information": [ { "code": "11106", "type": "CPT" } ], "standard_charges": [ { "gross_charge": 26061.70, "minimum": 560.75, "maximum": 22152.45, "setting": "inpatient", "payers_information": [ { "payer_name": "Aarp", "plan_name": "500102", "standard_charge_dollar": 560.75, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna", "plan_name": "700700", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna", "plan_name": "700700_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Mcare Ffs 6005", "plan_name": "700703", "standard_charge_dollar": 560.75, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Miscellaneous", "plan_name": "700720", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Miscellaneous", "plan_name": "700720_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Ppo Hmo", "plan_name": "701720", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Ppo Hmo", "plan_name": "701720_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Ambetter 68069", "plan_name": "500516", "standard_charge_dollar": 560.75, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Ms State Emplo", "plan_name": "401457", "standard_charge_percentage": 0.80, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Ms State Emplo", "plan_name": "401457_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Basic Pl", "plan_name": "400100", "standard_charge_percentage": 0.85, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Basic Pl", "plan_name": "400100_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Federal", "plan_name": "400110", "standard_charge_percentage": 0.85, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Federal", "plan_name": "400110_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Cigna Healthsprings Ffs", "plan_name": "500064", "standard_charge_dollar": 560.75, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Conseco", "plan_name": "500302", "standard_charge_dollar": 560.75, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Humana Ffs 61101", "plan_name": "500006", "standard_charge_dollar": 560.75, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Medicare A", "plan_name": "100100", "standard_charge_dollar": 560.75, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Medicare A", "plan_name": "100500", "standard_charge_dollar": 560.75, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Medicare Part B Only", "plan_name": "100300", "standard_charge_dollar": 560.75, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Medicare Railroad", "plan_name": "100103", "standard_charge_dollar": 560.75, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Ms Physicians Care N", "plan_name": "714210", "standard_charge_dollar": 700.94, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Peoples Hlth Ffs 72126", "plan_name": "500019", "standard_charge_dollar": 560.75, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Uhc/Secure Horizons", "plan_name": "500449", "standard_charge_dollar": 560.75, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "United Health Care/", "plan_name": "500292", "standard_charge_dollar": 633.65, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "United Healthcare", "plan_name": "750104", "standard_charge_dollar": 633.65, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "United Healthcare Ba", "plan_name": "750090", "standard_charge_dollar": 633.65, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "United Healthcare Me", "plan_name": "501310", "standard_charge_dollar": 560.75, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Windsor Mcare Extra", "plan_name": "500778", "standard_charge_dollar": 560.75, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." } ] } ] }, { "description": "Incal bx skn single les", "code_information": [ { "code": "11106", "type": "CPT" } ], "standard_charges": [ { "gross_charge": 400.00, "minimum": 320.00, "maximum": 700.94, "setting": "outpatient", "payers_information": [ { "payer_name": "Aarp", "plan_name": "500102", "standard_charge_dollar": 560.75, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna", "plan_name": "700700", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna", "plan_name": "700700_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Mcare Ffs 6005", "plan_name": "700703", "standard_charge_dollar": 560.75, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Miscellaneous", "plan_name": "700720", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Miscellaneous", "plan_name": "700720_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Ppo Hmo", "plan_name": "701720", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Ppo Hmo", "plan_name": "701720_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Ambetter 68069", "plan_name": "500516", "standard_charge_dollar": 560.75, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Ms State Emplo", "plan_name": "401457", "standard_charge_percentage": 0.80, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Ms State Emplo", "plan_name": "401457_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Basic Pl", "plan_name": "400100", "standard_charge_percentage": 0.85, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Basic Pl", "plan_name": "400100_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Federal", "plan_name": "400110", "standard_charge_percentage": 0.85, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Federal", "plan_name": "400110_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Cigna Healthsprings Ffs", "plan_name": "500064", "standard_charge_dollar": 560.75, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Conseco", "plan_name": "500302", "standard_charge_dollar": 560.75, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Humana Ffs 61101", "plan_name": "500006", "standard_charge_dollar": 560.75, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Medicare A", "plan_name": "100100", "standard_charge_dollar": 560.75, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Medicare A", "plan_name": "100500", "standard_charge_dollar": 560.75, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Medicare Part B Only", "plan_name": "100300", "standard_charge_dollar": 560.75, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Medicare Railroad", "plan_name": "100103", "standard_charge_dollar": 560.75, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Ms Physicians Care N", "plan_name": "714210", "standard_charge_dollar": 700.94, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Peoples Hlth Ffs 72126", "plan_name": "500019", "standard_charge_dollar": 560.75, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Uhc/Secure Horizons", "plan_name": "500449", "standard_charge_dollar": 560.75, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "United Health Care/", "plan_name": "500292", "standard_charge_dollar": 633.65, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "United Healthcare", "plan_name": "750104", "standard_charge_dollar": 633.65, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "United Healthcare Ba", "plan_name": "750090", "standard_charge_dollar": 633.65, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "United Healthcare Me", "plan_name": "501310", "standard_charge_dollar": 560.75, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Windsor Mcare Extra", "plan_name": "500778", "standard_charge_dollar": 560.75, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." } ] } ] }, { "description": "Hc incisional bx skin ea sep/addl les", "code_information": [ { "code": "11107", "type": "CPT" } ], "standard_charges": [ { "gross_charge": 400.00, "minimum": 320.00, "maximum": 340.00, "setting": "both", "payers_information": [ { "payer_name": "Aetna", "plan_name": "700700", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna", "plan_name": "700700_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Miscellaneous", "plan_name": "700720", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Miscellaneous", "plan_name": "700720_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Ppo Hmo", "plan_name": "701720", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Ppo Hmo", "plan_name": "701720_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Ms State Emplo", "plan_name": "401457", "standard_charge_percentage": 0.80, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Ms State Emplo", "plan_name": "401457_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Basic Pl", "plan_name": "400100", "standard_charge_percentage": 0.85, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Basic Pl", "plan_name": "400100_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Federal", "plan_name": "400110", "standard_charge_percentage": 0.85, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Federal", "plan_name": "400110_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." } ] } ] }, { "description": "Incal bx skn ea sep/addl", "code_information": [ { "code": "11107", "type": "CPT" } ], "standard_charges": [ { "gross_charge": 26061.70, "minimum": 20849.36, "maximum": 22152.45, "setting": "inpatient", "payers_information": [ { "payer_name": "Aetna", "plan_name": "700700", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna", "plan_name": "700700_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Miscellaneous", "plan_name": "700720", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Miscellaneous", "plan_name": "700720_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Ppo Hmo", "plan_name": "701720", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Ppo Hmo", "plan_name": "701720_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Ms State Emplo", "plan_name": "401457", "standard_charge_percentage": 0.80, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Ms State Emplo", "plan_name": "401457_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Basic Pl", "plan_name": "400100", "standard_charge_percentage": 0.85, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Basic Pl", "plan_name": "400100_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Federal", "plan_name": "400110", "standard_charge_percentage": 0.85, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Federal", "plan_name": "400110_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." } ] } ] }, { "description": "Incal bx skn ea sep/addl", "code_information": [ { "code": "11107", "type": "CPT" } ], "standard_charges": [ { "gross_charge": 400.00, "minimum": 320.00, "maximum": 340.00, "setting": "outpatient", "payers_information": [ { "payer_name": "Aetna", "plan_name": "700700", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna", "plan_name": "700700_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Miscellaneous", "plan_name": "700720", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Miscellaneous", "plan_name": "700720_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Ppo Hmo", "plan_name": "701720", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Ppo Hmo", "plan_name": "701720_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Ms State Emplo", "plan_name": "401457", "standard_charge_percentage": 0.80, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Ms State Emplo", "plan_name": "401457_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Basic Pl", "plan_name": "400100", "standard_charge_percentage": 0.85, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Basic Pl", "plan_name": "400100_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Federal", "plan_name": "400110", "standard_charge_percentage": 0.85, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Federal", "plan_name": "400110_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." } ] } ] }, { "description": "Removal of skin tags 2.0 cm", "code_information": [ { "code": "11303", "type": "CPT" } ], "standard_charges": [ { "gross_charge": 21836.76, "minimum": 366.00, "maximum": 457.50, "setting": "inpatient", "payers_information": [ { "payer_name": "Aarp", "plan_name": "500102", "standard_charge_dollar": 366.00, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna", "plan_name": "700700", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna", "plan_name": "700700_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Mcare Ffs 6005", "plan_name": "700703", "standard_charge_dollar": 366.00, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Miscellaneous", "plan_name": "700720", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Miscellaneous", "plan_name": "700720_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Ppo Hmo", "plan_name": "701720", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Ppo Hmo", "plan_name": "701720_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Ambetter 68069", "plan_name": "500516", "standard_charge_dollar": 366.00, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Ms State Emplo", "plan_name": "401457", "standard_charge_dollar": 438.74, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Ms State Emplo", "plan_name": "401457_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Basic Pl", "plan_name": "400100", "standard_charge_dollar": 438.74, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Basic Pl", "plan_name": "400100_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Federal", "plan_name": "400110", "standard_charge_dollar": 438.74, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Federal", "plan_name": "400110_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Cigna Healthsprings Ffs", "plan_name": "500064", "standard_charge_dollar": 366.00, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Conseco", "plan_name": "500302", "standard_charge_dollar": 366.00, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Humana Ffs 61101", "plan_name": "500006", "standard_charge_dollar": 366.00, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Medicare A", "plan_name": "100100", "standard_charge_dollar": 366.00, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Medicare A", "plan_name": "100500", "standard_charge_dollar": 366.00, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Medicare Part B Only", "plan_name": "100300", "standard_charge_dollar": 366.00, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Medicare Railroad", "plan_name": "100103", "standard_charge_dollar": 366.00, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Ms Physicians Care N", "plan_name": "714210", "standard_charge_dollar": 457.50, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Peoples Hlth Ffs 72126", "plan_name": "500019", "standard_charge_dollar": 366.00, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Uhc/Secure Horizons", "plan_name": "500449", "standard_charge_dollar": 366.00, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "United Health Care/", "plan_name": "500292", "standard_charge_dollar": 413.58, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "United Healthcare", "plan_name": "750104", "standard_charge_dollar": 413.58, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "United Healthcare Ba", "plan_name": "750090", "standard_charge_dollar": 413.58, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "United Healthcare Me", "plan_name": "501310", "standard_charge_dollar": 366.00, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Windsor Mcare Extra", "plan_name": "500778", "standard_charge_dollar": 366.00, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." } ] } ] }, { "description": "Shave skin lesion 0.5 cm/<", "code_information": [ { "code": "11305", "type": "CPT" } ], "standard_charges": [ { "gross_charge": 28884.87, "minimum": 182.02, "maximum": 229.58, "setting": "inpatient", "payers_information": [ { "payer_name": "Aarp", "plan_name": "500102", "standard_charge_dollar": 182.02, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna", "plan_name": "700700", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna", "plan_name": "700700_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Mcare Ffs 6005", "plan_name": "700703", "standard_charge_dollar": 182.02, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Miscellaneous", "plan_name": "700720", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Miscellaneous", "plan_name": "700720_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Ppo Hmo", "plan_name": "701720", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Ppo Hmo", "plan_name": "701720_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Ambetter 68069", "plan_name": "500516", "standard_charge_dollar": 182.02, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Ms State Emplo", "plan_name": "401457", "standard_charge_dollar": 229.58, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Ms State Emplo", "plan_name": "401457_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Basic Pl", "plan_name": "400100", "standard_charge_dollar": 229.58, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Basic Pl", "plan_name": "400100_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Federal", "plan_name": "400110", "standard_charge_dollar": 229.58, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Federal", "plan_name": "400110_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Cigna Healthsprings Ffs", "plan_name": "500064", "standard_charge_dollar": 182.02, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Conseco", "plan_name": "500302", "standard_charge_dollar": 182.02, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Humana Ffs 61101", "plan_name": "500006", "standard_charge_dollar": 182.02, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Medicare A", "plan_name": "100100", "standard_charge_dollar": 182.02, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Medicare A", "plan_name": "100500", "standard_charge_dollar": 182.02, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Medicare Part B Only", "plan_name": "100300", "standard_charge_dollar": 182.02, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Medicare Railroad", "plan_name": "100103", "standard_charge_dollar": 182.02, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Ms Physicians Care N", "plan_name": "714210", "standard_charge_dollar": 227.53, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Peoples Hlth Ffs 72126", "plan_name": "500019", "standard_charge_dollar": 182.02, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Uhc/Secure Horizons", "plan_name": "500449", "standard_charge_dollar": 182.02, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "United Health Care/", "plan_name": "500292", "standard_charge_dollar": 205.69, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "United Healthcare", "plan_name": "750104", "standard_charge_dollar": 205.69, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "United Healthcare Ba", "plan_name": "750090", "standard_charge_dollar": 205.69, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "United Healthcare Me", "plan_name": "501310", "standard_charge_dollar": 182.02, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Windsor Mcare Extra", "plan_name": "500778", "standard_charge_dollar": 182.02, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." } ] } ] }, { "description": "Shave skin lesion 0.6-1.0 cm", "code_information": [ { "code": "11306", "type": "CPT" } ], "standard_charges": [ { "gross_charge": 28884.87, "minimum": 182.02, "maximum": 229.58, "setting": "inpatient", "payers_information": [ { "payer_name": "Aarp", "plan_name": "500102", "standard_charge_dollar": 182.02, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna", "plan_name": "700700", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna", "plan_name": "700700_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Mcare Ffs 6005", "plan_name": "700703", "standard_charge_dollar": 182.02, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Miscellaneous", "plan_name": "700720", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Miscellaneous", "plan_name": "700720_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Ppo Hmo", "plan_name": "701720", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Ppo Hmo", "plan_name": "701720_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Ambetter 68069", "plan_name": "500516", "standard_charge_dollar": 182.02, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Ms State Emplo", "plan_name": "401457", "standard_charge_dollar": 229.58, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Ms State Emplo", "plan_name": "401457_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Basic Pl", "plan_name": "400100", "standard_charge_dollar": 229.58, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Basic Pl", "plan_name": "400100_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Federal", "plan_name": "400110", "standard_charge_dollar": 229.58, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Federal", "plan_name": "400110_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Cigna Healthsprings Ffs", "plan_name": "500064", "standard_charge_dollar": 182.02, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Conseco", "plan_name": "500302", "standard_charge_dollar": 182.02, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Humana Ffs 61101", "plan_name": "500006", "standard_charge_dollar": 182.02, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Medicare A", "plan_name": "100100", "standard_charge_dollar": 182.02, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Medicare A", "plan_name": "100500", "standard_charge_dollar": 182.02, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Medicare Part B Only", "plan_name": "100300", "standard_charge_dollar": 182.02, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Medicare Railroad", "plan_name": "100103", "standard_charge_dollar": 182.02, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Ms Physicians Care N", "plan_name": "714210", "standard_charge_dollar": 227.53, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Peoples Hlth Ffs 72126", "plan_name": "500019", "standard_charge_dollar": 182.02, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Uhc/Secure Horizons", "plan_name": "500449", "standard_charge_dollar": 182.02, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "United Health Care/", "plan_name": "500292", "standard_charge_dollar": 205.69, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "United Healthcare", "plan_name": "750104", "standard_charge_dollar": 205.69, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "United Healthcare Ba", "plan_name": "750090", "standard_charge_dollar": 205.69, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "United Healthcare Me", "plan_name": "501310", "standard_charge_dollar": 182.02, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Windsor Mcare Extra", "plan_name": "500778", "standard_charge_dollar": 182.02, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." } ] } ] }, { "description": "Shave skin lesion 1.1-2.0 cm", "code_information": [ { "code": "11307", "type": "CPT" } ], "standard_charges": [ { "gross_charge": 28884.87, "minimum": 182.02, "maximum": 24552.14, "setting": "inpatient", "payers_information": [ { "payer_name": "Aarp", "plan_name": "500102", "standard_charge_dollar": 182.02, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna", "plan_name": "700700", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna", "plan_name": "700700_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Mcare Ffs 6005", "plan_name": "700703", "standard_charge_dollar": 182.02, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Miscellaneous", "plan_name": "700720", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Miscellaneous", "plan_name": "700720_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Ppo Hmo", "plan_name": "701720", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Ppo Hmo", "plan_name": "701720_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Ambetter 68069", "plan_name": "500516", "standard_charge_dollar": 182.02, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Ms State Emplo", "plan_name": "401457", "standard_charge_percentage": 0.80, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Ms State Emplo", "plan_name": "401457_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Basic Pl", "plan_name": "400100", "standard_charge_percentage": 0.85, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Basic Pl", "plan_name": "400100_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Federal", "plan_name": "400110", "standard_charge_percentage": 0.85, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Federal", "plan_name": "400110_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Cigna Healthsprings Ffs", "plan_name": "500064", "standard_charge_dollar": 182.02, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Conseco", "plan_name": "500302", "standard_charge_dollar": 182.02, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Humana Ffs 61101", "plan_name": "500006", "standard_charge_dollar": 182.02, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Medicare A", "plan_name": "100100", "standard_charge_dollar": 182.02, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Medicare A", "plan_name": "100500", "standard_charge_dollar": 182.02, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Medicare Part B Only", "plan_name": "100300", "standard_charge_dollar": 182.02, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Medicare Railroad", "plan_name": "100103", "standard_charge_dollar": 182.02, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Ms Physicians Care N", "plan_name": "714210", "standard_charge_dollar": 227.53, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Peoples Hlth Ffs 72126", "plan_name": "500019", "standard_charge_dollar": 182.02, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Uhc/Secure Horizons", "plan_name": "500449", "standard_charge_dollar": 182.02, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "United Health Care/", "plan_name": "500292", "standard_charge_dollar": 205.69, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "United Healthcare", "plan_name": "750104", "standard_charge_dollar": 205.69, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "United Healthcare Ba", "plan_name": "750090", "standard_charge_dollar": 205.69, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "United Healthcare Me", "plan_name": "501310", "standard_charge_dollar": 182.02, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Windsor Mcare Extra", "plan_name": "500778", "standard_charge_dollar": 182.02, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." } ] } ] }, { "description": "Shave skin lesion >2.0 cm", "code_information": [ { "code": "11308", "type": "CPT" } ], "standard_charges": [ { "gross_charge": 26535.50, "minimum": 366.00, "maximum": 457.50, "setting": "inpatient", "payers_information": [ { "payer_name": "Aarp", "plan_name": "500102", "standard_charge_dollar": 366.00, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna", "plan_name": "700700", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna", "plan_name": "700700_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Mcare Ffs 6005", "plan_name": "700703", "standard_charge_dollar": 366.00, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Miscellaneous", "plan_name": "700720", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Miscellaneous", "plan_name": "700720_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Ppo Hmo", "plan_name": "701720", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Ppo Hmo", "plan_name": "701720_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Ambetter 68069", "plan_name": "500516", "standard_charge_dollar": 366.00, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Ms State Emplo", "plan_name": "401457", "standard_charge_dollar": 438.74, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Ms State Emplo", "plan_name": "401457_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Basic Pl", "plan_name": "400100", "standard_charge_dollar": 438.74, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Basic Pl", "plan_name": "400100_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Federal", "plan_name": "400110", "standard_charge_dollar": 438.74, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Federal", "plan_name": "400110_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Cigna Healthsprings Ffs", "plan_name": "500064", "standard_charge_dollar": 366.00, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Conseco", "plan_name": "500302", "standard_charge_dollar": 366.00, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Humana Ffs 61101", "plan_name": "500006", "standard_charge_dollar": 366.00, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Medicare A", "plan_name": "100100", "standard_charge_dollar": 366.00, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Medicare A", "plan_name": "100500", "standard_charge_dollar": 366.00, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Medicare Part B Only", "plan_name": "100300", "standard_charge_dollar": 366.00, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Medicare Railroad", "plan_name": "100103", "standard_charge_dollar": 366.00, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Ms Physicians Care N", "plan_name": "714210", "standard_charge_dollar": 457.50, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Peoples Hlth Ffs 72126", "plan_name": "500019", "standard_charge_dollar": 366.00, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Uhc/Secure Horizons", "plan_name": "500449", "standard_charge_dollar": 366.00, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "United Health Care/", "plan_name": "500292", "standard_charge_dollar": 413.58, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "United Healthcare", "plan_name": "750104", "standard_charge_dollar": 413.58, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "United Healthcare Ba", "plan_name": "750090", "standard_charge_dollar": 413.58, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "United Healthcare Me", "plan_name": "501310", "standard_charge_dollar": 366.00, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Windsor Mcare Extra", "plan_name": "500778", "standard_charge_dollar": 366.00, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." } ] } ] }, { "description": "Exc tr-ext b9+marg 0.5 cm<", "code_information": [ { "code": "11400", "type": "CPT" } ], "standard_charges": [ { "gross_charge": 21836.76, "minimum": 644.54, "maximum": 18561.25, "setting": "inpatient", "payers_information": [ { "payer_name": "Aarp", "plan_name": "500102", "standard_charge_dollar": 644.54, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna", "plan_name": "700700", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna", "plan_name": "700700_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Mcare Ffs 6005", "plan_name": "700703", "standard_charge_dollar": 644.54, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Miscellaneous", "plan_name": "700720", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Miscellaneous", "plan_name": "700720_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Ppo Hmo", "plan_name": "701720", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Ppo Hmo", "plan_name": "701720_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Ambetter 68069", "plan_name": "500516", "standard_charge_dollar": 644.54, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Ms State Emplo", "plan_name": "401457", "standard_charge_percentage": 0.80, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Ms State Emplo", "plan_name": "401457_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Basic Pl", "plan_name": "400100", "standard_charge_percentage": 0.85, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Basic Pl", "plan_name": "400100_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Federal", "plan_name": "400110", "standard_charge_percentage": 0.85, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Federal", "plan_name": "400110_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Cigna Healthsprings Ffs", "plan_name": "500064", "standard_charge_dollar": 644.54, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Conseco", "plan_name": "500302", "standard_charge_dollar": 644.54, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Humana Ffs 61101", "plan_name": "500006", "standard_charge_dollar": 644.54, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Medicare A", "plan_name": "100100", "standard_charge_dollar": 644.54, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Medicare A", "plan_name": "100500", "standard_charge_dollar": 644.54, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Medicare Part B Only", "plan_name": "100300", "standard_charge_dollar": 644.54, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Medicare Railroad", "plan_name": "100103", "standard_charge_dollar": 644.54, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Ms Physicians Care N", "plan_name": "714210", "standard_charge_dollar": 805.67, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Peoples Hlth Ffs 72126", "plan_name": "500019", "standard_charge_dollar": 644.54, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Uhc/Secure Horizons", "plan_name": "500449", "standard_charge_dollar": 644.54, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "United Health Care/", "plan_name": "500292", "standard_charge_dollar": 728.33, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "United Healthcare", "plan_name": "750104", "standard_charge_dollar": 728.33, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "United Healthcare Ba", "plan_name": "750090", "standard_charge_dollar": 728.33, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "United Healthcare Me", "plan_name": "501310", "standard_charge_dollar": 644.54, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Windsor Mcare Extra", "plan_name": "500778", "standard_charge_dollar": 644.54, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." } ] } ] }, { "description": "Exc tr-ext b9+marg 0.6-1 cm", "code_information": [ { "code": "11401", "type": "CPT" } ], "standard_charges": [ { "gross_charge": 21836.76, "minimum": 366.00, "maximum": 18561.25, "setting": "inpatient", "payers_information": [ { "payer_name": "Aarp", "plan_name": "500102", "standard_charge_dollar": 366.00, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna", "plan_name": "700700", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna", "plan_name": "700700_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Mcare Ffs 6005", "plan_name": "700703", "standard_charge_dollar": 366.00, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Miscellaneous", "plan_name": "700720", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Miscellaneous", "plan_name": "700720_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Ppo Hmo", "plan_name": "701720", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Ppo Hmo", "plan_name": "701720_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Ambetter 68069", "plan_name": "500516", "standard_charge_dollar": 366.00, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Ms State Emplo", "plan_name": "401457", "standard_charge_percentage": 0.80, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Ms State Emplo", "plan_name": "401457_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Basic Pl", "plan_name": "400100", "standard_charge_percentage": 0.85, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Basic Pl", "plan_name": "400100_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Federal", "plan_name": "400110", "standard_charge_percentage": 0.85, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Federal", "plan_name": "400110_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Cigna Healthsprings Ffs", "plan_name": "500064", "standard_charge_dollar": 366.00, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Conseco", "plan_name": "500302", "standard_charge_dollar": 366.00, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Humana Ffs 61101", "plan_name": "500006", "standard_charge_dollar": 366.00, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Medicare A", "plan_name": "100100", "standard_charge_dollar": 366.00, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Medicare A", "plan_name": "100500", "standard_charge_dollar": 366.00, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Medicare Part B Only", "plan_name": "100300", "standard_charge_dollar": 366.00, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Medicare Railroad", "plan_name": "100103", "standard_charge_dollar": 366.00, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Ms Physicians Care N", "plan_name": "714210", "standard_charge_dollar": 457.50, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Peoples Hlth Ffs 72126", "plan_name": "500019", "standard_charge_dollar": 366.00, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Uhc/Secure Horizons", "plan_name": "500449", "standard_charge_dollar": 366.00, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "United Health Care/", "plan_name": "500292", "standard_charge_dollar": 413.58, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "United Healthcare", "plan_name": "750104", "standard_charge_dollar": 413.58, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "United Healthcare Ba", "plan_name": "750090", "standard_charge_dollar": 413.58, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "United Healthcare Me", "plan_name": "501310", "standard_charge_dollar": 366.00, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Windsor Mcare Extra", "plan_name": "500778", "standard_charge_dollar": 366.00, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." } ] } ] }, { "description": "Exc tr-ext b9+marg 1.1-2 cm", "code_information": [ { "code": "11402", "type": "CPT" } ], "standard_charges": [ { "gross_charge": 36537.79, "minimum": 644.54, "maximum": 31057.12, "setting": "inpatient", "payers_information": [ { "payer_name": "Aarp", "plan_name": "500102", "standard_charge_dollar": 644.54, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna", "plan_name": "700700", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna", "plan_name": "700700_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Mcare Ffs 6005", "plan_name": "700703", "standard_charge_dollar": 644.54, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Miscellaneous", "plan_name": "700720", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Miscellaneous", "plan_name": "700720_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Ppo Hmo", "plan_name": "701720", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Ppo Hmo", "plan_name": "701720_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Ambetter 68069", "plan_name": "500516", "standard_charge_dollar": 644.54, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Ms State Emplo", "plan_name": "401457", "standard_charge_percentage": 0.80, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Ms State Emplo", "plan_name": "401457_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Basic Pl", "plan_name": "400100", "standard_charge_percentage": 0.85, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Basic Pl", "plan_name": "400100_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Federal", "plan_name": "400110", "standard_charge_percentage": 0.85, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Federal", "plan_name": "400110_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Cigna Healthsprings Ffs", "plan_name": "500064", "standard_charge_dollar": 644.54, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Conseco", "plan_name": "500302", "standard_charge_dollar": 644.54, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Humana Ffs 61101", "plan_name": "500006", "standard_charge_dollar": 644.54, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Medicare A", "plan_name": "100100", "standard_charge_dollar": 644.54, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Medicare A", "plan_name": "100500", "standard_charge_dollar": 644.54, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Medicare Part B Only", "plan_name": "100300", "standard_charge_dollar": 644.54, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Medicare Railroad", "plan_name": "100103", "standard_charge_dollar": 644.54, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Ms Physicians Care N", "plan_name": "714210", "standard_charge_dollar": 805.67, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Peoples Hlth Ffs 72126", "plan_name": "500019", "standard_charge_dollar": 644.54, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Uhc/Secure Horizons", "plan_name": "500449", "standard_charge_dollar": 644.54, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "United Health Care/", "plan_name": "500292", "standard_charge_dollar": 728.33, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "United Healthcare", "plan_name": "750104", "standard_charge_dollar": 728.33, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "United Healthcare Ba", "plan_name": "750090", "standard_charge_dollar": 728.33, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "United Healthcare Me", "plan_name": "501310", "standard_charge_dollar": 644.54, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Windsor Mcare Extra", "plan_name": "500778", "standard_charge_dollar": 644.54, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." } ] } ] }, { "description": "Exc tr-ext b9+marg 2.1-3cm", "code_information": [ { "code": "11403", "type": "CPT" } ], "standard_charges": [ { "gross_charge": 36537.79, "minimum": 644.54, "maximum": 31057.12, "setting": "inpatient", "payers_information": [ { "payer_name": "Aarp", "plan_name": "500102", "standard_charge_dollar": 644.54, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna", "plan_name": "700700", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna", "plan_name": "700700_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Mcare Ffs 6005", "plan_name": "700703", "standard_charge_dollar": 644.54, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Miscellaneous", "plan_name": "700720", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Miscellaneous", "plan_name": "700720_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Ppo Hmo", "plan_name": "701720", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Ppo Hmo", "plan_name": "701720_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Ambetter 68069", "plan_name": "500516", "standard_charge_dollar": 644.54, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Ms State Emplo", "plan_name": "401457", "standard_charge_percentage": 0.80, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Ms State Emplo", "plan_name": "401457_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Basic Pl", "plan_name": "400100", "standard_charge_percentage": 0.85, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Basic Pl", "plan_name": "400100_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Federal", "plan_name": "400110", "standard_charge_percentage": 0.85, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Federal", "plan_name": "400110_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Cigna Healthsprings Ffs", "plan_name": "500064", "standard_charge_dollar": 644.54, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Conseco", "plan_name": "500302", "standard_charge_dollar": 644.54, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Humana Ffs 61101", "plan_name": "500006", "standard_charge_dollar": 644.54, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Medicare A", "plan_name": "100100", "standard_charge_dollar": 644.54, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Medicare A", "plan_name": "100500", "standard_charge_dollar": 644.54, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Medicare Part B Only", "plan_name": "100300", "standard_charge_dollar": 644.54, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Medicare Railroad", "plan_name": "100103", "standard_charge_dollar": 644.54, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Ms Physicians Care N", "plan_name": "714210", "standard_charge_dollar": 805.67, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Peoples Hlth Ffs 72126", "plan_name": "500019", "standard_charge_dollar": 644.54, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Uhc/Secure Horizons", "plan_name": "500449", "standard_charge_dollar": 644.54, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "United Health Care/", "plan_name": "500292", "standard_charge_dollar": 728.33, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "United Healthcare", "plan_name": "750104", "standard_charge_dollar": 728.33, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "United Healthcare Ba", "plan_name": "750090", "standard_charge_dollar": 728.33, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "United Healthcare Me", "plan_name": "501310", "standard_charge_dollar": 644.54, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Windsor Mcare Extra", "plan_name": "500778", "standard_charge_dollar": 644.54, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." } ] } ] }, { "description": "Exc tr-ext b9+marg 3.1-4 cm", "code_information": [ { "code": "11404", "type": "CPT" } ], "standard_charges": [ { "gross_charge": 21836.76, "minimum": 1484.25, "maximum": 18561.25, "setting": "inpatient", "payers_information": [ { "payer_name": "Aarp", "plan_name": "500102", "standard_charge_dollar": 1484.25, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna", "plan_name": "700700", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna", "plan_name": "700700_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Mcare Ffs 6005", "plan_name": "700703", "standard_charge_dollar": 1484.25, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Miscellaneous", "plan_name": "700720", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Miscellaneous", "plan_name": "700720_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Ppo Hmo", "plan_name": "701720", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Ppo Hmo", "plan_name": "701720_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Ambetter 68069", "plan_name": "500516", "standard_charge_dollar": 1484.25, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Ms State Emplo", "plan_name": "401457", "standard_charge_percentage": 0.80, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Ms State Emplo", "plan_name": "401457_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Basic Pl", "plan_name": "400100", "standard_charge_percentage": 0.85, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Basic Pl", "plan_name": "400100_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Federal", "plan_name": "400110", "standard_charge_percentage": 0.85, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Federal", "plan_name": "400110_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Cigna Healthsprings Ffs", "plan_name": "500064", "standard_charge_dollar": 1484.25, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Conseco", "plan_name": "500302", "standard_charge_dollar": 1484.25, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Humana Ffs 61101", "plan_name": "500006", "standard_charge_dollar": 1484.25, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Medicare A", "plan_name": "100100", "standard_charge_dollar": 1484.25, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Medicare A", "plan_name": "100500", "standard_charge_dollar": 1484.25, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Medicare Part B Only", "plan_name": "100300", "standard_charge_dollar": 1484.25, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Medicare Railroad", "plan_name": "100103", "standard_charge_dollar": 1484.25, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Ms Physicians Care N", "plan_name": "714210", "standard_charge_dollar": 1855.31, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Peoples Hlth Ffs 72126", "plan_name": "500019", "standard_charge_dollar": 1484.25, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Uhc/Secure Horizons", "plan_name": "500449", "standard_charge_dollar": 1484.25, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "United Health Care/", "plan_name": "500292", "standard_charge_dollar": 1677.20, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "United Healthcare", "plan_name": "750104", "standard_charge_dollar": 1677.20, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "United Healthcare Ba", "plan_name": "750090", "standard_charge_dollar": 1677.20, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "United Healthcare Me", "plan_name": "501310", "standard_charge_dollar": 1484.25, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Windsor Mcare Extra", "plan_name": "500778", "standard_charge_dollar": 1484.25, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." } ] } ] }, { "description": "Exc tr-ext b9+marg >4.0 cm", "code_information": [ { "code": "11406", "type": "CPT" } ], "standard_charges": [ { "gross_charge": 21836.76, "minimum": 1484.25, "maximum": 18561.25, "setting": "inpatient", "payers_information": [ { "payer_name": "Aarp", "plan_name": "500102", "standard_charge_dollar": 1484.25, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna", "plan_name": "700700", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna", "plan_name": "700700_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Mcare Ffs 6005", "plan_name": "700703", "standard_charge_dollar": 1484.25, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Miscellaneous", "plan_name": "700720", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Miscellaneous", "plan_name": "700720_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Ppo Hmo", "plan_name": "701720", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Ppo Hmo", "plan_name": "701720_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Ambetter 68069", "plan_name": "500516", "standard_charge_dollar": 1484.25, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Ms State Emplo", "plan_name": "401457", "standard_charge_percentage": 0.80, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Ms State Emplo", "plan_name": "401457_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Basic Pl", "plan_name": "400100", "standard_charge_percentage": 0.85, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Basic Pl", "plan_name": "400100_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Federal", "plan_name": "400110", "standard_charge_percentage": 0.85, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Federal", "plan_name": "400110_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Cigna Healthsprings Ffs", "plan_name": "500064", "standard_charge_dollar": 1484.25, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Conseco", "plan_name": "500302", "standard_charge_dollar": 1484.25, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Humana Ffs 61101", "plan_name": "500006", "standard_charge_dollar": 1484.25, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Medicare A", "plan_name": "100100", "standard_charge_dollar": 1484.25, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Medicare A", "plan_name": "100500", "standard_charge_dollar": 1484.25, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Medicare Part B Only", "plan_name": "100300", "standard_charge_dollar": 1484.25, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Medicare Railroad", "plan_name": "100103", "standard_charge_dollar": 1484.25, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Ms Physicians Care N", "plan_name": "714210", "standard_charge_dollar": 1855.31, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Peoples Hlth Ffs 72126", "plan_name": "500019", "standard_charge_dollar": 1484.25, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Uhc/Secure Horizons", "plan_name": "500449", "standard_charge_dollar": 1484.25, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "United Health Care/", "plan_name": "500292", "standard_charge_dollar": 1677.20, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "United Healthcare", "plan_name": "750104", "standard_charge_dollar": 1677.20, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "United Healthcare Ba", "plan_name": "750090", "standard_charge_dollar": 1677.20, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "United Healthcare Me", "plan_name": "501310", "standard_charge_dollar": 1484.25, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Windsor Mcare Extra", "plan_name": "500778", "standard_charge_dollar": 1484.25, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." } ] } ] }, { "description": "Exc h-f-nk-sp b9+marg 0.5/<", "code_information": [ { "code": "11420", "type": "CPT" } ], "standard_charges": [ { "gross_charge": 35354.28, "minimum": 1484.25, "maximum": 30051.14, "setting": "inpatient", "payers_information": [ { "payer_name": "Aarp", "plan_name": "500102", "standard_charge_dollar": 1484.25, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna", "plan_name": "700700", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna", "plan_name": "700700_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Mcare Ffs 6005", "plan_name": "700703", "standard_charge_dollar": 1484.25, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Miscellaneous", "plan_name": "700720", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Miscellaneous", "plan_name": "700720_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Ppo Hmo", "plan_name": "701720", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Ppo Hmo", "plan_name": "701720_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Ambetter 68069", "plan_name": "500516", "standard_charge_dollar": 1484.25, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Ms State Emplo", "plan_name": "401457", "standard_charge_percentage": 0.80, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Ms State Emplo", "plan_name": "401457_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Basic Pl", "plan_name": "400100", "standard_charge_percentage": 0.85, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Basic Pl", "plan_name": "400100_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Federal", "plan_name": "400110", "standard_charge_percentage": 0.85, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Federal", "plan_name": "400110_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Cigna Healthsprings Ffs", "plan_name": "500064", "standard_charge_dollar": 1484.25, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Conseco", "plan_name": "500302", "standard_charge_dollar": 1484.25, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Humana Ffs 61101", "plan_name": "500006", "standard_charge_dollar": 1484.25, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Medicare A", "plan_name": "100100", "standard_charge_dollar": 1484.25, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Medicare A", "plan_name": "100500", "standard_charge_dollar": 1484.25, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Medicare Part B Only", "plan_name": "100300", "standard_charge_dollar": 1484.25, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Medicare Railroad", "plan_name": "100103", "standard_charge_dollar": 1484.25, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Ms Physicians Care N", "plan_name": "714210", "standard_charge_dollar": 1855.31, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Peoples Hlth Ffs 72126", "plan_name": "500019", "standard_charge_dollar": 1484.25, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Uhc/Secure Horizons", "plan_name": "500449", "standard_charge_dollar": 1484.25, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "United Health Care/", "plan_name": "500292", "standard_charge_dollar": 1677.20, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "United Healthcare", "plan_name": "750104", "standard_charge_dollar": 1677.20, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "United Healthcare Ba", "plan_name": "750090", "standard_charge_dollar": 1677.20, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "United Healthcare Me", "plan_name": "501310", "standard_charge_dollar": 1484.25, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Windsor Mcare Extra", "plan_name": "500778", "standard_charge_dollar": 1484.25, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." } ] } ] }, { "description": "Exc h-f-nk-sp b9+marg 0.6-1", "code_information": [ { "code": "11421", "type": "CPT" } ], "standard_charges": [ { "gross_charge": 34911.25, "minimum": 644.54, "maximum": 29674.56, "setting": "inpatient", "payers_information": [ { "payer_name": "Aarp", "plan_name": "500102", "standard_charge_dollar": 644.54, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna", "plan_name": "700700", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna", "plan_name": "700700_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Mcare Ffs 6005", "plan_name": "700703", "standard_charge_dollar": 644.54, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Miscellaneous", "plan_name": "700720", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Miscellaneous", "plan_name": "700720_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Ppo Hmo", "plan_name": "701720", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Ppo Hmo", "plan_name": "701720_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Ambetter 68069", "plan_name": "500516", "standard_charge_dollar": 644.54, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Ms State Emplo", "plan_name": "401457", "standard_charge_percentage": 0.80, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Ms State Emplo", "plan_name": "401457_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Basic Pl", "plan_name": "400100", "standard_charge_percentage": 0.85, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Basic Pl", "plan_name": "400100_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Federal", "plan_name": "400110", "standard_charge_percentage": 0.85, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Federal", "plan_name": "400110_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Cigna Healthsprings Ffs", "plan_name": "500064", "standard_charge_dollar": 644.54, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Conseco", "plan_name": "500302", "standard_charge_dollar": 644.54, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Humana Ffs 61101", "plan_name": "500006", "standard_charge_dollar": 644.54, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Medicare A", "plan_name": "100100", "standard_charge_dollar": 644.54, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Medicare A", "plan_name": "100500", "standard_charge_dollar": 644.54, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Medicare Part B Only", "plan_name": "100300", "standard_charge_dollar": 644.54, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Medicare Railroad", "plan_name": "100103", "standard_charge_dollar": 644.54, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Ms Physicians Care N", "plan_name": "714210", "standard_charge_dollar": 805.67, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Peoples Hlth Ffs 72126", "plan_name": "500019", "standard_charge_dollar": 644.54, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Uhc/Secure Horizons", "plan_name": "500449", "standard_charge_dollar": 644.54, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "United Health Care/", "plan_name": "500292", "standard_charge_dollar": 728.33, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "United Healthcare", "plan_name": "750104", "standard_charge_dollar": 728.33, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "United Healthcare Ba", "plan_name": "750090", "standard_charge_dollar": 728.33, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "United Healthcare Me", "plan_name": "501310", "standard_charge_dollar": 644.54, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Windsor Mcare Extra", "plan_name": "500778", "standard_charge_dollar": 644.54, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." } ] } ] }, { "description": "Exc h-f-nk-sp b9+marg 1.1-2", "code_information": [ { "code": "11422", "type": "CPT" } ], "standard_charges": [ { "gross_charge": 34848.71, "minimum": 1484.25, "maximum": 29621.40, "setting": "inpatient", "payers_information": [ { "payer_name": "Aarp", "plan_name": "500102", "standard_charge_dollar": 1484.25, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna", "plan_name": "700700", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna", "plan_name": "700700_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Mcare Ffs 6005", "plan_name": "700703", "standard_charge_dollar": 1484.25, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Miscellaneous", "plan_name": "700720", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Miscellaneous", "plan_name": "700720_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Ppo Hmo", "plan_name": "701720", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Ppo Hmo", "plan_name": "701720_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Ambetter 68069", "plan_name": "500516", "standard_charge_dollar": 1484.25, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Ms State Emplo", "plan_name": "401457", "standard_charge_percentage": 0.80, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Ms State Emplo", "plan_name": "401457_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Basic Pl", "plan_name": "400100", "standard_charge_percentage": 0.85, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Basic Pl", "plan_name": "400100_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Federal", "plan_name": "400110", "standard_charge_percentage": 0.85, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Federal", "plan_name": "400110_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Cigna Healthsprings Ffs", "plan_name": "500064", "standard_charge_dollar": 1484.25, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Conseco", "plan_name": "500302", "standard_charge_dollar": 1484.25, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Humana Ffs 61101", "plan_name": "500006", "standard_charge_dollar": 1484.25, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Medicare A", "plan_name": "100100", "standard_charge_dollar": 1484.25, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Medicare A", "plan_name": "100500", "standard_charge_dollar": 1484.25, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Medicare Part B Only", "plan_name": "100300", "standard_charge_dollar": 1484.25, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Medicare Railroad", "plan_name": "100103", "standard_charge_dollar": 1484.25, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Ms Physicians Care N", "plan_name": "714210", "standard_charge_dollar": 1855.31, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Peoples Hlth Ffs 72126", "plan_name": "500019", "standard_charge_dollar": 1484.25, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Uhc/Secure Horizons", "plan_name": "500449", "standard_charge_dollar": 1484.25, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "United Health Care/", "plan_name": "500292", "standard_charge_dollar": 1677.20, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "United Healthcare", "plan_name": "750104", "standard_charge_dollar": 1677.20, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "United Healthcare Ba", "plan_name": "750090", "standard_charge_dollar": 1677.20, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "United Healthcare Me", "plan_name": "501310", "standard_charge_dollar": 1484.25, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Windsor Mcare Extra", "plan_name": "500778", "standard_charge_dollar": 1484.25, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." } ] } ] }, { "description": "Exc h-f-nk-sp b9+marg 2.1-3", "code_information": [ { "code": "11423", "type": "CPT" } ], "standard_charges": [ { "gross_charge": 34848.71, "minimum": 1484.25, "maximum": 29621.40, "setting": "inpatient", "payers_information": [ { "payer_name": "Aarp", "plan_name": "500102", "standard_charge_dollar": 1484.25, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna", "plan_name": "700700", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna", "plan_name": "700700_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Mcare Ffs 6005", "plan_name": "700703", "standard_charge_dollar": 1484.25, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Miscellaneous", "plan_name": "700720", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Miscellaneous", "plan_name": "700720_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Ppo Hmo", "plan_name": "701720", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Ppo Hmo", "plan_name": "701720_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Ambetter 68069", "plan_name": "500516", "standard_charge_dollar": 1484.25, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Ms State Emplo", "plan_name": "401457", "standard_charge_percentage": 0.80, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Ms State Emplo", "plan_name": "401457_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Basic Pl", "plan_name": "400100", "standard_charge_percentage": 0.85, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Basic Pl", "plan_name": "400100_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Federal", "plan_name": "400110", "standard_charge_percentage": 0.85, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Federal", "plan_name": "400110_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Cigna Healthsprings Ffs", "plan_name": "500064", "standard_charge_dollar": 1484.25, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Conseco", "plan_name": "500302", "standard_charge_dollar": 1484.25, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Humana Ffs 61101", "plan_name": "500006", "standard_charge_dollar": 1484.25, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Medicare A", "plan_name": "100100", "standard_charge_dollar": 1484.25, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Medicare A", "plan_name": "100500", "standard_charge_dollar": 1484.25, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Medicare Part B Only", "plan_name": "100300", "standard_charge_dollar": 1484.25, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Medicare Railroad", "plan_name": "100103", "standard_charge_dollar": 1484.25, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Ms Physicians Care N", "plan_name": "714210", "standard_charge_dollar": 1855.31, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Peoples Hlth Ffs 72126", "plan_name": "500019", "standard_charge_dollar": 1484.25, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Uhc/Secure Horizons", "plan_name": "500449", "standard_charge_dollar": 1484.25, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "United Health Care/", "plan_name": "500292", "standard_charge_dollar": 1677.20, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "United Healthcare", "plan_name": "750104", "standard_charge_dollar": 1677.20, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "United Healthcare Ba", "plan_name": "750090", "standard_charge_dollar": 1677.20, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "United Healthcare Me", "plan_name": "501310", "standard_charge_dollar": 1484.25, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Windsor Mcare Extra", "plan_name": "500778", "standard_charge_dollar": 1484.25, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." } ] } ] }, { "description": "Exc h-f-nk-sp b9+marg 3.1-4", "code_information": [ { "code": "11424", "type": "CPT" } ], "standard_charges": [ { "gross_charge": 34848.71, "minimum": 1484.25, "maximum": 29621.40, "setting": "inpatient", "payers_information": [ { "payer_name": "Aarp", "plan_name": "500102", "standard_charge_dollar": 1484.25, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna", "plan_name": "700700", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna", "plan_name": "700700_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Mcare Ffs 6005", "plan_name": "700703", "standard_charge_dollar": 1484.25, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Miscellaneous", "plan_name": "700720", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Miscellaneous", "plan_name": "700720_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Ppo Hmo", "plan_name": "701720", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Ppo Hmo", "plan_name": "701720_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Ambetter 68069", "plan_name": "500516", "standard_charge_dollar": 1484.25, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Ms State Emplo", "plan_name": "401457", "standard_charge_percentage": 0.80, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Ms State Emplo", "plan_name": "401457_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Basic Pl", "plan_name": "400100", "standard_charge_percentage": 0.85, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Basic Pl", "plan_name": "400100_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Federal", "plan_name": "400110", "standard_charge_percentage": 0.85, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Federal", "plan_name": "400110_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Cigna Healthsprings Ffs", "plan_name": "500064", "standard_charge_dollar": 1484.25, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Conseco", "plan_name": "500302", "standard_charge_dollar": 1484.25, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Humana Ffs 61101", "plan_name": "500006", "standard_charge_dollar": 1484.25, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Medicare A", "plan_name": "100100", "standard_charge_dollar": 1484.25, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Medicare A", "plan_name": "100500", "standard_charge_dollar": 1484.25, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Medicare Part B Only", "plan_name": "100300", "standard_charge_dollar": 1484.25, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Medicare Railroad", "plan_name": "100103", "standard_charge_dollar": 1484.25, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Ms Physicians Care N", "plan_name": "714210", "standard_charge_dollar": 1855.31, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Peoples Hlth Ffs 72126", "plan_name": "500019", "standard_charge_dollar": 1484.25, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Uhc/Secure Horizons", "plan_name": "500449", "standard_charge_dollar": 1484.25, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "United Health Care/", "plan_name": "500292", "standard_charge_dollar": 1677.20, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "United Healthcare", "plan_name": "750104", "standard_charge_dollar": 1677.20, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "United Healthcare Ba", "plan_name": "750090", "standard_charge_dollar": 1677.20, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "United Healthcare Me", "plan_name": "501310", "standard_charge_dollar": 1484.25, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Windsor Mcare Extra", "plan_name": "500778", "standard_charge_dollar": 1484.25, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." } ] } ] }, { "description": "Exc h-f-nk-sp b9+marg >4 cm", "code_information": [ { "code": "11426", "type": "CPT" } ], "standard_charges": [ { "gross_charge": 35608.61, "minimum": 2621.84, "maximum": 30267.32, "setting": "inpatient", "payers_information": [ { "payer_name": "Aarp", "plan_name": "500102", "standard_charge_dollar": 2621.84, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna", "plan_name": "700700", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna", "plan_name": "700700_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Mcare Ffs 6005", "plan_name": "700703", "standard_charge_dollar": 2621.84, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Miscellaneous", "plan_name": "700720", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Miscellaneous", "plan_name": "700720_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Ppo Hmo", "plan_name": "701720", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Ppo Hmo", "plan_name": "701720_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Ambetter 68069", "plan_name": "500516", "standard_charge_dollar": 2621.84, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Ms State Emplo", "plan_name": "401457", "standard_charge_percentage": 0.80, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Ms State Emplo", "plan_name": "401457_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Basic Pl", "plan_name": "400100", "standard_charge_percentage": 0.85, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Basic Pl", "plan_name": "400100_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Federal", "plan_name": "400110", "standard_charge_percentage": 0.85, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Federal", "plan_name": "400110_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Cigna Healthsprings Ffs", "plan_name": "500064", "standard_charge_dollar": 2621.84, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Conseco", "plan_name": "500302", "standard_charge_dollar": 2621.84, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Humana Ffs 61101", "plan_name": "500006", "standard_charge_dollar": 2621.84, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Medicare A", "plan_name": "100100", "standard_charge_dollar": 2621.84, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Medicare A", "plan_name": "100500", "standard_charge_dollar": 2621.84, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Medicare Part B Only", "plan_name": "100300", "standard_charge_dollar": 2621.84, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Medicare Railroad", "plan_name": "100103", "standard_charge_dollar": 2621.84, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Ms Physicians Care N", "plan_name": "714210", "standard_charge_dollar": 3277.29, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Peoples Hlth Ffs 72126", "plan_name": "500019", "standard_charge_dollar": 2621.84, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Uhc/Secure Horizons", "plan_name": "500449", "standard_charge_dollar": 2621.84, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "United Health Care/", "plan_name": "500292", "standard_charge_dollar": 2962.67, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "United Healthcare", "plan_name": "750104", "standard_charge_dollar": 2962.67, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "United Healthcare Ba", "plan_name": "750090", "standard_charge_dollar": 2962.67, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "United Healthcare Me", "plan_name": "501310", "standard_charge_dollar": 2621.84, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Windsor Mcare Extra", "plan_name": "500778", "standard_charge_dollar": 2621.84, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." } ] } ] }, { "description": "Exc face-mm b9+marg 0.5 cm/<", "code_information": [ { "code": "11440", "type": "CPT" } ], "standard_charges": [ { "gross_charge": 2302.00, "minimum": 644.54, "maximum": 1956.70, "setting": "inpatient", "payers_information": [ { "payer_name": "Aarp", "plan_name": "500102", "standard_charge_dollar": 644.54, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna", "plan_name": "700700", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna", "plan_name": "700700_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Mcare Ffs 6005", "plan_name": "700703", "standard_charge_dollar": 644.54, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Miscellaneous", "plan_name": "700720", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Miscellaneous", "plan_name": "700720_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Ppo Hmo", "plan_name": "701720", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Ppo Hmo", "plan_name": "701720_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Ambetter 68069", "plan_name": "500516", "standard_charge_dollar": 644.54, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Ms State Emplo", "plan_name": "401457", "standard_charge_percentage": 0.80, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Ms State Emplo", "plan_name": "401457_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Basic Pl", "plan_name": "400100", "standard_charge_percentage": 0.85, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Basic Pl", "plan_name": "400100_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Federal", "plan_name": "400110", "standard_charge_percentage": 0.85, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Federal", "plan_name": "400110_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Cigna Healthsprings Ffs", "plan_name": "500064", "standard_charge_dollar": 644.54, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Conseco", "plan_name": "500302", "standard_charge_dollar": 644.54, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Humana Ffs 61101", "plan_name": "500006", "standard_charge_dollar": 644.54, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Medicare A", "plan_name": "100100", "standard_charge_dollar": 644.54, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Medicare A", "plan_name": "100500", "standard_charge_dollar": 644.54, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Medicare Part B Only", "plan_name": "100300", "standard_charge_dollar": 644.54, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Medicare Railroad", "plan_name": "100103", "standard_charge_dollar": 644.54, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Ms Physicians Care N", "plan_name": "714210", "standard_charge_dollar": 805.67, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Peoples Hlth Ffs 72126", "plan_name": "500019", "standard_charge_dollar": 644.54, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Uhc/Secure Horizons", "plan_name": "500449", "standard_charge_dollar": 644.54, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "United Health Care/", "plan_name": "500292", "standard_charge_dollar": 728.33, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "United Healthcare", "plan_name": "750104", "standard_charge_dollar": 728.33, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "United Healthcare Ba", "plan_name": "750090", "standard_charge_dollar": 728.33, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "United Healthcare Me", "plan_name": "501310", "standard_charge_dollar": 644.54, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Windsor Mcare Extra", "plan_name": "500778", "standard_charge_dollar": 644.54, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." } ] } ] }, { "description": "Exc face-mm b9+marg 0.6-1 cm", "code_information": [ { "code": "11441", "type": "CPT" } ], "standard_charges": [ { "gross_charge": 2302.00, "minimum": 644.54, "maximum": 1956.70, "setting": "inpatient", "payers_information": [ { "payer_name": "Aarp", "plan_name": "500102", "standard_charge_dollar": 644.54, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna", "plan_name": "700700", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna", "plan_name": "700700_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Mcare Ffs 6005", "plan_name": "700703", "standard_charge_dollar": 644.54, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Miscellaneous", "plan_name": "700720", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Miscellaneous", "plan_name": "700720_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Ppo Hmo", "plan_name": "701720", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Ppo Hmo", "plan_name": "701720_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Ambetter 68069", "plan_name": "500516", "standard_charge_dollar": 644.54, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Ms State Emplo", "plan_name": "401457", "standard_charge_percentage": 0.80, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Ms State Emplo", "plan_name": "401457_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Basic Pl", "plan_name": "400100", "standard_charge_percentage": 0.85, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Basic Pl", "plan_name": "400100_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Federal", "plan_name": "400110", "standard_charge_percentage": 0.85, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Federal", "plan_name": "400110_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Cigna Healthsprings Ffs", "plan_name": "500064", "standard_charge_dollar": 644.54, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Conseco", "plan_name": "500302", "standard_charge_dollar": 644.54, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Humana Ffs 61101", "plan_name": "500006", "standard_charge_dollar": 644.54, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Medicare A", "plan_name": "100100", "standard_charge_dollar": 644.54, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Medicare A", "plan_name": "100500", "standard_charge_dollar": 644.54, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Medicare Part B Only", "plan_name": "100300", "standard_charge_dollar": 644.54, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Medicare Railroad", "plan_name": "100103", "standard_charge_dollar": 644.54, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Ms Physicians Care N", "plan_name": "714210", "standard_charge_dollar": 805.67, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Peoples Hlth Ffs 72126", "plan_name": "500019", "standard_charge_dollar": 644.54, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Uhc/Secure Horizons", "plan_name": "500449", "standard_charge_dollar": 644.54, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "United Health Care/", "plan_name": "500292", "standard_charge_dollar": 728.33, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "United Healthcare", "plan_name": "750104", "standard_charge_dollar": 728.33, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "United Healthcare Ba", "plan_name": "750090", "standard_charge_dollar": 728.33, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "United Healthcare Me", "plan_name": "501310", "standard_charge_dollar": 644.54, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Windsor Mcare Extra", "plan_name": "500778", "standard_charge_dollar": 644.54, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." } ] } ] }, { "description": "Exc face-mm b9+marg 1.1-2 cm", "code_information": [ { "code": "11442", "type": "CPT" } ], "standard_charges": [ { "gross_charge": 2302.00, "minimum": 644.54, "maximum": 1956.70, "setting": "inpatient", "payers_information": [ { "payer_name": "Aarp", "plan_name": "500102", "standard_charge_dollar": 644.54, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna", "plan_name": "700700", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna", "plan_name": "700700_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Mcare Ffs 6005", "plan_name": "700703", "standard_charge_dollar": 644.54, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Miscellaneous", "plan_name": "700720", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Miscellaneous", "plan_name": "700720_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Ppo Hmo", "plan_name": "701720", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Ppo Hmo", "plan_name": "701720_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Ambetter 68069", "plan_name": "500516", "standard_charge_dollar": 644.54, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Ms State Emplo", "plan_name": "401457", "standard_charge_percentage": 0.80, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Ms State Emplo", "plan_name": "401457_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Basic Pl", "plan_name": "400100", "standard_charge_percentage": 0.85, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Basic Pl", "plan_name": "400100_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Federal", "plan_name": "400110", "standard_charge_percentage": 0.85, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Federal", "plan_name": "400110_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Cigna Healthsprings Ffs", "plan_name": "500064", "standard_charge_dollar": 644.54, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Conseco", "plan_name": "500302", "standard_charge_dollar": 644.54, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Humana Ffs 61101", "plan_name": "500006", "standard_charge_dollar": 644.54, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Medicare A", "plan_name": "100100", "standard_charge_dollar": 644.54, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Medicare A", "plan_name": "100500", "standard_charge_dollar": 644.54, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Medicare Part B Only", "plan_name": "100300", "standard_charge_dollar": 644.54, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Medicare Railroad", "plan_name": "100103", "standard_charge_dollar": 644.54, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Ms Physicians Care N", "plan_name": "714210", "standard_charge_dollar": 805.67, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Peoples Hlth Ffs 72126", "plan_name": "500019", "standard_charge_dollar": 644.54, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Uhc/Secure Horizons", "plan_name": "500449", "standard_charge_dollar": 644.54, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "United Health Care/", "plan_name": "500292", "standard_charge_dollar": 728.33, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "United Healthcare", "plan_name": "750104", "standard_charge_dollar": 728.33, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "United Healthcare Ba", "plan_name": "750090", "standard_charge_dollar": 728.33, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "United Healthcare Me", "plan_name": "501310", "standard_charge_dollar": 644.54, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Windsor Mcare Extra", "plan_name": "500778", "standard_charge_dollar": 644.54, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." } ] } ] }, { "description": "Exc face-mm b9+marg 3.1-4 cm", "code_information": [ { "code": "11444", "type": "CPT" } ], "standard_charges": [ { "gross_charge": 2302.00, "minimum": 1484.25, "maximum": 1956.70, "setting": "inpatient", "payers_information": [ { "payer_name": "Aarp", "plan_name": "500102", "standard_charge_dollar": 1484.25, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna", "plan_name": "700700", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna", "plan_name": "700700_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Mcare Ffs 6005", "plan_name": "700703", "standard_charge_dollar": 1484.25, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Miscellaneous", "plan_name": "700720", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Miscellaneous", "plan_name": "700720_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Ppo Hmo", "plan_name": "701720", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Ppo Hmo", "plan_name": "701720_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Ambetter 68069", "plan_name": "500516", "standard_charge_dollar": 1484.25, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Ms State Emplo", "plan_name": "401457", "standard_charge_percentage": 0.80, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Ms State Emplo", "plan_name": "401457_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Basic Pl", "plan_name": "400100", "standard_charge_percentage": 0.85, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Basic Pl", "plan_name": "400100_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Federal", "plan_name": "400110", "standard_charge_percentage": 0.85, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Federal", "plan_name": "400110_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Cigna Healthsprings Ffs", "plan_name": "500064", "standard_charge_dollar": 1484.25, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Conseco", "plan_name": "500302", "standard_charge_dollar": 1484.25, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Humana Ffs 61101", "plan_name": "500006", "standard_charge_dollar": 1484.25, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Medicare A", "plan_name": "100100", "standard_charge_dollar": 1484.25, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Medicare A", "plan_name": "100500", "standard_charge_dollar": 1484.25, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Medicare Part B Only", "plan_name": "100300", "standard_charge_dollar": 1484.25, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Medicare Railroad", "plan_name": "100103", "standard_charge_dollar": 1484.25, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Ms Physicians Care N", "plan_name": "714210", "standard_charge_dollar": 1855.31, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Peoples Hlth Ffs 72126", "plan_name": "500019", "standard_charge_dollar": 1484.25, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Uhc/Secure Horizons", "plan_name": "500449", "standard_charge_dollar": 1484.25, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "United Health Care/", "plan_name": "500292", "standard_charge_dollar": 1677.20, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "United Healthcare", "plan_name": "750104", "standard_charge_dollar": 1677.20, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "United Healthcare Ba", "plan_name": "750090", "standard_charge_dollar": 1677.20, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "United Healthcare Me", "plan_name": "501310", "standard_charge_dollar": 1484.25, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Windsor Mcare Extra", "plan_name": "500778", "standard_charge_dollar": 1484.25, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." } ] } ] }, { "description": "Exc face-mm b9+marg >4 cm", "code_information": [ { "code": "11446", "type": "CPT" } ], "standard_charges": [ { "gross_charge": 2302.00, "minimum": 1841.60, "maximum": 3277.29, "setting": "inpatient", "payers_information": [ { "payer_name": "Aarp", "plan_name": "500102", "standard_charge_dollar": 2621.84, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna", "plan_name": "700700", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna", "plan_name": "700700_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Mcare Ffs 6005", "plan_name": "700703", "standard_charge_dollar": 2621.84, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Miscellaneous", "plan_name": "700720", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Miscellaneous", "plan_name": "700720_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Ppo Hmo", "plan_name": "701720", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Ppo Hmo", "plan_name": "701720_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Ambetter 68069", "plan_name": "500516", "standard_charge_dollar": 2621.84, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Ms State Emplo", "plan_name": "401457", "standard_charge_percentage": 0.80, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Ms State Emplo", "plan_name": "401457_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Basic Pl", "plan_name": "400100", "standard_charge_percentage": 0.85, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Basic Pl", "plan_name": "400100_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Federal", "plan_name": "400110", "standard_charge_percentage": 0.85, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Federal", "plan_name": "400110_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Cigna Healthsprings Ffs", "plan_name": "500064", "standard_charge_dollar": 2621.84, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Conseco", "plan_name": "500302", "standard_charge_dollar": 2621.84, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Humana Ffs 61101", "plan_name": "500006", "standard_charge_dollar": 2621.84, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Medicare A", "plan_name": "100100", "standard_charge_dollar": 2621.84, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Medicare A", "plan_name": "100500", "standard_charge_dollar": 2621.84, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Medicare Part B Only", "plan_name": "100300", "standard_charge_dollar": 2621.84, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Medicare Railroad", "plan_name": "100103", "standard_charge_dollar": 2621.84, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Ms Physicians Care N", "plan_name": "714210", "standard_charge_dollar": 3277.29, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Peoples Hlth Ffs 72126", "plan_name": "500019", "standard_charge_dollar": 2621.84, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Uhc/Secure Horizons", "plan_name": "500449", "standard_charge_dollar": 2621.84, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "United Health Care/", "plan_name": "500292", "standard_charge_dollar": 2962.67, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "United Healthcare", "plan_name": "750104", "standard_charge_dollar": 2962.67, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "United Healthcare Ba", "plan_name": "750090", "standard_charge_dollar": 2962.67, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "United Healthcare Me", "plan_name": "501310", "standard_charge_dollar": 2621.84, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Windsor Mcare Extra", "plan_name": "500778", "standard_charge_dollar": 2621.84, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." } ] } ] }, { "description": "Exc tr-ext mal+marg 0.5 cm/<", "code_information": [ { "code": "11600", "type": "CPT" } ], "standard_charges": [ { "gross_charge": 37029.68, "minimum": 644.54, "maximum": 31475.23, "setting": "inpatient", "payers_information": [ { "payer_name": "Aarp", "plan_name": "500102", "standard_charge_dollar": 644.54, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna", "plan_name": "700700", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna", "plan_name": "700700_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Mcare Ffs 6005", "plan_name": "700703", "standard_charge_dollar": 644.54, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Miscellaneous", "plan_name": "700720", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Miscellaneous", "plan_name": "700720_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Ppo Hmo", "plan_name": "701720", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Ppo Hmo", "plan_name": "701720_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Ambetter 68069", "plan_name": "500516", "standard_charge_dollar": 644.54, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Ms State Emplo", "plan_name": "401457", "standard_charge_percentage": 0.80, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Ms State Emplo", "plan_name": "401457_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Basic Pl", "plan_name": "400100", "standard_charge_percentage": 0.85, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Basic Pl", "plan_name": "400100_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Federal", "plan_name": "400110", "standard_charge_percentage": 0.85, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Federal", "plan_name": "400110_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Cigna Healthsprings Ffs", "plan_name": "500064", "standard_charge_dollar": 644.54, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Conseco", "plan_name": "500302", "standard_charge_dollar": 644.54, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Humana Ffs 61101", "plan_name": "500006", "standard_charge_dollar": 644.54, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Medicare A", "plan_name": "100100", "standard_charge_dollar": 644.54, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Medicare A", "plan_name": "100500", "standard_charge_dollar": 644.54, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Medicare Part B Only", "plan_name": "100300", "standard_charge_dollar": 644.54, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Medicare Railroad", "plan_name": "100103", "standard_charge_dollar": 644.54, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Ms Physicians Care N", "plan_name": "714210", "standard_charge_dollar": 805.67, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Peoples Hlth Ffs 72126", "plan_name": "500019", "standard_charge_dollar": 644.54, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Uhc/Secure Horizons", "plan_name": "500449", "standard_charge_dollar": 644.54, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "United Health Care/", "plan_name": "500292", "standard_charge_dollar": 728.33, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "United Healthcare", "plan_name": "750104", "standard_charge_dollar": 728.33, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "United Healthcare Ba", "plan_name": "750090", "standard_charge_dollar": 728.33, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "United Healthcare Me", "plan_name": "501310", "standard_charge_dollar": 644.54, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Windsor Mcare Extra", "plan_name": "500778", "standard_charge_dollar": 644.54, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." } ] } ] }, { "description": "Exc tr-ext mal+marg 0.6-1 cm", "code_information": [ { "code": "11601", "type": "CPT" } ], "standard_charges": [ { "gross_charge": 36537.79, "minimum": 644.54, "maximum": 31057.12, "setting": "inpatient", "payers_information": [ { "payer_name": "Aarp", "plan_name": "500102", "standard_charge_dollar": 644.54, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna", "plan_name": "700700", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna", "plan_name": "700700_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Mcare Ffs 6005", "plan_name": "700703", "standard_charge_dollar": 644.54, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Miscellaneous", "plan_name": "700720", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Miscellaneous", "plan_name": "700720_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Ppo Hmo", "plan_name": "701720", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Ppo Hmo", "plan_name": "701720_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Ambetter 68069", "plan_name": "500516", "standard_charge_dollar": 644.54, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Ms State Emplo", "plan_name": "401457", "standard_charge_percentage": 0.80, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Ms State Emplo", "plan_name": "401457_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Basic Pl", "plan_name": "400100", "standard_charge_percentage": 0.85, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Basic Pl", "plan_name": "400100_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Federal", "plan_name": "400110", "standard_charge_percentage": 0.85, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Federal", "plan_name": "400110_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Cigna Healthsprings Ffs", "plan_name": "500064", "standard_charge_dollar": 644.54, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Conseco", "plan_name": "500302", "standard_charge_dollar": 644.54, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Humana Ffs 61101", "plan_name": "500006", "standard_charge_dollar": 644.54, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Medicare A", "plan_name": "100100", "standard_charge_dollar": 644.54, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Medicare A", "plan_name": "100500", "standard_charge_dollar": 644.54, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Medicare Part B Only", "plan_name": "100300", "standard_charge_dollar": 644.54, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Medicare Railroad", "plan_name": "100103", "standard_charge_dollar": 644.54, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Ms Physicians Care N", "plan_name": "714210", "standard_charge_dollar": 805.67, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Peoples Hlth Ffs 72126", "plan_name": "500019", "standard_charge_dollar": 644.54, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Uhc/Secure Horizons", "plan_name": "500449", "standard_charge_dollar": 644.54, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "United Health Care/", "plan_name": "500292", "standard_charge_dollar": 728.33, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "United Healthcare", "plan_name": "750104", "standard_charge_dollar": 728.33, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "United Healthcare Ba", "plan_name": "750090", "standard_charge_dollar": 728.33, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "United Healthcare Me", "plan_name": "501310", "standard_charge_dollar": 644.54, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Windsor Mcare Extra", "plan_name": "500778", "standard_charge_dollar": 644.54, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." } ] } ] }, { "description": "Exc tr-ext mal+marg 1.1-2 cm", "code_information": [ { "code": "11602", "type": "CPT" } ], "standard_charges": [ { "gross_charge": 36537.79, "minimum": 366.00, "maximum": 31057.12, "setting": "inpatient", "payers_information": [ { "payer_name": "Aarp", "plan_name": "500102", "standard_charge_dollar": 366.00, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna", "plan_name": "700700", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna", "plan_name": "700700_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Mcare Ffs 6005", "plan_name": "700703", "standard_charge_dollar": 366.00, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Miscellaneous", "plan_name": "700720", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Miscellaneous", "plan_name": "700720_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Ppo Hmo", "plan_name": "701720", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Ppo Hmo", "plan_name": "701720_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Ambetter 68069", "plan_name": "500516", "standard_charge_dollar": 366.00, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Ms State Emplo", "plan_name": "401457", "standard_charge_percentage": 0.80, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Ms State Emplo", "plan_name": "401457_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Basic Pl", "plan_name": "400100", "standard_charge_percentage": 0.85, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Basic Pl", "plan_name": "400100_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Federal", "plan_name": "400110", "standard_charge_percentage": 0.85, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Federal", "plan_name": "400110_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Cigna Healthsprings Ffs", "plan_name": "500064", "standard_charge_dollar": 366.00, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Conseco", "plan_name": "500302", "standard_charge_dollar": 366.00, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Humana Ffs 61101", "plan_name": "500006", "standard_charge_dollar": 366.00, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Medicare A", "plan_name": "100100", "standard_charge_dollar": 366.00, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Medicare A", "plan_name": "100500", "standard_charge_dollar": 366.00, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Medicare Part B Only", "plan_name": "100300", "standard_charge_dollar": 366.00, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Medicare Railroad", "plan_name": "100103", "standard_charge_dollar": 366.00, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Ms Physicians Care N", "plan_name": "714210", "standard_charge_dollar": 457.50, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Peoples Hlth Ffs 72126", "plan_name": "500019", "standard_charge_dollar": 366.00, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Uhc/Secure Horizons", "plan_name": "500449", "standard_charge_dollar": 366.00, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "United Health Care/", "plan_name": "500292", "standard_charge_dollar": 413.58, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "United Healthcare", "plan_name": "750104", "standard_charge_dollar": 413.58, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "United Healthcare Ba", "plan_name": "750090", "standard_charge_dollar": 413.58, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "United Healthcare Me", "plan_name": "501310", "standard_charge_dollar": 366.00, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Windsor Mcare Extra", "plan_name": "500778", "standard_charge_dollar": 366.00, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." } ] } ] }, { "description": "Exc tr-ext mal+marg 2.1-3 cm", "code_information": [ { "code": "11603", "type": "CPT" } ], "standard_charges": [ { "gross_charge": 36537.79, "minimum": 644.54, "maximum": 31057.12, "setting": "inpatient", "payers_information": [ { "payer_name": "Aarp", "plan_name": "500102", "standard_charge_dollar": 644.54, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna", "plan_name": "700700", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna", "plan_name": "700700_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Mcare Ffs 6005", "plan_name": "700703", "standard_charge_dollar": 644.54, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Miscellaneous", "plan_name": "700720", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Miscellaneous", "plan_name": "700720_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Ppo Hmo", "plan_name": "701720", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Ppo Hmo", "plan_name": "701720_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Ambetter 68069", "plan_name": "500516", "standard_charge_dollar": 644.54, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Ms State Emplo", "plan_name": "401457", "standard_charge_percentage": 0.80, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Ms State Emplo", "plan_name": "401457_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Basic Pl", "plan_name": "400100", "standard_charge_percentage": 0.85, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Basic Pl", "plan_name": "400100_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Federal", "plan_name": "400110", "standard_charge_percentage": 0.85, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Federal", "plan_name": "400110_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Cigna Healthsprings Ffs", "plan_name": "500064", "standard_charge_dollar": 644.54, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Conseco", "plan_name": "500302", "standard_charge_dollar": 644.54, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Humana Ffs 61101", "plan_name": "500006", "standard_charge_dollar": 644.54, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Medicare A", "plan_name": "100100", "standard_charge_dollar": 644.54, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Medicare A", "plan_name": "100500", "standard_charge_dollar": 644.54, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Medicare Part B Only", "plan_name": "100300", "standard_charge_dollar": 644.54, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Medicare Railroad", "plan_name": "100103", "standard_charge_dollar": 644.54, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Ms Physicians Care N", "plan_name": "714210", "standard_charge_dollar": 805.67, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Peoples Hlth Ffs 72126", "plan_name": "500019", "standard_charge_dollar": 644.54, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Uhc/Secure Horizons", "plan_name": "500449", "standard_charge_dollar": 644.54, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "United Health Care/", "plan_name": "500292", "standard_charge_dollar": 728.33, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "United Healthcare", "plan_name": "750104", "standard_charge_dollar": 728.33, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "United Healthcare Ba", "plan_name": "750090", "standard_charge_dollar": 728.33, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "United Healthcare Me", "plan_name": "501310", "standard_charge_dollar": 644.54, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Windsor Mcare Extra", "plan_name": "500778", "standard_charge_dollar": 644.54, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." } ] } ] }, { "description": "Exc tr-ext mal+marg 3.1-4 cm", "code_information": [ { "code": "11604", "type": "CPT" } ], "standard_charges": [ { "gross_charge": 36537.79, "minimum": 644.54, "maximum": 31057.12, "setting": "inpatient", "payers_information": [ { "payer_name": "Aarp", "plan_name": "500102", "standard_charge_dollar": 644.54, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna", "plan_name": "700700", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna", "plan_name": "700700_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Mcare Ffs 6005", "plan_name": "700703", "standard_charge_dollar": 644.54, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Miscellaneous", "plan_name": "700720", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Miscellaneous", "plan_name": "700720_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Ppo Hmo", "plan_name": "701720", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Ppo Hmo", "plan_name": "701720_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Ambetter 68069", "plan_name": "500516", "standard_charge_dollar": 644.54, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Ms State Emplo", "plan_name": "401457", "standard_charge_percentage": 0.80, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Ms State Emplo", "plan_name": "401457_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Basic Pl", "plan_name": "400100", "standard_charge_percentage": 0.85, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Basic Pl", "plan_name": "400100_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Federal", "plan_name": "400110", "standard_charge_percentage": 0.85, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Federal", "plan_name": "400110_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Cigna Healthsprings Ffs", "plan_name": "500064", "standard_charge_dollar": 644.54, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Conseco", "plan_name": "500302", "standard_charge_dollar": 644.54, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Humana Ffs 61101", "plan_name": "500006", "standard_charge_dollar": 644.54, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Medicare A", "plan_name": "100100", "standard_charge_dollar": 644.54, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Medicare A", "plan_name": "100500", "standard_charge_dollar": 644.54, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Medicare Part B Only", "plan_name": "100300", "standard_charge_dollar": 644.54, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Medicare Railroad", "plan_name": "100103", "standard_charge_dollar": 644.54, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Ms Physicians Care N", "plan_name": "714210", "standard_charge_dollar": 805.67, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Peoples Hlth Ffs 72126", "plan_name": "500019", "standard_charge_dollar": 644.54, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Uhc/Secure Horizons", "plan_name": "500449", "standard_charge_dollar": 644.54, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "United Health Care/", "plan_name": "500292", "standard_charge_dollar": 728.33, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "United Healthcare", "plan_name": "750104", "standard_charge_dollar": 728.33, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "United Healthcare Ba", "plan_name": "750090", "standard_charge_dollar": 728.33, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "United Healthcare Me", "plan_name": "501310", "standard_charge_dollar": 644.54, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Windsor Mcare Extra", "plan_name": "500778", "standard_charge_dollar": 644.54, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." } ] } ] }, { "description": "Exc tr-ext mal+marg >4 cm", "code_information": [ { "code": "11606", "type": "CPT" } ], "standard_charges": [ { "gross_charge": 36537.79, "minimum": 1484.25, "maximum": 31057.12, "setting": "inpatient", "payers_information": [ { "payer_name": "Aarp", "plan_name": "500102", "standard_charge_dollar": 1484.25, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna", "plan_name": "700700", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna", "plan_name": "700700_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Mcare Ffs 6005", "plan_name": "700703", "standard_charge_dollar": 1484.25, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Miscellaneous", "plan_name": "700720", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Miscellaneous", "plan_name": "700720_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Ppo Hmo", "plan_name": "701720", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Ppo Hmo", "plan_name": "701720_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Ambetter 68069", "plan_name": "500516", "standard_charge_dollar": 1484.25, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Ms State Emplo", "plan_name": "401457", "standard_charge_percentage": 0.80, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Ms State Emplo", "plan_name": "401457_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Basic Pl", "plan_name": "400100", "standard_charge_percentage": 0.85, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Basic Pl", "plan_name": "400100_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Federal", "plan_name": "400110", "standard_charge_percentage": 0.85, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Federal", "plan_name": "400110_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Cigna Healthsprings Ffs", "plan_name": "500064", "standard_charge_dollar": 1484.25, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Conseco", "plan_name": "500302", "standard_charge_dollar": 1484.25, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Humana Ffs 61101", "plan_name": "500006", "standard_charge_dollar": 1484.25, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Medicare A", "plan_name": "100100", "standard_charge_dollar": 1484.25, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Medicare A", "plan_name": "100500", "standard_charge_dollar": 1484.25, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Medicare Part B Only", "plan_name": "100300", "standard_charge_dollar": 1484.25, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Medicare Railroad", "plan_name": "100103", "standard_charge_dollar": 1484.25, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Ms Physicians Care N", "plan_name": "714210", "standard_charge_dollar": 1855.31, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Peoples Hlth Ffs 72126", "plan_name": "500019", "standard_charge_dollar": 1484.25, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Uhc/Secure Horizons", "plan_name": "500449", "standard_charge_dollar": 1484.25, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "United Health Care/", "plan_name": "500292", "standard_charge_dollar": 1677.20, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "United Healthcare", "plan_name": "750104", "standard_charge_dollar": 1677.20, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "United Healthcare Ba", "plan_name": "750090", "standard_charge_dollar": 1677.20, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "United Healthcare Me", "plan_name": "501310", "standard_charge_dollar": 1484.25, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Windsor Mcare Extra", "plan_name": "500778", "standard_charge_dollar": 1484.25, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." } ] } ] }, { "description": "Exc h-f-nk-sp mal+marg 0.5/<", "code_information": [ { "code": "11620", "type": "CPT" } ], "standard_charges": [ { "gross_charge": 28884.87, "minimum": 1484.25, "maximum": 24552.14, "setting": "inpatient", "payers_information": [ { "payer_name": "Aarp", "plan_name": "500102", "standard_charge_dollar": 1484.25, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna", "plan_name": "700700", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna", "plan_name": "700700_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Mcare Ffs 6005", "plan_name": "700703", "standard_charge_dollar": 1484.25, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Miscellaneous", "plan_name": "700720", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Miscellaneous", "plan_name": "700720_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Ppo Hmo", "plan_name": "701720", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Ppo Hmo", "plan_name": "701720_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Ambetter 68069", "plan_name": "500516", "standard_charge_dollar": 1484.25, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Ms State Emplo", "plan_name": "401457", "standard_charge_percentage": 0.80, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Ms State Emplo", "plan_name": "401457_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Basic Pl", "plan_name": "400100", "standard_charge_percentage": 0.85, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Basic Pl", "plan_name": "400100_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Federal", "plan_name": "400110", "standard_charge_percentage": 0.85, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Federal", "plan_name": "400110_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Cigna Healthsprings Ffs", "plan_name": "500064", "standard_charge_dollar": 1484.25, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Conseco", "plan_name": "500302", "standard_charge_dollar": 1484.25, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Humana Ffs 61101", "plan_name": "500006", "standard_charge_dollar": 1484.25, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Medicare A", "plan_name": "100100", "standard_charge_dollar": 1484.25, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Medicare A", "plan_name": "100500", "standard_charge_dollar": 1484.25, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Medicare Part B Only", "plan_name": "100300", "standard_charge_dollar": 1484.25, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Medicare Railroad", "plan_name": "100103", "standard_charge_dollar": 1484.25, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Ms Physicians Care N", "plan_name": "714210", "standard_charge_dollar": 1855.31, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Peoples Hlth Ffs 72126", "plan_name": "500019", "standard_charge_dollar": 1484.25, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Uhc/Secure Horizons", "plan_name": "500449", "standard_charge_dollar": 1484.25, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "United Health Care/", "plan_name": "500292", "standard_charge_dollar": 1677.20, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "United Healthcare", "plan_name": "750104", "standard_charge_dollar": 1677.20, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "United Healthcare Ba", "plan_name": "750090", "standard_charge_dollar": 1677.20, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "United Healthcare Me", "plan_name": "501310", "standard_charge_dollar": 1484.25, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Windsor Mcare Extra", "plan_name": "500778", "standard_charge_dollar": 1484.25, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." } ] } ] }, { "description": "Exc s/n/h/f/g mal+mrg 0.6-1", "code_information": [ { "code": "11621", "type": "CPT" } ], "standard_charges": [ { "gross_charge": 28884.87, "minimum": 644.54, "maximum": 24552.14, "setting": "inpatient", "payers_information": [ { "payer_name": "Aarp", "plan_name": "500102", "standard_charge_dollar": 644.54, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna", "plan_name": "700700", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna", "plan_name": "700700_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Mcare Ffs 6005", "plan_name": "700703", "standard_charge_dollar": 644.54, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Miscellaneous", "plan_name": "700720", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Miscellaneous", "plan_name": "700720_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Ppo Hmo", "plan_name": "701720", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Ppo Hmo", "plan_name": "701720_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Ambetter 68069", "plan_name": "500516", "standard_charge_dollar": 644.54, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Ms State Emplo", "plan_name": "401457", "standard_charge_percentage": 0.80, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Ms State Emplo", "plan_name": "401457_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Basic Pl", "plan_name": "400100", "standard_charge_percentage": 0.85, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Basic Pl", "plan_name": "400100_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Federal", "plan_name": "400110", "standard_charge_percentage": 0.85, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Federal", "plan_name": "400110_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Cigna Healthsprings Ffs", "plan_name": "500064", "standard_charge_dollar": 644.54, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Conseco", "plan_name": "500302", "standard_charge_dollar": 644.54, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Humana Ffs 61101", "plan_name": "500006", "standard_charge_dollar": 644.54, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Medicare A", "plan_name": "100100", "standard_charge_dollar": 644.54, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Medicare A", "plan_name": "100500", "standard_charge_dollar": 644.54, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Medicare Part B Only", "plan_name": "100300", "standard_charge_dollar": 644.54, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Medicare Railroad", "plan_name": "100103", "standard_charge_dollar": 644.54, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Ms Physicians Care N", "plan_name": "714210", "standard_charge_dollar": 805.67, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Peoples Hlth Ffs 72126", "plan_name": "500019", "standard_charge_dollar": 644.54, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Uhc/Secure Horizons", "plan_name": "500449", "standard_charge_dollar": 644.54, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "United Health Care/", "plan_name": "500292", "standard_charge_dollar": 728.33, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "United Healthcare", "plan_name": "750104", "standard_charge_dollar": 728.33, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "United Healthcare Ba", "plan_name": "750090", "standard_charge_dollar": 728.33, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "United Healthcare Me", "plan_name": "501310", "standard_charge_dollar": 644.54, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Windsor Mcare Extra", "plan_name": "500778", "standard_charge_dollar": 644.54, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." } ] } ] }, { "description": "Exc s/n/h/f/g mal+mrg 1.1-2", "code_information": [ { "code": "11622", "type": "CPT" } ], "standard_charges": [ { "gross_charge": 28884.87, "minimum": 644.54, "maximum": 24552.14, "setting": "inpatient", "payers_information": [ { "payer_name": "Aarp", "plan_name": "500102", "standard_charge_dollar": 644.54, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna", "plan_name": "700700", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna", "plan_name": "700700_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Mcare Ffs 6005", "plan_name": "700703", "standard_charge_dollar": 644.54, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Miscellaneous", "plan_name": "700720", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Miscellaneous", "plan_name": "700720_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Ppo Hmo", "plan_name": "701720", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Ppo Hmo", "plan_name": "701720_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Ambetter 68069", "plan_name": "500516", "standard_charge_dollar": 644.54, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Ms State Emplo", "plan_name": "401457", "standard_charge_percentage": 0.80, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Ms State Emplo", "plan_name": "401457_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Basic Pl", "plan_name": "400100", "standard_charge_percentage": 0.85, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Basic Pl", "plan_name": "400100_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Federal", "plan_name": "400110", "standard_charge_percentage": 0.85, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Federal", "plan_name": "400110_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Cigna Healthsprings Ffs", "plan_name": "500064", "standard_charge_dollar": 644.54, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Conseco", "plan_name": "500302", "standard_charge_dollar": 644.54, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Humana Ffs 61101", "plan_name": "500006", "standard_charge_dollar": 644.54, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Medicare A", "plan_name": "100100", "standard_charge_dollar": 644.54, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Medicare A", "plan_name": "100500", "standard_charge_dollar": 644.54, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Medicare Part B Only", "plan_name": "100300", "standard_charge_dollar": 644.54, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Medicare Railroad", "plan_name": "100103", "standard_charge_dollar": 644.54, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Ms Physicians Care N", "plan_name": "714210", "standard_charge_dollar": 805.67, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Peoples Hlth Ffs 72126", "plan_name": "500019", "standard_charge_dollar": 644.54, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Uhc/Secure Horizons", "plan_name": "500449", "standard_charge_dollar": 644.54, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "United Health Care/", "plan_name": "500292", "standard_charge_dollar": 728.33, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "United Healthcare", "plan_name": "750104", "standard_charge_dollar": 728.33, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "United Healthcare Ba", "plan_name": "750090", "standard_charge_dollar": 728.33, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "United Healthcare Me", "plan_name": "501310", "standard_charge_dollar": 644.54, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Windsor Mcare Extra", "plan_name": "500778", "standard_charge_dollar": 644.54, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." } ] } ] }, { "description": "Exc s/n/h/f/g mal+mrg 2.1-3", "code_information": [ { "code": "11623", "type": "CPT" } ], "standard_charges": [ { "gross_charge": 28884.87, "minimum": 1484.25, "maximum": 24552.14, "setting": "inpatient", "payers_information": [ { "payer_name": "Aarp", "plan_name": "500102", "standard_charge_dollar": 1484.25, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna", "plan_name": "700700", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna", "plan_name": "700700_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Mcare Ffs 6005", "plan_name": "700703", "standard_charge_dollar": 1484.25, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Miscellaneous", "plan_name": "700720", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Miscellaneous", "plan_name": "700720_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Ppo Hmo", "plan_name": "701720", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Ppo Hmo", "plan_name": "701720_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Ambetter 68069", "plan_name": "500516", "standard_charge_dollar": 1484.25, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Ms State Emplo", "plan_name": "401457", "standard_charge_percentage": 0.80, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Ms State Emplo", "plan_name": "401457_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Basic Pl", "plan_name": "400100", "standard_charge_percentage": 0.85, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Basic Pl", "plan_name": "400100_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Federal", "plan_name": "400110", "standard_charge_percentage": 0.85, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Federal", "plan_name": "400110_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Cigna Healthsprings Ffs", "plan_name": "500064", "standard_charge_dollar": 1484.25, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Conseco", "plan_name": "500302", "standard_charge_dollar": 1484.25, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Humana Ffs 61101", "plan_name": "500006", "standard_charge_dollar": 1484.25, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Medicare A", "plan_name": "100100", "standard_charge_dollar": 1484.25, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Medicare A", "plan_name": "100500", "standard_charge_dollar": 1484.25, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Medicare Part B Only", "plan_name": "100300", "standard_charge_dollar": 1484.25, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Medicare Railroad", "plan_name": "100103", "standard_charge_dollar": 1484.25, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Ms Physicians Care N", "plan_name": "714210", "standard_charge_dollar": 1855.31, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Peoples Hlth Ffs 72126", "plan_name": "500019", "standard_charge_dollar": 1484.25, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Uhc/Secure Horizons", "plan_name": "500449", "standard_charge_dollar": 1484.25, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "United Health Care/", "plan_name": "500292", "standard_charge_dollar": 1677.20, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "United Healthcare", "plan_name": "750104", "standard_charge_dollar": 1677.20, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "United Healthcare Ba", "plan_name": "750090", "standard_charge_dollar": 1677.20, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "United Healthcare Me", "plan_name": "501310", "standard_charge_dollar": 1484.25, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Windsor Mcare Extra", "plan_name": "500778", "standard_charge_dollar": 1484.25, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." } ] } ] }, { "description": "Exc s/n/h/f/g mal+mrg 3.1-4", "code_information": [ { "code": "11624", "type": "CPT" } ], "standard_charges": [ { "gross_charge": 28884.87, "minimum": 1484.25, "maximum": 24552.14, "setting": "inpatient", "payers_information": [ { "payer_name": "Aarp", "plan_name": "500102", "standard_charge_dollar": 1484.25, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna", "plan_name": "700700", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna", "plan_name": "700700_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Mcare Ffs 6005", "plan_name": "700703", "standard_charge_dollar": 1484.25, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Miscellaneous", "plan_name": "700720", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Miscellaneous", "plan_name": "700720_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Ppo Hmo", "plan_name": "701720", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Ppo Hmo", "plan_name": "701720_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Ambetter 68069", "plan_name": "500516", "standard_charge_dollar": 1484.25, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Ms State Emplo", "plan_name": "401457", "standard_charge_percentage": 0.80, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Ms State Emplo", "plan_name": "401457_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Basic Pl", "plan_name": "400100", "standard_charge_percentage": 0.85, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Basic Pl", "plan_name": "400100_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Federal", "plan_name": "400110", "standard_charge_percentage": 0.85, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Federal", "plan_name": "400110_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Cigna Healthsprings Ffs", "plan_name": "500064", "standard_charge_dollar": 1484.25, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Conseco", "plan_name": "500302", "standard_charge_dollar": 1484.25, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Humana Ffs 61101", "plan_name": "500006", "standard_charge_dollar": 1484.25, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Medicare A", "plan_name": "100100", "standard_charge_dollar": 1484.25, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Medicare A", "plan_name": "100500", "standard_charge_dollar": 1484.25, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Medicare Part B Only", "plan_name": "100300", "standard_charge_dollar": 1484.25, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Medicare Railroad", "plan_name": "100103", "standard_charge_dollar": 1484.25, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Ms Physicians Care N", "plan_name": "714210", "standard_charge_dollar": 1855.31, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Peoples Hlth Ffs 72126", "plan_name": "500019", "standard_charge_dollar": 1484.25, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Uhc/Secure Horizons", "plan_name": "500449", "standard_charge_dollar": 1484.25, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "United Health Care/", "plan_name": "500292", "standard_charge_dollar": 1677.20, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "United Healthcare", "plan_name": "750104", "standard_charge_dollar": 1677.20, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "United Healthcare Ba", "plan_name": "750090", "standard_charge_dollar": 1677.20, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "United Healthcare Me", "plan_name": "501310", "standard_charge_dollar": 1484.25, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Windsor Mcare Extra", "plan_name": "500778", "standard_charge_dollar": 1484.25, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." } ] } ] }, { "description": "Exc s/n/h/f/g mal+mrg >4 cm", "code_information": [ { "code": "11626", "type": "CPT" } ], "standard_charges": [ { "gross_charge": 28884.87, "minimum": 2621.84, "maximum": 24552.14, "setting": "inpatient", "payers_information": [ { "payer_name": "Aarp", "plan_name": "500102", "standard_charge_dollar": 2621.84, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna", "plan_name": "700700", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna", "plan_name": "700700_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Mcare Ffs 6005", "plan_name": "700703", "standard_charge_dollar": 2621.84, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Miscellaneous", "plan_name": "700720", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Miscellaneous", "plan_name": "700720_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Ppo Hmo", "plan_name": "701720", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Ppo Hmo", "plan_name": "701720_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Ambetter 68069", "plan_name": "500516", "standard_charge_dollar": 2621.84, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Ms State Emplo", "plan_name": "401457", "standard_charge_percentage": 0.80, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Ms State Emplo", "plan_name": "401457_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Basic Pl", "plan_name": "400100", "standard_charge_percentage": 0.85, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Basic Pl", "plan_name": "400100_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Federal", "plan_name": "400110", "standard_charge_percentage": 0.85, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Federal", "plan_name": "400110_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Cigna Healthsprings Ffs", "plan_name": "500064", "standard_charge_dollar": 2621.84, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Conseco", "plan_name": "500302", "standard_charge_dollar": 2621.84, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Humana Ffs 61101", "plan_name": "500006", "standard_charge_dollar": 2621.84, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Medicare A", "plan_name": "100100", "standard_charge_dollar": 2621.84, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Medicare A", "plan_name": "100500", "standard_charge_dollar": 2621.84, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Medicare Part B Only", "plan_name": "100300", "standard_charge_dollar": 2621.84, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Medicare Railroad", "plan_name": "100103", "standard_charge_dollar": 2621.84, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Ms Physicians Care N", "plan_name": "714210", "standard_charge_dollar": 3277.29, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Peoples Hlth Ffs 72126", "plan_name": "500019", "standard_charge_dollar": 2621.84, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Uhc/Secure Horizons", "plan_name": "500449", "standard_charge_dollar": 2621.84, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "United Health Care/", "plan_name": "500292", "standard_charge_dollar": 2962.67, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "United Healthcare", "plan_name": "750104", "standard_charge_dollar": 2962.67, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "United Healthcare Ba", "plan_name": "750090", "standard_charge_dollar": 2962.67, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "United Healthcare Me", "plan_name": "501310", "standard_charge_dollar": 2621.84, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Windsor Mcare Extra", "plan_name": "500778", "standard_charge_dollar": 2621.84, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." } ] } ] }, { "description": "Hc trim nails nondystrophic", "code_information": [ { "code": "11719", "type": "CPT" } ], "standard_charges": [ { "gross_charge": 92.00, "minimum": 54.41, "maximum": 81.80, "setting": "both", "payers_information": [ { "payer_name": "Aarp", "plan_name": "500102", "standard_charge_dollar": 54.41, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna", "plan_name": "700700", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna", "plan_name": "700700_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Mcare Ffs 6005", "plan_name": "700703", "standard_charge_dollar": 54.41, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Miscellaneous", "plan_name": "700720", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Miscellaneous", "plan_name": "700720_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Ppo Hmo", "plan_name": "701720", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Ppo Hmo", "plan_name": "701720_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Ambetter 68069", "plan_name": "500516", "standard_charge_dollar": 54.41, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Ms State Emplo", "plan_name": "401457", "standard_charge_dollar": 81.80, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Ms State Emplo", "plan_name": "401457_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Basic Pl", "plan_name": "400100", "standard_charge_dollar": 81.80, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Basic Pl", "plan_name": "400100_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Federal", "plan_name": "400110", "standard_charge_dollar": 81.80, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Federal", "plan_name": "400110_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Cigna Healthsprings Ffs", "plan_name": "500064", "standard_charge_dollar": 54.41, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Conseco", "plan_name": "500302", "standard_charge_dollar": 54.41, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Humana Ffs 61101", "plan_name": "500006", "standard_charge_dollar": 54.41, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Medicare A", "plan_name": "100100", "standard_charge_dollar": 54.41, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Medicare A", "plan_name": "100500", "standard_charge_dollar": 54.41, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Medicare Part B Only", "plan_name": "100300", "standard_charge_dollar": 54.41, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Medicare Railroad", "plan_name": "100103", "standard_charge_dollar": 54.41, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Ms Physicians Care N", "plan_name": "714210", "standard_charge_dollar": 68.02, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Peoples Hlth Ffs 72126", "plan_name": "500019", "standard_charge_dollar": 54.41, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Uhc/Secure Horizons", "plan_name": "500449", "standard_charge_dollar": 54.41, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "United Health Care/", "plan_name": "500292", "standard_charge_dollar": 61.49, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "United Healthcare", "plan_name": "750104", "standard_charge_dollar": 61.49, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "United Healthcare Ba", "plan_name": "750090", "standard_charge_dollar": 61.49, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "United Healthcare Me", "plan_name": "501310", "standard_charge_dollar": 54.41, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Windsor Mcare Extra", "plan_name": "500778", "standard_charge_dollar": 54.41, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." } ] } ] }, { "description": "Trim nail(s) any number", "code_information": [ { "code": "11719", "type": "CPT" } ], "standard_charges": [ { "gross_charge": 92.00, "minimum": 54.41, "maximum": 81.80, "setting": "both", "payers_information": [ { "payer_name": "Aarp", "plan_name": "500102", "standard_charge_dollar": 54.41, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna", "plan_name": "700700", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna", "plan_name": "700700_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Mcare Ffs 6005", "plan_name": "700703", "standard_charge_dollar": 54.41, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Miscellaneous", "plan_name": "700720", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Miscellaneous", "plan_name": "700720_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Ppo Hmo", "plan_name": "701720", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Ppo Hmo", "plan_name": "701720_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Ambetter 68069", "plan_name": "500516", "standard_charge_dollar": 54.41, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Ms State Emplo", "plan_name": "401457", "standard_charge_dollar": 81.80, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Ms State Emplo", "plan_name": "401457_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Basic Pl", "plan_name": "400100", "standard_charge_dollar": 81.80, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Basic Pl", "plan_name": "400100_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Federal", "plan_name": "400110", "standard_charge_dollar": 81.80, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Federal", "plan_name": "400110_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Cigna Healthsprings Ffs", "plan_name": "500064", "standard_charge_dollar": 54.41, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Conseco", "plan_name": "500302", "standard_charge_dollar": 54.41, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Humana Ffs 61101", "plan_name": "500006", "standard_charge_dollar": 54.41, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Medicare A", "plan_name": "100100", "standard_charge_dollar": 54.41, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Medicare A", "plan_name": "100500", "standard_charge_dollar": 54.41, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Medicare Part B Only", "plan_name": "100300", "standard_charge_dollar": 54.41, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Medicare Railroad", "plan_name": "100103", "standard_charge_dollar": 54.41, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Ms Physicians Care N", "plan_name": "714210", "standard_charge_dollar": 68.02, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Peoples Hlth Ffs 72126", "plan_name": "500019", "standard_charge_dollar": 54.41, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Uhc/Secure Horizons", "plan_name": "500449", "standard_charge_dollar": 54.41, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "United Health Care/", "plan_name": "500292", "standard_charge_dollar": 61.49, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "United Healthcare", "plan_name": "750104", "standard_charge_dollar": 61.49, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "United Healthcare Ba", "plan_name": "750090", "standard_charge_dollar": 61.49, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "United Healthcare Me", "plan_name": "501310", "standard_charge_dollar": 54.41, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Windsor Mcare Extra", "plan_name": "500778", "standard_charge_dollar": 54.41, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." } ] } ] }, { "description": "Debride nail 1-5", "code_information": [ { "code": "11720", "type": "CPT" } ], "standard_charges": [ { "gross_charge": 92.00, "minimum": 54.41, "maximum": 81.80, "setting": "both", "payers_information": [ { "payer_name": "Aarp", "plan_name": "500102", "standard_charge_dollar": 54.41, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna", "plan_name": "700700", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna", "plan_name": "700700_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Mcare Ffs 6005", "plan_name": "700703", "standard_charge_dollar": 54.41, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Miscellaneous", "plan_name": "700720", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Miscellaneous", "plan_name": "700720_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Ppo Hmo", "plan_name": "701720", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Ppo Hmo", "plan_name": "701720_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Ambetter 68069", "plan_name": "500516", "standard_charge_dollar": 54.41, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Ms State Emplo", "plan_name": "401457", "standard_charge_dollar": 81.80, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Ms State Emplo", "plan_name": "401457_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Basic Pl", "plan_name": "400100", "standard_charge_dollar": 81.80, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Basic Pl", "plan_name": "400100_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Federal", "plan_name": "400110", "standard_charge_dollar": 81.80, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Federal", "plan_name": "400110_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Cigna Healthsprings Ffs", "plan_name": "500064", "standard_charge_dollar": 54.41, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Conseco", "plan_name": "500302", "standard_charge_dollar": 54.41, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Humana Ffs 61101", "plan_name": "500006", "standard_charge_dollar": 54.41, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Medicare A", "plan_name": "100100", "standard_charge_dollar": 54.41, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Medicare A", "plan_name": "100500", "standard_charge_dollar": 54.41, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Medicare Part B Only", "plan_name": "100300", "standard_charge_dollar": 54.41, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Medicare Railroad", "plan_name": "100103", "standard_charge_dollar": 54.41, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Ms Physicians Care N", "plan_name": "714210", "standard_charge_dollar": 68.02, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Peoples Hlth Ffs 72126", "plan_name": "500019", "standard_charge_dollar": 54.41, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Uhc/Secure Horizons", "plan_name": "500449", "standard_charge_dollar": 54.41, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "United Health Care/", "plan_name": "500292", "standard_charge_dollar": 61.49, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "United Healthcare", "plan_name": "750104", "standard_charge_dollar": 61.49, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "United Healthcare Ba", "plan_name": "750090", "standard_charge_dollar": 61.49, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "United Healthcare Me", "plan_name": "501310", "standard_charge_dollar": 54.41, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Windsor Mcare Extra", "plan_name": "500778", "standard_charge_dollar": 54.41, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." } ] } ] }, { "description": "Hc debridement nails 1 to 5", "code_information": [ { "code": "11720", "type": "CPT" } ], "standard_charges": [ { "gross_charge": 92.00, "minimum": 54.41, "maximum": 81.80, "setting": "both", "payers_information": [ { "payer_name": "Aarp", "plan_name": "500102", "standard_charge_dollar": 54.41, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna", "plan_name": "700700", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna", "plan_name": "700700_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Mcare Ffs 6005", "plan_name": "700703", "standard_charge_dollar": 54.41, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Miscellaneous", "plan_name": "700720", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Miscellaneous", "plan_name": "700720_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Ppo Hmo", "plan_name": "701720", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Ppo Hmo", "plan_name": "701720_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Ambetter 68069", "plan_name": "500516", "standard_charge_dollar": 54.41, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Ms State Emplo", "plan_name": "401457", "standard_charge_dollar": 81.80, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Ms State Emplo", "plan_name": "401457_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Basic Pl", "plan_name": "400100", "standard_charge_dollar": 81.80, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Basic Pl", "plan_name": "400100_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Federal", "plan_name": "400110", "standard_charge_dollar": 81.80, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Federal", "plan_name": "400110_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Cigna Healthsprings Ffs", "plan_name": "500064", "standard_charge_dollar": 54.41, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Conseco", "plan_name": "500302", "standard_charge_dollar": 54.41, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Humana Ffs 61101", "plan_name": "500006", "standard_charge_dollar": 54.41, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Medicare A", "plan_name": "100100", "standard_charge_dollar": 54.41, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Medicare A", "plan_name": "100500", "standard_charge_dollar": 54.41, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Medicare Part B Only", "plan_name": "100300", "standard_charge_dollar": 54.41, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Medicare Railroad", "plan_name": "100103", "standard_charge_dollar": 54.41, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Ms Physicians Care N", "plan_name": "714210", "standard_charge_dollar": 68.02, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Peoples Hlth Ffs 72126", "plan_name": "500019", "standard_charge_dollar": 54.41, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Uhc/Secure Horizons", "plan_name": "500449", "standard_charge_dollar": 54.41, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "United Health Care/", "plan_name": "500292", "standard_charge_dollar": 61.49, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "United Healthcare", "plan_name": "750104", "standard_charge_dollar": 61.49, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "United Healthcare Ba", "plan_name": "750090", "standard_charge_dollar": 61.49, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "United Healthcare Me", "plan_name": "501310", "standard_charge_dollar": 54.41, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Windsor Mcare Extra", "plan_name": "500778", "standard_charge_dollar": 54.41, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." } ] } ] }, { "description": "Debride nail 6 or more", "code_information": [ { "code": "11721", "type": "CPT" } ], "standard_charges": [ { "gross_charge": 92.00, "minimum": 54.41, "maximum": 81.80, "setting": "both", "payers_information": [ { "payer_name": "Aarp", "plan_name": "500102", "standard_charge_dollar": 54.41, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna", "plan_name": "700700", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna", "plan_name": "700700_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Mcare Ffs 6005", "plan_name": "700703", "standard_charge_dollar": 54.41, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Miscellaneous", "plan_name": "700720", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Miscellaneous", "plan_name": "700720_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Ppo Hmo", "plan_name": "701720", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Ppo Hmo", "plan_name": "701720_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Ambetter 68069", "plan_name": "500516", "standard_charge_dollar": 54.41, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Ms State Emplo", "plan_name": "401457", "standard_charge_dollar": 81.80, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Ms State Emplo", "plan_name": "401457_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Basic Pl", "plan_name": "400100", "standard_charge_dollar": 81.80, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Basic Pl", "plan_name": "400100_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Federal", "plan_name": "400110", "standard_charge_dollar": 81.80, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Federal", "plan_name": "400110_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Cigna Healthsprings Ffs", "plan_name": "500064", "standard_charge_dollar": 54.41, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Conseco", "plan_name": "500302", "standard_charge_dollar": 54.41, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Humana Ffs 61101", "plan_name": "500006", "standard_charge_dollar": 54.41, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Medicare A", "plan_name": "100100", "standard_charge_dollar": 54.41, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Medicare A", "plan_name": "100500", "standard_charge_dollar": 54.41, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Medicare Part B Only", "plan_name": "100300", "standard_charge_dollar": 54.41, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Medicare Railroad", "plan_name": "100103", "standard_charge_dollar": 54.41, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Ms Physicians Care N", "plan_name": "714210", "standard_charge_dollar": 68.02, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Peoples Hlth Ffs 72126", "plan_name": "500019", "standard_charge_dollar": 54.41, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Uhc/Secure Horizons", "plan_name": "500449", "standard_charge_dollar": 54.41, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "United Health Care/", "plan_name": "500292", "standard_charge_dollar": 61.49, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "United Healthcare", "plan_name": "750104", "standard_charge_dollar": 61.49, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "United Healthcare Ba", "plan_name": "750090", "standard_charge_dollar": 61.49, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "United Healthcare Me", "plan_name": "501310", "standard_charge_dollar": 54.41, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Windsor Mcare Extra", "plan_name": "500778", "standard_charge_dollar": 54.41, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." } ] } ] }, { "description": "Hc debridement nails 6 or more", "code_information": [ { "code": "11721", "type": "CPT" } ], "standard_charges": [ { "gross_charge": 92.00, "minimum": 54.41, "maximum": 81.80, "setting": "both", "payers_information": [ { "payer_name": "Aarp", "plan_name": "500102", "standard_charge_dollar": 54.41, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna", "plan_name": "700700", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna", "plan_name": "700700_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Mcare Ffs 6005", "plan_name": "700703", "standard_charge_dollar": 54.41, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Miscellaneous", "plan_name": "700720", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Miscellaneous", "plan_name": "700720_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Ppo Hmo", "plan_name": "701720", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Ppo Hmo", "plan_name": "701720_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Ambetter 68069", "plan_name": "500516", "standard_charge_dollar": 54.41, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Ms State Emplo", "plan_name": "401457", "standard_charge_dollar": 81.80, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Ms State Emplo", "plan_name": "401457_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Basic Pl", "plan_name": "400100", "standard_charge_dollar": 81.80, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Basic Pl", "plan_name": "400100_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Federal", "plan_name": "400110", "standard_charge_dollar": 81.80, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Federal", "plan_name": "400110_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Cigna Healthsprings Ffs", "plan_name": "500064", "standard_charge_dollar": 54.41, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Conseco", "plan_name": "500302", "standard_charge_dollar": 54.41, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Humana Ffs 61101", "plan_name": "500006", "standard_charge_dollar": 54.41, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Medicare A", "plan_name": "100100", "standard_charge_dollar": 54.41, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Medicare A", "plan_name": "100500", "standard_charge_dollar": 54.41, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Medicare Part B Only", "plan_name": "100300", "standard_charge_dollar": 54.41, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Medicare Railroad", "plan_name": "100103", "standard_charge_dollar": 54.41, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Ms Physicians Care N", "plan_name": "714210", "standard_charge_dollar": 68.02, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Peoples Hlth Ffs 72126", "plan_name": "500019", "standard_charge_dollar": 54.41, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Uhc/Secure Horizons", "plan_name": "500449", "standard_charge_dollar": 54.41, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "United Health Care/", "plan_name": "500292", "standard_charge_dollar": 61.49, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "United Healthcare", "plan_name": "750104", "standard_charge_dollar": 61.49, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "United Healthcare Ba", "plan_name": "750090", "standard_charge_dollar": 61.49, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "United Healthcare Me", "plan_name": "501310", "standard_charge_dollar": 54.41, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Windsor Mcare Extra", "plan_name": "500778", "standard_charge_dollar": 54.41, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." } ] } ] }, { "description": "Hc nail excision", "code_information": [ { "code": "11730", "type": "CPT" } ], "standard_charges": [ { "gross_charge": 289.00, "minimum": 182.02, "maximum": 229.58, "setting": "both", "payers_information": [ { "payer_name": "Aarp", "plan_name": "500102", "standard_charge_dollar": 182.02, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna", "plan_name": "700700", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna", "plan_name": "700700_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Mcare Ffs 6005", "plan_name": "700703", "standard_charge_dollar": 182.02, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Miscellaneous", "plan_name": "700720", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Miscellaneous", "plan_name": "700720_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Ppo Hmo", "plan_name": "701720", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Ppo Hmo", "plan_name": "701720_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Ambetter 68069", "plan_name": "500516", "standard_charge_dollar": 182.02, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Ms State Emplo", "plan_name": "401457", "standard_charge_dollar": 229.58, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Ms State Emplo", "plan_name": "401457_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Basic Pl", "plan_name": "400100", "standard_charge_dollar": 229.58, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Basic Pl", "plan_name": "400100_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Federal", "plan_name": "400110", "standard_charge_dollar": 229.58, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Federal", "plan_name": "400110_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Cigna Healthsprings Ffs", "plan_name": "500064", "standard_charge_dollar": 182.02, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Conseco", "plan_name": "500302", "standard_charge_dollar": 182.02, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Humana Ffs 61101", "plan_name": "500006", "standard_charge_dollar": 182.02, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Medicare A", "plan_name": "100100", "standard_charge_dollar": 182.02, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Medicare A", "plan_name": "100500", "standard_charge_dollar": 182.02, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Medicare Part B Only", "plan_name": "100300", "standard_charge_dollar": 182.02, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Medicare Railroad", "plan_name": "100103", "standard_charge_dollar": 182.02, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Ms Physicians Care N", "plan_name": "714210", "standard_charge_dollar": 227.53, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Peoples Hlth Ffs 72126", "plan_name": "500019", "standard_charge_dollar": 182.02, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Uhc/Secure Horizons", "plan_name": "500449", "standard_charge_dollar": 182.02, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "United Health Care/", "plan_name": "500292", "standard_charge_dollar": 205.69, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "United Healthcare", "plan_name": "750104", "standard_charge_dollar": 205.69, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "United Healthcare Ba", "plan_name": "750090", "standard_charge_dollar": 205.69, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "United Healthcare Me", "plan_name": "501310", "standard_charge_dollar": 182.02, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Windsor Mcare Extra", "plan_name": "500778", "standard_charge_dollar": 182.02, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." } ] } ] }, { "description": "Removal of nail plate", "code_information": [ { "code": "11730", "type": "CPT" } ], "standard_charges": [ { "gross_charge": 289.00, "minimum": 182.02, "maximum": 229.58, "setting": "both", "payers_information": [ { "payer_name": "Aarp", "plan_name": "500102", "standard_charge_dollar": 182.02, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna", "plan_name": "700700", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna", "plan_name": "700700_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Mcare Ffs 6005", "plan_name": "700703", "standard_charge_dollar": 182.02, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Miscellaneous", "plan_name": "700720", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Miscellaneous", "plan_name": "700720_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Ppo Hmo", "plan_name": "701720", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Ppo Hmo", "plan_name": "701720_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Ambetter 68069", "plan_name": "500516", "standard_charge_dollar": 182.02, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Ms State Emplo", "plan_name": "401457", "standard_charge_dollar": 229.58, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Ms State Emplo", "plan_name": "401457_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Basic Pl", "plan_name": "400100", "standard_charge_dollar": 229.58, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Basic Pl", "plan_name": "400100_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Federal", "plan_name": "400110", "standard_charge_dollar": 229.58, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Federal", "plan_name": "400110_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Cigna Healthsprings Ffs", "plan_name": "500064", "standard_charge_dollar": 182.02, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Conseco", "plan_name": "500302", "standard_charge_dollar": 182.02, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Humana Ffs 61101", "plan_name": "500006", "standard_charge_dollar": 182.02, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Medicare A", "plan_name": "100100", "standard_charge_dollar": 182.02, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Medicare A", "plan_name": "100500", "standard_charge_dollar": 182.02, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Medicare Part B Only", "plan_name": "100300", "standard_charge_dollar": 182.02, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Medicare Railroad", "plan_name": "100103", "standard_charge_dollar": 182.02, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Ms Physicians Care N", "plan_name": "714210", "standard_charge_dollar": 227.53, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Peoples Hlth Ffs 72126", "plan_name": "500019", "standard_charge_dollar": 182.02, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Uhc/Secure Horizons", "plan_name": "500449", "standard_charge_dollar": 182.02, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "United Health Care/", "plan_name": "500292", "standard_charge_dollar": 205.69, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "United Healthcare", "plan_name": "750104", "standard_charge_dollar": 205.69, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "United Healthcare Ba", "plan_name": "750090", "standard_charge_dollar": 205.69, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "United Healthcare Me", "plan_name": "501310", "standard_charge_dollar": 182.02, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Windsor Mcare Extra", "plan_name": "500778", "standard_charge_dollar": 182.02, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." } ] } ] }, { "description": "Hc removal of nail plate ea addtl", "code_information": [ { "code": "11732", "type": "CPT" } ], "standard_charges": [ { "gross_charge": 289.00, "minimum": 231.20, "maximum": 245.65, "setting": "both", "payers_information": [ { "payer_name": "Aetna", "plan_name": "700700", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna", "plan_name": "700700_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Miscellaneous", "plan_name": "700720", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Miscellaneous", "plan_name": "700720_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Ppo Hmo", "plan_name": "701720", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Ppo Hmo", "plan_name": "701720_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Ms State Emplo", "plan_name": "401457", "standard_charge_percentage": 0.80, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Ms State Emplo", "plan_name": "401457_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Basic Pl", "plan_name": "400100", "standard_charge_percentage": 0.85, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Basic Pl", "plan_name": "400100_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Federal", "plan_name": "400110", "standard_charge_percentage": 0.85, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Federal", "plan_name": "400110_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." } ] } ] }, { "description": "Remove nail plate add-on", "code_information": [ { "code": "11732", "type": "CPT" } ], "standard_charges": [ { "gross_charge": 289.00, "minimum": 231.20, "maximum": 245.65, "setting": "both", "payers_information": [ { "payer_name": "Aetna", "plan_name": "700700", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna", "plan_name": "700700_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Miscellaneous", "plan_name": "700720", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Miscellaneous", "plan_name": "700720_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Ppo Hmo", "plan_name": "701720", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Ppo Hmo", "plan_name": "701720_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Ms State Emplo", "plan_name": "401457", "standard_charge_percentage": 0.80, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Ms State Emplo", "plan_name": "401457_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Basic Pl", "plan_name": "400100", "standard_charge_percentage": 0.85, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Basic Pl", "plan_name": "400100_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Federal", "plan_name": "400110", "standard_charge_percentage": 0.85, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Federal", "plan_name": "400110_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." } ] } ] }, { "description": "Drain blood from under nail", "code_information": [ { "code": "11740", "type": "CPT" } ], "standard_charges": [ { "gross_charge": 186.00, "minimum": 81.80, "maximum": 147.60, "setting": "both", "payers_information": [ { "payer_name": "Aarp", "plan_name": "500102", "standard_charge_dollar": 118.08, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna", "plan_name": "700700", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna", "plan_name": "700700_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Mcare Ffs 6005", "plan_name": "700703", "standard_charge_dollar": 118.08, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Miscellaneous", "plan_name": "700720", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Miscellaneous", "plan_name": "700720_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Ppo Hmo", "plan_name": "701720", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Ppo Hmo", "plan_name": "701720_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Ambetter 68069", "plan_name": "500516", "standard_charge_dollar": 118.08, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Ms State Emplo", "plan_name": "401457", "standard_charge_dollar": 81.80, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Ms State Emplo", "plan_name": "401457_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Basic Pl", "plan_name": "400100", "standard_charge_dollar": 81.80, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Basic Pl", "plan_name": "400100_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Federal", "plan_name": "400110", "standard_charge_dollar": 81.80, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Federal", "plan_name": "400110_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Cigna Healthsprings Ffs", "plan_name": "500064", "standard_charge_dollar": 118.08, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Conseco", "plan_name": "500302", "standard_charge_dollar": 118.08, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Humana Ffs 61101", "plan_name": "500006", "standard_charge_dollar": 118.08, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Medicare A", "plan_name": "100100", "standard_charge_dollar": 118.08, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Medicare A", "plan_name": "100500", "standard_charge_dollar": 118.08, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Medicare Part B Only", "plan_name": "100300", "standard_charge_dollar": 118.08, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Medicare Railroad", "plan_name": "100103", "standard_charge_dollar": 118.08, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Ms Physicians Care N", "plan_name": "714210", "standard_charge_dollar": 147.60, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Peoples Hlth Ffs 72126", "plan_name": "500019", "standard_charge_dollar": 118.08, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Uhc/Secure Horizons", "plan_name": "500449", "standard_charge_dollar": 118.08, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "United Health Care/", "plan_name": "500292", "standard_charge_dollar": 133.43, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "United Healthcare", "plan_name": "750104", "standard_charge_dollar": 133.43, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "United Healthcare Ba", "plan_name": "750090", "standard_charge_dollar": 133.43, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "United Healthcare Me", "plan_name": "501310", "standard_charge_dollar": 118.08, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Windsor Mcare Extra", "plan_name": "500778", "standard_charge_dollar": 118.08, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." } ] } ] }, { "description": "Hc drainage subungual hematoma", "code_information": [ { "code": "11740", "type": "CPT" } ], "standard_charges": [ { "gross_charge": 186.00, "minimum": 81.80, "maximum": 147.60, "setting": "both", "payers_information": [ { "payer_name": "Aarp", "plan_name": "500102", "standard_charge_dollar": 118.08, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna", "plan_name": "700700", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna", "plan_name": "700700_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Mcare Ffs 6005", "plan_name": "700703", "standard_charge_dollar": 118.08, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Miscellaneous", "plan_name": "700720", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Miscellaneous", "plan_name": "700720_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Ppo Hmo", "plan_name": "701720", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Ppo Hmo", "plan_name": "701720_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Ambetter 68069", "plan_name": "500516", "standard_charge_dollar": 118.08, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Ms State Emplo", "plan_name": "401457", "standard_charge_dollar": 81.80, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Ms State Emplo", "plan_name": "401457_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Basic Pl", "plan_name": "400100", "standard_charge_dollar": 81.80, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Basic Pl", "plan_name": "400100_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Federal", "plan_name": "400110", "standard_charge_dollar": 81.80, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Federal", "plan_name": "400110_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Cigna Healthsprings Ffs", "plan_name": "500064", "standard_charge_dollar": 118.08, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Conseco", "plan_name": "500302", "standard_charge_dollar": 118.08, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Humana Ffs 61101", "plan_name": "500006", "standard_charge_dollar": 118.08, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Medicare A", "plan_name": "100100", "standard_charge_dollar": 118.08, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Medicare A", "plan_name": "100500", "standard_charge_dollar": 118.08, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Medicare Part B Only", "plan_name": "100300", "standard_charge_dollar": 118.08, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Medicare Railroad", "plan_name": "100103", "standard_charge_dollar": 118.08, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Ms Physicians Care N", "plan_name": "714210", "standard_charge_dollar": 147.60, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Peoples Hlth Ffs 72126", "plan_name": "500019", "standard_charge_dollar": 118.08, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Uhc/Secure Horizons", "plan_name": "500449", "standard_charge_dollar": 118.08, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "United Health Care/", "plan_name": "500292", "standard_charge_dollar": 133.43, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "United Healthcare", "plan_name": "750104", "standard_charge_dollar": 133.43, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "United Healthcare Ba", "plan_name": "750090", "standard_charge_dollar": 133.43, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "United Healthcare Me", "plan_name": "501310", "standard_charge_dollar": 118.08, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Windsor Mcare Extra", "plan_name": "500778", "standard_charge_dollar": 118.08, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." } ] } ] }, { "description": "Hc excision of nail-part or comp", "code_information": [ { "code": "11750", "type": "CPT" } ], "standard_charges": [ { "gross_charge": 597.00, "minimum": 366.00, "maximum": 507.45, "setting": "both", "payers_information": [ { "payer_name": "Aarp", "plan_name": "500102", "standard_charge_dollar": 366.00, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna", "plan_name": "700700", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna", "plan_name": "700700_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Mcare Ffs 6005", "plan_name": "700703", "standard_charge_dollar": 366.00, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Miscellaneous", "plan_name": "700720", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Miscellaneous", "plan_name": "700720_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Ppo Hmo", "plan_name": "701720", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Ppo Hmo", "plan_name": "701720_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Ambetter 68069", "plan_name": "500516", "standard_charge_dollar": 366.00, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Ms State Emplo", "plan_name": "401457", "standard_charge_percentage": 0.80, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Ms State Emplo", "plan_name": "401457_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Basic Pl", "plan_name": "400100", "standard_charge_percentage": 0.85, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Basic Pl", "plan_name": "400100_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Federal", "plan_name": "400110", "standard_charge_percentage": 0.85, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Federal", "plan_name": "400110_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Cigna Healthsprings Ffs", "plan_name": "500064", "standard_charge_dollar": 366.00, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Conseco", "plan_name": "500302", "standard_charge_dollar": 366.00, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Humana Ffs 61101", "plan_name": "500006", "standard_charge_dollar": 366.00, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Medicare A", "plan_name": "100100", "standard_charge_dollar": 366.00, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Medicare A", "plan_name": "100500", "standard_charge_dollar": 366.00, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Medicare Part B Only", "plan_name": "100300", "standard_charge_dollar": 366.00, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Medicare Railroad", "plan_name": "100103", "standard_charge_dollar": 366.00, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Ms Physicians Care N", "plan_name": "714210", "standard_charge_dollar": 457.50, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Peoples Hlth Ffs 72126", "plan_name": "500019", "standard_charge_dollar": 366.00, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Uhc/Secure Horizons", "plan_name": "500449", "standard_charge_dollar": 366.00, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "United Health Care/", "plan_name": "500292", "standard_charge_dollar": 413.58, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "United Healthcare", "plan_name": "750104", "standard_charge_dollar": 413.58, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "United Healthcare Ba", "plan_name": "750090", "standard_charge_dollar": 413.58, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "United Healthcare Me", "plan_name": "501310", "standard_charge_dollar": 366.00, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Windsor Mcare Extra", "plan_name": "500778", "standard_charge_dollar": 366.00, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." } ] } ] }, { "description": "Removal of nail bed", "code_information": [ { "code": "11750", "type": "CPT" } ], "standard_charges": [ { "gross_charge": 597.00, "minimum": 366.00, "maximum": 507.45, "setting": "both", "payers_information": [ { "payer_name": "Aarp", "plan_name": "500102", "standard_charge_dollar": 366.00, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna", "plan_name": "700700", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna", "plan_name": "700700_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Mcare Ffs 6005", "plan_name": "700703", "standard_charge_dollar": 366.00, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Miscellaneous", "plan_name": "700720", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Miscellaneous", "plan_name": "700720_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Ppo Hmo", "plan_name": "701720", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Ppo Hmo", "plan_name": "701720_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Ambetter 68069", "plan_name": "500516", "standard_charge_dollar": 366.00, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Ms State Emplo", "plan_name": "401457", "standard_charge_percentage": 0.80, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Ms State Emplo", "plan_name": "401457_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Basic Pl", "plan_name": "400100", "standard_charge_percentage": 0.85, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Basic Pl", "plan_name": "400100_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Federal", "plan_name": "400110", "standard_charge_percentage": 0.85, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Federal", "plan_name": "400110_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Cigna Healthsprings Ffs", "plan_name": "500064", "standard_charge_dollar": 366.00, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Conseco", "plan_name": "500302", "standard_charge_dollar": 366.00, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Humana Ffs 61101", "plan_name": "500006", "standard_charge_dollar": 366.00, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Medicare A", "plan_name": "100100", "standard_charge_dollar": 366.00, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Medicare A", "plan_name": "100500", "standard_charge_dollar": 366.00, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Medicare Part B Only", "plan_name": "100300", "standard_charge_dollar": 366.00, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Medicare Railroad", "plan_name": "100103", "standard_charge_dollar": 366.00, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Ms Physicians Care N", "plan_name": "714210", "standard_charge_dollar": 457.50, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Peoples Hlth Ffs 72126", "plan_name": "500019", "standard_charge_dollar": 366.00, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Uhc/Secure Horizons", "plan_name": "500449", "standard_charge_dollar": 366.00, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "United Health Care/", "plan_name": "500292", "standard_charge_dollar": 413.58, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "United Healthcare", "plan_name": "750104", "standard_charge_dollar": 413.58, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "United Healthcare Ba", "plan_name": "750090", "standard_charge_dollar": 413.58, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "United Healthcare Me", "plan_name": "501310", "standard_charge_dollar": 366.00, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Windsor Mcare Extra", "plan_name": "500778", "standard_charge_dollar": 366.00, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." } ] } ] }, { "description": "Remove pilonidal cyst exten", "code_information": [ { "code": "11771", "type": "CPT" } ], "standard_charges": [ { "gross_charge": 41044.87, "minimum": 2621.84, "maximum": 34888.14, "setting": "inpatient", "payers_information": [ { "payer_name": "Aarp", "plan_name": "500102", "standard_charge_dollar": 2621.84, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna", "plan_name": "700700", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna", "plan_name": "700700_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Mcare Ffs 6005", "plan_name": "700703", "standard_charge_dollar": 2621.84, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Miscellaneous", "plan_name": "700720", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Miscellaneous", "plan_name": "700720_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Ppo Hmo", "plan_name": "701720", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Ppo Hmo", "plan_name": "701720_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Ambetter 68069", "plan_name": "500516", "standard_charge_dollar": 2621.84, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Ms State Emplo", "plan_name": "401457", "standard_charge_percentage": 0.80, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Ms State Emplo", "plan_name": "401457_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Basic Pl", "plan_name": "400100", "standard_charge_percentage": 0.85, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Basic Pl", "plan_name": "400100_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Federal", "plan_name": "400110", "standard_charge_percentage": 0.85, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Federal", "plan_name": "400110_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Cigna Healthsprings Ffs", "plan_name": "500064", "standard_charge_dollar": 2621.84, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Conseco", "plan_name": "500302", "standard_charge_dollar": 2621.84, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Humana Ffs 61101", "plan_name": "500006", "standard_charge_dollar": 2621.84, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Medicare A", "plan_name": "100100", "standard_charge_dollar": 2621.84, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Medicare A", "plan_name": "100500", "standard_charge_dollar": 2621.84, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Medicare Part B Only", "plan_name": "100300", "standard_charge_dollar": 2621.84, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Medicare Railroad", "plan_name": "100103", "standard_charge_dollar": 2621.84, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Ms Physicians Care N", "plan_name": "714210", "standard_charge_dollar": 3277.29, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Peoples Hlth Ffs 72126", "plan_name": "500019", "standard_charge_dollar": 2621.84, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Uhc/Secure Horizons", "plan_name": "500449", "standard_charge_dollar": 2621.84, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "United Health Care/", "plan_name": "500292", "standard_charge_dollar": 2962.67, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "United Healthcare", "plan_name": "750104", "standard_charge_dollar": 2962.67, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "United Healthcare Ba", "plan_name": "750090", "standard_charge_dollar": 2962.67, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "United Healthcare Me", "plan_name": "501310", "standard_charge_dollar": 2621.84, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Windsor Mcare Extra", "plan_name": "500778", "standard_charge_dollar": 2621.84, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." } ] } ] }, { "description": "Remove pilonidal cyst compl", "code_information": [ { "code": "11772", "type": "CPT" } ], "standard_charges": [ { "gross_charge": 41044.87, "minimum": 2621.84, "maximum": 34888.14, "setting": "inpatient", "payers_information": [ { "payer_name": "Aarp", "plan_name": "500102", "standard_charge_dollar": 2621.84, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna", "plan_name": "700700", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna", "plan_name": "700700_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Mcare Ffs 6005", "plan_name": "700703", "standard_charge_dollar": 2621.84, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Miscellaneous", "plan_name": "700720", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Miscellaneous", "plan_name": "700720_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Ppo Hmo", "plan_name": "701720", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Ppo Hmo", "plan_name": "701720_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Ambetter 68069", "plan_name": "500516", "standard_charge_dollar": 2621.84, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Ms State Emplo", "plan_name": "401457", "standard_charge_percentage": 0.80, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Ms State Emplo", "plan_name": "401457_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Basic Pl", "plan_name": "400100", "standard_charge_percentage": 0.85, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Basic Pl", "plan_name": "400100_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Federal", "plan_name": "400110", "standard_charge_percentage": 0.85, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Federal", "plan_name": "400110_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Cigna Healthsprings Ffs", "plan_name": "500064", "standard_charge_dollar": 2621.84, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Conseco", "plan_name": "500302", "standard_charge_dollar": 2621.84, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Humana Ffs 61101", "plan_name": "500006", "standard_charge_dollar": 2621.84, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Medicare A", "plan_name": "100100", "standard_charge_dollar": 2621.84, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Medicare A", "plan_name": "100500", "standard_charge_dollar": 2621.84, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Medicare Part B Only", "plan_name": "100300", "standard_charge_dollar": 2621.84, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Medicare Railroad", "plan_name": "100103", "standard_charge_dollar": 2621.84, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Ms Physicians Care N", "plan_name": "714210", "standard_charge_dollar": 3277.29, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Peoples Hlth Ffs 72126", "plan_name": "500019", "standard_charge_dollar": 2621.84, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Uhc/Secure Horizons", "plan_name": "500449", "standard_charge_dollar": 2621.84, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "United Health Care/", "plan_name": "500292", "standard_charge_dollar": 2962.67, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "United Healthcare", "plan_name": "750104", "standard_charge_dollar": 2962.67, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "United Healthcare Ba", "plan_name": "750090", "standard_charge_dollar": 2962.67, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "United Healthcare Me", "plan_name": "501310", "standard_charge_dollar": 2621.84, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Windsor Mcare Extra", "plan_name": "500778", "standard_charge_dollar": 2621.84, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." } ] } ] }, { "description": "Thromboemb risk assessed", "code_information": [ { "code": "1180F", "type": "CPT" } ], "standard_charges": [ { "gross_charge": 7199.69, "minimum": 5759.75, "maximum": 6119.74, "setting": "inpatient", "payers_information": [ { "payer_name": "Aetna", "plan_name": "700700", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna", "plan_name": "700700_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Miscellaneous", "plan_name": "700720", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Miscellaneous", "plan_name": "700720_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Ppo Hmo", "plan_name": "701720", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Ppo Hmo", "plan_name": "701720_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Ms State Emplo", "plan_name": "401457", "standard_charge_percentage": 0.80, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Ms State Emplo", "plan_name": "401457_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Basic Pl", "plan_name": "400100", "standard_charge_percentage": 0.85, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Basic Pl", "plan_name": "400100_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Federal", "plan_name": "400110", "standard_charge_percentage": 0.85, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Federal", "plan_name": "400110_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." } ] } ] }, { "description": "Laceration simple", "code_information": [ { "code": "12001", "type": "CPT" } ], "standard_charges": [ { "gross_charge": 475.00, "minimum": 182.02, "maximum": 229.58, "setting": "both", "payers_information": [ { "payer_name": "Aarp", "plan_name": "500102", "standard_charge_dollar": 182.02, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna", "plan_name": "700700", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna", "plan_name": "700700_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Mcare Ffs 6005", "plan_name": "700703", "standard_charge_dollar": 182.02, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Miscellaneous", "plan_name": "700720", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Miscellaneous", "plan_name": "700720_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Ppo Hmo", "plan_name": "701720", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Ppo Hmo", "plan_name": "701720_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Ambetter 68069", "plan_name": "500516", "standard_charge_dollar": 182.02, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Ms State Emplo", "plan_name": "401457", "standard_charge_dollar": 229.58, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Ms State Emplo", "plan_name": "401457_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Basic Pl", "plan_name": "400100", "standard_charge_dollar": 229.58, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Basic Pl", "plan_name": "400100_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Federal", "plan_name": "400110", "standard_charge_dollar": 229.58, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Federal", "plan_name": "400110_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Cigna Healthsprings Ffs", "plan_name": "500064", "standard_charge_dollar": 182.02, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Conseco", "plan_name": "500302", "standard_charge_dollar": 182.02, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Humana Ffs 61101", "plan_name": "500006", "standard_charge_dollar": 182.02, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Medicare A", "plan_name": "100100", "standard_charge_dollar": 182.02, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Medicare A", "plan_name": "100500", "standard_charge_dollar": 182.02, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Medicare Part B Only", "plan_name": "100300", "standard_charge_dollar": 182.02, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Medicare Railroad", "plan_name": "100103", "standard_charge_dollar": 182.02, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Ms Physicians Care N", "plan_name": "714210", "standard_charge_dollar": 227.53, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Peoples Hlth Ffs 72126", "plan_name": "500019", "standard_charge_dollar": 182.02, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Uhc/Secure Horizons", "plan_name": "500449", "standard_charge_dollar": 182.02, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "United Health Care/", "plan_name": "500292", "standard_charge_dollar": 205.69, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "United Healthcare", "plan_name": "750104", "standard_charge_dollar": 205.69, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "United Healthcare Ba", "plan_name": "750090", "standard_charge_dollar": 205.69, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "United Healthcare Me", "plan_name": "501310", "standard_charge_dollar": 182.02, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Windsor Mcare Extra", "plan_name": "500778", "standard_charge_dollar": 182.02, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." } ] } ] }, { "description": "Rpr s/n/ax/gen/trnk 2.5cm/<", "code_information": [ { "code": "12001", "type": "CPT" } ], "standard_charges": [ { "gross_charge": 14578.29, "minimum": 182.02, "maximum": 229.58, "setting": "inpatient", "payers_information": [ { "payer_name": "Aarp", "plan_name": "500102", "standard_charge_dollar": 182.02, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna", "plan_name": "700700", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna", "plan_name": "700700_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Mcare Ffs 6005", "plan_name": "700703", "standard_charge_dollar": 182.02, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Miscellaneous", "plan_name": "700720", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Miscellaneous", "plan_name": "700720_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Ppo Hmo", "plan_name": "701720", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Ppo Hmo", "plan_name": "701720_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Ambetter 68069", "plan_name": "500516", "standard_charge_dollar": 182.02, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Ms State Emplo", "plan_name": "401457", "standard_charge_dollar": 229.58, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Ms State Emplo", "plan_name": "401457_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Basic Pl", "plan_name": "400100", "standard_charge_dollar": 229.58, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Basic Pl", "plan_name": "400100_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Federal", "plan_name": "400110", "standard_charge_dollar": 229.58, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Federal", "plan_name": "400110_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Cigna Healthsprings Ffs", "plan_name": "500064", "standard_charge_dollar": 182.02, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Conseco", "plan_name": "500302", "standard_charge_dollar": 182.02, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Humana Ffs 61101", "plan_name": "500006", "standard_charge_dollar": 182.02, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Medicare A", "plan_name": "100100", "standard_charge_dollar": 182.02, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Medicare A", "plan_name": "100500", "standard_charge_dollar": 182.02, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Medicare Part B Only", "plan_name": "100300", "standard_charge_dollar": 182.02, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Medicare Railroad", "plan_name": "100103", "standard_charge_dollar": 182.02, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Ms Physicians Care N", "plan_name": "714210", "standard_charge_dollar": 227.53, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Peoples Hlth Ffs 72126", "plan_name": "500019", "standard_charge_dollar": 182.02, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Uhc/Secure Horizons", "plan_name": "500449", "standard_charge_dollar": 182.02, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "United Health Care/", "plan_name": "500292", "standard_charge_dollar": 205.69, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "United Healthcare", "plan_name": "750104", "standard_charge_dollar": 205.69, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "United Healthcare Ba", "plan_name": "750090", "standard_charge_dollar": 205.69, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "United Healthcare Me", "plan_name": "501310", "standard_charge_dollar": 182.02, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Windsor Mcare Extra", "plan_name": "500778", "standard_charge_dollar": 182.02, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." } ] } ] }, { "description": "Rpr s/n/ax/gen/trnk 2.5cm/<", "code_information": [ { "code": "12001", "type": "CPT" } ], "standard_charges": [ { "gross_charge": 475.00, "minimum": 182.02, "maximum": 229.58, "setting": "outpatient", "payers_information": [ { "payer_name": "Aarp", "plan_name": "500102", "standard_charge_dollar": 182.02, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna", "plan_name": "700700", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna", "plan_name": "700700_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Mcare Ffs 6005", "plan_name": "700703", "standard_charge_dollar": 182.02, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Miscellaneous", "plan_name": "700720", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Miscellaneous", "plan_name": "700720_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Ppo Hmo", "plan_name": "701720", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Ppo Hmo", "plan_name": "701720_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Ambetter 68069", "plan_name": "500516", "standard_charge_dollar": 182.02, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Ms State Emplo", "plan_name": "401457", "standard_charge_dollar": 229.58, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Ms State Emplo", "plan_name": "401457_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Basic Pl", "plan_name": "400100", "standard_charge_dollar": 229.58, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Basic Pl", "plan_name": "400100_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Federal", "plan_name": "400110", "standard_charge_dollar": 229.58, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Federal", "plan_name": "400110_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Cigna Healthsprings Ffs", "plan_name": "500064", "standard_charge_dollar": 182.02, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Conseco", "plan_name": "500302", "standard_charge_dollar": 182.02, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Humana Ffs 61101", "plan_name": "500006", "standard_charge_dollar": 182.02, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Medicare A", "plan_name": "100100", "standard_charge_dollar": 182.02, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Medicare A", "plan_name": "100500", "standard_charge_dollar": 182.02, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Medicare Part B Only", "plan_name": "100300", "standard_charge_dollar": 182.02, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Medicare Railroad", "plan_name": "100103", "standard_charge_dollar": 182.02, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Ms Physicians Care N", "plan_name": "714210", "standard_charge_dollar": 227.53, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Peoples Hlth Ffs 72126", "plan_name": "500019", "standard_charge_dollar": 182.02, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Uhc/Secure Horizons", "plan_name": "500449", "standard_charge_dollar": 182.02, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "United Health Care/", "plan_name": "500292", "standard_charge_dollar": 205.69, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "United Healthcare", "plan_name": "750104", "standard_charge_dollar": 205.69, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "United Healthcare Ba", "plan_name": "750090", "standard_charge_dollar": 205.69, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "United Healthcare Me", "plan_name": "501310", "standard_charge_dollar": 182.02, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Windsor Mcare Extra", "plan_name": "500778", "standard_charge_dollar": 182.02, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." } ] } ] }, { "description": "Laceration simple", "code_information": [ { "code": "12002", "type": "CPT" } ], "standard_charges": [ { "gross_charge": 475.00, "minimum": 182.02, "maximum": 229.58, "setting": "both", "payers_information": [ { "payer_name": "Aarp", "plan_name": "500102", "standard_charge_dollar": 182.02, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna", "plan_name": "700700", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna", "plan_name": "700700_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Mcare Ffs 6005", "plan_name": "700703", "standard_charge_dollar": 182.02, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Miscellaneous", "plan_name": "700720", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Miscellaneous", "plan_name": "700720_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Ppo Hmo", "plan_name": "701720", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Ppo Hmo", "plan_name": "701720_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Ambetter 68069", "plan_name": "500516", "standard_charge_dollar": 182.02, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Ms State Emplo", "plan_name": "401457", "standard_charge_dollar": 229.58, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Ms State Emplo", "plan_name": "401457_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Basic Pl", "plan_name": "400100", "standard_charge_dollar": 229.58, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Basic Pl", "plan_name": "400100_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Federal", "plan_name": "400110", "standard_charge_dollar": 229.58, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Federal", "plan_name": "400110_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Cigna Healthsprings Ffs", "plan_name": "500064", "standard_charge_dollar": 182.02, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Conseco", "plan_name": "500302", "standard_charge_dollar": 182.02, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Humana Ffs 61101", "plan_name": "500006", "standard_charge_dollar": 182.02, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Medicare A", "plan_name": "100100", "standard_charge_dollar": 182.02, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Medicare A", "plan_name": "100500", "standard_charge_dollar": 182.02, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Medicare Part B Only", "plan_name": "100300", "standard_charge_dollar": 182.02, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Medicare Railroad", "plan_name": "100103", "standard_charge_dollar": 182.02, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Ms Physicians Care N", "plan_name": "714210", "standard_charge_dollar": 227.53, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Peoples Hlth Ffs 72126", "plan_name": "500019", "standard_charge_dollar": 182.02, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Uhc/Secure Horizons", "plan_name": "500449", "standard_charge_dollar": 182.02, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "United Health Care/", "plan_name": "500292", "standard_charge_dollar": 205.69, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "United Healthcare", "plan_name": "750104", "standard_charge_dollar": 205.69, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "United Healthcare Ba", "plan_name": "750090", "standard_charge_dollar": 205.69, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "United Healthcare Me", "plan_name": "501310", "standard_charge_dollar": 182.02, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Windsor Mcare Extra", "plan_name": "500778", "standard_charge_dollar": 182.02, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." } ] } ] }, { "description": "Rpr s/n/ax/gen/trnk2.6-7.5cm", "code_information": [ { "code": "12002", "type": "CPT" } ], "standard_charges": [ { "gross_charge": 14578.29, "minimum": 182.02, "maximum": 229.58, "setting": "inpatient", "payers_information": [ { "payer_name": "Aarp", "plan_name": "500102", "standard_charge_dollar": 182.02, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna", "plan_name": "700700", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna", "plan_name": "700700_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Mcare Ffs 6005", "plan_name": "700703", "standard_charge_dollar": 182.02, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Miscellaneous", "plan_name": "700720", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Miscellaneous", "plan_name": "700720_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Ppo Hmo", "plan_name": "701720", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Ppo Hmo", "plan_name": "701720_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Ambetter 68069", "plan_name": "500516", "standard_charge_dollar": 182.02, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Ms State Emplo", "plan_name": "401457", "standard_charge_dollar": 229.58, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Ms State Emplo", "plan_name": "401457_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Basic Pl", "plan_name": "400100", "standard_charge_dollar": 229.58, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Basic Pl", "plan_name": "400100_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Federal", "plan_name": "400110", "standard_charge_dollar": 229.58, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Federal", "plan_name": "400110_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Cigna Healthsprings Ffs", "plan_name": "500064", "standard_charge_dollar": 182.02, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Conseco", "plan_name": "500302", "standard_charge_dollar": 182.02, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Humana Ffs 61101", "plan_name": "500006", "standard_charge_dollar": 182.02, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Medicare A", "plan_name": "100100", "standard_charge_dollar": 182.02, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Medicare A", "plan_name": "100500", "standard_charge_dollar": 182.02, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Medicare Part B Only", "plan_name": "100300", "standard_charge_dollar": 182.02, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Medicare Railroad", "plan_name": "100103", "standard_charge_dollar": 182.02, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Ms Physicians Care N", "plan_name": "714210", "standard_charge_dollar": 227.53, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Peoples Hlth Ffs 72126", "plan_name": "500019", "standard_charge_dollar": 182.02, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Uhc/Secure Horizons", "plan_name": "500449", "standard_charge_dollar": 182.02, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "United Health Care/", "plan_name": "500292", "standard_charge_dollar": 205.69, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "United Healthcare", "plan_name": "750104", "standard_charge_dollar": 205.69, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "United Healthcare Ba", "plan_name": "750090", "standard_charge_dollar": 205.69, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "United Healthcare Me", "plan_name": "501310", "standard_charge_dollar": 182.02, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Windsor Mcare Extra", "plan_name": "500778", "standard_charge_dollar": 182.02, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." } ] } ] }, { "description": "Rpr s/n/ax/gen/trnk2.6-7.5cm", "code_information": [ { "code": "12002", "type": "CPT" } ], "standard_charges": [ { "gross_charge": 475.00, "minimum": 182.02, "maximum": 229.58, "setting": "outpatient", "payers_information": [ { "payer_name": "Aarp", "plan_name": "500102", "standard_charge_dollar": 182.02, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna", "plan_name": "700700", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna", "plan_name": "700700_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Mcare Ffs 6005", "plan_name": "700703", "standard_charge_dollar": 182.02, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Miscellaneous", "plan_name": "700720", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Miscellaneous", "plan_name": "700720_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Ppo Hmo", "plan_name": "701720", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Ppo Hmo", "plan_name": "701720_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Ambetter 68069", "plan_name": "500516", "standard_charge_dollar": 182.02, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Ms State Emplo", "plan_name": "401457", "standard_charge_dollar": 229.58, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Ms State Emplo", "plan_name": "401457_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Basic Pl", "plan_name": "400100", "standard_charge_dollar": 229.58, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Basic Pl", "plan_name": "400100_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Federal", "plan_name": "400110", "standard_charge_dollar": 229.58, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Federal", "plan_name": "400110_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Cigna Healthsprings Ffs", "plan_name": "500064", "standard_charge_dollar": 182.02, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Conseco", "plan_name": "500302", "standard_charge_dollar": 182.02, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Humana Ffs 61101", "plan_name": "500006", "standard_charge_dollar": 182.02, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Medicare A", "plan_name": "100100", "standard_charge_dollar": 182.02, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Medicare A", "plan_name": "100500", "standard_charge_dollar": 182.02, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Medicare Part B Only", "plan_name": "100300", "standard_charge_dollar": 182.02, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Medicare Railroad", "plan_name": "100103", "standard_charge_dollar": 182.02, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Ms Physicians Care N", "plan_name": "714210", "standard_charge_dollar": 227.53, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Peoples Hlth Ffs 72126", "plan_name": "500019", "standard_charge_dollar": 182.02, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Uhc/Secure Horizons", "plan_name": "500449", "standard_charge_dollar": 182.02, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "United Health Care/", "plan_name": "500292", "standard_charge_dollar": 205.69, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "United Healthcare", "plan_name": "750104", "standard_charge_dollar": 205.69, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "United Healthcare Ba", "plan_name": "750090", "standard_charge_dollar": 205.69, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "United Healthcare Me", "plan_name": "501310", "standard_charge_dollar": 182.02, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Windsor Mcare Extra", "plan_name": "500778", "standard_charge_dollar": 182.02, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." } ] } ] }, { "description": "Laceration simple", "code_information": [ { "code": "12004", "type": "CPT" } ], "standard_charges": [ { "gross_charge": 475.00, "minimum": 182.02, "maximum": 229.58, "setting": "both", "payers_information": [ { "payer_name": "Aarp", "plan_name": "500102", "standard_charge_dollar": 182.02, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna", "plan_name": "700700", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna", "plan_name": "700700_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Mcare Ffs 6005", "plan_name": "700703", "standard_charge_dollar": 182.02, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Miscellaneous", "plan_name": "700720", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Miscellaneous", "plan_name": "700720_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Ppo Hmo", "plan_name": "701720", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Ppo Hmo", "plan_name": "701720_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Ambetter 68069", "plan_name": "500516", "standard_charge_dollar": 182.02, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Ms State Emplo", "plan_name": "401457", "standard_charge_dollar": 229.58, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Ms State Emplo", "plan_name": "401457_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Basic Pl", "plan_name": "400100", "standard_charge_dollar": 229.58, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Basic Pl", "plan_name": "400100_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Federal", "plan_name": "400110", "standard_charge_dollar": 229.58, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Federal", "plan_name": "400110_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Cigna Healthsprings Ffs", "plan_name": "500064", "standard_charge_dollar": 182.02, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Conseco", "plan_name": "500302", "standard_charge_dollar": 182.02, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Humana Ffs 61101", "plan_name": "500006", "standard_charge_dollar": 182.02, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Medicare A", "plan_name": "100100", "standard_charge_dollar": 182.02, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Medicare A", "plan_name": "100500", "standard_charge_dollar": 182.02, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Medicare Part B Only", "plan_name": "100300", "standard_charge_dollar": 182.02, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Medicare Railroad", "plan_name": "100103", "standard_charge_dollar": 182.02, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Ms Physicians Care N", "plan_name": "714210", "standard_charge_dollar": 227.53, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Peoples Hlth Ffs 72126", "plan_name": "500019", "standard_charge_dollar": 182.02, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Uhc/Secure Horizons", "plan_name": "500449", "standard_charge_dollar": 182.02, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "United Health Care/", "plan_name": "500292", "standard_charge_dollar": 205.69, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "United Healthcare", "plan_name": "750104", "standard_charge_dollar": 205.69, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "United Healthcare Ba", "plan_name": "750090", "standard_charge_dollar": 205.69, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "United Healthcare Me", "plan_name": "501310", "standard_charge_dollar": 182.02, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Windsor Mcare Extra", "plan_name": "500778", "standard_charge_dollar": 182.02, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." } ] } ] }, { "description": "Rpr s/n/ax/gen/trk7.6-12.5cm", "code_information": [ { "code": "12004", "type": "CPT" } ], "standard_charges": [ { "gross_charge": 14578.29, "minimum": 182.02, "maximum": 229.58, "setting": "inpatient", "payers_information": [ { "payer_name": "Aarp", "plan_name": "500102", "standard_charge_dollar": 182.02, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna", "plan_name": "700700", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna", "plan_name": "700700_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Mcare Ffs 6005", "plan_name": "700703", "standard_charge_dollar": 182.02, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Miscellaneous", "plan_name": "700720", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Miscellaneous", "plan_name": "700720_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Ppo Hmo", "plan_name": "701720", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Ppo Hmo", "plan_name": "701720_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Ambetter 68069", "plan_name": "500516", "standard_charge_dollar": 182.02, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Ms State Emplo", "plan_name": "401457", "standard_charge_dollar": 229.58, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Ms State Emplo", "plan_name": "401457_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Basic Pl", "plan_name": "400100", "standard_charge_dollar": 229.58, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Basic Pl", "plan_name": "400100_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Federal", "plan_name": "400110", "standard_charge_dollar": 229.58, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Federal", "plan_name": "400110_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Cigna Healthsprings Ffs", "plan_name": "500064", "standard_charge_dollar": 182.02, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Conseco", "plan_name": "500302", "standard_charge_dollar": 182.02, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Humana Ffs 61101", "plan_name": "500006", "standard_charge_dollar": 182.02, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Medicare A", "plan_name": "100100", "standard_charge_dollar": 182.02, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Medicare A", "plan_name": "100500", "standard_charge_dollar": 182.02, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Medicare Part B Only", "plan_name": "100300", "standard_charge_dollar": 182.02, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Medicare Railroad", "plan_name": "100103", "standard_charge_dollar": 182.02, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Ms Physicians Care N", "plan_name": "714210", "standard_charge_dollar": 227.53, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Peoples Hlth Ffs 72126", "plan_name": "500019", "standard_charge_dollar": 182.02, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Uhc/Secure Horizons", "plan_name": "500449", "standard_charge_dollar": 182.02, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "United Health Care/", "plan_name": "500292", "standard_charge_dollar": 205.69, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "United Healthcare", "plan_name": "750104", "standard_charge_dollar": 205.69, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "United Healthcare Ba", "plan_name": "750090", "standard_charge_dollar": 205.69, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "United Healthcare Me", "plan_name": "501310", "standard_charge_dollar": 182.02, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Windsor Mcare Extra", "plan_name": "500778", "standard_charge_dollar": 182.02, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." } ] } ] }, { "description": "Rpr s/n/ax/gen/trk7.6-12.5cm", "code_information": [ { "code": "12004", "type": "CPT" } ], "standard_charges": [ { "gross_charge": 475.00, "minimum": 182.02, "maximum": 229.58, "setting": "outpatient", "payers_information": [ { "payer_name": "Aarp", "plan_name": "500102", "standard_charge_dollar": 182.02, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna", "plan_name": "700700", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna", "plan_name": "700700_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Mcare Ffs 6005", "plan_name": "700703", "standard_charge_dollar": 182.02, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Miscellaneous", "plan_name": "700720", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Miscellaneous", "plan_name": "700720_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Ppo Hmo", "plan_name": "701720", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Ppo Hmo", "plan_name": "701720_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Ambetter 68069", "plan_name": "500516", "standard_charge_dollar": 182.02, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Ms State Emplo", "plan_name": "401457", "standard_charge_dollar": 229.58, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Ms State Emplo", "plan_name": "401457_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Basic Pl", "plan_name": "400100", "standard_charge_dollar": 229.58, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Basic Pl", "plan_name": "400100_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Federal", "plan_name": "400110", "standard_charge_dollar": 229.58, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Federal", "plan_name": "400110_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Cigna Healthsprings Ffs", "plan_name": "500064", "standard_charge_dollar": 182.02, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Conseco", "plan_name": "500302", "standard_charge_dollar": 182.02, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Humana Ffs 61101", "plan_name": "500006", "standard_charge_dollar": 182.02, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Medicare A", "plan_name": "100100", "standard_charge_dollar": 182.02, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Medicare A", "plan_name": "100500", "standard_charge_dollar": 182.02, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Medicare Part B Only", "plan_name": "100300", "standard_charge_dollar": 182.02, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Medicare Railroad", "plan_name": "100103", "standard_charge_dollar": 182.02, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Ms Physicians Care N", "plan_name": "714210", "standard_charge_dollar": 227.53, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Peoples Hlth Ffs 72126", "plan_name": "500019", "standard_charge_dollar": 182.02, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Uhc/Secure Horizons", "plan_name": "500449", "standard_charge_dollar": 182.02, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "United Health Care/", "plan_name": "500292", "standard_charge_dollar": 205.69, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "United Healthcare", "plan_name": "750104", "standard_charge_dollar": 205.69, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "United Healthcare Ba", "plan_name": "750090", "standard_charge_dollar": 205.69, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "United Healthcare Me", "plan_name": "501310", "standard_charge_dollar": 182.02, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Windsor Mcare Extra", "plan_name": "500778", "standard_charge_dollar": 182.02, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." } ] } ] }, { "description": "Laceration simple", "code_information": [ { "code": "12005", "type": "CPT" } ], "standard_charges": [ { "gross_charge": 475.00, "minimum": 366.00, "maximum": 457.50, "setting": "both", "payers_information": [ { "payer_name": "Aarp", "plan_name": "500102", "standard_charge_dollar": 366.00, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna", "plan_name": "700700", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna", "plan_name": "700700_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Mcare Ffs 6005", "plan_name": "700703", "standard_charge_dollar": 366.00, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Miscellaneous", "plan_name": "700720", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Miscellaneous", "plan_name": "700720_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Ppo Hmo", "plan_name": "701720", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Ppo Hmo", "plan_name": "701720_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Ambetter 68069", "plan_name": "500516", "standard_charge_dollar": 366.00, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Ms State Emplo", "plan_name": "401457", "standard_charge_dollar": 438.74, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Ms State Emplo", "plan_name": "401457_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Basic Pl", "plan_name": "400100", "standard_charge_dollar": 438.74, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Basic Pl", "plan_name": "400100_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Federal", "plan_name": "400110", "standard_charge_dollar": 438.74, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Federal", "plan_name": "400110_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Cigna Healthsprings Ffs", "plan_name": "500064", "standard_charge_dollar": 366.00, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Conseco", "plan_name": "500302", "standard_charge_dollar": 366.00, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Humana Ffs 61101", "plan_name": "500006", "standard_charge_dollar": 366.00, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Medicare A", "plan_name": "100100", "standard_charge_dollar": 366.00, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Medicare A", "plan_name": "100500", "standard_charge_dollar": 366.00, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Medicare Part B Only", "plan_name": "100300", "standard_charge_dollar": 366.00, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Medicare Railroad", "plan_name": "100103", "standard_charge_dollar": 366.00, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Ms Physicians Care N", "plan_name": "714210", "standard_charge_dollar": 457.50, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Peoples Hlth Ffs 72126", "plan_name": "500019", "standard_charge_dollar": 366.00, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Uhc/Secure Horizons", "plan_name": "500449", "standard_charge_dollar": 366.00, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "United Health Care/", "plan_name": "500292", "standard_charge_dollar": 413.58, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "United Healthcare", "plan_name": "750104", "standard_charge_dollar": 413.58, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "United Healthcare Ba", "plan_name": "750090", "standard_charge_dollar": 413.58, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "United Healthcare Me", "plan_name": "501310", "standard_charge_dollar": 366.00, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Windsor Mcare Extra", "plan_name": "500778", "standard_charge_dollar": 366.00, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." } ] } ] }, { "description": "Rpr s/n/a/gen/trk12.6-20.0cm", "code_information": [ { "code": "12005", "type": "CPT" } ], "standard_charges": [ { "gross_charge": 14578.29, "minimum": 366.00, "maximum": 457.50, "setting": "inpatient", "payers_information": [ { "payer_name": "Aarp", "plan_name": "500102", "standard_charge_dollar": 366.00, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna", "plan_name": "700700", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna", "plan_name": "700700_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Mcare Ffs 6005", "plan_name": "700703", "standard_charge_dollar": 366.00, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Miscellaneous", "plan_name": "700720", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Miscellaneous", "plan_name": "700720_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Ppo Hmo", "plan_name": "701720", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Ppo Hmo", "plan_name": "701720_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Ambetter 68069", "plan_name": "500516", "standard_charge_dollar": 366.00, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Ms State Emplo", "plan_name": "401457", "standard_charge_dollar": 438.74, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Ms State Emplo", "plan_name": "401457_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Basic Pl", "plan_name": "400100", "standard_charge_dollar": 438.74, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Basic Pl", "plan_name": "400100_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Federal", "plan_name": "400110", "standard_charge_dollar": 438.74, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Federal", "plan_name": "400110_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Cigna Healthsprings Ffs", "plan_name": "500064", "standard_charge_dollar": 366.00, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Conseco", "plan_name": "500302", "standard_charge_dollar": 366.00, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Humana Ffs 61101", "plan_name": "500006", "standard_charge_dollar": 366.00, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Medicare A", "plan_name": "100100", "standard_charge_dollar": 366.00, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Medicare A", "plan_name": "100500", "standard_charge_dollar": 366.00, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Medicare Part B Only", "plan_name": "100300", "standard_charge_dollar": 366.00, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Medicare Railroad", "plan_name": "100103", "standard_charge_dollar": 366.00, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Ms Physicians Care N", "plan_name": "714210", "standard_charge_dollar": 457.50, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Peoples Hlth Ffs 72126", "plan_name": "500019", "standard_charge_dollar": 366.00, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Uhc/Secure Horizons", "plan_name": "500449", "standard_charge_dollar": 366.00, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "United Health Care/", "plan_name": "500292", "standard_charge_dollar": 413.58, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "United Healthcare", "plan_name": "750104", "standard_charge_dollar": 413.58, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "United Healthcare Ba", "plan_name": "750090", "standard_charge_dollar": 413.58, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "United Healthcare Me", "plan_name": "501310", "standard_charge_dollar": 366.00, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Windsor Mcare Extra", "plan_name": "500778", "standard_charge_dollar": 366.00, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." } ] } ] }, { "description": "Rpr s/n/a/gen/trk12.6-20.0cm", "code_information": [ { "code": "12005", "type": "CPT" } ], "standard_charges": [ { "gross_charge": 475.00, "minimum": 366.00, "maximum": 457.50, "setting": "outpatient", "payers_information": [ { "payer_name": "Aarp", "plan_name": "500102", "standard_charge_dollar": 366.00, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna", "plan_name": "700700", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna", "plan_name": "700700_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Mcare Ffs 6005", "plan_name": "700703", "standard_charge_dollar": 366.00, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Miscellaneous", "plan_name": "700720", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Miscellaneous", "plan_name": "700720_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Ppo Hmo", "plan_name": "701720", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Ppo Hmo", "plan_name": "701720_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Ambetter 68069", "plan_name": "500516", "standard_charge_dollar": 366.00, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Ms State Emplo", "plan_name": "401457", "standard_charge_dollar": 438.74, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Ms State Emplo", "plan_name": "401457_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Basic Pl", "plan_name": "400100", "standard_charge_dollar": 438.74, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Basic Pl", "plan_name": "400100_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Federal", "plan_name": "400110", "standard_charge_dollar": 438.74, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Federal", "plan_name": "400110_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Cigna Healthsprings Ffs", "plan_name": "500064", "standard_charge_dollar": 366.00, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Conseco", "plan_name": "500302", "standard_charge_dollar": 366.00, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Humana Ffs 61101", "plan_name": "500006", "standard_charge_dollar": 366.00, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Medicare A", "plan_name": "100100", "standard_charge_dollar": 366.00, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Medicare A", "plan_name": "100500", "standard_charge_dollar": 366.00, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Medicare Part B Only", "plan_name": "100300", "standard_charge_dollar": 366.00, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Medicare Railroad", "plan_name": "100103", "standard_charge_dollar": 366.00, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Ms Physicians Care N", "plan_name": "714210", "standard_charge_dollar": 457.50, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Peoples Hlth Ffs 72126", "plan_name": "500019", "standard_charge_dollar": 366.00, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Uhc/Secure Horizons", "plan_name": "500449", "standard_charge_dollar": 366.00, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "United Health Care/", "plan_name": "500292", "standard_charge_dollar": 413.58, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "United Healthcare", "plan_name": "750104", "standard_charge_dollar": 413.58, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "United Healthcare Ba", "plan_name": "750090", "standard_charge_dollar": 413.58, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "United Healthcare Me", "plan_name": "501310", "standard_charge_dollar": 366.00, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Windsor Mcare Extra", "plan_name": "500778", "standard_charge_dollar": 366.00, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." } ] } ] }, { "description": "Laceration simple", "code_information": [ { "code": "12006", "type": "CPT" } ], "standard_charges": [ { "gross_charge": 475.00, "minimum": 366.00, "maximum": 457.50, "setting": "both", "payers_information": [ { "payer_name": "Aarp", "plan_name": "500102", "standard_charge_dollar": 366.00, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna", "plan_name": "700700", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna", "plan_name": "700700_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Mcare Ffs 6005", "plan_name": "700703", "standard_charge_dollar": 366.00, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Miscellaneous", "plan_name": "700720", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Miscellaneous", "plan_name": "700720_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Ppo Hmo", "plan_name": "701720", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Ppo Hmo", "plan_name": "701720_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Ambetter 68069", "plan_name": "500516", "standard_charge_dollar": 366.00, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Ms State Emplo", "plan_name": "401457", "standard_charge_dollar": 438.74, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Ms State Emplo", "plan_name": "401457_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Basic Pl", "plan_name": "400100", "standard_charge_dollar": 438.74, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Basic Pl", "plan_name": "400100_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Federal", "plan_name": "400110", "standard_charge_dollar": 438.74, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Federal", "plan_name": "400110_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Cigna Healthsprings Ffs", "plan_name": "500064", "standard_charge_dollar": 366.00, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Conseco", "plan_name": "500302", "standard_charge_dollar": 366.00, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Humana Ffs 61101", "plan_name": "500006", "standard_charge_dollar": 366.00, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Medicare A", "plan_name": "100100", "standard_charge_dollar": 366.00, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Medicare A", "plan_name": "100500", "standard_charge_dollar": 366.00, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Medicare Part B Only", "plan_name": "100300", "standard_charge_dollar": 366.00, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Medicare Railroad", "plan_name": "100103", "standard_charge_dollar": 366.00, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Ms Physicians Care N", "plan_name": "714210", "standard_charge_dollar": 457.50, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Peoples Hlth Ffs 72126", "plan_name": "500019", "standard_charge_dollar": 366.00, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Uhc/Secure Horizons", "plan_name": "500449", "standard_charge_dollar": 366.00, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "United Health Care/", "plan_name": "500292", "standard_charge_dollar": 413.58, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "United Healthcare", "plan_name": "750104", "standard_charge_dollar": 413.58, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "United Healthcare Ba", "plan_name": "750090", "standard_charge_dollar": 413.58, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "United Healthcare Me", "plan_name": "501310", "standard_charge_dollar": 366.00, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Windsor Mcare Extra", "plan_name": "500778", "standard_charge_dollar": 366.00, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." } ] } ] }, { "description": "Rpr s/n/a/gen/trk20.1-30.0cm", "code_information": [ { "code": "12006", "type": "CPT" } ], "standard_charges": [ { "gross_charge": 14578.29, "minimum": 366.00, "maximum": 457.50, "setting": "inpatient", "payers_information": [ { "payer_name": "Aarp", "plan_name": "500102", "standard_charge_dollar": 366.00, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna", "plan_name": "700700", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna", "plan_name": "700700_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Mcare Ffs 6005", "plan_name": "700703", "standard_charge_dollar": 366.00, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Miscellaneous", "plan_name": "700720", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Miscellaneous", "plan_name": "700720_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Ppo Hmo", "plan_name": "701720", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Ppo Hmo", "plan_name": "701720_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Ambetter 68069", "plan_name": "500516", "standard_charge_dollar": 366.00, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Ms State Emplo", "plan_name": "401457", "standard_charge_dollar": 438.74, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Ms State Emplo", "plan_name": "401457_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Basic Pl", "plan_name": "400100", "standard_charge_dollar": 438.74, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Basic Pl", "plan_name": "400100_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Federal", "plan_name": "400110", "standard_charge_dollar": 438.74, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Federal", "plan_name": "400110_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Cigna Healthsprings Ffs", "plan_name": "500064", "standard_charge_dollar": 366.00, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Conseco", "plan_name": "500302", "standard_charge_dollar": 366.00, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Humana Ffs 61101", "plan_name": "500006", "standard_charge_dollar": 366.00, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Medicare A", "plan_name": "100100", "standard_charge_dollar": 366.00, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Medicare A", "plan_name": "100500", "standard_charge_dollar": 366.00, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Medicare Part B Only", "plan_name": "100300", "standard_charge_dollar": 366.00, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Medicare Railroad", "plan_name": "100103", "standard_charge_dollar": 366.00, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Ms Physicians Care N", "plan_name": "714210", "standard_charge_dollar": 457.50, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Peoples Hlth Ffs 72126", "plan_name": "500019", "standard_charge_dollar": 366.00, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Uhc/Secure Horizons", "plan_name": "500449", "standard_charge_dollar": 366.00, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "United Health Care/", "plan_name": "500292", "standard_charge_dollar": 413.58, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "United Healthcare", "plan_name": "750104", "standard_charge_dollar": 413.58, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "United Healthcare Ba", "plan_name": "750090", "standard_charge_dollar": 413.58, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "United Healthcare Me", "plan_name": "501310", "standard_charge_dollar": 366.00, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Windsor Mcare Extra", "plan_name": "500778", "standard_charge_dollar": 366.00, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." } ] } ] }, { "description": "Rpr s/n/a/gen/trk20.1-30.0cm", "code_information": [ { "code": "12006", "type": "CPT" } ], "standard_charges": [ { "gross_charge": 475.00, "minimum": 366.00, "maximum": 457.50, "setting": "outpatient", "payers_information": [ { "payer_name": "Aarp", "plan_name": "500102", "standard_charge_dollar": 366.00, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna", "plan_name": "700700", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna", "plan_name": "700700_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Mcare Ffs 6005", "plan_name": "700703", "standard_charge_dollar": 366.00, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Miscellaneous", "plan_name": "700720", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Miscellaneous", "plan_name": "700720_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Ppo Hmo", "plan_name": "701720", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Ppo Hmo", "plan_name": "701720_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Ambetter 68069", "plan_name": "500516", "standard_charge_dollar": 366.00, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Ms State Emplo", "plan_name": "401457", "standard_charge_dollar": 438.74, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Ms State Emplo", "plan_name": "401457_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Basic Pl", "plan_name": "400100", "standard_charge_dollar": 438.74, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Basic Pl", "plan_name": "400100_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Federal", "plan_name": "400110", "standard_charge_dollar": 438.74, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Federal", "plan_name": "400110_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Cigna Healthsprings Ffs", "plan_name": "500064", "standard_charge_dollar": 366.00, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Conseco", "plan_name": "500302", "standard_charge_dollar": 366.00, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Humana Ffs 61101", "plan_name": "500006", "standard_charge_dollar": 366.00, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Medicare A", "plan_name": "100100", "standard_charge_dollar": 366.00, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Medicare A", "plan_name": "100500", "standard_charge_dollar": 366.00, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Medicare Part B Only", "plan_name": "100300", "standard_charge_dollar": 366.00, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Medicare Railroad", "plan_name": "100103", "standard_charge_dollar": 366.00, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Ms Physicians Care N", "plan_name": "714210", "standard_charge_dollar": 457.50, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Peoples Hlth Ffs 72126", "plan_name": "500019", "standard_charge_dollar": 366.00, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Uhc/Secure Horizons", "plan_name": "500449", "standard_charge_dollar": 366.00, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "United Health Care/", "plan_name": "500292", "standard_charge_dollar": 413.58, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "United Healthcare", "plan_name": "750104", "standard_charge_dollar": 413.58, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "United Healthcare Ba", "plan_name": "750090", "standard_charge_dollar": 413.58, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "United Healthcare Me", "plan_name": "501310", "standard_charge_dollar": 366.00, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Windsor Mcare Extra", "plan_name": "500778", "standard_charge_dollar": 366.00, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." } ] } ] }, { "description": "Laceration simple", "code_information": [ { "code": "12007", "type": "CPT" } ], "standard_charges": [ { "gross_charge": 475.00, "minimum": 182.02, "maximum": 403.75, "setting": "both", "payers_information": [ { "payer_name": "Aarp", "plan_name": "500102", "standard_charge_dollar": 182.02, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna", "plan_name": "700700", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna", "plan_name": "700700_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Mcare Ffs 6005", "plan_name": "700703", "standard_charge_dollar": 182.02, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Miscellaneous", "plan_name": "700720", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Miscellaneous", "plan_name": "700720_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Ppo Hmo", "plan_name": "701720", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Ppo Hmo", "plan_name": "701720_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Ambetter 68069", "plan_name": "500516", "standard_charge_dollar": 182.02, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Ms State Emplo", "plan_name": "401457", "standard_charge_percentage": 0.80, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Ms State Emplo", "plan_name": "401457_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Basic Pl", "plan_name": "400100", "standard_charge_percentage": 0.85, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Basic Pl", "plan_name": "400100_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Federal", "plan_name": "400110", "standard_charge_percentage": 0.85, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Federal", "plan_name": "400110_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Cigna Healthsprings Ffs", "plan_name": "500064", "standard_charge_dollar": 182.02, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Conseco", "plan_name": "500302", "standard_charge_dollar": 182.02, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Humana Ffs 61101", "plan_name": "500006", "standard_charge_dollar": 182.02, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Medicare A", "plan_name": "100100", "standard_charge_dollar": 182.02, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Medicare A", "plan_name": "100500", "standard_charge_dollar": 182.02, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Medicare Part B Only", "plan_name": "100300", "standard_charge_dollar": 182.02, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Medicare Railroad", "plan_name": "100103", "standard_charge_dollar": 182.02, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Ms Physicians Care N", "plan_name": "714210", "standard_charge_dollar": 227.53, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Peoples Hlth Ffs 72126", "plan_name": "500019", "standard_charge_dollar": 182.02, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Uhc/Secure Horizons", "plan_name": "500449", "standard_charge_dollar": 182.02, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "United Health Care/", "plan_name": "500292", "standard_charge_dollar": 205.69, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "United Healthcare", "plan_name": "750104", "standard_charge_dollar": 205.69, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "United Healthcare Ba", "plan_name": "750090", "standard_charge_dollar": 205.69, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "United Healthcare Me", "plan_name": "501310", "standard_charge_dollar": 182.02, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Windsor Mcare Extra", "plan_name": "500778", "standard_charge_dollar": 182.02, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." } ] } ] }, { "description": "Rpr s/n/ax/gen/trnk >30.0 cm", "code_information": [ { "code": "12007", "type": "CPT" } ], "standard_charges": [ { "gross_charge": 14578.29, "minimum": 182.02, "maximum": 12391.55, "setting": "inpatient", "payers_information": [ { "payer_name": "Aarp", "plan_name": "500102", "standard_charge_dollar": 182.02, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna", "plan_name": "700700", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna", "plan_name": "700700_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Mcare Ffs 6005", "plan_name": "700703", "standard_charge_dollar": 182.02, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Miscellaneous", "plan_name": "700720", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Miscellaneous", "plan_name": "700720_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Ppo Hmo", "plan_name": "701720", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Ppo Hmo", "plan_name": "701720_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Ambetter 68069", "plan_name": "500516", "standard_charge_dollar": 182.02, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Ms State Emplo", "plan_name": "401457", "standard_charge_percentage": 0.80, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Ms State Emplo", "plan_name": "401457_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Basic Pl", "plan_name": "400100", "standard_charge_percentage": 0.85, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Basic Pl", "plan_name": "400100_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Federal", "plan_name": "400110", "standard_charge_percentage": 0.85, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Federal", "plan_name": "400110_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Cigna Healthsprings Ffs", "plan_name": "500064", "standard_charge_dollar": 182.02, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Conseco", "plan_name": "500302", "standard_charge_dollar": 182.02, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Humana Ffs 61101", "plan_name": "500006", "standard_charge_dollar": 182.02, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Medicare A", "plan_name": "100100", "standard_charge_dollar": 182.02, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Medicare A", "plan_name": "100500", "standard_charge_dollar": 182.02, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Medicare Part B Only", "plan_name": "100300", "standard_charge_dollar": 182.02, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Medicare Railroad", "plan_name": "100103", "standard_charge_dollar": 182.02, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Ms Physicians Care N", "plan_name": "714210", "standard_charge_dollar": 227.53, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Peoples Hlth Ffs 72126", "plan_name": "500019", "standard_charge_dollar": 182.02, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Uhc/Secure Horizons", "plan_name": "500449", "standard_charge_dollar": 182.02, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "United Health Care/", "plan_name": "500292", "standard_charge_dollar": 205.69, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "United Healthcare", "plan_name": "750104", "standard_charge_dollar": 205.69, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "United Healthcare Ba", "plan_name": "750090", "standard_charge_dollar": 205.69, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "United Healthcare Me", "plan_name": "501310", "standard_charge_dollar": 182.02, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Windsor Mcare Extra", "plan_name": "500778", "standard_charge_dollar": 182.02, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." } ] } ] }, { "description": "Rpr s/n/ax/gen/trnk >30.0 cm", "code_information": [ { "code": "12007", "type": "CPT" } ], "standard_charges": [ { "gross_charge": 475.00, "minimum": 182.02, "maximum": 403.75, "setting": "outpatient", "payers_information": [ { "payer_name": "Aarp", "plan_name": "500102", "standard_charge_dollar": 182.02, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna", "plan_name": "700700", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna", "plan_name": "700700_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Mcare Ffs 6005", "plan_name": "700703", "standard_charge_dollar": 182.02, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Miscellaneous", "plan_name": "700720", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Miscellaneous", "plan_name": "700720_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Ppo Hmo", "plan_name": "701720", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Ppo Hmo", "plan_name": "701720_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Ambetter 68069", "plan_name": "500516", "standard_charge_dollar": 182.02, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Ms State Emplo", "plan_name": "401457", "standard_charge_percentage": 0.80, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Ms State Emplo", "plan_name": "401457_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Basic Pl", "plan_name": "400100", "standard_charge_percentage": 0.85, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Basic Pl", "plan_name": "400100_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Federal", "plan_name": "400110", "standard_charge_percentage": 0.85, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Federal", "plan_name": "400110_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Cigna Healthsprings Ffs", "plan_name": "500064", "standard_charge_dollar": 182.02, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Conseco", "plan_name": "500302", "standard_charge_dollar": 182.02, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Humana Ffs 61101", "plan_name": "500006", "standard_charge_dollar": 182.02, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Medicare A", "plan_name": "100100", "standard_charge_dollar": 182.02, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Medicare A", "plan_name": "100500", "standard_charge_dollar": 182.02, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Medicare Part B Only", "plan_name": "100300", "standard_charge_dollar": 182.02, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Medicare Railroad", "plan_name": "100103", "standard_charge_dollar": 182.02, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Ms Physicians Care N", "plan_name": "714210", "standard_charge_dollar": 227.53, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Peoples Hlth Ffs 72126", "plan_name": "500019", "standard_charge_dollar": 182.02, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Uhc/Secure Horizons", "plan_name": "500449", "standard_charge_dollar": 182.02, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "United Health Care/", "plan_name": "500292", "standard_charge_dollar": 205.69, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "United Healthcare", "plan_name": "750104", "standard_charge_dollar": 205.69, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "United Healthcare Ba", "plan_name": "750090", "standard_charge_dollar": 205.69, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "United Healthcare Me", "plan_name": "501310", "standard_charge_dollar": 182.02, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Windsor Mcare Extra", "plan_name": "500778", "standard_charge_dollar": 182.02, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." } ] } ] }, { "description": "Laceration simple", "code_information": [ { "code": "12011", "type": "CPT" } ], "standard_charges": [ { "gross_charge": 475.00, "minimum": 182.02, "maximum": 229.58, "setting": "both", "payers_information": [ { "payer_name": "Aarp", "plan_name": "500102", "standard_charge_dollar": 182.02, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna", "plan_name": "700700", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna", "plan_name": "700700_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Mcare Ffs 6005", "plan_name": "700703", "standard_charge_dollar": 182.02, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Miscellaneous", "plan_name": "700720", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Miscellaneous", "plan_name": "700720_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Ppo Hmo", "plan_name": "701720", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Ppo Hmo", "plan_name": "701720_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Ambetter 68069", "plan_name": "500516", "standard_charge_dollar": 182.02, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Ms State Emplo", "plan_name": "401457", "standard_charge_dollar": 229.58, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Ms State Emplo", "plan_name": "401457_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Basic Pl", "plan_name": "400100", "standard_charge_dollar": 229.58, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Basic Pl", "plan_name": "400100_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Federal", "plan_name": "400110", "standard_charge_dollar": 229.58, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Federal", "plan_name": "400110_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Cigna Healthsprings Ffs", "plan_name": "500064", "standard_charge_dollar": 182.02, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Conseco", "plan_name": "500302", "standard_charge_dollar": 182.02, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Humana Ffs 61101", "plan_name": "500006", "standard_charge_dollar": 182.02, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Medicare A", "plan_name": "100100", "standard_charge_dollar": 182.02, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Medicare A", "plan_name": "100500", "standard_charge_dollar": 182.02, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Medicare Part B Only", "plan_name": "100300", "standard_charge_dollar": 182.02, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Medicare Railroad", "plan_name": "100103", "standard_charge_dollar": 182.02, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Ms Physicians Care N", "plan_name": "714210", "standard_charge_dollar": 227.53, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Peoples Hlth Ffs 72126", "plan_name": "500019", "standard_charge_dollar": 182.02, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Uhc/Secure Horizons", "plan_name": "500449", "standard_charge_dollar": 182.02, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "United Health Care/", "plan_name": "500292", "standard_charge_dollar": 205.69, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "United Healthcare", "plan_name": "750104", "standard_charge_dollar": 205.69, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "United Healthcare Ba", "plan_name": "750090", "standard_charge_dollar": 205.69, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "United Healthcare Me", "plan_name": "501310", "standard_charge_dollar": 182.02, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Windsor Mcare Extra", "plan_name": "500778", "standard_charge_dollar": 182.02, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." } ] } ] }, { "description": "Rpr f/e/e/n/l/m 2.5 cm/<", "code_information": [ { "code": "12011", "type": "CPT" } ], "standard_charges": [ { "gross_charge": 14995.78, "minimum": 182.02, "maximum": 229.58, "setting": "inpatient", "payers_information": [ { "payer_name": "Aarp", "plan_name": "500102", "standard_charge_dollar": 182.02, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna", "plan_name": "700700", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna", "plan_name": "700700_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Mcare Ffs 6005", "plan_name": "700703", "standard_charge_dollar": 182.02, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Miscellaneous", "plan_name": "700720", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Miscellaneous", "plan_name": "700720_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Ppo Hmo", "plan_name": "701720", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Ppo Hmo", "plan_name": "701720_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Ambetter 68069", "plan_name": "500516", "standard_charge_dollar": 182.02, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Ms State Emplo", "plan_name": "401457", "standard_charge_dollar": 229.58, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Ms State Emplo", "plan_name": "401457_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Basic Pl", "plan_name": "400100", "standard_charge_dollar": 229.58, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Basic Pl", "plan_name": "400100_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Federal", "plan_name": "400110", "standard_charge_dollar": 229.58, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Federal", "plan_name": "400110_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Cigna Healthsprings Ffs", "plan_name": "500064", "standard_charge_dollar": 182.02, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Conseco", "plan_name": "500302", "standard_charge_dollar": 182.02, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Humana Ffs 61101", "plan_name": "500006", "standard_charge_dollar": 182.02, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Medicare A", "plan_name": "100100", "standard_charge_dollar": 182.02, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Medicare A", "plan_name": "100500", "standard_charge_dollar": 182.02, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Medicare Part B Only", "plan_name": "100300", "standard_charge_dollar": 182.02, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Medicare Railroad", "plan_name": "100103", "standard_charge_dollar": 182.02, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Ms Physicians Care N", "plan_name": "714210", "standard_charge_dollar": 227.53, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Peoples Hlth Ffs 72126", "plan_name": "500019", "standard_charge_dollar": 182.02, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Uhc/Secure Horizons", "plan_name": "500449", "standard_charge_dollar": 182.02, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "United Health Care/", "plan_name": "500292", "standard_charge_dollar": 205.69, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "United Healthcare", "plan_name": "750104", "standard_charge_dollar": 205.69, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "United Healthcare Ba", "plan_name": "750090", "standard_charge_dollar": 205.69, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "United Healthcare Me", "plan_name": "501310", "standard_charge_dollar": 182.02, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Windsor Mcare Extra", "plan_name": "500778", "standard_charge_dollar": 182.02, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." } ] } ] }, { "description": "Rpr f/e/e/n/l/m 2.5 cm/<", "code_information": [ { "code": "12011", "type": "CPT" } ], "standard_charges": [ { "gross_charge": 475.00, "minimum": 182.02, "maximum": 229.58, "setting": "outpatient", "payers_information": [ { "payer_name": "Aarp", "plan_name": "500102", "standard_charge_dollar": 182.02, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna", "plan_name": "700700", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna", "plan_name": "700700_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Mcare Ffs 6005", "plan_name": "700703", "standard_charge_dollar": 182.02, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Miscellaneous", "plan_name": "700720", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Miscellaneous", "plan_name": "700720_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Ppo Hmo", "plan_name": "701720", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Ppo Hmo", "plan_name": "701720_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Ambetter 68069", "plan_name": "500516", "standard_charge_dollar": 182.02, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Ms State Emplo", "plan_name": "401457", "standard_charge_dollar": 229.58, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Ms State Emplo", "plan_name": "401457_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Basic Pl", "plan_name": "400100", "standard_charge_dollar": 229.58, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Basic Pl", "plan_name": "400100_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Federal", "plan_name": "400110", "standard_charge_dollar": 229.58, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Federal", "plan_name": "400110_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Cigna Healthsprings Ffs", "plan_name": "500064", "standard_charge_dollar": 182.02, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Conseco", "plan_name": "500302", "standard_charge_dollar": 182.02, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Humana Ffs 61101", "plan_name": "500006", "standard_charge_dollar": 182.02, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Medicare A", "plan_name": "100100", "standard_charge_dollar": 182.02, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Medicare A", "plan_name": "100500", "standard_charge_dollar": 182.02, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Medicare Part B Only", "plan_name": "100300", "standard_charge_dollar": 182.02, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Medicare Railroad", "plan_name": "100103", "standard_charge_dollar": 182.02, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Ms Physicians Care N", "plan_name": "714210", "standard_charge_dollar": 227.53, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Peoples Hlth Ffs 72126", "plan_name": "500019", "standard_charge_dollar": 182.02, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Uhc/Secure Horizons", "plan_name": "500449", "standard_charge_dollar": 182.02, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "United Health Care/", "plan_name": "500292", "standard_charge_dollar": 205.69, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "United Healthcare", "plan_name": "750104", "standard_charge_dollar": 205.69, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "United Healthcare Ba", "plan_name": "750090", "standard_charge_dollar": 205.69, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "United Healthcare Me", "plan_name": "501310", "standard_charge_dollar": 182.02, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Windsor Mcare Extra", "plan_name": "500778", "standard_charge_dollar": 182.02, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." } ] } ] }, { "description": "Laceration simple", "code_information": [ { "code": "12013", "type": "CPT" } ], "standard_charges": [ { "gross_charge": 475.00, "minimum": 182.02, "maximum": 229.58, "setting": "both", "payers_information": [ { "payer_name": "Aarp", "plan_name": "500102", "standard_charge_dollar": 182.02, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna", "plan_name": "700700", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna", "plan_name": "700700_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Mcare Ffs 6005", "plan_name": "700703", "standard_charge_dollar": 182.02, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Miscellaneous", "plan_name": "700720", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Miscellaneous", "plan_name": "700720_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Ppo Hmo", "plan_name": "701720", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Ppo Hmo", "plan_name": "701720_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Ambetter 68069", "plan_name": "500516", "standard_charge_dollar": 182.02, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Ms State Emplo", "plan_name": "401457", "standard_charge_dollar": 229.58, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Ms State Emplo", "plan_name": "401457_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Basic Pl", "plan_name": "400100", "standard_charge_dollar": 229.58, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Basic Pl", "plan_name": "400100_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Federal", "plan_name": "400110", "standard_charge_dollar": 229.58, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Federal", "plan_name": "400110_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Cigna Healthsprings Ffs", "plan_name": "500064", "standard_charge_dollar": 182.02, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Conseco", "plan_name": "500302", "standard_charge_dollar": 182.02, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Humana Ffs 61101", "plan_name": "500006", "standard_charge_dollar": 182.02, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Medicare A", "plan_name": "100100", "standard_charge_dollar": 182.02, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Medicare A", "plan_name": "100500", "standard_charge_dollar": 182.02, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Medicare Part B Only", "plan_name": "100300", "standard_charge_dollar": 182.02, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Medicare Railroad", "plan_name": "100103", "standard_charge_dollar": 182.02, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Ms Physicians Care N", "plan_name": "714210", "standard_charge_dollar": 227.53, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Peoples Hlth Ffs 72126", "plan_name": "500019", "standard_charge_dollar": 182.02, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Uhc/Secure Horizons", "plan_name": "500449", "standard_charge_dollar": 182.02, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "United Health Care/", "plan_name": "500292", "standard_charge_dollar": 205.69, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "United Healthcare", "plan_name": "750104", "standard_charge_dollar": 205.69, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "United Healthcare Ba", "plan_name": "750090", "standard_charge_dollar": 205.69, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "United Healthcare Me", "plan_name": "501310", "standard_charge_dollar": 182.02, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Windsor Mcare Extra", "plan_name": "500778", "standard_charge_dollar": 182.02, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." } ] } ] }, { "description": "Rpr f/e/e/n/l/m 2.6-5.0 cm", "code_information": [ { "code": "12013", "type": "CPT" } ], "standard_charges": [ { "gross_charge": 14995.78, "minimum": 182.02, "maximum": 229.58, "setting": "inpatient", "payers_information": [ { "payer_name": "Aarp", "plan_name": "500102", "standard_charge_dollar": 182.02, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna", "plan_name": "700700", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna", "plan_name": "700700_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Mcare Ffs 6005", "plan_name": "700703", "standard_charge_dollar": 182.02, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Miscellaneous", "plan_name": "700720", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Miscellaneous", "plan_name": "700720_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Ppo Hmo", "plan_name": "701720", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Ppo Hmo", "plan_name": "701720_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Ambetter 68069", "plan_name": "500516", "standard_charge_dollar": 182.02, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Ms State Emplo", "plan_name": "401457", "standard_charge_dollar": 229.58, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Ms State Emplo", "plan_name": "401457_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Basic Pl", "plan_name": "400100", "standard_charge_dollar": 229.58, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Basic Pl", "plan_name": "400100_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Federal", "plan_name": "400110", "standard_charge_dollar": 229.58, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Federal", "plan_name": "400110_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Cigna Healthsprings Ffs", "plan_name": "500064", "standard_charge_dollar": 182.02, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Conseco", "plan_name": "500302", "standard_charge_dollar": 182.02, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Humana Ffs 61101", "plan_name": "500006", "standard_charge_dollar": 182.02, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Medicare A", "plan_name": "100100", "standard_charge_dollar": 182.02, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Medicare A", "plan_name": "100500", "standard_charge_dollar": 182.02, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Medicare Part B Only", "plan_name": "100300", "standard_charge_dollar": 182.02, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Medicare Railroad", "plan_name": "100103", "standard_charge_dollar": 182.02, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Ms Physicians Care N", "plan_name": "714210", "standard_charge_dollar": 227.53, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Peoples Hlth Ffs 72126", "plan_name": "500019", "standard_charge_dollar": 182.02, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Uhc/Secure Horizons", "plan_name": "500449", "standard_charge_dollar": 182.02, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "United Health Care/", "plan_name": "500292", "standard_charge_dollar": 205.69, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "United Healthcare", "plan_name": "750104", "standard_charge_dollar": 205.69, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "United Healthcare Ba", "plan_name": "750090", "standard_charge_dollar": 205.69, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "United Healthcare Me", "plan_name": "501310", "standard_charge_dollar": 182.02, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Windsor Mcare Extra", "plan_name": "500778", "standard_charge_dollar": 182.02, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." } ] } ] }, { "description": "Rpr f/e/e/n/l/m 2.6-5.0 cm", "code_information": [ { "code": "12013", "type": "CPT" } ], "standard_charges": [ { "gross_charge": 475.00, "minimum": 182.02, "maximum": 229.58, "setting": "outpatient", "payers_information": [ { "payer_name": "Aarp", "plan_name": "500102", "standard_charge_dollar": 182.02, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna", "plan_name": "700700", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna", "plan_name": "700700_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Mcare Ffs 6005", "plan_name": "700703", "standard_charge_dollar": 182.02, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Miscellaneous", "plan_name": "700720", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Miscellaneous", "plan_name": "700720_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Ppo Hmo", "plan_name": "701720", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Ppo Hmo", "plan_name": "701720_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Ambetter 68069", "plan_name": "500516", "standard_charge_dollar": 182.02, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Ms State Emplo", "plan_name": "401457", "standard_charge_dollar": 229.58, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Ms State Emplo", "plan_name": "401457_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Basic Pl", "plan_name": "400100", "standard_charge_dollar": 229.58, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Basic Pl", "plan_name": "400100_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Federal", "plan_name": "400110", "standard_charge_dollar": 229.58, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Federal", "plan_name": "400110_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Cigna Healthsprings Ffs", "plan_name": "500064", "standard_charge_dollar": 182.02, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Conseco", "plan_name": "500302", "standard_charge_dollar": 182.02, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Humana Ffs 61101", "plan_name": "500006", "standard_charge_dollar": 182.02, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Medicare A", "plan_name": "100100", "standard_charge_dollar": 182.02, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Medicare A", "plan_name": "100500", "standard_charge_dollar": 182.02, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Medicare Part B Only", "plan_name": "100300", "standard_charge_dollar": 182.02, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Medicare Railroad", "plan_name": "100103", "standard_charge_dollar": 182.02, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Ms Physicians Care N", "plan_name": "714210", "standard_charge_dollar": 227.53, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Peoples Hlth Ffs 72126", "plan_name": "500019", "standard_charge_dollar": 182.02, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Uhc/Secure Horizons", "plan_name": "500449", "standard_charge_dollar": 182.02, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "United Health Care/", "plan_name": "500292", "standard_charge_dollar": 205.69, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "United Healthcare", "plan_name": "750104", "standard_charge_dollar": 205.69, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "United Healthcare Ba", "plan_name": "750090", "standard_charge_dollar": 205.69, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "United Healthcare Me", "plan_name": "501310", "standard_charge_dollar": 182.02, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Windsor Mcare Extra", "plan_name": "500778", "standard_charge_dollar": 182.02, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." } ] } ] }, { "description": "Laceration simple", "code_information": [ { "code": "12014", "type": "CPT" } ], "standard_charges": [ { "gross_charge": 475.00, "minimum": 182.02, "maximum": 229.58, "setting": "both", "payers_information": [ { "payer_name": "Aarp", "plan_name": "500102", "standard_charge_dollar": 182.02, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna", "plan_name": "700700", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna", "plan_name": "700700_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Mcare Ffs 6005", "plan_name": "700703", "standard_charge_dollar": 182.02, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Miscellaneous", "plan_name": "700720", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Miscellaneous", "plan_name": "700720_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Ppo Hmo", "plan_name": "701720", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Ppo Hmo", "plan_name": "701720_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Ambetter 68069", "plan_name": "500516", "standard_charge_dollar": 182.02, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Ms State Emplo", "plan_name": "401457", "standard_charge_dollar": 229.58, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Ms State Emplo", "plan_name": "401457_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Basic Pl", "plan_name": "400100", "standard_charge_dollar": 229.58, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Basic Pl", "plan_name": "400100_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Federal", "plan_name": "400110", "standard_charge_dollar": 229.58, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Federal", "plan_name": "400110_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Cigna Healthsprings Ffs", "plan_name": "500064", "standard_charge_dollar": 182.02, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Conseco", "plan_name": "500302", "standard_charge_dollar": 182.02, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Humana Ffs 61101", "plan_name": "500006", "standard_charge_dollar": 182.02, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Medicare A", "plan_name": "100100", "standard_charge_dollar": 182.02, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Medicare A", "plan_name": "100500", "standard_charge_dollar": 182.02, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Medicare Part B Only", "plan_name": "100300", "standard_charge_dollar": 182.02, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Medicare Railroad", "plan_name": "100103", "standard_charge_dollar": 182.02, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Ms Physicians Care N", "plan_name": "714210", "standard_charge_dollar": 227.53, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Peoples Hlth Ffs 72126", "plan_name": "500019", "standard_charge_dollar": 182.02, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Uhc/Secure Horizons", "plan_name": "500449", "standard_charge_dollar": 182.02, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "United Health Care/", "plan_name": "500292", "standard_charge_dollar": 205.69, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "United Healthcare", "plan_name": "750104", "standard_charge_dollar": 205.69, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "United Healthcare Ba", "plan_name": "750090", "standard_charge_dollar": 205.69, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "United Healthcare Me", "plan_name": "501310", "standard_charge_dollar": 182.02, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Windsor Mcare Extra", "plan_name": "500778", "standard_charge_dollar": 182.02, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." } ] } ] }, { "description": "Rpr f/e/e/n/l/m 5.1-7.5 cm", "code_information": [ { "code": "12014", "type": "CPT" } ], "standard_charges": [ { "gross_charge": 14995.78, "minimum": 182.02, "maximum": 229.58, "setting": "inpatient", "payers_information": [ { "payer_name": "Aarp", "plan_name": "500102", "standard_charge_dollar": 182.02, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna", "plan_name": "700700", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna", "plan_name": "700700_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Mcare Ffs 6005", "plan_name": "700703", "standard_charge_dollar": 182.02, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Miscellaneous", "plan_name": "700720", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Miscellaneous", "plan_name": "700720_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Ppo Hmo", "plan_name": "701720", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Ppo Hmo", "plan_name": "701720_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Ambetter 68069", "plan_name": "500516", "standard_charge_dollar": 182.02, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Ms State Emplo", "plan_name": "401457", "standard_charge_dollar": 229.58, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Ms State Emplo", "plan_name": "401457_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Basic Pl", "plan_name": "400100", "standard_charge_dollar": 229.58, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Basic Pl", "plan_name": "400100_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Federal", "plan_name": "400110", "standard_charge_dollar": 229.58, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Federal", "plan_name": "400110_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Cigna Healthsprings Ffs", "plan_name": "500064", "standard_charge_dollar": 182.02, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Conseco", "plan_name": "500302", "standard_charge_dollar": 182.02, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Humana Ffs 61101", "plan_name": "500006", "standard_charge_dollar": 182.02, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Medicare A", "plan_name": "100100", "standard_charge_dollar": 182.02, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Medicare A", "plan_name": "100500", "standard_charge_dollar": 182.02, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Medicare Part B Only", "plan_name": "100300", "standard_charge_dollar": 182.02, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Medicare Railroad", "plan_name": "100103", "standard_charge_dollar": 182.02, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Ms Physicians Care N", "plan_name": "714210", "standard_charge_dollar": 227.53, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Peoples Hlth Ffs 72126", "plan_name": "500019", "standard_charge_dollar": 182.02, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Uhc/Secure Horizons", "plan_name": "500449", "standard_charge_dollar": 182.02, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "United Health Care/", "plan_name": "500292", "standard_charge_dollar": 205.69, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "United Healthcare", "plan_name": "750104", "standard_charge_dollar": 205.69, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "United Healthcare Ba", "plan_name": "750090", "standard_charge_dollar": 205.69, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "United Healthcare Me", "plan_name": "501310", "standard_charge_dollar": 182.02, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Windsor Mcare Extra", "plan_name": "500778", "standard_charge_dollar": 182.02, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." } ] } ] }, { "description": "Rpr f/e/e/n/l/m 5.1-7.5 cm", "code_information": [ { "code": "12014", "type": "CPT" } ], "standard_charges": [ { "gross_charge": 475.00, "minimum": 182.02, "maximum": 229.58, "setting": "outpatient", "payers_information": [ { "payer_name": "Aarp", "plan_name": "500102", "standard_charge_dollar": 182.02, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna", "plan_name": "700700", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna", "plan_name": "700700_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Mcare Ffs 6005", "plan_name": "700703", "standard_charge_dollar": 182.02, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Miscellaneous", "plan_name": "700720", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Miscellaneous", "plan_name": "700720_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Ppo Hmo", "plan_name": "701720", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Ppo Hmo", "plan_name": "701720_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Ambetter 68069", "plan_name": "500516", "standard_charge_dollar": 182.02, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Ms State Emplo", "plan_name": "401457", "standard_charge_dollar": 229.58, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Ms State Emplo", "plan_name": "401457_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Basic Pl", "plan_name": "400100", "standard_charge_dollar": 229.58, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Basic Pl", "plan_name": "400100_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Federal", "plan_name": "400110", "standard_charge_dollar": 229.58, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Federal", "plan_name": "400110_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Cigna Healthsprings Ffs", "plan_name": "500064", "standard_charge_dollar": 182.02, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Conseco", "plan_name": "500302", "standard_charge_dollar": 182.02, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Humana Ffs 61101", "plan_name": "500006", "standard_charge_dollar": 182.02, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Medicare A", "plan_name": "100100", "standard_charge_dollar": 182.02, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Medicare A", "plan_name": "100500", "standard_charge_dollar": 182.02, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Medicare Part B Only", "plan_name": "100300", "standard_charge_dollar": 182.02, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Medicare Railroad", "plan_name": "100103", "standard_charge_dollar": 182.02, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Ms Physicians Care N", "plan_name": "714210", "standard_charge_dollar": 227.53, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Peoples Hlth Ffs 72126", "plan_name": "500019", "standard_charge_dollar": 182.02, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Uhc/Secure Horizons", "plan_name": "500449", "standard_charge_dollar": 182.02, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "United Health Care/", "plan_name": "500292", "standard_charge_dollar": 205.69, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "United Healthcare", "plan_name": "750104", "standard_charge_dollar": 205.69, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "United Healthcare Ba", "plan_name": "750090", "standard_charge_dollar": 205.69, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "United Healthcare Me", "plan_name": "501310", "standard_charge_dollar": 182.02, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Windsor Mcare Extra", "plan_name": "500778", "standard_charge_dollar": 182.02, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." } ] } ] }, { "description": "Laceration simple", "code_information": [ { "code": "12015", "type": "CPT" } ], "standard_charges": [ { "gross_charge": 475.00, "minimum": 182.02, "maximum": 229.58, "setting": "both", "payers_information": [ { "payer_name": "Aarp", "plan_name": "500102", "standard_charge_dollar": 182.02, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna", "plan_name": "700700", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna", "plan_name": "700700_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Mcare Ffs 6005", "plan_name": "700703", "standard_charge_dollar": 182.02, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Miscellaneous", "plan_name": "700720", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Miscellaneous", "plan_name": "700720_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Ppo Hmo", "plan_name": "701720", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Ppo Hmo", "plan_name": "701720_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Ambetter 68069", "plan_name": "500516", "standard_charge_dollar": 182.02, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Ms State Emplo", "plan_name": "401457", "standard_charge_dollar": 229.58, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Ms State Emplo", "plan_name": "401457_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Basic Pl", "plan_name": "400100", "standard_charge_dollar": 229.58, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Basic Pl", "plan_name": "400100_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Federal", "plan_name": "400110", "standard_charge_dollar": 229.58, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Federal", "plan_name": "400110_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Cigna Healthsprings Ffs", "plan_name": "500064", "standard_charge_dollar": 182.02, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Conseco", "plan_name": "500302", "standard_charge_dollar": 182.02, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Humana Ffs 61101", "plan_name": "500006", "standard_charge_dollar": 182.02, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Medicare A", "plan_name": "100100", "standard_charge_dollar": 182.02, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Medicare A", "plan_name": "100500", "standard_charge_dollar": 182.02, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Medicare Part B Only", "plan_name": "100300", "standard_charge_dollar": 182.02, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Medicare Railroad", "plan_name": "100103", "standard_charge_dollar": 182.02, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Ms Physicians Care N", "plan_name": "714210", "standard_charge_dollar": 227.53, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Peoples Hlth Ffs 72126", "plan_name": "500019", "standard_charge_dollar": 182.02, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Uhc/Secure Horizons", "plan_name": "500449", "standard_charge_dollar": 182.02, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "United Health Care/", "plan_name": "500292", "standard_charge_dollar": 205.69, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "United Healthcare", "plan_name": "750104", "standard_charge_dollar": 205.69, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "United Healthcare Ba", "plan_name": "750090", "standard_charge_dollar": 205.69, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "United Healthcare Me", "plan_name": "501310", "standard_charge_dollar": 182.02, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Windsor Mcare Extra", "plan_name": "500778", "standard_charge_dollar": 182.02, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." } ] } ] }, { "description": "Rpr f/e/e/n/l/m 7.6-12.5 cm", "code_information": [ { "code": "12015", "type": "CPT" } ], "standard_charges": [ { "gross_charge": 14995.78, "minimum": 182.02, "maximum": 229.58, "setting": "inpatient", "payers_information": [ { "payer_name": "Aarp", "plan_name": "500102", "standard_charge_dollar": 182.02, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna", "plan_name": "700700", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna", "plan_name": "700700_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Mcare Ffs 6005", "plan_name": "700703", "standard_charge_dollar": 182.02, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Miscellaneous", "plan_name": "700720", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Miscellaneous", "plan_name": "700720_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Ppo Hmo", "plan_name": "701720", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Ppo Hmo", "plan_name": "701720_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Ambetter 68069", "plan_name": "500516", "standard_charge_dollar": 182.02, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Ms State Emplo", "plan_name": "401457", "standard_charge_dollar": 229.58, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Ms State Emplo", "plan_name": "401457_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Basic Pl", "plan_name": "400100", "standard_charge_dollar": 229.58, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Basic Pl", "plan_name": "400100_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Federal", "plan_name": "400110", "standard_charge_dollar": 229.58, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Federal", "plan_name": "400110_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Cigna Healthsprings Ffs", "plan_name": "500064", "standard_charge_dollar": 182.02, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Conseco", "plan_name": "500302", "standard_charge_dollar": 182.02, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Humana Ffs 61101", "plan_name": "500006", "standard_charge_dollar": 182.02, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Medicare A", "plan_name": "100100", "standard_charge_dollar": 182.02, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Medicare A", "plan_name": "100500", "standard_charge_dollar": 182.02, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Medicare Part B Only", "plan_name": "100300", "standard_charge_dollar": 182.02, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Medicare Railroad", "plan_name": "100103", "standard_charge_dollar": 182.02, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Ms Physicians Care N", "plan_name": "714210", "standard_charge_dollar": 227.53, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Peoples Hlth Ffs 72126", "plan_name": "500019", "standard_charge_dollar": 182.02, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Uhc/Secure Horizons", "plan_name": "500449", "standard_charge_dollar": 182.02, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "United Health Care/", "plan_name": "500292", "standard_charge_dollar": 205.69, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "United Healthcare", "plan_name": "750104", "standard_charge_dollar": 205.69, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "United Healthcare Ba", "plan_name": "750090", "standard_charge_dollar": 205.69, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "United Healthcare Me", "plan_name": "501310", "standard_charge_dollar": 182.02, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Windsor Mcare Extra", "plan_name": "500778", "standard_charge_dollar": 182.02, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." } ] } ] }, { "description": "Rpr f/e/e/n/l/m 7.6-12.5 cm", "code_information": [ { "code": "12015", "type": "CPT" } ], "standard_charges": [ { "gross_charge": 475.00, "minimum": 182.02, "maximum": 229.58, "setting": "outpatient", "payers_information": [ { "payer_name": "Aarp", "plan_name": "500102", "standard_charge_dollar": 182.02, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna", "plan_name": "700700", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna", "plan_name": "700700_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Mcare Ffs 6005", "plan_name": "700703", "standard_charge_dollar": 182.02, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Miscellaneous", "plan_name": "700720", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Miscellaneous", "plan_name": "700720_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Ppo Hmo", "plan_name": "701720", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Ppo Hmo", "plan_name": "701720_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Ambetter 68069", "plan_name": "500516", "standard_charge_dollar": 182.02, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Ms State Emplo", "plan_name": "401457", "standard_charge_dollar": 229.58, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Ms State Emplo", "plan_name": "401457_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Basic Pl", "plan_name": "400100", "standard_charge_dollar": 229.58, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Basic Pl", "plan_name": "400100_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Federal", "plan_name": "400110", "standard_charge_dollar": 229.58, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Federal", "plan_name": "400110_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Cigna Healthsprings Ffs", "plan_name": "500064", "standard_charge_dollar": 182.02, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Conseco", "plan_name": "500302", "standard_charge_dollar": 182.02, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Humana Ffs 61101", "plan_name": "500006", "standard_charge_dollar": 182.02, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Medicare A", "plan_name": "100100", "standard_charge_dollar": 182.02, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Medicare A", "plan_name": "100500", "standard_charge_dollar": 182.02, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Medicare Part B Only", "plan_name": "100300", "standard_charge_dollar": 182.02, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Medicare Railroad", "plan_name": "100103", "standard_charge_dollar": 182.02, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Ms Physicians Care N", "plan_name": "714210", "standard_charge_dollar": 227.53, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Peoples Hlth Ffs 72126", "plan_name": "500019", "standard_charge_dollar": 182.02, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Uhc/Secure Horizons", "plan_name": "500449", "standard_charge_dollar": 182.02, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "United Health Care/", "plan_name": "500292", "standard_charge_dollar": 205.69, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "United Healthcare", "plan_name": "750104", "standard_charge_dollar": 205.69, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "United Healthcare Ba", "plan_name": "750090", "standard_charge_dollar": 205.69, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "United Healthcare Me", "plan_name": "501310", "standard_charge_dollar": 182.02, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Windsor Mcare Extra", "plan_name": "500778", "standard_charge_dollar": 182.02, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." } ] } ] }, { "description": "Rpr f/e/e/n/l/m >30.0 cm", "code_information": [ { "code": "12018", "type": "CPT" } ], "standard_charges": [ { "gross_charge": 14995.78, "minimum": 182.02, "maximum": 229.58, "setting": "inpatient", "payers_information": [ { "payer_name": "Aarp", "plan_name": "500102", "standard_charge_dollar": 182.02, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna", "plan_name": "700700", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna", "plan_name": "700700_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Mcare Ffs 6005", "plan_name": "700703", "standard_charge_dollar": 182.02, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Miscellaneous", "plan_name": "700720", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Miscellaneous", "plan_name": "700720_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Ppo Hmo", "plan_name": "701720", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Ppo Hmo", "plan_name": "701720_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Ambetter 68069", "plan_name": "500516", "standard_charge_dollar": 182.02, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Ms State Emplo", "plan_name": "401457", "standard_charge_dollar": 229.58, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Ms State Emplo", "plan_name": "401457_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Basic Pl", "plan_name": "400100", "standard_charge_dollar": 229.58, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Basic Pl", "plan_name": "400100_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Federal", "plan_name": "400110", "standard_charge_dollar": 229.58, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Federal", "plan_name": "400110_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Cigna Healthsprings Ffs", "plan_name": "500064", "standard_charge_dollar": 182.02, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Conseco", "plan_name": "500302", "standard_charge_dollar": 182.02, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Humana Ffs 61101", "plan_name": "500006", "standard_charge_dollar": 182.02, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Medicare A", "plan_name": "100100", "standard_charge_dollar": 182.02, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Medicare A", "plan_name": "100500", "standard_charge_dollar": 182.02, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Medicare Part B Only", "plan_name": "100300", "standard_charge_dollar": 182.02, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Medicare Railroad", "plan_name": "100103", "standard_charge_dollar": 182.02, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Ms Physicians Care N", "plan_name": "714210", "standard_charge_dollar": 227.53, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Peoples Hlth Ffs 72126", "plan_name": "500019", "standard_charge_dollar": 182.02, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Uhc/Secure Horizons", "plan_name": "500449", "standard_charge_dollar": 182.02, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "United Health Care/", "plan_name": "500292", "standard_charge_dollar": 205.69, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "United Healthcare", "plan_name": "750104", "standard_charge_dollar": 205.69, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "United Healthcare Ba", "plan_name": "750090", "standard_charge_dollar": 205.69, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "United Healthcare Me", "plan_name": "501310", "standard_charge_dollar": 182.02, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Windsor Mcare Extra", "plan_name": "500778", "standard_charge_dollar": 182.02, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." } ] } ] }, { "description": "Closure of split wound", "code_information": [ { "code": "12020", "type": "CPT" } ], "standard_charges": [ { "gross_charge": 15070.64, "minimum": 560.75, "maximum": 12810.04, "setting": "inpatient", "payers_information": [ { "payer_name": "Aarp", "plan_name": "500102", "standard_charge_dollar": 560.75, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna", "plan_name": "700700", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna", "plan_name": "700700_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Mcare Ffs 6005", "plan_name": "700703", "standard_charge_dollar": 560.75, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Miscellaneous", "plan_name": "700720", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Miscellaneous", "plan_name": "700720_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Ppo Hmo", "plan_name": "701720", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Ppo Hmo", "plan_name": "701720_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Ambetter 68069", "plan_name": "500516", "standard_charge_dollar": 560.75, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Ms State Emplo", "plan_name": "401457", "standard_charge_percentage": 0.80, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Ms State Emplo", "plan_name": "401457_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Basic Pl", "plan_name": "400100", "standard_charge_percentage": 0.85, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Basic Pl", "plan_name": "400100_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Federal", "plan_name": "400110", "standard_charge_percentage": 0.85, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Federal", "plan_name": "400110_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Cigna Healthsprings Ffs", "plan_name": "500064", "standard_charge_dollar": 560.75, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Conseco", "plan_name": "500302", "standard_charge_dollar": 560.75, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Humana Ffs 61101", "plan_name": "500006", "standard_charge_dollar": 560.75, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Medicare A", "plan_name": "100100", "standard_charge_dollar": 560.75, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Medicare A", "plan_name": "100500", "standard_charge_dollar": 560.75, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Medicare Part B Only", "plan_name": "100300", "standard_charge_dollar": 560.75, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Medicare Railroad", "plan_name": "100103", "standard_charge_dollar": 560.75, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Ms Physicians Care N", "plan_name": "714210", "standard_charge_dollar": 700.94, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Peoples Hlth Ffs 72126", "plan_name": "500019", "standard_charge_dollar": 560.75, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Uhc/Secure Horizons", "plan_name": "500449", "standard_charge_dollar": 560.75, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "United Health Care/", "plan_name": "500292", "standard_charge_dollar": 633.65, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "United Healthcare", "plan_name": "750104", "standard_charge_dollar": 633.65, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "United Healthcare Ba", "plan_name": "750090", "standard_charge_dollar": 633.65, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "United Healthcare Me", "plan_name": "501310", "standard_charge_dollar": 560.75, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Windsor Mcare Extra", "plan_name": "500778", "standard_charge_dollar": 560.75, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." } ] } ] }, { "description": "Closure of split wound", "code_information": [ { "code": "12020", "type": "CPT" } ], "standard_charges": [ { "gross_charge": 930.00, "minimum": 560.75, "maximum": 790.50, "setting": "outpatient", "payers_information": [ { "payer_name": "Aarp", "plan_name": "500102", "standard_charge_dollar": 560.75, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna", "plan_name": "700700", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna", "plan_name": "700700_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Mcare Ffs 6005", "plan_name": "700703", "standard_charge_dollar": 560.75, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Miscellaneous", "plan_name": "700720", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Miscellaneous", "plan_name": "700720_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Ppo Hmo", "plan_name": "701720", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Ppo Hmo", "plan_name": "701720_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Ambetter 68069", "plan_name": "500516", "standard_charge_dollar": 560.75, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Ms State Emplo", "plan_name": "401457", "standard_charge_percentage": 0.80, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Ms State Emplo", "plan_name": "401457_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Basic Pl", "plan_name": "400100", "standard_charge_percentage": 0.85, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Basic Pl", "plan_name": "400100_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Federal", "plan_name": "400110", "standard_charge_percentage": 0.85, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Federal", "plan_name": "400110_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Cigna Healthsprings Ffs", "plan_name": "500064", "standard_charge_dollar": 560.75, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Conseco", "plan_name": "500302", "standard_charge_dollar": 560.75, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Humana Ffs 61101", "plan_name": "500006", "standard_charge_dollar": 560.75, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Medicare A", "plan_name": "100100", "standard_charge_dollar": 560.75, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Medicare A", "plan_name": "100500", "standard_charge_dollar": 560.75, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Medicare Part B Only", "plan_name": "100300", "standard_charge_dollar": 560.75, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Medicare Railroad", "plan_name": "100103", "standard_charge_dollar": 560.75, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Ms Physicians Care N", "plan_name": "714210", "standard_charge_dollar": 700.94, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Peoples Hlth Ffs 72126", "plan_name": "500019", "standard_charge_dollar": 560.75, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Uhc/Secure Horizons", "plan_name": "500449", "standard_charge_dollar": 560.75, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "United Health Care/", "plan_name": "500292", "standard_charge_dollar": 633.65, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "United Healthcare", "plan_name": "750104", "standard_charge_dollar": 633.65, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "United Healthcare Ba", "plan_name": "750090", "standard_charge_dollar": 633.65, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "United Healthcare Me", "plan_name": "501310", "standard_charge_dollar": 560.75, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Windsor Mcare Extra", "plan_name": "500778", "standard_charge_dollar": 560.75, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." } ] } ] }, { "description": "Hc closure wound dehiscence smp", "code_information": [ { "code": "12020", "type": "CPT" } ], "standard_charges": [ { "gross_charge": 930.00, "minimum": 560.75, "maximum": 790.50, "setting": "both", "payers_information": [ { "payer_name": "Aarp", "plan_name": "500102", "standard_charge_dollar": 560.75, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna", "plan_name": "700700", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna", "plan_name": "700700_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Mcare Ffs 6005", "plan_name": "700703", "standard_charge_dollar": 560.75, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Miscellaneous", "plan_name": "700720", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Miscellaneous", "plan_name": "700720_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Ppo Hmo", "plan_name": "701720", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Ppo Hmo", "plan_name": "701720_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Ambetter 68069", "plan_name": "500516", "standard_charge_dollar": 560.75, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Ms State Emplo", "plan_name": "401457", "standard_charge_percentage": 0.80, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Ms State Emplo", "plan_name": "401457_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Basic Pl", "plan_name": "400100", "standard_charge_percentage": 0.85, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Basic Pl", "plan_name": "400100_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Federal", "plan_name": "400110", "standard_charge_percentage": 0.85, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Federal", "plan_name": "400110_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Cigna Healthsprings Ffs", "plan_name": "500064", "standard_charge_dollar": 560.75, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Conseco", "plan_name": "500302", "standard_charge_dollar": 560.75, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Humana Ffs 61101", "plan_name": "500006", "standard_charge_dollar": 560.75, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Medicare A", "plan_name": "100100", "standard_charge_dollar": 560.75, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Medicare A", "plan_name": "100500", "standard_charge_dollar": 560.75, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Medicare Part B Only", "plan_name": "100300", "standard_charge_dollar": 560.75, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Medicare Railroad", "plan_name": "100103", "standard_charge_dollar": 560.75, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Ms Physicians Care N", "plan_name": "714210", "standard_charge_dollar": 700.94, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Peoples Hlth Ffs 72126", "plan_name": "500019", "standard_charge_dollar": 560.75, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Uhc/Secure Horizons", "plan_name": "500449", "standard_charge_dollar": 560.75, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "United Health Care/", "plan_name": "500292", "standard_charge_dollar": 633.65, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "United Healthcare", "plan_name": "750104", "standard_charge_dollar": 633.65, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "United Healthcare Ba", "plan_name": "750090", "standard_charge_dollar": 633.65, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "United Healthcare Me", "plan_name": "501310", "standard_charge_dollar": 560.75, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Windsor Mcare Extra", "plan_name": "500778", "standard_charge_dollar": 560.75, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." } ] } ] }, { "description": "Intmd rpr s/a/t/ext 2.5 cm/<", "code_information": [ { "code": "12031", "type": "CPT" } ], "standard_charges": [ { "gross_charge": 14841.25, "minimum": 366.00, "maximum": 12615.06, "setting": "inpatient", "payers_information": [ { "payer_name": "Aarp", "plan_name": "500102", "standard_charge_dollar": 366.00, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna", "plan_name": "700700", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna", "plan_name": "700700_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Mcare Ffs 6005", "plan_name": "700703", "standard_charge_dollar": 366.00, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Miscellaneous", "plan_name": "700720", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Miscellaneous", "plan_name": "700720_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Ppo Hmo", "plan_name": "701720", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Ppo Hmo", "plan_name": "701720_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Ambetter 68069", "plan_name": "500516", "standard_charge_dollar": 366.00, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Ms State Emplo", "plan_name": "401457", "standard_charge_percentage": 0.80, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Ms State Emplo", "plan_name": "401457_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Basic Pl", "plan_name": "400100", "standard_charge_percentage": 0.85, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Basic Pl", "plan_name": "400100_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Federal", "plan_name": "400110", "standard_charge_percentage": 0.85, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Federal", "plan_name": "400110_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Cigna Healthsprings Ffs", "plan_name": "500064", "standard_charge_dollar": 366.00, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Conseco", "plan_name": "500302", "standard_charge_dollar": 366.00, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Humana Ffs 61101", "plan_name": "500006", "standard_charge_dollar": 366.00, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Medicare A", "plan_name": "100100", "standard_charge_dollar": 366.00, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Medicare A", "plan_name": "100500", "standard_charge_dollar": 366.00, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Medicare Part B Only", "plan_name": "100300", "standard_charge_dollar": 366.00, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Medicare Railroad", "plan_name": "100103", "standard_charge_dollar": 366.00, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Ms Physicians Care N", "plan_name": "714210", "standard_charge_dollar": 457.50, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Peoples Hlth Ffs 72126", "plan_name": "500019", "standard_charge_dollar": 366.00, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Uhc/Secure Horizons", "plan_name": "500449", "standard_charge_dollar": 366.00, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "United Health Care/", "plan_name": "500292", "standard_charge_dollar": 413.58, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "United Healthcare", "plan_name": "750104", "standard_charge_dollar": 413.58, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "United Healthcare Ba", "plan_name": "750090", "standard_charge_dollar": 413.58, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "United Healthcare Me", "plan_name": "501310", "standard_charge_dollar": 366.00, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Windsor Mcare Extra", "plan_name": "500778", "standard_charge_dollar": 366.00, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." } ] } ] }, { "description": "Intmd rpr s/a/t/ext 2.5 cm/<", "code_information": [ { "code": "12031", "type": "CPT" } ], "standard_charges": [ { "gross_charge": 1016.00, "minimum": 366.00, "maximum": 863.60, "setting": "outpatient", "payers_information": [ { "payer_name": "Aarp", "plan_name": "500102", "standard_charge_dollar": 366.00, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna", "plan_name": "700700", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna", "plan_name": "700700_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Mcare Ffs 6005", "plan_name": "700703", "standard_charge_dollar": 366.00, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Miscellaneous", "plan_name": "700720", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Miscellaneous", "plan_name": "700720_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Ppo Hmo", "plan_name": "701720", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Ppo Hmo", "plan_name": "701720_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Ambetter 68069", "plan_name": "500516", "standard_charge_dollar": 366.00, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Ms State Emplo", "plan_name": "401457", "standard_charge_percentage": 0.80, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Ms State Emplo", "plan_name": "401457_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Basic Pl", "plan_name": "400100", "standard_charge_percentage": 0.85, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Basic Pl", "plan_name": "400100_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Federal", "plan_name": "400110", "standard_charge_percentage": 0.85, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Federal", "plan_name": "400110_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Cigna Healthsprings Ffs", "plan_name": "500064", "standard_charge_dollar": 366.00, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Conseco", "plan_name": "500302", "standard_charge_dollar": 366.00, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Humana Ffs 61101", "plan_name": "500006", "standard_charge_dollar": 366.00, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Medicare A", "plan_name": "100100", "standard_charge_dollar": 366.00, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Medicare A", "plan_name": "100500", "standard_charge_dollar": 366.00, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Medicare Part B Only", "plan_name": "100300", "standard_charge_dollar": 366.00, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Medicare Railroad", "plan_name": "100103", "standard_charge_dollar": 366.00, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Ms Physicians Care N", "plan_name": "714210", "standard_charge_dollar": 457.50, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Peoples Hlth Ffs 72126", "plan_name": "500019", "standard_charge_dollar": 366.00, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Uhc/Secure Horizons", "plan_name": "500449", "standard_charge_dollar": 366.00, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "United Health Care/", "plan_name": "500292", "standard_charge_dollar": 413.58, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "United Healthcare", "plan_name": "750104", "standard_charge_dollar": 413.58, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "United Healthcare Ba", "plan_name": "750090", "standard_charge_dollar": 413.58, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "United Healthcare Me", "plan_name": "501310", "standard_charge_dollar": 366.00, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Windsor Mcare Extra", "plan_name": "500778", "standard_charge_dollar": 366.00, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." } ] } ] }, { "description": "Laceration intermediate", "code_information": [ { "code": "12031", "type": "CPT" } ], "standard_charges": [ { "gross_charge": 1016.00, "minimum": 366.00, "maximum": 863.60, "setting": "both", "payers_information": [ { "payer_name": "Aarp", "plan_name": "500102", "standard_charge_dollar": 366.00, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna", "plan_name": "700700", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna", "plan_name": "700700_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Mcare Ffs 6005", "plan_name": "700703", "standard_charge_dollar": 366.00, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Miscellaneous", "plan_name": "700720", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Miscellaneous", "plan_name": "700720_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Ppo Hmo", "plan_name": "701720", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Ppo Hmo", "plan_name": "701720_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Ambetter 68069", "plan_name": "500516", "standard_charge_dollar": 366.00, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Ms State Emplo", "plan_name": "401457", "standard_charge_percentage": 0.80, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Ms State Emplo", "plan_name": "401457_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Basic Pl", "plan_name": "400100", "standard_charge_percentage": 0.85, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Basic Pl", "plan_name": "400100_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Federal", "plan_name": "400110", "standard_charge_percentage": 0.85, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Federal", "plan_name": "400110_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Cigna Healthsprings Ffs", "plan_name": "500064", "standard_charge_dollar": 366.00, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Conseco", "plan_name": "500302", "standard_charge_dollar": 366.00, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Humana Ffs 61101", "plan_name": "500006", "standard_charge_dollar": 366.00, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Medicare A", "plan_name": "100100", "standard_charge_dollar": 366.00, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Medicare A", "plan_name": "100500", "standard_charge_dollar": 366.00, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Medicare Part B Only", "plan_name": "100300", "standard_charge_dollar": 366.00, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Medicare Railroad", "plan_name": "100103", "standard_charge_dollar": 366.00, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Ms Physicians Care N", "plan_name": "714210", "standard_charge_dollar": 457.50, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Peoples Hlth Ffs 72126", "plan_name": "500019", "standard_charge_dollar": 366.00, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Uhc/Secure Horizons", "plan_name": "500449", "standard_charge_dollar": 366.00, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "United Health Care/", "plan_name": "500292", "standard_charge_dollar": 413.58, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "United Healthcare", "plan_name": "750104", "standard_charge_dollar": 413.58, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "United Healthcare Ba", "plan_name": "750090", "standard_charge_dollar": 413.58, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "United Healthcare Me", "plan_name": "501310", "standard_charge_dollar": 366.00, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Windsor Mcare Extra", "plan_name": "500778", "standard_charge_dollar": 366.00, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." } ] } ] }, { "description": "Intmd rpr s/a/t/ext 2.6-7.5", "code_information": [ { "code": "12032", "type": "CPT" } ], "standard_charges": [ { "gross_charge": 14841.25, "minimum": 366.00, "maximum": 12615.06, "setting": "inpatient", "payers_information": [ { "payer_name": "Aarp", "plan_name": "500102", "standard_charge_dollar": 366.00, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna", "plan_name": "700700", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna", "plan_name": "700700_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Mcare Ffs 6005", "plan_name": "700703", "standard_charge_dollar": 366.00, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Miscellaneous", "plan_name": "700720", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Miscellaneous", "plan_name": "700720_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Ppo Hmo", "plan_name": "701720", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Ppo Hmo", "plan_name": "701720_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Ambetter 68069", "plan_name": "500516", "standard_charge_dollar": 366.00, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Ms State Emplo", "plan_name": "401457", "standard_charge_percentage": 0.80, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Ms State Emplo", "plan_name": "401457_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Basic Pl", "plan_name": "400100", "standard_charge_percentage": 0.85, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Basic Pl", "plan_name": "400100_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Federal", "plan_name": "400110", "standard_charge_percentage": 0.85, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Federal", "plan_name": "400110_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Cigna Healthsprings Ffs", "plan_name": "500064", "standard_charge_dollar": 366.00, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Conseco", "plan_name": "500302", "standard_charge_dollar": 366.00, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Humana Ffs 61101", "plan_name": "500006", "standard_charge_dollar": 366.00, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Medicare A", "plan_name": "100100", "standard_charge_dollar": 366.00, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Medicare A", "plan_name": "100500", "standard_charge_dollar": 366.00, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Medicare Part B Only", "plan_name": "100300", "standard_charge_dollar": 366.00, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Medicare Railroad", "plan_name": "100103", "standard_charge_dollar": 366.00, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Ms Physicians Care N", "plan_name": "714210", "standard_charge_dollar": 457.50, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Peoples Hlth Ffs 72126", "plan_name": "500019", "standard_charge_dollar": 366.00, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Uhc/Secure Horizons", "plan_name": "500449", "standard_charge_dollar": 366.00, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "United Health Care/", "plan_name": "500292", "standard_charge_dollar": 413.58, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "United Healthcare", "plan_name": "750104", "standard_charge_dollar": 413.58, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "United Healthcare Ba", "plan_name": "750090", "standard_charge_dollar": 413.58, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "United Healthcare Me", "plan_name": "501310", "standard_charge_dollar": 366.00, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Windsor Mcare Extra", "plan_name": "500778", "standard_charge_dollar": 366.00, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." } ] } ] }, { "description": "Intmd rpr s/a/t/ext 2.6-7.5", "code_information": [ { "code": "12032", "type": "CPT" } ], "standard_charges": [ { "gross_charge": 1016.00, "minimum": 366.00, "maximum": 863.60, "setting": "outpatient", "payers_information": [ { "payer_name": "Aarp", "plan_name": "500102", "standard_charge_dollar": 366.00, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna", "plan_name": "700700", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna", "plan_name": "700700_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Mcare Ffs 6005", "plan_name": "700703", "standard_charge_dollar": 366.00, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Miscellaneous", "plan_name": "700720", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Miscellaneous", "plan_name": "700720_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Ppo Hmo", "plan_name": "701720", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Ppo Hmo", "plan_name": "701720_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Ambetter 68069", "plan_name": "500516", "standard_charge_dollar": 366.00, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Ms State Emplo", "plan_name": "401457", "standard_charge_percentage": 0.80, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Ms State Emplo", "plan_name": "401457_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Basic Pl", "plan_name": "400100", "standard_charge_percentage": 0.85, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Basic Pl", "plan_name": "400100_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Federal", "plan_name": "400110", "standard_charge_percentage": 0.85, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Federal", "plan_name": "400110_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Cigna Healthsprings Ffs", "plan_name": "500064", "standard_charge_dollar": 366.00, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Conseco", "plan_name": "500302", "standard_charge_dollar": 366.00, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Humana Ffs 61101", "plan_name": "500006", "standard_charge_dollar": 366.00, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Medicare A", "plan_name": "100100", "standard_charge_dollar": 366.00, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Medicare A", "plan_name": "100500", "standard_charge_dollar": 366.00, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Medicare Part B Only", "plan_name": "100300", "standard_charge_dollar": 366.00, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Medicare Railroad", "plan_name": "100103", "standard_charge_dollar": 366.00, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Ms Physicians Care N", "plan_name": "714210", "standard_charge_dollar": 457.50, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Peoples Hlth Ffs 72126", "plan_name": "500019", "standard_charge_dollar": 366.00, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Uhc/Secure Horizons", "plan_name": "500449", "standard_charge_dollar": 366.00, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "United Health Care/", "plan_name": "500292", "standard_charge_dollar": 413.58, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "United Healthcare", "plan_name": "750104", "standard_charge_dollar": 413.58, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "United Healthcare Ba", "plan_name": "750090", "standard_charge_dollar": 413.58, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "United Healthcare Me", "plan_name": "501310", "standard_charge_dollar": 366.00, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Windsor Mcare Extra", "plan_name": "500778", "standard_charge_dollar": 366.00, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." } ] } ] }, { "description": "Laceration intermediate", "code_information": [ { "code": "12032", "type": "CPT" } ], "standard_charges": [ { "gross_charge": 1016.00, "minimum": 366.00, "maximum": 863.60, "setting": "both", "payers_information": [ { "payer_name": "Aarp", "plan_name": "500102", "standard_charge_dollar": 366.00, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna", "plan_name": "700700", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna", "plan_name": "700700_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Mcare Ffs 6005", "plan_name": "700703", "standard_charge_dollar": 366.00, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Miscellaneous", "plan_name": "700720", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Miscellaneous", "plan_name": "700720_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Ppo Hmo", "plan_name": "701720", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Ppo Hmo", "plan_name": "701720_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Ambetter 68069", "plan_name": "500516", "standard_charge_dollar": 366.00, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Ms State Emplo", "plan_name": "401457", "standard_charge_percentage": 0.80, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Ms State Emplo", "plan_name": "401457_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Basic Pl", "plan_name": "400100", "standard_charge_percentage": 0.85, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Basic Pl", "plan_name": "400100_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Federal", "plan_name": "400110", "standard_charge_percentage": 0.85, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Federal", "plan_name": "400110_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Cigna Healthsprings Ffs", "plan_name": "500064", "standard_charge_dollar": 366.00, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Conseco", "plan_name": "500302", "standard_charge_dollar": 366.00, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Humana Ffs 61101", "plan_name": "500006", "standard_charge_dollar": 366.00, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Medicare A", "plan_name": "100100", "standard_charge_dollar": 366.00, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Medicare A", "plan_name": "100500", "standard_charge_dollar": 366.00, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Medicare Part B Only", "plan_name": "100300", "standard_charge_dollar": 366.00, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Medicare Railroad", "plan_name": "100103", "standard_charge_dollar": 366.00, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Ms Physicians Care N", "plan_name": "714210", "standard_charge_dollar": 457.50, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Peoples Hlth Ffs 72126", "plan_name": "500019", "standard_charge_dollar": 366.00, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Uhc/Secure Horizons", "plan_name": "500449", "standard_charge_dollar": 366.00, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "United Health Care/", "plan_name": "500292", "standard_charge_dollar": 413.58, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "United Healthcare", "plan_name": "750104", "standard_charge_dollar": 413.58, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "United Healthcare Ba", "plan_name": "750090", "standard_charge_dollar": 413.58, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "United Healthcare Me", "plan_name": "501310", "standard_charge_dollar": 366.00, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Windsor Mcare Extra", "plan_name": "500778", "standard_charge_dollar": 366.00, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." } ] } ] }, { "description": "Intmd rpr s/tr/ext 7.6-12.5", "code_information": [ { "code": "12034", "type": "CPT" } ], "standard_charges": [ { "gross_charge": 14841.25, "minimum": 366.00, "maximum": 12615.06, "setting": "inpatient", "payers_information": [ { "payer_name": "Aarp", "plan_name": "500102", "standard_charge_dollar": 366.00, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna", "plan_name": "700700", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna", "plan_name": "700700_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Mcare Ffs 6005", "plan_name": "700703", "standard_charge_dollar": 366.00, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Miscellaneous", "plan_name": "700720", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Miscellaneous", "plan_name": "700720_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Ppo Hmo", "plan_name": "701720", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Ppo Hmo", "plan_name": "701720_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Ambetter 68069", "plan_name": "500516", "standard_charge_dollar": 366.00, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Ms State Emplo", "plan_name": "401457", "standard_charge_percentage": 0.80, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Ms State Emplo", "plan_name": "401457_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Basic Pl", "plan_name": "400100", "standard_charge_percentage": 0.85, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Basic Pl", "plan_name": "400100_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Federal", "plan_name": "400110", "standard_charge_percentage": 0.85, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Federal", "plan_name": "400110_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Cigna Healthsprings Ffs", "plan_name": "500064", "standard_charge_dollar": 366.00, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Conseco", "plan_name": "500302", "standard_charge_dollar": 366.00, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Humana Ffs 61101", "plan_name": "500006", "standard_charge_dollar": 366.00, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Medicare A", "plan_name": "100100", "standard_charge_dollar": 366.00, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Medicare A", "plan_name": "100500", "standard_charge_dollar": 366.00, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Medicare Part B Only", "plan_name": "100300", "standard_charge_dollar": 366.00, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Medicare Railroad", "plan_name": "100103", "standard_charge_dollar": 366.00, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Ms Physicians Care N", "plan_name": "714210", "standard_charge_dollar": 457.50, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Peoples Hlth Ffs 72126", "plan_name": "500019", "standard_charge_dollar": 366.00, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Uhc/Secure Horizons", "plan_name": "500449", "standard_charge_dollar": 366.00, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "United Health Care/", "plan_name": "500292", "standard_charge_dollar": 413.58, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "United Healthcare", "plan_name": "750104", "standard_charge_dollar": 413.58, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "United Healthcare Ba", "plan_name": "750090", "standard_charge_dollar": 413.58, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "United Healthcare Me", "plan_name": "501310", "standard_charge_dollar": 366.00, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Windsor Mcare Extra", "plan_name": "500778", "standard_charge_dollar": 366.00, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." } ] } ] }, { "description": "Intmd rpr s/tr/ext 7.6-12.5", "code_information": [ { "code": "12034", "type": "CPT" } ], "standard_charges": [ { "gross_charge": 1016.00, "minimum": 366.00, "maximum": 863.60, "setting": "outpatient", "payers_information": [ { "payer_name": "Aarp", "plan_name": "500102", "standard_charge_dollar": 366.00, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna", "plan_name": "700700", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna", "plan_name": "700700_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Mcare Ffs 6005", "plan_name": "700703", "standard_charge_dollar": 366.00, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Miscellaneous", "plan_name": "700720", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Miscellaneous", "plan_name": "700720_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Ppo Hmo", "plan_name": "701720", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Ppo Hmo", "plan_name": "701720_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Ambetter 68069", "plan_name": "500516", "standard_charge_dollar": 366.00, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Ms State Emplo", "plan_name": "401457", "standard_charge_percentage": 0.80, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Ms State Emplo", "plan_name": "401457_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Basic Pl", "plan_name": "400100", "standard_charge_percentage": 0.85, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Basic Pl", "plan_name": "400100_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Federal", "plan_name": "400110", "standard_charge_percentage": 0.85, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Federal", "plan_name": "400110_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Cigna Healthsprings Ffs", "plan_name": "500064", "standard_charge_dollar": 366.00, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Conseco", "plan_name": "500302", "standard_charge_dollar": 366.00, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Humana Ffs 61101", "plan_name": "500006", "standard_charge_dollar": 366.00, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Medicare A", "plan_name": "100100", "standard_charge_dollar": 366.00, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Medicare A", "plan_name": "100500", "standard_charge_dollar": 366.00, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Medicare Part B Only", "plan_name": "100300", "standard_charge_dollar": 366.00, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Medicare Railroad", "plan_name": "100103", "standard_charge_dollar": 366.00, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Ms Physicians Care N", "plan_name": "714210", "standard_charge_dollar": 457.50, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Peoples Hlth Ffs 72126", "plan_name": "500019", "standard_charge_dollar": 366.00, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Uhc/Secure Horizons", "plan_name": "500449", "standard_charge_dollar": 366.00, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "United Health Care/", "plan_name": "500292", "standard_charge_dollar": 413.58, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "United Healthcare", "plan_name": "750104", "standard_charge_dollar": 413.58, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "United Healthcare Ba", "plan_name": "750090", "standard_charge_dollar": 413.58, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "United Healthcare Me", "plan_name": "501310", "standard_charge_dollar": 366.00, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Windsor Mcare Extra", "plan_name": "500778", "standard_charge_dollar": 366.00, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." } ] } ] }, { "description": "Laceration intermediate", "code_information": [ { "code": "12034", "type": "CPT" } ], "standard_charges": [ { "gross_charge": 1016.00, "minimum": 366.00, "maximum": 863.60, "setting": "both", "payers_information": [ { "payer_name": "Aarp", "plan_name": "500102", "standard_charge_dollar": 366.00, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna", "plan_name": "700700", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna", "plan_name": "700700_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Mcare Ffs 6005", "plan_name": "700703", "standard_charge_dollar": 366.00, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Miscellaneous", "plan_name": "700720", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Miscellaneous", "plan_name": "700720_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Ppo Hmo", "plan_name": "701720", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Ppo Hmo", "plan_name": "701720_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Ambetter 68069", "plan_name": "500516", "standard_charge_dollar": 366.00, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Ms State Emplo", "plan_name": "401457", "standard_charge_percentage": 0.80, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Ms State Emplo", "plan_name": "401457_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Basic Pl", "plan_name": "400100", "standard_charge_percentage": 0.85, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Basic Pl", "plan_name": "400100_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Federal", "plan_name": "400110", "standard_charge_percentage": 0.85, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Federal", "plan_name": "400110_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Cigna Healthsprings Ffs", "plan_name": "500064", "standard_charge_dollar": 366.00, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Conseco", "plan_name": "500302", "standard_charge_dollar": 366.00, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Humana Ffs 61101", "plan_name": "500006", "standard_charge_dollar": 366.00, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Medicare A", "plan_name": "100100", "standard_charge_dollar": 366.00, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Medicare A", "plan_name": "100500", "standard_charge_dollar": 366.00, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Medicare Part B Only", "plan_name": "100300", "standard_charge_dollar": 366.00, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Medicare Railroad", "plan_name": "100103", "standard_charge_dollar": 366.00, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Ms Physicians Care N", "plan_name": "714210", "standard_charge_dollar": 457.50, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Peoples Hlth Ffs 72126", "plan_name": "500019", "standard_charge_dollar": 366.00, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Uhc/Secure Horizons", "plan_name": "500449", "standard_charge_dollar": 366.00, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "United Health Care/", "plan_name": "500292", "standard_charge_dollar": 413.58, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "United Healthcare", "plan_name": "750104", "standard_charge_dollar": 413.58, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "United Healthcare Ba", "plan_name": "750090", "standard_charge_dollar": 413.58, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "United Healthcare Me", "plan_name": "501310", "standard_charge_dollar": 366.00, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Windsor Mcare Extra", "plan_name": "500778", "standard_charge_dollar": 366.00, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." } ] } ] }, { "description": "Intmd rpr s/a/t/ext 12.6-20", "code_information": [ { "code": "12035", "type": "CPT" } ], "standard_charges": [ { "gross_charge": 14841.25, "minimum": 366.00, "maximum": 12615.06, "setting": "inpatient", "payers_information": [ { "payer_name": "Aarp", "plan_name": "500102", "standard_charge_dollar": 366.00, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna", "plan_name": "700700", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna", "plan_name": "700700_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Mcare Ffs 6005", "plan_name": "700703", "standard_charge_dollar": 366.00, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Miscellaneous", "plan_name": "700720", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Miscellaneous", "plan_name": "700720_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Ppo Hmo", "plan_name": "701720", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Ppo Hmo", "plan_name": "701720_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Ambetter 68069", "plan_name": "500516", "standard_charge_dollar": 366.00, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Ms State Emplo", "plan_name": "401457", "standard_charge_percentage": 0.80, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Ms State Emplo", "plan_name": "401457_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Basic Pl", "plan_name": "400100", "standard_charge_percentage": 0.85, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Basic Pl", "plan_name": "400100_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Federal", "plan_name": "400110", "standard_charge_percentage": 0.85, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Federal", "plan_name": "400110_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Cigna Healthsprings Ffs", "plan_name": "500064", "standard_charge_dollar": 366.00, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Conseco", "plan_name": "500302", "standard_charge_dollar": 366.00, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Humana Ffs 61101", "plan_name": "500006", "standard_charge_dollar": 366.00, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Medicare A", "plan_name": "100100", "standard_charge_dollar": 366.00, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Medicare A", "plan_name": "100500", "standard_charge_dollar": 366.00, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Medicare Part B Only", "plan_name": "100300", "standard_charge_dollar": 366.00, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Medicare Railroad", "plan_name": "100103", "standard_charge_dollar": 366.00, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Ms Physicians Care N", "plan_name": "714210", "standard_charge_dollar": 457.50, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Peoples Hlth Ffs 72126", "plan_name": "500019", "standard_charge_dollar": 366.00, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Uhc/Secure Horizons", "plan_name": "500449", "standard_charge_dollar": 366.00, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "United Health Care/", "plan_name": "500292", "standard_charge_dollar": 413.58, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "United Healthcare", "plan_name": "750104", "standard_charge_dollar": 413.58, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "United Healthcare Ba", "plan_name": "750090", "standard_charge_dollar": 413.58, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "United Healthcare Me", "plan_name": "501310", "standard_charge_dollar": 366.00, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Windsor Mcare Extra", "plan_name": "500778", "standard_charge_dollar": 366.00, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." } ] } ] }, { "description": "Intmd rpr s/a/t/ext 12.6-20", "code_information": [ { "code": "12035", "type": "CPT" } ], "standard_charges": [ { "gross_charge": 1016.00, "minimum": 366.00, "maximum": 863.60, "setting": "outpatient", "payers_information": [ { "payer_name": "Aarp", "plan_name": "500102", "standard_charge_dollar": 366.00, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna", "plan_name": "700700", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna", "plan_name": "700700_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Mcare Ffs 6005", "plan_name": "700703", "standard_charge_dollar": 366.00, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Miscellaneous", "plan_name": "700720", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Miscellaneous", "plan_name": "700720_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Ppo Hmo", "plan_name": "701720", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Ppo Hmo", "plan_name": "701720_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Ambetter 68069", "plan_name": "500516", "standard_charge_dollar": 366.00, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Ms State Emplo", "plan_name": "401457", "standard_charge_percentage": 0.80, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Ms State Emplo", "plan_name": "401457_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Basic Pl", "plan_name": "400100", "standard_charge_percentage": 0.85, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Basic Pl", "plan_name": "400100_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Federal", "plan_name": "400110", "standard_charge_percentage": 0.85, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Federal", "plan_name": "400110_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Cigna Healthsprings Ffs", "plan_name": "500064", "standard_charge_dollar": 366.00, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Conseco", "plan_name": "500302", "standard_charge_dollar": 366.00, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Humana Ffs 61101", "plan_name": "500006", "standard_charge_dollar": 366.00, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Medicare A", "plan_name": "100100", "standard_charge_dollar": 366.00, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Medicare A", "plan_name": "100500", "standard_charge_dollar": 366.00, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Medicare Part B Only", "plan_name": "100300", "standard_charge_dollar": 366.00, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Medicare Railroad", "plan_name": "100103", "standard_charge_dollar": 366.00, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Ms Physicians Care N", "plan_name": "714210", "standard_charge_dollar": 457.50, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Peoples Hlth Ffs 72126", "plan_name": "500019", "standard_charge_dollar": 366.00, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Uhc/Secure Horizons", "plan_name": "500449", "standard_charge_dollar": 366.00, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "United Health Care/", "plan_name": "500292", "standard_charge_dollar": 413.58, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "United Healthcare", "plan_name": "750104", "standard_charge_dollar": 413.58, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "United Healthcare Ba", "plan_name": "750090", "standard_charge_dollar": 413.58, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "United Healthcare Me", "plan_name": "501310", "standard_charge_dollar": 366.00, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Windsor Mcare Extra", "plan_name": "500778", "standard_charge_dollar": 366.00, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." } ] } ] }, { "description": "Laceration intermediate", "code_information": [ { "code": "12035", "type": "CPT" } ], "standard_charges": [ { "gross_charge": 1016.00, "minimum": 366.00, "maximum": 863.60, "setting": "both", "payers_information": [ { "payer_name": "Aarp", "plan_name": "500102", "standard_charge_dollar": 366.00, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna", "plan_name": "700700", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna", "plan_name": "700700_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Mcare Ffs 6005", "plan_name": "700703", "standard_charge_dollar": 366.00, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Miscellaneous", "plan_name": "700720", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Miscellaneous", "plan_name": "700720_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Ppo Hmo", "plan_name": "701720", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Ppo Hmo", "plan_name": "701720_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Ambetter 68069", "plan_name": "500516", "standard_charge_dollar": 366.00, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Ms State Emplo", "plan_name": "401457", "standard_charge_percentage": 0.80, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Ms State Emplo", "plan_name": "401457_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Basic Pl", "plan_name": "400100", "standard_charge_percentage": 0.85, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Basic Pl", "plan_name": "400100_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Federal", "plan_name": "400110", "standard_charge_percentage": 0.85, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Federal", "plan_name": "400110_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Cigna Healthsprings Ffs", "plan_name": "500064", "standard_charge_dollar": 366.00, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Conseco", "plan_name": "500302", "standard_charge_dollar": 366.00, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Humana Ffs 61101", "plan_name": "500006", "standard_charge_dollar": 366.00, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Medicare A", "plan_name": "100100", "standard_charge_dollar": 366.00, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Medicare A", "plan_name": "100500", "standard_charge_dollar": 366.00, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Medicare Part B Only", "plan_name": "100300", "standard_charge_dollar": 366.00, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Medicare Railroad", "plan_name": "100103", "standard_charge_dollar": 366.00, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Ms Physicians Care N", "plan_name": "714210", "standard_charge_dollar": 457.50, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Peoples Hlth Ffs 72126", "plan_name": "500019", "standard_charge_dollar": 366.00, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Uhc/Secure Horizons", "plan_name": "500449", "standard_charge_dollar": 366.00, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "United Health Care/", "plan_name": "500292", "standard_charge_dollar": 413.58, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "United Healthcare", "plan_name": "750104", "standard_charge_dollar": 413.58, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "United Healthcare Ba", "plan_name": "750090", "standard_charge_dollar": 413.58, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "United Healthcare Me", "plan_name": "501310", "standard_charge_dollar": 366.00, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Windsor Mcare Extra", "plan_name": "500778", "standard_charge_dollar": 366.00, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." } ] } ] }, { "description": "Intmd rpr s/a/t/ext 20.1-30", "code_information": [ { "code": "12036", "type": "CPT" } ], "standard_charges": [ { "gross_charge": 14841.25, "minimum": 560.75, "maximum": 12615.06, "setting": "inpatient", "payers_information": [ { "payer_name": "Aarp", "plan_name": "500102", "standard_charge_dollar": 560.75, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna", "plan_name": "700700", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna", "plan_name": "700700_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Mcare Ffs 6005", "plan_name": "700703", "standard_charge_dollar": 560.75, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Miscellaneous", "plan_name": "700720", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Miscellaneous", "plan_name": "700720_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Ppo Hmo", "plan_name": "701720", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Ppo Hmo", "plan_name": "701720_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Ambetter 68069", "plan_name": "500516", "standard_charge_dollar": 560.75, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Ms State Emplo", "plan_name": "401457", "standard_charge_percentage": 0.80, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Ms State Emplo", "plan_name": "401457_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Basic Pl", "plan_name": "400100", "standard_charge_percentage": 0.85, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Basic Pl", "plan_name": "400100_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Federal", "plan_name": "400110", "standard_charge_percentage": 0.85, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Federal", "plan_name": "400110_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Cigna Healthsprings Ffs", "plan_name": "500064", "standard_charge_dollar": 560.75, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Conseco", "plan_name": "500302", "standard_charge_dollar": 560.75, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Humana Ffs 61101", "plan_name": "500006", "standard_charge_dollar": 560.75, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Medicare A", "plan_name": "100100", "standard_charge_dollar": 560.75, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Medicare A", "plan_name": "100500", "standard_charge_dollar": 560.75, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Medicare Part B Only", "plan_name": "100300", "standard_charge_dollar": 560.75, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Medicare Railroad", "plan_name": "100103", "standard_charge_dollar": 560.75, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Ms Physicians Care N", "plan_name": "714210", "standard_charge_dollar": 700.94, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Peoples Hlth Ffs 72126", "plan_name": "500019", "standard_charge_dollar": 560.75, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Uhc/Secure Horizons", "plan_name": "500449", "standard_charge_dollar": 560.75, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "United Health Care/", "plan_name": "500292", "standard_charge_dollar": 633.65, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "United Healthcare", "plan_name": "750104", "standard_charge_dollar": 633.65, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "United Healthcare Ba", "plan_name": "750090", "standard_charge_dollar": 633.65, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "United Healthcare Me", "plan_name": "501310", "standard_charge_dollar": 560.75, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Windsor Mcare Extra", "plan_name": "500778", "standard_charge_dollar": 560.75, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." } ] } ] }, { "description": "Intmd rpr s/a/t/ext 20.1-30", "code_information": [ { "code": "12036", "type": "CPT" } ], "standard_charges": [ { "gross_charge": 1016.00, "minimum": 560.75, "maximum": 863.60, "setting": "outpatient", "payers_information": [ { "payer_name": "Aarp", "plan_name": "500102", "standard_charge_dollar": 560.75, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna", "plan_name": "700700", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna", "plan_name": "700700_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Mcare Ffs 6005", "plan_name": "700703", "standard_charge_dollar": 560.75, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Miscellaneous", "plan_name": "700720", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Miscellaneous", "plan_name": "700720_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Ppo Hmo", "plan_name": "701720", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Ppo Hmo", "plan_name": "701720_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Ambetter 68069", "plan_name": "500516", "standard_charge_dollar": 560.75, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Ms State Emplo", "plan_name": "401457", "standard_charge_percentage": 0.80, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Ms State Emplo", "plan_name": "401457_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Basic Pl", "plan_name": "400100", "standard_charge_percentage": 0.85, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Basic Pl", "plan_name": "400100_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Federal", "plan_name": "400110", "standard_charge_percentage": 0.85, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Federal", "plan_name": "400110_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Cigna Healthsprings Ffs", "plan_name": "500064", "standard_charge_dollar": 560.75, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Conseco", "plan_name": "500302", "standard_charge_dollar": 560.75, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Humana Ffs 61101", "plan_name": "500006", "standard_charge_dollar": 560.75, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Medicare A", "plan_name": "100100", "standard_charge_dollar": 560.75, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Medicare A", "plan_name": "100500", "standard_charge_dollar": 560.75, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Medicare Part B Only", "plan_name": "100300", "standard_charge_dollar": 560.75, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Medicare Railroad", "plan_name": "100103", "standard_charge_dollar": 560.75, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Ms Physicians Care N", "plan_name": "714210", "standard_charge_dollar": 700.94, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Peoples Hlth Ffs 72126", "plan_name": "500019", "standard_charge_dollar": 560.75, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Uhc/Secure Horizons", "plan_name": "500449", "standard_charge_dollar": 560.75, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "United Health Care/", "plan_name": "500292", "standard_charge_dollar": 633.65, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "United Healthcare", "plan_name": "750104", "standard_charge_dollar": 633.65, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "United Healthcare Ba", "plan_name": "750090", "standard_charge_dollar": 633.65, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "United Healthcare Me", "plan_name": "501310", "standard_charge_dollar": 560.75, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Windsor Mcare Extra", "plan_name": "500778", "standard_charge_dollar": 560.75, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." } ] } ] }, { "description": "Laceration intermediate", "code_information": [ { "code": "12036", "type": "CPT" } ], "standard_charges": [ { "gross_charge": 1016.00, "minimum": 560.75, "maximum": 863.60, "setting": "both", "payers_information": [ { "payer_name": "Aarp", "plan_name": "500102", "standard_charge_dollar": 560.75, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna", "plan_name": "700700", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna", "plan_name": "700700_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Mcare Ffs 6005", "plan_name": "700703", "standard_charge_dollar": 560.75, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Miscellaneous", "plan_name": "700720", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Miscellaneous", "plan_name": "700720_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Ppo Hmo", "plan_name": "701720", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Ppo Hmo", "plan_name": "701720_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Ambetter 68069", "plan_name": "500516", "standard_charge_dollar": 560.75, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Ms State Emplo", "plan_name": "401457", "standard_charge_percentage": 0.80, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Ms State Emplo", "plan_name": "401457_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Basic Pl", "plan_name": "400100", "standard_charge_percentage": 0.85, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Basic Pl", "plan_name": "400100_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Federal", "plan_name": "400110", "standard_charge_percentage": 0.85, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Federal", "plan_name": "400110_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Cigna Healthsprings Ffs", "plan_name": "500064", "standard_charge_dollar": 560.75, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Conseco", "plan_name": "500302", "standard_charge_dollar": 560.75, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Humana Ffs 61101", "plan_name": "500006", "standard_charge_dollar": 560.75, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Medicare A", "plan_name": "100100", "standard_charge_dollar": 560.75, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Medicare A", "plan_name": "100500", "standard_charge_dollar": 560.75, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Medicare Part B Only", "plan_name": "100300", "standard_charge_dollar": 560.75, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Medicare Railroad", "plan_name": "100103", "standard_charge_dollar": 560.75, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Ms Physicians Care N", "plan_name": "714210", "standard_charge_dollar": 700.94, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Peoples Hlth Ffs 72126", "plan_name": "500019", "standard_charge_dollar": 560.75, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Uhc/Secure Horizons", "plan_name": "500449", "standard_charge_dollar": 560.75, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "United Health Care/", "plan_name": "500292", "standard_charge_dollar": 633.65, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "United Healthcare", "plan_name": "750104", "standard_charge_dollar": 633.65, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "United Healthcare Ba", "plan_name": "750090", "standard_charge_dollar": 633.65, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "United Healthcare Me", "plan_name": "501310", "standard_charge_dollar": 560.75, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Windsor Mcare Extra", "plan_name": "500778", "standard_charge_dollar": 560.75, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." } ] } ] }, { "description": "Intmd rpr s/tr/ext >30.0 cm", "code_information": [ { "code": "12037", "type": "CPT" } ], "standard_charges": [ { "gross_charge": 14841.25, "minimum": 1675.70, "maximum": 12615.06, "setting": "inpatient", "payers_information": [ { "payer_name": "Aarp", "plan_name": "500102", "standard_charge_dollar": 1675.70, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna", "plan_name": "700700", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna", "plan_name": "700700_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Mcare Ffs 6005", "plan_name": "700703", "standard_charge_dollar": 1675.70, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Miscellaneous", "plan_name": "700720", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Miscellaneous", "plan_name": "700720_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Ppo Hmo", "plan_name": "701720", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Ppo Hmo", "plan_name": "701720_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Ambetter 68069", "plan_name": "500516", "standard_charge_dollar": 1675.70, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Ms State Emplo", "plan_name": "401457", "standard_charge_percentage": 0.80, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Ms State Emplo", "plan_name": "401457_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Basic Pl", "plan_name": "400100", "standard_charge_percentage": 0.85, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Basic Pl", "plan_name": "400100_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Federal", "plan_name": "400110", "standard_charge_percentage": 0.85, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Federal", "plan_name": "400110_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Cigna Healthsprings Ffs", "plan_name": "500064", "standard_charge_dollar": 1675.70, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Conseco", "plan_name": "500302", "standard_charge_dollar": 1675.70, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Humana Ffs 61101", "plan_name": "500006", "standard_charge_dollar": 1675.70, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Medicare A", "plan_name": "100100", "standard_charge_dollar": 1675.70, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Medicare A", "plan_name": "100500", "standard_charge_dollar": 1675.70, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Medicare Part B Only", "plan_name": "100300", "standard_charge_dollar": 1675.70, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Medicare Railroad", "plan_name": "100103", "standard_charge_dollar": 1675.70, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Ms Physicians Care N", "plan_name": "714210", "standard_charge_dollar": 2094.63, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Peoples Hlth Ffs 72126", "plan_name": "500019", "standard_charge_dollar": 1675.70, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Uhc/Secure Horizons", "plan_name": "500449", "standard_charge_dollar": 1675.70, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "United Health Care/", "plan_name": "500292", "standard_charge_dollar": 1893.54, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "United Healthcare", "plan_name": "750104", "standard_charge_dollar": 1893.54, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "United Healthcare Ba", "plan_name": "750090", "standard_charge_dollar": 1893.54, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "United Healthcare Me", "plan_name": "501310", "standard_charge_dollar": 1675.70, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Windsor Mcare Extra", "plan_name": "500778", "standard_charge_dollar": 1675.70, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." } ] } ] }, { "description": "Intmd rpr s/tr/ext >30.0 cm", "code_information": [ { "code": "12037", "type": "CPT" } ], "standard_charges": [ { "gross_charge": 1016.00, "minimum": 812.80, "maximum": 2094.63, "setting": "outpatient", "payers_information": [ { "payer_name": "Aarp", "plan_name": "500102", "standard_charge_dollar": 1675.70, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna", "plan_name": "700700", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna", "plan_name": "700700_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Mcare Ffs 6005", "plan_name": "700703", "standard_charge_dollar": 1675.70, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Miscellaneous", "plan_name": "700720", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Miscellaneous", "plan_name": "700720_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Ppo Hmo", "plan_name": "701720", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Ppo Hmo", "plan_name": "701720_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Ambetter 68069", "plan_name": "500516", "standard_charge_dollar": 1675.70, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Ms State Emplo", "plan_name": "401457", "standard_charge_percentage": 0.80, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Ms State Emplo", "plan_name": "401457_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Basic Pl", "plan_name": "400100", "standard_charge_percentage": 0.85, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Basic Pl", "plan_name": "400100_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Federal", "plan_name": "400110", "standard_charge_percentage": 0.85, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Federal", "plan_name": "400110_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Cigna Healthsprings Ffs", "plan_name": "500064", "standard_charge_dollar": 1675.70, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Conseco", "plan_name": "500302", "standard_charge_dollar": 1675.70, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Humana Ffs 61101", "plan_name": "500006", "standard_charge_dollar": 1675.70, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Medicare A", "plan_name": "100100", "standard_charge_dollar": 1675.70, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Medicare A", "plan_name": "100500", "standard_charge_dollar": 1675.70, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Medicare Part B Only", "plan_name": "100300", "standard_charge_dollar": 1675.70, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Medicare Railroad", "plan_name": "100103", "standard_charge_dollar": 1675.70, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Ms Physicians Care N", "plan_name": "714210", "standard_charge_dollar": 2094.63, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Peoples Hlth Ffs 72126", "plan_name": "500019", "standard_charge_dollar": 1675.70, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Uhc/Secure Horizons", "plan_name": "500449", "standard_charge_dollar": 1675.70, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "United Health Care/", "plan_name": "500292", "standard_charge_dollar": 1893.54, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "United Healthcare", "plan_name": "750104", "standard_charge_dollar": 1893.54, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "United Healthcare Ba", "plan_name": "750090", "standard_charge_dollar": 1893.54, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "United Healthcare Me", "plan_name": "501310", "standard_charge_dollar": 1675.70, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Windsor Mcare Extra", "plan_name": "500778", "standard_charge_dollar": 1675.70, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." } ] } ] }, { "description": "Laceration intermediate", "code_information": [ { "code": "12037", "type": "CPT" } ], "standard_charges": [ { "gross_charge": 1016.00, "minimum": 812.80, "maximum": 2094.63, "setting": "both", "payers_information": [ { "payer_name": "Aarp", "plan_name": "500102", "standard_charge_dollar": 1675.70, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna", "plan_name": "700700", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna", "plan_name": "700700_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Mcare Ffs 6005", "plan_name": "700703", "standard_charge_dollar": 1675.70, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Miscellaneous", "plan_name": "700720", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Miscellaneous", "plan_name": "700720_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Ppo Hmo", "plan_name": "701720", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Ppo Hmo", "plan_name": "701720_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Ambetter 68069", "plan_name": "500516", "standard_charge_dollar": 1675.70, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Ms State Emplo", "plan_name": "401457", "standard_charge_percentage": 0.80, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Ms State Emplo", "plan_name": "401457_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Basic Pl", "plan_name": "400100", "standard_charge_percentage": 0.85, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Basic Pl", "plan_name": "400100_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Federal", "plan_name": "400110", "standard_charge_percentage": 0.85, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Federal", "plan_name": "400110_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Cigna Healthsprings Ffs", "plan_name": "500064", "standard_charge_dollar": 1675.70, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Conseco", "plan_name": "500302", "standard_charge_dollar": 1675.70, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Humana Ffs 61101", "plan_name": "500006", "standard_charge_dollar": 1675.70, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Medicare A", "plan_name": "100100", "standard_charge_dollar": 1675.70, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Medicare A", "plan_name": "100500", "standard_charge_dollar": 1675.70, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Medicare Part B Only", "plan_name": "100300", "standard_charge_dollar": 1675.70, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Medicare Railroad", "plan_name": "100103", "standard_charge_dollar": 1675.70, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Ms Physicians Care N", "plan_name": "714210", "standard_charge_dollar": 2094.63, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Peoples Hlth Ffs 72126", "plan_name": "500019", "standard_charge_dollar": 1675.70, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Uhc/Secure Horizons", "plan_name": "500449", "standard_charge_dollar": 1675.70, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "United Health Care/", "plan_name": "500292", "standard_charge_dollar": 1893.54, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "United Healthcare", "plan_name": "750104", "standard_charge_dollar": 1893.54, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "United Healthcare Ba", "plan_name": "750090", "standard_charge_dollar": 1893.54, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "United Healthcare Me", "plan_name": "501310", "standard_charge_dollar": 1675.70, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Windsor Mcare Extra", "plan_name": "500778", "standard_charge_dollar": 1675.70, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." } ] } ] }, { "description": "Intmd rpr n-hf/genit 2.5cm/<", "code_information": [ { "code": "12041", "type": "CPT" } ], "standard_charges": [ { "gross_charge": 1016.00, "minimum": 366.00, "maximum": 457.50, "setting": "both", "payers_information": [ { "payer_name": "Aarp", "plan_name": "500102", "standard_charge_dollar": 366.00, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna", "plan_name": "700700", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna", "plan_name": "700700_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Mcare Ffs 6005", "plan_name": "700703", "standard_charge_dollar": 366.00, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Miscellaneous", "plan_name": "700720", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Miscellaneous", "plan_name": "700720_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Ppo Hmo", "plan_name": "701720", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Ppo Hmo", "plan_name": "701720_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Ambetter 68069", "plan_name": "500516", "standard_charge_dollar": 366.00, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Ms State Emplo", "plan_name": "401457", "standard_charge_dollar": 438.74, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Ms State Emplo", "plan_name": "401457_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Basic Pl", "plan_name": "400100", "standard_charge_dollar": 438.74, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Basic Pl", "plan_name": "400100_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Federal", "plan_name": "400110", "standard_charge_dollar": 438.74, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Federal", "plan_name": "400110_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Cigna Healthsprings Ffs", "plan_name": "500064", "standard_charge_dollar": 366.00, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Conseco", "plan_name": "500302", "standard_charge_dollar": 366.00, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Humana Ffs 61101", "plan_name": "500006", "standard_charge_dollar": 366.00, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Medicare A", "plan_name": "100100", "standard_charge_dollar": 366.00, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Medicare A", "plan_name": "100500", "standard_charge_dollar": 366.00, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Medicare Part B Only", "plan_name": "100300", "standard_charge_dollar": 366.00, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Medicare Railroad", "plan_name": "100103", "standard_charge_dollar": 366.00, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Ms Physicians Care N", "plan_name": "714210", "standard_charge_dollar": 457.50, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Peoples Hlth Ffs 72126", "plan_name": "500019", "standard_charge_dollar": 366.00, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Uhc/Secure Horizons", "plan_name": "500449", "standard_charge_dollar": 366.00, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "United Health Care/", "plan_name": "500292", "standard_charge_dollar": 413.58, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "United Healthcare", "plan_name": "750104", "standard_charge_dollar": 413.58, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "United Healthcare Ba", "plan_name": "750090", "standard_charge_dollar": 413.58, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "United Healthcare Me", "plan_name": "501310", "standard_charge_dollar": 366.00, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Windsor Mcare Extra", "plan_name": "500778", "standard_charge_dollar": 366.00, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." } ] } ] }, { "description": "Laceration intermediate", "code_information": [ { "code": "12041", "type": "CPT" } ], "standard_charges": [ { "gross_charge": 1016.00, "minimum": 366.00, "maximum": 457.50, "setting": "both", "payers_information": [ { "payer_name": "Aarp", "plan_name": "500102", "standard_charge_dollar": 366.00, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna", "plan_name": "700700", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna", "plan_name": "700700_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Mcare Ffs 6005", "plan_name": "700703", "standard_charge_dollar": 366.00, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Miscellaneous", "plan_name": "700720", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Miscellaneous", "plan_name": "700720_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Ppo Hmo", "plan_name": "701720", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Ppo Hmo", "plan_name": "701720_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Ambetter 68069", "plan_name": "500516", "standard_charge_dollar": 366.00, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Ms State Emplo", "plan_name": "401457", "standard_charge_dollar": 438.74, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Ms State Emplo", "plan_name": "401457_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Basic Pl", "plan_name": "400100", "standard_charge_dollar": 438.74, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Basic Pl", "plan_name": "400100_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Federal", "plan_name": "400110", "standard_charge_dollar": 438.74, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Federal", "plan_name": "400110_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Cigna Healthsprings Ffs", "plan_name": "500064", "standard_charge_dollar": 366.00, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Conseco", "plan_name": "500302", "standard_charge_dollar": 366.00, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Humana Ffs 61101", "plan_name": "500006", "standard_charge_dollar": 366.00, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Medicare A", "plan_name": "100100", "standard_charge_dollar": 366.00, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Medicare A", "plan_name": "100500", "standard_charge_dollar": 366.00, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Medicare Part B Only", "plan_name": "100300", "standard_charge_dollar": 366.00, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Medicare Railroad", "plan_name": "100103", "standard_charge_dollar": 366.00, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Ms Physicians Care N", "plan_name": "714210", "standard_charge_dollar": 457.50, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Peoples Hlth Ffs 72126", "plan_name": "500019", "standard_charge_dollar": 366.00, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Uhc/Secure Horizons", "plan_name": "500449", "standard_charge_dollar": 366.00, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "United Health Care/", "plan_name": "500292", "standard_charge_dollar": 413.58, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "United Healthcare", "plan_name": "750104", "standard_charge_dollar": 413.58, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "United Healthcare Ba", "plan_name": "750090", "standard_charge_dollar": 413.58, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "United Healthcare Me", "plan_name": "501310", "standard_charge_dollar": 366.00, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Windsor Mcare Extra", "plan_name": "500778", "standard_charge_dollar": 366.00, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." } ] } ] }, { "description": "Intmd rpr n-hf/genit2.6-7.5", "code_information": [ { "code": "12042", "type": "CPT" } ], "standard_charges": [ { "gross_charge": 1016.00, "minimum": 366.00, "maximum": 863.60, "setting": "both", "payers_information": [ { "payer_name": "Aarp", "plan_name": "500102", "standard_charge_dollar": 366.00, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna", "plan_name": "700700", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna", "plan_name": "700700_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Mcare Ffs 6005", "plan_name": "700703", "standard_charge_dollar": 366.00, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Miscellaneous", "plan_name": "700720", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Miscellaneous", "plan_name": "700720_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Ppo Hmo", "plan_name": "701720", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Ppo Hmo", "plan_name": "701720_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Ambetter 68069", "plan_name": "500516", "standard_charge_dollar": 366.00, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Ms State Emplo", "plan_name": "401457", "standard_charge_percentage": 0.80, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Ms State Emplo", "plan_name": "401457_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Basic Pl", "plan_name": "400100", "standard_charge_percentage": 0.85, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Basic Pl", "plan_name": "400100_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Federal", "plan_name": "400110", "standard_charge_percentage": 0.85, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Federal", "plan_name": "400110_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Cigna Healthsprings Ffs", "plan_name": "500064", "standard_charge_dollar": 366.00, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Conseco", "plan_name": "500302", "standard_charge_dollar": 366.00, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Humana Ffs 61101", "plan_name": "500006", "standard_charge_dollar": 366.00, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Medicare A", "plan_name": "100100", "standard_charge_dollar": 366.00, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Medicare A", "plan_name": "100500", "standard_charge_dollar": 366.00, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Medicare Part B Only", "plan_name": "100300", "standard_charge_dollar": 366.00, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Medicare Railroad", "plan_name": "100103", "standard_charge_dollar": 366.00, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Ms Physicians Care N", "plan_name": "714210", "standard_charge_dollar": 457.50, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Peoples Hlth Ffs 72126", "plan_name": "500019", "standard_charge_dollar": 366.00, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Uhc/Secure Horizons", "plan_name": "500449", "standard_charge_dollar": 366.00, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "United Health Care/", "plan_name": "500292", "standard_charge_dollar": 413.58, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "United Healthcare", "plan_name": "750104", "standard_charge_dollar": 413.58, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "United Healthcare Ba", "plan_name": "750090", "standard_charge_dollar": 413.58, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "United Healthcare Me", "plan_name": "501310", "standard_charge_dollar": 366.00, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Windsor Mcare Extra", "plan_name": "500778", "standard_charge_dollar": 366.00, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." } ] } ] }, { "description": "Laceration intermediate", "code_information": [ { "code": "12042", "type": "CPT" } ], "standard_charges": [ { "gross_charge": 1016.00, "minimum": 366.00, "maximum": 863.60, "setting": "both", "payers_information": [ { "payer_name": "Aarp", "plan_name": "500102", "standard_charge_dollar": 366.00, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna", "plan_name": "700700", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna", "plan_name": "700700_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Mcare Ffs 6005", "plan_name": "700703", "standard_charge_dollar": 366.00, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Miscellaneous", "plan_name": "700720", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Miscellaneous", "plan_name": "700720_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Ppo Hmo", "plan_name": "701720", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Ppo Hmo", "plan_name": "701720_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Ambetter 68069", "plan_name": "500516", "standard_charge_dollar": 366.00, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Ms State Emplo", "plan_name": "401457", "standard_charge_percentage": 0.80, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Ms State Emplo", "plan_name": "401457_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Basic Pl", "plan_name": "400100", "standard_charge_percentage": 0.85, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Basic Pl", "plan_name": "400100_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Federal", "plan_name": "400110", "standard_charge_percentage": 0.85, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Federal", "plan_name": "400110_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Cigna Healthsprings Ffs", "plan_name": "500064", "standard_charge_dollar": 366.00, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Conseco", "plan_name": "500302", "standard_charge_dollar": 366.00, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Humana Ffs 61101", "plan_name": "500006", "standard_charge_dollar": 366.00, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Medicare A", "plan_name": "100100", "standard_charge_dollar": 366.00, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Medicare A", "plan_name": "100500", "standard_charge_dollar": 366.00, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Medicare Part B Only", "plan_name": "100300", "standard_charge_dollar": 366.00, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Medicare Railroad", "plan_name": "100103", "standard_charge_dollar": 366.00, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Ms Physicians Care N", "plan_name": "714210", "standard_charge_dollar": 457.50, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Peoples Hlth Ffs 72126", "plan_name": "500019", "standard_charge_dollar": 366.00, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Uhc/Secure Horizons", "plan_name": "500449", "standard_charge_dollar": 366.00, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "United Health Care/", "plan_name": "500292", "standard_charge_dollar": 413.58, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "United Healthcare", "plan_name": "750104", "standard_charge_dollar": 413.58, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "United Healthcare Ba", "plan_name": "750090", "standard_charge_dollar": 413.58, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "United Healthcare Me", "plan_name": "501310", "standard_charge_dollar": 366.00, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Windsor Mcare Extra", "plan_name": "500778", "standard_charge_dollar": 366.00, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." } ] } ] }, { "description": "Intmd rpr n-hf/genit7.6-12.5", "code_information": [ { "code": "12044", "type": "CPT" } ], "standard_charges": [ { "gross_charge": 1016.00, "minimum": 560.75, "maximum": 863.60, "setting": "both", "payers_information": [ { "payer_name": "Aarp", "plan_name": "500102", "standard_charge_dollar": 560.75, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna", "plan_name": "700700", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna", "plan_name": "700700_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Mcare Ffs 6005", "plan_name": "700703", "standard_charge_dollar": 560.75, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Miscellaneous", "plan_name": "700720", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Miscellaneous", "plan_name": "700720_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Ppo Hmo", "plan_name": "701720", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Ppo Hmo", "plan_name": "701720_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Ambetter 68069", "plan_name": "500516", "standard_charge_dollar": 560.75, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Ms State Emplo", "plan_name": "401457", "standard_charge_percentage": 0.80, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Ms State Emplo", "plan_name": "401457_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Basic Pl", "plan_name": "400100", "standard_charge_percentage": 0.85, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Basic Pl", "plan_name": "400100_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Federal", "plan_name": "400110", "standard_charge_percentage": 0.85, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Federal", "plan_name": "400110_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Cigna Healthsprings Ffs", "plan_name": "500064", "standard_charge_dollar": 560.75, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Conseco", "plan_name": "500302", "standard_charge_dollar": 560.75, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Humana Ffs 61101", "plan_name": "500006", "standard_charge_dollar": 560.75, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Medicare A", "plan_name": "100100", "standard_charge_dollar": 560.75, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Medicare A", "plan_name": "100500", "standard_charge_dollar": 560.75, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Medicare Part B Only", "plan_name": "100300", "standard_charge_dollar": 560.75, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Medicare Railroad", "plan_name": "100103", "standard_charge_dollar": 560.75, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Ms Physicians Care N", "plan_name": "714210", "standard_charge_dollar": 700.94, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Peoples Hlth Ffs 72126", "plan_name": "500019", "standard_charge_dollar": 560.75, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Uhc/Secure Horizons", "plan_name": "500449", "standard_charge_dollar": 560.75, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "United Health Care/", "plan_name": "500292", "standard_charge_dollar": 633.65, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "United Healthcare", "plan_name": "750104", "standard_charge_dollar": 633.65, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "United Healthcare Ba", "plan_name": "750090", "standard_charge_dollar": 633.65, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "United Healthcare Me", "plan_name": "501310", "standard_charge_dollar": 560.75, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Windsor Mcare Extra", "plan_name": "500778", "standard_charge_dollar": 560.75, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." } ] } ] }, { "description": "Laceration intermediate", "code_information": [ { "code": "12044", "type": "CPT" } ], "standard_charges": [ { "gross_charge": 1016.00, "minimum": 560.75, "maximum": 863.60, "setting": "both", "payers_information": [ { "payer_name": "Aarp", "plan_name": "500102", "standard_charge_dollar": 560.75, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna", "plan_name": "700700", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna", "plan_name": "700700_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Mcare Ffs 6005", "plan_name": "700703", "standard_charge_dollar": 560.75, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Miscellaneous", "plan_name": "700720", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Miscellaneous", "plan_name": "700720_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Ppo Hmo", "plan_name": "701720", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Ppo Hmo", "plan_name": "701720_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Ambetter 68069", "plan_name": "500516", "standard_charge_dollar": 560.75, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Ms State Emplo", "plan_name": "401457", "standard_charge_percentage": 0.80, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Ms State Emplo", "plan_name": "401457_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Basic Pl", "plan_name": "400100", "standard_charge_percentage": 0.85, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Basic Pl", "plan_name": "400100_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Federal", "plan_name": "400110", "standard_charge_percentage": 0.85, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Federal", "plan_name": "400110_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Cigna Healthsprings Ffs", "plan_name": "500064", "standard_charge_dollar": 560.75, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Conseco", "plan_name": "500302", "standard_charge_dollar": 560.75, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Humana Ffs 61101", "plan_name": "500006", "standard_charge_dollar": 560.75, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Medicare A", "plan_name": "100100", "standard_charge_dollar": 560.75, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Medicare A", "plan_name": "100500", "standard_charge_dollar": 560.75, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Medicare Part B Only", "plan_name": "100300", "standard_charge_dollar": 560.75, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Medicare Railroad", "plan_name": "100103", "standard_charge_dollar": 560.75, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Ms Physicians Care N", "plan_name": "714210", "standard_charge_dollar": 700.94, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Peoples Hlth Ffs 72126", "plan_name": "500019", "standard_charge_dollar": 560.75, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Uhc/Secure Horizons", "plan_name": "500449", "standard_charge_dollar": 560.75, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "United Health Care/", "plan_name": "500292", "standard_charge_dollar": 633.65, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "United Healthcare", "plan_name": "750104", "standard_charge_dollar": 633.65, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "United Healthcare Ba", "plan_name": "750090", "standard_charge_dollar": 633.65, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "United Healthcare Me", "plan_name": "501310", "standard_charge_dollar": 560.75, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Windsor Mcare Extra", "plan_name": "500778", "standard_charge_dollar": 560.75, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." } ] } ] }, { "description": "Intmd rpr n-hf/genit12.6-20", "code_information": [ { "code": "12045", "type": "CPT" } ], "standard_charges": [ { "gross_charge": 1016.00, "minimum": 560.75, "maximum": 863.60, "setting": "both", "payers_information": [ { "payer_name": "Aarp", "plan_name": "500102", "standard_charge_dollar": 560.75, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna", "plan_name": "700700", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna", "plan_name": "700700_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Mcare Ffs 6005", "plan_name": "700703", "standard_charge_dollar": 560.75, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Miscellaneous", "plan_name": "700720", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Miscellaneous", "plan_name": "700720_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Ppo Hmo", "plan_name": "701720", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Ppo Hmo", "plan_name": "701720_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Ambetter 68069", "plan_name": "500516", "standard_charge_dollar": 560.75, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Ms State Emplo", "plan_name": "401457", "standard_charge_percentage": 0.80, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Ms State Emplo", "plan_name": "401457_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Basic Pl", "plan_name": "400100", "standard_charge_percentage": 0.85, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Basic Pl", "plan_name": "400100_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Federal", "plan_name": "400110", "standard_charge_percentage": 0.85, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Federal", "plan_name": "400110_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Cigna Healthsprings Ffs", "plan_name": "500064", "standard_charge_dollar": 560.75, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Conseco", "plan_name": "500302", "standard_charge_dollar": 560.75, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Humana Ffs 61101", "plan_name": "500006", "standard_charge_dollar": 560.75, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Medicare A", "plan_name": "100100", "standard_charge_dollar": 560.75, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Medicare A", "plan_name": "100500", "standard_charge_dollar": 560.75, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Medicare Part B Only", "plan_name": "100300", "standard_charge_dollar": 560.75, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Medicare Railroad", "plan_name": "100103", "standard_charge_dollar": 560.75, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Ms Physicians Care N", "plan_name": "714210", "standard_charge_dollar": 700.94, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Peoples Hlth Ffs 72126", "plan_name": "500019", "standard_charge_dollar": 560.75, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Uhc/Secure Horizons", "plan_name": "500449", "standard_charge_dollar": 560.75, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "United Health Care/", "plan_name": "500292", "standard_charge_dollar": 633.65, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "United Healthcare", "plan_name": "750104", "standard_charge_dollar": 633.65, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "United Healthcare Ba", "plan_name": "750090", "standard_charge_dollar": 633.65, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "United Healthcare Me", "plan_name": "501310", "standard_charge_dollar": 560.75, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Windsor Mcare Extra", "plan_name": "500778", "standard_charge_dollar": 560.75, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." } ] } ] }, { "description": "Laceration intermediate", "code_information": [ { "code": "12045", "type": "CPT" } ], "standard_charges": [ { "gross_charge": 1016.00, "minimum": 560.75, "maximum": 863.60, "setting": "both", "payers_information": [ { "payer_name": "Aarp", "plan_name": "500102", "standard_charge_dollar": 560.75, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna", "plan_name": "700700", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna", "plan_name": "700700_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Mcare Ffs 6005", "plan_name": "700703", "standard_charge_dollar": 560.75, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Miscellaneous", "plan_name": "700720", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Miscellaneous", "plan_name": "700720_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Ppo Hmo", "plan_name": "701720", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Ppo Hmo", "plan_name": "701720_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Ambetter 68069", "plan_name": "500516", "standard_charge_dollar": 560.75, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Ms State Emplo", "plan_name": "401457", "standard_charge_percentage": 0.80, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Ms State Emplo", "plan_name": "401457_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Basic Pl", "plan_name": "400100", "standard_charge_percentage": 0.85, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Basic Pl", "plan_name": "400100_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Federal", "plan_name": "400110", "standard_charge_percentage": 0.85, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Federal", "plan_name": "400110_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Cigna Healthsprings Ffs", "plan_name": "500064", "standard_charge_dollar": 560.75, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Conseco", "plan_name": "500302", "standard_charge_dollar": 560.75, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Humana Ffs 61101", "plan_name": "500006", "standard_charge_dollar": 560.75, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Medicare A", "plan_name": "100100", "standard_charge_dollar": 560.75, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Medicare A", "plan_name": "100500", "standard_charge_dollar": 560.75, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Medicare Part B Only", "plan_name": "100300", "standard_charge_dollar": 560.75, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Medicare Railroad", "plan_name": "100103", "standard_charge_dollar": 560.75, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Ms Physicians Care N", "plan_name": "714210", "standard_charge_dollar": 700.94, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Peoples Hlth Ffs 72126", "plan_name": "500019", "standard_charge_dollar": 560.75, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Uhc/Secure Horizons", "plan_name": "500449", "standard_charge_dollar": 560.75, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "United Health Care/", "plan_name": "500292", "standard_charge_dollar": 633.65, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "United Healthcare", "plan_name": "750104", "standard_charge_dollar": 633.65, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "United Healthcare Ba", "plan_name": "750090", "standard_charge_dollar": 633.65, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "United Healthcare Me", "plan_name": "501310", "standard_charge_dollar": 560.75, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Windsor Mcare Extra", "plan_name": "500778", "standard_charge_dollar": 560.75, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." } ] } ] }, { "description": "Intmd rpr n-hf/genit20.1-30", "code_information": [ { "code": "12046", "type": "CPT" } ], "standard_charges": [ { "gross_charge": 1016.00, "minimum": 560.75, "maximum": 863.60, "setting": "both", "payers_information": [ { "payer_name": "Aarp", "plan_name": "500102", "standard_charge_dollar": 560.75, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna", "plan_name": "700700", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna", "plan_name": "700700_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Mcare Ffs 6005", "plan_name": "700703", "standard_charge_dollar": 560.75, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Miscellaneous", "plan_name": "700720", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Miscellaneous", "plan_name": "700720_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Ppo Hmo", "plan_name": "701720", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Ppo Hmo", "plan_name": "701720_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Ambetter 68069", "plan_name": "500516", "standard_charge_dollar": 560.75, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Ms State Emplo", "plan_name": "401457", "standard_charge_percentage": 0.80, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Ms State Emplo", "plan_name": "401457_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Basic Pl", "plan_name": "400100", "standard_charge_percentage": 0.85, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Basic Pl", "plan_name": "400100_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Federal", "plan_name": "400110", "standard_charge_percentage": 0.85, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Federal", "plan_name": "400110_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Cigna Healthsprings Ffs", "plan_name": "500064", "standard_charge_dollar": 560.75, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Conseco", "plan_name": "500302", "standard_charge_dollar": 560.75, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Humana Ffs 61101", "plan_name": "500006", "standard_charge_dollar": 560.75, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Medicare A", "plan_name": "100100", "standard_charge_dollar": 560.75, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Medicare A", "plan_name": "100500", "standard_charge_dollar": 560.75, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Medicare Part B Only", "plan_name": "100300", "standard_charge_dollar": 560.75, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Medicare Railroad", "plan_name": "100103", "standard_charge_dollar": 560.75, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Ms Physicians Care N", "plan_name": "714210", "standard_charge_dollar": 700.94, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Peoples Hlth Ffs 72126", "plan_name": "500019", "standard_charge_dollar": 560.75, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Uhc/Secure Horizons", "plan_name": "500449", "standard_charge_dollar": 560.75, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "United Health Care/", "plan_name": "500292", "standard_charge_dollar": 633.65, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "United Healthcare", "plan_name": "750104", "standard_charge_dollar": 633.65, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "United Healthcare Ba", "plan_name": "750090", "standard_charge_dollar": 633.65, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "United Healthcare Me", "plan_name": "501310", "standard_charge_dollar": 560.75, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Windsor Mcare Extra", "plan_name": "500778", "standard_charge_dollar": 560.75, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." } ] } ] }, { "description": "Laceration intermediate", "code_information": [ { "code": "12046", "type": "CPT" } ], "standard_charges": [ { "gross_charge": 1016.00, "minimum": 560.75, "maximum": 863.60, "setting": "both", "payers_information": [ { "payer_name": "Aarp", "plan_name": "500102", "standard_charge_dollar": 560.75, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna", "plan_name": "700700", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna", "plan_name": "700700_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Mcare Ffs 6005", "plan_name": "700703", "standard_charge_dollar": 560.75, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Miscellaneous", "plan_name": "700720", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Miscellaneous", "plan_name": "700720_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Ppo Hmo", "plan_name": "701720", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Ppo Hmo", "plan_name": "701720_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Ambetter 68069", "plan_name": "500516", "standard_charge_dollar": 560.75, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Ms State Emplo", "plan_name": "401457", "standard_charge_percentage": 0.80, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Ms State Emplo", "plan_name": "401457_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Basic Pl", "plan_name": "400100", "standard_charge_percentage": 0.85, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Basic Pl", "plan_name": "400100_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Federal", "plan_name": "400110", "standard_charge_percentage": 0.85, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Federal", "plan_name": "400110_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Cigna Healthsprings Ffs", "plan_name": "500064", "standard_charge_dollar": 560.75, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Conseco", "plan_name": "500302", "standard_charge_dollar": 560.75, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Humana Ffs 61101", "plan_name": "500006", "standard_charge_dollar": 560.75, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Medicare A", "plan_name": "100100", "standard_charge_dollar": 560.75, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Medicare A", "plan_name": "100500", "standard_charge_dollar": 560.75, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Medicare Part B Only", "plan_name": "100300", "standard_charge_dollar": 560.75, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Medicare Railroad", "plan_name": "100103", "standard_charge_dollar": 560.75, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Ms Physicians Care N", "plan_name": "714210", "standard_charge_dollar": 700.94, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Peoples Hlth Ffs 72126", "plan_name": "500019", "standard_charge_dollar": 560.75, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Uhc/Secure Horizons", "plan_name": "500449", "standard_charge_dollar": 560.75, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "United Health Care/", "plan_name": "500292", "standard_charge_dollar": 633.65, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "United Healthcare", "plan_name": "750104", "standard_charge_dollar": 633.65, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "United Healthcare Ba", "plan_name": "750090", "standard_charge_dollar": 633.65, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "United Healthcare Me", "plan_name": "501310", "standard_charge_dollar": 560.75, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Windsor Mcare Extra", "plan_name": "500778", "standard_charge_dollar": 560.75, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." } ] } ] }, { "description": "Intmd rpr n-hf/genit >30.0cm", "code_information": [ { "code": "12047", "type": "CPT" } ], "standard_charges": [ { "gross_charge": 1016.00, "minimum": 812.80, "maximum": 2094.63, "setting": "both", "payers_information": [ { "payer_name": "Aarp", "plan_name": "500102", "standard_charge_dollar": 1675.70, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna", "plan_name": "700700", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna", "plan_name": "700700_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Mcare Ffs 6005", "plan_name": "700703", "standard_charge_dollar": 1675.70, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Miscellaneous", "plan_name": "700720", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Miscellaneous", "plan_name": "700720_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Ppo Hmo", "plan_name": "701720", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Ppo Hmo", "plan_name": "701720_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Ambetter 68069", "plan_name": "500516", "standard_charge_dollar": 1675.70, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Ms State Emplo", "plan_name": "401457", "standard_charge_percentage": 0.80, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Ms State Emplo", "plan_name": "401457_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Basic Pl", "plan_name": "400100", "standard_charge_percentage": 0.85, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Basic Pl", "plan_name": "400100_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Federal", "plan_name": "400110", "standard_charge_percentage": 0.85, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Federal", "plan_name": "400110_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Cigna Healthsprings Ffs", "plan_name": "500064", "standard_charge_dollar": 1675.70, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Conseco", "plan_name": "500302", "standard_charge_dollar": 1675.70, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Humana Ffs 61101", "plan_name": "500006", "standard_charge_dollar": 1675.70, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Medicare A", "plan_name": "100100", "standard_charge_dollar": 1675.70, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Medicare A", "plan_name": "100500", "standard_charge_dollar": 1675.70, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Medicare Part B Only", "plan_name": "100300", "standard_charge_dollar": 1675.70, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Medicare Railroad", "plan_name": "100103", "standard_charge_dollar": 1675.70, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Ms Physicians Care N", "plan_name": "714210", "standard_charge_dollar": 2094.63, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Peoples Hlth Ffs 72126", "plan_name": "500019", "standard_charge_dollar": 1675.70, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Uhc/Secure Horizons", "plan_name": "500449", "standard_charge_dollar": 1675.70, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "United Health Care/", "plan_name": "500292", "standard_charge_dollar": 1893.54, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "United Healthcare", "plan_name": "750104", "standard_charge_dollar": 1893.54, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "United Healthcare Ba", "plan_name": "750090", "standard_charge_dollar": 1893.54, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "United Healthcare Me", "plan_name": "501310", "standard_charge_dollar": 1675.70, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Windsor Mcare Extra", "plan_name": "500778", "standard_charge_dollar": 1675.70, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." } ] } ] }, { "description": "Laceration intermediate", "code_information": [ { "code": "12047", "type": "CPT" } ], "standard_charges": [ { "gross_charge": 1016.00, "minimum": 812.80, "maximum": 2094.63, "setting": "both", "payers_information": [ { "payer_name": "Aarp", "plan_name": "500102", "standard_charge_dollar": 1675.70, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna", "plan_name": "700700", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna", "plan_name": "700700_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Mcare Ffs 6005", "plan_name": "700703", "standard_charge_dollar": 1675.70, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Miscellaneous", "plan_name": "700720", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Miscellaneous", "plan_name": "700720_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Ppo Hmo", "plan_name": "701720", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Ppo Hmo", "plan_name": "701720_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Ambetter 68069", "plan_name": "500516", "standard_charge_dollar": 1675.70, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Ms State Emplo", "plan_name": "401457", "standard_charge_percentage": 0.80, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Ms State Emplo", "plan_name": "401457_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Basic Pl", "plan_name": "400100", "standard_charge_percentage": 0.85, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Basic Pl", "plan_name": "400100_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Federal", "plan_name": "400110", "standard_charge_percentage": 0.85, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Federal", "plan_name": "400110_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Cigna Healthsprings Ffs", "plan_name": "500064", "standard_charge_dollar": 1675.70, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Conseco", "plan_name": "500302", "standard_charge_dollar": 1675.70, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Humana Ffs 61101", "plan_name": "500006", "standard_charge_dollar": 1675.70, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Medicare A", "plan_name": "100100", "standard_charge_dollar": 1675.70, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Medicare A", "plan_name": "100500", "standard_charge_dollar": 1675.70, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Medicare Part B Only", "plan_name": "100300", "standard_charge_dollar": 1675.70, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Medicare Railroad", "plan_name": "100103", "standard_charge_dollar": 1675.70, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Ms Physicians Care N", "plan_name": "714210", "standard_charge_dollar": 2094.63, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Peoples Hlth Ffs 72126", "plan_name": "500019", "standard_charge_dollar": 1675.70, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Uhc/Secure Horizons", "plan_name": "500449", "standard_charge_dollar": 1675.70, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "United Health Care/", "plan_name": "500292", "standard_charge_dollar": 1893.54, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "United Healthcare", "plan_name": "750104", "standard_charge_dollar": 1893.54, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "United Healthcare Ba", "plan_name": "750090", "standard_charge_dollar": 1893.54, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "United Healthcare Me", "plan_name": "501310", "standard_charge_dollar": 1675.70, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Windsor Mcare Extra", "plan_name": "500778", "standard_charge_dollar": 1675.70, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." } ] } ] }, { "description": "Intmd rpr face/mm 2.5 cm/<", "code_information": [ { "code": "12051", "type": "CPT" } ], "standard_charges": [ { "gross_charge": 1016.00, "minimum": 366.00, "maximum": 863.60, "setting": "both", "payers_information": [ { "payer_name": "Aarp", "plan_name": "500102", "standard_charge_dollar": 366.00, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna", "plan_name": "700700", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna", "plan_name": "700700_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Mcare Ffs 6005", "plan_name": "700703", "standard_charge_dollar": 366.00, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Miscellaneous", "plan_name": "700720", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Miscellaneous", "plan_name": "700720_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Ppo Hmo", "plan_name": "701720", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Ppo Hmo", "plan_name": "701720_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Ambetter 68069", "plan_name": "500516", "standard_charge_dollar": 366.00, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Ms State Emplo", "plan_name": "401457", "standard_charge_percentage": 0.80, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Ms State Emplo", "plan_name": "401457_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Basic Pl", "plan_name": "400100", "standard_charge_percentage": 0.85, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Basic Pl", "plan_name": "400100_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Federal", "plan_name": "400110", "standard_charge_percentage": 0.85, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Federal", "plan_name": "400110_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Cigna Healthsprings Ffs", "plan_name": "500064", "standard_charge_dollar": 366.00, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Conseco", "plan_name": "500302", "standard_charge_dollar": 366.00, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Humana Ffs 61101", "plan_name": "500006", "standard_charge_dollar": 366.00, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Medicare A", "plan_name": "100100", "standard_charge_dollar": 366.00, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Medicare A", "plan_name": "100500", "standard_charge_dollar": 366.00, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Medicare Part B Only", "plan_name": "100300", "standard_charge_dollar": 366.00, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Medicare Railroad", "plan_name": "100103", "standard_charge_dollar": 366.00, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Ms Physicians Care N", "plan_name": "714210", "standard_charge_dollar": 457.50, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Peoples Hlth Ffs 72126", "plan_name": "500019", "standard_charge_dollar": 366.00, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Uhc/Secure Horizons", "plan_name": "500449", "standard_charge_dollar": 366.00, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "United Health Care/", "plan_name": "500292", "standard_charge_dollar": 413.58, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "United Healthcare", "plan_name": "750104", "standard_charge_dollar": 413.58, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "United Healthcare Ba", "plan_name": "750090", "standard_charge_dollar": 413.58, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "United Healthcare Me", "plan_name": "501310", "standard_charge_dollar": 366.00, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Windsor Mcare Extra", "plan_name": "500778", "standard_charge_dollar": 366.00, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." } ] } ] }, { "description": "Laceration intermediate", "code_information": [ { "code": "12051", "type": "CPT" } ], "standard_charges": [ { "gross_charge": 1016.00, "minimum": 366.00, "maximum": 863.60, "setting": "both", "payers_information": [ { "payer_name": "Aarp", "plan_name": "500102", "standard_charge_dollar": 366.00, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna", "plan_name": "700700", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna", "plan_name": "700700_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Mcare Ffs 6005", "plan_name": "700703", "standard_charge_dollar": 366.00, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Miscellaneous", "plan_name": "700720", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Miscellaneous", "plan_name": "700720_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Ppo Hmo", "plan_name": "701720", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Ppo Hmo", "plan_name": "701720_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Ambetter 68069", "plan_name": "500516", "standard_charge_dollar": 366.00, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Ms State Emplo", "plan_name": "401457", "standard_charge_percentage": 0.80, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Ms State Emplo", "plan_name": "401457_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Basic Pl", "plan_name": "400100", "standard_charge_percentage": 0.85, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Basic Pl", "plan_name": "400100_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Federal", "plan_name": "400110", "standard_charge_percentage": 0.85, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Federal", "plan_name": "400110_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Cigna Healthsprings Ffs", "plan_name": "500064", "standard_charge_dollar": 366.00, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Conseco", "plan_name": "500302", "standard_charge_dollar": 366.00, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Humana Ffs 61101", "plan_name": "500006", "standard_charge_dollar": 366.00, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Medicare A", "plan_name": "100100", "standard_charge_dollar": 366.00, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Medicare A", "plan_name": "100500", "standard_charge_dollar": 366.00, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Medicare Part B Only", "plan_name": "100300", "standard_charge_dollar": 366.00, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Medicare Railroad", "plan_name": "100103", "standard_charge_dollar": 366.00, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Ms Physicians Care N", "plan_name": "714210", "standard_charge_dollar": 457.50, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Peoples Hlth Ffs 72126", "plan_name": "500019", "standard_charge_dollar": 366.00, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Uhc/Secure Horizons", "plan_name": "500449", "standard_charge_dollar": 366.00, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "United Health Care/", "plan_name": "500292", "standard_charge_dollar": 413.58, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "United Healthcare", "plan_name": "750104", "standard_charge_dollar": 413.58, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "United Healthcare Ba", "plan_name": "750090", "standard_charge_dollar": 413.58, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "United Healthcare Me", "plan_name": "501310", "standard_charge_dollar": 366.00, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Windsor Mcare Extra", "plan_name": "500778", "standard_charge_dollar": 366.00, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." } ] } ] }, { "description": "Intmd rpr face/mm 2.6-5.0 cm", "code_information": [ { "code": "12052", "type": "CPT" } ], "standard_charges": [ { "gross_charge": 1016.00, "minimum": 366.00, "maximum": 863.60, "setting": "both", "payers_information": [ { "payer_name": "Aarp", "plan_name": "500102", "standard_charge_dollar": 366.00, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna", "plan_name": "700700", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna", "plan_name": "700700_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Mcare Ffs 6005", "plan_name": "700703", "standard_charge_dollar": 366.00, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Miscellaneous", "plan_name": "700720", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Miscellaneous", "plan_name": "700720_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Ppo Hmo", "plan_name": "701720", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Ppo Hmo", "plan_name": "701720_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Ambetter 68069", "plan_name": "500516", "standard_charge_dollar": 366.00, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Ms State Emplo", "plan_name": "401457", "standard_charge_percentage": 0.80, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Ms State Emplo", "plan_name": "401457_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Basic Pl", "plan_name": "400100", "standard_charge_percentage": 0.85, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Basic Pl", "plan_name": "400100_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Federal", "plan_name": "400110", "standard_charge_percentage": 0.85, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Federal", "plan_name": "400110_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Cigna Healthsprings Ffs", "plan_name": "500064", "standard_charge_dollar": 366.00, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Conseco", "plan_name": "500302", "standard_charge_dollar": 366.00, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Humana Ffs 61101", "plan_name": "500006", "standard_charge_dollar": 366.00, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Medicare A", "plan_name": "100100", "standard_charge_dollar": 366.00, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Medicare A", "plan_name": "100500", "standard_charge_dollar": 366.00, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Medicare Part B Only", "plan_name": "100300", "standard_charge_dollar": 366.00, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Medicare Railroad", "plan_name": "100103", "standard_charge_dollar": 366.00, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Ms Physicians Care N", "plan_name": "714210", "standard_charge_dollar": 457.50, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Peoples Hlth Ffs 72126", "plan_name": "500019", "standard_charge_dollar": 366.00, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Uhc/Secure Horizons", "plan_name": "500449", "standard_charge_dollar": 366.00, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "United Health Care/", "plan_name": "500292", "standard_charge_dollar": 413.58, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "United Healthcare", "plan_name": "750104", "standard_charge_dollar": 413.58, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "United Healthcare Ba", "plan_name": "750090", "standard_charge_dollar": 413.58, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "United Healthcare Me", "plan_name": "501310", "standard_charge_dollar": 366.00, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Windsor Mcare Extra", "plan_name": "500778", "standard_charge_dollar": 366.00, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." } ] } ] }, { "description": "Laceration intermediate", "code_information": [ { "code": "12052", "type": "CPT" } ], "standard_charges": [ { "gross_charge": 1016.00, "minimum": 366.00, "maximum": 863.60, "setting": "both", "payers_information": [ { "payer_name": "Aarp", "plan_name": "500102", "standard_charge_dollar": 366.00, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna", "plan_name": "700700", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna", "plan_name": "700700_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Mcare Ffs 6005", "plan_name": "700703", "standard_charge_dollar": 366.00, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Miscellaneous", "plan_name": "700720", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Miscellaneous", "plan_name": "700720_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Ppo Hmo", "plan_name": "701720", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Ppo Hmo", "plan_name": "701720_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Ambetter 68069", "plan_name": "500516", "standard_charge_dollar": 366.00, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Ms State Emplo", "plan_name": "401457", "standard_charge_percentage": 0.80, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Ms State Emplo", "plan_name": "401457_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Basic Pl", "plan_name": "400100", "standard_charge_percentage": 0.85, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Basic Pl", "plan_name": "400100_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Federal", "plan_name": "400110", "standard_charge_percentage": 0.85, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Federal", "plan_name": "400110_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Cigna Healthsprings Ffs", "plan_name": "500064", "standard_charge_dollar": 366.00, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Conseco", "plan_name": "500302", "standard_charge_dollar": 366.00, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Humana Ffs 61101", "plan_name": "500006", "standard_charge_dollar": 366.00, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Medicare A", "plan_name": "100100", "standard_charge_dollar": 366.00, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Medicare A", "plan_name": "100500", "standard_charge_dollar": 366.00, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Medicare Part B Only", "plan_name": "100300", "standard_charge_dollar": 366.00, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Medicare Railroad", "plan_name": "100103", "standard_charge_dollar": 366.00, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Ms Physicians Care N", "plan_name": "714210", "standard_charge_dollar": 457.50, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Peoples Hlth Ffs 72126", "plan_name": "500019", "standard_charge_dollar": 366.00, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Uhc/Secure Horizons", "plan_name": "500449", "standard_charge_dollar": 366.00, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "United Health Care/", "plan_name": "500292", "standard_charge_dollar": 413.58, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "United Healthcare", "plan_name": "750104", "standard_charge_dollar": 413.58, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "United Healthcare Ba", "plan_name": "750090", "standard_charge_dollar": 413.58, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "United Healthcare Me", "plan_name": "501310", "standard_charge_dollar": 366.00, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Windsor Mcare Extra", "plan_name": "500778", "standard_charge_dollar": 366.00, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." } ] } ] }, { "description": "Intmd rpr face/mm 5.1-7.5 cm", "code_information": [ { "code": "12053", "type": "CPT" } ], "standard_charges": [ { "gross_charge": 1016.00, "minimum": 366.00, "maximum": 863.60, "setting": "both", "payers_information": [ { "payer_name": "Aarp", "plan_name": "500102", "standard_charge_dollar": 366.00, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna", "plan_name": "700700", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna", "plan_name": "700700_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Mcare Ffs 6005", "plan_name": "700703", "standard_charge_dollar": 366.00, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Miscellaneous", "plan_name": "700720", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Miscellaneous", "plan_name": "700720_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Ppo Hmo", "plan_name": "701720", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Ppo Hmo", "plan_name": "701720_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Ambetter 68069", "plan_name": "500516", "standard_charge_dollar": 366.00, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Ms State Emplo", "plan_name": "401457", "standard_charge_percentage": 0.80, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Ms State Emplo", "plan_name": "401457_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Basic Pl", "plan_name": "400100", "standard_charge_percentage": 0.85, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Basic Pl", "plan_name": "400100_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Federal", "plan_name": "400110", "standard_charge_percentage": 0.85, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Federal", "plan_name": "400110_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Cigna Healthsprings Ffs", "plan_name": "500064", "standard_charge_dollar": 366.00, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Conseco", "plan_name": "500302", "standard_charge_dollar": 366.00, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Humana Ffs 61101", "plan_name": "500006", "standard_charge_dollar": 366.00, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Medicare A", "plan_name": "100100", "standard_charge_dollar": 366.00, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Medicare A", "plan_name": "100500", "standard_charge_dollar": 366.00, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Medicare Part B Only", "plan_name": "100300", "standard_charge_dollar": 366.00, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Medicare Railroad", "plan_name": "100103", "standard_charge_dollar": 366.00, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Ms Physicians Care N", "plan_name": "714210", "standard_charge_dollar": 457.50, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Peoples Hlth Ffs 72126", "plan_name": "500019", "standard_charge_dollar": 366.00, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Uhc/Secure Horizons", "plan_name": "500449", "standard_charge_dollar": 366.00, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "United Health Care/", "plan_name": "500292", "standard_charge_dollar": 413.58, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "United Healthcare", "plan_name": "750104", "standard_charge_dollar": 413.58, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "United Healthcare Ba", "plan_name": "750090", "standard_charge_dollar": 413.58, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "United Healthcare Me", "plan_name": "501310", "standard_charge_dollar": 366.00, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Windsor Mcare Extra", "plan_name": "500778", "standard_charge_dollar": 366.00, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." } ] } ] }, { "description": "Laceration intermediate", "code_information": [ { "code": "12053", "type": "CPT" } ], "standard_charges": [ { "gross_charge": 1016.00, "minimum": 366.00, "maximum": 863.60, "setting": "both", "payers_information": [ { "payer_name": "Aarp", "plan_name": "500102", "standard_charge_dollar": 366.00, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna", "plan_name": "700700", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna", "plan_name": "700700_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Mcare Ffs 6005", "plan_name": "700703", "standard_charge_dollar": 366.00, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Miscellaneous", "plan_name": "700720", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Miscellaneous", "plan_name": "700720_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Ppo Hmo", "plan_name": "701720", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Ppo Hmo", "plan_name": "701720_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Ambetter 68069", "plan_name": "500516", "standard_charge_dollar": 366.00, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Ms State Emplo", "plan_name": "401457", "standard_charge_percentage": 0.80, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Ms State Emplo", "plan_name": "401457_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Basic Pl", "plan_name": "400100", "standard_charge_percentage": 0.85, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Basic Pl", "plan_name": "400100_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Federal", "plan_name": "400110", "standard_charge_percentage": 0.85, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Federal", "plan_name": "400110_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Cigna Healthsprings Ffs", "plan_name": "500064", "standard_charge_dollar": 366.00, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Conseco", "plan_name": "500302", "standard_charge_dollar": 366.00, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Humana Ffs 61101", "plan_name": "500006", "standard_charge_dollar": 366.00, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Medicare A", "plan_name": "100100", "standard_charge_dollar": 366.00, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Medicare A", "plan_name": "100500", "standard_charge_dollar": 366.00, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Medicare Part B Only", "plan_name": "100300", "standard_charge_dollar": 366.00, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Medicare Railroad", "plan_name": "100103", "standard_charge_dollar": 366.00, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Ms Physicians Care N", "plan_name": "714210", "standard_charge_dollar": 457.50, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Peoples Hlth Ffs 72126", "plan_name": "500019", "standard_charge_dollar": 366.00, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Uhc/Secure Horizons", "plan_name": "500449", "standard_charge_dollar": 366.00, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "United Health Care/", "plan_name": "500292", "standard_charge_dollar": 413.58, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "United Healthcare", "plan_name": "750104", "standard_charge_dollar": 413.58, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "United Healthcare Ba", "plan_name": "750090", "standard_charge_dollar": 413.58, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "United Healthcare Me", "plan_name": "501310", "standard_charge_dollar": 366.00, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Windsor Mcare Extra", "plan_name": "500778", "standard_charge_dollar": 366.00, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." } ] } ] }, { "description": "Intmd rpr face/mm 7.6-12.5cm", "code_information": [ { "code": "12054", "type": "CPT" } ], "standard_charges": [ { "gross_charge": 1016.00, "minimum": 366.00, "maximum": 457.50, "setting": "both", "payers_information": [ { "payer_name": "Aarp", "plan_name": "500102", "standard_charge_dollar": 366.00, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna", "plan_name": "700700", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna", "plan_name": "700700_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Mcare Ffs 6005", "plan_name": "700703", "standard_charge_dollar": 366.00, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Miscellaneous", "plan_name": "700720", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Miscellaneous", "plan_name": "700720_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Ppo Hmo", "plan_name": "701720", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Ppo Hmo", "plan_name": "701720_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Ambetter 68069", "plan_name": "500516", "standard_charge_dollar": 366.00, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Ms State Emplo", "plan_name": "401457", "standard_charge_dollar": 438.74, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Ms State Emplo", "plan_name": "401457_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Basic Pl", "plan_name": "400100", "standard_charge_dollar": 438.74, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Basic Pl", "plan_name": "400100_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Federal", "plan_name": "400110", "standard_charge_dollar": 438.74, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Federal", "plan_name": "400110_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Cigna Healthsprings Ffs", "plan_name": "500064", "standard_charge_dollar": 366.00, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Conseco", "plan_name": "500302", "standard_charge_dollar": 366.00, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Humana Ffs 61101", "plan_name": "500006", "standard_charge_dollar": 366.00, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Medicare A", "plan_name": "100100", "standard_charge_dollar": 366.00, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Medicare A", "plan_name": "100500", "standard_charge_dollar": 366.00, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Medicare Part B Only", "plan_name": "100300", "standard_charge_dollar": 366.00, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Medicare Railroad", "plan_name": "100103", "standard_charge_dollar": 366.00, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Ms Physicians Care N", "plan_name": "714210", "standard_charge_dollar": 457.50, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Peoples Hlth Ffs 72126", "plan_name": "500019", "standard_charge_dollar": 366.00, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Uhc/Secure Horizons", "plan_name": "500449", "standard_charge_dollar": 366.00, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "United Health Care/", "plan_name": "500292", "standard_charge_dollar": 413.58, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "United Healthcare", "plan_name": "750104", "standard_charge_dollar": 413.58, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "United Healthcare Ba", "plan_name": "750090", "standard_charge_dollar": 413.58, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "United Healthcare Me", "plan_name": "501310", "standard_charge_dollar": 366.00, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Windsor Mcare Extra", "plan_name": "500778", "standard_charge_dollar": 366.00, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." } ] } ] }, { "description": "Laceration intermediate", "code_information": [ { "code": "12054", "type": "CPT" } ], "standard_charges": [ { "gross_charge": 1016.00, "minimum": 366.00, "maximum": 457.50, "setting": "both", "payers_information": [ { "payer_name": "Aarp", "plan_name": "500102", "standard_charge_dollar": 366.00, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna", "plan_name": "700700", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna", "plan_name": "700700_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Mcare Ffs 6005", "plan_name": "700703", "standard_charge_dollar": 366.00, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Miscellaneous", "plan_name": "700720", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Miscellaneous", "plan_name": "700720_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Ppo Hmo", "plan_name": "701720", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Ppo Hmo", "plan_name": "701720_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Ambetter 68069", "plan_name": "500516", "standard_charge_dollar": 366.00, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Ms State Emplo", "plan_name": "401457", "standard_charge_dollar": 438.74, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Ms State Emplo", "plan_name": "401457_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Basic Pl", "plan_name": "400100", "standard_charge_dollar": 438.74, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Basic Pl", "plan_name": "400100_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Federal", "plan_name": "400110", "standard_charge_dollar": 438.74, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Federal", "plan_name": "400110_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Cigna Healthsprings Ffs", "plan_name": "500064", "standard_charge_dollar": 366.00, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Conseco", "plan_name": "500302", "standard_charge_dollar": 366.00, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Humana Ffs 61101", "plan_name": "500006", "standard_charge_dollar": 366.00, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Medicare A", "plan_name": "100100", "standard_charge_dollar": 366.00, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Medicare A", "plan_name": "100500", "standard_charge_dollar": 366.00, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Medicare Part B Only", "plan_name": "100300", "standard_charge_dollar": 366.00, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Medicare Railroad", "plan_name": "100103", "standard_charge_dollar": 366.00, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Ms Physicians Care N", "plan_name": "714210", "standard_charge_dollar": 457.50, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Peoples Hlth Ffs 72126", "plan_name": "500019", "standard_charge_dollar": 366.00, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Uhc/Secure Horizons", "plan_name": "500449", "standard_charge_dollar": 366.00, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "United Health Care/", "plan_name": "500292", "standard_charge_dollar": 413.58, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "United Healthcare", "plan_name": "750104", "standard_charge_dollar": 413.58, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "United Healthcare Ba", "plan_name": "750090", "standard_charge_dollar": 413.58, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "United Healthcare Me", "plan_name": "501310", "standard_charge_dollar": 366.00, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Windsor Mcare Extra", "plan_name": "500778", "standard_charge_dollar": 366.00, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." } ] } ] }, { "description": "Intmd rpr face/mm 12.6-20 cm", "code_information": [ { "code": "12055", "type": "CPT" } ], "standard_charges": [ { "gross_charge": 1016.00, "minimum": 366.00, "maximum": 863.60, "setting": "both", "payers_information": [ { "payer_name": "Aarp", "plan_name": "500102", "standard_charge_dollar": 366.00, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna", "plan_name": "700700", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna", "plan_name": "700700_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Mcare Ffs 6005", "plan_name": "700703", "standard_charge_dollar": 366.00, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Miscellaneous", "plan_name": "700720", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Miscellaneous", "plan_name": "700720_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Ppo Hmo", "plan_name": "701720", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Ppo Hmo", "plan_name": "701720_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Ambetter 68069", "plan_name": "500516", "standard_charge_dollar": 366.00, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Ms State Emplo", "plan_name": "401457", "standard_charge_percentage": 0.80, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Ms State Emplo", "plan_name": "401457_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Basic Pl", "plan_name": "400100", "standard_charge_percentage": 0.85, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Basic Pl", "plan_name": "400100_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Federal", "plan_name": "400110", "standard_charge_percentage": 0.85, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Federal", "plan_name": "400110_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Cigna Healthsprings Ffs", "plan_name": "500064", "standard_charge_dollar": 366.00, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Conseco", "plan_name": "500302", "standard_charge_dollar": 366.00, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Humana Ffs 61101", "plan_name": "500006", "standard_charge_dollar": 366.00, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Medicare A", "plan_name": "100100", "standard_charge_dollar": 366.00, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Medicare A", "plan_name": "100500", "standard_charge_dollar": 366.00, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Medicare Part B Only", "plan_name": "100300", "standard_charge_dollar": 366.00, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Medicare Railroad", "plan_name": "100103", "standard_charge_dollar": 366.00, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Ms Physicians Care N", "plan_name": "714210", "standard_charge_dollar": 457.50, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Peoples Hlth Ffs 72126", "plan_name": "500019", "standard_charge_dollar": 366.00, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Uhc/Secure Horizons", "plan_name": "500449", "standard_charge_dollar": 366.00, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "United Health Care/", "plan_name": "500292", "standard_charge_dollar": 413.58, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "United Healthcare", "plan_name": "750104", "standard_charge_dollar": 413.58, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "United Healthcare Ba", "plan_name": "750090", "standard_charge_dollar": 413.58, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "United Healthcare Me", "plan_name": "501310", "standard_charge_dollar": 366.00, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Windsor Mcare Extra", "plan_name": "500778", "standard_charge_dollar": 366.00, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." } ] } ] }, { "description": "Laceration intermediate", "code_information": [ { "code": "12055", "type": "CPT" } ], "standard_charges": [ { "gross_charge": 1016.00, "minimum": 366.00, "maximum": 863.60, "setting": "both", "payers_information": [ { "payer_name": "Aarp", "plan_name": "500102", "standard_charge_dollar": 366.00, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna", "plan_name": "700700", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna", "plan_name": "700700_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Mcare Ffs 6005", "plan_name": "700703", "standard_charge_dollar": 366.00, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Miscellaneous", "plan_name": "700720", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Miscellaneous", "plan_name": "700720_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Ppo Hmo", "plan_name": "701720", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Ppo Hmo", "plan_name": "701720_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Ambetter 68069", "plan_name": "500516", "standard_charge_dollar": 366.00, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Ms State Emplo", "plan_name": "401457", "standard_charge_percentage": 0.80, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Ms State Emplo", "plan_name": "401457_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Basic Pl", "plan_name": "400100", "standard_charge_percentage": 0.85, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Basic Pl", "plan_name": "400100_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Federal", "plan_name": "400110", "standard_charge_percentage": 0.85, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Federal", "plan_name": "400110_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Cigna Healthsprings Ffs", "plan_name": "500064", "standard_charge_dollar": 366.00, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Conseco", "plan_name": "500302", "standard_charge_dollar": 366.00, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Humana Ffs 61101", "plan_name": "500006", "standard_charge_dollar": 366.00, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Medicare A", "plan_name": "100100", "standard_charge_dollar": 366.00, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Medicare A", "plan_name": "100500", "standard_charge_dollar": 366.00, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Medicare Part B Only", "plan_name": "100300", "standard_charge_dollar": 366.00, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Medicare Railroad", "plan_name": "100103", "standard_charge_dollar": 366.00, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Ms Physicians Care N", "plan_name": "714210", "standard_charge_dollar": 457.50, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Peoples Hlth Ffs 72126", "plan_name": "500019", "standard_charge_dollar": 366.00, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Uhc/Secure Horizons", "plan_name": "500449", "standard_charge_dollar": 366.00, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "United Health Care/", "plan_name": "500292", "standard_charge_dollar": 413.58, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "United Healthcare", "plan_name": "750104", "standard_charge_dollar": 413.58, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "United Healthcare Ba", "plan_name": "750090", "standard_charge_dollar": 413.58, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "United Healthcare Me", "plan_name": "501310", "standard_charge_dollar": 366.00, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Windsor Mcare Extra", "plan_name": "500778", "standard_charge_dollar": 366.00, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." } ] } ] }, { "description": "Cmplx rpr trunk 2.6-7.5 cm", "code_information": [ { "code": "13101", "type": "CPT" } ], "standard_charges": [ { "gross_charge": 1237.00, "minimum": 560.75, "maximum": 1051.45, "setting": "both", "payers_information": [ { "payer_name": "Aarp", "plan_name": "500102", "standard_charge_dollar": 560.75, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna", "plan_name": "700700", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna", "plan_name": "700700_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Mcare Ffs 6005", "plan_name": "700703", "standard_charge_dollar": 560.75, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Miscellaneous", "plan_name": "700720", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Miscellaneous", "plan_name": "700720_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Ppo Hmo", "plan_name": "701720", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Ppo Hmo", "plan_name": "701720_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Ambetter 68069", "plan_name": "500516", "standard_charge_dollar": 560.75, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Ms State Emplo", "plan_name": "401457", "standard_charge_percentage": 0.80, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Ms State Emplo", "plan_name": "401457_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Basic Pl", "plan_name": "400100", "standard_charge_percentage": 0.85, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Basic Pl", "plan_name": "400100_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Federal", "plan_name": "400110", "standard_charge_percentage": 0.85, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Federal", "plan_name": "400110_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Cigna Healthsprings Ffs", "plan_name": "500064", "standard_charge_dollar": 560.75, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Conseco", "plan_name": "500302", "standard_charge_dollar": 560.75, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Humana Ffs 61101", "plan_name": "500006", "standard_charge_dollar": 560.75, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Medicare A", "plan_name": "100100", "standard_charge_dollar": 560.75, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Medicare A", "plan_name": "100500", "standard_charge_dollar": 560.75, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Medicare Part B Only", "plan_name": "100300", "standard_charge_dollar": 560.75, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Medicare Railroad", "plan_name": "100103", "standard_charge_dollar": 560.75, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Ms Physicians Care N", "plan_name": "714210", "standard_charge_dollar": 700.94, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Peoples Hlth Ffs 72126", "plan_name": "500019", "standard_charge_dollar": 560.75, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Uhc/Secure Horizons", "plan_name": "500449", "standard_charge_dollar": 560.75, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "United Health Care/", "plan_name": "500292", "standard_charge_dollar": 633.65, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "United Healthcare", "plan_name": "750104", "standard_charge_dollar": 633.65, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "United Healthcare Ba", "plan_name": "750090", "standard_charge_dollar": 633.65, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "United Healthcare Me", "plan_name": "501310", "standard_charge_dollar": 560.75, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Windsor Mcare Extra", "plan_name": "500778", "standard_charge_dollar": 560.75, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." } ] } ] }, { "description": "Laceration complex", "code_information": [ { "code": "13101", "type": "CPT" } ], "standard_charges": [ { "gross_charge": 1237.00, "minimum": 560.75, "maximum": 1051.45, "setting": "both", "payers_information": [ { "payer_name": "Aarp", "plan_name": "500102", "standard_charge_dollar": 560.75, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna", "plan_name": "700700", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna", "plan_name": "700700_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Mcare Ffs 6005", "plan_name": "700703", "standard_charge_dollar": 560.75, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Miscellaneous", "plan_name": "700720", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Miscellaneous", "plan_name": "700720_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Ppo Hmo", "plan_name": "701720", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Ppo Hmo", "plan_name": "701720_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Ambetter 68069", "plan_name": "500516", "standard_charge_dollar": 560.75, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Ms State Emplo", "plan_name": "401457", "standard_charge_percentage": 0.80, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Ms State Emplo", "plan_name": "401457_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Basic Pl", "plan_name": "400100", "standard_charge_percentage": 0.85, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Basic Pl", "plan_name": "400100_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Federal", "plan_name": "400110", "standard_charge_percentage": 0.85, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Federal", "plan_name": "400110_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Cigna Healthsprings Ffs", "plan_name": "500064", "standard_charge_dollar": 560.75, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Conseco", "plan_name": "500302", "standard_charge_dollar": 560.75, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Humana Ffs 61101", "plan_name": "500006", "standard_charge_dollar": 560.75, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Medicare A", "plan_name": "100100", "standard_charge_dollar": 560.75, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Medicare A", "plan_name": "100500", "standard_charge_dollar": 560.75, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Medicare Part B Only", "plan_name": "100300", "standard_charge_dollar": 560.75, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Medicare Railroad", "plan_name": "100103", "standard_charge_dollar": 560.75, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Ms Physicians Care N", "plan_name": "714210", "standard_charge_dollar": 700.94, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Peoples Hlth Ffs 72126", "plan_name": "500019", "standard_charge_dollar": 560.75, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Uhc/Secure Horizons", "plan_name": "500449", "standard_charge_dollar": 560.75, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "United Health Care/", "plan_name": "500292", "standard_charge_dollar": 633.65, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "United Healthcare", "plan_name": "750104", "standard_charge_dollar": 633.65, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "United Healthcare Ba", "plan_name": "750090", "standard_charge_dollar": 633.65, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "United Healthcare Me", "plan_name": "501310", "standard_charge_dollar": 560.75, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Windsor Mcare Extra", "plan_name": "500778", "standard_charge_dollar": 560.75, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." } ] } ] }, { "description": "Cmplx rpr trunk addl 5cm/<", "code_information": [ { "code": "13102", "type": "CPT" } ], "standard_charges": [ { "gross_charge": 500.00, "minimum": 400.00, "maximum": 425.00, "setting": "both", "payers_information": [ { "payer_name": "Aetna", "plan_name": "700700", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna", "plan_name": "700700_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Miscellaneous", "plan_name": "700720", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Miscellaneous", "plan_name": "700720_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Ppo Hmo", "plan_name": "701720", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Ppo Hmo", "plan_name": "701720_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Ms State Emplo", "plan_name": "401457", "standard_charge_percentage": 0.80, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Ms State Emplo", "plan_name": "401457_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Basic Pl", "plan_name": "400100", "standard_charge_percentage": 0.85, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Basic Pl", "plan_name": "400100_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Federal", "plan_name": "400110", "standard_charge_percentage": 0.85, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Federal", "plan_name": "400110_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." } ] } ] }, { "description": "Hc complex lac > 7.5cm trunk", "code_information": [ { "code": "13102", "type": "CPT" } ], "standard_charges": [ { "gross_charge": 500.00, "minimum": 400.00, "maximum": 425.00, "setting": "both", "payers_information": [ { "payer_name": "Aetna", "plan_name": "700700", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna", "plan_name": "700700_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Miscellaneous", "plan_name": "700720", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Miscellaneous", "plan_name": "700720_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Ppo Hmo", "plan_name": "701720", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Ppo Hmo", "plan_name": "701720_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Ms State Emplo", "plan_name": "401457", "standard_charge_percentage": 0.80, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Ms State Emplo", "plan_name": "401457_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Basic Pl", "plan_name": "400100", "standard_charge_percentage": 0.85, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Basic Pl", "plan_name": "400100_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Federal", "plan_name": "400110", "standard_charge_percentage": 0.85, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Federal", "plan_name": "400110_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." } ] } ] }, { "description": "Cmplx rpr s/a/l 1.1-2.5 cm", "code_information": [ { "code": "13120", "type": "CPT" } ], "standard_charges": [ { "gross_charge": 14841.25, "minimum": 560.75, "maximum": 12615.06, "setting": "inpatient", "payers_information": [ { "payer_name": "Aarp", "plan_name": "500102", "standard_charge_dollar": 560.75, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna", "plan_name": "700700", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna", "plan_name": "700700_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Mcare Ffs 6005", "plan_name": "700703", "standard_charge_dollar": 560.75, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Miscellaneous", "plan_name": "700720", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Miscellaneous", "plan_name": "700720_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Ppo Hmo", "plan_name": "701720", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Ppo Hmo", "plan_name": "701720_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Ambetter 68069", "plan_name": "500516", "standard_charge_dollar": 560.75, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Ms State Emplo", "plan_name": "401457", "standard_charge_percentage": 0.80, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Ms State Emplo", "plan_name": "401457_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Basic Pl", "plan_name": "400100", "standard_charge_percentage": 0.85, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Basic Pl", "plan_name": "400100_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Federal", "plan_name": "400110", "standard_charge_percentage": 0.85, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Federal", "plan_name": "400110_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Cigna Healthsprings Ffs", "plan_name": "500064", "standard_charge_dollar": 560.75, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Conseco", "plan_name": "500302", "standard_charge_dollar": 560.75, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Humana Ffs 61101", "plan_name": "500006", "standard_charge_dollar": 560.75, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Medicare A", "plan_name": "100100", "standard_charge_dollar": 560.75, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Medicare A", "plan_name": "100500", "standard_charge_dollar": 560.75, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Medicare Part B Only", "plan_name": "100300", "standard_charge_dollar": 560.75, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Medicare Railroad", "plan_name": "100103", "standard_charge_dollar": 560.75, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Ms Physicians Care N", "plan_name": "714210", "standard_charge_dollar": 700.94, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Peoples Hlth Ffs 72126", "plan_name": "500019", "standard_charge_dollar": 560.75, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Uhc/Secure Horizons", "plan_name": "500449", "standard_charge_dollar": 560.75, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "United Health Care/", "plan_name": "500292", "standard_charge_dollar": 633.65, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "United Healthcare", "plan_name": "750104", "standard_charge_dollar": 633.65, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "United Healthcare Ba", "plan_name": "750090", "standard_charge_dollar": 633.65, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "United Healthcare Me", "plan_name": "501310", "standard_charge_dollar": 560.75, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Windsor Mcare Extra", "plan_name": "500778", "standard_charge_dollar": 560.75, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." } ] } ] }, { "description": "Cmplx rpr s/a/l 1.1-2.5 cm", "code_information": [ { "code": "13120", "type": "CPT" } ], "standard_charges": [ { "gross_charge": 1237.00, "minimum": 560.75, "maximum": 1051.45, "setting": "outpatient", "payers_information": [ { "payer_name": "Aarp", "plan_name": "500102", "standard_charge_dollar": 560.75, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna", "plan_name": "700700", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna", "plan_name": "700700_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Mcare Ffs 6005", "plan_name": "700703", "standard_charge_dollar": 560.75, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Miscellaneous", "plan_name": "700720", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Miscellaneous", "plan_name": "700720_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Ppo Hmo", "plan_name": "701720", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Ppo Hmo", "plan_name": "701720_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Ambetter 68069", "plan_name": "500516", "standard_charge_dollar": 560.75, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Ms State Emplo", "plan_name": "401457", "standard_charge_percentage": 0.80, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Ms State Emplo", "plan_name": "401457_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Basic Pl", "plan_name": "400100", "standard_charge_percentage": 0.85, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Basic Pl", "plan_name": "400100_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Federal", "plan_name": "400110", "standard_charge_percentage": 0.85, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Federal", "plan_name": "400110_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Cigna Healthsprings Ffs", "plan_name": "500064", "standard_charge_dollar": 560.75, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Conseco", "plan_name": "500302", "standard_charge_dollar": 560.75, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Humana Ffs 61101", "plan_name": "500006", "standard_charge_dollar": 560.75, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Medicare A", "plan_name": "100100", "standard_charge_dollar": 560.75, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Medicare A", "plan_name": "100500", "standard_charge_dollar": 560.75, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Medicare Part B Only", "plan_name": "100300", "standard_charge_dollar": 560.75, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Medicare Railroad", "plan_name": "100103", "standard_charge_dollar": 560.75, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Ms Physicians Care N", "plan_name": "714210", "standard_charge_dollar": 700.94, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Peoples Hlth Ffs 72126", "plan_name": "500019", "standard_charge_dollar": 560.75, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Uhc/Secure Horizons", "plan_name": "500449", "standard_charge_dollar": 560.75, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "United Health Care/", "plan_name": "500292", "standard_charge_dollar": 633.65, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "United Healthcare", "plan_name": "750104", "standard_charge_dollar": 633.65, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "United Healthcare Ba", "plan_name": "750090", "standard_charge_dollar": 633.65, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "United Healthcare Me", "plan_name": "501310", "standard_charge_dollar": 560.75, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Windsor Mcare Extra", "plan_name": "500778", "standard_charge_dollar": 560.75, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." } ] } ] }, { "description": "Laceration complex", "code_information": [ { "code": "13120", "type": "CPT" } ], "standard_charges": [ { "gross_charge": 1237.00, "minimum": 560.75, "maximum": 1051.45, "setting": "both", "payers_information": [ { "payer_name": "Aarp", "plan_name": "500102", "standard_charge_dollar": 560.75, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna", "plan_name": "700700", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna", "plan_name": "700700_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Mcare Ffs 6005", "plan_name": "700703", "standard_charge_dollar": 560.75, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Miscellaneous", "plan_name": "700720", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Miscellaneous", "plan_name": "700720_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Ppo Hmo", "plan_name": "701720", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Ppo Hmo", "plan_name": "701720_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Ambetter 68069", "plan_name": "500516", "standard_charge_dollar": 560.75, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Ms State Emplo", "plan_name": "401457", "standard_charge_percentage": 0.80, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Ms State Emplo", "plan_name": "401457_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Basic Pl", "plan_name": "400100", "standard_charge_percentage": 0.85, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Basic Pl", "plan_name": "400100_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Federal", "plan_name": "400110", "standard_charge_percentage": 0.85, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Federal", "plan_name": "400110_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Cigna Healthsprings Ffs", "plan_name": "500064", "standard_charge_dollar": 560.75, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Conseco", "plan_name": "500302", "standard_charge_dollar": 560.75, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Humana Ffs 61101", "plan_name": "500006", "standard_charge_dollar": 560.75, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Medicare A", "plan_name": "100100", "standard_charge_dollar": 560.75, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Medicare A", "plan_name": "100500", "standard_charge_dollar": 560.75, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Medicare Part B Only", "plan_name": "100300", "standard_charge_dollar": 560.75, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Medicare Railroad", "plan_name": "100103", "standard_charge_dollar": 560.75, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Ms Physicians Care N", "plan_name": "714210", "standard_charge_dollar": 700.94, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Peoples Hlth Ffs 72126", "plan_name": "500019", "standard_charge_dollar": 560.75, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Uhc/Secure Horizons", "plan_name": "500449", "standard_charge_dollar": 560.75, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "United Health Care/", "plan_name": "500292", "standard_charge_dollar": 633.65, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "United Healthcare", "plan_name": "750104", "standard_charge_dollar": 633.65, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "United Healthcare Ba", "plan_name": "750090", "standard_charge_dollar": 633.65, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "United Healthcare Me", "plan_name": "501310", "standard_charge_dollar": 560.75, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Windsor Mcare Extra", "plan_name": "500778", "standard_charge_dollar": 560.75, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." } ] } ] }, { "description": "Cmplx rpr s/a/l 2.6-7.5 cm", "code_information": [ { "code": "13121", "type": "CPT" } ], "standard_charges": [ { "gross_charge": 14841.25, "minimum": 560.75, "maximum": 12615.06, "setting": "inpatient", "payers_information": [ { "payer_name": "Aarp", "plan_name": "500102", "standard_charge_dollar": 560.75, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna", "plan_name": "700700", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna", "plan_name": "700700_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Mcare Ffs 6005", "plan_name": "700703", "standard_charge_dollar": 560.75, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Miscellaneous", "plan_name": "700720", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Miscellaneous", "plan_name": "700720_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Ppo Hmo", "plan_name": "701720", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Ppo Hmo", "plan_name": "701720_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Ambetter 68069", "plan_name": "500516", "standard_charge_dollar": 560.75, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Ms State Emplo", "plan_name": "401457", "standard_charge_percentage": 0.80, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Ms State Emplo", "plan_name": "401457_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Basic Pl", "plan_name": "400100", "standard_charge_percentage": 0.85, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Basic Pl", "plan_name": "400100_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Federal", "plan_name": "400110", "standard_charge_percentage": 0.85, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Federal", "plan_name": "400110_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Cigna Healthsprings Ffs", "plan_name": "500064", "standard_charge_dollar": 560.75, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Conseco", "plan_name": "500302", "standard_charge_dollar": 560.75, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Humana Ffs 61101", "plan_name": "500006", "standard_charge_dollar": 560.75, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Medicare A", "plan_name": "100100", "standard_charge_dollar": 560.75, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Medicare A", "plan_name": "100500", "standard_charge_dollar": 560.75, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Medicare Part B Only", "plan_name": "100300", "standard_charge_dollar": 560.75, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Medicare Railroad", "plan_name": "100103", "standard_charge_dollar": 560.75, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Ms Physicians Care N", "plan_name": "714210", "standard_charge_dollar": 700.94, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Peoples Hlth Ffs 72126", "plan_name": "500019", "standard_charge_dollar": 560.75, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Uhc/Secure Horizons", "plan_name": "500449", "standard_charge_dollar": 560.75, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "United Health Care/", "plan_name": "500292", "standard_charge_dollar": 633.65, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "United Healthcare", "plan_name": "750104", "standard_charge_dollar": 633.65, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "United Healthcare Ba", "plan_name": "750090", "standard_charge_dollar": 633.65, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "United Healthcare Me", "plan_name": "501310", "standard_charge_dollar": 560.75, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Windsor Mcare Extra", "plan_name": "500778", "standard_charge_dollar": 560.75, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." } ] } ] }, { "description": "Cmplx rpr s/a/l 2.6-7.5 cm", "code_information": [ { "code": "13121", "type": "CPT" } ], "standard_charges": [ { "gross_charge": 1237.00, "minimum": 560.75, "maximum": 1051.45, "setting": "outpatient", "payers_information": [ { "payer_name": "Aarp", "plan_name": "500102", "standard_charge_dollar": 560.75, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna", "plan_name": "700700", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna", "plan_name": "700700_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Mcare Ffs 6005", "plan_name": "700703", "standard_charge_dollar": 560.75, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Miscellaneous", "plan_name": "700720", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Miscellaneous", "plan_name": "700720_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Ppo Hmo", "plan_name": "701720", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Ppo Hmo", "plan_name": "701720_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Ambetter 68069", "plan_name": "500516", "standard_charge_dollar": 560.75, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Ms State Emplo", "plan_name": "401457", "standard_charge_percentage": 0.80, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Ms State Emplo", "plan_name": "401457_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Basic Pl", "plan_name": "400100", "standard_charge_percentage": 0.85, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Basic Pl", "plan_name": "400100_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Federal", "plan_name": "400110", "standard_charge_percentage": 0.85, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Federal", "plan_name": "400110_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Cigna Healthsprings Ffs", "plan_name": "500064", "standard_charge_dollar": 560.75, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Conseco", "plan_name": "500302", "standard_charge_dollar": 560.75, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Humana Ffs 61101", "plan_name": "500006", "standard_charge_dollar": 560.75, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Medicare A", "plan_name": "100100", "standard_charge_dollar": 560.75, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Medicare A", "plan_name": "100500", "standard_charge_dollar": 560.75, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Medicare Part B Only", "plan_name": "100300", "standard_charge_dollar": 560.75, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Medicare Railroad", "plan_name": "100103", "standard_charge_dollar": 560.75, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Ms Physicians Care N", "plan_name": "714210", "standard_charge_dollar": 700.94, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Peoples Hlth Ffs 72126", "plan_name": "500019", "standard_charge_dollar": 560.75, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Uhc/Secure Horizons", "plan_name": "500449", "standard_charge_dollar": 560.75, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "United Health Care/", "plan_name": "500292", "standard_charge_dollar": 633.65, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "United Healthcare", "plan_name": "750104", "standard_charge_dollar": 633.65, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "United Healthcare Ba", "plan_name": "750090", "standard_charge_dollar": 633.65, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "United Healthcare Me", "plan_name": "501310", "standard_charge_dollar": 560.75, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Windsor Mcare Extra", "plan_name": "500778", "standard_charge_dollar": 560.75, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." } ] } ] }, { "description": "Laceration complex", "code_information": [ { "code": "13121", "type": "CPT" } ], "standard_charges": [ { "gross_charge": 1237.00, "minimum": 560.75, "maximum": 1051.45, "setting": "both", "payers_information": [ { "payer_name": "Aarp", "plan_name": "500102", "standard_charge_dollar": 560.75, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna", "plan_name": "700700", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna", "plan_name": "700700_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Mcare Ffs 6005", "plan_name": "700703", "standard_charge_dollar": 560.75, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Miscellaneous", "plan_name": "700720", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Miscellaneous", "plan_name": "700720_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Ppo Hmo", "plan_name": "701720", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Ppo Hmo", "plan_name": "701720_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Ambetter 68069", "plan_name": "500516", "standard_charge_dollar": 560.75, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Ms State Emplo", "plan_name": "401457", "standard_charge_percentage": 0.80, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Ms State Emplo", "plan_name": "401457_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Basic Pl", "plan_name": "400100", "standard_charge_percentage": 0.85, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Basic Pl", "plan_name": "400100_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Federal", "plan_name": "400110", "standard_charge_percentage": 0.85, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Federal", "plan_name": "400110_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Cigna Healthsprings Ffs", "plan_name": "500064", "standard_charge_dollar": 560.75, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Conseco", "plan_name": "500302", "standard_charge_dollar": 560.75, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Humana Ffs 61101", "plan_name": "500006", "standard_charge_dollar": 560.75, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Medicare A", "plan_name": "100100", "standard_charge_dollar": 560.75, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Medicare A", "plan_name": "100500", "standard_charge_dollar": 560.75, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Medicare Part B Only", "plan_name": "100300", "standard_charge_dollar": 560.75, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Medicare Railroad", "plan_name": "100103", "standard_charge_dollar": 560.75, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Ms Physicians Care N", "plan_name": "714210", "standard_charge_dollar": 700.94, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Peoples Hlth Ffs 72126", "plan_name": "500019", "standard_charge_dollar": 560.75, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Uhc/Secure Horizons", "plan_name": "500449", "standard_charge_dollar": 560.75, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "United Health Care/", "plan_name": "500292", "standard_charge_dollar": 633.65, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "United Healthcare", "plan_name": "750104", "standard_charge_dollar": 633.65, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "United Healthcare Ba", "plan_name": "750090", "standard_charge_dollar": 633.65, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "United Healthcare Me", "plan_name": "501310", "standard_charge_dollar": 560.75, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Windsor Mcare Extra", "plan_name": "500778", "standard_charge_dollar": 560.75, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." } ] } ] }, { "description": "Cmplx rpr s/a/l addl 5 cm/>", "code_information": [ { "code": "13122", "type": "CPT" } ], "standard_charges": [ { "gross_charge": 14841.25, "minimum": 11873.00, "maximum": 12615.06, "setting": "inpatient", "payers_information": [ { "payer_name": "Aetna", "plan_name": "700700", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna", "plan_name": "700700_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Miscellaneous", "plan_name": "700720", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Miscellaneous", "plan_name": "700720_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Ppo Hmo", "plan_name": "701720", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Ppo Hmo", "plan_name": "701720_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Ms State Emplo", "plan_name": "401457", "standard_charge_percentage": 0.80, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Ms State Emplo", "plan_name": "401457_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Basic Pl", "plan_name": "400100", "standard_charge_percentage": 0.85, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Basic Pl", "plan_name": "400100_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Federal", "plan_name": "400110", "standard_charge_percentage": 0.85, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Federal", "plan_name": "400110_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." } ] } ] }, { "description": "Cmplx rpr s/a/l addl 5 cm/>", "code_information": [ { "code": "13122", "type": "CPT" } ], "standard_charges": [ { "gross_charge": 500.00, "minimum": 400.00, "maximum": 425.00, "setting": "outpatient", "payers_information": [ { "payer_name": "Aetna", "plan_name": "700700", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna", "plan_name": "700700_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Miscellaneous", "plan_name": "700720", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Miscellaneous", "plan_name": "700720_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Ppo Hmo", "plan_name": "701720", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Ppo Hmo", "plan_name": "701720_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Ms State Emplo", "plan_name": "401457", "standard_charge_percentage": 0.80, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Ms State Emplo", "plan_name": "401457_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Basic Pl", "plan_name": "400100", "standard_charge_percentage": 0.85, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Basic Pl", "plan_name": "400100_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Federal", "plan_name": "400110", "standard_charge_percentage": 0.85, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Federal", "plan_name": "400110_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." } ] } ] }, { "description": "Hc complex lac>7.5cm.scalp arms legs", "code_information": [ { "code": "13122", "type": "CPT" } ], "standard_charges": [ { "gross_charge": 500.00, "minimum": 400.00, "maximum": 425.00, "setting": "both", "payers_information": [ { "payer_name": "Aetna", "plan_name": "700700", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna", "plan_name": "700700_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Miscellaneous", "plan_name": "700720", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Miscellaneous", "plan_name": "700720_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Ppo Hmo", "plan_name": "701720", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Ppo Hmo", "plan_name": "701720_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Ms State Emplo", "plan_name": "401457", "standard_charge_percentage": 0.80, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Ms State Emplo", "plan_name": "401457_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Basic Pl", "plan_name": "400100", "standard_charge_percentage": 0.85, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Basic Pl", "plan_name": "400100_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Federal", "plan_name": "400110", "standard_charge_percentage": 0.85, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Federal", "plan_name": "400110_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." } ] } ] }, { "description": "Cmplx rpr f/c/c/m/n/ax/g/h/f", "code_information": [ { "code": "13131", "type": "CPT" } ], "standard_charges": [ { "gross_charge": 1237.00, "minimum": 366.00, "maximum": 1051.45, "setting": "both", "payers_information": [ { "payer_name": "Aarp", "plan_name": "500102", "standard_charge_dollar": 366.00, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna", "plan_name": "700700", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna", "plan_name": "700700_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Mcare Ffs 6005", "plan_name": "700703", "standard_charge_dollar": 366.00, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Miscellaneous", "plan_name": "700720", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Miscellaneous", "plan_name": "700720_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Ppo Hmo", "plan_name": "701720", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Ppo Hmo", "plan_name": "701720_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Ambetter 68069", "plan_name": "500516", "standard_charge_dollar": 366.00, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Ms State Emplo", "plan_name": "401457", "standard_charge_percentage": 0.80, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Ms State Emplo", "plan_name": "401457_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Basic Pl", "plan_name": "400100", "standard_charge_percentage": 0.85, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Basic Pl", "plan_name": "400100_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Federal", "plan_name": "400110", "standard_charge_percentage": 0.85, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Federal", "plan_name": "400110_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Cigna Healthsprings Ffs", "plan_name": "500064", "standard_charge_dollar": 366.00, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Conseco", "plan_name": "500302", "standard_charge_dollar": 366.00, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Humana Ffs 61101", "plan_name": "500006", "standard_charge_dollar": 366.00, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Medicare A", "plan_name": "100100", "standard_charge_dollar": 366.00, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Medicare A", "plan_name": "100500", "standard_charge_dollar": 366.00, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Medicare Part B Only", "plan_name": "100300", "standard_charge_dollar": 366.00, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Medicare Railroad", "plan_name": "100103", "standard_charge_dollar": 366.00, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Ms Physicians Care N", "plan_name": "714210", "standard_charge_dollar": 457.50, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Peoples Hlth Ffs 72126", "plan_name": "500019", "standard_charge_dollar": 366.00, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Uhc/Secure Horizons", "plan_name": "500449", "standard_charge_dollar": 366.00, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "United Health Care/", "plan_name": "500292", "standard_charge_dollar": 413.58, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "United Healthcare", "plan_name": "750104", "standard_charge_dollar": 413.58, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "United Healthcare Ba", "plan_name": "750090", "standard_charge_dollar": 413.58, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "United Healthcare Me", "plan_name": "501310", "standard_charge_dollar": 366.00, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Windsor Mcare Extra", "plan_name": "500778", "standard_charge_dollar": 366.00, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." } ] } ] }, { "description": "Laceration complex", "code_information": [ { "code": "13131", "type": "CPT" } ], "standard_charges": [ { "gross_charge": 1237.00, "minimum": 366.00, "maximum": 1051.45, "setting": "both", "payers_information": [ { "payer_name": "Aarp", "plan_name": "500102", "standard_charge_dollar": 366.00, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna", "plan_name": "700700", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna", "plan_name": "700700_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Mcare Ffs 6005", "plan_name": "700703", "standard_charge_dollar": 366.00, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Miscellaneous", "plan_name": "700720", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Miscellaneous", "plan_name": "700720_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Ppo Hmo", "plan_name": "701720", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Ppo Hmo", "plan_name": "701720_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Ambetter 68069", "plan_name": "500516", "standard_charge_dollar": 366.00, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Ms State Emplo", "plan_name": "401457", "standard_charge_percentage": 0.80, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Ms State Emplo", "plan_name": "401457_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Basic Pl", "plan_name": "400100", "standard_charge_percentage": 0.85, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Basic Pl", "plan_name": "400100_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Federal", "plan_name": "400110", "standard_charge_percentage": 0.85, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Federal", "plan_name": "400110_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Cigna Healthsprings Ffs", "plan_name": "500064", "standard_charge_dollar": 366.00, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Conseco", "plan_name": "500302", "standard_charge_dollar": 366.00, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Humana Ffs 61101", "plan_name": "500006", "standard_charge_dollar": 366.00, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Medicare A", "plan_name": "100100", "standard_charge_dollar": 366.00, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Medicare A", "plan_name": "100500", "standard_charge_dollar": 366.00, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Medicare Part B Only", "plan_name": "100300", "standard_charge_dollar": 366.00, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Medicare Railroad", "plan_name": "100103", "standard_charge_dollar": 366.00, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Ms Physicians Care N", "plan_name": "714210", "standard_charge_dollar": 457.50, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Peoples Hlth Ffs 72126", "plan_name": "500019", "standard_charge_dollar": 366.00, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Uhc/Secure Horizons", "plan_name": "500449", "standard_charge_dollar": 366.00, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "United Health Care/", "plan_name": "500292", "standard_charge_dollar": 413.58, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "United Healthcare", "plan_name": "750104", "standard_charge_dollar": 413.58, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "United Healthcare Ba", "plan_name": "750090", "standard_charge_dollar": 413.58, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "United Healthcare Me", "plan_name": "501310", "standard_charge_dollar": 366.00, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Windsor Mcare Extra", "plan_name": "500778", "standard_charge_dollar": 366.00, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." } ] } ] }, { "description": "Cmplx rpr f/c/c/m/n/ax/g/h/f", "code_information": [ { "code": "13132", "type": "CPT" } ], "standard_charges": [ { "gross_charge": 1237.00, "minimum": 560.75, "maximum": 1051.45, "setting": "both", "payers_information": [ { "payer_name": "Aarp", "plan_name": "500102", "standard_charge_dollar": 560.75, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna", "plan_name": "700700", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna", "plan_name": "700700_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Mcare Ffs 6005", "plan_name": "700703", "standard_charge_dollar": 560.75, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Miscellaneous", "plan_name": "700720", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Miscellaneous", "plan_name": "700720_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Ppo Hmo", "plan_name": "701720", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Ppo Hmo", "plan_name": "701720_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Ambetter 68069", "plan_name": "500516", "standard_charge_dollar": 560.75, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Ms State Emplo", "plan_name": "401457", "standard_charge_percentage": 0.80, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Ms State Emplo", "plan_name": "401457_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Basic Pl", "plan_name": "400100", "standard_charge_percentage": 0.85, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Basic Pl", "plan_name": "400100_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Federal", "plan_name": "400110", "standard_charge_percentage": 0.85, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Federal", "plan_name": "400110_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Cigna Healthsprings Ffs", "plan_name": "500064", "standard_charge_dollar": 560.75, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Conseco", "plan_name": "500302", "standard_charge_dollar": 560.75, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Humana Ffs 61101", "plan_name": "500006", "standard_charge_dollar": 560.75, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Medicare A", "plan_name": "100100", "standard_charge_dollar": 560.75, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Medicare A", "plan_name": "100500", "standard_charge_dollar": 560.75, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Medicare Part B Only", "plan_name": "100300", "standard_charge_dollar": 560.75, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Medicare Railroad", "plan_name": "100103", "standard_charge_dollar": 560.75, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Ms Physicians Care N", "plan_name": "714210", "standard_charge_dollar": 700.94, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Peoples Hlth Ffs 72126", "plan_name": "500019", "standard_charge_dollar": 560.75, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Uhc/Secure Horizons", "plan_name": "500449", "standard_charge_dollar": 560.75, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "United Health Care/", "plan_name": "500292", "standard_charge_dollar": 633.65, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "United Healthcare", "plan_name": "750104", "standard_charge_dollar": 633.65, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "United Healthcare Ba", "plan_name": "750090", "standard_charge_dollar": 633.65, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "United Healthcare Me", "plan_name": "501310", "standard_charge_dollar": 560.75, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Windsor Mcare Extra", "plan_name": "500778", "standard_charge_dollar": 560.75, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." } ] } ] }, { "description": "Laceration complex", "code_information": [ { "code": "13132", "type": "CPT" } ], "standard_charges": [ { "gross_charge": 1237.00, "minimum": 560.75, "maximum": 1051.45, "setting": "both", "payers_information": [ { "payer_name": "Aarp", "plan_name": "500102", "standard_charge_dollar": 560.75, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna", "plan_name": "700700", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna", "plan_name": "700700_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Mcare Ffs 6005", "plan_name": "700703", "standard_charge_dollar": 560.75, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Miscellaneous", "plan_name": "700720", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Miscellaneous", "plan_name": "700720_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Ppo Hmo", "plan_name": "701720", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Ppo Hmo", "plan_name": "701720_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Ambetter 68069", "plan_name": "500516", "standard_charge_dollar": 560.75, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Ms State Emplo", "plan_name": "401457", "standard_charge_percentage": 0.80, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Ms State Emplo", "plan_name": "401457_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Basic Pl", "plan_name": "400100", "standard_charge_percentage": 0.85, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Basic Pl", "plan_name": "400100_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Federal", "plan_name": "400110", "standard_charge_percentage": 0.85, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Federal", "plan_name": "400110_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Cigna Healthsprings Ffs", "plan_name": "500064", "standard_charge_dollar": 560.75, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Conseco", "plan_name": "500302", "standard_charge_dollar": 560.75, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Humana Ffs 61101", "plan_name": "500006", "standard_charge_dollar": 560.75, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Medicare A", "plan_name": "100100", "standard_charge_dollar": 560.75, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Medicare A", "plan_name": "100500", "standard_charge_dollar": 560.75, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Medicare Part B Only", "plan_name": "100300", "standard_charge_dollar": 560.75, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Medicare Railroad", "plan_name": "100103", "standard_charge_dollar": 560.75, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Ms Physicians Care N", "plan_name": "714210", "standard_charge_dollar": 700.94, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Peoples Hlth Ffs 72126", "plan_name": "500019", "standard_charge_dollar": 560.75, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Uhc/Secure Horizons", "plan_name": "500449", "standard_charge_dollar": 560.75, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "United Health Care/", "plan_name": "500292", "standard_charge_dollar": 633.65, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "United Healthcare", "plan_name": "750104", "standard_charge_dollar": 633.65, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "United Healthcare Ba", "plan_name": "750090", "standard_charge_dollar": 633.65, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "United Healthcare Me", "plan_name": "501310", "standard_charge_dollar": 560.75, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Windsor Mcare Extra", "plan_name": "500778", "standard_charge_dollar": 560.75, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." } ] } ] }, { "description": "Cmplx rpr f/c/c/m/n/ax/g/h/f", "code_information": [ { "code": "13133", "type": "CPT" } ], "standard_charges": [ { "gross_charge": 500.00, "minimum": 400.00, "maximum": 425.00, "setting": "both", "payers_information": [ { "payer_name": "Aetna", "plan_name": "700700", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna", "plan_name": "700700_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Miscellaneous", "plan_name": "700720", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Miscellaneous", "plan_name": "700720_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Ppo Hmo", "plan_name": "701720", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Ppo Hmo", "plan_name": "701720_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Ms State Emplo", "plan_name": "401457", "standard_charge_percentage": 0.80, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Ms State Emplo", "plan_name": "401457_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Basic Pl", "plan_name": "400100", "standard_charge_percentage": 0.85, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Basic Pl", "plan_name": "400100_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Federal", "plan_name": "400110", "standard_charge_percentage": 0.85, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Federal", "plan_name": "400110_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." } ] } ] }, { "description": "Hc complex lac > 7.5cm other", "code_information": [ { "code": "13133", "type": "CPT" } ], "standard_charges": [ { "gross_charge": 500.00, "minimum": 400.00, "maximum": 425.00, "setting": "both", "payers_information": [ { "payer_name": "Aetna", "plan_name": "700700", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna", "plan_name": "700700_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Miscellaneous", "plan_name": "700720", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Miscellaneous", "plan_name": "700720_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Ppo Hmo", "plan_name": "701720", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Ppo Hmo", "plan_name": "701720_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Ms State Emplo", "plan_name": "401457", "standard_charge_percentage": 0.80, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Ms State Emplo", "plan_name": "401457_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Basic Pl", "plan_name": "400100", "standard_charge_percentage": 0.85, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Basic Pl", "plan_name": "400100_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Federal", "plan_name": "400110", "standard_charge_percentage": 0.85, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Federal", "plan_name": "400110_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." } ] } ] }, { "description": "Cmplx rpr e/n/e/l 1.1-2.5 cm", "code_information": [ { "code": "13151", "type": "CPT" } ], "standard_charges": [ { "gross_charge": 1237.00, "minimum": 560.75, "maximum": 1051.45, "setting": "both", "payers_information": [ { "payer_name": "Aarp", "plan_name": "500102", "standard_charge_dollar": 560.75, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna", "plan_name": "700700", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna", "plan_name": "700700_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Mcare Ffs 6005", "plan_name": "700703", "standard_charge_dollar": 560.75, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Miscellaneous", "plan_name": "700720", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Miscellaneous", "plan_name": "700720_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Ppo Hmo", "plan_name": "701720", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Ppo Hmo", "plan_name": "701720_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Ambetter 68069", "plan_name": "500516", "standard_charge_dollar": 560.75, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Ms State Emplo", "plan_name": "401457", "standard_charge_percentage": 0.80, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Ms State Emplo", "plan_name": "401457_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Basic Pl", "plan_name": "400100", "standard_charge_percentage": 0.85, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Basic Pl", "plan_name": "400100_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Federal", "plan_name": "400110", "standard_charge_percentage": 0.85, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Federal", "plan_name": "400110_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Cigna Healthsprings Ffs", "plan_name": "500064", "standard_charge_dollar": 560.75, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Conseco", "plan_name": "500302", "standard_charge_dollar": 560.75, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Humana Ffs 61101", "plan_name": "500006", "standard_charge_dollar": 560.75, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Medicare A", "plan_name": "100100", "standard_charge_dollar": 560.75, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Medicare A", "plan_name": "100500", "standard_charge_dollar": 560.75, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Medicare Part B Only", "plan_name": "100300", "standard_charge_dollar": 560.75, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Medicare Railroad", "plan_name": "100103", "standard_charge_dollar": 560.75, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Ms Physicians Care N", "plan_name": "714210", "standard_charge_dollar": 700.94, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Peoples Hlth Ffs 72126", "plan_name": "500019", "standard_charge_dollar": 560.75, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Uhc/Secure Horizons", "plan_name": "500449", "standard_charge_dollar": 560.75, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "United Health Care/", "plan_name": "500292", "standard_charge_dollar": 633.65, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "United Healthcare", "plan_name": "750104", "standard_charge_dollar": 633.65, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "United Healthcare Ba", "plan_name": "750090", "standard_charge_dollar": 633.65, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "United Healthcare Me", "plan_name": "501310", "standard_charge_dollar": 560.75, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Windsor Mcare Extra", "plan_name": "500778", "standard_charge_dollar": 560.75, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." } ] } ] }, { "description": "Laceration complex", "code_information": [ { "code": "13151", "type": "CPT" } ], "standard_charges": [ { "gross_charge": 1237.00, "minimum": 560.75, "maximum": 1051.45, "setting": "both", "payers_information": [ { "payer_name": "Aarp", "plan_name": "500102", "standard_charge_dollar": 560.75, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna", "plan_name": "700700", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna", "plan_name": "700700_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Mcare Ffs 6005", "plan_name": "700703", "standard_charge_dollar": 560.75, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Miscellaneous", "plan_name": "700720", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Miscellaneous", "plan_name": "700720_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Ppo Hmo", "plan_name": "701720", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Ppo Hmo", "plan_name": "701720_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Ambetter 68069", "plan_name": "500516", "standard_charge_dollar": 560.75, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Ms State Emplo", "plan_name": "401457", "standard_charge_percentage": 0.80, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Ms State Emplo", "plan_name": "401457_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Basic Pl", "plan_name": "400100", "standard_charge_percentage": 0.85, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Basic Pl", "plan_name": "400100_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Federal", "plan_name": "400110", "standard_charge_percentage": 0.85, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Federal", "plan_name": "400110_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Cigna Healthsprings Ffs", "plan_name": "500064", "standard_charge_dollar": 560.75, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Conseco", "plan_name": "500302", "standard_charge_dollar": 560.75, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Humana Ffs 61101", "plan_name": "500006", "standard_charge_dollar": 560.75, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Medicare A", "plan_name": "100100", "standard_charge_dollar": 560.75, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Medicare A", "plan_name": "100500", "standard_charge_dollar": 560.75, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Medicare Part B Only", "plan_name": "100300", "standard_charge_dollar": 560.75, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Medicare Railroad", "plan_name": "100103", "standard_charge_dollar": 560.75, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Ms Physicians Care N", "plan_name": "714210", "standard_charge_dollar": 700.94, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Peoples Hlth Ffs 72126", "plan_name": "500019", "standard_charge_dollar": 560.75, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Uhc/Secure Horizons", "plan_name": "500449", "standard_charge_dollar": 560.75, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "United Health Care/", "plan_name": "500292", "standard_charge_dollar": 633.65, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "United Healthcare", "plan_name": "750104", "standard_charge_dollar": 633.65, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "United Healthcare Ba", "plan_name": "750090", "standard_charge_dollar": 633.65, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "United Healthcare Me", "plan_name": "501310", "standard_charge_dollar": 560.75, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Windsor Mcare Extra", "plan_name": "500778", "standard_charge_dollar": 560.75, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." } ] } ] }, { "description": "Cmplx rpr e/n/e/l 2.6-7.5 cm", "code_information": [ { "code": "13152", "type": "CPT" } ], "standard_charges": [ { "gross_charge": 1237.00, "minimum": 560.75, "maximum": 1051.45, "setting": "both", "payers_information": [ { "payer_name": "Aarp", "plan_name": "500102", "standard_charge_dollar": 560.75, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna", "plan_name": "700700", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna", "plan_name": "700700_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Mcare Ffs 6005", "plan_name": "700703", "standard_charge_dollar": 560.75, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Miscellaneous", "plan_name": "700720", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Miscellaneous", "plan_name": "700720_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Ppo Hmo", "plan_name": "701720", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Ppo Hmo", "plan_name": "701720_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Ambetter 68069", "plan_name": "500516", "standard_charge_dollar": 560.75, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Ms State Emplo", "plan_name": "401457", "standard_charge_percentage": 0.80, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Ms State Emplo", "plan_name": "401457_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Basic Pl", "plan_name": "400100", "standard_charge_percentage": 0.85, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Basic Pl", "plan_name": "400100_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Federal", "plan_name": "400110", "standard_charge_percentage": 0.85, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Federal", "plan_name": "400110_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Cigna Healthsprings Ffs", "plan_name": "500064", "standard_charge_dollar": 560.75, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Conseco", "plan_name": "500302", "standard_charge_dollar": 560.75, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Humana Ffs 61101", "plan_name": "500006", "standard_charge_dollar": 560.75, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Medicare A", "plan_name": "100100", "standard_charge_dollar": 560.75, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Medicare A", "plan_name": "100500", "standard_charge_dollar": 560.75, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Medicare Part B Only", "plan_name": "100300", "standard_charge_dollar": 560.75, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Medicare Railroad", "plan_name": "100103", "standard_charge_dollar": 560.75, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Ms Physicians Care N", "plan_name": "714210", "standard_charge_dollar": 700.94, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Peoples Hlth Ffs 72126", "plan_name": "500019", "standard_charge_dollar": 560.75, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Uhc/Secure Horizons", "plan_name": "500449", "standard_charge_dollar": 560.75, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "United Health Care/", "plan_name": "500292", "standard_charge_dollar": 633.65, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "United Healthcare", "plan_name": "750104", "standard_charge_dollar": 633.65, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "United Healthcare Ba", "plan_name": "750090", "standard_charge_dollar": 633.65, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "United Healthcare Me", "plan_name": "501310", "standard_charge_dollar": 560.75, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Windsor Mcare Extra", "plan_name": "500778", "standard_charge_dollar": 560.75, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." } ] } ] }, { "description": "Laceration complex", "code_information": [ { "code": "13152", "type": "CPT" } ], "standard_charges": [ { "gross_charge": 1237.00, "minimum": 560.75, "maximum": 1051.45, "setting": "both", "payers_information": [ { "payer_name": "Aarp", "plan_name": "500102", "standard_charge_dollar": 560.75, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna", "plan_name": "700700", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna", "plan_name": "700700_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Mcare Ffs 6005", "plan_name": "700703", "standard_charge_dollar": 560.75, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Miscellaneous", "plan_name": "700720", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Miscellaneous", "plan_name": "700720_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Ppo Hmo", "plan_name": "701720", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Ppo Hmo", "plan_name": "701720_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Ambetter 68069", "plan_name": "500516", "standard_charge_dollar": 560.75, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Ms State Emplo", "plan_name": "401457", "standard_charge_percentage": 0.80, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Ms State Emplo", "plan_name": "401457_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Basic Pl", "plan_name": "400100", "standard_charge_percentage": 0.85, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Basic Pl", "plan_name": "400100_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Federal", "plan_name": "400110", "standard_charge_percentage": 0.85, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Federal", "plan_name": "400110_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Cigna Healthsprings Ffs", "plan_name": "500064", "standard_charge_dollar": 560.75, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Conseco", "plan_name": "500302", "standard_charge_dollar": 560.75, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Humana Ffs 61101", "plan_name": "500006", "standard_charge_dollar": 560.75, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Medicare A", "plan_name": "100100", "standard_charge_dollar": 560.75, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Medicare A", "plan_name": "100500", "standard_charge_dollar": 560.75, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Medicare Part B Only", "plan_name": "100300", "standard_charge_dollar": 560.75, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Medicare Railroad", "plan_name": "100103", "standard_charge_dollar": 560.75, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Ms Physicians Care N", "plan_name": "714210", "standard_charge_dollar": 700.94, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Peoples Hlth Ffs 72126", "plan_name": "500019", "standard_charge_dollar": 560.75, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Uhc/Secure Horizons", "plan_name": "500449", "standard_charge_dollar": 560.75, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "United Health Care/", "plan_name": "500292", "standard_charge_dollar": 633.65, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "United Healthcare", "plan_name": "750104", "standard_charge_dollar": 633.65, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "United Healthcare Ba", "plan_name": "750090", "standard_charge_dollar": 633.65, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "United Healthcare Me", "plan_name": "501310", "standard_charge_dollar": 560.75, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Windsor Mcare Extra", "plan_name": "500778", "standard_charge_dollar": 560.75, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." } ] } ] }, { "description": "Cmplx rpr e/n/e/l addl 5cm/<", "code_information": [ { "code": "13153", "type": "CPT" } ], "standard_charges": [ { "gross_charge": 500.00, "minimum": 400.00, "maximum": 425.00, "setting": "both", "payers_information": [ { "payer_name": "Aetna", "plan_name": "700700", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna", "plan_name": "700700_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Miscellaneous", "plan_name": "700720", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Miscellaneous", "plan_name": "700720_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Ppo Hmo", "plan_name": "701720", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Ppo Hmo", "plan_name": "701720_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Ms State Emplo", "plan_name": "401457", "standard_charge_percentage": 0.80, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Ms State Emplo", "plan_name": "401457_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Basic Pl", "plan_name": "400100", "standard_charge_percentage": 0.85, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Basic Pl", "plan_name": "400100_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Federal", "plan_name": "400110", "standard_charge_percentage": 0.85, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Federal", "plan_name": "400110_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." } ] } ] }, { "description": "Hc laceration complex ea add 5cm", "code_information": [ { "code": "13153", "type": "CPT" } ], "standard_charges": [ { "gross_charge": 500.00, "minimum": 400.00, "maximum": 425.00, "setting": "both", "payers_information": [ { "payer_name": "Aetna", "plan_name": "700700", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna", "plan_name": "700700_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Miscellaneous", "plan_name": "700720", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Miscellaneous", "plan_name": "700720_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Ppo Hmo", "plan_name": "701720", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Ppo Hmo", "plan_name": "701720_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Ms State Emplo", "plan_name": "401457", "standard_charge_percentage": 0.80, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Ms State Emplo", "plan_name": "401457_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Basic Pl", "plan_name": "400100", "standard_charge_percentage": 0.85, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Basic Pl", "plan_name": "400100_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Federal", "plan_name": "400110", "standard_charge_percentage": 0.85, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Federal", "plan_name": "400110_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." } ] } ] }, { "description": "Late closure of wound", "code_information": [ { "code": "13160", "type": "CPT" } ], "standard_charges": [ { "gross_charge": 29585.90, "minimum": 1675.70, "maximum": 25148.02, "setting": "inpatient", "payers_information": [ { "payer_name": "Aarp", "plan_name": "500102", "standard_charge_dollar": 1675.70, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna", "plan_name": "700700", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna", "plan_name": "700700_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Mcare Ffs 6005", "plan_name": "700703", "standard_charge_dollar": 1675.70, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Miscellaneous", "plan_name": "700720", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Miscellaneous", "plan_name": "700720_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Ppo Hmo", "plan_name": "701720", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Ppo Hmo", "plan_name": "701720_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Ambetter 68069", "plan_name": "500516", "standard_charge_dollar": 1675.70, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Ms State Emplo", "plan_name": "401457", "standard_charge_percentage": 0.80, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Ms State Emplo", "plan_name": "401457_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Basic Pl", "plan_name": "400100", "standard_charge_percentage": 0.85, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Basic Pl", "plan_name": "400100_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Federal", "plan_name": "400110", "standard_charge_percentage": 0.85, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Federal", "plan_name": "400110_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Cigna Healthsprings Ffs", "plan_name": "500064", "standard_charge_dollar": 1675.70, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Conseco", "plan_name": "500302", "standard_charge_dollar": 1675.70, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Humana Ffs 61101", "plan_name": "500006", "standard_charge_dollar": 1675.70, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Medicare A", "plan_name": "100100", "standard_charge_dollar": 1675.70, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Medicare A", "plan_name": "100500", "standard_charge_dollar": 1675.70, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Medicare Part B Only", "plan_name": "100300", "standard_charge_dollar": 1675.70, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Medicare Railroad", "plan_name": "100103", "standard_charge_dollar": 1675.70, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Ms Physicians Care N", "plan_name": "714210", "standard_charge_dollar": 2094.63, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Peoples Hlth Ffs 72126", "plan_name": "500019", "standard_charge_dollar": 1675.70, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Uhc/Secure Horizons", "plan_name": "500449", "standard_charge_dollar": 1675.70, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "United Health Care/", "plan_name": "500292", "standard_charge_dollar": 1893.54, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "United Healthcare", "plan_name": "750104", "standard_charge_dollar": 1893.54, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "United Healthcare Ba", "plan_name": "750090", "standard_charge_dollar": 1893.54, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "United Healthcare Me", "plan_name": "501310", "standard_charge_dollar": 1675.70, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Windsor Mcare Extra", "plan_name": "500778", "standard_charge_dollar": 1675.70, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." } ] } ] }, { "description": "Hc xpansion prep trunk arms legs", "code_information": [ { "code": "15002", "type": "CPT" } ], "standard_charges": [ { "gross_charge": 2761.00, "minimum": 1675.70, "maximum": 2346.85, "setting": "both", "payers_information": [ { "payer_name": "Aarp", "plan_name": "500102", "standard_charge_dollar": 1675.70, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna", "plan_name": "700700", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna", "plan_name": "700700_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Mcare Ffs 6005", "plan_name": "700703", "standard_charge_dollar": 1675.70, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Miscellaneous", "plan_name": "700720", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Miscellaneous", "plan_name": "700720_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Ppo Hmo", "plan_name": "701720", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Ppo Hmo", "plan_name": "701720_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Ambetter 68069", "plan_name": "500516", "standard_charge_dollar": 1675.70, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Ms State Emplo", "plan_name": "401457", "standard_charge_percentage": 0.80, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Ms State Emplo", "plan_name": "401457_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Basic Pl", "plan_name": "400100", "standard_charge_percentage": 0.85, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Basic Pl", "plan_name": "400100_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Federal", "plan_name": "400110", "standard_charge_percentage": 0.85, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Federal", "plan_name": "400110_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Cigna Healthsprings Ffs", "plan_name": "500064", "standard_charge_dollar": 1675.70, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Conseco", "plan_name": "500302", "standard_charge_dollar": 1675.70, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Humana Ffs 61101", "plan_name": "500006", "standard_charge_dollar": 1675.70, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Medicare A", "plan_name": "100100", "standard_charge_dollar": 1675.70, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Medicare A", "plan_name": "100500", "standard_charge_dollar": 1675.70, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Medicare Part B Only", "plan_name": "100300", "standard_charge_dollar": 1675.70, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Medicare Railroad", "plan_name": "100103", "standard_charge_dollar": 1675.70, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Ms Physicians Care N", "plan_name": "714210", "standard_charge_dollar": 2094.63, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Peoples Hlth Ffs 72126", "plan_name": "500019", "standard_charge_dollar": 1675.70, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Uhc/Secure Horizons", "plan_name": "500449", "standard_charge_dollar": 1675.70, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "United Health Care/", "plan_name": "500292", "standard_charge_dollar": 1893.54, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "United Healthcare", "plan_name": "750104", "standard_charge_dollar": 1893.54, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "United Healthcare Ba", "plan_name": "750090", "standard_charge_dollar": 1893.54, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "United Healthcare Me", "plan_name": "501310", "standard_charge_dollar": 1675.70, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Windsor Mcare Extra", "plan_name": "500778", "standard_charge_dollar": 1675.70, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." } ] } ] }, { "description": "Wound prep trk/arm/leg", "code_information": [ { "code": "15002", "type": "CPT" } ], "standard_charges": [ { "gross_charge": 37219.10, "minimum": 1675.70, "maximum": 31636.24, "setting": "inpatient", "payers_information": [ { "payer_name": "Aarp", "plan_name": "500102", "standard_charge_dollar": 1675.70, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna", "plan_name": "700700", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna", "plan_name": "700700_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Mcare Ffs 6005", "plan_name": "700703", "standard_charge_dollar": 1675.70, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Miscellaneous", "plan_name": "700720", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Miscellaneous", "plan_name": "700720_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Ppo Hmo", "plan_name": "701720", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Ppo Hmo", "plan_name": "701720_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Ambetter 68069", "plan_name": "500516", "standard_charge_dollar": 1675.70, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Ms State Emplo", "plan_name": "401457", "standard_charge_percentage": 0.80, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Ms State Emplo", "plan_name": "401457_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Basic Pl", "plan_name": "400100", "standard_charge_percentage": 0.85, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Basic Pl", "plan_name": "400100_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Federal", "plan_name": "400110", "standard_charge_percentage": 0.85, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Federal", "plan_name": "400110_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Cigna Healthsprings Ffs", "plan_name": "500064", "standard_charge_dollar": 1675.70, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Conseco", "plan_name": "500302", "standard_charge_dollar": 1675.70, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Humana Ffs 61101", "plan_name": "500006", "standard_charge_dollar": 1675.70, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Medicare A", "plan_name": "100100", "standard_charge_dollar": 1675.70, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Medicare A", "plan_name": "100500", "standard_charge_dollar": 1675.70, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Medicare Part B Only", "plan_name": "100300", "standard_charge_dollar": 1675.70, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Medicare Railroad", "plan_name": "100103", "standard_charge_dollar": 1675.70, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Ms Physicians Care N", "plan_name": "714210", "standard_charge_dollar": 2094.63, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Peoples Hlth Ffs 72126", "plan_name": "500019", "standard_charge_dollar": 1675.70, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Uhc/Secure Horizons", "plan_name": "500449", "standard_charge_dollar": 1675.70, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "United Health Care/", "plan_name": "500292", "standard_charge_dollar": 1893.54, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "United Healthcare", "plan_name": "750104", "standard_charge_dollar": 1893.54, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "United Healthcare Ba", "plan_name": "750090", "standard_charge_dollar": 1893.54, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "United Healthcare Me", "plan_name": "501310", "standard_charge_dollar": 1675.70, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Windsor Mcare Extra", "plan_name": "500778", "standard_charge_dollar": 1675.70, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." } ] } ] }, { "description": "Wound prep trk/arm/leg", "code_information": [ { "code": "15002", "type": "CPT" } ], "standard_charges": [ { "gross_charge": 2761.00, "minimum": 1675.70, "maximum": 2346.85, "setting": "outpatient", "payers_information": [ { "payer_name": "Aarp", "plan_name": "500102", "standard_charge_dollar": 1675.70, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna", "plan_name": "700700", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna", "plan_name": "700700_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Mcare Ffs 6005", "plan_name": "700703", "standard_charge_dollar": 1675.70, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Miscellaneous", "plan_name": "700720", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Miscellaneous", "plan_name": "700720_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Ppo Hmo", "plan_name": "701720", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Ppo Hmo", "plan_name": "701720_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Ambetter 68069", "plan_name": "500516", "standard_charge_dollar": 1675.70, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Ms State Emplo", "plan_name": "401457", "standard_charge_percentage": 0.80, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Ms State Emplo", "plan_name": "401457_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Basic Pl", "plan_name": "400100", "standard_charge_percentage": 0.85, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Basic Pl", "plan_name": "400100_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Federal", "plan_name": "400110", "standard_charge_percentage": 0.85, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Federal", "plan_name": "400110_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Cigna Healthsprings Ffs", "plan_name": "500064", "standard_charge_dollar": 1675.70, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Conseco", "plan_name": "500302", "standard_charge_dollar": 1675.70, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Humana Ffs 61101", "plan_name": "500006", "standard_charge_dollar": 1675.70, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Medicare A", "plan_name": "100100", "standard_charge_dollar": 1675.70, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Medicare A", "plan_name": "100500", "standard_charge_dollar": 1675.70, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Medicare Part B Only", "plan_name": "100300", "standard_charge_dollar": 1675.70, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Medicare Railroad", "plan_name": "100103", "standard_charge_dollar": 1675.70, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Ms Physicians Care N", "plan_name": "714210", "standard_charge_dollar": 2094.63, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Peoples Hlth Ffs 72126", "plan_name": "500019", "standard_charge_dollar": 1675.70, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Uhc/Secure Horizons", "plan_name": "500449", "standard_charge_dollar": 1675.70, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "United Health Care/", "plan_name": "500292", "standard_charge_dollar": 1893.54, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "United Healthcare", "plan_name": "750104", "standard_charge_dollar": 1893.54, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "United Healthcare Ba", "plan_name": "750090", "standard_charge_dollar": 1893.54, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "United Healthcare Me", "plan_name": "501310", "standard_charge_dollar": 1675.70, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Windsor Mcare Extra", "plan_name": "500778", "standard_charge_dollar": 1675.70, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." } ] } ] }, { "description": "Wound prep addl 100 cm", "code_information": [ { "code": "15003", "type": "CPT" } ], "standard_charges": [ { "gross_charge": 37219.10, "minimum": 29775.28, "maximum": 31636.24, "setting": "inpatient", "payers_information": [ { "payer_name": "Aetna", "plan_name": "700700", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna", "plan_name": "700700_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Miscellaneous", "plan_name": "700720", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Miscellaneous", "plan_name": "700720_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Ppo Hmo", "plan_name": "701720", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Ppo Hmo", "plan_name": "701720_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Ms State Emplo", "plan_name": "401457", "standard_charge_percentage": 0.80, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Ms State Emplo", "plan_name": "401457_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Basic Pl", "plan_name": "400100", "standard_charge_percentage": 0.85, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Basic Pl", "plan_name": "400100_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Federal", "plan_name": "400110", "standard_charge_percentage": 0.85, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Federal", "plan_name": "400110_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." } ] } ] }, { "description": "Hc wnd prep ped f/n/hf/g 100c", "code_information": [ { "code": "15004", "type": "CPT" } ], "standard_charges": [ { "gross_charge": 1616.00, "minimum": 560.75, "maximum": 1373.60, "setting": "both", "payers_information": [ { "payer_name": "Aarp", "plan_name": "500102", "standard_charge_dollar": 560.75, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna", "plan_name": "700700", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna", "plan_name": "700700_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Mcare Ffs 6005", "plan_name": "700703", "standard_charge_dollar": 560.75, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Miscellaneous", "plan_name": "700720", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Miscellaneous", "plan_name": "700720_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Ppo Hmo", "plan_name": "701720", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Ppo Hmo", "plan_name": "701720_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Ambetter 68069", "plan_name": "500516", "standard_charge_dollar": 560.75, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Ms State Emplo", "plan_name": "401457", "standard_charge_percentage": 0.80, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Ms State Emplo", "plan_name": "401457_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Basic Pl", "plan_name": "400100", "standard_charge_percentage": 0.85, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Basic Pl", "plan_name": "400100_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Federal", "plan_name": "400110", "standard_charge_percentage": 0.85, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Federal", "plan_name": "400110_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Cigna Healthsprings Ffs", "plan_name": "500064", "standard_charge_dollar": 560.75, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Conseco", "plan_name": "500302", "standard_charge_dollar": 560.75, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Humana Ffs 61101", "plan_name": "500006", "standard_charge_dollar": 560.75, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Medicare A", "plan_name": "100100", "standard_charge_dollar": 560.75, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Medicare A", "plan_name": "100500", "standard_charge_dollar": 560.75, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Medicare Part B Only", "plan_name": "100300", "standard_charge_dollar": 560.75, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Medicare Railroad", "plan_name": "100103", "standard_charge_dollar": 560.75, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Ms Physicians Care N", "plan_name": "714210", "standard_charge_dollar": 700.94, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Peoples Hlth Ffs 72126", "plan_name": "500019", "standard_charge_dollar": 560.75, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Uhc/Secure Horizons", "plan_name": "500449", "standard_charge_dollar": 560.75, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "United Health Care/", "plan_name": "500292", "standard_charge_dollar": 633.65, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "United Healthcare", "plan_name": "750104", "standard_charge_dollar": 633.65, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "United Healthcare Ba", "plan_name": "750090", "standard_charge_dollar": 633.65, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "United Healthcare Me", "plan_name": "501310", "standard_charge_dollar": 560.75, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Windsor Mcare Extra", "plan_name": "500778", "standard_charge_dollar": 560.75, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." } ] } ] }, { "description": "Wound prep f/n/hf/g", "code_information": [ { "code": "15004", "type": "CPT" } ], "standard_charges": [ { "gross_charge": 37219.10, "minimum": 560.75, "maximum": 31636.24, "setting": "inpatient", "payers_information": [ { "payer_name": "Aarp", "plan_name": "500102", "standard_charge_dollar": 560.75, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna", "plan_name": "700700", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna", "plan_name": "700700_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Mcare Ffs 6005", "plan_name": "700703", "standard_charge_dollar": 560.75, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Miscellaneous", "plan_name": "700720", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Miscellaneous", "plan_name": "700720_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Ppo Hmo", "plan_name": "701720", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Ppo Hmo", "plan_name": "701720_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Ambetter 68069", "plan_name": "500516", "standard_charge_dollar": 560.75, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Ms State Emplo", "plan_name": "401457", "standard_charge_percentage": 0.80, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Ms State Emplo", "plan_name": "401457_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Basic Pl", "plan_name": "400100", "standard_charge_percentage": 0.85, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Basic Pl", "plan_name": "400100_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Federal", "plan_name": "400110", "standard_charge_percentage": 0.85, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Federal", "plan_name": "400110_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Cigna Healthsprings Ffs", "plan_name": "500064", "standard_charge_dollar": 560.75, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Conseco", "plan_name": "500302", "standard_charge_dollar": 560.75, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Humana Ffs 61101", "plan_name": "500006", "standard_charge_dollar": 560.75, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Medicare A", "plan_name": "100100", "standard_charge_dollar": 560.75, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Medicare A", "plan_name": "100500", "standard_charge_dollar": 560.75, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Medicare Part B Only", "plan_name": "100300", "standard_charge_dollar": 560.75, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Medicare Railroad", "plan_name": "100103", "standard_charge_dollar": 560.75, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Ms Physicians Care N", "plan_name": "714210", "standard_charge_dollar": 700.94, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Peoples Hlth Ffs 72126", "plan_name": "500019", "standard_charge_dollar": 560.75, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Uhc/Secure Horizons", "plan_name": "500449", "standard_charge_dollar": 560.75, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "United Health Care/", "plan_name": "500292", "standard_charge_dollar": 633.65, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "United Healthcare", "plan_name": "750104", "standard_charge_dollar": 633.65, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "United Healthcare Ba", "plan_name": "750090", "standard_charge_dollar": 633.65, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "United Healthcare Me", "plan_name": "501310", "standard_charge_dollar": 560.75, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Windsor Mcare Extra", "plan_name": "500778", "standard_charge_dollar": 560.75, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." } ] } ] }, { "description": "Wound prep f/n/hf/g", "code_information": [ { "code": "15004", "type": "CPT" } ], "standard_charges": [ { "gross_charge": 1616.00, "minimum": 560.75, "maximum": 1373.60, "setting": "outpatient", "payers_information": [ { "payer_name": "Aarp", "plan_name": "500102", "standard_charge_dollar": 560.75, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna", "plan_name": "700700", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna", "plan_name": "700700_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Mcare Ffs 6005", "plan_name": "700703", "standard_charge_dollar": 560.75, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Miscellaneous", "plan_name": "700720", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Miscellaneous", "plan_name": "700720_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Ppo Hmo", "plan_name": "701720", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Ppo Hmo", "plan_name": "701720_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Ambetter 68069", "plan_name": "500516", "standard_charge_dollar": 560.75, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Ms State Emplo", "plan_name": "401457", "standard_charge_percentage": 0.80, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Ms State Emplo", "plan_name": "401457_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Basic Pl", "plan_name": "400100", "standard_charge_percentage": 0.85, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Basic Pl", "plan_name": "400100_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Federal", "plan_name": "400110", "standard_charge_percentage": 0.85, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Federal", "plan_name": "400110_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Cigna Healthsprings Ffs", "plan_name": "500064", "standard_charge_dollar": 560.75, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Conseco", "plan_name": "500302", "standard_charge_dollar": 560.75, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Humana Ffs 61101", "plan_name": "500006", "standard_charge_dollar": 560.75, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Medicare A", "plan_name": "100100", "standard_charge_dollar": 560.75, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Medicare A", "plan_name": "100500", "standard_charge_dollar": 560.75, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Medicare Part B Only", "plan_name": "100300", "standard_charge_dollar": 560.75, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Medicare Railroad", "plan_name": "100103", "standard_charge_dollar": 560.75, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Ms Physicians Care N", "plan_name": "714210", "standard_charge_dollar": 700.94, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Peoples Hlth Ffs 72126", "plan_name": "500019", "standard_charge_dollar": 560.75, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Uhc/Secure Horizons", "plan_name": "500449", "standard_charge_dollar": 560.75, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "United Health Care/", "plan_name": "500292", "standard_charge_dollar": 633.65, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "United Healthcare", "plan_name": "750104", "standard_charge_dollar": 633.65, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "United Healthcare Ba", "plan_name": "750090", "standard_charge_dollar": 633.65, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "United Healthcare Me", "plan_name": "501310", "standard_charge_dollar": 560.75, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Windsor Mcare Extra", "plan_name": "500778", "standard_charge_dollar": 560.75, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." } ] } ] }, { "description": "Wnd prep f/n/hf/g addl cm", "code_information": [ { "code": "15005", "type": "CPT" } ], "standard_charges": [ { "gross_charge": 37219.10, "minimum": 29775.28, "maximum": 31636.24, "setting": "inpatient", "payers_information": [ { "payer_name": "Aetna", "plan_name": "700700", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna", "plan_name": "700700_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Miscellaneous", "plan_name": "700720", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Miscellaneous", "plan_name": "700720_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Ppo Hmo", "plan_name": "701720", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Ppo Hmo", "plan_name": "701720_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Ms State Emplo", "plan_name": "401457", "standard_charge_percentage": 0.80, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Ms State Emplo", "plan_name": "401457_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Basic Pl", "plan_name": "400100", "standard_charge_percentage": 0.85, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Basic Pl", "plan_name": "400100_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Federal", "plan_name": "400110", "standard_charge_percentage": 0.85, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Federal", "plan_name": "400110_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." } ] } ] }, { "description": "Harvest cultured skin graft", "code_information": [ { "code": "15040", "type": "CPT" } ], "standard_charges": [ { "gross_charge": 26535.50, "minimum": 1675.70, "maximum": 22555.18, "setting": "inpatient", "payers_information": [ { "payer_name": "Aarp", "plan_name": "500102", "standard_charge_dollar": 1675.70, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna", "plan_name": "700700", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna", "plan_name": "700700_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Mcare Ffs 6005", "plan_name": "700703", "standard_charge_dollar": 1675.70, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Miscellaneous", "plan_name": "700720", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Miscellaneous", "plan_name": "700720_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Ppo Hmo", "plan_name": "701720", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Ppo Hmo", "plan_name": "701720_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Ambetter 68069", "plan_name": "500516", "standard_charge_dollar": 1675.70, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Ms State Emplo", "plan_name": "401457", "standard_charge_percentage": 0.80, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Ms State Emplo", "plan_name": "401457_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Basic Pl", "plan_name": "400100", "standard_charge_percentage": 0.85, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Basic Pl", "plan_name": "400100_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Federal", "plan_name": "400110", "standard_charge_percentage": 0.85, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Federal", "plan_name": "400110_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Cigna Healthsprings Ffs", "plan_name": "500064", "standard_charge_dollar": 1675.70, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Conseco", "plan_name": "500302", "standard_charge_dollar": 1675.70, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Humana Ffs 61101", "plan_name": "500006", "standard_charge_dollar": 1675.70, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Medicare A", "plan_name": "100100", "standard_charge_dollar": 1675.70, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Medicare A", "plan_name": "100500", "standard_charge_dollar": 1675.70, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Medicare Part B Only", "plan_name": "100300", "standard_charge_dollar": 1675.70, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Medicare Railroad", "plan_name": "100103", "standard_charge_dollar": 1675.70, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Ms Physicians Care N", "plan_name": "714210", "standard_charge_dollar": 2094.63, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Peoples Hlth Ffs 72126", "plan_name": "500019", "standard_charge_dollar": 1675.70, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Uhc/Secure Horizons", "plan_name": "500449", "standard_charge_dollar": 1675.70, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "United Health Care/", "plan_name": "500292", "standard_charge_dollar": 1893.54, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "United Healthcare", "plan_name": "750104", "standard_charge_dollar": 1893.54, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "United Healthcare Ba", "plan_name": "750090", "standard_charge_dollar": 1893.54, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "United Healthcare Me", "plan_name": "501310", "standard_charge_dollar": 1675.70, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Windsor Mcare Extra", "plan_name": "500778", "standard_charge_dollar": 1675.70, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." } ] } ] }, { "description": "Skin pinch graft", "code_information": [ { "code": "15050", "type": "CPT" } ], "standard_charges": [ { "gross_charge": 26535.50, "minimum": 560.75, "maximum": 22555.18, "setting": "inpatient", "payers_information": [ { "payer_name": "Aarp", "plan_name": "500102", "standard_charge_dollar": 560.75, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna", "plan_name": "700700", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna", "plan_name": "700700_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Mcare Ffs 6005", "plan_name": "700703", "standard_charge_dollar": 560.75, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Miscellaneous", "plan_name": "700720", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Miscellaneous", "plan_name": "700720_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Ppo Hmo", "plan_name": "701720", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Ppo Hmo", "plan_name": "701720_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Ambetter 68069", "plan_name": "500516", "standard_charge_dollar": 560.75, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Ms State Emplo", "plan_name": "401457", "standard_charge_percentage": 0.80, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Ms State Emplo", "plan_name": "401457_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Basic Pl", "plan_name": "400100", "standard_charge_percentage": 0.85, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Basic Pl", "plan_name": "400100_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Federal", "plan_name": "400110", "standard_charge_percentage": 0.85, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Federal", "plan_name": "400110_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Cigna Healthsprings Ffs", "plan_name": "500064", "standard_charge_dollar": 560.75, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Conseco", "plan_name": "500302", "standard_charge_dollar": 560.75, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Humana Ffs 61101", "plan_name": "500006", "standard_charge_dollar": 560.75, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Medicare A", "plan_name": "100100", "standard_charge_dollar": 560.75, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Medicare A", "plan_name": "100500", "standard_charge_dollar": 560.75, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Medicare Part B Only", "plan_name": "100300", "standard_charge_dollar": 560.75, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Medicare Railroad", "plan_name": "100103", "standard_charge_dollar": 560.75, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Ms Physicians Care N", "plan_name": "714210", "standard_charge_dollar": 700.94, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Peoples Hlth Ffs 72126", "plan_name": "500019", "standard_charge_dollar": 560.75, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Uhc/Secure Horizons", "plan_name": "500449", "standard_charge_dollar": 560.75, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "United Health Care/", "plan_name": "500292", "standard_charge_dollar": 633.65, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "United Healthcare", "plan_name": "750104", "standard_charge_dollar": 633.65, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "United Healthcare Ba", "plan_name": "750090", "standard_charge_dollar": 633.65, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "United Healthcare Me", "plan_name": "501310", "standard_charge_dollar": 560.75, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Windsor Mcare Extra", "plan_name": "500778", "standard_charge_dollar": 560.75, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." } ] } ] }, { "description": "Hc xpansion trunk arms legs", "code_information": [ { "code": "15100", "type": "CPT" } ], "standard_charges": [ { "gross_charge": 2761.00, "minimum": 1675.70, "maximum": 2346.85, "setting": "both", "payers_information": [ { "payer_name": "Aarp", "plan_name": "500102", "standard_charge_dollar": 1675.70, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna", "plan_name": "700700", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna", "plan_name": "700700_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Mcare Ffs 6005", "plan_name": "700703", "standard_charge_dollar": 1675.70, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Miscellaneous", "plan_name": "700720", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Miscellaneous", "plan_name": "700720_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Ppo Hmo", "plan_name": "701720", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Ppo Hmo", "plan_name": "701720_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Ambetter 68069", "plan_name": "500516", "standard_charge_dollar": 1675.70, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Ms State Emplo", "plan_name": "401457", "standard_charge_percentage": 0.80, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Ms State Emplo", "plan_name": "401457_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Basic Pl", "plan_name": "400100", "standard_charge_percentage": 0.85, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Basic Pl", "plan_name": "400100_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Federal", "plan_name": "400110", "standard_charge_percentage": 0.85, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Federal", "plan_name": "400110_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Cigna Healthsprings Ffs", "plan_name": "500064", "standard_charge_dollar": 1675.70, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Conseco", "plan_name": "500302", "standard_charge_dollar": 1675.70, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Humana Ffs 61101", "plan_name": "500006", "standard_charge_dollar": 1675.70, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Medicare A", "plan_name": "100100", "standard_charge_dollar": 1675.70, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Medicare A", "plan_name": "100500", "standard_charge_dollar": 1675.70, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Medicare Part B Only", "plan_name": "100300", "standard_charge_dollar": 1675.70, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Medicare Railroad", "plan_name": "100103", "standard_charge_dollar": 1675.70, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Ms Physicians Care N", "plan_name": "714210", "standard_charge_dollar": 2094.63, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Peoples Hlth Ffs 72126", "plan_name": "500019", "standard_charge_dollar": 1675.70, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Uhc/Secure Horizons", "plan_name": "500449", "standard_charge_dollar": 1675.70, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "United Health Care/", "plan_name": "500292", "standard_charge_dollar": 1893.54, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "United Healthcare", "plan_name": "750104", "standard_charge_dollar": 1893.54, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "United Healthcare Ba", "plan_name": "750090", "standard_charge_dollar": 1893.54, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "United Healthcare Me", "plan_name": "501310", "standard_charge_dollar": 1675.70, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Windsor Mcare Extra", "plan_name": "500778", "standard_charge_dollar": 1675.70, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." } ] } ] }, { "description": "Skin splt grft trnk/arm/leg", "code_information": [ { "code": "15100", "type": "CPT" } ], "standard_charges": [ { "gross_charge": 2761.00, "minimum": 1675.70, "maximum": 2346.85, "setting": "both", "payers_information": [ { "payer_name": "Aarp", "plan_name": "500102", "standard_charge_dollar": 1675.70, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna", "plan_name": "700700", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna", "plan_name": "700700_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Mcare Ffs 6005", "plan_name": "700703", "standard_charge_dollar": 1675.70, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Miscellaneous", "plan_name": "700720", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Miscellaneous", "plan_name": "700720_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Ppo Hmo", "plan_name": "701720", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Ppo Hmo", "plan_name": "701720_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Ambetter 68069", "plan_name": "500516", "standard_charge_dollar": 1675.70, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Ms State Emplo", "plan_name": "401457", "standard_charge_percentage": 0.80, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Ms State Emplo", "plan_name": "401457_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Basic Pl", "plan_name": "400100", "standard_charge_percentage": 0.85, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Basic Pl", "plan_name": "400100_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Federal", "plan_name": "400110", "standard_charge_percentage": 0.85, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Federal", "plan_name": "400110_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Cigna Healthsprings Ffs", "plan_name": "500064", "standard_charge_dollar": 1675.70, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Conseco", "plan_name": "500302", "standard_charge_dollar": 1675.70, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Humana Ffs 61101", "plan_name": "500006", "standard_charge_dollar": 1675.70, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Medicare A", "plan_name": "100100", "standard_charge_dollar": 1675.70, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Medicare A", "plan_name": "100500", "standard_charge_dollar": 1675.70, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Medicare Part B Only", "plan_name": "100300", "standard_charge_dollar": 1675.70, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Medicare Railroad", "plan_name": "100103", "standard_charge_dollar": 1675.70, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Ms Physicians Care N", "plan_name": "714210", "standard_charge_dollar": 2094.63, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Peoples Hlth Ffs 72126", "plan_name": "500019", "standard_charge_dollar": 1675.70, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Uhc/Secure Horizons", "plan_name": "500449", "standard_charge_dollar": 1675.70, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "United Health Care/", "plan_name": "500292", "standard_charge_dollar": 1893.54, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "United Healthcare", "plan_name": "750104", "standard_charge_dollar": 1893.54, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "United Healthcare Ba", "plan_name": "750090", "standard_charge_dollar": 1893.54, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "United Healthcare Me", "plan_name": "501310", "standard_charge_dollar": 1675.70, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Windsor Mcare Extra", "plan_name": "500778", "standard_charge_dollar": 1675.70, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." } ] } ] }, { "description": "Epidrm autogrft trnk/arm/leg", "code_information": [ { "code": "15110", "type": "CPT" } ], "standard_charges": [ { "gross_charge": 2761.00, "minimum": 1675.70, "maximum": 2346.85, "setting": "both", "payers_information": [ { "payer_name": "Aarp", "plan_name": "500102", "standard_charge_dollar": 1675.70, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna", "plan_name": "700700", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna", "plan_name": "700700_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Mcare Ffs 6005", "plan_name": "700703", "standard_charge_dollar": 1675.70, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Miscellaneous", "plan_name": "700720", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Miscellaneous", "plan_name": "700720_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Ppo Hmo", "plan_name": "701720", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Ppo Hmo", "plan_name": "701720_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Ambetter 68069", "plan_name": "500516", "standard_charge_dollar": 1675.70, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Ms State Emplo", "plan_name": "401457", "standard_charge_percentage": 0.80, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Ms State Emplo", "plan_name": "401457_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Basic Pl", "plan_name": "400100", "standard_charge_percentage": 0.85, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Basic Pl", "plan_name": "400100_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Federal", "plan_name": "400110", "standard_charge_percentage": 0.85, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Federal", "plan_name": "400110_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Cigna Healthsprings Ffs", "plan_name": "500064", "standard_charge_dollar": 1675.70, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Conseco", "plan_name": "500302", "standard_charge_dollar": 1675.70, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Humana Ffs 61101", "plan_name": "500006", "standard_charge_dollar": 1675.70, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Medicare A", "plan_name": "100100", "standard_charge_dollar": 1675.70, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Medicare A", "plan_name": "100500", "standard_charge_dollar": 1675.70, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Medicare Part B Only", "plan_name": "100300", "standard_charge_dollar": 1675.70, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Medicare Railroad", "plan_name": "100103", "standard_charge_dollar": 1675.70, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Ms Physicians Care N", "plan_name": "714210", "standard_charge_dollar": 2094.63, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Peoples Hlth Ffs 72126", "plan_name": "500019", "standard_charge_dollar": 1675.70, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Uhc/Secure Horizons", "plan_name": "500449", "standard_charge_dollar": 1675.70, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "United Health Care/", "plan_name": "500292", "standard_charge_dollar": 1893.54, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "United Healthcare", "plan_name": "750104", "standard_charge_dollar": 1893.54, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "United Healthcare Ba", "plan_name": "750090", "standard_charge_dollar": 1893.54, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "United Healthcare Me", "plan_name": "501310", "standard_charge_dollar": 1675.70, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Windsor Mcare Extra", "plan_name": "500778", "standard_charge_dollar": 1675.70, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." } ] } ] }, { "description": "Hc graft epidrml trunk 1st 100cm", "code_information": [ { "code": "15110", "type": "CPT" } ], "standard_charges": [ { "gross_charge": 2761.00, "minimum": 1675.70, "maximum": 2346.85, "setting": "both", "payers_information": [ { "payer_name": "Aarp", "plan_name": "500102", "standard_charge_dollar": 1675.70, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna", "plan_name": "700700", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna", "plan_name": "700700_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Mcare Ffs 6005", "plan_name": "700703", "standard_charge_dollar": 1675.70, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Miscellaneous", "plan_name": "700720", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Miscellaneous", "plan_name": "700720_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Ppo Hmo", "plan_name": "701720", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Ppo Hmo", "plan_name": "701720_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Ambetter 68069", "plan_name": "500516", "standard_charge_dollar": 1675.70, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Ms State Emplo", "plan_name": "401457", "standard_charge_percentage": 0.80, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Ms State Emplo", "plan_name": "401457_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Basic Pl", "plan_name": "400100", "standard_charge_percentage": 0.85, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Basic Pl", "plan_name": "400100_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Federal", "plan_name": "400110", "standard_charge_percentage": 0.85, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Federal", "plan_name": "400110_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Cigna Healthsprings Ffs", "plan_name": "500064", "standard_charge_dollar": 1675.70, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Conseco", "plan_name": "500302", "standard_charge_dollar": 1675.70, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Humana Ffs 61101", "plan_name": "500006", "standard_charge_dollar": 1675.70, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Medicare A", "plan_name": "100100", "standard_charge_dollar": 1675.70, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Medicare A", "plan_name": "100500", "standard_charge_dollar": 1675.70, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Medicare Part B Only", "plan_name": "100300", "standard_charge_dollar": 1675.70, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Medicare Railroad", "plan_name": "100103", "standard_charge_dollar": 1675.70, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Ms Physicians Care N", "plan_name": "714210", "standard_charge_dollar": 2094.63, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Peoples Hlth Ffs 72126", "plan_name": "500019", "standard_charge_dollar": 1675.70, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Uhc/Secure Horizons", "plan_name": "500449", "standard_charge_dollar": 1675.70, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "United Health Care/", "plan_name": "500292", "standard_charge_dollar": 1893.54, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "United Healthcare", "plan_name": "750104", "standard_charge_dollar": 1893.54, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "United Healthcare Ba", "plan_name": "750090", "standard_charge_dollar": 1893.54, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "United Healthcare Me", "plan_name": "501310", "standard_charge_dollar": 1675.70, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Windsor Mcare Extra", "plan_name": "500778", "standard_charge_dollar": 1675.70, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." } ] } ] }, { "description": "Epidrm a-grft face/nck/hf/g", "code_information": [ { "code": "15115", "type": "CPT" } ], "standard_charges": [ { "gross_charge": 2761.00, "minimum": 1675.70, "maximum": 2346.85, "setting": "both", "payers_information": [ { "payer_name": "Aarp", "plan_name": "500102", "standard_charge_dollar": 1675.70, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna", "plan_name": "700700", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna", "plan_name": "700700_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Mcare Ffs 6005", "plan_name": "700703", "standard_charge_dollar": 1675.70, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Miscellaneous", "plan_name": "700720", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Miscellaneous", "plan_name": "700720_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Ppo Hmo", "plan_name": "701720", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Ppo Hmo", "plan_name": "701720_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Ambetter 68069", "plan_name": "500516", "standard_charge_dollar": 1675.70, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Ms State Emplo", "plan_name": "401457", "standard_charge_percentage": 0.80, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Ms State Emplo", "plan_name": "401457_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Basic Pl", "plan_name": "400100", "standard_charge_percentage": 0.85, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Basic Pl", "plan_name": "400100_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Federal", "plan_name": "400110", "standard_charge_percentage": 0.85, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Federal", "plan_name": "400110_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Cigna Healthsprings Ffs", "plan_name": "500064", "standard_charge_dollar": 1675.70, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Conseco", "plan_name": "500302", "standard_charge_dollar": 1675.70, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Humana Ffs 61101", "plan_name": "500006", "standard_charge_dollar": 1675.70, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Medicare A", "plan_name": "100100", "standard_charge_dollar": 1675.70, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Medicare A", "plan_name": "100500", "standard_charge_dollar": 1675.70, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Medicare Part B Only", "plan_name": "100300", "standard_charge_dollar": 1675.70, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Medicare Railroad", "plan_name": "100103", "standard_charge_dollar": 1675.70, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Ms Physicians Care N", "plan_name": "714210", "standard_charge_dollar": 2094.63, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Peoples Hlth Ffs 72126", "plan_name": "500019", "standard_charge_dollar": 1675.70, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Uhc/Secure Horizons", "plan_name": "500449", "standard_charge_dollar": 1675.70, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "United Health Care/", "plan_name": "500292", "standard_charge_dollar": 1893.54, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "United Healthcare", "plan_name": "750104", "standard_charge_dollar": 1893.54, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "United Healthcare Ba", "plan_name": "750090", "standard_charge_dollar": 1893.54, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "United Healthcare Me", "plan_name": "501310", "standard_charge_dollar": 1675.70, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Windsor Mcare Extra", "plan_name": "500778", "standard_charge_dollar": 1675.70, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." } ] } ] }, { "description": "Hc epidermal autograft f/h/ft 1st 100 sq cm", "code_information": [ { "code": "15115", "type": "CPT" } ], "standard_charges": [ { "gross_charge": 2761.00, "minimum": 1675.70, "maximum": 2346.85, "setting": "both", "payers_information": [ { "payer_name": "Aarp", "plan_name": "500102", "standard_charge_dollar": 1675.70, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna", "plan_name": "700700", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna", "plan_name": "700700_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Mcare Ffs 6005", "plan_name": "700703", "standard_charge_dollar": 1675.70, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Miscellaneous", "plan_name": "700720", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Miscellaneous", "plan_name": "700720_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Ppo Hmo", "plan_name": "701720", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Ppo Hmo", "plan_name": "701720_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Ambetter 68069", "plan_name": "500516", "standard_charge_dollar": 1675.70, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Ms State Emplo", "plan_name": "401457", "standard_charge_percentage": 0.80, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Ms State Emplo", "plan_name": "401457_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Basic Pl", "plan_name": "400100", "standard_charge_percentage": 0.85, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Basic Pl", "plan_name": "400100_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Federal", "plan_name": "400110", "standard_charge_percentage": 0.85, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Federal", "plan_name": "400110_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Cigna Healthsprings Ffs", "plan_name": "500064", "standard_charge_dollar": 1675.70, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Conseco", "plan_name": "500302", "standard_charge_dollar": 1675.70, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Humana Ffs 61101", "plan_name": "500006", "standard_charge_dollar": 1675.70, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Medicare A", "plan_name": "100100", "standard_charge_dollar": 1675.70, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Medicare A", "plan_name": "100500", "standard_charge_dollar": 1675.70, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Medicare Part B Only", "plan_name": "100300", "standard_charge_dollar": 1675.70, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Medicare Railroad", "plan_name": "100103", "standard_charge_dollar": 1675.70, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Ms Physicians Care N", "plan_name": "714210", "standard_charge_dollar": 2094.63, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Peoples Hlth Ffs 72126", "plan_name": "500019", "standard_charge_dollar": 1675.70, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Uhc/Secure Horizons", "plan_name": "500449", "standard_charge_dollar": 1675.70, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "United Health Care/", "plan_name": "500292", "standard_charge_dollar": 1893.54, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "United Healthcare", "plan_name": "750104", "standard_charge_dollar": 1893.54, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "United Healthcare Ba", "plan_name": "750090", "standard_charge_dollar": 1893.54, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "United Healthcare Me", "plan_name": "501310", "standard_charge_dollar": 1675.70, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Windsor Mcare Extra", "plan_name": "500778", "standard_charge_dollar": 1675.70, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." } ] } ] }, { "description": "Hc split thickness autograft f/h/ft 1st 100 sq cm", "code_information": [ { "code": "15120", "type": "CPT" } ], "standard_charges": [ { "gross_charge": 5205.00, "minimum": 3353.70, "maximum": 4424.25, "setting": "both", "payers_information": [ { "payer_name": "Aarp", "plan_name": "500102", "standard_charge_dollar": 3353.70, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna", "plan_name": "700700", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna", "plan_name": "700700_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Mcare Ffs 6005", "plan_name": "700703", "standard_charge_dollar": 3353.70, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Miscellaneous", "plan_name": "700720", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Miscellaneous", "plan_name": "700720_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Ppo Hmo", "plan_name": "701720", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Ppo Hmo", "plan_name": "701720_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Ambetter 68069", "plan_name": "500516", "standard_charge_dollar": 3353.70, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Ms State Emplo", "plan_name": "401457", "standard_charge_percentage": 0.80, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Ms State Emplo", "plan_name": "401457_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Basic Pl", "plan_name": "400100", "standard_charge_percentage": 0.85, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Basic Pl", "plan_name": "400100_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Federal", "plan_name": "400110", "standard_charge_percentage": 0.85, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Federal", "plan_name": "400110_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Cigna Healthsprings Ffs", "plan_name": "500064", "standard_charge_dollar": 3353.70, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Conseco", "plan_name": "500302", "standard_charge_dollar": 3353.70, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Humana Ffs 61101", "plan_name": "500006", "standard_charge_dollar": 3353.70, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Medicare A", "plan_name": "100100", "standard_charge_dollar": 3353.70, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Medicare A", "plan_name": "100500", "standard_charge_dollar": 3353.70, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Medicare Part B Only", "plan_name": "100300", "standard_charge_dollar": 3353.70, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Medicare Railroad", "plan_name": "100103", "standard_charge_dollar": 3353.70, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Ms Physicians Care N", "plan_name": "714210", "standard_charge_dollar": 4192.13, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Peoples Hlth Ffs 72126", "plan_name": "500019", "standard_charge_dollar": 3353.70, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Uhc/Secure Horizons", "plan_name": "500449", "standard_charge_dollar": 3353.70, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "United Health Care/", "plan_name": "500292", "standard_charge_dollar": 3789.68, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "United Healthcare", "plan_name": "750104", "standard_charge_dollar": 3789.68, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "United Healthcare Ba", "plan_name": "750090", "standard_charge_dollar": 3789.68, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "United Healthcare Me", "plan_name": "501310", "standard_charge_dollar": 3353.70, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Windsor Mcare Extra", "plan_name": "500778", "standard_charge_dollar": 3353.70, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." } ] } ] }, { "description": "Skn splt a-grft fac/nck/hf/g", "code_information": [ { "code": "15120", "type": "CPT" } ], "standard_charges": [ { "gross_charge": 5205.00, "minimum": 3353.70, "maximum": 4424.25, "setting": "both", "payers_information": [ { "payer_name": "Aarp", "plan_name": "500102", "standard_charge_dollar": 3353.70, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna", "plan_name": "700700", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna", "plan_name": "700700_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Mcare Ffs 6005", "plan_name": "700703", "standard_charge_dollar": 3353.70, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Miscellaneous", "plan_name": "700720", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Miscellaneous", "plan_name": "700720_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Ppo Hmo", "plan_name": "701720", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Ppo Hmo", "plan_name": "701720_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Ambetter 68069", "plan_name": "500516", "standard_charge_dollar": 3353.70, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Ms State Emplo", "plan_name": "401457", "standard_charge_percentage": 0.80, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Ms State Emplo", "plan_name": "401457_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Basic Pl", "plan_name": "400100", "standard_charge_percentage": 0.85, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Basic Pl", "plan_name": "400100_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Federal", "plan_name": "400110", "standard_charge_percentage": 0.85, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Federal", "plan_name": "400110_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Cigna Healthsprings Ffs", "plan_name": "500064", "standard_charge_dollar": 3353.70, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Conseco", "plan_name": "500302", "standard_charge_dollar": 3353.70, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Humana Ffs 61101", "plan_name": "500006", "standard_charge_dollar": 3353.70, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Medicare A", "plan_name": "100100", "standard_charge_dollar": 3353.70, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Medicare A", "plan_name": "100500", "standard_charge_dollar": 3353.70, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Medicare Part B Only", "plan_name": "100300", "standard_charge_dollar": 3353.70, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Medicare Railroad", "plan_name": "100103", "standard_charge_dollar": 3353.70, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Ms Physicians Care N", "plan_name": "714210", "standard_charge_dollar": 4192.13, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Peoples Hlth Ffs 72126", "plan_name": "500019", "standard_charge_dollar": 3353.70, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Uhc/Secure Horizons", "plan_name": "500449", "standard_charge_dollar": 3353.70, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "United Health Care/", "plan_name": "500292", "standard_charge_dollar": 3789.68, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "United Healthcare", "plan_name": "750104", "standard_charge_dollar": 3789.68, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "United Healthcare Ba", "plan_name": "750090", "standard_charge_dollar": 3789.68, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "United Healthcare Me", "plan_name": "501310", "standard_charge_dollar": 3353.70, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Windsor Mcare Extra", "plan_name": "500778", "standard_charge_dollar": 3353.70, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." } ] } ] }, { "description": "Skin full graft sclp/arm/leg", "code_information": [ { "code": "15220", "type": "CPT" } ], "standard_charges": [ { "gross_charge": 21627.21, "minimum": 1675.70, "maximum": 18383.13, "setting": "inpatient", "payers_information": [ { "payer_name": "Aarp", "plan_name": "500102", "standard_charge_dollar": 1675.70, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna", "plan_name": "700700", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna", "plan_name": "700700_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Mcare Ffs 6005", "plan_name": "700703", "standard_charge_dollar": 1675.70, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Miscellaneous", "plan_name": "700720", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Miscellaneous", "plan_name": "700720_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Ppo Hmo", "plan_name": "701720", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Ppo Hmo", "plan_name": "701720_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Ambetter 68069", "plan_name": "500516", "standard_charge_dollar": 1675.70, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Ms State Emplo", "plan_name": "401457", "standard_charge_percentage": 0.80, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Ms State Emplo", "plan_name": "401457_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Basic Pl", "plan_name": "400100", "standard_charge_percentage": 0.85, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Basic Pl", "plan_name": "400100_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Federal", "plan_name": "400110", "standard_charge_percentage": 0.85, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Federal", "plan_name": "400110_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Cigna Healthsprings Ffs", "plan_name": "500064", "standard_charge_dollar": 1675.70, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Conseco", "plan_name": "500302", "standard_charge_dollar": 1675.70, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Humana Ffs 61101", "plan_name": "500006", "standard_charge_dollar": 1675.70, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Medicare A", "plan_name": "100100", "standard_charge_dollar": 1675.70, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Medicare A", "plan_name": "100500", "standard_charge_dollar": 1675.70, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Medicare Part B Only", "plan_name": "100300", "standard_charge_dollar": 1675.70, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Medicare Railroad", "plan_name": "100103", "standard_charge_dollar": 1675.70, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Ms Physicians Care N", "plan_name": "714210", "standard_charge_dollar": 2094.63, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Peoples Hlth Ffs 72126", "plan_name": "500019", "standard_charge_dollar": 1675.70, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Uhc/Secure Horizons", "plan_name": "500449", "standard_charge_dollar": 1675.70, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "United Health Care/", "plan_name": "500292", "standard_charge_dollar": 1893.54, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "United Healthcare", "plan_name": "750104", "standard_charge_dollar": 1893.54, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "United Healthcare Ba", "plan_name": "750090", "standard_charge_dollar": 1893.54, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "United Healthcare Me", "plan_name": "501310", "standard_charge_dollar": 1675.70, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Windsor Mcare Extra", "plan_name": "500778", "standard_charge_dollar": 1675.70, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." } ] } ] }, { "description": "Skin full graft add-on", "code_information": [ { "code": "15221", "type": "CPT" } ], "standard_charges": [ { "gross_charge": 21627.21, "minimum": 17301.77, "maximum": 18383.13, "setting": "inpatient", "payers_information": [ { "payer_name": "Aetna", "plan_name": "700700", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna", "plan_name": "700700_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Miscellaneous", "plan_name": "700720", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Miscellaneous", "plan_name": "700720_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Ppo Hmo", "plan_name": "701720", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Ppo Hmo", "plan_name": "701720_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Ms State Emplo", "plan_name": "401457", "standard_charge_percentage": 0.80, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Ms State Emplo", "plan_name": "401457_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Basic Pl", "plan_name": "400100", "standard_charge_percentage": 0.85, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Basic Pl", "plan_name": "400100_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Federal", "plan_name": "400110", "standard_charge_percentage": 0.85, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Federal", "plan_name": "400110_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." } ] } ] }, { "description": "Hc skn sub grft t/a/l 1st 25sqcm", "code_information": [ { "code": "15271", "type": "CPT" } ], "standard_charges": [ { "gross_charge": 2881.00, "minimum": 1675.70, "maximum": 2448.85, "setting": "both", "payers_information": [ { "payer_name": "Aarp", "plan_name": "500102", "standard_charge_dollar": 1675.70, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna", "plan_name": "700700", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna", "plan_name": "700700_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Mcare Ffs 6005", "plan_name": "700703", "standard_charge_dollar": 1675.70, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Miscellaneous", "plan_name": "700720", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Miscellaneous", "plan_name": "700720_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Ppo Hmo", "plan_name": "701720", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Ppo Hmo", "plan_name": "701720_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Ambetter 68069", "plan_name": "500516", "standard_charge_dollar": 1675.70, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Ms State Emplo", "plan_name": "401457", "standard_charge_percentage": 0.80, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Ms State Emplo", "plan_name": "401457_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Basic Pl", "plan_name": "400100", "standard_charge_percentage": 0.85, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Basic Pl", "plan_name": "400100_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Federal", "plan_name": "400110", "standard_charge_percentage": 0.85, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Federal", "plan_name": "400110_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Cigna Healthsprings Ffs", "plan_name": "500064", "standard_charge_dollar": 1675.70, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Conseco", "plan_name": "500302", "standard_charge_dollar": 1675.70, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Humana Ffs 61101", "plan_name": "500006", "standard_charge_dollar": 1675.70, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Medicare A", "plan_name": "100100", "standard_charge_dollar": 1675.70, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Medicare A", "plan_name": "100500", "standard_charge_dollar": 1675.70, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Medicare Part B Only", "plan_name": "100300", "standard_charge_dollar": 1675.70, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Medicare Railroad", "plan_name": "100103", "standard_charge_dollar": 1675.70, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Ms Physicians Care N", "plan_name": "714210", "standard_charge_dollar": 2094.63, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Peoples Hlth Ffs 72126", "plan_name": "500019", "standard_charge_dollar": 1675.70, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Uhc/Secure Horizons", "plan_name": "500449", "standard_charge_dollar": 1675.70, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "United Health Care/", "plan_name": "500292", "standard_charge_dollar": 1893.54, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "United Healthcare", "plan_name": "750104", "standard_charge_dollar": 1893.54, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "United Healthcare Ba", "plan_name": "750090", "standard_charge_dollar": 1893.54, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "United Healthcare Me", "plan_name": "501310", "standard_charge_dollar": 1675.70, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Windsor Mcare Extra", "plan_name": "500778", "standard_charge_dollar": 1675.70, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." } ] } ] }, { "description": "Skin sub graft trnk/arm/leg", "code_information": [ { "code": "15271", "type": "CPT" } ], "standard_charges": [ { "gross_charge": 2881.00, "minimum": 1675.70, "maximum": 2448.85, "setting": "both", "payers_information": [ { "payer_name": "Aarp", "plan_name": "500102", "standard_charge_dollar": 1675.70, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna", "plan_name": "700700", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna", "plan_name": "700700_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Mcare Ffs 6005", "plan_name": "700703", "standard_charge_dollar": 1675.70, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Miscellaneous", "plan_name": "700720", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Miscellaneous", "plan_name": "700720_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Ppo Hmo", "plan_name": "701720", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Ppo Hmo", "plan_name": "701720_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Ambetter 68069", "plan_name": "500516", "standard_charge_dollar": 1675.70, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Ms State Emplo", "plan_name": "401457", "standard_charge_percentage": 0.80, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Ms State Emplo", "plan_name": "401457_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Basic Pl", "plan_name": "400100", "standard_charge_percentage": 0.85, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Basic Pl", "plan_name": "400100_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Federal", "plan_name": "400110", "standard_charge_percentage": 0.85, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Federal", "plan_name": "400110_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Cigna Healthsprings Ffs", "plan_name": "500064", "standard_charge_dollar": 1675.70, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Conseco", "plan_name": "500302", "standard_charge_dollar": 1675.70, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Humana Ffs 61101", "plan_name": "500006", "standard_charge_dollar": 1675.70, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Medicare A", "plan_name": "100100", "standard_charge_dollar": 1675.70, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Medicare A", "plan_name": "100500", "standard_charge_dollar": 1675.70, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Medicare Part B Only", "plan_name": "100300", "standard_charge_dollar": 1675.70, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Medicare Railroad", "plan_name": "100103", "standard_charge_dollar": 1675.70, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Ms Physicians Care N", "plan_name": "714210", "standard_charge_dollar": 2094.63, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Peoples Hlth Ffs 72126", "plan_name": "500019", "standard_charge_dollar": 1675.70, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Uhc/Secure Horizons", "plan_name": "500449", "standard_charge_dollar": 1675.70, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "United Health Care/", "plan_name": "500292", "standard_charge_dollar": 1893.54, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "United Healthcare", "plan_name": "750104", "standard_charge_dollar": 1893.54, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "United Healthcare Ba", "plan_name": "750090", "standard_charge_dollar": 1893.54, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "United Healthcare Me", "plan_name": "501310", "standard_charge_dollar": 1675.70, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Windsor Mcare Extra", "plan_name": "500778", "standard_charge_dollar": 1675.70, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." } ] } ] }, { "description": "Hc skn sub grft t/a/l add 25sqcm", "code_information": [ { "code": "15272", "type": "CPT" } ], "standard_charges": [ { "gross_charge": 2881.00, "minimum": 2304.80, "maximum": 2448.85, "setting": "both", "payers_information": [ { "payer_name": "Aetna", "plan_name": "700700", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna", "plan_name": "700700_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Miscellaneous", "plan_name": "700720", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Miscellaneous", "plan_name": "700720_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Ppo Hmo", "plan_name": "701720", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Ppo Hmo", "plan_name": "701720_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Ms State Emplo", "plan_name": "401457", "standard_charge_percentage": 0.80, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Ms State Emplo", "plan_name": "401457_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Basic Pl", "plan_name": "400100", "standard_charge_percentage": 0.85, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Basic Pl", "plan_name": "400100_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Federal", "plan_name": "400110", "standard_charge_percentage": 0.85, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Federal", "plan_name": "400110_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." } ] } ] }, { "description": "Skin sub graft t/a/l add-on", "code_information": [ { "code": "15272", "type": "CPT" } ], "standard_charges": [ { "gross_charge": 2881.00, "minimum": 2304.80, "maximum": 2448.85, "setting": "both", "payers_information": [ { "payer_name": "Aetna", "plan_name": "700700", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna", "plan_name": "700700_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Miscellaneous", "plan_name": "700720", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Miscellaneous", "plan_name": "700720_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Ppo Hmo", "plan_name": "701720", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Ppo Hmo", "plan_name": "701720_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Ms State Emplo", "plan_name": "401457", "standard_charge_percentage": 0.80, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Ms State Emplo", "plan_name": "401457_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Basic Pl", "plan_name": "400100", "standard_charge_percentage": 0.85, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Basic Pl", "plan_name": "400100_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Federal", "plan_name": "400110", "standard_charge_percentage": 0.85, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Federal", "plan_name": "400110_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." } ] } ] }, { "description": "Hc application high cost graft legs 1st 100 sq cm or less (wound > 100 sq cm)", "code_information": [ { "code": "15273", "type": "CPT" } ], "standard_charges": [ { "gross_charge": 5205.00, "minimum": 3353.70, "maximum": 4424.25, "setting": "both", "payers_information": [ { "payer_name": "Aarp", "plan_name": "500102", "standard_charge_dollar": 3353.70, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna", "plan_name": "700700", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna", "plan_name": "700700_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Mcare Ffs 6005", "plan_name": "700703", "standard_charge_dollar": 3353.70, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Miscellaneous", "plan_name": "700720", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Miscellaneous", "plan_name": "700720_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Ppo Hmo", "plan_name": "701720", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Ppo Hmo", "plan_name": "701720_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Ambetter 68069", "plan_name": "500516", "standard_charge_dollar": 3353.70, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Ms State Emplo", "plan_name": "401457", "standard_charge_percentage": 0.80, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Ms State Emplo", "plan_name": "401457_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Basic Pl", "plan_name": "400100", "standard_charge_percentage": 0.85, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Basic Pl", "plan_name": "400100_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Federal", "plan_name": "400110", "standard_charge_percentage": 0.85, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Federal", "plan_name": "400110_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Cigna Healthsprings Ffs", "plan_name": "500064", "standard_charge_dollar": 3353.70, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Conseco", "plan_name": "500302", "standard_charge_dollar": 3353.70, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Humana Ffs 61101", "plan_name": "500006", "standard_charge_dollar": 3353.70, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Medicare A", "plan_name": "100100", "standard_charge_dollar": 3353.70, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Medicare A", "plan_name": "100500", "standard_charge_dollar": 3353.70, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Medicare Part B Only", "plan_name": "100300", "standard_charge_dollar": 3353.70, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Medicare Railroad", "plan_name": "100103", "standard_charge_dollar": 3353.70, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Ms Physicians Care N", "plan_name": "714210", "standard_charge_dollar": 4192.13, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Peoples Hlth Ffs 72126", "plan_name": "500019", "standard_charge_dollar": 3353.70, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Uhc/Secure Horizons", "plan_name": "500449", "standard_charge_dollar": 3353.70, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "United Health Care/", "plan_name": "500292", "standard_charge_dollar": 3789.68, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "United Healthcare", "plan_name": "750104", "standard_charge_dollar": 3789.68, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "United Healthcare Ba", "plan_name": "750090", "standard_charge_dollar": 3789.68, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "United Healthcare Me", "plan_name": "501310", "standard_charge_dollar": 3353.70, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Windsor Mcare Extra", "plan_name": "500778", "standard_charge_dollar": 3353.70, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." } ] } ] }, { "description": "Skin sub grft t/arm/lg child", "code_information": [ { "code": "15273", "type": "CPT" } ], "standard_charges": [ { "gross_charge": 5205.00, "minimum": 3353.70, "maximum": 4424.25, "setting": "both", "payers_information": [ { "payer_name": "Aarp", "plan_name": "500102", "standard_charge_dollar": 3353.70, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna", "plan_name": "700700", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna", "plan_name": "700700_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Mcare Ffs 6005", "plan_name": "700703", "standard_charge_dollar": 3353.70, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Miscellaneous", "plan_name": "700720", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Miscellaneous", "plan_name": "700720_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Ppo Hmo", "plan_name": "701720", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Ppo Hmo", "plan_name": "701720_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Ambetter 68069", "plan_name": "500516", "standard_charge_dollar": 3353.70, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Ms State Emplo", "plan_name": "401457", "standard_charge_percentage": 0.80, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Ms State Emplo", "plan_name": "401457_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Basic Pl", "plan_name": "400100", "standard_charge_percentage": 0.85, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Basic Pl", "plan_name": "400100_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Federal", "plan_name": "400110", "standard_charge_percentage": 0.85, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Federal", "plan_name": "400110_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Cigna Healthsprings Ffs", "plan_name": "500064", "standard_charge_dollar": 3353.70, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Conseco", "plan_name": "500302", "standard_charge_dollar": 3353.70, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Humana Ffs 61101", "plan_name": "500006", "standard_charge_dollar": 3353.70, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Medicare A", "plan_name": "100100", "standard_charge_dollar": 3353.70, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Medicare A", "plan_name": "100500", "standard_charge_dollar": 3353.70, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Medicare Part B Only", "plan_name": "100300", "standard_charge_dollar": 3353.70, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Medicare Railroad", "plan_name": "100103", "standard_charge_dollar": 3353.70, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Ms Physicians Care N", "plan_name": "714210", "standard_charge_dollar": 4192.13, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Peoples Hlth Ffs 72126", "plan_name": "500019", "standard_charge_dollar": 3353.70, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Uhc/Secure Horizons", "plan_name": "500449", "standard_charge_dollar": 3353.70, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "United Health Care/", "plan_name": "500292", "standard_charge_dollar": 3789.68, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "United Healthcare", "plan_name": "750104", "standard_charge_dollar": 3789.68, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "United Healthcare Ba", "plan_name": "750090", "standard_charge_dollar": 3789.68, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "United Healthcare Me", "plan_name": "501310", "standard_charge_dollar": 3353.70, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Windsor Mcare Extra", "plan_name": "500778", "standard_charge_dollar": 3353.70, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." } ] } ] }, { "description": "Hc application high cost graft legs each addl 100 sq cm or less (wound > 100 sq cm)", "code_information": [ { "code": "15274", "type": "CPT" } ], "standard_charges": [ { "gross_charge": 5205.00, "minimum": 4164.00, "maximum": 4424.25, "setting": "both", "payers_information": [ { "payer_name": "Aetna", "plan_name": "700700", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna", "plan_name": "700700_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Miscellaneous", "plan_name": "700720", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Miscellaneous", "plan_name": "700720_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Ppo Hmo", "plan_name": "701720", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Ppo Hmo", "plan_name": "701720_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Ms State Emplo", "plan_name": "401457", "standard_charge_percentage": 0.80, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Ms State Emplo", "plan_name": "401457_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Basic Pl", "plan_name": "400100", "standard_charge_percentage": 0.85, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Basic Pl", "plan_name": "400100_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Federal", "plan_name": "400110", "standard_charge_percentage": 0.85, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Federal", "plan_name": "400110_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." } ] } ] }, { "description": "Skn sub grft t/a/l child add", "code_information": [ { "code": "15274", "type": "CPT" } ], "standard_charges": [ { "gross_charge": 5205.00, "minimum": 4164.00, "maximum": 4424.25, "setting": "both", "payers_information": [ { "payer_name": "Aetna", "plan_name": "700700", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna", "plan_name": "700700_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Miscellaneous", "plan_name": "700720", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Miscellaneous", "plan_name": "700720_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Ppo Hmo", "plan_name": "701720", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Ppo Hmo", "plan_name": "701720_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Ms State Emplo", "plan_name": "401457", "standard_charge_percentage": 0.80, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Ms State Emplo", "plan_name": "401457_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Basic Pl", "plan_name": "400100", "standard_charge_percentage": 0.85, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Basic Pl", "plan_name": "400100_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Federal", "plan_name": "400110", "standard_charge_percentage": 0.85, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Federal", "plan_name": "400110_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." } ] } ] }, { "description": "Hc skn sub grft face/nk/hf/g 1st", "code_information": [ { "code": "15275", "type": "CPT" } ], "standard_charges": [ { "gross_charge": 2881.00, "minimum": 1675.70, "maximum": 2448.85, "setting": "both", "payers_information": [ { "payer_name": "Aarp", "plan_name": "500102", "standard_charge_dollar": 1675.70, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna", "plan_name": "700700", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna", "plan_name": "700700_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Mcare Ffs 6005", "plan_name": "700703", "standard_charge_dollar": 1675.70, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Miscellaneous", "plan_name": "700720", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Miscellaneous", "plan_name": "700720_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Ppo Hmo", "plan_name": "701720", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Ppo Hmo", "plan_name": "701720_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Ambetter 68069", "plan_name": "500516", "standard_charge_dollar": 1675.70, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Ms State Emplo", "plan_name": "401457", "standard_charge_percentage": 0.80, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Ms State Emplo", "plan_name": "401457_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Basic Pl", "plan_name": "400100", "standard_charge_percentage": 0.85, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Basic Pl", "plan_name": "400100_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Federal", "plan_name": "400110", "standard_charge_percentage": 0.85, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Federal", "plan_name": "400110_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Cigna Healthsprings Ffs", "plan_name": "500064", "standard_charge_dollar": 1675.70, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Conseco", "plan_name": "500302", "standard_charge_dollar": 1675.70, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Humana Ffs 61101", "plan_name": "500006", "standard_charge_dollar": 1675.70, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Medicare A", "plan_name": "100100", "standard_charge_dollar": 1675.70, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Medicare A", "plan_name": "100500", "standard_charge_dollar": 1675.70, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Medicare Part B Only", "plan_name": "100300", "standard_charge_dollar": 1675.70, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Medicare Railroad", "plan_name": "100103", "standard_charge_dollar": 1675.70, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Ms Physicians Care N", "plan_name": "714210", "standard_charge_dollar": 2094.63, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Peoples Hlth Ffs 72126", "plan_name": "500019", "standard_charge_dollar": 1675.70, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Uhc/Secure Horizons", "plan_name": "500449", "standard_charge_dollar": 1675.70, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "United Health Care/", "plan_name": "500292", "standard_charge_dollar": 1893.54, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "United Healthcare", "plan_name": "750104", "standard_charge_dollar": 1893.54, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "United Healthcare Ba", "plan_name": "750090", "standard_charge_dollar": 1893.54, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "United Healthcare Me", "plan_name": "501310", "standard_charge_dollar": 1675.70, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Windsor Mcare Extra", "plan_name": "500778", "standard_charge_dollar": 1675.70, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." } ] } ] }, { "description": "Skin sub graft face/nk/hf/g", "code_information": [ { "code": "15275", "type": "CPT" } ], "standard_charges": [ { "gross_charge": 2881.00, "minimum": 1675.70, "maximum": 2448.85, "setting": "both", "payers_information": [ { "payer_name": "Aarp", "plan_name": "500102", "standard_charge_dollar": 1675.70, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna", "plan_name": "700700", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna", "plan_name": "700700_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Mcare Ffs 6005", "plan_name": "700703", "standard_charge_dollar": 1675.70, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Miscellaneous", "plan_name": "700720", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Miscellaneous", "plan_name": "700720_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Ppo Hmo", "plan_name": "701720", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Ppo Hmo", "plan_name": "701720_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Ambetter 68069", "plan_name": "500516", "standard_charge_dollar": 1675.70, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Ms State Emplo", "plan_name": "401457", "standard_charge_percentage": 0.80, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Ms State Emplo", "plan_name": "401457_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Basic Pl", "plan_name": "400100", "standard_charge_percentage": 0.85, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Basic Pl", "plan_name": "400100_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Federal", "plan_name": "400110", "standard_charge_percentage": 0.85, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Federal", "plan_name": "400110_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Cigna Healthsprings Ffs", "plan_name": "500064", "standard_charge_dollar": 1675.70, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Conseco", "plan_name": "500302", "standard_charge_dollar": 1675.70, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Humana Ffs 61101", "plan_name": "500006", "standard_charge_dollar": 1675.70, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Medicare A", "plan_name": "100100", "standard_charge_dollar": 1675.70, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Medicare A", "plan_name": "100500", "standard_charge_dollar": 1675.70, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Medicare Part B Only", "plan_name": "100300", "standard_charge_dollar": 1675.70, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Medicare Railroad", "plan_name": "100103", "standard_charge_dollar": 1675.70, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Ms Physicians Care N", "plan_name": "714210", "standard_charge_dollar": 2094.63, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Peoples Hlth Ffs 72126", "plan_name": "500019", "standard_charge_dollar": 1675.70, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Uhc/Secure Horizons", "plan_name": "500449", "standard_charge_dollar": 1675.70, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "United Health Care/", "plan_name": "500292", "standard_charge_dollar": 1893.54, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "United Healthcare", "plan_name": "750104", "standard_charge_dollar": 1893.54, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "United Healthcare Ba", "plan_name": "750090", "standard_charge_dollar": 1893.54, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "United Healthcare Me", "plan_name": "501310", "standard_charge_dollar": 1675.70, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Windsor Mcare Extra", "plan_name": "500778", "standard_charge_dollar": 1675.70, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." } ] } ] }, { "description": "Hc skn sub grft face/nk/hf/g add", "code_information": [ { "code": "15276", "type": "CPT" } ], "standard_charges": [ { "gross_charge": 2881.00, "minimum": 2304.80, "maximum": 2448.85, "setting": "both", "payers_information": [ { "payer_name": "Aetna", "plan_name": "700700", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna", "plan_name": "700700_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Miscellaneous", "plan_name": "700720", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Miscellaneous", "plan_name": "700720_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Ppo Hmo", "plan_name": "701720", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Ppo Hmo", "plan_name": "701720_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Ms State Emplo", "plan_name": "401457", "standard_charge_percentage": 0.80, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Ms State Emplo", "plan_name": "401457_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Basic Pl", "plan_name": "400100", "standard_charge_percentage": 0.85, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Basic Pl", "plan_name": "400100_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Federal", "plan_name": "400110", "standard_charge_percentage": 0.85, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Federal", "plan_name": "400110_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." } ] } ] }, { "description": "Skin sub graft f/n/hf/g addl", "code_information": [ { "code": "15276", "type": "CPT" } ], "standard_charges": [ { "gross_charge": 2881.00, "minimum": 2304.80, "maximum": 2448.85, "setting": "both", "payers_information": [ { "payer_name": "Aetna", "plan_name": "700700", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna", "plan_name": "700700_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Miscellaneous", "plan_name": "700720", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Miscellaneous", "plan_name": "700720_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Ppo Hmo", "plan_name": "701720", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Ppo Hmo", "plan_name": "701720_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Ms State Emplo", "plan_name": "401457", "standard_charge_percentage": 0.80, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Ms State Emplo", "plan_name": "401457_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Basic Pl", "plan_name": "400100", "standard_charge_percentage": 0.85, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Basic Pl", "plan_name": "400100_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Federal", "plan_name": "400110", "standard_charge_percentage": 0.85, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Federal", "plan_name": "400110_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." } ] } ] }, { "description": "Hc application of skin substitute graft face scalp feet 1st 100 sq. cm or less (wound > 100 sq. cm)", "code_information": [ { "code": "15277", "type": "CPT" } ], "standard_charges": [ { "gross_charge": 2881.00, "minimum": 1675.70, "maximum": 2448.85, "setting": "both", "payers_information": [ { "payer_name": "Aarp", "plan_name": "500102", "standard_charge_dollar": 1675.70, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna", "plan_name": "700700", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna", "plan_name": "700700_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Mcare Ffs 6005", "plan_name": "700703", "standard_charge_dollar": 1675.70, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Miscellaneous", "plan_name": "700720", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Miscellaneous", "plan_name": "700720_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Ppo Hmo", "plan_name": "701720", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Ppo Hmo", "plan_name": "701720_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Ambetter 68069", "plan_name": "500516", "standard_charge_dollar": 1675.70, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Ms State Emplo", "plan_name": "401457", "standard_charge_percentage": 0.80, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Ms State Emplo", "plan_name": "401457_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Basic Pl", "plan_name": "400100", "standard_charge_percentage": 0.85, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Basic Pl", "plan_name": "400100_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Federal", "plan_name": "400110", "standard_charge_percentage": 0.85, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Federal", "plan_name": "400110_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Cigna Healthsprings Ffs", "plan_name": "500064", "standard_charge_dollar": 1675.70, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Conseco", "plan_name": "500302", "standard_charge_dollar": 1675.70, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Humana Ffs 61101", "plan_name": "500006", "standard_charge_dollar": 1675.70, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Medicare A", "plan_name": "100100", "standard_charge_dollar": 1675.70, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Medicare A", "plan_name": "100500", "standard_charge_dollar": 1675.70, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Medicare Part B Only", "plan_name": "100300", "standard_charge_dollar": 1675.70, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Medicare Railroad", "plan_name": "100103", "standard_charge_dollar": 1675.70, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Ms Physicians Care N", "plan_name": "714210", "standard_charge_dollar": 2094.63, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Peoples Hlth Ffs 72126", "plan_name": "500019", "standard_charge_dollar": 1675.70, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Uhc/Secure Horizons", "plan_name": "500449", "standard_charge_dollar": 1675.70, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "United Health Care/", "plan_name": "500292", "standard_charge_dollar": 1893.54, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "United Healthcare", "plan_name": "750104", "standard_charge_dollar": 1893.54, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "United Healthcare Ba", "plan_name": "750090", "standard_charge_dollar": 1893.54, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "United Healthcare Me", "plan_name": "501310", "standard_charge_dollar": 1675.70, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Windsor Mcare Extra", "plan_name": "500778", "standard_charge_dollar": 1675.70, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." } ] } ] }, { "description": "Skn sub grft f/n/hf/g child", "code_information": [ { "code": "15277", "type": "CPT" } ], "standard_charges": [ { "gross_charge": 2881.00, "minimum": 1675.70, "maximum": 2448.85, "setting": "both", "payers_information": [ { "payer_name": "Aarp", "plan_name": "500102", "standard_charge_dollar": 1675.70, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna", "plan_name": "700700", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna", "plan_name": "700700_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Mcare Ffs 6005", "plan_name": "700703", "standard_charge_dollar": 1675.70, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Miscellaneous", "plan_name": "700720", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Miscellaneous", "plan_name": "700720_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Ppo Hmo", "plan_name": "701720", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Ppo Hmo", "plan_name": "701720_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Ambetter 68069", "plan_name": "500516", "standard_charge_dollar": 1675.70, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Ms State Emplo", "plan_name": "401457", "standard_charge_percentage": 0.80, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Ms State Emplo", "plan_name": "401457_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Basic Pl", "plan_name": "400100", "standard_charge_percentage": 0.85, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Basic Pl", "plan_name": "400100_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Federal", "plan_name": "400110", "standard_charge_percentage": 0.85, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Federal", "plan_name": "400110_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Cigna Healthsprings Ffs", "plan_name": "500064", "standard_charge_dollar": 1675.70, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Conseco", "plan_name": "500302", "standard_charge_dollar": 1675.70, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Humana Ffs 61101", "plan_name": "500006", "standard_charge_dollar": 1675.70, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Medicare A", "plan_name": "100100", "standard_charge_dollar": 1675.70, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Medicare A", "plan_name": "100500", "standard_charge_dollar": 1675.70, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Medicare Part B Only", "plan_name": "100300", "standard_charge_dollar": 1675.70, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Medicare Railroad", "plan_name": "100103", "standard_charge_dollar": 1675.70, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Ms Physicians Care N", "plan_name": "714210", "standard_charge_dollar": 2094.63, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Peoples Hlth Ffs 72126", "plan_name": "500019", "standard_charge_dollar": 1675.70, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Uhc/Secure Horizons", "plan_name": "500449", "standard_charge_dollar": 1675.70, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "United Health Care/", "plan_name": "500292", "standard_charge_dollar": 1893.54, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "United Healthcare", "plan_name": "750104", "standard_charge_dollar": 1893.54, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "United Healthcare Ba", "plan_name": "750090", "standard_charge_dollar": 1893.54, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "United Healthcare Me", "plan_name": "501310", "standard_charge_dollar": 1675.70, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Windsor Mcare Extra", "plan_name": "500778", "standard_charge_dollar": 1675.70, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." } ] } ] }, { "description": "Hc application of skin substitute graft face scalp feet addtl 100 sq cm wound surface area", "code_information": [ { "code": "15278", "type": "CPT" } ], "standard_charges": [ { "gross_charge": 2881.00, "minimum": 2304.80, "maximum": 2448.85, "setting": "both", "payers_information": [ { "payer_name": "Aetna", "plan_name": "700700", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna", "plan_name": "700700_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Miscellaneous", "plan_name": "700720", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Miscellaneous", "plan_name": "700720_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Ppo Hmo", "plan_name": "701720", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Ppo Hmo", "plan_name": "701720_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Ms State Emplo", "plan_name": "401457", "standard_charge_percentage": 0.80, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Ms State Emplo", "plan_name": "401457_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Basic Pl", "plan_name": "400100", "standard_charge_percentage": 0.85, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Basic Pl", "plan_name": "400100_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Federal", "plan_name": "400110", "standard_charge_percentage": 0.85, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Federal", "plan_name": "400110_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." } ] } ] }, { "description": "Skn sub grft f/n/hf/g ch add", "code_information": [ { "code": "15278", "type": "CPT" } ], "standard_charges": [ { "gross_charge": 2881.00, "minimum": 2304.80, "maximum": 2448.85, "setting": "both", "payers_information": [ { "payer_name": "Aetna", "plan_name": "700700", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna", "plan_name": "700700_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Miscellaneous", "plan_name": "700720", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Miscellaneous", "plan_name": "700720_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Ppo Hmo", "plan_name": "701720", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Ppo Hmo", "plan_name": "701720_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Ms State Emplo", "plan_name": "401457", "standard_charge_percentage": 0.80, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Ms State Emplo", "plan_name": "401457_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Basic Pl", "plan_name": "400100", "standard_charge_percentage": 0.85, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Basic Pl", "plan_name": "400100_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Federal", "plan_name": "400110", "standard_charge_percentage": 0.85, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Federal", "plan_name": "400110_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." } ] } ] }, { "description": "Composite skin graft", "code_information": [ { "code": "15760", "type": "CPT" } ], "standard_charges": [ { "gross_charge": 21627.21, "minimum": 1675.70, "maximum": 18383.13, "setting": "inpatient", "payers_information": [ { "payer_name": "Aarp", "plan_name": "500102", "standard_charge_dollar": 1675.70, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna", "plan_name": "700700", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna", "plan_name": "700700_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Mcare Ffs 6005", "plan_name": "700703", "standard_charge_dollar": 1675.70, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Miscellaneous", "plan_name": "700720", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Miscellaneous", "plan_name": "700720_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Ppo Hmo", "plan_name": "701720", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Ppo Hmo", "plan_name": "701720_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Ambetter 68069", "plan_name": "500516", "standard_charge_dollar": 1675.70, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Ms State Emplo", "plan_name": "401457", "standard_charge_percentage": 0.80, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Ms State Emplo", "plan_name": "401457_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Basic Pl", "plan_name": "400100", "standard_charge_percentage": 0.85, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Basic Pl", "plan_name": "400100_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Federal", "plan_name": "400110", "standard_charge_percentage": 0.85, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Federal", "plan_name": "400110_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Cigna Healthsprings Ffs", "plan_name": "500064", "standard_charge_dollar": 1675.70, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Conseco", "plan_name": "500302", "standard_charge_dollar": 1675.70, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Humana Ffs 61101", "plan_name": "500006", "standard_charge_dollar": 1675.70, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Medicare A", "plan_name": "100100", "standard_charge_dollar": 1675.70, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Medicare A", "plan_name": "100500", "standard_charge_dollar": 1675.70, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Medicare Part B Only", "plan_name": "100300", "standard_charge_dollar": 1675.70, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Medicare Railroad", "plan_name": "100103", "standard_charge_dollar": 1675.70, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Ms Physicians Care N", "plan_name": "714210", "standard_charge_dollar": 2094.63, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Peoples Hlth Ffs 72126", "plan_name": "500019", "standard_charge_dollar": 1675.70, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Uhc/Secure Horizons", "plan_name": "500449", "standard_charge_dollar": 1675.70, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "United Health Care/", "plan_name": "500292", "standard_charge_dollar": 1893.54, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "United Healthcare", "plan_name": "750104", "standard_charge_dollar": 1893.54, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "United Healthcare Ba", "plan_name": "750090", "standard_charge_dollar": 1893.54, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "United Healthcare Me", "plan_name": "501310", "standard_charge_dollar": 1675.70, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Windsor Mcare Extra", "plan_name": "500778", "standard_charge_dollar": 1675.70, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." } ] } ] }, { "description": "Chemical peel nonfacial", "code_information": [ { "code": "15792", "type": "CPT" } ], "standard_charges": [ { "gross_charge": 1988.27, "minimum": 438.74, "maximum": 700.94, "setting": "inpatient", "payers_information": [ { "payer_name": "Aarp", "plan_name": "500102", "standard_charge_dollar": 560.75, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna", "plan_name": "700700", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna", "plan_name": "700700_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Mcare Ffs 6005", "plan_name": "700703", "standard_charge_dollar": 560.75, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Miscellaneous", "plan_name": "700720", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Miscellaneous", "plan_name": "700720_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Ppo Hmo", "plan_name": "701720", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Ppo Hmo", "plan_name": "701720_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Ambetter 68069", "plan_name": "500516", "standard_charge_dollar": 560.75, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Ms State Emplo", "plan_name": "401457", "standard_charge_dollar": 438.74, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Ms State Emplo", "plan_name": "401457_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Basic Pl", "plan_name": "400100", "standard_charge_dollar": 438.74, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Basic Pl", "plan_name": "400100_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Federal", "plan_name": "400110", "standard_charge_dollar": 438.74, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Federal", "plan_name": "400110_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Cigna Healthsprings Ffs", "plan_name": "500064", "standard_charge_dollar": 560.75, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Conseco", "plan_name": "500302", "standard_charge_dollar": 560.75, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Humana Ffs 61101", "plan_name": "500006", "standard_charge_dollar": 560.75, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Medicare A", "plan_name": "100100", "standard_charge_dollar": 560.75, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Medicare A", "plan_name": "100500", "standard_charge_dollar": 560.75, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Medicare Part B Only", "plan_name": "100300", "standard_charge_dollar": 560.75, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Medicare Railroad", "plan_name": "100103", "standard_charge_dollar": 560.75, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Ms Physicians Care N", "plan_name": "714210", "standard_charge_dollar": 700.94, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Peoples Hlth Ffs 72126", "plan_name": "500019", "standard_charge_dollar": 560.75, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Uhc/Secure Horizons", "plan_name": "500449", "standard_charge_dollar": 560.75, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "United Health Care/", "plan_name": "500292", "standard_charge_dollar": 633.65, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "United Healthcare", "plan_name": "750104", "standard_charge_dollar": 633.65, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "United Healthcare Ba", "plan_name": "750090", "standard_charge_dollar": 633.65, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "United Healthcare Me", "plan_name": "501310", "standard_charge_dollar": 560.75, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Windsor Mcare Extra", "plan_name": "500778", "standard_charge_dollar": 560.75, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." } ] } ] }, { "description": "Chemical peel nonfacial", "code_information": [ { "code": "15793", "type": "CPT" } ], "standard_charges": [ { "gross_charge": 1988.27, "minimum": 366.00, "maximum": 457.50, "setting": "inpatient", "payers_information": [ { "payer_name": "Aarp", "plan_name": "500102", "standard_charge_dollar": 366.00, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna", "plan_name": "700700", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna", "plan_name": "700700_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Mcare Ffs 6005", "plan_name": "700703", "standard_charge_dollar": 366.00, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Miscellaneous", "plan_name": "700720", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Miscellaneous", "plan_name": "700720_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Ppo Hmo", "plan_name": "701720", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Ppo Hmo", "plan_name": "701720_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Ambetter 68069", "plan_name": "500516", "standard_charge_dollar": 366.00, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Ms State Emplo", "plan_name": "401457", "standard_charge_dollar": 438.74, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Ms State Emplo", "plan_name": "401457_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Basic Pl", "plan_name": "400100", "standard_charge_dollar": 438.74, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Basic Pl", "plan_name": "400100_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Federal", "plan_name": "400110", "standard_charge_dollar": 438.74, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Federal", "plan_name": "400110_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Cigna Healthsprings Ffs", "plan_name": "500064", "standard_charge_dollar": 366.00, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Conseco", "plan_name": "500302", "standard_charge_dollar": 366.00, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Humana Ffs 61101", "plan_name": "500006", "standard_charge_dollar": 366.00, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Medicare A", "plan_name": "100100", "standard_charge_dollar": 366.00, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Medicare A", "plan_name": "100500", "standard_charge_dollar": 366.00, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Medicare Part B Only", "plan_name": "100300", "standard_charge_dollar": 366.00, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Medicare Railroad", "plan_name": "100103", "standard_charge_dollar": 366.00, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Ms Physicians Care N", "plan_name": "714210", "standard_charge_dollar": 457.50, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Peoples Hlth Ffs 72126", "plan_name": "500019", "standard_charge_dollar": 366.00, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Uhc/Secure Horizons", "plan_name": "500449", "standard_charge_dollar": 366.00, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "United Health Care/", "plan_name": "500292", "standard_charge_dollar": 413.58, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "United Healthcare", "plan_name": "750104", "standard_charge_dollar": 413.58, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "United Healthcare Ba", "plan_name": "750090", "standard_charge_dollar": 413.58, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "United Healthcare Me", "plan_name": "501310", "standard_charge_dollar": 366.00, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Windsor Mcare Extra", "plan_name": "500778", "standard_charge_dollar": 366.00, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." } ] } ] }, { "description": "Exc skin abd", "code_information": [ { "code": "15830", "type": "CPT" } ], "standard_charges": [ { "gross_charge": 32534.83, "minimum": 5974.11, "maximum": 27654.61, "setting": "inpatient", "payers_information": [ { "payer_name": "Aarp", "plan_name": "500102", "standard_charge_dollar": 5974.11, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna", "plan_name": "700700", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna", "plan_name": "700700_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Mcare Ffs 6005", "plan_name": "700703", "standard_charge_dollar": 5974.11, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Miscellaneous", "plan_name": "700720", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Miscellaneous", "plan_name": "700720_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Ppo Hmo", "plan_name": "701720", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Ppo Hmo", "plan_name": "701720_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Ambetter 68069", "plan_name": "500516", "standard_charge_dollar": 5974.11, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Ms State Emplo", "plan_name": "401457", "standard_charge_percentage": 0.80, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Ms State Emplo", "plan_name": "401457_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Basic Pl", "plan_name": "400100", "standard_charge_percentage": 0.85, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Basic Pl", "plan_name": "400100_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Federal", "plan_name": "400110", "standard_charge_percentage": 0.85, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Federal", "plan_name": "400110_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Cigna Healthsprings Ffs", "plan_name": "500064", "standard_charge_dollar": 5974.11, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Conseco", "plan_name": "500302", "standard_charge_dollar": 5974.11, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Humana Ffs 61101", "plan_name": "500006", "standard_charge_dollar": 5974.11, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Medicare A", "plan_name": "100100", "standard_charge_dollar": 5974.11, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Medicare A", "plan_name": "100500", "standard_charge_dollar": 5974.11, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Medicare Part B Only", "plan_name": "100300", "standard_charge_dollar": 5974.11, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Medicare Railroad", "plan_name": "100103", "standard_charge_dollar": 5974.11, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Ms Physicians Care N", "plan_name": "714210", "standard_charge_dollar": 7467.64, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Peoples Hlth Ffs 72126", "plan_name": "500019", "standard_charge_dollar": 5974.11, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Uhc/Secure Horizons", "plan_name": "500449", "standard_charge_dollar": 5974.11, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "United Health Care/", "plan_name": "500292", "standard_charge_dollar": 6750.74, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "United Healthcare", "plan_name": "750104", "standard_charge_dollar": 6750.74, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "United Healthcare Ba", "plan_name": "750090", "standard_charge_dollar": 6750.74, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "United Healthcare Me", "plan_name": "501310", "standard_charge_dollar": 5974.11, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Windsor Mcare Extra", "plan_name": "500778", "standard_charge_dollar": 5974.11, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." } ] } ] }, { "description": "Exc skin abd add-on", "code_information": [ { "code": "15847", "type": "CPT" } ], "standard_charges": [ { "gross_charge": 32534.83, "minimum": 26027.86, "maximum": 27654.61, "setting": "inpatient", "payers_information": [ { "payer_name": "Aetna", "plan_name": "700700", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna", "plan_name": "700700_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Miscellaneous", "plan_name": "700720", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Miscellaneous", "plan_name": "700720_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Ppo Hmo", "plan_name": "701720", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Ppo Hmo", "plan_name": "701720_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Ms State Emplo", "plan_name": "401457", "standard_charge_percentage": 0.80, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Ms State Emplo", "plan_name": "401457_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Basic Pl", "plan_name": "400100", "standard_charge_percentage": 0.85, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Basic Pl", "plan_name": "400100_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Federal", "plan_name": "400110", "standard_charge_percentage": 0.85, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Federal", "plan_name": "400110_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." } ] } ] }, { "description": "Remove sacrum pressure sore", "code_information": [ { "code": "15931", "type": "CPT" } ], "standard_charges": [ { "gross_charge": 37492.91, "minimum": 2621.84, "maximum": 31868.97, "setting": "inpatient", "payers_information": [ { "payer_name": "Aarp", "plan_name": "500102", "standard_charge_dollar": 2621.84, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna", "plan_name": "700700", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna", "plan_name": "700700_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Mcare Ffs 6005", "plan_name": "700703", "standard_charge_dollar": 2621.84, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Miscellaneous", "plan_name": "700720", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Miscellaneous", "plan_name": "700720_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Ppo Hmo", "plan_name": "701720", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Ppo Hmo", "plan_name": "701720_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Ambetter 68069", "plan_name": "500516", "standard_charge_dollar": 2621.84, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Ms State Emplo", "plan_name": "401457", "standard_charge_percentage": 0.80, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Ms State Emplo", "plan_name": "401457_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Basic Pl", "plan_name": "400100", "standard_charge_percentage": 0.85, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Basic Pl", "plan_name": "400100_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Federal", "plan_name": "400110", "standard_charge_percentage": 0.85, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Federal", "plan_name": "400110_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Cigna Healthsprings Ffs", "plan_name": "500064", "standard_charge_dollar": 2621.84, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Conseco", "plan_name": "500302", "standard_charge_dollar": 2621.84, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Humana Ffs 61101", "plan_name": "500006", "standard_charge_dollar": 2621.84, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Medicare A", "plan_name": "100100", "standard_charge_dollar": 2621.84, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Medicare A", "plan_name": "100500", "standard_charge_dollar": 2621.84, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Medicare Part B Only", "plan_name": "100300", "standard_charge_dollar": 2621.84, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Medicare Railroad", "plan_name": "100103", "standard_charge_dollar": 2621.84, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Ms Physicians Care N", "plan_name": "714210", "standard_charge_dollar": 3277.29, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Peoples Hlth Ffs 72126", "plan_name": "500019", "standard_charge_dollar": 2621.84, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Uhc/Secure Horizons", "plan_name": "500449", "standard_charge_dollar": 2621.84, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "United Health Care/", "plan_name": "500292", "standard_charge_dollar": 2962.67, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "United Healthcare", "plan_name": "750104", "standard_charge_dollar": 2962.67, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "United Healthcare Ba", "plan_name": "750090", "standard_charge_dollar": 2962.67, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "United Healthcare Me", "plan_name": "501310", "standard_charge_dollar": 2621.84, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Windsor Mcare Extra", "plan_name": "500778", "standard_charge_dollar": 2621.84, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." } ] } ] }, { "description": "Remove sacrum pressure sore", "code_information": [ { "code": "15933", "type": "CPT" } ], "standard_charges": [ { "gross_charge": 37492.91, "minimum": 2621.84, "maximum": 31868.97, "setting": "inpatient", "payers_information": [ { "payer_name": "Aarp", "plan_name": "500102", "standard_charge_dollar": 2621.84, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna", "plan_name": "700700", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna", "plan_name": "700700_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Mcare Ffs 6005", "plan_name": "700703", "standard_charge_dollar": 2621.84, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Miscellaneous", "plan_name": "700720", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Miscellaneous", "plan_name": "700720_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Ppo Hmo", "plan_name": "701720", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Ppo Hmo", "plan_name": "701720_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Ambetter 68069", "plan_name": "500516", "standard_charge_dollar": 2621.84, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Ms State Emplo", "plan_name": "401457", "standard_charge_percentage": 0.80, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Ms State Emplo", "plan_name": "401457_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Basic Pl", "plan_name": "400100", "standard_charge_percentage": 0.85, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Basic Pl", "plan_name": "400100_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Federal", "plan_name": "400110", "standard_charge_percentage": 0.85, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Federal", "plan_name": "400110_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Cigna Healthsprings Ffs", "plan_name": "500064", "standard_charge_dollar": 2621.84, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Conseco", "plan_name": "500302", "standard_charge_dollar": 2621.84, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Humana Ffs 61101", "plan_name": "500006", "standard_charge_dollar": 2621.84, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Medicare A", "plan_name": "100100", "standard_charge_dollar": 2621.84, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Medicare A", "plan_name": "100500", "standard_charge_dollar": 2621.84, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Medicare Part B Only", "plan_name": "100300", "standard_charge_dollar": 2621.84, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Medicare Railroad", "plan_name": "100103", "standard_charge_dollar": 2621.84, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Ms Physicians Care N", "plan_name": "714210", "standard_charge_dollar": 3277.29, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Peoples Hlth Ffs 72126", "plan_name": "500019", "standard_charge_dollar": 2621.84, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Uhc/Secure Horizons", "plan_name": "500449", "standard_charge_dollar": 2621.84, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "United Health Care/", "plan_name": "500292", "standard_charge_dollar": 2962.67, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "United Healthcare", "plan_name": "750104", "standard_charge_dollar": 2962.67, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "United Healthcare Ba", "plan_name": "750090", "standard_charge_dollar": 2962.67, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "United Healthcare Me", "plan_name": "501310", "standard_charge_dollar": 2621.84, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Windsor Mcare Extra", "plan_name": "500778", "standard_charge_dollar": 2621.84, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." } ] } ] }, { "description": "Remove sacrum pressure sore", "code_information": [ { "code": "15936", "type": "CPT" } ], "standard_charges": [ { "gross_charge": 37492.91, "minimum": 1675.70, "maximum": 31868.97, "setting": "inpatient", "payers_information": [ { "payer_name": "Aarp", "plan_name": "500102", "standard_charge_dollar": 1675.70, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna", "plan_name": "700700", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna", "plan_name": "700700_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Mcare Ffs 6005", "plan_name": "700703", "standard_charge_dollar": 1675.70, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Miscellaneous", "plan_name": "700720", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Miscellaneous", "plan_name": "700720_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Ppo Hmo", "plan_name": "701720", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Ppo Hmo", "plan_name": "701720_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Ambetter 68069", "plan_name": "500516", "standard_charge_dollar": 1675.70, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Ms State Emplo", "plan_name": "401457", "standard_charge_percentage": 0.80, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Ms State Emplo", "plan_name": "401457_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Basic Pl", "plan_name": "400100", "standard_charge_percentage": 0.85, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Basic Pl", "plan_name": "400100_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Federal", "plan_name": "400110", "standard_charge_percentage": 0.85, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Federal", "plan_name": "400110_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Cigna Healthsprings Ffs", "plan_name": "500064", "standard_charge_dollar": 1675.70, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Conseco", "plan_name": "500302", "standard_charge_dollar": 1675.70, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Humana Ffs 61101", "plan_name": "500006", "standard_charge_dollar": 1675.70, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Medicare A", "plan_name": "100100", "standard_charge_dollar": 1675.70, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Medicare A", "plan_name": "100500", "standard_charge_dollar": 1675.70, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Medicare Part B Only", "plan_name": "100300", "standard_charge_dollar": 1675.70, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Medicare Railroad", "plan_name": "100103", "standard_charge_dollar": 1675.70, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Ms Physicians Care N", "plan_name": "714210", "standard_charge_dollar": 2094.63, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Peoples Hlth Ffs 72126", "plan_name": "500019", "standard_charge_dollar": 1675.70, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Uhc/Secure Horizons", "plan_name": "500449", "standard_charge_dollar": 1675.70, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "United Health Care/", "plan_name": "500292", "standard_charge_dollar": 1893.54, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "United Healthcare", "plan_name": "750104", "standard_charge_dollar": 1893.54, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "United Healthcare Ba", "plan_name": "750090", "standard_charge_dollar": 1893.54, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "United Healthcare Me", "plan_name": "501310", "standard_charge_dollar": 1675.70, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Windsor Mcare Extra", "plan_name": "500778", "standard_charge_dollar": 1675.70, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." } ] } ] }, { "description": "Remove sacrum pressure sore", "code_information": [ { "code": "15937", "type": "CPT" } ], "standard_charges": [ { "gross_charge": 37492.91, "minimum": 1675.70, "maximum": 31868.97, "setting": "inpatient", "payers_information": [ { "payer_name": "Aarp", "plan_name": "500102", "standard_charge_dollar": 1675.70, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna", "plan_name": "700700", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna", "plan_name": "700700_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Mcare Ffs 6005", "plan_name": "700703", "standard_charge_dollar": 1675.70, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Miscellaneous", "plan_name": "700720", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Miscellaneous", "plan_name": "700720_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Ppo Hmo", "plan_name": "701720", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Ppo Hmo", "plan_name": "701720_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Ambetter 68069", "plan_name": "500516", "standard_charge_dollar": 1675.70, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Ms State Emplo", "plan_name": "401457", "standard_charge_percentage": 0.80, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Ms State Emplo", "plan_name": "401457_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Basic Pl", "plan_name": "400100", "standard_charge_percentage": 0.85, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Basic Pl", "plan_name": "400100_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Federal", "plan_name": "400110", "standard_charge_percentage": 0.85, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Federal", "plan_name": "400110_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Cigna Healthsprings Ffs", "plan_name": "500064", "standard_charge_dollar": 1675.70, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Conseco", "plan_name": "500302", "standard_charge_dollar": 1675.70, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Humana Ffs 61101", "plan_name": "500006", "standard_charge_dollar": 1675.70, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Medicare A", "plan_name": "100100", "standard_charge_dollar": 1675.70, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Medicare A", "plan_name": "100500", "standard_charge_dollar": 1675.70, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Medicare Part B Only", "plan_name": "100300", "standard_charge_dollar": 1675.70, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Medicare Railroad", "plan_name": "100103", "standard_charge_dollar": 1675.70, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Ms Physicians Care N", "plan_name": "714210", "standard_charge_dollar": 2094.63, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Peoples Hlth Ffs 72126", "plan_name": "500019", "standard_charge_dollar": 1675.70, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Uhc/Secure Horizons", "plan_name": "500449", "standard_charge_dollar": 1675.70, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "United Health Care/", "plan_name": "500292", "standard_charge_dollar": 1893.54, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "United Healthcare", "plan_name": "750104", "standard_charge_dollar": 1893.54, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "United Healthcare Ba", "plan_name": "750090", "standard_charge_dollar": 1893.54, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "United Healthcare Me", "plan_name": "501310", "standard_charge_dollar": 1675.70, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Windsor Mcare Extra", "plan_name": "500778", "standard_charge_dollar": 1675.70, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." } ] } ] }, { "description": "Remove hip pressure sore", "code_information": [ { "code": "15940", "type": "CPT" } ], "standard_charges": [ { "gross_charge": 39460.55, "minimum": 2621.84, "maximum": 33541.47, "setting": "inpatient", "payers_information": [ { "payer_name": "Aarp", "plan_name": "500102", "standard_charge_dollar": 2621.84, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna", "plan_name": "700700", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna", "plan_name": "700700_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Mcare Ffs 6005", "plan_name": "700703", "standard_charge_dollar": 2621.84, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Miscellaneous", "plan_name": "700720", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Miscellaneous", "plan_name": "700720_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Ppo Hmo", "plan_name": "701720", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Ppo Hmo", "plan_name": "701720_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Ambetter 68069", "plan_name": "500516", "standard_charge_dollar": 2621.84, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Ms State Emplo", "plan_name": "401457", "standard_charge_percentage": 0.80, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Ms State Emplo", "plan_name": "401457_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Basic Pl", "plan_name": "400100", "standard_charge_percentage": 0.85, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Basic Pl", "plan_name": "400100_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Federal", "plan_name": "400110", "standard_charge_percentage": 0.85, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Federal", "plan_name": "400110_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Cigna Healthsprings Ffs", "plan_name": "500064", "standard_charge_dollar": 2621.84, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Conseco", "plan_name": "500302", "standard_charge_dollar": 2621.84, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Humana Ffs 61101", "plan_name": "500006", "standard_charge_dollar": 2621.84, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Medicare A", "plan_name": "100100", "standard_charge_dollar": 2621.84, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Medicare A", "plan_name": "100500", "standard_charge_dollar": 2621.84, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Medicare Part B Only", "plan_name": "100300", "standard_charge_dollar": 2621.84, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Medicare Railroad", "plan_name": "100103", "standard_charge_dollar": 2621.84, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Ms Physicians Care N", "plan_name": "714210", "standard_charge_dollar": 3277.29, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Peoples Hlth Ffs 72126", "plan_name": "500019", "standard_charge_dollar": 2621.84, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Uhc/Secure Horizons", "plan_name": "500449", "standard_charge_dollar": 2621.84, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "United Health Care/", "plan_name": "500292", "standard_charge_dollar": 2962.67, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "United Healthcare", "plan_name": "750104", "standard_charge_dollar": 2962.67, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "United Healthcare Ba", "plan_name": "750090", "standard_charge_dollar": 2962.67, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "United Healthcare Me", "plan_name": "501310", "standard_charge_dollar": 2621.84, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Windsor Mcare Extra", "plan_name": "500778", "standard_charge_dollar": 2621.84, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." } ] } ] }, { "description": "Remove hip pressure sore", "code_information": [ { "code": "15941", "type": "CPT" } ], "standard_charges": [ { "gross_charge": 39460.55, "minimum": 2621.84, "maximum": 33541.47, "setting": "inpatient", "payers_information": [ { "payer_name": "Aarp", "plan_name": "500102", "standard_charge_dollar": 2621.84, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna", "plan_name": "700700", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna", "plan_name": "700700_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Mcare Ffs 6005", "plan_name": "700703", "standard_charge_dollar": 2621.84, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Miscellaneous", "plan_name": "700720", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Miscellaneous", "plan_name": "700720_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Ppo Hmo", "plan_name": "701720", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Ppo Hmo", "plan_name": "701720_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Ambetter 68069", "plan_name": "500516", "standard_charge_dollar": 2621.84, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Ms State Emplo", "plan_name": "401457", "standard_charge_percentage": 0.80, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Ms State Emplo", "plan_name": "401457_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Basic Pl", "plan_name": "400100", "standard_charge_percentage": 0.85, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Basic Pl", "plan_name": "400100_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Federal", "plan_name": "400110", "standard_charge_percentage": 0.85, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Federal", "plan_name": "400110_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Cigna Healthsprings Ffs", "plan_name": "500064", "standard_charge_dollar": 2621.84, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Conseco", "plan_name": "500302", "standard_charge_dollar": 2621.84, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Humana Ffs 61101", "plan_name": "500006", "standard_charge_dollar": 2621.84, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Medicare A", "plan_name": "100100", "standard_charge_dollar": 2621.84, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Medicare A", "plan_name": "100500", "standard_charge_dollar": 2621.84, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Medicare Part B Only", "plan_name": "100300", "standard_charge_dollar": 2621.84, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Medicare Railroad", "plan_name": "100103", "standard_charge_dollar": 2621.84, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Ms Physicians Care N", "plan_name": "714210", "standard_charge_dollar": 3277.29, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Peoples Hlth Ffs 72126", "plan_name": "500019", "standard_charge_dollar": 2621.84, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Uhc/Secure Horizons", "plan_name": "500449", "standard_charge_dollar": 2621.84, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "United Health Care/", "plan_name": "500292", "standard_charge_dollar": 2962.67, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "United Healthcare", "plan_name": "750104", "standard_charge_dollar": 2962.67, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "United Healthcare Ba", "plan_name": "750090", "standard_charge_dollar": 2962.67, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "United Healthcare Me", "plan_name": "501310", "standard_charge_dollar": 2621.84, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Windsor Mcare Extra", "plan_name": "500778", "standard_charge_dollar": 2621.84, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." } ] } ] }, { "description": "Remove hip pressure sore", "code_information": [ { "code": "15944", "type": "CPT" } ], "standard_charges": [ { "gross_charge": 39460.55, "minimum": 3353.70, "maximum": 33541.47, "setting": "inpatient", "payers_information": [ { "payer_name": "Aarp", "plan_name": "500102", "standard_charge_dollar": 3353.70, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna", "plan_name": "700700", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna", "plan_name": "700700_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Mcare Ffs 6005", "plan_name": "700703", "standard_charge_dollar": 3353.70, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Miscellaneous", "plan_name": "700720", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Miscellaneous", "plan_name": "700720_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Ppo Hmo", "plan_name": "701720", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Ppo Hmo", "plan_name": "701720_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Ambetter 68069", "plan_name": "500516", "standard_charge_dollar": 3353.70, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Ms State Emplo", "plan_name": "401457", "standard_charge_percentage": 0.80, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Ms State Emplo", "plan_name": "401457_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Basic Pl", "plan_name": "400100", "standard_charge_percentage": 0.85, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Basic Pl", "plan_name": "400100_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Federal", "plan_name": "400110", "standard_charge_percentage": 0.85, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Federal", "plan_name": "400110_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Cigna Healthsprings Ffs", "plan_name": "500064", "standard_charge_dollar": 3353.70, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Conseco", "plan_name": "500302", "standard_charge_dollar": 3353.70, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Humana Ffs 61101", "plan_name": "500006", "standard_charge_dollar": 3353.70, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Medicare A", "plan_name": "100100", "standard_charge_dollar": 3353.70, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Medicare A", "plan_name": "100500", "standard_charge_dollar": 3353.70, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Medicare Part B Only", "plan_name": "100300", "standard_charge_dollar": 3353.70, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Medicare Railroad", "plan_name": "100103", "standard_charge_dollar": 3353.70, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Ms Physicians Care N", "plan_name": "714210", "standard_charge_dollar": 4192.13, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Peoples Hlth Ffs 72126", "plan_name": "500019", "standard_charge_dollar": 3353.70, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Uhc/Secure Horizons", "plan_name": "500449", "standard_charge_dollar": 3353.70, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "United Health Care/", "plan_name": "500292", "standard_charge_dollar": 3789.68, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "United Healthcare", "plan_name": "750104", "standard_charge_dollar": 3789.68, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "United Healthcare Ba", "plan_name": "750090", "standard_charge_dollar": 3789.68, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "United Healthcare Me", "plan_name": "501310", "standard_charge_dollar": 3353.70, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Windsor Mcare Extra", "plan_name": "500778", "standard_charge_dollar": 3353.70, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." } ] } ] }, { "description": "Remove hip pressure sore", "code_information": [ { "code": "15945", "type": "CPT" } ], "standard_charges": [ { "gross_charge": 39460.55, "minimum": 1675.70, "maximum": 33541.47, "setting": "inpatient", "payers_information": [ { "payer_name": "Aarp", "plan_name": "500102", "standard_charge_dollar": 1675.70, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna", "plan_name": "700700", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna", "plan_name": "700700_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Mcare Ffs 6005", "plan_name": "700703", "standard_charge_dollar": 1675.70, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Miscellaneous", "plan_name": "700720", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Miscellaneous", "plan_name": "700720_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Ppo Hmo", "plan_name": "701720", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Ppo Hmo", "plan_name": "701720_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Ambetter 68069", "plan_name": "500516", "standard_charge_dollar": 1675.70, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Ms State Emplo", "plan_name": "401457", "standard_charge_percentage": 0.80, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Ms State Emplo", "plan_name": "401457_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Basic Pl", "plan_name": "400100", "standard_charge_percentage": 0.85, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Basic Pl", "plan_name": "400100_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Federal", "plan_name": "400110", "standard_charge_percentage": 0.85, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Federal", "plan_name": "400110_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Cigna Healthsprings Ffs", "plan_name": "500064", "standard_charge_dollar": 1675.70, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Conseco", "plan_name": "500302", "standard_charge_dollar": 1675.70, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Humana Ffs 61101", "plan_name": "500006", "standard_charge_dollar": 1675.70, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Medicare A", "plan_name": "100100", "standard_charge_dollar": 1675.70, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Medicare A", "plan_name": "100500", "standard_charge_dollar": 1675.70, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Medicare Part B Only", "plan_name": "100300", "standard_charge_dollar": 1675.70, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Medicare Railroad", "plan_name": "100103", "standard_charge_dollar": 1675.70, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Ms Physicians Care N", "plan_name": "714210", "standard_charge_dollar": 2094.63, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Peoples Hlth Ffs 72126", "plan_name": "500019", "standard_charge_dollar": 1675.70, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Uhc/Secure Horizons", "plan_name": "500449", "standard_charge_dollar": 1675.70, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "United Health Care/", "plan_name": "500292", "standard_charge_dollar": 1893.54, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "United Healthcare", "plan_name": "750104", "standard_charge_dollar": 1893.54, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "United Healthcare Ba", "plan_name": "750090", "standard_charge_dollar": 1893.54, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "United Healthcare Me", "plan_name": "501310", "standard_charge_dollar": 1675.70, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Windsor Mcare Extra", "plan_name": "500778", "standard_charge_dollar": 1675.70, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." } ] } ] }, { "description": "Remove hip pressure sore", "code_information": [ { "code": "15946", "type": "CPT" } ], "standard_charges": [ { "gross_charge": 39460.55, "minimum": 1675.70, "maximum": 33541.47, "setting": "inpatient", "payers_information": [ { "payer_name": "Aarp", "plan_name": "500102", "standard_charge_dollar": 1675.70, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna", "plan_name": "700700", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna", "plan_name": "700700_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Mcare Ffs 6005", "plan_name": "700703", "standard_charge_dollar": 1675.70, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Miscellaneous", "plan_name": "700720", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Miscellaneous", "plan_name": "700720_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Ppo Hmo", "plan_name": "701720", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Ppo Hmo", "plan_name": "701720_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Ambetter 68069", "plan_name": "500516", "standard_charge_dollar": 1675.70, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Ms State Emplo", "plan_name": "401457", "standard_charge_percentage": 0.80, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Ms State Emplo", "plan_name": "401457_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Basic Pl", "plan_name": "400100", "standard_charge_percentage": 0.85, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Basic Pl", "plan_name": "400100_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Federal", "plan_name": "400110", "standard_charge_percentage": 0.85, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Federal", "plan_name": "400110_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Cigna Healthsprings Ffs", "plan_name": "500064", "standard_charge_dollar": 1675.70, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Conseco", "plan_name": "500302", "standard_charge_dollar": 1675.70, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Humana Ffs 61101", "plan_name": "500006", "standard_charge_dollar": 1675.70, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Medicare A", "plan_name": "100100", "standard_charge_dollar": 1675.70, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Medicare A", "plan_name": "100500", "standard_charge_dollar": 1675.70, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Medicare Part B Only", "plan_name": "100300", "standard_charge_dollar": 1675.70, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Medicare Railroad", "plan_name": "100103", "standard_charge_dollar": 1675.70, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Ms Physicians Care N", "plan_name": "714210", "standard_charge_dollar": 2094.63, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Peoples Hlth Ffs 72126", "plan_name": "500019", "standard_charge_dollar": 1675.70, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Uhc/Secure Horizons", "plan_name": "500449", "standard_charge_dollar": 1675.70, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "United Health Care/", "plan_name": "500292", "standard_charge_dollar": 1893.54, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "United Healthcare", "plan_name": "750104", "standard_charge_dollar": 1893.54, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "United Healthcare Ba", "plan_name": "750090", "standard_charge_dollar": 1893.54, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "United Healthcare Me", "plan_name": "501310", "standard_charge_dollar": 1675.70, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Windsor Mcare Extra", "plan_name": "500778", "standard_charge_dollar": 1675.70, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." } ] } ] }, { "description": "Remove thigh pressure sore", "code_information": [ { "code": "15950", "type": "CPT" } ], "standard_charges": [ { "gross_charge": 36886.03, "minimum": 1484.25, "maximum": 31353.13, "setting": "inpatient", "payers_information": [ { "payer_name": "Aarp", "plan_name": "500102", "standard_charge_dollar": 1484.25, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna", "plan_name": "700700", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna", "plan_name": "700700_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Mcare Ffs 6005", "plan_name": "700703", "standard_charge_dollar": 1484.25, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Miscellaneous", "plan_name": "700720", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Miscellaneous", "plan_name": "700720_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Ppo Hmo", "plan_name": "701720", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Ppo Hmo", "plan_name": "701720_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Ambetter 68069", "plan_name": "500516", "standard_charge_dollar": 1484.25, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Ms State Emplo", "plan_name": "401457", "standard_charge_percentage": 0.80, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Ms State Emplo", "plan_name": "401457_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Basic Pl", "plan_name": "400100", "standard_charge_percentage": 0.85, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Basic Pl", "plan_name": "400100_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Federal", "plan_name": "400110", "standard_charge_percentage": 0.85, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Federal", "plan_name": "400110_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Cigna Healthsprings Ffs", "plan_name": "500064", "standard_charge_dollar": 1484.25, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Conseco", "plan_name": "500302", "standard_charge_dollar": 1484.25, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Humana Ffs 61101", "plan_name": "500006", "standard_charge_dollar": 1484.25, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Medicare A", "plan_name": "100100", "standard_charge_dollar": 1484.25, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Medicare A", "plan_name": "100500", "standard_charge_dollar": 1484.25, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Medicare Part B Only", "plan_name": "100300", "standard_charge_dollar": 1484.25, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Medicare Railroad", "plan_name": "100103", "standard_charge_dollar": 1484.25, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Ms Physicians Care N", "plan_name": "714210", "standard_charge_dollar": 1855.31, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Peoples Hlth Ffs 72126", "plan_name": "500019", "standard_charge_dollar": 1484.25, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Uhc/Secure Horizons", "plan_name": "500449", "standard_charge_dollar": 1484.25, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "United Health Care/", "plan_name": "500292", "standard_charge_dollar": 1677.20, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "United Healthcare", "plan_name": "750104", "standard_charge_dollar": 1677.20, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "United Healthcare Ba", "plan_name": "750090", "standard_charge_dollar": 1677.20, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "United Healthcare Me", "plan_name": "501310", "standard_charge_dollar": 1484.25, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Windsor Mcare Extra", "plan_name": "500778", "standard_charge_dollar": 1484.25, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." } ] } ] }, { "description": "Remove thigh pressure sore", "code_information": [ { "code": "15951", "type": "CPT" } ], "standard_charges": [ { "gross_charge": 36886.03, "minimum": 2621.84, "maximum": 31353.13, "setting": "inpatient", "payers_information": [ { "payer_name": "Aarp", "plan_name": "500102", "standard_charge_dollar": 2621.84, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna", "plan_name": "700700", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna", "plan_name": "700700_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Mcare Ffs 6005", "plan_name": "700703", "standard_charge_dollar": 2621.84, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Miscellaneous", "plan_name": "700720", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Miscellaneous", "plan_name": "700720_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Ppo Hmo", "plan_name": "701720", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Ppo Hmo", "plan_name": "701720_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Ambetter 68069", "plan_name": "500516", "standard_charge_dollar": 2621.84, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Ms State Emplo", "plan_name": "401457", "standard_charge_percentage": 0.80, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Ms State Emplo", "plan_name": "401457_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Basic Pl", "plan_name": "400100", "standard_charge_percentage": 0.85, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Basic Pl", "plan_name": "400100_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Federal", "plan_name": "400110", "standard_charge_percentage": 0.85, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Federal", "plan_name": "400110_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Cigna Healthsprings Ffs", "plan_name": "500064", "standard_charge_dollar": 2621.84, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Conseco", "plan_name": "500302", "standard_charge_dollar": 2621.84, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Humana Ffs 61101", "plan_name": "500006", "standard_charge_dollar": 2621.84, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Medicare A", "plan_name": "100100", "standard_charge_dollar": 2621.84, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Medicare A", "plan_name": "100500", "standard_charge_dollar": 2621.84, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Medicare Part B Only", "plan_name": "100300", "standard_charge_dollar": 2621.84, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Medicare Railroad", "plan_name": "100103", "standard_charge_dollar": 2621.84, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Ms Physicians Care N", "plan_name": "714210", "standard_charge_dollar": 3277.29, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Peoples Hlth Ffs 72126", "plan_name": "500019", "standard_charge_dollar": 2621.84, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Uhc/Secure Horizons", "plan_name": "500449", "standard_charge_dollar": 2621.84, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "United Health Care/", "plan_name": "500292", "standard_charge_dollar": 2962.67, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "United Healthcare", "plan_name": "750104", "standard_charge_dollar": 2962.67, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "United Healthcare Ba", "plan_name": "750090", "standard_charge_dollar": 2962.67, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "United Healthcare Me", "plan_name": "501310", "standard_charge_dollar": 2621.84, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Windsor Mcare Extra", "plan_name": "500778", "standard_charge_dollar": 2621.84, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." } ] } ] }, { "description": "Remove thigh pressure sore", "code_information": [ { "code": "15952", "type": "CPT" } ], "standard_charges": [ { "gross_charge": 36886.03, "minimum": 1675.70, "maximum": 31353.13, "setting": "inpatient", "payers_information": [ { "payer_name": "Aarp", "plan_name": "500102", "standard_charge_dollar": 1675.70, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna", "plan_name": "700700", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna", "plan_name": "700700_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Mcare Ffs 6005", "plan_name": "700703", "standard_charge_dollar": 1675.70, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Miscellaneous", "plan_name": "700720", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Miscellaneous", "plan_name": "700720_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Ppo Hmo", "plan_name": "701720", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Ppo Hmo", "plan_name": "701720_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Ambetter 68069", "plan_name": "500516", "standard_charge_dollar": 1675.70, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Ms State Emplo", "plan_name": "401457", "standard_charge_percentage": 0.80, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Ms State Emplo", "plan_name": "401457_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Basic Pl", "plan_name": "400100", "standard_charge_percentage": 0.85, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Basic Pl", "plan_name": "400100_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Federal", "plan_name": "400110", "standard_charge_percentage": 0.85, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Federal", "plan_name": "400110_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Cigna Healthsprings Ffs", "plan_name": "500064", "standard_charge_dollar": 1675.70, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Conseco", "plan_name": "500302", "standard_charge_dollar": 1675.70, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Humana Ffs 61101", "plan_name": "500006", "standard_charge_dollar": 1675.70, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Medicare A", "plan_name": "100100", "standard_charge_dollar": 1675.70, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Medicare A", "plan_name": "100500", "standard_charge_dollar": 1675.70, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Medicare Part B Only", "plan_name": "100300", "standard_charge_dollar": 1675.70, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Medicare Railroad", "plan_name": "100103", "standard_charge_dollar": 1675.70, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Ms Physicians Care N", "plan_name": "714210", "standard_charge_dollar": 2094.63, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Peoples Hlth Ffs 72126", "plan_name": "500019", "standard_charge_dollar": 1675.70, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Uhc/Secure Horizons", "plan_name": "500449", "standard_charge_dollar": 1675.70, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "United Health Care/", "plan_name": "500292", "standard_charge_dollar": 1893.54, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "United Healthcare", "plan_name": "750104", "standard_charge_dollar": 1893.54, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "United Healthcare Ba", "plan_name": "750090", "standard_charge_dollar": 1893.54, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "United Healthcare Me", "plan_name": "501310", "standard_charge_dollar": 1675.70, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Windsor Mcare Extra", "plan_name": "500778", "standard_charge_dollar": 1675.70, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." } ] } ] }, { "description": "Remove thigh pressure sore", "code_information": [ { "code": "15953", "type": "CPT" } ], "standard_charges": [ { "gross_charge": 36886.03, "minimum": 3353.70, "maximum": 31353.13, "setting": "inpatient", "payers_information": [ { "payer_name": "Aarp", "plan_name": "500102", "standard_charge_dollar": 3353.70, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna", "plan_name": "700700", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna", "plan_name": "700700_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Mcare Ffs 6005", "plan_name": "700703", "standard_charge_dollar": 3353.70, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Miscellaneous", "plan_name": "700720", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Miscellaneous", "plan_name": "700720_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Ppo Hmo", "plan_name": "701720", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Ppo Hmo", "plan_name": "701720_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Ambetter 68069", "plan_name": "500516", "standard_charge_dollar": 3353.70, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Ms State Emplo", "plan_name": "401457", "standard_charge_percentage": 0.80, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Ms State Emplo", "plan_name": "401457_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Basic Pl", "plan_name": "400100", "standard_charge_percentage": 0.85, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Basic Pl", "plan_name": "400100_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Federal", "plan_name": "400110", "standard_charge_percentage": 0.85, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Federal", "plan_name": "400110_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Cigna Healthsprings Ffs", "plan_name": "500064", "standard_charge_dollar": 3353.70, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Conseco", "plan_name": "500302", "standard_charge_dollar": 3353.70, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Humana Ffs 61101", "plan_name": "500006", "standard_charge_dollar": 3353.70, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Medicare A", "plan_name": "100100", "standard_charge_dollar": 3353.70, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Medicare A", "plan_name": "100500", "standard_charge_dollar": 3353.70, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Medicare Part B Only", "plan_name": "100300", "standard_charge_dollar": 3353.70, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Medicare Railroad", "plan_name": "100103", "standard_charge_dollar": 3353.70, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Ms Physicians Care N", "plan_name": "714210", "standard_charge_dollar": 4192.13, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Peoples Hlth Ffs 72126", "plan_name": "500019", "standard_charge_dollar": 3353.70, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Uhc/Secure Horizons", "plan_name": "500449", "standard_charge_dollar": 3353.70, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "United Health Care/", "plan_name": "500292", "standard_charge_dollar": 3789.68, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "United Healthcare", "plan_name": "750104", "standard_charge_dollar": 3789.68, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "United Healthcare Ba", "plan_name": "750090", "standard_charge_dollar": 3789.68, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "United Healthcare Me", "plan_name": "501310", "standard_charge_dollar": 3353.70, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Windsor Mcare Extra", "plan_name": "500778", "standard_charge_dollar": 3353.70, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." } ] } ] }, { "description": "Remove thigh pressure sore", "code_information": [ { "code": "15956", "type": "CPT" } ], "standard_charges": [ { "gross_charge": 36886.03, "minimum": 1675.70, "maximum": 31353.13, "setting": "inpatient", "payers_information": [ { "payer_name": "Aarp", "plan_name": "500102", "standard_charge_dollar": 1675.70, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna", "plan_name": "700700", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna", "plan_name": "700700_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Mcare Ffs 6005", "plan_name": "700703", "standard_charge_dollar": 1675.70, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Miscellaneous", "plan_name": "700720", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Miscellaneous", "plan_name": "700720_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Ppo Hmo", "plan_name": "701720", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Ppo Hmo", "plan_name": "701720_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Ambetter 68069", "plan_name": "500516", "standard_charge_dollar": 1675.70, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Ms State Emplo", "plan_name": "401457", "standard_charge_percentage": 0.80, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Ms State Emplo", "plan_name": "401457_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Basic Pl", "plan_name": "400100", "standard_charge_percentage": 0.85, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Basic Pl", "plan_name": "400100_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Federal", "plan_name": "400110", "standard_charge_percentage": 0.85, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Federal", "plan_name": "400110_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Cigna Healthsprings Ffs", "plan_name": "500064", "standard_charge_dollar": 1675.70, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Conseco", "plan_name": "500302", "standard_charge_dollar": 1675.70, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Humana Ffs 61101", "plan_name": "500006", "standard_charge_dollar": 1675.70, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Medicare A", "plan_name": "100100", "standard_charge_dollar": 1675.70, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Medicare A", "plan_name": "100500", "standard_charge_dollar": 1675.70, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Medicare Part B Only", "plan_name": "100300", "standard_charge_dollar": 1675.70, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Medicare Railroad", "plan_name": "100103", "standard_charge_dollar": 1675.70, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Ms Physicians Care N", "plan_name": "714210", "standard_charge_dollar": 2094.63, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Peoples Hlth Ffs 72126", "plan_name": "500019", "standard_charge_dollar": 1675.70, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Uhc/Secure Horizons", "plan_name": "500449", "standard_charge_dollar": 1675.70, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "United Health Care/", "plan_name": "500292", "standard_charge_dollar": 1893.54, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "United Healthcare", "plan_name": "750104", "standard_charge_dollar": 1893.54, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "United Healthcare Ba", "plan_name": "750090", "standard_charge_dollar": 1893.54, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "United Healthcare Me", "plan_name": "501310", "standard_charge_dollar": 1675.70, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Windsor Mcare Extra", "plan_name": "500778", "standard_charge_dollar": 1675.70, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." } ] } ] }, { "description": "Remove thigh pressure sore", "code_information": [ { "code": "15958", "type": "CPT" } ], "standard_charges": [ { "gross_charge": 36886.03, "minimum": 3353.70, "maximum": 31353.13, "setting": "inpatient", "payers_information": [ { "payer_name": "Aarp", "plan_name": "500102", "standard_charge_dollar": 3353.70, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna", "plan_name": "700700", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna", "plan_name": "700700_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Mcare Ffs 6005", "plan_name": "700703", "standard_charge_dollar": 3353.70, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Miscellaneous", "plan_name": "700720", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Miscellaneous", "plan_name": "700720_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Ppo Hmo", "plan_name": "701720", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Ppo Hmo", "plan_name": "701720_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Ambetter 68069", "plan_name": "500516", "standard_charge_dollar": 3353.70, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Ms State Emplo", "plan_name": "401457", "standard_charge_percentage": 0.80, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Ms State Emplo", "plan_name": "401457_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Basic Pl", "plan_name": "400100", "standard_charge_percentage": 0.85, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Basic Pl", "plan_name": "400100_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Federal", "plan_name": "400110", "standard_charge_percentage": 0.85, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Federal", "plan_name": "400110_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Cigna Healthsprings Ffs", "plan_name": "500064", "standard_charge_dollar": 3353.70, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Conseco", "plan_name": "500302", "standard_charge_dollar": 3353.70, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Humana Ffs 61101", "plan_name": "500006", "standard_charge_dollar": 3353.70, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Medicare A", "plan_name": "100100", "standard_charge_dollar": 3353.70, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Medicare A", "plan_name": "100500", "standard_charge_dollar": 3353.70, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Medicare Part B Only", "plan_name": "100300", "standard_charge_dollar": 3353.70, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Medicare Railroad", "plan_name": "100103", "standard_charge_dollar": 3353.70, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Ms Physicians Care N", "plan_name": "714210", "standard_charge_dollar": 4192.13, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Peoples Hlth Ffs 72126", "plan_name": "500019", "standard_charge_dollar": 3353.70, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Uhc/Secure Horizons", "plan_name": "500449", "standard_charge_dollar": 3353.70, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "United Health Care/", "plan_name": "500292", "standard_charge_dollar": 3789.68, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "United Healthcare", "plan_name": "750104", "standard_charge_dollar": 3789.68, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "United Healthcare Ba", "plan_name": "750090", "standard_charge_dollar": 3789.68, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "United Healthcare Me", "plan_name": "501310", "standard_charge_dollar": 3353.70, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Windsor Mcare Extra", "plan_name": "500778", "standard_charge_dollar": 3353.70, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." } ] } ] }, { "description": "Removal of pressure sore", "code_information": [ { "code": "15999", "type": "CPT" } ], "standard_charges": [ { "gross_charge": 35987.55, "minimum": 644.54, "maximum": 30589.42, "setting": "inpatient", "payers_information": [ { "payer_name": "Aarp", "plan_name": "500102", "standard_charge_dollar": 644.54, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna", "plan_name": "700700", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna", "plan_name": "700700_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Mcare Ffs 6005", "plan_name": "700703", "standard_charge_dollar": 644.54, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Miscellaneous", "plan_name": "700720", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Miscellaneous", "plan_name": "700720_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Ppo Hmo", "plan_name": "701720", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Ppo Hmo", "plan_name": "701720_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Ambetter 68069", "plan_name": "500516", "standard_charge_dollar": 644.54, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Ms State Emplo", "plan_name": "401457", "standard_charge_percentage": 0.80, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Ms State Emplo", "plan_name": "401457_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Basic Pl", "plan_name": "400100", "standard_charge_percentage": 0.85, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Basic Pl", "plan_name": "400100_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Federal", "plan_name": "400110", "standard_charge_percentage": 0.85, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Federal", "plan_name": "400110_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Cigna Healthsprings Ffs", "plan_name": "500064", "standard_charge_dollar": 644.54, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Conseco", "plan_name": "500302", "standard_charge_dollar": 644.54, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Humana Ffs 61101", "plan_name": "500006", "standard_charge_dollar": 644.54, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Medicare A", "plan_name": "100100", "standard_charge_dollar": 644.54, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Medicare A", "plan_name": "100500", "standard_charge_dollar": 644.54, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Medicare Part B Only", "plan_name": "100300", "standard_charge_dollar": 644.54, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Medicare Railroad", "plan_name": "100103", "standard_charge_dollar": 644.54, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Ms Physicians Care N", "plan_name": "714210", "standard_charge_dollar": 805.67, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Peoples Hlth Ffs 72126", "plan_name": "500019", "standard_charge_dollar": 644.54, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Uhc/Secure Horizons", "plan_name": "500449", "standard_charge_dollar": 644.54, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "United Health Care/", "plan_name": "500292", "standard_charge_dollar": 728.33, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "United Healthcare", "plan_name": "750104", "standard_charge_dollar": 728.33, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "United Healthcare Ba", "plan_name": "750090", "standard_charge_dollar": 728.33, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "United Healthcare Me", "plan_name": "501310", "standard_charge_dollar": 644.54, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Windsor Mcare Extra", "plan_name": "500778", "standard_charge_dollar": 644.54, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." } ] } ] }, { "description": "Hc initial treatment of burn", "code_information": [ { "code": "16000", "type": "CPT" } ], "standard_charges": [ { "gross_charge": 289.00, "minimum": 182.02, "maximum": 229.58, "setting": "both", "payers_information": [ { "payer_name": "Aarp", "plan_name": "500102", "standard_charge_dollar": 182.02, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna", "plan_name": "700700", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna", "plan_name": "700700_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Mcare Ffs 6005", "plan_name": "700703", "standard_charge_dollar": 182.02, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Miscellaneous", "plan_name": "700720", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Miscellaneous", "plan_name": "700720_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Ppo Hmo", "plan_name": "701720", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Ppo Hmo", "plan_name": "701720_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Ambetter 68069", "plan_name": "500516", "standard_charge_dollar": 182.02, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Ms State Emplo", "plan_name": "401457", "standard_charge_dollar": 229.58, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Ms State Emplo", "plan_name": "401457_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Basic Pl", "plan_name": "400100", "standard_charge_dollar": 229.58, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Basic Pl", "plan_name": "400100_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Federal", "plan_name": "400110", "standard_charge_dollar": 229.58, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Federal", "plan_name": "400110_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Cigna Healthsprings Ffs", "plan_name": "500064", "standard_charge_dollar": 182.02, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Conseco", "plan_name": "500302", "standard_charge_dollar": 182.02, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Humana Ffs 61101", "plan_name": "500006", "standard_charge_dollar": 182.02, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Medicare A", "plan_name": "100100", "standard_charge_dollar": 182.02, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Medicare A", "plan_name": "100500", "standard_charge_dollar": 182.02, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Medicare Part B Only", "plan_name": "100300", "standard_charge_dollar": 182.02, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Medicare Railroad", "plan_name": "100103", "standard_charge_dollar": 182.02, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Ms Physicians Care N", "plan_name": "714210", "standard_charge_dollar": 227.53, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Peoples Hlth Ffs 72126", "plan_name": "500019", "standard_charge_dollar": 182.02, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Uhc/Secure Horizons", "plan_name": "500449", "standard_charge_dollar": 182.02, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "United Health Care/", "plan_name": "500292", "standard_charge_dollar": 205.69, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "United Healthcare", "plan_name": "750104", "standard_charge_dollar": 205.69, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "United Healthcare Ba", "plan_name": "750090", "standard_charge_dollar": 205.69, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "United Healthcare Me", "plan_name": "501310", "standard_charge_dollar": 182.02, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Windsor Mcare Extra", "plan_name": "500778", "standard_charge_dollar": 182.02, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." } ] } ] }, { "description": "Initial treatment of burn(s)", "code_information": [ { "code": "16000", "type": "CPT" } ], "standard_charges": [ { "gross_charge": 289.00, "minimum": 182.02, "maximum": 229.58, "setting": "both", "payers_information": [ { "payer_name": "Aarp", "plan_name": "500102", "standard_charge_dollar": 182.02, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna", "plan_name": "700700", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna", "plan_name": "700700_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Mcare Ffs 6005", "plan_name": "700703", "standard_charge_dollar": 182.02, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Miscellaneous", "plan_name": "700720", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Miscellaneous", "plan_name": "700720_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Ppo Hmo", "plan_name": "701720", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Ppo Hmo", "plan_name": "701720_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Ambetter 68069", "plan_name": "500516", "standard_charge_dollar": 182.02, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Ms State Emplo", "plan_name": "401457", "standard_charge_dollar": 229.58, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Ms State Emplo", "plan_name": "401457_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Basic Pl", "plan_name": "400100", "standard_charge_dollar": 229.58, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Basic Pl", "plan_name": "400100_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Federal", "plan_name": "400110", "standard_charge_dollar": 229.58, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Federal", "plan_name": "400110_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Cigna Healthsprings Ffs", "plan_name": "500064", "standard_charge_dollar": 182.02, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Conseco", "plan_name": "500302", "standard_charge_dollar": 182.02, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Humana Ffs 61101", "plan_name": "500006", "standard_charge_dollar": 182.02, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Medicare A", "plan_name": "100100", "standard_charge_dollar": 182.02, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Medicare A", "plan_name": "100500", "standard_charge_dollar": 182.02, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Medicare Part B Only", "plan_name": "100300", "standard_charge_dollar": 182.02, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Medicare Railroad", "plan_name": "100103", "standard_charge_dollar": 182.02, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Ms Physicians Care N", "plan_name": "714210", "standard_charge_dollar": 227.53, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Peoples Hlth Ffs 72126", "plan_name": "500019", "standard_charge_dollar": 182.02, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Uhc/Secure Horizons", "plan_name": "500449", "standard_charge_dollar": 182.02, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "United Health Care/", "plan_name": "500292", "standard_charge_dollar": 205.69, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "United Healthcare", "plan_name": "750104", "standard_charge_dollar": 205.69, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "United Healthcare Ba", "plan_name": "750090", "standard_charge_dollar": 205.69, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "United Healthcare Me", "plan_name": "501310", "standard_charge_dollar": 182.02, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Windsor Mcare Extra", "plan_name": "500778", "standard_charge_dollar": 182.02, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." } ] } ] }, { "description": "Dress/debrid p-thick burn s", "code_information": [ { "code": "16020", "type": "CPT" } ], "standard_charges": [ { "gross_charge": 26535.50, "minimum": 182.02, "maximum": 229.58, "setting": "inpatient", "payers_information": [ { "payer_name": "Aarp", "plan_name": "500102", "standard_charge_dollar": 182.02, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna", "plan_name": "700700", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna", "plan_name": "700700_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Mcare Ffs 6005", "plan_name": "700703", "standard_charge_dollar": 182.02, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Miscellaneous", "plan_name": "700720", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Miscellaneous", "plan_name": "700720_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Ppo Hmo", "plan_name": "701720", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Ppo Hmo", "plan_name": "701720_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Ambetter 68069", "plan_name": "500516", "standard_charge_dollar": 182.02, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Ms State Emplo", "plan_name": "401457", "standard_charge_dollar": 229.58, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Ms State Emplo", "plan_name": "401457_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Basic Pl", "plan_name": "400100", "standard_charge_dollar": 229.58, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Basic Pl", "plan_name": "400100_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Federal", "plan_name": "400110", "standard_charge_dollar": 229.58, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Federal", "plan_name": "400110_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Cigna Healthsprings Ffs", "plan_name": "500064", "standard_charge_dollar": 182.02, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Conseco", "plan_name": "500302", "standard_charge_dollar": 182.02, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Humana Ffs 61101", "plan_name": "500006", "standard_charge_dollar": 182.02, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Medicare A", "plan_name": "100100", "standard_charge_dollar": 182.02, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Medicare A", "plan_name": "100500", "standard_charge_dollar": 182.02, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Medicare Part B Only", "plan_name": "100300", "standard_charge_dollar": 182.02, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Medicare Railroad", "plan_name": "100103", "standard_charge_dollar": 182.02, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Ms Physicians Care N", "plan_name": "714210", "standard_charge_dollar": 227.53, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Peoples Hlth Ffs 72126", "plan_name": "500019", "standard_charge_dollar": 182.02, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Uhc/Secure Horizons", "plan_name": "500449", "standard_charge_dollar": 182.02, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "United Health Care/", "plan_name": "500292", "standard_charge_dollar": 205.69, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "United Healthcare", "plan_name": "750104", "standard_charge_dollar": 205.69, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "United Healthcare Ba", "plan_name": "750090", "standard_charge_dollar": 205.69, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "United Healthcare Me", "plan_name": "501310", "standard_charge_dollar": 182.02, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Windsor Mcare Extra", "plan_name": "500778", "standard_charge_dollar": 182.02, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." } ] } ] }, { "description": "Dress/debrid p-thick burn s", "code_information": [ { "code": "16020", "type": "CPT" } ], "standard_charges": [ { "gross_charge": 260.00, "minimum": 182.02, "maximum": 229.58, "setting": "outpatient", "payers_information": [ { "payer_name": "Aarp", "plan_name": "500102", "standard_charge_dollar": 182.02, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna", "plan_name": "700700", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna", "plan_name": "700700_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Mcare Ffs 6005", "plan_name": "700703", "standard_charge_dollar": 182.02, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Miscellaneous", "plan_name": "700720", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Miscellaneous", "plan_name": "700720_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Ppo Hmo", "plan_name": "701720", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Ppo Hmo", "plan_name": "701720_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Ambetter 68069", "plan_name": "500516", "standard_charge_dollar": 182.02, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Ms State Emplo", "plan_name": "401457", "standard_charge_dollar": 229.58, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Ms State Emplo", "plan_name": "401457_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Basic Pl", "plan_name": "400100", "standard_charge_dollar": 229.58, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Basic Pl", "plan_name": "400100_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Federal", "plan_name": "400110", "standard_charge_dollar": 229.58, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Federal", "plan_name": "400110_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Cigna Healthsprings Ffs", "plan_name": "500064", "standard_charge_dollar": 182.02, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Conseco", "plan_name": "500302", "standard_charge_dollar": 182.02, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Humana Ffs 61101", "plan_name": "500006", "standard_charge_dollar": 182.02, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Medicare A", "plan_name": "100100", "standard_charge_dollar": 182.02, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Medicare A", "plan_name": "100500", "standard_charge_dollar": 182.02, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Medicare Part B Only", "plan_name": "100300", "standard_charge_dollar": 182.02, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Medicare Railroad", "plan_name": "100103", "standard_charge_dollar": 182.02, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Ms Physicians Care N", "plan_name": "714210", "standard_charge_dollar": 227.53, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Peoples Hlth Ffs 72126", "plan_name": "500019", "standard_charge_dollar": 182.02, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Uhc/Secure Horizons", "plan_name": "500449", "standard_charge_dollar": 182.02, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "United Health Care/", "plan_name": "500292", "standard_charge_dollar": 205.69, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "United Healthcare", "plan_name": "750104", "standard_charge_dollar": 205.69, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "United Healthcare Ba", "plan_name": "750090", "standard_charge_dollar": 205.69, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "United Healthcare Me", "plan_name": "501310", "standard_charge_dollar": 182.02, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Windsor Mcare Extra", "plan_name": "500778", "standard_charge_dollar": 182.02, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." } ] } ] }, { "description": "Hc dress/deb burn <5% total small", "code_information": [ { "code": "16020", "type": "CPT" } ], "standard_charges": [ { "gross_charge": 260.00, "minimum": 182.02, "maximum": 229.58, "setting": "both", "payers_information": [ { "payer_name": "Aarp", "plan_name": "500102", "standard_charge_dollar": 182.02, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna", "plan_name": "700700", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna", "plan_name": "700700_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Mcare Ffs 6005", "plan_name": "700703", "standard_charge_dollar": 182.02, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Miscellaneous", "plan_name": "700720", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Miscellaneous", "plan_name": "700720_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Ppo Hmo", "plan_name": "701720", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Ppo Hmo", "plan_name": "701720_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Ambetter 68069", "plan_name": "500516", "standard_charge_dollar": 182.02, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Ms State Emplo", "plan_name": "401457", "standard_charge_dollar": 229.58, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Ms State Emplo", "plan_name": "401457_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Basic Pl", "plan_name": "400100", "standard_charge_dollar": 229.58, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Basic Pl", "plan_name": "400100_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Federal", "plan_name": "400110", "standard_charge_dollar": 229.58, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Federal", "plan_name": "400110_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Cigna Healthsprings Ffs", "plan_name": "500064", "standard_charge_dollar": 182.02, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Conseco", "plan_name": "500302", "standard_charge_dollar": 182.02, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Humana Ffs 61101", "plan_name": "500006", "standard_charge_dollar": 182.02, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Medicare A", "plan_name": "100100", "standard_charge_dollar": 182.02, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Medicare A", "plan_name": "100500", "standard_charge_dollar": 182.02, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Medicare Part B Only", "plan_name": "100300", "standard_charge_dollar": 182.02, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Medicare Railroad", "plan_name": "100103", "standard_charge_dollar": 182.02, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Ms Physicians Care N", "plan_name": "714210", "standard_charge_dollar": 227.53, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Peoples Hlth Ffs 72126", "plan_name": "500019", "standard_charge_dollar": 182.02, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Uhc/Secure Horizons", "plan_name": "500449", "standard_charge_dollar": 182.02, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "United Health Care/", "plan_name": "500292", "standard_charge_dollar": 205.69, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "United Healthcare", "plan_name": "750104", "standard_charge_dollar": 205.69, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "United Healthcare Ba", "plan_name": "750090", "standard_charge_dollar": 205.69, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "United Healthcare Me", "plan_name": "501310", "standard_charge_dollar": 182.02, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Windsor Mcare Extra", "plan_name": "500778", "standard_charge_dollar": 182.02, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." } ] } ] }, { "description": "Dress/debrid p-thick burn m", "code_information": [ { "code": "16025", "type": "CPT" } ], "standard_charges": [ { "gross_charge": 26535.50, "minimum": 182.02, "maximum": 22555.18, "setting": "inpatient", "payers_information": [ { "payer_name": "Aarp", "plan_name": "500102", "standard_charge_dollar": 182.02, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna", "plan_name": "700700", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna", "plan_name": "700700_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Mcare Ffs 6005", "plan_name": "700703", "standard_charge_dollar": 182.02, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Miscellaneous", "plan_name": "700720", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Miscellaneous", "plan_name": "700720_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Ppo Hmo", "plan_name": "701720", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Ppo Hmo", "plan_name": "701720_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Ambetter 68069", "plan_name": "500516", "standard_charge_dollar": 182.02, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Ms State Emplo", "plan_name": "401457", "standard_charge_percentage": 0.80, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Ms State Emplo", "plan_name": "401457_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Basic Pl", "plan_name": "400100", "standard_charge_percentage": 0.85, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Basic Pl", "plan_name": "400100_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Federal", "plan_name": "400110", "standard_charge_percentage": 0.85, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Federal", "plan_name": "400110_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Cigna Healthsprings Ffs", "plan_name": "500064", "standard_charge_dollar": 182.02, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Conseco", "plan_name": "500302", "standard_charge_dollar": 182.02, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Humana Ffs 61101", "plan_name": "500006", "standard_charge_dollar": 182.02, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Medicare A", "plan_name": "100100", "standard_charge_dollar": 182.02, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Medicare A", "plan_name": "100500", "standard_charge_dollar": 182.02, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Medicare Part B Only", "plan_name": "100300", "standard_charge_dollar": 182.02, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Medicare Railroad", "plan_name": "100103", "standard_charge_dollar": 182.02, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Ms Physicians Care N", "plan_name": "714210", "standard_charge_dollar": 227.53, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Peoples Hlth Ffs 72126", "plan_name": "500019", "standard_charge_dollar": 182.02, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Uhc/Secure Horizons", "plan_name": "500449", "standard_charge_dollar": 182.02, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "United Health Care/", "plan_name": "500292", "standard_charge_dollar": 205.69, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "United Healthcare", "plan_name": "750104", "standard_charge_dollar": 205.69, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "United Healthcare Ba", "plan_name": "750090", "standard_charge_dollar": 205.69, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "United Healthcare Me", "plan_name": "501310", "standard_charge_dollar": 182.02, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Windsor Mcare Extra", "plan_name": "500778", "standard_charge_dollar": 182.02, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." } ] } ] }, { "description": "Dress/debrid p-thick burn m", "code_information": [ { "code": "16025", "type": "CPT" } ], "standard_charges": [ { "gross_charge": 340.00, "minimum": 182.02, "maximum": 289.00, "setting": "outpatient", "payers_information": [ { "payer_name": "Aarp", "plan_name": "500102", "standard_charge_dollar": 182.02, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna", "plan_name": "700700", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna", "plan_name": "700700_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Mcare Ffs 6005", "plan_name": "700703", "standard_charge_dollar": 182.02, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Miscellaneous", "plan_name": "700720", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Miscellaneous", "plan_name": "700720_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Ppo Hmo", "plan_name": "701720", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Ppo Hmo", "plan_name": "701720_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Ambetter 68069", "plan_name": "500516", "standard_charge_dollar": 182.02, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Ms State Emplo", "plan_name": "401457", "standard_charge_percentage": 0.80, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Ms State Emplo", "plan_name": "401457_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Basic Pl", "plan_name": "400100", "standard_charge_percentage": 0.85, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Basic Pl", "plan_name": "400100_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Federal", "plan_name": "400110", "standard_charge_percentage": 0.85, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Federal", "plan_name": "400110_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Cigna Healthsprings Ffs", "plan_name": "500064", "standard_charge_dollar": 182.02, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Conseco", "plan_name": "500302", "standard_charge_dollar": 182.02, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Humana Ffs 61101", "plan_name": "500006", "standard_charge_dollar": 182.02, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Medicare A", "plan_name": "100100", "standard_charge_dollar": 182.02, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Medicare A", "plan_name": "100500", "standard_charge_dollar": 182.02, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Medicare Part B Only", "plan_name": "100300", "standard_charge_dollar": 182.02, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Medicare Railroad", "plan_name": "100103", "standard_charge_dollar": 182.02, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Ms Physicians Care N", "plan_name": "714210", "standard_charge_dollar": 227.53, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Peoples Hlth Ffs 72126", "plan_name": "500019", "standard_charge_dollar": 182.02, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Uhc/Secure Horizons", "plan_name": "500449", "standard_charge_dollar": 182.02, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "United Health Care/", "plan_name": "500292", "standard_charge_dollar": 205.69, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "United Healthcare", "plan_name": "750104", "standard_charge_dollar": 205.69, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "United Healthcare Ba", "plan_name": "750090", "standard_charge_dollar": 205.69, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "United Healthcare Me", "plan_name": "501310", "standard_charge_dollar": 182.02, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Windsor Mcare Extra", "plan_name": "500778", "standard_charge_dollar": 182.02, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." } ] } ] }, { "description": "Hc dress/debrid partl thk burn med", "code_information": [ { "code": "16025", "type": "CPT" } ], "standard_charges": [ { "gross_charge": 340.00, "minimum": 182.02, "maximum": 289.00, "setting": "both", "payers_information": [ { "payer_name": "Aarp", "plan_name": "500102", "standard_charge_dollar": 182.02, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna", "plan_name": "700700", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna", "plan_name": "700700_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Mcare Ffs 6005", "plan_name": "700703", "standard_charge_dollar": 182.02, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Miscellaneous", "plan_name": "700720", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Miscellaneous", "plan_name": "700720_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Ppo Hmo", "plan_name": "701720", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Ppo Hmo", "plan_name": "701720_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Ambetter 68069", "plan_name": "500516", "standard_charge_dollar": 182.02, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Ms State Emplo", "plan_name": "401457", "standard_charge_percentage": 0.80, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Ms State Emplo", "plan_name": "401457_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Basic Pl", "plan_name": "400100", "standard_charge_percentage": 0.85, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Basic Pl", "plan_name": "400100_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Federal", "plan_name": "400110", "standard_charge_percentage": 0.85, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Federal", "plan_name": "400110_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Cigna Healthsprings Ffs", "plan_name": "500064", "standard_charge_dollar": 182.02, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Conseco", "plan_name": "500302", "standard_charge_dollar": 182.02, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Humana Ffs 61101", "plan_name": "500006", "standard_charge_dollar": 182.02, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Medicare A", "plan_name": "100100", "standard_charge_dollar": 182.02, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Medicare A", "plan_name": "100500", "standard_charge_dollar": 182.02, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Medicare Part B Only", "plan_name": "100300", "standard_charge_dollar": 182.02, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Medicare Railroad", "plan_name": "100103", "standard_charge_dollar": 182.02, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Ms Physicians Care N", "plan_name": "714210", "standard_charge_dollar": 227.53, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Peoples Hlth Ffs 72126", "plan_name": "500019", "standard_charge_dollar": 182.02, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Uhc/Secure Horizons", "plan_name": "500449", "standard_charge_dollar": 182.02, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "United Health Care/", "plan_name": "500292", "standard_charge_dollar": 205.69, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "United Healthcare", "plan_name": "750104", "standard_charge_dollar": 205.69, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "United Healthcare Ba", "plan_name": "750090", "standard_charge_dollar": 205.69, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "United Healthcare Me", "plan_name": "501310", "standard_charge_dollar": 182.02, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Windsor Mcare Extra", "plan_name": "500778", "standard_charge_dollar": 182.02, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." } ] } ] }, { "description": "Dress/debrid p-thick burn l", "code_information": [ { "code": "16030", "type": "CPT" } ], "standard_charges": [ { "gross_charge": 26535.50, "minimum": 366.00, "maximum": 22555.18, "setting": "inpatient", "payers_information": [ { "payer_name": "Aarp", "plan_name": "500102", "standard_charge_dollar": 366.00, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna", "plan_name": "700700", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna", "plan_name": "700700_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Mcare Ffs 6005", "plan_name": "700703", "standard_charge_dollar": 366.00, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Miscellaneous", "plan_name": "700720", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Miscellaneous", "plan_name": "700720_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Ppo Hmo", "plan_name": "701720", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Ppo Hmo", "plan_name": "701720_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Ambetter 68069", "plan_name": "500516", "standard_charge_dollar": 366.00, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Ms State Emplo", "plan_name": "401457", "standard_charge_percentage": 0.80, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Ms State Emplo", "plan_name": "401457_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Basic Pl", "plan_name": "400100", "standard_charge_percentage": 0.85, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Basic Pl", "plan_name": "400100_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Federal", "plan_name": "400110", "standard_charge_percentage": 0.85, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Federal", "plan_name": "400110_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Cigna Healthsprings Ffs", "plan_name": "500064", "standard_charge_dollar": 366.00, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Conseco", "plan_name": "500302", "standard_charge_dollar": 366.00, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Humana Ffs 61101", "plan_name": "500006", "standard_charge_dollar": 366.00, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Medicare A", "plan_name": "100100", "standard_charge_dollar": 366.00, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Medicare A", "plan_name": "100500", "standard_charge_dollar": 366.00, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Medicare Part B Only", "plan_name": "100300", "standard_charge_dollar": 366.00, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Medicare Railroad", "plan_name": "100103", "standard_charge_dollar": 366.00, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Ms Physicians Care N", "plan_name": "714210", "standard_charge_dollar": 457.50, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Peoples Hlth Ffs 72126", "plan_name": "500019", "standard_charge_dollar": 366.00, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Uhc/Secure Horizons", "plan_name": "500449", "standard_charge_dollar": 366.00, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "United Health Care/", "plan_name": "500292", "standard_charge_dollar": 413.58, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "United Healthcare", "plan_name": "750104", "standard_charge_dollar": 413.58, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "United Healthcare Ba", "plan_name": "750090", "standard_charge_dollar": 413.58, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "United Healthcare Me", "plan_name": "501310", "standard_charge_dollar": 366.00, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Windsor Mcare Extra", "plan_name": "500778", "standard_charge_dollar": 366.00, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." } ] } ] }, { "description": "Dress/debrid p-thick burn l", "code_information": [ { "code": "16030", "type": "CPT" } ], "standard_charges": [ { "gross_charge": 400.00, "minimum": 320.00, "maximum": 457.50, "setting": "outpatient", "payers_information": [ { "payer_name": "Aarp", "plan_name": "500102", "standard_charge_dollar": 366.00, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna", "plan_name": "700700", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna", "plan_name": "700700_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Mcare Ffs 6005", "plan_name": "700703", "standard_charge_dollar": 366.00, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Miscellaneous", "plan_name": "700720", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Miscellaneous", "plan_name": "700720_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Ppo Hmo", "plan_name": "701720", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Ppo Hmo", "plan_name": "701720_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Ambetter 68069", "plan_name": "500516", "standard_charge_dollar": 366.00, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Ms State Emplo", "plan_name": "401457", "standard_charge_percentage": 0.80, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Ms State Emplo", "plan_name": "401457_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Basic Pl", "plan_name": "400100", "standard_charge_percentage": 0.85, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Basic Pl", "plan_name": "400100_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Federal", "plan_name": "400110", "standard_charge_percentage": 0.85, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Federal", "plan_name": "400110_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Cigna Healthsprings Ffs", "plan_name": "500064", "standard_charge_dollar": 366.00, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Conseco", "plan_name": "500302", "standard_charge_dollar": 366.00, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Humana Ffs 61101", "plan_name": "500006", "standard_charge_dollar": 366.00, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Medicare A", "plan_name": "100100", "standard_charge_dollar": 366.00, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Medicare A", "plan_name": "100500", "standard_charge_dollar": 366.00, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Medicare Part B Only", "plan_name": "100300", "standard_charge_dollar": 366.00, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Medicare Railroad", "plan_name": "100103", "standard_charge_dollar": 366.00, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Ms Physicians Care N", "plan_name": "714210", "standard_charge_dollar": 457.50, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Peoples Hlth Ffs 72126", "plan_name": "500019", "standard_charge_dollar": 366.00, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Uhc/Secure Horizons", "plan_name": "500449", "standard_charge_dollar": 366.00, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "United Health Care/", "plan_name": "500292", "standard_charge_dollar": 413.58, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "United Healthcare", "plan_name": "750104", "standard_charge_dollar": 413.58, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "United Healthcare Ba", "plan_name": "750090", "standard_charge_dollar": 413.58, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "United Healthcare Me", "plan_name": "501310", "standard_charge_dollar": 366.00, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Windsor Mcare Extra", "plan_name": "500778", "standard_charge_dollar": 366.00, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." } ] } ] }, { "description": "Hc dress/debride partl thk burn lg", "code_information": [ { "code": "16030", "type": "CPT" } ], "standard_charges": [ { "gross_charge": 400.00, "minimum": 320.00, "maximum": 457.50, "setting": "both", "payers_information": [ { "payer_name": "Aarp", "plan_name": "500102", "standard_charge_dollar": 366.00, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna", "plan_name": "700700", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna", "plan_name": "700700_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Mcare Ffs 6005", "plan_name": "700703", "standard_charge_dollar": 366.00, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Miscellaneous", "plan_name": "700720", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Miscellaneous", "plan_name": "700720_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Ppo Hmo", "plan_name": "701720", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Ppo Hmo", "plan_name": "701720_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Ambetter 68069", "plan_name": "500516", "standard_charge_dollar": 366.00, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Ms State Emplo", "plan_name": "401457", "standard_charge_percentage": 0.80, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Ms State Emplo", "plan_name": "401457_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Basic Pl", "plan_name": "400100", "standard_charge_percentage": 0.85, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Basic Pl", "plan_name": "400100_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Federal", "plan_name": "400110", "standard_charge_percentage": 0.85, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Federal", "plan_name": "400110_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Cigna Healthsprings Ffs", "plan_name": "500064", "standard_charge_dollar": 366.00, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Conseco", "plan_name": "500302", "standard_charge_dollar": 366.00, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Humana Ffs 61101", "plan_name": "500006", "standard_charge_dollar": 366.00, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Medicare A", "plan_name": "100100", "standard_charge_dollar": 366.00, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Medicare A", "plan_name": "100500", "standard_charge_dollar": 366.00, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Medicare Part B Only", "plan_name": "100300", "standard_charge_dollar": 366.00, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Medicare Railroad", "plan_name": "100103", "standard_charge_dollar": 366.00, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Ms Physicians Care N", "plan_name": "714210", "standard_charge_dollar": 457.50, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Peoples Hlth Ffs 72126", "plan_name": "500019", "standard_charge_dollar": 366.00, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Uhc/Secure Horizons", "plan_name": "500449", "standard_charge_dollar": 366.00, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "United Health Care/", "plan_name": "500292", "standard_charge_dollar": 413.58, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "United Healthcare", "plan_name": "750104", "standard_charge_dollar": 413.58, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "United Healthcare Ba", "plan_name": "750090", "standard_charge_dollar": 413.58, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "United Healthcare Me", "plan_name": "501310", "standard_charge_dollar": 366.00, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Windsor Mcare Extra", "plan_name": "500778", "standard_charge_dollar": 366.00, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." } ] } ] }, { "description": "Destruct premalg lesion", "code_information": [ { "code": "17000", "type": "CPT" } ], "standard_charges": [ { "gross_charge": 1988.27, "minimum": 182.02, "maximum": 229.58, "setting": "inpatient", "payers_information": [ { "payer_name": "Aarp", "plan_name": "500102", "standard_charge_dollar": 182.02, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna", "plan_name": "700700", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna", "plan_name": "700700_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Mcare Ffs 6005", "plan_name": "700703", "standard_charge_dollar": 182.02, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Miscellaneous", "plan_name": "700720", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Miscellaneous", "plan_name": "700720_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Ppo Hmo", "plan_name": "701720", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Ppo Hmo", "plan_name": "701720_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Ambetter 68069", "plan_name": "500516", "standard_charge_dollar": 182.02, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Ms State Emplo", "plan_name": "401457", "standard_charge_dollar": 229.58, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Ms State Emplo", "plan_name": "401457_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Basic Pl", "plan_name": "400100", "standard_charge_dollar": 229.58, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Basic Pl", "plan_name": "400100_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Federal", "plan_name": "400110", "standard_charge_dollar": 229.58, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Federal", "plan_name": "400110_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Cigna Healthsprings Ffs", "plan_name": "500064", "standard_charge_dollar": 182.02, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Conseco", "plan_name": "500302", "standard_charge_dollar": 182.02, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Humana Ffs 61101", "plan_name": "500006", "standard_charge_dollar": 182.02, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Medicare A", "plan_name": "100100", "standard_charge_dollar": 182.02, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Medicare A", "plan_name": "100500", "standard_charge_dollar": 182.02, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Medicare Part B Only", "plan_name": "100300", "standard_charge_dollar": 182.02, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Medicare Railroad", "plan_name": "100103", "standard_charge_dollar": 182.02, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Ms Physicians Care N", "plan_name": "714210", "standard_charge_dollar": 227.53, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Peoples Hlth Ffs 72126", "plan_name": "500019", "standard_charge_dollar": 182.02, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Uhc/Secure Horizons", "plan_name": "500449", "standard_charge_dollar": 182.02, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "United Health Care/", "plan_name": "500292", "standard_charge_dollar": 205.69, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "United Healthcare", "plan_name": "750104", "standard_charge_dollar": 205.69, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "United Healthcare Ba", "plan_name": "750090", "standard_charge_dollar": 205.69, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "United Healthcare Me", "plan_name": "501310", "standard_charge_dollar": 182.02, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Windsor Mcare Extra", "plan_name": "500778", "standard_charge_dollar": 182.02, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." } ] } ] }, { "description": "Destruct premalg les 2-14", "code_information": [ { "code": "17003", "type": "CPT" } ], "standard_charges": [ { "gross_charge": 1988.27, "minimum": 1590.62, "maximum": 1690.03, "setting": "inpatient", "payers_information": [ { "payer_name": "Aetna", "plan_name": "700700", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna", "plan_name": "700700_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Miscellaneous", "plan_name": "700720", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Miscellaneous", "plan_name": "700720_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Ppo Hmo", "plan_name": "701720", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Ppo Hmo", "plan_name": "701720_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Ms State Emplo", "plan_name": "401457", "standard_charge_percentage": 0.80, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Ms State Emplo", "plan_name": "401457_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Basic Pl", "plan_name": "400100", "standard_charge_percentage": 0.85, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Basic Pl", "plan_name": "400100_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Federal", "plan_name": "400110", "standard_charge_percentage": 0.85, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Federal", "plan_name": "400110_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." } ] } ] }, { "description": "Destroy premal lesions 15/>", "code_information": [ { "code": "17004", "type": "CPT" } ], "standard_charges": [ { "gross_charge": 1988.27, "minimum": 366.00, "maximum": 1690.03, "setting": "inpatient", "payers_information": [ { "payer_name": "Aarp", "plan_name": "500102", "standard_charge_dollar": 366.00, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna", "plan_name": "700700", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna", "plan_name": "700700_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Mcare Ffs 6005", "plan_name": "700703", "standard_charge_dollar": 366.00, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Miscellaneous", "plan_name": "700720", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Miscellaneous", "plan_name": "700720_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Ppo Hmo", "plan_name": "701720", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Ppo Hmo", "plan_name": "701720_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Ambetter 68069", "plan_name": "500516", "standard_charge_dollar": 366.00, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Ms State Emplo", "plan_name": "401457", "standard_charge_percentage": 0.80, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Ms State Emplo", "plan_name": "401457_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Basic Pl", "plan_name": "400100", "standard_charge_percentage": 0.85, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Basic Pl", "plan_name": "400100_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Federal", "plan_name": "400110", "standard_charge_percentage": 0.85, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Federal", "plan_name": "400110_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Cigna Healthsprings Ffs", "plan_name": "500064", "standard_charge_dollar": 366.00, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Conseco", "plan_name": "500302", "standard_charge_dollar": 366.00, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Humana Ffs 61101", "plan_name": "500006", "standard_charge_dollar": 366.00, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Medicare A", "plan_name": "100100", "standard_charge_dollar": 366.00, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Medicare A", "plan_name": "100500", "standard_charge_dollar": 366.00, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Medicare Part B Only", "plan_name": "100300", "standard_charge_dollar": 366.00, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Medicare Railroad", "plan_name": "100103", "standard_charge_dollar": 366.00, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Ms Physicians Care N", "plan_name": "714210", "standard_charge_dollar": 457.50, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Peoples Hlth Ffs 72126", "plan_name": "500019", "standard_charge_dollar": 366.00, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Uhc/Secure Horizons", "plan_name": "500449", "standard_charge_dollar": 366.00, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "United Health Care/", "plan_name": "500292", "standard_charge_dollar": 413.58, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "United Healthcare", "plan_name": "750104", "standard_charge_dollar": 413.58, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "United Healthcare Ba", "plan_name": "750090", "standard_charge_dollar": 413.58, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "United Healthcare Me", "plan_name": "501310", "standard_charge_dollar": 366.00, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Windsor Mcare Extra", "plan_name": "500778", "standard_charge_dollar": 366.00, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." } ] } ] }, { "description": "Destruction of skin lesions", "code_information": [ { "code": "17106", "type": "CPT" } ], "standard_charges": [ { "gross_charge": 1988.27, "minimum": 366.00, "maximum": 1690.03, "setting": "inpatient", "payers_information": [ { "payer_name": "Aarp", "plan_name": "500102", "standard_charge_dollar": 366.00, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna", "plan_name": "700700", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna", "plan_name": "700700_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Mcare Ffs 6005", "plan_name": "700703", "standard_charge_dollar": 366.00, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Miscellaneous", "plan_name": "700720", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Miscellaneous", "plan_name": "700720_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Ppo Hmo", "plan_name": "701720", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Ppo Hmo", "plan_name": "701720_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Ambetter 68069", "plan_name": "500516", "standard_charge_dollar": 366.00, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Ms State Emplo", "plan_name": "401457", "standard_charge_percentage": 0.80, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Ms State Emplo", "plan_name": "401457_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Basic Pl", "plan_name": "400100", "standard_charge_percentage": 0.85, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Basic Pl", "plan_name": "400100_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Federal", "plan_name": "400110", "standard_charge_percentage": 0.85, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Federal", "plan_name": "400110_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Cigna Healthsprings Ffs", "plan_name": "500064", "standard_charge_dollar": 366.00, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Conseco", "plan_name": "500302", "standard_charge_dollar": 366.00, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Humana Ffs 61101", "plan_name": "500006", "standard_charge_dollar": 366.00, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Medicare A", "plan_name": "100100", "standard_charge_dollar": 366.00, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Medicare A", "plan_name": "100500", "standard_charge_dollar": 366.00, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Medicare Part B Only", "plan_name": "100300", "standard_charge_dollar": 366.00, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Medicare Railroad", "plan_name": "100103", "standard_charge_dollar": 366.00, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Ms Physicians Care N", "plan_name": "714210", "standard_charge_dollar": 457.50, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Peoples Hlth Ffs 72126", "plan_name": "500019", "standard_charge_dollar": 366.00, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Uhc/Secure Horizons", "plan_name": "500449", "standard_charge_dollar": 366.00, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "United Health Care/", "plan_name": "500292", "standard_charge_dollar": 413.58, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "United Healthcare", "plan_name": "750104", "standard_charge_dollar": 413.58, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "United Healthcare Ba", "plan_name": "750090", "standard_charge_dollar": 413.58, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "United Healthcare Me", "plan_name": "501310", "standard_charge_dollar": 366.00, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Windsor Mcare Extra", "plan_name": "500778", "standard_charge_dollar": 366.00, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." } ] } ] }, { "description": "Destruction of skin lesions", "code_information": [ { "code": "17107", "type": "CPT" } ], "standard_charges": [ { "gross_charge": 1988.27, "minimum": 560.75, "maximum": 1690.03, "setting": "inpatient", "payers_information": [ { "payer_name": "Aarp", "plan_name": "500102", "standard_charge_dollar": 560.75, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna", "plan_name": "700700", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna", "plan_name": "700700_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Mcare Ffs 6005", "plan_name": "700703", "standard_charge_dollar": 560.75, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Miscellaneous", "plan_name": "700720", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Miscellaneous", "plan_name": "700720_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Ppo Hmo", "plan_name": "701720", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Ppo Hmo", "plan_name": "701720_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Ambetter 68069", "plan_name": "500516", "standard_charge_dollar": 560.75, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Ms State Emplo", "plan_name": "401457", "standard_charge_percentage": 0.80, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Ms State Emplo", "plan_name": "401457_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Basic Pl", "plan_name": "400100", "standard_charge_percentage": 0.85, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Basic Pl", "plan_name": "400100_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Federal", "plan_name": "400110", "standard_charge_percentage": 0.85, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Federal", "plan_name": "400110_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Cigna Healthsprings Ffs", "plan_name": "500064", "standard_charge_dollar": 560.75, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Conseco", "plan_name": "500302", "standard_charge_dollar": 560.75, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Humana Ffs 61101", "plan_name": "500006", "standard_charge_dollar": 560.75, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Medicare A", "plan_name": "100100", "standard_charge_dollar": 560.75, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Medicare A", "plan_name": "100500", "standard_charge_dollar": 560.75, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Medicare Part B Only", "plan_name": "100300", "standard_charge_dollar": 560.75, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Medicare Railroad", "plan_name": "100103", "standard_charge_dollar": 560.75, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Ms Physicians Care N", "plan_name": "714210", "standard_charge_dollar": 700.94, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Peoples Hlth Ffs 72126", "plan_name": "500019", "standard_charge_dollar": 560.75, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Uhc/Secure Horizons", "plan_name": "500449", "standard_charge_dollar": 560.75, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "United Health Care/", "plan_name": "500292", "standard_charge_dollar": 633.65, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "United Healthcare", "plan_name": "750104", "standard_charge_dollar": 633.65, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "United Healthcare Ba", "plan_name": "750090", "standard_charge_dollar": 633.65, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "United Healthcare Me", "plan_name": "501310", "standard_charge_dollar": 560.75, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Windsor Mcare Extra", "plan_name": "500778", "standard_charge_dollar": 560.75, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." } ] } ] }, { "description": "Destruction of skin lesions", "code_information": [ { "code": "17108", "type": "CPT" } ], "standard_charges": [ { "gross_charge": 1988.27, "minimum": 1590.62, "maximum": 2094.63, "setting": "inpatient", "payers_information": [ { "payer_name": "Aarp", "plan_name": "500102", "standard_charge_dollar": 1675.70, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna", "plan_name": "700700", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna", "plan_name": "700700_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Mcare Ffs 6005", "plan_name": "700703", "standard_charge_dollar": 1675.70, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Miscellaneous", "plan_name": "700720", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Miscellaneous", "plan_name": "700720_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Ppo Hmo", "plan_name": "701720", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Ppo Hmo", "plan_name": "701720_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Ambetter 68069", "plan_name": "500516", "standard_charge_dollar": 1675.70, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Ms State Emplo", "plan_name": "401457", "standard_charge_percentage": 0.80, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Ms State Emplo", "plan_name": "401457_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Basic Pl", "plan_name": "400100", "standard_charge_percentage": 0.85, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Basic Pl", "plan_name": "400100_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Federal", "plan_name": "400110", "standard_charge_percentage": 0.85, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Federal", "plan_name": "400110_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Cigna Healthsprings Ffs", "plan_name": "500064", "standard_charge_dollar": 1675.70, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Conseco", "plan_name": "500302", "standard_charge_dollar": 1675.70, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Humana Ffs 61101", "plan_name": "500006", "standard_charge_dollar": 1675.70, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Medicare A", "plan_name": "100100", "standard_charge_dollar": 1675.70, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Medicare A", "plan_name": "100500", "standard_charge_dollar": 1675.70, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Medicare Part B Only", "plan_name": "100300", "standard_charge_dollar": 1675.70, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Medicare Railroad", "plan_name": "100103", "standard_charge_dollar": 1675.70, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Ms Physicians Care N", "plan_name": "714210", "standard_charge_dollar": 2094.63, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Peoples Hlth Ffs 72126", "plan_name": "500019", "standard_charge_dollar": 1675.70, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Uhc/Secure Horizons", "plan_name": "500449", "standard_charge_dollar": 1675.70, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "United Health Care/", "plan_name": "500292", "standard_charge_dollar": 1893.54, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "United Healthcare", "plan_name": "750104", "standard_charge_dollar": 1893.54, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "United Healthcare Ba", "plan_name": "750090", "standard_charge_dollar": 1893.54, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "United Healthcare Me", "plan_name": "501310", "standard_charge_dollar": 1675.70, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Windsor Mcare Extra", "plan_name": "500778", "standard_charge_dollar": 1675.70, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." } ] } ] }, { "description": "Destruct b9 lesion 1-14", "code_information": [ { "code": "17110", "type": "CPT" } ], "standard_charges": [ { "gross_charge": 1988.27, "minimum": 182.02, "maximum": 229.58, "setting": "inpatient", "payers_information": [ { "payer_name": "Aarp", "plan_name": "500102", "standard_charge_dollar": 182.02, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna", "plan_name": "700700", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna", "plan_name": "700700_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Mcare Ffs 6005", "plan_name": "700703", "standard_charge_dollar": 182.02, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Miscellaneous", "plan_name": "700720", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Miscellaneous", "plan_name": "700720_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Ppo Hmo", "plan_name": "701720", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Ppo Hmo", "plan_name": "701720_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Ambetter 68069", "plan_name": "500516", "standard_charge_dollar": 182.02, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Ms State Emplo", "plan_name": "401457", "standard_charge_dollar": 229.58, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Ms State Emplo", "plan_name": "401457_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Basic Pl", "plan_name": "400100", "standard_charge_dollar": 229.58, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Basic Pl", "plan_name": "400100_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Federal", "plan_name": "400110", "standard_charge_dollar": 229.58, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Federal", "plan_name": "400110_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Cigna Healthsprings Ffs", "plan_name": "500064", "standard_charge_dollar": 182.02, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Conseco", "plan_name": "500302", "standard_charge_dollar": 182.02, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Humana Ffs 61101", "plan_name": "500006", "standard_charge_dollar": 182.02, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Medicare A", "plan_name": "100100", "standard_charge_dollar": 182.02, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Medicare A", "plan_name": "100500", "standard_charge_dollar": 182.02, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Medicare Part B Only", "plan_name": "100300", "standard_charge_dollar": 182.02, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Medicare Railroad", "plan_name": "100103", "standard_charge_dollar": 182.02, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Ms Physicians Care N", "plan_name": "714210", "standard_charge_dollar": 227.53, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Peoples Hlth Ffs 72126", "plan_name": "500019", "standard_charge_dollar": 182.02, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Uhc/Secure Horizons", "plan_name": "500449", "standard_charge_dollar": 182.02, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "United Health Care/", "plan_name": "500292", "standard_charge_dollar": 205.69, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "United Healthcare", "plan_name": "750104", "standard_charge_dollar": 205.69, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "United Healthcare Ba", "plan_name": "750090", "standard_charge_dollar": 205.69, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "United Healthcare Me", "plan_name": "501310", "standard_charge_dollar": 182.02, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Windsor Mcare Extra", "plan_name": "500778", "standard_charge_dollar": 182.02, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." } ] } ] }, { "description": "Destruct lesion 15 or more", "code_information": [ { "code": "17111", "type": "CPT" } ], "standard_charges": [ { "gross_charge": 1988.27, "minimum": 182.02, "maximum": 229.58, "setting": "inpatient", "payers_information": [ { "payer_name": "Aarp", "plan_name": "500102", "standard_charge_dollar": 182.02, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna", "plan_name": "700700", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna", "plan_name": "700700_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Mcare Ffs 6005", "plan_name": "700703", "standard_charge_dollar": 182.02, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Miscellaneous", "plan_name": "700720", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Miscellaneous", "plan_name": "700720_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Ppo Hmo", "plan_name": "701720", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Ppo Hmo", "plan_name": "701720_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Ambetter 68069", "plan_name": "500516", "standard_charge_dollar": 182.02, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Ms State Emplo", "plan_name": "401457", "standard_charge_dollar": 229.58, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Ms State Emplo", "plan_name": "401457_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Basic Pl", "plan_name": "400100", "standard_charge_dollar": 229.58, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Basic Pl", "plan_name": "400100_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Federal", "plan_name": "400110", "standard_charge_dollar": 229.58, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Federal", "plan_name": "400110_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Cigna Healthsprings Ffs", "plan_name": "500064", "standard_charge_dollar": 182.02, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Conseco", "plan_name": "500302", "standard_charge_dollar": 182.02, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Humana Ffs 61101", "plan_name": "500006", "standard_charge_dollar": 182.02, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Medicare A", "plan_name": "100100", "standard_charge_dollar": 182.02, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Medicare A", "plan_name": "100500", "standard_charge_dollar": 182.02, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Medicare Part B Only", "plan_name": "100300", "standard_charge_dollar": 182.02, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Medicare Railroad", "plan_name": "100103", "standard_charge_dollar": 182.02, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Ms Physicians Care N", "plan_name": "714210", "standard_charge_dollar": 227.53, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Peoples Hlth Ffs 72126", "plan_name": "500019", "standard_charge_dollar": 182.02, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Uhc/Secure Horizons", "plan_name": "500449", "standard_charge_dollar": 182.02, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "United Health Care/", "plan_name": "500292", "standard_charge_dollar": 205.69, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "United Healthcare", "plan_name": "750104", "standard_charge_dollar": 205.69, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "United Healthcare Ba", "plan_name": "750090", "standard_charge_dollar": 205.69, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "United Healthcare Me", "plan_name": "501310", "standard_charge_dollar": 182.02, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Windsor Mcare Extra", "plan_name": "500778", "standard_charge_dollar": 182.02, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." } ] } ] }, { "description": "Chem caut of granltj tissue", "code_information": [ { "code": "17250", "type": "CPT" } ], "standard_charges": [ { "gross_charge": 1988.27, "minimum": 182.02, "maximum": 229.58, "setting": "inpatient", "payers_information": [ { "payer_name": "Aarp", "plan_name": "500102", "standard_charge_dollar": 182.02, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna", "plan_name": "700700", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna", "plan_name": "700700_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Mcare Ffs 6005", "plan_name": "700703", "standard_charge_dollar": 182.02, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Miscellaneous", "plan_name": "700720", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Miscellaneous", "plan_name": "700720_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Ppo Hmo", "plan_name": "701720", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Ppo Hmo", "plan_name": "701720_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Ambetter 68069", "plan_name": "500516", "standard_charge_dollar": 182.02, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Ms State Emplo", "plan_name": "401457", "standard_charge_dollar": 229.58, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Ms State Emplo", "plan_name": "401457_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Basic Pl", "plan_name": "400100", "standard_charge_dollar": 229.58, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Basic Pl", "plan_name": "400100_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Federal", "plan_name": "400110", "standard_charge_dollar": 229.58, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Federal", "plan_name": "400110_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Cigna Healthsprings Ffs", "plan_name": "500064", "standard_charge_dollar": 182.02, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Conseco", "plan_name": "500302", "standard_charge_dollar": 182.02, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Humana Ffs 61101", "plan_name": "500006", "standard_charge_dollar": 182.02, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Medicare A", "plan_name": "100100", "standard_charge_dollar": 182.02, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Medicare A", "plan_name": "100500", "standard_charge_dollar": 182.02, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Medicare Part B Only", "plan_name": "100300", "standard_charge_dollar": 182.02, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Medicare Railroad", "plan_name": "100103", "standard_charge_dollar": 182.02, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Ms Physicians Care N", "plan_name": "714210", "standard_charge_dollar": 227.53, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Peoples Hlth Ffs 72126", "plan_name": "500019", "standard_charge_dollar": 182.02, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Uhc/Secure Horizons", "plan_name": "500449", "standard_charge_dollar": 182.02, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "United Health Care/", "plan_name": "500292", "standard_charge_dollar": 205.69, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "United Healthcare", "plan_name": "750104", "standard_charge_dollar": 205.69, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "United Healthcare Ba", "plan_name": "750090", "standard_charge_dollar": 205.69, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "United Healthcare Me", "plan_name": "501310", "standard_charge_dollar": 182.02, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Windsor Mcare Extra", "plan_name": "500778", "standard_charge_dollar": 182.02, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." } ] } ] }, { "description": "Chem caut of granltj tissue", "code_information": [ { "code": "17250", "type": "CPT" } ], "standard_charges": [ { "gross_charge": 486.00, "minimum": 182.02, "maximum": 229.58, "setting": "outpatient", "payers_information": [ { "payer_name": "Aarp", "plan_name": "500102", "standard_charge_dollar": 182.02, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna", "plan_name": "700700", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna", "plan_name": "700700_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Mcare Ffs 6005", "plan_name": "700703", "standard_charge_dollar": 182.02, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Miscellaneous", "plan_name": "700720", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Miscellaneous", "plan_name": "700720_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Ppo Hmo", "plan_name": "701720", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Ppo Hmo", "plan_name": "701720_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Ambetter 68069", "plan_name": "500516", "standard_charge_dollar": 182.02, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Ms State Emplo", "plan_name": "401457", "standard_charge_dollar": 229.58, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Ms State Emplo", "plan_name": "401457_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Basic Pl", "plan_name": "400100", "standard_charge_dollar": 229.58, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Basic Pl", "plan_name": "400100_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Federal", "plan_name": "400110", "standard_charge_dollar": 229.58, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Federal", "plan_name": "400110_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Cigna Healthsprings Ffs", "plan_name": "500064", "standard_charge_dollar": 182.02, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Conseco", "plan_name": "500302", "standard_charge_dollar": 182.02, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Humana Ffs 61101", "plan_name": "500006", "standard_charge_dollar": 182.02, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Medicare A", "plan_name": "100100", "standard_charge_dollar": 182.02, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Medicare A", "plan_name": "100500", "standard_charge_dollar": 182.02, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Medicare Part B Only", "plan_name": "100300", "standard_charge_dollar": 182.02, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Medicare Railroad", "plan_name": "100103", "standard_charge_dollar": 182.02, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Ms Physicians Care N", "plan_name": "714210", "standard_charge_dollar": 227.53, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Peoples Hlth Ffs 72126", "plan_name": "500019", "standard_charge_dollar": 182.02, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Uhc/Secure Horizons", "plan_name": "500449", "standard_charge_dollar": 182.02, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "United Health Care/", "plan_name": "500292", "standard_charge_dollar": 205.69, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "United Healthcare", "plan_name": "750104", "standard_charge_dollar": 205.69, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "United Healthcare Ba", "plan_name": "750090", "standard_charge_dollar": 205.69, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "United Healthcare Me", "plan_name": "501310", "standard_charge_dollar": 182.02, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Windsor Mcare Extra", "plan_name": "500778", "standard_charge_dollar": 182.02, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." } ] } ] }, { "description": "Hc chemical cauterization of tissue", "code_information": [ { "code": "17250", "type": "CPT" } ], "standard_charges": [ { "gross_charge": 486.00, "minimum": 182.02, "maximum": 229.58, "setting": "both", "payers_information": [ { "payer_name": "Aarp", "plan_name": "500102", "standard_charge_dollar": 182.02, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna", "plan_name": "700700", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna", "plan_name": "700700_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Mcare Ffs 6005", "plan_name": "700703", "standard_charge_dollar": 182.02, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Miscellaneous", "plan_name": "700720", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Miscellaneous", "plan_name": "700720_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Ppo Hmo", "plan_name": "701720", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Ppo Hmo", "plan_name": "701720_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Ambetter 68069", "plan_name": "500516", "standard_charge_dollar": 182.02, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Ms State Emplo", "plan_name": "401457", "standard_charge_dollar": 229.58, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Ms State Emplo", "plan_name": "401457_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Basic Pl", "plan_name": "400100", "standard_charge_dollar": 229.58, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Basic Pl", "plan_name": "400100_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Federal", "plan_name": "400110", "standard_charge_dollar": 229.58, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Federal", "plan_name": "400110_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Cigna Healthsprings Ffs", "plan_name": "500064", "standard_charge_dollar": 182.02, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Conseco", "plan_name": "500302", "standard_charge_dollar": 182.02, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Humana Ffs 61101", "plan_name": "500006", "standard_charge_dollar": 182.02, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Medicare A", "plan_name": "100100", "standard_charge_dollar": 182.02, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Medicare A", "plan_name": "100500", "standard_charge_dollar": 182.02, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Medicare Part B Only", "plan_name": "100300", "standard_charge_dollar": 182.02, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Medicare Railroad", "plan_name": "100103", "standard_charge_dollar": 182.02, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Ms Physicians Care N", "plan_name": "714210", "standard_charge_dollar": 227.53, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Peoples Hlth Ffs 72126", "plan_name": "500019", "standard_charge_dollar": 182.02, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Uhc/Secure Horizons", "plan_name": "500449", "standard_charge_dollar": 182.02, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "United Health Care/", "plan_name": "500292", "standard_charge_dollar": 205.69, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "United Healthcare", "plan_name": "750104", "standard_charge_dollar": 205.69, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "United Healthcare Ba", "plan_name": "750090", "standard_charge_dollar": 205.69, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "United Healthcare Me", "plan_name": "501310", "standard_charge_dollar": 182.02, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Windsor Mcare Extra", "plan_name": "500778", "standard_charge_dollar": 182.02, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." } ] } ] }, { "description": "Destruction of skin lesions", "code_information": [ { "code": "17280", "type": "CPT" } ], "standard_charges": [ { "gross_charge": 1988.27, "minimum": 182.02, "maximum": 229.58, "setting": "inpatient", "payers_information": [ { "payer_name": "Aarp", "plan_name": "500102", "standard_charge_dollar": 182.02, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna", "plan_name": "700700", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna", "plan_name": "700700_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Mcare Ffs 6005", "plan_name": "700703", "standard_charge_dollar": 182.02, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Miscellaneous", "plan_name": "700720", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Miscellaneous", "plan_name": "700720_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Ppo Hmo", "plan_name": "701720", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Ppo Hmo", "plan_name": "701720_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Ambetter 68069", "plan_name": "500516", "standard_charge_dollar": 182.02, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Ms State Emplo", "plan_name": "401457", "standard_charge_dollar": 229.58, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Ms State Emplo", "plan_name": "401457_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Basic Pl", "plan_name": "400100", "standard_charge_dollar": 229.58, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Basic Pl", "plan_name": "400100_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Federal", "plan_name": "400110", "standard_charge_dollar": 229.58, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Federal", "plan_name": "400110_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Cigna Healthsprings Ffs", "plan_name": "500064", "standard_charge_dollar": 182.02, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Conseco", "plan_name": "500302", "standard_charge_dollar": 182.02, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Humana Ffs 61101", "plan_name": "500006", "standard_charge_dollar": 182.02, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Medicare A", "plan_name": "100100", "standard_charge_dollar": 182.02, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Medicare A", "plan_name": "100500", "standard_charge_dollar": 182.02, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Medicare Part B Only", "plan_name": "100300", "standard_charge_dollar": 182.02, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Medicare Railroad", "plan_name": "100103", "standard_charge_dollar": 182.02, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Ms Physicians Care N", "plan_name": "714210", "standard_charge_dollar": 227.53, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Peoples Hlth Ffs 72126", "plan_name": "500019", "standard_charge_dollar": 182.02, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Uhc/Secure Horizons", "plan_name": "500449", "standard_charge_dollar": 182.02, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "United Health Care/", "plan_name": "500292", "standard_charge_dollar": 205.69, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "United Healthcare", "plan_name": "750104", "standard_charge_dollar": 205.69, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "United Healthcare Ba", "plan_name": "750090", "standard_charge_dollar": 205.69, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "United Healthcare Me", "plan_name": "501310", "standard_charge_dollar": 182.02, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Windsor Mcare Extra", "plan_name": "500778", "standard_charge_dollar": 182.02, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." } ] } ] }, { "description": "Destruction of skin lesions", "code_information": [ { "code": "17281", "type": "CPT" } ], "standard_charges": [ { "gross_charge": 1988.27, "minimum": 182.02, "maximum": 1690.03, "setting": "inpatient", "payers_information": [ { "payer_name": "Aarp", "plan_name": "500102", "standard_charge_dollar": 182.02, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna", "plan_name": "700700", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna", "plan_name": "700700_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Mcare Ffs 6005", "plan_name": "700703", "standard_charge_dollar": 182.02, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Miscellaneous", "plan_name": "700720", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Miscellaneous", "plan_name": "700720_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Ppo Hmo", "plan_name": "701720", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Ppo Hmo", "plan_name": "701720_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Ambetter 68069", "plan_name": "500516", "standard_charge_dollar": 182.02, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Ms State Emplo", "plan_name": "401457", "standard_charge_percentage": 0.80, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Ms State Emplo", "plan_name": "401457_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Basic Pl", "plan_name": "400100", "standard_charge_percentage": 0.85, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Basic Pl", "plan_name": "400100_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Federal", "plan_name": "400110", "standard_charge_percentage": 0.85, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Federal", "plan_name": "400110_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Cigna Healthsprings Ffs", "plan_name": "500064", "standard_charge_dollar": 182.02, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Conseco", "plan_name": "500302", "standard_charge_dollar": 182.02, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Humana Ffs 61101", "plan_name": "500006", "standard_charge_dollar": 182.02, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Medicare A", "plan_name": "100100", "standard_charge_dollar": 182.02, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Medicare A", "plan_name": "100500", "standard_charge_dollar": 182.02, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Medicare Part B Only", "plan_name": "100300", "standard_charge_dollar": 182.02, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Medicare Railroad", "plan_name": "100103", "standard_charge_dollar": 182.02, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Ms Physicians Care N", "plan_name": "714210", "standard_charge_dollar": 227.53, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Peoples Hlth Ffs 72126", "plan_name": "500019", "standard_charge_dollar": 182.02, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Uhc/Secure Horizons", "plan_name": "500449", "standard_charge_dollar": 182.02, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "United Health Care/", "plan_name": "500292", "standard_charge_dollar": 205.69, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "United Healthcare", "plan_name": "750104", "standard_charge_dollar": 205.69, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "United Healthcare Ba", "plan_name": "750090", "standard_charge_dollar": 205.69, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "United Healthcare Me", "plan_name": "501310", "standard_charge_dollar": 182.02, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Windsor Mcare Extra", "plan_name": "500778", "standard_charge_dollar": 182.02, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." } ] } ] }, { "description": "Destruction of skin lesions", "code_information": [ { "code": "17282", "type": "CPT" } ], "standard_charges": [ { "gross_charge": 1988.27, "minimum": 182.02, "maximum": 1690.03, "setting": "inpatient", "payers_information": [ { "payer_name": "Aarp", "plan_name": "500102", "standard_charge_dollar": 182.02, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna", "plan_name": "700700", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna", "plan_name": "700700_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Mcare Ffs 6005", "plan_name": "700703", "standard_charge_dollar": 182.02, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Miscellaneous", "plan_name": "700720", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Miscellaneous", "plan_name": "700720_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Ppo Hmo", "plan_name": "701720", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Ppo Hmo", "plan_name": "701720_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Ambetter 68069", "plan_name": "500516", "standard_charge_dollar": 182.02, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Ms State Emplo", "plan_name": "401457", "standard_charge_percentage": 0.80, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Ms State Emplo", "plan_name": "401457_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Basic Pl", "plan_name": "400100", "standard_charge_percentage": 0.85, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Basic Pl", "plan_name": "400100_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Federal", "plan_name": "400110", "standard_charge_percentage": 0.85, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Federal", "plan_name": "400110_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Cigna Healthsprings Ffs", "plan_name": "500064", "standard_charge_dollar": 182.02, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Conseco", "plan_name": "500302", "standard_charge_dollar": 182.02, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Humana Ffs 61101", "plan_name": "500006", "standard_charge_dollar": 182.02, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Medicare A", "plan_name": "100100", "standard_charge_dollar": 182.02, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Medicare A", "plan_name": "100500", "standard_charge_dollar": 182.02, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Medicare Part B Only", "plan_name": "100300", "standard_charge_dollar": 182.02, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Medicare Railroad", "plan_name": "100103", "standard_charge_dollar": 182.02, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Ms Physicians Care N", "plan_name": "714210", "standard_charge_dollar": 227.53, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Peoples Hlth Ffs 72126", "plan_name": "500019", "standard_charge_dollar": 182.02, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Uhc/Secure Horizons", "plan_name": "500449", "standard_charge_dollar": 182.02, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "United Health Care/", "plan_name": "500292", "standard_charge_dollar": 205.69, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "United Healthcare", "plan_name": "750104", "standard_charge_dollar": 205.69, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "United Healthcare Ba", "plan_name": "750090", "standard_charge_dollar": 205.69, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "United Healthcare Me", "plan_name": "501310", "standard_charge_dollar": 182.02, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Windsor Mcare Extra", "plan_name": "500778", "standard_charge_dollar": 182.02, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." } ] } ] }, { "description": "Destruction of skin lesions", "code_information": [ { "code": "17283", "type": "CPT" } ], "standard_charges": [ { "gross_charge": 1988.27, "minimum": 366.00, "maximum": 1690.03, "setting": "inpatient", "payers_information": [ { "payer_name": "Aarp", "plan_name": "500102", "standard_charge_dollar": 366.00, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna", "plan_name": "700700", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna", "plan_name": "700700_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Mcare Ffs 6005", "plan_name": "700703", "standard_charge_dollar": 366.00, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Miscellaneous", "plan_name": "700720", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Miscellaneous", "plan_name": "700720_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Ppo Hmo", "plan_name": "701720", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Ppo Hmo", "plan_name": "701720_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Ambetter 68069", "plan_name": "500516", "standard_charge_dollar": 366.00, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Ms State Emplo", "plan_name": "401457", "standard_charge_percentage": 0.80, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Ms State Emplo", "plan_name": "401457_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Basic Pl", "plan_name": "400100", "standard_charge_percentage": 0.85, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Basic Pl", "plan_name": "400100_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Federal", "plan_name": "400110", "standard_charge_percentage": 0.85, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Federal", "plan_name": "400110_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Cigna Healthsprings Ffs", "plan_name": "500064", "standard_charge_dollar": 366.00, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Conseco", "plan_name": "500302", "standard_charge_dollar": 366.00, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Humana Ffs 61101", "plan_name": "500006", "standard_charge_dollar": 366.00, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Medicare A", "plan_name": "100100", "standard_charge_dollar": 366.00, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Medicare A", "plan_name": "100500", "standard_charge_dollar": 366.00, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Medicare Part B Only", "plan_name": "100300", "standard_charge_dollar": 366.00, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Medicare Railroad", "plan_name": "100103", "standard_charge_dollar": 366.00, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Ms Physicians Care N", "plan_name": "714210", "standard_charge_dollar": 457.50, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Peoples Hlth Ffs 72126", "plan_name": "500019", "standard_charge_dollar": 366.00, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Uhc/Secure Horizons", "plan_name": "500449", "standard_charge_dollar": 366.00, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "United Health Care/", "plan_name": "500292", "standard_charge_dollar": 413.58, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "United Healthcare", "plan_name": "750104", "standard_charge_dollar": 413.58, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "United Healthcare Ba", "plan_name": "750090", "standard_charge_dollar": 413.58, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "United Healthcare Me", "plan_name": "501310", "standard_charge_dollar": 366.00, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Windsor Mcare Extra", "plan_name": "500778", "standard_charge_dollar": 366.00, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." } ] } ] }, { "description": "Destruction of skin lesions", "code_information": [ { "code": "17284", "type": "CPT" } ], "standard_charges": [ { "gross_charge": 1988.27, "minimum": 560.75, "maximum": 1690.03, "setting": "inpatient", "payers_information": [ { "payer_name": "Aarp", "plan_name": "500102", "standard_charge_dollar": 560.75, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna", "plan_name": "700700", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna", "plan_name": "700700_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Mcare Ffs 6005", "plan_name": "700703", "standard_charge_dollar": 560.75, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Miscellaneous", "plan_name": "700720", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Miscellaneous", "plan_name": "700720_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Ppo Hmo", "plan_name": "701720", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Ppo Hmo", "plan_name": "701720_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Ambetter 68069", "plan_name": "500516", "standard_charge_dollar": 560.75, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Ms State Emplo", "plan_name": "401457", "standard_charge_percentage": 0.80, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Ms State Emplo", "plan_name": "401457_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Basic Pl", "plan_name": "400100", "standard_charge_percentage": 0.85, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Basic Pl", "plan_name": "400100_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Federal", "plan_name": "400110", "standard_charge_percentage": 0.85, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Federal", "plan_name": "400110_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Cigna Healthsprings Ffs", "plan_name": "500064", "standard_charge_dollar": 560.75, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Conseco", "plan_name": "500302", "standard_charge_dollar": 560.75, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Humana Ffs 61101", "plan_name": "500006", "standard_charge_dollar": 560.75, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Medicare A", "plan_name": "100100", "standard_charge_dollar": 560.75, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Medicare A", "plan_name": "100500", "standard_charge_dollar": 560.75, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Medicare Part B Only", "plan_name": "100300", "standard_charge_dollar": 560.75, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Medicare Railroad", "plan_name": "100103", "standard_charge_dollar": 560.75, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Ms Physicians Care N", "plan_name": "714210", "standard_charge_dollar": 700.94, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Peoples Hlth Ffs 72126", "plan_name": "500019", "standard_charge_dollar": 560.75, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Uhc/Secure Horizons", "plan_name": "500449", "standard_charge_dollar": 560.75, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "United Health Care/", "plan_name": "500292", "standard_charge_dollar": 633.65, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "United Healthcare", "plan_name": "750104", "standard_charge_dollar": 633.65, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "United Healthcare Ba", "plan_name": "750090", "standard_charge_dollar": 633.65, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "United Healthcare Me", "plan_name": "501310", "standard_charge_dollar": 560.75, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Windsor Mcare Extra", "plan_name": "500778", "standard_charge_dollar": 560.75, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." } ] } ] }, { "description": "Destruction of skin lesions", "code_information": [ { "code": "17286", "type": "CPT" } ], "standard_charges": [ { "gross_charge": 1988.27, "minimum": 560.75, "maximum": 1690.03, "setting": "inpatient", "payers_information": [ { "payer_name": "Aarp", "plan_name": "500102", "standard_charge_dollar": 560.75, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna", "plan_name": "700700", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna", "plan_name": "700700_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Mcare Ffs 6005", "plan_name": "700703", "standard_charge_dollar": 560.75, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Miscellaneous", "plan_name": "700720", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Miscellaneous", "plan_name": "700720_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Ppo Hmo", "plan_name": "701720", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Ppo Hmo", "plan_name": "701720_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Ambetter 68069", "plan_name": "500516", "standard_charge_dollar": 560.75, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Ms State Emplo", "plan_name": "401457", "standard_charge_percentage": 0.80, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Ms State Emplo", "plan_name": "401457_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Basic Pl", "plan_name": "400100", "standard_charge_percentage": 0.85, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Basic Pl", "plan_name": "400100_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Federal", "plan_name": "400110", "standard_charge_percentage": 0.85, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Federal", "plan_name": "400110_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Cigna Healthsprings Ffs", "plan_name": "500064", "standard_charge_dollar": 560.75, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Conseco", "plan_name": "500302", "standard_charge_dollar": 560.75, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Humana Ffs 61101", "plan_name": "500006", "standard_charge_dollar": 560.75, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Medicare A", "plan_name": "100100", "standard_charge_dollar": 560.75, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Medicare A", "plan_name": "100500", "standard_charge_dollar": 560.75, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Medicare Part B Only", "plan_name": "100300", "standard_charge_dollar": 560.75, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Medicare Railroad", "plan_name": "100103", "standard_charge_dollar": 560.75, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Ms Physicians Care N", "plan_name": "714210", "standard_charge_dollar": 700.94, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Peoples Hlth Ffs 72126", "plan_name": "500019", "standard_charge_dollar": 560.75, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Uhc/Secure Horizons", "plan_name": "500449", "standard_charge_dollar": 560.75, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "United Health Care/", "plan_name": "500292", "standard_charge_dollar": 633.65, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "United Healthcare", "plan_name": "750104", "standard_charge_dollar": 633.65, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "United Healthcare Ba", "plan_name": "750090", "standard_charge_dollar": 633.65, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "United Healthcare Me", "plan_name": "501310", "standard_charge_dollar": 560.75, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Windsor Mcare Extra", "plan_name": "500778", "standard_charge_dollar": 560.75, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." } ] } ] }, { "description": "Mohs 1 stage h/n/hf/g", "code_information": [ { "code": "17311", "type": "CPT" } ], "standard_charges": [ { "gross_charge": 28884.87, "minimum": 560.75, "maximum": 24552.14, "setting": "inpatient", "payers_information": [ { "payer_name": "Aarp", "plan_name": "500102", "standard_charge_dollar": 560.75, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna", "plan_name": "700700", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna", "plan_name": "700700_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Mcare Ffs 6005", "plan_name": "700703", "standard_charge_dollar": 560.75, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Miscellaneous", "plan_name": "700720", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Miscellaneous", "plan_name": "700720_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Ppo Hmo", "plan_name": "701720", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Ppo Hmo", "plan_name": "701720_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Ambetter 68069", "plan_name": "500516", "standard_charge_dollar": 560.75, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Ms State Emplo", "plan_name": "401457", "standard_charge_percentage": 0.80, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Ms State Emplo", "plan_name": "401457_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Basic Pl", "plan_name": "400100", "standard_charge_percentage": 0.85, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Basic Pl", "plan_name": "400100_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Federal", "plan_name": "400110", "standard_charge_percentage": 0.85, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Federal", "plan_name": "400110_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Cigna Healthsprings Ffs", "plan_name": "500064", "standard_charge_dollar": 560.75, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Conseco", "plan_name": "500302", "standard_charge_dollar": 560.75, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Humana Ffs 61101", "plan_name": "500006", "standard_charge_dollar": 560.75, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Medicare A", "plan_name": "100100", "standard_charge_dollar": 560.75, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Medicare A", "plan_name": "100500", "standard_charge_dollar": 560.75, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Medicare Part B Only", "plan_name": "100300", "standard_charge_dollar": 560.75, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Medicare Railroad", "plan_name": "100103", "standard_charge_dollar": 560.75, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Ms Physicians Care N", "plan_name": "714210", "standard_charge_dollar": 700.94, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Peoples Hlth Ffs 72126", "plan_name": "500019", "standard_charge_dollar": 560.75, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Uhc/Secure Horizons", "plan_name": "500449", "standard_charge_dollar": 560.75, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "United Health Care/", "plan_name": "500292", "standard_charge_dollar": 633.65, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "United Healthcare", "plan_name": "750104", "standard_charge_dollar": 633.65, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "United Healthcare Ba", "plan_name": "750090", "standard_charge_dollar": 633.65, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "United Healthcare Me", "plan_name": "501310", "standard_charge_dollar": 560.75, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Windsor Mcare Extra", "plan_name": "500778", "standard_charge_dollar": 560.75, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." } ] } ] }, { "description": "Mohs addl stage", "code_information": [ { "code": "17312", "type": "CPT" } ], "standard_charges": [ { "gross_charge": 28884.87, "minimum": 23107.90, "maximum": 24552.14, "setting": "inpatient", "payers_information": [ { "payer_name": "Aetna", "plan_name": "700700", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna", "plan_name": "700700_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Miscellaneous", "plan_name": "700720", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Miscellaneous", "plan_name": "700720_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Ppo Hmo", "plan_name": "701720", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Ppo Hmo", "plan_name": "701720_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Ms State Emplo", "plan_name": "401457", "standard_charge_percentage": 0.80, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Ms State Emplo", "plan_name": "401457_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Basic Pl", "plan_name": "400100", "standard_charge_percentage": 0.85, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Basic Pl", "plan_name": "400100_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Federal", "plan_name": "400110", "standard_charge_percentage": 0.85, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Federal", "plan_name": "400110_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." } ] } ] }, { "description": "Mohs 1 stage t/a/l", "code_information": [ { "code": "17313", "type": "CPT" } ], "standard_charges": [ { "gross_charge": 21836.76, "minimum": 560.75, "maximum": 18561.25, "setting": "inpatient", "payers_information": [ { "payer_name": "Aarp", "plan_name": "500102", "standard_charge_dollar": 560.75, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna", "plan_name": "700700", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna", "plan_name": "700700_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Mcare Ffs 6005", "plan_name": "700703", "standard_charge_dollar": 560.75, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Miscellaneous", "plan_name": "700720", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Miscellaneous", "plan_name": "700720_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Ppo Hmo", "plan_name": "701720", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Ppo Hmo", "plan_name": "701720_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Ambetter 68069", "plan_name": "500516", "standard_charge_dollar": 560.75, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Ms State Emplo", "plan_name": "401457", "standard_charge_percentage": 0.80, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Ms State Emplo", "plan_name": "401457_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Basic Pl", "plan_name": "400100", "standard_charge_percentage": 0.85, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Basic Pl", "plan_name": "400100_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Federal", "plan_name": "400110", "standard_charge_percentage": 0.85, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Federal", "plan_name": "400110_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Cigna Healthsprings Ffs", "plan_name": "500064", "standard_charge_dollar": 560.75, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Conseco", "plan_name": "500302", "standard_charge_dollar": 560.75, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Humana Ffs 61101", "plan_name": "500006", "standard_charge_dollar": 560.75, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Medicare A", "plan_name": "100100", "standard_charge_dollar": 560.75, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Medicare A", "plan_name": "100500", "standard_charge_dollar": 560.75, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Medicare Part B Only", "plan_name": "100300", "standard_charge_dollar": 560.75, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Medicare Railroad", "plan_name": "100103", "standard_charge_dollar": 560.75, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Ms Physicians Care N", "plan_name": "714210", "standard_charge_dollar": 700.94, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Peoples Hlth Ffs 72126", "plan_name": "500019", "standard_charge_dollar": 560.75, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Uhc/Secure Horizons", "plan_name": "500449", "standard_charge_dollar": 560.75, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "United Health Care/", "plan_name": "500292", "standard_charge_dollar": 633.65, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "United Healthcare", "plan_name": "750104", "standard_charge_dollar": 633.65, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "United Healthcare Ba", "plan_name": "750090", "standard_charge_dollar": 633.65, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "United Healthcare Me", "plan_name": "501310", "standard_charge_dollar": 560.75, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Windsor Mcare Extra", "plan_name": "500778", "standard_charge_dollar": 560.75, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." } ] } ] }, { "description": "Mohs addl stage t/a/l", "code_information": [ { "code": "17314", "type": "CPT" } ], "standard_charges": [ { "gross_charge": 21836.76, "minimum": 17469.41, "maximum": 18561.25, "setting": "inpatient", "payers_information": [ { "payer_name": "Aetna", "plan_name": "700700", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna", "plan_name": "700700_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Miscellaneous", "plan_name": "700720", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Miscellaneous", "plan_name": "700720_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Ppo Hmo", "plan_name": "701720", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Ppo Hmo", "plan_name": "701720_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Ms State Emplo", "plan_name": "401457", "standard_charge_percentage": 0.80, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Ms State Emplo", "plan_name": "401457_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Basic Pl", "plan_name": "400100", "standard_charge_percentage": 0.85, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Basic Pl", "plan_name": "400100_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Federal", "plan_name": "400110", "standard_charge_percentage": 0.85, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Federal", "plan_name": "400110_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." } ] } ] }, { "description": "Mohs surg addl block", "code_information": [ { "code": "17315", "type": "CPT" } ], "standard_charges": [ { "gross_charge": 26535.50, "minimum": 21228.40, "maximum": 22555.18, "setting": "inpatient", "payers_information": [ { "payer_name": "Aetna", "plan_name": "700700", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna", "plan_name": "700700_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Miscellaneous", "plan_name": "700720", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Miscellaneous", "plan_name": "700720_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Ppo Hmo", "plan_name": "701720", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Ppo Hmo", "plan_name": "701720_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Ms State Emplo", "plan_name": "401457", "standard_charge_percentage": 0.80, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Ms State Emplo", "plan_name": "401457_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Basic Pl", "plan_name": "400100", "standard_charge_percentage": 0.85, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Basic Pl", "plan_name": "400100_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Federal", "plan_name": "400110", "standard_charge_percentage": 0.85, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Federal", "plan_name": "400110_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." } ] } ] }, { "description": "Hc skin tissue procedure", "code_information": [ { "code": "17999", "type": "CPT" } ], "standard_charges": [ { "gross_charge": 406.00, "minimum": 182.02, "maximum": 229.58, "setting": "both", "payers_information": [ { "payer_name": "Aarp", "plan_name": "500102", "standard_charge_dollar": 182.02, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna", "plan_name": "700700", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna", "plan_name": "700700_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Mcare Ffs 6005", "plan_name": "700703", "standard_charge_dollar": 182.02, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Miscellaneous", "plan_name": "700720", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Miscellaneous", "plan_name": "700720_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Ppo Hmo", "plan_name": "701720", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Ppo Hmo", "plan_name": "701720_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Ambetter 68069", "plan_name": "500516", "standard_charge_dollar": 182.02, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Ms State Emplo", "plan_name": "401457", "standard_charge_dollar": 229.58, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Ms State Emplo", "plan_name": "401457_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Basic Pl", "plan_name": "400100", "standard_charge_dollar": 229.58, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Basic Pl", "plan_name": "400100_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Federal", "plan_name": "400110", "standard_charge_dollar": 229.58, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Federal", "plan_name": "400110_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Cigna Healthsprings Ffs", "plan_name": "500064", "standard_charge_dollar": 182.02, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Conseco", "plan_name": "500302", "standard_charge_dollar": 182.02, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Humana Ffs 61101", "plan_name": "500006", "standard_charge_dollar": 182.02, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Medicare A", "plan_name": "100100", "standard_charge_dollar": 182.02, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Medicare A", "plan_name": "100500", "standard_charge_dollar": 182.02, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Medicare Part B Only", "plan_name": "100300", "standard_charge_dollar": 182.02, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Medicare Railroad", "plan_name": "100103", "standard_charge_dollar": 182.02, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Ms Physicians Care N", "plan_name": "714210", "standard_charge_dollar": 227.53, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Peoples Hlth Ffs 72126", "plan_name": "500019", "standard_charge_dollar": 182.02, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Uhc/Secure Horizons", "plan_name": "500449", "standard_charge_dollar": 182.02, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "United Health Care/", "plan_name": "500292", "standard_charge_dollar": 205.69, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "United Healthcare", "plan_name": "750104", "standard_charge_dollar": 205.69, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "United Healthcare Ba", "plan_name": "750090", "standard_charge_dollar": 205.69, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "United Healthcare Me", "plan_name": "501310", "standard_charge_dollar": 182.02, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Windsor Mcare Extra", "plan_name": "500778", "standard_charge_dollar": 182.02, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." } ] } ] }, { "description": "Skin tissue procedure", "code_information": [ { "code": "17999", "type": "CPT" } ], "standard_charges": [ { "gross_charge": 406.00, "minimum": 182.02, "maximum": 229.58, "setting": "both", "payers_information": [ { "payer_name": "Aarp", "plan_name": "500102", "standard_charge_dollar": 182.02, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna", "plan_name": "700700", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna", "plan_name": "700700_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Mcare Ffs 6005", "plan_name": "700703", "standard_charge_dollar": 182.02, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Miscellaneous", "plan_name": "700720", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Miscellaneous", "plan_name": "700720_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Ppo Hmo", "plan_name": "701720", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Ppo Hmo", "plan_name": "701720_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Ambetter 68069", "plan_name": "500516", "standard_charge_dollar": 182.02, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Ms State Emplo", "plan_name": "401457", "standard_charge_dollar": 229.58, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Ms State Emplo", "plan_name": "401457_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Basic Pl", "plan_name": "400100", "standard_charge_dollar": 229.58, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Basic Pl", "plan_name": "400100_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Federal", "plan_name": "400110", "standard_charge_dollar": 229.58, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Federal", "plan_name": "400110_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Cigna Healthsprings Ffs", "plan_name": "500064", "standard_charge_dollar": 182.02, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Conseco", "plan_name": "500302", "standard_charge_dollar": 182.02, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Humana Ffs 61101", "plan_name": "500006", "standard_charge_dollar": 182.02, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Medicare A", "plan_name": "100100", "standard_charge_dollar": 182.02, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Medicare A", "plan_name": "100500", "standard_charge_dollar": 182.02, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Medicare Part B Only", "plan_name": "100300", "standard_charge_dollar": 182.02, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Medicare Railroad", "plan_name": "100103", "standard_charge_dollar": 182.02, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Ms Physicians Care N", "plan_name": "714210", "standard_charge_dollar": 227.53, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Peoples Hlth Ffs 72126", "plan_name": "500019", "standard_charge_dollar": 182.02, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Uhc/Secure Horizons", "plan_name": "500449", "standard_charge_dollar": 182.02, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "United Health Care/", "plan_name": "500292", "standard_charge_dollar": 205.69, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "United Healthcare", "plan_name": "750104", "standard_charge_dollar": 205.69, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "United Healthcare Ba", "plan_name": "750090", "standard_charge_dollar": 205.69, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "United Healthcare Me", "plan_name": "501310", "standard_charge_dollar": 182.02, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Windsor Mcare Extra", "plan_name": "500778", "standard_charge_dollar": 182.02, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." } ] } ] }, { "description": "Incision of breast lesion", "code_information": [ { "code": "19020", "type": "CPT" } ], "standard_charges": [ { "gross_charge": 18287.30, "minimum": 1484.25, "maximum": 15544.21, "setting": "inpatient", "payers_information": [ { "payer_name": "Aarp", "plan_name": "500102", "standard_charge_dollar": 1484.25, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna", "plan_name": "700700", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna", "plan_name": "700700_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Mcare Ffs 6005", "plan_name": "700703", "standard_charge_dollar": 1484.25, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Miscellaneous", "plan_name": "700720", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Miscellaneous", "plan_name": "700720_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Ppo Hmo", "plan_name": "701720", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Ppo Hmo", "plan_name": "701720_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Ambetter 68069", "plan_name": "500516", "standard_charge_dollar": 1484.25, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Ms State Emplo", "plan_name": "401457", "standard_charge_percentage": 0.80, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Ms State Emplo", "plan_name": "401457_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Basic Pl", "plan_name": "400100", "standard_charge_percentage": 0.85, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Basic Pl", "plan_name": "400100_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Federal", "plan_name": "400110", "standard_charge_percentage": 0.85, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Federal", "plan_name": "400110_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Cigna Healthsprings Ffs", "plan_name": "500064", "standard_charge_dollar": 1484.25, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Conseco", "plan_name": "500302", "standard_charge_dollar": 1484.25, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Humana Ffs 61101", "plan_name": "500006", "standard_charge_dollar": 1484.25, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Medicare A", "plan_name": "100100", "standard_charge_dollar": 1484.25, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Medicare A", "plan_name": "100500", "standard_charge_dollar": 1484.25, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Medicare Part B Only", "plan_name": "100300", "standard_charge_dollar": 1484.25, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Medicare Railroad", "plan_name": "100103", "standard_charge_dollar": 1484.25, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Ms Physicians Care N", "plan_name": "714210", "standard_charge_dollar": 1855.31, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Peoples Hlth Ffs 72126", "plan_name": "500019", "standard_charge_dollar": 1484.25, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Uhc/Secure Horizons", "plan_name": "500449", "standard_charge_dollar": 1484.25, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "United Health Care/", "plan_name": "500292", "standard_charge_dollar": 1677.20, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "United Healthcare", "plan_name": "750104", "standard_charge_dollar": 1677.20, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "United Healthcare Ba", "plan_name": "750090", "standard_charge_dollar": 1677.20, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "United Healthcare Me", "plan_name": "501310", "standard_charge_dollar": 1484.25, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Windsor Mcare Extra", "plan_name": "500778", "standard_charge_dollar": 1484.25, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." } ] } ] }, { "description": "Mast simple complete", "code_information": [ { "code": "19303", "type": "CPT" } ], "standard_charges": [ { "gross_charge": 17721.17, "minimum": 5974.11, "maximum": 15062.99, "setting": "inpatient", "payers_information": [ { "payer_name": "Aarp", "plan_name": "500102", "standard_charge_dollar": 5974.11, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna", "plan_name": "700700", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna", "plan_name": "700700_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Mcare Ffs 6005", "plan_name": "700703", "standard_charge_dollar": 5974.11, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Miscellaneous", "plan_name": "700720", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Miscellaneous", "plan_name": "700720_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Ppo Hmo", "plan_name": "701720", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Ppo Hmo", "plan_name": "701720_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Ambetter 68069", "plan_name": "500516", "standard_charge_dollar": 5974.11, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Ms State Emplo", "plan_name": "401457", "standard_charge_percentage": 0.80, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Ms State Emplo", "plan_name": "401457_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Basic Pl", "plan_name": "400100", "standard_charge_percentage": 0.85, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Basic Pl", "plan_name": "400100_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Federal", "plan_name": "400110", "standard_charge_percentage": 0.85, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Federal", "plan_name": "400110_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Cigna Healthsprings Ffs", "plan_name": "500064", "standard_charge_dollar": 5974.11, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Conseco", "plan_name": "500302", "standard_charge_dollar": 5974.11, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Humana Ffs 61101", "plan_name": "500006", "standard_charge_dollar": 5974.11, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Medicare A", "plan_name": "100100", "standard_charge_dollar": 5974.11, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Medicare A", "plan_name": "100500", "standard_charge_dollar": 5974.11, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Medicare Part B Only", "plan_name": "100300", "standard_charge_dollar": 5974.11, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Medicare Railroad", "plan_name": "100103", "standard_charge_dollar": 5974.11, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Ms Physicians Care N", "plan_name": "714210", "standard_charge_dollar": 7467.64, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Peoples Hlth Ffs 72126", "plan_name": "500019", "standard_charge_dollar": 5974.11, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Uhc/Secure Horizons", "plan_name": "500449", "standard_charge_dollar": 5974.11, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "United Health Care/", "plan_name": "500292", "standard_charge_dollar": 6750.74, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "United Healthcare", "plan_name": "750104", "standard_charge_dollar": 6750.74, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "United Healthcare Ba", "plan_name": "750090", "standard_charge_dollar": 6750.74, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "United Healthcare Me", "plan_name": "501310", "standard_charge_dollar": 5974.11, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Windsor Mcare Extra", "plan_name": "500778", "standard_charge_dollar": 5974.11, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." } ] } ] }, { "description": "Mast radical", "code_information": [ { "code": "19305", "type": "CPT" } ], "standard_charges": [ { "gross_charge": 17721.17, "minimum": 14176.94, "maximum": 15062.99, "setting": "inpatient", "payers_information": [ { "payer_name": "Aetna", "plan_name": "700700", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna", "plan_name": "700700_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Miscellaneous", "plan_name": "700720", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Miscellaneous", "plan_name": "700720_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Ppo Hmo", "plan_name": "701720", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Ppo Hmo", "plan_name": "701720_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Ms State Emplo", "plan_name": "401457", "standard_charge_percentage": 0.80, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Ms State Emplo", "plan_name": "401457_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Basic Pl", "plan_name": "400100", "standard_charge_percentage": 0.85, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Basic Pl", "plan_name": "400100_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Federal", "plan_name": "400110", "standard_charge_percentage": 0.85, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Federal", "plan_name": "400110_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." } ] } ] }, { "description": "Mast rad urban type", "code_information": [ { "code": "19306", "type": "CPT" } ], "standard_charges": [ { "gross_charge": 17721.17, "minimum": 14176.94, "maximum": 15062.99, "setting": "inpatient", "payers_information": [ { "payer_name": "Aetna", "plan_name": "700700", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna", "plan_name": "700700_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Miscellaneous", "plan_name": "700720", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Miscellaneous", "plan_name": "700720_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Ppo Hmo", "plan_name": "701720", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Ppo Hmo", "plan_name": "701720_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Ms State Emplo", "plan_name": "401457", "standard_charge_percentage": 0.80, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Ms State Emplo", "plan_name": "401457_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Basic Pl", "plan_name": "400100", "standard_charge_percentage": 0.85, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Basic Pl", "plan_name": "400100_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Federal", "plan_name": "400110", "standard_charge_percentage": 0.85, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Federal", "plan_name": "400110_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." } ] } ] }, { "description": "Mast mod rad", "code_information": [ { "code": "19307", "type": "CPT" } ], "standard_charges": [ { "gross_charge": 17721.17, "minimum": 5974.11, "maximum": 15062.99, "setting": "inpatient", "payers_information": [ { "payer_name": "Aarp", "plan_name": "500102", "standard_charge_dollar": 5974.11, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna", "plan_name": "700700", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna", "plan_name": "700700_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Mcare Ffs 6005", "plan_name": "700703", "standard_charge_dollar": 5974.11, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Miscellaneous", "plan_name": "700720", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Miscellaneous", "plan_name": "700720_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Ppo Hmo", "plan_name": "701720", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Ppo Hmo", "plan_name": "701720_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Ambetter 68069", "plan_name": "500516", "standard_charge_dollar": 5974.11, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Ms State Emplo", "plan_name": "401457", "standard_charge_percentage": 0.80, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Ms State Emplo", "plan_name": "401457_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Basic Pl", "plan_name": "400100", "standard_charge_percentage": 0.85, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Basic Pl", "plan_name": "400100_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Federal", "plan_name": "400110", "standard_charge_percentage": 0.85, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Federal", "plan_name": "400110_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Cigna Healthsprings Ffs", "plan_name": "500064", "standard_charge_dollar": 5974.11, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Conseco", "plan_name": "500302", "standard_charge_dollar": 5974.11, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Humana Ffs 61101", "plan_name": "500006", "standard_charge_dollar": 5974.11, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Medicare A", "plan_name": "100100", "standard_charge_dollar": 5974.11, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Medicare A", "plan_name": "100500", "standard_charge_dollar": 5974.11, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Medicare Part B Only", "plan_name": "100300", "standard_charge_dollar": 5974.11, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Medicare Railroad", "plan_name": "100103", "standard_charge_dollar": 5974.11, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Ms Physicians Care N", "plan_name": "714210", "standard_charge_dollar": 7467.64, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Peoples Hlth Ffs 72126", "plan_name": "500019", "standard_charge_dollar": 5974.11, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Uhc/Secure Horizons", "plan_name": "500449", "standard_charge_dollar": 5974.11, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "United Health Care/", "plan_name": "500292", "standard_charge_dollar": 6750.74, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "United Healthcare", "plan_name": "750104", "standard_charge_dollar": 6750.74, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "United Healthcare Ba", "plan_name": "750090", "standard_charge_dollar": 6750.74, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "United Healthcare Me", "plan_name": "501310", "standard_charge_dollar": 5974.11, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Windsor Mcare Extra", "plan_name": "500778", "standard_charge_dollar": 5974.11, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." } ] } ] }, { "description": "Explore wound abdomen", "code_information": [ { "code": "20102", "type": "CPT" } ], "standard_charges": [ { "gross_charge": 32534.83, "minimum": 1675.70, "maximum": 27654.61, "setting": "inpatient", "payers_information": [ { "payer_name": "Aarp", "plan_name": "500102", "standard_charge_dollar": 1675.70, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna", "plan_name": "700700", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna", "plan_name": "700700_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Mcare Ffs 6005", "plan_name": "700703", "standard_charge_dollar": 1675.70, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Miscellaneous", "plan_name": "700720", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Miscellaneous", "plan_name": "700720_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Ppo Hmo", "plan_name": "701720", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Ppo Hmo", "plan_name": "701720_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Ambetter 68069", "plan_name": "500516", "standard_charge_dollar": 1675.70, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Ms State Emplo", "plan_name": "401457", "standard_charge_percentage": 0.80, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Ms State Emplo", "plan_name": "401457_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Basic Pl", "plan_name": "400100", "standard_charge_percentage": 0.85, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Basic Pl", "plan_name": "400100_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Federal", "plan_name": "400110", "standard_charge_percentage": 0.85, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Federal", "plan_name": "400110_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Cigna Healthsprings Ffs", "plan_name": "500064", "standard_charge_dollar": 1675.70, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Conseco", "plan_name": "500302", "standard_charge_dollar": 1675.70, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Humana Ffs 61101", "plan_name": "500006", "standard_charge_dollar": 1675.70, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Medicare A", "plan_name": "100100", "standard_charge_dollar": 1675.70, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Medicare A", "plan_name": "100500", "standard_charge_dollar": 1675.70, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Medicare Part B Only", "plan_name": "100300", "standard_charge_dollar": 1675.70, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Medicare Railroad", "plan_name": "100103", "standard_charge_dollar": 1675.70, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Ms Physicians Care N", "plan_name": "714210", "standard_charge_dollar": 2094.63, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Peoples Hlth Ffs 72126", "plan_name": "500019", "standard_charge_dollar": 1675.70, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Uhc/Secure Horizons", "plan_name": "500449", "standard_charge_dollar": 1675.70, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "United Health Care/", "plan_name": "500292", "standard_charge_dollar": 1893.54, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "United Healthcare", "plan_name": "750104", "standard_charge_dollar": 1893.54, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "United Healthcare Ba", "plan_name": "750090", "standard_charge_dollar": 1893.54, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "United Healthcare Me", "plan_name": "501310", "standard_charge_dollar": 1675.70, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Windsor Mcare Extra", "plan_name": "500778", "standard_charge_dollar": 1675.70, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." } ] } ] }, { "description": "Excise epiphyseal bar", "code_information": [ { "code": "20150", "type": "CPT" } ], "standard_charges": [ { "gross_charge": 27897.12, "minimum": 2972.29, "maximum": 23712.55, "setting": "inpatient", "payers_information": [ { "payer_name": "Aarp", "plan_name": "500102", "standard_charge_dollar": 2972.29, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna", "plan_name": "700700", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna", "plan_name": "700700_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Mcare Ffs 6005", "plan_name": "700703", "standard_charge_dollar": 2972.29, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Miscellaneous", "plan_name": "700720", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Miscellaneous", "plan_name": "700720_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Ppo Hmo", "plan_name": "701720", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Ppo Hmo", "plan_name": "701720_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Ambetter 68069", "plan_name": "500516", "standard_charge_dollar": 2972.29, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Ms State Emplo", "plan_name": "401457", "standard_charge_percentage": 0.80, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Ms State Emplo", "plan_name": "401457_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Basic Pl", "plan_name": "400100", "standard_charge_percentage": 0.85, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Basic Pl", "plan_name": "400100_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Federal", "plan_name": "400110", "standard_charge_percentage": 0.85, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Federal", "plan_name": "400110_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Cigna Healthsprings Ffs", "plan_name": "500064", "standard_charge_dollar": 2972.29, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Conseco", "plan_name": "500302", "standard_charge_dollar": 2972.29, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Humana Ffs 61101", "plan_name": "500006", "standard_charge_dollar": 2972.29, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Medicare A", "plan_name": "100100", "standard_charge_dollar": 2972.29, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Medicare A", "plan_name": "100500", "standard_charge_dollar": 2972.29, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Medicare Part B Only", "plan_name": "100300", "standard_charge_dollar": 2972.29, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Medicare Railroad", "plan_name": "100103", "standard_charge_dollar": 2972.29, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Ms Physicians Care N", "plan_name": "714210", "standard_charge_dollar": 3715.36, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Peoples Hlth Ffs 72126", "plan_name": "500019", "standard_charge_dollar": 2972.29, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Uhc/Secure Horizons", "plan_name": "500449", "standard_charge_dollar": 2972.29, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "United Health Care/", "plan_name": "500292", "standard_charge_dollar": 3358.68, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "United Healthcare", "plan_name": "750104", "standard_charge_dollar": 3358.68, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "United Healthcare Ba", "plan_name": "750090", "standard_charge_dollar": 3358.68, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "United Healthcare Me", "plan_name": "501310", "standard_charge_dollar": 2972.29, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Windsor Mcare Extra", "plan_name": "500778", "standard_charge_dollar": 2972.29, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." } ] } ] }, { "description": "Bone biopsy trocar/needle", "code_information": [ { "code": "20220", "type": "CPT" } ], "standard_charges": [ { "gross_charge": 22646.08, "minimum": 1484.25, "maximum": 19249.17, "setting": "inpatient", "payers_information": [ { "payer_name": "Aarp", "plan_name": "500102", "standard_charge_dollar": 1484.25, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna", "plan_name": "700700", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna", "plan_name": "700700_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Mcare Ffs 6005", "plan_name": "700703", "standard_charge_dollar": 1484.25, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Miscellaneous", "plan_name": "700720", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Miscellaneous", "plan_name": "700720_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Ppo Hmo", "plan_name": "701720", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Ppo Hmo", "plan_name": "701720_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Ambetter 68069", "plan_name": "500516", "standard_charge_dollar": 1484.25, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Ms State Emplo", "plan_name": "401457", "standard_charge_percentage": 0.80, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Ms State Emplo", "plan_name": "401457_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Basic Pl", "plan_name": "400100", "standard_charge_percentage": 0.85, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Basic Pl", "plan_name": "400100_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Federal", "plan_name": "400110", "standard_charge_percentage": 0.85, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Federal", "plan_name": "400110_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Cigna Healthsprings Ffs", "plan_name": "500064", "standard_charge_dollar": 1484.25, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Conseco", "plan_name": "500302", "standard_charge_dollar": 1484.25, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Humana Ffs 61101", "plan_name": "500006", "standard_charge_dollar": 1484.25, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Medicare A", "plan_name": "100100", "standard_charge_dollar": 1484.25, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Medicare A", "plan_name": "100500", "standard_charge_dollar": 1484.25, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Medicare Part B Only", "plan_name": "100300", "standard_charge_dollar": 1484.25, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Medicare Railroad", "plan_name": "100103", "standard_charge_dollar": 1484.25, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Ms Physicians Care N", "plan_name": "714210", "standard_charge_dollar": 1855.31, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Peoples Hlth Ffs 72126", "plan_name": "500019", "standard_charge_dollar": 1484.25, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Uhc/Secure Horizons", "plan_name": "500449", "standard_charge_dollar": 1484.25, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "United Health Care/", "plan_name": "500292", "standard_charge_dollar": 1677.20, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "United Healthcare", "plan_name": "750104", "standard_charge_dollar": 1677.20, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "United Healthcare Ba", "plan_name": "750090", "standard_charge_dollar": 1677.20, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "United Healthcare Me", "plan_name": "501310", "standard_charge_dollar": 1484.25, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Windsor Mcare Extra", "plan_name": "500778", "standard_charge_dollar": 1484.25, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." } ] } ] }, { "description": "Inj tendon sheath/ligament", "code_information": [ { "code": "20550", "type": "CPT" } ], "standard_charges": [ { "gross_charge": 12855.44, "minimum": 270.41, "maximum": 10927.12, "setting": "inpatient", "payers_information": [ { "payer_name": "Aarp", "plan_name": "500102", "standard_charge_dollar": 270.41, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna", "plan_name": "700700", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna", "plan_name": "700700_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Mcare Ffs 6005", "plan_name": "700703", "standard_charge_dollar": 270.41, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Miscellaneous", "plan_name": "700720", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Miscellaneous", "plan_name": "700720_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Ppo Hmo", "plan_name": "701720", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Ppo Hmo", "plan_name": "701720_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Ambetter 68069", "plan_name": "500516", "standard_charge_dollar": 270.41, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Ms State Emplo", "plan_name": "401457", "standard_charge_percentage": 0.80, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Ms State Emplo", "plan_name": "401457_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Basic Pl", "plan_name": "400100", "standard_charge_percentage": 0.85, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Basic Pl", "plan_name": "400100_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Federal", "plan_name": "400110", "standard_charge_percentage": 0.85, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Federal", "plan_name": "400110_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Cigna Healthsprings Ffs", "plan_name": "500064", "standard_charge_dollar": 270.41, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Conseco", "plan_name": "500302", "standard_charge_dollar": 270.41, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Humana Ffs 61101", "plan_name": "500006", "standard_charge_dollar": 270.41, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Medicare A", "plan_name": "100100", "standard_charge_dollar": 270.41, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Medicare A", "plan_name": "100500", "standard_charge_dollar": 270.41, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Medicare Part B Only", "plan_name": "100300", "standard_charge_dollar": 270.41, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Medicare Railroad", "plan_name": "100103", "standard_charge_dollar": 270.41, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Ms Physicians Care N", "plan_name": "714210", "standard_charge_dollar": 338.02, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Peoples Hlth Ffs 72126", "plan_name": "500019", "standard_charge_dollar": 270.41, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Uhc/Secure Horizons", "plan_name": "500449", "standard_charge_dollar": 270.41, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "United Health Care/", "plan_name": "500292", "standard_charge_dollar": 305.57, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "United Healthcare", "plan_name": "750104", "standard_charge_dollar": 305.57, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "United Healthcare Ba", "plan_name": "750090", "standard_charge_dollar": 305.57, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "United Healthcare Me", "plan_name": "501310", "standard_charge_dollar": 270.41, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Windsor Mcare Extra", "plan_name": "500778", "standard_charge_dollar": 270.41, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." } ] } ] }, { "description": "Inj tendon origin/insertion", "code_information": [ { "code": "20551", "type": "CPT" } ], "standard_charges": [ { "gross_charge": 12855.44, "minimum": 270.41, "maximum": 10927.12, "setting": "inpatient", "payers_information": [ { "payer_name": "Aarp", "plan_name": "500102", "standard_charge_dollar": 270.41, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna", "plan_name": "700700", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna", "plan_name": "700700_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Mcare Ffs 6005", "plan_name": "700703", "standard_charge_dollar": 270.41, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Miscellaneous", "plan_name": "700720", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Miscellaneous", "plan_name": "700720_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Ppo Hmo", "plan_name": "701720", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Ppo Hmo", "plan_name": "701720_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Ambetter 68069", "plan_name": "500516", "standard_charge_dollar": 270.41, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Ms State Emplo", "plan_name": "401457", "standard_charge_percentage": 0.80, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Ms State Emplo", "plan_name": "401457_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Basic Pl", "plan_name": "400100", "standard_charge_percentage": 0.85, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Basic Pl", "plan_name": "400100_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Federal", "plan_name": "400110", "standard_charge_percentage": 0.85, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Federal", "plan_name": "400110_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Cigna Healthsprings Ffs", "plan_name": "500064", "standard_charge_dollar": 270.41, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Conseco", "plan_name": "500302", "standard_charge_dollar": 270.41, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Humana Ffs 61101", "plan_name": "500006", "standard_charge_dollar": 270.41, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Medicare A", "plan_name": "100100", "standard_charge_dollar": 270.41, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Medicare A", "plan_name": "100500", "standard_charge_dollar": 270.41, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Medicare Part B Only", "plan_name": "100300", "standard_charge_dollar": 270.41, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Medicare Railroad", "plan_name": "100103", "standard_charge_dollar": 270.41, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Ms Physicians Care N", "plan_name": "714210", "standard_charge_dollar": 338.02, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Peoples Hlth Ffs 72126", "plan_name": "500019", "standard_charge_dollar": 270.41, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Uhc/Secure Horizons", "plan_name": "500449", "standard_charge_dollar": 270.41, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "United Health Care/", "plan_name": "500292", "standard_charge_dollar": 305.57, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "United Healthcare", "plan_name": "750104", "standard_charge_dollar": 305.57, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "United Healthcare Ba", "plan_name": "750090", "standard_charge_dollar": 305.57, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "United Healthcare Me", "plan_name": "501310", "standard_charge_dollar": 270.41, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Windsor Mcare Extra", "plan_name": "500778", "standard_charge_dollar": 270.41, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." } ] } ] }, { "description": "Drain/inj joint/bursa w/o us", "code_information": [ { "code": "20600", "type": "CPT" } ], "standard_charges": [ { "gross_charge": 12855.44, "minimum": 270.41, "maximum": 10927.12, "setting": "inpatient", "payers_information": [ { "payer_name": "Aarp", "plan_name": "500102", "standard_charge_dollar": 270.41, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna", "plan_name": "700700", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna", "plan_name": "700700_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Mcare Ffs 6005", "plan_name": "700703", "standard_charge_dollar": 270.41, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Miscellaneous", "plan_name": "700720", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Miscellaneous", "plan_name": "700720_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Ppo Hmo", "plan_name": "701720", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Ppo Hmo", "plan_name": "701720_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Ambetter 68069", "plan_name": "500516", "standard_charge_dollar": 270.41, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Ms State Emplo", "plan_name": "401457", "standard_charge_percentage": 0.80, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Ms State Emplo", "plan_name": "401457_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Basic Pl", "plan_name": "400100", "standard_charge_percentage": 0.85, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Basic Pl", "plan_name": "400100_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Federal", "plan_name": "400110", "standard_charge_percentage": 0.85, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Federal", "plan_name": "400110_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Cigna Healthsprings Ffs", "plan_name": "500064", "standard_charge_dollar": 270.41, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Conseco", "plan_name": "500302", "standard_charge_dollar": 270.41, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Humana Ffs 61101", "plan_name": "500006", "standard_charge_dollar": 270.41, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Medicare A", "plan_name": "100100", "standard_charge_dollar": 270.41, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Medicare A", "plan_name": "100500", "standard_charge_dollar": 270.41, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Medicare Part B Only", "plan_name": "100300", "standard_charge_dollar": 270.41, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Medicare Railroad", "plan_name": "100103", "standard_charge_dollar": 270.41, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Ms Physicians Care N", "plan_name": "714210", "standard_charge_dollar": 338.02, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Peoples Hlth Ffs 72126", "plan_name": "500019", "standard_charge_dollar": 270.41, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Uhc/Secure Horizons", "plan_name": "500449", "standard_charge_dollar": 270.41, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "United Health Care/", "plan_name": "500292", "standard_charge_dollar": 305.57, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "United Healthcare", "plan_name": "750104", "standard_charge_dollar": 305.57, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "United Healthcare Ba", "plan_name": "750090", "standard_charge_dollar": 305.57, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "United Healthcare Me", "plan_name": "501310", "standard_charge_dollar": 270.41, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Windsor Mcare Extra", "plan_name": "500778", "standard_charge_dollar": 270.41, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." } ] } ] }, { "description": "Drain/inj joint/bursa w/o us", "code_information": [ { "code": "20600", "type": "CPT" } ], "standard_charges": [ { "gross_charge": 435.02, "minimum": 270.41, "maximum": 369.77, "setting": "outpatient", "payers_information": [ { "payer_name": "Aarp", "plan_name": "500102", "standard_charge_dollar": 270.41, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna", "plan_name": "700700", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna", "plan_name": "700700_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Mcare Ffs 6005", "plan_name": "700703", "standard_charge_dollar": 270.41, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Miscellaneous", "plan_name": "700720", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Miscellaneous", "plan_name": "700720_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Ppo Hmo", "plan_name": "701720", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Ppo Hmo", "plan_name": "701720_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Ambetter 68069", "plan_name": "500516", "standard_charge_dollar": 270.41, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Ms State Emplo", "plan_name": "401457", "standard_charge_percentage": 0.80, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Ms State Emplo", "plan_name": "401457_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Basic Pl", "plan_name": "400100", "standard_charge_percentage": 0.85, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Basic Pl", "plan_name": "400100_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Federal", "plan_name": "400110", "standard_charge_percentage": 0.85, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Federal", "plan_name": "400110_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Cigna Healthsprings Ffs", "plan_name": "500064", "standard_charge_dollar": 270.41, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Conseco", "plan_name": "500302", "standard_charge_dollar": 270.41, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Humana Ffs 61101", "plan_name": "500006", "standard_charge_dollar": 270.41, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Medicare A", "plan_name": "100100", "standard_charge_dollar": 270.41, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Medicare A", "plan_name": "100500", "standard_charge_dollar": 270.41, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Medicare Part B Only", "plan_name": "100300", "standard_charge_dollar": 270.41, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Medicare Railroad", "plan_name": "100103", "standard_charge_dollar": 270.41, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Ms Physicians Care N", "plan_name": "714210", "standard_charge_dollar": 338.02, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Peoples Hlth Ffs 72126", "plan_name": "500019", "standard_charge_dollar": 270.41, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Uhc/Secure Horizons", "plan_name": "500449", "standard_charge_dollar": 270.41, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "United Health Care/", "plan_name": "500292", "standard_charge_dollar": 305.57, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "United Healthcare", "plan_name": "750104", "standard_charge_dollar": 305.57, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "United Healthcare Ba", "plan_name": "750090", "standard_charge_dollar": 305.57, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "United Healthcare Me", "plan_name": "501310", "standard_charge_dollar": 270.41, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Windsor Mcare Extra", "plan_name": "500778", "standard_charge_dollar": 270.41, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." } ] } ] }, { "description": "Hc aspiration of joint effusion", "code_information": [ { "code": "20600", "type": "CPT" } ], "standard_charges": [ { "gross_charge": 435.02, "minimum": 270.41, "maximum": 369.77, "setting": "both", "payers_information": [ { "payer_name": "Aarp", "plan_name": "500102", "standard_charge_dollar": 270.41, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna", "plan_name": "700700", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna", "plan_name": "700700_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Mcare Ffs 6005", "plan_name": "700703", "standard_charge_dollar": 270.41, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Miscellaneous", "plan_name": "700720", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Miscellaneous", "plan_name": "700720_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Ppo Hmo", "plan_name": "701720", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Ppo Hmo", "plan_name": "701720_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Ambetter 68069", "plan_name": "500516", "standard_charge_dollar": 270.41, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Ms State Emplo", "plan_name": "401457", "standard_charge_percentage": 0.80, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Ms State Emplo", "plan_name": "401457_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Basic Pl", "plan_name": "400100", "standard_charge_percentage": 0.85, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Basic Pl", "plan_name": "400100_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Federal", "plan_name": "400110", "standard_charge_percentage": 0.85, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Federal", "plan_name": "400110_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Cigna Healthsprings Ffs", "plan_name": "500064", "standard_charge_dollar": 270.41, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Conseco", "plan_name": "500302", "standard_charge_dollar": 270.41, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Humana Ffs 61101", "plan_name": "500006", "standard_charge_dollar": 270.41, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Medicare A", "plan_name": "100100", "standard_charge_dollar": 270.41, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Medicare A", "plan_name": "100500", "standard_charge_dollar": 270.41, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Medicare Part B Only", "plan_name": "100300", "standard_charge_dollar": 270.41, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Medicare Railroad", "plan_name": "100103", "standard_charge_dollar": 270.41, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Ms Physicians Care N", "plan_name": "714210", "standard_charge_dollar": 338.02, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Peoples Hlth Ffs 72126", "plan_name": "500019", "standard_charge_dollar": 270.41, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Uhc/Secure Horizons", "plan_name": "500449", "standard_charge_dollar": 270.41, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "United Health Care/", "plan_name": "500292", "standard_charge_dollar": 305.57, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "United Healthcare", "plan_name": "750104", "standard_charge_dollar": 305.57, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "United Healthcare Ba", "plan_name": "750090", "standard_charge_dollar": 305.57, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "United Healthcare Me", "plan_name": "501310", "standard_charge_dollar": 270.41, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Windsor Mcare Extra", "plan_name": "500778", "standard_charge_dollar": 270.41, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." } ] } ] }, { "description": "Drain/inj joint/bursa w/us", "code_information": [ { "code": "20604", "type": "CPT" } ], "standard_charges": [ { "gross_charge": 12855.44, "minimum": 51.29, "maximum": 338.02, "setting": "inpatient", "payers_information": [ { "payer_name": "Aarp", "plan_name": "500102", "standard_charge_dollar": 270.41, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna", "plan_name": "700700", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna", "plan_name": "700700_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Mcare Ffs 6005", "plan_name": "700703", "standard_charge_dollar": 270.41, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Miscellaneous", "plan_name": "700720", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Miscellaneous", "plan_name": "700720_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Ppo Hmo", "plan_name": "701720", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Ppo Hmo", "plan_name": "701720_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Ambetter 68069", "plan_name": "500516", "standard_charge_dollar": 270.41, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Ms State Emplo", "plan_name": "401457", "standard_charge_dollar": 51.29, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Ms State Emplo", "plan_name": "401457_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Basic Pl", "plan_name": "400100", "standard_charge_dollar": 51.29, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Basic Pl", "plan_name": "400100_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Federal", "plan_name": "400110", "standard_charge_dollar": 51.29, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Federal", "plan_name": "400110_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Cigna Healthsprings Ffs", "plan_name": "500064", "standard_charge_dollar": 270.41, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Conseco", "plan_name": "500302", "standard_charge_dollar": 270.41, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Humana Ffs 61101", "plan_name": "500006", "standard_charge_dollar": 270.41, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Medicare A", "plan_name": "100100", "standard_charge_dollar": 270.41, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Medicare A", "plan_name": "100500", "standard_charge_dollar": 270.41, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Medicare Part B Only", "plan_name": "100300", "standard_charge_dollar": 270.41, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Medicare Railroad", "plan_name": "100103", "standard_charge_dollar": 270.41, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Ms Physicians Care N", "plan_name": "714210", "standard_charge_dollar": 338.02, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Peoples Hlth Ffs 72126", "plan_name": "500019", "standard_charge_dollar": 270.41, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Uhc/Secure Horizons", "plan_name": "500449", "standard_charge_dollar": 270.41, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "United Health Care/", "plan_name": "500292", "standard_charge_dollar": 305.57, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "United Healthcare", "plan_name": "750104", "standard_charge_dollar": 305.57, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "United Healthcare Ba", "plan_name": "750090", "standard_charge_dollar": 305.57, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "United Healthcare Me", "plan_name": "501310", "standard_charge_dollar": 270.41, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Windsor Mcare Extra", "plan_name": "500778", "standard_charge_dollar": 270.41, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." } ] } ] }, { "description": "Drain/inj joint/bursa w/o us", "code_information": [ { "code": "20605", "type": "CPT" } ], "standard_charges": [ { "gross_charge": 12855.44, "minimum": 270.41, "maximum": 10927.12, "setting": "inpatient", "payers_information": [ { "payer_name": "Aarp", "plan_name": "500102", "standard_charge_dollar": 270.41, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna", "plan_name": "700700", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna", "plan_name": "700700_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Mcare Ffs 6005", "plan_name": "700703", "standard_charge_dollar": 270.41, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Miscellaneous", "plan_name": "700720", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Miscellaneous", "plan_name": "700720_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Ppo Hmo", "plan_name": "701720", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Ppo Hmo", "plan_name": "701720_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Ambetter 68069", "plan_name": "500516", "standard_charge_dollar": 270.41, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Ms State Emplo", "plan_name": "401457", "standard_charge_percentage": 0.80, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Ms State Emplo", "plan_name": "401457_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Basic Pl", "plan_name": "400100", "standard_charge_percentage": 0.85, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Basic Pl", "plan_name": "400100_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Federal", "plan_name": "400110", "standard_charge_percentage": 0.85, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Federal", "plan_name": "400110_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Cigna Healthsprings Ffs", "plan_name": "500064", "standard_charge_dollar": 270.41, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Conseco", "plan_name": "500302", "standard_charge_dollar": 270.41, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Humana Ffs 61101", "plan_name": "500006", "standard_charge_dollar": 270.41, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Medicare A", "plan_name": "100100", "standard_charge_dollar": 270.41, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Medicare A", "plan_name": "100500", "standard_charge_dollar": 270.41, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Medicare Part B Only", "plan_name": "100300", "standard_charge_dollar": 270.41, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Medicare Railroad", "plan_name": "100103", "standard_charge_dollar": 270.41, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Ms Physicians Care N", "plan_name": "714210", "standard_charge_dollar": 338.02, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Peoples Hlth Ffs 72126", "plan_name": "500019", "standard_charge_dollar": 270.41, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Uhc/Secure Horizons", "plan_name": "500449", "standard_charge_dollar": 270.41, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "United Health Care/", "plan_name": "500292", "standard_charge_dollar": 305.57, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "United Healthcare", "plan_name": "750104", "standard_charge_dollar": 305.57, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "United Healthcare Ba", "plan_name": "750090", "standard_charge_dollar": 305.57, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "United Healthcare Me", "plan_name": "501310", "standard_charge_dollar": 270.41, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Windsor Mcare Extra", "plan_name": "500778", "standard_charge_dollar": 270.41, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." } ] } ] }, { "description": "Drain/inj joint/bursa w/o us", "code_information": [ { "code": "20605", "type": "CPT" } ], "standard_charges": [ { "gross_charge": 435.02, "minimum": 270.41, "maximum": 369.77, "setting": "outpatient", "payers_information": [ { "payer_name": "Aarp", "plan_name": "500102", "standard_charge_dollar": 270.41, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna", "plan_name": "700700", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna", "plan_name": "700700_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Mcare Ffs 6005", "plan_name": "700703", "standard_charge_dollar": 270.41, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Miscellaneous", "plan_name": "700720", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Miscellaneous", "plan_name": "700720_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Ppo Hmo", "plan_name": "701720", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Ppo Hmo", "plan_name": "701720_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Ambetter 68069", "plan_name": "500516", "standard_charge_dollar": 270.41, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Ms State Emplo", "plan_name": "401457", "standard_charge_percentage": 0.80, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Ms State Emplo", "plan_name": "401457_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Basic Pl", "plan_name": "400100", "standard_charge_percentage": 0.85, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Basic Pl", "plan_name": "400100_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Federal", "plan_name": "400110", "standard_charge_percentage": 0.85, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Federal", "plan_name": "400110_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Cigna Healthsprings Ffs", "plan_name": "500064", "standard_charge_dollar": 270.41, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Conseco", "plan_name": "500302", "standard_charge_dollar": 270.41, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Humana Ffs 61101", "plan_name": "500006", "standard_charge_dollar": 270.41, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Medicare A", "plan_name": "100100", "standard_charge_dollar": 270.41, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Medicare A", "plan_name": "100500", "standard_charge_dollar": 270.41, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Medicare Part B Only", "plan_name": "100300", "standard_charge_dollar": 270.41, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Medicare Railroad", "plan_name": "100103", "standard_charge_dollar": 270.41, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Ms Physicians Care N", "plan_name": "714210", "standard_charge_dollar": 338.02, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Peoples Hlth Ffs 72126", "plan_name": "500019", "standard_charge_dollar": 270.41, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Uhc/Secure Horizons", "plan_name": "500449", "standard_charge_dollar": 270.41, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "United Health Care/", "plan_name": "500292", "standard_charge_dollar": 305.57, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "United Healthcare", "plan_name": "750104", "standard_charge_dollar": 305.57, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "United Healthcare Ba", "plan_name": "750090", "standard_charge_dollar": 305.57, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "United Healthcare Me", "plan_name": "501310", "standard_charge_dollar": 270.41, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Windsor Mcare Extra", "plan_name": "500778", "standard_charge_dollar": 270.41, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." } ] } ] }, { "description": "Hc arthrocentesis interm joint", "code_information": [ { "code": "20605", "type": "CPT" } ], "standard_charges": [ { "gross_charge": 435.02, "minimum": 270.41, "maximum": 369.77, "setting": "both", "payers_information": [ { "payer_name": "Aarp", "plan_name": "500102", "standard_charge_dollar": 270.41, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna", "plan_name": "700700", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna", "plan_name": "700700_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Mcare Ffs 6005", "plan_name": "700703", "standard_charge_dollar": 270.41, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Miscellaneous", "plan_name": "700720", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Miscellaneous", "plan_name": "700720_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Ppo Hmo", "plan_name": "701720", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Ppo Hmo", "plan_name": "701720_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Ambetter 68069", "plan_name": "500516", "standard_charge_dollar": 270.41, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Ms State Emplo", "plan_name": "401457", "standard_charge_percentage": 0.80, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Ms State Emplo", "plan_name": "401457_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Basic Pl", "plan_name": "400100", "standard_charge_percentage": 0.85, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Basic Pl", "plan_name": "400100_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Federal", "plan_name": "400110", "standard_charge_percentage": 0.85, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Federal", "plan_name": "400110_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Cigna Healthsprings Ffs", "plan_name": "500064", "standard_charge_dollar": 270.41, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Conseco", "plan_name": "500302", "standard_charge_dollar": 270.41, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Humana Ffs 61101", "plan_name": "500006", "standard_charge_dollar": 270.41, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Medicare A", "plan_name": "100100", "standard_charge_dollar": 270.41, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Medicare A", "plan_name": "100500", "standard_charge_dollar": 270.41, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Medicare Part B Only", "plan_name": "100300", "standard_charge_dollar": 270.41, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Medicare Railroad", "plan_name": "100103", "standard_charge_dollar": 270.41, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Ms Physicians Care N", "plan_name": "714210", "standard_charge_dollar": 338.02, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Peoples Hlth Ffs 72126", "plan_name": "500019", "standard_charge_dollar": 270.41, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Uhc/Secure Horizons", "plan_name": "500449", "standard_charge_dollar": 270.41, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "United Health Care/", "plan_name": "500292", "standard_charge_dollar": 305.57, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "United Healthcare", "plan_name": "750104", "standard_charge_dollar": 305.57, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "United Healthcare Ba", "plan_name": "750090", "standard_charge_dollar": 305.57, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "United Healthcare Me", "plan_name": "501310", "standard_charge_dollar": 270.41, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Windsor Mcare Extra", "plan_name": "500778", "standard_charge_dollar": 270.41, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." } ] } ] }, { "description": "Drain/inj joint/bursa w/us", "code_information": [ { "code": "20606", "type": "CPT" } ], "standard_charges": [ { "gross_charge": 12855.44, "minimum": 58.02, "maximum": 793.00, "setting": "inpatient", "payers_information": [ { "payer_name": "Aarp", "plan_name": "500102", "standard_charge_dollar": 634.40, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna", "plan_name": "700700", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna", "plan_name": "700700_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Mcare Ffs 6005", "plan_name": "700703", "standard_charge_dollar": 634.40, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Miscellaneous", "plan_name": "700720", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Miscellaneous", "plan_name": "700720_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Ppo Hmo", "plan_name": "701720", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Ppo Hmo", "plan_name": "701720_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Ambetter 68069", "plan_name": "500516", "standard_charge_dollar": 634.40, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Ms State Emplo", "plan_name": "401457", "standard_charge_dollar": 58.02, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Ms State Emplo", "plan_name": "401457_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Basic Pl", "plan_name": "400100", "standard_charge_dollar": 58.02, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Basic Pl", "plan_name": "400100_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Federal", "plan_name": "400110", "standard_charge_dollar": 58.02, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Federal", "plan_name": "400110_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Cigna Healthsprings Ffs", "plan_name": "500064", "standard_charge_dollar": 634.40, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Conseco", "plan_name": "500302", "standard_charge_dollar": 634.40, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Humana Ffs 61101", "plan_name": "500006", "standard_charge_dollar": 634.40, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Medicare A", "plan_name": "100100", "standard_charge_dollar": 634.40, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Medicare A", "plan_name": "100500", "standard_charge_dollar": 634.40, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Medicare Part B Only", "plan_name": "100300", "standard_charge_dollar": 634.40, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Medicare Railroad", "plan_name": "100103", "standard_charge_dollar": 634.40, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Ms Physicians Care N", "plan_name": "714210", "standard_charge_dollar": 793.00, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Peoples Hlth Ffs 72126", "plan_name": "500019", "standard_charge_dollar": 634.40, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Uhc/Secure Horizons", "plan_name": "500449", "standard_charge_dollar": 634.40, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "United Health Care/", "plan_name": "500292", "standard_charge_dollar": 716.87, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "United Healthcare", "plan_name": "750104", "standard_charge_dollar": 716.87, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "United Healthcare Ba", "plan_name": "750090", "standard_charge_dollar": 716.87, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "United Healthcare Me", "plan_name": "501310", "standard_charge_dollar": 634.40, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Windsor Mcare Extra", "plan_name": "500778", "standard_charge_dollar": 634.40, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." } ] } ] }, { "description": "Drain/inj joint/bursa w/o us", "code_information": [ { "code": "20610", "type": "CPT" } ], "standard_charges": [ { "gross_charge": 12855.44, "minimum": 270.41, "maximum": 10927.12, "setting": "inpatient", "payers_information": [ { "payer_name": "Aarp", "plan_name": "500102", "standard_charge_dollar": 270.41, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna", "plan_name": "700700", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna", "plan_name": "700700_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Mcare Ffs 6005", "plan_name": "700703", "standard_charge_dollar": 270.41, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Miscellaneous", "plan_name": "700720", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Miscellaneous", "plan_name": "700720_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Ppo Hmo", "plan_name": "701720", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Ppo Hmo", "plan_name": "701720_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Ambetter 68069", "plan_name": "500516", "standard_charge_dollar": 270.41, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Ms State Emplo", "plan_name": "401457", "standard_charge_percentage": 0.80, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Ms State Emplo", "plan_name": "401457_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Basic Pl", "plan_name": "400100", "standard_charge_percentage": 0.85, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Basic Pl", "plan_name": "400100_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Federal", "plan_name": "400110", "standard_charge_percentage": 0.85, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Federal", "plan_name": "400110_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Cigna Healthsprings Ffs", "plan_name": "500064", "standard_charge_dollar": 270.41, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Conseco", "plan_name": "500302", "standard_charge_dollar": 270.41, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Humana Ffs 61101", "plan_name": "500006", "standard_charge_dollar": 270.41, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Medicare A", "plan_name": "100100", "standard_charge_dollar": 270.41, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Medicare A", "plan_name": "100500", "standard_charge_dollar": 270.41, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Medicare Part B Only", "plan_name": "100300", "standard_charge_dollar": 270.41, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Medicare Railroad", "plan_name": "100103", "standard_charge_dollar": 270.41, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Ms Physicians Care N", "plan_name": "714210", "standard_charge_dollar": 338.02, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Peoples Hlth Ffs 72126", "plan_name": "500019", "standard_charge_dollar": 270.41, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Uhc/Secure Horizons", "plan_name": "500449", "standard_charge_dollar": 270.41, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "United Health Care/", "plan_name": "500292", "standard_charge_dollar": 305.57, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "United Healthcare", "plan_name": "750104", "standard_charge_dollar": 305.57, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "United Healthcare Ba", "plan_name": "750090", "standard_charge_dollar": 305.57, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "United Healthcare Me", "plan_name": "501310", "standard_charge_dollar": 270.41, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Windsor Mcare Extra", "plan_name": "500778", "standard_charge_dollar": 270.41, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." } ] } ] }, { "description": "Drain/inj joint/bursa w/us", "code_information": [ { "code": "20611", "type": "CPT" } ], "standard_charges": [ { "gross_charge": 12855.44, "minimum": 66.90, "maximum": 338.02, "setting": "inpatient", "payers_information": [ { "payer_name": "Aarp", "plan_name": "500102", "standard_charge_dollar": 270.41, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna", "plan_name": "700700", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna", "plan_name": "700700_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Mcare Ffs 6005", "plan_name": "700703", "standard_charge_dollar": 270.41, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Miscellaneous", "plan_name": "700720", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Miscellaneous", "plan_name": "700720_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Ppo Hmo", "plan_name": "701720", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Ppo Hmo", "plan_name": "701720_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Ambetter 68069", "plan_name": "500516", "standard_charge_dollar": 270.41, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Ms State Emplo", "plan_name": "401457", "standard_charge_dollar": 66.90, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Ms State Emplo", "plan_name": "401457_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Basic Pl", "plan_name": "400100", "standard_charge_dollar": 66.90, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Basic Pl", "plan_name": "400100_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Federal", "plan_name": "400110", "standard_charge_dollar": 66.90, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Federal", "plan_name": "400110_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Cigna Healthsprings Ffs", "plan_name": "500064", "standard_charge_dollar": 270.41, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Conseco", "plan_name": "500302", "standard_charge_dollar": 270.41, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Humana Ffs 61101", "plan_name": "500006", "standard_charge_dollar": 270.41, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Medicare A", "plan_name": "100100", "standard_charge_dollar": 270.41, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Medicare A", "plan_name": "100500", "standard_charge_dollar": 270.41, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Medicare Part B Only", "plan_name": "100300", "standard_charge_dollar": 270.41, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Medicare Railroad", "plan_name": "100103", "standard_charge_dollar": 270.41, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Ms Physicians Care N", "plan_name": "714210", "standard_charge_dollar": 338.02, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Peoples Hlth Ffs 72126", "plan_name": "500019", "standard_charge_dollar": 270.41, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Uhc/Secure Horizons", "plan_name": "500449", "standard_charge_dollar": 270.41, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "United Health Care/", "plan_name": "500292", "standard_charge_dollar": 305.57, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "United Healthcare", "plan_name": "750104", "standard_charge_dollar": 305.57, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "United Healthcare Ba", "plan_name": "750090", "standard_charge_dollar": 305.57, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "United Healthcare Me", "plan_name": "501310", "standard_charge_dollar": 270.41, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Windsor Mcare Extra", "plan_name": "500778", "standard_charge_dollar": 270.41, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." } ] } ] }, { "description": "Removal of support implant", "code_information": [ { "code": "20680", "type": "CPT" } ], "standard_charges": [ { "gross_charge": 26197.74, "minimum": 2121.42, "maximum": 3277.29, "setting": "inpatient", "payers_information": [ { "payer_name": "Aarp", "plan_name": "500102", "standard_charge_dollar": 2621.84, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna", "plan_name": "700700", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna", "plan_name": "700700_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Mcare Ffs 6005", "plan_name": "700703", "standard_charge_dollar": 2621.84, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Miscellaneous", "plan_name": "700720", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Miscellaneous", "plan_name": "700720_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Ppo Hmo", "plan_name": "701720", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Ppo Hmo", "plan_name": "701720_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Ambetter 68069", "plan_name": "500516", "standard_charge_dollar": 2621.84, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Ms State Emplo", "plan_name": "401457", "standard_charge_dollar": 2121.42, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Ms State Emplo", "plan_name": "401457_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Basic Pl", "plan_name": "400100", "standard_charge_dollar": 2121.42, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Basic Pl", "plan_name": "400100_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Federal", "plan_name": "400110", "standard_charge_dollar": 2121.42, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Federal", "plan_name": "400110_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Cigna Healthsprings Ffs", "plan_name": "500064", "standard_charge_dollar": 2621.84, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Conseco", "plan_name": "500302", "standard_charge_dollar": 2621.84, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Humana Ffs 61101", "plan_name": "500006", "standard_charge_dollar": 2621.84, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Medicare A", "plan_name": "100100", "standard_charge_dollar": 2621.84, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Medicare A", "plan_name": "100500", "standard_charge_dollar": 2621.84, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Medicare Part B Only", "plan_name": "100300", "standard_charge_dollar": 2621.84, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Medicare Railroad", "plan_name": "100103", "standard_charge_dollar": 2621.84, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Ms Physicians Care N", "plan_name": "714210", "standard_charge_dollar": 3277.29, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Peoples Hlth Ffs 72126", "plan_name": "500019", "standard_charge_dollar": 2621.84, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Uhc/Secure Horizons", "plan_name": "500449", "standard_charge_dollar": 2621.84, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "United Health Care/", "plan_name": "500292", "standard_charge_dollar": 2962.67, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "United Healthcare", "plan_name": "750104", "standard_charge_dollar": 2962.67, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "United Healthcare Ba", "plan_name": "750090", "standard_charge_dollar": 2962.67, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "United Healthcare Me", "plan_name": "501310", "standard_charge_dollar": 2621.84, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Windsor Mcare Extra", "plan_name": "500778", "standard_charge_dollar": 2621.84, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." } ] } ] }, { "description": "Removal of bone for graft", "code_information": [ { "code": "20900", "type": "CPT" } ], "standard_charges": [ { "gross_charge": 25756.12, "minimum": 6544.15, "maximum": 21892.70, "setting": "inpatient", "payers_information": [ { "payer_name": "Aarp", "plan_name": "500102", "standard_charge_dollar": 6544.15, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna", "plan_name": "700700", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna", "plan_name": "700700_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Mcare Ffs 6005", "plan_name": "700703", "standard_charge_dollar": 6544.15, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Miscellaneous", "plan_name": "700720", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Miscellaneous", "plan_name": "700720_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Ppo Hmo", "plan_name": "701720", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Ppo Hmo", "plan_name": "701720_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Ambetter 68069", "plan_name": "500516", "standard_charge_dollar": 6544.15, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Ms State Emplo", "plan_name": "401457", "standard_charge_percentage": 0.80, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Ms State Emplo", "plan_name": "401457_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Basic Pl", "plan_name": "400100", "standard_charge_percentage": 0.85, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Basic Pl", "plan_name": "400100_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Federal", "plan_name": "400110", "standard_charge_percentage": 0.85, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Federal", "plan_name": "400110_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Cigna Healthsprings Ffs", "plan_name": "500064", "standard_charge_dollar": 6544.15, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Conseco", "plan_name": "500302", "standard_charge_dollar": 6544.15, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Humana Ffs 61101", "plan_name": "500006", "standard_charge_dollar": 6544.15, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Medicare A", "plan_name": "100100", "standard_charge_dollar": 6544.15, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Medicare A", "plan_name": "100500", "standard_charge_dollar": 6544.15, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Medicare Part B Only", "plan_name": "100300", "standard_charge_dollar": 6544.15, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Medicare Railroad", "plan_name": "100103", "standard_charge_dollar": 6544.15, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Ms Physicians Care N", "plan_name": "714210", "standard_charge_dollar": 8180.19, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Peoples Hlth Ffs 72126", "plan_name": "500019", "standard_charge_dollar": 6544.15, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Uhc/Secure Horizons", "plan_name": "500449", "standard_charge_dollar": 6544.15, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "United Health Care/", "plan_name": "500292", "standard_charge_dollar": 7394.89, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "United Healthcare", "plan_name": "750104", "standard_charge_dollar": 7394.89, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "United Healthcare Ba", "plan_name": "750090", "standard_charge_dollar": 7394.89, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "United Healthcare Me", "plan_name": "501310", "standard_charge_dollar": 6544.15, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Windsor Mcare Extra", "plan_name": "500778", "standard_charge_dollar": 6544.15, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." } ] } ] }, { "description": "Removal of bone for graft", "code_information": [ { "code": "20902", "type": "CPT" } ], "standard_charges": [ { "gross_charge": 25756.12, "minimum": 6544.15, "maximum": 21892.70, "setting": "inpatient", "payers_information": [ { "payer_name": "Aarp", "plan_name": "500102", "standard_charge_dollar": 6544.15, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna", "plan_name": "700700", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna", "plan_name": "700700_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Mcare Ffs 6005", "plan_name": "700703", "standard_charge_dollar": 6544.15, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Miscellaneous", "plan_name": "700720", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Miscellaneous", "plan_name": "700720_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Ppo Hmo", "plan_name": "701720", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Ppo Hmo", "plan_name": "701720_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Ambetter 68069", "plan_name": "500516", "standard_charge_dollar": 6544.15, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Ms State Emplo", "plan_name": "401457", "standard_charge_percentage": 0.80, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Ms State Emplo", "plan_name": "401457_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Basic Pl", "plan_name": "400100", "standard_charge_percentage": 0.85, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Basic Pl", "plan_name": "400100_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Federal", "plan_name": "400110", "standard_charge_percentage": 0.85, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Federal", "plan_name": "400110_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Cigna Healthsprings Ffs", "plan_name": "500064", "standard_charge_dollar": 6544.15, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Conseco", "plan_name": "500302", "standard_charge_dollar": 6544.15, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Humana Ffs 61101", "plan_name": "500006", "standard_charge_dollar": 6544.15, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Medicare A", "plan_name": "100100", "standard_charge_dollar": 6544.15, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Medicare A", "plan_name": "100500", "standard_charge_dollar": 6544.15, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Medicare Part B Only", "plan_name": "100300", "standard_charge_dollar": 6544.15, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Medicare Railroad", "plan_name": "100103", "standard_charge_dollar": 6544.15, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Ms Physicians Care N", "plan_name": "714210", "standard_charge_dollar": 8180.19, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Peoples Hlth Ffs 72126", "plan_name": "500019", "standard_charge_dollar": 6544.15, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Uhc/Secure Horizons", "plan_name": "500449", "standard_charge_dollar": 6544.15, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "United Health Care/", "plan_name": "500292", "standard_charge_dollar": 7394.89, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "United Healthcare", "plan_name": "750104", "standard_charge_dollar": 7394.89, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "United Healthcare Ba", "plan_name": "750090", "standard_charge_dollar": 7394.89, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "United Healthcare Me", "plan_name": "501310", "standard_charge_dollar": 6544.15, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Windsor Mcare Extra", "plan_name": "500778", "standard_charge_dollar": 6544.15, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." } ] } ] }, { "description": "Removal of tendon for graft", "code_information": [ { "code": "20924", "type": "CPT" } ], "standard_charges": [ { "gross_charge": 37648.65, "minimum": 6544.15, "maximum": 32001.35, "setting": "inpatient", "payers_information": [ { "payer_name": "Aarp", "plan_name": "500102", "standard_charge_dollar": 6544.15, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna", "plan_name": "700700", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna", "plan_name": "700700_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Mcare Ffs 6005", "plan_name": "700703", "standard_charge_dollar": 6544.15, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Miscellaneous", "plan_name": "700720", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Miscellaneous", "plan_name": "700720_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Ppo Hmo", "plan_name": "701720", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Ppo Hmo", "plan_name": "701720_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Ambetter 68069", "plan_name": "500516", "standard_charge_dollar": 6544.15, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Ms State Emplo", "plan_name": "401457", "standard_charge_percentage": 0.80, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Ms State Emplo", "plan_name": "401457_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Basic Pl", "plan_name": "400100", "standard_charge_percentage": 0.85, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Basic Pl", "plan_name": "400100_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Federal", "plan_name": "400110", "standard_charge_percentage": 0.85, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Federal", "plan_name": "400110_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Cigna Healthsprings Ffs", "plan_name": "500064", "standard_charge_dollar": 6544.15, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Conseco", "plan_name": "500302", "standard_charge_dollar": 6544.15, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Humana Ffs 61101", "plan_name": "500006", "standard_charge_dollar": 6544.15, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Medicare A", "plan_name": "100100", "standard_charge_dollar": 6544.15, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Medicare A", "plan_name": "100500", "standard_charge_dollar": 6544.15, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Medicare Part B Only", "plan_name": "100300", "standard_charge_dollar": 6544.15, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Medicare Railroad", "plan_name": "100103", "standard_charge_dollar": 6544.15, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Ms Physicians Care N", "plan_name": "714210", "standard_charge_dollar": 8180.19, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Peoples Hlth Ffs 72126", "plan_name": "500019", "standard_charge_dollar": 6544.15, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Uhc/Secure Horizons", "plan_name": "500449", "standard_charge_dollar": 6544.15, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "United Health Care/", "plan_name": "500292", "standard_charge_dollar": 7394.89, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "United Healthcare", "plan_name": "750104", "standard_charge_dollar": 7394.89, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "United Healthcare Ba", "plan_name": "750090", "standard_charge_dollar": 7394.89, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "United Healthcare Me", "plan_name": "501310", "standard_charge_dollar": 6544.15, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Windsor Mcare Extra", "plan_name": "500778", "standard_charge_dollar": 6544.15, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." } ] } ] }, { "description": "Mt bone graft microvasc", "code_information": [ { "code": "20957", "type": "CPT" } ], "standard_charges": [ { "gross_charge": 27897.12, "minimum": 22317.70, "maximum": 23712.55, "setting": "inpatient", "payers_information": [ { "payer_name": "Aetna", "plan_name": "700700", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna", "plan_name": "700700_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Miscellaneous", "plan_name": "700720", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Miscellaneous", "plan_name": "700720_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Ppo Hmo", "plan_name": "701720", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Ppo Hmo", "plan_name": "701720_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Ms State Emplo", "plan_name": "401457", "standard_charge_percentage": 0.80, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Ms State Emplo", "plan_name": "401457_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Basic Pl", "plan_name": "400100", "standard_charge_percentage": 0.85, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Basic Pl", "plan_name": "400100_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Federal", "plan_name": "400110", "standard_charge_percentage": 0.85, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Federal", "plan_name": "400110_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." } ] } ] }, { "description": "Other bone graft microvasc", "code_information": [ { "code": "20962", "type": "CPT" } ], "standard_charges": [ { "gross_charge": 17192.12, "minimum": 13753.70, "maximum": 14613.30, "setting": "inpatient", "payers_information": [ { "payer_name": "Aetna", "plan_name": "700700", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna", "plan_name": "700700_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Miscellaneous", "plan_name": "700720", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Miscellaneous", "plan_name": "700720_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Ppo Hmo", "plan_name": "701720", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Ppo Hmo", "plan_name": "701720_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Ms State Emplo", "plan_name": "401457", "standard_charge_percentage": 0.80, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Ms State Emplo", "plan_name": "401457_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Basic Pl", "plan_name": "400100", "standard_charge_percentage": 0.85, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Basic Pl", "plan_name": "400100_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Federal", "plan_name": "400110", "standard_charge_percentage": 0.85, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Federal", "plan_name": "400110_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." } ] } ] }, { "description": "Bone/skin graft microvasc", "code_information": [ { "code": "20969", "type": "CPT" } ], "standard_charges": [ { "gross_charge": 17192.12, "minimum": 13753.70, "maximum": 14613.30, "setting": "inpatient", "payers_information": [ { "payer_name": "Aetna", "plan_name": "700700", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna", "plan_name": "700700_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Miscellaneous", "plan_name": "700720", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Miscellaneous", "plan_name": "700720_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Ppo Hmo", "plan_name": "701720", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Ppo Hmo", "plan_name": "701720_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Ms State Emplo", "plan_name": "401457", "standard_charge_percentage": 0.80, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Ms State Emplo", "plan_name": "401457_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Basic Pl", "plan_name": "400100", "standard_charge_percentage": 0.85, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Basic Pl", "plan_name": "400100_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Federal", "plan_name": "400110", "standard_charge_percentage": 0.85, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Federal", "plan_name": "400110_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." } ] } ] }, { "description": "Bone/skin graft metatarsal", "code_information": [ { "code": "20972", "type": "CPT" } ], "standard_charges": [ { "gross_charge": 27897.12, "minimum": 6544.15, "maximum": 23712.55, "setting": "inpatient", "payers_information": [ { "payer_name": "Aarp", "plan_name": "500102", "standard_charge_dollar": 6544.15, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna", "plan_name": "700700", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna", "plan_name": "700700_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Mcare Ffs 6005", "plan_name": "700703", "standard_charge_dollar": 6544.15, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Miscellaneous", "plan_name": "700720", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Miscellaneous", "plan_name": "700720_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Ppo Hmo", "plan_name": "701720", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Ppo Hmo", "plan_name": "701720_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Ambetter 68069", "plan_name": "500516", "standard_charge_dollar": 6544.15, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Ms State Emplo", "plan_name": "401457", "standard_charge_percentage": 0.80, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Ms State Emplo", "plan_name": "401457_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Basic Pl", "plan_name": "400100", "standard_charge_percentage": 0.85, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Basic Pl", "plan_name": "400100_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Federal", "plan_name": "400110", "standard_charge_percentage": 0.85, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Federal", "plan_name": "400110_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Cigna Healthsprings Ffs", "plan_name": "500064", "standard_charge_dollar": 6544.15, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Conseco", "plan_name": "500302", "standard_charge_dollar": 6544.15, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Humana Ffs 61101", "plan_name": "500006", "standard_charge_dollar": 6544.15, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Medicare A", "plan_name": "100100", "standard_charge_dollar": 6544.15, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Medicare A", "plan_name": "100500", "standard_charge_dollar": 6544.15, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Medicare Part B Only", "plan_name": "100300", "standard_charge_dollar": 6544.15, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Medicare Railroad", "plan_name": "100103", "standard_charge_dollar": 6544.15, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Ms Physicians Care N", "plan_name": "714210", "standard_charge_dollar": 8180.19, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Peoples Hlth Ffs 72126", "plan_name": "500019", "standard_charge_dollar": 6544.15, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Uhc/Secure Horizons", "plan_name": "500449", "standard_charge_dollar": 6544.15, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "United Health Care/", "plan_name": "500292", "standard_charge_dollar": 7394.89, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "United Healthcare", "plan_name": "750104", "standard_charge_dollar": 7394.89, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "United Healthcare Ba", "plan_name": "750090", "standard_charge_dollar": 7394.89, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "United Healthcare Me", "plan_name": "501310", "standard_charge_dollar": 6544.15, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Windsor Mcare Extra", "plan_name": "500778", "standard_charge_dollar": 6544.15, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." } ] } ] }, { "description": "Musculoskeletal surgery", "code_information": [ { "code": "20999", "type": "CPT" } ], "standard_charges": [ { "gross_charge": 17839.10, "minimum": 219.75, "maximum": 15163.24, "setting": "inpatient", "payers_information": [ { "payer_name": "Aarp", "plan_name": "500102", "standard_charge_dollar": 219.75, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna", "plan_name": "700700", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna", "plan_name": "700700_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Mcare Ffs 6005", "plan_name": "700703", "standard_charge_dollar": 219.75, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Miscellaneous", "plan_name": "700720", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Miscellaneous", "plan_name": "700720_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Ppo Hmo", "plan_name": "701720", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Ppo Hmo", "plan_name": "701720_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Ambetter 68069", "plan_name": "500516", "standard_charge_dollar": 219.75, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Ms State Emplo", "plan_name": "401457", "standard_charge_percentage": 0.80, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Ms State Emplo", "plan_name": "401457_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Basic Pl", "plan_name": "400100", "standard_charge_percentage": 0.85, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Basic Pl", "plan_name": "400100_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Federal", "plan_name": "400110", "standard_charge_percentage": 0.85, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Federal", "plan_name": "400110_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Cigna Healthsprings Ffs", "plan_name": "500064", "standard_charge_dollar": 219.75, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Conseco", "plan_name": "500302", "standard_charge_dollar": 219.75, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Humana Ffs 61101", "plan_name": "500006", "standard_charge_dollar": 219.75, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Medicare A", "plan_name": "100100", "standard_charge_dollar": 219.75, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Medicare A", "plan_name": "100500", "standard_charge_dollar": 219.75, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Medicare Part B Only", "plan_name": "100300", "standard_charge_dollar": 219.75, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Medicare Railroad", "plan_name": "100103", "standard_charge_dollar": 219.75, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Ms Physicians Care N", "plan_name": "714210", "standard_charge_dollar": 274.68, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Peoples Hlth Ffs 72126", "plan_name": "500019", "standard_charge_dollar": 219.75, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Uhc/Secure Horizons", "plan_name": "500449", "standard_charge_dollar": 219.75, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "United Health Care/", "plan_name": "500292", "standard_charge_dollar": 248.31, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "United Healthcare", "plan_name": "750104", "standard_charge_dollar": 248.31, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "United Healthcare Ba", "plan_name": "750090", "standard_charge_dollar": 248.31, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "United Healthcare Me", "plan_name": "501310", "standard_charge_dollar": 219.75, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Windsor Mcare Extra", "plan_name": "500778", "standard_charge_dollar": 219.75, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." } ] } ] }, { "description": "Cranio/maxillofacial surgery", "code_information": [ { "code": "21299", "type": "CPT" } ], "standard_charges": [ { "gross_charge": 35878.65, "minimum": 212.73, "maximum": 30496.85, "setting": "inpatient", "payers_information": [ { "payer_name": "Aarp", "plan_name": "500102", "standard_charge_dollar": 212.73, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna", "plan_name": "700700", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna", "plan_name": "700700_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Mcare Ffs 6005", "plan_name": "700703", "standard_charge_dollar": 212.73, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Miscellaneous", "plan_name": "700720", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Miscellaneous", "plan_name": "700720_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Ppo Hmo", "plan_name": "701720", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Ppo Hmo", "plan_name": "701720_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Ambetter 68069", "plan_name": "500516", "standard_charge_dollar": 212.73, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Ms State Emplo", "plan_name": "401457", "standard_charge_percentage": 0.80, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Ms State Emplo", "plan_name": "401457_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Basic Pl", "plan_name": "400100", "standard_charge_percentage": 0.85, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Basic Pl", "plan_name": "400100_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Federal", "plan_name": "400110", "standard_charge_percentage": 0.85, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Federal", "plan_name": "400110_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Cigna Healthsprings Ffs", "plan_name": "500064", "standard_charge_dollar": 212.73, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Conseco", "plan_name": "500302", "standard_charge_dollar": 212.73, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Humana Ffs 61101", "plan_name": "500006", "standard_charge_dollar": 212.73, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Medicare A", "plan_name": "100100", "standard_charge_dollar": 212.73, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Medicare A", "plan_name": "100500", "standard_charge_dollar": 212.73, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Medicare Part B Only", "plan_name": "100300", "standard_charge_dollar": 212.73, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Medicare Railroad", "plan_name": "100103", "standard_charge_dollar": 212.73, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Ms Physicians Care N", "plan_name": "714210", "standard_charge_dollar": 265.91, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Peoples Hlth Ffs 72126", "plan_name": "500019", "standard_charge_dollar": 212.73, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Uhc/Secure Horizons", "plan_name": "500449", "standard_charge_dollar": 212.73, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "United Health Care/", "plan_name": "500292", "standard_charge_dollar": 240.38, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "United Healthcare", "plan_name": "750104", "standard_charge_dollar": 240.38, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "United Healthcare Ba", "plan_name": "750090", "standard_charge_dollar": 240.38, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "United Healthcare Me", "plan_name": "501310", "standard_charge_dollar": 212.73, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Windsor Mcare Extra", "plan_name": "500778", "standard_charge_dollar": 212.73, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." } ] } ] }, { "description": "Exc neck les sc 3 cm/>", "code_information": [ { "code": "21552", "type": "CPT" } ], "standard_charges": [ { "gross_charge": 56398.32, "minimum": 2621.84, "maximum": 47938.57, "setting": "inpatient", "payers_information": [ { "payer_name": "Aarp", "plan_name": "500102", "standard_charge_dollar": 2621.84, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna", "plan_name": "700700", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna", "plan_name": "700700_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Mcare Ffs 6005", "plan_name": "700703", "standard_charge_dollar": 2621.84, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Miscellaneous", "plan_name": "700720", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Miscellaneous", "plan_name": "700720_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Ppo Hmo", "plan_name": "701720", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Ppo Hmo", "plan_name": "701720_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Ambetter 68069", "plan_name": "500516", "standard_charge_dollar": 2621.84, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Ms State Emplo", "plan_name": "401457", "standard_charge_percentage": 0.80, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Ms State Emplo", "plan_name": "401457_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Basic Pl", "plan_name": "400100", "standard_charge_percentage": 0.85, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Basic Pl", "plan_name": "400100_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Federal", "plan_name": "400110", "standard_charge_percentage": 0.85, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Federal", "plan_name": "400110_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Cigna Healthsprings Ffs", "plan_name": "500064", "standard_charge_dollar": 2621.84, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Conseco", "plan_name": "500302", "standard_charge_dollar": 2621.84, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Humana Ffs 61101", "plan_name": "500006", "standard_charge_dollar": 2621.84, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Medicare A", "plan_name": "100100", "standard_charge_dollar": 2621.84, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Medicare A", "plan_name": "100500", "standard_charge_dollar": 2621.84, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Medicare Part B Only", "plan_name": "100300", "standard_charge_dollar": 2621.84, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Medicare Railroad", "plan_name": "100103", "standard_charge_dollar": 2621.84, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Ms Physicians Care N", "plan_name": "714210", "standard_charge_dollar": 3277.29, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Peoples Hlth Ffs 72126", "plan_name": "500019", "standard_charge_dollar": 2621.84, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Uhc/Secure Horizons", "plan_name": "500449", "standard_charge_dollar": 2621.84, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "United Health Care/", "plan_name": "500292", "standard_charge_dollar": 2962.67, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "United Healthcare", "plan_name": "750104", "standard_charge_dollar": 2962.67, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "United Healthcare Ba", "plan_name": "750090", "standard_charge_dollar": 2962.67, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "United Healthcare Me", "plan_name": "501310", "standard_charge_dollar": 2621.84, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Windsor Mcare Extra", "plan_name": "500778", "standard_charge_dollar": 2621.84, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." } ] } ] }, { "description": "Exc neck tum deep 5 cm/>", "code_information": [ { "code": "21554", "type": "CPT" } ], "standard_charges": [ { "gross_charge": 56398.32, "minimum": 2621.84, "maximum": 47938.57, "setting": "inpatient", "payers_information": [ { "payer_name": "Aarp", "plan_name": "500102", "standard_charge_dollar": 2621.84, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna", "plan_name": "700700", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna", "plan_name": "700700_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Mcare Ffs 6005", "plan_name": "700703", "standard_charge_dollar": 2621.84, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Miscellaneous", "plan_name": "700720", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Miscellaneous", "plan_name": "700720_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Ppo Hmo", "plan_name": "701720", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Ppo Hmo", "plan_name": "701720_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Ambetter 68069", "plan_name": "500516", "standard_charge_dollar": 2621.84, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Ms State Emplo", "plan_name": "401457", "standard_charge_percentage": 0.80, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Ms State Emplo", "plan_name": "401457_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Basic Pl", "plan_name": "400100", "standard_charge_percentage": 0.85, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Basic Pl", "plan_name": "400100_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Federal", "plan_name": "400110", "standard_charge_percentage": 0.85, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Federal", "plan_name": "400110_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Cigna Healthsprings Ffs", "plan_name": "500064", "standard_charge_dollar": 2621.84, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Conseco", "plan_name": "500302", "standard_charge_dollar": 2621.84, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Humana Ffs 61101", "plan_name": "500006", "standard_charge_dollar": 2621.84, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Medicare A", "plan_name": "100100", "standard_charge_dollar": 2621.84, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Medicare A", "plan_name": "100500", "standard_charge_dollar": 2621.84, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Medicare Part B Only", "plan_name": "100300", "standard_charge_dollar": 2621.84, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Medicare Railroad", "plan_name": "100103", "standard_charge_dollar": 2621.84, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Ms Physicians Care N", "plan_name": "714210", "standard_charge_dollar": 3277.29, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Peoples Hlth Ffs 72126", "plan_name": "500019", "standard_charge_dollar": 2621.84, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Uhc/Secure Horizons", "plan_name": "500449", "standard_charge_dollar": 2621.84, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "United Health Care/", "plan_name": "500292", "standard_charge_dollar": 2962.67, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "United Healthcare", "plan_name": "750104", "standard_charge_dollar": 2962.67, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "United Healthcare Ba", "plan_name": "750090", "standard_charge_dollar": 2962.67, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "United Healthcare Me", "plan_name": "501310", "standard_charge_dollar": 2621.84, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Windsor Mcare Extra", "plan_name": "500778", "standard_charge_dollar": 2621.84, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." } ] } ] }, { "description": "Exc neck les sc < 3 cm", "code_information": [ { "code": "21555", "type": "CPT" } ], "standard_charges": [ { "gross_charge": 56398.32, "minimum": 1484.25, "maximum": 47938.57, "setting": "inpatient", "payers_information": [ { "payer_name": "Aarp", "plan_name": "500102", "standard_charge_dollar": 1484.25, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna", "plan_name": "700700", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna", "plan_name": "700700_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Mcare Ffs 6005", "plan_name": "700703", "standard_charge_dollar": 1484.25, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Miscellaneous", "plan_name": "700720", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Miscellaneous", "plan_name": "700720_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Ppo Hmo", "plan_name": "701720", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Ppo Hmo", "plan_name": "701720_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Ambetter 68069", "plan_name": "500516", "standard_charge_dollar": 1484.25, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Ms State Emplo", "plan_name": "401457", "standard_charge_percentage": 0.80, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Ms State Emplo", "plan_name": "401457_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Basic Pl", "plan_name": "400100", "standard_charge_percentage": 0.85, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Basic Pl", "plan_name": "400100_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Federal", "plan_name": "400110", "standard_charge_percentage": 0.85, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Federal", "plan_name": "400110_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Cigna Healthsprings Ffs", "plan_name": "500064", "standard_charge_dollar": 1484.25, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Conseco", "plan_name": "500302", "standard_charge_dollar": 1484.25, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Humana Ffs 61101", "plan_name": "500006", "standard_charge_dollar": 1484.25, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Medicare A", "plan_name": "100100", "standard_charge_dollar": 1484.25, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Medicare A", "plan_name": "100500", "standard_charge_dollar": 1484.25, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Medicare Part B Only", "plan_name": "100300", "standard_charge_dollar": 1484.25, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Medicare Railroad", "plan_name": "100103", "standard_charge_dollar": 1484.25, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Ms Physicians Care N", "plan_name": "714210", "standard_charge_dollar": 1855.31, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Peoples Hlth Ffs 72126", "plan_name": "500019", "standard_charge_dollar": 1484.25, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Uhc/Secure Horizons", "plan_name": "500449", "standard_charge_dollar": 1484.25, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "United Health Care/", "plan_name": "500292", "standard_charge_dollar": 1677.20, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "United Healthcare", "plan_name": "750104", "standard_charge_dollar": 1677.20, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "United Healthcare Ba", "plan_name": "750090", "standard_charge_dollar": 1677.20, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "United Healthcare Me", "plan_name": "501310", "standard_charge_dollar": 1484.25, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Windsor Mcare Extra", "plan_name": "500778", "standard_charge_dollar": 1484.25, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." } ] } ] }, { "description": "Exc neck tum deep < 5 cm", "code_information": [ { "code": "21556", "type": "CPT" } ], "standard_charges": [ { "gross_charge": 56398.32, "minimum": 2621.84, "maximum": 47938.57, "setting": "inpatient", "payers_information": [ { "payer_name": "Aarp", "plan_name": "500102", "standard_charge_dollar": 2621.84, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna", "plan_name": "700700", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna", "plan_name": "700700_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Mcare Ffs 6005", "plan_name": "700703", "standard_charge_dollar": 2621.84, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Miscellaneous", "plan_name": "700720", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Miscellaneous", "plan_name": "700720_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Ppo Hmo", "plan_name": "701720", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Ppo Hmo", "plan_name": "701720_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Ambetter 68069", "plan_name": "500516", "standard_charge_dollar": 2621.84, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Ms State Emplo", "plan_name": "401457", "standard_charge_percentage": 0.80, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Ms State Emplo", "plan_name": "401457_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Basic Pl", "plan_name": "400100", "standard_charge_percentage": 0.85, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Basic Pl", "plan_name": "400100_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Federal", "plan_name": "400110", "standard_charge_percentage": 0.85, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Federal", "plan_name": "400110_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Cigna Healthsprings Ffs", "plan_name": "500064", "standard_charge_dollar": 2621.84, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Conseco", "plan_name": "500302", "standard_charge_dollar": 2621.84, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Humana Ffs 61101", "plan_name": "500006", "standard_charge_dollar": 2621.84, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Medicare A", "plan_name": "100100", "standard_charge_dollar": 2621.84, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Medicare A", "plan_name": "100500", "standard_charge_dollar": 2621.84, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Medicare Part B Only", "plan_name": "100300", "standard_charge_dollar": 2621.84, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Medicare Railroad", "plan_name": "100103", "standard_charge_dollar": 2621.84, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Ms Physicians Care N", "plan_name": "714210", "standard_charge_dollar": 3277.29, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Peoples Hlth Ffs 72126", "plan_name": "500019", "standard_charge_dollar": 2621.84, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Uhc/Secure Horizons", "plan_name": "500449", "standard_charge_dollar": 2621.84, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "United Health Care/", "plan_name": "500292", "standard_charge_dollar": 2962.67, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "United Healthcare", "plan_name": "750104", "standard_charge_dollar": 2962.67, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "United Healthcare Ba", "plan_name": "750090", "standard_charge_dollar": 2962.67, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "United Healthcare Me", "plan_name": "501310", "standard_charge_dollar": 2621.84, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Windsor Mcare Extra", "plan_name": "500778", "standard_charge_dollar": 2621.84, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." } ] } ] }, { "description": "Resect neck thorax tumor<5cm", "code_information": [ { "code": "21557", "type": "CPT" } ], "standard_charges": [ { "gross_charge": 56398.32, "minimum": 2621.84, "maximum": 47938.57, "setting": "inpatient", "payers_information": [ { "payer_name": "Aarp", "plan_name": "500102", "standard_charge_dollar": 2621.84, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna", "plan_name": "700700", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna", "plan_name": "700700_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Mcare Ffs 6005", "plan_name": "700703", "standard_charge_dollar": 2621.84, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Miscellaneous", "plan_name": "700720", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Miscellaneous", "plan_name": "700720_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Ppo Hmo", "plan_name": "701720", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Ppo Hmo", "plan_name": "701720_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Ambetter 68069", "plan_name": "500516", "standard_charge_dollar": 2621.84, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Ms State Emplo", "plan_name": "401457", "standard_charge_percentage": 0.80, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Ms State Emplo", "plan_name": "401457_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Basic Pl", "plan_name": "400100", "standard_charge_percentage": 0.85, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Basic Pl", "plan_name": "400100_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Federal", "plan_name": "400110", "standard_charge_percentage": 0.85, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Federal", "plan_name": "400110_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Cigna Healthsprings Ffs", "plan_name": "500064", "standard_charge_dollar": 2621.84, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Conseco", "plan_name": "500302", "standard_charge_dollar": 2621.84, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Humana Ffs 61101", "plan_name": "500006", "standard_charge_dollar": 2621.84, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Medicare A", "plan_name": "100100", "standard_charge_dollar": 2621.84, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Medicare A", "plan_name": "100500", "standard_charge_dollar": 2621.84, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Medicare Part B Only", "plan_name": "100300", "standard_charge_dollar": 2621.84, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Medicare Railroad", "plan_name": "100103", "standard_charge_dollar": 2621.84, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Ms Physicians Care N", "plan_name": "714210", "standard_charge_dollar": 3277.29, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Peoples Hlth Ffs 72126", "plan_name": "500019", "standard_charge_dollar": 2621.84, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Uhc/Secure Horizons", "plan_name": "500449", "standard_charge_dollar": 2621.84, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "United Health Care/", "plan_name": "500292", "standard_charge_dollar": 2962.67, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "United Healthcare", "plan_name": "750104", "standard_charge_dollar": 2962.67, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "United Healthcare Ba", "plan_name": "750090", "standard_charge_dollar": 2962.67, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "United Healthcare Me", "plan_name": "501310", "standard_charge_dollar": 2621.84, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Windsor Mcare Extra", "plan_name": "500778", "standard_charge_dollar": 2621.84, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." } ] } ] }, { "description": "Resect neck tumor 5 cm/>", "code_information": [ { "code": "21558", "type": "CPT" } ], "standard_charges": [ { "gross_charge": 56398.32, "minimum": 2621.84, "maximum": 47938.57, "setting": "inpatient", "payers_information": [ { "payer_name": "Aarp", "plan_name": "500102", "standard_charge_dollar": 2621.84, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna", "plan_name": "700700", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna", "plan_name": "700700_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Mcare Ffs 6005", "plan_name": "700703", "standard_charge_dollar": 2621.84, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Miscellaneous", "plan_name": "700720", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Miscellaneous", "plan_name": "700720_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Ppo Hmo", "plan_name": "701720", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Ppo Hmo", "plan_name": "701720_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Ambetter 68069", "plan_name": "500516", "standard_charge_dollar": 2621.84, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Ms State Emplo", "plan_name": "401457", "standard_charge_percentage": 0.80, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Ms State Emplo", "plan_name": "401457_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Basic Pl", "plan_name": "400100", "standard_charge_percentage": 0.85, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Basic Pl", "plan_name": "400100_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Federal", "plan_name": "400110", "standard_charge_percentage": 0.85, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Federal", "plan_name": "400110_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Cigna Healthsprings Ffs", "plan_name": "500064", "standard_charge_dollar": 2621.84, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Conseco", "plan_name": "500302", "standard_charge_dollar": 2621.84, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Humana Ffs 61101", "plan_name": "500006", "standard_charge_dollar": 2621.84, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Medicare A", "plan_name": "100100", "standard_charge_dollar": 2621.84, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Medicare A", "plan_name": "100500", "standard_charge_dollar": 2621.84, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Medicare Part B Only", "plan_name": "100300", "standard_charge_dollar": 2621.84, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Medicare Railroad", "plan_name": "100103", "standard_charge_dollar": 2621.84, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Ms Physicians Care N", "plan_name": "714210", "standard_charge_dollar": 3277.29, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Peoples Hlth Ffs 72126", "plan_name": "500019", "standard_charge_dollar": 2621.84, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Uhc/Secure Horizons", "plan_name": "500449", "standard_charge_dollar": 2621.84, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "United Health Care/", "plan_name": "500292", "standard_charge_dollar": 2962.67, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "United Healthcare", "plan_name": "750104", "standard_charge_dollar": 2962.67, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "United Healthcare Ba", "plan_name": "750090", "standard_charge_dollar": 2962.67, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "United Healthcare Me", "plan_name": "501310", "standard_charge_dollar": 2621.84, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Windsor Mcare Extra", "plan_name": "500778", "standard_charge_dollar": 2621.84, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." } ] } ] }, { "description": "Neck/chest surgery procedure", "code_information": [ { "code": "21899", "type": "CPT" } ], "standard_charges": [ { "gross_charge": 35878.65, "minimum": 212.73, "maximum": 30496.85, "setting": "inpatient", "payers_information": [ { "payer_name": "Aarp", "plan_name": "500102", "standard_charge_dollar": 212.73, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna", "plan_name": "700700", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna", "plan_name": "700700_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Mcare Ffs 6005", "plan_name": "700703", "standard_charge_dollar": 212.73, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Miscellaneous", "plan_name": "700720", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Miscellaneous", "plan_name": "700720_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Ppo Hmo", "plan_name": "701720", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Ppo Hmo", "plan_name": "701720_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Ambetter 68069", "plan_name": "500516", "standard_charge_dollar": 212.73, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Ms State Emplo", "plan_name": "401457", "standard_charge_percentage": 0.80, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Ms State Emplo", "plan_name": "401457_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Basic Pl", "plan_name": "400100", "standard_charge_percentage": 0.85, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Basic Pl", "plan_name": "400100_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Federal", "plan_name": "400110", "standard_charge_percentage": 0.85, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Federal", "plan_name": "400110_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Cigna Healthsprings Ffs", "plan_name": "500064", "standard_charge_dollar": 212.73, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Conseco", "plan_name": "500302", "standard_charge_dollar": 212.73, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Humana Ffs 61101", "plan_name": "500006", "standard_charge_dollar": 212.73, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Medicare A", "plan_name": "100100", "standard_charge_dollar": 212.73, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Medicare A", "plan_name": "100500", "standard_charge_dollar": 212.73, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Medicare Part B Only", "plan_name": "100300", "standard_charge_dollar": 212.73, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Medicare Railroad", "plan_name": "100103", "standard_charge_dollar": 212.73, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Ms Physicians Care N", "plan_name": "714210", "standard_charge_dollar": 265.91, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Peoples Hlth Ffs 72126", "plan_name": "500019", "standard_charge_dollar": 212.73, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Uhc/Secure Horizons", "plan_name": "500449", "standard_charge_dollar": 212.73, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "United Health Care/", "plan_name": "500292", "standard_charge_dollar": 240.38, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "United Healthcare", "plan_name": "750104", "standard_charge_dollar": 240.38, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "United Healthcare Ba", "plan_name": "750090", "standard_charge_dollar": 240.38, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "United Healthcare Me", "plan_name": "501310", "standard_charge_dollar": 212.73, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Windsor Mcare Extra", "plan_name": "500778", "standard_charge_dollar": 212.73, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." } ] } ] }, { "description": "Exc back les sc < 3 cm", "code_information": [ { "code": "21930", "type": "CPT" } ], "standard_charges": [ { "gross_charge": 36419.05, "minimum": 1484.25, "maximum": 30956.19, "setting": "inpatient", "payers_information": [ { "payer_name": "Aarp", "plan_name": "500102", "standard_charge_dollar": 1484.25, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna", "plan_name": "700700", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna", "plan_name": "700700_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Mcare Ffs 6005", "plan_name": "700703", "standard_charge_dollar": 1484.25, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Miscellaneous", "plan_name": "700720", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Miscellaneous", "plan_name": "700720_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Ppo Hmo", "plan_name": "701720", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Ppo Hmo", "plan_name": "701720_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Ambetter 68069", "plan_name": "500516", "standard_charge_dollar": 1484.25, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Ms State Emplo", "plan_name": "401457", "standard_charge_percentage": 0.80, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Ms State Emplo", "plan_name": "401457_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Basic Pl", "plan_name": "400100", "standard_charge_percentage": 0.85, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Basic Pl", "plan_name": "400100_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Federal", "plan_name": "400110", "standard_charge_percentage": 0.85, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Federal", "plan_name": "400110_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Cigna Healthsprings Ffs", "plan_name": "500064", "standard_charge_dollar": 1484.25, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Conseco", "plan_name": "500302", "standard_charge_dollar": 1484.25, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Humana Ffs 61101", "plan_name": "500006", "standard_charge_dollar": 1484.25, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Medicare A", "plan_name": "100100", "standard_charge_dollar": 1484.25, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Medicare A", "plan_name": "100500", "standard_charge_dollar": 1484.25, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Medicare Part B Only", "plan_name": "100300", "standard_charge_dollar": 1484.25, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Medicare Railroad", "plan_name": "100103", "standard_charge_dollar": 1484.25, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Ms Physicians Care N", "plan_name": "714210", "standard_charge_dollar": 1855.31, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Peoples Hlth Ffs 72126", "plan_name": "500019", "standard_charge_dollar": 1484.25, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Uhc/Secure Horizons", "plan_name": "500449", "standard_charge_dollar": 1484.25, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "United Health Care/", "plan_name": "500292", "standard_charge_dollar": 1677.20, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "United Healthcare", "plan_name": "750104", "standard_charge_dollar": 1677.20, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "United Healthcare Ba", "plan_name": "750090", "standard_charge_dollar": 1677.20, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "United Healthcare Me", "plan_name": "501310", "standard_charge_dollar": 1484.25, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Windsor Mcare Extra", "plan_name": "500778", "standard_charge_dollar": 1484.25, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." } ] } ] }, { "description": "Exc back les sc 3 cm/>", "code_information": [ { "code": "21931", "type": "CPT" } ], "standard_charges": [ { "gross_charge": 36419.05, "minimum": 1484.25, "maximum": 30956.19, "setting": "inpatient", "payers_information": [ { "payer_name": "Aarp", "plan_name": "500102", "standard_charge_dollar": 1484.25, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna", "plan_name": "700700", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna", "plan_name": "700700_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Mcare Ffs 6005", "plan_name": "700703", "standard_charge_dollar": 1484.25, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Miscellaneous", "plan_name": "700720", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Miscellaneous", "plan_name": "700720_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Ppo Hmo", "plan_name": "701720", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Ppo Hmo", "plan_name": "701720_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Ambetter 68069", "plan_name": "500516", "standard_charge_dollar": 1484.25, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Ms State Emplo", "plan_name": "401457", "standard_charge_percentage": 0.80, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Ms State Emplo", "plan_name": "401457_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Basic Pl", "plan_name": "400100", "standard_charge_percentage": 0.85, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Basic Pl", "plan_name": "400100_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Federal", "plan_name": "400110", "standard_charge_percentage": 0.85, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Federal", "plan_name": "400110_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Cigna Healthsprings Ffs", "plan_name": "500064", "standard_charge_dollar": 1484.25, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Conseco", "plan_name": "500302", "standard_charge_dollar": 1484.25, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Humana Ffs 61101", "plan_name": "500006", "standard_charge_dollar": 1484.25, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Medicare A", "plan_name": "100100", "standard_charge_dollar": 1484.25, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Medicare A", "plan_name": "100500", "standard_charge_dollar": 1484.25, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Medicare Part B Only", "plan_name": "100300", "standard_charge_dollar": 1484.25, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Medicare Railroad", "plan_name": "100103", "standard_charge_dollar": 1484.25, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Ms Physicians Care N", "plan_name": "714210", "standard_charge_dollar": 1855.31, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Peoples Hlth Ffs 72126", "plan_name": "500019", "standard_charge_dollar": 1484.25, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Uhc/Secure Horizons", "plan_name": "500449", "standard_charge_dollar": 1484.25, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "United Health Care/", "plan_name": "500292", "standard_charge_dollar": 1677.20, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "United Healthcare", "plan_name": "750104", "standard_charge_dollar": 1677.20, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "United Healthcare Ba", "plan_name": "750090", "standard_charge_dollar": 1677.20, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "United Healthcare Me", "plan_name": "501310", "standard_charge_dollar": 1484.25, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Windsor Mcare Extra", "plan_name": "500778", "standard_charge_dollar": 1484.25, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." } ] } ] }, { "description": "Resect back tum < 5 cm", "code_information": [ { "code": "21935", "type": "CPT" } ], "standard_charges": [ { "gross_charge": 36419.05, "minimum": 2621.84, "maximum": 30956.19, "setting": "inpatient", "payers_information": [ { "payer_name": "Aarp", "plan_name": "500102", "standard_charge_dollar": 2621.84, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna", "plan_name": "700700", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna", "plan_name": "700700_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Mcare Ffs 6005", "plan_name": "700703", "standard_charge_dollar": 2621.84, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Miscellaneous", "plan_name": "700720", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Miscellaneous", "plan_name": "700720_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Ppo Hmo", "plan_name": "701720", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Ppo Hmo", "plan_name": "701720_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Ambetter 68069", "plan_name": "500516", "standard_charge_dollar": 2621.84, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Ms State Emplo", "plan_name": "401457", "standard_charge_percentage": 0.80, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Ms State Emplo", "plan_name": "401457_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Basic Pl", "plan_name": "400100", "standard_charge_percentage": 0.85, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Basic Pl", "plan_name": "400100_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Federal", "plan_name": "400110", "standard_charge_percentage": 0.85, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Federal", "plan_name": "400110_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Cigna Healthsprings Ffs", "plan_name": "500064", "standard_charge_dollar": 2621.84, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Conseco", "plan_name": "500302", "standard_charge_dollar": 2621.84, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Humana Ffs 61101", "plan_name": "500006", "standard_charge_dollar": 2621.84, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Medicare A", "plan_name": "100100", "standard_charge_dollar": 2621.84, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Medicare A", "plan_name": "100500", "standard_charge_dollar": 2621.84, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Medicare Part B Only", "plan_name": "100300", "standard_charge_dollar": 2621.84, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Medicare Railroad", "plan_name": "100103", "standard_charge_dollar": 2621.84, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Ms Physicians Care N", "plan_name": "714210", "standard_charge_dollar": 3277.29, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Peoples Hlth Ffs 72126", "plan_name": "500019", "standard_charge_dollar": 2621.84, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Uhc/Secure Horizons", "plan_name": "500449", "standard_charge_dollar": 2621.84, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "United Health Care/", "plan_name": "500292", "standard_charge_dollar": 2962.67, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "United Healthcare", "plan_name": "750104", "standard_charge_dollar": 2962.67, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "United Healthcare Ba", "plan_name": "750090", "standard_charge_dollar": 2962.67, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "United Healthcare Me", "plan_name": "501310", "standard_charge_dollar": 2621.84, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Windsor Mcare Extra", "plan_name": "500778", "standard_charge_dollar": 2621.84, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." } ] } ] }, { "description": "Resect back tum 5 cm/>", "code_information": [ { "code": "21936", "type": "CPT" } ], "standard_charges": [ { "gross_charge": 36419.05, "minimum": 2621.84, "maximum": 30956.19, "setting": "inpatient", "payers_information": [ { "payer_name": "Aarp", "plan_name": "500102", "standard_charge_dollar": 2621.84, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna", "plan_name": "700700", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna", "plan_name": "700700_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Mcare Ffs 6005", "plan_name": "700703", "standard_charge_dollar": 2621.84, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Miscellaneous", "plan_name": "700720", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Miscellaneous", "plan_name": "700720_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Ppo Hmo", "plan_name": "701720", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Ppo Hmo", "plan_name": "701720_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Ambetter 68069", "plan_name": "500516", "standard_charge_dollar": 2621.84, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Ms State Emplo", "plan_name": "401457", "standard_charge_percentage": 0.80, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Ms State Emplo", "plan_name": "401457_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Basic Pl", "plan_name": "400100", "standard_charge_percentage": 0.85, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Basic Pl", "plan_name": "400100_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Federal", "plan_name": "400110", "standard_charge_percentage": 0.85, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Federal", "plan_name": "400110_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Cigna Healthsprings Ffs", "plan_name": "500064", "standard_charge_dollar": 2621.84, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Conseco", "plan_name": "500302", "standard_charge_dollar": 2621.84, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Humana Ffs 61101", "plan_name": "500006", "standard_charge_dollar": 2621.84, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Medicare A", "plan_name": "100100", "standard_charge_dollar": 2621.84, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Medicare A", "plan_name": "100500", "standard_charge_dollar": 2621.84, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Medicare Part B Only", "plan_name": "100300", "standard_charge_dollar": 2621.84, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Medicare Railroad", "plan_name": "100103", "standard_charge_dollar": 2621.84, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Ms Physicians Care N", "plan_name": "714210", "standard_charge_dollar": 3277.29, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Peoples Hlth Ffs 72126", "plan_name": "500019", "standard_charge_dollar": 2621.84, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Uhc/Secure Horizons", "plan_name": "500449", "standard_charge_dollar": 2621.84, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "United Health Care/", "plan_name": "500292", "standard_charge_dollar": 2962.67, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "United Healthcare", "plan_name": "750104", "standard_charge_dollar": 2962.67, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "United Healthcare Ba", "plan_name": "750090", "standard_charge_dollar": 2962.67, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "United Healthcare Me", "plan_name": "501310", "standard_charge_dollar": 2621.84, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Windsor Mcare Extra", "plan_name": "500778", "standard_charge_dollar": 2621.84, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." } ] } ] }, { "description": "Abdomen surgery procedure", "code_information": [ { "code": "22999", "type": "CPT" } ], "standard_charges": [ { "gross_charge": 35878.65, "minimum": 219.75, "maximum": 30496.85, "setting": "inpatient", "payers_information": [ { "payer_name": "Aarp", "plan_name": "500102", "standard_charge_dollar": 219.75, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna", "plan_name": "700700", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna", "plan_name": "700700_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Mcare Ffs 6005", "plan_name": "700703", "standard_charge_dollar": 219.75, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Miscellaneous", "plan_name": "700720", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Miscellaneous", "plan_name": "700720_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Ppo Hmo", "plan_name": "701720", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Ppo Hmo", "plan_name": "701720_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Ambetter 68069", "plan_name": "500516", "standard_charge_dollar": 219.75, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Ms State Emplo", "plan_name": "401457", "standard_charge_percentage": 0.80, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Ms State Emplo", "plan_name": "401457_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Basic Pl", "plan_name": "400100", "standard_charge_percentage": 0.85, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Basic Pl", "plan_name": "400100_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Federal", "plan_name": "400110", "standard_charge_percentage": 0.85, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Federal", "plan_name": "400110_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Cigna Healthsprings Ffs", "plan_name": "500064", "standard_charge_dollar": 219.75, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Conseco", "plan_name": "500302", "standard_charge_dollar": 219.75, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Humana Ffs 61101", "plan_name": "500006", "standard_charge_dollar": 219.75, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Medicare A", "plan_name": "100100", "standard_charge_dollar": 219.75, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Medicare A", "plan_name": "100500", "standard_charge_dollar": 219.75, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Medicare Part B Only", "plan_name": "100300", "standard_charge_dollar": 219.75, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Medicare Railroad", "plan_name": "100103", "standard_charge_dollar": 219.75, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Ms Physicians Care N", "plan_name": "714210", "standard_charge_dollar": 274.68, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Peoples Hlth Ffs 72126", "plan_name": "500019", "standard_charge_dollar": 219.75, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Uhc/Secure Horizons", "plan_name": "500449", "standard_charge_dollar": 219.75, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "United Health Care/", "plan_name": "500292", "standard_charge_dollar": 248.31, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "United Healthcare", "plan_name": "750104", "standard_charge_dollar": 248.31, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "United Healthcare Ba", "plan_name": "750090", "standard_charge_dollar": 248.31, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "United Healthcare Me", "plan_name": "501310", "standard_charge_dollar": 219.75, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Windsor Mcare Extra", "plan_name": "500778", "standard_charge_dollar": 219.75, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." } ] } ] }, { "description": "Treat clavicle dislocation", "code_information": [ { "code": "23532", "type": "CPT" } ], "standard_charges": [ { "gross_charge": 36148.67, "minimum": 6544.15, "maximum": 30726.37, "setting": "inpatient", "payers_information": [ { "payer_name": "Aarp", "plan_name": "500102", "standard_charge_dollar": 6544.15, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna", "plan_name": "700700", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna", "plan_name": "700700_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Mcare Ffs 6005", "plan_name": "700703", "standard_charge_dollar": 6544.15, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Miscellaneous", "plan_name": "700720", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Miscellaneous", "plan_name": "700720_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Ppo Hmo", "plan_name": "701720", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Ppo Hmo", "plan_name": "701720_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Ambetter 68069", "plan_name": "500516", "standard_charge_dollar": 6544.15, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Ms State Emplo", "plan_name": "401457", "standard_charge_percentage": 0.80, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Ms State Emplo", "plan_name": "401457_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Basic Pl", "plan_name": "400100", "standard_charge_percentage": 0.85, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Basic Pl", "plan_name": "400100_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Federal", "plan_name": "400110", "standard_charge_percentage": 0.85, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Federal", "plan_name": "400110_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Cigna Healthsprings Ffs", "plan_name": "500064", "standard_charge_dollar": 6544.15, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Conseco", "plan_name": "500302", "standard_charge_dollar": 6544.15, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Humana Ffs 61101", "plan_name": "500006", "standard_charge_dollar": 6544.15, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Medicare A", "plan_name": "100100", "standard_charge_dollar": 6544.15, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Medicare A", "plan_name": "100500", "standard_charge_dollar": 6544.15, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Medicare Part B Only", "plan_name": "100300", "standard_charge_dollar": 6544.15, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Medicare Railroad", "plan_name": "100103", "standard_charge_dollar": 6544.15, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Ms Physicians Care N", "plan_name": "714210", "standard_charge_dollar": 8180.19, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Peoples Hlth Ffs 72126", "plan_name": "500019", "standard_charge_dollar": 6544.15, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Uhc/Secure Horizons", "plan_name": "500449", "standard_charge_dollar": 6544.15, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "United Health Care/", "plan_name": "500292", "standard_charge_dollar": 7394.89, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "United Healthcare", "plan_name": "750104", "standard_charge_dollar": 7394.89, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "United Healthcare Ba", "plan_name": "750090", "standard_charge_dollar": 7394.89, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "United Healthcare Me", "plan_name": "501310", "standard_charge_dollar": 6544.15, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Windsor Mcare Extra", "plan_name": "500778", "standard_charge_dollar": 6544.15, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." } ] } ] }, { "description": "Treat clavicle dislocation", "code_information": [ { "code": "23552", "type": "CPT" } ], "standard_charges": [ { "gross_charge": 36148.67, "minimum": 6544.15, "maximum": 30726.37, "setting": "inpatient", "payers_information": [ { "payer_name": "Aarp", "plan_name": "500102", "standard_charge_dollar": 6544.15, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna", "plan_name": "700700", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna", "plan_name": "700700_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Mcare Ffs 6005", "plan_name": "700703", "standard_charge_dollar": 6544.15, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Miscellaneous", "plan_name": "700720", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Miscellaneous", "plan_name": "700720_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Ppo Hmo", "plan_name": "701720", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Ppo Hmo", "plan_name": "701720_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Ambetter 68069", "plan_name": "500516", "standard_charge_dollar": 6544.15, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Ms State Emplo", "plan_name": "401457", "standard_charge_percentage": 0.80, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Ms State Emplo", "plan_name": "401457_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Basic Pl", "plan_name": "400100", "standard_charge_percentage": 0.85, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Basic Pl", "plan_name": "400100_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Federal", "plan_name": "400110", "standard_charge_percentage": 0.85, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Federal", "plan_name": "400110_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Cigna Healthsprings Ffs", "plan_name": "500064", "standard_charge_dollar": 6544.15, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Conseco", "plan_name": "500302", "standard_charge_dollar": 6544.15, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Humana Ffs 61101", "plan_name": "500006", "standard_charge_dollar": 6544.15, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Medicare A", "plan_name": "100100", "standard_charge_dollar": 6544.15, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Medicare A", "plan_name": "100500", "standard_charge_dollar": 6544.15, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Medicare Part B Only", "plan_name": "100300", "standard_charge_dollar": 6544.15, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Medicare Railroad", "plan_name": "100103", "standard_charge_dollar": 6544.15, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Ms Physicians Care N", "plan_name": "714210", "standard_charge_dollar": 8180.19, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Peoples Hlth Ffs 72126", "plan_name": "500019", "standard_charge_dollar": 6544.15, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Uhc/Secure Horizons", "plan_name": "500449", "standard_charge_dollar": 6544.15, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "United Health Care/", "plan_name": "500292", "standard_charge_dollar": 7394.89, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "United Healthcare", "plan_name": "750104", "standard_charge_dollar": 7394.89, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "United Healthcare Ba", "plan_name": "750090", "standard_charge_dollar": 7394.89, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "United Healthcare Me", "plan_name": "501310", "standard_charge_dollar": 6544.15, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Windsor Mcare Extra", "plan_name": "500778", "standard_charge_dollar": 6544.15, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." } ] } ] }, { "description": "Hc closed reduction - shoulder", "code_information": [ { "code": "23650", "type": "CPT" } ], "standard_charges": [ { "gross_charge": 81.90, "minimum": 65.52, "maximum": 274.68, "setting": "both", "payers_information": [ { "payer_name": "Aarp", "plan_name": "500102", "standard_charge_dollar": 219.75, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna", "plan_name": "700700", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna", "plan_name": "700700_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Mcare Ffs 6005", "plan_name": "700703", "standard_charge_dollar": 219.75, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Miscellaneous", "plan_name": "700720", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Miscellaneous", "plan_name": "700720_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Ppo Hmo", "plan_name": "701720", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Ppo Hmo", "plan_name": "701720_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Ambetter 68069", "plan_name": "500516", "standard_charge_dollar": 219.75, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Ms State Emplo", "plan_name": "401457", "standard_charge_percentage": 0.80, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Ms State Emplo", "plan_name": "401457_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Basic Pl", "plan_name": "400100", "standard_charge_percentage": 0.85, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Basic Pl", "plan_name": "400100_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Federal", "plan_name": "400110", "standard_charge_percentage": 0.85, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Federal", "plan_name": "400110_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Cigna Healthsprings Ffs", "plan_name": "500064", "standard_charge_dollar": 219.75, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Conseco", "plan_name": "500302", "standard_charge_dollar": 219.75, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Humana Ffs 61101", "plan_name": "500006", "standard_charge_dollar": 219.75, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Medicare A", "plan_name": "100100", "standard_charge_dollar": 219.75, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Medicare A", "plan_name": "100500", "standard_charge_dollar": 219.75, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Medicare Part B Only", "plan_name": "100300", "standard_charge_dollar": 219.75, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Medicare Railroad", "plan_name": "100103", "standard_charge_dollar": 219.75, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Ms Physicians Care N", "plan_name": "714210", "standard_charge_dollar": 274.68, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Peoples Hlth Ffs 72126", "plan_name": "500019", "standard_charge_dollar": 219.75, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Uhc/Secure Horizons", "plan_name": "500449", "standard_charge_dollar": 219.75, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "United Health Care/", "plan_name": "500292", "standard_charge_dollar": 248.31, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "United Healthcare", "plan_name": "750104", "standard_charge_dollar": 248.31, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "United Healthcare Ba", "plan_name": "750090", "standard_charge_dollar": 248.31, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "United Healthcare Me", "plan_name": "501310", "standard_charge_dollar": 219.75, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Windsor Mcare Extra", "plan_name": "500778", "standard_charge_dollar": 219.75, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." } ] } ] }, { "description": "Treat shoulder dislocation", "code_information": [ { "code": "23650", "type": "CPT" } ], "standard_charges": [ { "gross_charge": 81.90, "minimum": 65.52, "maximum": 274.68, "setting": "both", "payers_information": [ { "payer_name": "Aarp", "plan_name": "500102", "standard_charge_dollar": 219.75, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna", "plan_name": "700700", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna", "plan_name": "700700_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Mcare Ffs 6005", "plan_name": "700703", "standard_charge_dollar": 219.75, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Miscellaneous", "plan_name": "700720", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Miscellaneous", "plan_name": "700720_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Ppo Hmo", "plan_name": "701720", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Ppo Hmo", "plan_name": "701720_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Ambetter 68069", "plan_name": "500516", "standard_charge_dollar": 219.75, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Ms State Emplo", "plan_name": "401457", "standard_charge_percentage": 0.80, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Ms State Emplo", "plan_name": "401457_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Basic Pl", "plan_name": "400100", "standard_charge_percentage": 0.85, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Basic Pl", "plan_name": "400100_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Federal", "plan_name": "400110", "standard_charge_percentage": 0.85, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Federal", "plan_name": "400110_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Cigna Healthsprings Ffs", "plan_name": "500064", "standard_charge_dollar": 219.75, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Conseco", "plan_name": "500302", "standard_charge_dollar": 219.75, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Humana Ffs 61101", "plan_name": "500006", "standard_charge_dollar": 219.75, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Medicare A", "plan_name": "100100", "standard_charge_dollar": 219.75, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Medicare A", "plan_name": "100500", "standard_charge_dollar": 219.75, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Medicare Part B Only", "plan_name": "100300", "standard_charge_dollar": 219.75, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Medicare Railroad", "plan_name": "100103", "standard_charge_dollar": 219.75, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Ms Physicians Care N", "plan_name": "714210", "standard_charge_dollar": 274.68, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Peoples Hlth Ffs 72126", "plan_name": "500019", "standard_charge_dollar": 219.75, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Uhc/Secure Horizons", "plan_name": "500449", "standard_charge_dollar": 219.75, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "United Health Care/", "plan_name": "500292", "standard_charge_dollar": 248.31, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "United Healthcare", "plan_name": "750104", "standard_charge_dollar": 248.31, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "United Healthcare Ba", "plan_name": "750090", "standard_charge_dollar": 248.31, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "United Healthcare Me", "plan_name": "501310", "standard_charge_dollar": 219.75, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Windsor Mcare Extra", "plan_name": "500778", "standard_charge_dollar": 219.75, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." } ] } ] }, { "description": "Hc fracture reduction other", "code_information": [ { "code": "23929", "type": "CPT" } ], "standard_charges": [ { "gross_charge": 478.00, "minimum": 219.75, "maximum": 406.30, "setting": "both", "payers_information": [ { "payer_name": "Aarp", "plan_name": "500102", "standard_charge_dollar": 219.75, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna", "plan_name": "700700", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna", "plan_name": "700700_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Mcare Ffs 6005", "plan_name": "700703", "standard_charge_dollar": 219.75, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Miscellaneous", "plan_name": "700720", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Miscellaneous", "plan_name": "700720_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Ppo Hmo", "plan_name": "701720", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Ppo Hmo", "plan_name": "701720_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Ambetter 68069", "plan_name": "500516", "standard_charge_dollar": 219.75, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Ms State Emplo", "plan_name": "401457", "standard_charge_percentage": 0.80, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Ms State Emplo", "plan_name": "401457_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Basic Pl", "plan_name": "400100", "standard_charge_percentage": 0.85, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Basic Pl", "plan_name": "400100_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Federal", "plan_name": "400110", "standard_charge_percentage": 0.85, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Federal", "plan_name": "400110_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Cigna Healthsprings Ffs", "plan_name": "500064", "standard_charge_dollar": 219.75, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Conseco", "plan_name": "500302", "standard_charge_dollar": 219.75, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Humana Ffs 61101", "plan_name": "500006", "standard_charge_dollar": 219.75, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Medicare A", "plan_name": "100100", "standard_charge_dollar": 219.75, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Medicare A", "plan_name": "100500", "standard_charge_dollar": 219.75, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Medicare Part B Only", "plan_name": "100300", "standard_charge_dollar": 219.75, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Medicare Railroad", "plan_name": "100103", "standard_charge_dollar": 219.75, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Ms Physicians Care N", "plan_name": "714210", "standard_charge_dollar": 274.68, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Peoples Hlth Ffs 72126", "plan_name": "500019", "standard_charge_dollar": 219.75, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Uhc/Secure Horizons", "plan_name": "500449", "standard_charge_dollar": 219.75, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "United Health Care/", "plan_name": "500292", "standard_charge_dollar": 248.31, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "United Healthcare", "plan_name": "750104", "standard_charge_dollar": 248.31, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "United Healthcare Ba", "plan_name": "750090", "standard_charge_dollar": 248.31, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "United Healthcare Me", "plan_name": "501310", "standard_charge_dollar": 219.75, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Windsor Mcare Extra", "plan_name": "500778", "standard_charge_dollar": 219.75, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." } ] } ] }, { "description": "Shoulder surgery procedure", "code_information": [ { "code": "23929", "type": "CPT" } ], "standard_charges": [ { "gross_charge": 478.00, "minimum": 219.75, "maximum": 406.30, "setting": "both", "payers_information": [ { "payer_name": "Aarp", "plan_name": "500102", "standard_charge_dollar": 219.75, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna", "plan_name": "700700", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna", "plan_name": "700700_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Mcare Ffs 6005", "plan_name": "700703", "standard_charge_dollar": 219.75, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Miscellaneous", "plan_name": "700720", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Miscellaneous", "plan_name": "700720_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Ppo Hmo", "plan_name": "701720", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Ppo Hmo", "plan_name": "701720_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Ambetter 68069", "plan_name": "500516", "standard_charge_dollar": 219.75, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Ms State Emplo", "plan_name": "401457", "standard_charge_percentage": 0.80, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Ms State Emplo", "plan_name": "401457_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Basic Pl", "plan_name": "400100", "standard_charge_percentage": 0.85, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Basic Pl", "plan_name": "400100_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Federal", "plan_name": "400110", "standard_charge_percentage": 0.85, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Federal", "plan_name": "400110_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Cigna Healthsprings Ffs", "plan_name": "500064", "standard_charge_dollar": 219.75, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Conseco", "plan_name": "500302", "standard_charge_dollar": 219.75, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Humana Ffs 61101", "plan_name": "500006", "standard_charge_dollar": 219.75, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Medicare A", "plan_name": "100100", "standard_charge_dollar": 219.75, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Medicare A", "plan_name": "100500", "standard_charge_dollar": 219.75, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Medicare Part B Only", "plan_name": "100300", "standard_charge_dollar": 219.75, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Medicare Railroad", "plan_name": "100103", "standard_charge_dollar": 219.75, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Ms Physicians Care N", "plan_name": "714210", "standard_charge_dollar": 274.68, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Peoples Hlth Ffs 72126", "plan_name": "500019", "standard_charge_dollar": 219.75, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Uhc/Secure Horizons", "plan_name": "500449", "standard_charge_dollar": 219.75, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "United Health Care/", "plan_name": "500292", "standard_charge_dollar": 248.31, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "United Healthcare", "plan_name": "750104", "standard_charge_dollar": 248.31, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "United Healthcare Ba", "plan_name": "750090", "standard_charge_dollar": 248.31, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "United Healthcare Me", "plan_name": "501310", "standard_charge_dollar": 219.75, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Windsor Mcare Extra", "plan_name": "500778", "standard_charge_dollar": 219.75, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." } ] } ] }, { "description": "Repair arm tendon/muscle", "code_information": [ { "code": "24341", "type": "CPT" } ], "standard_charges": [ { "gross_charge": 35876.53, "minimum": 6544.15, "maximum": 30495.05, "setting": "inpatient", "payers_information": [ { "payer_name": "Aarp", "plan_name": "500102", "standard_charge_dollar": 6544.15, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna", "plan_name": "700700", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna", "plan_name": "700700_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Mcare Ffs 6005", "plan_name": "700703", "standard_charge_dollar": 6544.15, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Miscellaneous", "plan_name": "700720", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Miscellaneous", "plan_name": "700720_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Ppo Hmo", "plan_name": "701720", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Ppo Hmo", "plan_name": "701720_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Ambetter 68069", "plan_name": "500516", "standard_charge_dollar": 6544.15, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Ms State Emplo", "plan_name": "401457", "standard_charge_percentage": 0.80, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Ms State Emplo", "plan_name": "401457_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Basic Pl", "plan_name": "400100", "standard_charge_percentage": 0.85, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Basic Pl", "plan_name": "400100_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Federal", "plan_name": "400110", "standard_charge_percentage": 0.85, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Federal", "plan_name": "400110_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Cigna Healthsprings Ffs", "plan_name": "500064", "standard_charge_dollar": 6544.15, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Conseco", "plan_name": "500302", "standard_charge_dollar": 6544.15, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Humana Ffs 61101", "plan_name": "500006", "standard_charge_dollar": 6544.15, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Medicare A", "plan_name": "100100", "standard_charge_dollar": 6544.15, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Medicare A", "plan_name": "100500", "standard_charge_dollar": 6544.15, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Medicare Part B Only", "plan_name": "100300", "standard_charge_dollar": 6544.15, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Medicare Railroad", "plan_name": "100103", "standard_charge_dollar": 6544.15, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Ms Physicians Care N", "plan_name": "714210", "standard_charge_dollar": 8180.19, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Peoples Hlth Ffs 72126", "plan_name": "500019", "standard_charge_dollar": 6544.15, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Uhc/Secure Horizons", "plan_name": "500449", "standard_charge_dollar": 6544.15, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "United Health Care/", "plan_name": "500292", "standard_charge_dollar": 7394.89, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "United Healthcare", "plan_name": "750104", "standard_charge_dollar": 7394.89, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "United Healthcare Ba", "plan_name": "750090", "standard_charge_dollar": 7394.89, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "United Healthcare Me", "plan_name": "501310", "standard_charge_dollar": 6544.15, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Windsor Mcare Extra", "plan_name": "500778", "standard_charge_dollar": 6544.15, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." } ] } ] }, { "description": "Decompression of forearm", "code_information": [ { "code": "24495", "type": "CPT" } ], "standard_charges": [ { "gross_charge": 24256.26, "minimum": 6544.15, "maximum": 20617.82, "setting": "inpatient", "payers_information": [ { "payer_name": "Aarp", "plan_name": "500102", "standard_charge_dollar": 6544.15, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna", "plan_name": "700700", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna", "plan_name": "700700_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Mcare Ffs 6005", "plan_name": "700703", "standard_charge_dollar": 6544.15, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Miscellaneous", "plan_name": "700720", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Miscellaneous", "plan_name": "700720_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Ppo Hmo", "plan_name": "701720", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Ppo Hmo", "plan_name": "701720_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Ambetter 68069", "plan_name": "500516", "standard_charge_dollar": 6544.15, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Ms State Emplo", "plan_name": "401457", "standard_charge_percentage": 0.80, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Ms State Emplo", "plan_name": "401457_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Basic Pl", "plan_name": "400100", "standard_charge_percentage": 0.85, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Basic Pl", "plan_name": "400100_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Federal", "plan_name": "400110", "standard_charge_percentage": 0.85, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Federal", "plan_name": "400110_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Cigna Healthsprings Ffs", "plan_name": "500064", "standard_charge_dollar": 6544.15, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Conseco", "plan_name": "500302", "standard_charge_dollar": 6544.15, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Humana Ffs 61101", "plan_name": "500006", "standard_charge_dollar": 6544.15, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Medicare A", "plan_name": "100100", "standard_charge_dollar": 6544.15, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Medicare A", "plan_name": "100500", "standard_charge_dollar": 6544.15, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Medicare Part B Only", "plan_name": "100300", "standard_charge_dollar": 6544.15, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Medicare Railroad", "plan_name": "100103", "standard_charge_dollar": 6544.15, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Ms Physicians Care N", "plan_name": "714210", "standard_charge_dollar": 8180.19, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Peoples Hlth Ffs 72126", "plan_name": "500019", "standard_charge_dollar": 6544.15, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Uhc/Secure Horizons", "plan_name": "500449", "standard_charge_dollar": 6544.15, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "United Health Care/", "plan_name": "500292", "standard_charge_dollar": 7394.89, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "United Healthcare", "plan_name": "750104", "standard_charge_dollar": 7394.89, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "United Healthcare Ba", "plan_name": "750090", "standard_charge_dollar": 7394.89, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "United Healthcare Me", "plan_name": "501310", "standard_charge_dollar": 6544.15, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Windsor Mcare Extra", "plan_name": "500778", "standard_charge_dollar": 6544.15, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." } ] } ] }, 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"standard_charge_dollar": 11786.90, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Miscellaneous", "plan_name": "700720", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Miscellaneous", "plan_name": "700720_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Ppo Hmo", "plan_name": "701720", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Ppo Hmo", "plan_name": "701720_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Ambetter 68069", "plan_name": "500516", "standard_charge_dollar": 11786.90, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Ms State Emplo", "plan_name": "401457", "standard_charge_percentage": 0.80, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Ms State Emplo", "plan_name": "401457_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Basic Pl", "plan_name": "400100", "standard_charge_percentage": 0.85, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Basic Pl", "plan_name": "400100_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Federal", "plan_name": "400110", "standard_charge_percentage": 0.85, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Federal", "plan_name": "400110_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Cigna Healthsprings Ffs", "plan_name": "500064", "standard_charge_dollar": 11786.90, "count": "0", "methodology": 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"count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "United Health Care/", "plan_name": "500292", "standard_charge_dollar": 13319.19, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "United Healthcare", "plan_name": "750104", "standard_charge_dollar": 13319.19, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "United Healthcare Ba", "plan_name": "750090", "standard_charge_dollar": 13319.19, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "United Healthcare Me", "plan_name": "501310", "standard_charge_dollar": 11786.90, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Windsor Mcare Extra", "plan_name": "500778", "standard_charge_dollar": 11786.90, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." } ] } ] }, { "description": "Hc treat elbow fracture", "code_information": [ { "code": "24620", "type": "CPT" } ], "standard_charges": [ { "gross_charge": 3054.00, "minimum": 1466.09, "maximum": 2595.90, "setting": "both", "payers_information": [ { "payer_name": "Aarp", "plan_name": "500102", "standard_charge_dollar": 1466.09, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna", "plan_name": "700700", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna", "plan_name": 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"standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Ppo Hmo", "plan_name": "701720_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Ambetter 68069", "plan_name": "500516", "standard_charge_dollar": 1466.09, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Ms State Emplo", "plan_name": "401457", "standard_charge_percentage": 0.80, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Ms State Emplo", "plan_name": "401457_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Basic Pl", "plan_name": "400100", "standard_charge_percentage": 0.85, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Basic Pl", "plan_name": "400100_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Federal", "plan_name": "400110", "standard_charge_percentage": 0.85, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Federal", "plan_name": "400110_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Cigna Healthsprings Ffs", "plan_name": "500064", "standard_charge_dollar": 1466.09, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Conseco", "plan_name": "500302", "standard_charge_dollar": 1466.09, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Humana Ffs 61101", "plan_name": "500006", "standard_charge_dollar": 1466.09, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Medicare A", "plan_name": "100100", "standard_charge_dollar": 1466.09, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Medicare A", "plan_name": "100500", "standard_charge_dollar": 1466.09, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Medicare Part B Only", "plan_name": "100300", "standard_charge_dollar": 1466.09, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Medicare Railroad", "plan_name": "100103", "standard_charge_dollar": 1466.09, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Ms Physicians Care N", "plan_name": "714210", "standard_charge_dollar": 1832.61, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Peoples Hlth Ffs 72126", "plan_name": "500019", "standard_charge_dollar": 1466.09, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Uhc/Secure Horizons", "plan_name": "500449", "standard_charge_dollar": 1466.09, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "United Health Care/", "plan_name": "500292", "standard_charge_dollar": 1656.68, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "United Healthcare", "plan_name": "750104", "standard_charge_dollar": 1656.68, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "United Healthcare Ba", "plan_name": "750090", "standard_charge_dollar": 1656.68, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "United Healthcare Me", "plan_name": "501310", "standard_charge_dollar": 1466.09, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Windsor Mcare Extra", "plan_name": "500778", "standard_charge_dollar": 1466.09, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." } ] } ] }, { "description": "Treat elbow fracture", "code_information": [ { "code": "24620", "type": "CPT" } ], "standard_charges": [ { "gross_charge": 3054.00, "minimum": 1466.09, "maximum": 2595.90, "setting": "both", "payers_information": [ { "payer_name": "Aarp", "plan_name": "500102", "standard_charge_dollar": 1466.09, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna", "plan_name": "700700", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna", "plan_name": "700700_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Mcare Ffs 6005", "plan_name": "700703", "standard_charge_dollar": 1466.09, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Miscellaneous", "plan_name": "700720", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Miscellaneous", "plan_name": "700720_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Ppo Hmo", "plan_name": "701720", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Ppo Hmo", "plan_name": "701720_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Ambetter 68069", "plan_name": "500516", "standard_charge_dollar": 1466.09, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Ms State Emplo", "plan_name": "401457", "standard_charge_percentage": 0.80, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Ms State Emplo", "plan_name": "401457_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Basic Pl", "plan_name": "400100", "standard_charge_percentage": 0.85, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Basic Pl", "plan_name": "400100_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Federal", "plan_name": "400110", "standard_charge_percentage": 0.85, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Federal", "plan_name": "400110_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Cigna Healthsprings Ffs", "plan_name": "500064", "standard_charge_dollar": 1466.09, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Conseco", "plan_name": "500302", "standard_charge_dollar": 1466.09, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Humana Ffs 61101", "plan_name": "500006", "standard_charge_dollar": 1466.09, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Medicare A", "plan_name": "100100", "standard_charge_dollar": 1466.09, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Medicare A", "plan_name": "100500", "standard_charge_dollar": 1466.09, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Medicare Part B Only", "plan_name": "100300", "standard_charge_dollar": 1466.09, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Medicare Railroad", "plan_name": "100103", "standard_charge_dollar": 1466.09, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Ms Physicians Care N", "plan_name": "714210", "standard_charge_dollar": 1832.61, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Peoples Hlth Ffs 72126", "plan_name": "500019", "standard_charge_dollar": 1466.09, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Uhc/Secure Horizons", "plan_name": "500449", "standard_charge_dollar": 1466.09, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "United Health Care/", "plan_name": "500292", "standard_charge_dollar": 1656.68, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "United Healthcare", "plan_name": "750104", "standard_charge_dollar": 1656.68, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "United Healthcare Ba", "plan_name": "750090", "standard_charge_dollar": 1656.68, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "United Healthcare Me", "plan_name": "501310", "standard_charge_dollar": 1466.09, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Windsor Mcare Extra", "plan_name": "500778", "standard_charge_dollar": 1466.09, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." } ] } ] }, { "description": "Treat elbow fracture", "code_information": [ { "code": "24635", "type": "CPT" } ], "standard_charges": [ { "gross_charge": 30511.93, "minimum": 6544.15, "maximum": 25935.14, "setting": "inpatient", "payers_information": [ { "payer_name": "Aarp", "plan_name": "500102", "standard_charge_dollar": 6544.15, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna", "plan_name": "700700", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna", "plan_name": "700700_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Mcare Ffs 6005", "plan_name": "700703", "standard_charge_dollar": 6544.15, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Miscellaneous", "plan_name": "700720", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Miscellaneous", "plan_name": "700720_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Ppo Hmo", "plan_name": "701720", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Ppo Hmo", "plan_name": "701720_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Ambetter 68069", "plan_name": "500516", "standard_charge_dollar": 6544.15, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Ms State Emplo", "plan_name": "401457", "standard_charge_percentage": 0.80, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Ms State Emplo", "plan_name": "401457_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Basic Pl", "plan_name": "400100", "standard_charge_percentage": 0.85, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Basic Pl", "plan_name": "400100_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Federal", "plan_name": "400110", "standard_charge_percentage": 0.85, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Federal", "plan_name": "400110_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Cigna Healthsprings Ffs", "plan_name": "500064", "standard_charge_dollar": 6544.15, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Conseco", "plan_name": "500302", "standard_charge_dollar": 6544.15, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Humana Ffs 61101", "plan_name": "500006", "standard_charge_dollar": 6544.15, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Medicare A", "plan_name": "100100", "standard_charge_dollar": 6544.15, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Medicare A", "plan_name": "100500", "standard_charge_dollar": 6544.15, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Medicare Part B Only", "plan_name": "100300", "standard_charge_dollar": 6544.15, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Medicare Railroad", "plan_name": "100103", "standard_charge_dollar": 6544.15, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Ms Physicians Care N", "plan_name": "714210", "standard_charge_dollar": 8180.19, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Peoples Hlth Ffs 72126", "plan_name": "500019", "standard_charge_dollar": 6544.15, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Uhc/Secure Horizons", "plan_name": "500449", "standard_charge_dollar": 6544.15, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "United Health Care/", "plan_name": "500292", "standard_charge_dollar": 7394.89, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "United Healthcare", "plan_name": "750104", "standard_charge_dollar": 7394.89, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "United Healthcare Ba", "plan_name": "750090", "standard_charge_dollar": 7394.89, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "United Healthcare Me", "plan_name": "501310", "standard_charge_dollar": 6544.15, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Windsor Mcare Extra", "plan_name": "500778", "standard_charge_dollar": 6544.15, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." } ] } ] }, { "description": "Treat radius fracture", "code_information": [ { "code": "24665", "type": "CPT" } ], "standard_charges": [ { "gross_charge": 30511.93, "minimum": 6544.15, "maximum": 25935.14, "setting": "inpatient", "payers_information": [ { "payer_name": "Aarp", "plan_name": "500102", "standard_charge_dollar": 6544.15, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna", "plan_name": "700700", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna", "plan_name": "700700_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Mcare Ffs 6005", "plan_name": "700703", "standard_charge_dollar": 6544.15, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Miscellaneous", "plan_name": "700720", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Miscellaneous", "plan_name": "700720_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Ppo Hmo", "plan_name": "701720", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Ppo Hmo", "plan_name": "701720_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Ambetter 68069", "plan_name": "500516", "standard_charge_dollar": 6544.15, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Ms State Emplo", "plan_name": "401457", "standard_charge_percentage": 0.80, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Ms State Emplo", "plan_name": "401457_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Basic Pl", "plan_name": "400100", "standard_charge_percentage": 0.85, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Basic Pl", "plan_name": "400100_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Federal", "plan_name": "400110", "standard_charge_percentage": 0.85, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Federal", "plan_name": "400110_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Cigna Healthsprings Ffs", "plan_name": "500064", "standard_charge_dollar": 6544.15, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Conseco", "plan_name": "500302", "standard_charge_dollar": 6544.15, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Humana Ffs 61101", "plan_name": "500006", "standard_charge_dollar": 6544.15, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Medicare A", "plan_name": "100100", "standard_charge_dollar": 6544.15, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Medicare A", "plan_name": "100500", "standard_charge_dollar": 6544.15, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Medicare Part B Only", "plan_name": "100300", "standard_charge_dollar": 6544.15, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Medicare Railroad", "plan_name": "100103", "standard_charge_dollar": 6544.15, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Ms Physicians Care N", "plan_name": "714210", "standard_charge_dollar": 8180.19, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Peoples Hlth Ffs 72126", "plan_name": "500019", "standard_charge_dollar": 6544.15, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Uhc/Secure Horizons", "plan_name": "500449", "standard_charge_dollar": 6544.15, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "United Health Care/", "plan_name": "500292", "standard_charge_dollar": 7394.89, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "United Healthcare", "plan_name": "750104", "standard_charge_dollar": 7394.89, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "United Healthcare Ba", "plan_name": "750090", "standard_charge_dollar": 7394.89, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "United Healthcare Me", "plan_name": "501310", "standard_charge_dollar": 6544.15, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Windsor Mcare Extra", "plan_name": "500778", "standard_charge_dollar": 6544.15, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." } ] } ] }, { "description": "Treat radius fracture", "code_information": [ { "code": "24666", "type": "CPT" } ], "standard_charges": [ { "gross_charge": 30511.93, "minimum": 11786.90, "maximum": 25935.14, "setting": "inpatient", "payers_information": [ { "payer_name": "Aarp", "plan_name": "500102", "standard_charge_dollar": 11786.90, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna", "plan_name": "700700", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna", "plan_name": "700700_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Mcare Ffs 6005", "plan_name": "700703", "standard_charge_dollar": 11786.90, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Miscellaneous", "plan_name": "700720", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Miscellaneous", "plan_name": "700720_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Ppo Hmo", "plan_name": "701720", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Ppo Hmo", "plan_name": "701720_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Ambetter 68069", "plan_name": "500516", "standard_charge_dollar": 11786.90, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Ms State Emplo", "plan_name": "401457", "standard_charge_percentage": 0.80, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Ms State Emplo", "plan_name": "401457_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Basic Pl", "plan_name": "400100", "standard_charge_percentage": 0.85, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Basic Pl", "plan_name": "400100_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Federal", "plan_name": "400110", "standard_charge_percentage": 0.85, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Federal", "plan_name": "400110_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Cigna Healthsprings Ffs", "plan_name": "500064", "standard_charge_dollar": 11786.90, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Conseco", "plan_name": "500302", "standard_charge_dollar": 11786.90, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Humana Ffs 61101", "plan_name": "500006", "standard_charge_dollar": 11786.90, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Medicare A", "plan_name": "100100", "standard_charge_dollar": 11786.90, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Medicare A", "plan_name": "100500", "standard_charge_dollar": 11786.90, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Medicare Part B Only", "plan_name": "100300", "standard_charge_dollar": 11786.90, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Medicare Railroad", "plan_name": "100103", "standard_charge_dollar": 11786.90, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Ms Physicians Care N", "plan_name": "714210", "standard_charge_dollar": 14733.62, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Peoples Hlth Ffs 72126", "plan_name": "500019", "standard_charge_dollar": 11786.90, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Uhc/Secure Horizons", "plan_name": "500449", "standard_charge_dollar": 11786.90, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "United Health Care/", "plan_name": "500292", "standard_charge_dollar": 13319.19, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "United Healthcare", "plan_name": "750104", "standard_charge_dollar": 13319.19, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "United Healthcare Ba", "plan_name": "750090", "standard_charge_dollar": 13319.19, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "United Healthcare Me", "plan_name": "501310", "standard_charge_dollar": 11786.90, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Windsor Mcare Extra", "plan_name": "500778", "standard_charge_dollar": 11786.90, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." } ] } ] }, { "description": "Decompress forearm 1 space", "code_information": [ { "code": "25020", "type": "CPT" } ], "standard_charges": [ { "gross_charge": 24256.26, "minimum": 1466.09, "maximum": 20617.82, "setting": "inpatient", "payers_information": [ { "payer_name": "Aarp", "plan_name": "500102", "standard_charge_dollar": 1466.09, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna", "plan_name": "700700", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna", "plan_name": "700700_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Mcare Ffs 6005", "plan_name": "700703", "standard_charge_dollar": 1466.09, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Miscellaneous", "plan_name": "700720", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Miscellaneous", "plan_name": "700720_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Ppo Hmo", "plan_name": "701720", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Ppo Hmo", "plan_name": "701720_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Ambetter 68069", "plan_name": "500516", "standard_charge_dollar": 1466.09, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Ms State Emplo", "plan_name": "401457", "standard_charge_percentage": 0.80, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Ms State Emplo", "plan_name": "401457_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Basic Pl", "plan_name": "400100", "standard_charge_percentage": 0.85, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Basic Pl", "plan_name": "400100_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Federal", "plan_name": "400110", "standard_charge_percentage": 0.85, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Federal", "plan_name": "400110_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Cigna Healthsprings Ffs", "plan_name": "500064", "standard_charge_dollar": 1466.09, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Conseco", "plan_name": "500302", "standard_charge_dollar": 1466.09, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Humana Ffs 61101", "plan_name": "500006", "standard_charge_dollar": 1466.09, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Medicare A", "plan_name": "100100", "standard_charge_dollar": 1466.09, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Medicare A", "plan_name": "100500", "standard_charge_dollar": 1466.09, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Medicare Part B Only", "plan_name": "100300", "standard_charge_dollar": 1466.09, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Medicare Railroad", "plan_name": "100103", "standard_charge_dollar": 1466.09, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Ms Physicians Care N", "plan_name": "714210", "standard_charge_dollar": 1832.61, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Peoples Hlth Ffs 72126", "plan_name": "500019", "standard_charge_dollar": 1466.09, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Uhc/Secure Horizons", "plan_name": "500449", "standard_charge_dollar": 1466.09, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "United Health Care/", "plan_name": "500292", "standard_charge_dollar": 1656.68, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "United Healthcare", "plan_name": "750104", "standard_charge_dollar": 1656.68, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "United Healthcare Ba", "plan_name": "750090", "standard_charge_dollar": 1656.68, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "United Healthcare Me", "plan_name": "501310", "standard_charge_dollar": 1466.09, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Windsor Mcare Extra", "plan_name": "500778", "standard_charge_dollar": 1466.09, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." } ] } ] }, { "description": "Decompress forearm 1 space", "code_information": [ { "code": "25023", "type": "CPT" } ], "standard_charges": [ { "gross_charge": 24256.26, "minimum": 2972.29, "maximum": 20617.82, "setting": "inpatient", "payers_information": [ { "payer_name": "Aarp", "plan_name": "500102", "standard_charge_dollar": 2972.29, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna", "plan_name": "700700", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna", "plan_name": "700700_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Mcare Ffs 6005", "plan_name": "700703", "standard_charge_dollar": 2972.29, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Miscellaneous", "plan_name": "700720", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Miscellaneous", "plan_name": "700720_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Ppo Hmo", "plan_name": "701720", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Ppo Hmo", "plan_name": "701720_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Ambetter 68069", "plan_name": "500516", "standard_charge_dollar": 2972.29, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Ms State Emplo", "plan_name": "401457", "standard_charge_percentage": 0.80, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Ms State Emplo", "plan_name": "401457_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Basic Pl", "plan_name": "400100", "standard_charge_percentage": 0.85, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Basic Pl", "plan_name": "400100_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Federal", "plan_name": "400110", "standard_charge_percentage": 0.85, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Federal", "plan_name": "400110_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Cigna Healthsprings Ffs", "plan_name": "500064", "standard_charge_dollar": 2972.29, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Conseco", "plan_name": "500302", "standard_charge_dollar": 2972.29, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Humana Ffs 61101", "plan_name": "500006", "standard_charge_dollar": 2972.29, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Medicare A", "plan_name": "100100", "standard_charge_dollar": 2972.29, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Medicare A", "plan_name": "100500", "standard_charge_dollar": 2972.29, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Medicare Part B Only", "plan_name": "100300", "standard_charge_dollar": 2972.29, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Medicare Railroad", "plan_name": "100103", "standard_charge_dollar": 2972.29, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Ms Physicians Care N", "plan_name": "714210", "standard_charge_dollar": 3715.36, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Peoples Hlth Ffs 72126", "plan_name": "500019", "standard_charge_dollar": 2972.29, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Uhc/Secure Horizons", "plan_name": "500449", "standard_charge_dollar": 2972.29, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "United Health Care/", "plan_name": "500292", "standard_charge_dollar": 3358.68, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "United Healthcare", "plan_name": "750104", "standard_charge_dollar": 3358.68, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "United Healthcare Ba", "plan_name": "750090", "standard_charge_dollar": 3358.68, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "United Healthcare Me", "plan_name": "501310", "standard_charge_dollar": 2972.29, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Windsor Mcare Extra", "plan_name": "500778", "standard_charge_dollar": 2972.29, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." } ] } ] }, { "description": "Decompress forearm 2 spaces", "code_information": [ { "code": "25024", "type": "CPT" } ], "standard_charges": [ { "gross_charge": 24256.26, "minimum": 2972.29, "maximum": 20617.82, "setting": "inpatient", "payers_information": [ { "payer_name": "Aarp", "plan_name": "500102", "standard_charge_dollar": 2972.29, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna", "plan_name": "700700", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna", "plan_name": "700700_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Mcare Ffs 6005", "plan_name": "700703", "standard_charge_dollar": 2972.29, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Miscellaneous", "plan_name": "700720", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Miscellaneous", "plan_name": "700720_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Ppo Hmo", "plan_name": "701720", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Ppo Hmo", "plan_name": "701720_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Ambetter 68069", "plan_name": "500516", "standard_charge_dollar": 2972.29, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Ms State Emplo", "plan_name": "401457", "standard_charge_percentage": 0.80, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Ms State Emplo", "plan_name": "401457_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Basic Pl", "plan_name": "400100", "standard_charge_percentage": 0.85, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Basic Pl", "plan_name": "400100_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Federal", "plan_name": "400110", "standard_charge_percentage": 0.85, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Federal", "plan_name": "400110_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Cigna Healthsprings Ffs", "plan_name": "500064", "standard_charge_dollar": 2972.29, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Conseco", "plan_name": "500302", "standard_charge_dollar": 2972.29, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Humana Ffs 61101", "plan_name": "500006", "standard_charge_dollar": 2972.29, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Medicare A", "plan_name": "100100", "standard_charge_dollar": 2972.29, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Medicare A", "plan_name": "100500", "standard_charge_dollar": 2972.29, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Medicare Part B Only", "plan_name": "100300", "standard_charge_dollar": 2972.29, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Medicare Railroad", "plan_name": "100103", "standard_charge_dollar": 2972.29, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Ms Physicians Care N", "plan_name": "714210", "standard_charge_dollar": 3715.36, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Peoples Hlth Ffs 72126", "plan_name": "500019", "standard_charge_dollar": 2972.29, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Uhc/Secure Horizons", "plan_name": "500449", "standard_charge_dollar": 2972.29, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "United Health Care/", "plan_name": "500292", "standard_charge_dollar": 3358.68, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "United Healthcare", "plan_name": "750104", "standard_charge_dollar": 3358.68, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "United Healthcare Ba", "plan_name": "750090", "standard_charge_dollar": 3358.68, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "United Healthcare Me", "plan_name": "501310", "standard_charge_dollar": 2972.29, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Windsor Mcare Extra", "plan_name": "500778", "standard_charge_dollar": 2972.29, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." } ] } ] }, { "description": "Decompress forearm 2 spaces", "code_information": [ { "code": "25025", "type": "CPT" } ], "standard_charges": [ { "gross_charge": 24256.26, "minimum": 1466.09, "maximum": 20617.82, "setting": "inpatient", "payers_information": [ { "payer_name": "Aarp", "plan_name": "500102", "standard_charge_dollar": 1466.09, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna", "plan_name": "700700", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna", "plan_name": "700700_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Mcare Ffs 6005", "plan_name": "700703", "standard_charge_dollar": 1466.09, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Miscellaneous", "plan_name": "700720", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Miscellaneous", "plan_name": "700720_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Ppo Hmo", "plan_name": "701720", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Ppo Hmo", "plan_name": "701720_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Ambetter 68069", "plan_name": "500516", "standard_charge_dollar": 1466.09, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Ms State Emplo", "plan_name": "401457", "standard_charge_percentage": 0.80, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Ms State Emplo", "plan_name": "401457_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Basic Pl", "plan_name": "400100", "standard_charge_percentage": 0.85, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Basic Pl", "plan_name": "400100_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Federal", "plan_name": "400110", "standard_charge_percentage": 0.85, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Federal", "plan_name": "400110_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Cigna Healthsprings Ffs", "plan_name": "500064", "standard_charge_dollar": 1466.09, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Conseco", "plan_name": "500302", "standard_charge_dollar": 1466.09, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Humana Ffs 61101", "plan_name": "500006", "standard_charge_dollar": 1466.09, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Medicare A", "plan_name": "100100", "standard_charge_dollar": 1466.09, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Medicare A", "plan_name": "100500", "standard_charge_dollar": 1466.09, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Medicare Part B Only", "plan_name": "100300", "standard_charge_dollar": 1466.09, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Medicare Railroad", "plan_name": "100103", "standard_charge_dollar": 1466.09, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Ms Physicians Care N", "plan_name": "714210", "standard_charge_dollar": 1832.61, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Peoples Hlth Ffs 72126", "plan_name": "500019", "standard_charge_dollar": 1466.09, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Uhc/Secure Horizons", "plan_name": "500449", "standard_charge_dollar": 1466.09, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "United Health Care/", "plan_name": "500292", "standard_charge_dollar": 1656.68, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "United Healthcare", "plan_name": "750104", "standard_charge_dollar": 1656.68, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "United Healthcare Ba", "plan_name": "750090", "standard_charge_dollar": 1656.68, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "United Healthcare Me", "plan_name": "501310", "standard_charge_dollar": 1466.09, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Windsor Mcare Extra", "plan_name": "500778", "standard_charge_dollar": 1466.09, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." } ] } ] }, { "description": "Repair forearm tendon/muscle", "code_information": [ { "code": "25265", "type": "CPT" } ], "standard_charges": [ { "gross_charge": 35876.53, "minimum": 2972.29, "maximum": 30495.05, "setting": "inpatient", "payers_information": [ { "payer_name": "Aarp", "plan_name": "500102", "standard_charge_dollar": 2972.29, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna", "plan_name": "700700", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna", "plan_name": "700700_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Mcare Ffs 6005", "plan_name": "700703", "standard_charge_dollar": 2972.29, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Miscellaneous", "plan_name": "700720", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Miscellaneous", "plan_name": "700720_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Ppo Hmo", "plan_name": "701720", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Ppo Hmo", "plan_name": "701720_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Ambetter 68069", "plan_name": "500516", "standard_charge_dollar": 2972.29, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Ms State Emplo", "plan_name": "401457", "standard_charge_percentage": 0.80, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Ms State Emplo", "plan_name": "401457_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Basic Pl", "plan_name": "400100", "standard_charge_percentage": 0.85, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Basic Pl", "plan_name": "400100_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Federal", "plan_name": "400110", "standard_charge_percentage": 0.85, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Federal", "plan_name": "400110_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Cigna Healthsprings Ffs", "plan_name": "500064", "standard_charge_dollar": 2972.29, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Conseco", "plan_name": "500302", "standard_charge_dollar": 2972.29, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Humana Ffs 61101", "plan_name": "500006", "standard_charge_dollar": 2972.29, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Medicare A", "plan_name": "100100", "standard_charge_dollar": 2972.29, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Medicare A", "plan_name": "100500", "standard_charge_dollar": 2972.29, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Medicare Part B Only", "plan_name": "100300", "standard_charge_dollar": 2972.29, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Medicare Railroad", "plan_name": "100103", "standard_charge_dollar": 2972.29, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Ms Physicians Care N", "plan_name": "714210", "standard_charge_dollar": 3715.36, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Peoples Hlth Ffs 72126", "plan_name": "500019", "standard_charge_dollar": 2972.29, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Uhc/Secure Horizons", "plan_name": "500449", "standard_charge_dollar": 2972.29, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "United Health Care/", "plan_name": "500292", "standard_charge_dollar": 3358.68, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "United Healthcare", "plan_name": "750104", "standard_charge_dollar": 3358.68, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "United Healthcare Ba", "plan_name": "750090", "standard_charge_dollar": 3358.68, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "United Healthcare Me", "plan_name": "501310", "standard_charge_dollar": 2972.29, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Windsor Mcare Extra", "plan_name": "500778", "standard_charge_dollar": 2972.29, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." } ] } ] }, { "description": "Repair radius or ulna", "code_information": [ { "code": "25400", "type": "CPT" } ], "standard_charges": [ { "gross_charge": 30511.93, "minimum": 6544.15, "maximum": 25935.14, "setting": "inpatient", "payers_information": [ { "payer_name": "Aarp", "plan_name": "500102", "standard_charge_dollar": 6544.15, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna", "plan_name": "700700", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna", "plan_name": "700700_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Mcare Ffs 6005", "plan_name": "700703", "standard_charge_dollar": 6544.15, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Miscellaneous", "plan_name": "700720", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Miscellaneous", "plan_name": "700720_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Ppo Hmo", "plan_name": "701720", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Ppo Hmo", "plan_name": "701720_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Ambetter 68069", "plan_name": "500516", "standard_charge_dollar": 6544.15, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Ms State Emplo", "plan_name": "401457", "standard_charge_percentage": 0.80, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Ms State Emplo", "plan_name": "401457_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Basic Pl", "plan_name": "400100", "standard_charge_percentage": 0.85, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Basic Pl", "plan_name": "400100_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Federal", "plan_name": "400110", "standard_charge_percentage": 0.85, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Federal", "plan_name": "400110_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Cigna Healthsprings Ffs", "plan_name": "500064", "standard_charge_dollar": 6544.15, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Conseco", "plan_name": "500302", "standard_charge_dollar": 6544.15, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Humana Ffs 61101", "plan_name": "500006", "standard_charge_dollar": 6544.15, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Medicare A", "plan_name": "100100", "standard_charge_dollar": 6544.15, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Medicare A", "plan_name": "100500", "standard_charge_dollar": 6544.15, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Medicare Part B Only", "plan_name": "100300", "standard_charge_dollar": 6544.15, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Medicare Railroad", "plan_name": "100103", "standard_charge_dollar": 6544.15, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Ms Physicians Care N", "plan_name": "714210", "standard_charge_dollar": 8180.19, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Peoples Hlth Ffs 72126", "plan_name": "500019", "standard_charge_dollar": 6544.15, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Uhc/Secure Horizons", "plan_name": "500449", "standard_charge_dollar": 6544.15, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "United Health Care/", "plan_name": "500292", "standard_charge_dollar": 7394.89, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "United Healthcare", "plan_name": "750104", "standard_charge_dollar": 7394.89, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "United Healthcare Ba", "plan_name": "750090", "standard_charge_dollar": 7394.89, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "United Healthcare Me", "plan_name": "501310", "standard_charge_dollar": 6544.15, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Windsor Mcare Extra", "plan_name": "500778", "standard_charge_dollar": 6544.15, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." } ] } ] }, { "description": "Repair radius & ulna", "code_information": [ { "code": "25415", "type": "CPT" } ], "standard_charges": [ { "gross_charge": 30511.93, "minimum": 6544.15, "maximum": 25935.14, "setting": "inpatient", "payers_information": [ { "payer_name": "Aarp", "plan_name": "500102", "standard_charge_dollar": 6544.15, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna", "plan_name": "700700", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna", "plan_name": "700700_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Mcare Ffs 6005", "plan_name": "700703", "standard_charge_dollar": 6544.15, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Miscellaneous", "plan_name": "700720", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Miscellaneous", "plan_name": "700720_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Ppo Hmo", "plan_name": "701720", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Ppo Hmo", "plan_name": "701720_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Ambetter 68069", "plan_name": "500516", "standard_charge_dollar": 6544.15, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Ms State Emplo", "plan_name": "401457", "standard_charge_percentage": 0.80, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Ms State Emplo", "plan_name": "401457_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Basic Pl", "plan_name": "400100", "standard_charge_percentage": 0.85, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Basic Pl", "plan_name": "400100_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Federal", "plan_name": "400110", "standard_charge_percentage": 0.85, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Federal", "plan_name": "400110_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Cigna Healthsprings Ffs", "plan_name": "500064", "standard_charge_dollar": 6544.15, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Conseco", "plan_name": "500302", "standard_charge_dollar": 6544.15, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Humana Ffs 61101", "plan_name": "500006", "standard_charge_dollar": 6544.15, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Medicare A", "plan_name": "100100", "standard_charge_dollar": 6544.15, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Medicare A", "plan_name": "100500", "standard_charge_dollar": 6544.15, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Medicare Part B Only", "plan_name": "100300", "standard_charge_dollar": 6544.15, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Medicare Railroad", "plan_name": "100103", "standard_charge_dollar": 6544.15, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Ms Physicians Care N", "plan_name": "714210", "standard_charge_dollar": 8180.19, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Peoples Hlth Ffs 72126", "plan_name": "500019", "standard_charge_dollar": 6544.15, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Uhc/Secure Horizons", "plan_name": "500449", "standard_charge_dollar": 6544.15, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "United Health Care/", "plan_name": "500292", "standard_charge_dollar": 7394.89, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "United Healthcare", "plan_name": "750104", "standard_charge_dollar": 7394.89, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "United Healthcare Ba", "plan_name": "750090", "standard_charge_dollar": 7394.89, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "United Healthcare Me", "plan_name": "501310", "standard_charge_dollar": 6544.15, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Windsor Mcare Extra", "plan_name": "500778", "standard_charge_dollar": 6544.15, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." } ] } ] }, { "description": "Repair/graft radius & ulna", "code_information": [ { "code": "25420", "type": "CPT" } ], "standard_charges": [ { "gross_charge": 30511.93, "minimum": 6544.15, "maximum": 25935.14, "setting": "inpatient", "payers_information": [ { "payer_name": "Aarp", "plan_name": "500102", "standard_charge_dollar": 6544.15, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna", "plan_name": "700700", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna", "plan_name": "700700_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Mcare Ffs 6005", "plan_name": "700703", "standard_charge_dollar": 6544.15, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Miscellaneous", "plan_name": "700720", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of 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"additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Ms State Emplo", "plan_name": "401457", "standard_charge_percentage": 0.80, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Ms State Emplo", "plan_name": "401457_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Basic Pl", "plan_name": "400100", "standard_charge_percentage": 0.85, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Basic Pl", "plan_name": "400100_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", 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"standard_charge_dollar": 6544.15, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Ms Physicians Care N", "plan_name": "714210", "standard_charge_dollar": 8180.19, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Peoples Hlth Ffs 72126", "plan_name": "500019", "standard_charge_dollar": 6544.15, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Uhc/Secure Horizons", "plan_name": "500449", "standard_charge_dollar": 6544.15, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "United Health Care/", "plan_name": "500292", "standard_charge_dollar": 7394.89, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "United Healthcare", "plan_name": "750104", "standard_charge_dollar": 7394.89, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "United Healthcare Ba", "plan_name": "750090", "standard_charge_dollar": 7394.89, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "United Healthcare Me", "plan_name": "501310", "standard_charge_dollar": 6544.15, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Windsor Mcare Extra", "plan_name": "500778", "standard_charge_dollar": 6544.15, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." } ] } ] }, { "description": "Treat fracture of radius", "code_information": [ { "code": "25515", "type": "CPT" } ], "standard_charges": [ { "gross_charge": 30511.93, "minimum": 6544.15, "maximum": 25935.14, "setting": "inpatient", "payers_information": [ { "payer_name": "Aarp", "plan_name": "500102", "standard_charge_dollar": 6544.15, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna", "plan_name": "700700", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna", "plan_name": "700700_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Mcare Ffs 6005", "plan_name": "700703", "standard_charge_dollar": 6544.15, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Miscellaneous", "plan_name": "700720", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Miscellaneous", "plan_name": "700720_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Ppo Hmo", "plan_name": "701720", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Ppo Hmo", "plan_name": "701720_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Ambetter 68069", "plan_name": "500516", "standard_charge_dollar": 6544.15, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Ms State Emplo", "plan_name": "401457", "standard_charge_percentage": 0.80, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Ms State Emplo", "plan_name": "401457_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Basic Pl", "plan_name": "400100", "standard_charge_percentage": 0.85, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Basic Pl", "plan_name": "400100_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Federal", "plan_name": "400110", "standard_charge_percentage": 0.85, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Federal", "plan_name": "400110_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Cigna Healthsprings Ffs", "plan_name": "500064", "standard_charge_dollar": 6544.15, "count": "0", "methodology": 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"Medicare Part B Only", "plan_name": "100300", "standard_charge_dollar": 6544.15, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Medicare Railroad", "plan_name": "100103", "standard_charge_dollar": 6544.15, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Ms Physicians Care N", "plan_name": "714210", "standard_charge_dollar": 8180.19, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Peoples Hlth Ffs 72126", "plan_name": "500019", "standard_charge_dollar": 6544.15, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Uhc/Secure Horizons", "plan_name": "500449", "standard_charge_dollar": 6544.15, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "United Health Care/", "plan_name": "500292", "standard_charge_dollar": 7394.89, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "United Healthcare", "plan_name": "750104", "standard_charge_dollar": 7394.89, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "United Healthcare Ba", "plan_name": "750090", "standard_charge_dollar": 7394.89, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "United Healthcare Me", "plan_name": "501310", "standard_charge_dollar": 6544.15, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Windsor Mcare Extra", "plan_name": "500778", "standard_charge_dollar": 6544.15, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." } ] } ] }, { "description": "Treat fracture of radius", "code_information": [ { "code": "25525", "type": "CPT" } ], "standard_charges": [ { "gross_charge": 30511.93, "minimum": 6544.15, "maximum": 25935.14, "setting": "inpatient", "payers_information": [ { "payer_name": "Aarp", "plan_name": "500102", "standard_charge_dollar": 6544.15, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna", "plan_name": "700700", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna", "plan_name": "700700_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Mcare Ffs 6005", "plan_name": "700703", "standard_charge_dollar": 6544.15, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Miscellaneous", "plan_name": "700720", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Miscellaneous", "plan_name": "700720_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Ppo Hmo", "plan_name": "701720", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Ppo Hmo", "plan_name": "701720_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Ambetter 68069", "plan_name": "500516", "standard_charge_dollar": 6544.15, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Ms State Emplo", "plan_name": "401457", "standard_charge_percentage": 0.80, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Ms State Emplo", "plan_name": "401457_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Basic Pl", "plan_name": "400100", "standard_charge_percentage": 0.85, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Basic Pl", "plan_name": "400100_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Federal", "plan_name": "400110", "standard_charge_percentage": 0.85, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Federal", "plan_name": "400110_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Cigna Healthsprings Ffs", "plan_name": "500064", "standard_charge_dollar": 6544.15, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Conseco", "plan_name": "500302", "standard_charge_dollar": 6544.15, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Humana Ffs 61101", "plan_name": "500006", "standard_charge_dollar": 6544.15, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Medicare A", "plan_name": "100100", "standard_charge_dollar": 6544.15, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Medicare A", "plan_name": "100500", "standard_charge_dollar": 6544.15, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Medicare Part B Only", "plan_name": "100300", "standard_charge_dollar": 6544.15, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Medicare Railroad", "plan_name": "100103", "standard_charge_dollar": 6544.15, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Ms Physicians Care N", "plan_name": "714210", "standard_charge_dollar": 8180.19, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Peoples Hlth Ffs 72126", "plan_name": "500019", "standard_charge_dollar": 6544.15, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Uhc/Secure Horizons", "plan_name": "500449", "standard_charge_dollar": 6544.15, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "United Health Care/", "plan_name": "500292", "standard_charge_dollar": 7394.89, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "United Healthcare", "plan_name": "750104", "standard_charge_dollar": 7394.89, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "United Healthcare Ba", "plan_name": "750090", "standard_charge_dollar": 7394.89, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "United Healthcare Me", "plan_name": "501310", "standard_charge_dollar": 6544.15, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Windsor Mcare Extra", "plan_name": "500778", "standard_charge_dollar": 6544.15, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." } ] } ] }, { "description": "Treat fracture of radius", "code_information": [ { "code": "25526", "type": "CPT" } ], "standard_charges": [ { "gross_charge": 30511.93, "minimum": 6544.15, "maximum": 25935.14, "setting": "inpatient", "payers_information": [ { "payer_name": "Aarp", "plan_name": "500102", "standard_charge_dollar": 6544.15, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna", "plan_name": "700700", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna", "plan_name": "700700_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Mcare Ffs 6005", "plan_name": "700703", "standard_charge_dollar": 6544.15, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Miscellaneous", "plan_name": "700720", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Miscellaneous", "plan_name": "700720_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Ppo Hmo", "plan_name": "701720", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Ppo Hmo", "plan_name": "701720_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Ambetter 68069", "plan_name": "500516", "standard_charge_dollar": 6544.15, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Ms State Emplo", "plan_name": "401457", "standard_charge_percentage": 0.80, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Ms State Emplo", "plan_name": "401457_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Basic Pl", "plan_name": "400100", "standard_charge_percentage": 0.85, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Basic Pl", "plan_name": "400100_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Federal", "plan_name": "400110", "standard_charge_percentage": 0.85, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Federal", "plan_name": "400110_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Cigna Healthsprings Ffs", "plan_name": "500064", "standard_charge_dollar": 6544.15, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Conseco", "plan_name": "500302", "standard_charge_dollar": 6544.15, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Humana Ffs 61101", "plan_name": "500006", "standard_charge_dollar": 6544.15, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Medicare A", "plan_name": "100100", "standard_charge_dollar": 6544.15, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Medicare A", "plan_name": "100500", "standard_charge_dollar": 6544.15, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Medicare Part B Only", "plan_name": "100300", "standard_charge_dollar": 6544.15, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Medicare Railroad", "plan_name": "100103", "standard_charge_dollar": 6544.15, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Ms Physicians Care N", "plan_name": "714210", "standard_charge_dollar": 8180.19, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Peoples Hlth Ffs 72126", "plan_name": "500019", "standard_charge_dollar": 6544.15, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Uhc/Secure Horizons", "plan_name": "500449", "standard_charge_dollar": 6544.15, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "United Health Care/", "plan_name": "500292", "standard_charge_dollar": 7394.89, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "United Healthcare", "plan_name": "750104", "standard_charge_dollar": 7394.89, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "United Healthcare Ba", "plan_name": "750090", "standard_charge_dollar": 7394.89, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "United Healthcare Me", "plan_name": "501310", "standard_charge_dollar": 6544.15, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Windsor Mcare Extra", "plan_name": "500778", "standard_charge_dollar": 6544.15, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." } ] } ] }, { "description": "Treat fracture radius & ulna", "code_information": [ { "code": "25574", "type": "CPT" } ], "standard_charges": [ { "gross_charge": 30511.93, "minimum": 6544.15, "maximum": 25935.14, "setting": "inpatient", "payers_information": [ { "payer_name": "Aarp", "plan_name": "500102", "standard_charge_dollar": 6544.15, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna", "plan_name": "700700", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna", "plan_name": "700700_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Mcare Ffs 6005", "plan_name": "700703", "standard_charge_dollar": 6544.15, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Miscellaneous", "plan_name": "700720", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Miscellaneous", "plan_name": "700720_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Ppo Hmo", "plan_name": "701720", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Ppo Hmo", "plan_name": "701720_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Ambetter 68069", "plan_name": "500516", "standard_charge_dollar": 6544.15, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Ms State Emplo", "plan_name": "401457", "standard_charge_percentage": 0.80, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Ms State Emplo", "plan_name": "401457_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Basic Pl", "plan_name": "400100", "standard_charge_percentage": 0.85, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Basic Pl", "plan_name": "400100_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Federal", "plan_name": "400110", "standard_charge_percentage": 0.85, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Federal", "plan_name": "400110_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Cigna Healthsprings Ffs", "plan_name": "500064", "standard_charge_dollar": 6544.15, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Conseco", "plan_name": "500302", "standard_charge_dollar": 6544.15, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Humana Ffs 61101", "plan_name": "500006", "standard_charge_dollar": 6544.15, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Medicare A", "plan_name": "100100", "standard_charge_dollar": 6544.15, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Medicare A", "plan_name": "100500", "standard_charge_dollar": 6544.15, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Medicare Part B Only", "plan_name": "100300", "standard_charge_dollar": 6544.15, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Medicare Railroad", "plan_name": "100103", "standard_charge_dollar": 6544.15, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Ms Physicians Care N", "plan_name": "714210", "standard_charge_dollar": 8180.19, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Peoples Hlth Ffs 72126", "plan_name": "500019", "standard_charge_dollar": 6544.15, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Uhc/Secure Horizons", "plan_name": "500449", "standard_charge_dollar": 6544.15, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "United Health Care/", "plan_name": "500292", "standard_charge_dollar": 7394.89, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "United Healthcare", "plan_name": "750104", "standard_charge_dollar": 7394.89, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "United Healthcare Ba", "plan_name": "750090", "standard_charge_dollar": 7394.89, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "United Healthcare Me", "plan_name": "501310", "standard_charge_dollar": 6544.15, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Windsor Mcare Extra", "plan_name": "500778", "standard_charge_dollar": 6544.15, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." } ] } ] }, { "description": "Treat fracture radius/ulna", "code_information": [ { "code": "25575", "type": "CPT" } ], "standard_charges": [ { "gross_charge": 30511.93, "minimum": 6544.15, "maximum": 25935.14, "setting": "inpatient", "payers_information": [ { "payer_name": "Aarp", "plan_name": "500102", "standard_charge_dollar": 6544.15, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna", "plan_name": "700700", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna", "plan_name": "700700_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Mcare Ffs 6005", "plan_name": "700703", "standard_charge_dollar": 6544.15, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Miscellaneous", "plan_name": "700720", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Miscellaneous", "plan_name": "700720_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Ppo Hmo", "plan_name": "701720", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Ppo Hmo", "plan_name": "701720_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Ambetter 68069", "plan_name": "500516", "standard_charge_dollar": 6544.15, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Ms State Emplo", "plan_name": "401457", "standard_charge_percentage": 0.80, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Ms State Emplo", "plan_name": "401457_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Basic Pl", "plan_name": "400100", "standard_charge_percentage": 0.85, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Basic Pl", "plan_name": "400100_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Federal", "plan_name": "400110", "standard_charge_percentage": 0.85, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Federal", "plan_name": "400110_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Cigna Healthsprings Ffs", "plan_name": "500064", "standard_charge_dollar": 6544.15, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Conseco", "plan_name": "500302", "standard_charge_dollar": 6544.15, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Humana Ffs 61101", "plan_name": "500006", "standard_charge_dollar": 6544.15, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Medicare A", "plan_name": "100100", "standard_charge_dollar": 6544.15, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Medicare A", "plan_name": "100500", "standard_charge_dollar": 6544.15, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Medicare Part B Only", "plan_name": "100300", "standard_charge_dollar": 6544.15, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Medicare Railroad", "plan_name": "100103", "standard_charge_dollar": 6544.15, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Ms Physicians Care N", "plan_name": "714210", "standard_charge_dollar": 8180.19, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Peoples Hlth Ffs 72126", "plan_name": "500019", "standard_charge_dollar": 6544.15, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Uhc/Secure Horizons", "plan_name": "500449", "standard_charge_dollar": 6544.15, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "United Health Care/", "plan_name": "500292", "standard_charge_dollar": 7394.89, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "United Healthcare", "plan_name": "750104", "standard_charge_dollar": 7394.89, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "United Healthcare Ba", "plan_name": "750090", "standard_charge_dollar": 7394.89, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "United Healthcare Me", "plan_name": "501310", "standard_charge_dollar": 6544.15, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Windsor Mcare Extra", "plan_name": "500778", "standard_charge_dollar": 6544.15, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." } ] } ] }, { "description": "Treat fx rad extra-articul", "code_information": [ { "code": "25607", "type": "CPT" } ], "standard_charges": [ { "gross_charge": 30511.93, "minimum": 6544.15, "maximum": 25935.14, "setting": "inpatient", "payers_information": [ { "payer_name": "Aarp", "plan_name": "500102", "standard_charge_dollar": 6544.15, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna", "plan_name": "700700", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna", "plan_name": "700700_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Mcare Ffs 6005", "plan_name": "700703", "standard_charge_dollar": 6544.15, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Miscellaneous", "plan_name": "700720", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Miscellaneous", "plan_name": "700720_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Ppo Hmo", "plan_name": "701720", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Ppo Hmo", "plan_name": "701720_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Ambetter 68069", "plan_name": "500516", "standard_charge_dollar": 6544.15, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Ms State Emplo", "plan_name": "401457", "standard_charge_percentage": 0.80, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Ms State Emplo", "plan_name": "401457_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Basic Pl", "plan_name": "400100", "standard_charge_percentage": 0.85, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Basic Pl", "plan_name": "400100_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Federal", "plan_name": "400110", "standard_charge_percentage": 0.85, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Federal", "plan_name": "400110_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Cigna Healthsprings Ffs", "plan_name": "500064", "standard_charge_dollar": 6544.15, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Conseco", "plan_name": "500302", "standard_charge_dollar": 6544.15, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Humana Ffs 61101", "plan_name": "500006", "standard_charge_dollar": 6544.15, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Medicare A", "plan_name": "100100", "standard_charge_dollar": 6544.15, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Medicare A", "plan_name": "100500", "standard_charge_dollar": 6544.15, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Medicare Part B Only", "plan_name": "100300", "standard_charge_dollar": 6544.15, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Medicare Railroad", "plan_name": "100103", "standard_charge_dollar": 6544.15, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Ms Physicians Care N", "plan_name": "714210", "standard_charge_dollar": 8180.19, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Peoples Hlth Ffs 72126", "plan_name": "500019", "standard_charge_dollar": 6544.15, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Uhc/Secure Horizons", "plan_name": "500449", "standard_charge_dollar": 6544.15, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "United Health Care/", "plan_name": "500292", "standard_charge_dollar": 7394.89, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "United Healthcare", "plan_name": "750104", "standard_charge_dollar": 7394.89, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "United Healthcare Ba", "plan_name": "750090", "standard_charge_dollar": 7394.89, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "United Healthcare Me", "plan_name": "501310", "standard_charge_dollar": 6544.15, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Windsor Mcare Extra", "plan_name": "500778", "standard_charge_dollar": 6544.15, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." } ] } ] }, { "description": "Treat fx rad intra-articul", "code_information": [ { "code": "25608", "type": "CPT" } ], "standard_charges": [ { "gross_charge": 30511.93, "minimum": 6544.15, "maximum": 25935.14, "setting": "inpatient", "payers_information": [ { "payer_name": "Aarp", "plan_name": "500102", "standard_charge_dollar": 6544.15, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna", "plan_name": "700700", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna", "plan_name": "700700_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Mcare Ffs 6005", "plan_name": "700703", "standard_charge_dollar": 6544.15, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Miscellaneous", "plan_name": "700720", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Miscellaneous", "plan_name": "700720_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Ppo Hmo", "plan_name": "701720", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Ppo Hmo", "plan_name": "701720_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Ambetter 68069", "plan_name": "500516", "standard_charge_dollar": 6544.15, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Ms State Emplo", "plan_name": "401457", "standard_charge_percentage": 0.80, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Ms State Emplo", "plan_name": "401457_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Basic Pl", "plan_name": "400100", "standard_charge_percentage": 0.85, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Basic Pl", "plan_name": "400100_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Federal", "plan_name": "400110", "standard_charge_percentage": 0.85, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Federal", "plan_name": "400110_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Cigna Healthsprings Ffs", "plan_name": "500064", "standard_charge_dollar": 6544.15, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Conseco", "plan_name": "500302", "standard_charge_dollar": 6544.15, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Humana Ffs 61101", "plan_name": "500006", "standard_charge_dollar": 6544.15, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Medicare A", "plan_name": "100100", "standard_charge_dollar": 6544.15, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Medicare A", "plan_name": "100500", "standard_charge_dollar": 6544.15, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Medicare Part B Only", "plan_name": "100300", "standard_charge_dollar": 6544.15, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Medicare Railroad", "plan_name": "100103", "standard_charge_dollar": 6544.15, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Ms Physicians Care N", "plan_name": "714210", "standard_charge_dollar": 8180.19, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Peoples Hlth Ffs 72126", "plan_name": "500019", "standard_charge_dollar": 6544.15, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Uhc/Secure Horizons", "plan_name": "500449", "standard_charge_dollar": 6544.15, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "United Health Care/", "plan_name": "500292", "standard_charge_dollar": 7394.89, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "United Healthcare", "plan_name": "750104", "standard_charge_dollar": 7394.89, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "United Healthcare Ba", "plan_name": "750090", "standard_charge_dollar": 7394.89, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "United Healthcare Me", "plan_name": "501310", "standard_charge_dollar": 6544.15, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Windsor Mcare Extra", "plan_name": "500778", "standard_charge_dollar": 6544.15, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." } ] } ] }, { "description": "Treat fx radial 3+ frag", "code_information": [ { "code": "25609", "type": "CPT" } ], "standard_charges": [ { "gross_charge": 30511.93, "minimum": 6544.15, "maximum": 25935.14, "setting": "inpatient", "payers_information": [ { "payer_name": "Aarp", "plan_name": "500102", "standard_charge_dollar": 6544.15, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna", "plan_name": "700700", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna", "plan_name": "700700_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Mcare Ffs 6005", "plan_name": "700703", "standard_charge_dollar": 6544.15, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Miscellaneous", "plan_name": "700720", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Miscellaneous", "plan_name": "700720_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Ppo Hmo", "plan_name": "701720", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Ppo Hmo", "plan_name": "701720_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Ambetter 68069", "plan_name": "500516", "standard_charge_dollar": 6544.15, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Ms State Emplo", "plan_name": "401457", "standard_charge_percentage": 0.80, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Ms State Emplo", "plan_name": "401457_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Basic Pl", "plan_name": "400100", "standard_charge_percentage": 0.85, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Basic Pl", "plan_name": "400100_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Federal", "plan_name": "400110", "standard_charge_percentage": 0.85, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Federal", "plan_name": "400110_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Cigna Healthsprings Ffs", "plan_name": "500064", "standard_charge_dollar": 6544.15, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Conseco", "plan_name": "500302", "standard_charge_dollar": 6544.15, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Humana Ffs 61101", "plan_name": "500006", "standard_charge_dollar": 6544.15, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Medicare A", "plan_name": "100100", "standard_charge_dollar": 6544.15, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Medicare A", "plan_name": "100500", "standard_charge_dollar": 6544.15, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Medicare Part B Only", "plan_name": "100300", "standard_charge_dollar": 6544.15, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Medicare Railroad", "plan_name": "100103", "standard_charge_dollar": 6544.15, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Ms Physicians Care N", "plan_name": "714210", "standard_charge_dollar": 8180.19, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Peoples Hlth Ffs 72126", "plan_name": "500019", "standard_charge_dollar": 6544.15, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Uhc/Secure Horizons", "plan_name": "500449", "standard_charge_dollar": 6544.15, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "United Health Care/", "plan_name": "500292", "standard_charge_dollar": 7394.89, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "United Healthcare", "plan_name": "750104", "standard_charge_dollar": 7394.89, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "United Healthcare Ba", "plan_name": "750090", "standard_charge_dollar": 7394.89, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "United Healthcare Me", "plan_name": "501310", "standard_charge_dollar": 6544.15, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Windsor Mcare Extra", "plan_name": "500778", "standard_charge_dollar": 6544.15, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." } ] } ] }, { "description": "Amputation follow-up surgery", "code_information": [ { "code": "25929", "type": "CPT" } ], "standard_charges": [ { "gross_charge": 18296.93, "minimum": 1675.70, "maximum": 15552.39, "setting": "inpatient", "payers_information": [ { "payer_name": "Aarp", "plan_name": "500102", "standard_charge_dollar": 1675.70, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna", "plan_name": "700700", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna", "plan_name": "700700_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Mcare Ffs 6005", "plan_name": "700703", "standard_charge_dollar": 1675.70, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Miscellaneous", "plan_name": "700720", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Miscellaneous", "plan_name": "700720_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Ppo Hmo", "plan_name": "701720", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Ppo Hmo", "plan_name": "701720_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Ambetter 68069", "plan_name": "500516", "standard_charge_dollar": 1675.70, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Ms State Emplo", "plan_name": "401457", "standard_charge_percentage": 0.80, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Ms State Emplo", "plan_name": "401457_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Basic Pl", "plan_name": "400100", "standard_charge_percentage": 0.85, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Basic Pl", "plan_name": "400100_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Federal", "plan_name": "400110", "standard_charge_percentage": 0.85, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Federal", "plan_name": "400110_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Cigna Healthsprings Ffs", "plan_name": "500064", "standard_charge_dollar": 1675.70, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Conseco", "plan_name": "500302", "standard_charge_dollar": 1675.70, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Humana Ffs 61101", "plan_name": "500006", "standard_charge_dollar": 1675.70, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Medicare A", "plan_name": "100100", "standard_charge_dollar": 1675.70, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Medicare A", "plan_name": "100500", "standard_charge_dollar": 1675.70, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Medicare Part B Only", "plan_name": "100300", "standard_charge_dollar": 1675.70, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Medicare Railroad", "plan_name": "100103", "standard_charge_dollar": 1675.70, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Ms Physicians Care N", "plan_name": "714210", "standard_charge_dollar": 2094.63, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Peoples Hlth Ffs 72126", "plan_name": "500019", "standard_charge_dollar": 1675.70, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Uhc/Secure Horizons", "plan_name": "500449", "standard_charge_dollar": 1675.70, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "United Health Care/", "plan_name": "500292", "standard_charge_dollar": 1893.54, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "United Healthcare", "plan_name": "750104", "standard_charge_dollar": 1893.54, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "United Healthcare Ba", "plan_name": "750090", "standard_charge_dollar": 1893.54, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "United Healthcare Me", "plan_name": "501310", "standard_charge_dollar": 1675.70, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Windsor Mcare Extra", "plan_name": "500778", "standard_charge_dollar": 1675.70, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." } ] } ] }, { "description": "Decompress fingers/hand", "code_information": [ { "code": "26035", "type": "CPT" } ], "standard_charges": [ { "gross_charge": 15651.62, "minimum": 2972.29, "maximum": 13303.88, "setting": "inpatient", "payers_information": [ { "payer_name": "Aarp", "plan_name": "500102", "standard_charge_dollar": 2972.29, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna", "plan_name": "700700", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna", "plan_name": "700700_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Mcare Ffs 6005", "plan_name": "700703", "standard_charge_dollar": 2972.29, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Miscellaneous", "plan_name": "700720", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Miscellaneous", "plan_name": "700720_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Ppo Hmo", "plan_name": "701720", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Ppo Hmo", "plan_name": "701720_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Ambetter 68069", "plan_name": "500516", "standard_charge_dollar": 2972.29, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Ms State Emplo", "plan_name": "401457", "standard_charge_percentage": 0.80, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Ms State Emplo", "plan_name": "401457_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Basic Pl", "plan_name": "400100", "standard_charge_percentage": 0.85, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Basic Pl", "plan_name": "400100_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Federal", "plan_name": "400110", "standard_charge_percentage": 0.85, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Federal", "plan_name": "400110_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Cigna Healthsprings Ffs", "plan_name": "500064", "standard_charge_dollar": 2972.29, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Conseco", "plan_name": "500302", "standard_charge_dollar": 2972.29, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Humana Ffs 61101", "plan_name": "500006", "standard_charge_dollar": 2972.29, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Medicare A", "plan_name": "100100", "standard_charge_dollar": 2972.29, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Medicare A", "plan_name": "100500", "standard_charge_dollar": 2972.29, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Medicare Part B Only", "plan_name": "100300", "standard_charge_dollar": 2972.29, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Medicare Railroad", "plan_name": "100103", "standard_charge_dollar": 2972.29, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Ms Physicians Care N", "plan_name": "714210", "standard_charge_dollar": 3715.36, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Peoples Hlth Ffs 72126", "plan_name": "500019", "standard_charge_dollar": 2972.29, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Uhc/Secure Horizons", "plan_name": "500449", "standard_charge_dollar": 2972.29, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "United Health Care/", "plan_name": "500292", "standard_charge_dollar": 3358.68, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "United Healthcare", "plan_name": "750104", "standard_charge_dollar": 3358.68, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "United Healthcare Ba", "plan_name": "750090", "standard_charge_dollar": 3358.68, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "United Healthcare Me", "plan_name": "501310", "standard_charge_dollar": 2972.29, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Windsor Mcare Extra", "plan_name": "500778", "standard_charge_dollar": 2972.29, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." } ] } ] }, { "description": "Release palm contracture", "code_information": [ { "code": "26045", "type": "CPT" } ], "standard_charges": [ { "gross_charge": 15651.62, "minimum": 2972.29, "maximum": 13303.88, "setting": "inpatient", "payers_information": [ { "payer_name": "Aarp", "plan_name": "500102", "standard_charge_dollar": 2972.29, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna", "plan_name": "700700", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna", "plan_name": "700700_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Mcare Ffs 6005", "plan_name": "700703", "standard_charge_dollar": 2972.29, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Miscellaneous", "plan_name": "700720", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Miscellaneous", "plan_name": "700720_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Ppo Hmo", "plan_name": "701720", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Ppo Hmo", "plan_name": "701720_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Ambetter 68069", "plan_name": "500516", "standard_charge_dollar": 2972.29, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Ms State Emplo", "plan_name": "401457", "standard_charge_percentage": 0.80, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Ms State Emplo", "plan_name": "401457_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Basic Pl", "plan_name": "400100", "standard_charge_percentage": 0.85, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Basic Pl", "plan_name": "400100_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Federal", "plan_name": "400110", "standard_charge_percentage": 0.85, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Federal", "plan_name": "400110_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Cigna Healthsprings Ffs", "plan_name": "500064", "standard_charge_dollar": 2972.29, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Conseco", "plan_name": "500302", "standard_charge_dollar": 2972.29, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Humana Ffs 61101", "plan_name": "500006", "standard_charge_dollar": 2972.29, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Medicare A", "plan_name": "100100", "standard_charge_dollar": 2972.29, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Medicare A", "plan_name": "100500", "standard_charge_dollar": 2972.29, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Medicare Part B Only", "plan_name": "100300", "standard_charge_dollar": 2972.29, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Medicare Railroad", "plan_name": "100103", "standard_charge_dollar": 2972.29, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Ms Physicians Care N", "plan_name": "714210", "standard_charge_dollar": 3715.36, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Peoples Hlth Ffs 72126", "plan_name": "500019", "standard_charge_dollar": 2972.29, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Uhc/Secure Horizons", "plan_name": "500449", "standard_charge_dollar": 2972.29, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "United Health Care/", "plan_name": "500292", "standard_charge_dollar": 3358.68, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "United Healthcare", "plan_name": "750104", "standard_charge_dollar": 3358.68, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "United Healthcare Ba", "plan_name": "750090", "standard_charge_dollar": 3358.68, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "United Healthcare Me", "plan_name": "501310", "standard_charge_dollar": 2972.29, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Windsor Mcare Extra", "plan_name": "500778", "standard_charge_dollar": 2972.29, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." } ] } ] }, { "description": "Hc closed reduction finger", "code_information": [ { "code": "26700", "type": "CPT" } ], "standard_charges": [ { "gross_charge": 275.00, "minimum": 219.75, "maximum": 274.68, "setting": "both", "payers_information": [ { "payer_name": "Aarp", "plan_name": "500102", "standard_charge_dollar": 219.75, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna", "plan_name": "700700", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna", "plan_name": "700700_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Mcare Ffs 6005", "plan_name": "700703", "standard_charge_dollar": 219.75, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Miscellaneous", "plan_name": "700720", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Miscellaneous", "plan_name": "700720_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Ppo Hmo", "plan_name": "701720", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Ppo Hmo", "plan_name": "701720_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Ambetter 68069", "plan_name": "500516", "standard_charge_dollar": 219.75, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Ms State Emplo", "plan_name": "401457", "standard_charge_percentage": 0.80, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Ms State Emplo", "plan_name": "401457_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Basic Pl", "plan_name": "400100", "standard_charge_percentage": 0.85, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Basic Pl", "plan_name": "400100_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Federal", "plan_name": "400110", "standard_charge_percentage": 0.85, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Federal", "plan_name": "400110_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Cigna Healthsprings Ffs", "plan_name": "500064", "standard_charge_dollar": 219.75, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Conseco", "plan_name": "500302", "standard_charge_dollar": 219.75, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Humana Ffs 61101", "plan_name": "500006", "standard_charge_dollar": 219.75, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Medicare A", "plan_name": "100100", "standard_charge_dollar": 219.75, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Medicare A", "plan_name": "100500", "standard_charge_dollar": 219.75, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Medicare Part B Only", "plan_name": "100300", "standard_charge_dollar": 219.75, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Medicare Railroad", "plan_name": "100103", "standard_charge_dollar": 219.75, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Ms Physicians Care N", "plan_name": "714210", "standard_charge_dollar": 274.68, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Peoples Hlth Ffs 72126", "plan_name": "500019", "standard_charge_dollar": 219.75, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Uhc/Secure Horizons", "plan_name": "500449", "standard_charge_dollar": 219.75, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "United Health Care/", "plan_name": "500292", "standard_charge_dollar": 248.31, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "United Healthcare", "plan_name": "750104", "standard_charge_dollar": 248.31, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "United Healthcare Ba", "plan_name": "750090", "standard_charge_dollar": 248.31, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "United Healthcare Me", "plan_name": "501310", "standard_charge_dollar": 219.75, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Windsor Mcare Extra", "plan_name": "500778", "standard_charge_dollar": 219.75, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." } ] } ] }, { "description": "Treat knuckle dislocation", "code_information": [ { "code": "26700", "type": "CPT" } ], "standard_charges": [ { "gross_charge": 275.00, "minimum": 219.75, "maximum": 274.68, "setting": "both", "payers_information": [ { "payer_name": "Aarp", "plan_name": "500102", "standard_charge_dollar": 219.75, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna", "plan_name": "700700", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna", "plan_name": "700700_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Mcare Ffs 6005", "plan_name": "700703", "standard_charge_dollar": 219.75, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Miscellaneous", "plan_name": "700720", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Miscellaneous", "plan_name": "700720_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Ppo Hmo", "plan_name": "701720", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Ppo Hmo", "plan_name": "701720_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Ambetter 68069", "plan_name": "500516", "standard_charge_dollar": 219.75, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Ms State Emplo", "plan_name": "401457", "standard_charge_percentage": 0.80, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Ms State Emplo", "plan_name": "401457_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Basic Pl", "plan_name": "400100", "standard_charge_percentage": 0.85, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Basic Pl", "plan_name": "400100_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Federal", "plan_name": "400110", "standard_charge_percentage": 0.85, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Federal", "plan_name": "400110_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Cigna Healthsprings Ffs", "plan_name": "500064", "standard_charge_dollar": 219.75, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Conseco", "plan_name": "500302", "standard_charge_dollar": 219.75, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Humana Ffs 61101", "plan_name": "500006", "standard_charge_dollar": 219.75, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Medicare A", "plan_name": "100100", "standard_charge_dollar": 219.75, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Medicare A", "plan_name": "100500", "standard_charge_dollar": 219.75, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Medicare Part B Only", "plan_name": "100300", "standard_charge_dollar": 219.75, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Medicare Railroad", "plan_name": "100103", "standard_charge_dollar": 219.75, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Ms Physicians Care N", "plan_name": "714210", "standard_charge_dollar": 274.68, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Peoples Hlth Ffs 72126", "plan_name": "500019", "standard_charge_dollar": 219.75, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Uhc/Secure Horizons", "plan_name": "500449", "standard_charge_dollar": 219.75, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "United Health Care/", "plan_name": "500292", "standard_charge_dollar": 248.31, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "United Healthcare", "plan_name": "750104", "standard_charge_dollar": 248.31, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "United Healthcare Ba", "plan_name": "750090", "standard_charge_dollar": 248.31, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "United Healthcare Me", "plan_name": "501310", "standard_charge_dollar": 219.75, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Windsor Mcare Extra", "plan_name": "500778", "standard_charge_dollar": 219.75, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." } ] } ] }, { "description": "Hc clsd trmnt intrphal jnt w/manip w/anesth", "code_information": [ { "code": "26775", "type": "CPT" } ], "standard_charges": [ { "gross_charge": 545.00, "minimum": 243.29, "maximum": 463.25, "setting": "both", "payers_information": [ { "payer_name": "Aarp", "plan_name": "500102", "standard_charge_dollar": 243.29, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna", "plan_name": "700700", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna", "plan_name": "700700_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Mcare Ffs 6005", "plan_name": "700703", "standard_charge_dollar": 243.29, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Miscellaneous", "plan_name": "700720", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Miscellaneous", "plan_name": "700720_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Ppo Hmo", "plan_name": "701720", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Ppo Hmo", "plan_name": "701720_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Ambetter 68069", "plan_name": "500516", "standard_charge_dollar": 243.29, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Ms State Emplo", "plan_name": "401457", "standard_charge_percentage": 0.80, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Ms State Emplo", "plan_name": "401457_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Basic Pl", "plan_name": "400100", "standard_charge_percentage": 0.85, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Basic Pl", "plan_name": "400100_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Federal", "plan_name": "400110", "standard_charge_percentage": 0.85, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Federal", "plan_name": "400110_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Cigna Healthsprings Ffs", "plan_name": "500064", "standard_charge_dollar": 243.29, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Conseco", "plan_name": "500302", "standard_charge_dollar": 243.29, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Humana Ffs 61101", "plan_name": "500006", "standard_charge_dollar": 243.29, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Medicare A", "plan_name": "100100", "standard_charge_dollar": 243.29, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Medicare A", "plan_name": "100500", "standard_charge_dollar": 243.29, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Medicare Part B Only", "plan_name": "100300", "standard_charge_dollar": 243.29, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Medicare Railroad", "plan_name": "100103", "standard_charge_dollar": 243.29, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Ms Physicians Care N", "plan_name": "714210", "standard_charge_dollar": 304.11, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Peoples Hlth Ffs 72126", "plan_name": "500019", "standard_charge_dollar": 243.29, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Uhc/Secure Horizons", "plan_name": "500449", "standard_charge_dollar": 243.29, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "United Health Care/", "plan_name": "500292", "standard_charge_dollar": 274.92, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "United Healthcare", "plan_name": "750104", "standard_charge_dollar": 274.92, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "United Healthcare Ba", "plan_name": "750090", "standard_charge_dollar": 274.92, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "United Healthcare Me", "plan_name": "501310", "standard_charge_dollar": 243.29, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Windsor Mcare Extra", "plan_name": "500778", "standard_charge_dollar": 243.29, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." } ] } ] }, { "description": "Treat finger dislocation", "code_information": [ { "code": "26775", "type": "CPT" } ], "standard_charges": [ { "gross_charge": 545.00, "minimum": 243.29, "maximum": 463.25, "setting": "both", "payers_information": [ { "payer_name": "Aarp", "plan_name": "500102", "standard_charge_dollar": 243.29, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna", "plan_name": "700700", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna", "plan_name": "700700_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Mcare Ffs 6005", "plan_name": "700703", "standard_charge_dollar": 243.29, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Miscellaneous", "plan_name": "700720", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Miscellaneous", "plan_name": "700720_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Ppo Hmo", "plan_name": "701720", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Ppo Hmo", "plan_name": "701720_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Ambetter 68069", "plan_name": "500516", "standard_charge_dollar": 243.29, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Ms State Emplo", "plan_name": "401457", "standard_charge_percentage": 0.80, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Ms State Emplo", "plan_name": "401457_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Basic Pl", "plan_name": "400100", "standard_charge_percentage": 0.85, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Basic Pl", "plan_name": "400100_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Federal", "plan_name": "400110", "standard_charge_percentage": 0.85, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Federal", "plan_name": "400110_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Cigna Healthsprings Ffs", "plan_name": "500064", "standard_charge_dollar": 243.29, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Conseco", "plan_name": "500302", "standard_charge_dollar": 243.29, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Humana Ffs 61101", "plan_name": "500006", "standard_charge_dollar": 243.29, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Medicare A", "plan_name": "100100", "standard_charge_dollar": 243.29, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Medicare A", "plan_name": "100500", "standard_charge_dollar": 243.29, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Medicare Part B Only", "plan_name": "100300", "standard_charge_dollar": 243.29, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Medicare Railroad", "plan_name": "100103", "standard_charge_dollar": 243.29, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Ms Physicians Care N", "plan_name": "714210", "standard_charge_dollar": 304.11, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Peoples Hlth Ffs 72126", "plan_name": "500019", "standard_charge_dollar": 243.29, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Uhc/Secure Horizons", "plan_name": "500449", "standard_charge_dollar": 243.29, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "United Health Care/", "plan_name": "500292", "standard_charge_dollar": 274.92, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "United Healthcare", "plan_name": "750104", "standard_charge_dollar": 274.92, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "United Healthcare Ba", "plan_name": "750090", "standard_charge_dollar": 274.92, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "United Healthcare Me", "plan_name": "501310", "standard_charge_dollar": 243.29, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Windsor Mcare Extra", "plan_name": "500778", "standard_charge_dollar": 243.29, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." } ] } ] }, { "description": "Amputate metacarpal bone", "code_information": [ { "code": "26910", "type": "CPT" } ], "standard_charges": [ { "gross_charge": 18296.93, "minimum": 2972.29, "maximum": 15552.39, "setting": "inpatient", "payers_information": [ { "payer_name": "Aarp", "plan_name": "500102", "standard_charge_dollar": 2972.29, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna", "plan_name": "700700", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna", "plan_name": "700700_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Mcare Ffs 6005", "plan_name": "700703", "standard_charge_dollar": 2972.29, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Miscellaneous", "plan_name": "700720", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Miscellaneous", "plan_name": "700720_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Ppo Hmo", "plan_name": "701720", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Ppo Hmo", "plan_name": "701720_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Ambetter 68069", "plan_name": "500516", "standard_charge_dollar": 2972.29, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Ms State Emplo", "plan_name": "401457", "standard_charge_percentage": 0.80, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Ms State Emplo", "plan_name": "401457_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Basic Pl", "plan_name": "400100", "standard_charge_percentage": 0.85, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Basic Pl", "plan_name": "400100_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Federal", "plan_name": "400110", "standard_charge_percentage": 0.85, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Federal", "plan_name": "400110_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Cigna Healthsprings Ffs", "plan_name": "500064", "standard_charge_dollar": 2972.29, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Conseco", "plan_name": "500302", "standard_charge_dollar": 2972.29, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Humana Ffs 61101", "plan_name": "500006", "standard_charge_dollar": 2972.29, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Medicare A", "plan_name": "100100", "standard_charge_dollar": 2972.29, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Medicare A", "plan_name": "100500", "standard_charge_dollar": 2972.29, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Medicare Part B Only", "plan_name": "100300", "standard_charge_dollar": 2972.29, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Medicare Railroad", "plan_name": "100103", "standard_charge_dollar": 2972.29, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Ms Physicians Care N", "plan_name": "714210", "standard_charge_dollar": 3715.36, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Peoples Hlth Ffs 72126", "plan_name": "500019", "standard_charge_dollar": 2972.29, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Uhc/Secure Horizons", "plan_name": "500449", "standard_charge_dollar": 2972.29, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "United Health Care/", "plan_name": "500292", "standard_charge_dollar": 3358.68, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "United Healthcare", "plan_name": "750104", "standard_charge_dollar": 3358.68, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "United Healthcare Ba", "plan_name": "750090", "standard_charge_dollar": 3358.68, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "United Healthcare Me", "plan_name": "501310", "standard_charge_dollar": 2972.29, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Windsor Mcare Extra", "plan_name": "500778", "standard_charge_dollar": 2972.29, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." } ] } ] }, { "description": "Amputation of finger/thumb", "code_information": [ { "code": "26951", "type": "CPT" } ], "standard_charges": [ { "gross_charge": 18296.93, "minimum": 2972.29, "maximum": 15552.39, "setting": "inpatient", "payers_information": [ { "payer_name": "Aarp", "plan_name": "500102", "standard_charge_dollar": 2972.29, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna", "plan_name": "700700", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna", "plan_name": "700700_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Mcare Ffs 6005", "plan_name": "700703", "standard_charge_dollar": 2972.29, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Miscellaneous", "plan_name": "700720", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Miscellaneous", "plan_name": "700720_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Ppo Hmo", "plan_name": "701720", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Ppo Hmo", "plan_name": "701720_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Ambetter 68069", "plan_name": "500516", "standard_charge_dollar": 2972.29, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Ms State Emplo", "plan_name": "401457", "standard_charge_percentage": 0.80, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Ms State Emplo", "plan_name": "401457_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Basic Pl", "plan_name": "400100", "standard_charge_percentage": 0.85, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Basic Pl", "plan_name": "400100_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Federal", "plan_name": "400110", "standard_charge_percentage": 0.85, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Federal", "plan_name": "400110_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Cigna Healthsprings Ffs", "plan_name": "500064", "standard_charge_dollar": 2972.29, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Conseco", "plan_name": "500302", "standard_charge_dollar": 2972.29, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Humana Ffs 61101", "plan_name": "500006", "standard_charge_dollar": 2972.29, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Medicare A", "plan_name": "100100", "standard_charge_dollar": 2972.29, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Medicare A", "plan_name": "100500", "standard_charge_dollar": 2972.29, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Medicare Part B Only", "plan_name": "100300", "standard_charge_dollar": 2972.29, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Medicare Railroad", "plan_name": "100103", "standard_charge_dollar": 2972.29, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Ms Physicians Care N", "plan_name": "714210", "standard_charge_dollar": 3715.36, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Peoples Hlth Ffs 72126", "plan_name": "500019", "standard_charge_dollar": 2972.29, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Uhc/Secure Horizons", "plan_name": "500449", "standard_charge_dollar": 2972.29, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "United Health Care/", "plan_name": "500292", "standard_charge_dollar": 3358.68, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "United Healthcare", "plan_name": "750104", "standard_charge_dollar": 3358.68, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "United Healthcare Ba", "plan_name": "750090", "standard_charge_dollar": 3358.68, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "United Healthcare Me", "plan_name": "501310", "standard_charge_dollar": 2972.29, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Windsor Mcare Extra", "plan_name": "500778", "standard_charge_dollar": 2972.29, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." } ] } ] }, { "description": "Amputation of finger/thumb", "code_information": [ { "code": "26952", "type": "CPT" } ], "standard_charges": [ { "gross_charge": 18296.93, "minimum": 2972.29, "maximum": 15552.39, "setting": "inpatient", "payers_information": [ { "payer_name": "Aarp", "plan_name": "500102", "standard_charge_dollar": 2972.29, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna", "plan_name": "700700", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna", "plan_name": "700700_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Mcare Ffs 6005", "plan_name": "700703", "standard_charge_dollar": 2972.29, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Miscellaneous", "plan_name": "700720", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Miscellaneous", "plan_name": "700720_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Ppo Hmo", "plan_name": "701720", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Ppo Hmo", "plan_name": "701720_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Ambetter 68069", "plan_name": "500516", "standard_charge_dollar": 2972.29, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Ms State Emplo", "plan_name": "401457", "standard_charge_percentage": 0.80, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Ms State Emplo", "plan_name": "401457_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Basic Pl", "plan_name": "400100", "standard_charge_percentage": 0.85, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Basic Pl", "plan_name": "400100_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Federal", "plan_name": "400110", "standard_charge_percentage": 0.85, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Federal", "plan_name": "400110_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Cigna Healthsprings Ffs", "plan_name": "500064", "standard_charge_dollar": 2972.29, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Conseco", "plan_name": "500302", "standard_charge_dollar": 2972.29, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Humana Ffs 61101", "plan_name": "500006", "standard_charge_dollar": 2972.29, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Medicare A", "plan_name": "100100", "standard_charge_dollar": 2972.29, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Medicare A", "plan_name": "100500", "standard_charge_dollar": 2972.29, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Medicare Part B Only", "plan_name": "100300", "standard_charge_dollar": 2972.29, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Medicare Railroad", "plan_name": "100103", "standard_charge_dollar": 2972.29, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Ms Physicians Care N", "plan_name": "714210", "standard_charge_dollar": 3715.36, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Peoples Hlth Ffs 72126", "plan_name": "500019", "standard_charge_dollar": 2972.29, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Uhc/Secure Horizons", "plan_name": "500449", "standard_charge_dollar": 2972.29, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "United Health Care/", "plan_name": "500292", "standard_charge_dollar": 3358.68, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "United Healthcare", "plan_name": "750104", "standard_charge_dollar": 3358.68, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "United Healthcare Ba", "plan_name": "750090", "standard_charge_dollar": 3358.68, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "United Healthcare Me", "plan_name": "501310", "standard_charge_dollar": 2972.29, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Windsor Mcare Extra", "plan_name": "500778", "standard_charge_dollar": 2972.29, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." } ] } ] }, { "description": "Hand/finger surgery", "code_information": [ { "code": "26989", "type": "CPT" } ], "standard_charges": [ { "gross_charge": 16347.68, "minimum": 219.75, "maximum": 13895.53, "setting": "inpatient", "payers_information": [ { "payer_name": "Aarp", "plan_name": "500102", "standard_charge_dollar": 219.75, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna", "plan_name": "700700", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna", "plan_name": "700700_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Mcare Ffs 6005", "plan_name": "700703", "standard_charge_dollar": 219.75, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Miscellaneous", "plan_name": "700720", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Miscellaneous", "plan_name": "700720_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Ppo Hmo", "plan_name": "701720", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Ppo Hmo", "plan_name": "701720_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Ambetter 68069", "plan_name": "500516", "standard_charge_dollar": 219.75, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Ms State Emplo", "plan_name": "401457", "standard_charge_percentage": 0.80, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Ms State Emplo", "plan_name": "401457_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Basic Pl", "plan_name": "400100", "standard_charge_percentage": 0.85, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Basic Pl", "plan_name": "400100_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Federal", "plan_name": "400110", "standard_charge_percentage": 0.85, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Federal", "plan_name": "400110_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Cigna Healthsprings Ffs", "plan_name": "500064", "standard_charge_dollar": 219.75, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Conseco", "plan_name": "500302", "standard_charge_dollar": 219.75, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Humana Ffs 61101", "plan_name": "500006", "standard_charge_dollar": 219.75, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Medicare A", "plan_name": "100100", "standard_charge_dollar": 219.75, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Medicare A", "plan_name": "100500", "standard_charge_dollar": 219.75, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Medicare Part B Only", "plan_name": "100300", "standard_charge_dollar": 219.75, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Medicare Railroad", "plan_name": "100103", "standard_charge_dollar": 219.75, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Ms Physicians Care N", "plan_name": "714210", "standard_charge_dollar": 274.68, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Peoples Hlth Ffs 72126", "plan_name": "500019", "standard_charge_dollar": 219.75, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Uhc/Secure Horizons", "plan_name": "500449", "standard_charge_dollar": 219.75, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "United Health Care/", "plan_name": "500292", "standard_charge_dollar": 248.31, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "United Healthcare", "plan_name": "750104", "standard_charge_dollar": 248.31, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "United Healthcare Ba", "plan_name": "750090", "standard_charge_dollar": 248.31, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "United Healthcare Me", "plan_name": "501310", "standard_charge_dollar": 219.75, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Windsor Mcare Extra", "plan_name": "500778", "standard_charge_dollar": 219.75, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." } ] } ] }, { "description": "Drainage of pelvis lesion", "code_information": [ { "code": "26990", "type": "CPT" } ], "standard_charges": [ { "gross_charge": 39375.67, "minimum": 2972.29, "maximum": 33469.32, "setting": "inpatient", "payers_information": [ { "payer_name": "Aarp", "plan_name": "500102", "standard_charge_dollar": 2972.29, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna", "plan_name": "700700", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna", "plan_name": "700700_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Mcare Ffs 6005", "plan_name": "700703", "standard_charge_dollar": 2972.29, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Miscellaneous", "plan_name": "700720", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Miscellaneous", "plan_name": "700720_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Ppo Hmo", "plan_name": "701720", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Ppo Hmo", "plan_name": "701720_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Ambetter 68069", "plan_name": "500516", "standard_charge_dollar": 2972.29, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Ms State Emplo", "plan_name": "401457", "standard_charge_percentage": 0.80, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Ms State Emplo", "plan_name": "401457_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Basic Pl", "plan_name": "400100", "standard_charge_percentage": 0.85, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Basic Pl", "plan_name": "400100_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Federal", "plan_name": "400110", "standard_charge_percentage": 0.85, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Federal", "plan_name": "400110_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Cigna Healthsprings Ffs", "plan_name": "500064", "standard_charge_dollar": 2972.29, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Conseco", "plan_name": "500302", "standard_charge_dollar": 2972.29, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Humana Ffs 61101", "plan_name": "500006", "standard_charge_dollar": 2972.29, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Medicare A", "plan_name": "100100", "standard_charge_dollar": 2972.29, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Medicare A", "plan_name": "100500", "standard_charge_dollar": 2972.29, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Medicare Part B Only", "plan_name": "100300", "standard_charge_dollar": 2972.29, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Medicare Railroad", "plan_name": "100103", "standard_charge_dollar": 2972.29, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Ms Physicians Care N", "plan_name": "714210", "standard_charge_dollar": 3715.36, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Peoples Hlth Ffs 72126", "plan_name": "500019", "standard_charge_dollar": 2972.29, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Uhc/Secure Horizons", "plan_name": "500449", "standard_charge_dollar": 2972.29, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "United Health Care/", "plan_name": "500292", "standard_charge_dollar": 3358.68, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "United Healthcare", "plan_name": "750104", "standard_charge_dollar": 3358.68, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "United Healthcare Ba", "plan_name": "750090", "standard_charge_dollar": 3358.68, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "United Healthcare Me", "plan_name": "501310", "standard_charge_dollar": 2972.29, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Windsor Mcare Extra", "plan_name": "500778", "standard_charge_dollar": 2972.29, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." } ] } ] }, { "description": "Drainage of hip joint", "code_information": [ { "code": "27030", "type": "CPT" } ], "standard_charges": [ { "gross_charge": 69318.05, "minimum": 55454.44, "maximum": 58920.34, "setting": "inpatient", "payers_information": [ { "payer_name": "Aetna", "plan_name": "700700", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna", "plan_name": "700700_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Miscellaneous", "plan_name": "700720", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Miscellaneous", "plan_name": "700720_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Ppo Hmo", "plan_name": "701720", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Ppo Hmo", "plan_name": "701720_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Ms State Emplo", "plan_name": "401457", "standard_charge_percentage": 0.80, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Ms State Emplo", "plan_name": "401457_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Basic Pl", "plan_name": "400100", "standard_charge_percentage": 0.85, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Basic Pl", "plan_name": "400100_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Federal", "plan_name": "400110", "standard_charge_percentage": 0.85, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Federal", "plan_name": "400110_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." } ] } ] }, { "description": "Exploration of hip joint", "code_information": [ { "code": "27033", "type": "CPT" } ], "standard_charges": [ { "gross_charge": 69318.05, "minimum": 6544.15, "maximum": 58920.34, "setting": "inpatient", "payers_information": [ { "payer_name": "Aarp", "plan_name": "500102", "standard_charge_dollar": 6544.15, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna", "plan_name": "700700", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna", "plan_name": "700700_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Mcare Ffs 6005", "plan_name": "700703", "standard_charge_dollar": 6544.15, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Miscellaneous", "plan_name": "700720", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Miscellaneous", "plan_name": "700720_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Ppo Hmo", "plan_name": "701720", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Ppo Hmo", "plan_name": "701720_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Ambetter 68069", "plan_name": "500516", "standard_charge_dollar": 6544.15, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Ms State Emplo", "plan_name": "401457", "standard_charge_percentage": 0.80, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Ms State Emplo", "plan_name": "401457_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Basic Pl", "plan_name": "400100", "standard_charge_percentage": 0.85, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Basic Pl", "plan_name": "400100_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Federal", "plan_name": "400110", "standard_charge_percentage": 0.85, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Federal", "plan_name": "400110_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Cigna Healthsprings Ffs", "plan_name": "500064", "standard_charge_dollar": 6544.15, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Conseco", "plan_name": "500302", "standard_charge_dollar": 6544.15, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Humana Ffs 61101", "plan_name": "500006", "standard_charge_dollar": 6544.15, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Medicare A", "plan_name": "100100", "standard_charge_dollar": 6544.15, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Medicare A", "plan_name": "100500", "standard_charge_dollar": 6544.15, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Medicare Part B Only", "plan_name": "100300", "standard_charge_dollar": 6544.15, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Medicare Railroad", "plan_name": "100103", "standard_charge_dollar": 6544.15, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Ms Physicians Care N", "plan_name": "714210", "standard_charge_dollar": 8180.19, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Peoples Hlth Ffs 72126", "plan_name": "500019", "standard_charge_dollar": 6544.15, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Uhc/Secure Horizons", "plan_name": "500449", "standard_charge_dollar": 6544.15, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "United Health Care/", "plan_name": "500292", "standard_charge_dollar": 7394.89, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "United Healthcare", "plan_name": "750104", "standard_charge_dollar": 7394.89, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "United Healthcare Ba", "plan_name": "750090", "standard_charge_dollar": 7394.89, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "United Healthcare Me", "plan_name": "501310", "standard_charge_dollar": 6544.15, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Windsor Mcare Extra", "plan_name": "500778", "standard_charge_dollar": 6544.15, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." } ] } ] }, { "description": "Exc hip pelvis les sc 3 cm/>", "code_information": [ { "code": "27043", "type": "CPT" } ], "standard_charges": [ { "gross_charge": 36886.03, "minimum": 2621.84, "maximum": 31353.13, "setting": "inpatient", "payers_information": [ { "payer_name": "Aarp", "plan_name": "500102", "standard_charge_dollar": 2621.84, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna", "plan_name": "700700", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna", "plan_name": "700700_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Mcare Ffs 6005", "plan_name": "700703", "standard_charge_dollar": 2621.84, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Miscellaneous", "plan_name": "700720", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Miscellaneous", "plan_name": "700720_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Ppo Hmo", "plan_name": "701720", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Ppo Hmo", "plan_name": "701720_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Ambetter 68069", "plan_name": "500516", "standard_charge_dollar": 2621.84, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Ms State Emplo", "plan_name": "401457", "standard_charge_percentage": 0.80, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Ms State Emplo", "plan_name": "401457_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Basic Pl", "plan_name": "400100", "standard_charge_percentage": 0.85, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Basic Pl", "plan_name": "400100_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Federal", "plan_name": "400110", "standard_charge_percentage": 0.85, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Federal", "plan_name": "400110_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Cigna Healthsprings Ffs", "plan_name": "500064", "standard_charge_dollar": 2621.84, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Conseco", "plan_name": "500302", "standard_charge_dollar": 2621.84, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Humana Ffs 61101", "plan_name": "500006", "standard_charge_dollar": 2621.84, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Medicare A", "plan_name": "100100", "standard_charge_dollar": 2621.84, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Medicare A", "plan_name": "100500", "standard_charge_dollar": 2621.84, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Medicare Part B Only", "plan_name": "100300", "standard_charge_dollar": 2621.84, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Medicare Railroad", "plan_name": "100103", "standard_charge_dollar": 2621.84, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Ms Physicians Care N", "plan_name": "714210", "standard_charge_dollar": 3277.29, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Peoples Hlth Ffs 72126", "plan_name": "500019", "standard_charge_dollar": 2621.84, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Uhc/Secure Horizons", "plan_name": "500449", "standard_charge_dollar": 2621.84, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "United Health Care/", "plan_name": "500292", "standard_charge_dollar": 2962.67, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "United Healthcare", "plan_name": "750104", "standard_charge_dollar": 2962.67, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "United Healthcare Ba", "plan_name": "750090", "standard_charge_dollar": 2962.67, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "United Healthcare Me", "plan_name": "501310", "standard_charge_dollar": 2621.84, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Windsor Mcare Extra", "plan_name": "500778", "standard_charge_dollar": 2621.84, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." } ] } ] }, { "description": "Exc hip/pelv tum deep 5 cm/>", "code_information": [ { "code": "27045", "type": "CPT" } ], "standard_charges": [ { "gross_charge": 29802.90, "minimum": 2621.84, "maximum": 25332.47, "setting": "inpatient", "payers_information": [ { "payer_name": "Aarp", "plan_name": "500102", "standard_charge_dollar": 2621.84, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna", "plan_name": "700700", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna", "plan_name": "700700_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Mcare Ffs 6005", "plan_name": "700703", "standard_charge_dollar": 2621.84, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Miscellaneous", "plan_name": "700720", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Miscellaneous", "plan_name": "700720_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Ppo Hmo", "plan_name": "701720", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Ppo Hmo", "plan_name": "701720_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Ambetter 68069", "plan_name": "500516", "standard_charge_dollar": 2621.84, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Ms State Emplo", "plan_name": "401457", "standard_charge_percentage": 0.80, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Ms State Emplo", "plan_name": "401457_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Basic Pl", "plan_name": "400100", "standard_charge_percentage": 0.85, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Basic Pl", "plan_name": "400100_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Federal", "plan_name": "400110", "standard_charge_percentage": 0.85, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Federal", "plan_name": "400110_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Cigna Healthsprings Ffs", "plan_name": "500064", "standard_charge_dollar": 2621.84, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Conseco", "plan_name": "500302", "standard_charge_dollar": 2621.84, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Humana Ffs 61101", "plan_name": "500006", "standard_charge_dollar": 2621.84, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Medicare A", "plan_name": "100100", "standard_charge_dollar": 2621.84, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Medicare A", "plan_name": "100500", "standard_charge_dollar": 2621.84, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Medicare Part B Only", "plan_name": "100300", "standard_charge_dollar": 2621.84, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Medicare Railroad", "plan_name": "100103", "standard_charge_dollar": 2621.84, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Ms Physicians Care N", "plan_name": "714210", "standard_charge_dollar": 3277.29, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Peoples Hlth Ffs 72126", "plan_name": "500019", "standard_charge_dollar": 2621.84, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Uhc/Secure Horizons", "plan_name": "500449", "standard_charge_dollar": 2621.84, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "United Health Care/", "plan_name": "500292", "standard_charge_dollar": 2962.67, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "United Healthcare", "plan_name": "750104", "standard_charge_dollar": 2962.67, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "United Healthcare Ba", "plan_name": "750090", "standard_charge_dollar": 2962.67, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "United Healthcare Me", "plan_name": "501310", "standard_charge_dollar": 2621.84, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Windsor Mcare Extra", "plan_name": "500778", "standard_charge_dollar": 2621.84, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." } ] } ] }, { "description": "Exc hip/pelv tum deep < 5 cm", "code_information": [ { "code": "27048", "type": "CPT" } ], "standard_charges": [ { "gross_charge": 29802.90, "minimum": 2621.84, "maximum": 25332.47, "setting": "inpatient", "payers_information": [ { "payer_name": "Aarp", "plan_name": "500102", "standard_charge_dollar": 2621.84, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna", "plan_name": "700700", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna", "plan_name": "700700_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Mcare Ffs 6005", "plan_name": "700703", "standard_charge_dollar": 2621.84, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Miscellaneous", "plan_name": "700720", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Miscellaneous", "plan_name": "700720_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Ppo Hmo", "plan_name": "701720", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Ppo Hmo", "plan_name": "701720_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Ambetter 68069", "plan_name": "500516", "standard_charge_dollar": 2621.84, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Ms State Emplo", "plan_name": "401457", "standard_charge_percentage": 0.80, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Ms State Emplo", "plan_name": "401457_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Basic Pl", "plan_name": "400100", "standard_charge_percentage": 0.85, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Basic Pl", "plan_name": "400100_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Federal", "plan_name": "400110", "standard_charge_percentage": 0.85, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Federal", "plan_name": "400110_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Cigna Healthsprings Ffs", "plan_name": "500064", "standard_charge_dollar": 2621.84, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Conseco", "plan_name": "500302", "standard_charge_dollar": 2621.84, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Humana Ffs 61101", "plan_name": "500006", "standard_charge_dollar": 2621.84, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Medicare A", "plan_name": "100100", "standard_charge_dollar": 2621.84, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Medicare A", "plan_name": "100500", "standard_charge_dollar": 2621.84, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Medicare Part B Only", "plan_name": "100300", "standard_charge_dollar": 2621.84, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Medicare Railroad", "plan_name": "100103", "standard_charge_dollar": 2621.84, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Ms Physicians Care N", "plan_name": "714210", "standard_charge_dollar": 3277.29, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Peoples Hlth Ffs 72126", "plan_name": "500019", "standard_charge_dollar": 2621.84, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Uhc/Secure Horizons", "plan_name": "500449", "standard_charge_dollar": 2621.84, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "United Health Care/", "plan_name": "500292", "standard_charge_dollar": 2962.67, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "United Healthcare", "plan_name": "750104", "standard_charge_dollar": 2962.67, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "United Healthcare Ba", "plan_name": "750090", "standard_charge_dollar": 2962.67, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "United Healthcare Me", "plan_name": "501310", "standard_charge_dollar": 2621.84, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Windsor Mcare Extra", "plan_name": "500778", "standard_charge_dollar": 2621.84, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." } ] } ] }, { "description": "Buttock fasciotomy w/dbrdmt", "code_information": [ { "code": "27057", "type": "CPT" } ], "standard_charges": [ { "gross_charge": 29802.90, "minimum": 1466.09, "maximum": 25332.47, "setting": "inpatient", "payers_information": [ { "payer_name": "Aarp", "plan_name": "500102", "standard_charge_dollar": 1466.09, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna", "plan_name": "700700", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna", "plan_name": "700700_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Mcare Ffs 6005", "plan_name": "700703", "standard_charge_dollar": 1466.09, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Miscellaneous", "plan_name": "700720", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Miscellaneous", "plan_name": "700720_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Ppo Hmo", "plan_name": "701720", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Ppo Hmo", "plan_name": "701720_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Ambetter 68069", "plan_name": "500516", "standard_charge_dollar": 1466.09, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Ms State Emplo", "plan_name": "401457", "standard_charge_percentage": 0.80, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Ms State Emplo", "plan_name": "401457_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Basic Pl", "plan_name": "400100", "standard_charge_percentage": 0.85, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Basic Pl", "plan_name": "400100_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Federal", "plan_name": "400110", "standard_charge_percentage": 0.85, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Federal", "plan_name": "400110_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Cigna Healthsprings Ffs", "plan_name": "500064", "standard_charge_dollar": 1466.09, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Conseco", "plan_name": "500302", "standard_charge_dollar": 1466.09, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Humana Ffs 61101", "plan_name": "500006", "standard_charge_dollar": 1466.09, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Medicare A", "plan_name": "100100", "standard_charge_dollar": 1466.09, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Medicare A", "plan_name": "100500", "standard_charge_dollar": 1466.09, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Medicare Part B Only", "plan_name": "100300", "standard_charge_dollar": 1466.09, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Medicare Railroad", "plan_name": "100103", "standard_charge_dollar": 1466.09, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Ms Physicians Care N", "plan_name": "714210", "standard_charge_dollar": 1832.61, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Peoples Hlth Ffs 72126", "plan_name": "500019", "standard_charge_dollar": 1466.09, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Uhc/Secure Horizons", "plan_name": "500449", "standard_charge_dollar": 1466.09, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "United Health Care/", "plan_name": "500292", "standard_charge_dollar": 1656.68, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "United Healthcare", "plan_name": "750104", "standard_charge_dollar": 1656.68, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "United Healthcare Ba", "plan_name": "750090", "standard_charge_dollar": 1656.68, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "United Healthcare Me", "plan_name": "501310", "standard_charge_dollar": 1466.09, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Windsor Mcare Extra", "plan_name": "500778", "standard_charge_dollar": 1466.09, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." } ] } ] }, { "description": "Remove hip bone les super", "code_information": [ { "code": "27065", "type": "CPT" } ], "standard_charges": [ { "gross_charge": 36886.03, "minimum": 6544.15, "maximum": 31353.13, "setting": "inpatient", "payers_information": [ { "payer_name": "Aarp", "plan_name": "500102", "standard_charge_dollar": 6544.15, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna", "plan_name": "700700", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna", "plan_name": "700700_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Mcare Ffs 6005", "plan_name": "700703", "standard_charge_dollar": 6544.15, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Miscellaneous", "plan_name": "700720", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Miscellaneous", "plan_name": "700720_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Ppo Hmo", "plan_name": "701720", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Ppo Hmo", "plan_name": "701720_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Ambetter 68069", "plan_name": "500516", "standard_charge_dollar": 6544.15, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Ms State Emplo", "plan_name": "401457", "standard_charge_percentage": 0.80, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Ms State Emplo", "plan_name": "401457_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Basic Pl", "plan_name": "400100", "standard_charge_percentage": 0.85, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Basic Pl", "plan_name": "400100_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Federal", "plan_name": "400110", "standard_charge_percentage": 0.85, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Federal", "plan_name": "400110_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Cigna Healthsprings Ffs", "plan_name": "500064", "standard_charge_dollar": 6544.15, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Conseco", "plan_name": "500302", "standard_charge_dollar": 6544.15, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Humana Ffs 61101", "plan_name": "500006", "standard_charge_dollar": 6544.15, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Medicare A", "plan_name": "100100", "standard_charge_dollar": 6544.15, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Medicare A", "plan_name": "100500", "standard_charge_dollar": 6544.15, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Medicare Part B Only", "plan_name": "100300", "standard_charge_dollar": 6544.15, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Medicare Railroad", "plan_name": "100103", "standard_charge_dollar": 6544.15, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Ms Physicians Care N", "plan_name": "714210", "standard_charge_dollar": 8180.19, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Peoples Hlth Ffs 72126", "plan_name": "500019", "standard_charge_dollar": 6544.15, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Uhc/Secure Horizons", "plan_name": "500449", "standard_charge_dollar": 6544.15, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "United Health Care/", "plan_name": "500292", "standard_charge_dollar": 7394.89, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "United Healthcare", "plan_name": "750104", "standard_charge_dollar": 7394.89, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "United Healthcare Ba", "plan_name": "750090", "standard_charge_dollar": 7394.89, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "United Healthcare Me", "plan_name": "501310", "standard_charge_dollar": 6544.15, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Windsor Mcare Extra", "plan_name": "500778", "standard_charge_dollar": 6544.15, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." } ] } ] }, { "description": "Remove hip foreign body", "code_information": [ { "code": "27086", "type": "CPT" } ], "standard_charges": [ { "gross_charge": 36886.03, "minimum": 2621.84, "maximum": 31353.13, "setting": "inpatient", "payers_information": [ { "payer_name": "Aarp", "plan_name": "500102", "standard_charge_dollar": 2621.84, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna", "plan_name": "700700", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna", "plan_name": "700700_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Mcare Ffs 6005", "plan_name": "700703", "standard_charge_dollar": 2621.84, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Miscellaneous", "plan_name": "700720", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Miscellaneous", "plan_name": "700720_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Ppo Hmo", "plan_name": "701720", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Ppo Hmo", "plan_name": "701720_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Ambetter 68069", "plan_name": "500516", "standard_charge_dollar": 2621.84, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Ms State Emplo", "plan_name": "401457", "standard_charge_percentage": 0.80, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Ms State Emplo", "plan_name": "401457_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Basic Pl", "plan_name": "400100", "standard_charge_percentage": 0.85, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Basic Pl", "plan_name": "400100_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Federal", "plan_name": "400110", "standard_charge_percentage": 0.85, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Federal", "plan_name": "400110_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Cigna Healthsprings Ffs", "plan_name": "500064", "standard_charge_dollar": 2621.84, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Conseco", "plan_name": "500302", "standard_charge_dollar": 2621.84, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Humana Ffs 61101", "plan_name": "500006", "standard_charge_dollar": 2621.84, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Medicare A", "plan_name": "100100", "standard_charge_dollar": 2621.84, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Medicare A", "plan_name": "100500", "standard_charge_dollar": 2621.84, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Medicare Part B Only", "plan_name": "100300", "standard_charge_dollar": 2621.84, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Medicare Railroad", "plan_name": "100103", "standard_charge_dollar": 2621.84, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Ms Physicians Care N", "plan_name": "714210", "standard_charge_dollar": 3277.29, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Peoples Hlth Ffs 72126", "plan_name": "500019", "standard_charge_dollar": 2621.84, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Uhc/Secure Horizons", "plan_name": "500449", "standard_charge_dollar": 2621.84, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "United Health Care/", "plan_name": "500292", "standard_charge_dollar": 2962.67, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "United Healthcare", "plan_name": "750104", "standard_charge_dollar": 2962.67, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "United Healthcare Ba", "plan_name": "750090", "standard_charge_dollar": 2962.67, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "United Healthcare Me", "plan_name": "501310", "standard_charge_dollar": 2621.84, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Windsor Mcare Extra", "plan_name": "500778", "standard_charge_dollar": 2621.84, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." } ] } ] }, { "description": "Partial hip replacement", "code_information": [ { "code": "27125", "type": "CPT" } ], "standard_charges": [ { "gross_charge": 38189.86, "minimum": 30551.89, "maximum": 32461.38, "setting": "inpatient", "payers_information": [ { "payer_name": "Aetna", "plan_name": "700700", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna", "plan_name": "700700_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Miscellaneous", "plan_name": "700720", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Miscellaneous", "plan_name": "700720_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Ppo Hmo", "plan_name": "701720", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Ppo Hmo", "plan_name": "701720_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Ms State Emplo", "plan_name": "401457", "standard_charge_percentage": 0.80, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Ms State Emplo", "plan_name": "401457_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Basic Pl", "plan_name": "400100", "standard_charge_percentage": 0.85, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Basic Pl", "plan_name": "400100_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Federal", "plan_name": "400110", "standard_charge_percentage": 0.85, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Federal", "plan_name": "400110_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." } ] } ] }, { "description": "Total hip arthroplasty", "code_information": [ { "code": "27130", "type": "CPT" } ], "standard_charges": [ { "gross_charge": 37510.06, "minimum": 11786.90, "maximum": 31883.55, "setting": "inpatient", "payers_information": [ { "payer_name": "Aarp", "plan_name": "500102", "standard_charge_dollar": 11786.90, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna", "plan_name": "700700", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna", "plan_name": "700700_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Mcare Ffs 6005", "plan_name": "700703", "standard_charge_dollar": 11786.90, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Miscellaneous", "plan_name": "700720", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Miscellaneous", "plan_name": "700720_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Ppo Hmo", "plan_name": "701720", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Ppo Hmo", "plan_name": "701720_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Ambetter 68069", "plan_name": "500516", "standard_charge_dollar": 11786.90, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Ms State Emplo", "plan_name": "401457", "standard_charge_percentage": 0.80, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Ms State Emplo", "plan_name": "401457_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Basic Pl", "plan_name": "400100", "standard_charge_percentage": 0.85, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Basic Pl", "plan_name": "400100_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Federal", "plan_name": "400110", "standard_charge_percentage": 0.85, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Federal", "plan_name": "400110_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Cigna Healthsprings Ffs", "plan_name": "500064", "standard_charge_dollar": 11786.90, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Conseco", "plan_name": "500302", "standard_charge_dollar": 11786.90, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Humana Ffs 61101", "plan_name": "500006", "standard_charge_dollar": 11786.90, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Medicare A", "plan_name": "100100", "standard_charge_dollar": 11786.90, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Medicare A", "plan_name": "100500", "standard_charge_dollar": 11786.90, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Medicare Part B Only", "plan_name": "100300", "standard_charge_dollar": 11786.90, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Medicare Railroad", "plan_name": "100103", "standard_charge_dollar": 11786.90, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Ms Physicians Care N", "plan_name": "714210", "standard_charge_dollar": 14733.62, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Peoples Hlth Ffs 72126", "plan_name": "500019", "standard_charge_dollar": 11786.90, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Uhc/Secure Horizons", "plan_name": "500449", "standard_charge_dollar": 11786.90, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "United Health Care/", "plan_name": "500292", "standard_charge_dollar": 13319.19, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "United Healthcare", "plan_name": "750104", "standard_charge_dollar": 13319.19, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "United Healthcare Ba", "plan_name": "750090", "standard_charge_dollar": 13319.19, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "United Healthcare Me", "plan_name": "501310", "standard_charge_dollar": 11786.90, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Windsor Mcare Extra", "plan_name": "500778", "standard_charge_dollar": 11786.90, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." } ] } ] }, { "description": "Total hip arthroplasty", "code_information": [ { "code": "27132", "type": "CPT" } ], "standard_charges": [ { "gross_charge": 37510.06, "minimum": 30008.05, "maximum": 31883.55, "setting": "inpatient", "payers_information": [ { "payer_name": "Aetna", "plan_name": "700700", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna", "plan_name": "700700_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Miscellaneous", "plan_name": "700720", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Miscellaneous", "plan_name": "700720_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Ppo Hmo", "plan_name": "701720", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Ppo Hmo", "plan_name": "701720_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Ms State Emplo", "plan_name": "401457", "standard_charge_percentage": 0.80, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Ms State Emplo", "plan_name": "401457_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Basic Pl", "plan_name": "400100", "standard_charge_percentage": 0.85, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Basic Pl", "plan_name": "400100_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Federal", "plan_name": "400110", "standard_charge_percentage": 0.85, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Federal", "plan_name": "400110_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." } ] } ] }, { "description": "Revise hip joint replacement", "code_information": [ { "code": "27134", "type": "CPT" } ], "standard_charges": [ { "gross_charge": 34417.47, "minimum": 27533.98, "maximum": 29254.85, "setting": "inpatient", "payers_information": [ { "payer_name": "Aetna", "plan_name": "700700", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna", "plan_name": "700700_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Miscellaneous", "plan_name": "700720", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Miscellaneous", "plan_name": "700720_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Ppo Hmo", "plan_name": "701720", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Ppo Hmo", "plan_name": "701720_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Ms State Emplo", "plan_name": "401457", "standard_charge_percentage": 0.80, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Ms State Emplo", "plan_name": "401457_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Basic Pl", "plan_name": "400100", "standard_charge_percentage": 0.85, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Basic Pl", "plan_name": "400100_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Federal", "plan_name": "400110", "standard_charge_percentage": 0.85, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Federal", "plan_name": "400110_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." } ] } ] }, { "description": "Revise hip joint replacement", "code_information": [ { "code": "27138", "type": "CPT" } ], "standard_charges": [ { "gross_charge": 33837.07, "minimum": 27069.66, "maximum": 28761.51, "setting": "inpatient", "payers_information": [ { "payer_name": "Aetna", "plan_name": "700700", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna", "plan_name": "700700_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Miscellaneous", "plan_name": "700720", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Miscellaneous", "plan_name": "700720_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Ppo Hmo", "plan_name": "701720", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Ppo Hmo", "plan_name": "701720_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Ms State Emplo", "plan_name": "401457", "standard_charge_percentage": 0.80, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Ms State Emplo", "plan_name": "401457_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Basic Pl", "plan_name": "400100", "standard_charge_percentage": 0.85, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Basic Pl", "plan_name": "400100_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Federal", "plan_name": "400110", "standard_charge_percentage": 0.85, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Federal", "plan_name": "400110_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." } ] } ] }, { "description": "Treat slipped epiphysis", "code_information": [ { "code": "27177", "type": "CPT" } ], "standard_charges": [ { "gross_charge": 27593.16, "minimum": 22074.53, "maximum": 23454.19, "setting": "inpatient", "payers_information": [ { "payer_name": "Aetna", "plan_name": "700700", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna", "plan_name": "700700_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Miscellaneous", "plan_name": "700720", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Miscellaneous", "plan_name": "700720_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Ppo Hmo", "plan_name": "701720", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Ppo Hmo", "plan_name": "701720_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Ms State Emplo", "plan_name": "401457", "standard_charge_percentage": 0.80, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Ms State Emplo", "plan_name": "401457_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Basic Pl", "plan_name": "400100", "standard_charge_percentage": 0.85, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Basic Pl", "plan_name": "400100_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Federal", "plan_name": "400110", "standard_charge_percentage": 0.85, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Federal", "plan_name": "400110_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." } ] } ] }, { "description": "Reinforce hip bones", "code_information": [ { "code": "27187", "type": "CPT" } ], "standard_charges": [ { "gross_charge": 30041.62, "minimum": 24033.30, "maximum": 25535.38, "setting": "inpatient", "payers_information": [ { "payer_name": "Aetna", "plan_name": "700700", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna", "plan_name": "700700_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Miscellaneous", "plan_name": "700720", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Miscellaneous", "plan_name": "700720_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Ppo Hmo", "plan_name": "701720", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Ppo Hmo", "plan_name": "701720_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Ms State Emplo", "plan_name": "401457", "standard_charge_percentage": 0.80, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Ms State Emplo", "plan_name": "401457_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Basic Pl", "plan_name": "400100", "standard_charge_percentage": 0.85, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Basic Pl", "plan_name": "400100_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Federal", "plan_name": "400110", "standard_charge_percentage": 0.85, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Federal", "plan_name": "400110_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." } ] } ] }, { "description": "Treat thigh fracture", "code_information": [ { "code": "27235", "type": "CPT" } ], "standard_charges": [ { "gross_charge": 30889.68, "minimum": 6544.15, "maximum": 26256.23, "setting": "inpatient", "payers_information": [ { "payer_name": "Aarp", "plan_name": "500102", "standard_charge_dollar": 6544.15, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna", "plan_name": "700700", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna", "plan_name": "700700_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Mcare Ffs 6005", "plan_name": "700703", "standard_charge_dollar": 6544.15, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Miscellaneous", "plan_name": "700720", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Miscellaneous", "plan_name": "700720_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Ppo Hmo", "plan_name": "701720", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Ppo Hmo", "plan_name": "701720_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Ambetter 68069", "plan_name": "500516", "standard_charge_dollar": 6544.15, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Ms State Emplo", "plan_name": "401457", "standard_charge_percentage": 0.80, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Ms State Emplo", "plan_name": "401457_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Basic Pl", "plan_name": "400100", "standard_charge_percentage": 0.85, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Basic Pl", "plan_name": "400100_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Federal", "plan_name": "400110", "standard_charge_percentage": 0.85, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Federal", "plan_name": "400110_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Cigna Healthsprings Ffs", "plan_name": "500064", "standard_charge_dollar": 6544.15, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Conseco", "plan_name": "500302", "standard_charge_dollar": 6544.15, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Humana Ffs 61101", "plan_name": "500006", "standard_charge_dollar": 6544.15, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Medicare A", "plan_name": "100100", "standard_charge_dollar": 6544.15, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Medicare A", "plan_name": "100500", "standard_charge_dollar": 6544.15, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Medicare Part B Only", "plan_name": "100300", "standard_charge_dollar": 6544.15, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Medicare Railroad", "plan_name": "100103", "standard_charge_dollar": 6544.15, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Ms Physicians Care N", "plan_name": "714210", "standard_charge_dollar": 8180.19, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Peoples Hlth Ffs 72126", "plan_name": "500019", "standard_charge_dollar": 6544.15, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Uhc/Secure Horizons", "plan_name": "500449", "standard_charge_dollar": 6544.15, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "United Health Care/", "plan_name": "500292", "standard_charge_dollar": 7394.89, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "United Healthcare", "plan_name": "750104", "standard_charge_dollar": 7394.89, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "United Healthcare Ba", "plan_name": "750090", "standard_charge_dollar": 7394.89, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "United Healthcare Me", "plan_name": "501310", "standard_charge_dollar": 6544.15, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Windsor Mcare Extra", "plan_name": "500778", "standard_charge_dollar": 6544.15, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." } ] } ] }, { "description": "Treat thigh fracture", "code_information": [ { "code": "27236", "type": "CPT" } ], "standard_charges": [ { "gross_charge": 35451.96, "minimum": 28361.57, "maximum": 30134.17, "setting": "inpatient", "payers_information": [ { "payer_name": "Aetna", "plan_name": "700700", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna", "plan_name": "700700_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Miscellaneous", "plan_name": "700720", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Miscellaneous", "plan_name": "700720_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Ppo Hmo", "plan_name": "701720", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Ppo Hmo", "plan_name": "701720_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Ms State Emplo", "plan_name": "401457", "standard_charge_percentage": 0.80, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Ms State Emplo", "plan_name": "401457_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Basic Pl", "plan_name": "400100", "standard_charge_percentage": 0.85, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Basic Pl", "plan_name": "400100_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Federal", "plan_name": "400110", "standard_charge_percentage": 0.85, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Federal", "plan_name": "400110_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." } ] } ] }, { "description": "Treat thigh fracture", "code_information": [ { "code": "27238", "type": "CPT" } ], "standard_charges": [ { "gross_charge": 30294.00, "minimum": 1466.09, "maximum": 25749.90, "setting": "inpatient", "payers_information": [ { "payer_name": "Aarp", "plan_name": "500102", "standard_charge_dollar": 1466.09, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna", "plan_name": "700700", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna", "plan_name": "700700_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Mcare Ffs 6005", "plan_name": "700703", "standard_charge_dollar": 1466.09, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Miscellaneous", "plan_name": "700720", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Miscellaneous", "plan_name": "700720_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Ppo Hmo", "plan_name": "701720", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Ppo Hmo", "plan_name": "701720_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Ambetter 68069", "plan_name": "500516", "standard_charge_dollar": 1466.09, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Ms State Emplo", "plan_name": "401457", "standard_charge_percentage": 0.80, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Ms State Emplo", "plan_name": "401457_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Basic Pl", "plan_name": "400100", "standard_charge_percentage": 0.85, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Basic Pl", "plan_name": "400100_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Federal", "plan_name": "400110", "standard_charge_percentage": 0.85, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Federal", "plan_name": "400110_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Cigna Healthsprings Ffs", "plan_name": "500064", "standard_charge_dollar": 1466.09, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Conseco", "plan_name": "500302", "standard_charge_dollar": 1466.09, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Humana Ffs 61101", "plan_name": "500006", "standard_charge_dollar": 1466.09, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Medicare A", "plan_name": "100100", "standard_charge_dollar": 1466.09, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Medicare A", "plan_name": "100500", "standard_charge_dollar": 1466.09, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Medicare Part B Only", "plan_name": "100300", "standard_charge_dollar": 1466.09, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Medicare Railroad", "plan_name": "100103", "standard_charge_dollar": 1466.09, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Ms Physicians Care N", "plan_name": "714210", "standard_charge_dollar": 1832.61, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Peoples Hlth Ffs 72126", "plan_name": "500019", "standard_charge_dollar": 1466.09, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Uhc/Secure Horizons", "plan_name": "500449", "standard_charge_dollar": 1466.09, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "United Health Care/", "plan_name": "500292", "standard_charge_dollar": 1656.68, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "United Healthcare", "plan_name": "750104", "standard_charge_dollar": 1656.68, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "United Healthcare Ba", "plan_name": "750090", "standard_charge_dollar": 1656.68, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "United Healthcare Me", "plan_name": "501310", "standard_charge_dollar": 1466.09, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Windsor Mcare Extra", "plan_name": "500778", "standard_charge_dollar": 1466.09, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." } ] } ] }, { "description": "Treat thigh fracture", "code_information": [ { "code": "27244", "type": "CPT" } ], 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total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Ppo Hmo", "plan_name": "701720", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Ppo Hmo", "plan_name": "701720_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Ms State Emplo", "plan_name": "401457", "standard_charge_percentage": 0.80, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Ms State Emplo", "plan_name": "401457_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Basic Pl", "plan_name": "400100", "standard_charge_percentage": 0.85, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Basic Pl", "plan_name": "400100_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Federal", "plan_name": "400110", "standard_charge_percentage": 0.85, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Federal", "plan_name": "400110_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." } ] } ] }, { "description": "Treat thigh fracture", "code_information": [ { "code": "27245", "type": "CPT" } ], "standard_charges": [ { "gross_charge": 35451.96, "minimum": 28361.57, "maximum": 30134.17, "setting": "inpatient", "payers_information": [ { "payer_name": "Aetna", "plan_name": "700700", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna", "plan_name": "700700_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Miscellaneous", "plan_name": "700720", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Miscellaneous", "plan_name": "700720_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Ppo Hmo", "plan_name": "701720", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Ppo Hmo", "plan_name": "701720_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Ms State Emplo", "plan_name": "401457", "standard_charge_percentage": 0.80, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Ms State Emplo", "plan_name": "401457_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Basic Pl", "plan_name": "400100", "standard_charge_percentage": 0.85, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Basic Pl", "plan_name": "400100_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Federal", "plan_name": "400110", "standard_charge_percentage": 0.85, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Federal", "plan_name": "400110_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." } ] } ] }, { "description": "Treat thigh fracture", "code_information": [ { "code": "27246", "type": "CPT" } ], "standard_charges": [ { "gross_charge": 30294.00, "minimum": 219.75, "maximum": 25749.90, "setting": "inpatient", "payers_information": [ { "payer_name": "Aarp", "plan_name": "500102", "standard_charge_dollar": 219.75, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna", "plan_name": "700700", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna", "plan_name": "700700_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Mcare Ffs 6005", "plan_name": "700703", "standard_charge_dollar": 219.75, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Miscellaneous", "plan_name": "700720", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Miscellaneous", "plan_name": "700720_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Ppo Hmo", "plan_name": "701720", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Ppo Hmo", "plan_name": "701720_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Ambetter 68069", "plan_name": "500516", "standard_charge_dollar": 219.75, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Ms State Emplo", "plan_name": "401457", "standard_charge_percentage": 0.80, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Ms State Emplo", "plan_name": "401457_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Basic Pl", "plan_name": "400100", "standard_charge_percentage": 0.85, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Basic Pl", "plan_name": "400100_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Federal", "plan_name": "400110", "standard_charge_percentage": 0.85, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Federal", "plan_name": "400110_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Cigna Healthsprings Ffs", "plan_name": "500064", "standard_charge_dollar": 219.75, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Conseco", "plan_name": "500302", "standard_charge_dollar": 219.75, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Humana Ffs 61101", "plan_name": "500006", "standard_charge_dollar": 219.75, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Medicare A", "plan_name": "100100", "standard_charge_dollar": 219.75, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Medicare A", "plan_name": "100500", "standard_charge_dollar": 219.75, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Medicare Part B Only", "plan_name": "100300", "standard_charge_dollar": 219.75, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Medicare Railroad", "plan_name": "100103", "standard_charge_dollar": 219.75, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Ms Physicians Care N", "plan_name": "714210", "standard_charge_dollar": 274.68, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Peoples Hlth Ffs 72126", "plan_name": "500019", "standard_charge_dollar": 219.75, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Uhc/Secure Horizons", "plan_name": "500449", "standard_charge_dollar": 219.75, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "United Health Care/", "plan_name": "500292", "standard_charge_dollar": 248.31, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "United Healthcare", "plan_name": "750104", "standard_charge_dollar": 248.31, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "United Healthcare Ba", "plan_name": "750090", "standard_charge_dollar": 248.31, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "United Healthcare Me", "plan_name": "501310", "standard_charge_dollar": 219.75, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Windsor Mcare Extra", "plan_name": "500778", "standard_charge_dollar": 219.75, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." } ] } ] }, { "description": "Treat thigh fracture", "code_information": [ { "code": "27248", "type": "CPT" } ], "standard_charges": [ { "gross_charge": 35451.96, "minimum": 28361.57, "maximum": 30134.17, "setting": "inpatient", "payers_information": [ { "payer_name": "Aetna", "plan_name": "700700", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna", "plan_name": "700700_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Miscellaneous", "plan_name": "700720", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Miscellaneous", "plan_name": "700720_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Ppo Hmo", "plan_name": "701720", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Ppo Hmo", "plan_name": "701720_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Ms State Emplo", "plan_name": "401457", "standard_charge_percentage": 0.80, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Ms State Emplo", "plan_name": "401457_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Basic Pl", "plan_name": "400100", "standard_charge_percentage": 0.85, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Basic Pl", "plan_name": "400100_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Federal", "plan_name": "400110", "standard_charge_percentage": 0.85, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Federal", "plan_name": "400110_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." } ] } ] }, { "description": "Treat hip dislocation", "code_information": [ { "code": "27254", "type": "CPT" } ], "standard_charges": [ { "gross_charge": 35451.96, "minimum": 28361.57, "maximum": 30134.17, "setting": "inpatient", "payers_information": [ { "payer_name": "Aetna", "plan_name": "700700", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna", "plan_name": "700700_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Miscellaneous", "plan_name": "700720", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Miscellaneous", "plan_name": "700720_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Ppo Hmo", "plan_name": "701720", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Ppo Hmo", "plan_name": "701720_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Ms State Emplo", "plan_name": "401457", "standard_charge_percentage": 0.80, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Ms State Emplo", "plan_name": "401457_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Basic Pl", "plan_name": "400100", "standard_charge_percentage": 0.85, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Basic Pl", "plan_name": "400100_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Federal", "plan_name": "400110", "standard_charge_percentage": 0.85, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Federal", "plan_name": "400110_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." } ] } ] }, { "description": "Pelvis/hip joint surgery", "code_information": [ { "code": "27299", "type": "CPT" } ], "standard_charges": [ { "gross_charge": 19809.97, "minimum": 219.75, "maximum": 16838.47, "setting": "inpatient", "payers_information": [ { "payer_name": "Aarp", "plan_name": "500102", "standard_charge_dollar": 219.75, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna", "plan_name": "700700", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna", "plan_name": "700700_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Mcare Ffs 6005", "plan_name": "700703", "standard_charge_dollar": 219.75, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Miscellaneous", "plan_name": "700720", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Miscellaneous", "plan_name": "700720_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Ppo Hmo", "plan_name": "701720", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Ppo Hmo", "plan_name": "701720_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Ambetter 68069", "plan_name": "500516", "standard_charge_dollar": 219.75, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Ms State Emplo", "plan_name": "401457", "standard_charge_percentage": 0.80, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Ms State Emplo", "plan_name": "401457_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Basic Pl", "plan_name": "400100", "standard_charge_percentage": 0.85, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Basic Pl", "plan_name": "400100_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Federal", "plan_name": "400110", "standard_charge_percentage": 0.85, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Federal", "plan_name": "400110_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Cigna Healthsprings Ffs", "plan_name": "500064", "standard_charge_dollar": 219.75, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Conseco", "plan_name": "500302", "standard_charge_dollar": 219.75, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Humana Ffs 61101", "plan_name": "500006", "standard_charge_dollar": 219.75, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Medicare A", "plan_name": "100100", "standard_charge_dollar": 219.75, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Medicare A", "plan_name": "100500", "standard_charge_dollar": 219.75, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Medicare Part B Only", "plan_name": "100300", "standard_charge_dollar": 219.75, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Medicare Railroad", "plan_name": "100103", "standard_charge_dollar": 219.75, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Ms Physicians Care N", "plan_name": "714210", "standard_charge_dollar": 274.68, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Peoples Hlth Ffs 72126", "plan_name": "500019", "standard_charge_dollar": 219.75, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Uhc/Secure Horizons", "plan_name": "500449", "standard_charge_dollar": 219.75, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "United Health Care/", "plan_name": "500292", "standard_charge_dollar": 248.31, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "United Healthcare", "plan_name": "750104", "standard_charge_dollar": 248.31, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "United Healthcare Ba", "plan_name": "750090", "standard_charge_dollar": 248.31, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "United Healthcare Me", "plan_name": "501310", "standard_charge_dollar": 219.75, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Windsor Mcare Extra", "plan_name": "500778", "standard_charge_dollar": 219.75, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." } ] } ] }, { "description": "Exploration of knee joint", "code_information": [ { "code": "27310", "type": "CPT" } ], "standard_charges": [ { "gross_charge": 31478.17, "minimum": 2972.29, "maximum": 26756.44, "setting": "inpatient", "payers_information": [ { "payer_name": "Aarp", "plan_name": "500102", "standard_charge_dollar": 2972.29, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna", "plan_name": "700700", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna", "plan_name": "700700_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Mcare Ffs 6005", "plan_name": "700703", "standard_charge_dollar": 2972.29, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Miscellaneous", "plan_name": "700720", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Miscellaneous", "plan_name": "700720_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Ppo Hmo", "plan_name": "701720", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Ppo Hmo", "plan_name": "701720_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Ambetter 68069", "plan_name": "500516", "standard_charge_dollar": 2972.29, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Ms State Emplo", "plan_name": "401457", "standard_charge_percentage": 0.80, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Ms State Emplo", "plan_name": "401457_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Basic Pl", "plan_name": "400100", "standard_charge_percentage": 0.85, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Basic Pl", "plan_name": "400100_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Federal", "plan_name": "400110", "standard_charge_percentage": 0.85, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Federal", "plan_name": "400110_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Cigna Healthsprings Ffs", "plan_name": "500064", "standard_charge_dollar": 2972.29, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Conseco", "plan_name": "500302", "standard_charge_dollar": 2972.29, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Humana Ffs 61101", "plan_name": "500006", "standard_charge_dollar": 2972.29, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Medicare A", "plan_name": "100100", "standard_charge_dollar": 2972.29, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Medicare A", "plan_name": "100500", "standard_charge_dollar": 2972.29, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Medicare Part B Only", "plan_name": "100300", "standard_charge_dollar": 2972.29, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Medicare Railroad", "plan_name": "100103", "standard_charge_dollar": 2972.29, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Ms Physicians Care N", "plan_name": "714210", "standard_charge_dollar": 3715.36, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Peoples Hlth Ffs 72126", "plan_name": "500019", "standard_charge_dollar": 2972.29, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Uhc/Secure Horizons", "plan_name": "500449", "standard_charge_dollar": 2972.29, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "United Health Care/", "plan_name": "500292", "standard_charge_dollar": 3358.68, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "United Healthcare", "plan_name": "750104", "standard_charge_dollar": 3358.68, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "United Healthcare Ba", "plan_name": "750090", "standard_charge_dollar": 3358.68, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "United Healthcare Me", "plan_name": "501310", "standard_charge_dollar": 2972.29, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Windsor Mcare Extra", "plan_name": "500778", "standard_charge_dollar": 2972.29, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." } ] } ] }, { "description": "Exc thigh/knee les sc < 3 cm", "code_information": [ { "code": "27327", "type": "CPT" } ], "standard_charges": [ { "gross_charge": 35800.23, "minimum": 1484.25, "maximum": 30430.20, "setting": "inpatient", "payers_information": [ { "payer_name": "Aarp", "plan_name": "500102", "standard_charge_dollar": 1484.25, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna", "plan_name": "700700", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna", "plan_name": "700700_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Mcare Ffs 6005", "plan_name": "700703", "standard_charge_dollar": 1484.25, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Miscellaneous", "plan_name": "700720", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Miscellaneous", "plan_name": "700720_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Ppo Hmo", "plan_name": "701720", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Ppo Hmo", "plan_name": "701720_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Ambetter 68069", "plan_name": "500516", "standard_charge_dollar": 1484.25, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Ms State Emplo", "plan_name": "401457", "standard_charge_percentage": 0.80, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Ms State Emplo", "plan_name": "401457_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Basic Pl", "plan_name": "400100", "standard_charge_percentage": 0.85, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Basic Pl", "plan_name": "400100_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Federal", "plan_name": "400110", "standard_charge_percentage": 0.85, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Federal", "plan_name": "400110_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Cigna Healthsprings Ffs", "plan_name": "500064", "standard_charge_dollar": 1484.25, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Conseco", "plan_name": "500302", "standard_charge_dollar": 1484.25, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Humana Ffs 61101", "plan_name": "500006", "standard_charge_dollar": 1484.25, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Medicare A", "plan_name": "100100", "standard_charge_dollar": 1484.25, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Medicare A", "plan_name": "100500", "standard_charge_dollar": 1484.25, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Medicare Part B Only", "plan_name": "100300", "standard_charge_dollar": 1484.25, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Medicare Railroad", "plan_name": "100103", "standard_charge_dollar": 1484.25, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Ms Physicians Care N", "plan_name": "714210", "standard_charge_dollar": 1855.31, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Peoples Hlth Ffs 72126", "plan_name": "500019", "standard_charge_dollar": 1484.25, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Uhc/Secure Horizons", "plan_name": "500449", "standard_charge_dollar": 1484.25, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "United Health Care/", "plan_name": "500292", "standard_charge_dollar": 1677.20, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "United Healthcare", "plan_name": "750104", "standard_charge_dollar": 1677.20, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "United Healthcare Ba", "plan_name": "750090", "standard_charge_dollar": 1677.20, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "United Healthcare Me", "plan_name": "501310", "standard_charge_dollar": 1484.25, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Windsor Mcare Extra", "plan_name": "500778", "standard_charge_dollar": 1484.25, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." } ] } ] }, { "description": "Exc thigh/knee tum deep <5cm", "code_information": [ { "code": "27328", "type": "CPT" } ], "standard_charges": [ { "gross_charge": 35800.23, "minimum": 2621.84, "maximum": 30430.20, "setting": "inpatient", "payers_information": [ { "payer_name": "Aarp", "plan_name": "500102", "standard_charge_dollar": 2621.84, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna", "plan_name": "700700", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna", "plan_name": "700700_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Mcare Ffs 6005", "plan_name": "700703", "standard_charge_dollar": 2621.84, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Miscellaneous", "plan_name": "700720", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Miscellaneous", "plan_name": "700720_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Ppo Hmo", "plan_name": "701720", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Ppo Hmo", "plan_name": "701720_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Ambetter 68069", "plan_name": "500516", "standard_charge_dollar": 2621.84, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Ms State Emplo", "plan_name": "401457", "standard_charge_percentage": 0.80, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Ms State Emplo", "plan_name": "401457_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Basic Pl", "plan_name": "400100", "standard_charge_percentage": 0.85, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Basic Pl", "plan_name": "400100_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Federal", "plan_name": "400110", "standard_charge_percentage": 0.85, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Federal", "plan_name": "400110_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Cigna Healthsprings Ffs", "plan_name": "500064", "standard_charge_dollar": 2621.84, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Conseco", "plan_name": "500302", "standard_charge_dollar": 2621.84, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Humana Ffs 61101", "plan_name": "500006", "standard_charge_dollar": 2621.84, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Medicare A", "plan_name": "100100", "standard_charge_dollar": 2621.84, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Medicare A", "plan_name": "100500", "standard_charge_dollar": 2621.84, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Medicare Part B Only", "plan_name": "100300", "standard_charge_dollar": 2621.84, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Medicare Railroad", "plan_name": "100103", "standard_charge_dollar": 2621.84, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Ms Physicians Care N", "plan_name": "714210", "standard_charge_dollar": 3277.29, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Peoples Hlth Ffs 72126", "plan_name": "500019", "standard_charge_dollar": 2621.84, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Uhc/Secure Horizons", "plan_name": "500449", "standard_charge_dollar": 2621.84, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "United Health Care/", "plan_name": "500292", "standard_charge_dollar": 2962.67, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "United Healthcare", "plan_name": "750104", "standard_charge_dollar": 2962.67, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "United Healthcare Ba", "plan_name": "750090", "standard_charge_dollar": 2962.67, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "United Healthcare Me", "plan_name": "501310", "standard_charge_dollar": 2621.84, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Windsor Mcare Extra", "plan_name": "500778", "standard_charge_dollar": 2621.84, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." } ] } ] }, { "description": "Biopsy knee joint lining", "code_information": [ { "code": "27330", "type": "CPT" } ], "standard_charges": [ { "gross_charge": 17957.46, "minimum": 2972.29, "maximum": 15263.84, "setting": "inpatient", "payers_information": [ { "payer_name": "Aarp", "plan_name": "500102", "standard_charge_dollar": 2972.29, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna", "plan_name": "700700", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna", "plan_name": "700700_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Mcare Ffs 6005", "plan_name": "700703", "standard_charge_dollar": 2972.29, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Miscellaneous", "plan_name": "700720", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Miscellaneous", "plan_name": "700720_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Ppo Hmo", "plan_name": "701720", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Ppo Hmo", "plan_name": "701720_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Ambetter 68069", "plan_name": "500516", "standard_charge_dollar": 2972.29, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Ms State Emplo", "plan_name": "401457", "standard_charge_percentage": 0.80, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Ms State Emplo", "plan_name": "401457_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Basic Pl", "plan_name": "400100", "standard_charge_percentage": 0.85, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Basic Pl", "plan_name": "400100_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Federal", "plan_name": "400110", "standard_charge_percentage": 0.85, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Federal", "plan_name": "400110_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Cigna Healthsprings Ffs", "plan_name": "500064", "standard_charge_dollar": 2972.29, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Conseco", "plan_name": "500302", "standard_charge_dollar": 2972.29, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Humana Ffs 61101", "plan_name": "500006", "standard_charge_dollar": 2972.29, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Medicare A", "plan_name": "100100", "standard_charge_dollar": 2972.29, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Medicare A", "plan_name": "100500", "standard_charge_dollar": 2972.29, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Medicare Part B Only", "plan_name": "100300", "standard_charge_dollar": 2972.29, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Medicare Railroad", "plan_name": "100103", "standard_charge_dollar": 2972.29, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Ms Physicians Care N", "plan_name": "714210", "standard_charge_dollar": 3715.36, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Peoples Hlth Ffs 72126", "plan_name": "500019", "standard_charge_dollar": 2972.29, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Uhc/Secure Horizons", "plan_name": "500449", "standard_charge_dollar": 2972.29, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "United Health Care/", "plan_name": "500292", "standard_charge_dollar": 3358.68, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "United Healthcare", "plan_name": "750104", "standard_charge_dollar": 3358.68, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "United Healthcare Ba", "plan_name": "750090", "standard_charge_dollar": 3358.68, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "United Healthcare Me", "plan_name": "501310", "standard_charge_dollar": 2972.29, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Windsor Mcare Extra", "plan_name": "500778", "standard_charge_dollar": 2972.29, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." } ] } ] }, { "description": "Explore/treat knee joint", "code_information": [ { "code": "27331", "type": "CPT" } ], "standard_charges": [ { "gross_charge": 58519.58, "minimum": 2972.29, "maximum": 49741.64, "setting": "inpatient", "payers_information": [ { "payer_name": "Aarp", "plan_name": "500102", "standard_charge_dollar": 2972.29, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna", "plan_name": "700700", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna", "plan_name": "700700_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Mcare Ffs 6005", "plan_name": "700703", "standard_charge_dollar": 2972.29, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Miscellaneous", "plan_name": "700720", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Miscellaneous", "plan_name": "700720_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Ppo Hmo", "plan_name": "701720", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Ppo Hmo", "plan_name": "701720_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Ambetter 68069", "plan_name": "500516", "standard_charge_dollar": 2972.29, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Ms State Emplo", "plan_name": "401457", "standard_charge_percentage": 0.80, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Ms State Emplo", "plan_name": "401457_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Basic Pl", "plan_name": "400100", "standard_charge_percentage": 0.85, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Basic Pl", "plan_name": "400100_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Federal", "plan_name": "400110", "standard_charge_percentage": 0.85, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Federal", "plan_name": "400110_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Cigna Healthsprings Ffs", "plan_name": "500064", "standard_charge_dollar": 2972.29, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Conseco", "plan_name": "500302", "standard_charge_dollar": 2972.29, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Humana Ffs 61101", "plan_name": "500006", "standard_charge_dollar": 2972.29, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Medicare A", "plan_name": "100100", "standard_charge_dollar": 2972.29, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Medicare A", "plan_name": "100500", "standard_charge_dollar": 2972.29, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Medicare Part B Only", "plan_name": "100300", "standard_charge_dollar": 2972.29, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Medicare Railroad", "plan_name": "100103", "standard_charge_dollar": 2972.29, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Ms Physicians Care N", "plan_name": "714210", "standard_charge_dollar": 3715.36, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Peoples Hlth Ffs 72126", "plan_name": "500019", "standard_charge_dollar": 2972.29, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Uhc/Secure Horizons", "plan_name": "500449", "standard_charge_dollar": 2972.29, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "United Health Care/", "plan_name": "500292", "standard_charge_dollar": 3358.68, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "United Healthcare", "plan_name": "750104", "standard_charge_dollar": 3358.68, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "United Healthcare Ba", "plan_name": "750090", "standard_charge_dollar": 3358.68, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "United Healthcare Me", "plan_name": "501310", "standard_charge_dollar": 2972.29, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Windsor Mcare Extra", "plan_name": "500778", "standard_charge_dollar": 2972.29, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." } ] } ] }, { "description": "Exc thigh/knee les sc 3 cm/>", "code_information": [ { "code": "27337", "type": "CPT" } ], "standard_charges": [ { "gross_charge": 35800.23, "minimum": 2621.84, "maximum": 30430.20, "setting": "inpatient", "payers_information": [ { "payer_name": "Aarp", "plan_name": "500102", "standard_charge_dollar": 2621.84, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna", "plan_name": "700700", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna", "plan_name": "700700_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Mcare Ffs 6005", "plan_name": "700703", "standard_charge_dollar": 2621.84, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Miscellaneous", "plan_name": "700720", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Miscellaneous", "plan_name": "700720_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Ppo Hmo", "plan_name": "701720", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Ppo Hmo", "plan_name": "701720_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Ambetter 68069", "plan_name": "500516", "standard_charge_dollar": 2621.84, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Ms State Emplo", "plan_name": "401457", "standard_charge_percentage": 0.80, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Ms State Emplo", "plan_name": "401457_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Basic Pl", "plan_name": "400100", "standard_charge_percentage": 0.85, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Basic Pl", "plan_name": "400100_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Federal", "plan_name": "400110", "standard_charge_percentage": 0.85, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Federal", "plan_name": "400110_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Cigna Healthsprings Ffs", "plan_name": "500064", "standard_charge_dollar": 2621.84, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Conseco", "plan_name": "500302", "standard_charge_dollar": 2621.84, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Humana Ffs 61101", "plan_name": "500006", "standard_charge_dollar": 2621.84, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Medicare A", "plan_name": "100100", "standard_charge_dollar": 2621.84, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Medicare A", "plan_name": "100500", "standard_charge_dollar": 2621.84, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Medicare Part B Only", "plan_name": "100300", "standard_charge_dollar": 2621.84, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Medicare Railroad", "plan_name": "100103", "standard_charge_dollar": 2621.84, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Ms Physicians Care N", "plan_name": "714210", "standard_charge_dollar": 3277.29, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Peoples Hlth Ffs 72126", "plan_name": "500019", "standard_charge_dollar": 2621.84, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Uhc/Secure Horizons", "plan_name": "500449", "standard_charge_dollar": 2621.84, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "United Health Care/", "plan_name": "500292", "standard_charge_dollar": 2962.67, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "United Healthcare", "plan_name": "750104", "standard_charge_dollar": 2962.67, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "United Healthcare Ba", "plan_name": "750090", "standard_charge_dollar": 2962.67, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "United Healthcare Me", "plan_name": "501310", "standard_charge_dollar": 2621.84, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Windsor Mcare Extra", "plan_name": "500778", "standard_charge_dollar": 2621.84, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." } ] } ] }, { "description": "Exc thigh/knee tum dep 5cm/>", "code_information": [ { "code": "27339", "type": "CPT" } ], "standard_charges": [ { "gross_charge": 35800.23, "minimum": 2621.84, "maximum": 30430.20, "setting": "inpatient", "payers_information": [ { "payer_name": "Aarp", "plan_name": "500102", "standard_charge_dollar": 2621.84, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna", "plan_name": "700700", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna", "plan_name": "700700_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Mcare Ffs 6005", "plan_name": "700703", "standard_charge_dollar": 2621.84, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Miscellaneous", "plan_name": "700720", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Miscellaneous", "plan_name": "700720_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Ppo Hmo", "plan_name": "701720", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Ppo Hmo", "plan_name": "701720_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Ambetter 68069", "plan_name": "500516", "standard_charge_dollar": 2621.84, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Ms State Emplo", "plan_name": "401457", "standard_charge_percentage": 0.80, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Ms State Emplo", "plan_name": "401457_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Basic Pl", "plan_name": "400100", "standard_charge_percentage": 0.85, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Basic Pl", "plan_name": "400100_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Federal", "plan_name": "400110", "standard_charge_percentage": 0.85, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Federal", "plan_name": "400110_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Cigna Healthsprings Ffs", "plan_name": "500064", "standard_charge_dollar": 2621.84, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Conseco", "plan_name": "500302", "standard_charge_dollar": 2621.84, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Humana Ffs 61101", "plan_name": "500006", "standard_charge_dollar": 2621.84, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Medicare A", "plan_name": "100100", "standard_charge_dollar": 2621.84, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Medicare A", "plan_name": "100500", "standard_charge_dollar": 2621.84, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Medicare Part B Only", "plan_name": "100300", "standard_charge_dollar": 2621.84, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Medicare Railroad", "plan_name": "100103", "standard_charge_dollar": 2621.84, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Ms Physicians Care N", "plan_name": "714210", "standard_charge_dollar": 3277.29, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Peoples Hlth Ffs 72126", "plan_name": "500019", "standard_charge_dollar": 2621.84, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Uhc/Secure Horizons", "plan_name": "500449", "standard_charge_dollar": 2621.84, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "United Health Care/", "plan_name": "500292", "standard_charge_dollar": 2962.67, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "United Healthcare", "plan_name": "750104", "standard_charge_dollar": 2962.67, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "United Healthcare Ba", "plan_name": "750090", "standard_charge_dollar": 2962.67, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "United Healthcare Me", "plan_name": "501310", "standard_charge_dollar": 2621.84, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Windsor Mcare Extra", "plan_name": "500778", "standard_charge_dollar": 2621.84, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." } ] } ] }, { "description": "Remove femur lesion/fixation", "code_information": [ { "code": "27358", "type": "CPT" } ], "standard_charges": [ { "gross_charge": 34925.69, "minimum": 27940.55, "maximum": 29686.84, "setting": "inpatient", "payers_information": [ { "payer_name": "Aetna", "plan_name": "700700", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna", "plan_name": "700700_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Miscellaneous", "plan_name": "700720", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Miscellaneous", "plan_name": "700720_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Ppo Hmo", "plan_name": "701720", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Ppo Hmo", "plan_name": "701720_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Ms State Emplo", "plan_name": "401457", "standard_charge_percentage": 0.80, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Ms State Emplo", "plan_name": "401457_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Basic Pl", "plan_name": "400100", "standard_charge_percentage": 0.85, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Basic Pl", "plan_name": "400100_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Federal", "plan_name": "400110", "standard_charge_percentage": 0.85, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Federal", "plan_name": "400110_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." } ] } ] }, { "description": "Resect thigh/knee tum 5 cm/>", "code_information": [ { "code": "27364", "type": "CPT" } ], "standard_charges": [ { "gross_charge": 35800.23, "minimum": 2621.84, "maximum": 30430.20, "setting": "inpatient", "payers_information": [ { "payer_name": "Aarp", "plan_name": "500102", "standard_charge_dollar": 2621.84, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna", "plan_name": "700700", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna", "plan_name": "700700_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Mcare Ffs 6005", "plan_name": "700703", "standard_charge_dollar": 2621.84, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Miscellaneous", "plan_name": "700720", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Miscellaneous", "plan_name": "700720_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Ppo Hmo", "plan_name": "701720", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Ppo Hmo", "plan_name": "701720_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Ambetter 68069", "plan_name": "500516", "standard_charge_dollar": 2621.84, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Ms State Emplo", "plan_name": "401457", "standard_charge_percentage": 0.80, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Ms State Emplo", "plan_name": "401457_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Basic Pl", "plan_name": "400100", "standard_charge_percentage": 0.85, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Basic Pl", "plan_name": "400100_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Federal", "plan_name": "400110", "standard_charge_percentage": 0.85, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Federal", "plan_name": "400110_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Cigna Healthsprings Ffs", "plan_name": "500064", "standard_charge_dollar": 2621.84, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Conseco", "plan_name": "500302", "standard_charge_dollar": 2621.84, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Humana Ffs 61101", "plan_name": "500006", "standard_charge_dollar": 2621.84, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Medicare A", "plan_name": "100100", "standard_charge_dollar": 2621.84, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Medicare A", "plan_name": "100500", "standard_charge_dollar": 2621.84, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Medicare Part B Only", "plan_name": "100300", "standard_charge_dollar": 2621.84, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Medicare Railroad", "plan_name": "100103", "standard_charge_dollar": 2621.84, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Ms Physicians Care N", "plan_name": "714210", "standard_charge_dollar": 3277.29, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Peoples Hlth Ffs 72126", "plan_name": "500019", "standard_charge_dollar": 2621.84, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Uhc/Secure Horizons", "plan_name": "500449", "standard_charge_dollar": 2621.84, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "United Health Care/", "plan_name": "500292", "standard_charge_dollar": 2962.67, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "United Healthcare", "plan_name": "750104", "standard_charge_dollar": 2962.67, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "United Healthcare Ba", "plan_name": "750090", "standard_charge_dollar": 2962.67, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "United Healthcare Me", "plan_name": "501310", "standard_charge_dollar": 2621.84, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Windsor Mcare Extra", "plan_name": "500778", "standard_charge_dollar": 2621.84, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." } ] } ] }, { "description": "Removal of foreign body", "code_information": [ { "code": "27372", "type": "CPT" } ], "standard_charges": [ { "gross_charge": 24709.90, "minimum": 2621.84, "maximum": 21003.42, "setting": "inpatient", "payers_information": [ { "payer_name": "Aarp", "plan_name": "500102", "standard_charge_dollar": 2621.84, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna", "plan_name": "700700", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna", "plan_name": "700700_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Mcare Ffs 6005", "plan_name": "700703", "standard_charge_dollar": 2621.84, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Miscellaneous", "plan_name": "700720", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Miscellaneous", "plan_name": "700720_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Ppo Hmo", "plan_name": "701720", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Ppo Hmo", "plan_name": "701720_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Ambetter 68069", "plan_name": "500516", "standard_charge_dollar": 2621.84, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Ms State Emplo", "plan_name": "401457", "standard_charge_percentage": 0.80, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Ms State Emplo", "plan_name": "401457_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Basic Pl", "plan_name": "400100", "standard_charge_percentage": 0.85, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Basic Pl", "plan_name": "400100_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Federal", "plan_name": "400110", "standard_charge_percentage": 0.85, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Federal", "plan_name": "400110_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Cigna Healthsprings Ffs", "plan_name": "500064", "standard_charge_dollar": 2621.84, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Conseco", "plan_name": "500302", "standard_charge_dollar": 2621.84, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Humana Ffs 61101", "plan_name": "500006", "standard_charge_dollar": 2621.84, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Medicare A", "plan_name": "100100", "standard_charge_dollar": 2621.84, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Medicare A", "plan_name": "100500", "standard_charge_dollar": 2621.84, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Medicare Part B Only", "plan_name": "100300", "standard_charge_dollar": 2621.84, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Medicare Railroad", "plan_name": "100103", "standard_charge_dollar": 2621.84, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Ms Physicians Care N", "plan_name": "714210", "standard_charge_dollar": 3277.29, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Peoples Hlth Ffs 72126", "plan_name": "500019", "standard_charge_dollar": 2621.84, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Uhc/Secure Horizons", "plan_name": "500449", "standard_charge_dollar": 2621.84, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "United Health Care/", "plan_name": "500292", "standard_charge_dollar": 2962.67, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "United Healthcare", "plan_name": "750104", "standard_charge_dollar": 2962.67, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "United Healthcare Ba", "plan_name": "750090", "standard_charge_dollar": 2962.67, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "United Healthcare Me", "plan_name": "501310", "standard_charge_dollar": 2621.84, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Windsor Mcare Extra", "plan_name": "500778", "standard_charge_dollar": 2621.84, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." } ] } ] }, { "description": "Repair of kneecap tendon", "code_information": [ { "code": "27380", "type": "CPT" } ], "standard_charges": [ { "gross_charge": 28184.41, "minimum": 6544.15, "maximum": 23956.75, "setting": "inpatient", "payers_information": [ { "payer_name": "Aarp", "plan_name": "500102", "standard_charge_dollar": 6544.15, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna", "plan_name": "700700", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna", "plan_name": "700700_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Mcare Ffs 6005", "plan_name": "700703", "standard_charge_dollar": 6544.15, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Miscellaneous", "plan_name": "700720", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Miscellaneous", "plan_name": "700720_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Ppo Hmo", "plan_name": "701720", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Ppo Hmo", "plan_name": "701720_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Ambetter 68069", "plan_name": "500516", "standard_charge_dollar": 6544.15, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Ms State Emplo", "plan_name": "401457", "standard_charge_percentage": 0.80, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Ms State Emplo", "plan_name": "401457_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Basic Pl", "plan_name": "400100", "standard_charge_percentage": 0.85, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Basic Pl", "plan_name": "400100_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Federal", "plan_name": "400110", "standard_charge_percentage": 0.85, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Federal", "plan_name": "400110_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Cigna Healthsprings Ffs", "plan_name": "500064", "standard_charge_dollar": 6544.15, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Conseco", "plan_name": "500302", "standard_charge_dollar": 6544.15, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Humana Ffs 61101", "plan_name": "500006", "standard_charge_dollar": 6544.15, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Medicare A", "plan_name": "100100", "standard_charge_dollar": 6544.15, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Medicare A", "plan_name": "100500", "standard_charge_dollar": 6544.15, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Medicare Part B Only", "plan_name": "100300", "standard_charge_dollar": 6544.15, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Medicare Railroad", "plan_name": "100103", "standard_charge_dollar": 6544.15, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Ms Physicians Care N", "plan_name": "714210", "standard_charge_dollar": 8180.19, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Peoples Hlth Ffs 72126", "plan_name": "500019", "standard_charge_dollar": 6544.15, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Uhc/Secure Horizons", "plan_name": "500449", "standard_charge_dollar": 6544.15, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "United Health Care/", "plan_name": "500292", "standard_charge_dollar": 7394.89, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "United Healthcare", "plan_name": "750104", "standard_charge_dollar": 7394.89, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "United Healthcare Ba", "plan_name": "750090", "standard_charge_dollar": 7394.89, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "United Healthcare Me", "plan_name": "501310", "standard_charge_dollar": 6544.15, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Windsor Mcare Extra", "plan_name": "500778", "standard_charge_dollar": 6544.15, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." } ] } ] }, { "description": "Repair/graft kneecap tendon", "code_information": [ { "code": "27381", "type": "CPT" } ], "standard_charges": [ { "gross_charge": 28184.41, "minimum": 6544.15, "maximum": 23956.75, "setting": "inpatient", "payers_information": [ { "payer_name": "Aarp", "plan_name": "500102", "standard_charge_dollar": 6544.15, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna", "plan_name": "700700", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna", "plan_name": "700700_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Mcare Ffs 6005", "plan_name": "700703", "standard_charge_dollar": 6544.15, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Miscellaneous", "plan_name": "700720", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Miscellaneous", "plan_name": "700720_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Ppo Hmo", "plan_name": "701720", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Ppo Hmo", "plan_name": "701720_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Ambetter 68069", "plan_name": "500516", "standard_charge_dollar": 6544.15, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Ms State Emplo", "plan_name": "401457", "standard_charge_percentage": 0.80, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Ms State Emplo", "plan_name": "401457_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Basic Pl", "plan_name": "400100", "standard_charge_percentage": 0.85, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Basic Pl", "plan_name": "400100_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Federal", "plan_name": "400110", "standard_charge_percentage": 0.85, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Federal", "plan_name": "400110_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Cigna Healthsprings Ffs", "plan_name": "500064", "standard_charge_dollar": 6544.15, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Conseco", "plan_name": "500302", "standard_charge_dollar": 6544.15, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Humana Ffs 61101", "plan_name": "500006", "standard_charge_dollar": 6544.15, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Medicare A", "plan_name": "100100", "standard_charge_dollar": 6544.15, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Medicare A", "plan_name": "100500", "standard_charge_dollar": 6544.15, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Medicare Part B Only", "plan_name": "100300", "standard_charge_dollar": 6544.15, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Medicare Railroad", "plan_name": "100103", "standard_charge_dollar": 6544.15, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Ms Physicians Care N", "plan_name": "714210", "standard_charge_dollar": 8180.19, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Peoples Hlth Ffs 72126", "plan_name": "500019", "standard_charge_dollar": 6544.15, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Uhc/Secure Horizons", "plan_name": "500449", "standard_charge_dollar": 6544.15, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "United Health Care/", "plan_name": "500292", "standard_charge_dollar": 7394.89, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "United Healthcare", "plan_name": "750104", "standard_charge_dollar": 7394.89, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "United Healthcare Ba", "plan_name": "750090", "standard_charge_dollar": 7394.89, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "United Healthcare Me", "plan_name": "501310", "standard_charge_dollar": 6544.15, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Windsor Mcare Extra", "plan_name": "500778", "standard_charge_dollar": 6544.15, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." } ] } ] }, { "description": "Total knee arthroplasty", "code_information": [ { "code": "27447", "type": "CPT" } ], "standard_charges": [ { "gross_charge": 33830.23, "minimum": 11786.90, "maximum": 28755.70, "setting": "inpatient", "payers_information": [ { "payer_name": "Aarp", "plan_name": "500102", "standard_charge_dollar": 11786.90, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna", "plan_name": "700700", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna", "plan_name": "700700_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Mcare Ffs 6005", "plan_name": "700703", "standard_charge_dollar": 11786.90, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Miscellaneous", "plan_name": "700720", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Miscellaneous", "plan_name": "700720_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Ppo Hmo", "plan_name": "701720", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Ppo Hmo", "plan_name": "701720_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Ambetter 68069", "plan_name": "500516", "standard_charge_dollar": 11786.90, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Ms State Emplo", "plan_name": "401457", "standard_charge_percentage": 0.80, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Ms State Emplo", "plan_name": "401457_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Basic Pl", "plan_name": "400100", "standard_charge_percentage": 0.85, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Basic Pl", "plan_name": "400100_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Federal", "plan_name": "400110", "standard_charge_percentage": 0.85, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Federal", "plan_name": "400110_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Cigna Healthsprings Ffs", "plan_name": "500064", "standard_charge_dollar": 11786.90, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Conseco", "plan_name": "500302", "standard_charge_dollar": 11786.90, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Humana Ffs 61101", "plan_name": "500006", "standard_charge_dollar": 11786.90, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Medicare A", "plan_name": "100100", "standard_charge_dollar": 11786.90, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Medicare A", "plan_name": "100500", "standard_charge_dollar": 11786.90, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Medicare Part B Only", "plan_name": "100300", "standard_charge_dollar": 11786.90, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Medicare Railroad", "plan_name": "100103", "standard_charge_dollar": 11786.90, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Ms Physicians Care N", "plan_name": "714210", "standard_charge_dollar": 14733.62, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Peoples Hlth Ffs 72126", "plan_name": "500019", "standard_charge_dollar": 11786.90, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Uhc/Secure Horizons", "plan_name": "500449", "standard_charge_dollar": 11786.90, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "United Health Care/", "plan_name": "500292", "standard_charge_dollar": 13319.19, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "United Healthcare", "plan_name": "750104", "standard_charge_dollar": 13319.19, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "United Healthcare Ba", "plan_name": "750090", "standard_charge_dollar": 13319.19, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "United Healthcare Me", "plan_name": "501310", "standard_charge_dollar": 11786.90, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Windsor Mcare Extra", "plan_name": "500778", "standard_charge_dollar": 11786.90, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." } ] } ] }, { "description": "Incision of thigh", "code_information": [ { "code": "27450", "type": "CPT" } ], "standard_charges": [ { "gross_charge": 41608.72, "minimum": 33286.98, "maximum": 35367.41, "setting": "inpatient", "payers_information": [ { "payer_name": "Aetna", "plan_name": "700700", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna", "plan_name": "700700_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Miscellaneous", "plan_name": "700720", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Miscellaneous", "plan_name": "700720_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Ppo Hmo", "plan_name": "701720", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Ppo Hmo", "plan_name": "701720_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Ms State Emplo", "plan_name": "401457", "standard_charge_percentage": 0.80, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Ms State Emplo", "plan_name": "401457_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Basic Pl", "plan_name": "400100", "standard_charge_percentage": 0.85, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Basic Pl", "plan_name": "400100_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Federal", "plan_name": "400110", "standard_charge_percentage": 0.85, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Federal", "plan_name": "400110_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." } ] } ] }, { "description": "Realignment of knee", "code_information": [ { "code": "27455", "type": "CPT" } ], "standard_charges": [ { "gross_charge": 30719.25, "minimum": 24575.40, "maximum": 26111.36, "setting": "inpatient", "payers_information": [ { "payer_name": "Aetna", "plan_name": "700700", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna", "plan_name": "700700_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Miscellaneous", "plan_name": "700720", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Miscellaneous", "plan_name": "700720_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Ppo Hmo", "plan_name": "701720", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Ppo Hmo", "plan_name": "701720_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Ms State Emplo", "plan_name": "401457", "standard_charge_percentage": 0.80, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Ms State Emplo", "plan_name": "401457_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Basic Pl", "plan_name": "400100", "standard_charge_percentage": 0.85, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Basic Pl", "plan_name": "400100_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Federal", "plan_name": "400110", "standard_charge_percentage": 0.85, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Federal", "plan_name": "400110_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." } ] } ] }, { "description": "Shortening of thigh bone", "code_information": [ { "code": "27465", "type": "CPT" } ], "standard_charges": [ { "gross_charge": 37358.38, "minimum": 29886.70, "maximum": 31754.62, "setting": "inpatient", "payers_information": [ { "payer_name": "Aetna", "plan_name": "700700", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna", "plan_name": "700700_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Miscellaneous", "plan_name": "700720", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Miscellaneous", "plan_name": "700720_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Ppo Hmo", "plan_name": "701720", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Ppo Hmo", "plan_name": "701720_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Ms State Emplo", "plan_name": "401457", "standard_charge_percentage": 0.80, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Ms State Emplo", "plan_name": "401457_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Basic Pl", "plan_name": "400100", "standard_charge_percentage": 0.85, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Basic Pl", "plan_name": "400100_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Federal", "plan_name": "400110", "standard_charge_percentage": 0.85, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Federal", "plan_name": "400110_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." } ] } ] }, { "description": "Revise/replace knee joint", "code_information": [ { "code": "27486", "type": "CPT" } ], "standard_charges": [ { "gross_charge": 79684.90, "minimum": 63747.92, "maximum": 67732.17, "setting": "inpatient", "payers_information": [ { "payer_name": "Aetna", "plan_name": "700700", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna", "plan_name": "700700_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Miscellaneous", "plan_name": "700720", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Miscellaneous", "plan_name": "700720_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Ppo Hmo", "plan_name": "701720", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Ppo Hmo", "plan_name": "701720_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Ms State Emplo", "plan_name": "401457", "standard_charge_percentage": 0.80, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Ms State Emplo", "plan_name": "401457_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Basic Pl", "plan_name": "400100", "standard_charge_percentage": 0.85, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Basic Pl", "plan_name": "400100_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Federal", "plan_name": "400110", "standard_charge_percentage": 0.85, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Federal", "plan_name": "400110_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." } ] } ] }, { "description": "Revise/replace knee joint", "code_information": [ { "code": "27487", "type": "CPT" } ], "standard_charges": [ { "gross_charge": 54993.92, "minimum": 43995.14, "maximum": 46744.83, "setting": "inpatient", "payers_information": [ { "payer_name": "Aetna", "plan_name": "700700", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna", "plan_name": "700700_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Miscellaneous", "plan_name": "700720", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Miscellaneous", "plan_name": "700720_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Ppo Hmo", "plan_name": "701720", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Ppo Hmo", "plan_name": "701720_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Ms State Emplo", "plan_name": "401457", "standard_charge_percentage": 0.80, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Ms State Emplo", "plan_name": "401457_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Basic Pl", "plan_name": "400100", "standard_charge_percentage": 0.85, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Basic Pl", "plan_name": "400100_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Federal", "plan_name": "400110", "standard_charge_percentage": 0.85, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Federal", "plan_name": "400110_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." } ] } ] }, { "description": "Removal of knee prosthesis", "code_information": [ { "code": "27488", "type": "CPT" } ], "standard_charges": [ { "gross_charge": 78056.79, "minimum": 62445.43, "maximum": 66348.27, "setting": "inpatient", "payers_information": [ { "payer_name": "Aetna", "plan_name": "700700", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna", "plan_name": "700700_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Miscellaneous", "plan_name": "700720", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Miscellaneous", "plan_name": "700720_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Ppo Hmo", "plan_name": "701720", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Ppo Hmo", "plan_name": "701720_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Ms State Emplo", "plan_name": "401457", "standard_charge_percentage": 0.80, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Ms State Emplo", "plan_name": "401457_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Basic Pl", "plan_name": "400100", "standard_charge_percentage": 0.85, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Basic Pl", "plan_name": "400100_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Federal", "plan_name": "400110", "standard_charge_percentage": 0.85, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Federal", "plan_name": "400110_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." } ] } ] }, { "description": "Reinforce thigh", "code_information": [ { "code": "27495", "type": "CPT" } ], "standard_charges": [ { "gross_charge": 36810.74, "minimum": 29448.59, "maximum": 31289.13, "setting": "inpatient", "payers_information": [ { "payer_name": "Aetna", "plan_name": "700700", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna", "plan_name": "700700_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Miscellaneous", "plan_name": "700720", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Miscellaneous", "plan_name": "700720_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Ppo Hmo", "plan_name": "701720", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Ppo Hmo", "plan_name": "701720_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Ms State Emplo", "plan_name": "401457", "standard_charge_percentage": 0.80, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Ms State Emplo", "plan_name": "401457_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Basic Pl", "plan_name": "400100", "standard_charge_percentage": 0.85, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Basic Pl", "plan_name": "400100_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Federal", "plan_name": "400110", "standard_charge_percentage": 0.85, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Federal", "plan_name": "400110_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." } ] } ] }, { "description": "Treatment of thigh fracture", "code_information": [ { "code": "27501", "type": "CPT" } ], "standard_charges": [ { "gross_charge": 30294.00, "minimum": 219.75, "maximum": 25749.90, "setting": "inpatient", "payers_information": [ { "payer_name": "Aarp", "plan_name": "500102", "standard_charge_dollar": 219.75, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna", "plan_name": "700700", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna", "plan_name": "700700_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Mcare Ffs 6005", "plan_name": "700703", "standard_charge_dollar": 219.75, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Miscellaneous", "plan_name": "700720", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Miscellaneous", "plan_name": "700720_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Ppo Hmo", "plan_name": "701720", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Ppo Hmo", "plan_name": "701720_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Ambetter 68069", "plan_name": "500516", "standard_charge_dollar": 219.75, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Ms State Emplo", "plan_name": "401457", "standard_charge_percentage": 0.80, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Ms State Emplo", "plan_name": "401457_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Basic Pl", "plan_name": "400100", "standard_charge_percentage": 0.85, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Basic Pl", "plan_name": "400100_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Federal", "plan_name": "400110", "standard_charge_percentage": 0.85, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Federal", "plan_name": "400110_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Cigna Healthsprings Ffs", "plan_name": "500064", "standard_charge_dollar": 219.75, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Conseco", "plan_name": "500302", "standard_charge_dollar": 219.75, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Humana Ffs 61101", "plan_name": "500006", "standard_charge_dollar": 219.75, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Medicare A", "plan_name": "100100", "standard_charge_dollar": 219.75, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Medicare A", "plan_name": "100500", "standard_charge_dollar": 219.75, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Medicare Part B Only", "plan_name": "100300", "standard_charge_dollar": 219.75, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Medicare Railroad", "plan_name": "100103", "standard_charge_dollar": 219.75, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Ms Physicians Care N", "plan_name": "714210", "standard_charge_dollar": 274.68, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Peoples Hlth Ffs 72126", "plan_name": "500019", "standard_charge_dollar": 219.75, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Uhc/Secure Horizons", "plan_name": "500449", "standard_charge_dollar": 219.75, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "United Health Care/", "plan_name": "500292", "standard_charge_dollar": 248.31, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "United Healthcare", "plan_name": "750104", "standard_charge_dollar": 248.31, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "United Healthcare Ba", "plan_name": "750090", "standard_charge_dollar": 248.31, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "United Healthcare Me", "plan_name": "501310", "standard_charge_dollar": 219.75, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Windsor Mcare Extra", "plan_name": "500778", "standard_charge_dollar": 219.75, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." } ] } ] }, { "description": "Treatment of thigh fracture", "code_information": [ { "code": "27508", "type": "CPT" } ], "standard_charges": [ { "gross_charge": 30294.00, "minimum": 219.75, "maximum": 25749.90, "setting": "inpatient", "payers_information": [ { "payer_name": "Aarp", "plan_name": "500102", "standard_charge_dollar": 219.75, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna", "plan_name": "700700", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna", "plan_name": "700700_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Mcare Ffs 6005", "plan_name": "700703", "standard_charge_dollar": 219.75, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Miscellaneous", "plan_name": "700720", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Miscellaneous", "plan_name": "700720_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Ppo Hmo", "plan_name": "701720", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Ppo Hmo", "plan_name": "701720_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Ambetter 68069", "plan_name": "500516", "standard_charge_dollar": 219.75, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Ms State Emplo", "plan_name": "401457", "standard_charge_percentage": 0.80, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Ms State Emplo", "plan_name": "401457_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Basic Pl", "plan_name": "400100", "standard_charge_percentage": 0.85, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Basic Pl", "plan_name": "400100_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Federal", "plan_name": "400110", "standard_charge_percentage": 0.85, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Federal", "plan_name": "400110_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Cigna Healthsprings Ffs", "plan_name": "500064", "standard_charge_dollar": 219.75, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Conseco", "plan_name": "500302", "standard_charge_dollar": 219.75, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Humana Ffs 61101", "plan_name": "500006", "standard_charge_dollar": 219.75, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Medicare A", "plan_name": "100100", "standard_charge_dollar": 219.75, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Medicare A", "plan_name": "100500", "standard_charge_dollar": 219.75, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Medicare Part B Only", "plan_name": "100300", "standard_charge_dollar": 219.75, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Medicare Railroad", "plan_name": "100103", "standard_charge_dollar": 219.75, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Ms Physicians Care N", "plan_name": "714210", "standard_charge_dollar": 274.68, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Peoples Hlth Ffs 72126", "plan_name": "500019", "standard_charge_dollar": 219.75, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Uhc/Secure Horizons", "plan_name": "500449", "standard_charge_dollar": 219.75, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "United Health Care/", "plan_name": "500292", "standard_charge_dollar": 248.31, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "United Healthcare", "plan_name": "750104", "standard_charge_dollar": 248.31, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "United Healthcare Ba", "plan_name": "750090", "standard_charge_dollar": 248.31, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "United Healthcare Me", "plan_name": "501310", "standard_charge_dollar": 219.75, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Windsor Mcare Extra", "plan_name": "500778", "standard_charge_dollar": 219.75, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." } ] } ] }, { "description": "Treatment of thigh fracture", "code_information": [ { "code": "27509", "type": "CPT" } ], "standard_charges": [ { "gross_charge": 31287.66, "minimum": 6544.15, "maximum": 26594.51, "setting": "inpatient", "payers_information": [ { "payer_name": "Aarp", "plan_name": "500102", "standard_charge_dollar": 6544.15, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna", "plan_name": "700700", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna", "plan_name": "700700_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Mcare Ffs 6005", "plan_name": "700703", "standard_charge_dollar": 6544.15, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Miscellaneous", "plan_name": "700720", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Miscellaneous", "plan_name": "700720_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Ppo Hmo", "plan_name": "701720", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Ppo Hmo", "plan_name": "701720_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Ambetter 68069", "plan_name": "500516", "standard_charge_dollar": 6544.15, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Ms State Emplo", "plan_name": "401457", "standard_charge_percentage": 0.80, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Ms State Emplo", "plan_name": "401457_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Basic Pl", "plan_name": "400100", "standard_charge_percentage": 0.85, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Basic Pl", "plan_name": "400100_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Federal", "plan_name": "400110", "standard_charge_percentage": 0.85, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Federal", "plan_name": "400110_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Cigna Healthsprings Ffs", "plan_name": "500064", "standard_charge_dollar": 6544.15, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Conseco", "plan_name": "500302", "standard_charge_dollar": 6544.15, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Humana Ffs 61101", "plan_name": "500006", "standard_charge_dollar": 6544.15, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Medicare A", "plan_name": "100100", "standard_charge_dollar": 6544.15, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Medicare A", "plan_name": "100500", "standard_charge_dollar": 6544.15, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Medicare Part B Only", "plan_name": "100300", "standard_charge_dollar": 6544.15, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Medicare Railroad", "plan_name": "100103", "standard_charge_dollar": 6544.15, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Ms Physicians Care N", "plan_name": "714210", "standard_charge_dollar": 8180.19, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Peoples Hlth Ffs 72126", "plan_name": "500019", "standard_charge_dollar": 6544.15, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Uhc/Secure Horizons", "plan_name": "500449", "standard_charge_dollar": 6544.15, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "United Health Care/", "plan_name": "500292", "standard_charge_dollar": 7394.89, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "United Healthcare", "plan_name": "750104", "standard_charge_dollar": 7394.89, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "United Healthcare Ba", "plan_name": "750090", "standard_charge_dollar": 7394.89, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "United Healthcare Me", "plan_name": "501310", "standard_charge_dollar": 6544.15, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Windsor Mcare Extra", "plan_name": "500778", "standard_charge_dollar": 6544.15, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." } ] } ] }, { "description": "Treatment of thigh fracture", "code_information": [ { "code": "27511", "type": "CPT" } ], "standard_charges": [ { "gross_charge": 41608.72, "minimum": 33286.98, "maximum": 35367.41, "setting": "inpatient", "payers_information": [ { "payer_name": "Aetna", "plan_name": "700700", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna", "plan_name": "700700_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Miscellaneous", "plan_name": "700720", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Miscellaneous", "plan_name": "700720_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Ppo Hmo", "plan_name": "701720", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Ppo Hmo", "plan_name": "701720_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Ms State Emplo", "plan_name": "401457", "standard_charge_percentage": 0.80, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Ms State Emplo", "plan_name": "401457_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Basic Pl", "plan_name": "400100", "standard_charge_percentage": 0.85, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Basic Pl", "plan_name": "400100_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Federal", "plan_name": "400110", "standard_charge_percentage": 0.85, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Federal", "plan_name": "400110_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." } ] } ] }, { "description": "Treatment of thigh fracture", "code_information": [ { "code": "27513", "type": "CPT" } ], "standard_charges": [ { "gross_charge": 41608.72, "minimum": 33286.98, "maximum": 35367.41, "setting": "inpatient", "payers_information": [ { "payer_name": "Aetna", "plan_name": "700700", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna", "plan_name": "700700_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Miscellaneous", "plan_name": "700720", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Miscellaneous", "plan_name": "700720_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Ppo Hmo", "plan_name": "701720", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Ppo Hmo", "plan_name": "701720_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Ms State Emplo", "plan_name": "401457", "standard_charge_percentage": 0.80, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Ms State Emplo", "plan_name": "401457_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Basic Pl", "plan_name": "400100", "standard_charge_percentage": 0.85, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Basic Pl", "plan_name": "400100_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Federal", "plan_name": "400110", "standard_charge_percentage": 0.85, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Federal", "plan_name": "400110_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." } ] } ] }, { "description": "Treatment of thigh fracture", "code_information": [ { "code": "27514", "type": "CPT" } ], "standard_charges": [ { "gross_charge": 41608.72, "minimum": 33286.98, "maximum": 35367.41, "setting": "inpatient", "payers_information": [ { "payer_name": "Aetna", "plan_name": "700700", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna", "plan_name": "700700_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Miscellaneous", "plan_name": "700720", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Miscellaneous", "plan_name": "700720_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Ppo Hmo", "plan_name": "701720", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Ppo Hmo", "plan_name": "701720_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Ms State Emplo", "plan_name": "401457", "standard_charge_percentage": 0.80, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Ms State Emplo", "plan_name": "401457_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Basic Pl", "plan_name": "400100", "standard_charge_percentage": 0.85, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Basic Pl", "plan_name": "400100_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Federal", "plan_name": "400110", "standard_charge_percentage": 0.85, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Federal", "plan_name": "400110_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." } ] } ] }, { "description": "Treat thigh fx growth plate", "code_information": [ { "code": "27519", "type": "CPT" } ], "standard_charges": [ { "gross_charge": 41608.72, "minimum": 33286.98, "maximum": 35367.41, "setting": "inpatient", "payers_information": [ { "payer_name": "Aetna", "plan_name": "700700", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna", "plan_name": "700700_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Miscellaneous", "plan_name": "700720", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Miscellaneous", "plan_name": "700720_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Ppo Hmo", "plan_name": "701720", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Ppo Hmo", "plan_name": "701720_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Ms State Emplo", "plan_name": "401457", "standard_charge_percentage": 0.80, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Ms State Emplo", "plan_name": "401457_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Basic Pl", "plan_name": "400100", "standard_charge_percentage": 0.85, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Basic Pl", "plan_name": "400100_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Federal", "plan_name": "400110", "standard_charge_percentage": 0.85, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Federal", "plan_name": "400110_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." } ] } ] }, { "description": "Treat kneecap fracture", "code_information": [ { "code": "27520", "type": "CPT" } ], "standard_charges": [ { "gross_charge": 30294.00, "minimum": 219.75, "maximum": 25749.90, "setting": "inpatient", "payers_information": [ { "payer_name": "Aarp", "plan_name": "500102", "standard_charge_dollar": 219.75, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna", "plan_name": "700700", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna", "plan_name": "700700_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Mcare Ffs 6005", "plan_name": "700703", "standard_charge_dollar": 219.75, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Miscellaneous", "plan_name": "700720", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Miscellaneous", "plan_name": "700720_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Ppo Hmo", "plan_name": "701720", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Ppo Hmo", "plan_name": "701720_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Ambetter 68069", "plan_name": "500516", "standard_charge_dollar": 219.75, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Ms State Emplo", "plan_name": "401457", "standard_charge_percentage": 0.80, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Ms State Emplo", "plan_name": "401457_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Basic Pl", "plan_name": "400100", "standard_charge_percentage": 0.85, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Basic Pl", "plan_name": "400100_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Federal", "plan_name": "400110", "standard_charge_percentage": 0.85, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Federal", "plan_name": "400110_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Cigna Healthsprings Ffs", "plan_name": "500064", "standard_charge_dollar": 219.75, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Conseco", "plan_name": "500302", "standard_charge_dollar": 219.75, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Humana Ffs 61101", "plan_name": "500006", "standard_charge_dollar": 219.75, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Medicare A", "plan_name": "100100", "standard_charge_dollar": 219.75, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Medicare A", "plan_name": "100500", "standard_charge_dollar": 219.75, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Medicare Part B Only", "plan_name": "100300", "standard_charge_dollar": 219.75, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Medicare Railroad", "plan_name": "100103", "standard_charge_dollar": 219.75, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Ms Physicians Care N", "plan_name": "714210", "standard_charge_dollar": 274.68, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Peoples Hlth Ffs 72126", "plan_name": "500019", "standard_charge_dollar": 219.75, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Uhc/Secure Horizons", "plan_name": "500449", "standard_charge_dollar": 219.75, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "United Health Care/", "plan_name": "500292", "standard_charge_dollar": 248.31, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "United Healthcare", "plan_name": "750104", "standard_charge_dollar": 248.31, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "United Healthcare Ba", "plan_name": "750090", "standard_charge_dollar": 248.31, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "United Healthcare Me", "plan_name": "501310", "standard_charge_dollar": 219.75, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Windsor Mcare Extra", "plan_name": "500778", "standard_charge_dollar": 219.75, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." } ] } ] }, { "description": "Treat knee fracture", "code_information": [ { "code": "27530", "type": "CPT" } ], "standard_charges": [ { "gross_charge": 30294.00, "minimum": 219.75, "maximum": 25749.90, "setting": "inpatient", "payers_information": [ { "payer_name": "Aarp", "plan_name": "500102", "standard_charge_dollar": 219.75, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna", "plan_name": "700700", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna", "plan_name": "700700_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Mcare Ffs 6005", "plan_name": "700703", "standard_charge_dollar": 219.75, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Miscellaneous", "plan_name": "700720", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Miscellaneous", "plan_name": "700720_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Ppo Hmo", "plan_name": "701720", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Ppo Hmo", "plan_name": "701720_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Ambetter 68069", "plan_name": "500516", "standard_charge_dollar": 219.75, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Ms State Emplo", "plan_name": "401457", "standard_charge_percentage": 0.80, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Ms State Emplo", "plan_name": "401457_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Basic Pl", "plan_name": "400100", "standard_charge_percentage": 0.85, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Basic Pl", "plan_name": "400100_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Federal", "plan_name": "400110", "standard_charge_percentage": 0.85, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Federal", "plan_name": "400110_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Cigna Healthsprings Ffs", "plan_name": "500064", "standard_charge_dollar": 219.75, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Conseco", "plan_name": "500302", "standard_charge_dollar": 219.75, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Humana Ffs 61101", "plan_name": "500006", "standard_charge_dollar": 219.75, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Medicare A", "plan_name": "100100", "standard_charge_dollar": 219.75, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Medicare A", "plan_name": "100500", "standard_charge_dollar": 219.75, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Medicare Part B Only", "plan_name": "100300", "standard_charge_dollar": 219.75, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Medicare Railroad", "plan_name": "100103", "standard_charge_dollar": 219.75, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Ms Physicians Care N", "plan_name": "714210", "standard_charge_dollar": 274.68, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Peoples Hlth Ffs 72126", "plan_name": "500019", "standard_charge_dollar": 219.75, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Uhc/Secure Horizons", "plan_name": "500449", "standard_charge_dollar": 219.75, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "United Health Care/", "plan_name": "500292", "standard_charge_dollar": 248.31, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "United Healthcare", "plan_name": "750104", "standard_charge_dollar": 248.31, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "United Healthcare Ba", "plan_name": "750090", "standard_charge_dollar": 248.31, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "United Healthcare Me", "plan_name": "501310", "standard_charge_dollar": 219.75, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Windsor Mcare Extra", "plan_name": "500778", "standard_charge_dollar": 219.75, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." } ] } ] }, { "description": "Treat knee fracture", "code_information": [ { "code": "27532", "type": "CPT" } ], "standard_charges": [ { "gross_charge": 13655.35, "minimum": 2972.29, "maximum": 11607.05, "setting": "inpatient", "payers_information": [ { "payer_name": "Aarp", "plan_name": "500102", "standard_charge_dollar": 2972.29, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna", "plan_name": "700700", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna", "plan_name": "700700_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Mcare Ffs 6005", "plan_name": "700703", "standard_charge_dollar": 2972.29, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Miscellaneous", "plan_name": "700720", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Miscellaneous", "plan_name": "700720_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Ppo Hmo", "plan_name": "701720", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Ppo Hmo", "plan_name": "701720_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Ambetter 68069", "plan_name": "500516", "standard_charge_dollar": 2972.29, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Ms State Emplo", "plan_name": "401457", "standard_charge_percentage": 0.80, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Ms State Emplo", "plan_name": "401457_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Basic Pl", "plan_name": "400100", "standard_charge_percentage": 0.85, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Basic Pl", "plan_name": "400100_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Federal", "plan_name": "400110", "standard_charge_percentage": 0.85, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Federal", "plan_name": "400110_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Cigna Healthsprings Ffs", "plan_name": "500064", "standard_charge_dollar": 2972.29, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Conseco", "plan_name": "500302", "standard_charge_dollar": 2972.29, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Humana Ffs 61101", "plan_name": "500006", "standard_charge_dollar": 2972.29, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Medicare A", "plan_name": "100100", "standard_charge_dollar": 2972.29, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Medicare A", "plan_name": "100500", "standard_charge_dollar": 2972.29, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Medicare Part B Only", "plan_name": "100300", "standard_charge_dollar": 2972.29, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Medicare Railroad", "plan_name": "100103", "standard_charge_dollar": 2972.29, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Ms Physicians Care N", "plan_name": "714210", "standard_charge_dollar": 3715.36, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Peoples Hlth Ffs 72126", "plan_name": "500019", "standard_charge_dollar": 2972.29, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Uhc/Secure Horizons", "plan_name": "500449", "standard_charge_dollar": 2972.29, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "United Health Care/", "plan_name": "500292", "standard_charge_dollar": 3358.68, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "United Healthcare", "plan_name": "750104", "standard_charge_dollar": 3358.68, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "United Healthcare Ba", "plan_name": "750090", "standard_charge_dollar": 3358.68, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "United Healthcare Me", "plan_name": "501310", "standard_charge_dollar": 2972.29, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Windsor Mcare Extra", "plan_name": "500778", "standard_charge_dollar": 2972.29, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." } ] } ] }, { "description": "Treat knee fracture", "code_information": [ { "code": "27535", "type": "CPT" } ], "standard_charges": [ { "gross_charge": 32336.15, "minimum": 25868.92, "maximum": 27485.73, "setting": "inpatient", "payers_information": [ { "payer_name": "Aetna", "plan_name": "700700", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna", "plan_name": "700700_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Miscellaneous", "plan_name": "700720", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Miscellaneous", "plan_name": "700720_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Ppo Hmo", "plan_name": "701720", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Ppo Hmo", "plan_name": "701720_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Ms State Emplo", "plan_name": "401457", "standard_charge_percentage": 0.80, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Ms State Emplo", "plan_name": "401457_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Basic Pl", "plan_name": "400100", "standard_charge_percentage": 0.85, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Basic Pl", "plan_name": "400100_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Federal", "plan_name": "400110", "standard_charge_percentage": 0.85, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Federal", "plan_name": "400110_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." } ] } ] }, { "description": "Treat knee fracture", "code_information": [ { "code": "27536", "type": "CPT" } ], "standard_charges": [ { "gross_charge": 32336.15, "minimum": 25868.92, "maximum": 27485.73, "setting": "inpatient", "payers_information": [ { "payer_name": "Aetna", "plan_name": "700700", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna", "plan_name": "700700_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Miscellaneous", "plan_name": "700720", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Miscellaneous", "plan_name": "700720_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Ppo Hmo", "plan_name": "701720", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Ppo Hmo", "plan_name": "701720_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Ms State Emplo", "plan_name": "401457", "standard_charge_percentage": 0.80, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Ms State Emplo", "plan_name": "401457_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Basic Pl", "plan_name": "400100", "standard_charge_percentage": 0.85, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Basic Pl", "plan_name": "400100_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Federal", "plan_name": "400110", "standard_charge_percentage": 0.85, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Federal", "plan_name": "400110_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." } ] } ] }, { "description": "Treat knee fracture(s)", "code_information": [ { "code": "27538", "type": "CPT" } ], "standard_charges": [ { "gross_charge": 21974.68, "minimum": 219.75, "maximum": 18678.48, "setting": "inpatient", "payers_information": [ { "payer_name": "Aarp", "plan_name": "500102", "standard_charge_dollar": 219.75, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna", "plan_name": "700700", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna", "plan_name": "700700_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Mcare Ffs 6005", "plan_name": "700703", "standard_charge_dollar": 219.75, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Miscellaneous", "plan_name": "700720", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Miscellaneous", "plan_name": "700720_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Ppo Hmo", "plan_name": "701720", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Ppo Hmo", "plan_name": "701720_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Ambetter 68069", "plan_name": "500516", "standard_charge_dollar": 219.75, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Ms State Emplo", "plan_name": "401457", "standard_charge_percentage": 0.80, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Ms State Emplo", "plan_name": "401457_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Basic Pl", "plan_name": "400100", "standard_charge_percentage": 0.85, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Basic Pl", "plan_name": "400100_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Federal", "plan_name": "400110", "standard_charge_percentage": 0.85, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Federal", "plan_name": "400110_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Cigna Healthsprings Ffs", "plan_name": "500064", "standard_charge_dollar": 219.75, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Conseco", "plan_name": "500302", "standard_charge_dollar": 219.75, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Humana Ffs 61101", "plan_name": "500006", "standard_charge_dollar": 219.75, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Medicare A", "plan_name": "100100", "standard_charge_dollar": 219.75, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Medicare A", "plan_name": "100500", "standard_charge_dollar": 219.75, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Medicare Part B Only", "plan_name": "100300", "standard_charge_dollar": 219.75, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Medicare Railroad", "plan_name": "100103", "standard_charge_dollar": 219.75, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Ms Physicians Care N", "plan_name": "714210", "standard_charge_dollar": 274.68, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Peoples Hlth Ffs 72126", "plan_name": "500019", "standard_charge_dollar": 219.75, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Uhc/Secure Horizons", "plan_name": "500449", "standard_charge_dollar": 219.75, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "United Health Care/", "plan_name": "500292", "standard_charge_dollar": 248.31, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "United Healthcare", "plan_name": "750104", "standard_charge_dollar": 248.31, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "United Healthcare Ba", "plan_name": "750090", "standard_charge_dollar": 248.31, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "United Healthcare Me", "plan_name": "501310", "standard_charge_dollar": 219.75, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Windsor Mcare Extra", "plan_name": "500778", "standard_charge_dollar": 219.75, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." } ] } ] }, { "description": "Treat knee fracture", "code_information": [ { "code": "27540", "type": "CPT" } ], "standard_charges": [ { "gross_charge": 32336.15, "minimum": 25868.92, "maximum": 27485.73, "setting": "inpatient", "payers_information": [ { "payer_name": "Aetna", "plan_name": "700700", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna", "plan_name": "700700_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Miscellaneous", "plan_name": "700720", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Miscellaneous", "plan_name": "700720_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Ppo Hmo", "plan_name": "701720", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Ppo Hmo", "plan_name": "701720_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Ms State Emplo", "plan_name": "401457", "standard_charge_percentage": 0.80, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Ms State Emplo", "plan_name": "401457_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Basic Pl", "plan_name": "400100", "standard_charge_percentage": 0.85, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Basic Pl", "plan_name": "400100_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Federal", "plan_name": "400110", "standard_charge_percentage": 0.85, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Federal", "plan_name": "400110_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." } ] } ] }, { "description": "Amputate leg at thigh", "code_information": [ { "code": "27590", "type": "CPT" } ], "standard_charges": [ { "gross_charge": 31175.67, "minimum": 24940.54, "maximum": 26499.32, "setting": "inpatient", "payers_information": [ { "payer_name": "Aetna", "plan_name": "700700", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna", "plan_name": "700700_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Miscellaneous", "plan_name": "700720", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Miscellaneous", "plan_name": "700720_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Ppo Hmo", "plan_name": "701720", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Ppo Hmo", "plan_name": "701720_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Ms State Emplo", "plan_name": "401457", "standard_charge_percentage": 0.80, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Ms State Emplo", "plan_name": "401457_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Basic Pl", "plan_name": "400100", "standard_charge_percentage": 0.85, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Basic Pl", "plan_name": "400100_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Federal", "plan_name": "400110", "standard_charge_percentage": 0.85, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Federal", "plan_name": "400110_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." } ] } ] }, { "description": "Amputate leg at thigh", "code_information": [ { "code": "27591", "type": "CPT" } ], "standard_charges": [ { "gross_charge": 31175.67, "minimum": 24940.54, "maximum": 26499.32, "setting": "inpatient", "payers_information": [ { "payer_name": "Aetna", "plan_name": "700700", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna", "plan_name": "700700_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Miscellaneous", "plan_name": "700720", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Miscellaneous", "plan_name": "700720_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Ppo Hmo", "plan_name": "701720", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Ppo Hmo", "plan_name": "701720_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Ms State Emplo", "plan_name": "401457", "standard_charge_percentage": 0.80, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Ms State Emplo", "plan_name": "401457_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Basic Pl", "plan_name": "400100", "standard_charge_percentage": 0.85, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Basic Pl", "plan_name": "400100_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Federal", "plan_name": "400110", "standard_charge_percentage": 0.85, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Federal", "plan_name": "400110_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." } ] } ] }, { "description": "Amputate leg at thigh", "code_information": [ { "code": "27592", "type": "CPT" } ], "standard_charges": [ { "gross_charge": 31175.67, "minimum": 24940.54, "maximum": 26499.32, "setting": "inpatient", "payers_information": [ { "payer_name": "Aetna", "plan_name": "700700", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna", "plan_name": "700700_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Miscellaneous", "plan_name": "700720", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Miscellaneous", "plan_name": "700720_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Ppo Hmo", "plan_name": "701720", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Ppo Hmo", "plan_name": "701720_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Ms State Emplo", "plan_name": "401457", "standard_charge_percentage": 0.80, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Ms State Emplo", "plan_name": "401457_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Basic Pl", "plan_name": "400100", "standard_charge_percentage": 0.85, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Basic Pl", "plan_name": "400100_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Federal", "plan_name": "400110", "standard_charge_percentage": 0.85, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Federal", "plan_name": "400110_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." } ] } ] }, { "description": "Amputation follow-up surgery", "code_information": [ { "code": "27596", "type": "CPT" } ], "standard_charges": [ { "gross_charge": 31175.67, "minimum": 24940.54, "maximum": 26499.32, "setting": "inpatient", "payers_information": [ { "payer_name": "Aetna", "plan_name": "700700", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna", "plan_name": "700700_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Miscellaneous", "plan_name": "700720", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Miscellaneous", "plan_name": "700720_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Ppo Hmo", "plan_name": "701720", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Ppo Hmo", "plan_name": "701720_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Ms State Emplo", "plan_name": "401457", "standard_charge_percentage": 0.80, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Ms State Emplo", "plan_name": "401457_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Basic Pl", "plan_name": "400100", "standard_charge_percentage": 0.85, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Basic Pl", "plan_name": "400100_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Federal", "plan_name": "400110", "standard_charge_percentage": 0.85, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Federal", "plan_name": "400110_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." } ] } ] }, { "description": "Amputate lower leg at knee", "code_information": [ { "code": "27598", "type": "CPT" } ], "standard_charges": [ { "gross_charge": 12867.24, "minimum": 10293.79, "maximum": 10937.15, "setting": "inpatient", "payers_information": [ { "payer_name": "Aetna", "plan_name": "700700", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna", "plan_name": "700700_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Miscellaneous", "plan_name": "700720", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Miscellaneous", "plan_name": "700720_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Ppo Hmo", "plan_name": "701720", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Ppo Hmo", "plan_name": "701720_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Ms State Emplo", "plan_name": "401457", "standard_charge_percentage": 0.80, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Ms State Emplo", "plan_name": "401457_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Basic Pl", "plan_name": "400100", "standard_charge_percentage": 0.85, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Basic Pl", "plan_name": "400100_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Federal", "plan_name": "400110", "standard_charge_percentage": 0.85, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Federal", "plan_name": "400110_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." } ] } ] }, { "description": "Drain lower leg lesion", "code_information": [ { "code": "27603", "type": "CPT" } ], "standard_charges": [ { "gross_charge": 22465.97, "minimum": 2621.84, "maximum": 19096.07, "setting": "inpatient", "payers_information": [ { "payer_name": "Aarp", "plan_name": "500102", "standard_charge_dollar": 2621.84, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna", "plan_name": "700700", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna", "plan_name": "700700_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Mcare Ffs 6005", "plan_name": "700703", "standard_charge_dollar": 2621.84, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Miscellaneous", "plan_name": "700720", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Miscellaneous", "plan_name": "700720_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Ppo Hmo", "plan_name": "701720", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Ppo Hmo", "plan_name": "701720_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Ambetter 68069", "plan_name": "500516", "standard_charge_dollar": 2621.84, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Ms State Emplo", "plan_name": "401457", "standard_charge_percentage": 0.80, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Ms State Emplo", "plan_name": "401457_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Basic Pl", "plan_name": "400100", "standard_charge_percentage": 0.85, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Basic Pl", "plan_name": "400100_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Federal", "plan_name": "400110", "standard_charge_percentage": 0.85, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Federal", "plan_name": "400110_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Cigna Healthsprings Ffs", "plan_name": "500064", "standard_charge_dollar": 2621.84, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Conseco", "plan_name": "500302", "standard_charge_dollar": 2621.84, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Humana Ffs 61101", "plan_name": "500006", "standard_charge_dollar": 2621.84, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Medicare A", "plan_name": "100100", "standard_charge_dollar": 2621.84, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Medicare A", "plan_name": "100500", "standard_charge_dollar": 2621.84, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Medicare Part B Only", "plan_name": "100300", "standard_charge_dollar": 2621.84, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Medicare Railroad", "plan_name": "100103", "standard_charge_dollar": 2621.84, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Ms Physicians Care N", "plan_name": "714210", "standard_charge_dollar": 3277.29, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Peoples Hlth Ffs 72126", "plan_name": "500019", "standard_charge_dollar": 2621.84, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Uhc/Secure Horizons", "plan_name": "500449", "standard_charge_dollar": 2621.84, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "United Health Care/", "plan_name": "500292", "standard_charge_dollar": 2962.67, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "United Healthcare", "plan_name": "750104", "standard_charge_dollar": 2962.67, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "United Healthcare Ba", "plan_name": "750090", "standard_charge_dollar": 2962.67, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "United Healthcare Me", "plan_name": "501310", "standard_charge_dollar": 2621.84, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Windsor Mcare Extra", "plan_name": "500778", "standard_charge_dollar": 2621.84, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." } ] } ] }, { "description": "Treat lower leg bone lesion", "code_information": [ { "code": "27607", "type": "CPT" } ], "standard_charges": [ { "gross_charge": 59977.68, "minimum": 2972.29, "maximum": 50981.03, "setting": "inpatient", "payers_information": [ { "payer_name": "Aarp", "plan_name": "500102", "standard_charge_dollar": 2972.29, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna", "plan_name": "700700", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna", "plan_name": "700700_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Mcare Ffs 6005", "plan_name": "700703", "standard_charge_dollar": 2972.29, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Miscellaneous", "plan_name": "700720", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Miscellaneous", "plan_name": "700720_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Ppo Hmo", "plan_name": "701720", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Ppo Hmo", "plan_name": "701720_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Ambetter 68069", "plan_name": "500516", "standard_charge_dollar": 2972.29, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Ms State Emplo", "plan_name": "401457", "standard_charge_percentage": 0.80, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Ms State Emplo", "plan_name": "401457_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Basic Pl", "plan_name": "400100", "standard_charge_percentage": 0.85, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Basic Pl", "plan_name": "400100_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Federal", "plan_name": "400110", "standard_charge_percentage": 0.85, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Federal", "plan_name": "400110_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Cigna Healthsprings Ffs", "plan_name": "500064", "standard_charge_dollar": 2972.29, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Conseco", "plan_name": "500302", "standard_charge_dollar": 2972.29, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Humana Ffs 61101", "plan_name": "500006", "standard_charge_dollar": 2972.29, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Medicare A", "plan_name": "100100", "standard_charge_dollar": 2972.29, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Medicare A", "plan_name": "100500", "standard_charge_dollar": 2972.29, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Medicare Part B Only", "plan_name": "100300", "standard_charge_dollar": 2972.29, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Medicare Railroad", "plan_name": "100103", "standard_charge_dollar": 2972.29, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Ms Physicians Care N", "plan_name": "714210", "standard_charge_dollar": 3715.36, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Peoples Hlth Ffs 72126", "plan_name": "500019", "standard_charge_dollar": 2972.29, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Uhc/Secure Horizons", "plan_name": "500449", "standard_charge_dollar": 2972.29, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "United Health Care/", "plan_name": "500292", "standard_charge_dollar": 3358.68, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "United Healthcare", "plan_name": "750104", "standard_charge_dollar": 3358.68, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "United Healthcare Ba", "plan_name": "750090", "standard_charge_dollar": 3358.68, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "United Healthcare Me", "plan_name": "501310", "standard_charge_dollar": 2972.29, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Windsor Mcare Extra", "plan_name": "500778", "standard_charge_dollar": 2972.29, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." } ] } ] }, { "description": "Explore/treat ankle joint", "code_information": [ { "code": "27610", "type": "CPT" } ], "standard_charges": [ { "gross_charge": 59977.68, "minimum": 2972.29, "maximum": 50981.03, "setting": "inpatient", "payers_information": [ { "payer_name": "Aarp", "plan_name": "500102", "standard_charge_dollar": 2972.29, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna", "plan_name": "700700", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna", "plan_name": "700700_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Mcare Ffs 6005", "plan_name": "700703", "standard_charge_dollar": 2972.29, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Miscellaneous", "plan_name": "700720", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Miscellaneous", "plan_name": "700720_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Ppo Hmo", "plan_name": "701720", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Ppo Hmo", "plan_name": "701720_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Ambetter 68069", "plan_name": "500516", "standard_charge_dollar": 2972.29, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Ms State Emplo", "plan_name": "401457", "standard_charge_percentage": 0.80, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Ms State Emplo", "plan_name": "401457_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Basic Pl", "plan_name": "400100", "standard_charge_percentage": 0.85, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Basic Pl", "plan_name": "400100_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Federal", "plan_name": "400110", "standard_charge_percentage": 0.85, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Federal", "plan_name": "400110_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Cigna Healthsprings Ffs", "plan_name": "500064", "standard_charge_dollar": 2972.29, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Conseco", "plan_name": "500302", "standard_charge_dollar": 2972.29, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Humana Ffs 61101", "plan_name": "500006", "standard_charge_dollar": 2972.29, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Medicare A", "plan_name": "100100", "standard_charge_dollar": 2972.29, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Medicare A", "plan_name": "100500", "standard_charge_dollar": 2972.29, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Medicare Part B Only", "plan_name": "100300", "standard_charge_dollar": 2972.29, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Medicare Railroad", "plan_name": "100103", "standard_charge_dollar": 2972.29, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Ms Physicians Care N", "plan_name": "714210", "standard_charge_dollar": 3715.36, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Peoples Hlth Ffs 72126", "plan_name": "500019", "standard_charge_dollar": 2972.29, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Uhc/Secure Horizons", "plan_name": "500449", "standard_charge_dollar": 2972.29, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "United Health Care/", "plan_name": "500292", "standard_charge_dollar": 3358.68, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "United Healthcare", "plan_name": "750104", "standard_charge_dollar": 3358.68, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "United Healthcare Ba", "plan_name": "750090", "standard_charge_dollar": 3358.68, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "United Healthcare Me", "plan_name": "501310", "standard_charge_dollar": 2972.29, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Windsor Mcare Extra", "plan_name": "500778", "standard_charge_dollar": 2972.29, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." } ] } ] }, { "description": "Resect leg/ankle tum < 5 cm", "code_information": [ { "code": "27615", "type": "CPT" } ], "standard_charges": [ { "gross_charge": 35800.23, "minimum": 2621.84, "maximum": 30430.20, "setting": "inpatient", "payers_information": [ { "payer_name": "Aarp", "plan_name": "500102", "standard_charge_dollar": 2621.84, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna", "plan_name": "700700", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna", "plan_name": "700700_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Mcare Ffs 6005", "plan_name": "700703", "standard_charge_dollar": 2621.84, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Miscellaneous", "plan_name": "700720", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Miscellaneous", "plan_name": "700720_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Ppo Hmo", "plan_name": "701720", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Ppo Hmo", "plan_name": "701720_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Ambetter 68069", "plan_name": "500516", "standard_charge_dollar": 2621.84, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Ms State Emplo", "plan_name": "401457", "standard_charge_percentage": 0.80, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Ms State Emplo", "plan_name": "401457_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Basic Pl", "plan_name": "400100", "standard_charge_percentage": 0.85, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Basic Pl", "plan_name": "400100_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Federal", "plan_name": "400110", "standard_charge_percentage": 0.85, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Federal", "plan_name": "400110_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Cigna Healthsprings Ffs", "plan_name": "500064", "standard_charge_dollar": 2621.84, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Conseco", "plan_name": "500302", "standard_charge_dollar": 2621.84, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Humana Ffs 61101", "plan_name": "500006", "standard_charge_dollar": 2621.84, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Medicare A", "plan_name": "100100", "standard_charge_dollar": 2621.84, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Medicare A", "plan_name": "100500", "standard_charge_dollar": 2621.84, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Medicare Part B Only", "plan_name": "100300", "standard_charge_dollar": 2621.84, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Medicare Railroad", "plan_name": "100103", "standard_charge_dollar": 2621.84, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Ms Physicians Care N", "plan_name": "714210", "standard_charge_dollar": 3277.29, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Peoples Hlth Ffs 72126", "plan_name": "500019", "standard_charge_dollar": 2621.84, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Uhc/Secure Horizons", "plan_name": "500449", "standard_charge_dollar": 2621.84, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "United Health Care/", "plan_name": "500292", "standard_charge_dollar": 2962.67, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "United Healthcare", "plan_name": "750104", "standard_charge_dollar": 2962.67, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "United Healthcare Ba", "plan_name": "750090", "standard_charge_dollar": 2962.67, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "United Healthcare Me", "plan_name": "501310", "standard_charge_dollar": 2621.84, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Windsor Mcare Extra", "plan_name": "500778", "standard_charge_dollar": 2621.84, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." } ] } ] }, { "description": "Resect leg/ankle tum 5 cm/>", "code_information": [ { "code": "27616", "type": "CPT" } ], "standard_charges": [ { "gross_charge": 35800.23, "minimum": 2621.84, "maximum": 30430.20, "setting": "inpatient", "payers_information": [ { "payer_name": "Aarp", "plan_name": "500102", "standard_charge_dollar": 2621.84, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna", "plan_name": "700700", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna", "plan_name": "700700_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Mcare Ffs 6005", "plan_name": "700703", "standard_charge_dollar": 2621.84, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Miscellaneous", "plan_name": "700720", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Miscellaneous", "plan_name": "700720_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Ppo Hmo", "plan_name": "701720", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Ppo Hmo", "plan_name": "701720_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Ambetter 68069", "plan_name": "500516", "standard_charge_dollar": 2621.84, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Ms State Emplo", "plan_name": "401457", "standard_charge_percentage": 0.80, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Ms State Emplo", "plan_name": "401457_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Basic Pl", "plan_name": "400100", "standard_charge_percentage": 0.85, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Basic Pl", "plan_name": "400100_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Federal", "plan_name": "400110", "standard_charge_percentage": 0.85, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Federal", "plan_name": "400110_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Cigna Healthsprings Ffs", "plan_name": "500064", "standard_charge_dollar": 2621.84, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Conseco", "plan_name": "500302", "standard_charge_dollar": 2621.84, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Humana Ffs 61101", "plan_name": "500006", "standard_charge_dollar": 2621.84, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Medicare A", "plan_name": "100100", "standard_charge_dollar": 2621.84, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Medicare A", "plan_name": "100500", "standard_charge_dollar": 2621.84, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Medicare Part B Only", "plan_name": "100300", "standard_charge_dollar": 2621.84, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Medicare Railroad", "plan_name": "100103", "standard_charge_dollar": 2621.84, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Ms Physicians Care N", "plan_name": "714210", "standard_charge_dollar": 3277.29, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Peoples Hlth Ffs 72126", "plan_name": "500019", "standard_charge_dollar": 2621.84, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Uhc/Secure Horizons", "plan_name": "500449", "standard_charge_dollar": 2621.84, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "United Health Care/", "plan_name": "500292", "standard_charge_dollar": 2962.67, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "United Healthcare", "plan_name": "750104", "standard_charge_dollar": 2962.67, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "United Healthcare Ba", "plan_name": "750090", "standard_charge_dollar": 2962.67, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "United Healthcare Me", "plan_name": "501310", "standard_charge_dollar": 2621.84, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Windsor Mcare Extra", "plan_name": "500778", "standard_charge_dollar": 2621.84, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." } ] } ] }, { "description": "Exc leg/ankle tum < 3 cm", "code_information": [ { "code": "27618", "type": "CPT" } ], "standard_charges": [ { "gross_charge": 35800.23, "minimum": 1484.25, "maximum": 30430.20, "setting": "inpatient", "payers_information": [ { "payer_name": "Aarp", "plan_name": "500102", "standard_charge_dollar": 1484.25, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna", "plan_name": "700700", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna", "plan_name": "700700_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Mcare Ffs 6005", "plan_name": "700703", "standard_charge_dollar": 1484.25, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Miscellaneous", "plan_name": "700720", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Miscellaneous", "plan_name": "700720_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Ppo Hmo", "plan_name": "701720", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Ppo Hmo", "plan_name": "701720_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Ambetter 68069", "plan_name": "500516", "standard_charge_dollar": 1484.25, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Ms State Emplo", "plan_name": "401457", "standard_charge_percentage": 0.80, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Ms State Emplo", "plan_name": "401457_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Basic Pl", "plan_name": "400100", "standard_charge_percentage": 0.85, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Basic Pl", "plan_name": "400100_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Federal", "plan_name": "400110", "standard_charge_percentage": 0.85, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Federal", "plan_name": "400110_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Cigna Healthsprings Ffs", "plan_name": "500064", "standard_charge_dollar": 1484.25, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Conseco", "plan_name": "500302", "standard_charge_dollar": 1484.25, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Humana Ffs 61101", "plan_name": "500006", "standard_charge_dollar": 1484.25, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Medicare A", "plan_name": "100100", "standard_charge_dollar": 1484.25, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Medicare A", "plan_name": "100500", "standard_charge_dollar": 1484.25, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Medicare Part B Only", "plan_name": "100300", "standard_charge_dollar": 1484.25, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Medicare Railroad", "plan_name": "100103", "standard_charge_dollar": 1484.25, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Ms Physicians Care N", "plan_name": "714210", "standard_charge_dollar": 1855.31, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Peoples Hlth Ffs 72126", "plan_name": "500019", "standard_charge_dollar": 1484.25, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Uhc/Secure Horizons", "plan_name": "500449", "standard_charge_dollar": 1484.25, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "United Health Care/", "plan_name": "500292", "standard_charge_dollar": 1677.20, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "United Healthcare", "plan_name": "750104", "standard_charge_dollar": 1677.20, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "United Healthcare Ba", "plan_name": "750090", "standard_charge_dollar": 1677.20, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "United Healthcare Me", "plan_name": "501310", "standard_charge_dollar": 1484.25, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Windsor Mcare Extra", "plan_name": "500778", "standard_charge_dollar": 1484.25, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." } ] } ] }, { "description": "Exc leg/ankle tum deep <5 cm", "code_information": [ { "code": "27619", "type": "CPT" } ], "standard_charges": [ { "gross_charge": 35800.23, "minimum": 2621.84, "maximum": 30430.20, "setting": "inpatient", "payers_information": [ { "payer_name": "Aarp", "plan_name": "500102", "standard_charge_dollar": 2621.84, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna", "plan_name": "700700", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna", "plan_name": "700700_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Mcare Ffs 6005", "plan_name": "700703", "standard_charge_dollar": 2621.84, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Miscellaneous", "plan_name": "700720", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Miscellaneous", "plan_name": "700720_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Ppo Hmo", "plan_name": "701720", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Ppo Hmo", "plan_name": "701720_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Ambetter 68069", "plan_name": "500516", "standard_charge_dollar": 2621.84, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Ms State Emplo", "plan_name": "401457", "standard_charge_percentage": 0.80, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Ms State Emplo", "plan_name": "401457_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Basic Pl", "plan_name": "400100", "standard_charge_percentage": 0.85, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Basic Pl", "plan_name": "400100_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Federal", "plan_name": "400110", "standard_charge_percentage": 0.85, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Federal", "plan_name": "400110_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Cigna Healthsprings Ffs", "plan_name": "500064", "standard_charge_dollar": 2621.84, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Conseco", "plan_name": "500302", "standard_charge_dollar": 2621.84, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Humana Ffs 61101", "plan_name": "500006", "standard_charge_dollar": 2621.84, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Medicare A", "plan_name": "100100", "standard_charge_dollar": 2621.84, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Medicare A", "plan_name": "100500", "standard_charge_dollar": 2621.84, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Medicare Part B Only", "plan_name": "100300", "standard_charge_dollar": 2621.84, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Medicare Railroad", "plan_name": "100103", "standard_charge_dollar": 2621.84, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Ms Physicians Care N", "plan_name": "714210", "standard_charge_dollar": 3277.29, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Peoples Hlth Ffs 72126", "plan_name": "500019", "standard_charge_dollar": 2621.84, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Uhc/Secure Horizons", "plan_name": "500449", "standard_charge_dollar": 2621.84, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "United Health Care/", "plan_name": "500292", "standard_charge_dollar": 2962.67, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "United Healthcare", "plan_name": "750104", "standard_charge_dollar": 2962.67, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "United Healthcare Ba", "plan_name": "750090", "standard_charge_dollar": 2962.67, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "United Healthcare Me", "plan_name": "501310", "standard_charge_dollar": 2621.84, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Windsor Mcare Extra", "plan_name": "500778", "standard_charge_dollar": 2621.84, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." } ] } ] }, { "description": "Removal of tendon lesion", "code_information": [ { "code": "27630", "type": "CPT" } ], "standard_charges": [ { "gross_charge": 37648.65, "minimum": 2972.29, "maximum": 32001.35, "setting": "inpatient", "payers_information": [ { "payer_name": "Aarp", "plan_name": "500102", "standard_charge_dollar": 2972.29, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna", "plan_name": "700700", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna", "plan_name": "700700_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Mcare Ffs 6005", "plan_name": "700703", "standard_charge_dollar": 2972.29, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Miscellaneous", "plan_name": "700720", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Miscellaneous", "plan_name": "700720_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Ppo Hmo", "plan_name": "701720", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Ppo Hmo", "plan_name": "701720_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Ambetter 68069", "plan_name": "500516", "standard_charge_dollar": 2972.29, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Ms State Emplo", "plan_name": "401457", "standard_charge_percentage": 0.80, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Ms State Emplo", "plan_name": "401457_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Basic Pl", "plan_name": "400100", "standard_charge_percentage": 0.85, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Basic Pl", "plan_name": "400100_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Federal", "plan_name": "400110", "standard_charge_percentage": 0.85, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Federal", "plan_name": "400110_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Cigna Healthsprings Ffs", "plan_name": "500064", "standard_charge_dollar": 2972.29, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Conseco", "plan_name": "500302", "standard_charge_dollar": 2972.29, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Humana Ffs 61101", "plan_name": "500006", "standard_charge_dollar": 2972.29, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Medicare A", "plan_name": "100100", "standard_charge_dollar": 2972.29, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Medicare A", "plan_name": "100500", "standard_charge_dollar": 2972.29, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Medicare Part B Only", "plan_name": "100300", "standard_charge_dollar": 2972.29, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Medicare Railroad", "plan_name": "100103", "standard_charge_dollar": 2972.29, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Ms Physicians Care N", "plan_name": "714210", "standard_charge_dollar": 3715.36, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Peoples Hlth Ffs 72126", "plan_name": "500019", "standard_charge_dollar": 2972.29, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Uhc/Secure Horizons", "plan_name": "500449", "standard_charge_dollar": 2972.29, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "United Health Care/", "plan_name": "500292", "standard_charge_dollar": 3358.68, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "United Healthcare", "plan_name": "750104", "standard_charge_dollar": 3358.68, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "United Healthcare Ba", "plan_name": "750090", "standard_charge_dollar": 3358.68, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "United Healthcare Me", "plan_name": "501310", "standard_charge_dollar": 2972.29, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Windsor Mcare Extra", "plan_name": "500778", "standard_charge_dollar": 2972.29, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." } ] } ] }, { "description": "Exc leg/ankle les sc 3 cm/>", "code_information": [ { "code": "27632", "type": "CPT" } ], "standard_charges": [ { "gross_charge": 35268.31, "minimum": 2621.84, "maximum": 29978.06, "setting": "inpatient", "payers_information": [ { "payer_name": "Aarp", "plan_name": "500102", "standard_charge_dollar": 2621.84, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna", "plan_name": "700700", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna", "plan_name": "700700_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Mcare Ffs 6005", "plan_name": "700703", "standard_charge_dollar": 2621.84, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Miscellaneous", "plan_name": "700720", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Miscellaneous", "plan_name": "700720_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Ppo Hmo", "plan_name": "701720", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Ppo Hmo", "plan_name": "701720_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Ambetter 68069", "plan_name": "500516", "standard_charge_dollar": 2621.84, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Ms State Emplo", "plan_name": "401457", "standard_charge_percentage": 0.80, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Ms State Emplo", "plan_name": "401457_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Basic Pl", "plan_name": "400100", "standard_charge_percentage": 0.85, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Basic Pl", "plan_name": "400100_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Federal", "plan_name": "400110", "standard_charge_percentage": 0.85, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Federal", "plan_name": "400110_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Cigna Healthsprings Ffs", "plan_name": "500064", "standard_charge_dollar": 2621.84, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Conseco", "plan_name": "500302", "standard_charge_dollar": 2621.84, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Humana Ffs 61101", "plan_name": "500006", "standard_charge_dollar": 2621.84, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Medicare A", "plan_name": "100100", "standard_charge_dollar": 2621.84, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Medicare A", "plan_name": "100500", "standard_charge_dollar": 2621.84, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Medicare Part B Only", "plan_name": "100300", "standard_charge_dollar": 2621.84, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Medicare Railroad", "plan_name": "100103", "standard_charge_dollar": 2621.84, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Ms Physicians Care N", "plan_name": "714210", "standard_charge_dollar": 3277.29, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Peoples Hlth Ffs 72126", "plan_name": "500019", "standard_charge_dollar": 2621.84, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Uhc/Secure Horizons", "plan_name": "500449", "standard_charge_dollar": 2621.84, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "United Health Care/", "plan_name": "500292", "standard_charge_dollar": 2962.67, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "United Healthcare", "plan_name": "750104", "standard_charge_dollar": 2962.67, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "United Healthcare Ba", "plan_name": "750090", "standard_charge_dollar": 2962.67, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "United Healthcare Me", "plan_name": "501310", "standard_charge_dollar": 2621.84, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Windsor Mcare Extra", "plan_name": "500778", "standard_charge_dollar": 2621.84, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." } ] } ] }, { "description": "Exc leg/ankle tum dep 5 cm/>", "code_information": [ { "code": "27634", "type": "CPT" } ], "standard_charges": [ { "gross_charge": 35800.23, "minimum": 2621.84, "maximum": 30430.20, "setting": "inpatient", "payers_information": [ { "payer_name": "Aarp", "plan_name": "500102", "standard_charge_dollar": 2621.84, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna", "plan_name": "700700", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna", "plan_name": "700700_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Mcare Ffs 6005", "plan_name": "700703", "standard_charge_dollar": 2621.84, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Miscellaneous", "plan_name": "700720", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Miscellaneous", "plan_name": "700720_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Ppo Hmo", "plan_name": "701720", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Ppo Hmo", "plan_name": "701720_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Ambetter 68069", "plan_name": "500516", "standard_charge_dollar": 2621.84, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Ms State Emplo", "plan_name": "401457", "standard_charge_percentage": 0.80, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Ms State Emplo", "plan_name": "401457_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Basic Pl", "plan_name": "400100", "standard_charge_percentage": 0.85, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Basic Pl", "plan_name": "400100_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Federal", "plan_name": "400110", "standard_charge_percentage": 0.85, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Federal", "plan_name": "400110_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Cigna Healthsprings Ffs", "plan_name": "500064", "standard_charge_dollar": 2621.84, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Conseco", "plan_name": "500302", "standard_charge_dollar": 2621.84, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Humana Ffs 61101", "plan_name": "500006", "standard_charge_dollar": 2621.84, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Medicare A", "plan_name": "100100", "standard_charge_dollar": 2621.84, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Medicare A", "plan_name": "100500", "standard_charge_dollar": 2621.84, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Medicare Part B Only", "plan_name": "100300", "standard_charge_dollar": 2621.84, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Medicare Railroad", "plan_name": "100103", "standard_charge_dollar": 2621.84, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Ms Physicians Care N", "plan_name": "714210", "standard_charge_dollar": 3277.29, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Peoples Hlth Ffs 72126", "plan_name": "500019", "standard_charge_dollar": 2621.84, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Uhc/Secure Horizons", "plan_name": "500449", "standard_charge_dollar": 2621.84, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "United Health Care/", "plan_name": "500292", "standard_charge_dollar": 2962.67, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "United Healthcare", "plan_name": "750104", "standard_charge_dollar": 2962.67, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "United Healthcare Ba", "plan_name": "750090", "standard_charge_dollar": 2962.67, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "United Healthcare Me", "plan_name": "501310", "standard_charge_dollar": 2621.84, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Windsor Mcare Extra", "plan_name": "500778", "standard_charge_dollar": 2621.84, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." } ] } ] }, { "description": "Repair/graft achilles tendon", "code_information": [ { "code": "27652", "type": "CPT" } ], "standard_charges": [ { "gross_charge": 34298.46, "minimum": 6544.15, "maximum": 29153.69, "setting": "inpatient", "payers_information": [ { "payer_name": "Aarp", "plan_name": "500102", "standard_charge_dollar": 6544.15, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna", "plan_name": "700700", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna", "plan_name": "700700_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Mcare Ffs 6005", "plan_name": "700703", "standard_charge_dollar": 6544.15, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Miscellaneous", "plan_name": "700720", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Miscellaneous", "plan_name": "700720_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Ppo Hmo", "plan_name": "701720", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Ppo Hmo", "plan_name": "701720_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Ambetter 68069", "plan_name": "500516", "standard_charge_dollar": 6544.15, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Ms State Emplo", "plan_name": "401457", "standard_charge_percentage": 0.80, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Ms State Emplo", "plan_name": "401457_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Basic Pl", "plan_name": "400100", "standard_charge_percentage": 0.85, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Basic Pl", "plan_name": "400100_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Federal", "plan_name": "400110", "standard_charge_percentage": 0.85, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Federal", "plan_name": "400110_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Cigna Healthsprings Ffs", "plan_name": "500064", "standard_charge_dollar": 6544.15, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Conseco", "plan_name": "500302", "standard_charge_dollar": 6544.15, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Humana Ffs 61101", "plan_name": "500006", "standard_charge_dollar": 6544.15, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Medicare A", "plan_name": "100100", "standard_charge_dollar": 6544.15, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Medicare A", "plan_name": "100500", "standard_charge_dollar": 6544.15, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Medicare Part B Only", "plan_name": "100300", "standard_charge_dollar": 6544.15, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Medicare Railroad", "plan_name": "100103", "standard_charge_dollar": 6544.15, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Ms Physicians Care N", "plan_name": "714210", "standard_charge_dollar": 8180.19, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Peoples Hlth Ffs 72126", "plan_name": "500019", "standard_charge_dollar": 6544.15, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Uhc/Secure Horizons", "plan_name": "500449", "standard_charge_dollar": 6544.15, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "United Health Care/", "plan_name": "500292", "standard_charge_dollar": 7394.89, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "United Healthcare", "plan_name": "750104", "standard_charge_dollar": 7394.89, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "United Healthcare Ba", "plan_name": "750090", "standard_charge_dollar": 7394.89, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "United Healthcare Me", "plan_name": "501310", "standard_charge_dollar": 6544.15, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Windsor Mcare Extra", "plan_name": "500778", "standard_charge_dollar": 6544.15, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." } ] } ] }, { "description": "Repair of achilles tendon", "code_information": [ { "code": "27654", "type": "CPT" } ], "standard_charges": [ { "gross_charge": 34298.46, "minimum": 6544.15, "maximum": 29153.69, "setting": "inpatient", "payers_information": [ { "payer_name": "Aarp", "plan_name": "500102", "standard_charge_dollar": 6544.15, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna", "plan_name": "700700", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna", "plan_name": "700700_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Mcare Ffs 6005", "plan_name": "700703", "standard_charge_dollar": 6544.15, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Miscellaneous", "plan_name": "700720", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Miscellaneous", "plan_name": "700720_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Ppo Hmo", "plan_name": "701720", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Ppo Hmo", "plan_name": "701720_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Ambetter 68069", "plan_name": "500516", "standard_charge_dollar": 6544.15, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Ms State Emplo", "plan_name": "401457", "standard_charge_percentage": 0.80, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Ms State Emplo", "plan_name": "401457_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Basic Pl", "plan_name": "400100", "standard_charge_percentage": 0.85, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Basic Pl", "plan_name": "400100_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Federal", "plan_name": "400110", "standard_charge_percentage": 0.85, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Federal", "plan_name": "400110_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Cigna Healthsprings Ffs", "plan_name": "500064", "standard_charge_dollar": 6544.15, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Conseco", "plan_name": "500302", "standard_charge_dollar": 6544.15, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Humana Ffs 61101", "plan_name": "500006", "standard_charge_dollar": 6544.15, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Medicare A", "plan_name": "100100", "standard_charge_dollar": 6544.15, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Medicare A", "plan_name": "100500", "standard_charge_dollar": 6544.15, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Medicare Part B Only", "plan_name": "100300", "standard_charge_dollar": 6544.15, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Medicare Railroad", "plan_name": "100103", "standard_charge_dollar": 6544.15, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Ms Physicians Care N", "plan_name": "714210", "standard_charge_dollar": 8180.19, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Peoples Hlth Ffs 72126", "plan_name": "500019", "standard_charge_dollar": 6544.15, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Uhc/Secure Horizons", "plan_name": "500449", "standard_charge_dollar": 6544.15, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "United Health Care/", "plan_name": "500292", "standard_charge_dollar": 7394.89, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "United Healthcare", "plan_name": "750104", "standard_charge_dollar": 7394.89, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "United Healthcare Ba", "plan_name": "750090", "standard_charge_dollar": 7394.89, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "United Healthcare Me", "plan_name": "501310", "standard_charge_dollar": 6544.15, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Windsor Mcare Extra", "plan_name": "500778", "standard_charge_dollar": 6544.15, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." } ] } ] }, { "description": "Repair leg fascia defect", "code_information": [ { "code": "27656", "type": "CPT" } ], "standard_charges": [ { "gross_charge": 14841.25, "minimum": 2972.29, "maximum": 12615.06, "setting": "inpatient", "payers_information": [ { "payer_name": "Aarp", "plan_name": "500102", "standard_charge_dollar": 2972.29, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna", "plan_name": "700700", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna", "plan_name": "700700_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Mcare Ffs 6005", "plan_name": "700703", "standard_charge_dollar": 2972.29, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Miscellaneous", "plan_name": "700720", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Miscellaneous", "plan_name": "700720_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Ppo Hmo", "plan_name": "701720", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Ppo Hmo", "plan_name": "701720_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Ambetter 68069", "plan_name": "500516", "standard_charge_dollar": 2972.29, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Ms State Emplo", "plan_name": "401457", "standard_charge_percentage": 0.80, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Ms State Emplo", "plan_name": "401457_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Basic Pl", "plan_name": "400100", "standard_charge_percentage": 0.85, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Basic Pl", "plan_name": "400100_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Federal", "plan_name": "400110", "standard_charge_percentage": 0.85, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Federal", "plan_name": "400110_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Cigna Healthsprings Ffs", "plan_name": "500064", "standard_charge_dollar": 2972.29, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Conseco", "plan_name": "500302", "standard_charge_dollar": 2972.29, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Humana Ffs 61101", "plan_name": "500006", "standard_charge_dollar": 2972.29, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Medicare A", "plan_name": "100100", "standard_charge_dollar": 2972.29, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Medicare A", "plan_name": "100500", "standard_charge_dollar": 2972.29, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Medicare Part B Only", "plan_name": "100300", "standard_charge_dollar": 2972.29, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Medicare Railroad", "plan_name": "100103", "standard_charge_dollar": 2972.29, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Ms Physicians Care N", "plan_name": "714210", "standard_charge_dollar": 3715.36, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Peoples Hlth Ffs 72126", "plan_name": "500019", "standard_charge_dollar": 2972.29, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Uhc/Secure Horizons", "plan_name": "500449", "standard_charge_dollar": 2972.29, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "United Health Care/", "plan_name": "500292", "standard_charge_dollar": 3358.68, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "United Healthcare", "plan_name": "750104", "standard_charge_dollar": 3358.68, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "United Healthcare Ba", "plan_name": "750090", "standard_charge_dollar": 3358.68, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "United Healthcare Me", "plan_name": "501310", "standard_charge_dollar": 2972.29, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Windsor Mcare Extra", "plan_name": "500778", "standard_charge_dollar": 2972.29, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." } ] } ] }, { "description": "Repair of leg tendon each", "code_information": [ { "code": "27658", "type": "CPT" } ], "standard_charges": [ { "gross_charge": 34298.46, "minimum": 2972.29, "maximum": 29153.69, "setting": "inpatient", "payers_information": [ { "payer_name": "Aarp", "plan_name": "500102", "standard_charge_dollar": 2972.29, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna", "plan_name": "700700", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna", "plan_name": "700700_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Mcare Ffs 6005", "plan_name": "700703", "standard_charge_dollar": 2972.29, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Miscellaneous", "plan_name": "700720", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Miscellaneous", "plan_name": "700720_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Ppo Hmo", "plan_name": "701720", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Ppo Hmo", "plan_name": "701720_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Ambetter 68069", "plan_name": "500516", "standard_charge_dollar": 2972.29, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Ms State Emplo", "plan_name": "401457", "standard_charge_percentage": 0.80, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Ms State Emplo", "plan_name": "401457_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Basic Pl", "plan_name": "400100", "standard_charge_percentage": 0.85, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Basic Pl", "plan_name": "400100_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Federal", "plan_name": "400110", "standard_charge_percentage": 0.85, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Federal", "plan_name": "400110_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Cigna Healthsprings Ffs", "plan_name": "500064", "standard_charge_dollar": 2972.29, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Conseco", "plan_name": "500302", "standard_charge_dollar": 2972.29, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Humana Ffs 61101", "plan_name": "500006", "standard_charge_dollar": 2972.29, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Medicare A", "plan_name": "100100", "standard_charge_dollar": 2972.29, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Medicare A", "plan_name": "100500", "standard_charge_dollar": 2972.29, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Medicare Part B Only", "plan_name": "100300", "standard_charge_dollar": 2972.29, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Medicare Railroad", "plan_name": "100103", "standard_charge_dollar": 2972.29, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Ms Physicians Care N", "plan_name": "714210", "standard_charge_dollar": 3715.36, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Peoples Hlth Ffs 72126", "plan_name": "500019", "standard_charge_dollar": 2972.29, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Uhc/Secure Horizons", "plan_name": "500449", "standard_charge_dollar": 2972.29, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "United Health Care/", "plan_name": "500292", "standard_charge_dollar": 3358.68, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "United Healthcare", "plan_name": "750104", "standard_charge_dollar": 3358.68, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "United Healthcare Ba", "plan_name": "750090", "standard_charge_dollar": 3358.68, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "United Healthcare Me", "plan_name": "501310", "standard_charge_dollar": 2972.29, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Windsor Mcare Extra", "plan_name": "500778", "standard_charge_dollar": 2972.29, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." } ] } ] }, { "description": "Repair of leg tendon each", "code_information": [ { "code": "27659", "type": "CPT" } ], "standard_charges": [ { "gross_charge": 34298.46, "minimum": 6544.15, "maximum": 29153.69, "setting": "inpatient", "payers_information": [ { "payer_name": "Aarp", "plan_name": "500102", "standard_charge_dollar": 6544.15, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna", "plan_name": "700700", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna", "plan_name": "700700_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Mcare Ffs 6005", "plan_name": "700703", "standard_charge_dollar": 6544.15, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Miscellaneous", "plan_name": "700720", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Miscellaneous", "plan_name": "700720_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Ppo Hmo", "plan_name": "701720", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Ppo Hmo", "plan_name": "701720_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Ambetter 68069", "plan_name": "500516", "standard_charge_dollar": 6544.15, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Ms State Emplo", "plan_name": "401457", "standard_charge_percentage": 0.80, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Ms State Emplo", "plan_name": "401457_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Basic Pl", "plan_name": "400100", "standard_charge_percentage": 0.85, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Basic Pl", "plan_name": "400100_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Federal", "plan_name": "400110", "standard_charge_percentage": 0.85, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Federal", "plan_name": "400110_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Cigna Healthsprings Ffs", "plan_name": "500064", "standard_charge_dollar": 6544.15, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Conseco", "plan_name": "500302", "standard_charge_dollar": 6544.15, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Humana Ffs 61101", "plan_name": "500006", "standard_charge_dollar": 6544.15, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Medicare A", "plan_name": "100100", "standard_charge_dollar": 6544.15, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Medicare A", "plan_name": "100500", "standard_charge_dollar": 6544.15, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Medicare Part B Only", "plan_name": "100300", "standard_charge_dollar": 6544.15, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Medicare Railroad", "plan_name": "100103", "standard_charge_dollar": 6544.15, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Ms Physicians Care N", "plan_name": "714210", "standard_charge_dollar": 8180.19, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Peoples Hlth Ffs 72126", "plan_name": "500019", "standard_charge_dollar": 6544.15, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Uhc/Secure Horizons", "plan_name": "500449", "standard_charge_dollar": 6544.15, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "United Health Care/", "plan_name": "500292", "standard_charge_dollar": 7394.89, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "United Healthcare", "plan_name": "750104", "standard_charge_dollar": 7394.89, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "United Healthcare Ba", "plan_name": "750090", "standard_charge_dollar": 7394.89, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "United Healthcare Me", "plan_name": "501310", "standard_charge_dollar": 6544.15, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Windsor Mcare Extra", "plan_name": "500778", "standard_charge_dollar": 6544.15, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." } ] } ] }, { "description": "Repair of leg tendon each", "code_information": [ { "code": "27664", "type": "CPT" } ], "standard_charges": [ { "gross_charge": 34298.46, "minimum": 6544.15, "maximum": 29153.69, "setting": "inpatient", "payers_information": [ { "payer_name": "Aarp", "plan_name": "500102", "standard_charge_dollar": 6544.15, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna", "plan_name": "700700", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna", "plan_name": "700700_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Mcare Ffs 6005", "plan_name": "700703", "standard_charge_dollar": 6544.15, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Miscellaneous", "plan_name": "700720", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Miscellaneous", "plan_name": "700720_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Ppo Hmo", "plan_name": "701720", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Ppo Hmo", "plan_name": "701720_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Ambetter 68069", "plan_name": "500516", "standard_charge_dollar": 6544.15, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Ms State Emplo", "plan_name": "401457", "standard_charge_percentage": 0.80, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Ms State Emplo", "plan_name": "401457_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Basic Pl", "plan_name": "400100", "standard_charge_percentage": 0.85, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Basic Pl", "plan_name": "400100_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Federal", "plan_name": "400110", "standard_charge_percentage": 0.85, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Federal", "plan_name": "400110_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Cigna Healthsprings Ffs", "plan_name": "500064", "standard_charge_dollar": 6544.15, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Conseco", "plan_name": "500302", "standard_charge_dollar": 6544.15, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Humana Ffs 61101", "plan_name": "500006", "standard_charge_dollar": 6544.15, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Medicare A", "plan_name": "100100", "standard_charge_dollar": 6544.15, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Medicare A", "plan_name": "100500", "standard_charge_dollar": 6544.15, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Medicare Part B Only", "plan_name": "100300", "standard_charge_dollar": 6544.15, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Medicare Railroad", "plan_name": "100103", "standard_charge_dollar": 6544.15, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Ms Physicians Care N", "plan_name": "714210", "standard_charge_dollar": 8180.19, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Peoples Hlth Ffs 72126", "plan_name": "500019", "standard_charge_dollar": 6544.15, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Uhc/Secure Horizons", "plan_name": "500449", "standard_charge_dollar": 6544.15, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "United Health Care/", "plan_name": "500292", "standard_charge_dollar": 7394.89, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "United Healthcare", "plan_name": "750104", "standard_charge_dollar": 7394.89, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "United Healthcare Ba", "plan_name": "750090", "standard_charge_dollar": 7394.89, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "United Healthcare Me", "plan_name": "501310", "standard_charge_dollar": 6544.15, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Windsor Mcare Extra", "plan_name": "500778", "standard_charge_dollar": 6544.15, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." } ] } ] }, { "description": "Repair of leg tendon each", "code_information": [ { "code": "27665", "type": "CPT" } ], "standard_charges": [ { "gross_charge": 34298.46, "minimum": 6544.15, "maximum": 29153.69, "setting": "inpatient", "payers_information": [ { "payer_name": "Aarp", "plan_name": "500102", "standard_charge_dollar": 6544.15, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna", "plan_name": "700700", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna", "plan_name": "700700_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Mcare Ffs 6005", "plan_name": "700703", "standard_charge_dollar": 6544.15, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Miscellaneous", "plan_name": "700720", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Miscellaneous", "plan_name": "700720_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Ppo Hmo", "plan_name": "701720", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Ppo Hmo", "plan_name": "701720_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Ambetter 68069", "plan_name": "500516", "standard_charge_dollar": 6544.15, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Ms State Emplo", "plan_name": "401457", "standard_charge_percentage": 0.80, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Ms State Emplo", "plan_name": "401457_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Basic Pl", "plan_name": "400100", "standard_charge_percentage": 0.85, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Basic Pl", "plan_name": "400100_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Federal", "plan_name": "400110", "standard_charge_percentage": 0.85, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Federal", "plan_name": "400110_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Cigna Healthsprings Ffs", "plan_name": "500064", "standard_charge_dollar": 6544.15, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Conseco", "plan_name": "500302", "standard_charge_dollar": 6544.15, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Humana Ffs 61101", "plan_name": "500006", "standard_charge_dollar": 6544.15, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Medicare A", "plan_name": "100100", "standard_charge_dollar": 6544.15, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Medicare A", "plan_name": "100500", "standard_charge_dollar": 6544.15, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Medicare Part B Only", "plan_name": "100300", "standard_charge_dollar": 6544.15, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Medicare Railroad", "plan_name": "100103", "standard_charge_dollar": 6544.15, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Ms Physicians Care N", "plan_name": "714210", "standard_charge_dollar": 8180.19, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Peoples Hlth Ffs 72126", "plan_name": "500019", "standard_charge_dollar": 6544.15, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Uhc/Secure Horizons", "plan_name": "500449", "standard_charge_dollar": 6544.15, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "United Health Care/", "plan_name": "500292", "standard_charge_dollar": 7394.89, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "United Healthcare", "plan_name": "750104", "standard_charge_dollar": 7394.89, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "United Healthcare Ba", "plan_name": "750090", "standard_charge_dollar": 7394.89, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "United Healthcare Me", "plan_name": "501310", "standard_charge_dollar": 6544.15, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Windsor Mcare Extra", "plan_name": "500778", "standard_charge_dollar": 6544.15, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." } ] } ] }, { "description": "Realignment of lower leg", "code_information": [ { "code": "27712", "type": "CPT" } ], "standard_charges": [ { "gross_charge": 41786.89, "minimum": 33429.51, "maximum": 35518.86, "setting": "inpatient", "payers_information": [ { "payer_name": "Aetna", "plan_name": "700700", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna", "plan_name": "700700_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Miscellaneous", "plan_name": "700720", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Miscellaneous", "plan_name": "700720_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Ppo Hmo", "plan_name": "701720", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Ppo Hmo", "plan_name": "701720_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Ms State Emplo", "plan_name": "401457", "standard_charge_percentage": 0.80, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Ms State Emplo", "plan_name": "401457_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Basic Pl", "plan_name": "400100", "standard_charge_percentage": 0.85, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Basic Pl", "plan_name": "400100_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Federal", "plan_name": "400110", "standard_charge_percentage": 0.85, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Federal", "plan_name": "400110_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." } ] } ] }, { "description": "Repair of tibia", "code_information": [ { "code": "27720", "type": "CPT" } ], "standard_charges": [ { "gross_charge": 32336.15, "minimum": 6544.15, "maximum": 27485.73, "setting": "inpatient", "payers_information": [ { "payer_name": "Aarp", "plan_name": "500102", "standard_charge_dollar": 6544.15, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna", "plan_name": "700700", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna", "plan_name": "700700_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Mcare Ffs 6005", "plan_name": "700703", "standard_charge_dollar": 6544.15, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Miscellaneous", "plan_name": "700720", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Miscellaneous", "plan_name": "700720_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Ppo Hmo", "plan_name": "701720", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Ppo Hmo", "plan_name": "701720_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Ambetter 68069", "plan_name": "500516", "standard_charge_dollar": 6544.15, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Ms State Emplo", "plan_name": "401457", "standard_charge_percentage": 0.80, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Ms State Emplo", "plan_name": "401457_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Basic Pl", "plan_name": "400100", "standard_charge_percentage": 0.85, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Basic Pl", "plan_name": "400100_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Federal", "plan_name": "400110", "standard_charge_percentage": 0.85, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Federal", "plan_name": "400110_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Cigna Healthsprings Ffs", "plan_name": "500064", "standard_charge_dollar": 6544.15, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Conseco", "plan_name": "500302", "standard_charge_dollar": 6544.15, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Humana Ffs 61101", "plan_name": "500006", "standard_charge_dollar": 6544.15, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Medicare A", "plan_name": "100100", "standard_charge_dollar": 6544.15, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Medicare A", "plan_name": "100500", "standard_charge_dollar": 6544.15, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Medicare Part B Only", "plan_name": "100300", "standard_charge_dollar": 6544.15, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Medicare Railroad", "plan_name": "100103", "standard_charge_dollar": 6544.15, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Ms Physicians Care N", "plan_name": "714210", "standard_charge_dollar": 8180.19, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Peoples Hlth Ffs 72126", "plan_name": "500019", "standard_charge_dollar": 6544.15, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Uhc/Secure Horizons", "plan_name": "500449", "standard_charge_dollar": 6544.15, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "United Health Care/", "plan_name": "500292", "standard_charge_dollar": 7394.89, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "United Healthcare", "plan_name": "750104", "standard_charge_dollar": 7394.89, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "United Healthcare Ba", "plan_name": "750090", "standard_charge_dollar": 7394.89, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "United Healthcare Me", "plan_name": "501310", "standard_charge_dollar": 6544.15, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Windsor Mcare Extra", "plan_name": "500778", "standard_charge_dollar": 6544.15, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." } ] } ] }, { "description": "Repair/graft of tibia", "code_information": [ { "code": "27722", "type": "CPT" } ], "standard_charges": [ { "gross_charge": 32336.15, "minimum": 6544.15, "maximum": 27485.73, "setting": "inpatient", "payers_information": [ { "payer_name": "Aarp", "plan_name": "500102", "standard_charge_dollar": 6544.15, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna", "plan_name": "700700", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna", "plan_name": "700700_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Mcare Ffs 6005", "plan_name": "700703", "standard_charge_dollar": 6544.15, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Miscellaneous", "plan_name": "700720", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Miscellaneous", "plan_name": "700720_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Ppo Hmo", "plan_name": "701720", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Ppo Hmo", "plan_name": "701720_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Ambetter 68069", "plan_name": "500516", "standard_charge_dollar": 6544.15, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Ms State Emplo", "plan_name": "401457", "standard_charge_percentage": 0.80, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Ms State Emplo", "plan_name": "401457_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Basic Pl", "plan_name": "400100", "standard_charge_percentage": 0.85, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Basic Pl", "plan_name": "400100_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Federal", "plan_name": "400110", "standard_charge_percentage": 0.85, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Federal", "plan_name": "400110_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Cigna Healthsprings Ffs", "plan_name": "500064", "standard_charge_dollar": 6544.15, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Conseco", "plan_name": "500302", "standard_charge_dollar": 6544.15, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Humana Ffs 61101", "plan_name": "500006", "standard_charge_dollar": 6544.15, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Medicare A", "plan_name": "100100", "standard_charge_dollar": 6544.15, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Medicare A", "plan_name": "100500", "standard_charge_dollar": 6544.15, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Medicare Part B Only", "plan_name": "100300", "standard_charge_dollar": 6544.15, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Medicare Railroad", "plan_name": "100103", "standard_charge_dollar": 6544.15, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Ms Physicians Care N", "plan_name": "714210", "standard_charge_dollar": 8180.19, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Peoples Hlth Ffs 72126", "plan_name": "500019", "standard_charge_dollar": 6544.15, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Uhc/Secure Horizons", "plan_name": "500449", "standard_charge_dollar": 6544.15, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "United Health Care/", "plan_name": "500292", "standard_charge_dollar": 7394.89, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "United Healthcare", "plan_name": "750104", "standard_charge_dollar": 7394.89, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "United Healthcare Ba", "plan_name": "750090", "standard_charge_dollar": 7394.89, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "United Healthcare Me", "plan_name": "501310", "standard_charge_dollar": 6544.15, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Windsor Mcare Extra", "plan_name": "500778", "standard_charge_dollar": 6544.15, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." } ] } ] }, { "description": "Repair/graft of tibia", "code_information": [ { "code": "27724", "type": "CPT" } ], "standard_charges": [ { "gross_charge": 32336.15, "minimum": 25868.92, "maximum": 27485.73, "setting": "inpatient", "payers_information": [ { "payer_name": "Aetna", "plan_name": "700700", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna", "plan_name": "700700_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Miscellaneous", "plan_name": "700720", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Miscellaneous", "plan_name": "700720_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Ppo Hmo", "plan_name": "701720", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Ppo Hmo", "plan_name": "701720_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Ms State Emplo", "plan_name": "401457", "standard_charge_percentage": 0.80, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Ms State Emplo", "plan_name": "401457_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Basic Pl", "plan_name": "400100", "standard_charge_percentage": 0.85, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Basic Pl", "plan_name": "400100_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Federal", "plan_name": "400110", "standard_charge_percentage": 0.85, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Federal", "plan_name": "400110_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." } ] } ] }, { "description": "Repair of lower leg", "code_information": [ { "code": "27725", "type": "CPT" } ], "standard_charges": [ { "gross_charge": 32336.15, "minimum": 25868.92, "maximum": 27485.73, "setting": "inpatient", "payers_information": [ { "payer_name": "Aetna", "plan_name": "700700", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna", "plan_name": "700700_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Miscellaneous", "plan_name": "700720", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Miscellaneous", "plan_name": "700720_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Ppo Hmo", "plan_name": "701720", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Ppo Hmo", "plan_name": "701720_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Ms State Emplo", "plan_name": "401457", "standard_charge_percentage": 0.80, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Ms State Emplo", "plan_name": "401457_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Basic Pl", "plan_name": "400100", "standard_charge_percentage": 0.85, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Basic Pl", "plan_name": "400100_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Federal", "plan_name": "400110", "standard_charge_percentage": 0.85, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Federal", "plan_name": "400110_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." } ] } ] }, { "description": "Repair fibula nonunion", "code_information": [ { "code": "27726", "type": "CPT" } ], "standard_charges": [ { "gross_charge": 29102.34, "minimum": 6544.15, "maximum": 24736.99, "setting": "inpatient", "payers_information": [ { "payer_name": "Aarp", "plan_name": "500102", "standard_charge_dollar": 6544.15, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna", "plan_name": "700700", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna", "plan_name": "700700_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Mcare Ffs 6005", "plan_name": "700703", "standard_charge_dollar": 6544.15, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Miscellaneous", "plan_name": "700720", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Miscellaneous", "plan_name": "700720_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Ppo Hmo", "plan_name": "701720", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Ppo Hmo", "plan_name": "701720_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Ambetter 68069", "plan_name": "500516", "standard_charge_dollar": 6544.15, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Ms State Emplo", "plan_name": "401457", "standard_charge_percentage": 0.80, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Ms State Emplo", "plan_name": "401457_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Basic Pl", "plan_name": "400100", "standard_charge_percentage": 0.85, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Basic Pl", "plan_name": "400100_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Federal", "plan_name": "400110", "standard_charge_percentage": 0.85, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Federal", "plan_name": "400110_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Cigna Healthsprings Ffs", "plan_name": "500064", "standard_charge_dollar": 6544.15, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Conseco", "plan_name": "500302", "standard_charge_dollar": 6544.15, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Humana Ffs 61101", "plan_name": "500006", "standard_charge_dollar": 6544.15, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Medicare A", "plan_name": "100100", "standard_charge_dollar": 6544.15, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Medicare A", "plan_name": "100500", "standard_charge_dollar": 6544.15, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Medicare Part B Only", "plan_name": "100300", "standard_charge_dollar": 6544.15, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Medicare Railroad", "plan_name": "100103", "standard_charge_dollar": 6544.15, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Ms Physicians Care N", "plan_name": "714210", "standard_charge_dollar": 8180.19, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Peoples Hlth Ffs 72126", "plan_name": "500019", "standard_charge_dollar": 6544.15, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Uhc/Secure Horizons", "plan_name": "500449", "standard_charge_dollar": 6544.15, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "United Health Care/", "plan_name": "500292", "standard_charge_dollar": 7394.89, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "United Healthcare", "plan_name": "750104", "standard_charge_dollar": 7394.89, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "United Healthcare Ba", "plan_name": "750090", "standard_charge_dollar": 7394.89, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "United Healthcare Me", "plan_name": "501310", "standard_charge_dollar": 6544.15, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Windsor Mcare Extra", "plan_name": "500778", "standard_charge_dollar": 6544.15, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." } ] } ] }, { "description": "Treatment of tibia fracture", "code_information": [ { "code": "27752", "type": "CPT" } ], "standard_charges": [ { "gross_charge": 13655.35, "minimum": 1466.09, "maximum": 11607.05, "setting": "inpatient", "payers_information": [ { "payer_name": "Aarp", "plan_name": "500102", "standard_charge_dollar": 1466.09, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna", "plan_name": "700700", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna", "plan_name": "700700_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Mcare Ffs 6005", "plan_name": "700703", "standard_charge_dollar": 1466.09, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Miscellaneous", "plan_name": "700720", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Miscellaneous", "plan_name": "700720_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Ppo Hmo", "plan_name": "701720", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Ppo Hmo", "plan_name": "701720_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Ambetter 68069", "plan_name": "500516", "standard_charge_dollar": 1466.09, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Ms State Emplo", "plan_name": "401457", "standard_charge_percentage": 0.80, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Ms State Emplo", "plan_name": "401457_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Basic Pl", "plan_name": "400100", "standard_charge_percentage": 0.85, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Basic Pl", "plan_name": "400100_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Federal", "plan_name": "400110", "standard_charge_percentage": 0.85, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Federal", "plan_name": "400110_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Cigna Healthsprings Ffs", "plan_name": "500064", "standard_charge_dollar": 1466.09, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Conseco", "plan_name": "500302", "standard_charge_dollar": 1466.09, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Humana Ffs 61101", "plan_name": "500006", "standard_charge_dollar": 1466.09, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Medicare A", "plan_name": "100100", "standard_charge_dollar": 1466.09, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Medicare A", "plan_name": "100500", "standard_charge_dollar": 1466.09, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Medicare Part B Only", "plan_name": "100300", "standard_charge_dollar": 1466.09, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Medicare Railroad", "plan_name": "100103", "standard_charge_dollar": 1466.09, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Ms Physicians Care N", "plan_name": "714210", "standard_charge_dollar": 1832.61, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Peoples Hlth Ffs 72126", "plan_name": "500019", "standard_charge_dollar": 1466.09, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Uhc/Secure Horizons", "plan_name": "500449", "standard_charge_dollar": 1466.09, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "United Health Care/", "plan_name": "500292", "standard_charge_dollar": 1656.68, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "United Healthcare", "plan_name": "750104", "standard_charge_dollar": 1656.68, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "United Healthcare Ba", "plan_name": "750090", "standard_charge_dollar": 1656.68, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "United Healthcare Me", "plan_name": "501310", "standard_charge_dollar": 1466.09, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Windsor Mcare Extra", "plan_name": "500778", "standard_charge_dollar": 1466.09, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." } ] } ] }, { "description": "Treatment of tibia fracture", "code_information": [ { "code": "27758", "type": "CPT" } ], "standard_charges": [ { "gross_charge": 30719.25, "minimum": 11786.90, "maximum": 26111.36, "setting": "inpatient", "payers_information": [ { "payer_name": "Aarp", "plan_name": "500102", "standard_charge_dollar": 11786.90, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna", "plan_name": "700700", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna", "plan_name": "700700_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Mcare Ffs 6005", "plan_name": "700703", "standard_charge_dollar": 11786.90, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Miscellaneous", "plan_name": "700720", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Miscellaneous", "plan_name": "700720_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Ppo Hmo", "plan_name": "701720", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Ppo Hmo", "plan_name": "701720_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Ambetter 68069", "plan_name": "500516", "standard_charge_dollar": 11786.90, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Ms State Emplo", "plan_name": "401457", "standard_charge_percentage": 0.80, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Ms State Emplo", "plan_name": "401457_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Basic Pl", "plan_name": "400100", "standard_charge_percentage": 0.85, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Basic Pl", "plan_name": "400100_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Federal", "plan_name": "400110", "standard_charge_percentage": 0.85, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Federal", "plan_name": "400110_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Cigna Healthsprings Ffs", "plan_name": "500064", "standard_charge_dollar": 11786.90, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Conseco", "plan_name": "500302", "standard_charge_dollar": 11786.90, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Humana Ffs 61101", "plan_name": "500006", "standard_charge_dollar": 11786.90, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Medicare A", "plan_name": "100100", "standard_charge_dollar": 11786.90, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Medicare A", "plan_name": "100500", "standard_charge_dollar": 11786.90, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Medicare Part B Only", "plan_name": "100300", "standard_charge_dollar": 11786.90, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Medicare Railroad", "plan_name": "100103", "standard_charge_dollar": 11786.90, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Ms Physicians Care N", "plan_name": "714210", "standard_charge_dollar": 14733.62, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Peoples Hlth Ffs 72126", "plan_name": "500019", "standard_charge_dollar": 11786.90, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Uhc/Secure Horizons", "plan_name": "500449", "standard_charge_dollar": 11786.90, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "United Health Care/", "plan_name": "500292", "standard_charge_dollar": 13319.19, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "United Healthcare", "plan_name": "750104", "standard_charge_dollar": 13319.19, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "United Healthcare Ba", "plan_name": "750090", "standard_charge_dollar": 13319.19, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "United Healthcare Me", "plan_name": "501310", "standard_charge_dollar": 11786.90, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Windsor Mcare Extra", "plan_name": "500778", "standard_charge_dollar": 11786.90, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." } ] } ] }, { "description": "Optx medial ankle fx", "code_information": [ { "code": "27766", "type": "CPT" } ], "standard_charges": [ { "gross_charge": 42680.12, "minimum": 6544.15, "maximum": 36278.10, "setting": "inpatient", "payers_information": [ { "payer_name": "Aarp", "plan_name": "500102", "standard_charge_dollar": 6544.15, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna", "plan_name": "700700", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna", "plan_name": "700700_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Mcare Ffs 6005", "plan_name": "700703", "standard_charge_dollar": 6544.15, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Miscellaneous", "plan_name": "700720", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Miscellaneous", "plan_name": "700720_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Ppo Hmo", "plan_name": "701720", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Ppo Hmo", "plan_name": "701720_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Ambetter 68069", "plan_name": "500516", "standard_charge_dollar": 6544.15, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Ms State Emplo", "plan_name": "401457", "standard_charge_percentage": 0.80, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Ms State Emplo", "plan_name": "401457_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Basic Pl", "plan_name": "400100", "standard_charge_percentage": 0.85, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Basic Pl", "plan_name": "400100_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Federal", "plan_name": "400110", "standard_charge_percentage": 0.85, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Federal", "plan_name": "400110_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Cigna Healthsprings Ffs", "plan_name": "500064", "standard_charge_dollar": 6544.15, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Conseco", "plan_name": "500302", "standard_charge_dollar": 6544.15, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Humana Ffs 61101", "plan_name": "500006", "standard_charge_dollar": 6544.15, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Medicare A", "plan_name": "100100", "standard_charge_dollar": 6544.15, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Medicare A", "plan_name": "100500", "standard_charge_dollar": 6544.15, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Medicare Part B Only", "plan_name": "100300", "standard_charge_dollar": 6544.15, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Medicare Railroad", "plan_name": "100103", "standard_charge_dollar": 6544.15, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Ms Physicians Care N", "plan_name": "714210", "standard_charge_dollar": 8180.19, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Peoples Hlth Ffs 72126", "plan_name": "500019", "standard_charge_dollar": 6544.15, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Uhc/Secure Horizons", "plan_name": "500449", "standard_charge_dollar": 6544.15, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "United Health Care/", "plan_name": "500292", "standard_charge_dollar": 7394.89, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "United Healthcare", "plan_name": "750104", "standard_charge_dollar": 7394.89, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "United Healthcare Ba", "plan_name": "750090", "standard_charge_dollar": 7394.89, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "United Healthcare Me", "plan_name": "501310", "standard_charge_dollar": 6544.15, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Windsor Mcare Extra", "plan_name": "500778", "standard_charge_dollar": 6544.15, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." } ] } ] }, { "description": "Optx post ankle fx", "code_information": [ { "code": "27769", "type": "CPT" } ], "standard_charges": [ { "gross_charge": 42680.12, "minimum": 6544.15, "maximum": 36278.10, "setting": "inpatient", "payers_information": [ { "payer_name": "Aarp", "plan_name": "500102", "standard_charge_dollar": 6544.15, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna", "plan_name": "700700", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna", "plan_name": "700700_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Mcare Ffs 6005", "plan_name": "700703", "standard_charge_dollar": 6544.15, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Miscellaneous", "plan_name": "700720", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Miscellaneous", "plan_name": "700720_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Ppo Hmo", "plan_name": "701720", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Ppo Hmo", "plan_name": "701720_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Ambetter 68069", "plan_name": "500516", "standard_charge_dollar": 6544.15, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Ms State Emplo", "plan_name": "401457", "standard_charge_percentage": 0.80, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Ms State Emplo", "plan_name": "401457_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Basic Pl", "plan_name": "400100", "standard_charge_percentage": 0.85, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Basic Pl", "plan_name": "400100_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Federal", "plan_name": "400110", "standard_charge_percentage": 0.85, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Federal", "plan_name": "400110_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Cigna Healthsprings Ffs", "plan_name": "500064", "standard_charge_dollar": 6544.15, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Conseco", "plan_name": "500302", "standard_charge_dollar": 6544.15, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Humana Ffs 61101", "plan_name": "500006", "standard_charge_dollar": 6544.15, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Medicare A", "plan_name": "100100", "standard_charge_dollar": 6544.15, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Medicare A", "plan_name": "100500", "standard_charge_dollar": 6544.15, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Medicare Part B Only", "plan_name": "100300", "standard_charge_dollar": 6544.15, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Medicare Railroad", "plan_name": "100103", "standard_charge_dollar": 6544.15, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Ms Physicians Care N", "plan_name": "714210", "standard_charge_dollar": 8180.19, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Peoples Hlth Ffs 72126", "plan_name": "500019", "standard_charge_dollar": 6544.15, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Uhc/Secure Horizons", "plan_name": "500449", "standard_charge_dollar": 6544.15, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "United Health Care/", "plan_name": "500292", "standard_charge_dollar": 7394.89, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "United Healthcare", "plan_name": "750104", "standard_charge_dollar": 7394.89, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "United Healthcare Ba", "plan_name": "750090", "standard_charge_dollar": 7394.89, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "United Healthcare Me", "plan_name": "501310", "standard_charge_dollar": 6544.15, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Windsor Mcare Extra", "plan_name": "500778", "standard_charge_dollar": 6544.15, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." } ] } ] }, { "description": "Treatment of fibula fracture", "code_information": [ { "code": "27784", "type": "CPT" } ], "standard_charges": [ { "gross_charge": 29102.34, "minimum": 6544.15, "maximum": 24736.99, "setting": "inpatient", "payers_information": [ { "payer_name": "Aarp", "plan_name": "500102", "standard_charge_dollar": 6544.15, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna", "plan_name": "700700", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna", "plan_name": "700700_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Mcare Ffs 6005", "plan_name": "700703", "standard_charge_dollar": 6544.15, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Miscellaneous", "plan_name": "700720", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Miscellaneous", "plan_name": "700720_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Ppo Hmo", "plan_name": "701720", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Ppo Hmo", "plan_name": "701720_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Ambetter 68069", "plan_name": "500516", "standard_charge_dollar": 6544.15, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Ms State Emplo", "plan_name": "401457", "standard_charge_percentage": 0.80, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Ms State Emplo", "plan_name": "401457_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Basic Pl", "plan_name": "400100", "standard_charge_percentage": 0.85, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Basic Pl", "plan_name": "400100_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Federal", "plan_name": "400110", "standard_charge_percentage": 0.85, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Federal", "plan_name": "400110_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Cigna Healthsprings Ffs", "plan_name": "500064", "standard_charge_dollar": 6544.15, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Conseco", "plan_name": "500302", "standard_charge_dollar": 6544.15, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Humana Ffs 61101", "plan_name": "500006", "standard_charge_dollar": 6544.15, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Medicare A", "plan_name": "100100", "standard_charge_dollar": 6544.15, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Medicare A", "plan_name": "100500", "standard_charge_dollar": 6544.15, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Medicare Part B Only", "plan_name": "100300", "standard_charge_dollar": 6544.15, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Medicare Railroad", "plan_name": "100103", "standard_charge_dollar": 6544.15, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Ms Physicians Care N", "plan_name": "714210", "standard_charge_dollar": 8180.19, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Peoples Hlth Ffs 72126", "plan_name": "500019", "standard_charge_dollar": 6544.15, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Uhc/Secure Horizons", "plan_name": "500449", "standard_charge_dollar": 6544.15, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "United Health Care/", "plan_name": "500292", "standard_charge_dollar": 7394.89, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "United Healthcare", "plan_name": "750104", "standard_charge_dollar": 7394.89, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "United Healthcare Ba", "plan_name": "750090", "standard_charge_dollar": 7394.89, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "United Healthcare Me", "plan_name": "501310", "standard_charge_dollar": 6544.15, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Windsor Mcare Extra", "plan_name": "500778", "standard_charge_dollar": 6544.15, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." } ] } ] }, { "description": "Hc open tx distal fibular fracture lat malleolus", "code_information": [ { "code": "27792", "type": "CPT" } ], "standard_charges": [ { "gross_charge": 14511.00, "minimum": 6544.15, "maximum": 12334.35, "setting": "both", "payers_information": [ { "payer_name": "Aarp", 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"standard_charge_dollar": 6544.15, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Miscellaneous", "plan_name": "700720", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Miscellaneous", "plan_name": "700720_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Ppo Hmo", "plan_name": "701720", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Ppo Hmo", "plan_name": "701720_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Ambetter 68069", "plan_name": "500516", "standard_charge_dollar": 6544.15, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Ms State Emplo", "plan_name": "401457", "standard_charge_percentage": 0.80, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Ms State Emplo", "plan_name": "401457_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Basic Pl", "plan_name": "400100", "standard_charge_percentage": 0.85, "count": "0", "methodology": 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"0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "United Health Care/", "plan_name": "500292", "standard_charge_dollar": 7394.89, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "United Healthcare", "plan_name": "750104", "standard_charge_dollar": 7394.89, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "United Healthcare Ba", "plan_name": "750090", "standard_charge_dollar": 7394.89, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "United Healthcare Me", "plan_name": "501310", "standard_charge_dollar": 6544.15, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Windsor Mcare Extra", "plan_name": "500778", "standard_charge_dollar": 6544.15, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." } ] } ] }, { "description": "Treatment of ankle fracture", "code_information": [ { "code": "27792", "type": "CPT" } ], "standard_charges": [ { "gross_charge": 14511.00, "minimum": 6544.15, "maximum": 12334.35, "setting": "outpatient", "payers_information": [ { "payer_name": "Aarp", "plan_name": "500102", "standard_charge_dollar": 6544.15, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna", "plan_name": "700700", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna", "plan_name": "700700_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Mcare Ffs 6005", "plan_name": "700703", "standard_charge_dollar": 6544.15, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Miscellaneous", "plan_name": "700720", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Miscellaneous", "plan_name": "700720_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Ppo Hmo", "plan_name": "701720", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Ppo Hmo", "plan_name": "701720_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Ambetter 68069", "plan_name": "500516", "standard_charge_dollar": 6544.15, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Ms State Emplo", "plan_name": "401457", "standard_charge_percentage": 0.80, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Ms State Emplo", "plan_name": "401457_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Basic Pl", "plan_name": "400100", "standard_charge_percentage": 0.85, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Basic Pl", "plan_name": "400100_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Federal", "plan_name": "400110", "standard_charge_percentage": 0.85, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Federal", "plan_name": "400110_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Cigna Healthsprings Ffs", "plan_name": "500064", "standard_charge_dollar": 6544.15, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Conseco", "plan_name": "500302", "standard_charge_dollar": 6544.15, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Humana Ffs 61101", "plan_name": "500006", "standard_charge_dollar": 6544.15, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Medicare A", "plan_name": "100100", "standard_charge_dollar": 6544.15, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Medicare A", "plan_name": "100500", "standard_charge_dollar": 6544.15, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Medicare Part B Only", "plan_name": "100300", "standard_charge_dollar": 6544.15, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Medicare Railroad", "plan_name": "100103", "standard_charge_dollar": 6544.15, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Ms Physicians Care N", "plan_name": "714210", "standard_charge_dollar": 8180.19, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Peoples Hlth Ffs 72126", "plan_name": "500019", "standard_charge_dollar": 6544.15, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Uhc/Secure Horizons", "plan_name": "500449", "standard_charge_dollar": 6544.15, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "United Health Care/", "plan_name": "500292", "standard_charge_dollar": 7394.89, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "United Healthcare", "plan_name": "750104", "standard_charge_dollar": 7394.89, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "United Healthcare Ba", "plan_name": "750090", "standard_charge_dollar": 7394.89, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "United Healthcare Me", "plan_name": "501310", "standard_charge_dollar": 6544.15, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Windsor Mcare Extra", "plan_name": "500778", "standard_charge_dollar": 6544.15, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." } ] } ] }, { "description": "Treatment of ankle fracture", "code_information": [ { "code": "27814", "type": "CPT" } ], "standard_charges": [ { "gross_charge": 42680.12, "minimum": 6544.15, "maximum": 36278.10, "setting": "inpatient", "payers_information": [ { "payer_name": "Aarp", "plan_name": "500102", "standard_charge_dollar": 6544.15, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna", "plan_name": "700700", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna", "plan_name": "700700_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Mcare Ffs 6005", "plan_name": "700703", "standard_charge_dollar": 6544.15, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Miscellaneous", "plan_name": "700720", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Miscellaneous", "plan_name": "700720_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Ppo Hmo", "plan_name": "701720", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Ppo Hmo", "plan_name": "701720_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Ambetter 68069", "plan_name": "500516", "standard_charge_dollar": 6544.15, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Ms State Emplo", "plan_name": "401457", "standard_charge_percentage": 0.80, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Ms State Emplo", "plan_name": "401457_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Basic Pl", "plan_name": "400100", "standard_charge_percentage": 0.85, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Basic Pl", "plan_name": "400100_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Federal", "plan_name": "400110", "standard_charge_percentage": 0.85, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Federal", "plan_name": "400110_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Cigna Healthsprings Ffs", "plan_name": "500064", "standard_charge_dollar": 6544.15, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Conseco", "plan_name": "500302", "standard_charge_dollar": 6544.15, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Humana Ffs 61101", "plan_name": "500006", "standard_charge_dollar": 6544.15, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Medicare A", "plan_name": "100100", "standard_charge_dollar": 6544.15, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Medicare A", "plan_name": "100500", "standard_charge_dollar": 6544.15, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Medicare Part B Only", "plan_name": "100300", "standard_charge_dollar": 6544.15, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Medicare Railroad", "plan_name": "100103", "standard_charge_dollar": 6544.15, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Ms Physicians Care N", "plan_name": "714210", "standard_charge_dollar": 8180.19, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Peoples Hlth Ffs 72126", "plan_name": "500019", "standard_charge_dollar": 6544.15, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Uhc/Secure Horizons", "plan_name": "500449", "standard_charge_dollar": 6544.15, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "United Health Care/", "plan_name": "500292", "standard_charge_dollar": 7394.89, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "United Healthcare", "plan_name": "750104", "standard_charge_dollar": 7394.89, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "United Healthcare Ba", "plan_name": "750090", "standard_charge_dollar": 7394.89, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "United Healthcare Me", "plan_name": "501310", "standard_charge_dollar": 6544.15, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Windsor Mcare Extra", "plan_name": "500778", "standard_charge_dollar": 6544.15, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." } ] } ] }, { "description": "Treatment of ankle fracture", "code_information": [ { "code": "27822", "type": "CPT" } ], "standard_charges": [ { "gross_charge": 42680.12, "minimum": 6544.15, "maximum": 36278.10, "setting": "inpatient", "payers_information": [ { "payer_name": "Aarp", "plan_name": "500102", "standard_charge_dollar": 6544.15, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna", "plan_name": "700700", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna", "plan_name": "700700_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Mcare Ffs 6005", "plan_name": "700703", "standard_charge_dollar": 6544.15, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Miscellaneous", "plan_name": "700720", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Miscellaneous", "plan_name": "700720_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Ppo Hmo", "plan_name": "701720", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Ppo Hmo", "plan_name": "701720_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Ambetter 68069", "plan_name": "500516", "standard_charge_dollar": 6544.15, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Ms State Emplo", "plan_name": "401457", "standard_charge_percentage": 0.80, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Ms State Emplo", "plan_name": "401457_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Basic Pl", "plan_name": "400100", "standard_charge_percentage": 0.85, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Basic Pl", "plan_name": "400100_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Federal", "plan_name": "400110", "standard_charge_percentage": 0.85, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Federal", "plan_name": "400110_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Cigna Healthsprings Ffs", "plan_name": "500064", "standard_charge_dollar": 6544.15, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Conseco", "plan_name": "500302", "standard_charge_dollar": 6544.15, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Humana Ffs 61101", "plan_name": "500006", "standard_charge_dollar": 6544.15, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Medicare A", "plan_name": "100100", "standard_charge_dollar": 6544.15, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Medicare A", "plan_name": "100500", "standard_charge_dollar": 6544.15, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Medicare Part B Only", "plan_name": "100300", "standard_charge_dollar": 6544.15, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Medicare Railroad", "plan_name": "100103", "standard_charge_dollar": 6544.15, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Ms Physicians Care N", "plan_name": "714210", "standard_charge_dollar": 8180.19, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Peoples Hlth Ffs 72126", "plan_name": "500019", "standard_charge_dollar": 6544.15, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Uhc/Secure Horizons", "plan_name": "500449", "standard_charge_dollar": 6544.15, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "United Health Care/", "plan_name": "500292", "standard_charge_dollar": 7394.89, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "United Healthcare", "plan_name": "750104", "standard_charge_dollar": 7394.89, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "United Healthcare Ba", "plan_name": "750090", "standard_charge_dollar": 7394.89, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "United Healthcare Me", "plan_name": "501310", "standard_charge_dollar": 6544.15, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Windsor Mcare Extra", "plan_name": "500778", "standard_charge_dollar": 6544.15, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." } ] } ] }, { "description": "Treatment of ankle fracture", "code_information": [ { "code": "27823", "type": "CPT" } ], "standard_charges": [ { "gross_charge": 42680.12, "minimum": 6544.15, "maximum": 36278.10, "setting": "inpatient", "payers_information": [ { "payer_name": "Aarp", "plan_name": "500102", "standard_charge_dollar": 6544.15, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna", "plan_name": "700700", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna", "plan_name": "700700_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Mcare Ffs 6005", "plan_name": "700703", "standard_charge_dollar": 6544.15, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Miscellaneous", "plan_name": "700720", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Miscellaneous", "plan_name": "700720_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Ppo Hmo", "plan_name": "701720", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Ppo Hmo", "plan_name": "701720_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Ambetter 68069", "plan_name": "500516", "standard_charge_dollar": 6544.15, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Ms State Emplo", "plan_name": "401457", "standard_charge_percentage": 0.80, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Ms State Emplo", "plan_name": "401457_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Basic Pl", "plan_name": "400100", "standard_charge_percentage": 0.85, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Basic Pl", "plan_name": "400100_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Federal", "plan_name": "400110", "standard_charge_percentage": 0.85, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Federal", "plan_name": "400110_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Cigna Healthsprings Ffs", "plan_name": "500064", "standard_charge_dollar": 6544.15, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Conseco", "plan_name": "500302", "standard_charge_dollar": 6544.15, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Humana Ffs 61101", "plan_name": "500006", "standard_charge_dollar": 6544.15, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Medicare A", "plan_name": "100100", "standard_charge_dollar": 6544.15, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Medicare A", "plan_name": "100500", "standard_charge_dollar": 6544.15, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Medicare Part B Only", "plan_name": "100300", "standard_charge_dollar": 6544.15, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Medicare Railroad", "plan_name": "100103", "standard_charge_dollar": 6544.15, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Ms Physicians Care N", "plan_name": "714210", "standard_charge_dollar": 8180.19, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Peoples Hlth Ffs 72126", "plan_name": "500019", "standard_charge_dollar": 6544.15, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Uhc/Secure Horizons", "plan_name": "500449", "standard_charge_dollar": 6544.15, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "United Health Care/", "plan_name": "500292", "standard_charge_dollar": 7394.89, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "United Healthcare", "plan_name": "750104", "standard_charge_dollar": 7394.89, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "United Healthcare Ba", "plan_name": "750090", "standard_charge_dollar": 7394.89, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "United Healthcare Me", "plan_name": "501310", "standard_charge_dollar": 6544.15, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Windsor Mcare Extra", "plan_name": "500778", "standard_charge_dollar": 6544.15, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." } ] } ] }, { "description": "Treat lower leg fracture", "code_information": [ { "code": "27825", "type": "CPT" } ], "standard_charges": [ { "gross_charge": 13655.35, "minimum": 1466.09, "maximum": 11607.05, "setting": "inpatient", "payers_information": [ { "payer_name": "Aarp", "plan_name": "500102", "standard_charge_dollar": 1466.09, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna", "plan_name": "700700", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna", "plan_name": "700700_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Mcare Ffs 6005", "plan_name": "700703", "standard_charge_dollar": 1466.09, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Miscellaneous", "plan_name": "700720", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Miscellaneous", "plan_name": "700720_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Ppo Hmo", "plan_name": "701720", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Ppo Hmo", "plan_name": "701720_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Ambetter 68069", "plan_name": "500516", "standard_charge_dollar": 1466.09, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Ms State Emplo", "plan_name": "401457", "standard_charge_percentage": 0.80, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Ms State Emplo", "plan_name": "401457_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Basic Pl", "plan_name": "400100", "standard_charge_percentage": 0.85, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Basic Pl", "plan_name": "400100_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Federal", "plan_name": "400110", "standard_charge_percentage": 0.85, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Federal", "plan_name": "400110_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Cigna Healthsprings Ffs", "plan_name": "500064", "standard_charge_dollar": 1466.09, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Conseco", "plan_name": "500302", "standard_charge_dollar": 1466.09, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Humana Ffs 61101", "plan_name": "500006", "standard_charge_dollar": 1466.09, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Medicare A", "plan_name": "100100", "standard_charge_dollar": 1466.09, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Medicare A", "plan_name": "100500", "standard_charge_dollar": 1466.09, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Medicare Part B Only", "plan_name": "100300", "standard_charge_dollar": 1466.09, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Medicare Railroad", "plan_name": "100103", "standard_charge_dollar": 1466.09, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Ms Physicians Care N", "plan_name": "714210", "standard_charge_dollar": 1832.61, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Peoples Hlth Ffs 72126", "plan_name": "500019", "standard_charge_dollar": 1466.09, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Uhc/Secure Horizons", "plan_name": "500449", "standard_charge_dollar": 1466.09, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "United Health Care/", "plan_name": "500292", "standard_charge_dollar": 1656.68, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "United Healthcare", "plan_name": "750104", "standard_charge_dollar": 1656.68, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "United Healthcare Ba", "plan_name": "750090", "standard_charge_dollar": 1656.68, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "United Healthcare Me", "plan_name": "501310", "standard_charge_dollar": 1466.09, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Windsor Mcare Extra", "plan_name": "500778", "standard_charge_dollar": 1466.09, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." } ] } ] }, { "description": "Treat lower leg fracture", "code_information": [ { "code": "27826", "type": "CPT" } ], "standard_charges": [ { "gross_charge": 29102.34, "minimum": 6544.15, "maximum": 24736.99, "setting": "inpatient", "payers_information": [ { "payer_name": "Aarp", "plan_name": "500102", "standard_charge_dollar": 6544.15, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna", "plan_name": "700700", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna", "plan_name": "700700_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Mcare Ffs 6005", "plan_name": "700703", "standard_charge_dollar": 6544.15, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Miscellaneous", "plan_name": "700720", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Miscellaneous", "plan_name": "700720_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Ppo Hmo", "plan_name": "701720", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Ppo Hmo", "plan_name": "701720_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Ambetter 68069", "plan_name": "500516", "standard_charge_dollar": 6544.15, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Ms State Emplo", "plan_name": "401457", "standard_charge_percentage": 0.80, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Ms State Emplo", "plan_name": "401457_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Basic Pl", "plan_name": "400100", "standard_charge_percentage": 0.85, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Basic Pl", "plan_name": "400100_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Federal", "plan_name": "400110", "standard_charge_percentage": 0.85, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Federal", "plan_name": "400110_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Cigna Healthsprings Ffs", "plan_name": "500064", "standard_charge_dollar": 6544.15, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Conseco", "plan_name": "500302", "standard_charge_dollar": 6544.15, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Humana Ffs 61101", "plan_name": "500006", "standard_charge_dollar": 6544.15, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Medicare A", "plan_name": "100100", "standard_charge_dollar": 6544.15, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Medicare A", "plan_name": "100500", "standard_charge_dollar": 6544.15, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Medicare Part B Only", "plan_name": "100300", "standard_charge_dollar": 6544.15, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Medicare Railroad", "plan_name": "100103", "standard_charge_dollar": 6544.15, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Ms Physicians Care N", "plan_name": "714210", "standard_charge_dollar": 8180.19, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Peoples Hlth Ffs 72126", "plan_name": "500019", "standard_charge_dollar": 6544.15, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Uhc/Secure Horizons", "plan_name": "500449", "standard_charge_dollar": 6544.15, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "United Health Care/", "plan_name": "500292", "standard_charge_dollar": 7394.89, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "United Healthcare", "plan_name": "750104", "standard_charge_dollar": 7394.89, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "United Healthcare Ba", "plan_name": "750090", "standard_charge_dollar": 7394.89, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "United Healthcare Me", "plan_name": "501310", "standard_charge_dollar": 6544.15, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Windsor Mcare Extra", "plan_name": "500778", "standard_charge_dollar": 6544.15, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." } ] } ] }, { "description": "Treat lower leg fracture", "code_information": [ { "code": "27827", "type": "CPT" } ], "standard_charges": [ { "gross_charge": 32336.15, "minimum": 11786.90, "maximum": 27485.73, "setting": "inpatient", "payers_information": [ { "payer_name": "Aarp", "plan_name": "500102", "standard_charge_dollar": 11786.90, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna", "plan_name": "700700", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna", "plan_name": "700700_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Mcare Ffs 6005", "plan_name": "700703", "standard_charge_dollar": 11786.90, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Miscellaneous", "plan_name": "700720", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Miscellaneous", "plan_name": "700720_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Ppo Hmo", "plan_name": "701720", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Ppo Hmo", "plan_name": "701720_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Ambetter 68069", "plan_name": "500516", "standard_charge_dollar": 11786.90, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Ms State Emplo", "plan_name": "401457", "standard_charge_percentage": 0.80, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Ms State Emplo", "plan_name": "401457_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Basic Pl", "plan_name": "400100", "standard_charge_percentage": 0.85, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Basic Pl", "plan_name": "400100_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Federal", "plan_name": "400110", "standard_charge_percentage": 0.85, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Federal", "plan_name": "400110_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Cigna Healthsprings Ffs", "plan_name": "500064", "standard_charge_dollar": 11786.90, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Conseco", "plan_name": "500302", "standard_charge_dollar": 11786.90, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Humana Ffs 61101", "plan_name": "500006", "standard_charge_dollar": 11786.90, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Medicare A", "plan_name": "100100", "standard_charge_dollar": 11786.90, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Medicare A", "plan_name": "100500", "standard_charge_dollar": 11786.90, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Medicare Part B Only", "plan_name": "100300", "standard_charge_dollar": 11786.90, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Medicare Railroad", "plan_name": "100103", "standard_charge_dollar": 11786.90, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Ms Physicians Care N", "plan_name": "714210", "standard_charge_dollar": 14733.62, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Peoples Hlth Ffs 72126", "plan_name": "500019", "standard_charge_dollar": 11786.90, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Uhc/Secure Horizons", "plan_name": "500449", "standard_charge_dollar": 11786.90, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "United Health Care/", "plan_name": "500292", "standard_charge_dollar": 13319.19, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "United Healthcare", "plan_name": "750104", "standard_charge_dollar": 13319.19, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "United Healthcare Ba", "plan_name": "750090", "standard_charge_dollar": 13319.19, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "United Healthcare Me", "plan_name": "501310", "standard_charge_dollar": 11786.90, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Windsor Mcare Extra", "plan_name": "500778", "standard_charge_dollar": 11786.90, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." } ] } ] }, { "description": "Treat lower leg fracture", "code_information": [ { "code": "27828", "type": "CPT" } ], "standard_charges": [ { "gross_charge": 30719.25, "minimum": 11786.90, "maximum": 26111.36, "setting": "inpatient", "payers_information": [ { "payer_name": "Aarp", "plan_name": "500102", "standard_charge_dollar": 11786.90, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna", "plan_name": "700700", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna", "plan_name": "700700_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Mcare Ffs 6005", "plan_name": "700703", "standard_charge_dollar": 11786.90, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Miscellaneous", "plan_name": "700720", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Miscellaneous", "plan_name": "700720_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Ppo Hmo", "plan_name": "701720", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Ppo Hmo", "plan_name": "701720_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Ambetter 68069", "plan_name": "500516", "standard_charge_dollar": 11786.90, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Ms State Emplo", "plan_name": "401457", "standard_charge_percentage": 0.80, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Ms State Emplo", "plan_name": "401457_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Basic Pl", "plan_name": "400100", "standard_charge_percentage": 0.85, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Basic Pl", "plan_name": "400100_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Federal", "plan_name": "400110", "standard_charge_percentage": 0.85, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Federal", "plan_name": "400110_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Cigna Healthsprings Ffs", "plan_name": "500064", "standard_charge_dollar": 11786.90, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Conseco", "plan_name": "500302", "standard_charge_dollar": 11786.90, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Humana Ffs 61101", "plan_name": "500006", "standard_charge_dollar": 11786.90, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Medicare A", "plan_name": "100100", "standard_charge_dollar": 11786.90, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Medicare A", "plan_name": "100500", "standard_charge_dollar": 11786.90, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Medicare Part B Only", "plan_name": "100300", "standard_charge_dollar": 11786.90, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Medicare Railroad", "plan_name": "100103", "standard_charge_dollar": 11786.90, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Ms Physicians Care N", "plan_name": "714210", "standard_charge_dollar": 14733.62, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Peoples Hlth Ffs 72126", "plan_name": "500019", "standard_charge_dollar": 11786.90, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Uhc/Secure Horizons", "plan_name": "500449", "standard_charge_dollar": 11786.90, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "United Health Care/", "plan_name": "500292", "standard_charge_dollar": 13319.19, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "United Healthcare", "plan_name": "750104", "standard_charge_dollar": 13319.19, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "United Healthcare Ba", "plan_name": "750090", "standard_charge_dollar": 13319.19, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "United Healthcare Me", "plan_name": "501310", "standard_charge_dollar": 11786.90, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Windsor Mcare Extra", "plan_name": "500778", "standard_charge_dollar": 11786.90, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." } ] } ] }, { "description": "Treat lower leg joint", "code_information": [ { "code": "27829", "type": "CPT" } ], "standard_charges": [ { "gross_charge": 32336.15, "minimum": 6544.15, "maximum": 27485.73, "setting": "inpatient", "payers_information": [ { "payer_name": "Aarp", "plan_name": "500102", "standard_charge_dollar": 6544.15, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna", "plan_name": "700700", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna", "plan_name": "700700_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Mcare Ffs 6005", "plan_name": "700703", "standard_charge_dollar": 6544.15, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Miscellaneous", "plan_name": "700720", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Miscellaneous", "plan_name": "700720_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Ppo Hmo", "plan_name": "701720", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Ppo Hmo", "plan_name": "701720_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Ambetter 68069", "plan_name": "500516", "standard_charge_dollar": 6544.15, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Ms State Emplo", "plan_name": "401457", "standard_charge_percentage": 0.80, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Ms State Emplo", "plan_name": "401457_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Basic Pl", "plan_name": "400100", "standard_charge_percentage": 0.85, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Basic Pl", "plan_name": "400100_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Federal", "plan_name": "400110", "standard_charge_percentage": 0.85, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Federal", "plan_name": "400110_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Cigna Healthsprings Ffs", "plan_name": "500064", "standard_charge_dollar": 6544.15, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Conseco", "plan_name": "500302", "standard_charge_dollar": 6544.15, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Humana Ffs 61101", "plan_name": "500006", "standard_charge_dollar": 6544.15, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Medicare A", "plan_name": "100100", "standard_charge_dollar": 6544.15, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Medicare A", "plan_name": "100500", "standard_charge_dollar": 6544.15, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Medicare Part B Only", "plan_name": "100300", "standard_charge_dollar": 6544.15, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Medicare Railroad", "plan_name": "100103", "standard_charge_dollar": 6544.15, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Ms Physicians Care N", "plan_name": "714210", "standard_charge_dollar": 8180.19, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Peoples Hlth Ffs 72126", "plan_name": "500019", "standard_charge_dollar": 6544.15, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Uhc/Secure Horizons", "plan_name": "500449", "standard_charge_dollar": 6544.15, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "United Health Care/", "plan_name": "500292", "standard_charge_dollar": 7394.89, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "United Healthcare", "plan_name": "750104", "standard_charge_dollar": 7394.89, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "United Healthcare Ba", "plan_name": "750090", "standard_charge_dollar": 7394.89, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "United Healthcare Me", "plan_name": "501310", "standard_charge_dollar": 6544.15, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Windsor Mcare Extra", "plan_name": "500778", "standard_charge_dollar": 6544.15, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." } ] } ] }, { "description": "Treat lower leg dislocation", "code_information": [ { "code": "27830", "type": "CPT" } ], "standard_charges": [ { "gross_charge": 13655.35, "minimum": 219.75, "maximum": 11607.05, "setting": "inpatient", "payers_information": [ { "payer_name": "Aarp", "plan_name": "500102", "standard_charge_dollar": 219.75, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna", "plan_name": "700700", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna", "plan_name": "700700_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Mcare Ffs 6005", "plan_name": "700703", "standard_charge_dollar": 219.75, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Miscellaneous", "plan_name": "700720", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Miscellaneous", "plan_name": "700720_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Ppo Hmo", "plan_name": "701720", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Ppo Hmo", "plan_name": "701720_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Ambetter 68069", "plan_name": "500516", "standard_charge_dollar": 219.75, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Ms State Emplo", "plan_name": "401457", "standard_charge_percentage": 0.80, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Ms State Emplo", "plan_name": "401457_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Basic Pl", "plan_name": "400100", "standard_charge_percentage": 0.85, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Basic Pl", "plan_name": "400100_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Federal", "plan_name": "400110", "standard_charge_percentage": 0.85, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Federal", "plan_name": "400110_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Cigna Healthsprings Ffs", "plan_name": "500064", "standard_charge_dollar": 219.75, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Conseco", "plan_name": "500302", "standard_charge_dollar": 219.75, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Humana Ffs 61101", "plan_name": "500006", "standard_charge_dollar": 219.75, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Medicare A", "plan_name": "100100", "standard_charge_dollar": 219.75, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Medicare A", "plan_name": "100500", "standard_charge_dollar": 219.75, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Medicare Part B Only", "plan_name": "100300", "standard_charge_dollar": 219.75, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Medicare Railroad", "plan_name": "100103", "standard_charge_dollar": 219.75, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Ms Physicians Care N", "plan_name": "714210", "standard_charge_dollar": 274.68, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Peoples Hlth Ffs 72126", "plan_name": "500019", "standard_charge_dollar": 219.75, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Uhc/Secure Horizons", "plan_name": "500449", "standard_charge_dollar": 219.75, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "United Health Care/", "plan_name": "500292", "standard_charge_dollar": 248.31, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "United Healthcare", "plan_name": "750104", "standard_charge_dollar": 248.31, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "United Healthcare Ba", "plan_name": "750090", "standard_charge_dollar": 248.31, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "United Healthcare Me", "plan_name": "501310", "standard_charge_dollar": 219.75, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Windsor Mcare Extra", "plan_name": "500778", "standard_charge_dollar": 219.75, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." } ] } ] }, { "description": "Treat lower leg dislocation", "code_information": [ { "code": "27831", "type": "CPT" } ], "standard_charges": [ { "gross_charge": 13655.35, "minimum": 2972.29, "maximum": 11607.05, "setting": "inpatient", "payers_information": [ { "payer_name": "Aarp", "plan_name": "500102", "standard_charge_dollar": 2972.29, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna", "plan_name": "700700", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna", "plan_name": "700700_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Mcare Ffs 6005", "plan_name": "700703", "standard_charge_dollar": 2972.29, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Miscellaneous", "plan_name": "700720", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Miscellaneous", "plan_name": "700720_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Ppo Hmo", "plan_name": "701720", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Ppo Hmo", "plan_name": "701720_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Ambetter 68069", "plan_name": "500516", "standard_charge_dollar": 2972.29, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Ms State Emplo", "plan_name": "401457", "standard_charge_percentage": 0.80, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Ms State Emplo", "plan_name": "401457_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Basic Pl", "plan_name": "400100", "standard_charge_percentage": 0.85, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Basic Pl", "plan_name": "400100_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Federal", "plan_name": "400110", "standard_charge_percentage": 0.85, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Federal", "plan_name": "400110_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Cigna Healthsprings Ffs", "plan_name": "500064", "standard_charge_dollar": 2972.29, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Conseco", "plan_name": "500302", "standard_charge_dollar": 2972.29, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Humana Ffs 61101", "plan_name": "500006", "standard_charge_dollar": 2972.29, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Medicare A", "plan_name": "100100", "standard_charge_dollar": 2972.29, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Medicare A", "plan_name": "100500", "standard_charge_dollar": 2972.29, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Medicare Part B Only", "plan_name": "100300", "standard_charge_dollar": 2972.29, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Medicare Railroad", "plan_name": "100103", "standard_charge_dollar": 2972.29, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Ms Physicians Care N", "plan_name": "714210", "standard_charge_dollar": 3715.36, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Peoples Hlth Ffs 72126", "plan_name": "500019", "standard_charge_dollar": 2972.29, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Uhc/Secure Horizons", "plan_name": "500449", "standard_charge_dollar": 2972.29, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "United Health Care/", "plan_name": "500292", "standard_charge_dollar": 3358.68, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "United Healthcare", "plan_name": "750104", "standard_charge_dollar": 3358.68, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "United Healthcare Ba", "plan_name": "750090", "standard_charge_dollar": 3358.68, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "United Healthcare Me", "plan_name": "501310", "standard_charge_dollar": 2972.29, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Windsor Mcare Extra", "plan_name": "500778", "standard_charge_dollar": 2972.29, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." } ] } ] }, { "description": "Treat lower leg dislocation", "code_information": [ { "code": "27832", "type": "CPT" } ], "standard_charges": [ { "gross_charge": 30719.25, "minimum": 6544.15, "maximum": 26111.36, "setting": "inpatient", "payers_information": [ { "payer_name": "Aarp", "plan_name": "500102", "standard_charge_dollar": 6544.15, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna", "plan_name": "700700", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna", "plan_name": "700700_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Mcare Ffs 6005", "plan_name": "700703", "standard_charge_dollar": 6544.15, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Miscellaneous", "plan_name": "700720", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Miscellaneous", "plan_name": "700720_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Ppo Hmo", "plan_name": "701720", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Ppo Hmo", "plan_name": "701720_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Ambetter 68069", "plan_name": "500516", "standard_charge_dollar": 6544.15, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Ms State Emplo", "plan_name": "401457", "standard_charge_percentage": 0.80, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Ms State Emplo", "plan_name": "401457_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Basic Pl", "plan_name": "400100", "standard_charge_percentage": 0.85, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Basic Pl", "plan_name": "400100_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Federal", "plan_name": "400110", "standard_charge_percentage": 0.85, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Federal", "plan_name": "400110_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Cigna Healthsprings Ffs", "plan_name": "500064", "standard_charge_dollar": 6544.15, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Conseco", "plan_name": "500302", "standard_charge_dollar": 6544.15, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Humana Ffs 61101", "plan_name": "500006", "standard_charge_dollar": 6544.15, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Medicare A", "plan_name": "100100", "standard_charge_dollar": 6544.15, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Medicare A", "plan_name": "100500", "standard_charge_dollar": 6544.15, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Medicare Part B Only", "plan_name": "100300", "standard_charge_dollar": 6544.15, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Medicare Railroad", "plan_name": "100103", "standard_charge_dollar": 6544.15, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Ms Physicians Care N", "plan_name": "714210", "standard_charge_dollar": 8180.19, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Peoples Hlth Ffs 72126", "plan_name": "500019", "standard_charge_dollar": 6544.15, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Uhc/Secure Horizons", "plan_name": "500449", "standard_charge_dollar": 6544.15, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "United Health Care/", "plan_name": "500292", "standard_charge_dollar": 7394.89, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "United Healthcare", "plan_name": "750104", "standard_charge_dollar": 7394.89, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "United Healthcare Ba", "plan_name": "750090", "standard_charge_dollar": 7394.89, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "United Healthcare Me", "plan_name": "501310", "standard_charge_dollar": 6544.15, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Windsor Mcare Extra", "plan_name": "500778", "standard_charge_dollar": 6544.15, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." } ] } ] }, { "description": "Hc tx ankle dislocation", "code_information": [ { "code": "27840", "type": "CPT" } ], "standard_charges": [ { "gross_charge": 441.00, "minimum": 219.75, "maximum": 374.85, "setting": "both", "payers_information": [ { "payer_name": "Aarp", "plan_name": "500102", "standard_charge_dollar": 219.75, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna", "plan_name": "700700", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna", "plan_name": "700700_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Mcare Ffs 6005", "plan_name": "700703", "standard_charge_dollar": 219.75, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Miscellaneous", "plan_name": "700720", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Miscellaneous", "plan_name": "700720_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Ppo Hmo", "plan_name": "701720", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Ppo Hmo", "plan_name": "701720_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Ambetter 68069", "plan_name": "500516", "standard_charge_dollar": 219.75, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Ms State Emplo", "plan_name": "401457", "standard_charge_percentage": 0.80, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Ms State Emplo", "plan_name": "401457_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Basic Pl", "plan_name": "400100", "standard_charge_percentage": 0.85, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Basic Pl", "plan_name": "400100_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Federal", "plan_name": "400110", "standard_charge_percentage": 0.85, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Federal", "plan_name": "400110_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Cigna Healthsprings Ffs", "plan_name": "500064", "standard_charge_dollar": 219.75, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Conseco", "plan_name": "500302", "standard_charge_dollar": 219.75, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Humana Ffs 61101", "plan_name": "500006", "standard_charge_dollar": 219.75, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Medicare A", "plan_name": "100100", "standard_charge_dollar": 219.75, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Medicare A", "plan_name": "100500", "standard_charge_dollar": 219.75, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Medicare Part B Only", "plan_name": "100300", "standard_charge_dollar": 219.75, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Medicare Railroad", "plan_name": "100103", "standard_charge_dollar": 219.75, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Ms Physicians Care N", "plan_name": "714210", "standard_charge_dollar": 274.68, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Peoples Hlth Ffs 72126", "plan_name": "500019", "standard_charge_dollar": 219.75, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Uhc/Secure Horizons", "plan_name": "500449", "standard_charge_dollar": 219.75, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "United Health Care/", "plan_name": "500292", "standard_charge_dollar": 248.31, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "United Healthcare", "plan_name": "750104", "standard_charge_dollar": 248.31, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "United Healthcare Ba", "plan_name": "750090", "standard_charge_dollar": 248.31, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "United Healthcare Me", "plan_name": "501310", "standard_charge_dollar": 219.75, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Windsor Mcare Extra", "plan_name": "500778", "standard_charge_dollar": 219.75, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." } ] } ] }, { "description": "Treat ankle dislocation", "code_information": [ { "code": "27840", "type": "CPT" } ], "standard_charges": [ { "gross_charge": 441.00, "minimum": 219.75, "maximum": 374.85, "setting": "both", "payers_information": [ { "payer_name": "Aarp", "plan_name": "500102", "standard_charge_dollar": 219.75, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna", "plan_name": "700700", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna", "plan_name": "700700_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Mcare Ffs 6005", "plan_name": "700703", "standard_charge_dollar": 219.75, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Miscellaneous", "plan_name": "700720", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Miscellaneous", "plan_name": "700720_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Ppo Hmo", "plan_name": "701720", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Ppo Hmo", "plan_name": "701720_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Ambetter 68069", "plan_name": "500516", "standard_charge_dollar": 219.75, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Ms State Emplo", "plan_name": "401457", "standard_charge_percentage": 0.80, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Ms State Emplo", "plan_name": "401457_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Basic Pl", "plan_name": "400100", "standard_charge_percentage": 0.85, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Basic Pl", "plan_name": "400100_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Federal", "plan_name": "400110", "standard_charge_percentage": 0.85, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Federal", "plan_name": "400110_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Cigna Healthsprings Ffs", "plan_name": "500064", "standard_charge_dollar": 219.75, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Conseco", "plan_name": "500302", "standard_charge_dollar": 219.75, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Humana Ffs 61101", "plan_name": "500006", "standard_charge_dollar": 219.75, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Medicare A", "plan_name": "100100", "standard_charge_dollar": 219.75, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Medicare A", "plan_name": "100500", "standard_charge_dollar": 219.75, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Medicare Part B Only", "plan_name": "100300", "standard_charge_dollar": 219.75, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Medicare Railroad", "plan_name": "100103", "standard_charge_dollar": 219.75, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Ms Physicians Care N", "plan_name": "714210", "standard_charge_dollar": 274.68, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Peoples Hlth Ffs 72126", "plan_name": "500019", "standard_charge_dollar": 219.75, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Uhc/Secure Horizons", "plan_name": "500449", "standard_charge_dollar": 219.75, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "United Health Care/", "plan_name": "500292", "standard_charge_dollar": 248.31, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "United Healthcare", "plan_name": "750104", "standard_charge_dollar": 248.31, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "United Healthcare Ba", "plan_name": "750090", "standard_charge_dollar": 248.31, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "United Healthcare Me", "plan_name": "501310", "standard_charge_dollar": 219.75, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Windsor Mcare Extra", "plan_name": "500778", "standard_charge_dollar": 219.75, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." } ] } ] }, { "description": "Treat ankle dislocation", "code_information": [ { "code": "27842", "type": "CPT" } ], "standard_charges": [ { "gross_charge": 35992.81, "minimum": 1466.09, "maximum": 30593.89, "setting": "inpatient", "payers_information": [ { "payer_name": "Aarp", "plan_name": "500102", "standard_charge_dollar": 1466.09, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna", "plan_name": "700700", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna", "plan_name": "700700_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Mcare Ffs 6005", "plan_name": "700703", "standard_charge_dollar": 1466.09, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Miscellaneous", "plan_name": "700720", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Miscellaneous", "plan_name": "700720_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Ppo Hmo", "plan_name": "701720", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Ppo Hmo", "plan_name": "701720_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Ambetter 68069", "plan_name": "500516", "standard_charge_dollar": 1466.09, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Ms State Emplo", "plan_name": "401457", "standard_charge_percentage": 0.80, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Ms State Emplo", "plan_name": "401457_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Basic Pl", "plan_name": "400100", "standard_charge_percentage": 0.85, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Basic Pl", "plan_name": "400100_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Federal", "plan_name": "400110", "standard_charge_percentage": 0.85, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Federal", "plan_name": "400110_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Cigna Healthsprings Ffs", "plan_name": "500064", "standard_charge_dollar": 1466.09, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Conseco", "plan_name": "500302", "standard_charge_dollar": 1466.09, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Humana Ffs 61101", "plan_name": "500006", "standard_charge_dollar": 1466.09, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Medicare A", "plan_name": "100100", "standard_charge_dollar": 1466.09, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Medicare A", "plan_name": "100500", "standard_charge_dollar": 1466.09, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Medicare Part B Only", "plan_name": "100300", "standard_charge_dollar": 1466.09, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Medicare Railroad", "plan_name": "100103", "standard_charge_dollar": 1466.09, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Ms Physicians Care N", "plan_name": "714210", "standard_charge_dollar": 1832.61, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Peoples Hlth Ffs 72126", "plan_name": "500019", "standard_charge_dollar": 1466.09, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Uhc/Secure Horizons", "plan_name": "500449", "standard_charge_dollar": 1466.09, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "United Health Care/", "plan_name": "500292", "standard_charge_dollar": 1656.68, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "United Healthcare", "plan_name": "750104", "standard_charge_dollar": 1656.68, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "United Healthcare Ba", "plan_name": "750090", "standard_charge_dollar": 1656.68, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "United Healthcare Me", "plan_name": "501310", "standard_charge_dollar": 1466.09, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Windsor Mcare Extra", "plan_name": "500778", "standard_charge_dollar": 1466.09, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." } ] } ] }, { "description": "Treat ankle dislocation", "code_information": [ { "code": "27848", "type": "CPT" } ], "standard_charges": [ { "gross_charge": 42680.12, "minimum": 6544.15, "maximum": 36278.10, "setting": "inpatient", "payers_information": [ { "payer_name": "Aarp", "plan_name": "500102", "standard_charge_dollar": 6544.15, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna", "plan_name": "700700", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna", "plan_name": "700700_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Mcare Ffs 6005", "plan_name": "700703", "standard_charge_dollar": 6544.15, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Miscellaneous", "plan_name": "700720", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Miscellaneous", "plan_name": "700720_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Ppo Hmo", "plan_name": "701720", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Ppo Hmo", "plan_name": "701720_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Ambetter 68069", "plan_name": "500516", "standard_charge_dollar": 6544.15, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Ms State Emplo", "plan_name": "401457", "standard_charge_percentage": 0.80, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Ms State Emplo", "plan_name": "401457_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Basic Pl", "plan_name": "400100", "standard_charge_percentage": 0.85, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Basic Pl", "plan_name": "400100_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Federal", "plan_name": "400110", "standard_charge_percentage": 0.85, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Federal", "plan_name": "400110_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Cigna Healthsprings Ffs", "plan_name": "500064", "standard_charge_dollar": 6544.15, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Conseco", "plan_name": "500302", "standard_charge_dollar": 6544.15, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Humana Ffs 61101", "plan_name": "500006", "standard_charge_dollar": 6544.15, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Medicare A", "plan_name": "100100", "standard_charge_dollar": 6544.15, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Medicare A", "plan_name": "100500", "standard_charge_dollar": 6544.15, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Medicare Part B Only", "plan_name": "100300", "standard_charge_dollar": 6544.15, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Medicare Railroad", "plan_name": "100103", "standard_charge_dollar": 6544.15, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Ms Physicians Care N", "plan_name": "714210", "standard_charge_dollar": 8180.19, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Peoples Hlth Ffs 72126", "plan_name": "500019", "standard_charge_dollar": 6544.15, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Uhc/Secure Horizons", "plan_name": "500449", "standard_charge_dollar": 6544.15, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "United Health Care/", "plan_name": "500292", "standard_charge_dollar": 7394.89, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "United Healthcare", "plan_name": "750104", "standard_charge_dollar": 7394.89, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "United Healthcare Ba", "plan_name": "750090", "standard_charge_dollar": 7394.89, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "United Healthcare Me", "plan_name": "501310", "standard_charge_dollar": 6544.15, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Windsor Mcare Extra", "plan_name": "500778", "standard_charge_dollar": 6544.15, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." } ] } ] }, { "description": "Amputation of lower leg", "code_information": [ { "code": "27880", "type": "CPT" } ], "standard_charges": [ { "gross_charge": 33118.29, "minimum": 26494.63, "maximum": 28150.55, "setting": "inpatient", "payers_information": [ { "payer_name": "Aetna", "plan_name": "700700", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna", "plan_name": "700700_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Miscellaneous", "plan_name": "700720", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Miscellaneous", "plan_name": "700720_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Ppo Hmo", "plan_name": "701720", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Ppo Hmo", "plan_name": "701720_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Ms State Emplo", "plan_name": "401457", "standard_charge_percentage": 0.80, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Ms State Emplo", "plan_name": "401457_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Basic Pl", "plan_name": "400100", "standard_charge_percentage": 0.85, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Basic Pl", "plan_name": "400100_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Federal", "plan_name": "400110", "standard_charge_percentage": 0.85, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Federal", "plan_name": "400110_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." } ] } ] }, { "description": "Amputation of lower leg", "code_information": [ { "code": "27881", "type": "CPT" } ], "standard_charges": [ { "gross_charge": 33118.29, "minimum": 26494.63, "maximum": 28150.55, "setting": "inpatient", "payers_information": [ { "payer_name": "Aetna", "plan_name": "700700", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna", "plan_name": "700700_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Miscellaneous", "plan_name": "700720", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Miscellaneous", "plan_name": "700720_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Ppo Hmo", "plan_name": "701720", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Ppo Hmo", "plan_name": "701720_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Ms State Emplo", "plan_name": "401457", "standard_charge_percentage": 0.80, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Ms State Emplo", "plan_name": "401457_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Basic Pl", "plan_name": "400100", "standard_charge_percentage": 0.85, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Basic Pl", "plan_name": "400100_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Federal", "plan_name": "400110", "standard_charge_percentage": 0.85, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Federal", "plan_name": "400110_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." } ] } ] }, { "description": "Amputation of lower leg", "code_information": [ { "code": "27882", "type": "CPT" } ], "standard_charges": [ { "gross_charge": 33118.29, "minimum": 26494.63, "maximum": 28150.55, "setting": "inpatient", "payers_information": [ { "payer_name": "Aetna", "plan_name": "700700", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna", "plan_name": "700700_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Miscellaneous", "plan_name": "700720", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Miscellaneous", "plan_name": "700720_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Ppo Hmo", "plan_name": "701720", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Ppo Hmo", "plan_name": "701720_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Ms State Emplo", "plan_name": "401457", "standard_charge_percentage": 0.80, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Ms State Emplo", "plan_name": "401457_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Basic Pl", "plan_name": "400100", "standard_charge_percentage": 0.85, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Basic Pl", "plan_name": "400100_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Federal", "plan_name": "400110", "standard_charge_percentage": 0.85, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Federal", "plan_name": "400110_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." } ] } ] }, { "description": "Amputation follow-up surgery", "code_information": [ { "code": "27884", "type": "CPT" } ], "standard_charges": [ { "gross_charge": 33118.29, "minimum": 2972.29, "maximum": 28150.55, "setting": "inpatient", "payers_information": [ { "payer_name": "Aarp", "plan_name": "500102", "standard_charge_dollar": 2972.29, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna", "plan_name": "700700", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna", "plan_name": "700700_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Mcare Ffs 6005", "plan_name": "700703", "standard_charge_dollar": 2972.29, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Miscellaneous", "plan_name": "700720", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Miscellaneous", "plan_name": "700720_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Ppo Hmo", "plan_name": "701720", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Ppo Hmo", "plan_name": "701720_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Ambetter 68069", "plan_name": "500516", "standard_charge_dollar": 2972.29, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Ms State Emplo", "plan_name": "401457", "standard_charge_percentage": 0.80, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Ms State Emplo", "plan_name": "401457_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Basic Pl", "plan_name": "400100", "standard_charge_percentage": 0.85, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Basic Pl", "plan_name": "400100_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Federal", "plan_name": "400110", "standard_charge_percentage": 0.85, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Federal", "plan_name": "400110_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Cigna Healthsprings Ffs", "plan_name": "500064", "standard_charge_dollar": 2972.29, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Conseco", "plan_name": "500302", "standard_charge_dollar": 2972.29, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Humana Ffs 61101", "plan_name": "500006", "standard_charge_dollar": 2972.29, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Medicare A", "plan_name": "100100", "standard_charge_dollar": 2972.29, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Medicare A", "plan_name": "100500", "standard_charge_dollar": 2972.29, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Medicare Part B Only", "plan_name": "100300", "standard_charge_dollar": 2972.29, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Medicare Railroad", "plan_name": "100103", "standard_charge_dollar": 2972.29, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Ms Physicians Care N", "plan_name": "714210", "standard_charge_dollar": 3715.36, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Peoples Hlth Ffs 72126", "plan_name": "500019", "standard_charge_dollar": 2972.29, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Uhc/Secure Horizons", "plan_name": "500449", "standard_charge_dollar": 2972.29, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "United Health Care/", "plan_name": "500292", "standard_charge_dollar": 3358.68, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "United Healthcare", "plan_name": "750104", "standard_charge_dollar": 3358.68, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "United Healthcare Ba", "plan_name": "750090", "standard_charge_dollar": 3358.68, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "United Healthcare Me", "plan_name": "501310", "standard_charge_dollar": 2972.29, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Windsor Mcare Extra", "plan_name": "500778", "standard_charge_dollar": 2972.29, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." } ] } ] }, { "description": "Amputation follow-up surgery", "code_information": [ { "code": "27886", "type": "CPT" } ], "standard_charges": [ { "gross_charge": 33118.29, "minimum": 26494.63, "maximum": 28150.55, "setting": "inpatient", "payers_information": [ { "payer_name": "Aetna", "plan_name": "700700", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna", "plan_name": "700700_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Miscellaneous", "plan_name": "700720", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Miscellaneous", "plan_name": "700720_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Ppo Hmo", "plan_name": "701720", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Ppo Hmo", "plan_name": "701720_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Ms State Emplo", "plan_name": "401457", "standard_charge_percentage": 0.80, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Ms State Emplo", "plan_name": "401457_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Basic Pl", "plan_name": "400100", "standard_charge_percentage": 0.85, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Basic Pl", "plan_name": "400100_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Federal", "plan_name": "400110", "standard_charge_percentage": 0.85, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Federal", "plan_name": "400110_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." } ] } ] }, { "description": "Amputation of foot at ankle", "code_information": [ { "code": "27888", "type": "CPT" } ], "standard_charges": [ { "gross_charge": 38189.38, "minimum": 30551.50, "maximum": 32460.97, "setting": "inpatient", "payers_information": [ { "payer_name": "Aetna", "plan_name": "700700", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna", "plan_name": "700700_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Miscellaneous", "plan_name": "700720", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Miscellaneous", "plan_name": "700720_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Ppo Hmo", "plan_name": "701720", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Ppo Hmo", "plan_name": "701720_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Ms State Emplo", "plan_name": "401457", "standard_charge_percentage": 0.80, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Ms State Emplo", "plan_name": "401457_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Basic Pl", "plan_name": "400100", "standard_charge_percentage": 0.85, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Basic Pl", "plan_name": "400100_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Federal", "plan_name": "400110", "standard_charge_percentage": 0.85, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Federal", "plan_name": "400110_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." } ] } ] }, { "description": "Leg/ankle surgery procedure", "code_information": [ { "code": "27899", "type": "CPT" } ], "standard_charges": [ { "gross_charge": 31945.04, "minimum": 219.75, "maximum": 27153.28, "setting": "inpatient", "payers_information": [ { "payer_name": "Aarp", "plan_name": "500102", "standard_charge_dollar": 219.75, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna", "plan_name": "700700", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna", "plan_name": "700700_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Mcare Ffs 6005", "plan_name": "700703", "standard_charge_dollar": 219.75, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Miscellaneous", "plan_name": "700720", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Miscellaneous", "plan_name": "700720_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Ppo Hmo", "plan_name": "701720", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Ppo Hmo", "plan_name": "701720_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Ambetter 68069", "plan_name": "500516", "standard_charge_dollar": 219.75, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Ms State Emplo", "plan_name": "401457", "standard_charge_percentage": 0.80, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Ms State Emplo", "plan_name": "401457_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Basic Pl", "plan_name": "400100", "standard_charge_percentage": 0.85, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Basic Pl", "plan_name": "400100_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Federal", "plan_name": "400110", "standard_charge_percentage": 0.85, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Federal", "plan_name": "400110_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Cigna Healthsprings Ffs", "plan_name": "500064", "standard_charge_dollar": 219.75, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Conseco", "plan_name": "500302", "standard_charge_dollar": 219.75, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Humana Ffs 61101", "plan_name": "500006", "standard_charge_dollar": 219.75, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Medicare A", "plan_name": "100100", "standard_charge_dollar": 219.75, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Medicare A", "plan_name": "100500", "standard_charge_dollar": 219.75, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Medicare Part B Only", "plan_name": "100300", "standard_charge_dollar": 219.75, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Medicare Railroad", "plan_name": "100103", "standard_charge_dollar": 219.75, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Ms Physicians Care N", "plan_name": "714210", "standard_charge_dollar": 274.68, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Peoples Hlth Ffs 72126", "plan_name": "500019", "standard_charge_dollar": 219.75, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Uhc/Secure Horizons", "plan_name": "500449", "standard_charge_dollar": 219.75, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "United Health Care/", "plan_name": "500292", "standard_charge_dollar": 248.31, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "United Healthcare", "plan_name": "750104", "standard_charge_dollar": 248.31, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "United Healthcare Ba", "plan_name": "750090", "standard_charge_dollar": 248.31, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "United Healthcare Me", "plan_name": "501310", "standard_charge_dollar": 219.75, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Windsor Mcare Extra", "plan_name": "500778", "standard_charge_dollar": 219.75, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." } ] } ] }, { "description": "Drainage of bursa of foot", "code_information": [ { "code": "28001", "type": "CPT" } ], "standard_charges": [ { "gross_charge": 2399.28, "minimum": 1484.25, "maximum": 2039.39, "setting": "both", "payers_information": [ { "payer_name": "Aarp", "plan_name": "500102", "standard_charge_dollar": 1484.25, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna", "plan_name": "700700", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna", "plan_name": "700700_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Mcare Ffs 6005", "plan_name": "700703", "standard_charge_dollar": 1484.25, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Miscellaneous", "plan_name": "700720", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Miscellaneous", "plan_name": "700720_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Ppo Hmo", "plan_name": "701720", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Ppo Hmo", "plan_name": "701720_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Ambetter 68069", "plan_name": "500516", "standard_charge_dollar": 1484.25, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Ms State Emplo", "plan_name": "401457", "standard_charge_percentage": 0.80, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Ms State Emplo", "plan_name": "401457_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Basic Pl", "plan_name": "400100", "standard_charge_percentage": 0.85, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Basic Pl", "plan_name": "400100_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Federal", "plan_name": "400110", "standard_charge_percentage": 0.85, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Federal", "plan_name": "400110_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Cigna Healthsprings Ffs", "plan_name": "500064", "standard_charge_dollar": 1484.25, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Conseco", "plan_name": "500302", "standard_charge_dollar": 1484.25, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Humana Ffs 61101", "plan_name": "500006", "standard_charge_dollar": 1484.25, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Medicare A", "plan_name": "100100", "standard_charge_dollar": 1484.25, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Medicare A", "plan_name": "100500", "standard_charge_dollar": 1484.25, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Medicare Part B Only", "plan_name": "100300", "standard_charge_dollar": 1484.25, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Medicare Railroad", "plan_name": "100103", "standard_charge_dollar": 1484.25, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Ms Physicians Care N", "plan_name": "714210", "standard_charge_dollar": 1855.31, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Peoples Hlth Ffs 72126", "plan_name": "500019", "standard_charge_dollar": 1484.25, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Uhc/Secure Horizons", "plan_name": "500449", "standard_charge_dollar": 1484.25, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "United Health Care/", "plan_name": "500292", "standard_charge_dollar": 1677.20, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "United Healthcare", "plan_name": "750104", "standard_charge_dollar": 1677.20, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "United Healthcare Ba", "plan_name": "750090", "standard_charge_dollar": 1677.20, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "United Healthcare Me", "plan_name": "501310", "standard_charge_dollar": 1484.25, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Windsor Mcare Extra", "plan_name": "500778", "standard_charge_dollar": 1484.25, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." } ] } ] }, { "description": "Hc incision & drainage bursa foot", "code_information": [ { "code": "28001", "type": "CPT" } ], "standard_charges": [ { "gross_charge": 2399.28, "minimum": 1484.25, "maximum": 2039.39, "setting": "both", "payers_information": [ { "payer_name": "Aarp", "plan_name": "500102", "standard_charge_dollar": 1484.25, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna", "plan_name": "700700", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna", "plan_name": "700700_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Mcare Ffs 6005", "plan_name": "700703", "standard_charge_dollar": 1484.25, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Miscellaneous", "plan_name": "700720", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Miscellaneous", "plan_name": "700720_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Ppo Hmo", "plan_name": "701720", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Ppo Hmo", "plan_name": "701720_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Ambetter 68069", "plan_name": "500516", "standard_charge_dollar": 1484.25, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Ms State Emplo", "plan_name": "401457", "standard_charge_percentage": 0.80, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Ms State Emplo", "plan_name": "401457_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Basic Pl", "plan_name": "400100", "standard_charge_percentage": 0.85, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Basic Pl", "plan_name": "400100_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Federal", "plan_name": "400110", "standard_charge_percentage": 0.85, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Federal", "plan_name": "400110_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Cigna Healthsprings Ffs", "plan_name": "500064", "standard_charge_dollar": 1484.25, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Conseco", "plan_name": "500302", "standard_charge_dollar": 1484.25, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Humana Ffs 61101", "plan_name": "500006", "standard_charge_dollar": 1484.25, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Medicare A", "plan_name": "100100", "standard_charge_dollar": 1484.25, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Medicare A", "plan_name": "100500", "standard_charge_dollar": 1484.25, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Medicare Part B Only", "plan_name": "100300", "standard_charge_dollar": 1484.25, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Medicare Railroad", "plan_name": "100103", "standard_charge_dollar": 1484.25, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Ms Physicians Care N", "plan_name": "714210", "standard_charge_dollar": 1855.31, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Peoples Hlth Ffs 72126", "plan_name": "500019", "standard_charge_dollar": 1484.25, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Uhc/Secure Horizons", "plan_name": "500449", "standard_charge_dollar": 1484.25, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "United Health Care/", "plan_name": "500292", "standard_charge_dollar": 1677.20, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "United Healthcare", "plan_name": "750104", "standard_charge_dollar": 1677.20, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "United Healthcare Ba", "plan_name": "750090", "standard_charge_dollar": 1677.20, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "United Healthcare Me", "plan_name": "501310", "standard_charge_dollar": 1484.25, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Windsor Mcare Extra", "plan_name": "500778", "standard_charge_dollar": 1484.25, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." } ] } ] }, { "description": "Treatment of foot infection", "code_information": [ { "code": "28002", "type": "CPT" } ], "standard_charges": [ { "gross_charge": 41811.36, "minimum": 1466.09, "maximum": 35539.66, "setting": "inpatient", "payers_information": [ { "payer_name": "Aarp", "plan_name": "500102", "standard_charge_dollar": 1466.09, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna", "plan_name": "700700", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna", "plan_name": "700700_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Mcare Ffs 6005", "plan_name": "700703", "standard_charge_dollar": 1466.09, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Miscellaneous", "plan_name": "700720", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Miscellaneous", "plan_name": "700720_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Ppo Hmo", "plan_name": "701720", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Ppo Hmo", "plan_name": "701720_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Ambetter 68069", "plan_name": "500516", "standard_charge_dollar": 1466.09, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Ms State Emplo", "plan_name": "401457", "standard_charge_percentage": 0.80, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Ms State Emplo", "plan_name": "401457_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Basic Pl", "plan_name": "400100", "standard_charge_percentage": 0.85, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Basic Pl", "plan_name": "400100_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Federal", "plan_name": "400110", "standard_charge_percentage": 0.85, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Federal", "plan_name": "400110_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Cigna Healthsprings Ffs", "plan_name": "500064", "standard_charge_dollar": 1466.09, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Conseco", "plan_name": "500302", "standard_charge_dollar": 1466.09, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Humana Ffs 61101", "plan_name": "500006", "standard_charge_dollar": 1466.09, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Medicare A", "plan_name": "100100", "standard_charge_dollar": 1466.09, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Medicare A", "plan_name": "100500", "standard_charge_dollar": 1466.09, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Medicare Part B Only", "plan_name": "100300", "standard_charge_dollar": 1466.09, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Medicare Railroad", "plan_name": "100103", "standard_charge_dollar": 1466.09, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Ms Physicians Care N", "plan_name": "714210", "standard_charge_dollar": 1832.61, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Peoples Hlth Ffs 72126", "plan_name": "500019", "standard_charge_dollar": 1466.09, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Uhc/Secure Horizons", "plan_name": "500449", "standard_charge_dollar": 1466.09, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "United Health Care/", "plan_name": "500292", "standard_charge_dollar": 1656.68, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "United Healthcare", "plan_name": "750104", "standard_charge_dollar": 1656.68, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "United Healthcare Ba", "plan_name": "750090", "standard_charge_dollar": 1656.68, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "United Healthcare Me", "plan_name": "501310", "standard_charge_dollar": 1466.09, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Windsor Mcare Extra", "plan_name": "500778", "standard_charge_dollar": 1466.09, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." } ] } ] }, { "description": "Treatment of foot infection", "code_information": [ { "code": "28003", "type": "CPT" } ], "standard_charges": [ { "gross_charge": 41811.36, "minimum": 2972.29, "maximum": 35539.66, "setting": "inpatient", "payers_information": [ { "payer_name": "Aarp", "plan_name": "500102", "standard_charge_dollar": 2972.29, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna", "plan_name": "700700", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna", "plan_name": "700700_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Mcare Ffs 6005", "plan_name": "700703", "standard_charge_dollar": 2972.29, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Miscellaneous", "plan_name": "700720", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Miscellaneous", "plan_name": "700720_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Ppo Hmo", "plan_name": "701720", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Ppo Hmo", "plan_name": "701720_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Ambetter 68069", "plan_name": "500516", "standard_charge_dollar": 2972.29, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Ms State Emplo", "plan_name": "401457", "standard_charge_percentage": 0.80, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Ms State Emplo", "plan_name": "401457_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Basic Pl", "plan_name": "400100", "standard_charge_percentage": 0.85, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Basic Pl", "plan_name": "400100_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Federal", "plan_name": "400110", "standard_charge_percentage": 0.85, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Federal", "plan_name": "400110_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Cigna Healthsprings Ffs", "plan_name": "500064", "standard_charge_dollar": 2972.29, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Conseco", "plan_name": "500302", "standard_charge_dollar": 2972.29, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Humana Ffs 61101", "plan_name": "500006", "standard_charge_dollar": 2972.29, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Medicare A", "plan_name": "100100", "standard_charge_dollar": 2972.29, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Medicare A", "plan_name": "100500", "standard_charge_dollar": 2972.29, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Medicare Part B Only", "plan_name": "100300", "standard_charge_dollar": 2972.29, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Medicare Railroad", "plan_name": "100103", "standard_charge_dollar": 2972.29, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Ms Physicians Care N", "plan_name": "714210", "standard_charge_dollar": 3715.36, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Peoples Hlth Ffs 72126", "plan_name": "500019", "standard_charge_dollar": 2972.29, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Uhc/Secure Horizons", "plan_name": "500449", "standard_charge_dollar": 2972.29, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "United Health Care/", "plan_name": "500292", "standard_charge_dollar": 3358.68, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "United Healthcare", "plan_name": "750104", "standard_charge_dollar": 3358.68, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "United Healthcare Ba", "plan_name": "750090", "standard_charge_dollar": 3358.68, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "United Healthcare Me", "plan_name": "501310", "standard_charge_dollar": 2972.29, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Windsor Mcare Extra", "plan_name": "500778", "standard_charge_dollar": 2972.29, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." } ] } ] }, { "description": "Hc closed rx toe fx", "code_information": [ { "code": "28010", "type": "CPT" } ], "standard_charges": [ { "gross_charge": 2295.23, "minimum": 1466.09, "maximum": 1950.95, "setting": "both", "payers_information": [ { "payer_name": "Aarp", "plan_name": "500102", "standard_charge_dollar": 1466.09, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna", "plan_name": "700700", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna", "plan_name": "700700_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Mcare Ffs 6005", "plan_name": "700703", "standard_charge_dollar": 1466.09, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Miscellaneous", "plan_name": "700720", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Miscellaneous", "plan_name": "700720_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Ppo Hmo", "plan_name": "701720", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Ppo Hmo", "plan_name": "701720_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Ambetter 68069", "plan_name": "500516", "standard_charge_dollar": 1466.09, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Ms State Emplo", "plan_name": "401457", "standard_charge_percentage": 0.80, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Ms State Emplo", "plan_name": "401457_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Basic Pl", "plan_name": "400100", "standard_charge_percentage": 0.85, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Basic Pl", "plan_name": "400100_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Federal", "plan_name": "400110", "standard_charge_percentage": 0.85, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Federal", "plan_name": "400110_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Cigna Healthsprings Ffs", "plan_name": "500064", "standard_charge_dollar": 1466.09, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Conseco", "plan_name": "500302", "standard_charge_dollar": 1466.09, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Humana Ffs 61101", "plan_name": "500006", "standard_charge_dollar": 1466.09, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Medicare A", "plan_name": "100100", "standard_charge_dollar": 1466.09, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Medicare A", "plan_name": "100500", "standard_charge_dollar": 1466.09, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Medicare Part B Only", "plan_name": "100300", "standard_charge_dollar": 1466.09, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Medicare Railroad", "plan_name": "100103", "standard_charge_dollar": 1466.09, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Ms Physicians Care N", "plan_name": "714210", "standard_charge_dollar": 1832.61, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Peoples Hlth Ffs 72126", "plan_name": "500019", "standard_charge_dollar": 1466.09, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Uhc/Secure Horizons", "plan_name": "500449", "standard_charge_dollar": 1466.09, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "United Health Care/", "plan_name": "500292", "standard_charge_dollar": 1656.68, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "United Healthcare", "plan_name": "750104", "standard_charge_dollar": 1656.68, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "United Healthcare Ba", "plan_name": "750090", "standard_charge_dollar": 1656.68, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "United Healthcare Me", "plan_name": "501310", "standard_charge_dollar": 1466.09, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Windsor Mcare Extra", "plan_name": "500778", "standard_charge_dollar": 1466.09, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." } ] } ] }, { "description": "Incision of toe tendon", "code_information": [ { "code": "28010", "type": "CPT" } ], "standard_charges": [ { "gross_charge": 2295.23, "minimum": 1466.09, "maximum": 1950.95, "setting": "both", "payers_information": [ { "payer_name": "Aarp", "plan_name": "500102", "standard_charge_dollar": 1466.09, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna", "plan_name": "700700", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna", "plan_name": "700700_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Mcare Ffs 6005", "plan_name": "700703", "standard_charge_dollar": 1466.09, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Miscellaneous", "plan_name": "700720", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Miscellaneous", "plan_name": "700720_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Ppo Hmo", "plan_name": "701720", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Ppo Hmo", "plan_name": "701720_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Ambetter 68069", "plan_name": "500516", "standard_charge_dollar": 1466.09, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Ms State Emplo", "plan_name": "401457", "standard_charge_percentage": 0.80, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Ms State Emplo", "plan_name": "401457_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Basic Pl", "plan_name": "400100", "standard_charge_percentage": 0.85, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Basic Pl", "plan_name": "400100_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Federal", "plan_name": "400110", "standard_charge_percentage": 0.85, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Federal", "plan_name": "400110_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Cigna Healthsprings Ffs", "plan_name": "500064", "standard_charge_dollar": 1466.09, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Conseco", "plan_name": "500302", "standard_charge_dollar": 1466.09, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Humana Ffs 61101", "plan_name": "500006", "standard_charge_dollar": 1466.09, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Medicare A", "plan_name": "100100", "standard_charge_dollar": 1466.09, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Medicare A", "plan_name": "100500", "standard_charge_dollar": 1466.09, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Medicare Part B Only", "plan_name": "100300", "standard_charge_dollar": 1466.09, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Medicare Railroad", "plan_name": "100103", "standard_charge_dollar": 1466.09, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Ms Physicians Care N", "plan_name": "714210", "standard_charge_dollar": 1832.61, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Peoples Hlth Ffs 72126", "plan_name": "500019", "standard_charge_dollar": 1466.09, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Uhc/Secure Horizons", "plan_name": "500449", "standard_charge_dollar": 1466.09, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "United Health Care/", "plan_name": "500292", "standard_charge_dollar": 1656.68, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "United Healthcare", "plan_name": "750104", "standard_charge_dollar": 1656.68, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "United Healthcare Ba", "plan_name": "750090", "standard_charge_dollar": 1656.68, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "United Healthcare Me", "plan_name": "501310", "standard_charge_dollar": 1466.09, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Windsor Mcare Extra", "plan_name": "500778", "standard_charge_dollar": 1466.09, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." } ] } ] }, { "description": "Exc foot/toe tum sc 1.5 cm/>", "code_information": [ { "code": "28039", "type": "CPT" } ], "standard_charges": [ { "gross_charge": 34797.67, "minimum": 2621.84, "maximum": 29578.02, "setting": "inpatient", "payers_information": [ { "payer_name": "Aarp", "plan_name": "500102", "standard_charge_dollar": 2621.84, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna", "plan_name": "700700", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna", "plan_name": "700700_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Mcare Ffs 6005", "plan_name": "700703", "standard_charge_dollar": 2621.84, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Miscellaneous", "plan_name": "700720", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Miscellaneous", "plan_name": "700720_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Ppo Hmo", "plan_name": "701720", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Ppo Hmo", "plan_name": "701720_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Ambetter 68069", "plan_name": "500516", "standard_charge_dollar": 2621.84, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Ms State Emplo", "plan_name": "401457", "standard_charge_percentage": 0.80, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Ms State Emplo", "plan_name": "401457_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Basic Pl", "plan_name": "400100", "standard_charge_percentage": 0.85, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Basic Pl", "plan_name": "400100_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Federal", "plan_name": "400110", "standard_charge_percentage": 0.85, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Federal", "plan_name": "400110_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Cigna Healthsprings Ffs", "plan_name": "500064", "standard_charge_dollar": 2621.84, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Conseco", "plan_name": "500302", "standard_charge_dollar": 2621.84, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Humana Ffs 61101", "plan_name": "500006", "standard_charge_dollar": 2621.84, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Medicare A", "plan_name": "100100", "standard_charge_dollar": 2621.84, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Medicare A", "plan_name": "100500", "standard_charge_dollar": 2621.84, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Medicare Part B Only", "plan_name": "100300", "standard_charge_dollar": 2621.84, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Medicare Railroad", "plan_name": "100103", "standard_charge_dollar": 2621.84, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Ms Physicians Care N", "plan_name": "714210", "standard_charge_dollar": 3277.29, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Peoples Hlth Ffs 72126", "plan_name": "500019", "standard_charge_dollar": 2621.84, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Uhc/Secure Horizons", "plan_name": "500449", "standard_charge_dollar": 2621.84, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "United Health Care/", "plan_name": "500292", "standard_charge_dollar": 2962.67, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "United Healthcare", "plan_name": "750104", "standard_charge_dollar": 2962.67, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "United Healthcare Ba", "plan_name": "750090", "standard_charge_dollar": 2962.67, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "United Healthcare Me", "plan_name": "501310", "standard_charge_dollar": 2621.84, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Windsor Mcare Extra", "plan_name": "500778", "standard_charge_dollar": 2621.84, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." } ] } ] }, { "description": "Exc foot/toe tum dep 1.5cm/>", "code_information": [ { "code": "28041", "type": "CPT" } ], "standard_charges": [ { "gross_charge": 32779.49, "minimum": 2621.84, "maximum": 27862.57, "setting": "inpatient", "payers_information": [ { "payer_name": "Aarp", "plan_name": "500102", "standard_charge_dollar": 2621.84, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna", "plan_name": "700700", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna", "plan_name": "700700_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Mcare Ffs 6005", "plan_name": "700703", "standard_charge_dollar": 2621.84, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Miscellaneous", "plan_name": "700720", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Miscellaneous", "plan_name": "700720_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Ppo Hmo", "plan_name": "701720", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Ppo Hmo", "plan_name": "701720_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Ambetter 68069", "plan_name": "500516", "standard_charge_dollar": 2621.84, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Ms State Emplo", "plan_name": "401457", "standard_charge_percentage": 0.80, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Ms State Emplo", "plan_name": "401457_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Basic Pl", "plan_name": "400100", "standard_charge_percentage": 0.85, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Basic Pl", "plan_name": "400100_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Federal", "plan_name": "400110", "standard_charge_percentage": 0.85, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Federal", "plan_name": "400110_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Cigna Healthsprings Ffs", "plan_name": "500064", "standard_charge_dollar": 2621.84, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Conseco", "plan_name": "500302", "standard_charge_dollar": 2621.84, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Humana Ffs 61101", "plan_name": "500006", "standard_charge_dollar": 2621.84, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Medicare A", "plan_name": "100100", "standard_charge_dollar": 2621.84, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Medicare A", "plan_name": "100500", "standard_charge_dollar": 2621.84, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Medicare Part B Only", "plan_name": "100300", "standard_charge_dollar": 2621.84, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Medicare Railroad", "plan_name": "100103", "standard_charge_dollar": 2621.84, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Ms Physicians Care N", "plan_name": "714210", "standard_charge_dollar": 3277.29, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Peoples Hlth Ffs 72126", "plan_name": "500019", "standard_charge_dollar": 2621.84, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Uhc/Secure Horizons", "plan_name": "500449", "standard_charge_dollar": 2621.84, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "United Health Care/", "plan_name": "500292", "standard_charge_dollar": 2962.67, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "United Healthcare", "plan_name": "750104", "standard_charge_dollar": 2962.67, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "United Healthcare Ba", "plan_name": "750090", "standard_charge_dollar": 2962.67, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "United Healthcare Me", "plan_name": "501310", "standard_charge_dollar": 2621.84, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Windsor Mcare Extra", "plan_name": "500778", "standard_charge_dollar": 2621.84, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." } ] } ] }, { "description": "Exc foot/toe tum sc < 1.5 cm", "code_information": [ { "code": "28043", "type": "CPT" } ], "standard_charges": [ { "gross_charge": 34797.67, "minimum": 1484.25, "maximum": 29578.02, "setting": "inpatient", "payers_information": [ { "payer_name": "Aarp", "plan_name": "500102", "standard_charge_dollar": 1484.25, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna", "plan_name": "700700", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna", "plan_name": "700700_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Mcare Ffs 6005", "plan_name": "700703", "standard_charge_dollar": 1484.25, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Miscellaneous", "plan_name": "700720", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Miscellaneous", "plan_name": "700720_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Ppo Hmo", "plan_name": "701720", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Ppo Hmo", "plan_name": "701720_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Ambetter 68069", "plan_name": "500516", "standard_charge_dollar": 1484.25, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Ms State Emplo", "plan_name": "401457", "standard_charge_percentage": 0.80, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Ms State Emplo", "plan_name": "401457_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Basic Pl", "plan_name": "400100", "standard_charge_percentage": 0.85, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Basic Pl", "plan_name": "400100_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Federal", "plan_name": "400110", "standard_charge_percentage": 0.85, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Federal", "plan_name": "400110_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Cigna Healthsprings Ffs", "plan_name": "500064", "standard_charge_dollar": 1484.25, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Conseco", "plan_name": "500302", "standard_charge_dollar": 1484.25, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Humana Ffs 61101", "plan_name": "500006", "standard_charge_dollar": 1484.25, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Medicare A", "plan_name": "100100", "standard_charge_dollar": 1484.25, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Medicare A", "plan_name": "100500", "standard_charge_dollar": 1484.25, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Medicare Part B Only", "plan_name": "100300", "standard_charge_dollar": 1484.25, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Medicare Railroad", "plan_name": "100103", "standard_charge_dollar": 1484.25, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Ms Physicians Care N", "plan_name": "714210", "standard_charge_dollar": 1855.31, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Peoples Hlth Ffs 72126", "plan_name": "500019", "standard_charge_dollar": 1484.25, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Uhc/Secure Horizons", "plan_name": "500449", "standard_charge_dollar": 1484.25, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "United Health Care/", "plan_name": "500292", "standard_charge_dollar": 1677.20, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "United Healthcare", "plan_name": "750104", "standard_charge_dollar": 1677.20, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "United Healthcare Ba", "plan_name": "750090", "standard_charge_dollar": 1677.20, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "United Healthcare Me", "plan_name": "501310", "standard_charge_dollar": 1484.25, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Windsor Mcare Extra", "plan_name": "500778", "standard_charge_dollar": 1484.25, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." } ] } ] }, { "description": "Exc foot/toe tum deep <1.5cm", "code_information": [ { "code": "28045", "type": "CPT" } ], "standard_charges": [ { "gross_charge": 32779.49, "minimum": 2621.84, "maximum": 27862.57, "setting": "inpatient", "payers_information": [ { "payer_name": "Aarp", "plan_name": "500102", "standard_charge_dollar": 2621.84, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna", "plan_name": "700700", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna", "plan_name": "700700_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Mcare Ffs 6005", "plan_name": "700703", "standard_charge_dollar": 2621.84, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Miscellaneous", "plan_name": "700720", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Miscellaneous", "plan_name": "700720_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Ppo Hmo", "plan_name": "701720", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Ppo Hmo", "plan_name": "701720_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Ambetter 68069", "plan_name": "500516", "standard_charge_dollar": 2621.84, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Ms State Emplo", "plan_name": "401457", "standard_charge_percentage": 0.80, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Ms State Emplo", "plan_name": "401457_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Basic Pl", "plan_name": "400100", "standard_charge_percentage": 0.85, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Basic Pl", "plan_name": "400100_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Federal", "plan_name": "400110", "standard_charge_percentage": 0.85, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Federal", "plan_name": "400110_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Cigna Healthsprings Ffs", "plan_name": "500064", "standard_charge_dollar": 2621.84, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Conseco", "plan_name": "500302", "standard_charge_dollar": 2621.84, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Humana Ffs 61101", "plan_name": "500006", "standard_charge_dollar": 2621.84, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Medicare A", "plan_name": "100100", "standard_charge_dollar": 2621.84, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Medicare A", "plan_name": "100500", "standard_charge_dollar": 2621.84, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Medicare Part B Only", "plan_name": "100300", "standard_charge_dollar": 2621.84, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Medicare Railroad", "plan_name": "100103", "standard_charge_dollar": 2621.84, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Ms Physicians Care N", "plan_name": "714210", "standard_charge_dollar": 3277.29, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Peoples Hlth Ffs 72126", "plan_name": "500019", "standard_charge_dollar": 2621.84, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Uhc/Secure Horizons", "plan_name": "500449", "standard_charge_dollar": 2621.84, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "United Health Care/", "plan_name": "500292", "standard_charge_dollar": 2962.67, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "United Healthcare", "plan_name": "750104", "standard_charge_dollar": 2962.67, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "United Healthcare Ba", "plan_name": "750090", "standard_charge_dollar": 2962.67, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "United Healthcare Me", "plan_name": "501310", "standard_charge_dollar": 2621.84, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Windsor Mcare Extra", "plan_name": "500778", "standard_charge_dollar": 2621.84, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." } ] } ] }, { "description": "Resect foot/toe tumor < 3 cm", "code_information": [ { "code": "28046", "type": "CPT" } ], "standard_charges": [ { "gross_charge": 34729.83, "minimum": 2621.84, "maximum": 29520.36, "setting": "inpatient", "payers_information": [ { "payer_name": "Aarp", "plan_name": "500102", "standard_charge_dollar": 2621.84, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna", "plan_name": "700700", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna", "plan_name": "700700_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Mcare Ffs 6005", "plan_name": "700703", "standard_charge_dollar": 2621.84, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Miscellaneous", "plan_name": "700720", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Miscellaneous", "plan_name": "700720_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Ppo Hmo", "plan_name": "701720", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Ppo Hmo", "plan_name": "701720_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Ambetter 68069", "plan_name": "500516", "standard_charge_dollar": 2621.84, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Ms State Emplo", "plan_name": "401457", "standard_charge_percentage": 0.80, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Ms State Emplo", "plan_name": "401457_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Basic Pl", "plan_name": "400100", "standard_charge_percentage": 0.85, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Basic Pl", "plan_name": "400100_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Federal", "plan_name": "400110", "standard_charge_percentage": 0.85, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Federal", "plan_name": "400110_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Cigna Healthsprings Ffs", "plan_name": "500064", "standard_charge_dollar": 2621.84, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Conseco", "plan_name": "500302", "standard_charge_dollar": 2621.84, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Humana Ffs 61101", "plan_name": "500006", "standard_charge_dollar": 2621.84, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Medicare A", "plan_name": "100100", "standard_charge_dollar": 2621.84, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Medicare A", "plan_name": "100500", "standard_charge_dollar": 2621.84, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Medicare Part B Only", "plan_name": "100300", "standard_charge_dollar": 2621.84, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Medicare Railroad", "plan_name": "100103", "standard_charge_dollar": 2621.84, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Ms Physicians Care N", "plan_name": "714210", "standard_charge_dollar": 3277.29, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Peoples Hlth Ffs 72126", "plan_name": "500019", "standard_charge_dollar": 2621.84, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Uhc/Secure Horizons", "plan_name": "500449", "standard_charge_dollar": 2621.84, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "United Health Care/", "plan_name": "500292", "standard_charge_dollar": 2962.67, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "United Healthcare", "plan_name": "750104", "standard_charge_dollar": 2962.67, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "United Healthcare Ba", "plan_name": "750090", "standard_charge_dollar": 2962.67, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "United Healthcare Me", "plan_name": "501310", "standard_charge_dollar": 2621.84, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Windsor Mcare Extra", "plan_name": "500778", "standard_charge_dollar": 2621.84, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." } ] } ] }, { "description": "Resect foot/toe tumor 3 cm/>", "code_information": [ { "code": "28047", "type": "CPT" } ], "standard_charges": [ { "gross_charge": 34729.83, "minimum": 2621.84, "maximum": 29520.36, "setting": "inpatient", "payers_information": [ { "payer_name": "Aarp", "plan_name": "500102", "standard_charge_dollar": 2621.84, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna", "plan_name": "700700", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna", "plan_name": "700700_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Mcare Ffs 6005", "plan_name": "700703", "standard_charge_dollar": 2621.84, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Miscellaneous", "plan_name": "700720", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Miscellaneous", "plan_name": "700720_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Ppo Hmo", "plan_name": "701720", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Ppo Hmo", "plan_name": "701720_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Ambetter 68069", "plan_name": "500516", "standard_charge_dollar": 2621.84, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Ms State Emplo", "plan_name": "401457", "standard_charge_percentage": 0.80, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Ms State Emplo", "plan_name": "401457_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Basic Pl", "plan_name": "400100", "standard_charge_percentage": 0.85, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Basic Pl", "plan_name": "400100_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Federal", "plan_name": "400110", "standard_charge_percentage": 0.85, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Federal", "plan_name": "400110_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Cigna Healthsprings Ffs", "plan_name": "500064", "standard_charge_dollar": 2621.84, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Conseco", "plan_name": "500302", "standard_charge_dollar": 2621.84, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Humana Ffs 61101", "plan_name": "500006", "standard_charge_dollar": 2621.84, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Medicare A", "plan_name": "100100", "standard_charge_dollar": 2621.84, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Medicare A", "plan_name": "100500", "standard_charge_dollar": 2621.84, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Medicare Part B Only", "plan_name": "100300", "standard_charge_dollar": 2621.84, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Medicare Railroad", "plan_name": "100103", "standard_charge_dollar": 2621.84, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Ms Physicians Care N", "plan_name": "714210", "standard_charge_dollar": 3277.29, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Peoples Hlth Ffs 72126", "plan_name": "500019", "standard_charge_dollar": 2621.84, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Uhc/Secure Horizons", "plan_name": "500449", "standard_charge_dollar": 2621.84, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "United Health Care/", "plan_name": "500292", "standard_charge_dollar": 2962.67, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "United Healthcare", "plan_name": "750104", "standard_charge_dollar": 2962.67, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "United Healthcare Ba", "plan_name": "750090", "standard_charge_dollar": 2962.67, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "United Healthcare Me", "plan_name": "501310", "standard_charge_dollar": 2621.84, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Windsor Mcare Extra", "plan_name": "500778", "standard_charge_dollar": 2621.84, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." } ] } ] }, { "description": "Partial removal foot fascia", "code_information": [ { "code": "28060", "type": "CPT" } ], "standard_charges": [ { "gross_charge": 34797.67, "minimum": 2972.29, "maximum": 29578.02, "setting": "inpatient", "payers_information": [ { "payer_name": "Aarp", "plan_name": "500102", "standard_charge_dollar": 2972.29, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna", "plan_name": "700700", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna", "plan_name": "700700_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Mcare Ffs 6005", "plan_name": "700703", "standard_charge_dollar": 2972.29, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Miscellaneous", "plan_name": "700720", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Miscellaneous", "plan_name": "700720_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Ppo Hmo", "plan_name": "701720", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Ppo Hmo", "plan_name": "701720_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Ambetter 68069", "plan_name": "500516", "standard_charge_dollar": 2972.29, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Ms State Emplo", "plan_name": "401457", "standard_charge_percentage": 0.80, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Ms State Emplo", "plan_name": "401457_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Basic Pl", "plan_name": "400100", "standard_charge_percentage": 0.85, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Basic Pl", "plan_name": "400100_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Federal", "plan_name": "400110", "standard_charge_percentage": 0.85, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Federal", "plan_name": "400110_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Cigna Healthsprings Ffs", "plan_name": "500064", "standard_charge_dollar": 2972.29, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Conseco", "plan_name": "500302", "standard_charge_dollar": 2972.29, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Humana Ffs 61101", "plan_name": "500006", "standard_charge_dollar": 2972.29, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Medicare A", "plan_name": "100100", "standard_charge_dollar": 2972.29, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Medicare A", "plan_name": "100500", "standard_charge_dollar": 2972.29, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Medicare Part B Only", "plan_name": "100300", "standard_charge_dollar": 2972.29, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Medicare Railroad", "plan_name": "100103", "standard_charge_dollar": 2972.29, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Ms Physicians Care N", "plan_name": "714210", "standard_charge_dollar": 3715.36, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Peoples Hlth Ffs 72126", "plan_name": "500019", "standard_charge_dollar": 2972.29, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Uhc/Secure Horizons", "plan_name": "500449", "standard_charge_dollar": 2972.29, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "United Health Care/", "plan_name": "500292", "standard_charge_dollar": 3358.68, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "United Healthcare", "plan_name": "750104", "standard_charge_dollar": 3358.68, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "United Healthcare Ba", "plan_name": "750090", "standard_charge_dollar": 3358.68, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "United Healthcare Me", "plan_name": "501310", "standard_charge_dollar": 2972.29, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Windsor Mcare Extra", "plan_name": "500778", "standard_charge_dollar": 2972.29, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." } ] } ] }, { "description": "Removal of foot fascia", "code_information": [ { "code": "28062", "type": "CPT" } ], "standard_charges": [ { "gross_charge": 34797.67, "minimum": 2972.29, "maximum": 29578.02, "setting": "inpatient", "payers_information": [ { "payer_name": "Aarp", "plan_name": "500102", "standard_charge_dollar": 2972.29, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna", "plan_name": "700700", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna", "plan_name": "700700_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Mcare Ffs 6005", "plan_name": "700703", "standard_charge_dollar": 2972.29, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Miscellaneous", "plan_name": "700720", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Miscellaneous", "plan_name": "700720_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Ppo Hmo", "plan_name": "701720", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Ppo Hmo", "plan_name": "701720_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Ambetter 68069", "plan_name": "500516", "standard_charge_dollar": 2972.29, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Ms State Emplo", "plan_name": "401457", "standard_charge_percentage": 0.80, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Ms State Emplo", "plan_name": "401457_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Basic Pl", "plan_name": "400100", "standard_charge_percentage": 0.85, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Basic Pl", "plan_name": "400100_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Federal", "plan_name": "400110", "standard_charge_percentage": 0.85, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Federal", "plan_name": "400110_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Cigna Healthsprings Ffs", "plan_name": "500064", "standard_charge_dollar": 2972.29, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Conseco", "plan_name": "500302", "standard_charge_dollar": 2972.29, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Humana Ffs 61101", "plan_name": "500006", "standard_charge_dollar": 2972.29, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Medicare A", "plan_name": "100100", "standard_charge_dollar": 2972.29, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Medicare A", "plan_name": "100500", "standard_charge_dollar": 2972.29, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Medicare Part B Only", "plan_name": "100300", "standard_charge_dollar": 2972.29, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Medicare Railroad", "plan_name": "100103", "standard_charge_dollar": 2972.29, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Ms Physicians Care N", "plan_name": "714210", "standard_charge_dollar": 3715.36, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Peoples Hlth Ffs 72126", "plan_name": "500019", "standard_charge_dollar": 2972.29, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Uhc/Secure Horizons", "plan_name": "500449", "standard_charge_dollar": 2972.29, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "United Health Care/", "plan_name": "500292", "standard_charge_dollar": 3358.68, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "United Healthcare", "plan_name": "750104", "standard_charge_dollar": 3358.68, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "United Healthcare Ba", "plan_name": "750090", "standard_charge_dollar": 3358.68, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "United Healthcare Me", "plan_name": "501310", "standard_charge_dollar": 2972.29, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Windsor Mcare Extra", "plan_name": "500778", "standard_charge_dollar": 2972.29, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." } ] } ] }, { "description": "Removal of ankle/heel lesion", "code_information": [ { "code": "28100", "type": "CPT" } ], "standard_charges": [ { "gross_charge": 17192.12, "minimum": 2972.29, "maximum": 14613.30, "setting": "inpatient", "payers_information": [ { "payer_name": "Aarp", "plan_name": "500102", "standard_charge_dollar": 2972.29, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna", "plan_name": "700700", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna", "plan_name": "700700_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Mcare Ffs 6005", "plan_name": "700703", "standard_charge_dollar": 2972.29, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Miscellaneous", "plan_name": "700720", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Miscellaneous", "plan_name": "700720_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Ppo Hmo", "plan_name": "701720", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Ppo Hmo", "plan_name": "701720_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Ambetter 68069", "plan_name": "500516", "standard_charge_dollar": 2972.29, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Ms State Emplo", "plan_name": "401457", "standard_charge_percentage": 0.80, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Ms State Emplo", "plan_name": "401457_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Basic Pl", "plan_name": "400100", "standard_charge_percentage": 0.85, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Basic Pl", "plan_name": "400100_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Federal", "plan_name": "400110", "standard_charge_percentage": 0.85, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Federal", "plan_name": "400110_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Cigna Healthsprings Ffs", "plan_name": "500064", "standard_charge_dollar": 2972.29, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Conseco", "plan_name": "500302", "standard_charge_dollar": 2972.29, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Humana Ffs 61101", "plan_name": "500006", "standard_charge_dollar": 2972.29, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Medicare A", "plan_name": "100100", "standard_charge_dollar": 2972.29, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Medicare A", "plan_name": "100500", "standard_charge_dollar": 2972.29, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Medicare Part B Only", "plan_name": "100300", "standard_charge_dollar": 2972.29, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Medicare Railroad", "plan_name": "100103", "standard_charge_dollar": 2972.29, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Ms Physicians Care N", "plan_name": "714210", "standard_charge_dollar": 3715.36, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Peoples Hlth Ffs 72126", "plan_name": "500019", "standard_charge_dollar": 2972.29, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Uhc/Secure Horizons", "plan_name": "500449", "standard_charge_dollar": 2972.29, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "United Health Care/", "plan_name": "500292", "standard_charge_dollar": 3358.68, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "United Healthcare", "plan_name": "750104", "standard_charge_dollar": 3358.68, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "United Healthcare Ba", "plan_name": "750090", "standard_charge_dollar": 3358.68, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "United Healthcare Me", "plan_name": "501310", "standard_charge_dollar": 2972.29, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Windsor Mcare Extra", "plan_name": "500778", "standard_charge_dollar": 2972.29, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." } ] } ] }, { "description": "Remove/graft foot lesion", "code_information": [ { "code": "28102", "type": "CPT" } ], "standard_charges": [ { "gross_charge": 17192.12, "minimum": 6544.15, "maximum": 14613.30, "setting": "inpatient", "payers_information": [ { "payer_name": "Aarp", "plan_name": "500102", "standard_charge_dollar": 6544.15, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna", "plan_name": "700700", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna", "plan_name": "700700_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Mcare Ffs 6005", "plan_name": "700703", "standard_charge_dollar": 6544.15, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Miscellaneous", "plan_name": "700720", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Miscellaneous", "plan_name": "700720_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Ppo Hmo", "plan_name": "701720", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Ppo Hmo", "plan_name": "701720_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Ambetter 68069", "plan_name": "500516", "standard_charge_dollar": 6544.15, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Ms State Emplo", "plan_name": "401457", "standard_charge_percentage": 0.80, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Ms State Emplo", "plan_name": "401457_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Basic Pl", "plan_name": "400100", "standard_charge_percentage": 0.85, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Basic Pl", "plan_name": "400100_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Federal", "plan_name": "400110", "standard_charge_percentage": 0.85, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Federal", "plan_name": "400110_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Cigna Healthsprings Ffs", "plan_name": "500064", "standard_charge_dollar": 6544.15, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Conseco", "plan_name": "500302", "standard_charge_dollar": 6544.15, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Humana Ffs 61101", "plan_name": "500006", "standard_charge_dollar": 6544.15, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Medicare A", "plan_name": "100100", "standard_charge_dollar": 6544.15, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Medicare A", "plan_name": "100500", "standard_charge_dollar": 6544.15, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Medicare Part B Only", "plan_name": "100300", "standard_charge_dollar": 6544.15, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Medicare Railroad", "plan_name": "100103", "standard_charge_dollar": 6544.15, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Ms Physicians Care N", "plan_name": "714210", "standard_charge_dollar": 8180.19, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Peoples Hlth Ffs 72126", "plan_name": "500019", "standard_charge_dollar": 6544.15, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Uhc/Secure Horizons", "plan_name": "500449", "standard_charge_dollar": 6544.15, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "United Health Care/", "plan_name": "500292", "standard_charge_dollar": 7394.89, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "United Healthcare", "plan_name": "750104", "standard_charge_dollar": 7394.89, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "United Healthcare Ba", "plan_name": "750090", "standard_charge_dollar": 7394.89, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "United Healthcare Me", "plan_name": "501310", "standard_charge_dollar": 6544.15, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Windsor Mcare Extra", "plan_name": "500778", "standard_charge_dollar": 6544.15, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." } ] } ] }, { "description": "Remove/graft foot lesion", "code_information": [ { "code": "28103", "type": "CPT" } ], "standard_charges": [ { "gross_charge": 17192.12, "minimum": 6544.15, "maximum": 14613.30, "setting": "inpatient", "payers_information": [ { "payer_name": "Aarp", "plan_name": "500102", "standard_charge_dollar": 6544.15, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna", "plan_name": "700700", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna", "plan_name": "700700_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Mcare Ffs 6005", "plan_name": "700703", "standard_charge_dollar": 6544.15, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Miscellaneous", "plan_name": "700720", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Miscellaneous", "plan_name": "700720_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Ppo Hmo", "plan_name": "701720", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Ppo Hmo", "plan_name": "701720_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Ambetter 68069", "plan_name": "500516", "standard_charge_dollar": 6544.15, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Ms State Emplo", "plan_name": "401457", "standard_charge_percentage": 0.80, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Ms State Emplo", "plan_name": "401457_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Basic Pl", "plan_name": "400100", "standard_charge_percentage": 0.85, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Basic Pl", "plan_name": "400100_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Federal", "plan_name": "400110", "standard_charge_percentage": 0.85, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Federal", "plan_name": "400110_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Cigna Healthsprings Ffs", "plan_name": "500064", "standard_charge_dollar": 6544.15, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Conseco", "plan_name": "500302", "standard_charge_dollar": 6544.15, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Humana Ffs 61101", "plan_name": "500006", "standard_charge_dollar": 6544.15, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Medicare A", "plan_name": "100100", "standard_charge_dollar": 6544.15, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Medicare A", "plan_name": "100500", "standard_charge_dollar": 6544.15, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Medicare Part B Only", "plan_name": "100300", "standard_charge_dollar": 6544.15, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Medicare Railroad", "plan_name": "100103", "standard_charge_dollar": 6544.15, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Ms Physicians Care N", "plan_name": "714210", "standard_charge_dollar": 8180.19, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Peoples Hlth Ffs 72126", "plan_name": "500019", "standard_charge_dollar": 6544.15, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Uhc/Secure Horizons", "plan_name": "500449", "standard_charge_dollar": 6544.15, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "United Health Care/", "plan_name": "500292", "standard_charge_dollar": 7394.89, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "United Healthcare", "plan_name": "750104", "standard_charge_dollar": 7394.89, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "United Healthcare Ba", "plan_name": "750090", "standard_charge_dollar": 7394.89, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "United Healthcare Me", "plan_name": "501310", "standard_charge_dollar": 6544.15, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Windsor Mcare Extra", "plan_name": "500778", "standard_charge_dollar": 6544.15, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." } ] } ] }, { "description": "Removal of foot lesion", "code_information": [ { "code": "28104", "type": "CPT" } ], "standard_charges": [ { "gross_charge": 25756.12, "minimum": 2972.29, "maximum": 21892.70, "setting": "inpatient", "payers_information": [ { "payer_name": "Aarp", "plan_name": "500102", "standard_charge_dollar": 2972.29, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna", "plan_name": "700700", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna", "plan_name": "700700_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Mcare Ffs 6005", "plan_name": "700703", "standard_charge_dollar": 2972.29, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Miscellaneous", "plan_name": "700720", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Miscellaneous", "plan_name": "700720_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Ppo Hmo", "plan_name": "701720", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Ppo Hmo", "plan_name": "701720_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Ambetter 68069", "plan_name": "500516", "standard_charge_dollar": 2972.29, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Ms State Emplo", "plan_name": "401457", "standard_charge_percentage": 0.80, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Ms State Emplo", "plan_name": "401457_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Basic Pl", "plan_name": "400100", "standard_charge_percentage": 0.85, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Basic Pl", "plan_name": "400100_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Federal", "plan_name": "400110", "standard_charge_percentage": 0.85, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Federal", "plan_name": "400110_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Cigna Healthsprings Ffs", "plan_name": "500064", "standard_charge_dollar": 2972.29, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Conseco", "plan_name": "500302", "standard_charge_dollar": 2972.29, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Humana Ffs 61101", "plan_name": "500006", "standard_charge_dollar": 2972.29, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Medicare A", "plan_name": "100100", "standard_charge_dollar": 2972.29, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Medicare A", "plan_name": "100500", "standard_charge_dollar": 2972.29, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Medicare Part B Only", "plan_name": "100300", "standard_charge_dollar": 2972.29, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Medicare Railroad", "plan_name": "100103", "standard_charge_dollar": 2972.29, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Ms Physicians Care N", "plan_name": "714210", "standard_charge_dollar": 3715.36, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Peoples Hlth Ffs 72126", "plan_name": "500019", "standard_charge_dollar": 2972.29, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Uhc/Secure Horizons", "plan_name": "500449", "standard_charge_dollar": 2972.29, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "United Health Care/", "plan_name": "500292", "standard_charge_dollar": 3358.68, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "United Healthcare", "plan_name": "750104", "standard_charge_dollar": 3358.68, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "United Healthcare Ba", "plan_name": "750090", "standard_charge_dollar": 3358.68, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "United Healthcare Me", "plan_name": "501310", "standard_charge_dollar": 2972.29, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Windsor Mcare Extra", "plan_name": "500778", "standard_charge_dollar": 2972.29, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." } ] } ] }, { "description": "Remove/graft foot lesion", "code_information": [ { "code": "28106", "type": "CPT" } ], "standard_charges": [ { "gross_charge": 25756.12, "minimum": 6544.15, "maximum": 21892.70, "setting": "inpatient", "payers_information": [ { "payer_name": "Aarp", "plan_name": "500102", "standard_charge_dollar": 6544.15, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna", "plan_name": "700700", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna", "plan_name": "700700_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Mcare Ffs 6005", "plan_name": "700703", "standard_charge_dollar": 6544.15, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Miscellaneous", "plan_name": "700720", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Miscellaneous", "plan_name": "700720_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Ppo Hmo", "plan_name": "701720", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Ppo Hmo", "plan_name": "701720_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Ambetter 68069", "plan_name": "500516", "standard_charge_dollar": 6544.15, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Ms State Emplo", "plan_name": "401457", "standard_charge_percentage": 0.80, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Ms State Emplo", "plan_name": "401457_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Basic Pl", "plan_name": "400100", "standard_charge_percentage": 0.85, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Basic Pl", "plan_name": "400100_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Federal", "plan_name": "400110", "standard_charge_percentage": 0.85, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Federal", "plan_name": "400110_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Cigna Healthsprings Ffs", "plan_name": "500064", "standard_charge_dollar": 6544.15, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Conseco", "plan_name": "500302", "standard_charge_dollar": 6544.15, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Humana Ffs 61101", "plan_name": "500006", "standard_charge_dollar": 6544.15, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Medicare A", "plan_name": "100100", "standard_charge_dollar": 6544.15, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Medicare A", "plan_name": "100500", "standard_charge_dollar": 6544.15, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Medicare Part B Only", "plan_name": "100300", "standard_charge_dollar": 6544.15, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Medicare Railroad", "plan_name": "100103", "standard_charge_dollar": 6544.15, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Ms Physicians Care N", "plan_name": "714210", "standard_charge_dollar": 8180.19, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Peoples Hlth Ffs 72126", "plan_name": "500019", "standard_charge_dollar": 6544.15, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Uhc/Secure Horizons", "plan_name": "500449", "standard_charge_dollar": 6544.15, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "United Health Care/", "plan_name": "500292", "standard_charge_dollar": 7394.89, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "United Healthcare", "plan_name": "750104", "standard_charge_dollar": 7394.89, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "United Healthcare Ba", "plan_name": "750090", "standard_charge_dollar": 7394.89, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "United Healthcare Me", "plan_name": "501310", "standard_charge_dollar": 6544.15, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Windsor Mcare Extra", "plan_name": "500778", "standard_charge_dollar": 6544.15, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." } ] } ] }, { "description": "Remove/graft foot lesion", "code_information": [ { "code": "28107", "type": "CPT" } ], "standard_charges": [ { "gross_charge": 25756.12, "minimum": 6544.15, "maximum": 21892.70, "setting": "inpatient", "payers_information": [ { "payer_name": "Aarp", "plan_name": "500102", "standard_charge_dollar": 6544.15, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna", "plan_name": "700700", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna", "plan_name": "700700_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Mcare Ffs 6005", "plan_name": "700703", "standard_charge_dollar": 6544.15, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Miscellaneous", "plan_name": "700720", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Miscellaneous", "plan_name": "700720_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Ppo Hmo", "plan_name": "701720", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Ppo Hmo", "plan_name": "701720_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Ambetter 68069", "plan_name": "500516", "standard_charge_dollar": 6544.15, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Ms State Emplo", "plan_name": "401457", "standard_charge_percentage": 0.80, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Ms State Emplo", "plan_name": "401457_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Basic Pl", "plan_name": "400100", "standard_charge_percentage": 0.85, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Basic Pl", "plan_name": "400100_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Federal", "plan_name": "400110", "standard_charge_percentage": 0.85, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Federal", "plan_name": "400110_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Cigna Healthsprings Ffs", "plan_name": "500064", "standard_charge_dollar": 6544.15, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Conseco", "plan_name": "500302", "standard_charge_dollar": 6544.15, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Humana Ffs 61101", "plan_name": "500006", "standard_charge_dollar": 6544.15, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Medicare A", "plan_name": "100100", "standard_charge_dollar": 6544.15, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Medicare A", "plan_name": "100500", "standard_charge_dollar": 6544.15, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Medicare Part B Only", "plan_name": "100300", "standard_charge_dollar": 6544.15, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Medicare Railroad", "plan_name": "100103", "standard_charge_dollar": 6544.15, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Ms Physicians Care N", "plan_name": "714210", "standard_charge_dollar": 8180.19, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Peoples Hlth Ffs 72126", "plan_name": "500019", "standard_charge_dollar": 6544.15, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Uhc/Secure Horizons", "plan_name": "500449", "standard_charge_dollar": 6544.15, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "United Health Care/", "plan_name": "500292", "standard_charge_dollar": 7394.89, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "United Healthcare", "plan_name": "750104", "standard_charge_dollar": 7394.89, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "United Healthcare Ba", "plan_name": "750090", "standard_charge_dollar": 7394.89, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "United Healthcare Me", "plan_name": "501310", "standard_charge_dollar": 6544.15, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Windsor Mcare Extra", "plan_name": "500778", "standard_charge_dollar": 6544.15, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." } ] } ] }, { "description": "Part removal of metatarsal", "code_information": [ { "code": "28110", "type": "CPT" } ], "standard_charges": [ { "gross_charge": 27897.12, "minimum": 2972.29, "maximum": 23712.55, "setting": "inpatient", "payers_information": [ { "payer_name": "Aarp", "plan_name": "500102", "standard_charge_dollar": 2972.29, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna", "plan_name": "700700", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna", "plan_name": "700700_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Mcare Ffs 6005", "plan_name": "700703", "standard_charge_dollar": 2972.29, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Miscellaneous", "plan_name": "700720", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Miscellaneous", "plan_name": "700720_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Ppo Hmo", "plan_name": "701720", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Ppo Hmo", "plan_name": "701720_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Ambetter 68069", "plan_name": "500516", "standard_charge_dollar": 2972.29, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Ms State Emplo", "plan_name": "401457", "standard_charge_percentage": 0.80, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Ms State Emplo", "plan_name": "401457_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Basic Pl", "plan_name": "400100", "standard_charge_percentage": 0.85, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Basic Pl", "plan_name": "400100_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Federal", "plan_name": "400110", "standard_charge_percentage": 0.85, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Federal", "plan_name": "400110_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Cigna Healthsprings Ffs", "plan_name": "500064", "standard_charge_dollar": 2972.29, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Conseco", "plan_name": "500302", "standard_charge_dollar": 2972.29, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Humana Ffs 61101", "plan_name": "500006", "standard_charge_dollar": 2972.29, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Medicare A", "plan_name": "100100", "standard_charge_dollar": 2972.29, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Medicare A", "plan_name": "100500", "standard_charge_dollar": 2972.29, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Medicare Part B Only", "plan_name": "100300", "standard_charge_dollar": 2972.29, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Medicare Railroad", "plan_name": "100103", "standard_charge_dollar": 2972.29, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Ms Physicians Care N", "plan_name": "714210", "standard_charge_dollar": 3715.36, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Peoples Hlth Ffs 72126", "plan_name": "500019", "standard_charge_dollar": 2972.29, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Uhc/Secure Horizons", "plan_name": "500449", "standard_charge_dollar": 2972.29, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "United Health Care/", "plan_name": "500292", "standard_charge_dollar": 3358.68, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "United Healthcare", "plan_name": "750104", "standard_charge_dollar": 3358.68, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "United Healthcare Ba", "plan_name": "750090", "standard_charge_dollar": 3358.68, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "United Healthcare Me", "plan_name": "501310", "standard_charge_dollar": 2972.29, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Windsor Mcare Extra", "plan_name": "500778", "standard_charge_dollar": 2972.29, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." } ] } ] }, { "description": "Part removal of metatarsal", "code_information": [ { "code": "28111", "type": "CPT" } ], "standard_charges": [ { "gross_charge": 27897.12, "minimum": 2972.29, "maximum": 23712.55, "setting": "inpatient", "payers_information": [ { "payer_name": "Aarp", "plan_name": "500102", "standard_charge_dollar": 2972.29, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna", "plan_name": "700700", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna", "plan_name": "700700_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Mcare Ffs 6005", "plan_name": "700703", "standard_charge_dollar": 2972.29, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Miscellaneous", "plan_name": "700720", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Miscellaneous", "plan_name": "700720_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Ppo Hmo", "plan_name": "701720", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Ppo Hmo", "plan_name": "701720_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Ambetter 68069", "plan_name": "500516", "standard_charge_dollar": 2972.29, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Ms State Emplo", "plan_name": "401457", "standard_charge_percentage": 0.80, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Ms State Emplo", "plan_name": "401457_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Basic Pl", "plan_name": "400100", "standard_charge_percentage": 0.85, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Basic Pl", "plan_name": "400100_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Federal", "plan_name": "400110", "standard_charge_percentage": 0.85, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Federal", "plan_name": "400110_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Cigna Healthsprings Ffs", "plan_name": "500064", "standard_charge_dollar": 2972.29, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Conseco", "plan_name": "500302", "standard_charge_dollar": 2972.29, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Humana Ffs 61101", "plan_name": "500006", "standard_charge_dollar": 2972.29, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Medicare A", "plan_name": "100100", "standard_charge_dollar": 2972.29, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Medicare A", "plan_name": "100500", "standard_charge_dollar": 2972.29, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Medicare Part B Only", "plan_name": "100300", "standard_charge_dollar": 2972.29, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Medicare Railroad", "plan_name": "100103", "standard_charge_dollar": 2972.29, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Ms Physicians Care N", "plan_name": "714210", "standard_charge_dollar": 3715.36, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Peoples Hlth Ffs 72126", "plan_name": "500019", "standard_charge_dollar": 2972.29, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Uhc/Secure Horizons", "plan_name": "500449", "standard_charge_dollar": 2972.29, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "United Health Care/", "plan_name": "500292", "standard_charge_dollar": 3358.68, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "United Healthcare", "plan_name": "750104", "standard_charge_dollar": 3358.68, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "United Healthcare Ba", "plan_name": "750090", "standard_charge_dollar": 3358.68, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "United Healthcare Me", "plan_name": "501310", "standard_charge_dollar": 2972.29, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Windsor Mcare Extra", "plan_name": "500778", "standard_charge_dollar": 2972.29, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." } ] } ] }, { "description": "Part removal of metatarsal", "code_information": [ { "code": "28112", "type": "CPT" } ], "standard_charges": [ { "gross_charge": 27897.12, "minimum": 2972.29, "maximum": 23712.55, "setting": "inpatient", "payers_information": [ { "payer_name": "Aarp", "plan_name": "500102", "standard_charge_dollar": 2972.29, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna", "plan_name": "700700", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna", "plan_name": "700700_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Mcare Ffs 6005", "plan_name": "700703", "standard_charge_dollar": 2972.29, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Miscellaneous", "plan_name": "700720", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Miscellaneous", "plan_name": "700720_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Ppo Hmo", "plan_name": "701720", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Ppo Hmo", "plan_name": "701720_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Ambetter 68069", "plan_name": "500516", "standard_charge_dollar": 2972.29, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Ms State Emplo", "plan_name": "401457", "standard_charge_percentage": 0.80, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Ms State Emplo", "plan_name": "401457_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Basic Pl", "plan_name": "400100", "standard_charge_percentage": 0.85, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Basic Pl", "plan_name": "400100_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Federal", "plan_name": "400110", "standard_charge_percentage": 0.85, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Federal", "plan_name": "400110_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Cigna Healthsprings Ffs", "plan_name": "500064", "standard_charge_dollar": 2972.29, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Conseco", "plan_name": "500302", "standard_charge_dollar": 2972.29, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Humana Ffs 61101", "plan_name": "500006", "standard_charge_dollar": 2972.29, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Medicare A", "plan_name": "100100", "standard_charge_dollar": 2972.29, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Medicare A", "plan_name": "100500", "standard_charge_dollar": 2972.29, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Medicare Part B Only", "plan_name": "100300", "standard_charge_dollar": 2972.29, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Medicare Railroad", "plan_name": "100103", "standard_charge_dollar": 2972.29, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Ms Physicians Care N", "plan_name": "714210", "standard_charge_dollar": 3715.36, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Peoples Hlth Ffs 72126", "plan_name": "500019", "standard_charge_dollar": 2972.29, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Uhc/Secure Horizons", "plan_name": "500449", "standard_charge_dollar": 2972.29, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "United Health Care/", "plan_name": "500292", "standard_charge_dollar": 3358.68, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "United Healthcare", "plan_name": "750104", "standard_charge_dollar": 3358.68, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "United Healthcare Ba", "plan_name": "750090", "standard_charge_dollar": 3358.68, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "United Healthcare Me", "plan_name": "501310", "standard_charge_dollar": 2972.29, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Windsor Mcare Extra", "plan_name": "500778", "standard_charge_dollar": 2972.29, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." } ] } ] }, { "description": "Part removal of metatarsal", "code_information": [ { "code": "28113", "type": "CPT" } ], "standard_charges": [ { "gross_charge": 27897.12, "minimum": 2972.29, "maximum": 23712.55, "setting": "inpatient", "payers_information": [ { "payer_name": "Aarp", "plan_name": "500102", "standard_charge_dollar": 2972.29, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna", "plan_name": "700700", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna", "plan_name": "700700_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Mcare Ffs 6005", "plan_name": "700703", "standard_charge_dollar": 2972.29, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Miscellaneous", "plan_name": "700720", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Miscellaneous", "plan_name": "700720_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Ppo Hmo", "plan_name": "701720", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Ppo Hmo", "plan_name": "701720_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Ambetter 68069", "plan_name": "500516", "standard_charge_dollar": 2972.29, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Ms State Emplo", "plan_name": "401457", "standard_charge_percentage": 0.80, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Ms State Emplo", "plan_name": "401457_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Basic Pl", "plan_name": "400100", "standard_charge_percentage": 0.85, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Basic Pl", "plan_name": "400100_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Federal", "plan_name": "400110", "standard_charge_percentage": 0.85, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Federal", "plan_name": "400110_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Cigna Healthsprings Ffs", "plan_name": "500064", "standard_charge_dollar": 2972.29, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Conseco", "plan_name": "500302", "standard_charge_dollar": 2972.29, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Humana Ffs 61101", "plan_name": "500006", "standard_charge_dollar": 2972.29, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Medicare A", "plan_name": "100100", "standard_charge_dollar": 2972.29, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Medicare A", "plan_name": "100500", "standard_charge_dollar": 2972.29, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Medicare Part B Only", "plan_name": "100300", "standard_charge_dollar": 2972.29, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Medicare Railroad", "plan_name": "100103", "standard_charge_dollar": 2972.29, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Ms Physicians Care N", "plan_name": "714210", "standard_charge_dollar": 3715.36, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Peoples Hlth Ffs 72126", "plan_name": "500019", "standard_charge_dollar": 2972.29, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Uhc/Secure Horizons", "plan_name": "500449", "standard_charge_dollar": 2972.29, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "United Health Care/", "plan_name": "500292", "standard_charge_dollar": 3358.68, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "United Healthcare", "plan_name": "750104", "standard_charge_dollar": 3358.68, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "United Healthcare Ba", "plan_name": "750090", "standard_charge_dollar": 3358.68, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "United Healthcare Me", "plan_name": "501310", "standard_charge_dollar": 2972.29, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Windsor Mcare Extra", "plan_name": "500778", "standard_charge_dollar": 2972.29, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." } ] } ] }, { "description": "Removal of metatarsal heads", "code_information": [ { "code": "28114", "type": "CPT" } ], "standard_charges": [ { "gross_charge": 27897.12, "minimum": 2972.29, "maximum": 23712.55, "setting": "inpatient", "payers_information": [ { "payer_name": "Aarp", "plan_name": "500102", "standard_charge_dollar": 2972.29, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna", "plan_name": "700700", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna", "plan_name": "700700_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Mcare Ffs 6005", "plan_name": "700703", "standard_charge_dollar": 2972.29, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Miscellaneous", "plan_name": "700720", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Miscellaneous", "plan_name": "700720_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Ppo Hmo", "plan_name": "701720", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Ppo Hmo", "plan_name": "701720_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Ambetter 68069", "plan_name": "500516", "standard_charge_dollar": 2972.29, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Ms State Emplo", "plan_name": "401457", "standard_charge_percentage": 0.80, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Ms State Emplo", "plan_name": "401457_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Basic Pl", "plan_name": "400100", "standard_charge_percentage": 0.85, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Basic Pl", "plan_name": "400100_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Federal", "plan_name": "400110", "standard_charge_percentage": 0.85, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Federal", "plan_name": "400110_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Cigna Healthsprings Ffs", "plan_name": "500064", "standard_charge_dollar": 2972.29, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Conseco", "plan_name": "500302", "standard_charge_dollar": 2972.29, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Humana Ffs 61101", "plan_name": "500006", "standard_charge_dollar": 2972.29, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Medicare A", "plan_name": "100100", "standard_charge_dollar": 2972.29, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Medicare A", "plan_name": "100500", "standard_charge_dollar": 2972.29, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Medicare Part B Only", "plan_name": "100300", "standard_charge_dollar": 2972.29, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Medicare Railroad", "plan_name": "100103", "standard_charge_dollar": 2972.29, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Ms Physicians Care N", "plan_name": "714210", "standard_charge_dollar": 3715.36, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Peoples Hlth Ffs 72126", "plan_name": "500019", "standard_charge_dollar": 2972.29, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Uhc/Secure Horizons", "plan_name": "500449", "standard_charge_dollar": 2972.29, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "United Health Care/", "plan_name": "500292", "standard_charge_dollar": 3358.68, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "United Healthcare", "plan_name": "750104", "standard_charge_dollar": 3358.68, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "United Healthcare Ba", "plan_name": "750090", "standard_charge_dollar": 3358.68, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "United Healthcare Me", "plan_name": "501310", "standard_charge_dollar": 2972.29, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Windsor Mcare Extra", "plan_name": "500778", "standard_charge_dollar": 2972.29, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." } ] } ] }, { "description": "Removal of heel bone", "code_information": [ { "code": "28118", "type": "CPT" } ], "standard_charges": [ { "gross_charge": 17192.12, "minimum": 2972.29, "maximum": 14613.30, "setting": "inpatient", "payers_information": [ { "payer_name": "Aarp", "plan_name": "500102", "standard_charge_dollar": 2972.29, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna", "plan_name": "700700", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna", "plan_name": "700700_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Mcare Ffs 6005", "plan_name": "700703", "standard_charge_dollar": 2972.29, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Miscellaneous", "plan_name": "700720", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Miscellaneous", "plan_name": "700720_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Ppo Hmo", "plan_name": "701720", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Ppo Hmo", "plan_name": "701720_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Ambetter 68069", "plan_name": "500516", "standard_charge_dollar": 2972.29, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Ms State Emplo", "plan_name": "401457", "standard_charge_percentage": 0.80, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Ms State Emplo", "plan_name": "401457_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Basic Pl", "plan_name": "400100", "standard_charge_percentage": 0.85, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Basic Pl", "plan_name": "400100_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Federal", "plan_name": "400110", "standard_charge_percentage": 0.85, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Federal", "plan_name": "400110_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Cigna Healthsprings Ffs", "plan_name": "500064", "standard_charge_dollar": 2972.29, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Conseco", "plan_name": "500302", "standard_charge_dollar": 2972.29, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Humana Ffs 61101", "plan_name": "500006", "standard_charge_dollar": 2972.29, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Medicare A", "plan_name": "100100", "standard_charge_dollar": 2972.29, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Medicare A", "plan_name": "100500", "standard_charge_dollar": 2972.29, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Medicare Part B Only", "plan_name": "100300", "standard_charge_dollar": 2972.29, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Medicare Railroad", "plan_name": "100103", "standard_charge_dollar": 2972.29, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Ms Physicians Care N", "plan_name": "714210", "standard_charge_dollar": 3715.36, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Peoples Hlth Ffs 72126", "plan_name": "500019", "standard_charge_dollar": 2972.29, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Uhc/Secure Horizons", "plan_name": "500449", "standard_charge_dollar": 2972.29, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "United Health Care/", "plan_name": "500292", "standard_charge_dollar": 3358.68, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "United Healthcare", "plan_name": "750104", "standard_charge_dollar": 3358.68, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "United Healthcare Ba", "plan_name": "750090", "standard_charge_dollar": 3358.68, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "United Healthcare Me", "plan_name": "501310", "standard_charge_dollar": 2972.29, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Windsor Mcare Extra", "plan_name": "500778", "standard_charge_dollar": 2972.29, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." } ] } ] }, { "description": "Removal of heel spur", "code_information": [ { "code": "28119", "type": "CPT" } ], "standard_charges": [ { "gross_charge": 17192.12, "minimum": 2972.29, "maximum": 14613.30, "setting": "inpatient", "payers_information": [ { "payer_name": "Aarp", "plan_name": "500102", "standard_charge_dollar": 2972.29, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna", "plan_name": "700700", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna", "plan_name": "700700_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Mcare Ffs 6005", "plan_name": "700703", "standard_charge_dollar": 2972.29, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Miscellaneous", "plan_name": "700720", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Miscellaneous", "plan_name": "700720_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Ppo Hmo", "plan_name": "701720", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Ppo Hmo", "plan_name": "701720_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Ambetter 68069", "plan_name": "500516", "standard_charge_dollar": 2972.29, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Ms State Emplo", "plan_name": "401457", "standard_charge_percentage": 0.80, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Ms State Emplo", "plan_name": "401457_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Basic Pl", "plan_name": "400100", "standard_charge_percentage": 0.85, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Basic Pl", "plan_name": "400100_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Federal", "plan_name": "400110", "standard_charge_percentage": 0.85, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Federal", "plan_name": "400110_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Cigna Healthsprings Ffs", "plan_name": "500064", "standard_charge_dollar": 2972.29, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Conseco", "plan_name": "500302", "standard_charge_dollar": 2972.29, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Humana Ffs 61101", "plan_name": "500006", "standard_charge_dollar": 2972.29, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Medicare A", "plan_name": "100100", "standard_charge_dollar": 2972.29, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Medicare A", "plan_name": "100500", "standard_charge_dollar": 2972.29, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Medicare Part B Only", "plan_name": "100300", "standard_charge_dollar": 2972.29, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Medicare Railroad", "plan_name": "100103", "standard_charge_dollar": 2972.29, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Ms Physicians Care N", "plan_name": "714210", "standard_charge_dollar": 3715.36, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Peoples Hlth Ffs 72126", "plan_name": "500019", "standard_charge_dollar": 2972.29, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Uhc/Secure Horizons", "plan_name": "500449", "standard_charge_dollar": 2972.29, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "United Health Care/", "plan_name": "500292", "standard_charge_dollar": 3358.68, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "United Healthcare", "plan_name": "750104", "standard_charge_dollar": 3358.68, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "United Healthcare Ba", "plan_name": "750090", "standard_charge_dollar": 3358.68, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "United Healthcare Me", "plan_name": "501310", "standard_charge_dollar": 2972.29, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Windsor Mcare Extra", "plan_name": "500778", "standard_charge_dollar": 2972.29, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." } ] } ] }, { "description": "Part removal of ankle/heel", "code_information": [ { "code": "28120", "type": "CPT" } ], "standard_charges": [ { "gross_charge": 17192.12, "minimum": 2972.29, "maximum": 14613.30, "setting": "inpatient", "payers_information": [ { "payer_name": "Aarp", "plan_name": "500102", "standard_charge_dollar": 2972.29, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna", "plan_name": "700700", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna", "plan_name": "700700_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Mcare Ffs 6005", "plan_name": "700703", "standard_charge_dollar": 2972.29, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Miscellaneous", "plan_name": "700720", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Miscellaneous", "plan_name": "700720_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Ppo Hmo", "plan_name": "701720", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Ppo Hmo", "plan_name": "701720_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Ambetter 68069", "plan_name": "500516", "standard_charge_dollar": 2972.29, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Ms State Emplo", "plan_name": "401457", "standard_charge_percentage": 0.80, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Ms State Emplo", "plan_name": "401457_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Basic Pl", "plan_name": "400100", "standard_charge_percentage": 0.85, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Basic Pl", "plan_name": "400100_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Federal", "plan_name": "400110", "standard_charge_percentage": 0.85, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Federal", "plan_name": "400110_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Cigna Healthsprings Ffs", "plan_name": "500064", "standard_charge_dollar": 2972.29, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Conseco", "plan_name": "500302", "standard_charge_dollar": 2972.29, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Humana Ffs 61101", "plan_name": "500006", "standard_charge_dollar": 2972.29, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Medicare A", "plan_name": "100100", "standard_charge_dollar": 2972.29, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Medicare A", "plan_name": "100500", "standard_charge_dollar": 2972.29, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Medicare Part B Only", "plan_name": "100300", "standard_charge_dollar": 2972.29, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Medicare Railroad", "plan_name": "100103", "standard_charge_dollar": 2972.29, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Ms Physicians Care N", "plan_name": "714210", "standard_charge_dollar": 3715.36, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Peoples Hlth Ffs 72126", "plan_name": "500019", "standard_charge_dollar": 2972.29, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Uhc/Secure Horizons", "plan_name": "500449", "standard_charge_dollar": 2972.29, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "United Health Care/", "plan_name": "500292", "standard_charge_dollar": 3358.68, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "United Healthcare", "plan_name": "750104", "standard_charge_dollar": 3358.68, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "United Healthcare Ba", "plan_name": "750090", "standard_charge_dollar": 3358.68, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "United Healthcare Me", "plan_name": "501310", "standard_charge_dollar": 2972.29, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Windsor Mcare Extra", "plan_name": "500778", "standard_charge_dollar": 2972.29, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." } ] } ] }, { "description": "Partial removal of foot bone", "code_information": [ { "code": "28122", "type": "CPT" } ], "standard_charges": [ { "gross_charge": 25756.12, "minimum": 2972.29, "maximum": 21892.70, "setting": "inpatient", "payers_information": [ { "payer_name": "Aarp", "plan_name": "500102", "standard_charge_dollar": 2972.29, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna", "plan_name": "700700", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna", "plan_name": "700700_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Mcare Ffs 6005", "plan_name": "700703", "standard_charge_dollar": 2972.29, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Miscellaneous", "plan_name": "700720", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Miscellaneous", "plan_name": "700720_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Ppo Hmo", "plan_name": "701720", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Ppo Hmo", "plan_name": "701720_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Ambetter 68069", "plan_name": "500516", "standard_charge_dollar": 2972.29, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Ms State Emplo", "plan_name": "401457", "standard_charge_percentage": 0.80, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Ms State Emplo", "plan_name": "401457_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Basic Pl", "plan_name": "400100", "standard_charge_percentage": 0.85, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Basic Pl", "plan_name": "400100_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Federal", "plan_name": "400110", "standard_charge_percentage": 0.85, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Federal", "plan_name": "400110_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Cigna Healthsprings Ffs", "plan_name": "500064", "standard_charge_dollar": 2972.29, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Conseco", "plan_name": "500302", "standard_charge_dollar": 2972.29, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Humana Ffs 61101", "plan_name": "500006", "standard_charge_dollar": 2972.29, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Medicare A", "plan_name": "100100", "standard_charge_dollar": 2972.29, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Medicare A", "plan_name": "100500", "standard_charge_dollar": 2972.29, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Medicare Part B Only", "plan_name": "100300", "standard_charge_dollar": 2972.29, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Medicare Railroad", "plan_name": "100103", "standard_charge_dollar": 2972.29, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Ms Physicians Care N", "plan_name": "714210", "standard_charge_dollar": 3715.36, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Peoples Hlth Ffs 72126", "plan_name": "500019", "standard_charge_dollar": 2972.29, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Uhc/Secure Horizons", "plan_name": "500449", "standard_charge_dollar": 2972.29, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "United Health Care/", "plan_name": "500292", "standard_charge_dollar": 3358.68, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "United Healthcare", "plan_name": "750104", "standard_charge_dollar": 3358.68, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "United Healthcare Ba", "plan_name": "750090", "standard_charge_dollar": 3358.68, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "United Healthcare Me", "plan_name": "501310", "standard_charge_dollar": 2972.29, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Windsor Mcare Extra", "plan_name": "500778", "standard_charge_dollar": 2972.29, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." } ] } ] }, { "description": "Removal of ankle bone", "code_information": [ { "code": "28130", "type": "CPT" } ], "standard_charges": [ { "gross_charge": 17192.12, "minimum": 6544.15, "maximum": 14613.30, "setting": "inpatient", "payers_information": [ { "payer_name": "Aarp", "plan_name": "500102", "standard_charge_dollar": 6544.15, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna", "plan_name": "700700", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna", "plan_name": "700700_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Mcare Ffs 6005", "plan_name": "700703", "standard_charge_dollar": 6544.15, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Miscellaneous", "plan_name": "700720", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Miscellaneous", "plan_name": "700720_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Ppo Hmo", "plan_name": "701720", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Ppo Hmo", "plan_name": "701720_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Ambetter 68069", "plan_name": "500516", "standard_charge_dollar": 6544.15, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Ms State Emplo", "plan_name": "401457", "standard_charge_percentage": 0.80, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Ms State Emplo", "plan_name": "401457_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Basic Pl", "plan_name": "400100", "standard_charge_percentage": 0.85, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Basic Pl", "plan_name": "400100_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Federal", "plan_name": "400110", "standard_charge_percentage": 0.85, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Federal", "plan_name": "400110_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Cigna Healthsprings Ffs", "plan_name": "500064", "standard_charge_dollar": 6544.15, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Conseco", "plan_name": "500302", "standard_charge_dollar": 6544.15, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Humana Ffs 61101", "plan_name": "500006", "standard_charge_dollar": 6544.15, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Medicare A", "plan_name": "100100", "standard_charge_dollar": 6544.15, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Medicare A", "plan_name": "100500", "standard_charge_dollar": 6544.15, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Medicare Part B Only", "plan_name": "100300", "standard_charge_dollar": 6544.15, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Medicare Railroad", "plan_name": "100103", "standard_charge_dollar": 6544.15, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Ms Physicians Care N", "plan_name": "714210", "standard_charge_dollar": 8180.19, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Peoples Hlth Ffs 72126", "plan_name": "500019", "standard_charge_dollar": 6544.15, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Uhc/Secure Horizons", "plan_name": "500449", "standard_charge_dollar": 6544.15, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "United Health Care/", "plan_name": "500292", "standard_charge_dollar": 7394.89, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "United Healthcare", "plan_name": "750104", "standard_charge_dollar": 7394.89, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "United Healthcare Ba", "plan_name": "750090", "standard_charge_dollar": 7394.89, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "United Healthcare Me", "plan_name": "501310", "standard_charge_dollar": 6544.15, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Windsor Mcare Extra", "plan_name": "500778", "standard_charge_dollar": 6544.15, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." } ] } ] }, { "description": "Removal of metatarsal", "code_information": [ { "code": "28140", "type": "CPT" } ], "standard_charges": [ { "gross_charge": 27897.12, "minimum": 2972.29, "maximum": 23712.55, "setting": "inpatient", "payers_information": [ { "payer_name": "Aarp", "plan_name": "500102", "standard_charge_dollar": 2972.29, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna", "plan_name": "700700", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna", "plan_name": "700700_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Mcare Ffs 6005", "plan_name": "700703", "standard_charge_dollar": 2972.29, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Miscellaneous", "plan_name": "700720", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Miscellaneous", "plan_name": "700720_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Ppo Hmo", "plan_name": "701720", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Ppo Hmo", "plan_name": "701720_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Ambetter 68069", "plan_name": "500516", "standard_charge_dollar": 2972.29, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Ms State Emplo", "plan_name": "401457", "standard_charge_percentage": 0.80, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Ms State Emplo", "plan_name": "401457_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Basic Pl", "plan_name": "400100", "standard_charge_percentage": 0.85, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Basic Pl", "plan_name": "400100_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Federal", "plan_name": "400110", "standard_charge_percentage": 0.85, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Federal", "plan_name": "400110_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Cigna Healthsprings Ffs", "plan_name": "500064", "standard_charge_dollar": 2972.29, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Conseco", "plan_name": "500302", "standard_charge_dollar": 2972.29, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Humana Ffs 61101", "plan_name": "500006", "standard_charge_dollar": 2972.29, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Medicare A", "plan_name": "100100", "standard_charge_dollar": 2972.29, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Medicare A", "plan_name": "100500", "standard_charge_dollar": 2972.29, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Medicare Part B Only", "plan_name": "100300", "standard_charge_dollar": 2972.29, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Medicare Railroad", "plan_name": "100103", "standard_charge_dollar": 2972.29, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Ms Physicians Care N", "plan_name": "714210", "standard_charge_dollar": 3715.36, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Peoples Hlth Ffs 72126", "plan_name": "500019", "standard_charge_dollar": 2972.29, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Uhc/Secure Horizons", "plan_name": "500449", "standard_charge_dollar": 2972.29, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "United Health Care/", "plan_name": "500292", "standard_charge_dollar": 3358.68, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "United Healthcare", "plan_name": "750104", "standard_charge_dollar": 3358.68, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "United Healthcare Ba", "plan_name": "750090", "standard_charge_dollar": 3358.68, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "United Healthcare Me", "plan_name": "501310", "standard_charge_dollar": 2972.29, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Windsor Mcare Extra", "plan_name": "500778", "standard_charge_dollar": 2972.29, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." } ] } ] }, { "description": "Partial removal of toe", "code_information": [ { "code": "28153", "type": "CPT" } ], "standard_charges": [ { "gross_charge": 30757.77, "minimum": 2972.29, "maximum": 26144.10, "setting": "inpatient", "payers_information": [ { "payer_name": "Aarp", "plan_name": "500102", "standard_charge_dollar": 2972.29, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna", "plan_name": "700700", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna", "plan_name": "700700_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Mcare Ffs 6005", "plan_name": "700703", "standard_charge_dollar": 2972.29, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Miscellaneous", "plan_name": "700720", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Miscellaneous", "plan_name": "700720_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Ppo Hmo", "plan_name": "701720", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Ppo Hmo", "plan_name": "701720_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Ambetter 68069", "plan_name": "500516", "standard_charge_dollar": 2972.29, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Ms State Emplo", "plan_name": "401457", "standard_charge_percentage": 0.80, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Ms State Emplo", "plan_name": "401457_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Basic Pl", "plan_name": "400100", "standard_charge_percentage": 0.85, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Basic Pl", "plan_name": "400100_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Federal", "plan_name": "400110", "standard_charge_percentage": 0.85, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Federal", "plan_name": "400110_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Cigna Healthsprings Ffs", "plan_name": "500064", "standard_charge_dollar": 2972.29, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Conseco", "plan_name": "500302", "standard_charge_dollar": 2972.29, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Humana Ffs 61101", "plan_name": "500006", "standard_charge_dollar": 2972.29, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Medicare A", "plan_name": "100100", "standard_charge_dollar": 2972.29, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Medicare A", "plan_name": "100500", "standard_charge_dollar": 2972.29, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Medicare Part B Only", "plan_name": "100300", "standard_charge_dollar": 2972.29, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Medicare Railroad", "plan_name": "100103", "standard_charge_dollar": 2972.29, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Ms Physicians Care N", "plan_name": "714210", "standard_charge_dollar": 3715.36, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Peoples Hlth Ffs 72126", "plan_name": "500019", "standard_charge_dollar": 2972.29, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Uhc/Secure Horizons", "plan_name": "500449", "standard_charge_dollar": 2972.29, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "United Health Care/", "plan_name": "500292", "standard_charge_dollar": 3358.68, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "United Healthcare", "plan_name": "750104", "standard_charge_dollar": 3358.68, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "United Healthcare Ba", "plan_name": "750090", "standard_charge_dollar": 3358.68, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "United Healthcare Me", "plan_name": "501310", "standard_charge_dollar": 2972.29, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Windsor Mcare Extra", "plan_name": "500778", "standard_charge_dollar": 2972.29, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." } ] } ] }, { "description": "Resect tarsal tumor", "code_information": [ { "code": "28171", "type": "CPT" } ], "standard_charges": [ { "gross_charge": 17192.12, "minimum": 2972.29, "maximum": 14613.30, "setting": "inpatient", "payers_information": [ { "payer_name": "Aarp", "plan_name": "500102", "standard_charge_dollar": 2972.29, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna", "plan_name": "700700", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna", "plan_name": "700700_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Mcare Ffs 6005", "plan_name": "700703", "standard_charge_dollar": 2972.29, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Miscellaneous", "plan_name": "700720", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Miscellaneous", "plan_name": "700720_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Ppo Hmo", "plan_name": "701720", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Ppo Hmo", "plan_name": "701720_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Ambetter 68069", "plan_name": "500516", "standard_charge_dollar": 2972.29, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Ms State Emplo", "plan_name": "401457", "standard_charge_percentage": 0.80, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Ms State Emplo", "plan_name": "401457_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Basic Pl", "plan_name": "400100", "standard_charge_percentage": 0.85, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Basic Pl", "plan_name": "400100_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Federal", "plan_name": "400110", "standard_charge_percentage": 0.85, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Federal", "plan_name": "400110_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Cigna Healthsprings Ffs", "plan_name": "500064", "standard_charge_dollar": 2972.29, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Conseco", "plan_name": "500302", "standard_charge_dollar": 2972.29, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Humana Ffs 61101", "plan_name": "500006", "standard_charge_dollar": 2972.29, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Medicare A", "plan_name": "100100", "standard_charge_dollar": 2972.29, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Medicare A", "plan_name": "100500", "standard_charge_dollar": 2972.29, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Medicare Part B Only", "plan_name": "100300", "standard_charge_dollar": 2972.29, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Medicare Railroad", "plan_name": "100103", "standard_charge_dollar": 2972.29, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Ms Physicians Care N", "plan_name": "714210", "standard_charge_dollar": 3715.36, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Peoples Hlth Ffs 72126", "plan_name": "500019", "standard_charge_dollar": 2972.29, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Uhc/Secure Horizons", "plan_name": "500449", "standard_charge_dollar": 2972.29, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "United Health Care/", "plan_name": "500292", "standard_charge_dollar": 3358.68, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "United Healthcare", "plan_name": "750104", "standard_charge_dollar": 3358.68, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "United Healthcare Ba", "plan_name": "750090", "standard_charge_dollar": 3358.68, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "United Healthcare Me", "plan_name": "501310", "standard_charge_dollar": 2972.29, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Windsor Mcare Extra", "plan_name": "500778", "standard_charge_dollar": 2972.29, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." } ] } ] }, { "description": "Resect metatarsal tumor", "code_information": [ { "code": "28173", "type": "CPT" } ], "standard_charges": [ { "gross_charge": 27897.12, "minimum": 2972.29, "maximum": 23712.55, "setting": "inpatient", "payers_information": [ { "payer_name": "Aarp", "plan_name": "500102", "standard_charge_dollar": 2972.29, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna", "plan_name": "700700", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna", "plan_name": "700700_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Mcare Ffs 6005", "plan_name": "700703", "standard_charge_dollar": 2972.29, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Miscellaneous", "plan_name": "700720", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Miscellaneous", "plan_name": "700720_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Ppo Hmo", "plan_name": "701720", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Ppo Hmo", "plan_name": "701720_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Ambetter 68069", "plan_name": "500516", "standard_charge_dollar": 2972.29, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Ms State Emplo", "plan_name": "401457", "standard_charge_percentage": 0.80, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Ms State Emplo", "plan_name": "401457_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Basic Pl", "plan_name": "400100", "standard_charge_percentage": 0.85, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Basic Pl", "plan_name": "400100_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Federal", "plan_name": "400110", "standard_charge_percentage": 0.85, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Federal", "plan_name": "400110_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Cigna Healthsprings Ffs", "plan_name": "500064", "standard_charge_dollar": 2972.29, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Conseco", "plan_name": "500302", "standard_charge_dollar": 2972.29, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Humana Ffs 61101", "plan_name": "500006", "standard_charge_dollar": 2972.29, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Medicare A", "plan_name": "100100", "standard_charge_dollar": 2972.29, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Medicare A", "plan_name": "100500", "standard_charge_dollar": 2972.29, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Medicare Part B Only", "plan_name": "100300", "standard_charge_dollar": 2972.29, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Medicare Railroad", "plan_name": "100103", "standard_charge_dollar": 2972.29, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Ms Physicians Care N", "plan_name": "714210", "standard_charge_dollar": 3715.36, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Peoples Hlth Ffs 72126", "plan_name": "500019", "standard_charge_dollar": 2972.29, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Uhc/Secure Horizons", "plan_name": "500449", "standard_charge_dollar": 2972.29, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "United Health Care/", "plan_name": "500292", "standard_charge_dollar": 3358.68, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "United Healthcare", "plan_name": "750104", "standard_charge_dollar": 3358.68, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "United Healthcare Ba", "plan_name": "750090", "standard_charge_dollar": 3358.68, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "United Healthcare Me", "plan_name": "501310", "standard_charge_dollar": 2972.29, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Windsor Mcare Extra", "plan_name": "500778", "standard_charge_dollar": 2972.29, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." } ] } ] }, { "description": "Hc fb rem foot subcutaneous", "code_information": [ { "code": "28190", "type": "CPT" } ], "standard_charges": [ { "gross_charge": 1038.00, "minimum": 644.54, "maximum": 882.30, "setting": "both", "payers_information": [ { "payer_name": "Aarp", "plan_name": "500102", "standard_charge_dollar": 644.54, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna", "plan_name": "700700", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna", "plan_name": "700700_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Mcare Ffs 6005", "plan_name": "700703", "standard_charge_dollar": 644.54, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Miscellaneous", "plan_name": "700720", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Miscellaneous", "plan_name": "700720_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Ppo Hmo", "plan_name": "701720", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Ppo Hmo", "plan_name": "701720_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Ambetter 68069", "plan_name": "500516", "standard_charge_dollar": 644.54, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Ms State Emplo", "plan_name": "401457", "standard_charge_percentage": 0.80, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Ms State Emplo", "plan_name": "401457_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Basic Pl", "plan_name": "400100", "standard_charge_percentage": 0.85, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Basic Pl", "plan_name": "400100_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Federal", "plan_name": "400110", "standard_charge_percentage": 0.85, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Federal", "plan_name": "400110_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Cigna Healthsprings Ffs", "plan_name": "500064", "standard_charge_dollar": 644.54, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Conseco", "plan_name": "500302", "standard_charge_dollar": 644.54, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Humana Ffs 61101", "plan_name": "500006", "standard_charge_dollar": 644.54, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Medicare A", "plan_name": "100100", "standard_charge_dollar": 644.54, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Medicare A", "plan_name": "100500", "standard_charge_dollar": 644.54, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Medicare Part B Only", "plan_name": "100300", "standard_charge_dollar": 644.54, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Medicare Railroad", "plan_name": "100103", "standard_charge_dollar": 644.54, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Ms Physicians Care N", "plan_name": "714210", "standard_charge_dollar": 805.67, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Peoples Hlth Ffs 72126", "plan_name": "500019", "standard_charge_dollar": 644.54, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Uhc/Secure Horizons", "plan_name": "500449", "standard_charge_dollar": 644.54, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "United Health Care/", "plan_name": "500292", "standard_charge_dollar": 728.33, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "United Healthcare", "plan_name": "750104", "standard_charge_dollar": 728.33, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "United Healthcare Ba", "plan_name": "750090", "standard_charge_dollar": 728.33, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "United Healthcare Me", "plan_name": "501310", "standard_charge_dollar": 644.54, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Windsor Mcare Extra", "plan_name": "500778", "standard_charge_dollar": 644.54, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." } ] } ] }, { "description": "Removal of foot foreign body", "code_information": [ { "code": "28190", "type": "CPT" } ], "standard_charges": [ { "gross_charge": 21354.16, "minimum": 644.54, "maximum": 18151.04, "setting": "inpatient", "payers_information": [ { "payer_name": "Aarp", "plan_name": "500102", "standard_charge_dollar": 644.54, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna", "plan_name": "700700", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna", "plan_name": "700700_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Mcare Ffs 6005", "plan_name": "700703", "standard_charge_dollar": 644.54, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Miscellaneous", "plan_name": "700720", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Miscellaneous", "plan_name": "700720_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Ppo Hmo", "plan_name": "701720", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Ppo Hmo", "plan_name": "701720_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Ambetter 68069", "plan_name": "500516", "standard_charge_dollar": 644.54, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Ms State Emplo", "plan_name": "401457", "standard_charge_percentage": 0.80, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Ms State Emplo", "plan_name": "401457_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Basic Pl", "plan_name": "400100", "standard_charge_percentage": 0.85, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Basic Pl", "plan_name": "400100_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Federal", "plan_name": "400110", "standard_charge_percentage": 0.85, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Federal", "plan_name": "400110_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Cigna Healthsprings Ffs", "plan_name": "500064", "standard_charge_dollar": 644.54, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Conseco", "plan_name": "500302", "standard_charge_dollar": 644.54, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Humana Ffs 61101", "plan_name": "500006", "standard_charge_dollar": 644.54, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Medicare A", "plan_name": "100100", "standard_charge_dollar": 644.54, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Medicare A", "plan_name": "100500", "standard_charge_dollar": 644.54, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Medicare Part B Only", "plan_name": "100300", "standard_charge_dollar": 644.54, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Medicare Railroad", "plan_name": "100103", "standard_charge_dollar": 644.54, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Ms Physicians Care N", "plan_name": "714210", "standard_charge_dollar": 805.67, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Peoples Hlth Ffs 72126", "plan_name": "500019", "standard_charge_dollar": 644.54, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Uhc/Secure Horizons", "plan_name": "500449", "standard_charge_dollar": 644.54, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "United Health Care/", "plan_name": "500292", "standard_charge_dollar": 728.33, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "United Healthcare", "plan_name": "750104", "standard_charge_dollar": 728.33, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "United Healthcare Ba", "plan_name": "750090", "standard_charge_dollar": 728.33, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "United Healthcare Me", "plan_name": "501310", "standard_charge_dollar": 644.54, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Windsor Mcare Extra", "plan_name": "500778", "standard_charge_dollar": 644.54, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." } ] } ] }, { "description": "Removal of foot foreign body", "code_information": [ { "code": "28190", "type": "CPT" } ], "standard_charges": [ { "gross_charge": 1038.00, "minimum": 644.54, "maximum": 882.30, "setting": "outpatient", "payers_information": [ { "payer_name": "Aarp", "plan_name": "500102", "standard_charge_dollar": 644.54, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna", "plan_name": "700700", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna", "plan_name": "700700_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Mcare Ffs 6005", "plan_name": "700703", "standard_charge_dollar": 644.54, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Miscellaneous", "plan_name": "700720", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Miscellaneous", "plan_name": "700720_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Ppo Hmo", "plan_name": "701720", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Ppo Hmo", "plan_name": "701720_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Ambetter 68069", "plan_name": "500516", "standard_charge_dollar": 644.54, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Ms State Emplo", "plan_name": "401457", "standard_charge_percentage": 0.80, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Ms State Emplo", "plan_name": "401457_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Basic Pl", "plan_name": "400100", "standard_charge_percentage": 0.85, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Basic Pl", "plan_name": "400100_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Federal", "plan_name": "400110", "standard_charge_percentage": 0.85, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Federal", "plan_name": "400110_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Cigna Healthsprings Ffs", "plan_name": "500064", "standard_charge_dollar": 644.54, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Conseco", "plan_name": "500302", "standard_charge_dollar": 644.54, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Humana Ffs 61101", "plan_name": "500006", "standard_charge_dollar": 644.54, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Medicare A", "plan_name": "100100", "standard_charge_dollar": 644.54, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Medicare A", "plan_name": "100500", "standard_charge_dollar": 644.54, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Medicare Part B Only", "plan_name": "100300", "standard_charge_dollar": 644.54, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Medicare Railroad", "plan_name": "100103", "standard_charge_dollar": 644.54, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Ms Physicians Care N", "plan_name": "714210", "standard_charge_dollar": 805.67, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Peoples Hlth Ffs 72126", "plan_name": "500019", "standard_charge_dollar": 644.54, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Uhc/Secure Horizons", "plan_name": "500449", "standard_charge_dollar": 644.54, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "United Health Care/", "plan_name": "500292", "standard_charge_dollar": 728.33, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "United Healthcare", "plan_name": "750104", "standard_charge_dollar": 728.33, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "United Healthcare Ba", "plan_name": "750090", "standard_charge_dollar": 728.33, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "United Healthcare Me", "plan_name": "501310", "standard_charge_dollar": 644.54, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Windsor Mcare Extra", "plan_name": "500778", "standard_charge_dollar": 644.54, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." } ] } ] }, { "description": "Removal of foot foreign body", "code_information": [ { "code": "28192", "type": "CPT" } ], "standard_charges": [ { "gross_charge": 21354.16, "minimum": 1484.25, "maximum": 18151.04, "setting": "inpatient", "payers_information": [ { "payer_name": "Aarp", "plan_name": "500102", "standard_charge_dollar": 1484.25, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna", "plan_name": "700700", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna", "plan_name": "700700_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Mcare Ffs 6005", "plan_name": "700703", "standard_charge_dollar": 1484.25, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Miscellaneous", "plan_name": "700720", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Miscellaneous", "plan_name": "700720_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Ppo Hmo", "plan_name": "701720", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Ppo Hmo", "plan_name": "701720_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Ambetter 68069", "plan_name": "500516", "standard_charge_dollar": 1484.25, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Ms State Emplo", "plan_name": "401457", "standard_charge_percentage": 0.80, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Ms State Emplo", "plan_name": "401457_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Basic Pl", "plan_name": "400100", "standard_charge_percentage": 0.85, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Basic Pl", "plan_name": "400100_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Federal", "plan_name": "400110", "standard_charge_percentage": 0.85, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Federal", "plan_name": "400110_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Cigna Healthsprings Ffs", "plan_name": "500064", "standard_charge_dollar": 1484.25, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Conseco", "plan_name": "500302", "standard_charge_dollar": 1484.25, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Humana Ffs 61101", "plan_name": "500006", "standard_charge_dollar": 1484.25, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Medicare A", "plan_name": "100100", "standard_charge_dollar": 1484.25, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Medicare A", "plan_name": "100500", "standard_charge_dollar": 1484.25, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Medicare Part B Only", "plan_name": "100300", "standard_charge_dollar": 1484.25, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Medicare Railroad", "plan_name": "100103", "standard_charge_dollar": 1484.25, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Ms Physicians Care N", "plan_name": "714210", "standard_charge_dollar": 1855.31, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Peoples Hlth Ffs 72126", "plan_name": "500019", "standard_charge_dollar": 1484.25, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Uhc/Secure Horizons", "plan_name": "500449", "standard_charge_dollar": 1484.25, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "United Health Care/", "plan_name": "500292", "standard_charge_dollar": 1677.20, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "United Healthcare", "plan_name": "750104", "standard_charge_dollar": 1677.20, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "United Healthcare Ba", "plan_name": "750090", "standard_charge_dollar": 1677.20, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "United Healthcare Me", "plan_name": "501310", "standard_charge_dollar": 1484.25, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Windsor Mcare Extra", "plan_name": "500778", "standard_charge_dollar": 1484.25, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." } ] } ] }, { "description": "Removal of foot foreign body", "code_information": [ { "code": "28193", "type": "CPT" } ], "standard_charges": [ { "gross_charge": 21354.16, "minimum": 1484.25, "maximum": 18151.04, "setting": "inpatient", "payers_information": [ { "payer_name": "Aarp", "plan_name": "500102", "standard_charge_dollar": 1484.25, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna", "plan_name": "700700", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna", "plan_name": "700700_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Mcare Ffs 6005", "plan_name": "700703", "standard_charge_dollar": 1484.25, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Miscellaneous", "plan_name": "700720", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Miscellaneous", "plan_name": "700720_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Ppo Hmo", "plan_name": "701720", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Ppo Hmo", "plan_name": "701720_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Ambetter 68069", "plan_name": "500516", "standard_charge_dollar": 1484.25, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Ms State Emplo", "plan_name": "401457", "standard_charge_percentage": 0.80, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Ms State Emplo", "plan_name": "401457_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Basic Pl", "plan_name": "400100", "standard_charge_percentage": 0.85, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Basic Pl", "plan_name": "400100_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Federal", "plan_name": "400110", "standard_charge_percentage": 0.85, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Federal", "plan_name": "400110_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Cigna Healthsprings Ffs", "plan_name": "500064", "standard_charge_dollar": 1484.25, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Conseco", "plan_name": "500302", "standard_charge_dollar": 1484.25, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Humana Ffs 61101", "plan_name": "500006", "standard_charge_dollar": 1484.25, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Medicare A", "plan_name": "100100", "standard_charge_dollar": 1484.25, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Medicare A", "plan_name": "100500", "standard_charge_dollar": 1484.25, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Medicare Part B Only", "plan_name": "100300", "standard_charge_dollar": 1484.25, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Medicare Railroad", "plan_name": "100103", "standard_charge_dollar": 1484.25, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Ms Physicians Care N", "plan_name": "714210", "standard_charge_dollar": 1855.31, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Peoples Hlth Ffs 72126", "plan_name": "500019", "standard_charge_dollar": 1484.25, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Uhc/Secure Horizons", "plan_name": "500449", "standard_charge_dollar": 1484.25, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "United Health Care/", "plan_name": "500292", "standard_charge_dollar": 1677.20, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "United Healthcare", "plan_name": "750104", "standard_charge_dollar": 1677.20, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "United Healthcare Ba", "plan_name": "750090", "standard_charge_dollar": 1677.20, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "United Healthcare Me", "plan_name": "501310", "standard_charge_dollar": 1484.25, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Windsor Mcare Extra", "plan_name": "500778", "standard_charge_dollar": 1484.25, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." } ] } ] }, { "description": "Revision of foot tendon", "code_information": [ { "code": "28238", "type": "CPT" } ], "standard_charges": [ { "gross_charge": 17192.12, "minimum": 6544.15, "maximum": 14613.30, "setting": "inpatient", "payers_information": [ { "payer_name": "Aarp", "plan_name": "500102", "standard_charge_dollar": 6544.15, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna", "plan_name": "700700", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna", "plan_name": "700700_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Mcare Ffs 6005", "plan_name": "700703", "standard_charge_dollar": 6544.15, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Miscellaneous", "plan_name": "700720", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Miscellaneous", "plan_name": "700720_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Ppo Hmo", "plan_name": "701720", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Ppo Hmo", "plan_name": "701720_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Ambetter 68069", "plan_name": "500516", "standard_charge_dollar": 6544.15, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Ms State Emplo", "plan_name": "401457", "standard_charge_percentage": 0.80, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Ms State Emplo", "plan_name": "401457_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Basic Pl", "plan_name": "400100", "standard_charge_percentage": 0.85, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Basic Pl", "plan_name": "400100_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Federal", "plan_name": "400110", "standard_charge_percentage": 0.85, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Federal", "plan_name": "400110_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Cigna Healthsprings Ffs", "plan_name": "500064", "standard_charge_dollar": 6544.15, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Conseco", "plan_name": "500302", "standard_charge_dollar": 6544.15, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Humana Ffs 61101", "plan_name": "500006", "standard_charge_dollar": 6544.15, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Medicare A", "plan_name": "100100", "standard_charge_dollar": 6544.15, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Medicare A", "plan_name": "100500", "standard_charge_dollar": 6544.15, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Medicare Part B Only", "plan_name": "100300", "standard_charge_dollar": 6544.15, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Medicare Railroad", "plan_name": "100103", "standard_charge_dollar": 6544.15, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Ms Physicians Care N", "plan_name": "714210", "standard_charge_dollar": 8180.19, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Peoples Hlth Ffs 72126", "plan_name": "500019", "standard_charge_dollar": 6544.15, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Uhc/Secure Horizons", "plan_name": "500449", "standard_charge_dollar": 6544.15, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "United Health Care/", "plan_name": "500292", "standard_charge_dollar": 7394.89, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "United Healthcare", "plan_name": "750104", "standard_charge_dollar": 7394.89, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "United Healthcare Ba", "plan_name": "750090", "standard_charge_dollar": 7394.89, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "United Healthcare Me", "plan_name": "501310", "standard_charge_dollar": 6544.15, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Windsor Mcare Extra", "plan_name": "500778", "standard_charge_dollar": 6544.15, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." } ] } ] }, { "description": "Partial removal of foot bone", "code_information": [ { "code": "28288", "type": "CPT" } ], "standard_charges": [ { "gross_charge": 27897.12, "minimum": 2972.29, "maximum": 23712.55, "setting": "inpatient", "payers_information": [ { "payer_name": "Aarp", "plan_name": "500102", "standard_charge_dollar": 2972.29, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna", "plan_name": "700700", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna", "plan_name": "700700_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Mcare Ffs 6005", "plan_name": "700703", "standard_charge_dollar": 2972.29, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Miscellaneous", "plan_name": "700720", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Miscellaneous", "plan_name": "700720_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Ppo Hmo", "plan_name": "701720", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Ppo Hmo", "plan_name": "701720_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Ambetter 68069", "plan_name": "500516", "standard_charge_dollar": 2972.29, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Ms State Emplo", "plan_name": "401457", "standard_charge_percentage": 0.80, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Ms State Emplo", "plan_name": "401457_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Basic Pl", "plan_name": "400100", "standard_charge_percentage": 0.85, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Basic Pl", "plan_name": "400100_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Federal", "plan_name": "400110", "standard_charge_percentage": 0.85, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Federal", "plan_name": "400110_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Cigna Healthsprings Ffs", "plan_name": "500064", "standard_charge_dollar": 2972.29, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Conseco", "plan_name": "500302", "standard_charge_dollar": 2972.29, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Humana Ffs 61101", "plan_name": "500006", "standard_charge_dollar": 2972.29, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Medicare A", "plan_name": "100100", "standard_charge_dollar": 2972.29, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Medicare A", "plan_name": "100500", "standard_charge_dollar": 2972.29, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Medicare Part B Only", "plan_name": "100300", "standard_charge_dollar": 2972.29, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Medicare Railroad", "plan_name": "100103", "standard_charge_dollar": 2972.29, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Ms Physicians Care N", "plan_name": "714210", "standard_charge_dollar": 3715.36, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Peoples Hlth Ffs 72126", "plan_name": "500019", "standard_charge_dollar": 2972.29, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Uhc/Secure Horizons", "plan_name": "500449", "standard_charge_dollar": 2972.29, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "United Health Care/", "plan_name": "500292", "standard_charge_dollar": 3358.68, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "United Healthcare", "plan_name": "750104", "standard_charge_dollar": 3358.68, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "United Healthcare Ba", "plan_name": "750090", "standard_charge_dollar": 3358.68, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "United Healthcare Me", "plan_name": "501310", "standard_charge_dollar": 2972.29, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Windsor Mcare Extra", "plan_name": "500778", "standard_charge_dollar": 2972.29, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." } ] } ] }, { "description": "Corrj halux rigdus w/implt", "code_information": [ { "code": "28291", "type": "CPT" } ], "standard_charges": [ { "gross_charge": 27897.12, "minimum": 6544.15, "maximum": 23712.55, "setting": "inpatient", "payers_information": [ { "payer_name": "Aarp", "plan_name": "500102", "standard_charge_dollar": 6544.15, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna", "plan_name": "700700", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna", "plan_name": "700700_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Mcare Ffs 6005", "plan_name": "700703", "standard_charge_dollar": 6544.15, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Miscellaneous", "plan_name": "700720", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Miscellaneous", "plan_name": "700720_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Ppo Hmo", "plan_name": "701720", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Ppo Hmo", "plan_name": "701720_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Ambetter 68069", "plan_name": "500516", "standard_charge_dollar": 6544.15, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Ms State Emplo", "plan_name": "401457", "standard_charge_percentage": 0.80, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Ms State Emplo", "plan_name": "401457_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Basic Pl", "plan_name": "400100", "standard_charge_percentage": 0.85, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Basic Pl", "plan_name": "400100_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Federal", "plan_name": "400110", "standard_charge_percentage": 0.85, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Federal", "plan_name": "400110_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Cigna Healthsprings Ffs", "plan_name": "500064", "standard_charge_dollar": 6544.15, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Conseco", "plan_name": "500302", "standard_charge_dollar": 6544.15, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Humana Ffs 61101", "plan_name": "500006", "standard_charge_dollar": 6544.15, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Medicare A", "plan_name": "100100", "standard_charge_dollar": 6544.15, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Medicare A", "plan_name": "100500", "standard_charge_dollar": 6544.15, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Medicare Part B Only", "plan_name": "100300", "standard_charge_dollar": 6544.15, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Medicare Railroad", "plan_name": "100103", "standard_charge_dollar": 6544.15, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Ms Physicians Care N", "plan_name": "714210", "standard_charge_dollar": 8180.19, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Peoples Hlth Ffs 72126", "plan_name": "500019", "standard_charge_dollar": 6544.15, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Uhc/Secure Horizons", "plan_name": "500449", "standard_charge_dollar": 6544.15, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "United Health Care/", "plan_name": "500292", "standard_charge_dollar": 7394.89, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "United Healthcare", "plan_name": "750104", "standard_charge_dollar": 7394.89, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "United Healthcare Ba", "plan_name": "750090", "standard_charge_dollar": 7394.89, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "United Healthcare Me", "plan_name": "501310", "standard_charge_dollar": 6544.15, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Windsor Mcare Extra", "plan_name": "500778", "standard_charge_dollar": 6544.15, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." } ] } ] }, { "description": "Correction hallux valgus", "code_information": [ { "code": "28292", "type": "CPT" } ], "standard_charges": [ { "gross_charge": 27897.12, "minimum": 2972.29, "maximum": 23712.55, "setting": "inpatient", "payers_information": [ { "payer_name": "Aarp", "plan_name": "500102", "standard_charge_dollar": 2972.29, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna", "plan_name": "700700", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna", "plan_name": "700700_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Mcare Ffs 6005", "plan_name": "700703", "standard_charge_dollar": 2972.29, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Miscellaneous", "plan_name": "700720", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Miscellaneous", "plan_name": "700720_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Ppo Hmo", "plan_name": "701720", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Ppo Hmo", "plan_name": "701720_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Ambetter 68069", "plan_name": "500516", "standard_charge_dollar": 2972.29, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Ms State Emplo", "plan_name": "401457", "standard_charge_percentage": 0.80, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Ms State Emplo", "plan_name": "401457_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Basic Pl", "plan_name": "400100", "standard_charge_percentage": 0.85, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Basic Pl", "plan_name": "400100_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Federal", "plan_name": "400110", "standard_charge_percentage": 0.85, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Federal", "plan_name": "400110_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Cigna Healthsprings Ffs", "plan_name": "500064", "standard_charge_dollar": 2972.29, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Conseco", "plan_name": "500302", "standard_charge_dollar": 2972.29, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Humana Ffs 61101", "plan_name": "500006", "standard_charge_dollar": 2972.29, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Medicare A", "plan_name": "100100", "standard_charge_dollar": 2972.29, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Medicare A", "plan_name": "100500", "standard_charge_dollar": 2972.29, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Medicare Part B Only", "plan_name": "100300", "standard_charge_dollar": 2972.29, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Medicare Railroad", "plan_name": "100103", "standard_charge_dollar": 2972.29, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Ms Physicians Care N", "plan_name": "714210", "standard_charge_dollar": 3715.36, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Peoples Hlth Ffs 72126", "plan_name": "500019", "standard_charge_dollar": 2972.29, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Uhc/Secure Horizons", "plan_name": "500449", "standard_charge_dollar": 2972.29, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "United Health Care/", "plan_name": "500292", "standard_charge_dollar": 3358.68, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "United Healthcare", "plan_name": "750104", "standard_charge_dollar": 3358.68, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "United Healthcare Ba", "plan_name": "750090", "standard_charge_dollar": 3358.68, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "United Healthcare Me", "plan_name": "501310", "standard_charge_dollar": 2972.29, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Windsor Mcare Extra", "plan_name": "500778", "standard_charge_dollar": 2972.29, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." } ] } ] }, { "description": "Correction hallux valgus", "code_information": [ { "code": "28295", "type": "CPT" } ], "standard_charges": [ { "gross_charge": 27897.12, "minimum": 2972.29, "maximum": 23712.55, "setting": "inpatient", "payers_information": [ { "payer_name": "Aarp", "plan_name": "500102", "standard_charge_dollar": 2972.29, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna", "plan_name": "700700", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna", "plan_name": "700700_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Mcare Ffs 6005", "plan_name": "700703", "standard_charge_dollar": 2972.29, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Miscellaneous", "plan_name": "700720", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Miscellaneous", "plan_name": "700720_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Ppo Hmo", "plan_name": "701720", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Ppo Hmo", "plan_name": "701720_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Ambetter 68069", "plan_name": "500516", "standard_charge_dollar": 2972.29, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Ms State Emplo", "plan_name": "401457", "standard_charge_percentage": 0.80, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Ms State Emplo", "plan_name": "401457_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Basic Pl", "plan_name": "400100", "standard_charge_percentage": 0.85, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Basic Pl", "plan_name": "400100_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Federal", "plan_name": "400110", "standard_charge_percentage": 0.85, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Federal", "plan_name": "400110_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Cigna Healthsprings Ffs", "plan_name": "500064", "standard_charge_dollar": 2972.29, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Conseco", "plan_name": "500302", "standard_charge_dollar": 2972.29, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Humana Ffs 61101", "plan_name": "500006", "standard_charge_dollar": 2972.29, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Medicare A", "plan_name": "100100", "standard_charge_dollar": 2972.29, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Medicare A", "plan_name": "100500", "standard_charge_dollar": 2972.29, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Medicare Part B Only", "plan_name": "100300", "standard_charge_dollar": 2972.29, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Medicare Railroad", "plan_name": "100103", "standard_charge_dollar": 2972.29, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Ms Physicians Care N", "plan_name": "714210", "standard_charge_dollar": 3715.36, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Peoples Hlth Ffs 72126", "plan_name": "500019", "standard_charge_dollar": 2972.29, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Uhc/Secure Horizons", "plan_name": "500449", "standard_charge_dollar": 2972.29, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "United Health Care/", "plan_name": "500292", "standard_charge_dollar": 3358.68, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "United Healthcare", "plan_name": "750104", "standard_charge_dollar": 3358.68, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "United Healthcare Ba", "plan_name": "750090", "standard_charge_dollar": 3358.68, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "United Healthcare Me", "plan_name": "501310", "standard_charge_dollar": 2972.29, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Windsor Mcare Extra", "plan_name": "500778", "standard_charge_dollar": 2972.29, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." } ] } ] }, { "description": "Correction hallux valgus", "code_information": [ { "code": "28296", "type": "CPT" } ], "standard_charges": [ { "gross_charge": 27897.12, "minimum": 2972.29, "maximum": 23712.55, "setting": "inpatient", "payers_information": [ { "payer_name": "Aarp", "plan_name": "500102", "standard_charge_dollar": 2972.29, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna", "plan_name": "700700", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna", "plan_name": "700700_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Mcare Ffs 6005", "plan_name": "700703", "standard_charge_dollar": 2972.29, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Miscellaneous", "plan_name": "700720", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Miscellaneous", "plan_name": "700720_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Ppo Hmo", "plan_name": "701720", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Ppo Hmo", "plan_name": "701720_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Ambetter 68069", "plan_name": "500516", "standard_charge_dollar": 2972.29, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Ms State Emplo", "plan_name": "401457", "standard_charge_percentage": 0.80, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Ms State Emplo", "plan_name": "401457_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Basic Pl", "plan_name": "400100", "standard_charge_percentage": 0.85, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Basic Pl", "plan_name": "400100_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Federal", "plan_name": "400110", "standard_charge_percentage": 0.85, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Federal", "plan_name": "400110_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Cigna Healthsprings Ffs", "plan_name": "500064", "standard_charge_dollar": 2972.29, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Conseco", "plan_name": "500302", "standard_charge_dollar": 2972.29, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Humana Ffs 61101", "plan_name": "500006", "standard_charge_dollar": 2972.29, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Medicare A", "plan_name": "100100", "standard_charge_dollar": 2972.29, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Medicare A", "plan_name": "100500", "standard_charge_dollar": 2972.29, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Medicare Part B Only", "plan_name": "100300", "standard_charge_dollar": 2972.29, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Medicare Railroad", "plan_name": "100103", "standard_charge_dollar": 2972.29, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Ms Physicians Care N", "plan_name": "714210", "standard_charge_dollar": 3715.36, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Peoples Hlth Ffs 72126", "plan_name": "500019", "standard_charge_dollar": 2972.29, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Uhc/Secure Horizons", "plan_name": "500449", "standard_charge_dollar": 2972.29, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "United Health Care/", "plan_name": "500292", "standard_charge_dollar": 3358.68, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "United Healthcare", "plan_name": "750104", "standard_charge_dollar": 3358.68, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "United Healthcare Ba", "plan_name": "750090", "standard_charge_dollar": 3358.68, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "United Healthcare Me", "plan_name": "501310", "standard_charge_dollar": 2972.29, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Windsor Mcare Extra", "plan_name": "500778", "standard_charge_dollar": 2972.29, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." } ] } ] }, { "description": "Correction hallux valgus", "code_information": [ { "code": "28297", "type": "CPT" } ], "standard_charges": [ { "gross_charge": 27897.12, "minimum": 11786.90, "maximum": 23712.55, "setting": "inpatient", "payers_information": [ { "payer_name": "Aarp", "plan_name": "500102", "standard_charge_dollar": 11786.90, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna", "plan_name": "700700", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna", "plan_name": "700700_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Mcare Ffs 6005", "plan_name": "700703", "standard_charge_dollar": 11786.90, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Miscellaneous", "plan_name": "700720", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Miscellaneous", "plan_name": "700720_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Ppo Hmo", "plan_name": "701720", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Ppo Hmo", "plan_name": "701720_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Ambetter 68069", "plan_name": "500516", "standard_charge_dollar": 11786.90, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Ms State Emplo", "plan_name": "401457", "standard_charge_percentage": 0.80, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Ms State Emplo", "plan_name": "401457_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Basic Pl", "plan_name": "400100", "standard_charge_percentage": 0.85, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Basic Pl", "plan_name": "400100_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Federal", "plan_name": "400110", "standard_charge_percentage": 0.85, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Federal", "plan_name": "400110_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Cigna Healthsprings Ffs", "plan_name": "500064", "standard_charge_dollar": 11786.90, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Conseco", "plan_name": "500302", "standard_charge_dollar": 11786.90, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Humana Ffs 61101", "plan_name": "500006", "standard_charge_dollar": 11786.90, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Medicare A", "plan_name": "100100", "standard_charge_dollar": 11786.90, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Medicare A", "plan_name": "100500", "standard_charge_dollar": 11786.90, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Medicare Part B Only", "plan_name": "100300", "standard_charge_dollar": 11786.90, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Medicare Railroad", "plan_name": "100103", "standard_charge_dollar": 11786.90, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Ms Physicians Care N", "plan_name": "714210", "standard_charge_dollar": 14733.62, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Peoples Hlth Ffs 72126", "plan_name": "500019", "standard_charge_dollar": 11786.90, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Uhc/Secure Horizons", "plan_name": "500449", "standard_charge_dollar": 11786.90, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "United Health Care/", "plan_name": "500292", "standard_charge_dollar": 13319.19, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "United Healthcare", "plan_name": "750104", "standard_charge_dollar": 13319.19, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "United Healthcare Ba", "plan_name": "750090", "standard_charge_dollar": 13319.19, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "United Healthcare Me", "plan_name": "501310", "standard_charge_dollar": 11786.90, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Windsor Mcare Extra", "plan_name": "500778", "standard_charge_dollar": 11786.90, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." } ] } ] }, { "description": "Correction hallux valgus", "code_information": [ { "code": "28298", "type": "CPT" } ], "standard_charges": [ { "gross_charge": 27897.12, "minimum": 6544.15, "maximum": 23712.55, "setting": "inpatient", "payers_information": [ { "payer_name": "Aarp", "plan_name": "500102", "standard_charge_dollar": 6544.15, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna", "plan_name": "700700", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna", "plan_name": "700700_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Mcare Ffs 6005", "plan_name": "700703", "standard_charge_dollar": 6544.15, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Miscellaneous", "plan_name": "700720", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Miscellaneous", "plan_name": "700720_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Ppo Hmo", "plan_name": "701720", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Ppo Hmo", "plan_name": "701720_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Ambetter 68069", "plan_name": "500516", "standard_charge_dollar": 6544.15, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Ms State Emplo", "plan_name": "401457", "standard_charge_percentage": 0.80, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Ms State Emplo", "plan_name": "401457_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Basic Pl", "plan_name": "400100", "standard_charge_percentage": 0.85, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Basic Pl", "plan_name": "400100_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Federal", "plan_name": "400110", "standard_charge_percentage": 0.85, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Federal", "plan_name": "400110_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Cigna Healthsprings Ffs", "plan_name": "500064", "standard_charge_dollar": 6544.15, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Conseco", "plan_name": "500302", "standard_charge_dollar": 6544.15, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Humana Ffs 61101", "plan_name": "500006", "standard_charge_dollar": 6544.15, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Medicare A", "plan_name": "100100", "standard_charge_dollar": 6544.15, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Medicare A", "plan_name": "100500", "standard_charge_dollar": 6544.15, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Medicare Part B Only", "plan_name": "100300", "standard_charge_dollar": 6544.15, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Medicare Railroad", "plan_name": "100103", "standard_charge_dollar": 6544.15, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Ms Physicians Care N", "plan_name": "714210", "standard_charge_dollar": 8180.19, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Peoples Hlth Ffs 72126", "plan_name": "500019", "standard_charge_dollar": 6544.15, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Uhc/Secure Horizons", "plan_name": "500449", "standard_charge_dollar": 6544.15, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "United Health Care/", "plan_name": "500292", "standard_charge_dollar": 7394.89, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "United Healthcare", "plan_name": "750104", "standard_charge_dollar": 7394.89, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "United Healthcare Ba", "plan_name": "750090", "standard_charge_dollar": 7394.89, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "United Healthcare Me", "plan_name": "501310", "standard_charge_dollar": 6544.15, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Windsor Mcare Extra", "plan_name": "500778", "standard_charge_dollar": 6544.15, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." } ] } ] }, { "description": "Correction hallux valgus", "code_information": [ { "code": "28299", "type": "CPT" } ], "standard_charges": [ { "gross_charge": 27897.12, "minimum": 6544.15, "maximum": 23712.55, "setting": "inpatient", "payers_information": [ { "payer_name": "Aarp", "plan_name": "500102", "standard_charge_dollar": 6544.15, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna", "plan_name": "700700", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna", "plan_name": "700700_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Mcare Ffs 6005", "plan_name": "700703", "standard_charge_dollar": 6544.15, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Miscellaneous", "plan_name": "700720", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Miscellaneous", "plan_name": "700720_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Ppo Hmo", "plan_name": "701720", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Ppo Hmo", "plan_name": "701720_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Ambetter 68069", "plan_name": "500516", "standard_charge_dollar": 6544.15, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Ms State Emplo", "plan_name": "401457", "standard_charge_percentage": 0.80, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Ms State Emplo", "plan_name": "401457_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Basic Pl", "plan_name": "400100", "standard_charge_percentage": 0.85, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Basic Pl", "plan_name": "400100_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Federal", "plan_name": "400110", "standard_charge_percentage": 0.85, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Federal", "plan_name": "400110_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Cigna Healthsprings Ffs", "plan_name": "500064", "standard_charge_dollar": 6544.15, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Conseco", "plan_name": "500302", "standard_charge_dollar": 6544.15, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Humana Ffs 61101", "plan_name": "500006", "standard_charge_dollar": 6544.15, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Medicare A", "plan_name": "100100", "standard_charge_dollar": 6544.15, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Medicare A", "plan_name": "100500", "standard_charge_dollar": 6544.15, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Medicare Part B Only", "plan_name": "100300", "standard_charge_dollar": 6544.15, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Medicare Railroad", "plan_name": "100103", "standard_charge_dollar": 6544.15, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Ms Physicians Care N", "plan_name": "714210", "standard_charge_dollar": 8180.19, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Peoples Hlth Ffs 72126", "plan_name": "500019", "standard_charge_dollar": 6544.15, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Uhc/Secure Horizons", "plan_name": "500449", "standard_charge_dollar": 6544.15, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "United Health Care/", "plan_name": "500292", "standard_charge_dollar": 7394.89, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "United Healthcare", "plan_name": "750104", "standard_charge_dollar": 7394.89, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "United Healthcare Ba", "plan_name": "750090", "standard_charge_dollar": 7394.89, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "United Healthcare Me", "plan_name": "501310", "standard_charge_dollar": 6544.15, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Windsor Mcare Extra", "plan_name": "500778", "standard_charge_dollar": 6544.15, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." } ] } ] }, { "description": "Incision of metatarsal", "code_information": [ { "code": "28306", "type": "CPT" } ], "standard_charges": [ { "gross_charge": 27897.12, "minimum": 6544.15, "maximum": 23712.55, "setting": "inpatient", "payers_information": [ { "payer_name": "Aarp", "plan_name": "500102", "standard_charge_dollar": 6544.15, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna", "plan_name": "700700", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna", "plan_name": "700700_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Mcare Ffs 6005", "plan_name": "700703", "standard_charge_dollar": 6544.15, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Miscellaneous", "plan_name": "700720", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Miscellaneous", "plan_name": "700720_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Ppo Hmo", "plan_name": "701720", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Ppo Hmo", "plan_name": "701720_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Ambetter 68069", "plan_name": "500516", "standard_charge_dollar": 6544.15, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Ms State Emplo", "plan_name": "401457", "standard_charge_percentage": 0.80, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Ms State Emplo", "plan_name": "401457_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Basic Pl", "plan_name": "400100", "standard_charge_percentage": 0.85, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Basic Pl", "plan_name": "400100_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Federal", "plan_name": "400110", "standard_charge_percentage": 0.85, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Federal", "plan_name": "400110_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Cigna Healthsprings Ffs", "plan_name": "500064", "standard_charge_dollar": 6544.15, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Conseco", "plan_name": "500302", "standard_charge_dollar": 6544.15, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Humana Ffs 61101", "plan_name": "500006", "standard_charge_dollar": 6544.15, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Medicare A", "plan_name": "100100", "standard_charge_dollar": 6544.15, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Medicare A", "plan_name": "100500", "standard_charge_dollar": 6544.15, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Medicare Part B Only", "plan_name": "100300", "standard_charge_dollar": 6544.15, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Medicare Railroad", "plan_name": "100103", "standard_charge_dollar": 6544.15, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Ms Physicians Care N", "plan_name": "714210", "standard_charge_dollar": 8180.19, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Peoples Hlth Ffs 72126", "plan_name": "500019", "standard_charge_dollar": 6544.15, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Uhc/Secure Horizons", "plan_name": "500449", "standard_charge_dollar": 6544.15, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "United Health Care/", "plan_name": "500292", "standard_charge_dollar": 7394.89, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "United Healthcare", "plan_name": "750104", "standard_charge_dollar": 7394.89, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "United Healthcare Ba", "plan_name": "750090", "standard_charge_dollar": 7394.89, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "United Healthcare Me", "plan_name": "501310", "standard_charge_dollar": 6544.15, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Windsor Mcare Extra", "plan_name": "500778", "standard_charge_dollar": 6544.15, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." } ] } ] }, { "description": "Incision of metatarsal", "code_information": [ { "code": "28307", "type": "CPT" } ], "standard_charges": [ { "gross_charge": 27897.12, "minimum": 6544.15, "maximum": 23712.55, "setting": "inpatient", "payers_information": [ { "payer_name": "Aarp", "plan_name": "500102", "standard_charge_dollar": 6544.15, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna", "plan_name": "700700", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna", "plan_name": "700700_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Mcare Ffs 6005", "plan_name": "700703", "standard_charge_dollar": 6544.15, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Miscellaneous", "plan_name": "700720", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Miscellaneous", "plan_name": "700720_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Ppo Hmo", "plan_name": "701720", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Ppo Hmo", "plan_name": "701720_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Ambetter 68069", "plan_name": "500516", "standard_charge_dollar": 6544.15, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Ms State Emplo", "plan_name": "401457", "standard_charge_percentage": 0.80, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Ms State Emplo", "plan_name": "401457_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Basic Pl", "plan_name": "400100", "standard_charge_percentage": 0.85, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Basic Pl", "plan_name": "400100_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Federal", "plan_name": "400110", "standard_charge_percentage": 0.85, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Federal", "plan_name": "400110_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Cigna Healthsprings Ffs", "plan_name": "500064", "standard_charge_dollar": 6544.15, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Conseco", "plan_name": "500302", "standard_charge_dollar": 6544.15, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Humana Ffs 61101", "plan_name": "500006", "standard_charge_dollar": 6544.15, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Medicare A", "plan_name": "100100", "standard_charge_dollar": 6544.15, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Medicare A", "plan_name": "100500", "standard_charge_dollar": 6544.15, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Medicare Part B Only", "plan_name": "100300", "standard_charge_dollar": 6544.15, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Medicare Railroad", "plan_name": "100103", "standard_charge_dollar": 6544.15, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Ms Physicians Care N", "plan_name": "714210", "standard_charge_dollar": 8180.19, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Peoples Hlth Ffs 72126", "plan_name": "500019", "standard_charge_dollar": 6544.15, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Uhc/Secure Horizons", "plan_name": "500449", "standard_charge_dollar": 6544.15, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "United Health Care/", "plan_name": "500292", "standard_charge_dollar": 7394.89, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "United Healthcare", "plan_name": "750104", "standard_charge_dollar": 7394.89, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "United Healthcare Ba", "plan_name": "750090", "standard_charge_dollar": 7394.89, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "United Healthcare Me", "plan_name": "501310", "standard_charge_dollar": 6544.15, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Windsor Mcare Extra", "plan_name": "500778", "standard_charge_dollar": 6544.15, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." } ] } ] }, { "description": "Incision of metatarsal", "code_information": [ { "code": "28308", "type": "CPT" } ], "standard_charges": [ { "gross_charge": 27897.12, "minimum": 2972.29, "maximum": 23712.55, "setting": "inpatient", "payers_information": [ { "payer_name": "Aarp", "plan_name": "500102", "standard_charge_dollar": 2972.29, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna", "plan_name": "700700", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna", "plan_name": "700700_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Mcare Ffs 6005", "plan_name": "700703", "standard_charge_dollar": 2972.29, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Miscellaneous", "plan_name": "700720", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Miscellaneous", "plan_name": "700720_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Ppo Hmo", "plan_name": "701720", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Ppo Hmo", "plan_name": "701720_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Ambetter 68069", "plan_name": "500516", "standard_charge_dollar": 2972.29, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Ms State Emplo", "plan_name": "401457", "standard_charge_percentage": 0.80, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Ms State Emplo", "plan_name": "401457_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Basic Pl", "plan_name": "400100", "standard_charge_percentage": 0.85, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Basic Pl", "plan_name": "400100_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Federal", "plan_name": "400110", "standard_charge_percentage": 0.85, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Federal", "plan_name": "400110_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Cigna Healthsprings Ffs", "plan_name": "500064", "standard_charge_dollar": 2972.29, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Conseco", "plan_name": "500302", "standard_charge_dollar": 2972.29, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Humana Ffs 61101", "plan_name": "500006", "standard_charge_dollar": 2972.29, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Medicare A", "plan_name": "100100", "standard_charge_dollar": 2972.29, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Medicare A", "plan_name": "100500", "standard_charge_dollar": 2972.29, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Medicare Part B Only", "plan_name": "100300", "standard_charge_dollar": 2972.29, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Medicare Railroad", "plan_name": "100103", "standard_charge_dollar": 2972.29, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Ms Physicians Care N", "plan_name": "714210", "standard_charge_dollar": 3715.36, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Peoples Hlth Ffs 72126", "plan_name": "500019", "standard_charge_dollar": 2972.29, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Uhc/Secure Horizons", "plan_name": "500449", "standard_charge_dollar": 2972.29, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "United Health Care/", "plan_name": "500292", "standard_charge_dollar": 3358.68, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "United Healthcare", "plan_name": "750104", "standard_charge_dollar": 3358.68, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "United Healthcare Ba", "plan_name": "750090", "standard_charge_dollar": 3358.68, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "United Healthcare Me", "plan_name": "501310", "standard_charge_dollar": 2972.29, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Windsor Mcare Extra", "plan_name": "500778", "standard_charge_dollar": 2972.29, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." } ] } ] }, { "description": "Incision of metatarsals", "code_information": [ { "code": "28309", "type": "CPT" } ], "standard_charges": [ { "gross_charge": 27897.12, "minimum": 6544.15, "maximum": 23712.55, "setting": "inpatient", "payers_information": [ { "payer_name": "Aarp", "plan_name": "500102", "standard_charge_dollar": 6544.15, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna", "plan_name": "700700", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna", "plan_name": "700700_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Mcare Ffs 6005", "plan_name": "700703", "standard_charge_dollar": 6544.15, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Miscellaneous", "plan_name": "700720", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Miscellaneous", "plan_name": "700720_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Ppo Hmo", "plan_name": "701720", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Ppo Hmo", "plan_name": "701720_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Ambetter 68069", "plan_name": "500516", "standard_charge_dollar": 6544.15, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Ms State Emplo", "plan_name": "401457", "standard_charge_percentage": 0.80, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Ms State Emplo", "plan_name": "401457_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Basic Pl", "plan_name": "400100", "standard_charge_percentage": 0.85, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Basic Pl", "plan_name": "400100_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Federal", "plan_name": "400110", "standard_charge_percentage": 0.85, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Federal", "plan_name": "400110_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Cigna Healthsprings Ffs", "plan_name": "500064", "standard_charge_dollar": 6544.15, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Conseco", "plan_name": "500302", "standard_charge_dollar": 6544.15, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Humana Ffs 61101", "plan_name": "500006", "standard_charge_dollar": 6544.15, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Medicare A", "plan_name": "100100", "standard_charge_dollar": 6544.15, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Medicare A", "plan_name": "100500", "standard_charge_dollar": 6544.15, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Medicare Part B Only", "plan_name": "100300", "standard_charge_dollar": 6544.15, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Medicare Railroad", "plan_name": "100103", "standard_charge_dollar": 6544.15, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Ms Physicians Care N", "plan_name": "714210", "standard_charge_dollar": 8180.19, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Peoples Hlth Ffs 72126", "plan_name": "500019", "standard_charge_dollar": 6544.15, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Uhc/Secure Horizons", "plan_name": "500449", "standard_charge_dollar": 6544.15, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "United Health Care/", "plan_name": "500292", "standard_charge_dollar": 7394.89, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "United Healthcare", "plan_name": "750104", "standard_charge_dollar": 7394.89, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "United Healthcare Ba", "plan_name": "750090", "standard_charge_dollar": 7394.89, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "United Healthcare Me", "plan_name": "501310", "standard_charge_dollar": 6544.15, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Windsor Mcare Extra", "plan_name": "500778", "standard_charge_dollar": 6544.15, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." } ] } ] }, { "description": "Repair webbed toe(s)", "code_information": [ { "code": "28345", "type": "CPT" } ], "standard_charges": [ { "gross_charge": 34501.71, "minimum": 1466.09, "maximum": 29326.45, "setting": "inpatient", "payers_information": [ { "payer_name": "Aarp", "plan_name": "500102", "standard_charge_dollar": 1466.09, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna", "plan_name": "700700", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna", "plan_name": "700700_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Mcare Ffs 6005", "plan_name": "700703", "standard_charge_dollar": 1466.09, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Miscellaneous", "plan_name": "700720", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Miscellaneous", "plan_name": "700720_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Ppo Hmo", "plan_name": "701720", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Ppo Hmo", "plan_name": "701720_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Ambetter 68069", "plan_name": "500516", "standard_charge_dollar": 1466.09, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Ms State Emplo", "plan_name": "401457", "standard_charge_percentage": 0.80, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Ms State Emplo", "plan_name": "401457_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Basic Pl", "plan_name": "400100", "standard_charge_percentage": 0.85, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Basic Pl", "plan_name": "400100_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Federal", "plan_name": "400110", "standard_charge_percentage": 0.85, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Federal", "plan_name": "400110_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Cigna Healthsprings Ffs", "plan_name": "500064", "standard_charge_dollar": 1466.09, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Conseco", "plan_name": "500302", "standard_charge_dollar": 1466.09, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Humana Ffs 61101", "plan_name": "500006", "standard_charge_dollar": 1466.09, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Medicare A", "plan_name": "100100", "standard_charge_dollar": 1466.09, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Medicare A", "plan_name": "100500", "standard_charge_dollar": 1466.09, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Medicare Part B Only", "plan_name": "100300", "standard_charge_dollar": 1466.09, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Medicare Railroad", "plan_name": "100103", "standard_charge_dollar": 1466.09, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Ms Physicians Care N", "plan_name": "714210", "standard_charge_dollar": 1832.61, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Peoples Hlth Ffs 72126", "plan_name": "500019", "standard_charge_dollar": 1466.09, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Uhc/Secure Horizons", "plan_name": "500449", "standard_charge_dollar": 1466.09, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "United Health Care/", "plan_name": "500292", "standard_charge_dollar": 1656.68, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "United Healthcare", "plan_name": "750104", "standard_charge_dollar": 1656.68, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "United Healthcare Ba", "plan_name": "750090", "standard_charge_dollar": 1656.68, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "United Healthcare Me", "plan_name": "501310", "standard_charge_dollar": 1466.09, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Windsor Mcare Extra", "plan_name": "500778", "standard_charge_dollar": 1466.09, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." } ] } ] }, { "description": "Hc reduction toe", "code_information": [ { "code": "28630", "type": "CPT" } ], "standard_charges": [ { "gross_charge": 462.50, "minimum": 219.75, "maximum": 393.13, "setting": "both", "payers_information": [ { "payer_name": "Aarp", "plan_name": "500102", "standard_charge_dollar": 219.75, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna", "plan_name": "700700", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna", "plan_name": "700700_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Mcare Ffs 6005", "plan_name": "700703", "standard_charge_dollar": 219.75, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Miscellaneous", "plan_name": "700720", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Miscellaneous", "plan_name": "700720_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Ppo Hmo", "plan_name": "701720", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Ppo Hmo", "plan_name": "701720_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Ambetter 68069", "plan_name": "500516", "standard_charge_dollar": 219.75, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Ms State Emplo", "plan_name": "401457", "standard_charge_percentage": 0.80, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Ms State Emplo", "plan_name": "401457_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Basic Pl", "plan_name": "400100", "standard_charge_percentage": 0.85, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Basic Pl", "plan_name": "400100_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Federal", "plan_name": "400110", "standard_charge_percentage": 0.85, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Federal", "plan_name": "400110_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Cigna Healthsprings Ffs", "plan_name": "500064", "standard_charge_dollar": 219.75, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Conseco", "plan_name": "500302", "standard_charge_dollar": 219.75, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Humana Ffs 61101", "plan_name": "500006", "standard_charge_dollar": 219.75, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Medicare A", "plan_name": "100100", "standard_charge_dollar": 219.75, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Medicare A", "plan_name": "100500", "standard_charge_dollar": 219.75, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Medicare Part B Only", "plan_name": "100300", "standard_charge_dollar": 219.75, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Medicare Railroad", "plan_name": "100103", "standard_charge_dollar": 219.75, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Ms Physicians Care N", "plan_name": "714210", "standard_charge_dollar": 274.68, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Peoples Hlth Ffs 72126", "plan_name": "500019", "standard_charge_dollar": 219.75, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Uhc/Secure Horizons", "plan_name": "500449", "standard_charge_dollar": 219.75, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "United Health Care/", "plan_name": "500292", "standard_charge_dollar": 248.31, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "United Healthcare", "plan_name": "750104", "standard_charge_dollar": 248.31, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "United Healthcare Ba", "plan_name": "750090", "standard_charge_dollar": 248.31, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "United Healthcare Me", "plan_name": "501310", "standard_charge_dollar": 219.75, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Windsor Mcare Extra", "plan_name": "500778", "standard_charge_dollar": 219.75, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." } ] } ] }, { "description": "Treat toe dislocation", "code_information": [ { "code": "28630", "type": "CPT" } ], "standard_charges": [ { "gross_charge": 462.50, "minimum": 219.75, "maximum": 393.13, "setting": "both", "payers_information": [ { "payer_name": "Aarp", "plan_name": "500102", "standard_charge_dollar": 219.75, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna", "plan_name": "700700", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna", "plan_name": "700700_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Mcare Ffs 6005", "plan_name": "700703", "standard_charge_dollar": 219.75, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Miscellaneous", "plan_name": "700720", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Miscellaneous", "plan_name": "700720_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Ppo Hmo", "plan_name": "701720", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Ppo Hmo", "plan_name": "701720_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Ambetter 68069", "plan_name": "500516", "standard_charge_dollar": 219.75, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Ms State Emplo", "plan_name": "401457", "standard_charge_percentage": 0.80, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Ms State Emplo", "plan_name": "401457_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Basic Pl", "plan_name": "400100", "standard_charge_percentage": 0.85, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Basic Pl", "plan_name": "400100_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Federal", "plan_name": "400110", "standard_charge_percentage": 0.85, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Federal", "plan_name": "400110_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Cigna Healthsprings Ffs", "plan_name": "500064", "standard_charge_dollar": 219.75, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Conseco", "plan_name": "500302", "standard_charge_dollar": 219.75, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Humana Ffs 61101", "plan_name": "500006", "standard_charge_dollar": 219.75, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Medicare A", "plan_name": "100100", "standard_charge_dollar": 219.75, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Medicare A", "plan_name": "100500", "standard_charge_dollar": 219.75, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Medicare Part B Only", "plan_name": "100300", "standard_charge_dollar": 219.75, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Medicare Railroad", "plan_name": "100103", "standard_charge_dollar": 219.75, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Ms Physicians Care N", "plan_name": "714210", "standard_charge_dollar": 274.68, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Peoples Hlth Ffs 72126", "plan_name": "500019", "standard_charge_dollar": 219.75, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Uhc/Secure Horizons", "plan_name": "500449", "standard_charge_dollar": 219.75, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "United Health Care/", "plan_name": "500292", "standard_charge_dollar": 248.31, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "United Healthcare", "plan_name": "750104", "standard_charge_dollar": 248.31, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "United Healthcare Ba", "plan_name": "750090", "standard_charge_dollar": 248.31, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "United Healthcare Me", "plan_name": "501310", "standard_charge_dollar": 219.75, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Windsor Mcare Extra", "plan_name": "500778", "standard_charge_dollar": 219.75, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." } ] } ] }, { "description": "Fusion of foot bones", "code_information": [ { "code": "28735", "type": "CPT" } ], "standard_charges": [ { "gross_charge": 27897.12, "minimum": 11786.90, "maximum": 23712.55, "setting": "inpatient", "payers_information": [ { "payer_name": "Aarp", "plan_name": "500102", "standard_charge_dollar": 11786.90, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna", "plan_name": "700700", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna", "plan_name": "700700_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Mcare Ffs 6005", "plan_name": "700703", "standard_charge_dollar": 11786.90, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Miscellaneous", "plan_name": "700720", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Miscellaneous", "plan_name": "700720_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Ppo Hmo", "plan_name": "701720", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Ppo Hmo", "plan_name": "701720_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Ambetter 68069", "plan_name": "500516", "standard_charge_dollar": 11786.90, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Ms State Emplo", "plan_name": "401457", "standard_charge_percentage": 0.80, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Ms State Emplo", "plan_name": "401457_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Basic Pl", "plan_name": "400100", "standard_charge_percentage": 0.85, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Basic Pl", "plan_name": "400100_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Federal", "plan_name": "400110", "standard_charge_percentage": 0.85, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Federal", "plan_name": "400110_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Cigna Healthsprings Ffs", "plan_name": "500064", "standard_charge_dollar": 11786.90, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Conseco", "plan_name": "500302", "standard_charge_dollar": 11786.90, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Humana Ffs 61101", "plan_name": "500006", "standard_charge_dollar": 11786.90, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Medicare A", "plan_name": "100100", "standard_charge_dollar": 11786.90, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Medicare A", "plan_name": "100500", "standard_charge_dollar": 11786.90, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Medicare Part B Only", "plan_name": "100300", "standard_charge_dollar": 11786.90, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Medicare Railroad", "plan_name": "100103", "standard_charge_dollar": 11786.90, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Ms Physicians Care N", "plan_name": "714210", "standard_charge_dollar": 14733.62, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Peoples Hlth Ffs 72126", "plan_name": "500019", "standard_charge_dollar": 11786.90, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Uhc/Secure Horizons", "plan_name": "500449", "standard_charge_dollar": 11786.90, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "United Health Care/", "plan_name": "500292", "standard_charge_dollar": 13319.19, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "United Healthcare", "plan_name": "750104", "standard_charge_dollar": 13319.19, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "United Healthcare Ba", "plan_name": "750090", "standard_charge_dollar": 13319.19, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "United Healthcare Me", "plan_name": "501310", "standard_charge_dollar": 11786.90, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Windsor Mcare Extra", "plan_name": "500778", "standard_charge_dollar": 11786.90, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." } ] } ] }, { "description": "Amputation of midfoot", "code_information": [ { "code": "28800", "type": "CPT" } ], "standard_charges": [ { "gross_charge": 38189.38, "minimum": 30551.50, "maximum": 32460.97, "setting": "inpatient", "payers_information": [ { "payer_name": "Aetna", "plan_name": "700700", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna", "plan_name": "700700_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Miscellaneous", "plan_name": "700720", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Miscellaneous", "plan_name": "700720_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Ppo Hmo", "plan_name": "701720", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Ppo Hmo", "plan_name": "701720_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Ms State Emplo", "plan_name": "401457", "standard_charge_percentage": 0.80, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Ms State Emplo", "plan_name": "401457_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Basic Pl", "plan_name": "400100", "standard_charge_percentage": 0.85, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Basic Pl", "plan_name": "400100_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Federal", "plan_name": "400110", "standard_charge_percentage": 0.85, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Federal", "plan_name": "400110_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." } ] } ] }, { "description": "Amputation thru metatarsal", "code_information": [ { "code": "28805", "type": "CPT" } ], "standard_charges": [ { "gross_charge": 38189.38, "minimum": 2972.29, "maximum": 32460.97, "setting": "inpatient", "payers_information": [ { "payer_name": "Aarp", "plan_name": "500102", "standard_charge_dollar": 2972.29, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna", "plan_name": "700700", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna", "plan_name": "700700_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Mcare Ffs 6005", "plan_name": "700703", "standard_charge_dollar": 2972.29, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Miscellaneous", "plan_name": "700720", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Miscellaneous", "plan_name": "700720_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Ppo Hmo", "plan_name": "701720", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Ppo Hmo", "plan_name": "701720_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Ambetter 68069", "plan_name": "500516", "standard_charge_dollar": 2972.29, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Ms State Emplo", "plan_name": "401457", "standard_charge_percentage": 0.80, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Ms State Emplo", "plan_name": "401457_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Basic Pl", "plan_name": "400100", "standard_charge_percentage": 0.85, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Basic Pl", "plan_name": "400100_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Federal", "plan_name": "400110", "standard_charge_percentage": 0.85, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Federal", "plan_name": "400110_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Cigna Healthsprings Ffs", "plan_name": "500064", "standard_charge_dollar": 2972.29, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Conseco", "plan_name": "500302", "standard_charge_dollar": 2972.29, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Humana Ffs 61101", "plan_name": "500006", "standard_charge_dollar": 2972.29, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Medicare A", "plan_name": "100100", "standard_charge_dollar": 2972.29, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Medicare A", "plan_name": "100500", "standard_charge_dollar": 2972.29, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Medicare Part B Only", "plan_name": "100300", "standard_charge_dollar": 2972.29, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Medicare Railroad", "plan_name": "100103", "standard_charge_dollar": 2972.29, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Ms Physicians Care N", "plan_name": "714210", "standard_charge_dollar": 3715.36, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Peoples Hlth Ffs 72126", "plan_name": "500019", "standard_charge_dollar": 2972.29, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Uhc/Secure Horizons", "plan_name": "500449", "standard_charge_dollar": 2972.29, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "United Health Care/", "plan_name": "500292", "standard_charge_dollar": 3358.68, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "United Healthcare", "plan_name": "750104", "standard_charge_dollar": 3358.68, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "United Healthcare Ba", "plan_name": "750090", "standard_charge_dollar": 3358.68, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "United Healthcare Me", "plan_name": "501310", "standard_charge_dollar": 2972.29, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Windsor Mcare Extra", "plan_name": "500778", "standard_charge_dollar": 2972.29, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." } ] } ] }, { "description": "Amputation toe & metatarsal", "code_information": [ { "code": "28810", "type": "CPT" } ], "standard_charges": [ { "gross_charge": 23163.14, "minimum": 2972.29, "maximum": 19688.67, "setting": "inpatient", "payers_information": [ { "payer_name": "Aarp", "plan_name": "500102", "standard_charge_dollar": 2972.29, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna", "plan_name": "700700", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna", "plan_name": "700700_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Mcare Ffs 6005", "plan_name": "700703", "standard_charge_dollar": 2972.29, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Miscellaneous", "plan_name": "700720", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Miscellaneous", "plan_name": "700720_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Ppo Hmo", "plan_name": "701720", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Ppo Hmo", "plan_name": "701720_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Ambetter 68069", "plan_name": "500516", "standard_charge_dollar": 2972.29, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Ms State Emplo", "plan_name": "401457", "standard_charge_percentage": 0.80, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Ms State Emplo", "plan_name": "401457_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Basic Pl", "plan_name": "400100", "standard_charge_percentage": 0.85, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Basic Pl", "plan_name": "400100_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Federal", "plan_name": "400110", "standard_charge_percentage": 0.85, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Federal", "plan_name": "400110_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Cigna Healthsprings Ffs", "plan_name": "500064", "standard_charge_dollar": 2972.29, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Conseco", "plan_name": "500302", "standard_charge_dollar": 2972.29, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Humana Ffs 61101", "plan_name": "500006", "standard_charge_dollar": 2972.29, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Medicare A", "plan_name": "100100", "standard_charge_dollar": 2972.29, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Medicare A", "plan_name": "100500", "standard_charge_dollar": 2972.29, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Medicare Part B Only", "plan_name": "100300", "standard_charge_dollar": 2972.29, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Medicare Railroad", "plan_name": "100103", "standard_charge_dollar": 2972.29, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Ms Physicians Care N", "plan_name": "714210", "standard_charge_dollar": 3715.36, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Peoples Hlth Ffs 72126", "plan_name": "500019", "standard_charge_dollar": 2972.29, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Uhc/Secure Horizons", "plan_name": "500449", "standard_charge_dollar": 2972.29, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "United Health Care/", "plan_name": "500292", "standard_charge_dollar": 3358.68, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "United Healthcare", "plan_name": "750104", "standard_charge_dollar": 3358.68, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "United Healthcare Ba", "plan_name": "750090", "standard_charge_dollar": 3358.68, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "United Healthcare Me", "plan_name": "501310", "standard_charge_dollar": 2972.29, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Windsor Mcare Extra", "plan_name": "500778", "standard_charge_dollar": 2972.29, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." } ] } ] }, { "description": "Amputation of toe", "code_information": [ { "code": "28820", "type": "CPT" } ], "standard_charges": [ { "gross_charge": 24919.42, "minimum": 2972.29, "maximum": 21181.51, "setting": "inpatient", "payers_information": [ { "payer_name": "Aarp", "plan_name": "500102", "standard_charge_dollar": 2972.29, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna", "plan_name": "700700", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna", "plan_name": "700700_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Mcare Ffs 6005", "plan_name": "700703", "standard_charge_dollar": 2972.29, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Miscellaneous", "plan_name": "700720", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Miscellaneous", "plan_name": "700720_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Ppo Hmo", "plan_name": "701720", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Ppo Hmo", "plan_name": "701720_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Ambetter 68069", "plan_name": "500516", "standard_charge_dollar": 2972.29, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Ms State Emplo", "plan_name": "401457", "standard_charge_percentage": 0.80, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Ms State Emplo", "plan_name": "401457_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Basic Pl", "plan_name": "400100", "standard_charge_percentage": 0.85, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Basic Pl", "plan_name": "400100_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Federal", "plan_name": "400110", "standard_charge_percentage": 0.85, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Federal", "plan_name": "400110_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Cigna Healthsprings Ffs", "plan_name": "500064", "standard_charge_dollar": 2972.29, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Conseco", "plan_name": "500302", "standard_charge_dollar": 2972.29, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Humana Ffs 61101", "plan_name": "500006", "standard_charge_dollar": 2972.29, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Medicare A", "plan_name": "100100", "standard_charge_dollar": 2972.29, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Medicare A", "plan_name": "100500", "standard_charge_dollar": 2972.29, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Medicare Part B Only", "plan_name": "100300", "standard_charge_dollar": 2972.29, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Medicare Railroad", "plan_name": "100103", "standard_charge_dollar": 2972.29, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Ms Physicians Care N", "plan_name": "714210", "standard_charge_dollar": 3715.36, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Peoples Hlth Ffs 72126", "plan_name": "500019", "standard_charge_dollar": 2972.29, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Uhc/Secure Horizons", "plan_name": "500449", "standard_charge_dollar": 2972.29, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "United Health Care/", "plan_name": "500292", "standard_charge_dollar": 3358.68, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "United Healthcare", "plan_name": "750104", "standard_charge_dollar": 3358.68, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "United Healthcare Ba", "plan_name": "750090", "standard_charge_dollar": 3358.68, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "United Healthcare Me", "plan_name": "501310", "standard_charge_dollar": 2972.29, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Windsor Mcare Extra", "plan_name": "500778", "standard_charge_dollar": 2972.29, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." } ] } ] }, { "description": "Partial amputation of toe", "code_information": [ { "code": "28825", "type": "CPT" } ], "standard_charges": [ { "gross_charge": 32910.96, "minimum": 2972.29, "maximum": 27974.32, "setting": "inpatient", "payers_information": [ { "payer_name": "Aarp", "plan_name": "500102", "standard_charge_dollar": 2972.29, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna", "plan_name": "700700", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna", "plan_name": "700700_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Mcare Ffs 6005", "plan_name": "700703", "standard_charge_dollar": 2972.29, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Miscellaneous", "plan_name": "700720", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Miscellaneous", "plan_name": "700720_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Ppo Hmo", "plan_name": "701720", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Ppo Hmo", "plan_name": "701720_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Ambetter 68069", "plan_name": "500516", "standard_charge_dollar": 2972.29, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Ms State Emplo", "plan_name": "401457", "standard_charge_percentage": 0.80, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Ms State Emplo", "plan_name": "401457_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Basic Pl", "plan_name": "400100", "standard_charge_percentage": 0.85, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Basic Pl", "plan_name": "400100_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Federal", "plan_name": "400110", "standard_charge_percentage": 0.85, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Federal", "plan_name": "400110_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Cigna Healthsprings Ffs", "plan_name": "500064", "standard_charge_dollar": 2972.29, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Conseco", "plan_name": "500302", "standard_charge_dollar": 2972.29, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Humana Ffs 61101", "plan_name": "500006", "standard_charge_dollar": 2972.29, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Medicare A", "plan_name": "100100", "standard_charge_dollar": 2972.29, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Medicare A", "plan_name": "100500", "standard_charge_dollar": 2972.29, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Medicare Part B Only", "plan_name": "100300", "standard_charge_dollar": 2972.29, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Medicare Railroad", "plan_name": "100103", "standard_charge_dollar": 2972.29, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Ms Physicians Care N", "plan_name": "714210", "standard_charge_dollar": 3715.36, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Peoples Hlth Ffs 72126", "plan_name": "500019", "standard_charge_dollar": 2972.29, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Uhc/Secure Horizons", "plan_name": "500449", "standard_charge_dollar": 2972.29, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "United Health Care/", "plan_name": "500292", "standard_charge_dollar": 3358.68, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "United Healthcare", "plan_name": "750104", "standard_charge_dollar": 3358.68, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "United Healthcare Ba", "plan_name": "750090", "standard_charge_dollar": 3358.68, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "United Healthcare Me", "plan_name": "501310", "standard_charge_dollar": 2972.29, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Windsor Mcare Extra", "plan_name": "500778", "standard_charge_dollar": 2972.29, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." } ] } ] }, { "description": "Apply long arm splint", "code_information": [ { "code": "29105", "type": "CPT" } ], "standard_charges": [ { "gross_charge": 310.00, "minimum": 144.55, "maximum": 263.50, "setting": "both", "payers_information": [ { "payer_name": "Aarp", "plan_name": "500102", "standard_charge_dollar": 144.55, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna", "plan_name": "700700", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna", "plan_name": "700700_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Mcare Ffs 6005", "plan_name": "700703", "standard_charge_dollar": 144.55, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Miscellaneous", "plan_name": "700720", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Miscellaneous", "plan_name": "700720_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Ppo Hmo", "plan_name": "701720", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Ppo Hmo", "plan_name": "701720_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Ambetter 68069", "plan_name": "500516", "standard_charge_dollar": 144.55, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Ms State Emplo", "plan_name": "401457", "standard_charge_percentage": 0.80, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Ms State Emplo", "plan_name": "401457_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Basic Pl", "plan_name": "400100", "standard_charge_percentage": 0.85, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Basic Pl", "plan_name": "400100_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Federal", "plan_name": "400110", "standard_charge_percentage": 0.85, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Federal", "plan_name": "400110_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Cigna Healthsprings Ffs", "plan_name": "500064", "standard_charge_dollar": 144.55, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Conseco", "plan_name": "500302", "standard_charge_dollar": 144.55, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Humana Ffs 61101", "plan_name": "500006", "standard_charge_dollar": 144.55, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Medicare A", "plan_name": "100100", "standard_charge_dollar": 144.55, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Medicare A", "plan_name": "100500", "standard_charge_dollar": 144.55, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Medicare Part B Only", "plan_name": "100300", "standard_charge_dollar": 144.55, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Medicare Railroad", "plan_name": "100103", "standard_charge_dollar": 144.55, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Ms Physicians Care N", "plan_name": "714210", "standard_charge_dollar": 180.68, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Peoples Hlth Ffs 72126", "plan_name": "500019", "standard_charge_dollar": 144.55, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Uhc/Secure Horizons", "plan_name": "500449", "standard_charge_dollar": 144.55, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "United Health Care/", "plan_name": "500292", "standard_charge_dollar": 163.34, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "United Healthcare", "plan_name": "750104", "standard_charge_dollar": 163.34, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "United Healthcare Ba", "plan_name": "750090", "standard_charge_dollar": 163.34, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "United Healthcare Me", "plan_name": "501310", "standard_charge_dollar": 144.55, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Windsor Mcare Extra", "plan_name": "500778", "standard_charge_dollar": 144.55, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." } ] } ] }, { "description": "Hc application long arm splint", "code_information": [ { "code": "29105", "type": "CPT" } ], "standard_charges": [ { "gross_charge": 310.00, "minimum": 144.55, "maximum": 263.50, "setting": "both", "payers_information": [ { "payer_name": "Aarp", "plan_name": "500102", "standard_charge_dollar": 144.55, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna", "plan_name": "700700", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna", "plan_name": "700700_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Mcare Ffs 6005", "plan_name": "700703", "standard_charge_dollar": 144.55, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Miscellaneous", "plan_name": "700720", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Miscellaneous", "plan_name": "700720_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Ppo Hmo", "plan_name": "701720", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Ppo Hmo", "plan_name": "701720_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Ambetter 68069", "plan_name": "500516", "standard_charge_dollar": 144.55, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Ms State Emplo", "plan_name": "401457", "standard_charge_percentage": 0.80, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Ms State Emplo", "plan_name": "401457_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Basic Pl", "plan_name": "400100", "standard_charge_percentage": 0.85, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Basic Pl", "plan_name": "400100_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Federal", "plan_name": "400110", "standard_charge_percentage": 0.85, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Federal", "plan_name": "400110_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Cigna Healthsprings Ffs", "plan_name": "500064", "standard_charge_dollar": 144.55, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Conseco", "plan_name": "500302", "standard_charge_dollar": 144.55, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Humana Ffs 61101", "plan_name": "500006", "standard_charge_dollar": 144.55, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Medicare A", "plan_name": "100100", "standard_charge_dollar": 144.55, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Medicare A", "plan_name": "100500", "standard_charge_dollar": 144.55, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Medicare Part B Only", "plan_name": "100300", "standard_charge_dollar": 144.55, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Medicare Railroad", "plan_name": "100103", "standard_charge_dollar": 144.55, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Ms Physicians Care N", "plan_name": "714210", "standard_charge_dollar": 180.68, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Peoples Hlth Ffs 72126", "plan_name": "500019", "standard_charge_dollar": 144.55, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Uhc/Secure Horizons", "plan_name": "500449", "standard_charge_dollar": 144.55, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "United Health Care/", "plan_name": "500292", "standard_charge_dollar": 163.34, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "United Healthcare", "plan_name": "750104", "standard_charge_dollar": 163.34, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "United Healthcare Ba", "plan_name": "750090", "standard_charge_dollar": 163.34, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "United Healthcare Me", "plan_name": "501310", "standard_charge_dollar": 144.55, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Windsor Mcare Extra", "plan_name": "500778", "standard_charge_dollar": 144.55, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." } ] } ] }, { "description": "Apply forearm splint", "code_information": [ { "code": "29125", "type": "CPT" } ], "standard_charges": [ { "gross_charge": 95.50, "minimum": 118.08, "maximum": 149.97, "setting": "both", "payers_information": [ { "payer_name": "Aarp", "plan_name": "500102", "standard_charge_dollar": 118.08, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna", "plan_name": "700700", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna", "plan_name": "700700_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Mcare Ffs 6005", "plan_name": "700703", "standard_charge_dollar": 118.08, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Miscellaneous", "plan_name": "700720", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Miscellaneous", "plan_name": "700720_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Ppo Hmo", "plan_name": "701720", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Ppo Hmo", "plan_name": "701720_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Ambetter 68069", "plan_name": "500516", "standard_charge_dollar": 118.08, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Ms State Emplo", "plan_name": "401457", "standard_charge_dollar": 149.97, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Ms State Emplo", "plan_name": "401457_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Basic Pl", "plan_name": "400100", "standard_charge_dollar": 149.97, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Basic Pl", "plan_name": "400100_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Federal", "plan_name": "400110", "standard_charge_dollar": 149.97, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Federal", "plan_name": "400110_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Cigna Healthsprings Ffs", "plan_name": "500064", "standard_charge_dollar": 118.08, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Conseco", "plan_name": "500302", "standard_charge_dollar": 118.08, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Humana Ffs 61101", "plan_name": "500006", "standard_charge_dollar": 118.08, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Medicare A", "plan_name": "100100", "standard_charge_dollar": 118.08, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Medicare A", "plan_name": "100500", "standard_charge_dollar": 118.08, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Medicare Part B Only", "plan_name": "100300", "standard_charge_dollar": 118.08, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Medicare Railroad", "plan_name": "100103", "standard_charge_dollar": 118.08, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Ms Physicians Care N", "plan_name": "714210", "standard_charge_dollar": 147.60, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Peoples Hlth Ffs 72126", "plan_name": "500019", "standard_charge_dollar": 118.08, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Uhc/Secure Horizons", "plan_name": "500449", "standard_charge_dollar": 118.08, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "United Health Care/", "plan_name": "500292", "standard_charge_dollar": 133.43, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "United Healthcare", "plan_name": "750104", "standard_charge_dollar": 133.43, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "United Healthcare Ba", "plan_name": "750090", "standard_charge_dollar": 133.43, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "United Healthcare Me", "plan_name": "501310", "standard_charge_dollar": 118.08, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Windsor Mcare Extra", "plan_name": "500778", "standard_charge_dollar": 118.08, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." } ] } ] }, { "description": "Hc application forearm splint", "code_information": [ { "code": "29125", "type": "CPT" } ], "standard_charges": [ { "gross_charge": 95.50, "minimum": 118.08, "maximum": 149.97, "setting": "both", "payers_information": [ { "payer_name": "Aarp", "plan_name": "500102", "standard_charge_dollar": 118.08, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna", "plan_name": "700700", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna", "plan_name": "700700_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Mcare Ffs 6005", "plan_name": "700703", "standard_charge_dollar": 118.08, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Miscellaneous", "plan_name": "700720", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Miscellaneous", "plan_name": "700720_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Ppo Hmo", "plan_name": "701720", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Ppo Hmo", "plan_name": "701720_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Ambetter 68069", "plan_name": "500516", "standard_charge_dollar": 118.08, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Ms State Emplo", "plan_name": "401457", "standard_charge_dollar": 149.97, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Ms State Emplo", "plan_name": "401457_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Basic Pl", "plan_name": "400100", "standard_charge_dollar": 149.97, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Basic Pl", "plan_name": "400100_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Federal", "plan_name": "400110", "standard_charge_dollar": 149.97, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Federal", "plan_name": "400110_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Cigna Healthsprings Ffs", "plan_name": "500064", "standard_charge_dollar": 118.08, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Conseco", "plan_name": "500302", "standard_charge_dollar": 118.08, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Humana Ffs 61101", "plan_name": "500006", "standard_charge_dollar": 118.08, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Medicare A", "plan_name": "100100", "standard_charge_dollar": 118.08, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Medicare A", "plan_name": "100500", "standard_charge_dollar": 118.08, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Medicare Part B Only", "plan_name": "100300", "standard_charge_dollar": 118.08, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Medicare Railroad", "plan_name": "100103", "standard_charge_dollar": 118.08, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Ms Physicians Care N", "plan_name": "714210", "standard_charge_dollar": 147.60, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Peoples Hlth Ffs 72126", "plan_name": "500019", "standard_charge_dollar": 118.08, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Uhc/Secure Horizons", "plan_name": "500449", "standard_charge_dollar": 118.08, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "United Health Care/", "plan_name": "500292", "standard_charge_dollar": 133.43, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "United Healthcare", "plan_name": "750104", "standard_charge_dollar": 133.43, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "United Healthcare Ba", "plan_name": "750090", "standard_charge_dollar": 133.43, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "United Healthcare Me", "plan_name": "501310", "standard_charge_dollar": 118.08, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Windsor Mcare Extra", "plan_name": "500778", "standard_charge_dollar": 118.08, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." } ] } ] }, { "description": "Hc application forearm splint", "code_information": [ { "code": "29125", "type": "CPT" } ], "standard_charges": [ { "gross_charge": 382.00, "minimum": 118.08, "maximum": 324.70, "setting": "both", "payers_information": [ { "payer_name": "Aarp", "plan_name": "500102", "standard_charge_dollar": 118.08, "count": "0", "methodology": "fee schedule", "modifiers": "50", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna", "plan_name": "700700", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna", "plan_name": "700700_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Mcare Ffs 6005", "plan_name": "700703", "standard_charge_dollar": 118.08, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Miscellaneous", "plan_name": "700720", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Miscellaneous", "plan_name": "700720_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Ppo Hmo", "plan_name": "701720", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Ppo Hmo", "plan_name": "701720_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Ambetter 68069", "plan_name": "500516", "standard_charge_dollar": 118.08, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Ms State Emplo", "plan_name": "401457", "standard_charge_percentage": 0.80, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Ms State Emplo", "plan_name": "401457_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Basic Pl", "plan_name": "400100", "standard_charge_percentage": 0.85, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Basic Pl", "plan_name": "400100_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Federal", "plan_name": "400110", "standard_charge_percentage": 0.85, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Federal", "plan_name": "400110_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Cigna Healthsprings Ffs", "plan_name": "500064", "standard_charge_dollar": 118.08, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Conseco", "plan_name": "500302", "standard_charge_dollar": 118.08, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Humana Ffs 61101", "plan_name": "500006", "standard_charge_dollar": 118.08, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Medicare A", "plan_name": "100100", "standard_charge_dollar": 118.08, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Medicare A", "plan_name": "100500", "standard_charge_dollar": 118.08, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Medicare Part B Only", "plan_name": "100300", "standard_charge_dollar": 118.08, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Medicare Railroad", "plan_name": "100103", "standard_charge_dollar": 118.08, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Ms Physicians Care N", "plan_name": "714210", "standard_charge_dollar": 147.60, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Peoples Hlth Ffs 72126", "plan_name": "500019", "standard_charge_dollar": 118.08, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Uhc/Secure Horizons", "plan_name": "500449", "standard_charge_dollar": 118.08, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "United Health Care/", "plan_name": "500292", "standard_charge_dollar": 133.43, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "United Healthcare", "plan_name": "750104", "standard_charge_dollar": 133.43, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "United Healthcare Ba", "plan_name": "750090", "standard_charge_dollar": 133.43, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "United Healthcare Me", "plan_name": "501310", "standard_charge_dollar": 118.08, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Windsor Mcare Extra", "plan_name": "500778", "standard_charge_dollar": 118.08, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." } ] } ] }, { "description": "Application of finger splint", "code_information": [ { "code": "29130", "type": "CPT" } ], "standard_charges": [ { "gross_charge": 247.00, "minimum": 81.80, "maximum": 147.60, "setting": "both", "payers_information": [ { "payer_name": "Aarp", "plan_name": "500102", "standard_charge_dollar": 118.08, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna", "plan_name": "700700", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna", "plan_name": "700700_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Mcare Ffs 6005", "plan_name": "700703", "standard_charge_dollar": 118.08, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Miscellaneous", "plan_name": "700720", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Miscellaneous", "plan_name": "700720_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Ppo Hmo", "plan_name": "701720", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Ppo Hmo", "plan_name": "701720_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Ambetter 68069", "plan_name": "500516", "standard_charge_dollar": 118.08, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Ms State Emplo", "plan_name": "401457", "standard_charge_dollar": 81.80, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Ms State Emplo", "plan_name": "401457_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Basic Pl", "plan_name": "400100", "standard_charge_dollar": 81.80, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Basic Pl", "plan_name": "400100_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Federal", "plan_name": "400110", "standard_charge_dollar": 81.80, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Federal", "plan_name": "400110_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Cigna Healthsprings Ffs", "plan_name": "500064", "standard_charge_dollar": 118.08, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Conseco", "plan_name": "500302", "standard_charge_dollar": 118.08, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Humana Ffs 61101", "plan_name": "500006", "standard_charge_dollar": 118.08, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Medicare A", "plan_name": "100100", "standard_charge_dollar": 118.08, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Medicare A", "plan_name": "100500", "standard_charge_dollar": 118.08, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Medicare Part B Only", "plan_name": "100300", "standard_charge_dollar": 118.08, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Medicare Railroad", "plan_name": "100103", "standard_charge_dollar": 118.08, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Ms Physicians Care N", "plan_name": "714210", "standard_charge_dollar": 147.60, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Peoples Hlth Ffs 72126", "plan_name": "500019", "standard_charge_dollar": 118.08, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Uhc/Secure Horizons", "plan_name": "500449", "standard_charge_dollar": 118.08, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "United Health Care/", "plan_name": "500292", "standard_charge_dollar": 133.43, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "United Healthcare", "plan_name": "750104", "standard_charge_dollar": 133.43, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "United Healthcare Ba", "plan_name": "750090", "standard_charge_dollar": 133.43, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "United Healthcare Me", "plan_name": "501310", "standard_charge_dollar": 118.08, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Windsor Mcare Extra", "plan_name": "500778", "standard_charge_dollar": 118.08, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." } ] } ] }, { "description": "Hc application finger splint", "code_information": [ { "code": "29130", "type": "CPT" } ], "standard_charges": [ { "gross_charge": 247.00, "minimum": 81.80, "maximum": 147.60, "setting": "both", "payers_information": [ { "payer_name": "Aarp", "plan_name": "500102", "standard_charge_dollar": 118.08, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna", "plan_name": "700700", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna", "plan_name": "700700_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Mcare Ffs 6005", "plan_name": "700703", "standard_charge_dollar": 118.08, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Miscellaneous", "plan_name": "700720", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Miscellaneous", "plan_name": "700720_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Ppo Hmo", "plan_name": "701720", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Ppo Hmo", "plan_name": "701720_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Ambetter 68069", "plan_name": "500516", "standard_charge_dollar": 118.08, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Ms State Emplo", "plan_name": "401457", "standard_charge_dollar": 81.80, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Ms State Emplo", "plan_name": "401457_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Basic Pl", "plan_name": "400100", "standard_charge_dollar": 81.80, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Basic Pl", "plan_name": "400100_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Federal", "plan_name": "400110", "standard_charge_dollar": 81.80, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Federal", "plan_name": "400110_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Cigna Healthsprings Ffs", "plan_name": "500064", "standard_charge_dollar": 118.08, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Conseco", "plan_name": "500302", "standard_charge_dollar": 118.08, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Humana Ffs 61101", "plan_name": "500006", "standard_charge_dollar": 118.08, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Medicare A", "plan_name": "100100", "standard_charge_dollar": 118.08, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Medicare A", "plan_name": "100500", "standard_charge_dollar": 118.08, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Medicare Part B Only", "plan_name": "100300", "standard_charge_dollar": 118.08, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Medicare Railroad", "plan_name": "100103", "standard_charge_dollar": 118.08, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Ms Physicians Care N", "plan_name": "714210", "standard_charge_dollar": 147.60, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Peoples Hlth Ffs 72126", "plan_name": "500019", "standard_charge_dollar": 118.08, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Uhc/Secure Horizons", "plan_name": "500449", "standard_charge_dollar": 118.08, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "United Health Care/", "plan_name": "500292", "standard_charge_dollar": 133.43, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "United Healthcare", "plan_name": "750104", "standard_charge_dollar": 133.43, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "United Healthcare Ba", "plan_name": "750090", "standard_charge_dollar": 133.43, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "United Healthcare Me", "plan_name": "501310", "standard_charge_dollar": 118.08, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Windsor Mcare Extra", "plan_name": "500778", "standard_charge_dollar": 118.08, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." } ] } ] }, { "description": "Application of finger splint", "code_information": [ { "code": "29131", "type": "CPT" } ], "standard_charges": [ { "gross_charge": 150.00, "minimum": 54.41, "maximum": 81.80, "setting": "both", "payers_information": [ { "payer_name": "Aarp", "plan_name": "500102", "standard_charge_dollar": 54.41, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna", "plan_name": "700700", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna", "plan_name": "700700_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Mcare Ffs 6005", "plan_name": "700703", "standard_charge_dollar": 54.41, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Miscellaneous", "plan_name": "700720", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Miscellaneous", "plan_name": "700720_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Ppo Hmo", "plan_name": "701720", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Ppo Hmo", "plan_name": "701720_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Ambetter 68069", "plan_name": "500516", "standard_charge_dollar": 54.41, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Ms State Emplo", "plan_name": "401457", "standard_charge_dollar": 81.80, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Ms State Emplo", "plan_name": "401457_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Basic Pl", "plan_name": "400100", "standard_charge_dollar": 81.80, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Basic Pl", "plan_name": "400100_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Federal", "plan_name": "400110", "standard_charge_dollar": 81.80, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Federal", "plan_name": "400110_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Cigna Healthsprings Ffs", "plan_name": "500064", "standard_charge_dollar": 54.41, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Conseco", "plan_name": "500302", "standard_charge_dollar": 54.41, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Humana Ffs 61101", "plan_name": "500006", "standard_charge_dollar": 54.41, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Medicare A", "plan_name": "100100", "standard_charge_dollar": 54.41, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Medicare A", "plan_name": "100500", "standard_charge_dollar": 54.41, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Medicare Part B Only", "plan_name": "100300", "standard_charge_dollar": 54.41, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Medicare Railroad", "plan_name": "100103", "standard_charge_dollar": 54.41, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Ms Physicians Care N", "plan_name": "714210", "standard_charge_dollar": 68.02, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Peoples Hlth Ffs 72126", "plan_name": "500019", "standard_charge_dollar": 54.41, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Uhc/Secure Horizons", "plan_name": "500449", "standard_charge_dollar": 54.41, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "United Health Care/", "plan_name": "500292", "standard_charge_dollar": 61.49, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "United Healthcare", "plan_name": "750104", "standard_charge_dollar": 61.49, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "United Healthcare Ba", "plan_name": "750090", "standard_charge_dollar": 61.49, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "United Healthcare Me", "plan_name": "501310", "standard_charge_dollar": 54.41, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Windsor Mcare Extra", "plan_name": "500778", "standard_charge_dollar": 54.41, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." } ] } ] }, { "description": "Hc application of finger splint", "code_information": [ { "code": "29131", "type": "CPT" } ], "standard_charges": [ { "gross_charge": 150.00, "minimum": 54.41, "maximum": 81.80, "setting": "both", "payers_information": [ { "payer_name": "Aarp", "plan_name": "500102", "standard_charge_dollar": 54.41, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna", "plan_name": "700700", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna", "plan_name": "700700_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Mcare Ffs 6005", "plan_name": "700703", "standard_charge_dollar": 54.41, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Miscellaneous", "plan_name": "700720", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Miscellaneous", "plan_name": "700720_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Ppo Hmo", "plan_name": "701720", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Ppo Hmo", "plan_name": "701720_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Ambetter 68069", "plan_name": "500516", "standard_charge_dollar": 54.41, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Ms State Emplo", "plan_name": "401457", "standard_charge_dollar": 81.80, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Ms State Emplo", "plan_name": "401457_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Basic Pl", "plan_name": "400100", "standard_charge_dollar": 81.80, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Basic Pl", "plan_name": "400100_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Federal", "plan_name": "400110", "standard_charge_dollar": 81.80, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Federal", "plan_name": "400110_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Cigna Healthsprings Ffs", "plan_name": "500064", "standard_charge_dollar": 54.41, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Conseco", "plan_name": "500302", "standard_charge_dollar": 54.41, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Humana Ffs 61101", "plan_name": "500006", "standard_charge_dollar": 54.41, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Medicare A", "plan_name": "100100", "standard_charge_dollar": 54.41, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Medicare A", "plan_name": "100500", "standard_charge_dollar": 54.41, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Medicare Part B Only", "plan_name": "100300", "standard_charge_dollar": 54.41, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Medicare Railroad", "plan_name": "100103", "standard_charge_dollar": 54.41, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Ms Physicians Care N", "plan_name": "714210", "standard_charge_dollar": 68.02, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Peoples Hlth Ffs 72126", "plan_name": "500019", "standard_charge_dollar": 54.41, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Uhc/Secure Horizons", "plan_name": "500449", "standard_charge_dollar": 54.41, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "United Health Care/", "plan_name": "500292", "standard_charge_dollar": 61.49, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "United Healthcare", "plan_name": "750104", "standard_charge_dollar": 61.49, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "United Healthcare Ba", "plan_name": "750090", "standard_charge_dollar": 61.49, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "United Healthcare Me", "plan_name": "501310", "standard_charge_dollar": 54.41, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Windsor Mcare Extra", "plan_name": "500778", "standard_charge_dollar": 54.41, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." } ] } ] }, { "description": "Hc application of elbow/wrist strapping", "code_information": [ { "code": "29260", "type": "CPT" } ], "standard_charges": [ { "gross_charge": 122.00, "minimum": 42.56, "maximum": 68.02, "setting": "both", "payers_information": [ { "payer_name": "Aarp", "plan_name": "500102", "standard_charge_dollar": 54.41, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna", "plan_name": "700700", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna", "plan_name": "700700_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Mcare Ffs 6005", "plan_name": "700703", "standard_charge_dollar": 54.41, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Miscellaneous", "plan_name": "700720", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Miscellaneous", "plan_name": "700720_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Ppo Hmo", "plan_name": "701720", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Ppo Hmo", "plan_name": "701720_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Ambetter 68069", "plan_name": "500516", "standard_charge_dollar": 54.41, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Ms State Emplo", "plan_name": "401457", "standard_charge_dollar": 42.56, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Ms State Emplo", "plan_name": "401457_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Basic Pl", "plan_name": "400100", "standard_charge_dollar": 42.56, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Basic Pl", "plan_name": "400100_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Federal", "plan_name": "400110", "standard_charge_dollar": 42.56, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Federal", "plan_name": "400110_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Cigna Healthsprings Ffs", "plan_name": "500064", "standard_charge_dollar": 54.41, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Conseco", "plan_name": "500302", "standard_charge_dollar": 54.41, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Humana Ffs 61101", "plan_name": "500006", "standard_charge_dollar": 54.41, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Medicare A", "plan_name": "100100", "standard_charge_dollar": 54.41, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Medicare A", "plan_name": "100500", "standard_charge_dollar": 54.41, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Medicare Part B Only", "plan_name": "100300", "standard_charge_dollar": 54.41, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Medicare Railroad", "plan_name": "100103", "standard_charge_dollar": 54.41, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Ms Physicians Care N", "plan_name": "714210", "standard_charge_dollar": 68.02, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Peoples Hlth Ffs 72126", "plan_name": "500019", "standard_charge_dollar": 54.41, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Uhc/Secure Horizons", "plan_name": "500449", "standard_charge_dollar": 54.41, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "United Health Care/", "plan_name": "500292", "standard_charge_dollar": 61.49, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "United Healthcare", "plan_name": "750104", "standard_charge_dollar": 61.49, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "United Healthcare Ba", "plan_name": "750090", "standard_charge_dollar": 61.49, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "United Healthcare Me", "plan_name": "501310", "standard_charge_dollar": 54.41, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Windsor Mcare Extra", "plan_name": "500778", "standard_charge_dollar": 54.41, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." } ] } ] }, { "description": "Strapping of elbow or wrist", "code_information": [ { "code": "29260", "type": "CPT" } ], "standard_charges": [ { "gross_charge": 122.00, "minimum": 42.56, "maximum": 68.02, "setting": "both", "payers_information": [ { "payer_name": "Aarp", "plan_name": "500102", "standard_charge_dollar": 54.41, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna", "plan_name": "700700", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna", "plan_name": "700700_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Mcare Ffs 6005", "plan_name": "700703", "standard_charge_dollar": 54.41, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Miscellaneous", "plan_name": "700720", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Miscellaneous", "plan_name": "700720_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Ppo Hmo", "plan_name": "701720", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Ppo Hmo", "plan_name": "701720_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Ambetter 68069", "plan_name": "500516", "standard_charge_dollar": 54.41, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Ms State Emplo", "plan_name": "401457", "standard_charge_dollar": 42.56, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Ms State Emplo", "plan_name": "401457_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Basic Pl", "plan_name": "400100", "standard_charge_dollar": 42.56, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Basic Pl", "plan_name": "400100_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Federal", "plan_name": "400110", "standard_charge_dollar": 42.56, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Federal", "plan_name": "400110_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Cigna Healthsprings Ffs", "plan_name": "500064", "standard_charge_dollar": 54.41, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Conseco", "plan_name": "500302", "standard_charge_dollar": 54.41, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Humana Ffs 61101", "plan_name": "500006", "standard_charge_dollar": 54.41, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Medicare A", "plan_name": "100100", "standard_charge_dollar": 54.41, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Medicare A", "plan_name": "100500", "standard_charge_dollar": 54.41, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Medicare Part B Only", "plan_name": "100300", "standard_charge_dollar": 54.41, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Medicare Railroad", "plan_name": "100103", "standard_charge_dollar": 54.41, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Ms Physicians Care N", "plan_name": "714210", "standard_charge_dollar": 68.02, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Peoples Hlth Ffs 72126", "plan_name": "500019", "standard_charge_dollar": 54.41, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Uhc/Secure Horizons", "plan_name": "500449", "standard_charge_dollar": 54.41, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "United Health Care/", "plan_name": "500292", "standard_charge_dollar": 61.49, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "United Healthcare", "plan_name": "750104", "standard_charge_dollar": 61.49, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "United Healthcare Ba", "plan_name": "750090", "standard_charge_dollar": 61.49, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "United Healthcare Me", "plan_name": "501310", "standard_charge_dollar": 54.41, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Windsor Mcare Extra", "plan_name": "500778", "standard_charge_dollar": 54.41, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." } ] } ] }, { "description": "Application of hip cast", "code_information": [ { "code": "29305", "type": "CPT" } ], "standard_charges": [ { "gross_charge": 30294.00, "minimum": 243.29, "maximum": 25749.90, "setting": "inpatient", "payers_information": [ { "payer_name": "Aarp", "plan_name": "500102", "standard_charge_dollar": 243.29, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna", "plan_name": "700700", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna", "plan_name": "700700_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Mcare Ffs 6005", "plan_name": "700703", "standard_charge_dollar": 243.29, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Miscellaneous", "plan_name": "700720", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Miscellaneous", "plan_name": "700720_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Ppo Hmo", "plan_name": "701720", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Ppo Hmo", "plan_name": "701720_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Ambetter 68069", "plan_name": "500516", "standard_charge_dollar": 243.29, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Ms State Emplo", "plan_name": "401457", "standard_charge_percentage": 0.80, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Ms State Emplo", "plan_name": "401457_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Basic Pl", "plan_name": "400100", "standard_charge_percentage": 0.85, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Basic Pl", "plan_name": "400100_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Federal", "plan_name": "400110", "standard_charge_percentage": 0.85, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Federal", "plan_name": "400110_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Cigna Healthsprings Ffs", "plan_name": "500064", "standard_charge_dollar": 243.29, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Conseco", "plan_name": "500302", "standard_charge_dollar": 243.29, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Humana Ffs 61101", "plan_name": "500006", "standard_charge_dollar": 243.29, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Medicare A", "plan_name": "100100", "standard_charge_dollar": 243.29, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Medicare A", "plan_name": "100500", "standard_charge_dollar": 243.29, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Medicare Part B Only", "plan_name": "100300", "standard_charge_dollar": 243.29, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Medicare Railroad", "plan_name": "100103", "standard_charge_dollar": 243.29, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Ms Physicians Care N", "plan_name": "714210", "standard_charge_dollar": 304.11, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Peoples Hlth Ffs 72126", "plan_name": "500019", "standard_charge_dollar": 243.29, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Uhc/Secure Horizons", "plan_name": "500449", "standard_charge_dollar": 243.29, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "United Health Care/", "plan_name": "500292", "standard_charge_dollar": 274.92, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "United Healthcare", "plan_name": "750104", "standard_charge_dollar": 274.92, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "United Healthcare Ba", "plan_name": "750090", "standard_charge_dollar": 274.92, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "United Healthcare Me", "plan_name": "501310", "standard_charge_dollar": 243.29, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Windsor Mcare Extra", "plan_name": "500778", "standard_charge_dollar": 243.29, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." } ] } ] }, { "description": "Application of hip casts", "code_information": [ { "code": "29325", "type": "CPT" } ], "standard_charges": [ { "gross_charge": 30294.00, "minimum": 243.29, "maximum": 25749.90, "setting": "inpatient", "payers_information": [ { "payer_name": "Aarp", "plan_name": "500102", "standard_charge_dollar": 243.29, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna", "plan_name": "700700", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna", "plan_name": "700700_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Mcare Ffs 6005", "plan_name": "700703", "standard_charge_dollar": 243.29, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Miscellaneous", "plan_name": "700720", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Miscellaneous", "plan_name": "700720_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Ppo Hmo", "plan_name": "701720", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Ppo Hmo", "plan_name": "701720_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Ambetter 68069", "plan_name": "500516", "standard_charge_dollar": 243.29, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Ms State Emplo", "plan_name": "401457", "standard_charge_percentage": 0.80, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Ms State Emplo", "plan_name": "401457_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Basic Pl", "plan_name": "400100", "standard_charge_percentage": 0.85, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Basic Pl", "plan_name": "400100_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Federal", "plan_name": "400110", "standard_charge_percentage": 0.85, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Federal", "plan_name": "400110_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Cigna Healthsprings Ffs", "plan_name": "500064", "standard_charge_dollar": 243.29, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Conseco", "plan_name": "500302", "standard_charge_dollar": 243.29, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Humana Ffs 61101", "plan_name": "500006", "standard_charge_dollar": 243.29, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Medicare A", "plan_name": "100100", "standard_charge_dollar": 243.29, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Medicare A", "plan_name": "100500", "standard_charge_dollar": 243.29, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Medicare Part B Only", "plan_name": "100300", "standard_charge_dollar": 243.29, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Medicare Railroad", "plan_name": "100103", "standard_charge_dollar": 243.29, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Ms Physicians Care N", "plan_name": "714210", "standard_charge_dollar": 304.11, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Peoples Hlth Ffs 72126", "plan_name": "500019", "standard_charge_dollar": 243.29, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Uhc/Secure Horizons", "plan_name": "500449", "standard_charge_dollar": 243.29, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "United Health Care/", "plan_name": "500292", "standard_charge_dollar": 274.92, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "United Healthcare", "plan_name": "750104", "standard_charge_dollar": 274.92, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "United Healthcare Ba", "plan_name": "750090", "standard_charge_dollar": 274.92, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "United Healthcare Me", "plan_name": "501310", "standard_charge_dollar": 243.29, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Windsor Mcare Extra", "plan_name": "500778", "standard_charge_dollar": 243.29, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." } ] } ] }, { "description": "Application of long leg cast", "code_information": [ { "code": "29345", "type": "CPT" } ], "standard_charges": [ { "gross_charge": 30294.00, "minimum": 243.29, "maximum": 25749.90, "setting": "inpatient", "payers_information": [ { "payer_name": "Aarp", "plan_name": "500102", "standard_charge_dollar": 243.29, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna", "plan_name": "700700", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna", "plan_name": "700700_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Mcare Ffs 6005", "plan_name": "700703", "standard_charge_dollar": 243.29, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Miscellaneous", "plan_name": "700720", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Miscellaneous", "plan_name": "700720_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Ppo Hmo", "plan_name": "701720", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Ppo Hmo", "plan_name": "701720_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Ambetter 68069", "plan_name": "500516", "standard_charge_dollar": 243.29, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Ms State Emplo", "plan_name": "401457", "standard_charge_percentage": 0.80, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Ms State Emplo", "plan_name": "401457_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Basic Pl", "plan_name": "400100", "standard_charge_percentage": 0.85, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Basic Pl", "plan_name": "400100_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Federal", "plan_name": "400110", "standard_charge_percentage": 0.85, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Federal", "plan_name": "400110_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Cigna Healthsprings Ffs", "plan_name": "500064", "standard_charge_dollar": 243.29, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Conseco", "plan_name": "500302", "standard_charge_dollar": 243.29, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Humana Ffs 61101", "plan_name": "500006", "standard_charge_dollar": 243.29, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Medicare A", "plan_name": "100100", "standard_charge_dollar": 243.29, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Medicare A", "plan_name": "100500", "standard_charge_dollar": 243.29, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Medicare Part B Only", "plan_name": "100300", "standard_charge_dollar": 243.29, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Medicare Railroad", "plan_name": "100103", "standard_charge_dollar": 243.29, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Ms Physicians Care N", "plan_name": "714210", "standard_charge_dollar": 304.11, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Peoples Hlth Ffs 72126", "plan_name": "500019", "standard_charge_dollar": 243.29, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Uhc/Secure Horizons", "plan_name": "500449", "standard_charge_dollar": 243.29, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "United Health Care/", "plan_name": "500292", "standard_charge_dollar": 274.92, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "United Healthcare", "plan_name": "750104", "standard_charge_dollar": 274.92, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "United Healthcare Ba", "plan_name": "750090", "standard_charge_dollar": 274.92, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "United Healthcare Me", "plan_name": "501310", "standard_charge_dollar": 243.29, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Windsor Mcare Extra", "plan_name": "500778", "standard_charge_dollar": 243.29, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." } ] } ] }, { "description": "Application of long leg cast", "code_information": [ { "code": "29355", "type": "CPT" } ], "standard_charges": [ { "gross_charge": 30294.00, "minimum": 243.29, "maximum": 25749.90, "setting": "inpatient", "payers_information": [ { "payer_name": "Aarp", "plan_name": "500102", "standard_charge_dollar": 243.29, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna", "plan_name": "700700", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna", "plan_name": "700700_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Mcare Ffs 6005", "plan_name": "700703", "standard_charge_dollar": 243.29, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Miscellaneous", "plan_name": "700720", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Miscellaneous", "plan_name": "700720_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Ppo Hmo", "plan_name": "701720", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Ppo Hmo", "plan_name": "701720_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Ambetter 68069", "plan_name": "500516", "standard_charge_dollar": 243.29, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Ms State Emplo", "plan_name": "401457", "standard_charge_percentage": 0.80, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Ms State Emplo", "plan_name": "401457_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Basic Pl", "plan_name": "400100", "standard_charge_percentage": 0.85, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Basic Pl", "plan_name": "400100_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Federal", "plan_name": "400110", "standard_charge_percentage": 0.85, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Federal", "plan_name": "400110_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Cigna Healthsprings Ffs", "plan_name": "500064", "standard_charge_dollar": 243.29, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Conseco", "plan_name": "500302", "standard_charge_dollar": 243.29, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Humana Ffs 61101", "plan_name": "500006", "standard_charge_dollar": 243.29, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Medicare A", "plan_name": "100100", "standard_charge_dollar": 243.29, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Medicare A", "plan_name": "100500", "standard_charge_dollar": 243.29, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Medicare Part B Only", "plan_name": "100300", "standard_charge_dollar": 243.29, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Medicare Railroad", "plan_name": "100103", "standard_charge_dollar": 243.29, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Ms Physicians Care N", "plan_name": "714210", "standard_charge_dollar": 304.11, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Peoples Hlth Ffs 72126", "plan_name": "500019", "standard_charge_dollar": 243.29, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Uhc/Secure Horizons", "plan_name": "500449", "standard_charge_dollar": 243.29, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "United Health Care/", "plan_name": "500292", "standard_charge_dollar": 274.92, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "United Healthcare", "plan_name": "750104", "standard_charge_dollar": 274.92, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "United Healthcare Ba", "plan_name": "750090", "standard_charge_dollar": 274.92, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "United Healthcare Me", "plan_name": "501310", "standard_charge_dollar": 243.29, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Windsor Mcare Extra", "plan_name": "500778", "standard_charge_dollar": 243.29, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." } ] } ] }, { "description": "Application of long leg cast", "code_information": [ { "code": "29365", "type": "CPT" } ], "standard_charges": [ { "gross_charge": 30294.00, "minimum": 243.29, "maximum": 25749.90, "setting": "inpatient", "payers_information": [ { "payer_name": "Aarp", "plan_name": "500102", "standard_charge_dollar": 243.29, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna", "plan_name": "700700", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna", "plan_name": "700700_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Mcare Ffs 6005", "plan_name": "700703", "standard_charge_dollar": 243.29, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Miscellaneous", "plan_name": "700720", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Miscellaneous", "plan_name": "700720_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Ppo Hmo", "plan_name": "701720", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Ppo Hmo", "plan_name": "701720_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Ambetter 68069", "plan_name": "500516", "standard_charge_dollar": 243.29, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Ms State Emplo", "plan_name": "401457", "standard_charge_percentage": 0.80, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Ms State Emplo", "plan_name": "401457_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Basic Pl", "plan_name": "400100", "standard_charge_percentage": 0.85, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Basic Pl", "plan_name": "400100_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Federal", "plan_name": "400110", "standard_charge_percentage": 0.85, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Federal", "plan_name": "400110_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Cigna Healthsprings Ffs", "plan_name": "500064", "standard_charge_dollar": 243.29, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Conseco", "plan_name": "500302", "standard_charge_dollar": 243.29, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Humana Ffs 61101", "plan_name": "500006", "standard_charge_dollar": 243.29, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Medicare A", "plan_name": "100100", "standard_charge_dollar": 243.29, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Medicare A", "plan_name": "100500", "standard_charge_dollar": 243.29, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Medicare Part B Only", "plan_name": "100300", "standard_charge_dollar": 243.29, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Medicare Railroad", "plan_name": "100103", "standard_charge_dollar": 243.29, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Ms Physicians Care N", "plan_name": "714210", "standard_charge_dollar": 304.11, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Peoples Hlth Ffs 72126", "plan_name": "500019", "standard_charge_dollar": 243.29, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Uhc/Secure Horizons", "plan_name": "500449", "standard_charge_dollar": 243.29, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "United Health Care/", "plan_name": "500292", "standard_charge_dollar": 274.92, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "United Healthcare", "plan_name": "750104", "standard_charge_dollar": 274.92, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "United Healthcare Ba", "plan_name": "750090", "standard_charge_dollar": 274.92, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "United Healthcare Me", "plan_name": "501310", "standard_charge_dollar": 243.29, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Windsor Mcare Extra", "plan_name": "500778", "standard_charge_dollar": 243.29, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." } ] } ] }, { "description": "Apply short leg cast", "code_information": [ { "code": "29405", "type": "CPT" } ], "standard_charges": [ { "gross_charge": 165.00, "minimum": 132.00, "maximum": 304.11, "setting": "both", "payers_information": [ { "payer_name": "Aarp", "plan_name": "500102", "standard_charge_dollar": 243.29, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna", "plan_name": "700700", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna", "plan_name": "700700_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Mcare Ffs 6005", "plan_name": "700703", "standard_charge_dollar": 243.29, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Miscellaneous", "plan_name": "700720", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Miscellaneous", "plan_name": "700720_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Ppo Hmo", "plan_name": "701720", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Ppo Hmo", "plan_name": "701720_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Ambetter 68069", "plan_name": "500516", "standard_charge_dollar": 243.29, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Ms State Emplo", "plan_name": "401457", "standard_charge_percentage": 0.80, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Ms State Emplo", "plan_name": "401457_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Basic Pl", "plan_name": "400100", "standard_charge_percentage": 0.85, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Basic Pl", "plan_name": "400100_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Federal", "plan_name": "400110", "standard_charge_percentage": 0.85, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Federal", "plan_name": "400110_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Cigna Healthsprings Ffs", "plan_name": "500064", "standard_charge_dollar": 243.29, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Conseco", "plan_name": "500302", "standard_charge_dollar": 243.29, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Humana Ffs 61101", "plan_name": "500006", "standard_charge_dollar": 243.29, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Medicare A", "plan_name": "100100", "standard_charge_dollar": 243.29, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Medicare A", "plan_name": "100500", "standard_charge_dollar": 243.29, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Medicare Part B Only", "plan_name": "100300", "standard_charge_dollar": 243.29, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Medicare Railroad", "plan_name": "100103", "standard_charge_dollar": 243.29, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Ms Physicians Care N", "plan_name": "714210", "standard_charge_dollar": 304.11, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Peoples Hlth Ffs 72126", "plan_name": "500019", "standard_charge_dollar": 243.29, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Uhc/Secure Horizons", "plan_name": "500449", "standard_charge_dollar": 243.29, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "United Health Care/", "plan_name": "500292", "standard_charge_dollar": 274.92, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "United Healthcare", "plan_name": "750104", "standard_charge_dollar": 274.92, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "United Healthcare Ba", "plan_name": "750090", "standard_charge_dollar": 274.92, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "United Healthcare Me", "plan_name": "501310", "standard_charge_dollar": 243.29, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Windsor Mcare Extra", "plan_name": "500778", "standard_charge_dollar": 243.29, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." } ] } ] }, { "description": "Hc application lower leg cast", "code_information": [ { "code": "29405", "type": "CPT" } ], "standard_charges": [ { "gross_charge": 165.00, "minimum": 132.00, "maximum": 304.11, "setting": "both", "payers_information": [ { "payer_name": "Aarp", "plan_name": "500102", "standard_charge_dollar": 243.29, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna", "plan_name": "700700", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna", "plan_name": "700700_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Mcare Ffs 6005", "plan_name": "700703", "standard_charge_dollar": 243.29, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Miscellaneous", "plan_name": "700720", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Miscellaneous", "plan_name": "700720_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Ppo Hmo", "plan_name": "701720", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Ppo Hmo", "plan_name": "701720_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Ambetter 68069", "plan_name": "500516", "standard_charge_dollar": 243.29, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Ms State Emplo", "plan_name": "401457", "standard_charge_percentage": 0.80, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Ms State Emplo", "plan_name": "401457_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Basic Pl", "plan_name": "400100", "standard_charge_percentage": 0.85, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Basic Pl", "plan_name": "400100_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Federal", "plan_name": "400110", "standard_charge_percentage": 0.85, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Federal", "plan_name": "400110_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Cigna Healthsprings Ffs", "plan_name": "500064", "standard_charge_dollar": 243.29, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Conseco", "plan_name": "500302", "standard_charge_dollar": 243.29, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Humana Ffs 61101", "plan_name": "500006", "standard_charge_dollar": 243.29, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Medicare A", "plan_name": "100100", "standard_charge_dollar": 243.29, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Medicare A", "plan_name": "100500", "standard_charge_dollar": 243.29, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Medicare Part B Only", "plan_name": "100300", "standard_charge_dollar": 243.29, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Medicare Railroad", "plan_name": "100103", "standard_charge_dollar": 243.29, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Ms Physicians Care N", "plan_name": "714210", "standard_charge_dollar": 304.11, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Peoples Hlth Ffs 72126", "plan_name": "500019", "standard_charge_dollar": 243.29, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Uhc/Secure Horizons", "plan_name": "500449", "standard_charge_dollar": 243.29, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "United Health Care/", "plan_name": "500292", "standard_charge_dollar": 274.92, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "United Healthcare", "plan_name": "750104", "standard_charge_dollar": 274.92, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "United Healthcare Ba", "plan_name": "750090", "standard_charge_dollar": 274.92, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "United Healthcare Me", "plan_name": "501310", "standard_charge_dollar": 243.29, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Windsor Mcare Extra", "plan_name": "500778", "standard_charge_dollar": 243.29, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." } ] } ] }, { "description": "Apply short leg cast", "code_information": [ { "code": "29425", "type": "CPT" } ], "standard_charges": [ { "gross_charge": 475.00, "minimum": 243.29, "maximum": 403.75, "setting": "both", "payers_information": [ { "payer_name": "Aarp", "plan_name": "500102", "standard_charge_dollar": 243.29, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna", "plan_name": "700700", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna", "plan_name": "700700_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Mcare Ffs 6005", "plan_name": "700703", "standard_charge_dollar": 243.29, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Miscellaneous", "plan_name": "700720", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Miscellaneous", "plan_name": "700720_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Ppo Hmo", "plan_name": "701720", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Ppo Hmo", "plan_name": "701720_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Ambetter 68069", "plan_name": "500516", "standard_charge_dollar": 243.29, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Ms State Emplo", "plan_name": "401457", "standard_charge_percentage": 0.80, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Ms State Emplo", "plan_name": "401457_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Basic Pl", "plan_name": "400100", "standard_charge_percentage": 0.85, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Basic Pl", "plan_name": "400100_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Federal", "plan_name": "400110", "standard_charge_percentage": 0.85, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Federal", "plan_name": "400110_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Cigna Healthsprings Ffs", "plan_name": "500064", "standard_charge_dollar": 243.29, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Conseco", "plan_name": "500302", "standard_charge_dollar": 243.29, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Humana Ffs 61101", "plan_name": "500006", "standard_charge_dollar": 243.29, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Medicare A", "plan_name": "100100", "standard_charge_dollar": 243.29, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Medicare A", "plan_name": "100500", "standard_charge_dollar": 243.29, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Medicare Part B Only", "plan_name": "100300", "standard_charge_dollar": 243.29, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Medicare Railroad", "plan_name": "100103", "standard_charge_dollar": 243.29, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Ms Physicians Care N", "plan_name": "714210", "standard_charge_dollar": 304.11, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Peoples Hlth Ffs 72126", "plan_name": "500019", "standard_charge_dollar": 243.29, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Uhc/Secure Horizons", "plan_name": "500449", "standard_charge_dollar": 243.29, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "United Health Care/", "plan_name": "500292", "standard_charge_dollar": 274.92, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "United Healthcare", "plan_name": "750104", "standard_charge_dollar": 274.92, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "United Healthcare Ba", "plan_name": "750090", "standard_charge_dollar": 274.92, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "United Healthcare Me", "plan_name": "501310", "standard_charge_dollar": 243.29, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Windsor Mcare Extra", "plan_name": "500778", "standard_charge_dollar": 243.29, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." } ] } ] }, { "description": "Hc apply short leg cast", "code_information": [ { "code": "29425", "type": "CPT" } ], "standard_charges": [ { "gross_charge": 475.00, "minimum": 243.29, "maximum": 403.75, "setting": "both", "payers_information": [ { "payer_name": "Aarp", "plan_name": "500102", "standard_charge_dollar": 243.29, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna", "plan_name": "700700", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna", "plan_name": "700700_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Mcare Ffs 6005", "plan_name": "700703", "standard_charge_dollar": 243.29, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Miscellaneous", "plan_name": "700720", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Miscellaneous", "plan_name": "700720_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Ppo Hmo", "plan_name": "701720", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Ppo Hmo", "plan_name": "701720_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Ambetter 68069", "plan_name": "500516", "standard_charge_dollar": 243.29, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Ms State Emplo", "plan_name": "401457", "standard_charge_percentage": 0.80, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Ms State Emplo", "plan_name": "401457_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Basic Pl", "plan_name": "400100", "standard_charge_percentage": 0.85, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Basic Pl", "plan_name": "400100_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Federal", "plan_name": "400110", "standard_charge_percentage": 0.85, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Federal", "plan_name": "400110_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Cigna Healthsprings Ffs", "plan_name": "500064", "standard_charge_dollar": 243.29, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Conseco", "plan_name": "500302", "standard_charge_dollar": 243.29, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Humana Ffs 61101", "plan_name": "500006", "standard_charge_dollar": 243.29, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Medicare A", "plan_name": "100100", "standard_charge_dollar": 243.29, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Medicare A", "plan_name": "100500", "standard_charge_dollar": 243.29, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Medicare Part B Only", "plan_name": "100300", "standard_charge_dollar": 243.29, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Medicare Railroad", "plan_name": "100103", "standard_charge_dollar": 243.29, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Ms Physicians Care N", "plan_name": "714210", "standard_charge_dollar": 304.11, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Peoples Hlth Ffs 72126", "plan_name": "500019", "standard_charge_dollar": 243.29, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Uhc/Secure Horizons", "plan_name": "500449", "standard_charge_dollar": 243.29, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "United Health Care/", "plan_name": "500292", "standard_charge_dollar": 274.92, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "United Healthcare", "plan_name": "750104", "standard_charge_dollar": 274.92, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "United Healthcare Ba", "plan_name": "750090", "standard_charge_dollar": 274.92, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "United Healthcare Me", "plan_name": "501310", "standard_charge_dollar": 243.29, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Windsor Mcare Extra", "plan_name": "500778", "standard_charge_dollar": 243.29, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." } ] } ] }, { "description": "Apply rigid leg cast", "code_information": [ { "code": "29445", "type": "CPT" } ], "standard_charges": [ { "gross_charge": 350.00, "minimum": 243.29, "maximum": 304.11, "setting": "both", "payers_information": [ { "payer_name": "Aarp", "plan_name": "500102", "standard_charge_dollar": 243.29, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna", "plan_name": "700700", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna", "plan_name": "700700_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Mcare Ffs 6005", "plan_name": "700703", "standard_charge_dollar": 243.29, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Miscellaneous", "plan_name": "700720", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Miscellaneous", "plan_name": "700720_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Ppo Hmo", "plan_name": "701720", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Ppo Hmo", "plan_name": "701720_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Ambetter 68069", "plan_name": "500516", "standard_charge_dollar": 243.29, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Ms State Emplo", "plan_name": "401457", "standard_charge_percentage": 0.80, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Ms State Emplo", "plan_name": "401457_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Basic Pl", "plan_name": "400100", "standard_charge_percentage": 0.85, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Basic Pl", "plan_name": "400100_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Federal", "plan_name": "400110", "standard_charge_percentage": 0.85, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Federal", "plan_name": "400110_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Cigna Healthsprings Ffs", "plan_name": "500064", "standard_charge_dollar": 243.29, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Conseco", "plan_name": "500302", "standard_charge_dollar": 243.29, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Humana Ffs 61101", "plan_name": "500006", "standard_charge_dollar": 243.29, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Medicare A", "plan_name": "100100", "standard_charge_dollar": 243.29, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Medicare A", "plan_name": "100500", "standard_charge_dollar": 243.29, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Medicare Part B Only", "plan_name": "100300", "standard_charge_dollar": 243.29, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Medicare Railroad", "plan_name": "100103", "standard_charge_dollar": 243.29, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Ms Physicians Care N", "plan_name": "714210", "standard_charge_dollar": 304.11, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Peoples Hlth Ffs 72126", "plan_name": "500019", "standard_charge_dollar": 243.29, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Uhc/Secure Horizons", "plan_name": "500449", "standard_charge_dollar": 243.29, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "United Health Care/", "plan_name": "500292", "standard_charge_dollar": 274.92, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "United Healthcare", "plan_name": "750104", "standard_charge_dollar": 274.92, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "United Healthcare Ba", "plan_name": "750090", "standard_charge_dollar": 274.92, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "United Healthcare Me", "plan_name": "501310", "standard_charge_dollar": 243.29, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Windsor Mcare Extra", "plan_name": "500778", "standard_charge_dollar": 243.29, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." } ] } ] }, { "description": "Hc applic rigid contact leg cast", "code_information": [ { "code": "29445", "type": "CPT" } ], "standard_charges": [ { "gross_charge": 350.00, "minimum": 243.29, "maximum": 304.11, "setting": "both", "payers_information": [ { "payer_name": "Aarp", "plan_name": "500102", "standard_charge_dollar": 243.29, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna", "plan_name": "700700", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna", "plan_name": "700700_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Mcare Ffs 6005", "plan_name": "700703", "standard_charge_dollar": 243.29, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Miscellaneous", "plan_name": "700720", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Miscellaneous", "plan_name": "700720_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Ppo Hmo", "plan_name": "701720", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Ppo Hmo", "plan_name": "701720_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Ambetter 68069", "plan_name": "500516", "standard_charge_dollar": 243.29, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Ms State Emplo", "plan_name": "401457", "standard_charge_percentage": 0.80, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Ms State Emplo", "plan_name": "401457_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Basic Pl", "plan_name": "400100", "standard_charge_percentage": 0.85, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Basic Pl", "plan_name": "400100_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Federal", "plan_name": "400110", "standard_charge_percentage": 0.85, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Federal", "plan_name": "400110_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Cigna Healthsprings Ffs", "plan_name": "500064", "standard_charge_dollar": 243.29, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Conseco", "plan_name": "500302", "standard_charge_dollar": 243.29, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Humana Ffs 61101", "plan_name": "500006", "standard_charge_dollar": 243.29, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Medicare A", "plan_name": "100100", "standard_charge_dollar": 243.29, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Medicare A", "plan_name": "100500", "standard_charge_dollar": 243.29, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Medicare Part B Only", "plan_name": "100300", "standard_charge_dollar": 243.29, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Medicare Railroad", "plan_name": "100103", "standard_charge_dollar": 243.29, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Ms Physicians Care N", "plan_name": "714210", "standard_charge_dollar": 304.11, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Peoples Hlth Ffs 72126", "plan_name": "500019", "standard_charge_dollar": 243.29, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Uhc/Secure Horizons", "plan_name": "500449", "standard_charge_dollar": 243.29, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "United Health Care/", "plan_name": "500292", "standard_charge_dollar": 274.92, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "United Healthcare", "plan_name": "750104", "standard_charge_dollar": 274.92, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "United Healthcare Ba", "plan_name": "750090", "standard_charge_dollar": 274.92, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "United Healthcare Me", "plan_name": "501310", "standard_charge_dollar": 243.29, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Windsor Mcare Extra", "plan_name": "500778", "standard_charge_dollar": 243.29, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." } ] } ] }, { "description": "Application of leg cast", "code_information": [ { "code": "29450", "type": "CPT" } ], "standard_charges": [ { "gross_charge": 30294.00, "minimum": 144.55, "maximum": 25749.90, "setting": "inpatient", "payers_information": [ { "payer_name": "Aarp", "plan_name": "500102", "standard_charge_dollar": 144.55, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna", "plan_name": "700700", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna", "plan_name": "700700_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Mcare Ffs 6005", "plan_name": "700703", "standard_charge_dollar": 144.55, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Miscellaneous", "plan_name": "700720", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Miscellaneous", "plan_name": "700720_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Ppo Hmo", "plan_name": "701720", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Ppo Hmo", "plan_name": "701720_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Ambetter 68069", "plan_name": "500516", "standard_charge_dollar": 144.55, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Ms State Emplo", "plan_name": "401457", "standard_charge_percentage": 0.80, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Ms State Emplo", "plan_name": "401457_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Basic Pl", "plan_name": "400100", "standard_charge_percentage": 0.85, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Basic Pl", "plan_name": "400100_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Federal", "plan_name": "400110", "standard_charge_percentage": 0.85, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Federal", "plan_name": "400110_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Cigna Healthsprings Ffs", "plan_name": "500064", "standard_charge_dollar": 144.55, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Conseco", "plan_name": "500302", "standard_charge_dollar": 144.55, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Humana Ffs 61101", "plan_name": "500006", "standard_charge_dollar": 144.55, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Medicare A", "plan_name": "100100", "standard_charge_dollar": 144.55, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Medicare A", "plan_name": "100500", "standard_charge_dollar": 144.55, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Medicare Part B Only", "plan_name": "100300", "standard_charge_dollar": 144.55, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Medicare Railroad", "plan_name": "100103", "standard_charge_dollar": 144.55, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Ms Physicians Care N", "plan_name": "714210", "standard_charge_dollar": 180.68, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Peoples Hlth Ffs 72126", "plan_name": "500019", "standard_charge_dollar": 144.55, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Uhc/Secure Horizons", "plan_name": "500449", "standard_charge_dollar": 144.55, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "United Health Care/", "plan_name": "500292", "standard_charge_dollar": 163.34, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "United Healthcare", "plan_name": "750104", "standard_charge_dollar": 163.34, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "United Healthcare Ba", "plan_name": "750090", "standard_charge_dollar": 163.34, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "United Healthcare Me", "plan_name": "501310", "standard_charge_dollar": 144.55, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Windsor Mcare Extra", "plan_name": "500778", "standard_charge_dollar": 144.55, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." } ] } ] }, { "description": "Application lower leg splint", "code_information": [ { "code": "29515", "type": "CPT" } ], "standard_charges": [ { "gross_charge": 233.00, "minimum": 144.55, "maximum": 198.05, "setting": "both", "payers_information": [ { "payer_name": "Aarp", "plan_name": "500102", "standard_charge_dollar": 144.55, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna", "plan_name": "700700", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna", "plan_name": "700700_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Mcare Ffs 6005", "plan_name": "700703", "standard_charge_dollar": 144.55, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Miscellaneous", "plan_name": "700720", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Miscellaneous", "plan_name": "700720_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Ppo Hmo", "plan_name": "701720", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Ppo Hmo", "plan_name": "701720_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Ambetter 68069", "plan_name": "500516", "standard_charge_dollar": 144.55, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Ms State Emplo", "plan_name": "401457", "standard_charge_percentage": 0.80, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Ms State Emplo", "plan_name": "401457_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Basic Pl", "plan_name": "400100", "standard_charge_percentage": 0.85, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Basic Pl", "plan_name": "400100_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Federal", "plan_name": "400110", "standard_charge_percentage": 0.85, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Federal", "plan_name": "400110_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Cigna Healthsprings Ffs", "plan_name": "500064", "standard_charge_dollar": 144.55, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Conseco", "plan_name": "500302", "standard_charge_dollar": 144.55, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Humana Ffs 61101", "plan_name": "500006", "standard_charge_dollar": 144.55, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Medicare A", "plan_name": "100100", "standard_charge_dollar": 144.55, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Medicare A", "plan_name": "100500", "standard_charge_dollar": 144.55, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Medicare Part B Only", "plan_name": "100300", "standard_charge_dollar": 144.55, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Medicare Railroad", "plan_name": "100103", "standard_charge_dollar": 144.55, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Ms Physicians Care N", "plan_name": "714210", "standard_charge_dollar": 180.68, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Peoples Hlth Ffs 72126", "plan_name": "500019", "standard_charge_dollar": 144.55, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Uhc/Secure Horizons", "plan_name": "500449", "standard_charge_dollar": 144.55, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "United Health Care/", "plan_name": "500292", "standard_charge_dollar": 163.34, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "United Healthcare", "plan_name": "750104", "standard_charge_dollar": 163.34, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "United Healthcare Ba", "plan_name": "750090", "standard_charge_dollar": 163.34, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "United Healthcare Me", "plan_name": "501310", "standard_charge_dollar": 144.55, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Windsor Mcare Extra", "plan_name": "500778", "standard_charge_dollar": 144.55, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." } ] } ] }, { "description": "Hc appl splint short leg", "code_information": [ { "code": "29515", "type": "CPT" } ], "standard_charges": [ { "gross_charge": 233.00, "minimum": 144.55, "maximum": 198.05, "setting": "both", "payers_information": [ { "payer_name": "Aarp", "plan_name": "500102", "standard_charge_dollar": 144.55, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna", "plan_name": "700700", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna", "plan_name": "700700_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Mcare Ffs 6005", "plan_name": "700703", "standard_charge_dollar": 144.55, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Miscellaneous", "plan_name": "700720", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Miscellaneous", "plan_name": "700720_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Ppo Hmo", "plan_name": "701720", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Ppo Hmo", "plan_name": "701720_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Ambetter 68069", "plan_name": "500516", "standard_charge_dollar": 144.55, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Ms State Emplo", "plan_name": "401457", "standard_charge_percentage": 0.80, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Ms State Emplo", "plan_name": "401457_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Basic Pl", "plan_name": "400100", "standard_charge_percentage": 0.85, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Basic Pl", "plan_name": "400100_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Federal", "plan_name": "400110", "standard_charge_percentage": 0.85, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Federal", "plan_name": "400110_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Cigna Healthsprings Ffs", "plan_name": "500064", "standard_charge_dollar": 144.55, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Conseco", "plan_name": "500302", "standard_charge_dollar": 144.55, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Humana Ffs 61101", "plan_name": "500006", "standard_charge_dollar": 144.55, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Medicare A", "plan_name": "100100", "standard_charge_dollar": 144.55, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Medicare A", "plan_name": "100500", "standard_charge_dollar": 144.55, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Medicare Part B Only", "plan_name": "100300", "standard_charge_dollar": 144.55, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Medicare Railroad", "plan_name": "100103", "standard_charge_dollar": 144.55, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Ms Physicians Care N", "plan_name": "714210", "standard_charge_dollar": 180.68, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Peoples Hlth Ffs 72126", "plan_name": "500019", "standard_charge_dollar": 144.55, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Uhc/Secure Horizons", "plan_name": "500449", "standard_charge_dollar": 144.55, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "United Health Care/", "plan_name": "500292", "standard_charge_dollar": 163.34, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "United Healthcare", "plan_name": "750104", "standard_charge_dollar": 163.34, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "United Healthcare Ba", "plan_name": "750090", "standard_charge_dollar": 163.34, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "United Healthcare Me", "plan_name": "501310", "standard_charge_dollar": 144.55, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Windsor Mcare Extra", "plan_name": "500778", "standard_charge_dollar": 144.55, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." } ] } ] }, { "description": "Application of paste boot", "code_information": [ { "code": "29580", "type": "CPT" } ], "standard_charges": [ { "gross_charge": 486.00, "minimum": 144.55, "maximum": 413.10, "setting": "both", "payers_information": [ { "payer_name": "Aarp", "plan_name": "500102", "standard_charge_dollar": 144.55, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna", "plan_name": "700700", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna", "plan_name": "700700_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Mcare Ffs 6005", "plan_name": "700703", "standard_charge_dollar": 144.55, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Miscellaneous", "plan_name": "700720", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Miscellaneous", "plan_name": "700720_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Ppo Hmo", "plan_name": "701720", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Ppo Hmo", "plan_name": "701720_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Ambetter 68069", "plan_name": "500516", "standard_charge_dollar": 144.55, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Ms State Emplo", "plan_name": "401457", "standard_charge_percentage": 0.80, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Ms State Emplo", "plan_name": "401457_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Basic Pl", "plan_name": "400100", "standard_charge_percentage": 0.85, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Basic Pl", "plan_name": "400100_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Federal", "plan_name": "400110", "standard_charge_percentage": 0.85, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Federal", "plan_name": "400110_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Cigna Healthsprings Ffs", "plan_name": "500064", "standard_charge_dollar": 144.55, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Conseco", "plan_name": "500302", "standard_charge_dollar": 144.55, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Humana Ffs 61101", "plan_name": "500006", "standard_charge_dollar": 144.55, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Medicare A", "plan_name": "100100", "standard_charge_dollar": 144.55, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Medicare A", "plan_name": "100500", "standard_charge_dollar": 144.55, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Medicare Part B Only", "plan_name": "100300", "standard_charge_dollar": 144.55, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Medicare Railroad", "plan_name": "100103", "standard_charge_dollar": 144.55, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Ms Physicians Care N", "plan_name": "714210", "standard_charge_dollar": 180.68, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Peoples Hlth Ffs 72126", "plan_name": "500019", "standard_charge_dollar": 144.55, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Uhc/Secure Horizons", "plan_name": "500449", "standard_charge_dollar": 144.55, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "United Health Care/", "plan_name": "500292", "standard_charge_dollar": 163.34, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "United Healthcare", "plan_name": "750104", "standard_charge_dollar": 163.34, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "United Healthcare Ba", "plan_name": "750090", "standard_charge_dollar": 163.34, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "United Healthcare Me", "plan_name": "501310", "standard_charge_dollar": 144.55, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Windsor Mcare Extra", "plan_name": "500778", "standard_charge_dollar": 144.55, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." } ] } ] }, { "description": "Hc unna boot 2 layer", "code_information": [ { "code": "29580", "type": "CPT" } ], "standard_charges": [ { "gross_charge": 486.00, "minimum": 144.55, "maximum": 413.10, "setting": "both", "payers_information": [ { "payer_name": "Aarp", "plan_name": "500102", "standard_charge_dollar": 144.55, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna", "plan_name": "700700", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna", "plan_name": "700700_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Mcare Ffs 6005", "plan_name": "700703", "standard_charge_dollar": 144.55, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Miscellaneous", "plan_name": "700720", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Miscellaneous", "plan_name": "700720_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Ppo Hmo", "plan_name": "701720", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Ppo Hmo", "plan_name": "701720_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Ambetter 68069", "plan_name": "500516", "standard_charge_dollar": 144.55, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Ms State Emplo", "plan_name": "401457", "standard_charge_percentage": 0.80, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Ms State Emplo", "plan_name": "401457_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Basic Pl", "plan_name": "400100", "standard_charge_percentage": 0.85, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Basic Pl", "plan_name": "400100_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Federal", "plan_name": "400110", "standard_charge_percentage": 0.85, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Federal", "plan_name": "400110_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Cigna Healthsprings Ffs", "plan_name": "500064", "standard_charge_dollar": 144.55, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Conseco", "plan_name": "500302", "standard_charge_dollar": 144.55, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Humana Ffs 61101", "plan_name": "500006", "standard_charge_dollar": 144.55, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Medicare A", "plan_name": "100100", "standard_charge_dollar": 144.55, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Medicare A", "plan_name": "100500", "standard_charge_dollar": 144.55, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Medicare Part B Only", "plan_name": "100300", "standard_charge_dollar": 144.55, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Medicare Railroad", "plan_name": "100103", "standard_charge_dollar": 144.55, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Ms Physicians Care N", "plan_name": "714210", "standard_charge_dollar": 180.68, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Peoples Hlth Ffs 72126", "plan_name": "500019", "standard_charge_dollar": 144.55, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Uhc/Secure Horizons", "plan_name": "500449", "standard_charge_dollar": 144.55, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "United Health Care/", "plan_name": "500292", "standard_charge_dollar": 163.34, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "United Healthcare", "plan_name": "750104", "standard_charge_dollar": 163.34, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "United Healthcare Ba", "plan_name": "750090", "standard_charge_dollar": 163.34, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "United Healthcare Me", "plan_name": "501310", "standard_charge_dollar": 144.55, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Windsor Mcare Extra", "plan_name": "500778", "standard_charge_dollar": 144.55, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." } ] } ] }, { "description": "Hc unna boot 2 layer", "code_information": [ { "code": "29580", "type": "CPT" } ], "standard_charges": [ { "gross_charge": 1944.00, "minimum": 144.55, "maximum": 1652.40, "setting": "both", "payers_information": [ { "payer_name": "Aarp", "plan_name": "500102", "standard_charge_dollar": 144.55, "count": "0", "methodology": "fee schedule", "modifiers": "50", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna", "plan_name": "700700", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna", "plan_name": "700700_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Mcare Ffs 6005", "plan_name": "700703", "standard_charge_dollar": 144.55, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Miscellaneous", "plan_name": "700720", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Miscellaneous", "plan_name": "700720_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Ppo Hmo", "plan_name": "701720", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Ppo Hmo", "plan_name": "701720_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Ambetter 68069", "plan_name": "500516", "standard_charge_dollar": 144.55, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Ms State Emplo", "plan_name": "401457", "standard_charge_percentage": 0.80, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Ms State Emplo", "plan_name": "401457_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Basic Pl", "plan_name": "400100", "standard_charge_percentage": 0.85, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Basic Pl", "plan_name": "400100_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Federal", "plan_name": "400110", "standard_charge_percentage": 0.85, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Federal", "plan_name": "400110_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Cigna Healthsprings Ffs", "plan_name": "500064", "standard_charge_dollar": 144.55, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Conseco", "plan_name": "500302", "standard_charge_dollar": 144.55, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Humana Ffs 61101", "plan_name": "500006", "standard_charge_dollar": 144.55, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Medicare A", "plan_name": "100100", "standard_charge_dollar": 144.55, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Medicare A", "plan_name": "100500", "standard_charge_dollar": 144.55, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Medicare Part B Only", "plan_name": "100300", "standard_charge_dollar": 144.55, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Medicare Railroad", "plan_name": "100103", "standard_charge_dollar": 144.55, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Ms Physicians Care N", "plan_name": "714210", "standard_charge_dollar": 180.68, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Peoples Hlth Ffs 72126", "plan_name": "500019", "standard_charge_dollar": 144.55, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Uhc/Secure Horizons", "plan_name": "500449", "standard_charge_dollar": 144.55, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "United Health Care/", "plan_name": "500292", "standard_charge_dollar": 163.34, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "United Healthcare", "plan_name": "750104", "standard_charge_dollar": 163.34, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "United Healthcare Ba", "plan_name": "750090", "standard_charge_dollar": 163.34, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "United Healthcare Me", "plan_name": "501310", "standard_charge_dollar": 144.55, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Windsor Mcare Extra", "plan_name": "500778", "standard_charge_dollar": 144.55, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." } ] } ] }, { "description": "Apply multlay comprs lwr leg", "code_information": [ { "code": "29581", "type": "CPT" } ], "standard_charges": [ { "gross_charge": 486.00, "minimum": 144.55, "maximum": 413.10, "setting": "both", "payers_information": [ { "payer_name": "Aarp", "plan_name": "500102", "standard_charge_dollar": 144.55, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna", "plan_name": "700700", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna", "plan_name": "700700_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Mcare Ffs 6005", "plan_name": "700703", "standard_charge_dollar": 144.55, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Miscellaneous", "plan_name": "700720", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Miscellaneous", "plan_name": "700720_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Ppo Hmo", "plan_name": "701720", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Ppo Hmo", "plan_name": "701720_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Ambetter 68069", "plan_name": "500516", "standard_charge_dollar": 144.55, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Ms State Emplo", "plan_name": "401457", "standard_charge_percentage": 0.80, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Ms State Emplo", "plan_name": "401457_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Basic Pl", "plan_name": "400100", "standard_charge_percentage": 0.85, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Basic Pl", "plan_name": "400100_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Federal", "plan_name": "400110", "standard_charge_percentage": 0.85, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Federal", "plan_name": "400110_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Cigna Healthsprings Ffs", "plan_name": "500064", "standard_charge_dollar": 144.55, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Conseco", "plan_name": "500302", "standard_charge_dollar": 144.55, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Humana Ffs 61101", "plan_name": "500006", "standard_charge_dollar": 144.55, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Medicare A", "plan_name": "100100", "standard_charge_dollar": 144.55, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Medicare A", "plan_name": "100500", "standard_charge_dollar": 144.55, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Medicare Part B Only", "plan_name": "100300", "standard_charge_dollar": 144.55, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Medicare Railroad", "plan_name": "100103", "standard_charge_dollar": 144.55, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Ms Physicians Care N", "plan_name": "714210", "standard_charge_dollar": 180.68, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Peoples Hlth Ffs 72126", "plan_name": "500019", "standard_charge_dollar": 144.55, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Uhc/Secure Horizons", "plan_name": "500449", "standard_charge_dollar": 144.55, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "United Health Care/", "plan_name": "500292", "standard_charge_dollar": 163.34, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "United Healthcare", "plan_name": "750104", "standard_charge_dollar": 163.34, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "United Healthcare Ba", "plan_name": "750090", "standard_charge_dollar": 163.34, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "United Healthcare Me", "plan_name": "501310", "standard_charge_dollar": 144.55, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Windsor Mcare Extra", "plan_name": "500778", "standard_charge_dollar": 144.55, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." } ] } ] }, { "description": "Hc apply mltlay comprss blw kn", "code_information": [ { "code": "29581", "type": "CPT" } ], "standard_charges": [ { "gross_charge": 486.00, "minimum": 144.55, "maximum": 413.10, "setting": "both", "payers_information": [ { "payer_name": "Aarp", "plan_name": "500102", "standard_charge_dollar": 144.55, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna", "plan_name": "700700", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna", "plan_name": "700700_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Mcare Ffs 6005", "plan_name": "700703", "standard_charge_dollar": 144.55, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Miscellaneous", "plan_name": "700720", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Miscellaneous", "plan_name": "700720_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Ppo Hmo", "plan_name": "701720", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Ppo Hmo", "plan_name": "701720_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Ambetter 68069", "plan_name": "500516", "standard_charge_dollar": 144.55, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Ms State Emplo", "plan_name": "401457", "standard_charge_percentage": 0.80, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Ms State Emplo", "plan_name": "401457_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Basic Pl", "plan_name": "400100", "standard_charge_percentage": 0.85, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Basic Pl", "plan_name": "400100_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Federal", "plan_name": "400110", "standard_charge_percentage": 0.85, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Federal", "plan_name": "400110_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Cigna Healthsprings Ffs", "plan_name": "500064", "standard_charge_dollar": 144.55, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Conseco", "plan_name": "500302", "standard_charge_dollar": 144.55, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Humana Ffs 61101", "plan_name": "500006", "standard_charge_dollar": 144.55, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Medicare A", "plan_name": "100100", "standard_charge_dollar": 144.55, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Medicare A", "plan_name": "100500", "standard_charge_dollar": 144.55, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Medicare Part B Only", "plan_name": "100300", "standard_charge_dollar": 144.55, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Medicare Railroad", "plan_name": "100103", "standard_charge_dollar": 144.55, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Ms Physicians Care N", "plan_name": "714210", "standard_charge_dollar": 180.68, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Peoples Hlth Ffs 72126", "plan_name": "500019", "standard_charge_dollar": 144.55, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Uhc/Secure Horizons", "plan_name": "500449", "standard_charge_dollar": 144.55, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "United Health Care/", "plan_name": "500292", "standard_charge_dollar": 163.34, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "United Healthcare", "plan_name": "750104", "standard_charge_dollar": 163.34, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "United Healthcare Ba", "plan_name": "750090", "standard_charge_dollar": 163.34, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "United Healthcare Me", "plan_name": "501310", "standard_charge_dollar": 144.55, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Windsor Mcare Extra", "plan_name": "500778", "standard_charge_dollar": 144.55, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." } ] } ] }, { "description": "Hc apply mltlay comprss blw kn", "code_information": [ { "code": "29581", "type": "CPT" } ], "standard_charges": [ { "gross_charge": 1944.00, "minimum": 144.55, "maximum": 1652.40, "setting": "both", "payers_information": [ { "payer_name": "Aarp", "plan_name": "500102", "standard_charge_dollar": 144.55, "count": "0", "methodology": "fee schedule", "modifiers": "50", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna", "plan_name": "700700", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna", "plan_name": "700700_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Mcare Ffs 6005", "plan_name": "700703", "standard_charge_dollar": 144.55, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Miscellaneous", "plan_name": "700720", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Miscellaneous", "plan_name": "700720_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Ppo Hmo", "plan_name": "701720", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Ppo Hmo", "plan_name": "701720_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Ambetter 68069", "plan_name": "500516", "standard_charge_dollar": 144.55, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Ms State Emplo", "plan_name": "401457", "standard_charge_percentage": 0.80, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Ms State Emplo", "plan_name": "401457_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Basic Pl", "plan_name": "400100", "standard_charge_percentage": 0.85, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Basic Pl", "plan_name": "400100_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Federal", "plan_name": "400110", "standard_charge_percentage": 0.85, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Federal", "plan_name": "400110_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Cigna Healthsprings Ffs", "plan_name": "500064", "standard_charge_dollar": 144.55, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Conseco", "plan_name": "500302", "standard_charge_dollar": 144.55, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Humana Ffs 61101", "plan_name": "500006", "standard_charge_dollar": 144.55, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Medicare A", "plan_name": "100100", "standard_charge_dollar": 144.55, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Medicare A", "plan_name": "100500", "standard_charge_dollar": 144.55, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Medicare Part B Only", "plan_name": "100300", "standard_charge_dollar": 144.55, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Medicare Railroad", "plan_name": "100103", "standard_charge_dollar": 144.55, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Ms Physicians Care N", "plan_name": "714210", "standard_charge_dollar": 180.68, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Peoples Hlth Ffs 72126", "plan_name": "500019", "standard_charge_dollar": 144.55, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Uhc/Secure Horizons", "plan_name": "500449", "standard_charge_dollar": 144.55, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "United Health Care/", "plan_name": "500292", "standard_charge_dollar": 163.34, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "United Healthcare", "plan_name": "750104", "standard_charge_dollar": 163.34, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "United Healthcare Ba", "plan_name": "750090", "standard_charge_dollar": 163.34, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "United Healthcare Me", "plan_name": "501310", "standard_charge_dollar": 144.55, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Windsor Mcare Extra", "plan_name": "500778", "standard_charge_dollar": 144.55, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." } ] } ] }, { "description": "Hc removal of gauntlet/boot/body cast", "code_information": [ { "code": "29700", "type": "CPT" } ], "standard_charges": [ { "gross_charge": 384.00, "minimum": 243.29, "maximum": 326.40, "setting": "both", "payers_information": [ { "payer_name": "Aarp", "plan_name": "500102", "standard_charge_dollar": 243.29, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna", "plan_name": "700700", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna", "plan_name": "700700_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Mcare Ffs 6005", "plan_name": "700703", "standard_charge_dollar": 243.29, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Miscellaneous", "plan_name": "700720", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Miscellaneous", "plan_name": "700720_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Ppo Hmo", "plan_name": "701720", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Ppo Hmo", "plan_name": "701720_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Ambetter 68069", "plan_name": "500516", "standard_charge_dollar": 243.29, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Ms State Emplo", "plan_name": "401457", "standard_charge_percentage": 0.80, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Ms State Emplo", "plan_name": "401457_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Basic Pl", "plan_name": "400100", "standard_charge_percentage": 0.85, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Basic Pl", "plan_name": "400100_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Federal", "plan_name": "400110", "standard_charge_percentage": 0.85, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Federal", "plan_name": "400110_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Cigna Healthsprings Ffs", "plan_name": "500064", "standard_charge_dollar": 243.29, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Conseco", "plan_name": "500302", "standard_charge_dollar": 243.29, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Humana Ffs 61101", "plan_name": "500006", "standard_charge_dollar": 243.29, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Medicare A", "plan_name": "100100", "standard_charge_dollar": 243.29, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Medicare A", "plan_name": "100500", "standard_charge_dollar": 243.29, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Medicare Part B Only", "plan_name": "100300", "standard_charge_dollar": 243.29, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Medicare Railroad", "plan_name": "100103", "standard_charge_dollar": 243.29, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Ms Physicians Care N", "plan_name": "714210", "standard_charge_dollar": 304.11, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Peoples Hlth Ffs 72126", "plan_name": "500019", "standard_charge_dollar": 243.29, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Uhc/Secure Horizons", "plan_name": "500449", "standard_charge_dollar": 243.29, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "United Health Care/", "plan_name": "500292", "standard_charge_dollar": 274.92, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "United Healthcare", "plan_name": "750104", "standard_charge_dollar": 274.92, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "United Healthcare Ba", "plan_name": "750090", "standard_charge_dollar": 274.92, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "United Healthcare Me", "plan_name": "501310", "standard_charge_dollar": 243.29, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Windsor Mcare Extra", "plan_name": "500778", "standard_charge_dollar": 243.29, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." } ] } ] }, { "description": "Removal/revision of cast", "code_information": [ { "code": "29700", "type": "CPT" } ], "standard_charges": [ { "gross_charge": 384.00, "minimum": 243.29, "maximum": 326.40, "setting": "both", "payers_information": [ { "payer_name": "Aarp", "plan_name": "500102", "standard_charge_dollar": 243.29, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna", "plan_name": "700700", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna", "plan_name": "700700_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Mcare Ffs 6005", "plan_name": "700703", "standard_charge_dollar": 243.29, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Miscellaneous", "plan_name": "700720", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Miscellaneous", "plan_name": "700720_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Ppo Hmo", "plan_name": "701720", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Ppo Hmo", "plan_name": "701720_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Ambetter 68069", "plan_name": "500516", "standard_charge_dollar": 243.29, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Ms State Emplo", "plan_name": "401457", "standard_charge_percentage": 0.80, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Ms State Emplo", "plan_name": "401457_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Basic Pl", "plan_name": "400100", "standard_charge_percentage": 0.85, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Basic Pl", "plan_name": "400100_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Federal", "plan_name": "400110", "standard_charge_percentage": 0.85, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Federal", "plan_name": "400110_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Cigna Healthsprings Ffs", "plan_name": "500064", "standard_charge_dollar": 243.29, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Conseco", "plan_name": "500302", "standard_charge_dollar": 243.29, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Humana Ffs 61101", "plan_name": "500006", "standard_charge_dollar": 243.29, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Medicare A", "plan_name": "100100", "standard_charge_dollar": 243.29, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Medicare A", "plan_name": "100500", "standard_charge_dollar": 243.29, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Medicare Part B Only", "plan_name": "100300", "standard_charge_dollar": 243.29, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Medicare Railroad", "plan_name": "100103", "standard_charge_dollar": 243.29, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Ms Physicians Care N", "plan_name": "714210", "standard_charge_dollar": 304.11, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Peoples Hlth Ffs 72126", "plan_name": "500019", "standard_charge_dollar": 243.29, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Uhc/Secure Horizons", "plan_name": "500449", "standard_charge_dollar": 243.29, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "United Health Care/", "plan_name": "500292", "standard_charge_dollar": 274.92, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "United Healthcare", "plan_name": "750104", "standard_charge_dollar": 274.92, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "United Healthcare Ba", "plan_name": "750090", "standard_charge_dollar": 274.92, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "United Healthcare Me", "plan_name": "501310", "standard_charge_dollar": 243.29, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Windsor Mcare Extra", "plan_name": "500778", "standard_charge_dollar": 243.29, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." } ] } ] }, { "description": "Repair of body cast", "code_information": [ { "code": "29720", "type": "CPT" } ], "standard_charges": [ { "gross_charge": 30294.00, "minimum": 144.55, "maximum": 25749.90, "setting": "inpatient", "payers_information": [ { "payer_name": "Aarp", "plan_name": "500102", "standard_charge_dollar": 144.55, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna", "plan_name": "700700", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna", "plan_name": "700700_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Mcare Ffs 6005", "plan_name": "700703", "standard_charge_dollar": 144.55, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Miscellaneous", "plan_name": "700720", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Miscellaneous", "plan_name": "700720_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Ppo Hmo", "plan_name": "701720", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Ppo Hmo", "plan_name": "701720_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Ambetter 68069", "plan_name": "500516", "standard_charge_dollar": 144.55, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Ms State Emplo", "plan_name": "401457", "standard_charge_percentage": 0.80, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Ms State Emplo", "plan_name": "401457_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Basic Pl", "plan_name": "400100", "standard_charge_percentage": 0.85, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Basic Pl", "plan_name": "400100_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Federal", "plan_name": "400110", "standard_charge_percentage": 0.85, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Federal", "plan_name": "400110_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Cigna Healthsprings Ffs", "plan_name": "500064", "standard_charge_dollar": 144.55, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Conseco", "plan_name": "500302", "standard_charge_dollar": 144.55, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Humana Ffs 61101", "plan_name": "500006", "standard_charge_dollar": 144.55, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Medicare A", "plan_name": "100100", "standard_charge_dollar": 144.55, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Medicare A", "plan_name": "100500", "standard_charge_dollar": 144.55, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Medicare Part B Only", "plan_name": "100300", "standard_charge_dollar": 144.55, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Medicare Railroad", "plan_name": "100103", "standard_charge_dollar": 144.55, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Ms Physicians Care N", "plan_name": "714210", "standard_charge_dollar": 180.68, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Peoples Hlth Ffs 72126", "plan_name": "500019", "standard_charge_dollar": 144.55, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Uhc/Secure Horizons", "plan_name": "500449", "standard_charge_dollar": 144.55, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "United Health Care/", "plan_name": "500292", "standard_charge_dollar": 163.34, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "United Healthcare", "plan_name": "750104", "standard_charge_dollar": 163.34, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "United Healthcare Ba", "plan_name": "750090", "standard_charge_dollar": 163.34, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "United Healthcare Me", "plan_name": "501310", "standard_charge_dollar": 144.55, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Windsor Mcare Extra", "plan_name": "500778", "standard_charge_dollar": 144.55, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." } ] } ] }, { "description": "Knee arthroscopy dx", "code_information": [ { "code": "29870", "type": "CPT" } ], "standard_charges": [ { "gross_charge": 109206.48, "minimum": 2972.29, "maximum": 92825.51, "setting": "inpatient", "payers_information": [ { "payer_name": "Aarp", "plan_name": "500102", "standard_charge_dollar": 2972.29, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna", "plan_name": "700700", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna", "plan_name": "700700_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Mcare Ffs 6005", "plan_name": "700703", "standard_charge_dollar": 2972.29, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Miscellaneous", "plan_name": "700720", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Miscellaneous", "plan_name": "700720_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Ppo Hmo", "plan_name": "701720", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Ppo Hmo", "plan_name": "701720_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Ambetter 68069", "plan_name": "500516", "standard_charge_dollar": 2972.29, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Ms State Emplo", "plan_name": "401457", "standard_charge_percentage": 0.80, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Ms State Emplo", "plan_name": "401457_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Basic Pl", "plan_name": "400100", "standard_charge_percentage": 0.85, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Basic Pl", "plan_name": "400100_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Federal", "plan_name": "400110", "standard_charge_percentage": 0.85, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Federal", "plan_name": "400110_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Cigna Healthsprings Ffs", "plan_name": "500064", "standard_charge_dollar": 2972.29, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Conseco", "plan_name": "500302", "standard_charge_dollar": 2972.29, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Humana Ffs 61101", "plan_name": "500006", "standard_charge_dollar": 2972.29, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Medicare A", "plan_name": "100100", "standard_charge_dollar": 2972.29, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Medicare A", "plan_name": "100500", "standard_charge_dollar": 2972.29, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Medicare Part B Only", "plan_name": "100300", "standard_charge_dollar": 2972.29, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Medicare Railroad", "plan_name": "100103", "standard_charge_dollar": 2972.29, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Ms Physicians Care N", "plan_name": "714210", "standard_charge_dollar": 3715.36, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Peoples Hlth Ffs 72126", "plan_name": "500019", "standard_charge_dollar": 2972.29, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Uhc/Secure Horizons", "plan_name": "500449", "standard_charge_dollar": 2972.29, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "United Health Care/", "plan_name": "500292", "standard_charge_dollar": 3358.68, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "United Healthcare", "plan_name": "750104", "standard_charge_dollar": 3358.68, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "United Healthcare Ba", "plan_name": "750090", "standard_charge_dollar": 3358.68, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "United Healthcare Me", "plan_name": "501310", "standard_charge_dollar": 2972.29, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Windsor Mcare Extra", "plan_name": "500778", "standard_charge_dollar": 2972.29, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." } ] } ] }, { "description": "Knee arthroscopy/drainage", "code_information": [ { "code": "29871", "type": "CPT" } ], "standard_charges": [ { "gross_charge": 109206.48, "minimum": 2972.29, "maximum": 92825.51, "setting": "inpatient", "payers_information": [ { "payer_name": "Aarp", "plan_name": "500102", "standard_charge_dollar": 2972.29, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna", "plan_name": "700700", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna", "plan_name": "700700_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Mcare Ffs 6005", "plan_name": "700703", "standard_charge_dollar": 2972.29, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Miscellaneous", "plan_name": "700720", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Miscellaneous", "plan_name": "700720_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Ppo Hmo", "plan_name": "701720", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Ppo Hmo", "plan_name": "701720_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Ambetter 68069", "plan_name": "500516", "standard_charge_dollar": 2972.29, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Ms State Emplo", "plan_name": "401457", "standard_charge_percentage": 0.80, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Ms State Emplo", "plan_name": "401457_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Basic Pl", "plan_name": "400100", "standard_charge_percentage": 0.85, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Basic Pl", "plan_name": "400100_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Federal", "plan_name": "400110", "standard_charge_percentage": 0.85, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Federal", "plan_name": "400110_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Cigna Healthsprings Ffs", "plan_name": "500064", "standard_charge_dollar": 2972.29, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Conseco", "plan_name": "500302", "standard_charge_dollar": 2972.29, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Humana Ffs 61101", "plan_name": "500006", "standard_charge_dollar": 2972.29, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Medicare A", "plan_name": "100100", "standard_charge_dollar": 2972.29, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Medicare A", "plan_name": "100500", "standard_charge_dollar": 2972.29, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Medicare Part B Only", "plan_name": "100300", "standard_charge_dollar": 2972.29, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Medicare Railroad", "plan_name": "100103", "standard_charge_dollar": 2972.29, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Ms Physicians Care N", "plan_name": "714210", "standard_charge_dollar": 3715.36, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Peoples Hlth Ffs 72126", "plan_name": "500019", "standard_charge_dollar": 2972.29, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Uhc/Secure Horizons", "plan_name": "500449", "standard_charge_dollar": 2972.29, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "United Health Care/", "plan_name": "500292", "standard_charge_dollar": 3358.68, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "United Healthcare", "plan_name": "750104", "standard_charge_dollar": 3358.68, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "United Healthcare Ba", "plan_name": "750090", "standard_charge_dollar": 3358.68, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "United Healthcare Me", "plan_name": "501310", "standard_charge_dollar": 2972.29, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Windsor Mcare Extra", "plan_name": "500778", "standard_charge_dollar": 2972.29, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." } ] } ] }, { "description": "Knee arthroscopy/surgery", "code_information": [ { "code": "29888", "type": "CPT" } ], "standard_charges": [ { "gross_charge": 109206.48, "minimum": 6544.15, "maximum": 92825.51, "setting": "inpatient", "payers_information": [ { "payer_name": "Aarp", "plan_name": "500102", "standard_charge_dollar": 6544.15, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna", "plan_name": "700700", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna", "plan_name": "700700_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Mcare Ffs 6005", "plan_name": "700703", "standard_charge_dollar": 6544.15, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Miscellaneous", "plan_name": "700720", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Miscellaneous", "plan_name": "700720_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Ppo Hmo", "plan_name": "701720", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Ppo Hmo", "plan_name": "701720_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Ambetter 68069", "plan_name": "500516", "standard_charge_dollar": 6544.15, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Ms State Emplo", "plan_name": "401457", "standard_charge_percentage": 0.80, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Ms State Emplo", "plan_name": "401457_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Basic Pl", "plan_name": "400100", "standard_charge_percentage": 0.85, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Basic Pl", "plan_name": "400100_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Federal", "plan_name": "400110", "standard_charge_percentage": 0.85, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Federal", "plan_name": "400110_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Cigna Healthsprings Ffs", "plan_name": "500064", "standard_charge_dollar": 6544.15, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Conseco", "plan_name": "500302", "standard_charge_dollar": 6544.15, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Humana Ffs 61101", "plan_name": "500006", "standard_charge_dollar": 6544.15, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Medicare A", "plan_name": "100100", "standard_charge_dollar": 6544.15, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Medicare A", "plan_name": "100500", "standard_charge_dollar": 6544.15, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Medicare Part B Only", "plan_name": "100300", "standard_charge_dollar": 6544.15, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Medicare Railroad", "plan_name": "100103", "standard_charge_dollar": 6544.15, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Ms Physicians Care N", "plan_name": "714210", "standard_charge_dollar": 8180.19, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Peoples Hlth Ffs 72126", "plan_name": "500019", "standard_charge_dollar": 6544.15, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Uhc/Secure Horizons", "plan_name": "500449", "standard_charge_dollar": 6544.15, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "United Health Care/", "plan_name": "500292", "standard_charge_dollar": 7394.89, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "United Healthcare", "plan_name": "750104", "standard_charge_dollar": 7394.89, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "United Healthcare Ba", "plan_name": "750090", "standard_charge_dollar": 7394.89, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "United Healthcare Me", "plan_name": "501310", "standard_charge_dollar": 6544.15, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Windsor Mcare Extra", "plan_name": "500778", "standard_charge_dollar": 6544.15, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." } ] } ] }, { "description": "Knee arthroscopy/surgery", "code_information": [ { "code": "29889", "type": "CPT" } ], "standard_charges": [ { "gross_charge": 109206.48, "minimum": 11786.90, "maximum": 92825.51, "setting": "inpatient", "payers_information": [ { "payer_name": "Aarp", "plan_name": "500102", "standard_charge_dollar": 11786.90, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna", "plan_name": "700700", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna", "plan_name": "700700_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Mcare Ffs 6005", "plan_name": "700703", "standard_charge_dollar": 11786.90, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Miscellaneous", "plan_name": "700720", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Miscellaneous", "plan_name": "700720_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Ppo Hmo", "plan_name": "701720", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Ppo Hmo", "plan_name": "701720_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Ambetter 68069", "plan_name": "500516", "standard_charge_dollar": 11786.90, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Ms State Emplo", "plan_name": "401457", "standard_charge_percentage": 0.80, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Ms State Emplo", "plan_name": "401457_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Basic Pl", "plan_name": "400100", "standard_charge_percentage": 0.85, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Basic Pl", "plan_name": "400100_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Federal", "plan_name": "400110", "standard_charge_percentage": 0.85, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Federal", "plan_name": "400110_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Cigna Healthsprings Ffs", "plan_name": "500064", "standard_charge_dollar": 11786.90, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Conseco", "plan_name": "500302", "standard_charge_dollar": 11786.90, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Humana Ffs 61101", "plan_name": "500006", "standard_charge_dollar": 11786.90, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Medicare A", "plan_name": "100100", "standard_charge_dollar": 11786.90, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Medicare A", "plan_name": "100500", "standard_charge_dollar": 11786.90, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Medicare Part B Only", "plan_name": "100300", "standard_charge_dollar": 11786.90, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Medicare Railroad", "plan_name": "100103", "standard_charge_dollar": 11786.90, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Ms Physicians Care N", "plan_name": "714210", "standard_charge_dollar": 14733.62, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Peoples Hlth Ffs 72126", "plan_name": "500019", "standard_charge_dollar": 11786.90, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Uhc/Secure Horizons", "plan_name": "500449", "standard_charge_dollar": 11786.90, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "United Health Care/", "plan_name": "500292", "standard_charge_dollar": 13319.19, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "United Healthcare", "plan_name": "750104", "standard_charge_dollar": 13319.19, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "United Healthcare Ba", "plan_name": "750090", "standard_charge_dollar": 13319.19, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "United Healthcare Me", "plan_name": "501310", "standard_charge_dollar": 11786.90, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Windsor Mcare Extra", "plan_name": "500778", "standard_charge_dollar": 11786.90, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." } ] } ] }, { "description": "Hc removal nasal foreign body", "code_information": [ { "code": "30300", "type": "CPT" } ], "standard_charges": [ { "gross_charge": 168.00, "minimum": 118.08, "maximum": 149.97, "setting": "both", "payers_information": [ { "payer_name": "Aarp", "plan_name": "500102", "standard_charge_dollar": 118.08, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna", "plan_name": "700700", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna", "plan_name": "700700_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Mcare Ffs 6005", "plan_name": "700703", "standard_charge_dollar": 118.08, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Miscellaneous", "plan_name": "700720", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Miscellaneous", "plan_name": "700720_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Ppo Hmo", "plan_name": "701720", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Ppo Hmo", "plan_name": "701720_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Ambetter 68069", "plan_name": "500516", "standard_charge_dollar": 118.08, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Ms State Emplo", "plan_name": "401457", "standard_charge_dollar": 149.97, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Ms State Emplo", "plan_name": "401457_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Basic Pl", "plan_name": "400100", "standard_charge_dollar": 149.97, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Basic Pl", "plan_name": "400100_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Federal", "plan_name": "400110", "standard_charge_dollar": 149.97, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Federal", "plan_name": "400110_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Cigna Healthsprings Ffs", "plan_name": "500064", "standard_charge_dollar": 118.08, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Conseco", "plan_name": "500302", "standard_charge_dollar": 118.08, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Humana Ffs 61101", "plan_name": "500006", "standard_charge_dollar": 118.08, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Medicare A", "plan_name": "100100", "standard_charge_dollar": 118.08, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Medicare A", "plan_name": "100500", "standard_charge_dollar": 118.08, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Medicare Part B Only", "plan_name": "100300", "standard_charge_dollar": 118.08, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Medicare Railroad", "plan_name": "100103", "standard_charge_dollar": 118.08, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Ms Physicians Care N", "plan_name": "714210", "standard_charge_dollar": 147.60, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Peoples Hlth Ffs 72126", "plan_name": "500019", "standard_charge_dollar": 118.08, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Uhc/Secure Horizons", "plan_name": "500449", "standard_charge_dollar": 118.08, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "United Health Care/", "plan_name": "500292", "standard_charge_dollar": 133.43, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "United Healthcare", "plan_name": "750104", "standard_charge_dollar": 133.43, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "United Healthcare Ba", "plan_name": "750090", "standard_charge_dollar": 133.43, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "United Healthcare Me", "plan_name": "501310", "standard_charge_dollar": 118.08, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Windsor Mcare Extra", "plan_name": "500778", "standard_charge_dollar": 118.08, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." } ] } ] }, { "description": "Remove nasal foreign body", "code_information": [ { "code": "30300", "type": "CPT" } ], "standard_charges": [ { "gross_charge": 168.00, "minimum": 118.08, "maximum": 149.97, "setting": "both", "payers_information": [ { "payer_name": "Aarp", "plan_name": "500102", "standard_charge_dollar": 118.08, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna", "plan_name": "700700", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna", "plan_name": "700700_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Mcare Ffs 6005", "plan_name": "700703", "standard_charge_dollar": 118.08, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Miscellaneous", "plan_name": "700720", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Miscellaneous", "plan_name": "700720_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Ppo Hmo", "plan_name": "701720", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Ppo Hmo", "plan_name": "701720_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Ambetter 68069", "plan_name": "500516", "standard_charge_dollar": 118.08, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Ms State Emplo", "plan_name": "401457", "standard_charge_dollar": 149.97, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Ms State Emplo", "plan_name": "401457_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Basic Pl", "plan_name": "400100", "standard_charge_dollar": 149.97, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Basic Pl", "plan_name": "400100_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Federal", "plan_name": "400110", "standard_charge_dollar": 149.97, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Federal", "plan_name": "400110_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Cigna Healthsprings Ffs", "plan_name": "500064", "standard_charge_dollar": 118.08, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Conseco", "plan_name": "500302", "standard_charge_dollar": 118.08, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Humana Ffs 61101", "plan_name": "500006", "standard_charge_dollar": 118.08, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Medicare A", "plan_name": "100100", "standard_charge_dollar": 118.08, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Medicare A", "plan_name": "100500", "standard_charge_dollar": 118.08, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Medicare Part B Only", "plan_name": "100300", "standard_charge_dollar": 118.08, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Medicare Railroad", "plan_name": "100103", "standard_charge_dollar": 118.08, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Ms Physicians Care N", "plan_name": "714210", "standard_charge_dollar": 147.60, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Peoples Hlth Ffs 72126", "plan_name": "500019", "standard_charge_dollar": 118.08, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Uhc/Secure Horizons", "plan_name": "500449", "standard_charge_dollar": 118.08, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "United Health Care/", "plan_name": "500292", "standard_charge_dollar": 133.43, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "United Healthcare", "plan_name": "750104", "standard_charge_dollar": 133.43, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "United Healthcare Ba", "plan_name": "750090", "standard_charge_dollar": 133.43, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "United Healthcare Me", "plan_name": "501310", "standard_charge_dollar": 118.08, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Windsor Mcare Extra", "plan_name": "500778", "standard_charge_dollar": 118.08, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." } ] } ] }, { "description": "Control of nosebleed", "code_information": [ { "code": "30901", "type": "CPT" } ], "standard_charges": [ { "gross_charge": 21502.71, "minimum": 118.08, "maximum": 149.97, "setting": "inpatient", "payers_information": [ { "payer_name": "Aarp", "plan_name": "500102", "standard_charge_dollar": 118.08, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna", "plan_name": "700700", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna", "plan_name": "700700_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Mcare Ffs 6005", "plan_name": "700703", "standard_charge_dollar": 118.08, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Miscellaneous", "plan_name": "700720", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Miscellaneous", "plan_name": "700720_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Ppo Hmo", "plan_name": "701720", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Ppo Hmo", "plan_name": "701720_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Ambetter 68069", "plan_name": "500516", "standard_charge_dollar": 118.08, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Ms State Emplo", "plan_name": "401457", "standard_charge_dollar": 149.97, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Ms State Emplo", "plan_name": "401457_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Basic Pl", "plan_name": "400100", "standard_charge_dollar": 149.97, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Basic Pl", "plan_name": "400100_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Federal", "plan_name": "400110", "standard_charge_dollar": 149.97, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Federal", "plan_name": "400110_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Cigna Healthsprings Ffs", "plan_name": "500064", "standard_charge_dollar": 118.08, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Conseco", "plan_name": "500302", "standard_charge_dollar": 118.08, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Humana Ffs 61101", "plan_name": "500006", "standard_charge_dollar": 118.08, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Medicare A", "plan_name": "100100", "standard_charge_dollar": 118.08, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Medicare A", "plan_name": "100500", "standard_charge_dollar": 118.08, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Medicare Part B Only", "plan_name": "100300", "standard_charge_dollar": 118.08, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Medicare Railroad", "plan_name": "100103", "standard_charge_dollar": 118.08, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Ms Physicians Care N", "plan_name": "714210", "standard_charge_dollar": 147.60, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Peoples Hlth Ffs 72126", "plan_name": "500019", "standard_charge_dollar": 118.08, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Uhc/Secure Horizons", "plan_name": "500449", "standard_charge_dollar": 118.08, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "United Health Care/", "plan_name": "500292", "standard_charge_dollar": 133.43, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "United Healthcare", "plan_name": "750104", "standard_charge_dollar": 133.43, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "United Healthcare Ba", "plan_name": "750090", "standard_charge_dollar": 133.43, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "United Healthcare Me", "plan_name": "501310", "standard_charge_dollar": 118.08, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Windsor Mcare Extra", "plan_name": "500778", "standard_charge_dollar": 118.08, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." } ] } ] }, { "description": "Control of nosebleed", "code_information": [ { "code": "30901", "type": "CPT" } ], "standard_charges": [ { "gross_charge": 115.50, "minimum": 118.08, "maximum": 149.97, "setting": "outpatient", "payers_information": [ { "payer_name": "Aarp", "plan_name": "500102", "standard_charge_dollar": 118.08, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna", "plan_name": "700700", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna", "plan_name": "700700_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Mcare Ffs 6005", "plan_name": "700703", "standard_charge_dollar": 118.08, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Miscellaneous", "plan_name": "700720", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Miscellaneous", "plan_name": "700720_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Ppo Hmo", "plan_name": "701720", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Ppo Hmo", "plan_name": "701720_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Ambetter 68069", "plan_name": "500516", "standard_charge_dollar": 118.08, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Ms State Emplo", "plan_name": "401457", "standard_charge_dollar": 149.97, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Ms State Emplo", "plan_name": "401457_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Basic Pl", "plan_name": "400100", "standard_charge_dollar": 149.97, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Basic Pl", "plan_name": "400100_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Federal", "plan_name": "400110", "standard_charge_dollar": 149.97, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Federal", "plan_name": "400110_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Cigna Healthsprings Ffs", "plan_name": "500064", "standard_charge_dollar": 118.08, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Conseco", "plan_name": "500302", "standard_charge_dollar": 118.08, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Humana Ffs 61101", "plan_name": "500006", "standard_charge_dollar": 118.08, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Medicare A", "plan_name": "100100", "standard_charge_dollar": 118.08, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Medicare A", "plan_name": "100500", "standard_charge_dollar": 118.08, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Medicare Part B Only", "plan_name": "100300", "standard_charge_dollar": 118.08, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Medicare Railroad", "plan_name": "100103", "standard_charge_dollar": 118.08, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Ms Physicians Care N", "plan_name": "714210", "standard_charge_dollar": 147.60, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Peoples Hlth Ffs 72126", "plan_name": "500019", "standard_charge_dollar": 118.08, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Uhc/Secure Horizons", "plan_name": "500449", "standard_charge_dollar": 118.08, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "United Health Care/", "plan_name": "500292", "standard_charge_dollar": 133.43, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "United Healthcare", "plan_name": "750104", "standard_charge_dollar": 133.43, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "United Healthcare Ba", "plan_name": "750090", "standard_charge_dollar": 133.43, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "United Healthcare Me", "plan_name": "501310", "standard_charge_dollar": 118.08, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Windsor Mcare Extra", "plan_name": "500778", "standard_charge_dollar": 118.08, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." } ] } ] }, { "description": "Hc control nasal hemorrhage simple", "code_information": [ { "code": "30901", "type": "CPT" } ], "standard_charges": [ { "gross_charge": 115.50, "minimum": 118.08, "maximum": 149.97, "setting": "both", "payers_information": [ { "payer_name": "Aarp", "plan_name": "500102", "standard_charge_dollar": 118.08, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna", "plan_name": "700700", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna", "plan_name": "700700_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Mcare Ffs 6005", "plan_name": "700703", "standard_charge_dollar": 118.08, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Miscellaneous", "plan_name": "700720", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Miscellaneous", "plan_name": "700720_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Ppo Hmo", "plan_name": "701720", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Ppo Hmo", "plan_name": "701720_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Ambetter 68069", "plan_name": "500516", "standard_charge_dollar": 118.08, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Ms State Emplo", "plan_name": "401457", "standard_charge_dollar": 149.97, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Ms State Emplo", "plan_name": "401457_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Basic Pl", "plan_name": "400100", "standard_charge_dollar": 149.97, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Basic Pl", "plan_name": "400100_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Federal", "plan_name": "400110", "standard_charge_dollar": 149.97, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Federal", "plan_name": "400110_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Cigna Healthsprings Ffs", "plan_name": "500064", "standard_charge_dollar": 118.08, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Conseco", "plan_name": "500302", "standard_charge_dollar": 118.08, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Humana Ffs 61101", "plan_name": "500006", "standard_charge_dollar": 118.08, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Medicare A", "plan_name": "100100", "standard_charge_dollar": 118.08, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Medicare A", "plan_name": "100500", "standard_charge_dollar": 118.08, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Medicare Part B Only", "plan_name": "100300", "standard_charge_dollar": 118.08, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Medicare Railroad", "plan_name": "100103", "standard_charge_dollar": 118.08, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Ms Physicians Care N", "plan_name": "714210", "standard_charge_dollar": 147.60, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Peoples Hlth Ffs 72126", "plan_name": "500019", "standard_charge_dollar": 118.08, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Uhc/Secure Horizons", "plan_name": "500449", "standard_charge_dollar": 118.08, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "United Health Care/", "plan_name": "500292", "standard_charge_dollar": 133.43, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "United Healthcare", "plan_name": "750104", "standard_charge_dollar": 133.43, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "United Healthcare Ba", "plan_name": "750090", "standard_charge_dollar": 133.43, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "United Healthcare Me", "plan_name": "501310", "standard_charge_dollar": 118.08, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Windsor Mcare Extra", "plan_name": "500778", "standard_charge_dollar": 118.08, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." } ] } ] }, { "description": "Control of nosebleed", "code_information": [ { "code": "30903", "type": "CPT" } ], "standard_charges": [ { "gross_charge": 21502.71, "minimum": 118.08, "maximum": 18277.30, "setting": "inpatient", "payers_information": [ { "payer_name": "Aarp", "plan_name": "500102", "standard_charge_dollar": 118.08, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna", "plan_name": "700700", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna", "plan_name": "700700_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Mcare Ffs 6005", "plan_name": "700703", "standard_charge_dollar": 118.08, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Miscellaneous", "plan_name": "700720", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Miscellaneous", "plan_name": "700720_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Ppo Hmo", "plan_name": "701720", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Ppo Hmo", "plan_name": "701720_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Ambetter 68069", "plan_name": "500516", "standard_charge_dollar": 118.08, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Ms State Emplo", "plan_name": "401457", "standard_charge_percentage": 0.80, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Ms State Emplo", "plan_name": "401457_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Basic Pl", "plan_name": "400100", "standard_charge_percentage": 0.85, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Basic Pl", "plan_name": "400100_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Federal", "plan_name": "400110", "standard_charge_percentage": 0.85, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Federal", "plan_name": "400110_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Cigna Healthsprings Ffs", "plan_name": "500064", "standard_charge_dollar": 118.08, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Conseco", "plan_name": "500302", "standard_charge_dollar": 118.08, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Humana Ffs 61101", "plan_name": "500006", "standard_charge_dollar": 118.08, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Medicare A", "plan_name": "100100", "standard_charge_dollar": 118.08, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Medicare A", "plan_name": "100500", "standard_charge_dollar": 118.08, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Medicare Part B Only", "plan_name": "100300", "standard_charge_dollar": 118.08, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Medicare Railroad", "plan_name": "100103", "standard_charge_dollar": 118.08, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Ms Physicians Care N", "plan_name": "714210", "standard_charge_dollar": 147.60, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Peoples Hlth Ffs 72126", "plan_name": "500019", "standard_charge_dollar": 118.08, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Uhc/Secure Horizons", "plan_name": "500449", "standard_charge_dollar": 118.08, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "United Health Care/", "plan_name": "500292", "standard_charge_dollar": 133.43, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "United Healthcare", "plan_name": "750104", "standard_charge_dollar": 133.43, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "United Healthcare Ba", "plan_name": "750090", "standard_charge_dollar": 133.43, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "United Healthcare Me", "plan_name": "501310", "standard_charge_dollar": 118.08, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Windsor Mcare Extra", "plan_name": "500778", "standard_charge_dollar": 118.08, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." } ] } ] }, { "description": "Control of nosebleed", "code_information": [ { "code": "30905", "type": "CPT" } ], "standard_charges": [ { "gross_charge": 21502.71, "minimum": 118.08, "maximum": 18277.30, "setting": "inpatient", "payers_information": [ { "payer_name": "Aarp", "plan_name": "500102", "standard_charge_dollar": 118.08, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna", "plan_name": "700700", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna", "plan_name": "700700_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Mcare Ffs 6005", "plan_name": "700703", "standard_charge_dollar": 118.08, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Miscellaneous", "plan_name": "700720", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Miscellaneous", "plan_name": "700720_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Ppo Hmo", "plan_name": "701720", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Ppo Hmo", "plan_name": "701720_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Ambetter 68069", "plan_name": "500516", "standard_charge_dollar": 118.08, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Ms State Emplo", "plan_name": "401457", "standard_charge_percentage": 0.80, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Ms State Emplo", "plan_name": "401457_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Basic Pl", "plan_name": "400100", "standard_charge_percentage": 0.85, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Basic Pl", "plan_name": "400100_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Federal", "plan_name": "400110", "standard_charge_percentage": 0.85, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Federal", "plan_name": "400110_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Cigna Healthsprings Ffs", "plan_name": "500064", "standard_charge_dollar": 118.08, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Conseco", "plan_name": "500302", "standard_charge_dollar": 118.08, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Humana Ffs 61101", "plan_name": "500006", "standard_charge_dollar": 118.08, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Medicare A", "plan_name": "100100", "standard_charge_dollar": 118.08, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Medicare A", "plan_name": "100500", "standard_charge_dollar": 118.08, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Medicare Part B Only", "plan_name": "100300", "standard_charge_dollar": 118.08, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Medicare Railroad", "plan_name": "100103", "standard_charge_dollar": 118.08, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Ms Physicians Care N", "plan_name": "714210", "standard_charge_dollar": 147.60, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Peoples Hlth Ffs 72126", "plan_name": "500019", "standard_charge_dollar": 118.08, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Uhc/Secure Horizons", "plan_name": "500449", "standard_charge_dollar": 118.08, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "United Health Care/", "plan_name": "500292", "standard_charge_dollar": 133.43, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "United Healthcare", "plan_name": "750104", "standard_charge_dollar": 133.43, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "United Healthcare Ba", "plan_name": "750090", "standard_charge_dollar": 133.43, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "United Healthcare Me", "plan_name": "501310", "standard_charge_dollar": 118.08, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Windsor Mcare Extra", "plan_name": "500778", "standard_charge_dollar": 118.08, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." } ] } ] }, { "description": "Repeat control of nosebleed", "code_information": [ { "code": "30906", "type": "CPT" } ], "standard_charges": [ { "gross_charge": 21502.71, "minimum": 212.73, "maximum": 18277.30, "setting": "inpatient", "payers_information": [ { "payer_name": "Aarp", "plan_name": "500102", "standard_charge_dollar": 212.73, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna", "plan_name": "700700", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna", "plan_name": "700700_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Mcare Ffs 6005", "plan_name": "700703", "standard_charge_dollar": 212.73, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Miscellaneous", "plan_name": "700720", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Miscellaneous", "plan_name": "700720_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Ppo Hmo", "plan_name": "701720", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Ppo Hmo", "plan_name": "701720_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Ambetter 68069", "plan_name": "500516", "standard_charge_dollar": 212.73, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Ms State Emplo", "plan_name": "401457", "standard_charge_percentage": 0.80, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Ms State Emplo", "plan_name": "401457_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Basic Pl", "plan_name": "400100", "standard_charge_percentage": 0.85, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Basic Pl", "plan_name": "400100_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Federal", "plan_name": "400110", "standard_charge_percentage": 0.85, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Federal", "plan_name": "400110_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Cigna Healthsprings Ffs", "plan_name": "500064", "standard_charge_dollar": 212.73, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Conseco", "plan_name": "500302", "standard_charge_dollar": 212.73, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Humana Ffs 61101", "plan_name": "500006", "standard_charge_dollar": 212.73, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Medicare A", "plan_name": "100100", "standard_charge_dollar": 212.73, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Medicare A", "plan_name": "100500", "standard_charge_dollar": 212.73, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Medicare Part B Only", "plan_name": "100300", "standard_charge_dollar": 212.73, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Medicare Railroad", "plan_name": "100103", "standard_charge_dollar": 212.73, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Ms Physicians Care N", "plan_name": "714210", "standard_charge_dollar": 265.91, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Peoples Hlth Ffs 72126", "plan_name": "500019", "standard_charge_dollar": 212.73, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Uhc/Secure Horizons", "plan_name": "500449", "standard_charge_dollar": 212.73, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "United Health Care/", "plan_name": "500292", "standard_charge_dollar": 240.38, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "United Healthcare", "plan_name": "750104", "standard_charge_dollar": 240.38, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "United Healthcare Ba", "plan_name": "750090", "standard_charge_dollar": 240.38, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "United Healthcare Me", "plan_name": "501310", "standard_charge_dollar": 212.73, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Windsor Mcare Extra", "plan_name": "500778", "standard_charge_dollar": 212.73, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." } ] } ] }, { "description": "Nasal surgery procedure", "code_information": [ { "code": "30999", "type": "CPT" } ], "standard_charges": [ { "gross_charge": 24509.80, "minimum": 212.73, "maximum": 20833.33, "setting": "inpatient", "payers_information": [ { "payer_name": "Aarp", "plan_name": "500102", "standard_charge_dollar": 212.73, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna", "plan_name": "700700", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna", "plan_name": "700700_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Mcare Ffs 6005", "plan_name": "700703", "standard_charge_dollar": 212.73, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Miscellaneous", "plan_name": "700720", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Miscellaneous", "plan_name": "700720_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Ppo Hmo", "plan_name": "701720", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Ppo Hmo", "plan_name": "701720_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Ambetter 68069", "plan_name": "500516", "standard_charge_dollar": 212.73, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Ms State Emplo", "plan_name": "401457", "standard_charge_percentage": 0.80, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Ms State Emplo", "plan_name": "401457_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Basic Pl", "plan_name": "400100", "standard_charge_percentage": 0.85, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Basic Pl", "plan_name": "400100_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Federal", "plan_name": "400110", "standard_charge_percentage": 0.85, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Federal", "plan_name": "400110_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Cigna Healthsprings Ffs", "plan_name": "500064", "standard_charge_dollar": 212.73, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Conseco", "plan_name": "500302", "standard_charge_dollar": 212.73, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Humana Ffs 61101", "plan_name": "500006", "standard_charge_dollar": 212.73, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Medicare A", "plan_name": "100100", "standard_charge_dollar": 212.73, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Medicare A", "plan_name": "100500", "standard_charge_dollar": 212.73, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Medicare Part B Only", "plan_name": "100300", "standard_charge_dollar": 212.73, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Medicare Railroad", "plan_name": "100103", "standard_charge_dollar": 212.73, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Ms Physicians Care N", "plan_name": "714210", "standard_charge_dollar": 265.91, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Peoples Hlth Ffs 72126", "plan_name": "500019", "standard_charge_dollar": 212.73, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Uhc/Secure Horizons", "plan_name": "500449", "standard_charge_dollar": 212.73, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "United Health Care/", "plan_name": "500292", "standard_charge_dollar": 240.38, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "United Healthcare", "plan_name": "750104", "standard_charge_dollar": 240.38, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "United Healthcare Ba", "plan_name": "750090", "standard_charge_dollar": 240.38, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "United Healthcare Me", "plan_name": "501310", "standard_charge_dollar": 212.73, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Windsor Mcare Extra", "plan_name": "500778", "standard_charge_dollar": 212.73, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." } ] } ] }, { "description": "Nasal/sinus endoscopy surg", "code_information": [ { "code": "31238", "type": "CPT" } ], "standard_charges": [ { "gross_charge": 99380.28, "minimum": 1579.73, "maximum": 84473.24, "setting": "inpatient", "payers_information": [ { "payer_name": "Aarp", "plan_name": "500102", "standard_charge_dollar": 1579.73, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna", "plan_name": "700700", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna", "plan_name": "700700_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Mcare Ffs 6005", "plan_name": "700703", "standard_charge_dollar": 1579.73, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Miscellaneous", "plan_name": "700720", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Miscellaneous", "plan_name": "700720_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Ppo Hmo", "plan_name": "701720", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Ppo Hmo", "plan_name": "701720_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Ambetter 68069", "plan_name": "500516", "standard_charge_dollar": 1579.73, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Ms State Emplo", "plan_name": "401457", "standard_charge_percentage": 0.80, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Ms State Emplo", "plan_name": "401457_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Basic Pl", "plan_name": "400100", "standard_charge_percentage": 0.85, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Basic Pl", "plan_name": "400100_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Federal", "plan_name": "400110", "standard_charge_percentage": 0.85, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Federal", "plan_name": "400110_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Cigna Healthsprings Ffs", "plan_name": "500064", "standard_charge_dollar": 1579.73, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Conseco", "plan_name": "500302", "standard_charge_dollar": 1579.73, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Humana Ffs 61101", "plan_name": "500006", "standard_charge_dollar": 1579.73, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Medicare A", "plan_name": "100100", "standard_charge_dollar": 1579.73, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Medicare A", "plan_name": "100500", "standard_charge_dollar": 1579.73, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Medicare Part B Only", "plan_name": "100300", "standard_charge_dollar": 1579.73, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Medicare Railroad", "plan_name": "100103", "standard_charge_dollar": 1579.73, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Ms Physicians Care N", "plan_name": "714210", "standard_charge_dollar": 1974.67, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Peoples Hlth Ffs 72126", "plan_name": "500019", "standard_charge_dollar": 1579.73, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Uhc/Secure Horizons", "plan_name": "500449", "standard_charge_dollar": 1579.73, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "United Health Care/", "plan_name": "500292", "standard_charge_dollar": 1785.10, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "United Healthcare", "plan_name": "750104", "standard_charge_dollar": 1785.10, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "United Healthcare Ba", "plan_name": "750090", "standard_charge_dollar": 1785.10, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "United Healthcare Me", "plan_name": "501310", "standard_charge_dollar": 1579.73, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Windsor Mcare Extra", "plan_name": "500778", "standard_charge_dollar": 1579.73, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." } ] } ] }, { "description": "Upper gi endoscopy performed", "code_information": [ { "code": "3130F", "type": "CPT" } ], "standard_charges": [ { "gross_charge": 25206.81, "minimum": 20165.45, "maximum": 21425.79, "setting": "inpatient", "payers_information": [ { "payer_name": "Aetna", "plan_name": "700700", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna", "plan_name": "700700_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Miscellaneous", "plan_name": "700720", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Miscellaneous", "plan_name": "700720_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Ppo Hmo", "plan_name": "701720", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Ppo Hmo", "plan_name": "701720_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Ms State Emplo", "plan_name": "401457", "standard_charge_percentage": 0.80, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Ms State Emplo", "plan_name": "401457_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Basic Pl", "plan_name": "400100", "standard_charge_percentage": 0.85, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Basic Pl", "plan_name": "400100_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Federal", "plan_name": "400110", "standard_charge_percentage": 0.85, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Federal", "plan_name": "400110_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." } ] } ] }, { "description": "Hc intubation endotrchl emergent", "code_information": [ { "code": "31500", "type": "CPT" } ], "standard_charges": [ { "gross_charge": 178.50, "minimum": 142.80, "maximum": 265.91, "setting": "both", "payers_information": [ { "payer_name": "Aarp", "plan_name": "500102", "standard_charge_dollar": 212.73, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna", "plan_name": "700700", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna", "plan_name": "700700_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Mcare Ffs 6005", "plan_name": "700703", "standard_charge_dollar": 212.73, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Miscellaneous", "plan_name": "700720", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Miscellaneous", "plan_name": "700720_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Ppo Hmo", "plan_name": "701720", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Ppo Hmo", "plan_name": "701720_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Ambetter 68069", "plan_name": "500516", "standard_charge_dollar": 212.73, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Ms State Emplo", "plan_name": "401457", "standard_charge_percentage": 0.80, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Ms State Emplo", "plan_name": "401457_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Basic Pl", "plan_name": "400100", "standard_charge_percentage": 0.85, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Basic Pl", "plan_name": "400100_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Federal", "plan_name": "400110", "standard_charge_percentage": 0.85, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Federal", "plan_name": "400110_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Cigna Healthsprings Ffs", "plan_name": "500064", "standard_charge_dollar": 212.73, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Conseco", "plan_name": "500302", "standard_charge_dollar": 212.73, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Humana Ffs 61101", "plan_name": "500006", "standard_charge_dollar": 212.73, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Medicare A", "plan_name": "100100", "standard_charge_dollar": 212.73, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Medicare A", "plan_name": "100500", "standard_charge_dollar": 212.73, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Medicare Part B Only", "plan_name": "100300", "standard_charge_dollar": 212.73, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Medicare Railroad", "plan_name": "100103", "standard_charge_dollar": 212.73, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Ms Physicians Care N", "plan_name": "714210", "standard_charge_dollar": 265.91, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Peoples Hlth Ffs 72126", "plan_name": "500019", "standard_charge_dollar": 212.73, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Uhc/Secure Horizons", "plan_name": "500449", "standard_charge_dollar": 212.73, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "United Health Care/", "plan_name": "500292", "standard_charge_dollar": 240.38, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "United Healthcare", "plan_name": "750104", "standard_charge_dollar": 240.38, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "United Healthcare Ba", "plan_name": "750090", "standard_charge_dollar": 240.38, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "United Healthcare Me", "plan_name": "501310", "standard_charge_dollar": 212.73, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Windsor Mcare Extra", "plan_name": "500778", "standard_charge_dollar": 212.73, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." } ] } ] }, { "description": "Insert emergency airway", "code_information": [ { "code": "31500", "type": "CPT" } ], "standard_charges": [ { "gross_charge": 178.50, "minimum": 142.80, "maximum": 265.91, "setting": "both", "payers_information": [ { "payer_name": "Aarp", "plan_name": "500102", "standard_charge_dollar": 212.73, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna", "plan_name": "700700", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna", "plan_name": "700700_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Mcare Ffs 6005", "plan_name": "700703", "standard_charge_dollar": 212.73, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Miscellaneous", "plan_name": "700720", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Miscellaneous", "plan_name": "700720_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Ppo Hmo", "plan_name": "701720", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Ppo Hmo", "plan_name": "701720_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Ambetter 68069", "plan_name": "500516", "standard_charge_dollar": 212.73, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Ms State Emplo", "plan_name": "401457", "standard_charge_percentage": 0.80, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Ms State Emplo", "plan_name": "401457_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Basic Pl", "plan_name": "400100", "standard_charge_percentage": 0.85, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Basic Pl", "plan_name": "400100_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Federal", "plan_name": "400110", "standard_charge_percentage": 0.85, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Federal", "plan_name": "400110_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Cigna Healthsprings Ffs", "plan_name": "500064", "standard_charge_dollar": 212.73, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Conseco", "plan_name": "500302", "standard_charge_dollar": 212.73, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Humana Ffs 61101", "plan_name": "500006", "standard_charge_dollar": 212.73, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Medicare A", "plan_name": "100100", "standard_charge_dollar": 212.73, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Medicare A", "plan_name": "100500", "standard_charge_dollar": 212.73, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Medicare Part B Only", "plan_name": "100300", "standard_charge_dollar": 212.73, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Medicare Railroad", "plan_name": "100103", "standard_charge_dollar": 212.73, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Ms Physicians Care N", "plan_name": "714210", "standard_charge_dollar": 265.91, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Peoples Hlth Ffs 72126", "plan_name": "500019", "standard_charge_dollar": 212.73, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Uhc/Secure Horizons", "plan_name": "500449", "standard_charge_dollar": 212.73, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "United Health Care/", "plan_name": "500292", "standard_charge_dollar": 240.38, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "United Healthcare", "plan_name": "750104", "standard_charge_dollar": 240.38, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "United Healthcare Ba", "plan_name": "750090", "standard_charge_dollar": 240.38, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "United Healthcare Me", "plan_name": "501310", "standard_charge_dollar": 212.73, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Windsor Mcare Extra", "plan_name": "500778", "standard_charge_dollar": 212.73, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." } ] } ] }, { "description": "Remove foreign body larynx", "code_information": [ { "code": "31511", "type": "CPT" } ], "standard_charges": [ { "gross_charge": 92034.10, "minimum": 177.85, "maximum": 78228.99, "setting": "inpatient", "payers_information": [ { "payer_name": "Aarp", "plan_name": "500102", "standard_charge_dollar": 177.85, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna", "plan_name": "700700", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna", "plan_name": "700700_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Mcare Ffs 6005", "plan_name": "700703", "standard_charge_dollar": 177.85, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Miscellaneous", "plan_name": "700720", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Miscellaneous", "plan_name": "700720_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Ppo Hmo", "plan_name": "701720", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Ppo Hmo", "plan_name": "701720_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Ambetter 68069", "plan_name": "500516", "standard_charge_dollar": 177.85, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Ms State Emplo", "plan_name": "401457", "standard_charge_percentage": 0.80, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Ms State Emplo", "plan_name": "401457_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Basic Pl", "plan_name": "400100", "standard_charge_percentage": 0.85, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Basic Pl", "plan_name": "400100_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Federal", "plan_name": "400110", "standard_charge_percentage": 0.85, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Federal", "plan_name": "400110_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Cigna Healthsprings Ffs", "plan_name": "500064", "standard_charge_dollar": 177.85, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Conseco", "plan_name": "500302", "standard_charge_dollar": 177.85, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Humana Ffs 61101", "plan_name": "500006", "standard_charge_dollar": 177.85, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Medicare A", "plan_name": "100100", "standard_charge_dollar": 177.85, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Medicare A", "plan_name": "100500", "standard_charge_dollar": 177.85, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Medicare Part B Only", "plan_name": "100300", "standard_charge_dollar": 177.85, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Medicare Railroad", "plan_name": "100103", "standard_charge_dollar": 177.85, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Ms Physicians Care N", "plan_name": "714210", "standard_charge_dollar": 222.31, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Peoples Hlth Ffs 72126", "plan_name": "500019", "standard_charge_dollar": 177.85, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Uhc/Secure Horizons", "plan_name": "500449", "standard_charge_dollar": 177.85, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "United Health Care/", "plan_name": "500292", "standard_charge_dollar": 200.97, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "United Healthcare", "plan_name": "750104", "standard_charge_dollar": 200.97, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "United Healthcare Ba", "plan_name": "750090", "standard_charge_dollar": 200.97, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "United Healthcare Me", "plan_name": "501310", "standard_charge_dollar": 177.85, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Windsor Mcare Extra", "plan_name": "500778", "standard_charge_dollar": 177.85, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." } ] } ] }, { "description": "Largsc w/rmvl foreign bdy(s)", "code_information": [ { "code": "31577", "type": "CPT" } ], "standard_charges": [ { "gross_charge": 92034.10, "minimum": 355.72, "maximum": 78228.99, "setting": "inpatient", "payers_information": [ { "payer_name": "Aarp", "plan_name": "500102", "standard_charge_dollar": 355.72, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna", "plan_name": "700700", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna", "plan_name": "700700_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Mcare Ffs 6005", "plan_name": "700703", "standard_charge_dollar": 355.72, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Miscellaneous", "plan_name": "700720", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Miscellaneous", "plan_name": "700720_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Ppo Hmo", "plan_name": "701720", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Ppo Hmo", "plan_name": "701720_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Ambetter 68069", "plan_name": "500516", "standard_charge_dollar": 355.72, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Ms State Emplo", "plan_name": "401457", "standard_charge_percentage": 0.80, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Ms State Emplo", "plan_name": "401457_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Basic Pl", "plan_name": "400100", "standard_charge_percentage": 0.85, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Basic Pl", "plan_name": "400100_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Federal", "plan_name": "400110", "standard_charge_percentage": 0.85, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Federal", "plan_name": "400110_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Cigna Healthsprings Ffs", "plan_name": "500064", "standard_charge_dollar": 355.72, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Conseco", "plan_name": "500302", "standard_charge_dollar": 355.72, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Humana Ffs 61101", "plan_name": "500006", "standard_charge_dollar": 355.72, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Medicare A", "plan_name": "100100", "standard_charge_dollar": 355.72, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Medicare A", "plan_name": "100500", "standard_charge_dollar": 355.72, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Medicare Part B Only", "plan_name": "100300", "standard_charge_dollar": 355.72, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Medicare Railroad", "plan_name": "100103", "standard_charge_dollar": 355.72, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Ms Physicians Care N", "plan_name": "714210", "standard_charge_dollar": 444.65, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Peoples Hlth Ffs 72126", "plan_name": "500019", "standard_charge_dollar": 355.72, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Uhc/Secure Horizons", "plan_name": "500449", "standard_charge_dollar": 355.72, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "United Health Care/", "plan_name": "500292", "standard_charge_dollar": 401.96, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "United Healthcare", "plan_name": "750104", "standard_charge_dollar": 401.96, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "United Healthcare Ba", "plan_name": "750090", "standard_charge_dollar": 401.96, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "United Healthcare Me", "plan_name": "501310", "standard_charge_dollar": 355.72, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Windsor Mcare Extra", "plan_name": "500778", "standard_charge_dollar": 355.72, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." } ] } ] }, { "description": "Visualization of windpipe", "code_information": [ { "code": "31615", "type": "CPT" } ], "standard_charges": [ { "gross_charge": 40831.65, "minimum": 466.51, "maximum": 34706.90, "setting": "inpatient", "payers_information": [ { "payer_name": "Aarp", "plan_name": "500102", "standard_charge_dollar": 466.51, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna", "plan_name": "700700", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna", "plan_name": "700700_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Mcare Ffs 6005", "plan_name": "700703", "standard_charge_dollar": 466.51, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Miscellaneous", "plan_name": "700720", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Miscellaneous", "plan_name": "700720_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Ppo Hmo", "plan_name": "701720", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Ppo Hmo", "plan_name": "701720_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Ambetter 68069", "plan_name": "500516", "standard_charge_dollar": 466.51, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Ms State Emplo", "plan_name": "401457", "standard_charge_percentage": 0.80, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Ms State Emplo", "plan_name": "401457_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Basic Pl", "plan_name": "400100", "standard_charge_percentage": 0.85, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Basic Pl", "plan_name": "400100_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Federal", "plan_name": "400110", "standard_charge_percentage": 0.85, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Federal", "plan_name": "400110_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Cigna Healthsprings Ffs", "plan_name": "500064", "standard_charge_dollar": 466.51, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Conseco", "plan_name": "500302", "standard_charge_dollar": 466.51, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Humana Ffs 61101", "plan_name": "500006", "standard_charge_dollar": 466.51, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Medicare A", "plan_name": "100100", "standard_charge_dollar": 466.51, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Medicare A", "plan_name": "100500", "standard_charge_dollar": 466.51, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Medicare Part B Only", "plan_name": "100300", "standard_charge_dollar": 466.51, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Medicare Railroad", "plan_name": "100103", "standard_charge_dollar": 466.51, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Ms Physicians Care N", "plan_name": "714210", "standard_charge_dollar": 583.14, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Peoples Hlth Ffs 72126", "plan_name": "500019", "standard_charge_dollar": 466.51, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Uhc/Secure Horizons", "plan_name": "500449", "standard_charge_dollar": 466.51, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "United Health Care/", "plan_name": "500292", "standard_charge_dollar": 527.15, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "United Healthcare", "plan_name": "750104", "standard_charge_dollar": 527.15, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "United Healthcare Ba", "plan_name": "750090", "standard_charge_dollar": 527.15, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "United Healthcare Me", "plan_name": "501310", "standard_charge_dollar": 466.51, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Windsor Mcare Extra", "plan_name": "500778", "standard_charge_dollar": 466.51, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." } ] } ] }, { "description": "Bronchoscopy w/biopsy(s)", "code_information": [ { "code": "31625", "type": "CPT" } ], "standard_charges": [ { "gross_charge": 36919.08, "minimum": 1579.73, "maximum": 31381.22, "setting": "inpatient", "payers_information": [ { "payer_name": "Aarp", "plan_name": "500102", "standard_charge_dollar": 1579.73, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna", "plan_name": "700700", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna", "plan_name": "700700_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Mcare Ffs 6005", "plan_name": "700703", "standard_charge_dollar": 1579.73, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Miscellaneous", "plan_name": "700720", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Miscellaneous", "plan_name": "700720_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Ppo Hmo", "plan_name": "701720", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Ppo Hmo", "plan_name": "701720_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Ambetter 68069", "plan_name": "500516", "standard_charge_dollar": 1579.73, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Ms State Emplo", "plan_name": "401457", "standard_charge_percentage": 0.80, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Ms State Emplo", "plan_name": "401457_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Basic Pl", "plan_name": "400100", "standard_charge_percentage": 0.85, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Basic Pl", "plan_name": "400100_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Federal", "plan_name": "400110", "standard_charge_percentage": 0.85, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Federal", "plan_name": "400110_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Cigna Healthsprings Ffs", "plan_name": "500064", "standard_charge_dollar": 1579.73, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Conseco", "plan_name": "500302", "standard_charge_dollar": 1579.73, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Humana Ffs 61101", "plan_name": "500006", "standard_charge_dollar": 1579.73, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Medicare A", "plan_name": "100100", "standard_charge_dollar": 1579.73, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Medicare A", "plan_name": "100500", "standard_charge_dollar": 1579.73, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Medicare Part B Only", "plan_name": "100300", "standard_charge_dollar": 1579.73, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Medicare Railroad", "plan_name": "100103", "standard_charge_dollar": 1579.73, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Ms Physicians Care N", "plan_name": "714210", "standard_charge_dollar": 1974.67, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Peoples Hlth Ffs 72126", "plan_name": "500019", "standard_charge_dollar": 1579.73, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Uhc/Secure Horizons", "plan_name": "500449", "standard_charge_dollar": 1579.73, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "United Health Care/", "plan_name": "500292", "standard_charge_dollar": 1785.10, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "United Healthcare", "plan_name": "750104", "standard_charge_dollar": 1785.10, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "United Healthcare Ba", "plan_name": "750090", "standard_charge_dollar": 1785.10, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "United Healthcare Me", "plan_name": "501310", "standard_charge_dollar": 1579.73, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Windsor Mcare Extra", "plan_name": "500778", "standard_charge_dollar": 1579.73, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." } ] } ] }, { "description": "Bronchoscopy/lung bx each", "code_information": [ { "code": "31628", "type": "CPT" } ], "standard_charges": [ { "gross_charge": 45280.07, "minimum": 3377.50, "maximum": 38488.06, "setting": "inpatient", "payers_information": [ { "payer_name": "Aarp", "plan_name": "500102", "standard_charge_dollar": 3377.50, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna", "plan_name": "700700", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna", "plan_name": "700700_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Mcare Ffs 6005", "plan_name": "700703", "standard_charge_dollar": 3377.50, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Miscellaneous", "plan_name": "700720", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Miscellaneous", "plan_name": "700720_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Ppo Hmo", "plan_name": "701720", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Ppo Hmo", "plan_name": "701720_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Ambetter 68069", "plan_name": "500516", "standard_charge_dollar": 3377.50, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Ms State Emplo", "plan_name": "401457", "standard_charge_percentage": 0.80, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Ms State Emplo", "plan_name": "401457_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Basic Pl", "plan_name": "400100", "standard_charge_percentage": 0.85, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Basic Pl", "plan_name": "400100_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Federal", "plan_name": "400110", "standard_charge_percentage": 0.85, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Federal", "plan_name": "400110_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Cigna Healthsprings Ffs", "plan_name": "500064", "standard_charge_dollar": 3377.50, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Conseco", "plan_name": "500302", "standard_charge_dollar": 3377.50, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Humana Ffs 61101", "plan_name": "500006", "standard_charge_dollar": 3377.50, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Medicare A", "plan_name": "100100", "standard_charge_dollar": 3377.50, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Medicare A", "plan_name": "100500", "standard_charge_dollar": 3377.50, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Medicare Part B Only", "plan_name": "100300", "standard_charge_dollar": 3377.50, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Medicare Railroad", "plan_name": "100103", "standard_charge_dollar": 3377.50, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Ms Physicians Care N", "plan_name": "714210", "standard_charge_dollar": 4221.88, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Peoples Hlth Ffs 72126", "plan_name": "500019", "standard_charge_dollar": 3377.50, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Uhc/Secure Horizons", "plan_name": "500449", "standard_charge_dollar": 3377.50, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "United Health Care/", "plan_name": "500292", "standard_charge_dollar": 3816.58, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "United Healthcare", "plan_name": "750104", "standard_charge_dollar": 3816.58, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "United Healthcare Ba", "plan_name": "750090", "standard_charge_dollar": 3816.58, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "United Healthcare Me", "plan_name": "501310", "standard_charge_dollar": 3377.50, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Windsor Mcare Extra", "plan_name": "500778", "standard_charge_dollar": 3377.50, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." } ] } ] }, { "description": "Bronchoscopy/needle bx each", "code_information": [ { "code": "31629", "type": "CPT" } ], "standard_charges": [ { "gross_charge": 28739.96, "minimum": 3377.50, "maximum": 24428.97, "setting": "inpatient", "payers_information": [ { "payer_name": "Aarp", "plan_name": "500102", "standard_charge_dollar": 3377.50, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna", "plan_name": "700700", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna", "plan_name": "700700_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Mcare Ffs 6005", "plan_name": "700703", "standard_charge_dollar": 3377.50, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Miscellaneous", "plan_name": "700720", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Miscellaneous", "plan_name": "700720_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Ppo Hmo", "plan_name": "701720", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Ppo Hmo", "plan_name": "701720_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Ambetter 68069", "plan_name": "500516", "standard_charge_dollar": 3377.50, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Ms State Emplo", "plan_name": "401457", "standard_charge_percentage": 0.80, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Ms State Emplo", "plan_name": "401457_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Basic Pl", "plan_name": "400100", "standard_charge_percentage": 0.85, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Basic Pl", "plan_name": "400100_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Federal", "plan_name": "400110", "standard_charge_percentage": 0.85, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Federal", "plan_name": "400110_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Cigna Healthsprings Ffs", "plan_name": "500064", "standard_charge_dollar": 3377.50, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Conseco", "plan_name": "500302", "standard_charge_dollar": 3377.50, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Humana Ffs 61101", "plan_name": "500006", "standard_charge_dollar": 3377.50, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Medicare A", "plan_name": "100100", "standard_charge_dollar": 3377.50, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Medicare A", "plan_name": "100500", "standard_charge_dollar": 3377.50, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Medicare Part B Only", "plan_name": "100300", "standard_charge_dollar": 3377.50, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Medicare Railroad", "plan_name": "100103", "standard_charge_dollar": 3377.50, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Ms Physicians Care N", "plan_name": "714210", "standard_charge_dollar": 4221.88, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Peoples Hlth Ffs 72126", "plan_name": "500019", "standard_charge_dollar": 3377.50, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Uhc/Secure Horizons", "plan_name": "500449", "standard_charge_dollar": 3377.50, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "United Health Care/", "plan_name": "500292", "standard_charge_dollar": 3816.58, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "United Healthcare", "plan_name": "750104", "standard_charge_dollar": 3816.58, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "United Healthcare Ba", "plan_name": "750090", "standard_charge_dollar": 3816.58, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "United Healthcare Me", "plan_name": "501310", "standard_charge_dollar": 3377.50, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Windsor Mcare Extra", "plan_name": "500778", "standard_charge_dollar": 3377.50, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." } ] } ] }, { "description": "Bronchoscopy/lung bx addl", "code_information": [ { "code": "31632", "type": "CPT" } ], "standard_charges": [ { "gross_charge": 45280.07, "minimum": 36224.06, "maximum": 38488.06, "setting": "inpatient", "payers_information": [ { "payer_name": "Aetna", "plan_name": "700700", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna", "plan_name": "700700_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Miscellaneous", "plan_name": "700720", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Miscellaneous", "plan_name": "700720_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Ppo Hmo", "plan_name": "701720", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Ppo Hmo", "plan_name": "701720_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Ms State Emplo", "plan_name": "401457", "standard_charge_percentage": 0.80, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Ms State Emplo", "plan_name": "401457_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Basic Pl", "plan_name": "400100", "standard_charge_percentage": 0.85, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Basic Pl", "plan_name": "400100_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Federal", "plan_name": "400110", "standard_charge_percentage": 0.85, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Federal", "plan_name": "400110_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." } ] } ] }, { "description": "Bronchoscopy/needle bx addl", "code_information": [ { "code": "31633", "type": "CPT" } ], "standard_charges": [ { "gross_charge": 28739.96, "minimum": 22991.97, "maximum": 24428.97, "setting": "inpatient", "payers_information": [ { "payer_name": "Aetna", "plan_name": "700700", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna", "plan_name": "700700_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Miscellaneous", "plan_name": "700720", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Miscellaneous", "plan_name": "700720_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Ppo Hmo", "plan_name": "701720", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Ppo Hmo", "plan_name": "701720_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Ms State Emplo", "plan_name": "401457", "standard_charge_percentage": 0.80, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Ms State Emplo", "plan_name": "401457_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Basic Pl", "plan_name": "400100", "standard_charge_percentage": 0.85, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Basic Pl", "plan_name": "400100_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Federal", "plan_name": "400110", "standard_charge_percentage": 0.85, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Federal", "plan_name": "400110_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." } ] } ] }, { "description": "Bronchoscopy w/fb removal", "code_information": [ { "code": "31635", "type": "CPT" } ], "standard_charges": [ { "gross_charge": 92034.10, "minimum": 1579.73, "maximum": 78228.99, "setting": "inpatient", "payers_information": [ { "payer_name": "Aarp", "plan_name": "500102", "standard_charge_dollar": 1579.73, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna", "plan_name": "700700", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna", "plan_name": "700700_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Mcare Ffs 6005", "plan_name": "700703", "standard_charge_dollar": 1579.73, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Miscellaneous", "plan_name": "700720", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Miscellaneous", "plan_name": "700720_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Ppo Hmo", "plan_name": "701720", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Ppo Hmo", "plan_name": "701720_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Ambetter 68069", "plan_name": "500516", "standard_charge_dollar": 1579.73, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Ms State Emplo", "plan_name": "401457", "standard_charge_percentage": 0.80, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Ms State Emplo", "plan_name": "401457_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Basic Pl", "plan_name": "400100", "standard_charge_percentage": 0.85, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Basic Pl", "plan_name": "400100_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Federal", "plan_name": "400110", "standard_charge_percentage": 0.85, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Federal", "plan_name": "400110_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Cigna Healthsprings Ffs", "plan_name": "500064", "standard_charge_dollar": 1579.73, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Conseco", "plan_name": "500302", "standard_charge_dollar": 1579.73, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Humana Ffs 61101", "plan_name": "500006", "standard_charge_dollar": 1579.73, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Medicare A", "plan_name": "100100", "standard_charge_dollar": 1579.73, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Medicare A", "plan_name": "100500", "standard_charge_dollar": 1579.73, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Medicare Part B Only", "plan_name": "100300", "standard_charge_dollar": 1579.73, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Medicare Railroad", "plan_name": "100103", "standard_charge_dollar": 1579.73, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Ms Physicians Care N", "plan_name": "714210", "standard_charge_dollar": 1974.67, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Peoples Hlth Ffs 72126", "plan_name": "500019", "standard_charge_dollar": 1579.73, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Uhc/Secure Horizons", "plan_name": "500449", "standard_charge_dollar": 1579.73, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "United Health Care/", "plan_name": "500292", "standard_charge_dollar": 1785.10, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "United Healthcare", "plan_name": "750104", "standard_charge_dollar": 1785.10, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "United Healthcare Ba", "plan_name": "750090", "standard_charge_dollar": 1785.10, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "United Healthcare Me", "plan_name": "501310", "standard_charge_dollar": 1579.73, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Windsor Mcare Extra", "plan_name": "500778", "standard_charge_dollar": 1579.73, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." } ] } ] }, { "description": "Airways surgical procedure", "code_information": [ { "code": "31899", "type": "CPT" } ], "standard_charges": [ { "gross_charge": 35688.29, "minimum": 177.85, "maximum": 30335.05, "setting": "inpatient", "payers_information": [ { "payer_name": "Aarp", "plan_name": "500102", "standard_charge_dollar": 177.85, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna", "plan_name": "700700", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna", "plan_name": "700700_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Mcare Ffs 6005", "plan_name": "700703", "standard_charge_dollar": 177.85, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Miscellaneous", "plan_name": "700720", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Miscellaneous", "plan_name": "700720_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Ppo Hmo", "plan_name": "701720", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Ppo Hmo", "plan_name": "701720_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Ambetter 68069", "plan_name": "500516", "standard_charge_dollar": 177.85, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Ms State Emplo", "plan_name": "401457", "standard_charge_percentage": 0.80, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Ms State Emplo", "plan_name": "401457_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Basic Pl", "plan_name": "400100", "standard_charge_percentage": 0.85, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Basic Pl", "plan_name": "400100_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Federal", "plan_name": "400110", "standard_charge_percentage": 0.85, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Federal", "plan_name": "400110_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Cigna Healthsprings Ffs", "plan_name": "500064", "standard_charge_dollar": 177.85, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Conseco", "plan_name": "500302", "standard_charge_dollar": 177.85, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Humana Ffs 61101", "plan_name": "500006", "standard_charge_dollar": 177.85, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Medicare A", "plan_name": "100100", "standard_charge_dollar": 177.85, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Medicare A", "plan_name": "100500", "standard_charge_dollar": 177.85, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Medicare Part B Only", "plan_name": "100300", "standard_charge_dollar": 177.85, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Medicare Railroad", "plan_name": "100103", "standard_charge_dollar": 177.85, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Ms Physicians Care N", "plan_name": "714210", "standard_charge_dollar": 222.31, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Peoples Hlth Ffs 72126", "plan_name": "500019", "standard_charge_dollar": 177.85, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Uhc/Secure Horizons", "plan_name": "500449", "standard_charge_dollar": 177.85, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "United Health Care/", "plan_name": "500292", "standard_charge_dollar": 200.97, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "United Healthcare", "plan_name": "750104", "standard_charge_dollar": 200.97, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "United Healthcare Ba", "plan_name": "750090", "standard_charge_dollar": 200.97, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "United Healthcare Me", "plan_name": "501310", "standard_charge_dollar": 177.85, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Windsor Mcare Extra", "plan_name": "500778", "standard_charge_dollar": 177.85, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." } ] } ] }, { "description": "Explore chest free adhesions", "code_information": [ { "code": "32124", "type": "CPT" } ], "standard_charges": [ { "gross_charge": 97521.55, "minimum": 78017.24, "maximum": 82893.32, "setting": "inpatient", "payers_information": [ { "payer_name": "Aetna", "plan_name": "700700", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna", "plan_name": "700700_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Miscellaneous", "plan_name": "700720", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Miscellaneous", "plan_name": "700720_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Ppo Hmo", "plan_name": "701720", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Ppo Hmo", "plan_name": "701720_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Ms State Emplo", "plan_name": "401457", "standard_charge_percentage": 0.80, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Ms State Emplo", "plan_name": "401457_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Basic Pl", "plan_name": "400100", "standard_charge_percentage": 0.85, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Basic Pl", "plan_name": "400100_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Federal", "plan_name": "400110", "standard_charge_percentage": 0.85, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Federal", "plan_name": "400110_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." } ] } ] }, { "description": "Wedge resect of lung initial", "code_information": [ { "code": "32505", "type": "CPT" } ], "standard_charges": [ { "gross_charge": 38861.59, "minimum": 31089.27, "maximum": 33032.35, "setting": "inpatient", "payers_information": [ { "payer_name": "Aetna", "plan_name": "700700", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna", "plan_name": "700700_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Miscellaneous", "plan_name": "700720", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Miscellaneous", "plan_name": "700720_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Ppo Hmo", "plan_name": "701720", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Ppo Hmo", "plan_name": "701720_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Ms State Emplo", "plan_name": "401457", "standard_charge_percentage": 0.80, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Ms State Emplo", "plan_name": "401457_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Basic Pl", "plan_name": "400100", "standard_charge_percentage": 0.85, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Basic Pl", "plan_name": "400100_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Federal", "plan_name": "400110", "standard_charge_percentage": 0.85, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Federal", "plan_name": "400110_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." } ] } ] }, { "description": "Wedge resect of lung add-on", "code_information": [ { "code": "32506", "type": "CPT" } ], "standard_charges": [ { "gross_charge": 38861.59, "minimum": 31089.27, "maximum": 33032.35, "setting": "inpatient", "payers_information": [ { "payer_name": "Aetna", "plan_name": "700700", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna", "plan_name": "700700_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Miscellaneous", "plan_name": "700720", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Miscellaneous", "plan_name": "700720_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Ppo Hmo", "plan_name": "701720", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Ppo Hmo", "plan_name": "701720_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Ms State Emplo", "plan_name": "401457", "standard_charge_percentage": 0.80, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Ms State Emplo", "plan_name": "401457_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Basic Pl", "plan_name": "400100", "standard_charge_percentage": 0.85, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Basic Pl", "plan_name": "400100_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Federal", "plan_name": "400110", "standard_charge_percentage": 0.85, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Federal", "plan_name": "400110_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." } ] } ] }, { "description": "Insert pleural cath", "code_information": [ { "code": "32550", "type": "CPT" } ], "standard_charges": [ { "gross_charge": 27240.70, "minimum": 3232.86, "maximum": 23154.60, "setting": "inpatient", "payers_information": [ { "payer_name": "Aarp", "plan_name": "500102", "standard_charge_dollar": 3232.86, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna", "plan_name": "700700", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna", "plan_name": "700700_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Mcare Ffs 6005", "plan_name": "700703", "standard_charge_dollar": 3232.86, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Miscellaneous", "plan_name": "700720", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Miscellaneous", "plan_name": "700720_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Ppo Hmo", "plan_name": "701720", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Ppo Hmo", "plan_name": "701720_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Ambetter 68069", "plan_name": "500516", "standard_charge_dollar": 3232.86, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Ms State Emplo", "plan_name": "401457", "standard_charge_percentage": 0.80, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Ms State Emplo", "plan_name": "401457_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Basic Pl", "plan_name": "400100", "standard_charge_percentage": 0.85, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Basic Pl", "plan_name": "400100_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Federal", "plan_name": "400110", "standard_charge_percentage": 0.85, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Federal", "plan_name": "400110_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Cigna Healthsprings Ffs", "plan_name": "500064", "standard_charge_dollar": 3232.86, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Conseco", "plan_name": "500302", "standard_charge_dollar": 3232.86, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Humana Ffs 61101", "plan_name": "500006", "standard_charge_dollar": 3232.86, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Medicare A", "plan_name": "100100", "standard_charge_dollar": 3232.86, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Medicare A", "plan_name": "100500", "standard_charge_dollar": 3232.86, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Medicare Part B Only", "plan_name": "100300", "standard_charge_dollar": 3232.86, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Medicare Railroad", "plan_name": "100103", "standard_charge_dollar": 3232.86, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Ms Physicians Care N", "plan_name": "714210", "standard_charge_dollar": 4041.08, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Peoples Hlth Ffs 72126", "plan_name": "500019", "standard_charge_dollar": 3232.86, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Uhc/Secure Horizons", "plan_name": "500449", "standard_charge_dollar": 3232.86, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "United Health Care/", "plan_name": "500292", "standard_charge_dollar": 3653.14, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "United Healthcare", "plan_name": "750104", "standard_charge_dollar": 3653.14, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "United Healthcare Ba", "plan_name": "750090", "standard_charge_dollar": 3653.14, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "United Healthcare Me", "plan_name": "501310", "standard_charge_dollar": 3232.86, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Windsor Mcare Extra", "plan_name": "500778", "standard_charge_dollar": 3232.86, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." } ] } ] }, { "description": "Ins mark thor for rt perq", "code_information": [ { "code": "32553", "type": "CPT" } ], "standard_charges": [ { "gross_charge": 15994.00, "minimum": 202.39, "maximum": 1566.78, "setting": "inpatient", "payers_information": [ { "payer_name": "Aarp", "plan_name": "500102", "standard_charge_dollar": 1253.42, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna", "plan_name": "700700", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna", "plan_name": "700700_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Mcare Ffs 6005", "plan_name": "700703", "standard_charge_dollar": 1253.42, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Miscellaneous", "plan_name": "700720", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Miscellaneous", "plan_name": "700720_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Ppo Hmo", "plan_name": "701720", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Ppo Hmo", "plan_name": "701720_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Ambetter 68069", "plan_name": "500516", "standard_charge_dollar": 1253.42, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Ms State Emplo", "plan_name": "401457", "standard_charge_dollar": 202.39, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Ms State Emplo", "plan_name": "401457_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Basic Pl", "plan_name": "400100", "standard_charge_dollar": 202.39, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Basic Pl", "plan_name": "400100_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Federal", "plan_name": "400110", "standard_charge_dollar": 202.39, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Federal", "plan_name": "400110_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Cigna Healthsprings Ffs", "plan_name": "500064", "standard_charge_dollar": 1253.42, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Conseco", "plan_name": "500302", "standard_charge_dollar": 1253.42, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Humana Ffs 61101", "plan_name": "500006", "standard_charge_dollar": 1253.42, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Medicare A", "plan_name": "100100", "standard_charge_dollar": 1253.42, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Medicare A", "plan_name": "100500", "standard_charge_dollar": 1253.42, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Medicare Part B Only", "plan_name": "100300", "standard_charge_dollar": 1253.42, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Medicare Railroad", "plan_name": "100103", "standard_charge_dollar": 1253.42, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Ms Physicians Care N", "plan_name": "714210", "standard_charge_dollar": 1566.78, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Peoples Hlth Ffs 72126", "plan_name": "500019", "standard_charge_dollar": 1253.42, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Uhc/Secure Horizons", "plan_name": "500449", "standard_charge_dollar": 1253.42, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "United Health Care/", "plan_name": "500292", "standard_charge_dollar": 1416.37, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "United Healthcare", "plan_name": "750104", "standard_charge_dollar": 1416.37, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "United Healthcare Ba", "plan_name": "750090", "standard_charge_dollar": 1416.37, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "United Healthcare Me", "plan_name": "501310", "standard_charge_dollar": 1253.42, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Windsor Mcare Extra", "plan_name": "500778", "standard_charge_dollar": 1253.42, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." } ] } ] }, { "description": "Aspirate pleura w/o imaging", "code_information": [ { "code": "32554", "type": "CPT" } ], "standard_charges": [ { "gross_charge": 33614.79, "minimum": 566.37, "maximum": 28572.57, "setting": "inpatient", "payers_information": [ { "payer_name": "Aarp", "plan_name": "500102", "standard_charge_dollar": 566.37, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna", "plan_name": "700700", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna", "plan_name": "700700_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Mcare Ffs 6005", "plan_name": "700703", "standard_charge_dollar": 566.37, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Miscellaneous", "plan_name": "700720", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Miscellaneous", "plan_name": "700720_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Ppo Hmo", "plan_name": "701720", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Ppo Hmo", "plan_name": "701720_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Ambetter 68069", "plan_name": "500516", "standard_charge_dollar": 566.37, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Ms State Emplo", "plan_name": "401457", "standard_charge_percentage": 0.80, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Ms State Emplo", "plan_name": "401457_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Basic Pl", "plan_name": "400100", "standard_charge_percentage": 0.85, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Basic Pl", "plan_name": "400100_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Federal", "plan_name": "400110", "standard_charge_percentage": 0.85, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Federal", "plan_name": "400110_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Cigna Healthsprings Ffs", "plan_name": "500064", "standard_charge_dollar": 566.37, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Conseco", "plan_name": "500302", "standard_charge_dollar": 566.37, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Humana Ffs 61101", "plan_name": "500006", "standard_charge_dollar": 566.37, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Medicare A", "plan_name": "100100", "standard_charge_dollar": 566.37, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Medicare A", "plan_name": "100500", "standard_charge_dollar": 566.37, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Medicare Part B Only", "plan_name": "100300", "standard_charge_dollar": 566.37, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Medicare Railroad", "plan_name": "100103", "standard_charge_dollar": 566.37, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Ms Physicians Care N", "plan_name": "714210", "standard_charge_dollar": 707.96, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Peoples Hlth Ffs 72126", "plan_name": "500019", "standard_charge_dollar": 566.37, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Uhc/Secure Horizons", "plan_name": "500449", "standard_charge_dollar": 566.37, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "United Health Care/", "plan_name": "500292", "standard_charge_dollar": 640.00, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "United Healthcare", "plan_name": "750104", "standard_charge_dollar": 640.00, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "United Healthcare Ba", "plan_name": "750090", "standard_charge_dollar": 640.00, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "United Healthcare Me", "plan_name": "501310", "standard_charge_dollar": 566.37, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Windsor Mcare Extra", "plan_name": "500778", "standard_charge_dollar": 566.37, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." } ] } ] }, { "description": "Aspirate pleura w/ imaging", "code_information": [ { "code": "32555", "type": "CPT" } ], "standard_charges": [ { "gross_charge": 33614.79, "minimum": 566.37, "maximum": 28572.57, "setting": "inpatient", "payers_information": [ { "payer_name": "Aarp", "plan_name": "500102", "standard_charge_dollar": 566.37, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna", "plan_name": "700700", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna", "plan_name": "700700_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Mcare Ffs 6005", "plan_name": "700703", "standard_charge_dollar": 566.37, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Miscellaneous", "plan_name": "700720", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Miscellaneous", "plan_name": "700720_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Ppo Hmo", "plan_name": "701720", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Ppo Hmo", "plan_name": "701720_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Ambetter 68069", "plan_name": "500516", "standard_charge_dollar": 566.37, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Ms State Emplo", "plan_name": "401457", "standard_charge_percentage": 0.80, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Ms State Emplo", "plan_name": "401457_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Basic Pl", "plan_name": "400100", "standard_charge_percentage": 0.85, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Basic Pl", "plan_name": "400100_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Federal", "plan_name": "400110", "standard_charge_percentage": 0.85, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Federal", "plan_name": "400110_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Cigna Healthsprings Ffs", "plan_name": "500064", "standard_charge_dollar": 566.37, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Conseco", "plan_name": "500302", "standard_charge_dollar": 566.37, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Humana Ffs 61101", "plan_name": "500006", "standard_charge_dollar": 566.37, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Medicare A", "plan_name": "100100", "standard_charge_dollar": 566.37, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Medicare A", "plan_name": "100500", "standard_charge_dollar": 566.37, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Medicare Part B Only", "plan_name": "100300", "standard_charge_dollar": 566.37, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Medicare Railroad", "plan_name": "100103", "standard_charge_dollar": 566.37, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Ms Physicians Care N", "plan_name": "714210", "standard_charge_dollar": 707.96, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Peoples Hlth Ffs 72126", "plan_name": "500019", "standard_charge_dollar": 566.37, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Uhc/Secure Horizons", "plan_name": "500449", "standard_charge_dollar": 566.37, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "United Health Care/", "plan_name": "500292", "standard_charge_dollar": 640.00, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "United Healthcare", "plan_name": "750104", "standard_charge_dollar": 640.00, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "United Healthcare Ba", "plan_name": "750090", "standard_charge_dollar": 640.00, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "United Healthcare Me", "plan_name": "501310", "standard_charge_dollar": 566.37, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Windsor Mcare Extra", "plan_name": "500778", "standard_charge_dollar": 566.37, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." } ] } ] }, { "description": "Insert cath pleura w/o image", "code_information": [ { "code": "32556", "type": "CPT" } ], "standard_charges": [ { "gross_charge": 27405.27, "minimum": 1737.77, "maximum": 23294.48, "setting": "inpatient", "payers_information": [ { "payer_name": "Aarp", "plan_name": "500102", "standard_charge_dollar": 1737.77, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna", "plan_name": "700700", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna", "plan_name": "700700_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Mcare Ffs 6005", "plan_name": "700703", "standard_charge_dollar": 1737.77, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Miscellaneous", "plan_name": "700720", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Miscellaneous", "plan_name": "700720_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Ppo Hmo", "plan_name": "701720", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Ppo Hmo", "plan_name": "701720_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Ambetter 68069", "plan_name": "500516", "standard_charge_dollar": 1737.77, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Ms State Emplo", "plan_name": "401457", "standard_charge_percentage": 0.80, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Ms State Emplo", "plan_name": "401457_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Basic Pl", "plan_name": "400100", "standard_charge_percentage": 0.85, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Basic Pl", "plan_name": "400100_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Federal", "plan_name": "400110", "standard_charge_percentage": 0.85, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Federal", "plan_name": "400110_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Cigna Healthsprings Ffs", "plan_name": "500064", "standard_charge_dollar": 1737.77, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Conseco", "plan_name": "500302", "standard_charge_dollar": 1737.77, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Humana Ffs 61101", "plan_name": "500006", "standard_charge_dollar": 1737.77, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Medicare A", "plan_name": "100100", "standard_charge_dollar": 1737.77, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Medicare A", "plan_name": "100500", "standard_charge_dollar": 1737.77, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Medicare Part B Only", "plan_name": "100300", "standard_charge_dollar": 1737.77, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Medicare Railroad", "plan_name": "100103", "standard_charge_dollar": 1737.77, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Ms Physicians Care N", "plan_name": "714210", "standard_charge_dollar": 2172.22, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Peoples Hlth Ffs 72126", "plan_name": "500019", "standard_charge_dollar": 1737.77, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Uhc/Secure Horizons", "plan_name": "500449", "standard_charge_dollar": 1737.77, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "United Health Care/", "plan_name": "500292", "standard_charge_dollar": 1963.68, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "United Healthcare", "plan_name": "750104", "standard_charge_dollar": 1963.68, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "United Healthcare Ba", "plan_name": "750090", "standard_charge_dollar": 1963.68, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "United Healthcare Me", "plan_name": "501310", "standard_charge_dollar": 1737.77, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Windsor Mcare Extra", "plan_name": "500778", "standard_charge_dollar": 1737.77, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." } ] } ] }, { "description": "Insert cath pleura w/ image", "code_information": [ { "code": "32557", "type": "CPT" } ], "standard_charges": [ { "gross_charge": 27405.27, "minimum": 1423.06, "maximum": 23294.48, "setting": "inpatient", "payers_information": [ { "payer_name": "Aarp", "plan_name": "500102", "standard_charge_dollar": 1423.06, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna", "plan_name": "700700", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna", "plan_name": "700700_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Mcare Ffs 6005", "plan_name": "700703", "standard_charge_dollar": 1423.06, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Miscellaneous", "plan_name": "700720", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Miscellaneous", "plan_name": "700720_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Ppo Hmo", "plan_name": "701720", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Ppo Hmo", "plan_name": "701720_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Ambetter 68069", "plan_name": "500516", "standard_charge_dollar": 1423.06, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Ms State Emplo", "plan_name": "401457", "standard_charge_percentage": 0.80, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Ms State Emplo", "plan_name": "401457_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Basic Pl", "plan_name": "400100", "standard_charge_percentage": 0.85, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Basic Pl", "plan_name": "400100_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Federal", "plan_name": "400110", "standard_charge_percentage": 0.85, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Federal", "plan_name": "400110_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Cigna Healthsprings Ffs", "plan_name": "500064", "standard_charge_dollar": 1423.06, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Conseco", "plan_name": "500302", "standard_charge_dollar": 1423.06, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Humana Ffs 61101", "plan_name": "500006", "standard_charge_dollar": 1423.06, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Medicare A", "plan_name": "100100", "standard_charge_dollar": 1423.06, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Medicare A", "plan_name": "100500", "standard_charge_dollar": 1423.06, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Medicare Part B Only", "plan_name": "100300", "standard_charge_dollar": 1423.06, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Medicare Railroad", "plan_name": "100103", "standard_charge_dollar": 1423.06, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Ms Physicians Care N", "plan_name": "714210", "standard_charge_dollar": 1778.82, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Peoples Hlth Ffs 72126", "plan_name": "500019", "standard_charge_dollar": 1423.06, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Uhc/Secure Horizons", "plan_name": "500449", "standard_charge_dollar": 1423.06, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "United Health Care/", "plan_name": "500292", "standard_charge_dollar": 1608.06, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "United Healthcare", "plan_name": "750104", "standard_charge_dollar": 1608.06, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "United Healthcare Ba", "plan_name": "750090", "standard_charge_dollar": 1608.06, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "United Healthcare Me", "plan_name": "501310", "standard_charge_dollar": 1423.06, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Windsor Mcare Extra", "plan_name": "500778", "standard_charge_dollar": 1423.06, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." } ] } ] }, { "description": "Thoracoscopy diagnostic", "code_information": [ { "code": "32601", "type": "CPT" } ], "standard_charges": [ { "gross_charge": 58638.15, "minimum": 5344.68, "maximum": 49842.43, "setting": "inpatient", "payers_information": [ { "payer_name": "Aarp", "plan_name": "500102", "standard_charge_dollar": 5344.68, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna", "plan_name": "700700", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna", "plan_name": "700700_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Mcare Ffs 6005", "plan_name": "700703", "standard_charge_dollar": 5344.68, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Miscellaneous", "plan_name": "700720", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Miscellaneous", "plan_name": "700720_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Ppo Hmo", "plan_name": "701720", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Ppo Hmo", "plan_name": "701720_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Ambetter 68069", "plan_name": "500516", "standard_charge_dollar": 5344.68, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Ms State Emplo", "plan_name": "401457", "standard_charge_percentage": 0.80, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Ms State Emplo", "plan_name": "401457_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Basic Pl", "plan_name": "400100", "standard_charge_percentage": 0.85, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Basic Pl", "plan_name": "400100_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Federal", "plan_name": "400110", "standard_charge_percentage": 0.85, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Federal", "plan_name": "400110_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Cigna Healthsprings Ffs", "plan_name": "500064", "standard_charge_dollar": 5344.68, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Conseco", "plan_name": "500302", "standard_charge_dollar": 5344.68, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Humana Ffs 61101", "plan_name": "500006", "standard_charge_dollar": 5344.68, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Medicare A", "plan_name": "100100", "standard_charge_dollar": 5344.68, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Medicare A", "plan_name": "100500", "standard_charge_dollar": 5344.68, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Medicare Part B Only", "plan_name": "100300", "standard_charge_dollar": 5344.68, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Medicare Railroad", "plan_name": "100103", "standard_charge_dollar": 5344.68, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Ms Physicians Care N", "plan_name": "714210", "standard_charge_dollar": 6680.85, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Peoples Hlth Ffs 72126", "plan_name": "500019", "standard_charge_dollar": 5344.68, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Uhc/Secure Horizons", "plan_name": "500449", "standard_charge_dollar": 5344.68, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "United Health Care/", "plan_name": "500292", "standard_charge_dollar": 6039.49, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "United Healthcare", "plan_name": "750104", "standard_charge_dollar": 6039.49, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "United Healthcare Ba", "plan_name": "750090", "standard_charge_dollar": 6039.49, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "United Healthcare Me", "plan_name": "501310", "standard_charge_dollar": 5344.68, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Windsor Mcare Extra", "plan_name": "500778", "standard_charge_dollar": 5344.68, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." } ] } ] }, { "description": "Thoracoscopy remov fb/fibrin", "code_information": [ { "code": "32653", "type": "CPT" } ], "standard_charges": [ { "gross_charge": 32337.68, "minimum": 25870.14, "maximum": 27487.03, "setting": "inpatient", "payers_information": [ { "payer_name": "Aetna", "plan_name": "700700", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna", "plan_name": "700700_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Miscellaneous", "plan_name": "700720", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Miscellaneous", "plan_name": "700720_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Ppo Hmo", "plan_name": "701720", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Ppo Hmo", "plan_name": "701720_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Ms State Emplo", "plan_name": "401457", "standard_charge_percentage": 0.80, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Ms State Emplo", "plan_name": "401457_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Basic Pl", "plan_name": "400100", "standard_charge_percentage": 0.85, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Basic Pl", "plan_name": "400100_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Federal", "plan_name": "400110", "standard_charge_percentage": 0.85, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Federal", "plan_name": "400110_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." } ] } ] }, { "description": "Thoracoscopy resect bullae", "code_information": [ { "code": "32655", "type": "CPT" } ], "standard_charges": [ { "gross_charge": 61825.75, "minimum": 49460.60, "maximum": 52551.89, "setting": "inpatient", "payers_information": [ { "payer_name": "Aetna", "plan_name": "700700", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna", "plan_name": "700700_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Miscellaneous", "plan_name": "700720", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Miscellaneous", "plan_name": "700720_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Ppo Hmo", "plan_name": "701720", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Ppo Hmo", "plan_name": "701720_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Ms State Emplo", "plan_name": "401457", "standard_charge_percentage": 0.80, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Ms State Emplo", "plan_name": "401457_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Basic Pl", "plan_name": "400100", "standard_charge_percentage": 0.85, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Basic Pl", "plan_name": "400100_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Federal", "plan_name": "400110", "standard_charge_percentage": 0.85, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Federal", "plan_name": "400110_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." } ] } ] }, { "description": "Thoracoscopy w/pleurectomy", "code_information": [ { "code": "32656", "type": "CPT" } ], "standard_charges": [ { "gross_charge": 61825.75, "minimum": 49460.60, "maximum": 52551.89, "setting": "inpatient", "payers_information": [ { "payer_name": "Aetna", "plan_name": "700700", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna", "plan_name": "700700_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Miscellaneous", "plan_name": "700720", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Miscellaneous", "plan_name": "700720_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Ppo Hmo", "plan_name": "701720", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Ppo Hmo", "plan_name": "701720_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Ms State Emplo", "plan_name": "401457", "standard_charge_percentage": 0.80, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Ms State Emplo", "plan_name": "401457_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Basic Pl", "plan_name": "400100", "standard_charge_percentage": 0.85, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Basic Pl", "plan_name": "400100_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Federal", "plan_name": "400110", "standard_charge_percentage": 0.85, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Federal", "plan_name": "400110_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." } ] } ] }, { "description": "Thoracoscopy w/sac drainage", "code_information": [ { "code": "32659", "type": "CPT" } ], "standard_charges": [ { "gross_charge": 58039.73, "minimum": 46431.78, "maximum": 49333.77, "setting": "inpatient", "payers_information": [ { "payer_name": "Aetna", "plan_name": "700700", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna", "plan_name": "700700_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Miscellaneous", "plan_name": "700720", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Miscellaneous", "plan_name": "700720_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Ppo Hmo", "plan_name": "701720", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Ppo Hmo", "plan_name": "701720_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Ms State Emplo", "plan_name": "401457", "standard_charge_percentage": 0.80, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Ms State Emplo", "plan_name": "401457_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Basic Pl", "plan_name": "400100", "standard_charge_percentage": 0.85, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Basic Pl", "plan_name": "400100_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Federal", "plan_name": "400110", "standard_charge_percentage": 0.85, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Federal", "plan_name": "400110_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." } ] } ] }, { "description": "Thoracoscopy w/pericard exc", "code_information": [ { "code": "32661", "type": "CPT" } ], "standard_charges": [ { "gross_charge": 61825.75, "minimum": 49460.60, "maximum": 52551.89, "setting": "inpatient", "payers_information": [ { "payer_name": "Aetna", "plan_name": "700700", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna", "plan_name": "700700_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Miscellaneous", "plan_name": "700720", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Miscellaneous", "plan_name": "700720_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Ppo Hmo", "plan_name": "701720", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Ppo Hmo", "plan_name": "701720_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Ms State Emplo", "plan_name": "401457", "standard_charge_percentage": 0.80, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Ms State Emplo", "plan_name": "401457_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Basic Pl", "plan_name": "400100", "standard_charge_percentage": 0.85, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Basic Pl", "plan_name": "400100_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Federal", "plan_name": "400110", "standard_charge_percentage": 0.85, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Federal", "plan_name": "400110_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." } ] } ] }, { "description": "Thoracoscopy w/mediast exc", "code_information": [ { "code": "32662", "type": "CPT" } ], "standard_charges": [ { "gross_charge": 61825.75, "minimum": 49460.60, "maximum": 52551.89, "setting": "inpatient", "payers_information": [ { "payer_name": "Aetna", "plan_name": "700700", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna", "plan_name": "700700_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Miscellaneous", "plan_name": "700720", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Miscellaneous", "plan_name": "700720_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Ppo Hmo", "plan_name": "701720", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Ppo Hmo", "plan_name": "701720_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Ms State Emplo", "plan_name": "401457", "standard_charge_percentage": 0.80, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Ms State Emplo", "plan_name": "401457_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Basic Pl", "plan_name": "400100", "standard_charge_percentage": 0.85, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Basic Pl", "plan_name": "400100_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Federal", "plan_name": "400110", "standard_charge_percentage": 0.85, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Federal", "plan_name": "400110_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." } ] } ] }, { "description": "Thoracoscopy w/lobectomy", "code_information": [ { "code": "32663", "type": "CPT" } ], "standard_charges": [ { "gross_charge": 61825.75, "minimum": 49460.60, "maximum": 52551.89, "setting": "inpatient", "payers_information": [ { "payer_name": "Aetna", "plan_name": "700700", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna", "plan_name": "700700_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Miscellaneous", "plan_name": "700720", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Miscellaneous", "plan_name": "700720_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Ppo Hmo", "plan_name": "701720", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Ppo Hmo", "plan_name": "701720_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Ms State Emplo", "plan_name": "401457", "standard_charge_percentage": 0.80, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Ms State Emplo", "plan_name": "401457_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Basic Pl", "plan_name": "400100", "standard_charge_percentage": 0.85, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Basic Pl", "plan_name": "400100_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Federal", "plan_name": "400110", "standard_charge_percentage": 0.85, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Federal", "plan_name": "400110_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." } ] } ] }, { "description": "Thoracoscopy w/ th nrv exc", "code_information": [ { "code": "32664", "type": "CPT" } ], "standard_charges": [ { "gross_charge": 61825.75, "minimum": 49460.60, "maximum": 52551.89, "setting": "inpatient", "payers_information": [ { "payer_name": "Aetna", "plan_name": "700700", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna", "plan_name": "700700_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Miscellaneous", "plan_name": "700720", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Miscellaneous", "plan_name": "700720_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Ppo Hmo", "plan_name": "701720", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Ppo Hmo", "plan_name": "701720_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Ms State Emplo", "plan_name": "401457", "standard_charge_percentage": 0.80, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Ms State Emplo", "plan_name": "401457_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Basic Pl", "plan_name": "400100", "standard_charge_percentage": 0.85, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Basic Pl", "plan_name": "400100_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Federal", "plan_name": "400110", "standard_charge_percentage": 0.85, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Federal", "plan_name": "400110_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." } ] } ] }, { "description": "Thoracoscopy w/wedge resect", "code_information": [ { "code": "32666", "type": "CPT" } ], "standard_charges": [ { "gross_charge": 61825.75, "minimum": 49460.60, "maximum": 52551.89, "setting": "inpatient", "payers_information": [ { "payer_name": "Aetna", "plan_name": "700700", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna", "plan_name": "700700_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Miscellaneous", "plan_name": "700720", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Miscellaneous", "plan_name": "700720_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Ppo Hmo", "plan_name": "701720", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Ppo Hmo", "plan_name": "701720_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Ms State Emplo", "plan_name": "401457", "standard_charge_percentage": 0.80, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Ms State Emplo", "plan_name": "401457_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Basic Pl", "plan_name": "400100", "standard_charge_percentage": 0.85, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Basic Pl", "plan_name": "400100_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Federal", "plan_name": "400110", "standard_charge_percentage": 0.85, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Federal", "plan_name": "400110_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." } ] } ] }, { "description": "Thoracoscopy w/w resect addl", "code_information": [ { "code": "32667", "type": "CPT" } ], "standard_charges": [ { "gross_charge": 61825.75, "minimum": 49460.60, "maximum": 52551.89, "setting": "inpatient", "payers_information": [ { "payer_name": "Aetna", "plan_name": "700700", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna", "plan_name": "700700_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Miscellaneous", "plan_name": "700720", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Miscellaneous", "plan_name": "700720_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Ppo Hmo", "plan_name": "701720", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Ppo Hmo", "plan_name": "701720_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Ms State Emplo", "plan_name": "401457", "standard_charge_percentage": 0.80, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Ms State Emplo", "plan_name": "401457_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Basic Pl", "plan_name": "400100", "standard_charge_percentage": 0.85, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Basic Pl", "plan_name": "400100_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Federal", "plan_name": "400110", "standard_charge_percentage": 0.85, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Federal", "plan_name": "400110_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." } ] } ] }, { "description": "Thoracoscopy w/w resect diag", "code_information": [ { "code": "32668", "type": "CPT" } ], "standard_charges": [ { "gross_charge": 61825.75, "minimum": 49460.60, "maximum": 52551.89, "setting": "inpatient", "payers_information": [ { "payer_name": "Aetna", "plan_name": "700700", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna", "plan_name": "700700_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Miscellaneous", "plan_name": "700720", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Miscellaneous", "plan_name": "700720_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Ppo Hmo", "plan_name": "701720", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Ppo Hmo", "plan_name": "701720_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Ms State Emplo", "plan_name": "401457", "standard_charge_percentage": 0.80, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Ms State Emplo", "plan_name": "401457_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Basic Pl", "plan_name": "400100", "standard_charge_percentage": 0.85, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Basic Pl", "plan_name": "400100_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Federal", "plan_name": "400110", "standard_charge_percentage": 0.85, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Federal", "plan_name": "400110_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." } ] } ] }, { "description": "Thoracoscopy remove segment", "code_information": [ { "code": "32669", "type": "CPT" } ], "standard_charges": [ { "gross_charge": 61825.75, "minimum": 49460.60, "maximum": 52551.89, "setting": "inpatient", "payers_information": [ { "payer_name": "Aetna", "plan_name": "700700", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna", "plan_name": "700700_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Miscellaneous", "plan_name": "700720", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Miscellaneous", "plan_name": "700720_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Ppo Hmo", "plan_name": "701720", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Ppo Hmo", "plan_name": "701720_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Ms State Emplo", "plan_name": "401457", "standard_charge_percentage": 0.80, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Ms State Emplo", "plan_name": "401457_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Basic Pl", "plan_name": "400100", "standard_charge_percentage": 0.85, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Basic Pl", "plan_name": "400100_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Federal", "plan_name": "400110", "standard_charge_percentage": 0.85, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Federal", "plan_name": "400110_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." } ] } ] }, { "description": "Thoracoscopy for lvrs", "code_information": [ { "code": "32672", "type": "CPT" } ], "standard_charges": [ { "gross_charge": 61825.75, "minimum": 49460.60, "maximum": 52551.89, "setting": "inpatient", "payers_information": [ { "payer_name": "Aetna", "plan_name": "700700", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna", "plan_name": "700700_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Miscellaneous", "plan_name": "700720", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Miscellaneous", "plan_name": "700720_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Ppo Hmo", "plan_name": "701720", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Ppo Hmo", "plan_name": "701720_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Ms State Emplo", "plan_name": "401457", "standard_charge_percentage": 0.80, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Ms State Emplo", "plan_name": "401457_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Basic Pl", "plan_name": "400100", "standard_charge_percentage": 0.85, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Basic Pl", "plan_name": "400100_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Federal", "plan_name": "400110", "standard_charge_percentage": 0.85, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Federal", "plan_name": "400110_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." } ] } ] }, { "description": "Chest surgery procedure", "code_information": [ { "code": "32999", "type": "CPT" } ], "standard_charges": [ { "gross_charge": 40831.65, "minimum": 566.37, "maximum": 34706.90, "setting": "inpatient", "payers_information": [ { "payer_name": "Aarp", "plan_name": "500102", "standard_charge_dollar": 566.37, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna", "plan_name": "700700", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna", "plan_name": "700700_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Mcare Ffs 6005", "plan_name": "700703", "standard_charge_dollar": 566.37, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Miscellaneous", "plan_name": "700720", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Miscellaneous", "plan_name": "700720_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Ppo Hmo", "plan_name": "701720", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Ppo Hmo", "plan_name": "701720_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Ambetter 68069", "plan_name": "500516", "standard_charge_dollar": 566.37, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Ms State Emplo", "plan_name": "401457", "standard_charge_percentage": 0.80, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Ms State Emplo", "plan_name": "401457_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Basic Pl", "plan_name": "400100", "standard_charge_percentage": 0.85, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Basic Pl", "plan_name": "400100_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Federal", "plan_name": "400110", "standard_charge_percentage": 0.85, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Federal", "plan_name": "400110_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Cigna Healthsprings Ffs", "plan_name": "500064", "standard_charge_dollar": 566.37, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Conseco", "plan_name": "500302", "standard_charge_dollar": 566.37, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Humana Ffs 61101", "plan_name": "500006", "standard_charge_dollar": 566.37, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Medicare A", "plan_name": "100100", "standard_charge_dollar": 566.37, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Medicare A", "plan_name": "100500", "standard_charge_dollar": 566.37, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Medicare Part B Only", "plan_name": "100300", "standard_charge_dollar": 566.37, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Medicare Railroad", "plan_name": "100103", "standard_charge_dollar": 566.37, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Ms Physicians Care N", "plan_name": "714210", "standard_charge_dollar": 707.96, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Peoples Hlth Ffs 72126", "plan_name": "500019", "standard_charge_dollar": 566.37, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Uhc/Secure Horizons", "plan_name": "500449", "standard_charge_dollar": 566.37, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "United Health Care/", "plan_name": "500292", "standard_charge_dollar": 640.00, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "United Healthcare", "plan_name": "750104", "standard_charge_dollar": 640.00, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "United Healthcare Ba", "plan_name": "750090", "standard_charge_dollar": 640.00, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "United Healthcare Me", "plan_name": "501310", "standard_charge_dollar": 566.37, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Windsor Mcare Extra", "plan_name": "500778", "standard_charge_dollar": 566.37, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." } ] } ] }, { "description": "Prcrd drg 6yr+ w/o cgen car", "code_information": [ { "code": "33017", "type": "CPT" } ], "standard_charges": [ { "gross_charge": 14152.14, "minimum": 11321.71, "maximum": 12029.32, "setting": "inpatient", "payers_information": [ { "payer_name": "Aetna", "plan_name": "700700", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna", "plan_name": "700700_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Miscellaneous", "plan_name": "700720", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Miscellaneous", "plan_name": "700720_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Ppo Hmo", "plan_name": "701720", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Ppo Hmo", "plan_name": "701720_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Ms State Emplo", "plan_name": "401457", "standard_charge_percentage": 0.80, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Ms State Emplo", "plan_name": "401457_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Basic Pl", "plan_name": "400100", "standard_charge_percentage": 0.85, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Basic Pl", "plan_name": "400100_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Federal", "plan_name": "400110", "standard_charge_percentage": 0.85, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Federal", "plan_name": "400110_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." } ] } ] }, { "description": "Prcrd drg 0-5yr or w/anomly", "code_information": [ { "code": "33018", "type": "CPT" } ], "standard_charges": [ { "gross_charge": 14152.14, "minimum": 11321.71, "maximum": 12029.32, "setting": "inpatient", "payers_information": [ { "payer_name": "Aetna", "plan_name": "700700", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna", "plan_name": "700700_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Miscellaneous", "plan_name": "700720", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Miscellaneous", "plan_name": "700720_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Ppo Hmo", "plan_name": "701720", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Ppo Hmo", "plan_name": "701720_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Ms State Emplo", "plan_name": "401457", "standard_charge_percentage": 0.80, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Ms State Emplo", "plan_name": "401457_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Basic Pl", "plan_name": "400100", "standard_charge_percentage": 0.85, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Basic Pl", "plan_name": "400100_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Federal", "plan_name": "400110", "standard_charge_percentage": 0.85, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Federal", "plan_name": "400110_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." } ] } ] }, { "description": "Perq prcrd drg insj cath ct", "code_information": [ { "code": "33019", "type": "CPT" } ], "standard_charges": [ { "gross_charge": 14152.14, "minimum": 11321.71, "maximum": 12029.32, "setting": "inpatient", "payers_information": [ { "payer_name": "Aetna", "plan_name": "700700", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna", "plan_name": "700700_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Miscellaneous", "plan_name": "700720", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Miscellaneous", "plan_name": "700720_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Ppo Hmo", "plan_name": "701720", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Ppo Hmo", "plan_name": "701720_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Ms State Emplo", "plan_name": "401457", "standard_charge_percentage": 0.80, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Ms State Emplo", "plan_name": "401457_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Basic Pl", "plan_name": "400100", "standard_charge_percentage": 0.85, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Basic Pl", "plan_name": "400100_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Federal", "plan_name": "400110", "standard_charge_percentage": 0.85, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Federal", "plan_name": "400110_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." } ] } ] }, { "description": "Incision of heart sac", "code_information": [ { "code": "33020", "type": "CPT" } ], "standard_charges": [ { "gross_charge": 58039.73, "minimum": 46431.78, "maximum": 49333.77, "setting": "inpatient", "payers_information": [ { "payer_name": "Aetna", "plan_name": "700700", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna", "plan_name": "700700_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Miscellaneous", "plan_name": "700720", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Miscellaneous", "plan_name": "700720_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Ppo Hmo", "plan_name": "701720", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Ppo Hmo", "plan_name": "701720_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Ms State Emplo", "plan_name": "401457", "standard_charge_percentage": 0.80, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Ms State Emplo", "plan_name": "401457_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Basic Pl", "plan_name": "400100", "standard_charge_percentage": 0.85, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Basic Pl", "plan_name": "400100_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Federal", "plan_name": "400110", "standard_charge_percentage": 0.85, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Federal", "plan_name": "400110_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." } ] } ] }, { "description": "Incision of heart sac", "code_information": [ { "code": "33025", "type": "CPT" } ], "standard_charges": [ { "gross_charge": 58039.73, "minimum": 46431.78, "maximum": 49333.77, "setting": "inpatient", "payers_information": [ { "payer_name": "Aetna", "plan_name": "700700", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna", "plan_name": "700700_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Miscellaneous", "plan_name": "700720", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Miscellaneous", "plan_name": "700720_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Ppo Hmo", "plan_name": "701720", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Ppo Hmo", "plan_name": "701720_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Ms State Emplo", "plan_name": "401457", "standard_charge_percentage": 0.80, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Ms State Emplo", "plan_name": "401457_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Basic Pl", "plan_name": "400100", "standard_charge_percentage": 0.85, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Basic Pl", "plan_name": "400100_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Federal", "plan_name": "400110", "standard_charge_percentage": 0.85, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Federal", "plan_name": "400110_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." } ] } ] }, { "description": "Insert heart pm atrial", "code_information": [ { "code": "33206", "type": "CPT" } ], "standard_charges": [ { "gross_charge": 80016.41, "minimum": 9586.97, "maximum": 68013.95, "setting": "inpatient", "payers_information": [ { "payer_name": "Aarp", "plan_name": "500102", "standard_charge_dollar": 9586.97, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna", "plan_name": "700700", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna", "plan_name": "700700_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Mcare Ffs 6005", "plan_name": "700703", "standard_charge_dollar": 9586.97, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Miscellaneous", "plan_name": "700720", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Miscellaneous", "plan_name": "700720_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Ppo Hmo", "plan_name": "701720", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Ppo Hmo", "plan_name": "701720_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Ambetter 68069", "plan_name": "500516", "standard_charge_dollar": 9586.97, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Ms State Emplo", "plan_name": "401457", "standard_charge_percentage": 0.80, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Ms State Emplo", "plan_name": "401457_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Basic Pl", "plan_name": "400100", "standard_charge_percentage": 0.85, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Basic Pl", "plan_name": "400100_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Federal", "plan_name": "400110", "standard_charge_percentage": 0.85, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Federal", "plan_name": "400110_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Cigna Healthsprings Ffs", "plan_name": "500064", "standard_charge_dollar": 9586.97, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Conseco", "plan_name": "500302", "standard_charge_dollar": 9586.97, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Humana Ffs 61101", "plan_name": "500006", "standard_charge_dollar": 9586.97, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Medicare A", "plan_name": "100100", "standard_charge_dollar": 9586.97, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Medicare A", "plan_name": "100500", "standard_charge_dollar": 9586.97, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Medicare Part B Only", "plan_name": "100300", "standard_charge_dollar": 9586.97, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Medicare Railroad", "plan_name": "100103", "standard_charge_dollar": 9586.97, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Ms Physicians Care N", "plan_name": "714210", "standard_charge_dollar": 11983.71, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Peoples Hlth Ffs 72126", "plan_name": "500019", "standard_charge_dollar": 9586.97, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Uhc/Secure Horizons", "plan_name": "500449", "standard_charge_dollar": 9586.97, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "United Health Care/", "plan_name": "500292", "standard_charge_dollar": 10833.27, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "United Healthcare", "plan_name": "750104", "standard_charge_dollar": 10833.27, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "United Healthcare Ba", "plan_name": "750090", "standard_charge_dollar": 10833.27, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "United Healthcare Me", "plan_name": "501310", "standard_charge_dollar": 9586.97, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Windsor Mcare Extra", "plan_name": "500778", "standard_charge_dollar": 9586.97, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." } ] } ] }, { "description": "Insrt heart pm atrial & vent", "code_information": [ { "code": "33208", "type": "CPT" } ], "standard_charges": [ { "gross_charge": 42367.30, "minimum": 9586.97, "maximum": 36012.21, "setting": "inpatient", "payers_information": [ { "payer_name": "Aarp", "plan_name": "500102", "standard_charge_dollar": 9586.97, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna", "plan_name": "700700", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna", "plan_name": "700700_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Mcare Ffs 6005", "plan_name": "700703", "standard_charge_dollar": 9586.97, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Miscellaneous", "plan_name": "700720", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Miscellaneous", "plan_name": "700720_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Ppo Hmo", "plan_name": "701720", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Ppo Hmo", "plan_name": "701720_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Ambetter 68069", "plan_name": "500516", "standard_charge_dollar": 9586.97, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Ms State Emplo", "plan_name": "401457", "standard_charge_percentage": 0.80, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Ms State Emplo", "plan_name": "401457_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Basic Pl", "plan_name": "400100", "standard_charge_percentage": 0.85, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Basic Pl", "plan_name": "400100_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Federal", "plan_name": "400110", "standard_charge_percentage": 0.85, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Federal", "plan_name": "400110_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Cigna Healthsprings Ffs", "plan_name": "500064", "standard_charge_dollar": 9586.97, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Conseco", "plan_name": "500302", "standard_charge_dollar": 9586.97, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Humana Ffs 61101", "plan_name": "500006", "standard_charge_dollar": 9586.97, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Medicare A", "plan_name": "100100", "standard_charge_dollar": 9586.97, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Medicare A", "plan_name": "100500", "standard_charge_dollar": 9586.97, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Medicare Part B Only", "plan_name": "100300", "standard_charge_dollar": 9586.97, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Medicare Railroad", "plan_name": "100103", "standard_charge_dollar": 9586.97, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Ms Physicians Care N", "plan_name": "714210", "standard_charge_dollar": 11983.71, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Peoples Hlth Ffs 72126", "plan_name": "500019", "standard_charge_dollar": 9586.97, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Uhc/Secure Horizons", "plan_name": "500449", "standard_charge_dollar": 9586.97, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "United Health Care/", "plan_name": "500292", "standard_charge_dollar": 10833.27, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "United Healthcare", "plan_name": "750104", "standard_charge_dollar": 10833.27, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "United Healthcare Ba", "plan_name": "750090", "standard_charge_dollar": 10833.27, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "United Healthcare Me", "plan_name": "501310", "standard_charge_dollar": 9586.97, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Windsor Mcare Extra", "plan_name": "500778", "standard_charge_dollar": 9586.97, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." } ] } ] }, { "description": "Insert electrd/pm cath sngl", "code_information": [ { "code": "33210", "type": "CPT" } ], "standard_charges": [ { "gross_charge": 46696.73, "minimum": 7581.37, "maximum": 39692.22, "setting": "inpatient", "payers_information": [ { "payer_name": "Aarp", "plan_name": "500102", "standard_charge_dollar": 7581.37, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna", "plan_name": "700700", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna", "plan_name": "700700_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Mcare Ffs 6005", "plan_name": "700703", "standard_charge_dollar": 7581.37, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Miscellaneous", "plan_name": "700720", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Miscellaneous", "plan_name": "700720_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Ppo Hmo", "plan_name": "701720", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Ppo Hmo", "plan_name": "701720_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Ambetter 68069", "plan_name": "500516", "standard_charge_dollar": 7581.37, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Ms State Emplo", "plan_name": "401457", "standard_charge_percentage": 0.80, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Ms State Emplo", "plan_name": "401457_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Basic Pl", "plan_name": "400100", "standard_charge_percentage": 0.85, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Basic Pl", "plan_name": "400100_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Federal", "plan_name": "400110", "standard_charge_percentage": 0.85, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Federal", "plan_name": "400110_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Cigna Healthsprings Ffs", "plan_name": "500064", "standard_charge_dollar": 7581.37, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Conseco", "plan_name": "500302", "standard_charge_dollar": 7581.37, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Humana Ffs 61101", "plan_name": "500006", "standard_charge_dollar": 7581.37, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Medicare A", "plan_name": "100100", "standard_charge_dollar": 7581.37, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Medicare A", "plan_name": "100500", "standard_charge_dollar": 7581.37, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Medicare Part B Only", "plan_name": "100300", "standard_charge_dollar": 7581.37, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Medicare Railroad", "plan_name": "100103", "standard_charge_dollar": 7581.37, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Ms Physicians Care N", "plan_name": "714210", "standard_charge_dollar": 9476.71, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Peoples Hlth Ffs 72126", "plan_name": "500019", "standard_charge_dollar": 7581.37, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Uhc/Secure Horizons", "plan_name": "500449", "standard_charge_dollar": 7581.37, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "United Health Care/", "plan_name": "500292", "standard_charge_dollar": 8566.95, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "United Healthcare", "plan_name": "750104", "standard_charge_dollar": 8566.95, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "United Healthcare Ba", "plan_name": "750090", "standard_charge_dollar": 8566.95, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "United Healthcare Me", "plan_name": "501310", "standard_charge_dollar": 7581.37, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Windsor Mcare Extra", "plan_name": "500778", "standard_charge_dollar": 7581.37, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." } ] } ] }, { "description": "Insert card electrodes dual", "code_information": [ { "code": "33211", "type": "CPT" } ], "standard_charges": [ { "gross_charge": 46696.73, "minimum": 7581.37, "maximum": 39692.22, "setting": "inpatient", "payers_information": [ { "payer_name": "Aarp", "plan_name": "500102", "standard_charge_dollar": 7581.37, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna", "plan_name": "700700", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna", "plan_name": "700700_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Mcare Ffs 6005", "plan_name": "700703", "standard_charge_dollar": 7581.37, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Miscellaneous", "plan_name": "700720", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Miscellaneous", "plan_name": "700720_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Ppo Hmo", "plan_name": "701720", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Ppo Hmo", "plan_name": "701720_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Ambetter 68069", "plan_name": "500516", "standard_charge_dollar": 7581.37, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Ms State Emplo", "plan_name": "401457", "standard_charge_percentage": 0.80, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Ms State Emplo", "plan_name": "401457_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Basic Pl", "plan_name": "400100", "standard_charge_percentage": 0.85, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Basic Pl", "plan_name": "400100_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Federal", "plan_name": "400110", "standard_charge_percentage": 0.85, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Federal", "plan_name": "400110_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Cigna Healthsprings Ffs", "plan_name": "500064", "standard_charge_dollar": 7581.37, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Conseco", "plan_name": "500302", "standard_charge_dollar": 7581.37, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Humana Ffs 61101", "plan_name": "500006", "standard_charge_dollar": 7581.37, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Medicare A", "plan_name": "100100", "standard_charge_dollar": 7581.37, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Medicare A", "plan_name": "100500", "standard_charge_dollar": 7581.37, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Medicare Part B Only", "plan_name": "100300", "standard_charge_dollar": 7581.37, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Medicare Railroad", "plan_name": "100103", "standard_charge_dollar": 7581.37, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Ms Physicians Care N", "plan_name": "714210", "standard_charge_dollar": 9476.71, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Peoples Hlth Ffs 72126", "plan_name": "500019", "standard_charge_dollar": 7581.37, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Uhc/Secure Horizons", "plan_name": "500449", "standard_charge_dollar": 7581.37, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "United Health Care/", "plan_name": "500292", "standard_charge_dollar": 8566.95, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "United Healthcare", "plan_name": "750104", "standard_charge_dollar": 8566.95, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "United Healthcare Ba", "plan_name": "750090", "standard_charge_dollar": 8566.95, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "United Healthcare Me", "plan_name": "501310", "standard_charge_dollar": 7581.37, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Windsor Mcare Extra", "plan_name": "500778", "standard_charge_dollar": 7581.37, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." } ] } ] }, { "description": "Insert pulse gen sngl lead", "code_information": [ { "code": "33212", "type": "CPT" } ], "standard_charges": [ { "gross_charge": 80016.41, "minimum": 7581.37, "maximum": 68013.95, "setting": "inpatient", "payers_information": [ { "payer_name": "Aarp", "plan_name": "500102", "standard_charge_dollar": 7581.37, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna", "plan_name": "700700", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna", "plan_name": "700700_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Mcare Ffs 6005", "plan_name": "700703", "standard_charge_dollar": 7581.37, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Miscellaneous", "plan_name": "700720", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Miscellaneous", "plan_name": "700720_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Ppo Hmo", "plan_name": "701720", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Ppo Hmo", "plan_name": "701720_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Ambetter 68069", "plan_name": "500516", "standard_charge_dollar": 7581.37, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Ms State Emplo", "plan_name": "401457", "standard_charge_percentage": 0.80, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Ms State Emplo", "plan_name": "401457_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Basic Pl", "plan_name": "400100", "standard_charge_percentage": 0.85, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Basic Pl", "plan_name": "400100_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Federal", "plan_name": "400110", "standard_charge_percentage": 0.85, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Federal", "plan_name": "400110_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Cigna Healthsprings Ffs", "plan_name": "500064", "standard_charge_dollar": 7581.37, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Conseco", "plan_name": "500302", "standard_charge_dollar": 7581.37, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Humana Ffs 61101", "plan_name": "500006", "standard_charge_dollar": 7581.37, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Medicare A", "plan_name": "100100", "standard_charge_dollar": 7581.37, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Medicare A", "plan_name": "100500", "standard_charge_dollar": 7581.37, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Medicare Part B Only", "plan_name": "100300", "standard_charge_dollar": 7581.37, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Medicare Railroad", "plan_name": "100103", "standard_charge_dollar": 7581.37, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Ms Physicians Care N", "plan_name": "714210", "standard_charge_dollar": 9476.71, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Peoples Hlth Ffs 72126", "plan_name": "500019", "standard_charge_dollar": 7581.37, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Uhc/Secure Horizons", "plan_name": "500449", "standard_charge_dollar": 7581.37, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "United Health Care/", "plan_name": "500292", "standard_charge_dollar": 8566.95, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "United Healthcare", "plan_name": "750104", "standard_charge_dollar": 8566.95, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "United Healthcare Ba", "plan_name": "750090", "standard_charge_dollar": 8566.95, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "United Healthcare Me", "plan_name": "501310", "standard_charge_dollar": 7581.37, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Windsor Mcare Extra", "plan_name": "500778", "standard_charge_dollar": 7581.37, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." } ] } ] }, { "description": "Insert pulse gen dual leads", "code_information": [ { "code": "33213", "type": "CPT" } ], "standard_charges": [ { "gross_charge": 42367.30, "minimum": 9586.97, "maximum": 36012.21, "setting": "inpatient", "payers_information": [ { "payer_name": "Aarp", "plan_name": "500102", "standard_charge_dollar": 9586.97, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna", "plan_name": "700700", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna", "plan_name": "700700_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Mcare Ffs 6005", "plan_name": "700703", "standard_charge_dollar": 9586.97, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Miscellaneous", "plan_name": "700720", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Miscellaneous", "plan_name": "700720_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Ppo Hmo", "plan_name": "701720", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Ppo Hmo", "plan_name": "701720_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Ambetter 68069", "plan_name": "500516", "standard_charge_dollar": 9586.97, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Ms State Emplo", "plan_name": "401457", "standard_charge_percentage": 0.80, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Ms State Emplo", "plan_name": "401457_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Basic Pl", "plan_name": "400100", "standard_charge_percentage": 0.85, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Basic Pl", "plan_name": "400100_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Federal", "plan_name": "400110", "standard_charge_percentage": 0.85, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Federal", "plan_name": "400110_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Cigna Healthsprings Ffs", "plan_name": "500064", "standard_charge_dollar": 9586.97, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Conseco", "plan_name": "500302", "standard_charge_dollar": 9586.97, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Humana Ffs 61101", "plan_name": "500006", "standard_charge_dollar": 9586.97, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Medicare A", "plan_name": "100100", "standard_charge_dollar": 9586.97, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Medicare A", "plan_name": "100500", "standard_charge_dollar": 9586.97, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Medicare Part B Only", "plan_name": "100300", "standard_charge_dollar": 9586.97, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Medicare Railroad", "plan_name": "100103", "standard_charge_dollar": 9586.97, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Ms Physicians Care N", "plan_name": "714210", "standard_charge_dollar": 11983.71, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Peoples Hlth Ffs 72126", "plan_name": "500019", "standard_charge_dollar": 9586.97, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Uhc/Secure Horizons", "plan_name": "500449", "standard_charge_dollar": 9586.97, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "United Health Care/", "plan_name": "500292", "standard_charge_dollar": 10833.27, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "United Healthcare", "plan_name": "750104", "standard_charge_dollar": 10833.27, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "United Healthcare Ba", "plan_name": "750090", "standard_charge_dollar": 10833.27, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "United Healthcare Me", "plan_name": "501310", "standard_charge_dollar": 9586.97, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Windsor Mcare Extra", "plan_name": "500778", "standard_charge_dollar": 9586.97, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." } ] } ] }, { "description": "Upgrade of pacemaker system", "code_information": [ { "code": "33214", "type": "CPT" } ], "standard_charges": [ { "gross_charge": 42367.30, "minimum": 9586.97, "maximum": 36012.21, "setting": "inpatient", "payers_information": [ { "payer_name": "Aarp", "plan_name": "500102", "standard_charge_dollar": 9586.97, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna", "plan_name": "700700", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna", "plan_name": "700700_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Mcare Ffs 6005", "plan_name": "700703", "standard_charge_dollar": 9586.97, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Miscellaneous", "plan_name": "700720", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Miscellaneous", "plan_name": "700720_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Ppo Hmo", "plan_name": "701720", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Ppo Hmo", "plan_name": "701720_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Ambetter 68069", "plan_name": "500516", "standard_charge_dollar": 9586.97, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Ms State Emplo", "plan_name": "401457", "standard_charge_percentage": 0.80, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Ms State Emplo", "plan_name": "401457_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Basic Pl", "plan_name": "400100", "standard_charge_percentage": 0.85, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Basic Pl", "plan_name": "400100_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Federal", "plan_name": "400110", "standard_charge_percentage": 0.85, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Federal", "plan_name": "400110_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Cigna Healthsprings Ffs", "plan_name": "500064", "standard_charge_dollar": 9586.97, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Conseco", "plan_name": "500302", "standard_charge_dollar": 9586.97, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Humana Ffs 61101", "plan_name": "500006", "standard_charge_dollar": 9586.97, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Medicare A", "plan_name": "100100", "standard_charge_dollar": 9586.97, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Medicare A", "plan_name": "100500", "standard_charge_dollar": 9586.97, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Medicare Part B Only", "plan_name": "100300", "standard_charge_dollar": 9586.97, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Medicare Railroad", "plan_name": "100103", "standard_charge_dollar": 9586.97, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Ms Physicians Care N", "plan_name": "714210", "standard_charge_dollar": 11983.71, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Peoples Hlth Ffs 72126", "plan_name": "500019", "standard_charge_dollar": 9586.97, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Uhc/Secure Horizons", "plan_name": "500449", "standard_charge_dollar": 9586.97, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "United Health Care/", "plan_name": "500292", "standard_charge_dollar": 10833.27, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "United Healthcare", "plan_name": "750104", "standard_charge_dollar": 10833.27, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "United Healthcare Ba", "plan_name": "750090", "standard_charge_dollar": 10833.27, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "United Healthcare Me", "plan_name": "501310", "standard_charge_dollar": 9586.97, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Windsor Mcare Extra", "plan_name": "500778", "standard_charge_dollar": 9586.97, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." } ] } ] }, { "description": "Insert 1 electrode pm-defib", "code_information": [ { "code": "33216", "type": "CPT" } ], "standard_charges": [ { "gross_charge": 50089.98, "minimum": 7581.37, "maximum": 42576.48, "setting": "inpatient", "payers_information": [ { "payer_name": "Aarp", "plan_name": "500102", "standard_charge_dollar": 7581.37, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna", "plan_name": "700700", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna", "plan_name": "700700_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Mcare Ffs 6005", "plan_name": "700703", "standard_charge_dollar": 7581.37, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Miscellaneous", "plan_name": "700720", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Miscellaneous", "plan_name": "700720_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Ppo Hmo", "plan_name": "701720", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Ppo Hmo", "plan_name": "701720_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Ambetter 68069", "plan_name": "500516", "standard_charge_dollar": 7581.37, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Ms State Emplo", "plan_name": "401457", "standard_charge_percentage": 0.80, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Ms State Emplo", "plan_name": "401457_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Basic Pl", "plan_name": "400100", "standard_charge_percentage": 0.85, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Basic Pl", "plan_name": "400100_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Federal", "plan_name": "400110", "standard_charge_percentage": 0.85, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Federal", "plan_name": "400110_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Cigna Healthsprings Ffs", "plan_name": "500064", "standard_charge_dollar": 7581.37, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Conseco", "plan_name": "500302", "standard_charge_dollar": 7581.37, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Humana Ffs 61101", "plan_name": "500006", "standard_charge_dollar": 7581.37, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Medicare A", "plan_name": "100100", "standard_charge_dollar": 7581.37, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Medicare A", "plan_name": "100500", "standard_charge_dollar": 7581.37, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Medicare Part B Only", "plan_name": "100300", "standard_charge_dollar": 7581.37, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Medicare Railroad", "plan_name": "100103", "standard_charge_dollar": 7581.37, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Ms Physicians Care N", "plan_name": "714210", "standard_charge_dollar": 9476.71, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Peoples Hlth Ffs 72126", "plan_name": "500019", "standard_charge_dollar": 7581.37, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Uhc/Secure Horizons", "plan_name": "500449", "standard_charge_dollar": 7581.37, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "United Health Care/", "plan_name": "500292", "standard_charge_dollar": 8566.95, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "United Healthcare", "plan_name": "750104", "standard_charge_dollar": 8566.95, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "United Healthcare Ba", "plan_name": "750090", "standard_charge_dollar": 8566.95, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "United Healthcare Me", "plan_name": "501310", "standard_charge_dollar": 7581.37, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Windsor Mcare Extra", "plan_name": "500778", "standard_charge_dollar": 7581.37, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." } ] } ] }, { "description": "Insert 2 electrode pm-defib", "code_information": [ { "code": "33217", "type": "CPT" } ], "standard_charges": [ { "gross_charge": 48393.36, "minimum": 7581.37, "maximum": 41134.36, "setting": "inpatient", "payers_information": [ { "payer_name": "Aarp", "plan_name": "500102", "standard_charge_dollar": 7581.37, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna", "plan_name": "700700", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna", "plan_name": "700700_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Mcare Ffs 6005", "plan_name": "700703", "standard_charge_dollar": 7581.37, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Miscellaneous", "plan_name": "700720", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Miscellaneous", "plan_name": "700720_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Ppo Hmo", "plan_name": "701720", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Ppo Hmo", "plan_name": "701720_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Ambetter 68069", "plan_name": "500516", "standard_charge_dollar": 7581.37, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Ms State Emplo", "plan_name": "401457", "standard_charge_percentage": 0.80, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Ms State Emplo", "plan_name": "401457_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Basic Pl", "plan_name": "400100", "standard_charge_percentage": 0.85, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Basic Pl", "plan_name": "400100_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Federal", "plan_name": "400110", "standard_charge_percentage": 0.85, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Federal", "plan_name": "400110_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Cigna Healthsprings Ffs", "plan_name": "500064", "standard_charge_dollar": 7581.37, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Conseco", "plan_name": "500302", "standard_charge_dollar": 7581.37, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Humana Ffs 61101", "plan_name": "500006", "standard_charge_dollar": 7581.37, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Medicare A", "plan_name": "100100", "standard_charge_dollar": 7581.37, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Medicare A", "plan_name": "100500", "standard_charge_dollar": 7581.37, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Medicare Part B Only", "plan_name": "100300", "standard_charge_dollar": 7581.37, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Medicare Railroad", "plan_name": "100103", "standard_charge_dollar": 7581.37, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Ms Physicians Care N", "plan_name": "714210", "standard_charge_dollar": 9476.71, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Peoples Hlth Ffs 72126", "plan_name": "500019", "standard_charge_dollar": 7581.37, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Uhc/Secure Horizons", "plan_name": "500449", "standard_charge_dollar": 7581.37, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "United Health Care/", "plan_name": "500292", "standard_charge_dollar": 8566.95, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "United Healthcare", "plan_name": "750104", "standard_charge_dollar": 8566.95, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "United Healthcare Ba", "plan_name": "750090", "standard_charge_dollar": 8566.95, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "United Healthcare Me", "plan_name": "501310", "standard_charge_dollar": 7581.37, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Windsor Mcare Extra", "plan_name": "500778", "standard_charge_dollar": 7581.37, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." } ] } ] }, { "description": "Insert pulse gen mult leads", "code_information": [ { "code": "33221", "type": "CPT" } ], "standard_charges": [ { "gross_charge": 80016.41, "minimum": 17470.50, "maximum": 68013.95, "setting": "inpatient", "payers_information": [ { "payer_name": "Aarp", "plan_name": "500102", "standard_charge_dollar": 17470.50, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna", "plan_name": "700700", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna", "plan_name": "700700_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Mcare Ffs 6005", "plan_name": "700703", "standard_charge_dollar": 17470.50, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Miscellaneous", "plan_name": "700720", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Miscellaneous", "plan_name": "700720_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Ppo Hmo", "plan_name": "701720", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Ppo Hmo", "plan_name": "701720_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Ambetter 68069", "plan_name": "500516", "standard_charge_dollar": 17470.50, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Ms State Emplo", "plan_name": "401457", "standard_charge_percentage": 0.80, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Ms State Emplo", "plan_name": "401457_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Basic Pl", "plan_name": "400100", "standard_charge_percentage": 0.85, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Basic Pl", "plan_name": "400100_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Federal", "plan_name": "400110", "standard_charge_percentage": 0.85, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Federal", "plan_name": "400110_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Cigna Healthsprings Ffs", "plan_name": "500064", "standard_charge_dollar": 17470.50, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Conseco", "plan_name": "500302", "standard_charge_dollar": 17470.50, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Humana Ffs 61101", "plan_name": "500006", "standard_charge_dollar": 17470.50, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Medicare A", "plan_name": "100100", "standard_charge_dollar": 17470.50, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Medicare A", "plan_name": "100500", "standard_charge_dollar": 17470.50, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Medicare Part B Only", "plan_name": "100300", "standard_charge_dollar": 17470.50, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Medicare Railroad", "plan_name": "100103", "standard_charge_dollar": 17470.50, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Ms Physicians Care N", "plan_name": "714210", "standard_charge_dollar": 21838.13, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Peoples Hlth Ffs 72126", "plan_name": "500019", "standard_charge_dollar": 17470.50, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Uhc/Secure Horizons", "plan_name": "500449", "standard_charge_dollar": 17470.50, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "United Health Care/", "plan_name": "500292", "standard_charge_dollar": 19741.67, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "United Healthcare", "plan_name": "750104", "standard_charge_dollar": 19741.67, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "United Healthcare Ba", "plan_name": "750090", "standard_charge_dollar": 19741.67, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "United Healthcare Me", "plan_name": "501310", "standard_charge_dollar": 17470.50, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Windsor Mcare Extra", "plan_name": "500778", "standard_charge_dollar": 17470.50, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." } ] } ] }, { "description": "Insert pacing lead & connect", "code_information": [ { "code": "33224", "type": "CPT" } ], "standard_charges": [ { "gross_charge": 50089.98, "minimum": 9586.97, "maximum": 42576.48, "setting": "inpatient", "payers_information": [ { "payer_name": "Aarp", "plan_name": "500102", "standard_charge_dollar": 9586.97, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna", "plan_name": "700700", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna", "plan_name": "700700_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Mcare Ffs 6005", "plan_name": "700703", "standard_charge_dollar": 9586.97, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Miscellaneous", "plan_name": "700720", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Miscellaneous", "plan_name": "700720_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Ppo Hmo", "plan_name": "701720", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Ppo Hmo", "plan_name": "701720_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Ambetter 68069", "plan_name": "500516", "standard_charge_dollar": 9586.97, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Ms State Emplo", "plan_name": "401457", "standard_charge_percentage": 0.80, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Ms State Emplo", "plan_name": "401457_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Basic Pl", "plan_name": "400100", "standard_charge_percentage": 0.85, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Basic Pl", "plan_name": "400100_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Federal", "plan_name": "400110", "standard_charge_percentage": 0.85, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Federal", "plan_name": "400110_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Cigna Healthsprings Ffs", "plan_name": "500064", "standard_charge_dollar": 9586.97, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Conseco", "plan_name": "500302", "standard_charge_dollar": 9586.97, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Humana Ffs 61101", "plan_name": "500006", "standard_charge_dollar": 9586.97, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Medicare A", "plan_name": "100100", "standard_charge_dollar": 9586.97, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Medicare A", "plan_name": "100500", "standard_charge_dollar": 9586.97, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Medicare Part B Only", "plan_name": "100300", "standard_charge_dollar": 9586.97, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Medicare Railroad", "plan_name": "100103", "standard_charge_dollar": 9586.97, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Ms Physicians Care N", "plan_name": "714210", "standard_charge_dollar": 11983.71, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Peoples Hlth Ffs 72126", "plan_name": "500019", "standard_charge_dollar": 9586.97, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Uhc/Secure Horizons", "plan_name": "500449", "standard_charge_dollar": 9586.97, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "United Health Care/", "plan_name": "500292", "standard_charge_dollar": 10833.27, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "United Healthcare", "plan_name": "750104", "standard_charge_dollar": 10833.27, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "United Healthcare Ba", "plan_name": "750090", "standard_charge_dollar": 10833.27, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "United Healthcare Me", "plan_name": "501310", "standard_charge_dollar": 9586.97, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Windsor Mcare Extra", "plan_name": "500778", "standard_charge_dollar": 9586.97, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." } ] } ] }, { "description": "L ventric pacing lead add-on", "code_information": [ { "code": "33225", "type": "CPT" } ], "standard_charges": [ { "gross_charge": 50089.98, "minimum": 505.72, "maximum": 505.72, "setting": "inpatient", "payers_information": [ { "payer_name": "Aetna", "plan_name": "700700", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna", "plan_name": "700700_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Miscellaneous", "plan_name": "700720", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Miscellaneous", "plan_name": "700720_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Ppo Hmo", "plan_name": "701720", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Ppo Hmo", "plan_name": "701720_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Ms State Emplo", "plan_name": "401457", "standard_charge_dollar": 505.72, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Ms State Emplo", "plan_name": "401457_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Basic Pl", "plan_name": "400100", "standard_charge_dollar": 505.72, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Basic Pl", "plan_name": "400100_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Federal", "plan_name": "400110", "standard_charge_dollar": 505.72, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Federal", "plan_name": "400110_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." } ] } ] }, { "description": "Remove&replace pm gen singl", "code_information": [ { "code": "33227", "type": "CPT" } ], "standard_charges": [ { "gross_charge": 80016.41, "minimum": 7581.37, "maximum": 68013.95, "setting": "inpatient", "payers_information": [ { "payer_name": "Aarp", "plan_name": "500102", "standard_charge_dollar": 7581.37, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna", "plan_name": "700700", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna", "plan_name": "700700_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Mcare Ffs 6005", "plan_name": "700703", "standard_charge_dollar": 7581.37, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Miscellaneous", "plan_name": "700720", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Miscellaneous", "plan_name": "700720_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Ppo Hmo", "plan_name": "701720", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Ppo Hmo", "plan_name": "701720_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Ambetter 68069", "plan_name": "500516", "standard_charge_dollar": 7581.37, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Ms State Emplo", "plan_name": "401457", "standard_charge_percentage": 0.80, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Ms State Emplo", "plan_name": "401457_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Basic Pl", "plan_name": "400100", "standard_charge_percentage": 0.85, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Basic Pl", "plan_name": "400100_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Federal", "plan_name": "400110", "standard_charge_percentage": 0.85, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Federal", "plan_name": "400110_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Cigna Healthsprings Ffs", "plan_name": "500064", "standard_charge_dollar": 7581.37, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Conseco", "plan_name": "500302", "standard_charge_dollar": 7581.37, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Humana Ffs 61101", "plan_name": "500006", "standard_charge_dollar": 7581.37, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Medicare A", "plan_name": "100100", "standard_charge_dollar": 7581.37, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Medicare A", "plan_name": "100500", "standard_charge_dollar": 7581.37, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Medicare Part B Only", "plan_name": "100300", "standard_charge_dollar": 7581.37, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Medicare Railroad", "plan_name": "100103", "standard_charge_dollar": 7581.37, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Ms Physicians Care N", "plan_name": "714210", "standard_charge_dollar": 9476.71, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Peoples Hlth Ffs 72126", "plan_name": "500019", "standard_charge_dollar": 7581.37, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Uhc/Secure Horizons", "plan_name": "500449", "standard_charge_dollar": 7581.37, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "United Health Care/", "plan_name": "500292", "standard_charge_dollar": 8566.95, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "United Healthcare", "plan_name": "750104", "standard_charge_dollar": 8566.95, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "United Healthcare Ba", "plan_name": "750090", "standard_charge_dollar": 8566.95, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "United Healthcare Me", "plan_name": "501310", "standard_charge_dollar": 7581.37, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Windsor Mcare Extra", "plan_name": "500778", "standard_charge_dollar": 7581.37, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." } ] } ] }, { "description": "Remv&replc pm gen dual lead", "code_information": [ { "code": "33228", "type": "CPT" } ], "standard_charges": [ { "gross_charge": 42367.30, "minimum": 9586.97, "maximum": 36012.21, "setting": "inpatient", "payers_information": [ { "payer_name": "Aarp", "plan_name": "500102", "standard_charge_dollar": 9586.97, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna", "plan_name": "700700", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna", "plan_name": "700700_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Mcare Ffs 6005", "plan_name": "700703", "standard_charge_dollar": 9586.97, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Miscellaneous", "plan_name": "700720", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Miscellaneous", "plan_name": "700720_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Ppo Hmo", "plan_name": "701720", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Ppo Hmo", "plan_name": "701720_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Ambetter 68069", "plan_name": "500516", "standard_charge_dollar": 9586.97, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Ms State Emplo", "plan_name": "401457", "standard_charge_percentage": 0.80, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Ms State Emplo", "plan_name": "401457_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Basic Pl", "plan_name": "400100", "standard_charge_percentage": 0.85, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Basic Pl", "plan_name": "400100_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Federal", "plan_name": "400110", "standard_charge_percentage": 0.85, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Federal", "plan_name": "400110_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Cigna Healthsprings Ffs", "plan_name": "500064", "standard_charge_dollar": 9586.97, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Conseco", "plan_name": "500302", "standard_charge_dollar": 9586.97, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Humana Ffs 61101", "plan_name": "500006", "standard_charge_dollar": 9586.97, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Medicare A", "plan_name": "100100", "standard_charge_dollar": 9586.97, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Medicare A", "plan_name": "100500", "standard_charge_dollar": 9586.97, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Medicare Part B Only", "plan_name": "100300", "standard_charge_dollar": 9586.97, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Medicare Railroad", "plan_name": "100103", "standard_charge_dollar": 9586.97, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Ms Physicians Care N", "plan_name": "714210", "standard_charge_dollar": 11983.71, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Peoples Hlth Ffs 72126", "plan_name": "500019", "standard_charge_dollar": 9586.97, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Uhc/Secure Horizons", "plan_name": "500449", "standard_charge_dollar": 9586.97, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "United Health Care/", "plan_name": "500292", "standard_charge_dollar": 10833.27, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "United Healthcare", "plan_name": "750104", "standard_charge_dollar": 10833.27, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "United Healthcare Ba", "plan_name": "750090", "standard_charge_dollar": 10833.27, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "United Healthcare Me", "plan_name": "501310", "standard_charge_dollar": 9586.97, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Windsor Mcare Extra", "plan_name": "500778", "standard_charge_dollar": 9586.97, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." } ] } ] }, { "description": "Remv&replc pm gen mult leads", "code_information": [ { "code": "33229", "type": "CPT" } ], "standard_charges": [ { "gross_charge": 42367.30, "minimum": 17470.50, "maximum": 36012.21, "setting": "inpatient", "payers_information": [ { "payer_name": "Aarp", "plan_name": "500102", "standard_charge_dollar": 17470.50, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna", "plan_name": "700700", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna", "plan_name": "700700_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Mcare Ffs 6005", "plan_name": "700703", "standard_charge_dollar": 17470.50, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Miscellaneous", "plan_name": "700720", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Miscellaneous", "plan_name": "700720_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Ppo Hmo", "plan_name": "701720", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Ppo Hmo", "plan_name": "701720_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Ambetter 68069", "plan_name": "500516", "standard_charge_dollar": 17470.50, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Ms State Emplo", "plan_name": "401457", "standard_charge_percentage": 0.80, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Ms State Emplo", "plan_name": "401457_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Basic Pl", "plan_name": "400100", "standard_charge_percentage": 0.85, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Basic Pl", "plan_name": "400100_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Federal", "plan_name": "400110", "standard_charge_percentage": 0.85, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Federal", "plan_name": "400110_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Cigna Healthsprings Ffs", "plan_name": "500064", "standard_charge_dollar": 17470.50, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Conseco", "plan_name": "500302", "standard_charge_dollar": 17470.50, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Humana Ffs 61101", "plan_name": "500006", "standard_charge_dollar": 17470.50, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Medicare A", "plan_name": "100100", "standard_charge_dollar": 17470.50, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Medicare A", "plan_name": "100500", "standard_charge_dollar": 17470.50, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Medicare Part B Only", "plan_name": "100300", "standard_charge_dollar": 17470.50, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Medicare Railroad", "plan_name": "100103", "standard_charge_dollar": 17470.50, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Ms Physicians Care N", "plan_name": "714210", "standard_charge_dollar": 21838.13, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Peoples Hlth Ffs 72126", "plan_name": "500019", "standard_charge_dollar": 17470.50, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Uhc/Secure Horizons", "plan_name": "500449", "standard_charge_dollar": 17470.50, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "United Health Care/", "plan_name": "500292", "standard_charge_dollar": 19741.67, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "United Healthcare", "plan_name": "750104", "standard_charge_dollar": 19741.67, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "United Healthcare Ba", "plan_name": "750090", "standard_charge_dollar": 19741.67, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "United Healthcare Me", "plan_name": "501310", "standard_charge_dollar": 17470.50, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Windsor Mcare Extra", "plan_name": "500778", "standard_charge_dollar": 17470.50, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." } ] } ] }, { "description": "Insrt pulse gen w/dual leads", "code_information": [ { "code": "33230", "type": "CPT" } ], "standard_charges": [ { "gross_charge": 125731.94, "minimum": 20562.26, "maximum": 106872.15, "setting": "inpatient", "payers_information": [ { "payer_name": "Aarp", "plan_name": "500102", "standard_charge_dollar": 20562.26, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna", "plan_name": "700700", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna", "plan_name": "700700_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Mcare Ffs 6005", "plan_name": "700703", "standard_charge_dollar": 20562.26, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Miscellaneous", "plan_name": "700720", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Miscellaneous", "plan_name": "700720_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Ppo Hmo", "plan_name": "701720", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Ppo Hmo", "plan_name": "701720_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Ambetter 68069", "plan_name": "500516", "standard_charge_dollar": 20562.26, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Ms State Emplo", "plan_name": "401457", "standard_charge_percentage": 0.80, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Ms State Emplo", "plan_name": "401457_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Basic Pl", "plan_name": "400100", "standard_charge_percentage": 0.85, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Basic Pl", "plan_name": "400100_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Federal", "plan_name": "400110", "standard_charge_percentage": 0.85, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Federal", "plan_name": "400110_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Cigna Healthsprings Ffs", "plan_name": "500064", "standard_charge_dollar": 20562.26, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Conseco", "plan_name": "500302", "standard_charge_dollar": 20562.26, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Humana Ffs 61101", "plan_name": "500006", "standard_charge_dollar": 20562.26, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Medicare A", "plan_name": "100100", "standard_charge_dollar": 20562.26, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Medicare A", "plan_name": "100500", "standard_charge_dollar": 20562.26, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Medicare Part B Only", "plan_name": "100300", "standard_charge_dollar": 20562.26, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Medicare Railroad", "plan_name": "100103", "standard_charge_dollar": 20562.26, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Ms Physicians Care N", "plan_name": "714210", "standard_charge_dollar": 25702.83, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Peoples Hlth Ffs 72126", "plan_name": "500019", "standard_charge_dollar": 20562.26, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Uhc/Secure Horizons", "plan_name": "500449", "standard_charge_dollar": 20562.26, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "United Health Care/", "plan_name": "500292", "standard_charge_dollar": 23235.36, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "United Healthcare", "plan_name": "750104", "standard_charge_dollar": 23235.36, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "United Healthcare Ba", "plan_name": "750090", "standard_charge_dollar": 23235.36, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "United Healthcare Me", "plan_name": "501310", "standard_charge_dollar": 20562.26, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Windsor Mcare Extra", "plan_name": "500778", "standard_charge_dollar": 20562.26, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." } ] } ] }, { "description": "Insrt pulse gen w/mult leads", "code_information": [ { "code": "33231", "type": "CPT" } ], "standard_charges": [ { "gross_charge": 125731.94, "minimum": 29370.62, "maximum": 106872.15, "setting": "inpatient", "payers_information": [ { "payer_name": "Aarp", "plan_name": "500102", "standard_charge_dollar": 29370.62, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna", "plan_name": "700700", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna", "plan_name": "700700_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Mcare Ffs 6005", "plan_name": "700703", "standard_charge_dollar": 29370.62, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Miscellaneous", "plan_name": "700720", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Miscellaneous", "plan_name": "700720_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Ppo Hmo", "plan_name": "701720", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Ppo Hmo", "plan_name": "701720_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Ambetter 68069", "plan_name": "500516", "standard_charge_dollar": 29370.62, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Ms State Emplo", "plan_name": "401457", "standard_charge_percentage": 0.80, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Ms State Emplo", "plan_name": "401457_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Basic Pl", "plan_name": "400100", "standard_charge_percentage": 0.85, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Basic Pl", "plan_name": "400100_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Federal", "plan_name": "400110", "standard_charge_percentage": 0.85, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Federal", "plan_name": "400110_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Cigna Healthsprings Ffs", "plan_name": "500064", "standard_charge_dollar": 29370.62, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Conseco", "plan_name": "500302", "standard_charge_dollar": 29370.62, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Humana Ffs 61101", "plan_name": "500006", "standard_charge_dollar": 29370.62, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Medicare A", "plan_name": "100100", "standard_charge_dollar": 29370.62, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Medicare A", "plan_name": "100500", "standard_charge_dollar": 29370.62, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Medicare Part B Only", "plan_name": "100300", "standard_charge_dollar": 29370.62, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Medicare Railroad", "plan_name": "100103", "standard_charge_dollar": 29370.62, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Ms Physicians Care N", "plan_name": "714210", "standard_charge_dollar": 36713.28, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Peoples Hlth Ffs 72126", "plan_name": "500019", "standard_charge_dollar": 29370.62, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Uhc/Secure Horizons", "plan_name": "500449", "standard_charge_dollar": 29370.62, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "United Health Care/", "plan_name": "500292", "standard_charge_dollar": 33188.81, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "United Healthcare", "plan_name": "750104", "standard_charge_dollar": 33188.81, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "United Healthcare Ba", "plan_name": "750090", "standard_charge_dollar": 33188.81, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "United Healthcare Me", "plan_name": "501310", "standard_charge_dollar": 29370.62, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Windsor Mcare Extra", "plan_name": "500778", "standard_charge_dollar": 29370.62, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." } ] } ] }, { "description": "Insrt pulse gen w/singl lead", "code_information": [ { "code": "33240", "type": "CPT" } ], "standard_charges": [ { "gross_charge": 125731.94, "minimum": 390.19, "maximum": 25702.83, "setting": "inpatient", "payers_information": [ { "payer_name": "Aarp", "plan_name": "500102", "standard_charge_dollar": 20562.26, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna", "plan_name": "700700", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna", "plan_name": "700700_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Mcare Ffs 6005", "plan_name": "700703", "standard_charge_dollar": 20562.26, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Miscellaneous", "plan_name": "700720", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Miscellaneous", "plan_name": "700720_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Ppo Hmo", "plan_name": "701720", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Ppo Hmo", "plan_name": "701720_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Ambetter 68069", "plan_name": "500516", "standard_charge_dollar": 20562.26, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Ms State Emplo", "plan_name": "401457", "standard_charge_dollar": 390.19, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Ms State Emplo", "plan_name": "401457_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Basic Pl", "plan_name": "400100", "standard_charge_dollar": 390.19, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Basic Pl", "plan_name": "400100_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Federal", "plan_name": "400110", "standard_charge_dollar": 390.19, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Federal", "plan_name": "400110_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Cigna Healthsprings Ffs", "plan_name": "500064", "standard_charge_dollar": 20562.26, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Conseco", "plan_name": "500302", "standard_charge_dollar": 20562.26, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Humana Ffs 61101", "plan_name": "500006", "standard_charge_dollar": 20562.26, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Medicare A", "plan_name": "100100", "standard_charge_dollar": 20562.26, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Medicare A", "plan_name": "100500", "standard_charge_dollar": 20562.26, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Medicare Part B Only", "plan_name": "100300", "standard_charge_dollar": 20562.26, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Medicare Railroad", "plan_name": "100103", "standard_charge_dollar": 20562.26, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Ms Physicians Care N", "plan_name": "714210", "standard_charge_dollar": 25702.83, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Peoples Hlth Ffs 72126", "plan_name": "500019", "standard_charge_dollar": 20562.26, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Uhc/Secure Horizons", "plan_name": "500449", "standard_charge_dollar": 20562.26, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "United Health Care/", "plan_name": "500292", "standard_charge_dollar": 23235.36, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "United Healthcare", "plan_name": "750104", "standard_charge_dollar": 23235.36, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "United Healthcare Ba", "plan_name": "750090", "standard_charge_dollar": 23235.36, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "United Healthcare Me", "plan_name": "501310", "standard_charge_dollar": 20562.26, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Windsor Mcare Extra", "plan_name": "500778", "standard_charge_dollar": 20562.26, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." } ] } ] }, { "description": "Insj/rplcmt defib w/lead(s)", "code_information": [ { "code": "33249", "type": "CPT" } ], "standard_charges": [ { "gross_charge": 50089.98, "minimum": 980.99, "maximum": 36713.28, "setting": "inpatient", "payers_information": [ { "payer_name": "Aarp", "plan_name": "500102", "standard_charge_dollar": 29370.62, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna", "plan_name": "700700", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna", "plan_name": "700700_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Mcare Ffs 6005", "plan_name": "700703", "standard_charge_dollar": 29370.62, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Miscellaneous", "plan_name": "700720", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Miscellaneous", "plan_name": "700720_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Ppo Hmo", "plan_name": "701720", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Ppo Hmo", "plan_name": "701720_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Ambetter 68069", "plan_name": "500516", "standard_charge_dollar": 29370.62, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Ms State Emplo", "plan_name": "401457", "standard_charge_dollar": 980.99, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Ms State Emplo", "plan_name": "401457_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Basic Pl", "plan_name": "400100", "standard_charge_dollar": 980.99, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Basic Pl", "plan_name": "400100_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Federal", "plan_name": "400110", "standard_charge_dollar": 980.99, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Federal", "plan_name": "400110_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Cigna Healthsprings Ffs", "plan_name": "500064", "standard_charge_dollar": 29370.62, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Conseco", "plan_name": "500302", "standard_charge_dollar": 29370.62, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Humana Ffs 61101", "plan_name": "500006", "standard_charge_dollar": 29370.62, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Medicare A", "plan_name": "100100", "standard_charge_dollar": 29370.62, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Medicare A", "plan_name": "100500", "standard_charge_dollar": 29370.62, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Medicare Part B Only", "plan_name": "100300", "standard_charge_dollar": 29370.62, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Medicare Railroad", "plan_name": "100103", "standard_charge_dollar": 29370.62, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Ms Physicians Care N", "plan_name": "714210", "standard_charge_dollar": 36713.28, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Peoples Hlth Ffs 72126", "plan_name": "500019", "standard_charge_dollar": 29370.62, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Uhc/Secure Horizons", "plan_name": "500449", "standard_charge_dollar": 29370.62, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "United Health Care/", "plan_name": "500292", "standard_charge_dollar": 33188.81, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "United Healthcare", "plan_name": "750104", "standard_charge_dollar": 33188.81, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "United Healthcare Ba", "plan_name": "750090", "standard_charge_dollar": 33188.81, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "United Healthcare Me", "plan_name": "501310", "standard_charge_dollar": 29370.62, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Windsor Mcare Extra", "plan_name": "500778", "standard_charge_dollar": 29370.62, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." } ] } ] }, { "description": "Rmvl& replc pulse gen 1 lead", "code_information": [ { "code": "33262", "type": "CPT" } ], "standard_charges": [ { "gross_charge": 125731.94, "minimum": 20562.26, "maximum": 106872.15, "setting": "inpatient", "payers_information": [ { "payer_name": "Aarp", "plan_name": "500102", "standard_charge_dollar": 20562.26, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna", "plan_name": "700700", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna", "plan_name": "700700_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Mcare Ffs 6005", "plan_name": "700703", "standard_charge_dollar": 20562.26, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Miscellaneous", "plan_name": "700720", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Miscellaneous", "plan_name": "700720_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Ppo Hmo", "plan_name": "701720", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Ppo Hmo", "plan_name": "701720_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Ambetter 68069", "plan_name": "500516", "standard_charge_dollar": 20562.26, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Ms State Emplo", "plan_name": "401457", "standard_charge_percentage": 0.80, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Ms State Emplo", "plan_name": "401457_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Basic Pl", "plan_name": "400100", "standard_charge_percentage": 0.85, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Basic Pl", "plan_name": "400100_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Federal", "plan_name": "400110", "standard_charge_percentage": 0.85, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Federal", "plan_name": "400110_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Cigna Healthsprings Ffs", "plan_name": "500064", "standard_charge_dollar": 20562.26, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Conseco", "plan_name": "500302", "standard_charge_dollar": 20562.26, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Humana Ffs 61101", "plan_name": "500006", "standard_charge_dollar": 20562.26, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Medicare A", "plan_name": "100100", "standard_charge_dollar": 20562.26, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Medicare A", "plan_name": "100500", "standard_charge_dollar": 20562.26, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Medicare Part B Only", "plan_name": "100300", "standard_charge_dollar": 20562.26, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Medicare Railroad", "plan_name": "100103", "standard_charge_dollar": 20562.26, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Ms Physicians Care N", "plan_name": "714210", "standard_charge_dollar": 25702.83, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Peoples Hlth Ffs 72126", "plan_name": "500019", "standard_charge_dollar": 20562.26, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Uhc/Secure Horizons", "plan_name": "500449", "standard_charge_dollar": 20562.26, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "United Health Care/", "plan_name": "500292", "standard_charge_dollar": 23235.36, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "United Healthcare", "plan_name": "750104", "standard_charge_dollar": 23235.36, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "United Healthcare Ba", "plan_name": "750090", "standard_charge_dollar": 23235.36, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "United Healthcare Me", "plan_name": "501310", "standard_charge_dollar": 20562.26, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Windsor Mcare Extra", "plan_name": "500778", "standard_charge_dollar": 20562.26, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." } ] } ] }, { "description": "Rmvl & rplcmt dfb gen 2 lead", "code_information": [ { "code": "33263", "type": "CPT" } ], "standard_charges": [ { "gross_charge": 125731.94, "minimum": 20562.26, "maximum": 106872.15, "setting": "inpatient", "payers_information": [ { "payer_name": "Aarp", "plan_name": "500102", "standard_charge_dollar": 20562.26, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna", "plan_name": "700700", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna", "plan_name": "700700_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Mcare Ffs 6005", "plan_name": "700703", "standard_charge_dollar": 20562.26, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Miscellaneous", "plan_name": "700720", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Miscellaneous", "plan_name": "700720_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Ppo Hmo", "plan_name": "701720", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Ppo Hmo", "plan_name": "701720_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Ambetter 68069", "plan_name": "500516", "standard_charge_dollar": 20562.26, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Ms State Emplo", "plan_name": "401457", "standard_charge_percentage": 0.80, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Ms State Emplo", "plan_name": "401457_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Basic Pl", "plan_name": "400100", "standard_charge_percentage": 0.85, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Basic Pl", "plan_name": "400100_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Federal", "plan_name": "400110", "standard_charge_percentage": 0.85, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Federal", "plan_name": "400110_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Cigna Healthsprings Ffs", "plan_name": "500064", "standard_charge_dollar": 20562.26, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Conseco", "plan_name": "500302", "standard_charge_dollar": 20562.26, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Humana Ffs 61101", "plan_name": "500006", "standard_charge_dollar": 20562.26, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Medicare A", "plan_name": "100100", "standard_charge_dollar": 20562.26, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Medicare A", "plan_name": "100500", "standard_charge_dollar": 20562.26, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Medicare Part B Only", "plan_name": "100300", "standard_charge_dollar": 20562.26, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Medicare Railroad", "plan_name": "100103", "standard_charge_dollar": 20562.26, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Ms Physicians Care N", "plan_name": "714210", "standard_charge_dollar": 25702.83, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Peoples Hlth Ffs 72126", "plan_name": "500019", "standard_charge_dollar": 20562.26, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Uhc/Secure Horizons", "plan_name": "500449", "standard_charge_dollar": 20562.26, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "United Health Care/", "plan_name": "500292", "standard_charge_dollar": 23235.36, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "United Healthcare", "plan_name": "750104", "standard_charge_dollar": 23235.36, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "United Healthcare Ba", "plan_name": "750090", "standard_charge_dollar": 23235.36, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "United Healthcare Me", "plan_name": "501310", "standard_charge_dollar": 20562.26, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Windsor Mcare Extra", "plan_name": "500778", "standard_charge_dollar": 20562.26, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." } ] } ] }, { "description": "Rmvl & rplcmt dfb gen mlt ld", "code_information": [ { "code": "33264", "type": "CPT" } ], "standard_charges": [ { "gross_charge": 125731.94, "minimum": 29370.62, "maximum": 106872.15, "setting": "inpatient", "payers_information": [ { "payer_name": "Aarp", "plan_name": "500102", "standard_charge_dollar": 29370.62, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna", "plan_name": "700700", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna", "plan_name": "700700_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Mcare Ffs 6005", "plan_name": "700703", "standard_charge_dollar": 29370.62, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Miscellaneous", "plan_name": "700720", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Miscellaneous", "plan_name": "700720_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Ppo Hmo", "plan_name": "701720", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Ppo Hmo", "plan_name": "701720_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Ambetter 68069", "plan_name": "500516", "standard_charge_dollar": 29370.62, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Ms State Emplo", "plan_name": "401457", "standard_charge_percentage": 0.80, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Ms State Emplo", "plan_name": "401457_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Basic Pl", "plan_name": "400100", "standard_charge_percentage": 0.85, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Basic Pl", "plan_name": "400100_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Federal", "plan_name": "400110", "standard_charge_percentage": 0.85, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Federal", "plan_name": "400110_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Cigna Healthsprings Ffs", "plan_name": "500064", "standard_charge_dollar": 29370.62, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Conseco", "plan_name": "500302", "standard_charge_dollar": 29370.62, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Humana Ffs 61101", "plan_name": "500006", "standard_charge_dollar": 29370.62, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Medicare A", "plan_name": "100100", "standard_charge_dollar": 29370.62, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Medicare A", "plan_name": "100500", "standard_charge_dollar": 29370.62, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Medicare Part B Only", "plan_name": "100300", "standard_charge_dollar": 29370.62, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Medicare Railroad", "plan_name": "100103", "standard_charge_dollar": 29370.62, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Ms Physicians Care N", "plan_name": "714210", "standard_charge_dollar": 36713.28, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Peoples Hlth Ffs 72126", "plan_name": "500019", "standard_charge_dollar": 29370.62, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Uhc/Secure Horizons", "plan_name": "500449", "standard_charge_dollar": 29370.62, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "United Health Care/", "plan_name": "500292", "standard_charge_dollar": 33188.81, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "United Healthcare", "plan_name": "750104", "standard_charge_dollar": 33188.81, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "United Healthcare Ba", "plan_name": "750090", "standard_charge_dollar": 33188.81, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "United Healthcare Me", "plan_name": "501310", "standard_charge_dollar": 29370.62, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Windsor Mcare Extra", "plan_name": "500778", "standard_charge_dollar": 29370.62, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." } ] } ] }, { "description": "Ins/rep subq defibrillator", "code_information": [ { "code": "33270", "type": "CPT" } ], "standard_charges": [ { "gross_charge": 125731.94, "minimum": 629.95, "maximum": 36713.28, "setting": "inpatient", "payers_information": [ { "payer_name": "Aarp", "plan_name": "500102", "standard_charge_dollar": 29370.62, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna", "plan_name": "700700", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna", "plan_name": "700700_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Mcare Ffs 6005", "plan_name": "700703", "standard_charge_dollar": 29370.62, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Miscellaneous", "plan_name": "700720", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Miscellaneous", "plan_name": "700720_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Ppo Hmo", "plan_name": "701720", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Ppo Hmo", "plan_name": "701720_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Ambetter 68069", "plan_name": "500516", "standard_charge_dollar": 29370.62, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Ms State Emplo", "plan_name": "401457", "standard_charge_dollar": 629.95, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Ms State Emplo", "plan_name": "401457_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Basic Pl", "plan_name": "400100", "standard_charge_dollar": 629.95, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Basic Pl", "plan_name": "400100_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Federal", "plan_name": "400110", "standard_charge_dollar": 629.95, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Federal", "plan_name": "400110_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Cigna Healthsprings Ffs", "plan_name": "500064", "standard_charge_dollar": 29370.62, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Conseco", "plan_name": "500302", "standard_charge_dollar": 29370.62, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Humana Ffs 61101", "plan_name": "500006", "standard_charge_dollar": 29370.62, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Medicare A", "plan_name": "100100", "standard_charge_dollar": 29370.62, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Medicare A", "plan_name": "100500", "standard_charge_dollar": 29370.62, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Medicare Part B Only", "plan_name": "100300", "standard_charge_dollar": 29370.62, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Medicare Railroad", "plan_name": "100103", "standard_charge_dollar": 29370.62, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Ms Physicians Care N", "plan_name": "714210", "standard_charge_dollar": 36713.28, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Peoples Hlth Ffs 72126", "plan_name": "500019", "standard_charge_dollar": 29370.62, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Uhc/Secure Horizons", "plan_name": "500449", "standard_charge_dollar": 29370.62, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "United Health Care/", "plan_name": "500292", "standard_charge_dollar": 33188.81, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "United Healthcare", "plan_name": "750104", "standard_charge_dollar": 33188.81, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "United Healthcare Ba", "plan_name": "750090", "standard_charge_dollar": 33188.81, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "United Healthcare Me", "plan_name": "501310", "standard_charge_dollar": 29370.62, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Windsor Mcare Extra", "plan_name": "500778", "standard_charge_dollar": 29370.62, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." } ] } ] }, { "description": "Tcat insj/rpl perm ldls pm", "code_information": [ { "code": "33274", "type": "CPT" } ], "standard_charges": [ { "gross_charge": 46696.73, "minimum": 17470.50, "maximum": 39692.22, "setting": "inpatient", "payers_information": [ { "payer_name": "Aarp", "plan_name": "500102", "standard_charge_dollar": 17470.50, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna", "plan_name": "700700", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna", "plan_name": "700700_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Mcare Ffs 6005", "plan_name": "700703", "standard_charge_dollar": 17470.50, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Miscellaneous", "plan_name": "700720", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Miscellaneous", "plan_name": "700720_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Ppo Hmo", "plan_name": "701720", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Ppo Hmo", "plan_name": "701720_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Ambetter 68069", "plan_name": "500516", "standard_charge_dollar": 17470.50, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Ms State Emplo", "plan_name": "401457", "standard_charge_percentage": 0.80, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Ms State Emplo", "plan_name": "401457_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Basic Pl", "plan_name": "400100", "standard_charge_percentage": 0.85, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Basic Pl", "plan_name": "400100_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Federal", "plan_name": "400110", "standard_charge_percentage": 0.85, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Federal", "plan_name": "400110_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Cigna Healthsprings Ffs", "plan_name": "500064", "standard_charge_dollar": 17470.50, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Conseco", "plan_name": "500302", "standard_charge_dollar": 17470.50, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Humana Ffs 61101", "plan_name": "500006", "standard_charge_dollar": 17470.50, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Medicare A", "plan_name": "100100", "standard_charge_dollar": 17470.50, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Medicare A", "plan_name": "100500", "standard_charge_dollar": 17470.50, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Medicare Part B Only", "plan_name": "100300", "standard_charge_dollar": 17470.50, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Medicare Railroad", "plan_name": "100103", "standard_charge_dollar": 17470.50, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Ms Physicians Care N", "plan_name": "714210", "standard_charge_dollar": 21838.13, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Peoples Hlth Ffs 72126", "plan_name": "500019", "standard_charge_dollar": 17470.50, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Uhc/Secure Horizons", "plan_name": "500449", "standard_charge_dollar": 17470.50, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "United Health Care/", "plan_name": "500292", "standard_charge_dollar": 19741.67, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "United Healthcare", "plan_name": "750104", "standard_charge_dollar": 19741.67, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "United Healthcare Ba", "plan_name": "750090", "standard_charge_dollar": 19741.67, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "United Healthcare Me", "plan_name": "501310", "standard_charge_dollar": 17470.50, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Windsor Mcare Extra", "plan_name": "500778", "standard_charge_dollar": 17470.50, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." } ] } ] }, { "description": "Exploratory heart surgery", "code_information": [ { "code": "33310", "type": "CPT" } ], "standard_charges": [ { "gross_charge": 27035.82, "minimum": 21628.66, "maximum": 22980.45, "setting": "inpatient", "payers_information": [ { "payer_name": "Aetna", "plan_name": "700700", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna", "plan_name": "700700_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Miscellaneous", "plan_name": "700720", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Miscellaneous", "plan_name": "700720_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Ppo Hmo", "plan_name": "701720", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Ppo Hmo", "plan_name": "701720_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Ms State Emplo", "plan_name": "401457", "standard_charge_percentage": 0.80, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Ms State Emplo", "plan_name": "401457_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Basic Pl", "plan_name": "400100", "standard_charge_percentage": 0.85, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Basic Pl", "plan_name": "400100_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Federal", "plan_name": "400110", "standard_charge_percentage": 0.85, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Federal", "plan_name": "400110_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." } ] } ] }, { "description": "Cabg vein two", "code_information": [ { "code": "33511", "type": "CPT" } ], "standard_charges": [ { "gross_charge": 109927.40, "minimum": 87941.92, "maximum": 93438.29, "setting": "inpatient", "payers_information": [ { "payer_name": "Aetna", "plan_name": "700700", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna", "plan_name": "700700_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Miscellaneous", "plan_name": "700720", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Miscellaneous", "plan_name": "700720_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Ppo Hmo", "plan_name": "701720", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Ppo Hmo", "plan_name": "701720_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Ms State Emplo", "plan_name": "401457", "standard_charge_percentage": 0.80, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Ms State Emplo", "plan_name": "401457_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Basic Pl", "plan_name": "400100", "standard_charge_percentage": 0.85, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Basic Pl", "plan_name": "400100_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Federal", "plan_name": "400110", "standard_charge_percentage": 0.85, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Federal", "plan_name": "400110_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." } ] } ] }, { "description": "Cabg vein three", "code_information": [ { "code": "33512", "type": "CPT" } ], "standard_charges": [ { "gross_charge": 93681.03, "minimum": 74944.82, "maximum": 79628.88, "setting": "inpatient", "payers_information": [ { "payer_name": "Aetna", "plan_name": "700700", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna", "plan_name": "700700_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Miscellaneous", "plan_name": "700720", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Miscellaneous", "plan_name": "700720_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Ppo Hmo", "plan_name": "701720", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Ppo Hmo", "plan_name": "701720_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Ms State Emplo", "plan_name": "401457", "standard_charge_percentage": 0.80, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Ms State Emplo", "plan_name": "401457_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Basic Pl", "plan_name": "400100", "standard_charge_percentage": 0.85, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Basic Pl", "plan_name": "400100_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Federal", "plan_name": "400110", "standard_charge_percentage": 0.85, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Federal", "plan_name": "400110_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." } ] } ] }, { "description": "Cabg artery-vein three", "code_information": [ { "code": "33519", "type": "CPT" } ], "standard_charges": [ { "gross_charge": 93681.03, "minimum": 74944.82, "maximum": 79628.88, "setting": "inpatient", "payers_information": [ { "payer_name": "Aetna", "plan_name": "700700", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna", "plan_name": "700700_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Miscellaneous", "plan_name": "700720", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Miscellaneous", "plan_name": "700720_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Ppo Hmo", "plan_name": "701720", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Ppo Hmo", "plan_name": "701720_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Ms State Emplo", "plan_name": "401457", "standard_charge_percentage": 0.80, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Ms State Emplo", "plan_name": "401457_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Basic Pl", "plan_name": "400100", "standard_charge_percentage": 0.85, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Basic Pl", "plan_name": "400100_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Federal", "plan_name": "400110", "standard_charge_percentage": 0.85, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Federal", "plan_name": "400110_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." } ] } ] }, { "description": "Coronary artery bypass/reop", "code_information": [ { "code": "33530", "type": "CPT" } ], "standard_charges": [ { "gross_charge": 101804.22, "minimum": 81443.38, "maximum": 86533.59, "setting": "inpatient", "payers_information": [ { "payer_name": "Aetna", "plan_name": "700700", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna", "plan_name": "700700_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Miscellaneous", "plan_name": "700720", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Miscellaneous", "plan_name": "700720_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Ppo Hmo", "plan_name": "701720", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Ppo Hmo", "plan_name": "701720_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Ms State Emplo", "plan_name": "401457", "standard_charge_percentage": 0.80, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Ms State Emplo", "plan_name": "401457_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Basic Pl", "plan_name": "400100", "standard_charge_percentage": 0.85, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Basic Pl", "plan_name": "400100_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Federal", "plan_name": "400110", "standard_charge_percentage": 0.85, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Federal", "plan_name": "400110_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." } ] } ] }, { "description": "Cabg arterial single", "code_information": [ { "code": "33533", "type": "CPT" } ], "standard_charges": [ { "gross_charge": 93226.67, "minimum": 74581.34, "maximum": 79242.67, "setting": "inpatient", "payers_information": [ { "payer_name": "Aetna", "plan_name": "700700", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna", "plan_name": "700700_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Miscellaneous", "plan_name": "700720", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Miscellaneous", "plan_name": "700720_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Ppo Hmo", "plan_name": "701720", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Ppo Hmo", "plan_name": "701720_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Ms State Emplo", "plan_name": "401457", "standard_charge_percentage": 0.80, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Ms State Emplo", "plan_name": "401457_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Basic Pl", "plan_name": "400100", "standard_charge_percentage": 0.85, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Basic Pl", "plan_name": "400100_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Federal", "plan_name": "400110", "standard_charge_percentage": 0.85, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Federal", "plan_name": "400110_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." } ] } ] }, { "description": "Cabg arterial two", "code_information": [ { "code": "33534", "type": "CPT" } ], "standard_charges": [ { "gross_charge": 93226.67, "minimum": 74581.34, "maximum": 79242.67, "setting": "inpatient", "payers_information": [ { "payer_name": "Aetna", "plan_name": "700700", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna", "plan_name": "700700_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Miscellaneous", "plan_name": "700720", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Miscellaneous", "plan_name": "700720_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Ppo Hmo", "plan_name": "701720", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Ppo Hmo", "plan_name": "701720_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Ms State Emplo", "plan_name": "401457", "standard_charge_percentage": 0.80, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Ms State Emplo", "plan_name": "401457_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Basic Pl", "plan_name": "400100", "standard_charge_percentage": 0.85, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Basic Pl", "plan_name": "400100_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Federal", "plan_name": "400110", "standard_charge_percentage": 0.85, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Federal", "plan_name": "400110_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." } ] } ] }, { "description": "Cabg arterial three", "code_information": [ { "code": "33535", "type": "CPT" } ], "standard_charges": [ { "gross_charge": 93226.67, "minimum": 74581.34, "maximum": 79242.67, "setting": "inpatient", "payers_information": [ { "payer_name": "Aetna", "plan_name": "700700", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna", "plan_name": "700700_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Miscellaneous", "plan_name": "700720", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Miscellaneous", "plan_name": "700720_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Ppo Hmo", "plan_name": "701720", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Ppo Hmo", "plan_name": "701720_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Ms State Emplo", "plan_name": "401457", "standard_charge_percentage": 0.80, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Ms State Emplo", "plan_name": "401457_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Basic Pl", "plan_name": "400100", "standard_charge_percentage": 0.85, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Basic Pl", "plan_name": "400100_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Federal", "plan_name": "400110", "standard_charge_percentage": 0.85, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Federal", "plan_name": "400110_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." } ] } ] }, { "description": "Cabg arterial four or more", "code_information": [ { "code": "33536", "type": "CPT" } ], "standard_charges": [ { "gross_charge": 93226.67, "minimum": 74581.34, "maximum": 79242.67, "setting": "inpatient", "payers_information": [ { "payer_name": "Aetna", "plan_name": "700700", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna", "plan_name": "700700_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Miscellaneous", "plan_name": "700720", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Miscellaneous", "plan_name": "700720_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Ppo Hmo", "plan_name": "701720", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Ppo Hmo", "plan_name": "701720_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Ms State Emplo", "plan_name": "401457", "standard_charge_percentage": 0.80, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Ms State Emplo", "plan_name": "401457_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Basic Pl", "plan_name": "400100", "standard_charge_percentage": 0.85, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Basic Pl", "plan_name": "400100_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Federal", "plan_name": "400110", "standard_charge_percentage": 0.85, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Federal", "plan_name": "400110_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." } ] } ] }, { "description": "Open coronary endarterectomy", "code_information": [ { "code": "33572", "type": "CPT" } ], "standard_charges": [ { "gross_charge": 101804.22, "minimum": 81443.38, "maximum": 86533.59, "setting": "inpatient", "payers_information": [ { "payer_name": "Aetna", "plan_name": "700700", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna", "plan_name": "700700_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Miscellaneous", "plan_name": "700720", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Miscellaneous", "plan_name": "700720_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Ppo Hmo", "plan_name": "701720", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Ppo Hmo", "plan_name": "701720_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Ms State Emplo", "plan_name": "401457", "standard_charge_percentage": 0.80, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Ms State Emplo", "plan_name": "401457_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Basic Pl", "plan_name": "400100", "standard_charge_percentage": 0.85, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Basic Pl", "plan_name": "400100_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Federal", "plan_name": "400110", "standard_charge_percentage": 0.85, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Federal", "plan_name": "400110_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." } ] } ] }, { "description": "Repair great vessels defect", "code_information": [ { "code": "33774", "type": "CPT" } ], "standard_charges": [ { "gross_charge": 113145.31, "minimum": 90516.25, "maximum": 96173.51, "setting": "inpatient", "payers_information": [ { "payer_name": "Aetna", "plan_name": "700700", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna", "plan_name": "700700_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Miscellaneous", "plan_name": "700720", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Miscellaneous", "plan_name": "700720_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Ppo Hmo", "plan_name": "701720", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Ppo Hmo", "plan_name": "701720_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Ms State Emplo", "plan_name": "401457", "standard_charge_percentage": 0.80, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Ms State Emplo", "plan_name": "401457_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Basic Pl", "plan_name": "400100", "standard_charge_percentage": 0.85, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Basic Pl", "plan_name": "400100_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Federal", "plan_name": "400110", "standard_charge_percentage": 0.85, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Federal", "plan_name": "400110_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." } ] } ] }, { "description": "Repair great vessels defect", "code_information": [ { "code": "33775", "type": "CPT" } ], "standard_charges": [ { "gross_charge": 113145.31, "minimum": 90516.25, "maximum": 96173.51, "setting": "inpatient", "payers_information": [ { "payer_name": "Aetna", "plan_name": "700700", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna", "plan_name": "700700_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Miscellaneous", "plan_name": "700720", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Miscellaneous", "plan_name": "700720_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Ppo Hmo", "plan_name": "701720", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Ppo Hmo", "plan_name": "701720_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Ms State Emplo", "plan_name": "401457", "standard_charge_percentage": 0.80, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Ms State Emplo", "plan_name": "401457_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Basic Pl", "plan_name": "400100", "standard_charge_percentage": 0.85, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Basic Pl", "plan_name": "400100_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Federal", "plan_name": "400110", "standard_charge_percentage": 0.85, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Federal", "plan_name": "400110_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." } ] } ] }, { "description": "Repair great vessels defect", "code_information": [ { "code": "33776", "type": "CPT" } ], "standard_charges": [ { "gross_charge": 113145.31, "minimum": 90516.25, "maximum": 96173.51, "setting": "inpatient", "payers_information": [ { "payer_name": "Aetna", "plan_name": "700700", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna", "plan_name": "700700_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Miscellaneous", "plan_name": "700720", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Miscellaneous", "plan_name": "700720_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Ppo Hmo", "plan_name": "701720", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Ppo Hmo", "plan_name": "701720_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Ms State Emplo", "plan_name": "401457", "standard_charge_percentage": 0.80, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Ms State Emplo", "plan_name": "401457_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Basic Pl", "plan_name": "400100", "standard_charge_percentage": 0.85, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Basic Pl", "plan_name": "400100_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Federal", "plan_name": "400110", "standard_charge_percentage": 0.85, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Federal", "plan_name": "400110_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." } ] } ] }, { "description": "Repair great vessels defect", "code_information": [ { "code": "33777", "type": "CPT" } ], "standard_charges": [ { "gross_charge": 113145.31, "minimum": 90516.25, "maximum": 96173.51, "setting": "inpatient", "payers_information": [ { "payer_name": "Aetna", "plan_name": "700700", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna", "plan_name": "700700_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Miscellaneous", "plan_name": "700720", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Miscellaneous", "plan_name": "700720_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Ppo Hmo", "plan_name": "701720", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Ppo Hmo", "plan_name": "701720_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Ms State Emplo", "plan_name": "401457", "standard_charge_percentage": 0.80, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Ms State Emplo", "plan_name": "401457_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Basic Pl", "plan_name": "400100", "standard_charge_percentage": 0.85, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Basic Pl", "plan_name": "400100_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Federal", "plan_name": "400110", "standard_charge_percentage": 0.85, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Federal", "plan_name": "400110_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." } ] } ] }, { "description": "Ecmo/ecls insj prph cannula", "code_information": [ { "code": "33951", "type": "CPT" } ], "standard_charges": [ { "gross_charge": 29706.74, "minimum": 23765.39, "maximum": 25250.73, "setting": "inpatient", "payers_information": [ { "payer_name": "Aetna", "plan_name": "700700", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna", "plan_name": "700700_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Miscellaneous", "plan_name": "700720", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Miscellaneous", "plan_name": "700720_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Ppo Hmo", "plan_name": "701720", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Ppo Hmo", "plan_name": "701720_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Ms State Emplo", "plan_name": "401457", "standard_charge_percentage": 0.80, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Ms State Emplo", "plan_name": "401457_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Basic Pl", "plan_name": "400100", "standard_charge_percentage": 0.85, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Basic Pl", "plan_name": "400100_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Federal", "plan_name": "400110", "standard_charge_percentage": 0.85, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Federal", "plan_name": "400110_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." } ] } ] }, { "description": "Ecmo/ecls insj prph cannula", "code_information": [ { "code": "33952", "type": "CPT" } ], "standard_charges": [ { "gross_charge": 29706.74, "minimum": 23765.39, "maximum": 25250.73, "setting": "inpatient", "payers_information": [ { "payer_name": "Aetna", "plan_name": "700700", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna", "plan_name": "700700_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Miscellaneous", "plan_name": "700720", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Miscellaneous", "plan_name": "700720_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Ppo Hmo", "plan_name": "701720", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Ppo Hmo", "plan_name": "701720_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Ms State Emplo", "plan_name": "401457", "standard_charge_percentage": 0.80, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Ms State Emplo", "plan_name": "401457_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Basic Pl", "plan_name": "400100", "standard_charge_percentage": 0.85, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Basic Pl", "plan_name": "400100_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Federal", "plan_name": "400110", "standard_charge_percentage": 0.85, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Federal", "plan_name": "400110_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." } ] } ] }, { "description": "Insert i-aort percut device", "code_information": [ { "code": "33967", "type": "CPT" } ], "standard_charges": [ { "gross_charge": 71486.88, "minimum": 57189.50, "maximum": 60763.85, "setting": "inpatient", "payers_information": [ { "payer_name": "Aetna", "plan_name": "700700", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna", "plan_name": "700700_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Miscellaneous", "plan_name": "700720", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Miscellaneous", "plan_name": "700720_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Ppo Hmo", "plan_name": "701720", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Ppo Hmo", "plan_name": "701720_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Ms State Emplo", "plan_name": "401457", "standard_charge_percentage": 0.80, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Ms State Emplo", "plan_name": "401457_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Basic Pl", "plan_name": "400100", "standard_charge_percentage": 0.85, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Basic Pl", "plan_name": "400100_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Federal", "plan_name": "400110", "standard_charge_percentage": 0.85, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Federal", "plan_name": "400110_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." } ] } ] }, { "description": "Aortic circulation assist", "code_information": [ { "code": "33970", "type": "CPT" } ], "standard_charges": [ { "gross_charge": 71486.88, "minimum": 57189.50, "maximum": 60763.85, "setting": "inpatient", "payers_information": [ { "payer_name": "Aetna", "plan_name": "700700", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna", "plan_name": "700700_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Miscellaneous", "plan_name": "700720", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Miscellaneous", "plan_name": "700720_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Ppo Hmo", "plan_name": "701720", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Ppo Hmo", "plan_name": "701720_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Ms State Emplo", "plan_name": "401457", "standard_charge_percentage": 0.80, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Ms State Emplo", "plan_name": "401457_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Basic Pl", "plan_name": "400100", "standard_charge_percentage": 0.85, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Basic Pl", "plan_name": "400100_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Federal", "plan_name": "400110", "standard_charge_percentage": 0.85, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Federal", "plan_name": "400110_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." } ] } ] }, { "description": "Insert balloon device", "code_information": [ { "code": "33973", "type": "CPT" } ], "standard_charges": [ { "gross_charge": 71486.88, "minimum": 57189.50, "maximum": 60763.85, "setting": "inpatient", "payers_information": [ { "payer_name": "Aetna", "plan_name": "700700", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna", "plan_name": "700700_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Miscellaneous", "plan_name": "700720", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Miscellaneous", "plan_name": "700720_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Ppo Hmo", "plan_name": "701720", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Ppo Hmo", "plan_name": "701720_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Ms State Emplo", "plan_name": "401457", "standard_charge_percentage": 0.80, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Ms State Emplo", "plan_name": "401457_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Basic Pl", "plan_name": "400100", "standard_charge_percentage": 0.85, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Basic Pl", "plan_name": "400100_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Federal", "plan_name": "400110", "standard_charge_percentage": 0.85, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Federal", "plan_name": "400110_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." } ] } ] }, { "description": "Implant ventricular device", "code_information": [ { "code": "33975", "type": "CPT" } ], "standard_charges": [ { "gross_charge": 113195.17, "minimum": 90556.14, "maximum": 96215.89, "setting": "inpatient", "payers_information": [ { "payer_name": "Aetna", "plan_name": "700700", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna", "plan_name": "700700_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Miscellaneous", "plan_name": "700720", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Miscellaneous", "plan_name": "700720_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Ppo Hmo", "plan_name": "701720", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Ppo Hmo", "plan_name": "701720_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Ms State Emplo", "plan_name": "401457", "standard_charge_percentage": 0.80, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Ms State Emplo", "plan_name": "401457_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Basic Pl", "plan_name": "400100", "standard_charge_percentage": 0.85, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Basic Pl", "plan_name": "400100_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Federal", "plan_name": "400110", "standard_charge_percentage": 0.85, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Federal", "plan_name": "400110_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." } ] } ] }, { "description": "Implant ventricular device", "code_information": [ { "code": "33976", "type": "CPT" } ], "standard_charges": [ { "gross_charge": 124215.25, "minimum": 99372.20, "maximum": 105582.96, "setting": "inpatient", "payers_information": [ { "payer_name": "Aetna", "plan_name": "700700", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna", "plan_name": "700700_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Miscellaneous", "plan_name": "700720", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Miscellaneous", "plan_name": "700720_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Ppo Hmo", "plan_name": "701720", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Ppo Hmo", "plan_name": "701720_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Ms State Emplo", "plan_name": "401457", "standard_charge_percentage": 0.80, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Ms State Emplo", "plan_name": "401457_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Basic Pl", "plan_name": "400100", "standard_charge_percentage": 0.85, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Basic Pl", "plan_name": "400100_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Federal", "plan_name": "400110", "standard_charge_percentage": 0.85, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Federal", "plan_name": "400110_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." } ] } ] }, { "description": "Remove ventricular device", "code_information": [ { "code": "33977", "type": "CPT" } ], "standard_charges": [ { "gross_charge": 113145.31, "minimum": 90516.25, "maximum": 96173.51, "setting": "inpatient", "payers_information": [ { "payer_name": "Aetna", "plan_name": "700700", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna", "plan_name": "700700_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Miscellaneous", "plan_name": "700720", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Miscellaneous", "plan_name": "700720_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Ppo Hmo", "plan_name": "701720", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Ppo Hmo", "plan_name": "701720_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Ms State Emplo", "plan_name": "401457", "standard_charge_percentage": 0.80, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Ms State Emplo", "plan_name": "401457_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Basic Pl", "plan_name": "400100", "standard_charge_percentage": 0.85, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Basic Pl", "plan_name": "400100_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Federal", "plan_name": "400110", "standard_charge_percentage": 0.85, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Federal", "plan_name": "400110_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." } ] } ] }, { "description": "Remove ventricular device", "code_information": [ { "code": "33978", "type": "CPT" } ], "standard_charges": [ { "gross_charge": 113145.31, "minimum": 90516.25, "maximum": 96173.51, "setting": "inpatient", "payers_information": [ { "payer_name": "Aetna", "plan_name": "700700", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna", "plan_name": "700700_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Miscellaneous", "plan_name": "700720", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Miscellaneous", "plan_name": "700720_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Ppo Hmo", "plan_name": "701720", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Ppo Hmo", "plan_name": "701720_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Ms State Emplo", "plan_name": "401457", "standard_charge_percentage": 0.80, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Ms State Emplo", "plan_name": "401457_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Basic Pl", "plan_name": "400100", "standard_charge_percentage": 0.85, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Basic Pl", "plan_name": "400100_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Federal", "plan_name": "400110", "standard_charge_percentage": 0.85, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Federal", "plan_name": "400110_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." } ] } ] }, { "description": "Insert intracorporeal device", "code_information": [ { "code": "33979", "type": "CPT" } ], "standard_charges": [ { "gross_charge": 113145.31, "minimum": 90516.25, "maximum": 96173.51, "setting": "inpatient", "payers_information": [ { "payer_name": "Aetna", "plan_name": "700700", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna", "plan_name": "700700_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Miscellaneous", "plan_name": "700720", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Miscellaneous", "plan_name": "700720_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Ppo Hmo", "plan_name": "701720", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Ppo Hmo", "plan_name": "701720_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Ms State Emplo", "plan_name": "401457", "standard_charge_percentage": 0.80, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Ms State Emplo", "plan_name": "401457_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Basic Pl", "plan_name": "400100", "standard_charge_percentage": 0.85, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Basic Pl", "plan_name": "400100_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Federal", "plan_name": "400110", "standard_charge_percentage": 0.85, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Federal", "plan_name": "400110_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." } ] } ] }, { "description": "Cardiac surgery procedure", "code_information": [ { "code": "33999", "type": "CPT" } ], "standard_charges": [ { "gross_charge": 106959.67, "minimum": 566.37, "maximum": 90915.72, "setting": "inpatient", "payers_information": [ { "payer_name": "Aarp", "plan_name": "500102", "standard_charge_dollar": 566.37, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna", "plan_name": "700700", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna", "plan_name": "700700_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Mcare Ffs 6005", "plan_name": "700703", "standard_charge_dollar": 566.37, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Miscellaneous", "plan_name": "700720", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Miscellaneous", "plan_name": "700720_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Ppo Hmo", "plan_name": "701720", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Ppo Hmo", "plan_name": "701720_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Ambetter 68069", "plan_name": "500516", "standard_charge_dollar": 566.37, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Ms State Emplo", "plan_name": "401457", "standard_charge_percentage": 0.80, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Ms State Emplo", "plan_name": "401457_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Basic Pl", "plan_name": "400100", "standard_charge_percentage": 0.85, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Basic Pl", "plan_name": "400100_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Federal", "plan_name": "400110", "standard_charge_percentage": 0.85, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Federal", "plan_name": "400110_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Cigna Healthsprings Ffs", "plan_name": "500064", "standard_charge_dollar": 566.37, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Conseco", "plan_name": "500302", "standard_charge_dollar": 566.37, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Humana Ffs 61101", "plan_name": "500006", "standard_charge_dollar": 566.37, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Medicare A", "plan_name": "100100", "standard_charge_dollar": 566.37, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Medicare A", "plan_name": "100500", "standard_charge_dollar": 566.37, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Medicare Part B Only", "plan_name": "100300", "standard_charge_dollar": 566.37, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Medicare Railroad", "plan_name": "100103", "standard_charge_dollar": 566.37, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Ms Physicians Care N", "plan_name": "714210", "standard_charge_dollar": 707.96, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Peoples Hlth Ffs 72126", "plan_name": "500019", "standard_charge_dollar": 566.37, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Uhc/Secure Horizons", "plan_name": "500449", "standard_charge_dollar": 566.37, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "United Health Care/", "plan_name": "500292", "standard_charge_dollar": 640.00, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "United Healthcare", "plan_name": "750104", "standard_charge_dollar": 640.00, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "United Healthcare Ba", "plan_name": "750090", "standard_charge_dollar": 640.00, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "United Healthcare Me", "plan_name": "501310", "standard_charge_dollar": 566.37, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Windsor Mcare Extra", "plan_name": "500778", "standard_charge_dollar": 566.37, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." } ] } ] }, { "description": "Removal of artery clot", "code_information": [ { "code": "34001", "type": "CPT" } ], "standard_charges": [ { "gross_charge": 22219.95, "minimum": 17775.96, "maximum": 18886.96, "setting": "inpatient", "payers_information": [ { "payer_name": "Aetna", "plan_name": "700700", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna", "plan_name": "700700_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Miscellaneous", "plan_name": "700720", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Miscellaneous", "plan_name": "700720_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Ppo Hmo", "plan_name": "701720", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Ppo Hmo", "plan_name": "701720_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Ms State Emplo", "plan_name": "401457", "standard_charge_percentage": 0.80, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Ms State Emplo", "plan_name": "401457_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Basic Pl", "plan_name": "400100", "standard_charge_percentage": 0.85, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Basic Pl", "plan_name": "400100_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Federal", "plan_name": "400110", "standard_charge_percentage": 0.85, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Federal", "plan_name": "400110_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." } ] } ] }, { "description": "Removal of artery clot", "code_information": [ { "code": "34051", "type": "CPT" } ], "standard_charges": [ { "gross_charge": 22219.95, "minimum": 17775.96, "maximum": 18886.96, "setting": "inpatient", "payers_information": [ { "payer_name": "Aetna", "plan_name": "700700", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna", "plan_name": "700700_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Miscellaneous", "plan_name": "700720", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Miscellaneous", "plan_name": "700720_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Ppo Hmo", "plan_name": "701720", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Ppo Hmo", "plan_name": "701720_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Ms State Emplo", "plan_name": "401457", "standard_charge_percentage": 0.80, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Ms State Emplo", "plan_name": "401457_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Basic Pl", "plan_name": "400100", "standard_charge_percentage": 0.85, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Basic Pl", "plan_name": "400100_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Federal", "plan_name": "400110", "standard_charge_percentage": 0.85, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Federal", "plan_name": "400110_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." } ] } ] }, { "description": "Ra disease activity low", "code_information": [ { "code": "3470F", "type": "CPT" } ], "standard_charges": [ { "gross_charge": 11707.75, "minimum": 9366.20, "maximum": 9951.59, "setting": "inpatient", "payers_information": [ { "payer_name": "Aetna", "plan_name": "700700", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna", "plan_name": "700700_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Miscellaneous", "plan_name": "700720", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Miscellaneous", "plan_name": "700720_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Ppo Hmo", "plan_name": "701720", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Ppo Hmo", "plan_name": "701720_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Ms State Emplo", "plan_name": "401457", "standard_charge_percentage": 0.80, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Ms State Emplo", "plan_name": "401457_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Basic Pl", "plan_name": "400100", "standard_charge_percentage": 0.85, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Basic Pl", "plan_name": "400100_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Federal", "plan_name": "400110", "standard_charge_percentage": 0.85, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Federal", "plan_name": "400110_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." } ] } ] }, { "description": "Ra disease activity mod", "code_information": [ { "code": "3471F", "type": "CPT" } ], "standard_charges": [ { "gross_charge": 11707.75, "minimum": 9366.20, "maximum": 9951.59, "setting": "inpatient", "payers_information": [ { "payer_name": "Aetna", "plan_name": "700700", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna", "plan_name": "700700_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Miscellaneous", "plan_name": "700720", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Miscellaneous", "plan_name": "700720_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Ppo Hmo", "plan_name": "701720", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Ppo Hmo", "plan_name": "701720_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Ms State Emplo", "plan_name": "401457", "standard_charge_percentage": 0.80, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Ms State Emplo", "plan_name": "401457_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Basic Pl", "plan_name": "400100", "standard_charge_percentage": 0.85, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Basic Pl", "plan_name": "400100_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Federal", "plan_name": "400110", "standard_charge_percentage": 0.85, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Federal", "plan_name": "400110_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." } ] } ] }, { "description": "Ra disease activity high", "code_information": [ { "code": "3472F", "type": "CPT" } ], "standard_charges": [ { "gross_charge": 11707.75, "minimum": 9366.20, "maximum": 9951.59, "setting": "inpatient", "payers_information": [ { "payer_name": "Aetna", "plan_name": "700700", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna", "plan_name": "700700_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Miscellaneous", "plan_name": "700720", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Miscellaneous", "plan_name": "700720_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Ppo Hmo", "plan_name": "701720", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Ppo Hmo", "plan_name": "701720_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Ms State Emplo", "plan_name": "401457", "standard_charge_percentage": 0.80, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Ms State Emplo", "plan_name": "401457_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Basic Pl", "plan_name": "400100", "standard_charge_percentage": 0.85, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Basic Pl", "plan_name": "400100_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Federal", "plan_name": "400110", "standard_charge_percentage": 0.85, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Federal", "plan_name": "400110_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." } ] } ] }, { "description": "Disease progn ra poor docd", "code_information": [ { "code": "3475F", "type": "CPT" } ], "standard_charges": [ { "gross_charge": 11707.75, "minimum": 9366.20, "maximum": 9951.59, "setting": "inpatient", "payers_information": [ { "payer_name": "Aetna", "plan_name": "700700", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna", "plan_name": "700700_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Miscellaneous", "plan_name": "700720", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Miscellaneous", "plan_name": "700720_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Ppo Hmo", "plan_name": "701720", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Ppo Hmo", "plan_name": "701720_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Ms State Emplo", "plan_name": "401457", "standard_charge_percentage": 0.80, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Ms State Emplo", "plan_name": "401457_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Basic Pl", "plan_name": "400100", "standard_charge_percentage": 0.85, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Basic Pl", "plan_name": "400100_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Federal", "plan_name": "400110", "standard_charge_percentage": 0.85, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Federal", "plan_name": "400110_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." } ] } ] }, { "description": "Disease progn ra good docd", "code_information": [ { "code": "3476F", "type": "CPT" } ], "standard_charges": [ { "gross_charge": 11707.75, "minimum": 9366.20, "maximum": 9951.59, "setting": "inpatient", "payers_information": [ { "payer_name": "Aetna", "plan_name": "700700", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna", "plan_name": "700700_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Miscellaneous", "plan_name": "700720", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Miscellaneous", "plan_name": "700720_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Ppo Hmo", "plan_name": "701720", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Ppo Hmo", "plan_name": "701720_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Ms State Emplo", "plan_name": "401457", "standard_charge_percentage": 0.80, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Ms State Emplo", "plan_name": "401457_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Basic Pl", "plan_name": "400100", "standard_charge_percentage": 0.85, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Basic Pl", "plan_name": "400100_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Federal", "plan_name": "400110", "standard_charge_percentage": 0.85, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Federal", "plan_name": "400110_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." } ] } ] }, { "description": "Open aortic tube prosth repr", "code_information": [ { "code": "34830", "type": "CPT" } ], "standard_charges": [ { "gross_charge": 69962.01, "minimum": 55969.61, "maximum": 59467.71, "setting": "inpatient", "payers_information": [ { "payer_name": "Aetna", "plan_name": "700700", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna", "plan_name": "700700_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Miscellaneous", "plan_name": "700720", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Miscellaneous", "plan_name": "700720_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Ppo Hmo", "plan_name": "701720", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Ppo Hmo", "plan_name": "701720_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Ms State Emplo", "plan_name": "401457", "standard_charge_percentage": 0.80, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Ms State Emplo", "plan_name": "401457_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Basic Pl", "plan_name": "400100", "standard_charge_percentage": 0.85, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Basic Pl", "plan_name": "400100_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Federal", "plan_name": "400110", "standard_charge_percentage": 0.85, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Federal", "plan_name": "400110_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." } ] } ] }, { "description": "Open aortoiliac prosth repr", "code_information": [ { "code": "34831", "type": "CPT" } ], "standard_charges": [ { "gross_charge": 69962.01, "minimum": 55969.61, "maximum": 59467.71, "setting": "inpatient", "payers_information": [ { "payer_name": "Aetna", "plan_name": "700700", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna", "plan_name": "700700_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Miscellaneous", "plan_name": "700720", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Miscellaneous", "plan_name": "700720_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Ppo Hmo", "plan_name": "701720", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Ppo Hmo", "plan_name": "701720_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Ms State Emplo", "plan_name": "401457", "standard_charge_percentage": 0.80, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Ms State Emplo", "plan_name": "401457_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Basic Pl", "plan_name": "400100", "standard_charge_percentage": 0.85, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Basic Pl", "plan_name": "400100_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Federal", "plan_name": "400110", "standard_charge_percentage": 0.85, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Federal", "plan_name": "400110_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." } ] } ] }, { "description": "Open aortofemor prosth repr", "code_information": [ { "code": "34832", "type": "CPT" } ], "standard_charges": [ { "gross_charge": 69962.01, "minimum": 55969.61, "maximum": 59467.71, "setting": "inpatient", "payers_information": [ { "payer_name": "Aetna", "plan_name": "700700", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna", "plan_name": "700700_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Miscellaneous", "plan_name": "700720", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Miscellaneous", "plan_name": "700720_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Ppo Hmo", "plan_name": "701720", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Ppo Hmo", "plan_name": "701720_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Ms State Emplo", "plan_name": "401457", "standard_charge_percentage": 0.80, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Ms State Emplo", "plan_name": "401457_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Basic Pl", "plan_name": "400100", "standard_charge_percentage": 0.85, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Basic Pl", "plan_name": "400100_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Federal", "plan_name": "400110", "standard_charge_percentage": 0.85, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Federal", "plan_name": "400110_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." } ] } ] }, { "description": "Rechanneling of artery", "code_information": [ { "code": "35301", "type": "CPT" } ], "standard_charges": [ { "gross_charge": 22219.95, "minimum": 17775.96, "maximum": 18886.96, "setting": "inpatient", "payers_information": [ { "payer_name": "Aetna", "plan_name": "700700", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna", "plan_name": "700700_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Miscellaneous", "plan_name": "700720", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Miscellaneous", "plan_name": "700720_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Ppo Hmo", "plan_name": "701720", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Ppo Hmo", "plan_name": "701720_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Ms State Emplo", "plan_name": "401457", "standard_charge_percentage": 0.80, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Ms State Emplo", "plan_name": "401457_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Basic Pl", "plan_name": "400100", "standard_charge_percentage": 0.85, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Basic Pl", "plan_name": "400100_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Federal", "plan_name": "400110", "standard_charge_percentage": 0.85, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Federal", "plan_name": "400110_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." } ] } ] }, { "description": "Explore neck vessels", "code_information": [ { "code": "35800", "type": "CPT" } ], "standard_charges": [ { "gross_charge": 22219.95, "minimum": 17775.96, "maximum": 18886.96, "setting": "inpatient", "payers_information": [ { "payer_name": "Aetna", "plan_name": "700700", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna", "plan_name": "700700_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Miscellaneous", "plan_name": "700720", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Miscellaneous", "plan_name": "700720_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Ppo Hmo", "plan_name": "701720", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Ppo Hmo", "plan_name": "701720_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Ms State Emplo", "plan_name": "401457", "standard_charge_percentage": 0.80, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Ms State Emplo", "plan_name": "401457_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Basic Pl", "plan_name": "400100", "standard_charge_percentage": 0.85, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Basic Pl", "plan_name": "400100_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Federal", "plan_name": "400110", "standard_charge_percentage": 0.85, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Federal", "plan_name": "400110_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." } ] } ] }, { "description": "Repair vessel graft defect", "code_information": [ { "code": "35870", "type": "CPT" } ], "standard_charges": [ { "gross_charge": 98709.33, "minimum": 78967.46, "maximum": 83902.93, "setting": "inpatient", "payers_information": [ { "payer_name": "Aetna", "plan_name": "700700", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna", "plan_name": "700700_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Miscellaneous", "plan_name": "700720", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Miscellaneous", "plan_name": "700720_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Ppo Hmo", "plan_name": "701720", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Ppo Hmo", "plan_name": "701720_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Ms State Emplo", "plan_name": "401457", "standard_charge_percentage": 0.80, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Ms State Emplo", "plan_name": "401457_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Basic Pl", "plan_name": "400100", "standard_charge_percentage": 0.85, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Basic Pl", "plan_name": "400100_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Federal", "plan_name": "400110", "standard_charge_percentage": 0.85, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Federal", "plan_name": "400110_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." } ] } ] }, { "description": "Removal of clot in graft", "code_information": [ { "code": "35875", "type": "CPT" } ], "standard_charges": [ { "gross_charge": 22219.95, "minimum": 4951.99, "maximum": 18886.96, "setting": "inpatient", "payers_information": [ { "payer_name": "Aarp", "plan_name": "500102", "standard_charge_dollar": 4951.99, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna", "plan_name": "700700", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna", "plan_name": "700700_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Mcare Ffs 6005", "plan_name": "700703", "standard_charge_dollar": 4951.99, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Miscellaneous", "plan_name": "700720", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Miscellaneous", "plan_name": "700720_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Ppo Hmo", "plan_name": "701720", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Ppo Hmo", "plan_name": "701720_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Ambetter 68069", "plan_name": "500516", "standard_charge_dollar": 4951.99, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Ms State Emplo", "plan_name": "401457", "standard_charge_percentage": 0.80, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Ms State Emplo", "plan_name": "401457_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Basic Pl", "plan_name": "400100", "standard_charge_percentage": 0.85, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Basic Pl", "plan_name": "400100_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Federal", "plan_name": "400110", "standard_charge_percentage": 0.85, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Federal", "plan_name": "400110_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Cigna Healthsprings Ffs", "plan_name": "500064", "standard_charge_dollar": 4951.99, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Conseco", "plan_name": "500302", "standard_charge_dollar": 4951.99, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Humana Ffs 61101", "plan_name": "500006", "standard_charge_dollar": 4951.99, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Medicare A", "plan_name": "100100", "standard_charge_dollar": 4951.99, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Medicare A", "plan_name": "100500", "standard_charge_dollar": 4951.99, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Medicare Part B Only", "plan_name": "100300", "standard_charge_dollar": 4951.99, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Medicare Railroad", "plan_name": "100103", "standard_charge_dollar": 4951.99, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Ms Physicians Care N", "plan_name": "714210", "standard_charge_dollar": 6189.99, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Peoples Hlth Ffs 72126", "plan_name": "500019", "standard_charge_dollar": 4951.99, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Uhc/Secure Horizons", "plan_name": "500449", "standard_charge_dollar": 4951.99, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "United Health Care/", "plan_name": "500292", "standard_charge_dollar": 5595.75, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "United Healthcare", "plan_name": "750104", "standard_charge_dollar": 5595.75, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "United Healthcare Ba", "plan_name": "750090", "standard_charge_dollar": 5595.75, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "United Healthcare Me", "plan_name": "501310", "standard_charge_dollar": 4951.99, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Windsor Mcare Extra", "plan_name": "500778", "standard_charge_dollar": 4951.99, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." } ] } ] }, { "description": "Removal of clot in graft", "code_information": [ { "code": "35876", "type": "CPT" } ], "standard_charges": [ { "gross_charge": 22219.95, "minimum": 4951.99, "maximum": 18886.96, "setting": "inpatient", "payers_information": [ { "payer_name": "Aarp", "plan_name": "500102", "standard_charge_dollar": 4951.99, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna", "plan_name": "700700", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna", "plan_name": "700700_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Mcare Ffs 6005", "plan_name": "700703", "standard_charge_dollar": 4951.99, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Miscellaneous", "plan_name": "700720", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Miscellaneous", "plan_name": "700720_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Ppo Hmo", "plan_name": "701720", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Ppo Hmo", "plan_name": "701720_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Ambetter 68069", "plan_name": "500516", "standard_charge_dollar": 4951.99, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Ms State Emplo", "plan_name": "401457", "standard_charge_percentage": 0.80, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Ms State Emplo", "plan_name": "401457_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Basic Pl", "plan_name": "400100", "standard_charge_percentage": 0.85, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Basic Pl", "plan_name": "400100_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Federal", "plan_name": "400110", "standard_charge_percentage": 0.85, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Federal", "plan_name": "400110_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Cigna Healthsprings Ffs", "plan_name": "500064", "standard_charge_dollar": 4951.99, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Conseco", "plan_name": "500302", "standard_charge_dollar": 4951.99, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Humana Ffs 61101", "plan_name": "500006", "standard_charge_dollar": 4951.99, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Medicare A", "plan_name": "100100", "standard_charge_dollar": 4951.99, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Medicare A", "plan_name": "100500", "standard_charge_dollar": 4951.99, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Medicare Part B Only", "plan_name": "100300", "standard_charge_dollar": 4951.99, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Medicare Railroad", "plan_name": "100103", "standard_charge_dollar": 4951.99, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Ms Physicians Care N", "plan_name": "714210", "standard_charge_dollar": 6189.99, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Peoples Hlth Ffs 72126", "plan_name": "500019", "standard_charge_dollar": 4951.99, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Uhc/Secure Horizons", "plan_name": "500449", "standard_charge_dollar": 4951.99, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "United Health Care/", "plan_name": "500292", "standard_charge_dollar": 5595.75, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "United Healthcare", "plan_name": "750104", "standard_charge_dollar": 5595.75, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "United Healthcare Ba", "plan_name": "750090", "standard_charge_dollar": 5595.75, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "United Healthcare Me", "plan_name": "501310", "standard_charge_dollar": 4951.99, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Windsor Mcare Extra", "plan_name": "500778", "standard_charge_dollar": 4951.99, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." } ] } ] }, { "description": "Place needle in vein", "code_information": [ { "code": "36000", "type": "CPT" } ], "standard_charges": [ { "gross_charge": 30830.99, "minimum": 24664.79, "maximum": 26206.34, "setting": "inpatient", "payers_information": [ { "payer_name": "Aetna", "plan_name": "700700", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna", "plan_name": "700700_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Miscellaneous", "plan_name": "700720", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Miscellaneous", "plan_name": "700720_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Ppo Hmo", "plan_name": "701720", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Ppo Hmo", "plan_name": "701720_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Ms State Emplo", "plan_name": "401457", "standard_charge_percentage": 0.80, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Ms State Emplo", "plan_name": "401457_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Basic Pl", "plan_name": "400100", "standard_charge_percentage": 0.85, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Basic Pl", "plan_name": "400100_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Federal", "plan_name": "400110", "standard_charge_percentage": 0.85, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Federal", "plan_name": "400110_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." } ] } ] }, { "description": "Place catheter in vein", "code_information": [ { "code": "36010", "type": "CPT" } ], "standard_charges": [ { "gross_charge": 31685.56, "minimum": 25348.45, "maximum": 26932.73, "setting": "inpatient", "payers_information": [ { "payer_name": "Aetna", "plan_name": "700700", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna", "plan_name": "700700_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Miscellaneous", "plan_name": "700720", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Miscellaneous", "plan_name": "700720_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Ppo Hmo", "plan_name": "701720", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Ppo Hmo", "plan_name": "701720_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Ms State Emplo", "plan_name": "401457", "standard_charge_percentage": 0.80, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Ms State Emplo", "plan_name": "401457_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Basic Pl", "plan_name": "400100", "standard_charge_percentage": 0.85, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Basic Pl", "plan_name": "400100_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Federal", "plan_name": "400110", "standard_charge_percentage": 0.85, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Federal", "plan_name": "400110_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." } ] } ] }, { "description": "Place catheter in vein", "code_information": [ { "code": "36012", "type": "CPT" } ], "standard_charges": [ { "gross_charge": 21768.28, "minimum": 17414.62, "maximum": 18503.04, "setting": "inpatient", "payers_information": [ { "payer_name": "Aetna", "plan_name": "700700", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna", "plan_name": "700700_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Miscellaneous", "plan_name": "700720", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Miscellaneous", "plan_name": "700720_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Ppo Hmo", "plan_name": "701720", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Ppo Hmo", "plan_name": "701720_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Ms State Emplo", "plan_name": "401457", "standard_charge_percentage": 0.80, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Ms State Emplo", "plan_name": "401457_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Basic Pl", "plan_name": "400100", "standard_charge_percentage": 0.85, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Basic Pl", "plan_name": "400100_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Federal", "plan_name": "400110", "standard_charge_percentage": 0.85, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Federal", "plan_name": "400110_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." } ] } ] }, { "description": "Hc venipuncture", "code_information": [ { "code": "36415", "type": "CPT" } ], "standard_charges": [ { "gross_charge": 15.00, "minimum": 4.00, "maximum": 4.00, "setting": "both", "payers_information": [ { "payer_name": "Aetna", "plan_name": "700700", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna", "plan_name": "700700_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Miscellaneous", "plan_name": "700720", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Miscellaneous", "plan_name": "700720_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Ppo Hmo", "plan_name": "701720", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Ppo Hmo", "plan_name": "701720_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Ms State Emplo", "plan_name": "401457", "standard_charge_dollar": 4.00, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Ms State Emplo", "plan_name": "401457_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Basic Pl", "plan_name": "400100", "standard_charge_dollar": 4.00, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Basic Pl", "plan_name": "400100_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Federal", "plan_name": "400110", "standard_charge_dollar": 4.00, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Federal", "plan_name": "400110_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." } ] } ] }, { "description": "Routine venipuncture", "code_information": [ { "code": "36415", "type": "CPT" } ], "standard_charges": [ { "gross_charge": 15.00, "minimum": 4.00, "maximum": 4.00, "setting": "both", "payers_information": [ { "payer_name": "Aetna", "plan_name": "700700", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna", "plan_name": "700700_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Miscellaneous", "plan_name": "700720", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Miscellaneous", "plan_name": "700720_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Ppo Hmo", "plan_name": "701720", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Ppo Hmo", "plan_name": "701720_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Ms State Emplo", "plan_name": "401457", "standard_charge_dollar": 4.00, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Ms State Emplo", "plan_name": "401457_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Basic Pl", "plan_name": "400100", "standard_charge_dollar": 4.00, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Basic Pl", "plan_name": "400100_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Federal", "plan_name": "400110", "standard_charge_dollar": 4.00, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Federal", "plan_name": "400110_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." } ] } ] }, { "description": "Blood transfusion service", "code_information": [ { "code": "36430", "type": "CPT" } ], "standard_charges": [ { "gross_charge": 20853.51, "minimum": 400.49, "maximum": 17725.48, "setting": "inpatient", "payers_information": [ { "payer_name": "Aarp", "plan_name": "500102", "standard_charge_dollar": 400.49, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna", "plan_name": "700700", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna", "plan_name": "700700_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Mcare Ffs 6005", "plan_name": "700703", "standard_charge_dollar": 400.49, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Miscellaneous", "plan_name": "700720", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Miscellaneous", "plan_name": "700720_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Ppo Hmo", "plan_name": "701720", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Ppo Hmo", "plan_name": "701720_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Ambetter 68069", "plan_name": "500516", "standard_charge_dollar": 400.49, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Ms State Emplo", "plan_name": "401457", "standard_charge_percentage": 0.80, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Ms State Emplo", "plan_name": "401457_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Basic Pl", "plan_name": "400100", "standard_charge_percentage": 0.85, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Basic Pl", "plan_name": "400100_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Federal", "plan_name": "400110", "standard_charge_percentage": 0.85, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Federal", "plan_name": "400110_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Cigna Healthsprings Ffs", "plan_name": "500064", "standard_charge_dollar": 400.49, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Conseco", "plan_name": "500302", "standard_charge_dollar": 400.49, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Humana Ffs 61101", "plan_name": "500006", "standard_charge_dollar": 400.49, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Medicare A", "plan_name": "100100", "standard_charge_dollar": 400.49, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Medicare A", "plan_name": "100500", "standard_charge_dollar": 400.49, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Medicare Part B Only", "plan_name": "100300", "standard_charge_dollar": 400.49, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Medicare Railroad", "plan_name": "100103", "standard_charge_dollar": 400.49, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Ms Physicians Care N", "plan_name": "714210", "standard_charge_dollar": 500.61, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Peoples Hlth Ffs 72126", "plan_name": "500019", "standard_charge_dollar": 400.49, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Uhc/Secure Horizons", "plan_name": "500449", "standard_charge_dollar": 400.49, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "United Health Care/", "plan_name": "500292", "standard_charge_dollar": 452.55, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "United Healthcare", "plan_name": "750104", "standard_charge_dollar": 452.55, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "United Healthcare Ba", "plan_name": "750090", "standard_charge_dollar": 452.55, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "United Healthcare Me", "plan_name": "501310", "standard_charge_dollar": 400.49, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Windsor Mcare Extra", "plan_name": "500778", "standard_charge_dollar": 400.49, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." } ] } ] }, { "description": "Blood transfusion service", "code_information": [ { "code": "36430", "type": "CPT" } ], "standard_charges": [ { "gross_charge": 505.98, "minimum": 400.49, "maximum": 500.61, "setting": "outpatient", "payers_information": [ { "payer_name": "Aarp", "plan_name": "500102", "standard_charge_dollar": 400.49, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna", "plan_name": "700700", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna", "plan_name": "700700_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Mcare Ffs 6005", "plan_name": "700703", "standard_charge_dollar": 400.49, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Miscellaneous", "plan_name": "700720", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Miscellaneous", "plan_name": "700720_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Ppo Hmo", "plan_name": "701720", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Ppo Hmo", "plan_name": "701720_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Ambetter 68069", "plan_name": "500516", "standard_charge_dollar": 400.49, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Ms State Emplo", "plan_name": "401457", "standard_charge_percentage": 0.80, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Ms State Emplo", "plan_name": "401457_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Basic Pl", "plan_name": "400100", "standard_charge_percentage": 0.85, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Basic Pl", "plan_name": "400100_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Federal", "plan_name": "400110", "standard_charge_percentage": 0.85, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Federal", "plan_name": "400110_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Cigna Healthsprings Ffs", "plan_name": "500064", "standard_charge_dollar": 400.49, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Conseco", "plan_name": "500302", "standard_charge_dollar": 400.49, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Humana Ffs 61101", "plan_name": "500006", "standard_charge_dollar": 400.49, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Medicare A", "plan_name": "100100", "standard_charge_dollar": 400.49, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Medicare A", "plan_name": "100500", "standard_charge_dollar": 400.49, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Medicare Part B Only", "plan_name": "100300", "standard_charge_dollar": 400.49, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Medicare Railroad", "plan_name": "100103", "standard_charge_dollar": 400.49, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Ms Physicians Care N", "plan_name": "714210", "standard_charge_dollar": 500.61, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Peoples Hlth Ffs 72126", "plan_name": "500019", "standard_charge_dollar": 400.49, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Uhc/Secure Horizons", "plan_name": "500449", "standard_charge_dollar": 400.49, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "United Health Care/", "plan_name": "500292", "standard_charge_dollar": 452.55, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "United Healthcare", "plan_name": "750104", "standard_charge_dollar": 452.55, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "United Healthcare Ba", "plan_name": "750090", "standard_charge_dollar": 452.55, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "United Healthcare Me", "plan_name": "501310", "standard_charge_dollar": 400.49, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Windsor Mcare Extra", "plan_name": "500778", "standard_charge_dollar": 400.49, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." } ] } ] }, { "description": "Hc transfusion blood or blood components", "code_information": [ { "code": "36430", "type": "CPT" } ], "standard_charges": [ { "gross_charge": 505.98, "minimum": 400.49, "maximum": 500.61, "setting": "both", "payers_information": [ { "payer_name": "Aarp", "plan_name": "500102", "standard_charge_dollar": 400.49, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna", "plan_name": "700700", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna", "plan_name": "700700_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Mcare Ffs 6005", "plan_name": "700703", "standard_charge_dollar": 400.49, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Miscellaneous", "plan_name": "700720", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Miscellaneous", "plan_name": "700720_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Ppo Hmo", "plan_name": "701720", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Ppo Hmo", "plan_name": "701720_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Ambetter 68069", "plan_name": "500516", "standard_charge_dollar": 400.49, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Ms State Emplo", "plan_name": "401457", "standard_charge_percentage": 0.80, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Ms State Emplo", "plan_name": "401457_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Basic Pl", "plan_name": "400100", "standard_charge_percentage": 0.85, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Basic Pl", "plan_name": "400100_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Federal", "plan_name": "400110", "standard_charge_percentage": 0.85, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Federal", "plan_name": "400110_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Cigna Healthsprings Ffs", "plan_name": "500064", "standard_charge_dollar": 400.49, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Conseco", "plan_name": "500302", "standard_charge_dollar": 400.49, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Humana Ffs 61101", "plan_name": "500006", "standard_charge_dollar": 400.49, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Medicare A", "plan_name": "100100", "standard_charge_dollar": 400.49, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Medicare A", "plan_name": "100500", "standard_charge_dollar": 400.49, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Medicare Part B Only", "plan_name": "100300", "standard_charge_dollar": 400.49, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Medicare Railroad", "plan_name": "100103", "standard_charge_dollar": 400.49, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Ms Physicians Care N", "plan_name": "714210", "standard_charge_dollar": 500.61, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Peoples Hlth Ffs 72126", "plan_name": "500019", "standard_charge_dollar": 400.49, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Uhc/Secure Horizons", "plan_name": "500449", "standard_charge_dollar": 400.49, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "United Health Care/", "plan_name": "500292", "standard_charge_dollar": 452.55, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "United Healthcare", "plan_name": "750104", "standard_charge_dollar": 452.55, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "United Healthcare Ba", "plan_name": "750090", "standard_charge_dollar": 452.55, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "United Healthcare Me", "plan_name": "501310", "standard_charge_dollar": 400.49, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Windsor Mcare Extra", "plan_name": "500778", "standard_charge_dollar": 400.49, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." } ] } ] }, { "description": "Hc additional transfusion blood or blood components after initial", "code_information": [ { "code": "36430", "type": "CPT" } ], "standard_charges": [ { "gross_charge": 505.98, "minimum": 400.49, "maximum": 500.61, "setting": "both", "payers_information": [ { "payer_name": "Aarp", "plan_name": "500102", "standard_charge_dollar": 400.49, "count": "0", "methodology": "fee schedule", "modifiers": "GZ", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna", "plan_name": "700700", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna", "plan_name": "700700_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Mcare Ffs 6005", "plan_name": "700703", "standard_charge_dollar": 400.49, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Miscellaneous", "plan_name": "700720", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Miscellaneous", "plan_name": "700720_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Ppo Hmo", "plan_name": "701720", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Ppo Hmo", "plan_name": "701720_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Ambetter 68069", "plan_name": "500516", "standard_charge_dollar": 400.49, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Ms State Emplo", "plan_name": "401457", "standard_charge_percentage": 0.80, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Ms State Emplo", "plan_name": "401457_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Basic Pl", "plan_name": "400100", "standard_charge_percentage": 0.85, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Basic Pl", "plan_name": "400100_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Federal", "plan_name": "400110", "standard_charge_percentage": 0.85, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Federal", "plan_name": "400110_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Cigna Healthsprings Ffs", "plan_name": "500064", "standard_charge_dollar": 400.49, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Conseco", "plan_name": "500302", "standard_charge_dollar": 400.49, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Humana Ffs 61101", "plan_name": "500006", "standard_charge_dollar": 400.49, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Medicare A", "plan_name": "100100", "standard_charge_dollar": 400.49, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Medicare A", "plan_name": "100500", "standard_charge_dollar": 400.49, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Medicare Part B Only", "plan_name": "100300", "standard_charge_dollar": 400.49, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Medicare Railroad", "plan_name": "100103", "standard_charge_dollar": 400.49, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Ms Physicians Care N", "plan_name": "714210", "standard_charge_dollar": 500.61, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Peoples Hlth Ffs 72126", "plan_name": "500019", "standard_charge_dollar": 400.49, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Uhc/Secure Horizons", "plan_name": "500449", "standard_charge_dollar": 400.49, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "United Health Care/", "plan_name": "500292", "standard_charge_dollar": 452.55, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "United Healthcare", "plan_name": "750104", "standard_charge_dollar": 452.55, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "United Healthcare Ba", "plan_name": "750090", "standard_charge_dollar": 452.55, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "United Healthcare Me", "plan_name": "501310", "standard_charge_dollar": 400.49, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Windsor Mcare Extra", "plan_name": "500778", "standard_charge_dollar": 400.49, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." } ] } ] }, { "description": "Bl push transfuse 2 yr/<", "code_information": [ { "code": "36440", "type": "CPT" } ], "standard_charges": [ { "gross_charge": 20896.27, "minimum": 400.49, "maximum": 17761.83, "setting": "inpatient", "payers_information": [ { "payer_name": "Aarp", "plan_name": "500102", "standard_charge_dollar": 400.49, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna", "plan_name": "700700", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna", "plan_name": "700700_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Mcare Ffs 6005", "plan_name": "700703", "standard_charge_dollar": 400.49, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Miscellaneous", "plan_name": "700720", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Miscellaneous", "plan_name": "700720_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Ppo Hmo", "plan_name": "701720", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Ppo Hmo", "plan_name": "701720_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Ambetter 68069", "plan_name": "500516", "standard_charge_dollar": 400.49, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Ms State Emplo", "plan_name": "401457", "standard_charge_percentage": 0.80, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Ms State Emplo", "plan_name": "401457_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Basic Pl", "plan_name": "400100", "standard_charge_percentage": 0.85, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Basic Pl", "plan_name": "400100_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Federal", "plan_name": "400110", "standard_charge_percentage": 0.85, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Federal", "plan_name": "400110_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Cigna Healthsprings Ffs", "plan_name": "500064", "standard_charge_dollar": 400.49, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Conseco", "plan_name": "500302", "standard_charge_dollar": 400.49, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Humana Ffs 61101", "plan_name": "500006", "standard_charge_dollar": 400.49, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Medicare A", "plan_name": "100100", "standard_charge_dollar": 400.49, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Medicare A", "plan_name": "100500", "standard_charge_dollar": 400.49, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Medicare Part B Only", "plan_name": "100300", "standard_charge_dollar": 400.49, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Medicare Railroad", "plan_name": "100103", "standard_charge_dollar": 400.49, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Ms Physicians Care N", "plan_name": "714210", "standard_charge_dollar": 500.61, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Peoples Hlth Ffs 72126", "plan_name": "500019", "standard_charge_dollar": 400.49, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Uhc/Secure Horizons", "plan_name": "500449", "standard_charge_dollar": 400.49, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "United Health Care/", "plan_name": "500292", "standard_charge_dollar": 452.55, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "United Healthcare", "plan_name": "750104", "standard_charge_dollar": 452.55, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "United Healthcare Ba", "plan_name": "750090", "standard_charge_dollar": 452.55, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "United Healthcare Me", "plan_name": "501310", "standard_charge_dollar": 400.49, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Windsor Mcare Extra", "plan_name": "500778", "standard_charge_dollar": 400.49, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." } ] } ] }, { "description": "Endovenous rf 1st vein", "code_information": [ { "code": "36475", "type": "CPT" } ], "standard_charges": [ { "gross_charge": 28813.95, "minimum": 2883.33, "maximum": 24491.86, "setting": "inpatient", "payers_information": [ { "payer_name": "Aarp", "plan_name": "500102", "standard_charge_dollar": 2883.33, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna", "plan_name": "700700", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna", "plan_name": "700700_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Mcare Ffs 6005", "plan_name": "700703", "standard_charge_dollar": 2883.33, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Miscellaneous", "plan_name": "700720", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Miscellaneous", "plan_name": "700720_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Ppo Hmo", "plan_name": "701720", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Ppo Hmo", "plan_name": "701720_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Ambetter 68069", "plan_name": "500516", "standard_charge_dollar": 2883.33, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Ms State Emplo", "plan_name": "401457", "standard_charge_percentage": 0.80, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Ms State Emplo", "plan_name": "401457_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Basic Pl", "plan_name": "400100", "standard_charge_percentage": 0.85, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Basic Pl", "plan_name": "400100_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Federal", "plan_name": "400110", "standard_charge_percentage": 0.85, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Federal", "plan_name": "400110_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Cigna Healthsprings Ffs", "plan_name": "500064", "standard_charge_dollar": 2883.33, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Conseco", "plan_name": "500302", "standard_charge_dollar": 2883.33, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Humana Ffs 61101", "plan_name": "500006", "standard_charge_dollar": 2883.33, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Medicare A", "plan_name": "100100", "standard_charge_dollar": 2883.33, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Medicare A", "plan_name": "100500", "standard_charge_dollar": 2883.33, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Medicare Part B Only", "plan_name": "100300", "standard_charge_dollar": 2883.33, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Medicare Railroad", "plan_name": "100103", "standard_charge_dollar": 2883.33, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Ms Physicians Care N", "plan_name": "714210", "standard_charge_dollar": 3604.16, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Peoples Hlth Ffs 72126", "plan_name": "500019", "standard_charge_dollar": 2883.33, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Uhc/Secure Horizons", "plan_name": "500449", "standard_charge_dollar": 2883.33, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "United Health Care/", "plan_name": "500292", "standard_charge_dollar": 3258.16, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "United Healthcare", "plan_name": "750104", "standard_charge_dollar": 3258.16, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "United Healthcare Ba", "plan_name": "750090", "standard_charge_dollar": 3258.16, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "United Healthcare Me", "plan_name": "501310", "standard_charge_dollar": 2883.33, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Windsor Mcare Extra", "plan_name": "500778", "standard_charge_dollar": 2883.33, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." } ] } ] }, { "description": "Endovenous rf vein add-on", "code_information": [ { "code": "36476", "type": "CPT" } ], "standard_charges": [ { "gross_charge": 28813.95, "minimum": 23051.16, "maximum": 24491.86, "setting": "inpatient", "payers_information": [ { "payer_name": "Aetna", "plan_name": "700700", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna", "plan_name": "700700_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Miscellaneous", "plan_name": "700720", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Miscellaneous", "plan_name": "700720_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Ppo Hmo", "plan_name": "701720", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Ppo Hmo", "plan_name": "701720_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Ms State Emplo", "plan_name": "401457", "standard_charge_percentage": 0.80, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Ms State Emplo", "plan_name": "401457_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Basic Pl", "plan_name": "400100", "standard_charge_percentage": 0.85, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Basic Pl", "plan_name": "400100_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Federal", "plan_name": "400110", "standard_charge_percentage": 0.85, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Federal", "plan_name": "400110_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." } ] } ] }, { "description": "Endovenous laser 1st vein", "code_information": [ { "code": "36478", "type": "CPT" } ], "standard_charges": [ { "gross_charge": 28813.95, "minimum": 2883.33, "maximum": 24491.86, "setting": "inpatient", "payers_information": [ { "payer_name": "Aarp", "plan_name": "500102", "standard_charge_dollar": 2883.33, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna", "plan_name": "700700", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna", "plan_name": "700700_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Mcare Ffs 6005", "plan_name": "700703", "standard_charge_dollar": 2883.33, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Miscellaneous", "plan_name": "700720", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Miscellaneous", "plan_name": "700720_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Ppo Hmo", "plan_name": "701720", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Ppo Hmo", "plan_name": "701720_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Ambetter 68069", "plan_name": "500516", "standard_charge_dollar": 2883.33, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Ms State Emplo", "plan_name": "401457", "standard_charge_percentage": 0.80, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Ms State Emplo", "plan_name": "401457_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Basic Pl", "plan_name": "400100", "standard_charge_percentage": 0.85, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Basic Pl", "plan_name": "400100_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Federal", "plan_name": "400110", "standard_charge_percentage": 0.85, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Federal", "plan_name": "400110_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Cigna Healthsprings Ffs", "plan_name": "500064", "standard_charge_dollar": 2883.33, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Conseco", "plan_name": "500302", "standard_charge_dollar": 2883.33, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Humana Ffs 61101", "plan_name": "500006", "standard_charge_dollar": 2883.33, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Medicare A", "plan_name": "100100", "standard_charge_dollar": 2883.33, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Medicare A", "plan_name": "100500", "standard_charge_dollar": 2883.33, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Medicare Part B Only", "plan_name": "100300", "standard_charge_dollar": 2883.33, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Medicare Railroad", "plan_name": "100103", "standard_charge_dollar": 2883.33, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Ms Physicians Care N", "plan_name": "714210", "standard_charge_dollar": 3604.16, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Peoples Hlth Ffs 72126", "plan_name": "500019", "standard_charge_dollar": 2883.33, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Uhc/Secure Horizons", "plan_name": "500449", "standard_charge_dollar": 2883.33, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "United Health Care/", "plan_name": "500292", "standard_charge_dollar": 3258.16, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "United Healthcare", "plan_name": "750104", "standard_charge_dollar": 3258.16, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "United Healthcare Ba", "plan_name": "750090", "standard_charge_dollar": 3258.16, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "United Healthcare Me", "plan_name": "501310", "standard_charge_dollar": 2883.33, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Windsor Mcare Extra", "plan_name": "500778", "standard_charge_dollar": 2883.33, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." } ] } ] }, { "description": "Endovenous laser vein addon", "code_information": [ { "code": "36479", "type": "CPT" } ], "standard_charges": [ { "gross_charge": 28813.95, "minimum": 23051.16, "maximum": 24491.86, "setting": "inpatient", "payers_information": [ { "payer_name": "Aetna", "plan_name": "700700", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna", "plan_name": "700700_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Miscellaneous", "plan_name": "700720", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Miscellaneous", "plan_name": "700720_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Ppo Hmo", "plan_name": "701720", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Ppo Hmo", "plan_name": "701720_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Ms State Emplo", "plan_name": "401457", "standard_charge_percentage": 0.80, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Ms State Emplo", "plan_name": "401457_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Basic Pl", "plan_name": "400100", "standard_charge_percentage": 0.85, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Basic Pl", "plan_name": "400100_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Federal", "plan_name": "400110", "standard_charge_percentage": 0.85, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Federal", "plan_name": "400110_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." } ] } ] }, { "description": "Endoven ther chem adhes 1st", "code_information": [ { "code": "36482", "type": "CPT" } ], "standard_charges": [ { "gross_charge": 28813.95, "minimum": 4951.99, "maximum": 24491.86, "setting": "inpatient", "payers_information": [ { "payer_name": "Aarp", "plan_name": "500102", "standard_charge_dollar": 4951.99, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna", "plan_name": "700700", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna", "plan_name": "700700_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Mcare Ffs 6005", "plan_name": "700703", "standard_charge_dollar": 4951.99, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Miscellaneous", "plan_name": "700720", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Miscellaneous", "plan_name": "700720_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Ppo Hmo", "plan_name": "701720", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Ppo Hmo", "plan_name": "701720_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Ambetter 68069", "plan_name": "500516", "standard_charge_dollar": 4951.99, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Ms State Emplo", "plan_name": "401457", "standard_charge_percentage": 0.80, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Ms State Emplo", "plan_name": "401457_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Basic Pl", "plan_name": "400100", "standard_charge_percentage": 0.85, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Basic Pl", "plan_name": "400100_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Federal", "plan_name": "400110", "standard_charge_percentage": 0.85, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Federal", "plan_name": "400110_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Cigna Healthsprings Ffs", "plan_name": "500064", "standard_charge_dollar": 4951.99, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Conseco", "plan_name": "500302", "standard_charge_dollar": 4951.99, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Humana Ffs 61101", "plan_name": "500006", "standard_charge_dollar": 4951.99, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Medicare A", "plan_name": "100100", "standard_charge_dollar": 4951.99, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Medicare A", "plan_name": "100500", "standard_charge_dollar": 4951.99, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Medicare Part B Only", "plan_name": "100300", "standard_charge_dollar": 4951.99, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Medicare Railroad", "plan_name": "100103", "standard_charge_dollar": 4951.99, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Ms Physicians Care N", "plan_name": "714210", "standard_charge_dollar": 6189.99, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Peoples Hlth Ffs 72126", "plan_name": "500019", "standard_charge_dollar": 4951.99, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Uhc/Secure Horizons", "plan_name": "500449", "standard_charge_dollar": 4951.99, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "United Health Care/", "plan_name": "500292", "standard_charge_dollar": 5595.75, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "United Healthcare", "plan_name": "750104", "standard_charge_dollar": 5595.75, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "United Healthcare Ba", "plan_name": "750090", "standard_charge_dollar": 5595.75, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "United Healthcare Me", "plan_name": "501310", "standard_charge_dollar": 4951.99, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Windsor Mcare Extra", "plan_name": "500778", "standard_charge_dollar": 4951.99, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." } ] } ] }, { "description": "Endoven ther chem adhes sbsq", "code_information": [ { "code": "36483", "type": "CPT" } ], "standard_charges": [ { "gross_charge": 28813.95, "minimum": 23051.16, "maximum": 24491.86, "setting": "inpatient", "payers_information": [ { "payer_name": "Aetna", "plan_name": "700700", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna", "plan_name": "700700_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Miscellaneous", "plan_name": "700720", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Miscellaneous", "plan_name": "700720_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Ppo Hmo", "plan_name": "701720", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Ppo Hmo", "plan_name": "701720_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Ms State Emplo", "plan_name": "401457", "standard_charge_percentage": 0.80, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Ms State Emplo", "plan_name": "401457_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Basic Pl", "plan_name": "400100", "standard_charge_percentage": 0.85, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Basic Pl", "plan_name": "400100_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Federal", "plan_name": "400110", "standard_charge_percentage": 0.85, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Federal", "plan_name": "400110_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." } ] } ] }, { "description": "Insertion of catheter vein", "code_information": [ { "code": "36500", "type": "CPT" } ], "standard_charges": [ { "gross_charge": 42632.98, "minimum": 34106.38, "maximum": 36238.03, "setting": "inpatient", "payers_information": [ { "payer_name": "Aetna", "plan_name": "700700", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna", "plan_name": "700700_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Miscellaneous", "plan_name": "700720", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Miscellaneous", "plan_name": "700720_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Ppo Hmo", "plan_name": "701720", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Ppo Hmo", "plan_name": "701720_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Ms State Emplo", "plan_name": "401457", "standard_charge_percentage": 0.80, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Ms State Emplo", "plan_name": "401457_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Basic Pl", "plan_name": "400100", "standard_charge_percentage": 0.85, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Basic Pl", "plan_name": "400100_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Federal", "plan_name": "400110", "standard_charge_percentage": 0.85, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Federal", "plan_name": "400110_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." } ] } ] }, { "description": "Insertion of catheter vein", "code_information": [ { "code": "36510", "type": "CPT" } ], "standard_charges": [ { "gross_charge": 45242.10, "minimum": 36193.68, "maximum": 38455.79, "setting": "inpatient", "payers_information": [ { "payer_name": "Aetna", "plan_name": "700700", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna", "plan_name": "700700_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Miscellaneous", "plan_name": "700720", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Miscellaneous", "plan_name": "700720_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Ppo Hmo", "plan_name": "701720", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Ppo Hmo", "plan_name": "701720_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Ms State Emplo", "plan_name": "401457", "standard_charge_percentage": 0.80, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Ms State Emplo", "plan_name": "401457_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Basic Pl", "plan_name": "400100", "standard_charge_percentage": 0.85, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Basic Pl", "plan_name": "400100_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Federal", "plan_name": "400110", "standard_charge_percentage": 0.85, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Federal", "plan_name": "400110_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." } ] } ] }, { "description": "Hc central line insert < 5 yrs", "code_information": [ { "code": "36555", "type": "CPT" } ], "standard_charges": [ { "gross_charge": 6466.00, "minimum": 2883.33, "maximum": 5496.10, "setting": "both", "payers_information": [ { "payer_name": "Aarp", "plan_name": "500102", "standard_charge_dollar": 2883.33, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna", "plan_name": "700700", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna", "plan_name": "700700_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Mcare Ffs 6005", "plan_name": "700703", "standard_charge_dollar": 2883.33, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Miscellaneous", "plan_name": "700720", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Miscellaneous", "plan_name": "700720_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Ppo Hmo", "plan_name": "701720", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Ppo Hmo", "plan_name": "701720_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Ambetter 68069", "plan_name": "500516", "standard_charge_dollar": 2883.33, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Ms State Emplo", "plan_name": "401457", "standard_charge_percentage": 0.80, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Ms State Emplo", "plan_name": "401457_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Basic Pl", "plan_name": "400100", "standard_charge_percentage": 0.85, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Basic Pl", "plan_name": "400100_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Federal", "plan_name": "400110", "standard_charge_percentage": 0.85, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Federal", "plan_name": "400110_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Cigna Healthsprings Ffs", "plan_name": "500064", "standard_charge_dollar": 2883.33, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Conseco", "plan_name": "500302", "standard_charge_dollar": 2883.33, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Humana Ffs 61101", "plan_name": "500006", "standard_charge_dollar": 2883.33, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Medicare A", "plan_name": "100100", "standard_charge_dollar": 2883.33, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Medicare A", "plan_name": "100500", "standard_charge_dollar": 2883.33, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Medicare Part B Only", "plan_name": "100300", "standard_charge_dollar": 2883.33, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Medicare Railroad", "plan_name": "100103", "standard_charge_dollar": 2883.33, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Ms Physicians Care N", "plan_name": "714210", "standard_charge_dollar": 3604.16, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Peoples Hlth Ffs 72126", "plan_name": "500019", "standard_charge_dollar": 2883.33, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Uhc/Secure Horizons", "plan_name": "500449", "standard_charge_dollar": 2883.33, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "United Health Care/", "plan_name": "500292", "standard_charge_dollar": 3258.16, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "United Healthcare", "plan_name": "750104", "standard_charge_dollar": 3258.16, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "United Healthcare Ba", "plan_name": "750090", "standard_charge_dollar": 3258.16, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "United Healthcare Me", "plan_name": "501310", "standard_charge_dollar": 2883.33, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Windsor Mcare Extra", "plan_name": "500778", "standard_charge_dollar": 2883.33, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." } ] } ] }, { "description": "Insert non-tunnel cv cath", "code_information": [ { "code": "36555", "type": "CPT" } ], "standard_charges": [ { "gross_charge": 40138.35, "minimum": 2883.33, "maximum": 34117.60, "setting": "inpatient", "payers_information": [ { "payer_name": "Aarp", "plan_name": "500102", "standard_charge_dollar": 2883.33, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna", "plan_name": "700700", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna", "plan_name": "700700_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Mcare Ffs 6005", "plan_name": "700703", "standard_charge_dollar": 2883.33, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Miscellaneous", "plan_name": "700720", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Miscellaneous", "plan_name": "700720_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Ppo Hmo", "plan_name": "701720", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Ppo Hmo", "plan_name": "701720_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Ambetter 68069", "plan_name": "500516", "standard_charge_dollar": 2883.33, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Ms State Emplo", "plan_name": "401457", "standard_charge_percentage": 0.80, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Ms State Emplo", "plan_name": "401457_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Basic Pl", "plan_name": "400100", "standard_charge_percentage": 0.85, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Basic Pl", "plan_name": "400100_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Federal", "plan_name": "400110", "standard_charge_percentage": 0.85, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Federal", "plan_name": "400110_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Cigna Healthsprings Ffs", "plan_name": "500064", "standard_charge_dollar": 2883.33, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Conseco", "plan_name": "500302", "standard_charge_dollar": 2883.33, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Humana Ffs 61101", "plan_name": "500006", "standard_charge_dollar": 2883.33, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Medicare A", "plan_name": "100100", "standard_charge_dollar": 2883.33, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Medicare A", "plan_name": "100500", "standard_charge_dollar": 2883.33, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Medicare Part B Only", "plan_name": "100300", "standard_charge_dollar": 2883.33, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Medicare Railroad", "plan_name": "100103", "standard_charge_dollar": 2883.33, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Ms Physicians Care N", "plan_name": "714210", "standard_charge_dollar": 3604.16, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Peoples Hlth Ffs 72126", "plan_name": "500019", "standard_charge_dollar": 2883.33, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Uhc/Secure Horizons", "plan_name": "500449", "standard_charge_dollar": 2883.33, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "United Health Care/", "plan_name": "500292", "standard_charge_dollar": 3258.16, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "United Healthcare", "plan_name": "750104", "standard_charge_dollar": 3258.16, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "United Healthcare Ba", "plan_name": "750090", "standard_charge_dollar": 3258.16, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "United Healthcare Me", "plan_name": "501310", "standard_charge_dollar": 2883.33, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Windsor Mcare Extra", "plan_name": "500778", "standard_charge_dollar": 2883.33, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." } ] } ] }, { "description": "Insert non-tunnel cv cath", "code_information": [ { "code": "36555", "type": "CPT" } ], "standard_charges": [ { "gross_charge": 6466.00, "minimum": 2883.33, "maximum": 5496.10, "setting": "outpatient", "payers_information": [ { "payer_name": "Aarp", "plan_name": "500102", "standard_charge_dollar": 2883.33, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna", "plan_name": "700700", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna", "plan_name": "700700_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Mcare Ffs 6005", "plan_name": "700703", "standard_charge_dollar": 2883.33, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Miscellaneous", "plan_name": "700720", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Miscellaneous", "plan_name": "700720_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Ppo Hmo", "plan_name": "701720", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Ppo Hmo", "plan_name": "701720_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Ambetter 68069", "plan_name": "500516", "standard_charge_dollar": 2883.33, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Ms State Emplo", "plan_name": "401457", "standard_charge_percentage": 0.80, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Ms State Emplo", "plan_name": "401457_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Basic Pl", "plan_name": "400100", "standard_charge_percentage": 0.85, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Basic Pl", "plan_name": "400100_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Federal", "plan_name": "400110", "standard_charge_percentage": 0.85, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Federal", "plan_name": "400110_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Cigna Healthsprings Ffs", "plan_name": "500064", "standard_charge_dollar": 2883.33, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Conseco", "plan_name": "500302", "standard_charge_dollar": 2883.33, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Humana Ffs 61101", "plan_name": "500006", "standard_charge_dollar": 2883.33, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Medicare A", "plan_name": "100100", "standard_charge_dollar": 2883.33, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Medicare A", "plan_name": "100500", "standard_charge_dollar": 2883.33, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Medicare Part B Only", "plan_name": "100300", "standard_charge_dollar": 2883.33, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Medicare Railroad", "plan_name": "100103", "standard_charge_dollar": 2883.33, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Ms Physicians Care N", "plan_name": "714210", "standard_charge_dollar": 3604.16, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Peoples Hlth Ffs 72126", "plan_name": "500019", "standard_charge_dollar": 2883.33, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Uhc/Secure Horizons", "plan_name": "500449", "standard_charge_dollar": 2883.33, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "United Health Care/", "plan_name": "500292", "standard_charge_dollar": 3258.16, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "United Healthcare", "plan_name": "750104", "standard_charge_dollar": 3258.16, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "United Healthcare Ba", "plan_name": "750090", "standard_charge_dollar": 3258.16, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "United Healthcare Me", "plan_name": "501310", "standard_charge_dollar": 2883.33, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Windsor Mcare Extra", "plan_name": "500778", "standard_charge_dollar": 2883.33, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." } ] } ] }, { "description": "Hc central line insert > 5 + yrs", "code_information": [ { "code": "36556", "type": "CPT" } ], "standard_charges": [ { "gross_charge": 6466.00, "minimum": 2883.33, "maximum": 5496.10, "setting": "both", "payers_information": [ { "payer_name": "Aarp", "plan_name": "500102", "standard_charge_dollar": 2883.33, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna", "plan_name": "700700", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna", "plan_name": "700700_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Mcare Ffs 6005", "plan_name": "700703", "standard_charge_dollar": 2883.33, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Miscellaneous", "plan_name": "700720", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Miscellaneous", "plan_name": "700720_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Ppo Hmo", "plan_name": "701720", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Ppo Hmo", "plan_name": "701720_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Ambetter 68069", "plan_name": "500516", "standard_charge_dollar": 2883.33, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Ms State Emplo", "plan_name": "401457", "standard_charge_percentage": 0.80, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Ms State Emplo", "plan_name": "401457_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Basic Pl", "plan_name": "400100", "standard_charge_percentage": 0.85, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Basic Pl", "plan_name": "400100_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Federal", "plan_name": "400110", "standard_charge_percentage": 0.85, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Federal", "plan_name": "400110_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Cigna Healthsprings Ffs", "plan_name": "500064", "standard_charge_dollar": 2883.33, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Conseco", "plan_name": "500302", "standard_charge_dollar": 2883.33, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Humana Ffs 61101", "plan_name": "500006", "standard_charge_dollar": 2883.33, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Medicare A", "plan_name": "100100", "standard_charge_dollar": 2883.33, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Medicare A", "plan_name": "100500", "standard_charge_dollar": 2883.33, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Medicare Part B Only", "plan_name": "100300", "standard_charge_dollar": 2883.33, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Medicare Railroad", "plan_name": "100103", "standard_charge_dollar": 2883.33, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Ms Physicians Care N", "plan_name": "714210", "standard_charge_dollar": 3604.16, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Peoples Hlth Ffs 72126", "plan_name": "500019", "standard_charge_dollar": 2883.33, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Uhc/Secure Horizons", "plan_name": "500449", "standard_charge_dollar": 2883.33, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "United Health Care/", "plan_name": "500292", "standard_charge_dollar": 3258.16, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "United Healthcare", "plan_name": "750104", "standard_charge_dollar": 3258.16, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "United Healthcare Ba", "plan_name": "750090", "standard_charge_dollar": 3258.16, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "United Healthcare Me", "plan_name": "501310", "standard_charge_dollar": 2883.33, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Windsor Mcare Extra", "plan_name": "500778", "standard_charge_dollar": 2883.33, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." } ] } ] }, { "description": "Insert non-tunnel cv cath", "code_information": [ { "code": "36556", "type": "CPT" } ], "standard_charges": [ { "gross_charge": 31959.27, "minimum": 2883.33, "maximum": 27165.38, "setting": "inpatient", "payers_information": [ { "payer_name": "Aarp", "plan_name": "500102", "standard_charge_dollar": 2883.33, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna", "plan_name": "700700", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna", "plan_name": "700700_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Mcare Ffs 6005", "plan_name": "700703", "standard_charge_dollar": 2883.33, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Miscellaneous", "plan_name": "700720", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Miscellaneous", "plan_name": "700720_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Ppo Hmo", "plan_name": "701720", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Ppo Hmo", "plan_name": "701720_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Ambetter 68069", "plan_name": "500516", "standard_charge_dollar": 2883.33, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Ms State Emplo", "plan_name": "401457", "standard_charge_percentage": 0.80, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Ms State Emplo", "plan_name": "401457_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Basic Pl", "plan_name": "400100", "standard_charge_percentage": 0.85, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Basic Pl", "plan_name": "400100_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Federal", "plan_name": "400110", "standard_charge_percentage": 0.85, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Federal", "plan_name": "400110_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Cigna Healthsprings Ffs", "plan_name": "500064", "standard_charge_dollar": 2883.33, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Conseco", "plan_name": "500302", "standard_charge_dollar": 2883.33, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Humana Ffs 61101", "plan_name": "500006", "standard_charge_dollar": 2883.33, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Medicare A", "plan_name": "100100", "standard_charge_dollar": 2883.33, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Medicare A", "plan_name": "100500", "standard_charge_dollar": 2883.33, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Medicare Part B Only", "plan_name": "100300", "standard_charge_dollar": 2883.33, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Medicare Railroad", "plan_name": "100103", "standard_charge_dollar": 2883.33, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Ms Physicians Care N", "plan_name": "714210", "standard_charge_dollar": 3604.16, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Peoples Hlth Ffs 72126", "plan_name": "500019", "standard_charge_dollar": 2883.33, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Uhc/Secure Horizons", "plan_name": "500449", "standard_charge_dollar": 2883.33, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "United Health Care/", "plan_name": "500292", "standard_charge_dollar": 3258.16, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "United Healthcare", "plan_name": "750104", "standard_charge_dollar": 3258.16, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "United Healthcare Ba", "plan_name": "750090", "standard_charge_dollar": 3258.16, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "United Healthcare Me", "plan_name": "501310", "standard_charge_dollar": 2883.33, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Windsor Mcare Extra", "plan_name": "500778", "standard_charge_dollar": 2883.33, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." } ] } ] }, { "description": "Insert non-tunnel cv cath", "code_information": [ { "code": "36556", "type": "CPT" } ], "standard_charges": [ { "gross_charge": 6466.00, "minimum": 2883.33, "maximum": 5496.10, "setting": "outpatient", "payers_information": [ { "payer_name": "Aarp", "plan_name": "500102", "standard_charge_dollar": 2883.33, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna", "plan_name": "700700", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna", "plan_name": "700700_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Mcare Ffs 6005", "plan_name": "700703", "standard_charge_dollar": 2883.33, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Miscellaneous", "plan_name": "700720", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Miscellaneous", "plan_name": "700720_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Ppo Hmo", "plan_name": "701720", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Ppo Hmo", "plan_name": "701720_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Ambetter 68069", "plan_name": "500516", "standard_charge_dollar": 2883.33, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Ms State Emplo", "plan_name": "401457", "standard_charge_percentage": 0.80, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Ms State Emplo", "plan_name": "401457_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Basic Pl", "plan_name": "400100", "standard_charge_percentage": 0.85, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Basic Pl", "plan_name": "400100_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Federal", "plan_name": "400110", "standard_charge_percentage": 0.85, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Federal", "plan_name": "400110_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Cigna Healthsprings Ffs", "plan_name": "500064", "standard_charge_dollar": 2883.33, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Conseco", "plan_name": "500302", "standard_charge_dollar": 2883.33, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Humana Ffs 61101", "plan_name": "500006", "standard_charge_dollar": 2883.33, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Medicare A", "plan_name": "100100", "standard_charge_dollar": 2883.33, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Medicare A", "plan_name": "100500", "standard_charge_dollar": 2883.33, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Medicare Part B Only", "plan_name": "100300", "standard_charge_dollar": 2883.33, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Medicare Railroad", "plan_name": "100103", "standard_charge_dollar": 2883.33, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Ms Physicians Care N", "plan_name": "714210", "standard_charge_dollar": 3604.16, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Peoples Hlth Ffs 72126", "plan_name": "500019", "standard_charge_dollar": 2883.33, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Uhc/Secure Horizons", "plan_name": "500449", "standard_charge_dollar": 2883.33, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "United Health Care/", "plan_name": "500292", "standard_charge_dollar": 3258.16, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "United Healthcare", "plan_name": "750104", "standard_charge_dollar": 3258.16, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "United Healthcare Ba", "plan_name": "750090", "standard_charge_dollar": 3258.16, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "United Healthcare Me", "plan_name": "501310", "standard_charge_dollar": 2883.33, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Windsor Mcare Extra", "plan_name": "500778", "standard_charge_dollar": 2883.33, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." } ] } ] }, { "description": "Insert tunneled cv cath", "code_information": [ { "code": "36557", "type": "CPT" } ], "standard_charges": [ { "gross_charge": 30265.18, "minimum": 4951.99, "maximum": 25725.40, "setting": "inpatient", "payers_information": [ { "payer_name": "Aarp", "plan_name": "500102", "standard_charge_dollar": 4951.99, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna", "plan_name": "700700", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna", "plan_name": "700700_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Mcare Ffs 6005", "plan_name": "700703", "standard_charge_dollar": 4951.99, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Miscellaneous", "plan_name": "700720", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Miscellaneous", "plan_name": "700720_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Ppo Hmo", "plan_name": "701720", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Ppo Hmo", "plan_name": "701720_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Ambetter 68069", "plan_name": "500516", "standard_charge_dollar": 4951.99, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Ms State Emplo", "plan_name": "401457", "standard_charge_percentage": 0.80, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Ms State Emplo", "plan_name": "401457_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Basic Pl", "plan_name": "400100", "standard_charge_percentage": 0.85, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Basic Pl", "plan_name": "400100_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Federal", "plan_name": "400110", "standard_charge_percentage": 0.85, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Federal", "plan_name": "400110_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Cigna Healthsprings Ffs", "plan_name": "500064", "standard_charge_dollar": 4951.99, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Conseco", "plan_name": "500302", "standard_charge_dollar": 4951.99, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Humana Ffs 61101", "plan_name": "500006", "standard_charge_dollar": 4951.99, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Medicare A", "plan_name": "100100", "standard_charge_dollar": 4951.99, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Medicare A", "plan_name": "100500", "standard_charge_dollar": 4951.99, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Medicare Part B Only", "plan_name": "100300", "standard_charge_dollar": 4951.99, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Medicare Railroad", "plan_name": "100103", "standard_charge_dollar": 4951.99, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Ms Physicians Care N", "plan_name": "714210", "standard_charge_dollar": 6189.99, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Peoples Hlth Ffs 72126", "plan_name": "500019", "standard_charge_dollar": 4951.99, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Uhc/Secure Horizons", "plan_name": "500449", "standard_charge_dollar": 4951.99, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "United Health Care/", "plan_name": "500292", "standard_charge_dollar": 5595.75, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "United Healthcare", "plan_name": "750104", "standard_charge_dollar": 5595.75, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "United Healthcare Ba", "plan_name": "750090", "standard_charge_dollar": 5595.75, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "United Healthcare Me", "plan_name": "501310", "standard_charge_dollar": 4951.99, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Windsor Mcare Extra", "plan_name": "500778", "standard_charge_dollar": 4951.99, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." } ] } ] }, { "description": "Insert tunneled cv cath", "code_information": [ { "code": "36558", "type": "CPT" } ], "standard_charges": [ { "gross_charge": 31959.27, "minimum": 2883.33, "maximum": 27165.38, "setting": "inpatient", "payers_information": [ { "payer_name": "Aarp", "plan_name": "500102", "standard_charge_dollar": 2883.33, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna", "plan_name": "700700", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna", "plan_name": "700700_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Mcare Ffs 6005", "plan_name": "700703", "standard_charge_dollar": 2883.33, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Miscellaneous", "plan_name": "700720", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Miscellaneous", "plan_name": "700720_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Ppo Hmo", "plan_name": "701720", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Ppo Hmo", "plan_name": "701720_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Ambetter 68069", "plan_name": "500516", "standard_charge_dollar": 2883.33, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Ms State Emplo", "plan_name": "401457", "standard_charge_percentage": 0.80, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Ms State Emplo", "plan_name": "401457_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Basic Pl", "plan_name": "400100", "standard_charge_percentage": 0.85, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Basic Pl", "plan_name": "400100_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Federal", "plan_name": "400110", "standard_charge_percentage": 0.85, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Federal", "plan_name": "400110_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Cigna Healthsprings Ffs", "plan_name": "500064", "standard_charge_dollar": 2883.33, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Conseco", "plan_name": "500302", "standard_charge_dollar": 2883.33, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Humana Ffs 61101", "plan_name": "500006", "standard_charge_dollar": 2883.33, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Medicare A", "plan_name": "100100", "standard_charge_dollar": 2883.33, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Medicare A", "plan_name": "100500", "standard_charge_dollar": 2883.33, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Medicare Part B Only", "plan_name": "100300", "standard_charge_dollar": 2883.33, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Medicare Railroad", "plan_name": "100103", "standard_charge_dollar": 2883.33, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Ms Physicians Care N", "plan_name": "714210", "standard_charge_dollar": 3604.16, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Peoples Hlth Ffs 72126", "plan_name": "500019", "standard_charge_dollar": 2883.33, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Uhc/Secure Horizons", "plan_name": "500449", "standard_charge_dollar": 2883.33, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "United Health Care/", "plan_name": "500292", "standard_charge_dollar": 3258.16, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "United Healthcare", "plan_name": "750104", "standard_charge_dollar": 3258.16, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "United Healthcare Ba", "plan_name": "750090", "standard_charge_dollar": 3258.16, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "United Healthcare Me", "plan_name": "501310", "standard_charge_dollar": 2883.33, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Windsor Mcare Extra", "plan_name": "500778", "standard_charge_dollar": 2883.33, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." } ] } ] }, { "description": "Insert tunneled cv cath", "code_information": [ { "code": "36560", "type": "CPT" } ], "standard_charges": [ { "gross_charge": 41696.19, "minimum": 2883.33, "maximum": 35441.76, "setting": "inpatient", "payers_information": [ { "payer_name": "Aarp", "plan_name": "500102", "standard_charge_dollar": 2883.33, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna", "plan_name": "700700", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna", "plan_name": "700700_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Mcare Ffs 6005", "plan_name": "700703", "standard_charge_dollar": 2883.33, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Miscellaneous", "plan_name": "700720", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Miscellaneous", "plan_name": "700720_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Ppo Hmo", "plan_name": "701720", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Ppo Hmo", "plan_name": "701720_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Ambetter 68069", "plan_name": "500516", "standard_charge_dollar": 2883.33, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Ms State Emplo", "plan_name": "401457", "standard_charge_percentage": 0.80, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Ms State Emplo", "plan_name": "401457_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Basic Pl", "plan_name": "400100", "standard_charge_percentage": 0.85, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Basic Pl", "plan_name": "400100_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Federal", "plan_name": "400110", "standard_charge_percentage": 0.85, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Federal", "plan_name": "400110_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Cigna Healthsprings Ffs", "plan_name": "500064", "standard_charge_dollar": 2883.33, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Conseco", "plan_name": "500302", "standard_charge_dollar": 2883.33, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Humana Ffs 61101", "plan_name": "500006", "standard_charge_dollar": 2883.33, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Medicare A", "plan_name": "100100", "standard_charge_dollar": 2883.33, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Medicare A", "plan_name": "100500", "standard_charge_dollar": 2883.33, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Medicare Part B Only", "plan_name": "100300", "standard_charge_dollar": 2883.33, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Medicare Railroad", "plan_name": "100103", "standard_charge_dollar": 2883.33, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Ms Physicians Care N", "plan_name": "714210", "standard_charge_dollar": 3604.16, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Peoples Hlth Ffs 72126", "plan_name": "500019", "standard_charge_dollar": 2883.33, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Uhc/Secure Horizons", "plan_name": "500449", "standard_charge_dollar": 2883.33, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "United Health Care/", "plan_name": "500292", "standard_charge_dollar": 3258.16, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "United Healthcare", "plan_name": "750104", "standard_charge_dollar": 3258.16, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "United Healthcare Ba", "plan_name": "750090", "standard_charge_dollar": 3258.16, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "United Healthcare Me", "plan_name": "501310", "standard_charge_dollar": 2883.33, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Windsor Mcare Extra", "plan_name": "500778", "standard_charge_dollar": 2883.33, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." } ] } ] }, { "description": "Insert tunneled cv cath", "code_information": [ { "code": "36561", "type": "CPT" } ], "standard_charges": [ { "gross_charge": 41696.19, "minimum": 2883.33, "maximum": 35441.76, "setting": "inpatient", "payers_information": [ { "payer_name": "Aarp", "plan_name": "500102", "standard_charge_dollar": 2883.33, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna", "plan_name": "700700", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna", "plan_name": "700700_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Mcare Ffs 6005", "plan_name": "700703", "standard_charge_dollar": 2883.33, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Miscellaneous", "plan_name": "700720", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Miscellaneous", "plan_name": "700720_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Ppo Hmo", "plan_name": "701720", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Ppo Hmo", "plan_name": "701720_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Ambetter 68069", "plan_name": "500516", "standard_charge_dollar": 2883.33, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Ms State Emplo", "plan_name": "401457", "standard_charge_percentage": 0.80, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Ms State Emplo", "plan_name": "401457_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Basic Pl", "plan_name": "400100", "standard_charge_percentage": 0.85, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Basic Pl", "plan_name": "400100_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Federal", "plan_name": "400110", "standard_charge_percentage": 0.85, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Federal", "plan_name": "400110_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Cigna Healthsprings Ffs", "plan_name": "500064", "standard_charge_dollar": 2883.33, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Conseco", "plan_name": "500302", "standard_charge_dollar": 2883.33, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Humana Ffs 61101", "plan_name": "500006", "standard_charge_dollar": 2883.33, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Medicare A", "plan_name": "100100", "standard_charge_dollar": 2883.33, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Medicare A", "plan_name": "100500", "standard_charge_dollar": 2883.33, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Medicare Part B Only", "plan_name": "100300", "standard_charge_dollar": 2883.33, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Medicare Railroad", "plan_name": "100103", "standard_charge_dollar": 2883.33, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Ms Physicians Care N", "plan_name": "714210", "standard_charge_dollar": 3604.16, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Peoples Hlth Ffs 72126", "plan_name": "500019", "standard_charge_dollar": 2883.33, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Uhc/Secure Horizons", "plan_name": "500449", "standard_charge_dollar": 2883.33, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "United Health Care/", "plan_name": "500292", "standard_charge_dollar": 3258.16, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "United Healthcare", "plan_name": "750104", "standard_charge_dollar": 3258.16, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "United Healthcare Ba", "plan_name": "750090", "standard_charge_dollar": 3258.16, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "United Healthcare Me", "plan_name": "501310", "standard_charge_dollar": 2883.33, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Windsor Mcare Extra", "plan_name": "500778", "standard_charge_dollar": 2883.33, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." } ] } ] }, { "description": "Insert tunneled cv cath", "code_information": [ { "code": "36563", "type": "CPT" } ], "standard_charges": [ { "gross_charge": 31959.27, "minimum": 4951.99, "maximum": 27165.38, "setting": "inpatient", "payers_information": [ { "payer_name": "Aarp", "plan_name": "500102", "standard_charge_dollar": 4951.99, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna", "plan_name": "700700", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna", "plan_name": "700700_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Mcare Ffs 6005", "plan_name": "700703", "standard_charge_dollar": 4951.99, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Miscellaneous", "plan_name": "700720", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Miscellaneous", "plan_name": "700720_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Ppo Hmo", "plan_name": "701720", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Ppo Hmo", "plan_name": "701720_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Ambetter 68069", "plan_name": "500516", "standard_charge_dollar": 4951.99, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Ms State Emplo", "plan_name": "401457", "standard_charge_percentage": 0.80, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Ms State Emplo", "plan_name": "401457_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Basic Pl", "plan_name": "400100", "standard_charge_percentage": 0.85, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Basic Pl", "plan_name": "400100_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Federal", "plan_name": "400110", "standard_charge_percentage": 0.85, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Federal", "plan_name": "400110_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Cigna Healthsprings Ffs", "plan_name": "500064", "standard_charge_dollar": 4951.99, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Conseco", "plan_name": "500302", "standard_charge_dollar": 4951.99, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Humana Ffs 61101", "plan_name": "500006", "standard_charge_dollar": 4951.99, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Medicare A", "plan_name": "100100", "standard_charge_dollar": 4951.99, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Medicare A", "plan_name": "100500", "standard_charge_dollar": 4951.99, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Medicare Part B Only", "plan_name": "100300", "standard_charge_dollar": 4951.99, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Medicare Railroad", "plan_name": "100103", "standard_charge_dollar": 4951.99, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Ms Physicians Care N", "plan_name": "714210", "standard_charge_dollar": 6189.99, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Peoples Hlth Ffs 72126", "plan_name": "500019", "standard_charge_dollar": 4951.99, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Uhc/Secure Horizons", "plan_name": "500449", "standard_charge_dollar": 4951.99, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "United Health Care/", "plan_name": "500292", "standard_charge_dollar": 5595.75, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "United Healthcare", "plan_name": "750104", "standard_charge_dollar": 5595.75, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "United Healthcare Ba", "plan_name": "750090", "standard_charge_dollar": 5595.75, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "United Healthcare Me", "plan_name": "501310", "standard_charge_dollar": 4951.99, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Windsor Mcare Extra", "plan_name": "500778", "standard_charge_dollar": 4951.99, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." } ] } ] }, { "description": "Insert tunneled cv cath", "code_information": [ { "code": "36565", "type": "CPT" } ], "standard_charges": [ { "gross_charge": 31959.27, "minimum": 2883.33, "maximum": 27165.38, "setting": "inpatient", "payers_information": [ { "payer_name": "Aarp", "plan_name": "500102", "standard_charge_dollar": 2883.33, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna", "plan_name": "700700", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna", "plan_name": "700700_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Mcare Ffs 6005", "plan_name": "700703", "standard_charge_dollar": 2883.33, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Miscellaneous", "plan_name": "700720", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Miscellaneous", "plan_name": "700720_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Ppo Hmo", "plan_name": "701720", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Ppo Hmo", "plan_name": "701720_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Ambetter 68069", "plan_name": "500516", "standard_charge_dollar": 2883.33, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Ms State Emplo", "plan_name": "401457", "standard_charge_percentage": 0.80, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Ms State Emplo", "plan_name": "401457_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Basic Pl", "plan_name": "400100", "standard_charge_percentage": 0.85, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Basic Pl", "plan_name": "400100_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Federal", "plan_name": "400110", "standard_charge_percentage": 0.85, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Federal", "plan_name": "400110_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Cigna Healthsprings Ffs", "plan_name": "500064", "standard_charge_dollar": 2883.33, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Conseco", "plan_name": "500302", "standard_charge_dollar": 2883.33, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Humana Ffs 61101", "plan_name": "500006", "standard_charge_dollar": 2883.33, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Medicare A", "plan_name": "100100", "standard_charge_dollar": 2883.33, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Medicare A", "plan_name": "100500", "standard_charge_dollar": 2883.33, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Medicare Part B Only", "plan_name": "100300", "standard_charge_dollar": 2883.33, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Medicare Railroad", "plan_name": "100103", "standard_charge_dollar": 2883.33, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Ms Physicians Care N", "plan_name": "714210", "standard_charge_dollar": 3604.16, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Peoples Hlth Ffs 72126", "plan_name": "500019", "standard_charge_dollar": 2883.33, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Uhc/Secure Horizons", "plan_name": "500449", "standard_charge_dollar": 2883.33, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "United Health Care/", "plan_name": "500292", "standard_charge_dollar": 3258.16, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "United Healthcare", "plan_name": "750104", "standard_charge_dollar": 3258.16, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "United Healthcare Ba", "plan_name": "750090", "standard_charge_dollar": 3258.16, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "United Healthcare Me", "plan_name": "501310", "standard_charge_dollar": 2883.33, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Windsor Mcare Extra", "plan_name": "500778", "standard_charge_dollar": 2883.33, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." } ] } ] }, { "description": "Insert tunneled cv cath", "code_information": [ { "code": "36566", "type": "CPT" } ], "standard_charges": [ { "gross_charge": 41696.19, "minimum": 4951.99, "maximum": 35441.76, "setting": "inpatient", "payers_information": [ { "payer_name": "Aarp", "plan_name": "500102", "standard_charge_dollar": 4951.99, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna", "plan_name": "700700", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna", "plan_name": "700700_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Mcare Ffs 6005", "plan_name": "700703", "standard_charge_dollar": 4951.99, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Miscellaneous", "plan_name": "700720", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Miscellaneous", "plan_name": "700720_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Ppo Hmo", "plan_name": "701720", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Ppo Hmo", "plan_name": "701720_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Ambetter 68069", "plan_name": "500516", "standard_charge_dollar": 4951.99, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Ms State Emplo", "plan_name": "401457", "standard_charge_percentage": 0.80, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Ms State Emplo", "plan_name": "401457_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Basic Pl", "plan_name": "400100", "standard_charge_percentage": 0.85, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Basic Pl", "plan_name": "400100_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Federal", "plan_name": "400110", "standard_charge_percentage": 0.85, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Federal", "plan_name": "400110_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Cigna Healthsprings Ffs", "plan_name": "500064", "standard_charge_dollar": 4951.99, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Conseco", "plan_name": "500302", "standard_charge_dollar": 4951.99, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Humana Ffs 61101", "plan_name": "500006", "standard_charge_dollar": 4951.99, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Medicare A", "plan_name": "100100", "standard_charge_dollar": 4951.99, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Medicare A", "plan_name": "100500", "standard_charge_dollar": 4951.99, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Medicare Part B Only", "plan_name": "100300", "standard_charge_dollar": 4951.99, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Medicare Railroad", "plan_name": "100103", "standard_charge_dollar": 4951.99, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Ms Physicians Care N", "plan_name": "714210", "standard_charge_dollar": 6189.99, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Peoples Hlth Ffs 72126", "plan_name": "500019", "standard_charge_dollar": 4951.99, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Uhc/Secure Horizons", "plan_name": "500449", "standard_charge_dollar": 4951.99, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "United Health Care/", "plan_name": "500292", "standard_charge_dollar": 5595.75, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "United Healthcare", "plan_name": "750104", "standard_charge_dollar": 5595.75, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "United Healthcare Ba", "plan_name": "750090", "standard_charge_dollar": 5595.75, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "United Healthcare Me", "plan_name": "501310", "standard_charge_dollar": 4951.99, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Windsor Mcare Extra", "plan_name": "500778", "standard_charge_dollar": 4951.99, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." } ] } ] }, { "description": "Insj picc <5 yr w/o imaging", "code_information": [ { "code": "36568", "type": "CPT" } ], "standard_charges": [ { "gross_charge": 31687.53, "minimum": 1423.06, "maximum": 26934.40, "setting": "inpatient", "payers_information": [ { "payer_name": "Aarp", "plan_name": "500102", "standard_charge_dollar": 1423.06, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna", "plan_name": "700700", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna", "plan_name": "700700_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Mcare Ffs 6005", "plan_name": "700703", "standard_charge_dollar": 1423.06, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Miscellaneous", "plan_name": "700720", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Miscellaneous", "plan_name": "700720_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Ppo Hmo", "plan_name": "701720", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Ppo Hmo", "plan_name": "701720_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Ambetter 68069", "plan_name": "500516", "standard_charge_dollar": 1423.06, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Ms State Emplo", "plan_name": "401457", "standard_charge_percentage": 0.80, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Ms State Emplo", "plan_name": "401457_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Basic Pl", "plan_name": "400100", "standard_charge_percentage": 0.85, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Basic Pl", "plan_name": "400100_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Federal", "plan_name": "400110", "standard_charge_percentage": 0.85, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Federal", "plan_name": "400110_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Cigna Healthsprings Ffs", "plan_name": "500064", "standard_charge_dollar": 1423.06, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Conseco", "plan_name": "500302", "standard_charge_dollar": 1423.06, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Humana Ffs 61101", "plan_name": "500006", "standard_charge_dollar": 1423.06, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Medicare A", "plan_name": "100100", "standard_charge_dollar": 1423.06, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Medicare A", "plan_name": "100500", "standard_charge_dollar": 1423.06, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Medicare Part B Only", "plan_name": "100300", "standard_charge_dollar": 1423.06, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Medicare Railroad", "plan_name": "100103", "standard_charge_dollar": 1423.06, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Ms Physicians Care N", "plan_name": "714210", "standard_charge_dollar": 1778.82, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Peoples Hlth Ffs 72126", "plan_name": "500019", "standard_charge_dollar": 1423.06, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Uhc/Secure Horizons", "plan_name": "500449", "standard_charge_dollar": 1423.06, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "United Health Care/", "plan_name": "500292", "standard_charge_dollar": 1608.06, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "United Healthcare", "plan_name": "750104", "standard_charge_dollar": 1608.06, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "United Healthcare Ba", "plan_name": "750090", "standard_charge_dollar": 1608.06, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "United Healthcare Me", "plan_name": "501310", "standard_charge_dollar": 1423.06, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Windsor Mcare Extra", "plan_name": "500778", "standard_charge_dollar": 1423.06, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." } ] } ] }, { "description": "Insj picc 5 yr+ w/o imaging", "code_information": [ { "code": "36569", "type": "CPT" } ], "standard_charges": [ { "gross_charge": 31818.05, "minimum": 1423.06, "maximum": 27045.34, "setting": "inpatient", "payers_information": [ { "payer_name": "Aarp", "plan_name": "500102", "standard_charge_dollar": 1423.06, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna", "plan_name": "700700", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna", "plan_name": "700700_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Mcare Ffs 6005", "plan_name": "700703", "standard_charge_dollar": 1423.06, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Miscellaneous", "plan_name": "700720", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Miscellaneous", "plan_name": "700720_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Ppo Hmo", "plan_name": "701720", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Ppo Hmo", "plan_name": "701720_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Ambetter 68069", "plan_name": "500516", "standard_charge_dollar": 1423.06, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Ms State Emplo", "plan_name": "401457", "standard_charge_percentage": 0.80, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Ms State Emplo", "plan_name": "401457_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Basic Pl", "plan_name": "400100", "standard_charge_percentage": 0.85, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Basic Pl", "plan_name": "400100_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Federal", "plan_name": "400110", "standard_charge_percentage": 0.85, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Federal", "plan_name": "400110_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Cigna Healthsprings Ffs", "plan_name": "500064", "standard_charge_dollar": 1423.06, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Conseco", "plan_name": "500302", "standard_charge_dollar": 1423.06, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Humana Ffs 61101", "plan_name": "500006", "standard_charge_dollar": 1423.06, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Medicare A", "plan_name": "100100", "standard_charge_dollar": 1423.06, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Medicare A", "plan_name": "100500", "standard_charge_dollar": 1423.06, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Medicare Part B Only", "plan_name": "100300", "standard_charge_dollar": 1423.06, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Medicare Railroad", "plan_name": "100103", "standard_charge_dollar": 1423.06, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Ms Physicians Care N", "plan_name": "714210", "standard_charge_dollar": 1778.82, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Peoples Hlth Ffs 72126", "plan_name": "500019", "standard_charge_dollar": 1423.06, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Uhc/Secure Horizons", "plan_name": "500449", "standard_charge_dollar": 1423.06, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "United Health Care/", "plan_name": "500292", "standard_charge_dollar": 1608.06, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "United Healthcare", "plan_name": "750104", "standard_charge_dollar": 1608.06, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "United Healthcare Ba", "plan_name": "750090", "standard_charge_dollar": 1608.06, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "United Healthcare Me", "plan_name": "501310", "standard_charge_dollar": 1423.06, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Windsor Mcare Extra", "plan_name": "500778", "standard_charge_dollar": 1423.06, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." } ] } ] }, { "description": "Insert picvad cath", "code_information": [ { "code": "36570", "type": "CPT" } ], "standard_charges": [ { "gross_charge": 31647.73, "minimum": 2883.33, "maximum": 26900.57, "setting": "inpatient", "payers_information": [ { "payer_name": "Aarp", "plan_name": "500102", "standard_charge_dollar": 2883.33, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna", "plan_name": "700700", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna", "plan_name": "700700_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Mcare Ffs 6005", "plan_name": "700703", "standard_charge_dollar": 2883.33, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Miscellaneous", "plan_name": "700720", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Miscellaneous", "plan_name": "700720_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Ppo Hmo", "plan_name": "701720", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Ppo Hmo", "plan_name": "701720_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Ambetter 68069", "plan_name": "500516", "standard_charge_dollar": 2883.33, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Ms State Emplo", "plan_name": "401457", "standard_charge_percentage": 0.80, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Ms State Emplo", "plan_name": "401457_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Basic Pl", "plan_name": "400100", "standard_charge_percentage": 0.85, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Basic Pl", "plan_name": "400100_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Federal", "plan_name": "400110", "standard_charge_percentage": 0.85, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Federal", "plan_name": "400110_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Cigna Healthsprings Ffs", "plan_name": "500064", "standard_charge_dollar": 2883.33, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Conseco", "plan_name": "500302", "standard_charge_dollar": 2883.33, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Humana Ffs 61101", "plan_name": "500006", "standard_charge_dollar": 2883.33, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Medicare A", "plan_name": "100100", "standard_charge_dollar": 2883.33, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Medicare A", "plan_name": "100500", "standard_charge_dollar": 2883.33, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Medicare Part B Only", "plan_name": "100300", "standard_charge_dollar": 2883.33, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Medicare Railroad", "plan_name": "100103", "standard_charge_dollar": 2883.33, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Ms Physicians Care N", "plan_name": "714210", "standard_charge_dollar": 3604.16, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Peoples Hlth Ffs 72126", "plan_name": "500019", "standard_charge_dollar": 2883.33, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Uhc/Secure Horizons", "plan_name": "500449", "standard_charge_dollar": 2883.33, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "United Health Care/", "plan_name": "500292", "standard_charge_dollar": 3258.16, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "United Healthcare", "plan_name": "750104", "standard_charge_dollar": 3258.16, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "United Healthcare Ba", "plan_name": "750090", "standard_charge_dollar": 3258.16, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "United Healthcare Me", "plan_name": "501310", "standard_charge_dollar": 2883.33, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Windsor Mcare Extra", "plan_name": "500778", "standard_charge_dollar": 2883.33, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." } ] } ] }, { "description": "Insert picvad cath", "code_information": [ { "code": "36571", "type": "CPT" } ], "standard_charges": [ { "gross_charge": 31647.73, "minimum": 2883.33, "maximum": 26900.57, "setting": "inpatient", "payers_information": [ { "payer_name": "Aarp", "plan_name": "500102", "standard_charge_dollar": 2883.33, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna", "plan_name": "700700", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna", "plan_name": "700700_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Mcare Ffs 6005", "plan_name": "700703", "standard_charge_dollar": 2883.33, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Miscellaneous", "plan_name": "700720", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Miscellaneous", "plan_name": "700720_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Ppo Hmo", "plan_name": "701720", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Ppo Hmo", "plan_name": "701720_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Ambetter 68069", "plan_name": "500516", "standard_charge_dollar": 2883.33, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Ms State Emplo", "plan_name": "401457", "standard_charge_percentage": 0.80, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Ms State Emplo", "plan_name": "401457_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Basic Pl", "plan_name": "400100", "standard_charge_percentage": 0.85, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Basic Pl", "plan_name": "400100_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Federal", "plan_name": "400110", "standard_charge_percentage": 0.85, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Federal", "plan_name": "400110_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Cigna Healthsprings Ffs", "plan_name": "500064", "standard_charge_dollar": 2883.33, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Conseco", "plan_name": "500302", "standard_charge_dollar": 2883.33, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Humana Ffs 61101", "plan_name": "500006", "standard_charge_dollar": 2883.33, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Medicare A", "plan_name": "100100", "standard_charge_dollar": 2883.33, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Medicare A", "plan_name": "100500", "standard_charge_dollar": 2883.33, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Medicare Part B Only", "plan_name": "100300", "standard_charge_dollar": 2883.33, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Medicare Railroad", "plan_name": "100103", "standard_charge_dollar": 2883.33, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Ms Physicians Care N", "plan_name": "714210", "standard_charge_dollar": 3604.16, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Peoples Hlth Ffs 72126", "plan_name": "500019", "standard_charge_dollar": 2883.33, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Uhc/Secure Horizons", "plan_name": "500449", "standard_charge_dollar": 2883.33, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "United Health Care/", "plan_name": "500292", "standard_charge_dollar": 3258.16, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "United Healthcare", "plan_name": "750104", "standard_charge_dollar": 3258.16, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "United Healthcare Ba", "plan_name": "750090", "standard_charge_dollar": 3258.16, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "United Healthcare Me", "plan_name": "501310", "standard_charge_dollar": 2883.33, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Windsor Mcare Extra", "plan_name": "500778", "standard_charge_dollar": 2883.33, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." } ] } ] }, { "description": "Insj picc rs&i <5 yr", "code_information": [ { "code": "36572", "type": "CPT" } ], "standard_charges": [ { "gross_charge": 30559.11, "minimum": 566.37, "maximum": 25975.24, "setting": "inpatient", "payers_information": [ { "payer_name": "Aarp", "plan_name": "500102", "standard_charge_dollar": 566.37, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna", "plan_name": "700700", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna", "plan_name": "700700_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Mcare Ffs 6005", "plan_name": "700703", "standard_charge_dollar": 566.37, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Miscellaneous", "plan_name": "700720", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Miscellaneous", "plan_name": "700720_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Ppo Hmo", "plan_name": "701720", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Ppo Hmo", "plan_name": "701720_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Ambetter 68069", "plan_name": "500516", "standard_charge_dollar": 566.37, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Ms State Emplo", "plan_name": "401457", "standard_charge_percentage": 0.80, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Ms State Emplo", "plan_name": "401457_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Basic Pl", "plan_name": "400100", "standard_charge_percentage": 0.85, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Basic Pl", "plan_name": "400100_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Federal", "plan_name": "400110", "standard_charge_percentage": 0.85, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Federal", "plan_name": "400110_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Cigna Healthsprings Ffs", "plan_name": "500064", "standard_charge_dollar": 566.37, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Conseco", "plan_name": "500302", "standard_charge_dollar": 566.37, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Humana Ffs 61101", "plan_name": "500006", "standard_charge_dollar": 566.37, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Medicare A", "plan_name": "100100", "standard_charge_dollar": 566.37, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Medicare A", "plan_name": "100500", "standard_charge_dollar": 566.37, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Medicare Part B Only", "plan_name": "100300", "standard_charge_dollar": 566.37, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Medicare Railroad", "plan_name": "100103", "standard_charge_dollar": 566.37, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Ms Physicians Care N", "plan_name": "714210", "standard_charge_dollar": 707.96, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Peoples Hlth Ffs 72126", "plan_name": "500019", "standard_charge_dollar": 566.37, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Uhc/Secure Horizons", "plan_name": "500449", "standard_charge_dollar": 566.37, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "United Health Care/", "plan_name": "500292", "standard_charge_dollar": 640.00, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "United Healthcare", "plan_name": "750104", "standard_charge_dollar": 640.00, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "United Healthcare Ba", "plan_name": "750090", "standard_charge_dollar": 640.00, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "United Healthcare Me", "plan_name": "501310", "standard_charge_dollar": 566.37, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Windsor Mcare Extra", "plan_name": "500778", "standard_charge_dollar": 566.37, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." } ] } ] }, { "description": "Insj picc rs&i 5 yr+", "code_information": [ { "code": "36573", "type": "CPT" } ], "standard_charges": [ { "gross_charge": 30559.11, "minimum": 1423.06, "maximum": 25975.24, "setting": "inpatient", "payers_information": [ { "payer_name": "Aarp", "plan_name": "500102", "standard_charge_dollar": 1423.06, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna", "plan_name": "700700", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna", "plan_name": "700700_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Mcare Ffs 6005", "plan_name": "700703", "standard_charge_dollar": 1423.06, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Miscellaneous", "plan_name": "700720", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Miscellaneous", "plan_name": "700720_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Ppo Hmo", "plan_name": "701720", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Ppo Hmo", "plan_name": "701720_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Ambetter 68069", "plan_name": "500516", "standard_charge_dollar": 1423.06, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Ms State Emplo", "plan_name": "401457", "standard_charge_percentage": 0.80, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Ms State Emplo", "plan_name": "401457_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Basic Pl", "plan_name": "400100", "standard_charge_percentage": 0.85, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Basic Pl", "plan_name": "400100_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Federal", "plan_name": "400110", "standard_charge_percentage": 0.85, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Federal", "plan_name": "400110_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Cigna Healthsprings Ffs", "plan_name": "500064", "standard_charge_dollar": 1423.06, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Conseco", "plan_name": "500302", "standard_charge_dollar": 1423.06, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Humana Ffs 61101", "plan_name": "500006", "standard_charge_dollar": 1423.06, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Medicare A", "plan_name": "100100", "standard_charge_dollar": 1423.06, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Medicare A", "plan_name": "100500", "standard_charge_dollar": 1423.06, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Medicare Part B Only", "plan_name": "100300", "standard_charge_dollar": 1423.06, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Medicare Railroad", "plan_name": "100103", "standard_charge_dollar": 1423.06, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Ms Physicians Care N", "plan_name": "714210", "standard_charge_dollar": 1778.82, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Peoples Hlth Ffs 72126", "plan_name": "500019", "standard_charge_dollar": 1423.06, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Uhc/Secure Horizons", "plan_name": "500449", "standard_charge_dollar": 1423.06, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "United Health Care/", "plan_name": "500292", "standard_charge_dollar": 1608.06, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "United Healthcare", "plan_name": "750104", "standard_charge_dollar": 1608.06, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "United Healthcare Ba", "plan_name": "750090", "standard_charge_dollar": 1608.06, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "United Healthcare Me", "plan_name": "501310", "standard_charge_dollar": 1423.06, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Windsor Mcare Extra", "plan_name": "500778", "standard_charge_dollar": 1423.06, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." } ] } ] }, { "description": "Replace tunneled cv cath", "code_information": [ { "code": "36583", "type": "CPT" } ], "standard_charges": [ { "gross_charge": 27332.94, "minimum": 4951.99, "maximum": 23233.00, "setting": "inpatient", "payers_information": [ { "payer_name": "Aarp", "plan_name": "500102", "standard_charge_dollar": 4951.99, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna", "plan_name": "700700", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna", "plan_name": "700700_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Mcare Ffs 6005", "plan_name": "700703", "standard_charge_dollar": 4951.99, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Miscellaneous", "plan_name": "700720", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Miscellaneous", "plan_name": "700720_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Ppo Hmo", "plan_name": "701720", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Ppo Hmo", "plan_name": "701720_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Ambetter 68069", "plan_name": "500516", "standard_charge_dollar": 4951.99, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Ms State Emplo", "plan_name": "401457", "standard_charge_percentage": 0.80, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Ms State Emplo", "plan_name": "401457_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Basic Pl", "plan_name": "400100", "standard_charge_percentage": 0.85, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Basic Pl", "plan_name": "400100_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Federal", "plan_name": "400110", "standard_charge_percentage": 0.85, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Federal", "plan_name": "400110_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Cigna Healthsprings Ffs", "plan_name": "500064", "standard_charge_dollar": 4951.99, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Conseco", "plan_name": "500302", "standard_charge_dollar": 4951.99, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Humana Ffs 61101", "plan_name": "500006", "standard_charge_dollar": 4951.99, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Medicare A", "plan_name": "100100", "standard_charge_dollar": 4951.99, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Medicare A", "plan_name": "100500", "standard_charge_dollar": 4951.99, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Medicare Part B Only", "plan_name": "100300", "standard_charge_dollar": 4951.99, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Medicare Railroad", "plan_name": "100103", "standard_charge_dollar": 4951.99, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Ms Physicians Care N", "plan_name": "714210", "standard_charge_dollar": 6189.99, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Peoples Hlth Ffs 72126", "plan_name": "500019", "standard_charge_dollar": 4951.99, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Uhc/Secure Horizons", "plan_name": "500449", "standard_charge_dollar": 4951.99, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "United Health Care/", "plan_name": "500292", "standard_charge_dollar": 5595.75, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "United Healthcare", "plan_name": "750104", "standard_charge_dollar": 5595.75, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "United Healthcare Ba", "plan_name": "750090", "standard_charge_dollar": 5595.75, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "United Healthcare Me", "plan_name": "501310", "standard_charge_dollar": 4951.99, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Windsor Mcare Extra", "plan_name": "500778", "standard_charge_dollar": 4951.99, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." } ] } ] }, { "description": "Removal tunneled cv cath", "code_information": [ { "code": "36590", "type": "CPT" } ], "standard_charges": [ { "gross_charge": 32126.15, "minimum": 1293.77, "maximum": 1778.82, "setting": "inpatient", "payers_information": [ { "payer_name": "Aarp", "plan_name": "500102", "standard_charge_dollar": 1423.06, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna", "plan_name": "700700", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna", "plan_name": "700700_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Mcare Ffs 6005", "plan_name": "700703", "standard_charge_dollar": 1423.06, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Miscellaneous", "plan_name": "700720", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Miscellaneous", "plan_name": "700720_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Ppo Hmo", "plan_name": "701720", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Ppo Hmo", "plan_name": "701720_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Ambetter 68069", "plan_name": "500516", "standard_charge_dollar": 1423.06, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Ms State Emplo", "plan_name": "401457", "standard_charge_dollar": 1293.77, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Ms State Emplo", "plan_name": "401457_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Basic Pl", "plan_name": "400100", "standard_charge_dollar": 1293.77, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Basic Pl", "plan_name": "400100_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Federal", "plan_name": "400110", "standard_charge_dollar": 1293.77, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Federal", "plan_name": "400110_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Cigna Healthsprings Ffs", "plan_name": "500064", "standard_charge_dollar": 1423.06, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Conseco", "plan_name": "500302", "standard_charge_dollar": 1423.06, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Humana Ffs 61101", "plan_name": "500006", "standard_charge_dollar": 1423.06, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Medicare A", "plan_name": "100100", "standard_charge_dollar": 1423.06, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Medicare A", "plan_name": "100500", "standard_charge_dollar": 1423.06, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Medicare Part B Only", "plan_name": "100300", "standard_charge_dollar": 1423.06, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Medicare Railroad", "plan_name": "100103", "standard_charge_dollar": 1423.06, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Ms Physicians Care N", "plan_name": "714210", "standard_charge_dollar": 1778.82, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Peoples Hlth Ffs 72126", "plan_name": "500019", "standard_charge_dollar": 1423.06, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Uhc/Secure Horizons", "plan_name": "500449", "standard_charge_dollar": 1423.06, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "United Health Care/", "plan_name": "500292", "standard_charge_dollar": 1608.06, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "United Healthcare", "plan_name": "750104", "standard_charge_dollar": 1608.06, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "United Healthcare Ba", "plan_name": "750090", "standard_charge_dollar": 1608.06, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "United Healthcare Me", "plan_name": "501310", "standard_charge_dollar": 1423.06, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Windsor Mcare Extra", "plan_name": "500778", "standard_charge_dollar": 1423.06, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." } ] } ] }, { "description": "Draw blood off venous device", "code_information": [ { "code": "36591", "type": "CPT" } ], "standard_charges": [ { "gross_charge": 259.00, "minimum": 118.08, "maximum": 149.97, "setting": "both", "payers_information": [ { "payer_name": "Aarp", "plan_name": "500102", "standard_charge_dollar": 118.08, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna", "plan_name": "700700", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna", "plan_name": "700700_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Mcare Ffs 6005", "plan_name": "700703", "standard_charge_dollar": 118.08, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Miscellaneous", "plan_name": "700720", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Miscellaneous", "plan_name": "700720_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Ppo Hmo", "plan_name": "701720", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Ppo Hmo", "plan_name": "701720_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Ambetter 68069", "plan_name": "500516", "standard_charge_dollar": 118.08, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Ms State Emplo", "plan_name": "401457", "standard_charge_dollar": 149.97, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Ms State Emplo", "plan_name": "401457_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Basic Pl", "plan_name": "400100", "standard_charge_dollar": 149.97, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Basic Pl", "plan_name": "400100_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Federal", "plan_name": "400110", "standard_charge_dollar": 149.97, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Federal", "plan_name": "400110_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Cigna Healthsprings Ffs", "plan_name": "500064", "standard_charge_dollar": 118.08, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Conseco", "plan_name": "500302", "standard_charge_dollar": 118.08, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Humana Ffs 61101", "plan_name": "500006", "standard_charge_dollar": 118.08, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Medicare A", "plan_name": "100100", "standard_charge_dollar": 118.08, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Medicare A", "plan_name": "100500", "standard_charge_dollar": 118.08, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Medicare Part B Only", "plan_name": "100300", "standard_charge_dollar": 118.08, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Medicare Railroad", "plan_name": "100103", "standard_charge_dollar": 118.08, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Ms Physicians Care N", "plan_name": "714210", "standard_charge_dollar": 147.60, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Peoples Hlth Ffs 72126", "plan_name": "500019", "standard_charge_dollar": 118.08, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Uhc/Secure Horizons", "plan_name": "500449", "standard_charge_dollar": 118.08, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "United Health Care/", "plan_name": "500292", "standard_charge_dollar": 133.43, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "United Healthcare", "plan_name": "750104", "standard_charge_dollar": 133.43, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "United Healthcare Ba", "plan_name": "750090", "standard_charge_dollar": 133.43, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "United Healthcare Me", "plan_name": "501310", "standard_charge_dollar": 118.08, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Windsor Mcare Extra", "plan_name": "500778", "standard_charge_dollar": 118.08, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." } ] } ] }, { "description": "Hc collect blood from implanted port", "code_information": [ { "code": "36591", "type": "CPT" } ], "standard_charges": [ { "gross_charge": 259.00, "minimum": 118.08, "maximum": 149.97, "setting": "both", "payers_information": [ { "payer_name": "Aarp", "plan_name": "500102", "standard_charge_dollar": 118.08, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna", "plan_name": "700700", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna", "plan_name": "700700_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Mcare Ffs 6005", "plan_name": "700703", "standard_charge_dollar": 118.08, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Miscellaneous", "plan_name": "700720", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Miscellaneous", "plan_name": "700720_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Ppo Hmo", "plan_name": "701720", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Ppo Hmo", "plan_name": "701720_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Ambetter 68069", "plan_name": "500516", "standard_charge_dollar": 118.08, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Ms State Emplo", "plan_name": "401457", "standard_charge_dollar": 149.97, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Ms State Emplo", "plan_name": "401457_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Basic Pl", "plan_name": "400100", "standard_charge_dollar": 149.97, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Basic Pl", "plan_name": "400100_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Federal", "plan_name": "400110", "standard_charge_dollar": 149.97, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Federal", "plan_name": "400110_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Cigna Healthsprings Ffs", "plan_name": "500064", "standard_charge_dollar": 118.08, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Conseco", "plan_name": "500302", "standard_charge_dollar": 118.08, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Humana Ffs 61101", "plan_name": "500006", "standard_charge_dollar": 118.08, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Medicare A", "plan_name": "100100", "standard_charge_dollar": 118.08, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Medicare A", "plan_name": "100500", "standard_charge_dollar": 118.08, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Medicare Part B Only", "plan_name": "100300", "standard_charge_dollar": 118.08, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Medicare Railroad", "plan_name": "100103", "standard_charge_dollar": 118.08, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Ms Physicians Care N", "plan_name": "714210", "standard_charge_dollar": 147.60, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Peoples Hlth Ffs 72126", "plan_name": "500019", "standard_charge_dollar": 118.08, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Uhc/Secure Horizons", "plan_name": "500449", "standard_charge_dollar": 118.08, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "United Health Care/", "plan_name": "500292", "standard_charge_dollar": 133.43, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "United Healthcare", "plan_name": "750104", "standard_charge_dollar": 133.43, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "United Healthcare Ba", "plan_name": "750090", "standard_charge_dollar": 133.43, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "United Healthcare Me", "plan_name": "501310", "standard_charge_dollar": 118.08, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Windsor Mcare Extra", "plan_name": "500778", "standard_charge_dollar": 118.08, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." } ] } ] }, { "description": "Declot vascular device", "code_information": [ { "code": "36593", "type": "CPT" } ], "standard_charges": [ { "gross_charge": 49733.86, "minimum": 303.85, "maximum": 42273.78, "setting": "inpatient", "payers_information": [ { "payer_name": "Aarp", "plan_name": "500102", "standard_charge_dollar": 303.85, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna", "plan_name": "700700", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna", "plan_name": "700700_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Mcare Ffs 6005", "plan_name": "700703", "standard_charge_dollar": 303.85, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Miscellaneous", "plan_name": "700720", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Miscellaneous", "plan_name": "700720_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Ppo Hmo", "plan_name": "701720", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Ppo Hmo", "plan_name": "701720_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Ambetter 68069", "plan_name": "500516", "standard_charge_dollar": 303.85, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Ms State Emplo", "plan_name": "401457", "standard_charge_percentage": 0.80, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Ms State Emplo", "plan_name": "401457_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Basic Pl", "plan_name": "400100", "standard_charge_percentage": 0.85, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Basic Pl", "plan_name": "400100_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Federal", "plan_name": "400110", "standard_charge_percentage": 0.85, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Federal", "plan_name": "400110_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Cigna Healthsprings Ffs", "plan_name": "500064", "standard_charge_dollar": 303.85, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Conseco", "plan_name": "500302", "standard_charge_dollar": 303.85, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Humana Ffs 61101", "plan_name": "500006", "standard_charge_dollar": 303.85, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Medicare A", "plan_name": "100100", "standard_charge_dollar": 303.85, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Medicare A", "plan_name": "100500", "standard_charge_dollar": 303.85, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Medicare Part B Only", "plan_name": "100300", "standard_charge_dollar": 303.85, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Medicare Railroad", "plan_name": "100103", "standard_charge_dollar": 303.85, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Ms Physicians Care N", "plan_name": "714210", "standard_charge_dollar": 379.81, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Peoples Hlth Ffs 72126", "plan_name": "500019", "standard_charge_dollar": 303.85, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Uhc/Secure Horizons", "plan_name": "500449", "standard_charge_dollar": 303.85, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "United Health Care/", "plan_name": "500292", "standard_charge_dollar": 343.35, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "United Healthcare", "plan_name": "750104", "standard_charge_dollar": 343.35, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "United Healthcare Ba", "plan_name": "750090", "standard_charge_dollar": 343.35, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "United Healthcare Me", "plan_name": "501310", "standard_charge_dollar": 303.85, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Windsor Mcare Extra", "plan_name": "500778", "standard_charge_dollar": 303.85, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." } ] } ] }, { "description": "Hc interossous access", "code_information": [ { "code": "36680", "type": "CPT" } ], "standard_charges": [ { "gross_charge": 141.75, "minimum": 365.55, "maximum": 456.94, "setting": "both", "payers_information": [ { "payer_name": "Aarp", "plan_name": "500102", "standard_charge_dollar": 365.55, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna", "plan_name": "700700", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna", "plan_name": "700700_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Mcare Ffs 6005", "plan_name": "700703", "standard_charge_dollar": 365.55, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Miscellaneous", "plan_name": "700720", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Miscellaneous", "plan_name": "700720_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Ppo Hmo", "plan_name": "701720", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Ppo Hmo", "plan_name": "701720_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Ambetter 68069", "plan_name": "500516", "standard_charge_dollar": 365.55, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Ms State Emplo", "plan_name": "401457", "standard_charge_dollar": 395.24, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Ms State Emplo", "plan_name": "401457_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Basic Pl", "plan_name": "400100", "standard_charge_dollar": 395.24, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Basic Pl", "plan_name": "400100_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Federal", "plan_name": "400110", "standard_charge_dollar": 395.24, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Federal", "plan_name": "400110_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Cigna Healthsprings Ffs", "plan_name": "500064", "standard_charge_dollar": 365.55, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Conseco", "plan_name": "500302", "standard_charge_dollar": 365.55, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Humana Ffs 61101", "plan_name": "500006", "standard_charge_dollar": 365.55, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Medicare A", "plan_name": "100100", "standard_charge_dollar": 365.55, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Medicare A", "plan_name": "100500", "standard_charge_dollar": 365.55, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Medicare Part B Only", "plan_name": "100300", "standard_charge_dollar": 365.55, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Medicare Railroad", "plan_name": "100103", "standard_charge_dollar": 365.55, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Ms Physicians Care N", "plan_name": "714210", "standard_charge_dollar": 456.94, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Peoples Hlth Ffs 72126", "plan_name": "500019", "standard_charge_dollar": 365.55, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Uhc/Secure Horizons", "plan_name": "500449", "standard_charge_dollar": 365.55, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "United Health Care/", "plan_name": "500292", "standard_charge_dollar": 413.07, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "United Healthcare", "plan_name": "750104", "standard_charge_dollar": 413.07, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "United Healthcare Ba", "plan_name": "750090", "standard_charge_dollar": 413.07, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "United Healthcare Me", "plan_name": "501310", "standard_charge_dollar": 365.55, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Windsor Mcare Extra", "plan_name": "500778", "standard_charge_dollar": 365.55, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." } ] } ] }, { "description": "Insert needle bone cavity", "code_information": [ { "code": "36680", "type": "CPT" } ], "standard_charges": [ { "gross_charge": 141.75, "minimum": 365.55, "maximum": 456.94, "setting": "both", "payers_information": [ { "payer_name": "Aarp", "plan_name": "500102", "standard_charge_dollar": 365.55, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna", "plan_name": "700700", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna", "plan_name": "700700_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Mcare Ffs 6005", "plan_name": "700703", "standard_charge_dollar": 365.55, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Miscellaneous", "plan_name": "700720", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Miscellaneous", "plan_name": "700720_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Ppo Hmo", "plan_name": "701720", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Ppo Hmo", "plan_name": "701720_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Ambetter 68069", "plan_name": "500516", "standard_charge_dollar": 365.55, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Ms State Emplo", "plan_name": "401457", "standard_charge_dollar": 395.24, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Ms State Emplo", "plan_name": "401457_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Basic Pl", "plan_name": "400100", "standard_charge_dollar": 395.24, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Basic Pl", "plan_name": "400100_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Federal", "plan_name": "400110", "standard_charge_dollar": 395.24, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Federal", "plan_name": "400110_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Cigna Healthsprings Ffs", "plan_name": "500064", "standard_charge_dollar": 365.55, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Conseco", "plan_name": "500302", "standard_charge_dollar": 365.55, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Humana Ffs 61101", "plan_name": "500006", "standard_charge_dollar": 365.55, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Medicare A", "plan_name": "100100", "standard_charge_dollar": 365.55, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Medicare A", "plan_name": "100500", "standard_charge_dollar": 365.55, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Medicare Part B Only", "plan_name": "100300", "standard_charge_dollar": 365.55, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Medicare Railroad", "plan_name": "100103", "standard_charge_dollar": 365.55, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Ms Physicians Care N", "plan_name": "714210", "standard_charge_dollar": 456.94, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Peoples Hlth Ffs 72126", "plan_name": "500019", "standard_charge_dollar": 365.55, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Uhc/Secure Horizons", "plan_name": "500449", "standard_charge_dollar": 365.55, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "United Health Care/", "plan_name": "500292", "standard_charge_dollar": 413.07, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "United Healthcare", "plan_name": "750104", "standard_charge_dollar": 413.07, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "United Healthcare Ba", "plan_name": "750090", "standard_charge_dollar": 413.07, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "United Healthcare Me", "plan_name": "501310", "standard_charge_dollar": 365.55, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Windsor Mcare Extra", "plan_name": "500778", "standard_charge_dollar": 365.55, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." } ] } ] }, { "description": "Dist revas ligation hemo", "code_information": [ { "code": "36838", "type": "CPT" } ], "standard_charges": [ { "gross_charge": 66977.58, "minimum": 4951.99, "maximum": 56930.94, "setting": "inpatient", "payers_information": [ { "payer_name": "Aarp", "plan_name": "500102", "standard_charge_dollar": 4951.99, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna", "plan_name": "700700", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna", "plan_name": "700700_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Mcare Ffs 6005", "plan_name": "700703", "standard_charge_dollar": 4951.99, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Miscellaneous", "plan_name": "700720", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Miscellaneous", "plan_name": "700720_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Ppo Hmo", "plan_name": "701720", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Ppo Hmo", "plan_name": "701720_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Ambetter 68069", "plan_name": "500516", "standard_charge_dollar": 4951.99, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Ms State Emplo", "plan_name": "401457", "standard_charge_percentage": 0.80, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Ms State Emplo", "plan_name": "401457_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Basic Pl", "plan_name": "400100", "standard_charge_percentage": 0.85, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Basic Pl", "plan_name": "400100_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Federal", "plan_name": "400110", "standard_charge_percentage": 0.85, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Federal", "plan_name": "400110_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Cigna Healthsprings Ffs", "plan_name": "500064", "standard_charge_dollar": 4951.99, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Conseco", "plan_name": "500302", "standard_charge_dollar": 4951.99, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Humana Ffs 61101", "plan_name": "500006", "standard_charge_dollar": 4951.99, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Medicare A", "plan_name": "100100", "standard_charge_dollar": 4951.99, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Medicare A", "plan_name": "100500", "standard_charge_dollar": 4951.99, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Medicare Part B Only", "plan_name": "100300", "standard_charge_dollar": 4951.99, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Medicare Railroad", "plan_name": "100103", "standard_charge_dollar": 4951.99, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Ms Physicians Care N", "plan_name": "714210", "standard_charge_dollar": 6189.99, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Peoples Hlth Ffs 72126", "plan_name": "500019", "standard_charge_dollar": 4951.99, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Uhc/Secure Horizons", "plan_name": "500449", "standard_charge_dollar": 4951.99, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "United Health Care/", "plan_name": "500292", "standard_charge_dollar": 5595.75, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "United Healthcare", "plan_name": "750104", "standard_charge_dollar": 5595.75, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "United Healthcare Ba", "plan_name": "750090", "standard_charge_dollar": 5595.75, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "United Healthcare Me", "plan_name": "501310", "standard_charge_dollar": 4951.99, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Windsor Mcare Extra", "plan_name": "500778", "standard_charge_dollar": 4951.99, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." } ] } ] }, { "description": "External cannula declotting", "code_information": [ { "code": "36860", "type": "CPT" } ], "standard_charges": [ { "gross_charge": 49733.86, "minimum": 1423.06, "maximum": 42273.78, "setting": "inpatient", "payers_information": [ { "payer_name": "Aarp", "plan_name": "500102", "standard_charge_dollar": 1423.06, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna", "plan_name": "700700", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna", "plan_name": "700700_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Mcare Ffs 6005", "plan_name": "700703", "standard_charge_dollar": 1423.06, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Miscellaneous", "plan_name": "700720", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Miscellaneous", "plan_name": "700720_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Ppo Hmo", "plan_name": "701720", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Ppo Hmo", "plan_name": "701720_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Ambetter 68069", "plan_name": "500516", "standard_charge_dollar": 1423.06, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Ms State Emplo", "plan_name": "401457", "standard_charge_percentage": 0.80, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Ms State Emplo", "plan_name": "401457_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Basic Pl", "plan_name": "400100", "standard_charge_percentage": 0.85, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Basic Pl", "plan_name": "400100_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Federal", "plan_name": "400110", "standard_charge_percentage": 0.85, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Federal", "plan_name": "400110_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Cigna Healthsprings Ffs", "plan_name": "500064", "standard_charge_dollar": 1423.06, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Conseco", "plan_name": "500302", "standard_charge_dollar": 1423.06, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Humana Ffs 61101", "plan_name": "500006", "standard_charge_dollar": 1423.06, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Medicare A", "plan_name": "100100", "standard_charge_dollar": 1423.06, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Medicare A", "plan_name": "100500", "standard_charge_dollar": 1423.06, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Medicare Part B Only", "plan_name": "100300", "standard_charge_dollar": 1423.06, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Medicare Railroad", "plan_name": "100103", "standard_charge_dollar": 1423.06, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Ms Physicians Care N", "plan_name": "714210", "standard_charge_dollar": 1778.82, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Peoples Hlth Ffs 72126", "plan_name": "500019", "standard_charge_dollar": 1423.06, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Uhc/Secure Horizons", "plan_name": "500449", "standard_charge_dollar": 1423.06, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "United Health Care/", "plan_name": "500292", "standard_charge_dollar": 1608.06, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "United Healthcare", "plan_name": "750104", "standard_charge_dollar": 1608.06, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "United Healthcare Ba", "plan_name": "750090", "standard_charge_dollar": 1608.06, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "United Healthcare Me", "plan_name": "501310", "standard_charge_dollar": 1423.06, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Windsor Mcare Extra", "plan_name": "500778", "standard_charge_dollar": 1423.06, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." } ] } ] }, { "description": "Prim art m-thrmbc 1st vsl", "code_information": [ { "code": "37184", "type": "CPT" } ], "standard_charges": [ { "gross_charge": 49733.86, "minimum": 16449.60, "maximum": 42273.78, "setting": "inpatient", "payers_information": [ { "payer_name": "Aarp", "plan_name": "500102", "standard_charge_dollar": 16449.60, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna", "plan_name": "700700", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna", "plan_name": "700700_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Mcare Ffs 6005", "plan_name": "700703", "standard_charge_dollar": 16449.60, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Miscellaneous", "plan_name": "700720", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Miscellaneous", "plan_name": "700720_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Ppo Hmo", "plan_name": "701720", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Ppo Hmo", "plan_name": "701720_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Ambetter 68069", "plan_name": "500516", "standard_charge_dollar": 16449.60, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Ms State Emplo", "plan_name": "401457", "standard_charge_percentage": 0.80, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Ms State Emplo", "plan_name": "401457_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Basic Pl", "plan_name": "400100", "standard_charge_percentage": 0.85, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Basic Pl", "plan_name": "400100_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Federal", "plan_name": "400110", "standard_charge_percentage": 0.85, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Federal", "plan_name": "400110_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Cigna Healthsprings Ffs", "plan_name": "500064", "standard_charge_dollar": 16449.60, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Conseco", "plan_name": "500302", "standard_charge_dollar": 16449.60, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Humana Ffs 61101", "plan_name": "500006", "standard_charge_dollar": 16449.60, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Medicare A", "plan_name": "100100", "standard_charge_dollar": 16449.60, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Medicare A", "plan_name": "100500", "standard_charge_dollar": 16449.60, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Medicare Part B Only", "plan_name": "100300", "standard_charge_dollar": 16449.60, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Medicare Railroad", "plan_name": "100103", "standard_charge_dollar": 16449.60, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Ms Physicians Care N", "plan_name": "714210", "standard_charge_dollar": 20562.00, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Peoples Hlth Ffs 72126", "plan_name": "500019", "standard_charge_dollar": 16449.60, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Uhc/Secure Horizons", "plan_name": "500449", "standard_charge_dollar": 16449.60, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "United Health Care/", "plan_name": "500292", "standard_charge_dollar": 18588.04, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "United Healthcare", "plan_name": "750104", "standard_charge_dollar": 18588.04, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "United Healthcare Ba", "plan_name": "750090", "standard_charge_dollar": 18588.04, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "United Healthcare Me", "plan_name": "501310", "standard_charge_dollar": 16449.60, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Windsor Mcare Extra", "plan_name": "500778", "standard_charge_dollar": 16449.60, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." } ] } ] }, { "description": "Prim art m-thrmbc sbsq vsl", "code_information": [ { "code": "37185", "type": "CPT" } ], "standard_charges": [ { "gross_charge": 49733.86, "minimum": 39787.09, "maximum": 42273.78, "setting": "inpatient", "payers_information": [ { "payer_name": "Aetna", "plan_name": "700700", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna", "plan_name": "700700_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Miscellaneous", "plan_name": "700720", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Miscellaneous", "plan_name": "700720_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Ppo Hmo", "plan_name": "701720", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Ppo Hmo", "plan_name": "701720_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Ms State Emplo", "plan_name": "401457", "standard_charge_percentage": 0.80, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Ms State Emplo", "plan_name": "401457_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Basic Pl", "plan_name": "400100", "standard_charge_percentage": 0.85, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Basic Pl", "plan_name": "400100_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Federal", "plan_name": "400110", "standard_charge_percentage": 0.85, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Federal", "plan_name": "400110_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." } ] } ] }, { "description": "Sec art thrombectomy add-on", "code_information": [ { "code": "37186", "type": "CPT" } ], "standard_charges": [ { "gross_charge": 66123.06, "minimum": 52898.45, "maximum": 56204.60, "setting": "inpatient", "payers_information": [ { "payer_name": "Aetna", "plan_name": "700700", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna", "plan_name": "700700_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Miscellaneous", "plan_name": "700720", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Miscellaneous", "plan_name": "700720_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Ppo Hmo", "plan_name": "701720", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Ppo Hmo", "plan_name": "701720_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Ms State Emplo", "plan_name": "401457", "standard_charge_percentage": 0.80, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Ms State Emplo", "plan_name": "401457_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Basic Pl", "plan_name": "400100", "standard_charge_percentage": 0.85, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Basic Pl", "plan_name": "400100_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Federal", "plan_name": "400110", "standard_charge_percentage": 0.85, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Federal", "plan_name": "400110_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." } ] } ] }, { "description": "Venous mech thrombectomy", "code_information": [ { "code": "37187", "type": "CPT" } ], "standard_charges": [ { "gross_charge": 49733.86, "minimum": 10388.75, "maximum": 42273.78, "setting": "inpatient", "payers_information": [ { "payer_name": "Aarp", "plan_name": "500102", "standard_charge_dollar": 10388.75, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna", "plan_name": "700700", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna", "plan_name": "700700_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Mcare Ffs 6005", "plan_name": "700703", "standard_charge_dollar": 10388.75, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Miscellaneous", "plan_name": "700720", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Miscellaneous", "plan_name": "700720_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Ppo Hmo", "plan_name": "701720", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Ppo Hmo", "plan_name": "701720_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Ambetter 68069", "plan_name": "500516", "standard_charge_dollar": 10388.75, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Ms State Emplo", "plan_name": "401457", "standard_charge_percentage": 0.80, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Ms State Emplo", "plan_name": "401457_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Basic Pl", "plan_name": "400100", "standard_charge_percentage": 0.85, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Basic Pl", "plan_name": "400100_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Federal", "plan_name": "400110", "standard_charge_percentage": 0.85, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Federal", "plan_name": "400110_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Cigna Healthsprings Ffs", "plan_name": "500064", "standard_charge_dollar": 10388.75, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Conseco", "plan_name": "500302", "standard_charge_dollar": 10388.75, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Humana Ffs 61101", "plan_name": "500006", "standard_charge_dollar": 10388.75, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Medicare A", "plan_name": "100100", "standard_charge_dollar": 10388.75, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Medicare A", "plan_name": "100500", "standard_charge_dollar": 10388.75, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Medicare Part B Only", "plan_name": "100300", "standard_charge_dollar": 10388.75, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Medicare Railroad", "plan_name": "100103", "standard_charge_dollar": 10388.75, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Ms Physicians Care N", "plan_name": "714210", "standard_charge_dollar": 12985.93, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Peoples Hlth Ffs 72126", "plan_name": "500019", "standard_charge_dollar": 10388.75, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Uhc/Secure Horizons", "plan_name": "500449", "standard_charge_dollar": 10388.75, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "United Health Care/", "plan_name": "500292", "standard_charge_dollar": 11739.28, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "United Healthcare", "plan_name": "750104", "standard_charge_dollar": 11739.28, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "United Healthcare Ba", "plan_name": "750090", "standard_charge_dollar": 11739.28, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "United Healthcare Me", "plan_name": "501310", "standard_charge_dollar": 10388.75, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Windsor Mcare Extra", "plan_name": "500778", "standard_charge_dollar": 10388.75, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." } ] } ] }, { "description": "Ven mechnl thrmbc repeat tx", "code_information": [ { "code": "37188", "type": "CPT" } ], "standard_charges": [ { "gross_charge": 49733.86, "minimum": 2883.33, "maximum": 42273.78, "setting": "inpatient", "payers_information": [ { "payer_name": "Aarp", "plan_name": "500102", "standard_charge_dollar": 2883.33, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna", "plan_name": "700700", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna", "plan_name": "700700_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Mcare Ffs 6005", "plan_name": "700703", "standard_charge_dollar": 2883.33, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Miscellaneous", "plan_name": "700720", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Miscellaneous", "plan_name": "700720_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Ppo Hmo", "plan_name": "701720", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Ppo Hmo", "plan_name": "701720_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Ambetter 68069", "plan_name": "500516", "standard_charge_dollar": 2883.33, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Ms State Emplo", "plan_name": "401457", "standard_charge_percentage": 0.80, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Ms State Emplo", "plan_name": "401457_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Basic Pl", "plan_name": "400100", "standard_charge_percentage": 0.85, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Basic Pl", "plan_name": "400100_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Federal", "plan_name": "400110", "standard_charge_percentage": 0.85, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Federal", "plan_name": "400110_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Cigna Healthsprings Ffs", "plan_name": "500064", "standard_charge_dollar": 2883.33, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Conseco", "plan_name": "500302", "standard_charge_dollar": 2883.33, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Humana Ffs 61101", "plan_name": "500006", "standard_charge_dollar": 2883.33, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Medicare A", "plan_name": "100100", "standard_charge_dollar": 2883.33, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Medicare A", "plan_name": "100500", "standard_charge_dollar": 2883.33, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Medicare Part B Only", "plan_name": "100300", "standard_charge_dollar": 2883.33, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Medicare Railroad", "plan_name": "100103", "standard_charge_dollar": 2883.33, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Ms Physicians Care N", "plan_name": "714210", "standard_charge_dollar": 3604.16, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Peoples Hlth Ffs 72126", "plan_name": "500019", "standard_charge_dollar": 2883.33, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Uhc/Secure Horizons", "plan_name": "500449", "standard_charge_dollar": 2883.33, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "United Health Care/", "plan_name": "500292", "standard_charge_dollar": 3258.16, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "United Healthcare", "plan_name": "750104", "standard_charge_dollar": 3258.16, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "United Healthcare Ba", "plan_name": "750090", "standard_charge_dollar": 3258.16, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "United Healthcare Me", "plan_name": "501310", "standard_charge_dollar": 2883.33, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Windsor Mcare Extra", "plan_name": "500778", "standard_charge_dollar": 2883.33, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." } ] } ] }, { "description": "Ins endovas vena cava filtr", "code_information": [ { "code": "37191", "type": "CPT" } ], "standard_charges": [ { "gross_charge": 40138.35, "minimum": 4951.99, "maximum": 34117.60, "setting": "inpatient", "payers_information": [ { "payer_name": "Aarp", "plan_name": "500102", "standard_charge_dollar": 4951.99, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna", "plan_name": "700700", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna", "plan_name": "700700_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Mcare Ffs 6005", "plan_name": "700703", "standard_charge_dollar": 4951.99, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Miscellaneous", "plan_name": "700720", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Miscellaneous", "plan_name": "700720_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Ppo Hmo", "plan_name": "701720", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Ppo Hmo", "plan_name": "701720_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Ambetter 68069", "plan_name": "500516", "standard_charge_dollar": 4951.99, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Ms State Emplo", "plan_name": "401457", "standard_charge_percentage": 0.80, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Ms State Emplo", "plan_name": "401457_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Basic Pl", "plan_name": "400100", "standard_charge_percentage": 0.85, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Basic Pl", "plan_name": "400100_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Federal", "plan_name": "400110", "standard_charge_percentage": 0.85, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Federal", "plan_name": "400110_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Cigna Healthsprings Ffs", "plan_name": "500064", "standard_charge_dollar": 4951.99, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Conseco", "plan_name": "500302", "standard_charge_dollar": 4951.99, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Humana Ffs 61101", "plan_name": "500006", "standard_charge_dollar": 4951.99, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Medicare A", "plan_name": "100100", "standard_charge_dollar": 4951.99, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Medicare A", "plan_name": "100500", "standard_charge_dollar": 4951.99, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Medicare Part B Only", "plan_name": "100300", "standard_charge_dollar": 4951.99, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Medicare Railroad", "plan_name": "100103", "standard_charge_dollar": 4951.99, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Ms Physicians Care N", "plan_name": "714210", "standard_charge_dollar": 6189.99, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Peoples Hlth Ffs 72126", "plan_name": "500019", "standard_charge_dollar": 4951.99, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Uhc/Secure Horizons", "plan_name": "500449", "standard_charge_dollar": 4951.99, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "United Health Care/", "plan_name": "500292", "standard_charge_dollar": 5595.75, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "United Healthcare", "plan_name": "750104", "standard_charge_dollar": 5595.75, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "United Healthcare Ba", "plan_name": "750090", "standard_charge_dollar": 5595.75, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "United Healthcare Me", "plan_name": "501310", "standard_charge_dollar": 4951.99, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Windsor Mcare Extra", "plan_name": "500778", "standard_charge_dollar": 4951.99, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." } ] } ] }, { "description": "Thrombolytic venous therapy", "code_information": [ { "code": "37212", "type": "CPT" } ], "standard_charges": [ { "gross_charge": 49733.86, "minimum": 2883.33, "maximum": 42273.78, "setting": "inpatient", "payers_information": [ { "payer_name": "Aarp", "plan_name": "500102", "standard_charge_dollar": 2883.33, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna", "plan_name": "700700", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna", "plan_name": "700700_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Mcare Ffs 6005", "plan_name": "700703", "standard_charge_dollar": 2883.33, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Miscellaneous", "plan_name": "700720", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Miscellaneous", "plan_name": "700720_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Ppo Hmo", "plan_name": "701720", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Ppo Hmo", "plan_name": "701720_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Ambetter 68069", "plan_name": "500516", "standard_charge_dollar": 2883.33, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Ms State Emplo", "plan_name": "401457", "standard_charge_percentage": 0.80, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Ms State Emplo", "plan_name": "401457_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Basic Pl", "plan_name": "400100", "standard_charge_percentage": 0.85, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Basic Pl", "plan_name": "400100_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Federal", "plan_name": "400110", "standard_charge_percentage": 0.85, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Federal", "plan_name": "400110_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Cigna Healthsprings Ffs", "plan_name": "500064", "standard_charge_dollar": 2883.33, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Conseco", "plan_name": "500302", "standard_charge_dollar": 2883.33, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Humana Ffs 61101", "plan_name": "500006", "standard_charge_dollar": 2883.33, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Medicare A", "plan_name": "100100", "standard_charge_dollar": 2883.33, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Medicare A", "plan_name": "100500", "standard_charge_dollar": 2883.33, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Medicare Part B Only", "plan_name": "100300", "standard_charge_dollar": 2883.33, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Medicare Railroad", "plan_name": "100103", "standard_charge_dollar": 2883.33, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Ms Physicians Care N", "plan_name": "714210", "standard_charge_dollar": 3604.16, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Peoples Hlth Ffs 72126", "plan_name": "500019", "standard_charge_dollar": 2883.33, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Uhc/Secure Horizons", "plan_name": "500449", "standard_charge_dollar": 2883.33, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "United Health Care/", "plan_name": "500292", "standard_charge_dollar": 3258.16, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "United Healthcare", "plan_name": "750104", "standard_charge_dollar": 3258.16, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "United Healthcare Ba", "plan_name": "750090", "standard_charge_dollar": 3258.16, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "United Healthcare Me", "plan_name": "501310", "standard_charge_dollar": 2883.33, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Windsor Mcare Extra", "plan_name": "500778", "standard_charge_dollar": 2883.33, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." } ] } ] }, { "description": "Thromblytic art/ven therapy", "code_information": [ { "code": "37213", "type": "CPT" } ], "standard_charges": [ { "gross_charge": 49733.86, "minimum": 2883.33, "maximum": 42273.78, "setting": "inpatient", "payers_information": [ { "payer_name": "Aarp", "plan_name": "500102", "standard_charge_dollar": 2883.33, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna", "plan_name": "700700", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna", "plan_name": "700700_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Mcare Ffs 6005", "plan_name": "700703", "standard_charge_dollar": 2883.33, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Miscellaneous", "plan_name": "700720", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Miscellaneous", "plan_name": "700720_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Ppo Hmo", "plan_name": "701720", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Ppo Hmo", "plan_name": "701720_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Ambetter 68069", "plan_name": "500516", "standard_charge_dollar": 2883.33, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Ms State Emplo", "plan_name": "401457", "standard_charge_percentage": 0.80, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Ms State Emplo", "plan_name": "401457_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Basic Pl", "plan_name": "400100", "standard_charge_percentage": 0.85, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Basic Pl", "plan_name": "400100_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Federal", "plan_name": "400110", "standard_charge_percentage": 0.85, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Federal", "plan_name": "400110_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Cigna Healthsprings Ffs", "plan_name": "500064", "standard_charge_dollar": 2883.33, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Conseco", "plan_name": "500302", "standard_charge_dollar": 2883.33, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Humana Ffs 61101", "plan_name": "500006", "standard_charge_dollar": 2883.33, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Medicare A", "plan_name": "100100", "standard_charge_dollar": 2883.33, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Medicare A", "plan_name": "100500", "standard_charge_dollar": 2883.33, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Medicare Part B Only", "plan_name": "100300", "standard_charge_dollar": 2883.33, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Medicare Railroad", "plan_name": "100103", "standard_charge_dollar": 2883.33, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Ms Physicians Care N", "plan_name": "714210", "standard_charge_dollar": 3604.16, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Peoples Hlth Ffs 72126", "plan_name": "500019", "standard_charge_dollar": 2883.33, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Uhc/Secure Horizons", "plan_name": "500449", "standard_charge_dollar": 2883.33, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "United Health Care/", "plan_name": "500292", "standard_charge_dollar": 3258.16, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "United Healthcare", "plan_name": "750104", "standard_charge_dollar": 3258.16, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "United Healthcare Ba", "plan_name": "750090", "standard_charge_dollar": 3258.16, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "United Healthcare Me", "plan_name": "501310", "standard_charge_dollar": 2883.33, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Windsor Mcare Extra", "plan_name": "500778", "standard_charge_dollar": 2883.33, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." } ] } ] }, { "description": "Cessj therapy cath removal", "code_information": [ { "code": "37214", "type": "CPT" } ], "standard_charges": [ { "gross_charge": 49733.86, "minimum": 2883.33, "maximum": 42273.78, "setting": "inpatient", "payers_information": [ { "payer_name": "Aarp", "plan_name": "500102", "standard_charge_dollar": 2883.33, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna", "plan_name": "700700", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna", "plan_name": "700700_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Mcare Ffs 6005", "plan_name": "700703", "standard_charge_dollar": 2883.33, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Miscellaneous", "plan_name": "700720", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Miscellaneous", "plan_name": "700720_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Ppo Hmo", "plan_name": "701720", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Ppo Hmo", "plan_name": "701720_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Ambetter 68069", "plan_name": "500516", "standard_charge_dollar": 2883.33, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Ms State Emplo", "plan_name": "401457", "standard_charge_percentage": 0.80, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Ms State Emplo", "plan_name": "401457_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Basic Pl", "plan_name": "400100", "standard_charge_percentage": 0.85, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Basic Pl", "plan_name": "400100_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Federal", "plan_name": "400110", "standard_charge_percentage": 0.85, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Federal", "plan_name": "400110_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Cigna Healthsprings Ffs", "plan_name": "500064", "standard_charge_dollar": 2883.33, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Conseco", "plan_name": "500302", "standard_charge_dollar": 2883.33, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Humana Ffs 61101", "plan_name": "500006", "standard_charge_dollar": 2883.33, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Medicare A", "plan_name": "100100", "standard_charge_dollar": 2883.33, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Medicare A", "plan_name": "100500", "standard_charge_dollar": 2883.33, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Medicare Part B Only", "plan_name": "100300", "standard_charge_dollar": 2883.33, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Medicare Railroad", "plan_name": "100103", "standard_charge_dollar": 2883.33, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Ms Physicians Care N", "plan_name": "714210", "standard_charge_dollar": 3604.16, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Peoples Hlth Ffs 72126", "plan_name": "500019", "standard_charge_dollar": 2883.33, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Uhc/Secure Horizons", "plan_name": "500449", "standard_charge_dollar": 2883.33, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "United Health Care/", "plan_name": "500292", "standard_charge_dollar": 3258.16, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "United Healthcare", "plan_name": "750104", "standard_charge_dollar": 3258.16, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "United Healthcare Ba", "plan_name": "750090", "standard_charge_dollar": 3258.16, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "United Healthcare Me", "plan_name": "501310", "standard_charge_dollar": 2883.33, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Windsor Mcare Extra", "plan_name": "500778", "standard_charge_dollar": 2883.33, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." } ] } ] }, { "description": "Transcath stent cca w/eps", "code_information": [ { "code": "37215", "type": "CPT" } ], "standard_charges": [ { "gross_charge": 21553.89, "minimum": 17243.11, "maximum": 18320.81, "setting": "inpatient", "payers_information": [ { "payer_name": "Aetna", "plan_name": "700700", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna", "plan_name": "700700_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Miscellaneous", "plan_name": "700720", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Miscellaneous", "plan_name": "700720_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Ppo Hmo", "plan_name": "701720", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Ppo Hmo", "plan_name": "701720_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Ms State Emplo", "plan_name": "401457", "standard_charge_percentage": 0.80, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Ms State Emplo", "plan_name": "401457_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Basic Pl", "plan_name": "400100", "standard_charge_percentage": 0.85, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Basic Pl", "plan_name": "400100_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Federal", "plan_name": "400110", "standard_charge_percentage": 0.85, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Federal", "plan_name": "400110_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." } ] } ] }, { "description": "Transcath stent cca w/o eps", "code_information": [ { "code": "37216", "type": "CPT" } ], "standard_charges": [ { "gross_charge": 21553.89, "minimum": 2061.00, "maximum": 2061.00, "setting": "inpatient", "payers_information": [ { "payer_name": "Aetna", "plan_name": "700700", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna", "plan_name": "700700_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Miscellaneous", "plan_name": "700720", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Miscellaneous", "plan_name": "700720_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Ppo Hmo", "plan_name": "701720", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Ppo Hmo", "plan_name": "701720_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Ms State Emplo", "plan_name": "401457", "standard_charge_dollar": 2061.00, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Ms State Emplo", "plan_name": "401457_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Basic Pl", "plan_name": "400100", "standard_charge_dollar": 2061.00, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Basic Pl", "plan_name": "400100_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Federal", "plan_name": "400110", "standard_charge_dollar": 2061.00, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Federal", "plan_name": "400110_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." } ] } ] }, { "description": "Stent placemt retro carotid", "code_information": [ { "code": "37217", "type": "CPT" } ], "standard_charges": [ { "gross_charge": 21553.89, "minimum": 17243.11, "maximum": 18320.81, "setting": "inpatient", "payers_information": [ { "payer_name": "Aetna", "plan_name": "700700", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna", "plan_name": "700700_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Miscellaneous", "plan_name": "700720", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Miscellaneous", "plan_name": "700720_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Ppo Hmo", "plan_name": "701720", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Ppo Hmo", "plan_name": "701720_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Ms State Emplo", "plan_name": "401457", "standard_charge_percentage": 0.80, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Ms State Emplo", "plan_name": "401457_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Basic Pl", "plan_name": "400100", "standard_charge_percentage": 0.85, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Basic Pl", "plan_name": "400100_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Federal", "plan_name": "400110", "standard_charge_percentage": 0.85, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Federal", "plan_name": "400110_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." } ] } ] }, { "description": "Stent placemt ante carotid", "code_information": [ { "code": "37218", "type": "CPT" } ], "standard_charges": [ { "gross_charge": 20227.64, "minimum": 16182.11, "maximum": 17193.49, "setting": "inpatient", "payers_information": [ { "payer_name": "Aetna", "plan_name": "700700", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna", "plan_name": "700700_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Miscellaneous", "plan_name": "700720", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Miscellaneous", "plan_name": "700720_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Ppo Hmo", "plan_name": "701720", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Ppo Hmo", "plan_name": "701720_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Ms State Emplo", "plan_name": "401457", "standard_charge_percentage": 0.80, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Ms State Emplo", "plan_name": "401457_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Basic Pl", "plan_name": "400100", "standard_charge_percentage": 0.85, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Basic Pl", "plan_name": "400100_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Federal", "plan_name": "400110", "standard_charge_percentage": 0.85, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Federal", "plan_name": "400110_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." } ] } ] }, { "description": "Vasc embolize/occlude artery", "code_information": [ { "code": "37242", "type": "CPT" } ], "standard_charges": [ { "gross_charge": 98480.36, "minimum": 536.27, "maximum": 20562.00, "setting": "inpatient", "payers_information": [ { "payer_name": "Aarp", "plan_name": "500102", "standard_charge_dollar": 16449.60, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna", "plan_name": "700700", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna", "plan_name": "700700_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Mcare Ffs 6005", "plan_name": "700703", "standard_charge_dollar": 16449.60, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Miscellaneous", "plan_name": "700720", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Miscellaneous", "plan_name": "700720_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Ppo Hmo", "plan_name": "701720", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Ppo Hmo", "plan_name": "701720_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Ambetter 68069", "plan_name": "500516", "standard_charge_dollar": 16449.60, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Ms State Emplo", "plan_name": "401457", "standard_charge_dollar": 536.27, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Ms State Emplo", "plan_name": "401457_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Basic Pl", "plan_name": "400100", "standard_charge_dollar": 536.27, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Basic Pl", "plan_name": "400100_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Federal", "plan_name": "400110", "standard_charge_dollar": 536.27, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Federal", "plan_name": "400110_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Cigna Healthsprings Ffs", "plan_name": "500064", "standard_charge_dollar": 16449.60, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Conseco", "plan_name": "500302", "standard_charge_dollar": 16449.60, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Humana Ffs 61101", "plan_name": "500006", "standard_charge_dollar": 16449.60, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Medicare A", "plan_name": "100100", "standard_charge_dollar": 16449.60, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Medicare A", "plan_name": "100500", "standard_charge_dollar": 16449.60, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Medicare Part B Only", "plan_name": "100300", "standard_charge_dollar": 16449.60, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Medicare Railroad", "plan_name": "100103", "standard_charge_dollar": 16449.60, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Ms Physicians Care N", "plan_name": "714210", "standard_charge_dollar": 20562.00, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Peoples Hlth Ffs 72126", "plan_name": "500019", "standard_charge_dollar": 16449.60, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Uhc/Secure Horizons", "plan_name": "500449", "standard_charge_dollar": 16449.60, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "United Health Care/", "plan_name": "500292", "standard_charge_dollar": 18588.04, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "United Healthcare", "plan_name": "750104", "standard_charge_dollar": 18588.04, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "United Healthcare Ba", "plan_name": "750090", "standard_charge_dollar": 18588.04, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "United Healthcare Me", "plan_name": "501310", "standard_charge_dollar": 16449.60, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Windsor Mcare Extra", "plan_name": "500778", "standard_charge_dollar": 16449.60, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." } ] } ] }, { "description": "Vasc embolize/occlude organ", "code_information": [ { "code": "37243", "type": "CPT" } ], "standard_charges": [ { "gross_charge": 98480.36, "minimum": 640.08, "maximum": 12985.93, "setting": "inpatient", "payers_information": [ { "payer_name": "Aarp", "plan_name": "500102", "standard_charge_dollar": 10388.75, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna", "plan_name": "700700", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna", "plan_name": "700700_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Mcare Ffs 6005", "plan_name": "700703", "standard_charge_dollar": 10388.75, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Miscellaneous", "plan_name": "700720", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Miscellaneous", "plan_name": "700720_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Ppo Hmo", "plan_name": "701720", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Ppo Hmo", "plan_name": "701720_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Ambetter 68069", "plan_name": "500516", "standard_charge_dollar": 10388.75, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Ms State Emplo", "plan_name": "401457", "standard_charge_dollar": 640.08, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Ms State Emplo", "plan_name": "401457_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Basic Pl", "plan_name": "400100", "standard_charge_dollar": 640.08, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Basic Pl", "plan_name": "400100_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Federal", "plan_name": "400110", "standard_charge_dollar": 640.08, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Federal", "plan_name": "400110_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Cigna Healthsprings Ffs", "plan_name": "500064", "standard_charge_dollar": 10388.75, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Conseco", "plan_name": "500302", "standard_charge_dollar": 10388.75, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Humana Ffs 61101", "plan_name": "500006", "standard_charge_dollar": 10388.75, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Medicare A", "plan_name": "100100", "standard_charge_dollar": 10388.75, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Medicare A", "plan_name": "100500", "standard_charge_dollar": 10388.75, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Medicare Part B Only", "plan_name": "100300", "standard_charge_dollar": 10388.75, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Medicare Railroad", "plan_name": "100103", "standard_charge_dollar": 10388.75, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Ms Physicians Care N", "plan_name": "714210", "standard_charge_dollar": 12985.93, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Peoples Hlth Ffs 72126", "plan_name": "500019", "standard_charge_dollar": 10388.75, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Uhc/Secure Horizons", "plan_name": "500449", "standard_charge_dollar": 10388.75, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "United Health Care/", "plan_name": "500292", "standard_charge_dollar": 11739.28, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "United Healthcare", "plan_name": "750104", "standard_charge_dollar": 11739.28, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "United Healthcare Ba", "plan_name": "750090", "standard_charge_dollar": 11739.28, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "United Healthcare Me", "plan_name": "501310", "standard_charge_dollar": 10388.75, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Windsor Mcare Extra", "plan_name": "500778", "standard_charge_dollar": 10388.75, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." } ] } ] }, { "description": "Vasc embolize/occlude bleed", "code_information": [ { "code": "37244", "type": "CPT" } ], "standard_charges": [ { "gross_charge": 98480.36, "minimum": 752.91, "maximum": 12985.93, "setting": "inpatient", "payers_information": [ { "payer_name": "Aarp", "plan_name": "500102", "standard_charge_dollar": 10388.75, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna", "plan_name": "700700", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna", "plan_name": "700700_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Mcare Ffs 6005", "plan_name": "700703", "standard_charge_dollar": 10388.75, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Miscellaneous", "plan_name": "700720", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Miscellaneous", "plan_name": "700720_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Ppo Hmo", "plan_name": "701720", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Ppo Hmo", "plan_name": "701720_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Ambetter 68069", "plan_name": "500516", "standard_charge_dollar": 10388.75, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Ms State Emplo", "plan_name": "401457", "standard_charge_dollar": 752.91, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Ms State Emplo", "plan_name": "401457_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Basic Pl", "plan_name": "400100", "standard_charge_dollar": 752.91, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Basic Pl", "plan_name": "400100_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Federal", "plan_name": "400110", "standard_charge_dollar": 752.91, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Federal", "plan_name": "400110_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Cigna Healthsprings Ffs", "plan_name": "500064", "standard_charge_dollar": 10388.75, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Conseco", "plan_name": "500302", "standard_charge_dollar": 10388.75, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Humana Ffs 61101", "plan_name": "500006", "standard_charge_dollar": 10388.75, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Medicare A", "plan_name": "100100", "standard_charge_dollar": 10388.75, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Medicare A", "plan_name": "100500", "standard_charge_dollar": 10388.75, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Medicare Part B Only", "plan_name": "100300", "standard_charge_dollar": 10388.75, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Medicare Railroad", "plan_name": "100103", "standard_charge_dollar": 10388.75, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Ms Physicians Care N", "plan_name": "714210", "standard_charge_dollar": 12985.93, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Peoples Hlth Ffs 72126", "plan_name": "500019", "standard_charge_dollar": 10388.75, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Uhc/Secure Horizons", "plan_name": "500449", "standard_charge_dollar": 10388.75, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "United Health Care/", "plan_name": "500292", "standard_charge_dollar": 11739.28, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "United Healthcare", "plan_name": "750104", "standard_charge_dollar": 11739.28, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "United Healthcare Ba", "plan_name": "750090", "standard_charge_dollar": 11739.28, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "United Healthcare Me", "plan_name": "501310", "standard_charge_dollar": 10388.75, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Windsor Mcare Extra", "plan_name": "500778", "standard_charge_dollar": 10388.75, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." } ] } ] }, { "description": "Vascular endoscopy procedure", "code_information": [ { "code": "37501", "type": "CPT" } ], "standard_charges": [ { "gross_charge": 31137.95, "minimum": 566.37, "maximum": 26467.26, "setting": "inpatient", "payers_information": [ { "payer_name": "Aarp", "plan_name": "500102", "standard_charge_dollar": 566.37, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna", "plan_name": "700700", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna", "plan_name": "700700_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Mcare Ffs 6005", "plan_name": "700703", "standard_charge_dollar": 566.37, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Miscellaneous", "plan_name": "700720", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Miscellaneous", "plan_name": "700720_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Ppo Hmo", "plan_name": "701720", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Ppo Hmo", "plan_name": "701720_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Ambetter 68069", "plan_name": "500516", "standard_charge_dollar": 566.37, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Ms State Emplo", "plan_name": "401457", "standard_charge_percentage": 0.80, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Ms State Emplo", "plan_name": "401457_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Basic Pl", "plan_name": "400100", "standard_charge_percentage": 0.85, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Basic Pl", "plan_name": "400100_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Federal", "plan_name": "400110", "standard_charge_percentage": 0.85, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Federal", "plan_name": "400110_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Cigna Healthsprings Ffs", "plan_name": "500064", "standard_charge_dollar": 566.37, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Conseco", "plan_name": "500302", "standard_charge_dollar": 566.37, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Humana Ffs 61101", "plan_name": "500006", "standard_charge_dollar": 566.37, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Medicare A", "plan_name": "100100", "standard_charge_dollar": 566.37, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Medicare A", "plan_name": "100500", "standard_charge_dollar": 566.37, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Medicare Part B Only", "plan_name": "100300", "standard_charge_dollar": 566.37, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Medicare Railroad", "plan_name": "100103", "standard_charge_dollar": 566.37, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Ms Physicians Care N", "plan_name": "714210", "standard_charge_dollar": 707.96, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Peoples Hlth Ffs 72126", "plan_name": "500019", "standard_charge_dollar": 566.37, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Uhc/Secure Horizons", "plan_name": "500449", "standard_charge_dollar": 566.37, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "United Health Care/", "plan_name": "500292", "standard_charge_dollar": 640.00, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "United Healthcare", "plan_name": "750104", "standard_charge_dollar": 640.00, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "United Healthcare Ba", "plan_name": "750090", "standard_charge_dollar": 640.00, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "United Healthcare Me", "plan_name": "501310", "standard_charge_dollar": 566.37, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Windsor Mcare Extra", "plan_name": "500778", "standard_charge_dollar": 566.37, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." } ] } ] }, { "description": "Ligation of extremity artery", "code_information": [ { "code": "37618", "type": "CPT" } ], "standard_charges": [ { "gross_charge": 66977.58, "minimum": 53582.06, "maximum": 56930.94, "setting": "inpatient", "payers_information": [ { "payer_name": "Aetna", "plan_name": "700700", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna", "plan_name": "700700_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Miscellaneous", "plan_name": "700720", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Miscellaneous", "plan_name": "700720_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Ppo Hmo", "plan_name": "701720", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Ppo Hmo", "plan_name": "701720_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Ms State Emplo", "plan_name": "401457", "standard_charge_percentage": 0.80, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Ms State Emplo", "plan_name": "401457_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Basic Pl", "plan_name": "400100", "standard_charge_percentage": 0.85, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Basic Pl", "plan_name": "400100_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Federal", "plan_name": "400110", "standard_charge_percentage": 0.85, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Federal", "plan_name": "400110_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." } ] } ] }, { "description": "Ligate leg veins radical", "code_information": [ { "code": "37760", "type": "CPT" } ], "standard_charges": [ { "gross_charge": 35343.05, "minimum": 2883.33, "maximum": 30041.59, "setting": "inpatient", "payers_information": [ { "payer_name": "Aarp", "plan_name": "500102", "standard_charge_dollar": 2883.33, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna", "plan_name": "700700", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna", "plan_name": "700700_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Mcare Ffs 6005", "plan_name": "700703", "standard_charge_dollar": 2883.33, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Miscellaneous", "plan_name": "700720", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Miscellaneous", "plan_name": "700720_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Ppo Hmo", "plan_name": "701720", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Ppo Hmo", "plan_name": "701720_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Ambetter 68069", "plan_name": "500516", "standard_charge_dollar": 2883.33, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Ms State Emplo", "plan_name": "401457", "standard_charge_percentage": 0.80, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Ms State Emplo", "plan_name": "401457_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Basic Pl", "plan_name": "400100", "standard_charge_percentage": 0.85, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Basic Pl", "plan_name": "400100_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Federal", "plan_name": "400110", "standard_charge_percentage": 0.85, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Federal", "plan_name": "400110_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Cigna Healthsprings Ffs", "plan_name": "500064", "standard_charge_dollar": 2883.33, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Conseco", "plan_name": "500302", "standard_charge_dollar": 2883.33, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Humana Ffs 61101", "plan_name": "500006", "standard_charge_dollar": 2883.33, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Medicare A", "plan_name": "100100", "standard_charge_dollar": 2883.33, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Medicare A", "plan_name": "100500", "standard_charge_dollar": 2883.33, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Medicare Part B Only", "plan_name": "100300", "standard_charge_dollar": 2883.33, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Medicare Railroad", "plan_name": "100103", "standard_charge_dollar": 2883.33, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Ms Physicians Care N", "plan_name": "714210", "standard_charge_dollar": 3604.16, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Peoples Hlth Ffs 72126", "plan_name": "500019", "standard_charge_dollar": 2883.33, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Uhc/Secure Horizons", "plan_name": "500449", "standard_charge_dollar": 2883.33, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "United Health Care/", "plan_name": "500292", "standard_charge_dollar": 3258.16, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "United Healthcare", "plan_name": "750104", "standard_charge_dollar": 3258.16, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "United Healthcare Ba", "plan_name": "750090", "standard_charge_dollar": 3258.16, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "United Healthcare Me", "plan_name": "501310", "standard_charge_dollar": 2883.33, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Windsor Mcare Extra", "plan_name": "500778", "standard_charge_dollar": 2883.33, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." } ] } ] }, { "description": "Ligate leg veins open", "code_information": [ { "code": "37761", "type": "CPT" } ], "standard_charges": [ { "gross_charge": 35343.05, "minimum": 2883.33, "maximum": 30041.59, "setting": "inpatient", "payers_information": [ { "payer_name": "Aarp", "plan_name": "500102", "standard_charge_dollar": 2883.33, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna", "plan_name": "700700", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna", "plan_name": "700700_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Mcare Ffs 6005", "plan_name": "700703", "standard_charge_dollar": 2883.33, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Miscellaneous", "plan_name": "700720", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Miscellaneous", "plan_name": "700720_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Ppo Hmo", "plan_name": "701720", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Ppo Hmo", "plan_name": "701720_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Ambetter 68069", "plan_name": "500516", "standard_charge_dollar": 2883.33, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Ms State Emplo", "plan_name": "401457", "standard_charge_percentage": 0.80, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Ms State Emplo", "plan_name": "401457_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Basic Pl", "plan_name": "400100", "standard_charge_percentage": 0.85, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Basic Pl", "plan_name": "400100_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Federal", "plan_name": "400110", "standard_charge_percentage": 0.85, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Federal", "plan_name": "400110_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Cigna Healthsprings Ffs", "plan_name": "500064", "standard_charge_dollar": 2883.33, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Conseco", "plan_name": "500302", "standard_charge_dollar": 2883.33, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Humana Ffs 61101", "plan_name": "500006", "standard_charge_dollar": 2883.33, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Medicare A", "plan_name": "100100", "standard_charge_dollar": 2883.33, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Medicare A", "plan_name": "100500", "standard_charge_dollar": 2883.33, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Medicare Part B Only", "plan_name": "100300", "standard_charge_dollar": 2883.33, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Medicare Railroad", "plan_name": "100103", "standard_charge_dollar": 2883.33, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Ms Physicians Care N", "plan_name": "714210", "standard_charge_dollar": 3604.16, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Peoples Hlth Ffs 72126", "plan_name": "500019", "standard_charge_dollar": 2883.33, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Uhc/Secure Horizons", "plan_name": "500449", "standard_charge_dollar": 2883.33, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "United Health Care/", "plan_name": "500292", "standard_charge_dollar": 3258.16, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "United Healthcare", "plan_name": "750104", "standard_charge_dollar": 3258.16, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "United Healthcare Ba", "plan_name": "750090", "standard_charge_dollar": 3258.16, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "United Healthcare Me", "plan_name": "501310", "standard_charge_dollar": 2883.33, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Windsor Mcare Extra", "plan_name": "500778", "standard_charge_dollar": 2883.33, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." } ] } ] }, { "description": "Vascular surgery procedure", "code_information": [ { "code": "37799", "type": "CPT" } ], "standard_charges": [ { "gross_charge": 64943.19, "minimum": 85.40, "maximum": 707.96, "setting": "inpatient", "payers_information": [ { "payer_name": "Aarp", "plan_name": "500102", "standard_charge_dollar": 566.37, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna", "plan_name": "700700", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna", "plan_name": "700700_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Mcare Ffs 6005", "plan_name": "700703", "standard_charge_dollar": 566.37, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Miscellaneous", "plan_name": "700720", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Miscellaneous", "plan_name": "700720_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Ppo Hmo", "plan_name": "701720", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Ppo Hmo", "plan_name": "701720_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Ambetter 68069", "plan_name": "500516", "standard_charge_dollar": 566.37, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Ms State Emplo", "plan_name": "401457", "standard_charge_dollar": 85.40, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Ms State Emplo", "plan_name": "401457_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Basic Pl", "plan_name": "400100", "standard_charge_dollar": 85.40, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Basic Pl", "plan_name": "400100_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Federal", "plan_name": "400110", "standard_charge_dollar": 85.40, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Federal", "plan_name": "400110_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Cigna Healthsprings Ffs", "plan_name": "500064", "standard_charge_dollar": 566.37, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Conseco", "plan_name": "500302", "standard_charge_dollar": 566.37, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Humana Ffs 61101", "plan_name": "500006", "standard_charge_dollar": 566.37, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Medicare A", "plan_name": "100100", "standard_charge_dollar": 566.37, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Medicare A", "plan_name": "100500", "standard_charge_dollar": 566.37, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Medicare Part B Only", "plan_name": "100300", "standard_charge_dollar": 566.37, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Medicare Railroad", "plan_name": "100103", "standard_charge_dollar": 566.37, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Ms Physicians Care N", "plan_name": "714210", "standard_charge_dollar": 707.96, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Peoples Hlth Ffs 72126", "plan_name": "500019", "standard_charge_dollar": 566.37, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Uhc/Secure Horizons", "plan_name": "500449", "standard_charge_dollar": 566.37, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "United Health Care/", "plan_name": "500292", "standard_charge_dollar": 640.00, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "United Healthcare", "plan_name": "750104", "standard_charge_dollar": 640.00, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "United Healthcare Ba", "plan_name": "750090", "standard_charge_dollar": 640.00, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "United Healthcare Me", "plan_name": "501310", "standard_charge_dollar": 566.37, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Windsor Mcare Extra", "plan_name": "500778", "standard_charge_dollar": 566.37, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." } ] } ] }, { "description": "Removal of spleen total", "code_information": [ { "code": "38100", "type": "CPT" } ], "standard_charges": [ { "gross_charge": 84640.63, "minimum": 67712.50, "maximum": 71944.54, "setting": "inpatient", "payers_information": [ { "payer_name": "Aetna", "plan_name": "700700", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna", "plan_name": "700700_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Miscellaneous", "plan_name": "700720", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Miscellaneous", "plan_name": "700720_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Ppo Hmo", "plan_name": "701720", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Ppo Hmo", "plan_name": "701720_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Ms State Emplo", "plan_name": "401457", "standard_charge_percentage": 0.80, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Ms State Emplo", "plan_name": "401457_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Basic Pl", "plan_name": "400100", "standard_charge_percentage": 0.85, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Basic Pl", "plan_name": "400100_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Federal", "plan_name": "400110", "standard_charge_percentage": 0.85, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Federal", "plan_name": "400110_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." } ] } ] }, { "description": "Removal of spleen total", "code_information": [ { "code": "38102", "type": "CPT" } ], "standard_charges": [ { "gross_charge": 84640.63, "minimum": 67712.50, "maximum": 71944.54, "setting": "inpatient", "payers_information": [ { "payer_name": "Aetna", "plan_name": "700700", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna", "plan_name": "700700_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Miscellaneous", "plan_name": "700720", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Miscellaneous", "plan_name": "700720_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Ppo Hmo", "plan_name": "701720", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Ppo Hmo", "plan_name": "701720_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Ms State Emplo", "plan_name": "401457", "standard_charge_percentage": 0.80, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Ms State Emplo", "plan_name": "401457_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Basic Pl", "plan_name": "400100", "standard_charge_percentage": 0.85, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Basic Pl", "plan_name": "400100_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Federal", "plan_name": "400110", "standard_charge_percentage": 0.85, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Federal", "plan_name": "400110_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." } ] } ] }, { "description": "Laparoscopy splenectomy", "code_information": [ { "code": "38120", "type": "CPT" } ], "standard_charges": [ { "gross_charge": 84640.63, "minimum": 9537.40, "maximum": 71944.54, "setting": "inpatient", "payers_information": [ { "payer_name": "Aarp", "plan_name": "500102", "standard_charge_dollar": 9537.40, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna", "plan_name": "700700", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna", "plan_name": "700700_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Mcare Ffs 6005", "plan_name": "700703", "standard_charge_dollar": 9537.40, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Miscellaneous", "plan_name": "700720", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Miscellaneous", "plan_name": "700720_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Ppo Hmo", "plan_name": "701720", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Ppo Hmo", "plan_name": "701720_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Ambetter 68069", "plan_name": "500516", "standard_charge_dollar": 9537.40, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Ms State Emplo", "plan_name": "401457", "standard_charge_percentage": 0.80, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Ms State Emplo", "plan_name": "401457_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Basic Pl", "plan_name": "400100", "standard_charge_percentage": 0.85, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Basic Pl", "plan_name": "400100_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Federal", "plan_name": "400110", "standard_charge_percentage": 0.85, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Federal", "plan_name": "400110_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Cigna Healthsprings Ffs", "plan_name": "500064", "standard_charge_dollar": 9537.40, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Conseco", "plan_name": "500302", "standard_charge_dollar": 9537.40, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Humana Ffs 61101", "plan_name": "500006", "standard_charge_dollar": 9537.40, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Medicare A", "plan_name": "100100", "standard_charge_dollar": 9537.40, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Medicare A", "plan_name": "100500", "standard_charge_dollar": 9537.40, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Medicare Part B Only", "plan_name": "100300", "standard_charge_dollar": 9537.40, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Medicare Railroad", "plan_name": "100103", "standard_charge_dollar": 9537.40, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Ms Physicians Care N", "plan_name": "714210", "standard_charge_dollar": 11921.75, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Peoples Hlth Ffs 72126", "plan_name": "500019", "standard_charge_dollar": 9537.40, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Uhc/Secure Horizons", "plan_name": "500449", "standard_charge_dollar": 9537.40, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "United Health Care/", "plan_name": "500292", "standard_charge_dollar": 10777.26, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "United Healthcare", "plan_name": "750104", "standard_charge_dollar": 10777.26, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "United Healthcare Ba", "plan_name": "750090", "standard_charge_dollar": 10777.26, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "United Healthcare Me", "plan_name": "501310", "standard_charge_dollar": 9537.40, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Windsor Mcare Extra", "plan_name": "500778", "standard_charge_dollar": 9537.40, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." } ] } ] }, { "description": "Dx bone marrow biopsies", "code_information": [ { "code": "38221", "type": "CPT" } ], "standard_charges": [ { "gross_charge": 33754.44, "minimum": 1484.25, "maximum": 28691.27, "setting": "inpatient", "payers_information": [ { "payer_name": "Aarp", "plan_name": "500102", "standard_charge_dollar": 1484.25, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna", "plan_name": "700700", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna", "plan_name": "700700_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Mcare Ffs 6005", "plan_name": "700703", "standard_charge_dollar": 1484.25, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Miscellaneous", "plan_name": "700720", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Miscellaneous", "plan_name": "700720_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Ppo Hmo", "plan_name": "701720", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Ppo Hmo", "plan_name": "701720_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Ambetter 68069", "plan_name": "500516", "standard_charge_dollar": 1484.25, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Ms State Emplo", "plan_name": "401457", "standard_charge_percentage": 0.80, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Ms State Emplo", "plan_name": "401457_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Basic Pl", "plan_name": "400100", "standard_charge_percentage": 0.85, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Basic Pl", "plan_name": "400100_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Federal", "plan_name": "400110", "standard_charge_percentage": 0.85, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Federal", "plan_name": "400110_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Cigna Healthsprings Ffs", "plan_name": "500064", "standard_charge_dollar": 1484.25, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Conseco", "plan_name": "500302", "standard_charge_dollar": 1484.25, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Humana Ffs 61101", "plan_name": "500006", "standard_charge_dollar": 1484.25, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Medicare A", "plan_name": "100100", "standard_charge_dollar": 1484.25, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Medicare A", "plan_name": "100500", "standard_charge_dollar": 1484.25, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Medicare Part B Only", "plan_name": "100300", "standard_charge_dollar": 1484.25, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Medicare Railroad", "plan_name": "100103", "standard_charge_dollar": 1484.25, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Ms Physicians Care N", "plan_name": "714210", "standard_charge_dollar": 1855.31, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Peoples Hlth Ffs 72126", "plan_name": "500019", "standard_charge_dollar": 1484.25, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Uhc/Secure Horizons", "plan_name": "500449", "standard_charge_dollar": 1484.25, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "United Health Care/", "plan_name": "500292", "standard_charge_dollar": 1677.20, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "United Healthcare", "plan_name": "750104", "standard_charge_dollar": 1677.20, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "United Healthcare Ba", "plan_name": "750090", "standard_charge_dollar": 1677.20, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "United Healthcare Me", "plan_name": "501310", "standard_charge_dollar": 1484.25, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Windsor Mcare Extra", "plan_name": "500778", "standard_charge_dollar": 1484.25, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." } ] } ] }, { "description": "Dx bone marrow bx & aspir", "code_information": [ { "code": "38222", "type": "CPT" } ], "standard_charges": [ { "gross_charge": 31773.24, "minimum": 2348.59, "maximum": 3277.29, "setting": "inpatient", "payers_information": [ { "payer_name": "Aarp", "plan_name": "500102", "standard_charge_dollar": 2621.84, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna", "plan_name": "700700", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna", "plan_name": "700700_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Mcare Ffs 6005", "plan_name": "700703", "standard_charge_dollar": 2621.84, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Miscellaneous", "plan_name": "700720", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Miscellaneous", "plan_name": "700720_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Ppo Hmo", "plan_name": "701720", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Ppo Hmo", "plan_name": "701720_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Ambetter 68069", "plan_name": "500516", "standard_charge_dollar": 2621.84, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Ms State Emplo", "plan_name": "401457", "standard_charge_dollar": 2348.59, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Ms State Emplo", "plan_name": "401457_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Basic Pl", "plan_name": "400100", "standard_charge_dollar": 2348.59, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Basic Pl", "plan_name": "400100_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Federal", "plan_name": "400110", "standard_charge_dollar": 2348.59, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Federal", "plan_name": "400110_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Cigna Healthsprings Ffs", "plan_name": "500064", "standard_charge_dollar": 2621.84, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Conseco", "plan_name": "500302", "standard_charge_dollar": 2621.84, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Humana Ffs 61101", "plan_name": "500006", "standard_charge_dollar": 2621.84, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Medicare A", "plan_name": "100100", "standard_charge_dollar": 2621.84, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Medicare A", "plan_name": "100500", "standard_charge_dollar": 2621.84, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Medicare Part B Only", "plan_name": "100300", "standard_charge_dollar": 2621.84, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Medicare Railroad", "plan_name": "100103", "standard_charge_dollar": 2621.84, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Ms Physicians Care N", "plan_name": "714210", "standard_charge_dollar": 3277.29, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Peoples Hlth Ffs 72126", "plan_name": "500019", "standard_charge_dollar": 2621.84, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Uhc/Secure Horizons", "plan_name": "500449", "standard_charge_dollar": 2621.84, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "United Health Care/", "plan_name": "500292", "standard_charge_dollar": 2962.67, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "United Healthcare", "plan_name": "750104", "standard_charge_dollar": 2962.67, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "United Healthcare Ba", "plan_name": "750090", "standard_charge_dollar": 2962.67, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "United Healthcare Me", "plan_name": "501310", "standard_charge_dollar": 2621.84, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Windsor Mcare Extra", "plan_name": "500778", "standard_charge_dollar": 2621.84, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." } ] } ] }, { "description": "Biopsy/removal lymph nodes", "code_information": [ { "code": "38500", "type": "CPT" } ], "standard_charges": [ { "gross_charge": 66040.80, "minimum": 3507.89, "maximum": 56134.68, "setting": "inpatient", "payers_information": [ { "payer_name": "Aarp", "plan_name": "500102", "standard_charge_dollar": 3507.89, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna", "plan_name": "700700", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna", "plan_name": "700700_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Mcare Ffs 6005", "plan_name": "700703", "standard_charge_dollar": 3507.89, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Miscellaneous", "plan_name": "700720", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Miscellaneous", "plan_name": "700720_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Ppo Hmo", "plan_name": "701720", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Ppo Hmo", "plan_name": "701720_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Ambetter 68069", "plan_name": "500516", "standard_charge_dollar": 3507.89, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Ms State Emplo", "plan_name": "401457", "standard_charge_percentage": 0.80, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Ms State Emplo", "plan_name": "401457_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Basic Pl", "plan_name": "400100", "standard_charge_percentage": 0.85, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Basic Pl", "plan_name": "400100_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Federal", "plan_name": "400110", "standard_charge_percentage": 0.85, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Federal", "plan_name": "400110_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Cigna Healthsprings Ffs", "plan_name": "500064", "standard_charge_dollar": 3507.89, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Conseco", "plan_name": "500302", "standard_charge_dollar": 3507.89, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Humana Ffs 61101", "plan_name": "500006", "standard_charge_dollar": 3507.89, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Medicare A", "plan_name": "100100", "standard_charge_dollar": 3507.89, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Medicare A", "plan_name": "100500", "standard_charge_dollar": 3507.89, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Medicare Part B Only", "plan_name": "100300", "standard_charge_dollar": 3507.89, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Medicare Railroad", "plan_name": "100103", "standard_charge_dollar": 3507.89, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Ms Physicians Care N", "plan_name": "714210", "standard_charge_dollar": 4384.86, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Peoples Hlth Ffs 72126", "plan_name": "500019", "standard_charge_dollar": 3507.89, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Uhc/Secure Horizons", "plan_name": "500449", "standard_charge_dollar": 3507.89, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "United Health Care/", "plan_name": "500292", "standard_charge_dollar": 3963.91, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "United Healthcare", "plan_name": "750104", "standard_charge_dollar": 3963.91, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "United Healthcare Ba", "plan_name": "750090", "standard_charge_dollar": 3963.91, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "United Healthcare Me", "plan_name": "501310", "standard_charge_dollar": 3507.89, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Windsor Mcare Extra", "plan_name": "500778", "standard_charge_dollar": 3507.89, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." } ] } ] }, { "description": "Biopsy/removal lymph nodes", "code_information": [ { "code": "38525", "type": "CPT" } ], "standard_charges": [ { "gross_charge": 18587.02, "minimum": 3507.89, "maximum": 15798.97, "setting": "inpatient", "payers_information": [ { "payer_name": "Aarp", "plan_name": "500102", "standard_charge_dollar": 3507.89, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna", "plan_name": "700700", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna", "plan_name": "700700_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Mcare Ffs 6005", "plan_name": "700703", "standard_charge_dollar": 3507.89, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Miscellaneous", "plan_name": "700720", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Miscellaneous", "plan_name": "700720_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Ppo Hmo", "plan_name": "701720", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Ppo Hmo", "plan_name": "701720_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Ambetter 68069", "plan_name": "500516", "standard_charge_dollar": 3507.89, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Ms State Emplo", "plan_name": "401457", "standard_charge_percentage": 0.80, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Ms State Emplo", "plan_name": "401457_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Basic Pl", "plan_name": "400100", "standard_charge_percentage": 0.85, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Basic Pl", "plan_name": "400100_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Federal", "plan_name": "400110", "standard_charge_percentage": 0.85, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Federal", "plan_name": "400110_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Cigna Healthsprings Ffs", "plan_name": "500064", "standard_charge_dollar": 3507.89, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Conseco", "plan_name": "500302", "standard_charge_dollar": 3507.89, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Humana Ffs 61101", "plan_name": "500006", "standard_charge_dollar": 3507.89, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Medicare A", "plan_name": "100100", "standard_charge_dollar": 3507.89, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Medicare A", "plan_name": "100500", "standard_charge_dollar": 3507.89, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Medicare Part B Only", "plan_name": "100300", "standard_charge_dollar": 3507.89, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Medicare Railroad", "plan_name": "100103", "standard_charge_dollar": 3507.89, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Ms Physicians Care N", "plan_name": "714210", "standard_charge_dollar": 4384.86, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Peoples Hlth Ffs 72126", "plan_name": "500019", "standard_charge_dollar": 3507.89, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Uhc/Secure Horizons", "plan_name": "500449", "standard_charge_dollar": 3507.89, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "United Health Care/", "plan_name": "500292", "standard_charge_dollar": 3963.91, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "United Healthcare", "plan_name": "750104", "standard_charge_dollar": 3963.91, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "United Healthcare Ba", "plan_name": "750090", "standard_charge_dollar": 3963.91, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "United Healthcare Me", "plan_name": "501310", "standard_charge_dollar": 3507.89, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Windsor Mcare Extra", "plan_name": "500778", "standard_charge_dollar": 3507.89, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." } ] } ] }, { "description": "Repair of diaphragm hernia", "code_information": [ { "code": "39503", "type": "CPT" } ], "standard_charges": [ { "gross_charge": 15057.44, "minimum": 12045.95, "maximum": 12798.82, "setting": "inpatient", "payers_information": [ { "payer_name": "Aetna", "plan_name": "700700", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna", "plan_name": "700700_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Miscellaneous", "plan_name": "700720", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Miscellaneous", "plan_name": "700720_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Ppo Hmo", "plan_name": "701720", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Ppo Hmo", "plan_name": "701720_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Ms State Emplo", "plan_name": "401457", "standard_charge_percentage": 0.80, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Ms State Emplo", "plan_name": "401457_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Basic Pl", "plan_name": "400100", "standard_charge_percentage": 0.85, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Basic Pl", "plan_name": "400100_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Federal", "plan_name": "400110", "standard_charge_percentage": 0.85, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Federal", "plan_name": "400110_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." } ] } ] }, { "description": "Diaphragm surgery procedure", "code_information": [ { "code": "39599", "type": "CPT" } ], "standard_charges": [ { "gross_charge": 80016.41, "minimum": 64013.13, "maximum": 68013.95, "setting": "inpatient", "payers_information": [ { "payer_name": "Aetna", "plan_name": "700700", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna", "plan_name": "700700_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Miscellaneous", "plan_name": "700720", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Miscellaneous", "plan_name": "700720_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Ppo Hmo", "plan_name": "701720", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Ppo Hmo", "plan_name": "701720_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Ms State Emplo", "plan_name": "401457", "standard_charge_percentage": 0.80, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Ms State Emplo", "plan_name": "401457_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Basic Pl", "plan_name": "400100", "standard_charge_percentage": 0.85, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Basic Pl", "plan_name": "400100_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Federal", "plan_name": "400110", "standard_charge_percentage": 0.85, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Federal", "plan_name": "400110_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." } ] } ] }, { "description": "Removal of tongue", "code_information": [ { "code": "41140", "type": "CPT" } ], "standard_charges": [ { "gross_charge": 241530.87, "minimum": 193224.70, "maximum": 205301.24, "setting": "inpatient", "payers_information": [ { "payer_name": "Aetna", "plan_name": "700700", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna", "plan_name": "700700_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Miscellaneous", "plan_name": "700720", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Miscellaneous", "plan_name": "700720_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Ppo Hmo", "plan_name": "701720", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Ppo Hmo", "plan_name": "701720_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Ms State Emplo", "plan_name": "401457", "standard_charge_percentage": 0.80, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Ms State Emplo", "plan_name": "401457_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Basic Pl", "plan_name": "400100", "standard_charge_percentage": 0.85, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Basic Pl", "plan_name": "400100_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Federal", "plan_name": "400110", "standard_charge_percentage": 0.85, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Federal", "plan_name": "400110_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." } ] } ] }, { "description": "Tongue removal neck surgery", "code_information": [ { "code": "41145", "type": "CPT" } ], "standard_charges": [ { "gross_charge": 241530.87, "minimum": 193224.70, "maximum": 205301.24, "setting": "inpatient", "payers_information": [ { "payer_name": "Aetna", "plan_name": "700700", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna", "plan_name": "700700_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Miscellaneous", "plan_name": "700720", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Miscellaneous", "plan_name": "700720_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Ppo Hmo", "plan_name": "701720", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Ppo Hmo", "plan_name": "701720_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Ms State Emplo", "plan_name": "401457", "standard_charge_percentage": 0.80, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Ms State Emplo", "plan_name": "401457_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Basic Pl", "plan_name": "400100", "standard_charge_percentage": 0.85, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Basic Pl", "plan_name": "400100_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Federal", "plan_name": "400110", "standard_charge_percentage": 0.85, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Federal", "plan_name": "400110_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." } ] } ] }, { "description": "Pt care icu&vent w/in 24hrs", "code_information": [ { "code": "4168F", "type": "CPT" } ], "standard_charges": [ { "gross_charge": 28041.51, "minimum": 22433.21, "maximum": 23835.28, "setting": "inpatient", "payers_information": [ { "payer_name": "Aetna", "plan_name": "700700", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna", "plan_name": "700700_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Miscellaneous", "plan_name": "700720", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Miscellaneous", "plan_name": "700720_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Ppo Hmo", "plan_name": "701720", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Ppo Hmo", "plan_name": "701720_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Ms State Emplo", "plan_name": "401457", "standard_charge_percentage": 0.80, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Ms State Emplo", "plan_name": "401457_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Basic Pl", "plan_name": "400100", "standard_charge_percentage": 0.85, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Basic Pl", "plan_name": "400100_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Federal", "plan_name": "400110", "standard_charge_percentage": 0.85, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Federal", "plan_name": "400110_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." } ] } ] }, { "description": "No pt care icu/vent in 24hrs", "code_information": [ { "code": "4169F", "type": "CPT" } ], "standard_charges": [ { "gross_charge": 92938.98, "minimum": 74351.18, "maximum": 78998.13, "setting": "inpatient", "payers_information": [ { "payer_name": "Aetna", "plan_name": "700700", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna", "plan_name": "700700_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Miscellaneous", "plan_name": "700720", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Miscellaneous", "plan_name": "700720_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Ppo Hmo", "plan_name": "701720", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Ppo Hmo", "plan_name": "701720_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Ms State Emplo", "plan_name": "401457", "standard_charge_percentage": 0.80, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Ms State Emplo", "plan_name": "401457_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Basic Pl", "plan_name": "400100", "standard_charge_percentage": 0.85, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Basic Pl", "plan_name": "400100_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Federal", "plan_name": "400110", "standard_charge_percentage": 0.85, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Federal", "plan_name": "400110_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." } ] } ] }, { "description": "Approp diuretic tstng done", "code_information": [ { "code": "4190F", "type": "CPT" } ], "standard_charges": [ { "gross_charge": 18463.19, "minimum": 14770.55, "maximum": 15693.71, "setting": "inpatient", "payers_information": [ { "payer_name": "Aetna", "plan_name": "700700", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna", "plan_name": "700700_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Miscellaneous", "plan_name": "700720", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Miscellaneous", "plan_name": "700720_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Ppo Hmo", "plan_name": "701720", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Ppo Hmo", "plan_name": "701720_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Ms State Emplo", "plan_name": "401457", "standard_charge_percentage": 0.80, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Ms State Emplo", "plan_name": "401457_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Basic Pl", "plan_name": "400100", "standard_charge_percentage": 0.85, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Basic Pl", "plan_name": "400100_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Federal", "plan_name": "400110", "standard_charge_percentage": 0.85, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Federal", "plan_name": "400110_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." } ] } ] }, { "description": "Pt rcvng anti-rheum thxpy ra", "code_information": [ { "code": "4195F", "type": "CPT" } ], "standard_charges": [ { "gross_charge": 11707.75, "minimum": 9366.20, "maximum": 9951.59, "setting": "inpatient", "payers_information": [ { "payer_name": "Aetna", "plan_name": "700700", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna", "plan_name": "700700_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Miscellaneous", "plan_name": "700720", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Miscellaneous", "plan_name": "700720_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Ppo Hmo", "plan_name": "701720", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Ppo Hmo", "plan_name": "701720_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Ms State Emplo", "plan_name": "401457", "standard_charge_percentage": 0.80, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Ms State Emplo", "plan_name": "401457_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Basic Pl", "plan_name": "400100", "standard_charge_percentage": 0.85, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Basic Pl", "plan_name": "400100_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Federal", "plan_name": "400110", "standard_charge_percentage": 0.85, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Federal", "plan_name": "400110_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." } ] } ] }, { "description": "Removal of esophagus", "code_information": [ { "code": "43113", "type": "CPT" } ], "standard_charges": [ { "gross_charge": 39944.42, "minimum": 31955.54, "maximum": 33952.76, "setting": "inpatient", "payers_information": [ { "payer_name": "Aetna", "plan_name": "700700", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna", "plan_name": "700700_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Miscellaneous", "plan_name": "700720", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Miscellaneous", "plan_name": "700720_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Ppo Hmo", "plan_name": "701720", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Ppo Hmo", "plan_name": "701720_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Ms State Emplo", "plan_name": "401457", "standard_charge_percentage": 0.80, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Ms State Emplo", "plan_name": "401457_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Basic Pl", "plan_name": "400100", "standard_charge_percentage": 0.85, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Basic Pl", "plan_name": "400100_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Federal", "plan_name": "400110", "standard_charge_percentage": 0.85, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Federal", "plan_name": "400110_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." } ] } ] }, { "description": "Partial removal of esophagus", "code_information": [ { "code": "43118", "type": "CPT" } ], "standard_charges": [ { "gross_charge": 39944.42, "minimum": 31955.54, "maximum": 33952.76, "setting": "inpatient", "payers_information": [ { "payer_name": "Aetna", "plan_name": "700700", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna", "plan_name": "700700_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Miscellaneous", "plan_name": "700720", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Miscellaneous", "plan_name": "700720_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Ppo Hmo", "plan_name": "701720", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Ppo Hmo", "plan_name": "701720_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Ms State Emplo", "plan_name": "401457", "standard_charge_percentage": 0.80, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Ms State Emplo", "plan_name": "401457_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Basic Pl", "plan_name": "400100", "standard_charge_percentage": 0.85, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Basic Pl", "plan_name": "400100_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Federal", "plan_name": "400110", "standard_charge_percentage": 0.85, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Federal", "plan_name": "400110_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." } ] } ] }, { "description": "Esophagoscopy rigid trnso dx", "code_information": [ { "code": "43191", "type": "CPT" } ], "standard_charges": [ { "gross_charge": 25703.80, "minimum": 167.89, "maximum": 2172.22, "setting": "inpatient", "payers_information": [ { "payer_name": "Aarp", "plan_name": "500102", "standard_charge_dollar": 1737.77, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna", "plan_name": "700700", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna", "plan_name": "700700_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Mcare Ffs 6005", "plan_name": "700703", "standard_charge_dollar": 1737.77, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Miscellaneous", "plan_name": "700720", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Miscellaneous", "plan_name": "700720_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Ppo Hmo", "plan_name": "701720", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Ppo Hmo", "plan_name": "701720_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Ambetter 68069", "plan_name": "500516", "standard_charge_dollar": 1737.77, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Ms State Emplo", "plan_name": "401457", "standard_charge_dollar": 167.89, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Ms State Emplo", "plan_name": "401457_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Basic Pl", "plan_name": "400100", "standard_charge_dollar": 167.89, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Basic Pl", "plan_name": "400100_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Federal", "plan_name": "400110", "standard_charge_dollar": 167.89, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Federal", "plan_name": "400110_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Cigna Healthsprings Ffs", "plan_name": "500064", "standard_charge_dollar": 1737.77, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Conseco", "plan_name": "500302", "standard_charge_dollar": 1737.77, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Humana Ffs 61101", "plan_name": "500006", "standard_charge_dollar": 1737.77, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Medicare A", "plan_name": "100100", "standard_charge_dollar": 1737.77, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Medicare A", "plan_name": "100500", "standard_charge_dollar": 1737.77, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Medicare Part B Only", "plan_name": "100300", "standard_charge_dollar": 1737.77, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Medicare Railroad", "plan_name": "100103", "standard_charge_dollar": 1737.77, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Ms Physicians Care N", "plan_name": "714210", "standard_charge_dollar": 2172.22, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Peoples Hlth Ffs 72126", "plan_name": "500019", "standard_charge_dollar": 1737.77, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Uhc/Secure Horizons", "plan_name": "500449", "standard_charge_dollar": 1737.77, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "United Health Care/", "plan_name": "500292", "standard_charge_dollar": 1963.68, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "United Healthcare", "plan_name": "750104", "standard_charge_dollar": 1963.68, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "United Healthcare Ba", "plan_name": "750090", "standard_charge_dollar": 1963.68, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "United Healthcare Me", "plan_name": "501310", "standard_charge_dollar": 1737.77, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Windsor Mcare Extra", "plan_name": "500778", "standard_charge_dollar": 1737.77, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." } ] } ] }, { "description": "Esophagoscp rig trnso biopsy", "code_information": [ { "code": "43193", "type": "CPT" } ], "standard_charges": [ { "gross_charge": 21648.94, "minimum": 184.66, "maximum": 2172.22, "setting": "inpatient", "payers_information": [ { "payer_name": "Aarp", "plan_name": "500102", "standard_charge_dollar": 1737.77, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna", "plan_name": "700700", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna", "plan_name": "700700_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Mcare Ffs 6005", "plan_name": "700703", "standard_charge_dollar": 1737.77, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Miscellaneous", "plan_name": "700720", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Miscellaneous", "plan_name": "700720_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Ppo Hmo", "plan_name": "701720", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Ppo Hmo", "plan_name": "701720_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Ambetter 68069", "plan_name": "500516", "standard_charge_dollar": 1737.77, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Ms State Emplo", "plan_name": "401457", "standard_charge_dollar": 184.66, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Ms State Emplo", "plan_name": "401457_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Basic Pl", "plan_name": "400100", "standard_charge_dollar": 184.66, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Basic Pl", "plan_name": "400100_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Federal", "plan_name": "400110", "standard_charge_dollar": 184.66, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Federal", "plan_name": "400110_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Cigna Healthsprings Ffs", "plan_name": "500064", "standard_charge_dollar": 1737.77, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Conseco", "plan_name": "500302", "standard_charge_dollar": 1737.77, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Humana Ffs 61101", "plan_name": "500006", "standard_charge_dollar": 1737.77, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Medicare A", "plan_name": "100100", "standard_charge_dollar": 1737.77, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Medicare A", "plan_name": "100500", "standard_charge_dollar": 1737.77, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Medicare Part B Only", "plan_name": "100300", "standard_charge_dollar": 1737.77, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Medicare Railroad", "plan_name": "100103", "standard_charge_dollar": 1737.77, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Ms Physicians Care N", "plan_name": "714210", "standard_charge_dollar": 2172.22, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Peoples Hlth Ffs 72126", "plan_name": "500019", "standard_charge_dollar": 1737.77, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Uhc/Secure Horizons", "plan_name": "500449", "standard_charge_dollar": 1737.77, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "United Health Care/", "plan_name": "500292", "standard_charge_dollar": 1963.68, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "United Healthcare", "plan_name": "750104", "standard_charge_dollar": 1963.68, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "United Healthcare Ba", "plan_name": "750090", "standard_charge_dollar": 1963.68, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "United Healthcare Me", "plan_name": "501310", "standard_charge_dollar": 1737.77, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Windsor Mcare Extra", "plan_name": "500778", "standard_charge_dollar": 1737.77, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." } ] } ] }, { "description": "Esophagoscp rig trnso rem fb", "code_information": [ { "code": "43194", "type": "CPT" } ], "standard_charges": [ { "gross_charge": 20303.99, "minimum": 211.03, "maximum": 2172.22, "setting": "inpatient", "payers_information": [ { "payer_name": "Aarp", "plan_name": "500102", "standard_charge_dollar": 1737.77, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna", "plan_name": "700700", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna", "plan_name": "700700_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Mcare Ffs 6005", "plan_name": "700703", "standard_charge_dollar": 1737.77, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Miscellaneous", "plan_name": "700720", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Miscellaneous", "plan_name": "700720_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Ppo Hmo", "plan_name": "701720", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Ppo Hmo", "plan_name": "701720_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Ambetter 68069", "plan_name": "500516", "standard_charge_dollar": 1737.77, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Ms State Emplo", "plan_name": "401457", "standard_charge_dollar": 211.03, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Ms State Emplo", "plan_name": "401457_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Basic Pl", "plan_name": "400100", "standard_charge_dollar": 211.03, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Basic Pl", "plan_name": "400100_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Federal", "plan_name": "400110", "standard_charge_dollar": 211.03, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Federal", "plan_name": "400110_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Cigna Healthsprings Ffs", "plan_name": "500064", "standard_charge_dollar": 1737.77, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Conseco", "plan_name": "500302", "standard_charge_dollar": 1737.77, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Humana Ffs 61101", "plan_name": "500006", "standard_charge_dollar": 1737.77, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Medicare A", "plan_name": "100100", "standard_charge_dollar": 1737.77, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Medicare A", "plan_name": "100500", "standard_charge_dollar": 1737.77, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Medicare Part B Only", "plan_name": "100300", "standard_charge_dollar": 1737.77, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Medicare Railroad", "plan_name": "100103", "standard_charge_dollar": 1737.77, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Ms Physicians Care N", "plan_name": "714210", "standard_charge_dollar": 2172.22, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Peoples Hlth Ffs 72126", "plan_name": "500019", "standard_charge_dollar": 1737.77, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Uhc/Secure Horizons", "plan_name": "500449", "standard_charge_dollar": 1737.77, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "United Health Care/", "plan_name": "500292", "standard_charge_dollar": 1963.68, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "United Healthcare", "plan_name": "750104", "standard_charge_dollar": 1963.68, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "United Healthcare Ba", "plan_name": "750090", "standard_charge_dollar": 1963.68, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "United Healthcare Me", "plan_name": "501310", "standard_charge_dollar": 1737.77, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Windsor Mcare Extra", "plan_name": "500778", "standard_charge_dollar": 1737.77, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." } ] } ] }, { "description": "Esophagoscopy rigid balloon", "code_information": [ { "code": "43195", "type": "CPT" } ], "standard_charges": [ { "gross_charge": 25703.80, "minimum": 201.68, "maximum": 4356.52, "setting": "inpatient", "payers_information": [ { "payer_name": "Aarp", "plan_name": "500102", "standard_charge_dollar": 3485.21, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna", "plan_name": "700700", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna", "plan_name": "700700_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Mcare Ffs 6005", "plan_name": "700703", "standard_charge_dollar": 3485.21, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Miscellaneous", "plan_name": "700720", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Miscellaneous", "plan_name": "700720_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Ppo Hmo", "plan_name": "701720", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Ppo Hmo", "plan_name": "701720_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Ambetter 68069", "plan_name": "500516", "standard_charge_dollar": 3485.21, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Ms State Emplo", "plan_name": "401457", "standard_charge_dollar": 201.68, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Ms State Emplo", "plan_name": "401457_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Basic Pl", "plan_name": "400100", "standard_charge_dollar": 201.68, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Basic Pl", "plan_name": "400100_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Federal", "plan_name": "400110", "standard_charge_dollar": 201.68, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Federal", "plan_name": "400110_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Cigna Healthsprings Ffs", "plan_name": "500064", "standard_charge_dollar": 3485.21, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Conseco", "plan_name": "500302", "standard_charge_dollar": 3485.21, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Humana Ffs 61101", "plan_name": "500006", "standard_charge_dollar": 3485.21, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Medicare A", "plan_name": "100100", "standard_charge_dollar": 3485.21, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Medicare A", "plan_name": "100500", "standard_charge_dollar": 3485.21, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Medicare Part B Only", "plan_name": "100300", "standard_charge_dollar": 3485.21, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Medicare Railroad", "plan_name": "100103", "standard_charge_dollar": 3485.21, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Ms Physicians Care N", "plan_name": "714210", "standard_charge_dollar": 4356.52, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Peoples Hlth Ffs 72126", "plan_name": "500019", "standard_charge_dollar": 3485.21, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Uhc/Secure Horizons", "plan_name": "500449", "standard_charge_dollar": 3485.21, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "United Health Care/", "plan_name": "500292", "standard_charge_dollar": 3938.29, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "United Healthcare", "plan_name": "750104", "standard_charge_dollar": 3938.29, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "United Healthcare Ba", "plan_name": "750090", "standard_charge_dollar": 3938.29, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "United Healthcare Me", "plan_name": "501310", "standard_charge_dollar": 3485.21, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Windsor Mcare Extra", "plan_name": "500778", "standard_charge_dollar": 3485.21, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." } ] } ] }, { "description": "Esophagoscp guide wire dilat", "code_information": [ { "code": "43196", "type": "CPT" } ], "standard_charges": [ { "gross_charge": 32155.30, "minimum": 215.11, "maximum": 2172.22, "setting": "inpatient", "payers_information": [ { "payer_name": "Aarp", "plan_name": "500102", "standard_charge_dollar": 1737.77, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna", "plan_name": "700700", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna", "plan_name": "700700_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Mcare Ffs 6005", "plan_name": "700703", "standard_charge_dollar": 1737.77, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Miscellaneous", "plan_name": "700720", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Miscellaneous", "plan_name": "700720_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Ppo Hmo", "plan_name": "701720", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Ppo Hmo", "plan_name": "701720_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Ambetter 68069", "plan_name": "500516", "standard_charge_dollar": 1737.77, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Ms State Emplo", "plan_name": "401457", "standard_charge_dollar": 215.11, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Ms State Emplo", "plan_name": "401457_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Basic Pl", "plan_name": "400100", "standard_charge_dollar": 215.11, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Basic Pl", "plan_name": "400100_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Federal", "plan_name": "400110", "standard_charge_dollar": 215.11, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Federal", "plan_name": "400110_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Cigna Healthsprings Ffs", "plan_name": "500064", "standard_charge_dollar": 1737.77, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Conseco", "plan_name": "500302", "standard_charge_dollar": 1737.77, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Humana Ffs 61101", "plan_name": "500006", "standard_charge_dollar": 1737.77, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Medicare A", "plan_name": "100100", "standard_charge_dollar": 1737.77, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Medicare A", "plan_name": "100500", "standard_charge_dollar": 1737.77, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Medicare Part B Only", "plan_name": "100300", "standard_charge_dollar": 1737.77, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Medicare Railroad", "plan_name": "100103", "standard_charge_dollar": 1737.77, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Ms Physicians Care N", "plan_name": "714210", "standard_charge_dollar": 2172.22, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Peoples Hlth Ffs 72126", "plan_name": "500019", "standard_charge_dollar": 1737.77, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Uhc/Secure Horizons", "plan_name": "500449", "standard_charge_dollar": 1737.77, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "United Health Care/", "plan_name": "500292", "standard_charge_dollar": 1963.68, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "United Healthcare", "plan_name": "750104", "standard_charge_dollar": 1963.68, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "United Healthcare Ba", "plan_name": "750090", "standard_charge_dollar": 1963.68, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "United Healthcare Me", "plan_name": "501310", "standard_charge_dollar": 1737.77, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Windsor Mcare Extra", "plan_name": "500778", "standard_charge_dollar": 1737.77, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." } ] } ] }, { "description": "Esophagoscopy flex dx brush", "code_information": [ { "code": "43197", "type": "CPT" } ], "standard_charges": [ { "gross_charge": 25703.80, "minimum": 90.87, "maximum": 1073.59, "setting": "inpatient", "payers_information": [ { "payer_name": "Aarp", "plan_name": "500102", "standard_charge_dollar": 858.87, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna", "plan_name": "700700", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna", "plan_name": "700700_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Mcare Ffs 6005", "plan_name": "700703", "standard_charge_dollar": 858.87, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Miscellaneous", "plan_name": "700720", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Miscellaneous", "plan_name": "700720_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Ppo Hmo", "plan_name": "701720", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Ppo Hmo", "plan_name": "701720_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Ambetter 68069", "plan_name": "500516", "standard_charge_dollar": 858.87, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Ms State Emplo", "plan_name": "401457", "standard_charge_dollar": 90.87, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Ms State Emplo", "plan_name": "401457_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Basic Pl", "plan_name": "400100", "standard_charge_dollar": 90.87, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Basic Pl", "plan_name": "400100_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Federal", "plan_name": "400110", "standard_charge_dollar": 90.87, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Federal", "plan_name": "400110_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Cigna Healthsprings Ffs", "plan_name": "500064", "standard_charge_dollar": 858.87, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Conseco", "plan_name": "500302", "standard_charge_dollar": 858.87, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Humana Ffs 61101", "plan_name": "500006", "standard_charge_dollar": 858.87, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Medicare A", "plan_name": "100100", "standard_charge_dollar": 858.87, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Medicare A", "plan_name": "100500", "standard_charge_dollar": 858.87, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Medicare Part B Only", "plan_name": "100300", "standard_charge_dollar": 858.87, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Medicare Railroad", "plan_name": "100103", "standard_charge_dollar": 858.87, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Ms Physicians Care N", "plan_name": "714210", "standard_charge_dollar": 1073.59, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Peoples Hlth Ffs 72126", "plan_name": "500019", "standard_charge_dollar": 858.87, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Uhc/Secure Horizons", "plan_name": "500449", "standard_charge_dollar": 858.87, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "United Health Care/", "plan_name": "500292", "standard_charge_dollar": 970.52, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "United Healthcare", "plan_name": "750104", "standard_charge_dollar": 970.52, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "United Healthcare Ba", "plan_name": "750090", "standard_charge_dollar": 970.52, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "United Healthcare Me", "plan_name": "501310", "standard_charge_dollar": 858.87, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Windsor Mcare Extra", "plan_name": "500778", "standard_charge_dollar": 858.87, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." } ] } ] }, { "description": "Esophagosc flex trnsn biopsy", "code_information": [ { "code": "43198", "type": "CPT" } ], "standard_charges": [ { "gross_charge": 21648.94, "minimum": 108.71, "maximum": 1073.59, "setting": "inpatient", "payers_information": [ { "payer_name": "Aarp", "plan_name": "500102", "standard_charge_dollar": 858.87, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna", "plan_name": "700700", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna", "plan_name": "700700_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Mcare Ffs 6005", "plan_name": "700703", "standard_charge_dollar": 858.87, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Miscellaneous", "plan_name": "700720", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Miscellaneous", "plan_name": "700720_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Ppo Hmo", "plan_name": "701720", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Ppo Hmo", "plan_name": "701720_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Ambetter 68069", "plan_name": "500516", "standard_charge_dollar": 858.87, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Ms State Emplo", "plan_name": "401457", "standard_charge_dollar": 108.71, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Ms State Emplo", "plan_name": "401457_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Basic Pl", "plan_name": "400100", "standard_charge_dollar": 108.71, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Basic Pl", "plan_name": "400100_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Federal", "plan_name": "400110", "standard_charge_dollar": 108.71, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Federal", "plan_name": "400110_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Cigna Healthsprings Ffs", "plan_name": "500064", "standard_charge_dollar": 858.87, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Conseco", "plan_name": "500302", "standard_charge_dollar": 858.87, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Humana Ffs 61101", "plan_name": "500006", "standard_charge_dollar": 858.87, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Medicare A", "plan_name": "100100", "standard_charge_dollar": 858.87, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Medicare A", "plan_name": "100500", "standard_charge_dollar": 858.87, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Medicare Part B Only", "plan_name": "100300", "standard_charge_dollar": 858.87, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Medicare Railroad", "plan_name": "100103", "standard_charge_dollar": 858.87, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Ms Physicians Care N", "plan_name": "714210", "standard_charge_dollar": 1073.59, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Peoples Hlth Ffs 72126", "plan_name": "500019", "standard_charge_dollar": 858.87, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Uhc/Secure Horizons", "plan_name": "500449", "standard_charge_dollar": 858.87, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "United Health Care/", "plan_name": "500292", "standard_charge_dollar": 970.52, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "United Healthcare", "plan_name": "750104", "standard_charge_dollar": 970.52, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "United Healthcare Ba", "plan_name": "750090", "standard_charge_dollar": 970.52, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "United Healthcare Me", "plan_name": "501310", "standard_charge_dollar": 858.87, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Windsor Mcare Extra", "plan_name": "500778", "standard_charge_dollar": 858.87, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." } ] } ] }, { "description": "Esophagoscopy flexible brush", "code_information": [ { "code": "43200", "type": "CPT" } ], "standard_charges": [ { "gross_charge": 25703.80, "minimum": 858.87, "maximum": 21848.23, "setting": "inpatient", "payers_information": [ { "payer_name": "Aarp", "plan_name": "500102", "standard_charge_dollar": 858.87, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna", "plan_name": "700700", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna", "plan_name": "700700_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Mcare Ffs 6005", "plan_name": "700703", "standard_charge_dollar": 858.87, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Miscellaneous", "plan_name": "700720", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Miscellaneous", "plan_name": "700720_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Ppo Hmo", "plan_name": "701720", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Ppo Hmo", "plan_name": "701720_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Ambetter 68069", "plan_name": "500516", "standard_charge_dollar": 858.87, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Ms State Emplo", "plan_name": "401457", "standard_charge_percentage": 0.80, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Ms State Emplo", "plan_name": "401457_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Basic Pl", "plan_name": "400100", "standard_charge_percentage": 0.85, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Basic Pl", "plan_name": "400100_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Federal", "plan_name": "400110", "standard_charge_percentage": 0.85, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Federal", "plan_name": "400110_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Cigna Healthsprings Ffs", "plan_name": "500064", "standard_charge_dollar": 858.87, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Conseco", "plan_name": "500302", "standard_charge_dollar": 858.87, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Humana Ffs 61101", "plan_name": "500006", "standard_charge_dollar": 858.87, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Medicare A", "plan_name": "100100", "standard_charge_dollar": 858.87, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Medicare A", "plan_name": "100500", "standard_charge_dollar": 858.87, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Medicare Part B Only", "plan_name": "100300", "standard_charge_dollar": 858.87, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Medicare Railroad", "plan_name": "100103", "standard_charge_dollar": 858.87, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Ms Physicians Care N", "plan_name": "714210", "standard_charge_dollar": 1073.59, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Peoples Hlth Ffs 72126", "plan_name": "500019", "standard_charge_dollar": 858.87, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Uhc/Secure Horizons", "plan_name": "500449", "standard_charge_dollar": 858.87, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "United Health Care/", "plan_name": "500292", "standard_charge_dollar": 970.52, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "United Healthcare", "plan_name": "750104", "standard_charge_dollar": 970.52, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "United Healthcare Ba", "plan_name": "750090", "standard_charge_dollar": 970.52, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "United Healthcare Me", "plan_name": "501310", "standard_charge_dollar": 858.87, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Windsor Mcare Extra", "plan_name": "500778", "standard_charge_dollar": 858.87, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." } ] } ] }, { "description": "Esoph scope w/submucous inj", "code_information": [ { "code": "43201", "type": "CPT" } ], "standard_charges": [ { "gross_charge": 17132.65, "minimum": 1737.77, "maximum": 14562.75, "setting": "inpatient", "payers_information": [ { "payer_name": "Aarp", "plan_name": "500102", "standard_charge_dollar": 1737.77, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna", "plan_name": "700700", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna", "plan_name": "700700_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Mcare Ffs 6005", "plan_name": "700703", "standard_charge_dollar": 1737.77, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Miscellaneous", "plan_name": "700720", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Miscellaneous", "plan_name": "700720_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Ppo Hmo", "plan_name": "701720", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Ppo Hmo", "plan_name": "701720_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Ambetter 68069", "plan_name": "500516", "standard_charge_dollar": 1737.77, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Ms State Emplo", "plan_name": "401457", "standard_charge_percentage": 0.80, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Ms State Emplo", "plan_name": "401457_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Basic Pl", "plan_name": "400100", "standard_charge_percentage": 0.85, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Basic Pl", "plan_name": "400100_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Federal", "plan_name": "400110", "standard_charge_percentage": 0.85, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Federal", "plan_name": "400110_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Cigna Healthsprings Ffs", "plan_name": "500064", "standard_charge_dollar": 1737.77, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Conseco", "plan_name": "500302", "standard_charge_dollar": 1737.77, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Humana Ffs 61101", "plan_name": "500006", "standard_charge_dollar": 1737.77, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Medicare A", "plan_name": "100100", "standard_charge_dollar": 1737.77, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Medicare A", "plan_name": "100500", "standard_charge_dollar": 1737.77, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Medicare Part B Only", "plan_name": "100300", "standard_charge_dollar": 1737.77, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Medicare Railroad", "plan_name": "100103", "standard_charge_dollar": 1737.77, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Ms Physicians Care N", "plan_name": "714210", "standard_charge_dollar": 2172.22, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Peoples Hlth Ffs 72126", "plan_name": "500019", "standard_charge_dollar": 1737.77, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Uhc/Secure Horizons", "plan_name": "500449", "standard_charge_dollar": 1737.77, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "United Health Care/", "plan_name": "500292", "standard_charge_dollar": 1963.68, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "United Healthcare", "plan_name": "750104", "standard_charge_dollar": 1963.68, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "United Healthcare Ba", "plan_name": "750090", "standard_charge_dollar": 1963.68, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "United Healthcare Me", "plan_name": "501310", "standard_charge_dollar": 1737.77, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Windsor Mcare Extra", "plan_name": "500778", "standard_charge_dollar": 1737.77, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." } ] } ] }, { "description": "Esophagoscopy flex biopsy", "code_information": [ { "code": "43202", "type": "CPT" } ], "standard_charges": [ { "gross_charge": 21648.94, "minimum": 1737.77, "maximum": 18401.60, "setting": "inpatient", "payers_information": [ { "payer_name": "Aarp", "plan_name": "500102", "standard_charge_dollar": 1737.77, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna", "plan_name": "700700", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna", "plan_name": "700700_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Mcare Ffs 6005", "plan_name": "700703", "standard_charge_dollar": 1737.77, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Miscellaneous", "plan_name": "700720", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Miscellaneous", "plan_name": "700720_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Ppo Hmo", "plan_name": "701720", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Ppo Hmo", "plan_name": "701720_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Ambetter 68069", "plan_name": "500516", "standard_charge_dollar": 1737.77, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Ms State Emplo", "plan_name": "401457", "standard_charge_percentage": 0.80, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Ms State Emplo", "plan_name": "401457_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Basic Pl", "plan_name": "400100", "standard_charge_percentage": 0.85, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Basic Pl", "plan_name": "400100_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Federal", "plan_name": "400110", "standard_charge_percentage": 0.85, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Federal", "plan_name": "400110_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Cigna Healthsprings Ffs", "plan_name": "500064", "standard_charge_dollar": 1737.77, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Conseco", "plan_name": "500302", "standard_charge_dollar": 1737.77, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Humana Ffs 61101", "plan_name": "500006", "standard_charge_dollar": 1737.77, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Medicare A", "plan_name": "100100", "standard_charge_dollar": 1737.77, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Medicare A", "plan_name": "100500", "standard_charge_dollar": 1737.77, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Medicare Part B Only", "plan_name": "100300", "standard_charge_dollar": 1737.77, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Medicare Railroad", "plan_name": "100103", "standard_charge_dollar": 1737.77, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Ms Physicians Care N", "plan_name": "714210", "standard_charge_dollar": 2172.22, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Peoples Hlth Ffs 72126", "plan_name": "500019", "standard_charge_dollar": 1737.77, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Uhc/Secure Horizons", "plan_name": "500449", "standard_charge_dollar": 1737.77, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "United Health Care/", "plan_name": "500292", "standard_charge_dollar": 1963.68, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "United Healthcare", "plan_name": "750104", "standard_charge_dollar": 1963.68, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "United Healthcare Ba", "plan_name": "750090", "standard_charge_dollar": 1963.68, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "United Healthcare Me", "plan_name": "501310", "standard_charge_dollar": 1737.77, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Windsor Mcare Extra", "plan_name": "500778", "standard_charge_dollar": 1737.77, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." } ] } ] }, { "description": "Esoph optical endomicroscopy", "code_information": [ { "code": "43206", "type": "CPT" } ], "standard_charges": [ { "gross_charge": 25703.80, "minimum": 1737.77, "maximum": 21848.23, "setting": "inpatient", "payers_information": [ { "payer_name": "Aarp", "plan_name": "500102", "standard_charge_dollar": 1737.77, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna", "plan_name": "700700", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna", "plan_name": "700700_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Mcare Ffs 6005", "plan_name": "700703", "standard_charge_dollar": 1737.77, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Miscellaneous", "plan_name": "700720", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Miscellaneous", "plan_name": "700720_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Ppo Hmo", "plan_name": "701720", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Ppo Hmo", "plan_name": "701720_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Ambetter 68069", "plan_name": "500516", "standard_charge_dollar": 1737.77, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Ms State Emplo", "plan_name": "401457", "standard_charge_percentage": 0.80, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Ms State Emplo", "plan_name": "401457_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Basic Pl", "plan_name": "400100", "standard_charge_percentage": 0.85, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Basic Pl", "plan_name": "400100_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Federal", "plan_name": "400110", "standard_charge_percentage": 0.85, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Federal", "plan_name": "400110_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Cigna Healthsprings Ffs", "plan_name": "500064", "standard_charge_dollar": 1737.77, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Conseco", "plan_name": "500302", "standard_charge_dollar": 1737.77, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Humana Ffs 61101", "plan_name": "500006", "standard_charge_dollar": 1737.77, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Medicare A", "plan_name": "100100", "standard_charge_dollar": 1737.77, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Medicare A", "plan_name": "100500", "standard_charge_dollar": 1737.77, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Medicare Part B Only", "plan_name": "100300", "standard_charge_dollar": 1737.77, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Medicare Railroad", "plan_name": "100103", "standard_charge_dollar": 1737.77, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Ms Physicians Care N", "plan_name": "714210", "standard_charge_dollar": 2172.22, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Peoples Hlth Ffs 72126", "plan_name": "500019", "standard_charge_dollar": 1737.77, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Uhc/Secure Horizons", "plan_name": "500449", "standard_charge_dollar": 1737.77, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "United Health Care/", "plan_name": "500292", "standard_charge_dollar": 1963.68, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "United Healthcare", "plan_name": "750104", "standard_charge_dollar": 1963.68, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "United Healthcare Ba", "plan_name": "750090", "standard_charge_dollar": 1963.68, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "United Healthcare Me", "plan_name": "501310", "standard_charge_dollar": 1737.77, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Windsor Mcare Extra", "plan_name": "500778", "standard_charge_dollar": 1737.77, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." } ] } ] }, { "description": "Egd esophagogastrc fndoplsty", "code_information": [ { "code": "43210", "type": "CPT" } ], "standard_charges": [ { "gross_charge": 24676.07, "minimum": 9537.40, "maximum": 20974.66, "setting": "inpatient", "payers_information": [ { "payer_name": "Aarp", "plan_name": "500102", "standard_charge_dollar": 9537.40, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna", "plan_name": "700700", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna", "plan_name": "700700_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Mcare Ffs 6005", "plan_name": "700703", "standard_charge_dollar": 9537.40, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Miscellaneous", "plan_name": "700720", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Miscellaneous", "plan_name": "700720_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Ppo Hmo", "plan_name": "701720", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Ppo Hmo", "plan_name": "701720_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Ambetter 68069", "plan_name": "500516", "standard_charge_dollar": 9537.40, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Ms State Emplo", "plan_name": "401457", "standard_charge_percentage": 0.80, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Ms State Emplo", "plan_name": "401457_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Basic Pl", "plan_name": "400100", "standard_charge_percentage": 0.85, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Basic Pl", "plan_name": "400100_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Federal", "plan_name": "400110", "standard_charge_percentage": 0.85, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Federal", "plan_name": "400110_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Cigna Healthsprings Ffs", "plan_name": "500064", "standard_charge_dollar": 9537.40, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Conseco", "plan_name": "500302", "standard_charge_dollar": 9537.40, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Humana Ffs 61101", "plan_name": "500006", "standard_charge_dollar": 9537.40, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Medicare A", "plan_name": "100100", "standard_charge_dollar": 9537.40, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Medicare A", "plan_name": "100500", "standard_charge_dollar": 9537.40, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Medicare Part B Only", "plan_name": "100300", "standard_charge_dollar": 9537.40, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Medicare Railroad", "plan_name": "100103", "standard_charge_dollar": 9537.40, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Ms Physicians Care N", "plan_name": "714210", "standard_charge_dollar": 11921.75, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Peoples Hlth Ffs 72126", "plan_name": "500019", "standard_charge_dollar": 9537.40, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Uhc/Secure Horizons", "plan_name": "500449", "standard_charge_dollar": 9537.40, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "United Health Care/", "plan_name": "500292", "standard_charge_dollar": 10777.26, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "United Healthcare", "plan_name": "750104", "standard_charge_dollar": 10777.26, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "United Healthcare Ba", "plan_name": "750090", "standard_charge_dollar": 10777.26, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "United Healthcare Me", "plan_name": "501310", "standard_charge_dollar": 9537.40, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Windsor Mcare Extra", "plan_name": "500778", "standard_charge_dollar": 9537.40, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." } ] } ] }, { "description": "Esophagoscop mucosal resect", "code_information": [ { "code": "43211", "type": "CPT" } ], "standard_charges": [ { "gross_charge": 25703.80, "minimum": 262.52, "maximum": 2172.22, "setting": "inpatient", "payers_information": [ { "payer_name": "Aarp", "plan_name": "500102", "standard_charge_dollar": 1737.77, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna", "plan_name": "700700", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna", "plan_name": "700700_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Mcare Ffs 6005", "plan_name": "700703", "standard_charge_dollar": 1737.77, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Miscellaneous", "plan_name": "700720", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Miscellaneous", "plan_name": "700720_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Ppo Hmo", "plan_name": "701720", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Ppo Hmo", "plan_name": "701720_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Ambetter 68069", "plan_name": "500516", "standard_charge_dollar": 1737.77, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Ms State Emplo", "plan_name": "401457", "standard_charge_dollar": 262.52, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Ms State Emplo", "plan_name": "401457_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Basic Pl", "plan_name": "400100", "standard_charge_dollar": 262.52, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Basic Pl", "plan_name": "400100_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Federal", "plan_name": "400110", "standard_charge_dollar": 262.52, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Federal", "plan_name": "400110_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Cigna Healthsprings Ffs", "plan_name": "500064", "standard_charge_dollar": 1737.77, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Conseco", "plan_name": "500302", "standard_charge_dollar": 1737.77, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Humana Ffs 61101", "plan_name": "500006", "standard_charge_dollar": 1737.77, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Medicare A", "plan_name": "100100", "standard_charge_dollar": 1737.77, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Medicare A", "plan_name": "100500", "standard_charge_dollar": 1737.77, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Medicare Part B Only", "plan_name": "100300", "standard_charge_dollar": 1737.77, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Medicare Railroad", "plan_name": "100103", "standard_charge_dollar": 1737.77, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Ms Physicians Care N", "plan_name": "714210", "standard_charge_dollar": 2172.22, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Peoples Hlth Ffs 72126", "plan_name": "500019", "standard_charge_dollar": 1737.77, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Uhc/Secure Horizons", "plan_name": "500449", "standard_charge_dollar": 1737.77, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "United Health Care/", "plan_name": "500292", "standard_charge_dollar": 1963.68, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "United Healthcare", "plan_name": "750104", "standard_charge_dollar": 1963.68, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "United Healthcare Ba", "plan_name": "750090", "standard_charge_dollar": 1963.68, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "United Healthcare Me", "plan_name": "501310", "standard_charge_dollar": 1737.77, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Windsor Mcare Extra", "plan_name": "500778", "standard_charge_dollar": 1737.77, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." } ] } ] }, { "description": "Esophagoscop stent placement", "code_information": [ { "code": "43212", "type": "CPT" } ], "standard_charges": [ { "gross_charge": 25855.32, "minimum": 209.05, "maximum": 6816.48, "setting": "inpatient", "payers_information": [ { "payer_name": "Aarp", "plan_name": "500102", "standard_charge_dollar": 5453.19, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna", "plan_name": "700700", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna", "plan_name": "700700_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Mcare Ffs 6005", "plan_name": "700703", "standard_charge_dollar": 5453.19, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Miscellaneous", "plan_name": "700720", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Miscellaneous", "plan_name": "700720_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Ppo Hmo", "plan_name": "701720", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Ppo Hmo", "plan_name": "701720_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Ambetter 68069", "plan_name": "500516", "standard_charge_dollar": 5453.19, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Ms State Emplo", "plan_name": "401457", "standard_charge_dollar": 209.05, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Ms State Emplo", "plan_name": "401457_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Basic Pl", "plan_name": "400100", "standard_charge_dollar": 209.05, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Basic Pl", "plan_name": "400100_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Federal", "plan_name": "400110", "standard_charge_dollar": 209.05, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Federal", "plan_name": "400110_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Cigna Healthsprings Ffs", "plan_name": "500064", "standard_charge_dollar": 5453.19, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Conseco", "plan_name": "500302", "standard_charge_dollar": 5453.19, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Humana Ffs 61101", "plan_name": "500006", "standard_charge_dollar": 5453.19, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Medicare A", "plan_name": "100100", "standard_charge_dollar": 5453.19, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Medicare A", "plan_name": "100500", "standard_charge_dollar": 5453.19, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Medicare Part B Only", "plan_name": "100300", "standard_charge_dollar": 5453.19, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Medicare Railroad", "plan_name": "100103", "standard_charge_dollar": 5453.19, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Ms Physicians Care N", "plan_name": "714210", "standard_charge_dollar": 6816.48, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Peoples Hlth Ffs 72126", "plan_name": "500019", "standard_charge_dollar": 5453.19, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Uhc/Secure Horizons", "plan_name": "500449", "standard_charge_dollar": 5453.19, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "United Health Care/", "plan_name": "500292", "standard_charge_dollar": 6162.10, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "United Healthcare", "plan_name": "750104", "standard_charge_dollar": 6162.10, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "United Healthcare Ba", "plan_name": "750090", "standard_charge_dollar": 6162.10, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "United Healthcare Me", "plan_name": "501310", "standard_charge_dollar": 5453.19, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Windsor Mcare Extra", "plan_name": "500778", "standard_charge_dollar": 5453.19, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." } ] } ] }, { "description": "Esophagoscopy retro balloon", "code_information": [ { "code": "43213", "type": "CPT" } ], "standard_charges": [ { "gross_charge": 21231.04, "minimum": 286.95, "maximum": 2172.22, "setting": "inpatient", "payers_information": [ { "payer_name": "Aarp", "plan_name": "500102", "standard_charge_dollar": 1737.77, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna", "plan_name": "700700", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna", "plan_name": "700700_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Mcare Ffs 6005", "plan_name": "700703", "standard_charge_dollar": 1737.77, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Miscellaneous", "plan_name": "700720", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Miscellaneous", "plan_name": "700720_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Ppo Hmo", "plan_name": "701720", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Ppo Hmo", "plan_name": "701720_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Ambetter 68069", "plan_name": "500516", "standard_charge_dollar": 1737.77, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Ms State Emplo", "plan_name": "401457", "standard_charge_dollar": 286.95, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Ms State Emplo", "plan_name": "401457_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Basic Pl", "plan_name": "400100", "standard_charge_dollar": 286.95, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Basic Pl", "plan_name": "400100_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Federal", "plan_name": "400110", "standard_charge_dollar": 286.95, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Federal", "plan_name": "400110_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Cigna Healthsprings Ffs", "plan_name": "500064", "standard_charge_dollar": 1737.77, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Conseco", "plan_name": "500302", "standard_charge_dollar": 1737.77, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Humana Ffs 61101", "plan_name": "500006", "standard_charge_dollar": 1737.77, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Medicare A", "plan_name": "100100", "standard_charge_dollar": 1737.77, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Medicare A", "plan_name": "100500", "standard_charge_dollar": 1737.77, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Medicare Part B Only", "plan_name": "100300", "standard_charge_dollar": 1737.77, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Medicare Railroad", "plan_name": "100103", "standard_charge_dollar": 1737.77, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Ms Physicians Care N", "plan_name": "714210", "standard_charge_dollar": 2172.22, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Peoples Hlth Ffs 72126", "plan_name": "500019", "standard_charge_dollar": 1737.77, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Uhc/Secure Horizons", "plan_name": "500449", "standard_charge_dollar": 1737.77, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "United Health Care/", "plan_name": "500292", "standard_charge_dollar": 1963.68, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "United Healthcare", "plan_name": "750104", "standard_charge_dollar": 1963.68, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "United Healthcare Ba", "plan_name": "750090", "standard_charge_dollar": 1963.68, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "United Healthcare Me", "plan_name": "501310", "standard_charge_dollar": 1737.77, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Windsor Mcare Extra", "plan_name": "500778", "standard_charge_dollar": 1737.77, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." } ] } ] }, { "description": "Esophagosc dilate balloon 30", "code_information": [ { "code": "43214", "type": "CPT" } ], "standard_charges": [ { "gross_charge": 21231.04, "minimum": 213.41, "maximum": 2172.22, "setting": "inpatient", "payers_information": [ { "payer_name": "Aarp", "plan_name": "500102", "standard_charge_dollar": 1737.77, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna", "plan_name": "700700", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna", "plan_name": "700700_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Mcare Ffs 6005", "plan_name": "700703", "standard_charge_dollar": 1737.77, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Miscellaneous", "plan_name": "700720", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Miscellaneous", "plan_name": "700720_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Ppo Hmo", "plan_name": "701720", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Ppo Hmo", "plan_name": "701720_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Ambetter 68069", "plan_name": "500516", "standard_charge_dollar": 1737.77, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Ms State Emplo", "plan_name": "401457", "standard_charge_dollar": 213.41, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Ms State Emplo", "plan_name": "401457_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Basic Pl", "plan_name": "400100", "standard_charge_dollar": 213.41, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Basic Pl", "plan_name": "400100_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Federal", "plan_name": "400110", "standard_charge_dollar": 213.41, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Federal", "plan_name": "400110_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Cigna Healthsprings Ffs", "plan_name": "500064", "standard_charge_dollar": 1737.77, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Conseco", "plan_name": "500302", "standard_charge_dollar": 1737.77, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Humana Ffs 61101", "plan_name": "500006", "standard_charge_dollar": 1737.77, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Medicare A", "plan_name": "100100", "standard_charge_dollar": 1737.77, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Medicare A", "plan_name": "100500", "standard_charge_dollar": 1737.77, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Medicare Part B Only", "plan_name": "100300", "standard_charge_dollar": 1737.77, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Medicare Railroad", "plan_name": "100103", "standard_charge_dollar": 1737.77, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Ms Physicians Care N", "plan_name": "714210", "standard_charge_dollar": 2172.22, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Peoples Hlth Ffs 72126", "plan_name": "500019", "standard_charge_dollar": 1737.77, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Uhc/Secure Horizons", "plan_name": "500449", "standard_charge_dollar": 1737.77, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "United Health Care/", "plan_name": "500292", "standard_charge_dollar": 1963.68, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "United Healthcare", "plan_name": "750104", "standard_charge_dollar": 1963.68, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "United Healthcare Ba", "plan_name": "750090", "standard_charge_dollar": 1963.68, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "United Healthcare Me", "plan_name": "501310", "standard_charge_dollar": 1737.77, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Windsor Mcare Extra", "plan_name": "500778", "standard_charge_dollar": 1737.77, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." } ] } ] }, { "description": "Esophagoscopy flex remove fb", "code_information": [ { "code": "43215", "type": "CPT" } ], "standard_charges": [ { "gross_charge": 20303.99, "minimum": 1737.77, "maximum": 17258.39, "setting": "inpatient", "payers_information": [ { "payer_name": "Aarp", "plan_name": "500102", "standard_charge_dollar": 1737.77, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna", "plan_name": "700700", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna", "plan_name": "700700_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Mcare Ffs 6005", "plan_name": "700703", "standard_charge_dollar": 1737.77, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Miscellaneous", "plan_name": "700720", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Miscellaneous", "plan_name": "700720_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Ppo Hmo", "plan_name": "701720", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Ppo Hmo", "plan_name": "701720_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Ambetter 68069", "plan_name": "500516", "standard_charge_dollar": 1737.77, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Ms State Emplo", "plan_name": "401457", "standard_charge_percentage": 0.80, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Ms State Emplo", "plan_name": "401457_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Basic Pl", "plan_name": "400100", "standard_charge_percentage": 0.85, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Basic Pl", "plan_name": "400100_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Federal", "plan_name": "400110", "standard_charge_percentage": 0.85, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Federal", "plan_name": "400110_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Cigna Healthsprings Ffs", "plan_name": "500064", "standard_charge_dollar": 1737.77, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Conseco", "plan_name": "500302", "standard_charge_dollar": 1737.77, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Humana Ffs 61101", "plan_name": "500006", "standard_charge_dollar": 1737.77, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Medicare A", "plan_name": "100100", "standard_charge_dollar": 1737.77, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Medicare A", "plan_name": "100500", "standard_charge_dollar": 1737.77, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Medicare Part B Only", "plan_name": "100300", "standard_charge_dollar": 1737.77, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Medicare Railroad", "plan_name": "100103", "standard_charge_dollar": 1737.77, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Ms Physicians Care N", "plan_name": "714210", "standard_charge_dollar": 2172.22, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Peoples Hlth Ffs 72126", "plan_name": "500019", "standard_charge_dollar": 1737.77, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Uhc/Secure Horizons", "plan_name": "500449", "standard_charge_dollar": 1737.77, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "United Health Care/", "plan_name": "500292", "standard_charge_dollar": 1963.68, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "United Healthcare", "plan_name": "750104", "standard_charge_dollar": 1963.68, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "United Healthcare Ba", "plan_name": "750090", "standard_charge_dollar": 1963.68, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "United Healthcare Me", "plan_name": "501310", "standard_charge_dollar": 1737.77, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Windsor Mcare Extra", "plan_name": "500778", "standard_charge_dollar": 1737.77, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." } ] } ] }, { "description": "Esophagoscopy balloon <30mm", "code_information": [ { "code": "43220", "type": "CPT" } ], "standard_charges": [ { "gross_charge": 23457.99, "minimum": 1737.77, "maximum": 19939.29, "setting": "inpatient", "payers_information": [ { "payer_name": "Aarp", "plan_name": "500102", "standard_charge_dollar": 1737.77, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna", "plan_name": "700700", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna", "plan_name": "700700_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Mcare Ffs 6005", "plan_name": "700703", "standard_charge_dollar": 1737.77, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Miscellaneous", "plan_name": "700720", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Miscellaneous", "plan_name": "700720_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Ppo Hmo", "plan_name": "701720", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Ppo Hmo", "plan_name": "701720_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Ambetter 68069", "plan_name": "500516", "standard_charge_dollar": 1737.77, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Ms State Emplo", "plan_name": "401457", "standard_charge_percentage": 0.80, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Ms State Emplo", "plan_name": "401457_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Basic Pl", "plan_name": "400100", "standard_charge_percentage": 0.85, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Basic Pl", "plan_name": "400100_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Federal", "plan_name": "400110", "standard_charge_percentage": 0.85, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Federal", "plan_name": "400110_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Cigna Healthsprings Ffs", "plan_name": "500064", "standard_charge_dollar": 1737.77, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Conseco", "plan_name": "500302", "standard_charge_dollar": 1737.77, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Humana Ffs 61101", "plan_name": "500006", "standard_charge_dollar": 1737.77, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Medicare A", "plan_name": "100100", "standard_charge_dollar": 1737.77, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Medicare A", "plan_name": "100500", "standard_charge_dollar": 1737.77, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Medicare Part B Only", "plan_name": "100300", "standard_charge_dollar": 1737.77, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Medicare Railroad", "plan_name": "100103", "standard_charge_dollar": 1737.77, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Ms Physicians Care N", "plan_name": "714210", "standard_charge_dollar": 2172.22, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Peoples Hlth Ffs 72126", "plan_name": "500019", "standard_charge_dollar": 1737.77, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Uhc/Secure Horizons", "plan_name": "500449", "standard_charge_dollar": 1737.77, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "United Health Care/", "plan_name": "500292", "standard_charge_dollar": 1963.68, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "United Healthcare", "plan_name": "750104", "standard_charge_dollar": 1963.68, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "United Healthcare Ba", "plan_name": "750090", "standard_charge_dollar": 1963.68, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "United Healthcare Me", "plan_name": "501310", "standard_charge_dollar": 1737.77, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Windsor Mcare Extra", "plan_name": "500778", "standard_charge_dollar": 1737.77, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." } ] } ] }, { "description": "Esoph endoscopy dilation", "code_information": [ { "code": "43226", "type": "CPT" } ], "standard_charges": [ { "gross_charge": 24352.26, "minimum": 1737.77, "maximum": 20699.42, "setting": "inpatient", "payers_information": [ { "payer_name": "Aarp", "plan_name": "500102", "standard_charge_dollar": 1737.77, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna", "plan_name": "700700", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna", "plan_name": "700700_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Mcare Ffs 6005", "plan_name": "700703", "standard_charge_dollar": 1737.77, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Miscellaneous", "plan_name": "700720", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Miscellaneous", "plan_name": "700720_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Ppo Hmo", "plan_name": "701720", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Ppo Hmo", "plan_name": "701720_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Ambetter 68069", "plan_name": "500516", "standard_charge_dollar": 1737.77, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Ms State Emplo", "plan_name": "401457", "standard_charge_percentage": 0.80, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Ms State Emplo", "plan_name": "401457_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Basic Pl", "plan_name": "400100", "standard_charge_percentage": 0.85, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Basic Pl", "plan_name": "400100_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Federal", "plan_name": "400110", "standard_charge_percentage": 0.85, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Federal", "plan_name": "400110_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Cigna Healthsprings Ffs", "plan_name": "500064", "standard_charge_dollar": 1737.77, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Conseco", "plan_name": "500302", "standard_charge_dollar": 1737.77, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Humana Ffs 61101", "plan_name": "500006", "standard_charge_dollar": 1737.77, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Medicare A", "plan_name": "100100", "standard_charge_dollar": 1737.77, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Medicare A", "plan_name": "100500", "standard_charge_dollar": 1737.77, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Medicare Part B Only", "plan_name": "100300", "standard_charge_dollar": 1737.77, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Medicare Railroad", "plan_name": "100103", "standard_charge_dollar": 1737.77, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Ms Physicians Care N", "plan_name": "714210", "standard_charge_dollar": 2172.22, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Peoples Hlth Ffs 72126", "plan_name": "500019", "standard_charge_dollar": 1737.77, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Uhc/Secure Horizons", "plan_name": "500449", "standard_charge_dollar": 1737.77, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "United Health Care/", "plan_name": "500292", "standard_charge_dollar": 1963.68, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "United Healthcare", "plan_name": "750104", "standard_charge_dollar": 1963.68, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "United Healthcare Ba", "plan_name": "750090", "standard_charge_dollar": 1963.68, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "United Healthcare Me", "plan_name": "501310", "standard_charge_dollar": 1737.77, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Windsor Mcare Extra", "plan_name": "500778", "standard_charge_dollar": 1737.77, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." } ] } ] }, { "description": "Esophagoscopy control bleed", "code_information": [ { "code": "43227", "type": "CPT" } ], "standard_charges": [ { "gross_charge": 17132.65, "minimum": 1737.77, "maximum": 14562.75, "setting": "inpatient", "payers_information": [ { "payer_name": "Aarp", "plan_name": "500102", "standard_charge_dollar": 1737.77, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna", "plan_name": "700700", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna", "plan_name": "700700_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Mcare Ffs 6005", "plan_name": "700703", "standard_charge_dollar": 1737.77, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Miscellaneous", "plan_name": "700720", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Miscellaneous", "plan_name": "700720_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Ppo Hmo", "plan_name": "701720", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Ppo Hmo", "plan_name": "701720_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Ambetter 68069", "plan_name": "500516", "standard_charge_dollar": 1737.77, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Ms State Emplo", "plan_name": "401457", "standard_charge_percentage": 0.80, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Ms State Emplo", "plan_name": "401457_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Basic Pl", "plan_name": "400100", "standard_charge_percentage": 0.85, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Basic Pl", "plan_name": "400100_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Federal", "plan_name": "400110", "standard_charge_percentage": 0.85, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Federal", "plan_name": "400110_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Cigna Healthsprings Ffs", "plan_name": "500064", "standard_charge_dollar": 1737.77, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Conseco", "plan_name": "500302", "standard_charge_dollar": 1737.77, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Humana Ffs 61101", "plan_name": "500006", "standard_charge_dollar": 1737.77, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Medicare A", "plan_name": "100100", "standard_charge_dollar": 1737.77, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Medicare A", "plan_name": "100500", "standard_charge_dollar": 1737.77, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Medicare Part B Only", "plan_name": "100300", "standard_charge_dollar": 1737.77, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Medicare Railroad", "plan_name": "100103", "standard_charge_dollar": 1737.77, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Ms Physicians Care N", "plan_name": "714210", "standard_charge_dollar": 2172.22, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Peoples Hlth Ffs 72126", "plan_name": "500019", "standard_charge_dollar": 1737.77, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Uhc/Secure Horizons", "plan_name": "500449", "standard_charge_dollar": 1737.77, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "United Health Care/", "plan_name": "500292", "standard_charge_dollar": 1963.68, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "United Healthcare", "plan_name": "750104", "standard_charge_dollar": 1963.68, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "United Healthcare Ba", "plan_name": "750090", "standard_charge_dollar": 1963.68, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "United Healthcare Me", "plan_name": "501310", "standard_charge_dollar": 1737.77, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Windsor Mcare Extra", "plan_name": "500778", "standard_charge_dollar": 1737.77, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." } ] } ] }, { "description": "Esophagoscop ultrasound exam", "code_information": [ { "code": "43231", "type": "CPT" } ], "standard_charges": [ { "gross_charge": 25703.80, "minimum": 1737.77, "maximum": 21848.23, "setting": "inpatient", "payers_information": [ { "payer_name": "Aarp", "plan_name": "500102", "standard_charge_dollar": 1737.77, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna", "plan_name": "700700", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna", "plan_name": "700700_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Mcare Ffs 6005", "plan_name": "700703", "standard_charge_dollar": 1737.77, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Miscellaneous", "plan_name": "700720", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Miscellaneous", "plan_name": "700720_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Ppo Hmo", "plan_name": "701720", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Ppo Hmo", "plan_name": "701720_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Ambetter 68069", "plan_name": "500516", "standard_charge_dollar": 1737.77, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Ms State Emplo", "plan_name": "401457", "standard_charge_percentage": 0.80, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Ms State Emplo", "plan_name": "401457_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Basic Pl", "plan_name": "400100", "standard_charge_percentage": 0.85, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Basic Pl", "plan_name": "400100_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Federal", "plan_name": "400110", "standard_charge_percentage": 0.85, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Federal", "plan_name": "400110_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Cigna Healthsprings Ffs", "plan_name": "500064", "standard_charge_dollar": 1737.77, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Conseco", "plan_name": "500302", "standard_charge_dollar": 1737.77, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Humana Ffs 61101", "plan_name": "500006", "standard_charge_dollar": 1737.77, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Medicare A", "plan_name": "100100", "standard_charge_dollar": 1737.77, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Medicare A", "plan_name": "100500", "standard_charge_dollar": 1737.77, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Medicare Part B Only", "plan_name": "100300", "standard_charge_dollar": 1737.77, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Medicare Railroad", "plan_name": "100103", "standard_charge_dollar": 1737.77, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Ms Physicians Care N", "plan_name": "714210", "standard_charge_dollar": 2172.22, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Peoples Hlth Ffs 72126", "plan_name": "500019", "standard_charge_dollar": 1737.77, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Uhc/Secure Horizons", "plan_name": "500449", "standard_charge_dollar": 1737.77, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "United Health Care/", "plan_name": "500292", "standard_charge_dollar": 1963.68, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "United Healthcare", "plan_name": "750104", "standard_charge_dollar": 1963.68, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "United Healthcare Ba", "plan_name": "750090", "standard_charge_dollar": 1963.68, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "United Healthcare Me", "plan_name": "501310", "standard_charge_dollar": 1737.77, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Windsor Mcare Extra", "plan_name": "500778", "standard_charge_dollar": 1737.77, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." } ] } ] }, { "description": "Esophagoscopy w/us needle bx", "code_information": [ { "code": "43232", "type": "CPT" } ], "standard_charges": [ { "gross_charge": 21648.94, "minimum": 1737.77, "maximum": 18401.60, "setting": "inpatient", "payers_information": [ { "payer_name": "Aarp", "plan_name": "500102", "standard_charge_dollar": 1737.77, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna", "plan_name": "700700", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna", "plan_name": "700700_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Mcare Ffs 6005", "plan_name": "700703", "standard_charge_dollar": 1737.77, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Miscellaneous", "plan_name": "700720", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Miscellaneous", "plan_name": "700720_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Ppo Hmo", "plan_name": "701720", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Ppo Hmo", "plan_name": "701720_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Ambetter 68069", "plan_name": "500516", "standard_charge_dollar": 1737.77, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Ms State Emplo", "plan_name": "401457", "standard_charge_percentage": 0.80, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Ms State Emplo", "plan_name": "401457_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Basic Pl", "plan_name": "400100", "standard_charge_percentage": 0.85, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Basic Pl", "plan_name": "400100_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Federal", "plan_name": "400110", "standard_charge_percentage": 0.85, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Federal", "plan_name": "400110_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Cigna Healthsprings Ffs", "plan_name": "500064", "standard_charge_dollar": 1737.77, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Conseco", "plan_name": "500302", "standard_charge_dollar": 1737.77, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Humana Ffs 61101", "plan_name": "500006", "standard_charge_dollar": 1737.77, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Medicare A", "plan_name": "100100", "standard_charge_dollar": 1737.77, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Medicare A", "plan_name": "100500", "standard_charge_dollar": 1737.77, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Medicare Part B Only", "plan_name": "100300", "standard_charge_dollar": 1737.77, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Medicare Railroad", "plan_name": "100103", "standard_charge_dollar": 1737.77, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Ms Physicians Care N", "plan_name": "714210", "standard_charge_dollar": 2172.22, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Peoples Hlth Ffs 72126", "plan_name": "500019", "standard_charge_dollar": 1737.77, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Uhc/Secure Horizons", "plan_name": "500449", "standard_charge_dollar": 1737.77, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "United Health Care/", "plan_name": "500292", "standard_charge_dollar": 1963.68, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "United Healthcare", "plan_name": "750104", "standard_charge_dollar": 1963.68, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "United Healthcare Ba", "plan_name": "750090", "standard_charge_dollar": 1963.68, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "United Healthcare Me", "plan_name": "501310", "standard_charge_dollar": 1737.77, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Windsor Mcare Extra", "plan_name": "500778", "standard_charge_dollar": 1737.77, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." } ] } ] }, { "description": "Egd balloon dil esoph30 mm/>", "code_information": [ { "code": "43233", "type": "CPT" } ], "standard_charges": [ { "gross_charge": 25117.64, "minimum": 252.75, "maximum": 2172.22, "setting": "inpatient", "payers_information": [ { "payer_name": "Aarp", "plan_name": "500102", "standard_charge_dollar": 1737.77, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna", "plan_name": "700700", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna", "plan_name": "700700_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Mcare Ffs 6005", "plan_name": "700703", "standard_charge_dollar": 1737.77, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Miscellaneous", "plan_name": "700720", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Miscellaneous", "plan_name": "700720_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Ppo Hmo", "plan_name": "701720", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Ppo Hmo", "plan_name": "701720_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Ambetter 68069", "plan_name": "500516", "standard_charge_dollar": 1737.77, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Ms State Emplo", "plan_name": "401457", "standard_charge_dollar": 252.75, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Ms State Emplo", "plan_name": "401457_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Basic Pl", "plan_name": "400100", "standard_charge_dollar": 252.75, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Basic Pl", "plan_name": "400100_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Federal", "plan_name": "400110", "standard_charge_dollar": 252.75, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Federal", "plan_name": "400110_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Cigna Healthsprings Ffs", "plan_name": "500064", "standard_charge_dollar": 1737.77, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Conseco", "plan_name": "500302", "standard_charge_dollar": 1737.77, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Humana Ffs 61101", "plan_name": "500006", "standard_charge_dollar": 1737.77, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Medicare A", "plan_name": "100100", "standard_charge_dollar": 1737.77, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Medicare A", "plan_name": "100500", "standard_charge_dollar": 1737.77, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Medicare Part B Only", "plan_name": "100300", "standard_charge_dollar": 1737.77, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Medicare Railroad", "plan_name": "100103", "standard_charge_dollar": 1737.77, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Ms Physicians Care N", "plan_name": "714210", "standard_charge_dollar": 2172.22, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Peoples Hlth Ffs 72126", "plan_name": "500019", "standard_charge_dollar": 1737.77, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Uhc/Secure Horizons", "plan_name": "500449", "standard_charge_dollar": 1737.77, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "United Health Care/", "plan_name": "500292", "standard_charge_dollar": 1963.68, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "United Healthcare", "plan_name": "750104", "standard_charge_dollar": 1963.68, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "United Healthcare Ba", "plan_name": "750090", "standard_charge_dollar": 1963.68, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "United Healthcare Me", "plan_name": "501310", "standard_charge_dollar": 1737.77, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Windsor Mcare Extra", "plan_name": "500778", "standard_charge_dollar": 1737.77, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." } ] } ] }, { "description": "Egd diagnostic brush wash", "code_information": [ { "code": "43235", "type": "CPT" } ], "standard_charges": [ { "gross_charge": 25324.19, "minimum": 858.87, "maximum": 21525.56, "setting": "inpatient", "payers_information": [ { "payer_name": "Aarp", "plan_name": "500102", "standard_charge_dollar": 858.87, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna", "plan_name": "700700", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna", "plan_name": "700700_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Mcare Ffs 6005", "plan_name": "700703", "standard_charge_dollar": 858.87, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Miscellaneous", "plan_name": "700720", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Miscellaneous", "plan_name": "700720_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Ppo Hmo", "plan_name": "701720", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Ppo Hmo", "plan_name": "701720_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Ambetter 68069", "plan_name": "500516", "standard_charge_dollar": 858.87, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Ms State Emplo", "plan_name": "401457", "standard_charge_percentage": 0.80, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Ms State Emplo", "plan_name": "401457_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Basic Pl", "plan_name": "400100", "standard_charge_percentage": 0.85, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Basic Pl", "plan_name": "400100_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Federal", "plan_name": "400110", "standard_charge_percentage": 0.85, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Federal", "plan_name": "400110_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Cigna Healthsprings Ffs", "plan_name": "500064", "standard_charge_dollar": 858.87, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Conseco", "plan_name": "500302", "standard_charge_dollar": 858.87, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Humana Ffs 61101", "plan_name": "500006", "standard_charge_dollar": 858.87, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Medicare A", "plan_name": "100100", "standard_charge_dollar": 858.87, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Medicare A", "plan_name": "100500", "standard_charge_dollar": 858.87, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Medicare Part B Only", "plan_name": "100300", "standard_charge_dollar": 858.87, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Medicare Railroad", "plan_name": "100103", "standard_charge_dollar": 858.87, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Ms Physicians Care N", "plan_name": "714210", "standard_charge_dollar": 1073.59, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Peoples Hlth Ffs 72126", "plan_name": "500019", "standard_charge_dollar": 858.87, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Uhc/Secure Horizons", "plan_name": "500449", "standard_charge_dollar": 858.87, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "United Health Care/", "plan_name": "500292", "standard_charge_dollar": 970.52, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "United Healthcare", "plan_name": "750104", "standard_charge_dollar": 970.52, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "United Healthcare Ba", "plan_name": "750090", "standard_charge_dollar": 970.52, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "United Healthcare Me", "plan_name": "501310", "standard_charge_dollar": 858.87, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Windsor Mcare Extra", "plan_name": "500778", "standard_charge_dollar": 858.87, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." } ] } ] }, { "description": "Uppr gi scope w/submuc inj", "code_information": [ { "code": "43236", "type": "CPT" } ], "standard_charges": [ { "gross_charge": 25183.29, "minimum": 858.87, "maximum": 21405.80, "setting": "inpatient", "payers_information": [ { "payer_name": "Aarp", "plan_name": "500102", "standard_charge_dollar": 858.87, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna", "plan_name": "700700", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna", "plan_name": "700700_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Mcare Ffs 6005", "plan_name": "700703", "standard_charge_dollar": 858.87, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Miscellaneous", "plan_name": "700720", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Miscellaneous", "plan_name": "700720_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Ppo Hmo", "plan_name": "701720", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Ppo Hmo", "plan_name": "701720_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Ambetter 68069", "plan_name": "500516", "standard_charge_dollar": 858.87, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Ms State Emplo", "plan_name": "401457", "standard_charge_percentage": 0.80, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Ms State Emplo", "plan_name": "401457_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Basic Pl", "plan_name": "400100", "standard_charge_percentage": 0.85, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Basic Pl", "plan_name": "400100_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Federal", "plan_name": "400110", "standard_charge_percentage": 0.85, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Federal", "plan_name": "400110_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Cigna Healthsprings Ffs", "plan_name": "500064", "standard_charge_dollar": 858.87, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Conseco", "plan_name": "500302", "standard_charge_dollar": 858.87, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Humana Ffs 61101", "plan_name": "500006", "standard_charge_dollar": 858.87, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Medicare A", "plan_name": "100100", "standard_charge_dollar": 858.87, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Medicare A", "plan_name": "100500", "standard_charge_dollar": 858.87, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Medicare Part B Only", "plan_name": "100300", "standard_charge_dollar": 858.87, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Medicare Railroad", "plan_name": "100103", "standard_charge_dollar": 858.87, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Ms Physicians Care N", "plan_name": "714210", "standard_charge_dollar": 1073.59, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Peoples Hlth Ffs 72126", "plan_name": "500019", "standard_charge_dollar": 858.87, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Uhc/Secure Horizons", "plan_name": "500449", "standard_charge_dollar": 858.87, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "United Health Care/", "plan_name": "500292", "standard_charge_dollar": 970.52, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "United Healthcare", "plan_name": "750104", "standard_charge_dollar": 970.52, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "United Healthcare Ba", "plan_name": "750090", "standard_charge_dollar": 970.52, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "United Healthcare Me", "plan_name": "501310", "standard_charge_dollar": 858.87, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Windsor Mcare Extra", "plan_name": "500778", "standard_charge_dollar": 858.87, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." } ] } ] }, { "description": "Endoscopic us exam esoph", "code_information": [ { "code": "43237", "type": "CPT" } ], "standard_charges": [ { "gross_charge": 24676.07, "minimum": 1737.77, "maximum": 20974.66, "setting": "inpatient", "payers_information": [ { "payer_name": "Aarp", "plan_name": "500102", "standard_charge_dollar": 1737.77, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna", "plan_name": "700700", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna", "plan_name": "700700_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Mcare Ffs 6005", "plan_name": "700703", "standard_charge_dollar": 1737.77, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Miscellaneous", "plan_name": "700720", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Miscellaneous", "plan_name": "700720_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Ppo Hmo", "plan_name": "701720", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Ppo Hmo", "plan_name": "701720_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Ambetter 68069", "plan_name": "500516", "standard_charge_dollar": 1737.77, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Ms State Emplo", "plan_name": "401457", "standard_charge_percentage": 0.80, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Ms State Emplo", "plan_name": "401457_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Basic Pl", "plan_name": "400100", "standard_charge_percentage": 0.85, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Basic Pl", "plan_name": "400100_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Federal", "plan_name": "400110", "standard_charge_percentage": 0.85, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Federal", "plan_name": "400110_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Cigna Healthsprings Ffs", "plan_name": "500064", "standard_charge_dollar": 1737.77, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Conseco", "plan_name": "500302", "standard_charge_dollar": 1737.77, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Humana Ffs 61101", "plan_name": "500006", "standard_charge_dollar": 1737.77, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Medicare A", "plan_name": "100100", "standard_charge_dollar": 1737.77, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Medicare A", "plan_name": "100500", "standard_charge_dollar": 1737.77, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Medicare Part B Only", "plan_name": "100300", "standard_charge_dollar": 1737.77, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Medicare Railroad", "plan_name": "100103", "standard_charge_dollar": 1737.77, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Ms Physicians Care N", "plan_name": "714210", "standard_charge_dollar": 2172.22, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Peoples Hlth Ffs 72126", "plan_name": "500019", "standard_charge_dollar": 1737.77, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Uhc/Secure Horizons", "plan_name": "500449", "standard_charge_dollar": 1737.77, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "United Health Care/", "plan_name": "500292", "standard_charge_dollar": 1963.68, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "United Healthcare", "plan_name": "750104", "standard_charge_dollar": 1963.68, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "United Healthcare Ba", "plan_name": "750090", "standard_charge_dollar": 1963.68, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "United Healthcare Me", "plan_name": "501310", "standard_charge_dollar": 1737.77, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Windsor Mcare Extra", "plan_name": "500778", "standard_charge_dollar": 1737.77, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." } ] } ] }, { "description": "Egd us fine needle bx/aspir", "code_information": [ { "code": "43238", "type": "CPT" } ], "standard_charges": [ { "gross_charge": 25206.81, "minimum": 1737.77, "maximum": 21425.79, "setting": "inpatient", "payers_information": [ { "payer_name": "Aarp", "plan_name": "500102", "standard_charge_dollar": 1737.77, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna", "plan_name": "700700", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna", "plan_name": "700700_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Mcare Ffs 6005", "plan_name": "700703", "standard_charge_dollar": 1737.77, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Miscellaneous", "plan_name": "700720", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Miscellaneous", "plan_name": "700720_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Ppo Hmo", "plan_name": "701720", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Ppo Hmo", "plan_name": "701720_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Ambetter 68069", "plan_name": "500516", "standard_charge_dollar": 1737.77, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Ms State Emplo", "plan_name": "401457", "standard_charge_percentage": 0.80, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Ms State Emplo", "plan_name": "401457_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Basic Pl", "plan_name": "400100", "standard_charge_percentage": 0.85, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Basic Pl", "plan_name": "400100_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Federal", "plan_name": "400110", "standard_charge_percentage": 0.85, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Federal", "plan_name": "400110_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Cigna Healthsprings Ffs", "plan_name": "500064", "standard_charge_dollar": 1737.77, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Conseco", "plan_name": "500302", "standard_charge_dollar": 1737.77, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Humana Ffs 61101", "plan_name": "500006", "standard_charge_dollar": 1737.77, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Medicare A", "plan_name": "100100", "standard_charge_dollar": 1737.77, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Medicare A", "plan_name": "100500", "standard_charge_dollar": 1737.77, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Medicare Part B Only", "plan_name": "100300", "standard_charge_dollar": 1737.77, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Medicare Railroad", "plan_name": "100103", "standard_charge_dollar": 1737.77, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Ms Physicians Care N", "plan_name": "714210", "standard_charge_dollar": 2172.22, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Peoples Hlth Ffs 72126", "plan_name": "500019", "standard_charge_dollar": 1737.77, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Uhc/Secure Horizons", "plan_name": "500449", "standard_charge_dollar": 1737.77, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "United Health Care/", "plan_name": "500292", "standard_charge_dollar": 1963.68, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "United Healthcare", "plan_name": "750104", "standard_charge_dollar": 1963.68, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "United Healthcare Ba", "plan_name": "750090", "standard_charge_dollar": 1963.68, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "United Healthcare Me", "plan_name": "501310", "standard_charge_dollar": 1737.77, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Windsor Mcare Extra", "plan_name": "500778", "standard_charge_dollar": 1737.77, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." } ] } ] }, { "description": "Egd biopsy single/multiple", "code_information": [ { "code": "43239", "type": "CPT" } ], "standard_charges": [ { "gross_charge": 25352.07, "minimum": 858.87, "maximum": 21549.26, "setting": "inpatient", "payers_information": [ { "payer_name": "Aarp", "plan_name": "500102", "standard_charge_dollar": 858.87, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna", "plan_name": "700700", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna", "plan_name": "700700_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Mcare Ffs 6005", "plan_name": "700703", "standard_charge_dollar": 858.87, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Miscellaneous", "plan_name": "700720", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Miscellaneous", "plan_name": "700720_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Ppo Hmo", "plan_name": "701720", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Ppo Hmo", "plan_name": "701720_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Ambetter 68069", "plan_name": "500516", "standard_charge_dollar": 858.87, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Ms State Emplo", "plan_name": "401457", "standard_charge_percentage": 0.80, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Ms State Emplo", "plan_name": "401457_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Basic Pl", "plan_name": "400100", "standard_charge_percentage": 0.85, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Basic Pl", "plan_name": "400100_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Federal", "plan_name": "400110", "standard_charge_percentage": 0.85, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Federal", "plan_name": "400110_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Cigna Healthsprings Ffs", "plan_name": "500064", "standard_charge_dollar": 858.87, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Conseco", "plan_name": "500302", "standard_charge_dollar": 858.87, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Humana Ffs 61101", "plan_name": "500006", "standard_charge_dollar": 858.87, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Medicare A", "plan_name": "100100", "standard_charge_dollar": 858.87, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Medicare A", "plan_name": "100500", "standard_charge_dollar": 858.87, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Medicare Part B Only", "plan_name": "100300", "standard_charge_dollar": 858.87, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Medicare Railroad", "plan_name": "100103", "standard_charge_dollar": 858.87, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Ms Physicians Care N", "plan_name": "714210", "standard_charge_dollar": 1073.59, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Peoples Hlth Ffs 72126", "plan_name": "500019", "standard_charge_dollar": 858.87, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Uhc/Secure Horizons", "plan_name": "500449", "standard_charge_dollar": 858.87, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "United Health Care/", "plan_name": "500292", "standard_charge_dollar": 970.52, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "United Healthcare", "plan_name": "750104", "standard_charge_dollar": 970.52, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "United Healthcare Ba", "plan_name": "750090", "standard_charge_dollar": 970.52, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "United Healthcare Me", "plan_name": "501310", "standard_charge_dollar": 858.87, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Windsor Mcare Extra", "plan_name": "500778", "standard_charge_dollar": 858.87, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." } ] } ] }, { "description": "Egd w/transmural drain cyst", "code_information": [ { "code": "43240", "type": "CPT" } ], "standard_charges": [ { "gross_charge": 24676.07, "minimum": 5453.19, "maximum": 20974.66, "setting": "inpatient", "payers_information": [ { "payer_name": "Aarp", "plan_name": "500102", "standard_charge_dollar": 5453.19, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna", "plan_name": "700700", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna", "plan_name": "700700_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Mcare Ffs 6005", "plan_name": "700703", "standard_charge_dollar": 5453.19, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Miscellaneous", "plan_name": "700720", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Miscellaneous", "plan_name": "700720_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Ppo Hmo", "plan_name": "701720", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Ppo Hmo", "plan_name": "701720_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Ambetter 68069", "plan_name": "500516", "standard_charge_dollar": 5453.19, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Ms State Emplo", "plan_name": "401457", "standard_charge_percentage": 0.80, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Ms State Emplo", "plan_name": "401457_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Basic Pl", "plan_name": "400100", "standard_charge_percentage": 0.85, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Basic Pl", "plan_name": "400100_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Federal", "plan_name": "400110", "standard_charge_percentage": 0.85, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Federal", "plan_name": "400110_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Cigna Healthsprings Ffs", "plan_name": "500064", "standard_charge_dollar": 5453.19, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Conseco", "plan_name": "500302", "standard_charge_dollar": 5453.19, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Humana Ffs 61101", "plan_name": "500006", "standard_charge_dollar": 5453.19, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Medicare A", "plan_name": "100100", "standard_charge_dollar": 5453.19, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Medicare A", "plan_name": "100500", "standard_charge_dollar": 5453.19, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Medicare Part B Only", "plan_name": "100300", "standard_charge_dollar": 5453.19, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Medicare Railroad", "plan_name": "100103", "standard_charge_dollar": 5453.19, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Ms Physicians Care N", "plan_name": "714210", "standard_charge_dollar": 6816.48, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Peoples Hlth Ffs 72126", "plan_name": "500019", "standard_charge_dollar": 5453.19, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Uhc/Secure Horizons", "plan_name": "500449", "standard_charge_dollar": 5453.19, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "United Health Care/", "plan_name": "500292", "standard_charge_dollar": 6162.10, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "United Healthcare", "plan_name": "750104", "standard_charge_dollar": 6162.10, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "United Healthcare Ba", "plan_name": "750090", "standard_charge_dollar": 6162.10, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "United Healthcare Me", "plan_name": "501310", "standard_charge_dollar": 5453.19, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Windsor Mcare Extra", "plan_name": "500778", "standard_charge_dollar": 5453.19, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." } ] } ] }, { "description": "Egd tube/cath insertion", "code_information": [ { "code": "43241", "type": "CPT" } ], "standard_charges": [ { "gross_charge": 25206.81, "minimum": 1737.77, "maximum": 21425.79, "setting": "inpatient", "payers_information": [ { "payer_name": "Aarp", "plan_name": "500102", "standard_charge_dollar": 1737.77, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna", "plan_name": "700700", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna", "plan_name": "700700_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Mcare Ffs 6005", "plan_name": "700703", "standard_charge_dollar": 1737.77, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Miscellaneous", "plan_name": "700720", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Miscellaneous", "plan_name": "700720_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Ppo Hmo", "plan_name": "701720", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Ppo Hmo", "plan_name": "701720_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Ambetter 68069", "plan_name": "500516", "standard_charge_dollar": 1737.77, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Ms State Emplo", "plan_name": "401457", "standard_charge_percentage": 0.80, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Ms State Emplo", "plan_name": "401457_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Basic Pl", "plan_name": "400100", "standard_charge_percentage": 0.85, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Basic Pl", "plan_name": "400100_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Federal", "plan_name": "400110", "standard_charge_percentage": 0.85, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Federal", "plan_name": "400110_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Cigna Healthsprings Ffs", "plan_name": "500064", "standard_charge_dollar": 1737.77, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Conseco", "plan_name": "500302", "standard_charge_dollar": 1737.77, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Humana Ffs 61101", "plan_name": "500006", "standard_charge_dollar": 1737.77, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Medicare A", "plan_name": "100100", "standard_charge_dollar": 1737.77, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Medicare A", "plan_name": "100500", "standard_charge_dollar": 1737.77, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Medicare Part B Only", "plan_name": "100300", "standard_charge_dollar": 1737.77, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Medicare Railroad", "plan_name": "100103", "standard_charge_dollar": 1737.77, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Ms Physicians Care N", "plan_name": "714210", "standard_charge_dollar": 2172.22, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Peoples Hlth Ffs 72126", "plan_name": "500019", "standard_charge_dollar": 1737.77, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Uhc/Secure Horizons", "plan_name": "500449", "standard_charge_dollar": 1737.77, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "United Health Care/", "plan_name": "500292", "standard_charge_dollar": 1963.68, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "United Healthcare", "plan_name": "750104", "standard_charge_dollar": 1963.68, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "United Healthcare Ba", "plan_name": "750090", "standard_charge_dollar": 1963.68, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "United Healthcare Me", "plan_name": "501310", "standard_charge_dollar": 1737.77, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Windsor Mcare Extra", "plan_name": "500778", "standard_charge_dollar": 1737.77, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." } ] } ] }, { "description": "Egd us fine needle bx/aspir", "code_information": [ { "code": "43242", "type": "CPT" } ], "standard_charges": [ { "gross_charge": 25206.81, "minimum": 1737.77, "maximum": 21425.79, "setting": "inpatient", "payers_information": [ { "payer_name": "Aarp", "plan_name": "500102", "standard_charge_dollar": 1737.77, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna", "plan_name": "700700", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna", "plan_name": "700700_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Mcare Ffs 6005", "plan_name": "700703", "standard_charge_dollar": 1737.77, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Miscellaneous", "plan_name": "700720", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Miscellaneous", "plan_name": "700720_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Ppo Hmo", "plan_name": "701720", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Ppo Hmo", "plan_name": "701720_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Ambetter 68069", "plan_name": "500516", "standard_charge_dollar": 1737.77, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Ms State Emplo", "plan_name": "401457", "standard_charge_percentage": 0.80, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Ms State Emplo", "plan_name": "401457_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Basic Pl", "plan_name": "400100", "standard_charge_percentage": 0.85, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Basic Pl", "plan_name": "400100_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Federal", "plan_name": "400110", "standard_charge_percentage": 0.85, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Federal", "plan_name": "400110_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Cigna Healthsprings Ffs", "plan_name": "500064", "standard_charge_dollar": 1737.77, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Conseco", "plan_name": "500302", "standard_charge_dollar": 1737.77, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Humana Ffs 61101", "plan_name": "500006", "standard_charge_dollar": 1737.77, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Medicare A", "plan_name": "100100", "standard_charge_dollar": 1737.77, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Medicare A", "plan_name": "100500", "standard_charge_dollar": 1737.77, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Medicare Part B Only", "plan_name": "100300", "standard_charge_dollar": 1737.77, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Medicare Railroad", "plan_name": "100103", "standard_charge_dollar": 1737.77, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Ms Physicians Care N", "plan_name": "714210", "standard_charge_dollar": 2172.22, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Peoples Hlth Ffs 72126", "plan_name": "500019", "standard_charge_dollar": 1737.77, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Uhc/Secure Horizons", "plan_name": "500449", "standard_charge_dollar": 1737.77, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "United Health Care/", "plan_name": "500292", "standard_charge_dollar": 1963.68, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "United Healthcare", "plan_name": "750104", "standard_charge_dollar": 1963.68, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "United Healthcare Ba", "plan_name": "750090", "standard_charge_dollar": 1963.68, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "United Healthcare Me", "plan_name": "501310", "standard_charge_dollar": 1737.77, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Windsor Mcare Extra", "plan_name": "500778", "standard_charge_dollar": 1737.77, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." } ] } ] }, { "description": "Egd injection varices", "code_information": [ { "code": "43243", "type": "CPT" } ], "standard_charges": [ { "gross_charge": 25079.63, "minimum": 1737.77, "maximum": 21317.69, "setting": "inpatient", "payers_information": [ { "payer_name": "Aarp", "plan_name": "500102", "standard_charge_dollar": 1737.77, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna", "plan_name": "700700", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna", "plan_name": "700700_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Mcare Ffs 6005", "plan_name": "700703", "standard_charge_dollar": 1737.77, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Miscellaneous", "plan_name": "700720", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Miscellaneous", "plan_name": "700720_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Ppo Hmo", "plan_name": "701720", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Ppo Hmo", "plan_name": "701720_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Ambetter 68069", "plan_name": "500516", "standard_charge_dollar": 1737.77, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Ms State Emplo", "plan_name": "401457", "standard_charge_percentage": 0.80, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Ms State Emplo", "plan_name": "401457_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Basic Pl", "plan_name": "400100", "standard_charge_percentage": 0.85, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Basic Pl", "plan_name": "400100_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Federal", "plan_name": "400110", "standard_charge_percentage": 0.85, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Federal", "plan_name": "400110_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Cigna Healthsprings Ffs", "plan_name": "500064", "standard_charge_dollar": 1737.77, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Conseco", "plan_name": "500302", "standard_charge_dollar": 1737.77, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Humana Ffs 61101", "plan_name": "500006", "standard_charge_dollar": 1737.77, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Medicare A", "plan_name": "100100", "standard_charge_dollar": 1737.77, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Medicare A", "plan_name": "100500", "standard_charge_dollar": 1737.77, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Medicare Part B Only", "plan_name": "100300", "standard_charge_dollar": 1737.77, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Medicare Railroad", "plan_name": "100103", "standard_charge_dollar": 1737.77, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Ms Physicians Care N", "plan_name": "714210", "standard_charge_dollar": 2172.22, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Peoples Hlth Ffs 72126", "plan_name": "500019", "standard_charge_dollar": 1737.77, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Uhc/Secure Horizons", "plan_name": "500449", "standard_charge_dollar": 1737.77, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "United Health Care/", "plan_name": "500292", "standard_charge_dollar": 1963.68, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "United Healthcare", "plan_name": "750104", "standard_charge_dollar": 1963.68, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "United Healthcare Ba", "plan_name": "750090", "standard_charge_dollar": 1963.68, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "United Healthcare Me", "plan_name": "501310", "standard_charge_dollar": 1737.77, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Windsor Mcare Extra", "plan_name": "500778", "standard_charge_dollar": 1737.77, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." } ] } ] }, { "description": "Egd varices ligation", "code_information": [ { "code": "43244", "type": "CPT" } ], "standard_charges": [ { "gross_charge": 24676.07, "minimum": 1737.77, "maximum": 20974.66, "setting": "inpatient", "payers_information": [ { "payer_name": "Aarp", "plan_name": "500102", "standard_charge_dollar": 1737.77, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna", "plan_name": "700700", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna", "plan_name": "700700_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Mcare Ffs 6005", "plan_name": "700703", "standard_charge_dollar": 1737.77, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Miscellaneous", "plan_name": "700720", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Miscellaneous", "plan_name": "700720_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Ppo Hmo", "plan_name": "701720", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Ppo Hmo", "plan_name": "701720_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Ambetter 68069", "plan_name": "500516", "standard_charge_dollar": 1737.77, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Ms State Emplo", "plan_name": "401457", "standard_charge_percentage": 0.80, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Ms State Emplo", "plan_name": "401457_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Basic Pl", "plan_name": "400100", "standard_charge_percentage": 0.85, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Basic Pl", "plan_name": "400100_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Federal", "plan_name": "400110", "standard_charge_percentage": 0.85, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Federal", "plan_name": "400110_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Cigna Healthsprings Ffs", "plan_name": "500064", "standard_charge_dollar": 1737.77, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Conseco", "plan_name": "500302", "standard_charge_dollar": 1737.77, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Humana Ffs 61101", "plan_name": "500006", "standard_charge_dollar": 1737.77, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Medicare A", "plan_name": "100100", "standard_charge_dollar": 1737.77, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Medicare A", "plan_name": "100500", "standard_charge_dollar": 1737.77, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Medicare Part B Only", "plan_name": "100300", "standard_charge_dollar": 1737.77, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Medicare Railroad", "plan_name": "100103", "standard_charge_dollar": 1737.77, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Ms Physicians Care N", "plan_name": "714210", "standard_charge_dollar": 2172.22, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Peoples Hlth Ffs 72126", "plan_name": "500019", "standard_charge_dollar": 1737.77, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Uhc/Secure Horizons", "plan_name": "500449", "standard_charge_dollar": 1737.77, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "United Health Care/", "plan_name": "500292", "standard_charge_dollar": 1963.68, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "United Healthcare", "plan_name": "750104", "standard_charge_dollar": 1963.68, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "United Healthcare Ba", "plan_name": "750090", "standard_charge_dollar": 1963.68, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "United Healthcare Me", "plan_name": "501310", "standard_charge_dollar": 1737.77, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Windsor Mcare Extra", "plan_name": "500778", "standard_charge_dollar": 1737.77, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." } ] } ] }, { "description": "Egd dilate stricture", "code_information": [ { "code": "43245", "type": "CPT" } ], "standard_charges": [ { "gross_charge": 24676.07, "minimum": 1737.77, "maximum": 20974.66, "setting": "inpatient", "payers_information": [ { "payer_name": "Aarp", "plan_name": "500102", "standard_charge_dollar": 1737.77, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna", "plan_name": "700700", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna", "plan_name": "700700_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Mcare Ffs 6005", "plan_name": "700703", "standard_charge_dollar": 1737.77, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Miscellaneous", "plan_name": "700720", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Miscellaneous", "plan_name": "700720_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Ppo Hmo", "plan_name": "701720", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Ppo Hmo", "plan_name": "701720_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Ambetter 68069", "plan_name": "500516", "standard_charge_dollar": 1737.77, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Ms State Emplo", "plan_name": "401457", "standard_charge_percentage": 0.80, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Ms State Emplo", "plan_name": "401457_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Basic Pl", "plan_name": "400100", "standard_charge_percentage": 0.85, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Basic Pl", "plan_name": "400100_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Federal", "plan_name": "400110", "standard_charge_percentage": 0.85, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Federal", "plan_name": "400110_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Cigna Healthsprings Ffs", "plan_name": "500064", "standard_charge_dollar": 1737.77, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Conseco", "plan_name": "500302", "standard_charge_dollar": 1737.77, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Humana Ffs 61101", "plan_name": "500006", "standard_charge_dollar": 1737.77, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Medicare A", "plan_name": "100100", "standard_charge_dollar": 1737.77, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Medicare A", "plan_name": "100500", "standard_charge_dollar": 1737.77, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Medicare Part B Only", "plan_name": "100300", "standard_charge_dollar": 1737.77, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Medicare Railroad", "plan_name": "100103", "standard_charge_dollar": 1737.77, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Ms Physicians Care N", "plan_name": "714210", "standard_charge_dollar": 2172.22, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Peoples Hlth Ffs 72126", "plan_name": "500019", "standard_charge_dollar": 1737.77, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Uhc/Secure Horizons", "plan_name": "500449", "standard_charge_dollar": 1737.77, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "United Health Care/", "plan_name": "500292", "standard_charge_dollar": 1963.68, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "United Healthcare", "plan_name": "750104", "standard_charge_dollar": 1963.68, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "United Healthcare Ba", "plan_name": "750090", "standard_charge_dollar": 1963.68, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "United Healthcare Me", "plan_name": "501310", "standard_charge_dollar": 1737.77, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Windsor Mcare Extra", "plan_name": "500778", "standard_charge_dollar": 1737.77, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." } ] } ] }, { "description": "Egd place gastrostomy tube", "code_information": [ { "code": "43246", "type": "CPT" } ], "standard_charges": [ { "gross_charge": 24952.96, "minimum": 1737.77, "maximum": 21210.02, "setting": "inpatient", "payers_information": [ { "payer_name": "Aarp", "plan_name": "500102", "standard_charge_dollar": 1737.77, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna", "plan_name": "700700", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna", "plan_name": "700700_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Mcare Ffs 6005", "plan_name": "700703", "standard_charge_dollar": 1737.77, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Miscellaneous", "plan_name": "700720", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Miscellaneous", "plan_name": "700720_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Ppo Hmo", "plan_name": "701720", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Ppo Hmo", "plan_name": "701720_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Ambetter 68069", "plan_name": "500516", "standard_charge_dollar": 1737.77, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Ms State Emplo", "plan_name": "401457", "standard_charge_percentage": 0.80, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Ms State Emplo", "plan_name": "401457_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Basic Pl", "plan_name": "400100", "standard_charge_percentage": 0.85, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Basic Pl", "plan_name": "400100_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Federal", "plan_name": "400110", "standard_charge_percentage": 0.85, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Federal", "plan_name": "400110_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Cigna Healthsprings Ffs", "plan_name": "500064", "standard_charge_dollar": 1737.77, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Conseco", "plan_name": "500302", "standard_charge_dollar": 1737.77, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Humana Ffs 61101", "plan_name": "500006", "standard_charge_dollar": 1737.77, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Medicare A", "plan_name": "100100", "standard_charge_dollar": 1737.77, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Medicare A", "plan_name": "100500", "standard_charge_dollar": 1737.77, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Medicare Part B Only", "plan_name": "100300", "standard_charge_dollar": 1737.77, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Medicare Railroad", "plan_name": "100103", "standard_charge_dollar": 1737.77, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Ms Physicians Care N", "plan_name": "714210", "standard_charge_dollar": 2172.22, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Peoples Hlth Ffs 72126", "plan_name": "500019", "standard_charge_dollar": 1737.77, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Uhc/Secure Horizons", "plan_name": "500449", "standard_charge_dollar": 1737.77, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "United Health Care/", "plan_name": "500292", "standard_charge_dollar": 1963.68, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "United Healthcare", "plan_name": "750104", "standard_charge_dollar": 1963.68, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "United Healthcare Ba", "plan_name": "750090", "standard_charge_dollar": 1963.68, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "United Healthcare Me", "plan_name": "501310", "standard_charge_dollar": 1737.77, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Windsor Mcare Extra", "plan_name": "500778", "standard_charge_dollar": 1737.77, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." } ] } ] }, { "description": "Egd place gastrostomy tube", "code_information": [ { "code": "43246", "type": "CPT" } ], "standard_charges": [ { "gross_charge": 3708.00, "minimum": 1737.77, "maximum": 3151.80, "setting": "outpatient", "payers_information": [ { "payer_name": "Aarp", "plan_name": "500102", "standard_charge_dollar": 1737.77, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna", "plan_name": "700700", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna", "plan_name": "700700_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Mcare Ffs 6005", "plan_name": "700703", "standard_charge_dollar": 1737.77, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Miscellaneous", "plan_name": "700720", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Miscellaneous", "plan_name": "700720_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Ppo Hmo", "plan_name": "701720", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Ppo Hmo", "plan_name": "701720_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Ambetter 68069", "plan_name": "500516", "standard_charge_dollar": 1737.77, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Ms State Emplo", "plan_name": "401457", "standard_charge_percentage": 0.80, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Ms State Emplo", "plan_name": "401457_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Basic Pl", "plan_name": "400100", "standard_charge_percentage": 0.85, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Basic Pl", "plan_name": "400100_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Federal", "plan_name": "400110", "standard_charge_percentage": 0.85, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Federal", "plan_name": "400110_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Cigna Healthsprings Ffs", "plan_name": "500064", "standard_charge_dollar": 1737.77, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Conseco", "plan_name": "500302", "standard_charge_dollar": 1737.77, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Humana Ffs 61101", "plan_name": "500006", "standard_charge_dollar": 1737.77, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Medicare A", "plan_name": "100100", "standard_charge_dollar": 1737.77, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Medicare A", "plan_name": "100500", "standard_charge_dollar": 1737.77, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Medicare Part B Only", "plan_name": "100300", "standard_charge_dollar": 1737.77, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Medicare Railroad", "plan_name": "100103", "standard_charge_dollar": 1737.77, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Ms Physicians Care N", "plan_name": "714210", "standard_charge_dollar": 2172.22, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Peoples Hlth Ffs 72126", "plan_name": "500019", "standard_charge_dollar": 1737.77, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Uhc/Secure Horizons", "plan_name": "500449", "standard_charge_dollar": 1737.77, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "United Health Care/", "plan_name": "500292", "standard_charge_dollar": 1963.68, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "United Healthcare", "plan_name": "750104", "standard_charge_dollar": 1963.68, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "United Healthcare Ba", "plan_name": "750090", "standard_charge_dollar": 1963.68, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "United Healthcare Me", "plan_name": "501310", "standard_charge_dollar": 1737.77, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Windsor Mcare Extra", "plan_name": "500778", "standard_charge_dollar": 1737.77, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." } ] } ] }, { "description": "Hc peg tube insertion", "code_information": [ { "code": "43246", "type": "CPT" } ], "standard_charges": [ { "gross_charge": 3708.00, "minimum": 1737.77, "maximum": 3151.80, "setting": "both", "payers_information": [ { "payer_name": "Aarp", "plan_name": "500102", "standard_charge_dollar": 1737.77, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna", "plan_name": "700700", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna", "plan_name": "700700_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Mcare Ffs 6005", "plan_name": "700703", "standard_charge_dollar": 1737.77, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Miscellaneous", "plan_name": "700720", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Miscellaneous", "plan_name": "700720_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Ppo Hmo", "plan_name": "701720", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Ppo Hmo", "plan_name": "701720_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Ambetter 68069", "plan_name": "500516", "standard_charge_dollar": 1737.77, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Ms State Emplo", "plan_name": "401457", "standard_charge_percentage": 0.80, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Ms State Emplo", "plan_name": "401457_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Basic Pl", "plan_name": "400100", "standard_charge_percentage": 0.85, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Basic Pl", "plan_name": "400100_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Federal", "plan_name": "400110", "standard_charge_percentage": 0.85, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Federal", "plan_name": "400110_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Cigna Healthsprings Ffs", "plan_name": "500064", "standard_charge_dollar": 1737.77, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Conseco", "plan_name": "500302", "standard_charge_dollar": 1737.77, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Humana Ffs 61101", "plan_name": "500006", "standard_charge_dollar": 1737.77, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Medicare A", "plan_name": "100100", "standard_charge_dollar": 1737.77, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Medicare A", "plan_name": "100500", "standard_charge_dollar": 1737.77, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Medicare Part B Only", "plan_name": "100300", "standard_charge_dollar": 1737.77, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Medicare Railroad", "plan_name": "100103", "standard_charge_dollar": 1737.77, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Ms Physicians Care N", "plan_name": "714210", "standard_charge_dollar": 2172.22, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Peoples Hlth Ffs 72126", "plan_name": "500019", "standard_charge_dollar": 1737.77, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Uhc/Secure Horizons", "plan_name": "500449", "standard_charge_dollar": 1737.77, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "United Health Care/", "plan_name": "500292", "standard_charge_dollar": 1963.68, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "United Healthcare", "plan_name": "750104", "standard_charge_dollar": 1963.68, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "United Healthcare Ba", "plan_name": "750090", "standard_charge_dollar": 1963.68, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "United Healthcare Me", "plan_name": "501310", "standard_charge_dollar": 1737.77, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Windsor Mcare Extra", "plan_name": "500778", "standard_charge_dollar": 1737.77, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." } ] } ] }, { "description": "Egd remove foreign body", "code_information": [ { "code": "43247", "type": "CPT" } ], "standard_charges": [ { "gross_charge": 24676.07, "minimum": 858.87, "maximum": 20974.66, "setting": "inpatient", "payers_information": [ { "payer_name": "Aarp", "plan_name": "500102", "standard_charge_dollar": 858.87, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna", "plan_name": "700700", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna", "plan_name": "700700_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Mcare Ffs 6005", "plan_name": "700703", "standard_charge_dollar": 858.87, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Miscellaneous", "plan_name": "700720", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Miscellaneous", "plan_name": "700720_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Ppo Hmo", "plan_name": "701720", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Ppo Hmo", "plan_name": "701720_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Ambetter 68069", "plan_name": "500516", "standard_charge_dollar": 858.87, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Ms State Emplo", "plan_name": "401457", "standard_charge_percentage": 0.80, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Ms State Emplo", "plan_name": "401457_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Basic Pl", "plan_name": "400100", "standard_charge_percentage": 0.85, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Basic Pl", "plan_name": "400100_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Federal", "plan_name": "400110", "standard_charge_percentage": 0.85, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Federal", "plan_name": "400110_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Cigna Healthsprings Ffs", "plan_name": "500064", "standard_charge_dollar": 858.87, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Conseco", "plan_name": "500302", "standard_charge_dollar": 858.87, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Humana Ffs 61101", "plan_name": "500006", "standard_charge_dollar": 858.87, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Medicare A", "plan_name": "100100", "standard_charge_dollar": 858.87, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Medicare A", "plan_name": "100500", "standard_charge_dollar": 858.87, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Medicare Part B Only", "plan_name": "100300", "standard_charge_dollar": 858.87, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Medicare Railroad", "plan_name": "100103", "standard_charge_dollar": 858.87, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Ms Physicians Care N", "plan_name": "714210", "standard_charge_dollar": 1073.59, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Peoples Hlth Ffs 72126", "plan_name": "500019", "standard_charge_dollar": 858.87, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Uhc/Secure Horizons", "plan_name": "500449", "standard_charge_dollar": 858.87, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "United Health Care/", "plan_name": "500292", "standard_charge_dollar": 970.52, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "United Healthcare", "plan_name": "750104", "standard_charge_dollar": 970.52, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "United Healthcare Ba", "plan_name": "750090", "standard_charge_dollar": 970.52, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "United Healthcare Me", "plan_name": "501310", "standard_charge_dollar": 858.87, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Windsor Mcare Extra", "plan_name": "500778", "standard_charge_dollar": 858.87, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." } ] } ] }, { "description": "Egd guide wire insertion", "code_information": [ { "code": "43248", "type": "CPT" } ], "standard_charges": [ { "gross_charge": 24767.74, "minimum": 858.87, "maximum": 21052.58, "setting": "inpatient", "payers_information": [ { "payer_name": "Aarp", "plan_name": "500102", "standard_charge_dollar": 858.87, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna", "plan_name": "700700", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna", "plan_name": "700700_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Mcare Ffs 6005", "plan_name": "700703", "standard_charge_dollar": 858.87, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Miscellaneous", "plan_name": "700720", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Miscellaneous", "plan_name": "700720_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Ppo Hmo", "plan_name": "701720", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Ppo Hmo", "plan_name": "701720_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Ambetter 68069", "plan_name": "500516", "standard_charge_dollar": 858.87, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Ms State Emplo", "plan_name": "401457", "standard_charge_percentage": 0.80, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Ms State Emplo", "plan_name": "401457_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Basic Pl", "plan_name": "400100", "standard_charge_percentage": 0.85, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Basic Pl", "plan_name": "400100_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Federal", "plan_name": "400110", "standard_charge_percentage": 0.85, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Federal", "plan_name": "400110_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Cigna Healthsprings Ffs", "plan_name": "500064", "standard_charge_dollar": 858.87, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Conseco", "plan_name": "500302", "standard_charge_dollar": 858.87, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Humana Ffs 61101", "plan_name": "500006", "standard_charge_dollar": 858.87, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Medicare A", "plan_name": "100100", "standard_charge_dollar": 858.87, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Medicare A", "plan_name": "100500", "standard_charge_dollar": 858.87, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Medicare Part B Only", "plan_name": "100300", "standard_charge_dollar": 858.87, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Medicare Railroad", "plan_name": "100103", "standard_charge_dollar": 858.87, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Ms Physicians Care N", "plan_name": "714210", "standard_charge_dollar": 1073.59, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Peoples Hlth Ffs 72126", "plan_name": "500019", "standard_charge_dollar": 858.87, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Uhc/Secure Horizons", "plan_name": "500449", "standard_charge_dollar": 858.87, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "United Health Care/", "plan_name": "500292", "standard_charge_dollar": 970.52, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "United Healthcare", "plan_name": "750104", "standard_charge_dollar": 970.52, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "United Healthcare Ba", "plan_name": "750090", "standard_charge_dollar": 970.52, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "United Healthcare Me", "plan_name": "501310", "standard_charge_dollar": 858.87, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Windsor Mcare Extra", "plan_name": "500778", "standard_charge_dollar": 858.87, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." } ] } ] }, { "description": "Esoph egd dilation <30 mm", "code_information": [ { "code": "43249", "type": "CPT" } ], "standard_charges": [ { "gross_charge": 24638.92, "minimum": 1737.77, "maximum": 20943.08, "setting": "inpatient", "payers_information": [ { "payer_name": "Aarp", "plan_name": "500102", "standard_charge_dollar": 1737.77, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna", "plan_name": "700700", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna", "plan_name": "700700_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Mcare Ffs 6005", "plan_name": "700703", "standard_charge_dollar": 1737.77, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Miscellaneous", "plan_name": "700720", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Miscellaneous", "plan_name": "700720_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Ppo Hmo", "plan_name": "701720", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Ppo Hmo", "plan_name": "701720_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Ambetter 68069", "plan_name": "500516", "standard_charge_dollar": 1737.77, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Ms State Emplo", "plan_name": "401457", "standard_charge_percentage": 0.80, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Ms State Emplo", "plan_name": "401457_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Basic Pl", "plan_name": "400100", "standard_charge_percentage": 0.85, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Basic Pl", "plan_name": "400100_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Federal", "plan_name": "400110", "standard_charge_percentage": 0.85, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Federal", "plan_name": "400110_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Cigna Healthsprings Ffs", "plan_name": "500064", "standard_charge_dollar": 1737.77, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Conseco", "plan_name": "500302", "standard_charge_dollar": 1737.77, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Humana Ffs 61101", "plan_name": "500006", "standard_charge_dollar": 1737.77, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Medicare A", "plan_name": "100100", "standard_charge_dollar": 1737.77, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Medicare A", "plan_name": "100500", "standard_charge_dollar": 1737.77, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Medicare Part B Only", "plan_name": "100300", "standard_charge_dollar": 1737.77, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Medicare Railroad", "plan_name": "100103", "standard_charge_dollar": 1737.77, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Ms Physicians Care N", "plan_name": "714210", "standard_charge_dollar": 2172.22, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Peoples Hlth Ffs 72126", "plan_name": "500019", "standard_charge_dollar": 1737.77, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Uhc/Secure Horizons", "plan_name": "500449", "standard_charge_dollar": 1737.77, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "United Health Care/", "plan_name": "500292", "standard_charge_dollar": 1963.68, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "United Healthcare", "plan_name": "750104", "standard_charge_dollar": 1963.68, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "United Healthcare Ba", "plan_name": "750090", "standard_charge_dollar": 1963.68, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "United Healthcare Me", "plan_name": "501310", "standard_charge_dollar": 1737.77, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Windsor Mcare Extra", "plan_name": "500778", "standard_charge_dollar": 1737.77, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." } ] } ] }, { "description": "Egd cautery tumor polyp", "code_information": [ { "code": "43250", "type": "CPT" } ], "standard_charges": [ { "gross_charge": 25079.63, "minimum": 1737.77, "maximum": 21317.69, "setting": "inpatient", "payers_information": [ { "payer_name": "Aarp", "plan_name": "500102", "standard_charge_dollar": 1737.77, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna", "plan_name": "700700", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna", "plan_name": "700700_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Mcare Ffs 6005", "plan_name": "700703", "standard_charge_dollar": 1737.77, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Miscellaneous", "plan_name": "700720", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Miscellaneous", "plan_name": "700720_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Ppo Hmo", "plan_name": "701720", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Ppo Hmo", "plan_name": "701720_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Ambetter 68069", "plan_name": "500516", "standard_charge_dollar": 1737.77, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Ms State Emplo", "plan_name": "401457", "standard_charge_percentage": 0.80, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Ms State Emplo", "plan_name": "401457_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Basic Pl", "plan_name": "400100", "standard_charge_percentage": 0.85, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Basic Pl", "plan_name": "400100_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Federal", "plan_name": "400110", "standard_charge_percentage": 0.85, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Federal", "plan_name": "400110_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Cigna Healthsprings Ffs", "plan_name": "500064", "standard_charge_dollar": 1737.77, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Conseco", "plan_name": "500302", "standard_charge_dollar": 1737.77, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Humana Ffs 61101", "plan_name": "500006", "standard_charge_dollar": 1737.77, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Medicare A", "plan_name": "100100", "standard_charge_dollar": 1737.77, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Medicare A", "plan_name": "100500", "standard_charge_dollar": 1737.77, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Medicare Part B Only", "plan_name": "100300", "standard_charge_dollar": 1737.77, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Medicare Railroad", "plan_name": "100103", "standard_charge_dollar": 1737.77, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Ms Physicians Care N", "plan_name": "714210", "standard_charge_dollar": 2172.22, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Peoples Hlth Ffs 72126", "plan_name": "500019", "standard_charge_dollar": 1737.77, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Uhc/Secure Horizons", "plan_name": "500449", "standard_charge_dollar": 1737.77, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "United Health Care/", "plan_name": "500292", "standard_charge_dollar": 1963.68, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "United Healthcare", "plan_name": "750104", "standard_charge_dollar": 1963.68, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "United Healthcare Ba", "plan_name": "750090", "standard_charge_dollar": 1963.68, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "United Healthcare Me", "plan_name": "501310", "standard_charge_dollar": 1737.77, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Windsor Mcare Extra", "plan_name": "500778", "standard_charge_dollar": 1737.77, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." } ] } ] }, { "description": "Egd remove lesion snare", "code_information": [ { "code": "43251", "type": "CPT" } ], "standard_charges": [ { "gross_charge": 25833.48, "minimum": 1737.77, "maximum": 21958.46, "setting": "inpatient", "payers_information": [ { "payer_name": "Aarp", "plan_name": "500102", "standard_charge_dollar": 1737.77, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna", "plan_name": "700700", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna", "plan_name": "700700_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Mcare Ffs 6005", "plan_name": "700703", "standard_charge_dollar": 1737.77, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Miscellaneous", "plan_name": "700720", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Miscellaneous", "plan_name": "700720_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Ppo Hmo", "plan_name": "701720", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Ppo Hmo", "plan_name": "701720_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Ambetter 68069", "plan_name": "500516", "standard_charge_dollar": 1737.77, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Ms State Emplo", "plan_name": "401457", "standard_charge_percentage": 0.80, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Ms State Emplo", "plan_name": "401457_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Basic Pl", "plan_name": "400100", "standard_charge_percentage": 0.85, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Basic Pl", "plan_name": "400100_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Federal", "plan_name": "400110", "standard_charge_percentage": 0.85, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Federal", "plan_name": "400110_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Cigna Healthsprings Ffs", "plan_name": "500064", "standard_charge_dollar": 1737.77, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Conseco", "plan_name": "500302", "standard_charge_dollar": 1737.77, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Humana Ffs 61101", "plan_name": "500006", "standard_charge_dollar": 1737.77, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Medicare A", "plan_name": "100100", "standard_charge_dollar": 1737.77, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Medicare A", "plan_name": "100500", "standard_charge_dollar": 1737.77, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Medicare Part B Only", "plan_name": "100300", "standard_charge_dollar": 1737.77, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Medicare Railroad", "plan_name": "100103", "standard_charge_dollar": 1737.77, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Ms Physicians Care N", "plan_name": "714210", "standard_charge_dollar": 2172.22, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Peoples Hlth Ffs 72126", "plan_name": "500019", "standard_charge_dollar": 1737.77, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Uhc/Secure Horizons", "plan_name": "500449", "standard_charge_dollar": 1737.77, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "United Health Care/", "plan_name": "500292", "standard_charge_dollar": 1963.68, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "United Healthcare", "plan_name": "750104", "standard_charge_dollar": 1963.68, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "United Healthcare Ba", "plan_name": "750090", "standard_charge_dollar": 1963.68, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "United Healthcare Me", "plan_name": "501310", "standard_charge_dollar": 1737.77, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Windsor Mcare Extra", "plan_name": "500778", "standard_charge_dollar": 1737.77, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." } ] } ] }, { "description": "Egd optical endomicroscopy", "code_information": [ { "code": "43252", "type": "CPT" } ], "standard_charges": [ { "gross_charge": 25206.81, "minimum": 1737.77, "maximum": 21425.79, "setting": "inpatient", "payers_information": [ { "payer_name": "Aarp", "plan_name": "500102", "standard_charge_dollar": 1737.77, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna", "plan_name": "700700", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna", "plan_name": "700700_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Mcare Ffs 6005", "plan_name": "700703", "standard_charge_dollar": 1737.77, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Miscellaneous", "plan_name": "700720", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Miscellaneous", "plan_name": "700720_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Ppo Hmo", "plan_name": "701720", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Ppo Hmo", "plan_name": "701720_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Ambetter 68069", "plan_name": "500516", "standard_charge_dollar": 1737.77, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Ms State Emplo", "plan_name": "401457", "standard_charge_percentage": 0.80, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Ms State Emplo", "plan_name": "401457_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Basic Pl", "plan_name": "400100", "standard_charge_percentage": 0.85, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Basic Pl", "plan_name": "400100_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Federal", "plan_name": "400110", "standard_charge_percentage": 0.85, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Federal", "plan_name": "400110_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Cigna Healthsprings Ffs", "plan_name": "500064", "standard_charge_dollar": 1737.77, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Conseco", "plan_name": "500302", "standard_charge_dollar": 1737.77, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Humana Ffs 61101", "plan_name": "500006", "standard_charge_dollar": 1737.77, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Medicare A", "plan_name": "100100", "standard_charge_dollar": 1737.77, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Medicare A", "plan_name": "100500", "standard_charge_dollar": 1737.77, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Medicare Part B Only", "plan_name": "100300", "standard_charge_dollar": 1737.77, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Medicare Railroad", "plan_name": "100103", "standard_charge_dollar": 1737.77, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Ms Physicians Care N", "plan_name": "714210", "standard_charge_dollar": 2172.22, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Peoples Hlth Ffs 72126", "plan_name": "500019", "standard_charge_dollar": 1737.77, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Uhc/Secure Horizons", "plan_name": "500449", "standard_charge_dollar": 1737.77, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "United Health Care/", "plan_name": "500292", "standard_charge_dollar": 1963.68, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "United Healthcare", "plan_name": "750104", "standard_charge_dollar": 1963.68, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "United Healthcare Ba", "plan_name": "750090", "standard_charge_dollar": 1963.68, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "United Healthcare Me", "plan_name": "501310", "standard_charge_dollar": 1737.77, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Windsor Mcare Extra", "plan_name": "500778", "standard_charge_dollar": 1737.77, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." } ] } ] }, { "description": "Egd us transmural injxn/mark", "code_information": [ { "code": "43253", "type": "CPT" } ], "standard_charges": [ { "gross_charge": 24629.80, "minimum": 293.43, "maximum": 2172.22, "setting": "inpatient", "payers_information": [ { "payer_name": "Aarp", "plan_name": "500102", "standard_charge_dollar": 1737.77, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna", "plan_name": "700700", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna", "plan_name": "700700_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Mcare Ffs 6005", "plan_name": "700703", "standard_charge_dollar": 1737.77, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Miscellaneous", "plan_name": "700720", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Miscellaneous", "plan_name": "700720_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Ppo Hmo", "plan_name": "701720", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Ppo Hmo", "plan_name": "701720_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Ambetter 68069", "plan_name": "500516", "standard_charge_dollar": 1737.77, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Ms State Emplo", "plan_name": "401457", "standard_charge_dollar": 293.43, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Ms State Emplo", "plan_name": "401457_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Basic Pl", "plan_name": "400100", "standard_charge_dollar": 293.43, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Basic Pl", "plan_name": "400100_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Federal", "plan_name": "400110", "standard_charge_dollar": 293.43, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Federal", "plan_name": "400110_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Cigna Healthsprings Ffs", "plan_name": "500064", "standard_charge_dollar": 1737.77, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Conseco", "plan_name": "500302", "standard_charge_dollar": 1737.77, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Humana Ffs 61101", "plan_name": "500006", "standard_charge_dollar": 1737.77, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Medicare A", "plan_name": "100100", "standard_charge_dollar": 1737.77, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Medicare A", "plan_name": "100500", "standard_charge_dollar": 1737.77, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Medicare Part B Only", "plan_name": "100300", "standard_charge_dollar": 1737.77, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Medicare Railroad", "plan_name": "100103", "standard_charge_dollar": 1737.77, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Ms Physicians Care N", "plan_name": "714210", "standard_charge_dollar": 2172.22, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Peoples Hlth Ffs 72126", "plan_name": "500019", "standard_charge_dollar": 1737.77, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Uhc/Secure Horizons", "plan_name": "500449", "standard_charge_dollar": 1737.77, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "United Health Care/", "plan_name": "500292", "standard_charge_dollar": 1963.68, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "United Healthcare", "plan_name": "750104", "standard_charge_dollar": 1963.68, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "United Healthcare Ba", "plan_name": "750090", "standard_charge_dollar": 1963.68, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "United Healthcare Me", "plan_name": "501310", "standard_charge_dollar": 1737.77, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Windsor Mcare Extra", "plan_name": "500778", "standard_charge_dollar": 1737.77, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." } ] } ] }, { "description": "Egd endo mucosal resection", "code_information": [ { "code": "43254", "type": "CPT" } ], "standard_charges": [ { "gross_charge": 24676.07, "minimum": 301.81, "maximum": 2172.22, "setting": "inpatient", "payers_information": [ { "payer_name": "Aarp", "plan_name": "500102", "standard_charge_dollar": 1737.77, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna", "plan_name": "700700", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna", "plan_name": "700700_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Mcare Ffs 6005", "plan_name": "700703", "standard_charge_dollar": 1737.77, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Miscellaneous", "plan_name": "700720", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Miscellaneous", "plan_name": "700720_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Ppo Hmo", "plan_name": "701720", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Ppo Hmo", "plan_name": "701720_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Ambetter 68069", "plan_name": "500516", "standard_charge_dollar": 1737.77, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Ms State Emplo", "plan_name": "401457", "standard_charge_dollar": 301.81, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Ms State Emplo", "plan_name": "401457_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Basic Pl", "plan_name": "400100", "standard_charge_dollar": 301.81, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Basic Pl", "plan_name": "400100_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Federal", "plan_name": "400110", "standard_charge_dollar": 301.81, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Federal", "plan_name": "400110_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Cigna Healthsprings Ffs", "plan_name": "500064", "standard_charge_dollar": 1737.77, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Conseco", "plan_name": "500302", "standard_charge_dollar": 1737.77, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Humana Ffs 61101", "plan_name": "500006", "standard_charge_dollar": 1737.77, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Medicare A", "plan_name": "100100", "standard_charge_dollar": 1737.77, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Medicare A", "plan_name": "100500", "standard_charge_dollar": 1737.77, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Medicare Part B Only", "plan_name": "100300", "standard_charge_dollar": 1737.77, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Medicare Railroad", "plan_name": "100103", "standard_charge_dollar": 1737.77, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Ms Physicians Care N", "plan_name": "714210", "standard_charge_dollar": 2172.22, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Peoples Hlth Ffs 72126", "plan_name": "500019", "standard_charge_dollar": 1737.77, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Uhc/Secure Horizons", "plan_name": "500449", "standard_charge_dollar": 1737.77, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "United Health Care/", "plan_name": "500292", "standard_charge_dollar": 1963.68, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "United Healthcare", "plan_name": "750104", "standard_charge_dollar": 1963.68, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "United Healthcare Ba", "plan_name": "750090", "standard_charge_dollar": 1963.68, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "United Healthcare Me", "plan_name": "501310", "standard_charge_dollar": 1737.77, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Windsor Mcare Extra", "plan_name": "500778", "standard_charge_dollar": 1737.77, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." } ] } ] }, { "description": "Egd control bleeding any", "code_information": [ { "code": "43255", "type": "CPT" } ], "standard_charges": [ { "gross_charge": 24629.80, "minimum": 1737.77, "maximum": 20935.33, "setting": "inpatient", "payers_information": [ { "payer_name": "Aarp", "plan_name": "500102", "standard_charge_dollar": 1737.77, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna", "plan_name": "700700", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna", "plan_name": "700700_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Mcare Ffs 6005", "plan_name": "700703", "standard_charge_dollar": 1737.77, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Miscellaneous", "plan_name": "700720", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Miscellaneous", "plan_name": "700720_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Ppo Hmo", "plan_name": "701720", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Ppo Hmo", "plan_name": "701720_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Ambetter 68069", "plan_name": "500516", "standard_charge_dollar": 1737.77, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Ms State Emplo", "plan_name": "401457", "standard_charge_percentage": 0.80, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Ms State Emplo", "plan_name": "401457_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Basic Pl", "plan_name": "400100", "standard_charge_percentage": 0.85, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Basic Pl", "plan_name": "400100_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Federal", "plan_name": "400110", "standard_charge_percentage": 0.85, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Federal", "plan_name": "400110_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Cigna Healthsprings Ffs", "plan_name": "500064", "standard_charge_dollar": 1737.77, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Conseco", "plan_name": "500302", "standard_charge_dollar": 1737.77, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Humana Ffs 61101", "plan_name": "500006", "standard_charge_dollar": 1737.77, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Medicare A", "plan_name": "100100", "standard_charge_dollar": 1737.77, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Medicare A", "plan_name": "100500", "standard_charge_dollar": 1737.77, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Medicare Part B Only", "plan_name": "100300", "standard_charge_dollar": 1737.77, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Medicare Railroad", "plan_name": "100103", "standard_charge_dollar": 1737.77, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Ms Physicians Care N", "plan_name": "714210", "standard_charge_dollar": 2172.22, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Peoples Hlth Ffs 72126", "plan_name": "500019", "standard_charge_dollar": 1737.77, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Uhc/Secure Horizons", "plan_name": "500449", "standard_charge_dollar": 1737.77, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "United Health Care/", "plan_name": "500292", "standard_charge_dollar": 1963.68, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "United Healthcare", "plan_name": "750104", "standard_charge_dollar": 1963.68, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "United Healthcare Ba", "plan_name": "750090", "standard_charge_dollar": 1963.68, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "United Healthcare Me", "plan_name": "501310", "standard_charge_dollar": 1737.77, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Windsor Mcare Extra", "plan_name": "500778", "standard_charge_dollar": 1737.77, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." } ] } ] }, { "description": "Egd w/thrml txmnt gerd", "code_information": [ { "code": "43257", "type": "CPT" } ], "standard_charges": [ { "gross_charge": 24676.07, "minimum": 3485.21, "maximum": 20974.66, "setting": "inpatient", "payers_information": [ { "payer_name": "Aarp", "plan_name": "500102", "standard_charge_dollar": 3485.21, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna", "plan_name": "700700", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna", "plan_name": "700700_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Mcare Ffs 6005", "plan_name": "700703", "standard_charge_dollar": 3485.21, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Miscellaneous", "plan_name": "700720", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Miscellaneous", "plan_name": "700720_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Ppo Hmo", "plan_name": "701720", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Ppo Hmo", "plan_name": "701720_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Ambetter 68069", "plan_name": "500516", "standard_charge_dollar": 3485.21, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Ms State Emplo", "plan_name": "401457", "standard_charge_percentage": 0.80, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Ms State Emplo", "plan_name": "401457_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Basic Pl", "plan_name": "400100", "standard_charge_percentage": 0.85, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Basic Pl", "plan_name": "400100_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Federal", "plan_name": "400110", "standard_charge_percentage": 0.85, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Federal", "plan_name": "400110_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Cigna Healthsprings Ffs", "plan_name": "500064", "standard_charge_dollar": 3485.21, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Conseco", "plan_name": "500302", "standard_charge_dollar": 3485.21, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Humana Ffs 61101", "plan_name": "500006", "standard_charge_dollar": 3485.21, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Medicare A", "plan_name": "100100", "standard_charge_dollar": 3485.21, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Medicare A", "plan_name": "100500", "standard_charge_dollar": 3485.21, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Medicare Part B Only", "plan_name": "100300", "standard_charge_dollar": 3485.21, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Medicare Railroad", "plan_name": "100103", "standard_charge_dollar": 3485.21, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Ms Physicians Care N", "plan_name": "714210", "standard_charge_dollar": 4356.52, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Peoples Hlth Ffs 72126", "plan_name": "500019", "standard_charge_dollar": 3485.21, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Uhc/Secure Horizons", "plan_name": "500449", "standard_charge_dollar": 3485.21, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "United Health Care/", "plan_name": "500292", "standard_charge_dollar": 3938.29, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "United Healthcare", "plan_name": "750104", "standard_charge_dollar": 3938.29, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "United Healthcare Ba", "plan_name": "750090", "standard_charge_dollar": 3938.29, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "United Healthcare Me", "plan_name": "501310", "standard_charge_dollar": 3485.21, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Windsor Mcare Extra", "plan_name": "500778", "standard_charge_dollar": 3485.21, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." } ] } ] }, { "description": "Egd us exam duodenum/jejunum", "code_information": [ { "code": "43259", "type": "CPT" } ], "standard_charges": [ { "gross_charge": 25206.81, "minimum": 1737.77, "maximum": 21425.79, "setting": "inpatient", "payers_information": [ { "payer_name": "Aarp", "plan_name": "500102", "standard_charge_dollar": 1737.77, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna", "plan_name": "700700", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna", "plan_name": "700700_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Mcare Ffs 6005", "plan_name": "700703", "standard_charge_dollar": 1737.77, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Miscellaneous", "plan_name": "700720", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Miscellaneous", "plan_name": "700720_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Ppo Hmo", "plan_name": "701720", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Ppo Hmo", "plan_name": "701720_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Ambetter 68069", "plan_name": "500516", "standard_charge_dollar": 1737.77, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Ms State Emplo", "plan_name": "401457", "standard_charge_percentage": 0.80, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Ms State Emplo", "plan_name": "401457_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Basic Pl", "plan_name": "400100", "standard_charge_percentage": 0.85, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Basic Pl", "plan_name": "400100_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Federal", "plan_name": "400110", "standard_charge_percentage": 0.85, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Federal", "plan_name": "400110_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Cigna Healthsprings Ffs", "plan_name": "500064", "standard_charge_dollar": 1737.77, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Conseco", "plan_name": "500302", "standard_charge_dollar": 1737.77, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Humana Ffs 61101", "plan_name": "500006", "standard_charge_dollar": 1737.77, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Medicare A", "plan_name": "100100", "standard_charge_dollar": 1737.77, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Medicare A", "plan_name": "100500", "standard_charge_dollar": 1737.77, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Medicare Part B Only", "plan_name": "100300", "standard_charge_dollar": 1737.77, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Medicare Railroad", "plan_name": "100103", "standard_charge_dollar": 1737.77, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Ms Physicians Care N", "plan_name": "714210", "standard_charge_dollar": 2172.22, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Peoples Hlth Ffs 72126", "plan_name": "500019", "standard_charge_dollar": 1737.77, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Uhc/Secure Horizons", "plan_name": "500449", "standard_charge_dollar": 1737.77, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "United Health Care/", "plan_name": "500292", "standard_charge_dollar": 1963.68, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "United Healthcare", "plan_name": "750104", "standard_charge_dollar": 1963.68, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "United Healthcare Ba", "plan_name": "750090", "standard_charge_dollar": 1963.68, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "United Healthcare Me", "plan_name": "501310", "standard_charge_dollar": 1737.77, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Windsor Mcare Extra", "plan_name": "500778", "standard_charge_dollar": 1737.77, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." } ] } ] }, { "description": "Ercp w/specimen collection", "code_information": [ { "code": "43260", "type": "CPT" } ], "standard_charges": [ { "gross_charge": 35993.40, "minimum": 3485.21, "maximum": 30594.39, "setting": "inpatient", "payers_information": [ { "payer_name": "Aarp", "plan_name": "500102", "standard_charge_dollar": 3485.21, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna", "plan_name": "700700", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna", "plan_name": "700700_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Mcare Ffs 6005", "plan_name": "700703", "standard_charge_dollar": 3485.21, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Miscellaneous", "plan_name": "700720", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Miscellaneous", "plan_name": "700720_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Ppo Hmo", "plan_name": "701720", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Ppo Hmo", "plan_name": "701720_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Ambetter 68069", "plan_name": "500516", "standard_charge_dollar": 3485.21, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Ms State Emplo", "plan_name": "401457", "standard_charge_percentage": 0.80, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Ms State Emplo", "plan_name": "401457_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Basic Pl", "plan_name": "400100", "standard_charge_percentage": 0.85, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Basic Pl", "plan_name": "400100_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Federal", "plan_name": "400110", "standard_charge_percentage": 0.85, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Federal", "plan_name": "400110_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Cigna Healthsprings Ffs", "plan_name": "500064", "standard_charge_dollar": 3485.21, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Conseco", "plan_name": "500302", "standard_charge_dollar": 3485.21, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Humana Ffs 61101", "plan_name": "500006", "standard_charge_dollar": 3485.21, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Medicare A", "plan_name": "100100", "standard_charge_dollar": 3485.21, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Medicare A", "plan_name": "100500", "standard_charge_dollar": 3485.21, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Medicare Part B Only", "plan_name": "100300", "standard_charge_dollar": 3485.21, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Medicare Railroad", "plan_name": "100103", "standard_charge_dollar": 3485.21, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Ms Physicians Care N", "plan_name": "714210", "standard_charge_dollar": 4356.52, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Peoples Hlth Ffs 72126", "plan_name": "500019", "standard_charge_dollar": 3485.21, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Uhc/Secure Horizons", "plan_name": "500449", "standard_charge_dollar": 3485.21, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "United Health Care/", "plan_name": "500292", "standard_charge_dollar": 3938.29, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "United Healthcare", "plan_name": "750104", "standard_charge_dollar": 3938.29, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "United Healthcare Ba", "plan_name": "750090", "standard_charge_dollar": 3938.29, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "United Healthcare Me", "plan_name": "501310", "standard_charge_dollar": 3485.21, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Windsor Mcare Extra", "plan_name": "500778", "standard_charge_dollar": 3485.21, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." } ] } ] }, { "description": "Endo cholangiopancreatograph", "code_information": [ { "code": "43261", "type": "CPT" } ], "standard_charges": [ { "gross_charge": 16391.22, "minimum": 3485.21, "maximum": 13932.54, "setting": "inpatient", "payers_information": [ { "payer_name": "Aarp", "plan_name": "500102", "standard_charge_dollar": 3485.21, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna", "plan_name": "700700", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna", "plan_name": "700700_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Mcare Ffs 6005", "plan_name": "700703", "standard_charge_dollar": 3485.21, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Miscellaneous", "plan_name": "700720", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Miscellaneous", "plan_name": "700720_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Ppo Hmo", "plan_name": "701720", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Ppo Hmo", "plan_name": "701720_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Ambetter 68069", "plan_name": "500516", "standard_charge_dollar": 3485.21, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Ms State Emplo", "plan_name": "401457", "standard_charge_percentage": 0.80, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Ms State Emplo", "plan_name": "401457_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Basic Pl", "plan_name": "400100", "standard_charge_percentage": 0.85, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Basic Pl", "plan_name": "400100_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Federal", "plan_name": "400110", "standard_charge_percentage": 0.85, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Federal", "plan_name": "400110_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Cigna Healthsprings Ffs", "plan_name": "500064", "standard_charge_dollar": 3485.21, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Conseco", "plan_name": "500302", "standard_charge_dollar": 3485.21, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Humana Ffs 61101", "plan_name": "500006", "standard_charge_dollar": 3485.21, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Medicare A", "plan_name": "100100", "standard_charge_dollar": 3485.21, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Medicare A", "plan_name": "100500", "standard_charge_dollar": 3485.21, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Medicare Part B Only", "plan_name": "100300", "standard_charge_dollar": 3485.21, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Medicare Railroad", "plan_name": "100103", "standard_charge_dollar": 3485.21, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Ms Physicians Care N", "plan_name": "714210", "standard_charge_dollar": 4356.52, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Peoples Hlth Ffs 72126", "plan_name": "500019", "standard_charge_dollar": 3485.21, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Uhc/Secure Horizons", "plan_name": "500449", "standard_charge_dollar": 3485.21, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "United Health Care/", "plan_name": "500292", "standard_charge_dollar": 3938.29, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "United Healthcare", "plan_name": "750104", "standard_charge_dollar": 3938.29, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "United Healthcare Ba", "plan_name": "750090", "standard_charge_dollar": 3938.29, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "United Healthcare Me", "plan_name": "501310", "standard_charge_dollar": 3485.21, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Windsor Mcare Extra", "plan_name": "500778", "standard_charge_dollar": 3485.21, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." } ] } ] }, { "description": "Ercp remove duct calculi", "code_information": [ { "code": "43264", "type": "CPT" } ], "standard_charges": [ { "gross_charge": 53959.43, "minimum": 3485.21, "maximum": 45865.52, "setting": "inpatient", "payers_information": [ { "payer_name": "Aarp", "plan_name": "500102", "standard_charge_dollar": 3485.21, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna", "plan_name": "700700", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna", "plan_name": "700700_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Mcare Ffs 6005", "plan_name": "700703", "standard_charge_dollar": 3485.21, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Miscellaneous", "plan_name": "700720", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Miscellaneous", "plan_name": "700720_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Ppo Hmo", "plan_name": "701720", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Ppo Hmo", "plan_name": "701720_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Ambetter 68069", "plan_name": "500516", "standard_charge_dollar": 3485.21, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Ms State Emplo", "plan_name": "401457", "standard_charge_percentage": 0.80, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Ms State Emplo", "plan_name": "401457_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Basic Pl", "plan_name": "400100", "standard_charge_percentage": 0.85, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Basic Pl", "plan_name": "400100_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Federal", "plan_name": "400110", "standard_charge_percentage": 0.85, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Federal", "plan_name": "400110_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Cigna Healthsprings Ffs", "plan_name": "500064", "standard_charge_dollar": 3485.21, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Conseco", "plan_name": "500302", "standard_charge_dollar": 3485.21, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Humana Ffs 61101", "plan_name": "500006", "standard_charge_dollar": 3485.21, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Medicare A", "plan_name": "100100", "standard_charge_dollar": 3485.21, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Medicare A", "plan_name": "100500", "standard_charge_dollar": 3485.21, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Medicare Part B Only", "plan_name": "100300", "standard_charge_dollar": 3485.21, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Medicare Railroad", "plan_name": "100103", "standard_charge_dollar": 3485.21, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Ms Physicians Care N", "plan_name": "714210", "standard_charge_dollar": 4356.52, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Peoples Hlth Ffs 72126", "plan_name": "500019", "standard_charge_dollar": 3485.21, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Uhc/Secure Horizons", "plan_name": "500449", "standard_charge_dollar": 3485.21, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "United Health Care/", "plan_name": "500292", "standard_charge_dollar": 3938.29, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "United Healthcare", "plan_name": "750104", "standard_charge_dollar": 3938.29, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "United Healthcare Ba", "plan_name": "750090", "standard_charge_dollar": 3938.29, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "United Healthcare Me", "plan_name": "501310", "standard_charge_dollar": 3485.21, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Windsor Mcare Extra", "plan_name": "500778", "standard_charge_dollar": 3485.21, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." } ] } ] }, { "description": "Ercp lithotripsy calculi", "code_information": [ { "code": "43265", "type": "CPT" } ], "standard_charges": [ { "gross_charge": 53959.43, "minimum": 5453.19, "maximum": 45865.52, "setting": "inpatient", "payers_information": [ { "payer_name": "Aarp", "plan_name": "500102", "standard_charge_dollar": 5453.19, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna", "plan_name": "700700", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna", "plan_name": "700700_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Mcare Ffs 6005", "plan_name": "700703", "standard_charge_dollar": 5453.19, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Miscellaneous", "plan_name": "700720", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Miscellaneous", "plan_name": "700720_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Ppo Hmo", "plan_name": "701720", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Ppo Hmo", "plan_name": "701720_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Ambetter 68069", "plan_name": "500516", "standard_charge_dollar": 5453.19, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Ms State Emplo", "plan_name": "401457", "standard_charge_percentage": 0.80, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Ms State Emplo", "plan_name": "401457_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Basic Pl", "plan_name": "400100", "standard_charge_percentage": 0.85, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Basic Pl", "plan_name": "400100_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Federal", "plan_name": "400110", "standard_charge_percentage": 0.85, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Federal", "plan_name": "400110_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Cigna Healthsprings Ffs", "plan_name": "500064", "standard_charge_dollar": 5453.19, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Conseco", "plan_name": "500302", "standard_charge_dollar": 5453.19, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Humana Ffs 61101", "plan_name": "500006", "standard_charge_dollar": 5453.19, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Medicare A", "plan_name": "100100", "standard_charge_dollar": 5453.19, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Medicare A", "plan_name": "100500", "standard_charge_dollar": 5453.19, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Medicare Part B Only", "plan_name": "100300", "standard_charge_dollar": 5453.19, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Medicare Railroad", "plan_name": "100103", "standard_charge_dollar": 5453.19, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Ms Physicians Care N", "plan_name": "714210", "standard_charge_dollar": 6816.48, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Peoples Hlth Ffs 72126", "plan_name": "500019", "standard_charge_dollar": 5453.19, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Uhc/Secure Horizons", "plan_name": "500449", "standard_charge_dollar": 5453.19, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "United Health Care/", "plan_name": "500292", "standard_charge_dollar": 6162.10, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "United Healthcare", "plan_name": "750104", "standard_charge_dollar": 6162.10, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "United Healthcare Ba", "plan_name": "750090", "standard_charge_dollar": 6162.10, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "United Healthcare Me", "plan_name": "501310", "standard_charge_dollar": 5453.19, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Windsor Mcare Extra", "plan_name": "500778", "standard_charge_dollar": 5453.19, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." } ] } ] }, { "description": "Egd endoscopic stent place", "code_information": [ { "code": "43266", "type": "CPT" } ], "standard_charges": [ { "gross_charge": 24554.27, "minimum": 242.58, "maximum": 6816.48, "setting": "inpatient", "payers_information": [ { "payer_name": "Aarp", "plan_name": "500102", "standard_charge_dollar": 5453.19, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna", "plan_name": "700700", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna", "plan_name": "700700_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Mcare Ffs 6005", "plan_name": "700703", "standard_charge_dollar": 5453.19, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Miscellaneous", "plan_name": "700720", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Miscellaneous", "plan_name": "700720_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Ppo Hmo", "plan_name": "701720", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Ppo Hmo", "plan_name": "701720_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Ambetter 68069", "plan_name": "500516", "standard_charge_dollar": 5453.19, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Ms State Emplo", "plan_name": "401457", "standard_charge_dollar": 242.58, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Ms State Emplo", "plan_name": "401457_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Basic Pl", "plan_name": "400100", "standard_charge_dollar": 242.58, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Basic Pl", "plan_name": "400100_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Federal", "plan_name": "400110", "standard_charge_dollar": 242.58, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Federal", "plan_name": "400110_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Cigna Healthsprings Ffs", "plan_name": "500064", "standard_charge_dollar": 5453.19, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Conseco", "plan_name": "500302", "standard_charge_dollar": 5453.19, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Humana Ffs 61101", "plan_name": "500006", "standard_charge_dollar": 5453.19, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Medicare A", "plan_name": "100100", "standard_charge_dollar": 5453.19, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Medicare A", "plan_name": "100500", "standard_charge_dollar": 5453.19, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Medicare Part B Only", "plan_name": "100300", "standard_charge_dollar": 5453.19, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Medicare Railroad", "plan_name": "100103", "standard_charge_dollar": 5453.19, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Ms Physicians Care N", "plan_name": "714210", "standard_charge_dollar": 6816.48, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Peoples Hlth Ffs 72126", "plan_name": "500019", "standard_charge_dollar": 5453.19, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Uhc/Secure Horizons", "plan_name": "500449", "standard_charge_dollar": 5453.19, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "United Health Care/", "plan_name": "500292", "standard_charge_dollar": 6162.10, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "United Healthcare", "plan_name": "750104", "standard_charge_dollar": 6162.10, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "United Healthcare Ba", "plan_name": "750090", "standard_charge_dollar": 6162.10, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "United Healthcare Me", "plan_name": "501310", "standard_charge_dollar": 5453.19, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Windsor Mcare Extra", "plan_name": "500778", "standard_charge_dollar": 5453.19, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." } ] } ] }, { "description": "Egd lesion ablation", "code_information": [ { "code": "43270", "type": "CPT" } ], "standard_charges": [ { "gross_charge": 24758.06, "minimum": 250.49, "maximum": 2172.22, "setting": "inpatient", "payers_information": [ { "payer_name": "Aarp", "plan_name": "500102", "standard_charge_dollar": 1737.77, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna", "plan_name": "700700", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna", "plan_name": "700700_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Mcare Ffs 6005", "plan_name": "700703", "standard_charge_dollar": 1737.77, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Miscellaneous", "plan_name": "700720", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Miscellaneous", "plan_name": "700720_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Ppo Hmo", "plan_name": "701720", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Ppo Hmo", "plan_name": "701720_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Ambetter 68069", "plan_name": "500516", "standard_charge_dollar": 1737.77, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Ms State Emplo", "plan_name": "401457", "standard_charge_dollar": 250.49, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Ms State Emplo", "plan_name": "401457_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Basic Pl", "plan_name": "400100", "standard_charge_dollar": 250.49, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Basic Pl", "plan_name": "400100_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Federal", "plan_name": "400110", "standard_charge_dollar": 250.49, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Federal", "plan_name": "400110_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Cigna Healthsprings Ffs", "plan_name": "500064", "standard_charge_dollar": 1737.77, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Conseco", "plan_name": "500302", "standard_charge_dollar": 1737.77, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Humana Ffs 61101", "plan_name": "500006", "standard_charge_dollar": 1737.77, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Medicare A", "plan_name": "100100", "standard_charge_dollar": 1737.77, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Medicare A", "plan_name": "100500", "standard_charge_dollar": 1737.77, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Medicare Part B Only", "plan_name": "100300", "standard_charge_dollar": 1737.77, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Medicare Railroad", "plan_name": "100103", "standard_charge_dollar": 1737.77, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Ms Physicians Care N", "plan_name": "714210", "standard_charge_dollar": 2172.22, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Peoples Hlth Ffs 72126", "plan_name": "500019", "standard_charge_dollar": 1737.77, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Uhc/Secure Horizons", "plan_name": "500449", "standard_charge_dollar": 1737.77, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "United Health Care/", "plan_name": "500292", "standard_charge_dollar": 1963.68, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "United Healthcare", "plan_name": "750104", "standard_charge_dollar": 1963.68, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "United Healthcare Ba", "plan_name": "750090", "standard_charge_dollar": 1963.68, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "United Healthcare Me", "plan_name": "501310", "standard_charge_dollar": 1737.77, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Windsor Mcare Extra", "plan_name": "500778", "standard_charge_dollar": 1737.77, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." } ] } ] }, { "description": "Endoscopic pancreatoscopy", "code_information": [ { "code": "43273", "type": "CPT" } ], "standard_charges": [ { "gross_charge": 16391.22, "minimum": 13112.98, "maximum": 13932.54, "setting": "inpatient", "payers_information": [ { "payer_name": "Aetna", "plan_name": "700700", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna", "plan_name": "700700_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Miscellaneous", "plan_name": "700720", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Miscellaneous", "plan_name": "700720_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Ppo Hmo", "plan_name": "701720", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Ppo Hmo", "plan_name": "701720_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Ms State Emplo", "plan_name": "401457", "standard_charge_percentage": 0.80, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Ms State Emplo", "plan_name": "401457_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Basic Pl", "plan_name": "400100", "standard_charge_percentage": 0.85, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Basic Pl", "plan_name": "400100_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Federal", "plan_name": "400110", "standard_charge_percentage": 0.85, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Federal", "plan_name": "400110_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." } ] } ] }, { "description": "Ercp duct stent placement", "code_information": [ { "code": "43274", "type": "CPT" } ], "standard_charges": [ { "gross_charge": 19701.70, "minimum": 517.35, "maximum": 6816.48, "setting": "inpatient", "payers_information": [ { "payer_name": "Aarp", "plan_name": "500102", "standard_charge_dollar": 5453.19, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna", "plan_name": "700700", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna", "plan_name": "700700_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Mcare Ffs 6005", "plan_name": "700703", "standard_charge_dollar": 5453.19, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Miscellaneous", "plan_name": "700720", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Miscellaneous", "plan_name": "700720_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Ppo Hmo", "plan_name": "701720", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Ppo Hmo", "plan_name": "701720_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Ambetter 68069", "plan_name": "500516", "standard_charge_dollar": 5453.19, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Ms State Emplo", "plan_name": "401457", "standard_charge_dollar": 517.35, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Ms State Emplo", "plan_name": "401457_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Basic Pl", "plan_name": "400100", "standard_charge_dollar": 517.35, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Basic Pl", "plan_name": "400100_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Federal", "plan_name": "400110", "standard_charge_dollar": 517.35, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Federal", "plan_name": "400110_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Cigna Healthsprings Ffs", "plan_name": "500064", "standard_charge_dollar": 5453.19, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Conseco", "plan_name": "500302", "standard_charge_dollar": 5453.19, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Humana Ffs 61101", "plan_name": "500006", "standard_charge_dollar": 5453.19, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Medicare A", "plan_name": "100100", "standard_charge_dollar": 5453.19, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Medicare A", "plan_name": "100500", "standard_charge_dollar": 5453.19, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Medicare Part B Only", "plan_name": "100300", "standard_charge_dollar": 5453.19, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Medicare Railroad", "plan_name": "100103", "standard_charge_dollar": 5453.19, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Ms Physicians Care N", "plan_name": "714210", "standard_charge_dollar": 6816.48, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Peoples Hlth Ffs 72126", "plan_name": "500019", "standard_charge_dollar": 5453.19, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Uhc/Secure Horizons", "plan_name": "500449", "standard_charge_dollar": 5453.19, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "United Health Care/", "plan_name": "500292", "standard_charge_dollar": 6162.10, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "United Healthcare", "plan_name": "750104", "standard_charge_dollar": 6162.10, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "United Healthcare Ba", "plan_name": "750090", "standard_charge_dollar": 6162.10, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "United Healthcare Me", "plan_name": "501310", "standard_charge_dollar": 5453.19, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Windsor Mcare Extra", "plan_name": "500778", "standard_charge_dollar": 5453.19, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." } ] } ] }, { "description": "Ercp remove forgn body duct", "code_information": [ { "code": "43275", "type": "CPT" } ], "standard_charges": [ { "gross_charge": 53959.43, "minimum": 420.66, "maximum": 2172.22, "setting": "inpatient", "payers_information": [ { "payer_name": "Aarp", "plan_name": "500102", "standard_charge_dollar": 1737.77, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna", "plan_name": "700700", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna", "plan_name": "700700_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Mcare Ffs 6005", "plan_name": "700703", "standard_charge_dollar": 1737.77, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Miscellaneous", "plan_name": "700720", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Miscellaneous", "plan_name": "700720_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Ppo Hmo", "plan_name": "701720", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Ppo Hmo", "plan_name": "701720_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Ambetter 68069", "plan_name": "500516", "standard_charge_dollar": 1737.77, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Ms State Emplo", "plan_name": "401457", "standard_charge_dollar": 420.66, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Ms State Emplo", "plan_name": "401457_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Basic Pl", "plan_name": "400100", "standard_charge_dollar": 420.66, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Basic Pl", "plan_name": "400100_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Federal", "plan_name": "400110", "standard_charge_dollar": 420.66, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Federal", "plan_name": "400110_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Cigna Healthsprings Ffs", "plan_name": "500064", "standard_charge_dollar": 1737.77, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Conseco", "plan_name": "500302", "standard_charge_dollar": 1737.77, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Humana Ffs 61101", "plan_name": "500006", "standard_charge_dollar": 1737.77, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Medicare A", "plan_name": "100100", "standard_charge_dollar": 1737.77, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Medicare A", "plan_name": "100500", "standard_charge_dollar": 1737.77, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Medicare Part B Only", "plan_name": "100300", "standard_charge_dollar": 1737.77, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Medicare Railroad", "plan_name": "100103", "standard_charge_dollar": 1737.77, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Ms Physicians Care N", "plan_name": "714210", "standard_charge_dollar": 2172.22, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Peoples Hlth Ffs 72126", "plan_name": "500019", "standard_charge_dollar": 1737.77, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Uhc/Secure Horizons", "plan_name": "500449", "standard_charge_dollar": 1737.77, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "United Health Care/", "plan_name": "500292", "standard_charge_dollar": 1963.68, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "United Healthcare", "plan_name": "750104", "standard_charge_dollar": 1963.68, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "United Healthcare Ba", "plan_name": "750090", "standard_charge_dollar": 1963.68, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "United Healthcare Me", "plan_name": "501310", "standard_charge_dollar": 1737.77, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Windsor Mcare Extra", "plan_name": "500778", "standard_charge_dollar": 1737.77, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." } ] } ] }, { "description": "Ercp stent exchange w/dilate", "code_information": [ { "code": "43276", "type": "CPT" } ], "standard_charges": [ { "gross_charge": 22463.27, "minimum": 538.75, "maximum": 6816.48, "setting": "inpatient", "payers_information": [ { "payer_name": "Aarp", "plan_name": "500102", "standard_charge_dollar": 5453.19, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna", "plan_name": "700700", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna", "plan_name": "700700_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Mcare Ffs 6005", "plan_name": "700703", "standard_charge_dollar": 5453.19, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Miscellaneous", "plan_name": "700720", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Miscellaneous", "plan_name": "700720_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Ppo Hmo", "plan_name": "701720", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Ppo Hmo", "plan_name": "701720_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Ambetter 68069", "plan_name": "500516", "standard_charge_dollar": 5453.19, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Ms State Emplo", "plan_name": "401457", "standard_charge_dollar": 538.75, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Ms State Emplo", "plan_name": "401457_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Basic Pl", "plan_name": "400100", "standard_charge_dollar": 538.75, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Basic Pl", "plan_name": "400100_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Federal", "plan_name": "400110", "standard_charge_dollar": 538.75, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Federal", "plan_name": "400110_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Cigna Healthsprings Ffs", "plan_name": "500064", "standard_charge_dollar": 5453.19, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Conseco", "plan_name": "500302", "standard_charge_dollar": 5453.19, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Humana Ffs 61101", "plan_name": "500006", "standard_charge_dollar": 5453.19, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Medicare A", "plan_name": "100100", "standard_charge_dollar": 5453.19, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Medicare A", "plan_name": "100500", "standard_charge_dollar": 5453.19, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Medicare Part B Only", "plan_name": "100300", "standard_charge_dollar": 5453.19, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Medicare Railroad", "plan_name": "100103", "standard_charge_dollar": 5453.19, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Ms Physicians Care N", "plan_name": "714210", "standard_charge_dollar": 6816.48, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Peoples Hlth Ffs 72126", "plan_name": "500019", "standard_charge_dollar": 5453.19, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Uhc/Secure Horizons", "plan_name": "500449", "standard_charge_dollar": 5453.19, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "United Health Care/", "plan_name": "500292", "standard_charge_dollar": 6162.10, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "United Healthcare", "plan_name": "750104", "standard_charge_dollar": 6162.10, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "United Healthcare Ba", "plan_name": "750090", "standard_charge_dollar": 6162.10, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "United Healthcare Me", "plan_name": "501310", "standard_charge_dollar": 5453.19, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Windsor Mcare Extra", "plan_name": "500778", "standard_charge_dollar": 5453.19, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." } ] } ] }, { "description": "Ercp ea duct/ampulla dilate", "code_information": [ { "code": "43277", "type": "CPT" } ], "standard_charges": [ { "gross_charge": 22463.27, "minimum": 423.03, "maximum": 4356.52, "setting": "inpatient", "payers_information": [ { "payer_name": "Aarp", "plan_name": "500102", "standard_charge_dollar": 3485.21, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna", "plan_name": "700700", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna", "plan_name": "700700_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Mcare Ffs 6005", "plan_name": "700703", "standard_charge_dollar": 3485.21, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Miscellaneous", "plan_name": "700720", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Miscellaneous", "plan_name": "700720_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Ppo Hmo", "plan_name": "701720", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Ppo Hmo", "plan_name": "701720_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Ambetter 68069", "plan_name": "500516", "standard_charge_dollar": 3485.21, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Ms State Emplo", "plan_name": "401457", "standard_charge_dollar": 423.03, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Ms State Emplo", "plan_name": "401457_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Basic Pl", "plan_name": "400100", "standard_charge_dollar": 423.03, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Basic Pl", "plan_name": "400100_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Federal", "plan_name": "400110", "standard_charge_dollar": 423.03, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Federal", "plan_name": "400110_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Cigna Healthsprings Ffs", "plan_name": "500064", "standard_charge_dollar": 3485.21, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Conseco", "plan_name": "500302", "standard_charge_dollar": 3485.21, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Humana Ffs 61101", "plan_name": "500006", "standard_charge_dollar": 3485.21, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Medicare A", "plan_name": "100100", "standard_charge_dollar": 3485.21, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Medicare A", "plan_name": "100500", "standard_charge_dollar": 3485.21, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Medicare Part B Only", "plan_name": "100300", "standard_charge_dollar": 3485.21, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Medicare Railroad", "plan_name": "100103", "standard_charge_dollar": 3485.21, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Ms Physicians Care N", "plan_name": "714210", "standard_charge_dollar": 4356.52, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Peoples Hlth Ffs 72126", "plan_name": "500019", "standard_charge_dollar": 3485.21, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Uhc/Secure Horizons", "plan_name": "500449", "standard_charge_dollar": 3485.21, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "United Health Care/", "plan_name": "500292", "standard_charge_dollar": 3938.29, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "United Healthcare", "plan_name": "750104", "standard_charge_dollar": 3938.29, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "United Healthcare Ba", "plan_name": "750090", "standard_charge_dollar": 3938.29, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "United Healthcare Me", "plan_name": "501310", "standard_charge_dollar": 3485.21, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Windsor Mcare Extra", "plan_name": "500778", "standard_charge_dollar": 3485.21, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." } ] } ] }, { "description": "Ercp lesion ablate w/dilate", "code_information": [ { "code": "43278", "type": "CPT" } ], "standard_charges": [ { "gross_charge": 22463.27, "minimum": 483.87, "maximum": 4356.52, "setting": "inpatient", "payers_information": [ { "payer_name": "Aarp", "plan_name": "500102", "standard_charge_dollar": 3485.21, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna", "plan_name": "700700", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna", "plan_name": "700700_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Mcare Ffs 6005", "plan_name": "700703", "standard_charge_dollar": 3485.21, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Miscellaneous", "plan_name": "700720", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Miscellaneous", "plan_name": "700720_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Ppo Hmo", "plan_name": "701720", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Ppo Hmo", "plan_name": "701720_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Ambetter 68069", "plan_name": "500516", "standard_charge_dollar": 3485.21, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Ms State Emplo", "plan_name": "401457", "standard_charge_dollar": 483.87, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Ms State Emplo", "plan_name": "401457_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Basic Pl", "plan_name": "400100", "standard_charge_dollar": 483.87, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Basic Pl", "plan_name": "400100_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Federal", "plan_name": "400110", "standard_charge_dollar": 483.87, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Federal", "plan_name": "400110_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Cigna Healthsprings Ffs", "plan_name": "500064", "standard_charge_dollar": 3485.21, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Conseco", "plan_name": "500302", "standard_charge_dollar": 3485.21, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Humana Ffs 61101", "plan_name": "500006", "standard_charge_dollar": 3485.21, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Medicare A", "plan_name": "100100", "standard_charge_dollar": 3485.21, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Medicare A", "plan_name": "100500", "standard_charge_dollar": 3485.21, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Medicare Part B Only", "plan_name": "100300", "standard_charge_dollar": 3485.21, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Medicare Railroad", "plan_name": "100103", "standard_charge_dollar": 3485.21, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Ms Physicians Care N", "plan_name": "714210", "standard_charge_dollar": 4356.52, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Peoples Hlth Ffs 72126", "plan_name": "500019", "standard_charge_dollar": 3485.21, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Uhc/Secure Horizons", "plan_name": "500449", "standard_charge_dollar": 3485.21, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "United Health Care/", "plan_name": "500292", "standard_charge_dollar": 3938.29, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "United Healthcare", "plan_name": "750104", "standard_charge_dollar": 3938.29, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "United Healthcare Ba", "plan_name": "750090", "standard_charge_dollar": 3938.29, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "United Healthcare Me", "plan_name": "501310", "standard_charge_dollar": 3485.21, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Windsor Mcare Extra", "plan_name": "500778", "standard_charge_dollar": 3485.21, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." } ] } ] }, { "description": "Fuse esophagus & intestine", "code_information": [ { "code": "43341", "type": "CPT" } ], "standard_charges": [ { "gross_charge": 62580.64, "minimum": 50064.51, "maximum": 53193.54, "setting": "inpatient", "payers_information": [ { "payer_name": "Aetna", "plan_name": "700700", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna", "plan_name": "700700_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Miscellaneous", "plan_name": "700720", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Miscellaneous", "plan_name": "700720_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Ppo Hmo", "plan_name": "701720", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Ppo Hmo", "plan_name": "701720_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Ms State Emplo", "plan_name": "401457", "standard_charge_percentage": 0.80, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Ms State Emplo", "plan_name": "401457_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Basic Pl", "plan_name": "400100", "standard_charge_percentage": 0.85, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Basic Pl", "plan_name": "400100_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Federal", "plan_name": "400110", "standard_charge_percentage": 0.85, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Federal", "plan_name": "400110_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." } ] } ] }, { "description": "Gastrointestinal repair", "code_information": [ { "code": "43360", "type": "CPT" } ], "standard_charges": [ { "gross_charge": 24676.07, "minimum": 19740.86, "maximum": 20974.66, "setting": "inpatient", "payers_information": [ { "payer_name": "Aetna", "plan_name": "700700", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna", "plan_name": "700700_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Miscellaneous", "plan_name": "700720", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Miscellaneous", "plan_name": "700720_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Ppo Hmo", "plan_name": "701720", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Ppo Hmo", "plan_name": "701720_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Ms State Emplo", "plan_name": "401457", "standard_charge_percentage": 0.80, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Ms State Emplo", "plan_name": "401457_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Basic Pl", "plan_name": "400100", "standard_charge_percentage": 0.85, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Basic Pl", "plan_name": "400100_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Federal", "plan_name": "400110", "standard_charge_percentage": 0.85, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Federal", "plan_name": "400110_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." } ] } ] }, { "description": "Dilate esophagus", "code_information": [ { "code": "43453", "type": "CPT" } ], "standard_charges": [ { "gross_charge": 24352.26, "minimum": 1737.77, "maximum": 20699.42, "setting": "inpatient", "payers_information": [ { "payer_name": "Aarp", "plan_name": "500102", "standard_charge_dollar": 1737.77, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna", "plan_name": "700700", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna", "plan_name": "700700_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Mcare Ffs 6005", "plan_name": "700703", "standard_charge_dollar": 1737.77, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Miscellaneous", "plan_name": "700720", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Miscellaneous", "plan_name": "700720_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Ppo Hmo", "plan_name": "701720", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Ppo Hmo", "plan_name": "701720_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Ambetter 68069", "plan_name": "500516", "standard_charge_dollar": 1737.77, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Ms State Emplo", "plan_name": "401457", "standard_charge_percentage": 0.80, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Ms State Emplo", "plan_name": "401457_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Basic Pl", "plan_name": "400100", "standard_charge_percentage": 0.85, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Basic Pl", "plan_name": "400100_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Federal", "plan_name": "400110", "standard_charge_percentage": 0.85, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Federal", "plan_name": "400110_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Cigna Healthsprings Ffs", "plan_name": "500064", "standard_charge_dollar": 1737.77, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Conseco", "plan_name": "500302", "standard_charge_dollar": 1737.77, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Humana Ffs 61101", "plan_name": "500006", "standard_charge_dollar": 1737.77, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Medicare A", "plan_name": "100100", "standard_charge_dollar": 1737.77, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Medicare A", "plan_name": "100500", "standard_charge_dollar": 1737.77, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Medicare Part B Only", "plan_name": "100300", "standard_charge_dollar": 1737.77, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Medicare Railroad", "plan_name": "100103", "standard_charge_dollar": 1737.77, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Ms Physicians Care N", "plan_name": "714210", "standard_charge_dollar": 2172.22, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Peoples Hlth Ffs 72126", "plan_name": "500019", "standard_charge_dollar": 1737.77, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Uhc/Secure Horizons", "plan_name": "500449", "standard_charge_dollar": 1737.77, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "United Health Care/", "plan_name": "500292", "standard_charge_dollar": 1963.68, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "United Healthcare", "plan_name": "750104", "standard_charge_dollar": 1963.68, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "United Healthcare Ba", "plan_name": "750090", "standard_charge_dollar": 1963.68, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "United Healthcare Me", "plan_name": "501310", "standard_charge_dollar": 1737.77, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Windsor Mcare Extra", "plan_name": "500778", "standard_charge_dollar": 1737.77, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." } ] } ] }, { "description": "Free jejunum flap microvasc", "code_information": [ { "code": "43496", "type": "CPT" } ], "standard_charges": [ { "gross_charge": 55372.98, "minimum": 44298.38, "maximum": 47067.03, "setting": "inpatient", "payers_information": [ { "payer_name": "Aetna", "plan_name": "700700", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna", "plan_name": "700700_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Miscellaneous", "plan_name": "700720", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Miscellaneous", "plan_name": "700720_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Ppo Hmo", "plan_name": "701720", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Ppo Hmo", "plan_name": "701720_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Ms State Emplo", "plan_name": "401457", "standard_charge_percentage": 0.80, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Ms State Emplo", "plan_name": "401457_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Basic Pl", "plan_name": "400100", "standard_charge_percentage": 0.85, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Basic Pl", "plan_name": "400100_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Federal", "plan_name": "400110", "standard_charge_percentage": 0.85, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Federal", "plan_name": "400110_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." } ] } ] }, { "description": "Biopsy of stomach", "code_information": [ { "code": "43605", "type": "CPT" } ], "standard_charges": [ { "gross_charge": 38416.02, "minimum": 30732.82, "maximum": 32653.62, "setting": "inpatient", "payers_information": [ { "payer_name": "Aetna", "plan_name": "700700", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna", "plan_name": "700700_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Miscellaneous", "plan_name": "700720", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Miscellaneous", "plan_name": "700720_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Ppo Hmo", "plan_name": "701720", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Ppo Hmo", "plan_name": "701720_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Ms State Emplo", "plan_name": "401457", "standard_charge_percentage": 0.80, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Ms State Emplo", "plan_name": "401457_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Basic Pl", "plan_name": "400100", "standard_charge_percentage": 0.85, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Basic Pl", "plan_name": "400100_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Federal", "plan_name": "400110", "standard_charge_percentage": 0.85, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Federal", "plan_name": "400110_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." } ] } ] }, { "description": "Excision of stomach lesion", "code_information": [ { "code": "43610", "type": "CPT" } ], "standard_charges": [ { "gross_charge": 24676.07, "minimum": 19740.86, "maximum": 20974.66, "setting": "inpatient", "payers_information": [ { "payer_name": "Aetna", "plan_name": "700700", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna", "plan_name": "700700_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Miscellaneous", "plan_name": "700720", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Miscellaneous", "plan_name": "700720_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Ppo Hmo", "plan_name": "701720", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Ppo Hmo", "plan_name": "701720_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Ms State Emplo", "plan_name": "401457", "standard_charge_percentage": 0.80, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Ms State Emplo", "plan_name": "401457_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Basic Pl", "plan_name": "400100", "standard_charge_percentage": 0.85, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Basic Pl", "plan_name": "400100_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Federal", "plan_name": "400110", "standard_charge_percentage": 0.85, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Federal", "plan_name": "400110_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." } ] } ] }, { "description": "Excision of stomach lesion", "code_information": [ { "code": "43611", "type": "CPT" } ], "standard_charges": [ { "gross_charge": 24676.07, "minimum": 19740.86, "maximum": 20974.66, "setting": "inpatient", "payers_information": [ { "payer_name": "Aetna", "plan_name": "700700", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna", "plan_name": "700700_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Miscellaneous", "plan_name": "700720", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Miscellaneous", "plan_name": "700720_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Ppo Hmo", "plan_name": "701720", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Ppo Hmo", "plan_name": "701720_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Ms State Emplo", "plan_name": "401457", "standard_charge_percentage": 0.80, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Ms State Emplo", "plan_name": "401457_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Basic Pl", "plan_name": "400100", "standard_charge_percentage": 0.85, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Basic Pl", "plan_name": "400100_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Federal", "plan_name": "400110", "standard_charge_percentage": 0.85, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Federal", "plan_name": "400110_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." } ] } ] }, { "description": "Removal of stomach partial", "code_information": [ { "code": "43632", "type": "CPT" } ], "standard_charges": [ { "gross_charge": 62580.64, "minimum": 50064.51, "maximum": 53193.54, "setting": "inpatient", "payers_information": [ { "payer_name": "Aetna", "plan_name": "700700", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna", "plan_name": "700700_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Miscellaneous", "plan_name": "700720", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Miscellaneous", "plan_name": "700720_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Ppo Hmo", "plan_name": "701720", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Ppo Hmo", "plan_name": "701720_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Ms State Emplo", "plan_name": "401457", "standard_charge_percentage": 0.80, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Ms State Emplo", "plan_name": "401457_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Basic Pl", "plan_name": "400100", "standard_charge_percentage": 0.85, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Basic Pl", "plan_name": "400100_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Federal", "plan_name": "400110", "standard_charge_percentage": 0.85, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Federal", "plan_name": "400110_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." } ] } ] }, { "description": "Removal of stomach partial", "code_information": [ { "code": "43633", "type": "CPT" } ], "standard_charges": [ { "gross_charge": 62580.64, "minimum": 50064.51, "maximum": 53193.54, "setting": "inpatient", "payers_information": [ { "payer_name": "Aetna", "plan_name": "700700", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna", "plan_name": "700700_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Miscellaneous", "plan_name": "700720", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Miscellaneous", "plan_name": "700720_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Ppo Hmo", "plan_name": "701720", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Ppo Hmo", "plan_name": "701720_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Ms State Emplo", "plan_name": "401457", "standard_charge_percentage": 0.80, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Ms State Emplo", "plan_name": "401457_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Basic Pl", "plan_name": "400100", "standard_charge_percentage": 0.85, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Basic Pl", "plan_name": "400100_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Federal", "plan_name": "400110", "standard_charge_percentage": 0.85, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Federal", "plan_name": "400110_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." } ] } ] }, { "description": "Removal of stomach partial", "code_information": [ { "code": "43634", "type": "CPT" } ], "standard_charges": [ { "gross_charge": 62580.64, "minimum": 50064.51, "maximum": 53193.54, "setting": "inpatient", "payers_information": [ { "payer_name": "Aetna", "plan_name": "700700", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna", "plan_name": "700700_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Miscellaneous", "plan_name": "700720", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Miscellaneous", "plan_name": "700720_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Ppo Hmo", "plan_name": "701720", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Ppo Hmo", "plan_name": "701720_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Ms State Emplo", "plan_name": "401457", "standard_charge_percentage": 0.80, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Ms State Emplo", "plan_name": "401457_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Basic Pl", "plan_name": "400100", "standard_charge_percentage": 0.85, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Basic Pl", "plan_name": "400100_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Federal", "plan_name": "400110", "standard_charge_percentage": 0.85, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Federal", "plan_name": "400110_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." } ] } ] }, { "description": "Lap gastric bypass/roux-en-y", "code_information": [ { "code": "43644", "type": "CPT" } ], "standard_charges": [ { "gross_charge": 24676.07, "minimum": 19740.86, "maximum": 20974.66, "setting": "inpatient", "payers_information": [ { "payer_name": "Aetna", "plan_name": "700700", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna", "plan_name": "700700_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Miscellaneous", "plan_name": "700720", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Miscellaneous", "plan_name": "700720_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Ppo Hmo", "plan_name": "701720", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Ppo Hmo", "plan_name": "701720_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Ms State Emplo", "plan_name": "401457", "standard_charge_percentage": 0.80, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Ms State Emplo", "plan_name": "401457_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Basic Pl", "plan_name": "400100", "standard_charge_percentage": 0.85, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Basic Pl", "plan_name": "400100_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Federal", "plan_name": "400110", "standard_charge_percentage": 0.85, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Federal", "plan_name": "400110_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." } ] } ] }, { "description": "Lap gastr bypass incl smll i", "code_information": [ { "code": "43645", "type": "CPT" } ], "standard_charges": [ { "gross_charge": 24676.07, "minimum": 19740.86, "maximum": 20974.66, "setting": "inpatient", "payers_information": [ { "payer_name": "Aetna", "plan_name": "700700", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna", "plan_name": "700700_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Miscellaneous", "plan_name": "700720", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Miscellaneous", "plan_name": "700720_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Ppo Hmo", "plan_name": "701720", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Ppo Hmo", "plan_name": "701720_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Ms State Emplo", "plan_name": "401457", "standard_charge_percentage": 0.80, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Ms State Emplo", "plan_name": "401457_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Basic Pl", "plan_name": "400100", "standard_charge_percentage": 0.85, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Basic Pl", "plan_name": "400100_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Federal", "plan_name": "400110", "standard_charge_percentage": 0.85, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Federal", "plan_name": "400110_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." } ] } ] }, { "description": "Laparoscopy gastrostomy", "code_information": [ { "code": "43653", "type": "CPT" } ], "standard_charges": [ { "gross_charge": 24676.07, "minimum": 5344.68, "maximum": 20974.66, "setting": "inpatient", "payers_information": [ { "payer_name": "Aarp", "plan_name": "500102", "standard_charge_dollar": 5344.68, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna", "plan_name": "700700", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna", "plan_name": "700700_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Mcare Ffs 6005", "plan_name": "700703", "standard_charge_dollar": 5344.68, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Miscellaneous", "plan_name": "700720", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Miscellaneous", "plan_name": "700720_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Ppo Hmo", "plan_name": "701720", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Ppo Hmo", "plan_name": "701720_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Ambetter 68069", "plan_name": "500516", "standard_charge_dollar": 5344.68, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Ms State Emplo", "plan_name": "401457", "standard_charge_percentage": 0.80, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Ms State Emplo", "plan_name": "401457_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Basic Pl", "plan_name": "400100", "standard_charge_percentage": 0.85, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Basic Pl", "plan_name": "400100_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Federal", "plan_name": "400110", "standard_charge_percentage": 0.85, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Federal", "plan_name": "400110_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Cigna Healthsprings Ffs", "plan_name": "500064", "standard_charge_dollar": 5344.68, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Conseco", "plan_name": "500302", "standard_charge_dollar": 5344.68, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Humana Ffs 61101", "plan_name": "500006", "standard_charge_dollar": 5344.68, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Medicare A", "plan_name": "100100", "standard_charge_dollar": 5344.68, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Medicare A", "plan_name": "100500", "standard_charge_dollar": 5344.68, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Medicare Part B Only", "plan_name": "100300", "standard_charge_dollar": 5344.68, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Medicare Railroad", "plan_name": "100103", "standard_charge_dollar": 5344.68, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Ms Physicians Care N", "plan_name": "714210", "standard_charge_dollar": 6680.85, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Peoples Hlth Ffs 72126", "plan_name": "500019", "standard_charge_dollar": 5344.68, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Uhc/Secure Horizons", "plan_name": "500449", "standard_charge_dollar": 5344.68, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "United Health Care/", "plan_name": "500292", "standard_charge_dollar": 6039.49, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "United Healthcare", "plan_name": "750104", "standard_charge_dollar": 6039.49, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "United Healthcare Ba", "plan_name": "750090", "standard_charge_dollar": 6039.49, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "United Healthcare Me", "plan_name": "501310", "standard_charge_dollar": 5344.68, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Windsor Mcare Extra", "plan_name": "500778", "standard_charge_dollar": 5344.68, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." } ] } ] }, { "description": "Laparoscope proc stom", "code_information": [ { "code": "43659", "type": "CPT" } ], "standard_charges": [ { "gross_charge": 24676.07, "minimum": 5344.68, "maximum": 20974.66, "setting": "inpatient", "payers_information": [ { "payer_name": "Aarp", "plan_name": "500102", "standard_charge_dollar": 5344.68, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna", "plan_name": "700700", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna", "plan_name": "700700_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Mcare Ffs 6005", "plan_name": "700703", "standard_charge_dollar": 5344.68, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Miscellaneous", "plan_name": "700720", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Miscellaneous", "plan_name": "700720_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Ppo Hmo", "plan_name": "701720", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Ppo Hmo", "plan_name": "701720_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Ambetter 68069", "plan_name": "500516", "standard_charge_dollar": 5344.68, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Ms State Emplo", "plan_name": "401457", "standard_charge_percentage": 0.80, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Ms State Emplo", "plan_name": "401457_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Basic Pl", "plan_name": "400100", "standard_charge_percentage": 0.85, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Basic Pl", "plan_name": "400100_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Federal", "plan_name": "400110", "standard_charge_percentage": 0.85, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Federal", "plan_name": "400110_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Cigna Healthsprings Ffs", "plan_name": "500064", "standard_charge_dollar": 5344.68, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Conseco", "plan_name": "500302", "standard_charge_dollar": 5344.68, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Humana Ffs 61101", "plan_name": "500006", "standard_charge_dollar": 5344.68, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Medicare A", "plan_name": "100100", "standard_charge_dollar": 5344.68, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Medicare A", "plan_name": "100500", "standard_charge_dollar": 5344.68, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Medicare Part B Only", "plan_name": "100300", "standard_charge_dollar": 5344.68, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Medicare Railroad", "plan_name": "100103", "standard_charge_dollar": 5344.68, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Ms Physicians Care N", "plan_name": "714210", "standard_charge_dollar": 6680.85, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Peoples Hlth Ffs 72126", "plan_name": "500019", "standard_charge_dollar": 5344.68, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Uhc/Secure Horizons", "plan_name": "500449", "standard_charge_dollar": 5344.68, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "United Health Care/", "plan_name": "500292", "standard_charge_dollar": 6039.49, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "United Healthcare", "plan_name": "750104", "standard_charge_dollar": 6039.49, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "United Healthcare Ba", "plan_name": "750090", "standard_charge_dollar": 6039.49, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "United Healthcare Me", "plan_name": "501310", "standard_charge_dollar": 5344.68, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Windsor Mcare Extra", "plan_name": "500778", "standard_charge_dollar": 5344.68, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." } ] } ] }, { "description": "Nasal/orogastric w/tube plmt", "code_information": [ { "code": "43752", "type": "CPT" } ], "standard_charges": [ { "gross_charge": 21274.27, "minimum": 365.55, "maximum": 456.94, "setting": "inpatient", "payers_information": [ { "payer_name": "Aarp", "plan_name": "500102", "standard_charge_dollar": 365.55, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna", "plan_name": "700700", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna", "plan_name": "700700_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Mcare Ffs 6005", "plan_name": "700703", "standard_charge_dollar": 365.55, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Miscellaneous", "plan_name": "700720", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Miscellaneous", "plan_name": "700720_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Ppo Hmo", "plan_name": "701720", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Ppo Hmo", "plan_name": "701720_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Ambetter 68069", "plan_name": "500516", "standard_charge_dollar": 365.55, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Ms State Emplo", "plan_name": "401457", "standard_charge_dollar": 395.24, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Ms State Emplo", "plan_name": "401457_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Basic Pl", "plan_name": "400100", "standard_charge_dollar": 395.24, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Basic Pl", "plan_name": "400100_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Federal", "plan_name": "400110", "standard_charge_dollar": 395.24, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Federal", "plan_name": "400110_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Cigna Healthsprings Ffs", "plan_name": "500064", "standard_charge_dollar": 365.55, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Conseco", "plan_name": "500302", "standard_charge_dollar": 365.55, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Humana Ffs 61101", "plan_name": "500006", "standard_charge_dollar": 365.55, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Medicare A", "plan_name": "100100", "standard_charge_dollar": 365.55, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Medicare A", "plan_name": "100500", "standard_charge_dollar": 365.55, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Medicare Part B Only", "plan_name": "100300", "standard_charge_dollar": 365.55, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Medicare Railroad", "plan_name": "100103", "standard_charge_dollar": 365.55, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Ms Physicians Care N", "plan_name": "714210", "standard_charge_dollar": 456.94, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Peoples Hlth Ffs 72126", "plan_name": "500019", "standard_charge_dollar": 365.55, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Uhc/Secure Horizons", "plan_name": "500449", "standard_charge_dollar": 365.55, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "United Health Care/", "plan_name": "500292", "standard_charge_dollar": 413.07, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "United Healthcare", "plan_name": "750104", "standard_charge_dollar": 413.07, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "United Healthcare Ba", "plan_name": "750090", "standard_charge_dollar": 413.07, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "United Healthcare Me", "plan_name": "501310", "standard_charge_dollar": 365.55, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Windsor Mcare Extra", "plan_name": "500778", "standard_charge_dollar": 365.55, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." } ] } ] }, { "description": "Hc gastric lavage", "code_information": [ { "code": "43753", "type": "CPT" } ], "standard_charges": [ { "gross_charge": 231.00, "minimum": 285.26, "maximum": 356.58, "setting": "both", "payers_information": [ { "payer_name": "Aarp", "plan_name": "500102", "standard_charge_dollar": 285.26, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna", "plan_name": "700700", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna", "plan_name": "700700_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Mcare Ffs 6005", "plan_name": "700703", "standard_charge_dollar": 285.26, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Miscellaneous", "plan_name": "700720", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Miscellaneous", "plan_name": "700720_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Ppo Hmo", "plan_name": "701720", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Ppo Hmo", "plan_name": "701720_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Ambetter 68069", "plan_name": "500516", "standard_charge_dollar": 285.26, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Ms State Emplo", "plan_name": "401457", "standard_charge_dollar": 330.53, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Ms State Emplo", "plan_name": "401457_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Basic Pl", "plan_name": "400100", "standard_charge_dollar": 330.53, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Basic Pl", "plan_name": "400100_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Federal", "plan_name": "400110", "standard_charge_dollar": 330.53, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Federal", "plan_name": "400110_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Cigna Healthsprings Ffs", "plan_name": "500064", "standard_charge_dollar": 285.26, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Conseco", "plan_name": "500302", "standard_charge_dollar": 285.26, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Humana Ffs 61101", "plan_name": "500006", "standard_charge_dollar": 285.26, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Medicare A", "plan_name": "100100", "standard_charge_dollar": 285.26, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Medicare A", "plan_name": "100500", "standard_charge_dollar": 285.26, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Medicare Part B Only", "plan_name": "100300", "standard_charge_dollar": 285.26, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Medicare Railroad", "plan_name": "100103", "standard_charge_dollar": 285.26, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Ms Physicians Care N", "plan_name": "714210", "standard_charge_dollar": 356.58, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Peoples Hlth Ffs 72126", "plan_name": "500019", "standard_charge_dollar": 285.26, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Uhc/Secure Horizons", "plan_name": "500449", "standard_charge_dollar": 285.26, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "United Health Care/", "plan_name": "500292", "standard_charge_dollar": 322.35, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "United Healthcare", "plan_name": "750104", "standard_charge_dollar": 322.35, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "United Healthcare Ba", "plan_name": "750090", "standard_charge_dollar": 322.35, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "United Healthcare Me", "plan_name": "501310", "standard_charge_dollar": 285.26, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Windsor Mcare Extra", "plan_name": "500778", "standard_charge_dollar": 285.26, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." } ] } ] }, { "description": "Tx gastro intub w/asp", "code_information": [ { "code": "43753", "type": "CPT" } ], "standard_charges": [ { "gross_charge": 20737.61, "minimum": 285.26, "maximum": 356.58, "setting": "inpatient", "payers_information": [ { "payer_name": "Aarp", "plan_name": "500102", "standard_charge_dollar": 285.26, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna", "plan_name": "700700", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna", "plan_name": "700700_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Mcare Ffs 6005", "plan_name": "700703", "standard_charge_dollar": 285.26, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Miscellaneous", "plan_name": "700720", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Miscellaneous", "plan_name": "700720_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Ppo Hmo", "plan_name": "701720", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Ppo Hmo", "plan_name": "701720_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Ambetter 68069", "plan_name": "500516", "standard_charge_dollar": 285.26, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Ms State Emplo", "plan_name": "401457", "standard_charge_dollar": 330.53, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Ms State Emplo", "plan_name": "401457_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Basic Pl", "plan_name": "400100", "standard_charge_dollar": 330.53, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Basic Pl", "plan_name": "400100_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Federal", "plan_name": "400110", "standard_charge_dollar": 330.53, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Federal", "plan_name": "400110_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Cigna Healthsprings Ffs", "plan_name": "500064", "standard_charge_dollar": 285.26, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Conseco", "plan_name": "500302", "standard_charge_dollar": 285.26, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Humana Ffs 61101", "plan_name": "500006", "standard_charge_dollar": 285.26, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Medicare A", "plan_name": "100100", "standard_charge_dollar": 285.26, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Medicare A", "plan_name": "100500", "standard_charge_dollar": 285.26, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Medicare Part B Only", "plan_name": "100300", "standard_charge_dollar": 285.26, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Medicare Railroad", "plan_name": "100103", "standard_charge_dollar": 285.26, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Ms Physicians Care N", "plan_name": "714210", "standard_charge_dollar": 356.58, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Peoples Hlth Ffs 72126", "plan_name": "500019", "standard_charge_dollar": 285.26, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Uhc/Secure Horizons", "plan_name": "500449", "standard_charge_dollar": 285.26, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "United Health Care/", "plan_name": "500292", "standard_charge_dollar": 322.35, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "United Healthcare", "plan_name": "750104", "standard_charge_dollar": 322.35, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "United Healthcare Ba", "plan_name": "750090", "standard_charge_dollar": 322.35, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "United Healthcare Me", "plan_name": "501310", "standard_charge_dollar": 285.26, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Windsor Mcare Extra", "plan_name": "500778", "standard_charge_dollar": 285.26, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." } ] } ] }, { "description": "Tx gastro intub w/asp", "code_information": [ { "code": "43753", "type": "CPT" } ], "standard_charges": [ { "gross_charge": 231.00, "minimum": 285.26, "maximum": 356.58, "setting": "outpatient", "payers_information": [ { "payer_name": "Aarp", "plan_name": "500102", "standard_charge_dollar": 285.26, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna", "plan_name": "700700", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna", "plan_name": "700700_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Mcare Ffs 6005", "plan_name": "700703", "standard_charge_dollar": 285.26, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Miscellaneous", "plan_name": "700720", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Miscellaneous", "plan_name": "700720_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Ppo Hmo", "plan_name": "701720", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Ppo Hmo", "plan_name": "701720_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Ambetter 68069", "plan_name": "500516", "standard_charge_dollar": 285.26, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Ms State Emplo", "plan_name": "401457", "standard_charge_dollar": 330.53, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Ms State Emplo", "plan_name": "401457_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Basic Pl", "plan_name": "400100", "standard_charge_dollar": 330.53, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Basic Pl", "plan_name": "400100_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Federal", "plan_name": "400110", "standard_charge_dollar": 330.53, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Federal", "plan_name": "400110_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Cigna Healthsprings Ffs", "plan_name": "500064", "standard_charge_dollar": 285.26, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Conseco", "plan_name": "500302", "standard_charge_dollar": 285.26, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Humana Ffs 61101", "plan_name": "500006", "standard_charge_dollar": 285.26, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Medicare A", "plan_name": "100100", "standard_charge_dollar": 285.26, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Medicare A", "plan_name": "100500", "standard_charge_dollar": 285.26, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Medicare Part B Only", "plan_name": "100300", "standard_charge_dollar": 285.26, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Medicare Railroad", "plan_name": "100103", "standard_charge_dollar": 285.26, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Ms Physicians Care N", "plan_name": "714210", "standard_charge_dollar": 356.58, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Peoples Hlth Ffs 72126", "plan_name": "500019", "standard_charge_dollar": 285.26, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Uhc/Secure Horizons", "plan_name": "500449", "standard_charge_dollar": 285.26, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "United Health Care/", "plan_name": "500292", "standard_charge_dollar": 322.35, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "United Healthcare", "plan_name": "750104", "standard_charge_dollar": 322.35, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "United Healthcare Ba", "plan_name": "750090", "standard_charge_dollar": 322.35, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "United Healthcare Me", "plan_name": "501310", "standard_charge_dollar": 285.26, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Windsor Mcare Extra", "plan_name": "500778", "standard_charge_dollar": 285.26, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." } ] } ] }, { "description": "Dx gastr intub w/asp specs", "code_information": [ { "code": "43755", "type": "CPT" } ], "standard_charges": [ { "gross_charge": 20737.61, "minimum": 143.33, "maximum": 17626.97, "setting": "inpatient", "payers_information": [ { "payer_name": "Aarp", "plan_name": "500102", "standard_charge_dollar": 143.33, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna", "plan_name": "700700", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna", "plan_name": "700700_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Mcare Ffs 6005", "plan_name": "700703", "standard_charge_dollar": 143.33, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Miscellaneous", "plan_name": "700720", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Miscellaneous", "plan_name": "700720_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Ppo Hmo", "plan_name": "701720", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Ppo Hmo", "plan_name": "701720_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Ambetter 68069", "plan_name": "500516", "standard_charge_dollar": 143.33, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Ms State Emplo", "plan_name": "401457", "standard_charge_percentage": 0.80, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Ms State Emplo", "plan_name": "401457_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Basic Pl", "plan_name": "400100", "standard_charge_percentage": 0.85, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Basic Pl", "plan_name": "400100_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Federal", "plan_name": "400110", "standard_charge_percentage": 0.85, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Federal", "plan_name": "400110_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Cigna Healthsprings Ffs", "plan_name": "500064", "standard_charge_dollar": 143.33, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Conseco", "plan_name": "500302", "standard_charge_dollar": 143.33, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Humana Ffs 61101", "plan_name": "500006", "standard_charge_dollar": 143.33, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Medicare A", "plan_name": "100100", "standard_charge_dollar": 143.33, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Medicare A", "plan_name": "100500", "standard_charge_dollar": 143.33, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Medicare Part B Only", "plan_name": "100300", "standard_charge_dollar": 143.33, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Medicare Railroad", "plan_name": "100103", "standard_charge_dollar": 143.33, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Ms Physicians Care N", "plan_name": "714210", "standard_charge_dollar": 179.16, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Peoples Hlth Ffs 72126", "plan_name": "500019", "standard_charge_dollar": 143.33, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Uhc/Secure Horizons", "plan_name": "500449", "standard_charge_dollar": 143.33, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "United Health Care/", "plan_name": "500292", "standard_charge_dollar": 161.96, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "United Healthcare", "plan_name": "750104", "standard_charge_dollar": 161.96, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "United Healthcare Ba", "plan_name": "750090", "standard_charge_dollar": 161.96, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "United Healthcare Me", "plan_name": "501310", "standard_charge_dollar": 143.33, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Windsor Mcare Extra", "plan_name": "500778", "standard_charge_dollar": 143.33, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." } ] } ] }, { "description": "Hc perq rplc gtube w/o imag no revision of tract", "code_information": [ { "code": "43762", "type": "CPT" } ], "standard_charges": [ { "gross_charge": 75.60, "minimum": 60.48, "maximum": 278.50, "setting": "both", "payers_information": [ { "payer_name": "Aarp", "plan_name": "500102", "standard_charge_dollar": 222.80, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna", "plan_name": "700700", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna", "plan_name": "700700_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Mcare Ffs 6005", "plan_name": "700703", "standard_charge_dollar": 222.80, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Miscellaneous", "plan_name": "700720", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Miscellaneous", "plan_name": "700720_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Ppo Hmo", "plan_name": "701720", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Ppo Hmo", "plan_name": "701720_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Ambetter 68069", "plan_name": "500516", "standard_charge_dollar": 222.80, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Ms State Emplo", "plan_name": "401457", "standard_charge_percentage": 0.80, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Ms State Emplo", "plan_name": "401457_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Basic Pl", "plan_name": "400100", "standard_charge_percentage": 0.85, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Basic Pl", "plan_name": "400100_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Federal", "plan_name": "400110", "standard_charge_percentage": 0.85, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Federal", "plan_name": "400110_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Cigna Healthsprings Ffs", "plan_name": "500064", "standard_charge_dollar": 222.80, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Conseco", "plan_name": "500302", "standard_charge_dollar": 222.80, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Humana Ffs 61101", "plan_name": "500006", "standard_charge_dollar": 222.80, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Medicare A", "plan_name": "100100", "standard_charge_dollar": 222.80, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Medicare A", "plan_name": "100500", "standard_charge_dollar": 222.80, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Medicare Part B Only", "plan_name": "100300", "standard_charge_dollar": 222.80, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Medicare Railroad", "plan_name": "100103", "standard_charge_dollar": 222.80, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Ms Physicians Care N", "plan_name": "714210", "standard_charge_dollar": 278.50, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Peoples Hlth Ffs 72126", "plan_name": "500019", "standard_charge_dollar": 222.80, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Uhc/Secure Horizons", "plan_name": "500449", "standard_charge_dollar": 222.80, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "United Health Care/", "plan_name": "500292", "standard_charge_dollar": 251.76, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "United Healthcare", "plan_name": "750104", "standard_charge_dollar": 251.76, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "United Healthcare Ba", "plan_name": "750090", "standard_charge_dollar": 251.76, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "United Healthcare Me", "plan_name": "501310", "standard_charge_dollar": 222.80, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Windsor Mcare Extra", "plan_name": "500778", "standard_charge_dollar": 222.80, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." } ] } ] }, { "description": "Rplc gtube no revj trc", "code_information": [ { "code": "43762", "type": "CPT" } ], "standard_charges": [ { "gross_charge": 75.60, "minimum": 60.48, "maximum": 278.50, "setting": "both", "payers_information": [ { "payer_name": "Aarp", "plan_name": "500102", "standard_charge_dollar": 222.80, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna", "plan_name": "700700", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna", "plan_name": "700700_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Mcare Ffs 6005", "plan_name": "700703", "standard_charge_dollar": 222.80, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Miscellaneous", "plan_name": "700720", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Miscellaneous", "plan_name": "700720_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Ppo Hmo", "plan_name": "701720", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Ppo Hmo", "plan_name": "701720_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Ambetter 68069", "plan_name": "500516", "standard_charge_dollar": 222.80, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Ms State Emplo", "plan_name": "401457", "standard_charge_percentage": 0.80, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Ms State Emplo", "plan_name": "401457_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Basic Pl", "plan_name": "400100", "standard_charge_percentage": 0.85, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Basic Pl", "plan_name": "400100_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Federal", "plan_name": "400110", "standard_charge_percentage": 0.85, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Federal", "plan_name": "400110_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Cigna Healthsprings Ffs", "plan_name": "500064", "standard_charge_dollar": 222.80, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Conseco", "plan_name": "500302", "standard_charge_dollar": 222.80, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Humana Ffs 61101", "plan_name": "500006", "standard_charge_dollar": 222.80, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Medicare A", "plan_name": "100100", "standard_charge_dollar": 222.80, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Medicare A", "plan_name": "100500", "standard_charge_dollar": 222.80, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Medicare Part B Only", "plan_name": "100300", "standard_charge_dollar": 222.80, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Medicare Railroad", "plan_name": "100103", "standard_charge_dollar": 222.80, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Ms Physicians Care N", "plan_name": "714210", "standard_charge_dollar": 278.50, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Peoples Hlth Ffs 72126", "plan_name": "500019", "standard_charge_dollar": 222.80, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Uhc/Secure Horizons", "plan_name": "500449", "standard_charge_dollar": 222.80, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "United Health Care/", "plan_name": "500292", "standard_charge_dollar": 251.76, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "United Healthcare", "plan_name": "750104", "standard_charge_dollar": 251.76, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "United Healthcare Ba", "plan_name": "750090", "standard_charge_dollar": 251.76, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "United Healthcare Me", "plan_name": "501310", "standard_charge_dollar": 222.80, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Windsor Mcare Extra", "plan_name": "500778", "standard_charge_dollar": 222.80, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." } ] } ] }, { "description": "Lap place gastr adj device", "code_information": [ { "code": "43770", "type": "CPT" } ], "standard_charges": [ { "gross_charge": 24676.07, "minimum": 9537.40, "maximum": 20974.66, "setting": "inpatient", "payers_information": [ { "payer_name": "Aarp", "plan_name": "500102", "standard_charge_dollar": 9537.40, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna", "plan_name": "700700", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna", "plan_name": "700700_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Mcare Ffs 6005", "plan_name": "700703", "standard_charge_dollar": 9537.40, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Miscellaneous", "plan_name": "700720", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Miscellaneous", "plan_name": "700720_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Ppo Hmo", "plan_name": "701720", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Ppo Hmo", "plan_name": "701720_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Ambetter 68069", "plan_name": "500516", "standard_charge_dollar": 9537.40, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Ms State Emplo", "plan_name": "401457", "standard_charge_percentage": 0.80, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Ms State Emplo", "plan_name": "401457_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Basic Pl", "plan_name": "400100", "standard_charge_percentage": 0.85, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Basic Pl", "plan_name": "400100_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Federal", "plan_name": "400110", "standard_charge_percentage": 0.85, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Federal", "plan_name": "400110_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Cigna Healthsprings Ffs", "plan_name": "500064", "standard_charge_dollar": 9537.40, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Conseco", "plan_name": "500302", "standard_charge_dollar": 9537.40, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Humana Ffs 61101", "plan_name": "500006", "standard_charge_dollar": 9537.40, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Medicare A", "plan_name": "100100", "standard_charge_dollar": 9537.40, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Medicare A", "plan_name": "100500", "standard_charge_dollar": 9537.40, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Medicare Part B Only", "plan_name": "100300", "standard_charge_dollar": 9537.40, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Medicare Railroad", "plan_name": "100103", "standard_charge_dollar": 9537.40, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Ms Physicians Care N", "plan_name": "714210", "standard_charge_dollar": 11921.75, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Peoples Hlth Ffs 72126", "plan_name": "500019", "standard_charge_dollar": 9537.40, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Uhc/Secure Horizons", "plan_name": "500449", "standard_charge_dollar": 9537.40, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "United Health Care/", "plan_name": "500292", "standard_charge_dollar": 10777.26, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "United Healthcare", "plan_name": "750104", "standard_charge_dollar": 10777.26, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "United Healthcare Ba", "plan_name": "750090", "standard_charge_dollar": 10777.26, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "United Healthcare Me", "plan_name": "501310", "standard_charge_dollar": 9537.40, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Windsor Mcare Extra", "plan_name": "500778", "standard_charge_dollar": 9537.40, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." } ] } ] }, { "description": "Lap revise gastr adj device", "code_information": [ { "code": "43771", "type": "CPT" } ], "standard_charges": [ { "gross_charge": 24676.07, "minimum": 19740.86, "maximum": 20974.66, "setting": "inpatient", "payers_information": [ { "payer_name": "Aetna", "plan_name": "700700", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna", "plan_name": "700700_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Miscellaneous", "plan_name": "700720", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Miscellaneous", "plan_name": "700720_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Ppo Hmo", "plan_name": "701720", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Ppo Hmo", "plan_name": "701720_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Ms State Emplo", "plan_name": "401457", "standard_charge_percentage": 0.80, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Ms State Emplo", "plan_name": "401457_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Basic Pl", "plan_name": "400100", "standard_charge_percentage": 0.85, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Basic Pl", "plan_name": "400100_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Federal", "plan_name": "400110", "standard_charge_percentage": 0.85, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Federal", "plan_name": "400110_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." } ] } ] }, { "description": "Lap rmvl gastr adj device", "code_information": [ { "code": "43772", "type": "CPT" } ], "standard_charges": [ { "gross_charge": 24676.07, "minimum": 3485.21, "maximum": 20974.66, "setting": "inpatient", "payers_information": [ { "payer_name": "Aarp", "plan_name": "500102", "standard_charge_dollar": 3485.21, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna", "plan_name": "700700", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna", "plan_name": "700700_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Mcare Ffs 6005", "plan_name": "700703", "standard_charge_dollar": 3485.21, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Miscellaneous", "plan_name": "700720", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Miscellaneous", "plan_name": "700720_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Ppo Hmo", "plan_name": "701720", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Ppo Hmo", "plan_name": "701720_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Ambetter 68069", "plan_name": "500516", "standard_charge_dollar": 3485.21, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Ms State Emplo", "plan_name": "401457", "standard_charge_percentage": 0.80, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Ms State Emplo", "plan_name": "401457_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Basic Pl", "plan_name": "400100", "standard_charge_percentage": 0.85, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Basic Pl", "plan_name": "400100_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Federal", "plan_name": "400110", "standard_charge_percentage": 0.85, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Federal", "plan_name": "400110_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Cigna Healthsprings Ffs", "plan_name": "500064", "standard_charge_dollar": 3485.21, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Conseco", "plan_name": "500302", "standard_charge_dollar": 3485.21, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Humana Ffs 61101", "plan_name": "500006", "standard_charge_dollar": 3485.21, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Medicare A", "plan_name": "100100", "standard_charge_dollar": 3485.21, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Medicare A", "plan_name": "100500", "standard_charge_dollar": 3485.21, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Medicare Part B Only", "plan_name": "100300", "standard_charge_dollar": 3485.21, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Medicare Railroad", "plan_name": "100103", "standard_charge_dollar": 3485.21, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Ms Physicians Care N", "plan_name": "714210", "standard_charge_dollar": 4356.52, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Peoples Hlth Ffs 72126", "plan_name": "500019", "standard_charge_dollar": 3485.21, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Uhc/Secure Horizons", "plan_name": "500449", "standard_charge_dollar": 3485.21, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "United Health Care/", "plan_name": "500292", "standard_charge_dollar": 3938.29, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "United Healthcare", "plan_name": "750104", "standard_charge_dollar": 3938.29, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "United Healthcare Ba", "plan_name": "750090", "standard_charge_dollar": 3938.29, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "United Healthcare Me", "plan_name": "501310", "standard_charge_dollar": 3485.21, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Windsor Mcare Extra", "plan_name": "500778", "standard_charge_dollar": 3485.21, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." } ] } ] }, { "description": "Lap replace gastr adj device", "code_information": [ { "code": "43773", "type": "CPT" } ], "standard_charges": [ { "gross_charge": 24676.07, "minimum": 5344.68, "maximum": 20974.66, "setting": "inpatient", "payers_information": [ { "payer_name": "Aarp", "plan_name": "500102", "standard_charge_dollar": 5344.68, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna", "plan_name": "700700", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna", "plan_name": "700700_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Mcare Ffs 6005", "plan_name": "700703", "standard_charge_dollar": 5344.68, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Miscellaneous", "plan_name": "700720", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Miscellaneous", "plan_name": "700720_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Ppo Hmo", "plan_name": "701720", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Ppo Hmo", "plan_name": "701720_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Ambetter 68069", "plan_name": "500516", "standard_charge_dollar": 5344.68, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Ms State Emplo", "plan_name": "401457", "standard_charge_percentage": 0.80, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Ms State Emplo", "plan_name": "401457_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Basic Pl", "plan_name": "400100", "standard_charge_percentage": 0.85, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Basic Pl", "plan_name": "400100_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Federal", "plan_name": "400110", "standard_charge_percentage": 0.85, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Federal", "plan_name": "400110_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Cigna Healthsprings Ffs", "plan_name": "500064", "standard_charge_dollar": 5344.68, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Conseco", "plan_name": "500302", "standard_charge_dollar": 5344.68, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Humana Ffs 61101", "plan_name": "500006", "standard_charge_dollar": 5344.68, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Medicare A", "plan_name": "100100", "standard_charge_dollar": 5344.68, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Medicare A", "plan_name": "100500", "standard_charge_dollar": 5344.68, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Medicare Part B Only", "plan_name": "100300", "standard_charge_dollar": 5344.68, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Medicare Railroad", "plan_name": "100103", "standard_charge_dollar": 5344.68, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Ms Physicians Care N", "plan_name": "714210", "standard_charge_dollar": 6680.85, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Peoples Hlth Ffs 72126", "plan_name": "500019", "standard_charge_dollar": 5344.68, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Uhc/Secure Horizons", "plan_name": "500449", "standard_charge_dollar": 5344.68, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "United Health Care/", "plan_name": "500292", "standard_charge_dollar": 6039.49, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "United Healthcare", "plan_name": "750104", "standard_charge_dollar": 6039.49, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "United Healthcare Ba", "plan_name": "750090", "standard_charge_dollar": 6039.49, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "United Healthcare Me", "plan_name": "501310", "standard_charge_dollar": 5344.68, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Windsor Mcare Extra", "plan_name": "500778", "standard_charge_dollar": 5344.68, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." } ] } ] }, { "description": "Lap rmvl gastr adj all parts", "code_information": [ { "code": "43774", "type": "CPT" } ], "standard_charges": [ { "gross_charge": 24676.07, "minimum": 3485.21, "maximum": 20974.66, "setting": "inpatient", "payers_information": [ { "payer_name": "Aarp", "plan_name": "500102", "standard_charge_dollar": 3485.21, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna", "plan_name": "700700", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna", "plan_name": "700700_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Mcare Ffs 6005", "plan_name": "700703", "standard_charge_dollar": 3485.21, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Miscellaneous", "plan_name": "700720", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Miscellaneous", "plan_name": "700720_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Ppo Hmo", "plan_name": "701720", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Ppo Hmo", "plan_name": "701720_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Ambetter 68069", "plan_name": "500516", "standard_charge_dollar": 3485.21, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Ms State Emplo", "plan_name": "401457", "standard_charge_percentage": 0.80, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Ms State Emplo", "plan_name": "401457_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Basic Pl", "plan_name": "400100", "standard_charge_percentage": 0.85, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Basic Pl", "plan_name": "400100_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Federal", "plan_name": "400110", "standard_charge_percentage": 0.85, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Federal", "plan_name": "400110_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Cigna Healthsprings Ffs", "plan_name": "500064", "standard_charge_dollar": 3485.21, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Conseco", "plan_name": "500302", "standard_charge_dollar": 3485.21, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Humana Ffs 61101", "plan_name": "500006", "standard_charge_dollar": 3485.21, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Medicare A", "plan_name": "100100", "standard_charge_dollar": 3485.21, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Medicare A", "plan_name": "100500", "standard_charge_dollar": 3485.21, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Medicare Part B Only", "plan_name": "100300", "standard_charge_dollar": 3485.21, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Medicare Railroad", "plan_name": "100103", "standard_charge_dollar": 3485.21, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Ms Physicians Care N", "plan_name": "714210", "standard_charge_dollar": 4356.52, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Peoples Hlth Ffs 72126", "plan_name": "500019", "standard_charge_dollar": 3485.21, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Uhc/Secure Horizons", "plan_name": "500449", "standard_charge_dollar": 3485.21, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "United Health Care/", "plan_name": "500292", "standard_charge_dollar": 3938.29, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "United Healthcare", "plan_name": "750104", "standard_charge_dollar": 3938.29, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "United Healthcare Ba", "plan_name": "750090", "standard_charge_dollar": 3938.29, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "United Healthcare Me", "plan_name": "501310", "standard_charge_dollar": 3485.21, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Windsor Mcare Extra", "plan_name": "500778", "standard_charge_dollar": 3485.21, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." } ] } ] }, { "description": "Lap sleeve gastrectomy", "code_information": [ { "code": "43775", "type": "CPT" } ], "standard_charges": [ { "gross_charge": 24676.07, "minimum": 19740.86, "maximum": 20974.66, "setting": "inpatient", "payers_information": [ { "payer_name": "Aetna", "plan_name": "700700", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna", "plan_name": "700700_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Miscellaneous", "plan_name": "700720", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Miscellaneous", "plan_name": "700720_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Ppo Hmo", "plan_name": "701720", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Ppo Hmo", "plan_name": "701720_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Ms State Emplo", "plan_name": "401457", "standard_charge_percentage": 0.80, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Ms State Emplo", "plan_name": "401457_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Basic Pl", "plan_name": "400100", "standard_charge_percentage": 0.85, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Basic Pl", "plan_name": "400100_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Federal", "plan_name": "400110", "standard_charge_percentage": 0.85, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Federal", "plan_name": "400110_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." } ] } ] }, { "description": "Fusion of stomach and bowel", "code_information": [ { "code": "43820", "type": "CPT" } ], "standard_charges": [ { "gross_charge": 62580.64, "minimum": 50064.51, "maximum": 53193.54, "setting": "inpatient", "payers_information": [ { "payer_name": "Aetna", "plan_name": "700700", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna", "plan_name": "700700_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Miscellaneous", "plan_name": "700720", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Miscellaneous", "plan_name": "700720_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Ppo Hmo", "plan_name": "701720", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Ppo Hmo", "plan_name": "701720_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Ms State Emplo", "plan_name": "401457", "standard_charge_percentage": 0.80, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Ms State Emplo", "plan_name": "401457_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Basic Pl", "plan_name": "400100", "standard_charge_percentage": 0.85, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Basic Pl", "plan_name": "400100_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Federal", "plan_name": "400110", "standard_charge_percentage": 0.85, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Federal", "plan_name": "400110_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." } ] } ] }, { "description": "Fusion of stomach and bowel", "code_information": [ { "code": "43825", "type": "CPT" } ], "standard_charges": [ { "gross_charge": 62580.64, "minimum": 50064.51, "maximum": 53193.54, "setting": "inpatient", "payers_information": [ { "payer_name": "Aetna", "plan_name": "700700", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna", "plan_name": "700700_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Miscellaneous", "plan_name": "700720", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Miscellaneous", "plan_name": "700720_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Ppo Hmo", "plan_name": "701720", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Ppo Hmo", "plan_name": "701720_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Ms State Emplo", "plan_name": "401457", "standard_charge_percentage": 0.80, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Ms State Emplo", "plan_name": "401457_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Basic Pl", "plan_name": "400100", "standard_charge_percentage": 0.85, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Basic Pl", "plan_name": "400100_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Federal", "plan_name": "400110", "standard_charge_percentage": 0.85, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Federal", "plan_name": "400110_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." } ] } ] }, { "description": "Place gastrostomy tube", "code_information": [ { "code": "43831", "type": "CPT" } ], "standard_charges": [ { "gross_charge": 27488.57, "minimum": 858.87, "maximum": 23365.28, "setting": "inpatient", "payers_information": [ { "payer_name": "Aarp", "plan_name": "500102", "standard_charge_dollar": 858.87, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna", "plan_name": "700700", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna", "plan_name": "700700_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Mcare Ffs 6005", "plan_name": "700703", "standard_charge_dollar": 858.87, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Miscellaneous", "plan_name": "700720", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Miscellaneous", "plan_name": "700720_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Ppo Hmo", "plan_name": "701720", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Ppo Hmo", "plan_name": "701720_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Ambetter 68069", "plan_name": "500516", "standard_charge_dollar": 858.87, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Ms State Emplo", "plan_name": "401457", "standard_charge_percentage": 0.80, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Ms State Emplo", "plan_name": "401457_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Basic Pl", "plan_name": "400100", "standard_charge_percentage": 0.85, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Basic Pl", "plan_name": "400100_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Federal", "plan_name": "400110", "standard_charge_percentage": 0.85, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Federal", "plan_name": "400110_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Cigna Healthsprings Ffs", "plan_name": "500064", "standard_charge_dollar": 858.87, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Conseco", "plan_name": "500302", "standard_charge_dollar": 858.87, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Humana Ffs 61101", "plan_name": "500006", "standard_charge_dollar": 858.87, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Medicare A", "plan_name": "100100", "standard_charge_dollar": 858.87, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Medicare A", "plan_name": "100500", "standard_charge_dollar": 858.87, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Medicare Part B Only", "plan_name": "100300", "standard_charge_dollar": 858.87, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Medicare Railroad", "plan_name": "100103", "standard_charge_dollar": 858.87, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Ms Physicians Care N", "plan_name": "714210", "standard_charge_dollar": 1073.59, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Peoples Hlth Ffs 72126", "plan_name": "500019", "standard_charge_dollar": 858.87, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Uhc/Secure Horizons", "plan_name": "500449", "standard_charge_dollar": 858.87, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "United Health Care/", "plan_name": "500292", "standard_charge_dollar": 970.52, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "United Healthcare", "plan_name": "750104", "standard_charge_dollar": 970.52, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "United Healthcare Ba", "plan_name": "750090", "standard_charge_dollar": 970.52, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "United Healthcare Me", "plan_name": "501310", "standard_charge_dollar": 858.87, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Windsor Mcare Extra", "plan_name": "500778", "standard_charge_dollar": 858.87, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." } ] } ] }, { "description": "Repair of stomach lesion", "code_information": [ { "code": "43840", "type": "CPT" } ], "standard_charges": [ { "gross_charge": 98709.33, "minimum": 78967.46, "maximum": 83902.93, "setting": "inpatient", "payers_information": [ { "payer_name": "Aetna", "plan_name": "700700", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna", "plan_name": "700700_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Miscellaneous", "plan_name": "700720", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Miscellaneous", "plan_name": "700720_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Ppo Hmo", "plan_name": "701720", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Ppo Hmo", "plan_name": "701720_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Ms State Emplo", "plan_name": "401457", "standard_charge_percentage": 0.80, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Ms State Emplo", "plan_name": "401457_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Basic Pl", "plan_name": "400100", "standard_charge_percentage": 0.85, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Basic Pl", "plan_name": "400100_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Federal", "plan_name": "400110", "standard_charge_percentage": 0.85, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Federal", "plan_name": "400110_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." } ] } ] }, { "description": "Gastric bypass for obesity", "code_information": [ { "code": "43846", "type": "CPT" } ], "standard_charges": [ { "gross_charge": 62580.64, "minimum": 50064.51, "maximum": 53193.54, "setting": "inpatient", "payers_information": [ { "payer_name": "Aetna", "plan_name": "700700", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna", "plan_name": "700700_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Miscellaneous", "plan_name": "700720", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Miscellaneous", "plan_name": "700720_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Ppo Hmo", "plan_name": "701720", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Ppo Hmo", "plan_name": "701720_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Ms State Emplo", "plan_name": "401457", "standard_charge_percentage": 0.80, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Ms State Emplo", "plan_name": "401457_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Basic Pl", "plan_name": "400100", "standard_charge_percentage": 0.85, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Basic Pl", "plan_name": "400100_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Federal", "plan_name": "400110", "standard_charge_percentage": 0.85, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Federal", "plan_name": "400110_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." } ] } ] }, { "description": "Gastric bypass incl small i", "code_information": [ { "code": "43847", "type": "CPT" } ], "standard_charges": [ { "gross_charge": 62580.64, "minimum": 50064.51, "maximum": 53193.54, "setting": "inpatient", "payers_information": [ { "payer_name": "Aetna", "plan_name": "700700", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna", "plan_name": "700700_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Miscellaneous", "plan_name": "700720", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Miscellaneous", "plan_name": "700720_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Ppo Hmo", "plan_name": "701720", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Ppo Hmo", "plan_name": "701720_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Ms State Emplo", "plan_name": "401457", "standard_charge_percentage": 0.80, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Ms State Emplo", "plan_name": "401457_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Basic Pl", "plan_name": "400100", "standard_charge_percentage": 0.85, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Basic Pl", "plan_name": "400100_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Federal", "plan_name": "400110", "standard_charge_percentage": 0.85, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Federal", "plan_name": "400110_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." } ] } ] }, { "description": "Revision gastroplasty", "code_information": [ { "code": "43848", "type": "CPT" } ], "standard_charges": [ { "gross_charge": 48840.09, "minimum": 39072.07, "maximum": 41514.08, "setting": "inpatient", "payers_information": [ { "payer_name": "Aetna", "plan_name": "700700", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna", "plan_name": "700700_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Miscellaneous", "plan_name": "700720", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Miscellaneous", "plan_name": "700720_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Ppo Hmo", "plan_name": "701720", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Ppo Hmo", "plan_name": "701720_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Ms State Emplo", "plan_name": "401457", "standard_charge_percentage": 0.80, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Ms State Emplo", "plan_name": "401457_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Basic Pl", "plan_name": "400100", "standard_charge_percentage": 0.85, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Basic Pl", "plan_name": "400100_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Federal", "plan_name": "400110", "standard_charge_percentage": 0.85, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Federal", "plan_name": "400110_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." } ] } ] }, { "description": "Stomach surgery procedure", "code_information": [ { "code": "43999", "type": "CPT" } ], "standard_charges": [ { "gross_charge": 67284.46, "minimum": 858.87, "maximum": 57191.79, "setting": "inpatient", "payers_information": [ { "payer_name": "Aarp", "plan_name": "500102", "standard_charge_dollar": 858.87, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna", "plan_name": "700700", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna", "plan_name": "700700_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Mcare Ffs 6005", "plan_name": "700703", "standard_charge_dollar": 858.87, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Miscellaneous", "plan_name": "700720", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Miscellaneous", "plan_name": "700720_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Ppo Hmo", "plan_name": "701720", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Ppo Hmo", "plan_name": "701720_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Ambetter 68069", "plan_name": "500516", "standard_charge_dollar": 858.87, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Ms State Emplo", "plan_name": "401457", "standard_charge_percentage": 0.80, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Ms State Emplo", "plan_name": "401457_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Basic Pl", "plan_name": "400100", "standard_charge_percentage": 0.85, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Basic Pl", "plan_name": "400100_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Federal", "plan_name": "400110", "standard_charge_percentage": 0.85, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Federal", "plan_name": "400110_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Cigna Healthsprings Ffs", "plan_name": "500064", "standard_charge_dollar": 858.87, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Conseco", "plan_name": "500302", "standard_charge_dollar": 858.87, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Humana Ffs 61101", "plan_name": "500006", "standard_charge_dollar": 858.87, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Medicare A", "plan_name": "100100", "standard_charge_dollar": 858.87, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Medicare A", "plan_name": "100500", "standard_charge_dollar": 858.87, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Medicare Part B Only", "plan_name": "100300", "standard_charge_dollar": 858.87, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Medicare Railroad", "plan_name": "100103", "standard_charge_dollar": 858.87, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Ms Physicians Care N", "plan_name": "714210", "standard_charge_dollar": 1073.59, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Peoples Hlth Ffs 72126", "plan_name": "500019", "standard_charge_dollar": 858.87, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Uhc/Secure Horizons", "plan_name": "500449", "standard_charge_dollar": 858.87, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "United Health Care/", "plan_name": "500292", "standard_charge_dollar": 970.52, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "United Healthcare", "plan_name": "750104", "standard_charge_dollar": 970.52, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "United Healthcare Ba", "plan_name": "750090", "standard_charge_dollar": 970.52, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "United Healthcare Me", "plan_name": "501310", "standard_charge_dollar": 858.87, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Windsor Mcare Extra", "plan_name": "500778", "standard_charge_dollar": 858.87, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." } ] } ] }, { "description": "Freeing of bowel adhesion", "code_information": [ { "code": "44005", "type": "CPT" } ], "standard_charges": [ { "gross_charge": 34477.34, "minimum": 27581.87, "maximum": 29305.74, "setting": "inpatient", "payers_information": [ { "payer_name": "Aetna", "plan_name": "700700", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna", "plan_name": "700700_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Miscellaneous", "plan_name": "700720", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Miscellaneous", "plan_name": "700720_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Ppo Hmo", "plan_name": "701720", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Ppo Hmo", "plan_name": "701720_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Ms State Emplo", "plan_name": "401457", "standard_charge_percentage": 0.80, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Ms State Emplo", "plan_name": "401457_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Basic Pl", "plan_name": "400100", "standard_charge_percentage": 0.85, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Basic Pl", "plan_name": "400100_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Federal", "plan_name": "400110", "standard_charge_percentage": 0.85, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Federal", "plan_name": "400110_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." } ] } ] }, { "description": "Incision of small bowel", "code_information": [ { "code": "44010", "type": "CPT" } ], "standard_charges": [ { "gross_charge": 75437.76, "minimum": 60350.21, "maximum": 64122.10, "setting": "inpatient", "payers_information": [ { "payer_name": "Aetna", "plan_name": "700700", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna", "plan_name": "700700_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Miscellaneous", "plan_name": "700720", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Miscellaneous", "plan_name": "700720_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Ppo Hmo", "plan_name": "701720", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Ppo Hmo", "plan_name": "701720_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Ms State Emplo", "plan_name": "401457", "standard_charge_percentage": 0.80, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Ms State Emplo", "plan_name": "401457_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Basic Pl", "plan_name": "400100", "standard_charge_percentage": 0.85, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Basic Pl", "plan_name": "400100_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Federal", "plan_name": "400110", "standard_charge_percentage": 0.85, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Federal", "plan_name": "400110_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." } ] } ] }, { "description": "Insert needle cath bowel", "code_information": [ { "code": "44015", "type": "CPT" } ], "standard_charges": [ { "gross_charge": 18587.20, "minimum": 14869.76, "maximum": 15799.12, "setting": "inpatient", "payers_information": [ { "payer_name": "Aetna", "plan_name": "700700", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna", "plan_name": "700700_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Miscellaneous", "plan_name": "700720", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Miscellaneous", "plan_name": "700720_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Ppo Hmo", "plan_name": "701720", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Ppo Hmo", "plan_name": "701720_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Ms State Emplo", "plan_name": "401457", "standard_charge_percentage": 0.80, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Ms State Emplo", "plan_name": "401457_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Basic Pl", "plan_name": "400100", "standard_charge_percentage": 0.85, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Basic Pl", "plan_name": "400100_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Federal", "plan_name": "400110", "standard_charge_percentage": 0.85, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Federal", "plan_name": "400110_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." } ] } ] }, { "description": "Explore small intestine", "code_information": [ { "code": "44020", "type": "CPT" } ], "standard_charges": [ { "gross_charge": 75437.76, "minimum": 60350.21, "maximum": 64122.10, "setting": "inpatient", "payers_information": [ { "payer_name": "Aetna", "plan_name": "700700", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna", "plan_name": "700700_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Miscellaneous", "plan_name": "700720", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Miscellaneous", "plan_name": "700720_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Ppo Hmo", "plan_name": "701720", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Ppo Hmo", "plan_name": "701720_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Ms State Emplo", "plan_name": "401457", "standard_charge_percentage": 0.80, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Ms State Emplo", "plan_name": "401457_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Basic Pl", "plan_name": "400100", "standard_charge_percentage": 0.85, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Basic Pl", "plan_name": "400100_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Federal", "plan_name": "400110", "standard_charge_percentage": 0.85, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Federal", "plan_name": "400110_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." } ] } ] }, { "description": "Reduce bowel obstruction", "code_information": [ { "code": "44050", "type": "CPT" } ], "standard_charges": [ { "gross_charge": 21031.74, "minimum": 16825.39, "maximum": 17876.98, "setting": "inpatient", "payers_information": [ { "payer_name": "Aetna", "plan_name": "700700", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna", "plan_name": "700700_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Miscellaneous", "plan_name": "700720", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Miscellaneous", "plan_name": "700720_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Ppo Hmo", "plan_name": "701720", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Ppo Hmo", "plan_name": "701720_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Ms State Emplo", "plan_name": "401457", "standard_charge_percentage": 0.80, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Ms State Emplo", "plan_name": "401457_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Basic Pl", "plan_name": "400100", "standard_charge_percentage": 0.85, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Basic Pl", "plan_name": "400100_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Federal", "plan_name": "400110", "standard_charge_percentage": 0.85, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Federal", "plan_name": "400110_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." } ] } ] }, { "description": "Biopsy of bowel", "code_information": [ { "code": "44100", "type": "CPT" } ], "standard_charges": [ { "gross_charge": 22698.89, "minimum": 858.87, "maximum": 19294.06, "setting": "inpatient", "payers_information": [ { "payer_name": "Aarp", "plan_name": "500102", "standard_charge_dollar": 858.87, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna", "plan_name": "700700", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna", "plan_name": "700700_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Mcare Ffs 6005", "plan_name": "700703", "standard_charge_dollar": 858.87, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Miscellaneous", "plan_name": "700720", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Miscellaneous", "plan_name": "700720_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Ppo Hmo", "plan_name": "701720", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Ppo Hmo", "plan_name": "701720_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Ambetter 68069", "plan_name": "500516", "standard_charge_dollar": 858.87, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Ms State Emplo", "plan_name": "401457", "standard_charge_percentage": 0.80, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Ms State Emplo", "plan_name": "401457_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Basic Pl", "plan_name": "400100", "standard_charge_percentage": 0.85, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Basic Pl", "plan_name": "400100_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Federal", "plan_name": "400110", "standard_charge_percentage": 0.85, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Federal", "plan_name": "400110_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Cigna Healthsprings Ffs", "plan_name": "500064", "standard_charge_dollar": 858.87, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Conseco", "plan_name": "500302", "standard_charge_dollar": 858.87, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Humana Ffs 61101", "plan_name": "500006", "standard_charge_dollar": 858.87, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Medicare A", "plan_name": "100100", "standard_charge_dollar": 858.87, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Medicare A", "plan_name": "100500", "standard_charge_dollar": 858.87, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Medicare Part B Only", "plan_name": "100300", "standard_charge_dollar": 858.87, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Medicare Railroad", "plan_name": "100103", "standard_charge_dollar": 858.87, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Ms Physicians Care N", "plan_name": "714210", "standard_charge_dollar": 1073.59, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Peoples Hlth Ffs 72126", "plan_name": "500019", "standard_charge_dollar": 858.87, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Uhc/Secure Horizons", "plan_name": "500449", "standard_charge_dollar": 858.87, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "United Health Care/", "plan_name": "500292", "standard_charge_dollar": 970.52, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "United Healthcare", "plan_name": "750104", "standard_charge_dollar": 970.52, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "United Healthcare Ba", "plan_name": "750090", "standard_charge_dollar": 970.52, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "United Healthcare Me", "plan_name": "501310", "standard_charge_dollar": 858.87, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Windsor Mcare Extra", "plan_name": "500778", "standard_charge_dollar": 858.87, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." } ] } ] }, { "description": "Excise intestine lesion(s)", "code_information": [ { "code": "44110", "type": "CPT" } ], "standard_charges": [ { "gross_charge": 42152.63, "minimum": 33722.10, "maximum": 35829.74, "setting": "inpatient", "payers_information": [ { "payer_name": "Aetna", "plan_name": "700700", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna", "plan_name": "700700_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Miscellaneous", "plan_name": "700720", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Miscellaneous", "plan_name": "700720_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Ppo Hmo", "plan_name": "701720", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Ppo Hmo", "plan_name": "701720_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Ms State Emplo", "plan_name": "401457", "standard_charge_percentage": 0.80, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Ms State Emplo", "plan_name": "401457_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Basic Pl", "plan_name": "400100", "standard_charge_percentage": 0.85, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Basic Pl", "plan_name": "400100_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Federal", "plan_name": "400110", "standard_charge_percentage": 0.85, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Federal", "plan_name": "400110_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." } ] } ] }, { "description": "Excision of bowel lesion(s)", "code_information": [ { "code": "44111", "type": "CPT" } ], "standard_charges": [ { "gross_charge": 42152.63, "minimum": 33722.10, "maximum": 35829.74, "setting": "inpatient", "payers_information": [ { "payer_name": "Aetna", "plan_name": "700700", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna", "plan_name": "700700_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Miscellaneous", "plan_name": "700720", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Miscellaneous", "plan_name": "700720_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Ppo Hmo", "plan_name": "701720", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Ppo Hmo", "plan_name": "701720_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Ms State Emplo", "plan_name": "401457", "standard_charge_percentage": 0.80, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Ms State Emplo", "plan_name": "401457_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Basic Pl", "plan_name": "400100", "standard_charge_percentage": 0.85, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Basic Pl", "plan_name": "400100_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Federal", "plan_name": "400110", "standard_charge_percentage": 0.85, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Federal", "plan_name": "400110_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." } ] } ] }, { "description": "Removal of small intestine", "code_information": [ { "code": "44120", "type": "CPT" } ], "standard_charges": [ { "gross_charge": 40260.27, "minimum": 32208.22, "maximum": 34221.23, "setting": "inpatient", "payers_information": [ { "payer_name": "Aetna", "plan_name": "700700", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna", "plan_name": "700700_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Miscellaneous", "plan_name": "700720", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Miscellaneous", "plan_name": "700720_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Ppo Hmo", "plan_name": "701720", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Ppo Hmo", "plan_name": "701720_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Ms State Emplo", "plan_name": "401457", "standard_charge_percentage": 0.80, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Ms State Emplo", "plan_name": "401457_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Basic Pl", "plan_name": "400100", "standard_charge_percentage": 0.85, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Basic Pl", "plan_name": "400100_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Federal", "plan_name": "400110", "standard_charge_percentage": 0.85, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Federal", "plan_name": "400110_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." } ] } ] }, { "description": "Removal of small intestine", "code_information": [ { "code": "44121", "type": "CPT" } ], "standard_charges": [ { "gross_charge": 40260.27, "minimum": 32208.22, "maximum": 34221.23, "setting": "inpatient", "payers_information": [ { "payer_name": "Aetna", "plan_name": "700700", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna", "plan_name": "700700_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Miscellaneous", "plan_name": "700720", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Miscellaneous", "plan_name": "700720_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Ppo Hmo", "plan_name": "701720", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Ppo Hmo", "plan_name": "701720_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Ms State Emplo", "plan_name": "401457", "standard_charge_percentage": 0.80, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Ms State Emplo", "plan_name": "401457_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Basic Pl", "plan_name": "400100", "standard_charge_percentage": 0.85, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Basic Pl", "plan_name": "400100_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Federal", "plan_name": "400110", "standard_charge_percentage": 0.85, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Federal", "plan_name": "400110_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." } ] } ] }, { "description": "Removal of small intestine", "code_information": [ { "code": "44125", "type": "CPT" } ], "standard_charges": [ { "gross_charge": 40260.27, "minimum": 32208.22, "maximum": 34221.23, "setting": "inpatient", "payers_information": [ { "payer_name": "Aetna", "plan_name": "700700", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna", "plan_name": "700700_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Miscellaneous", "plan_name": "700720", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Miscellaneous", "plan_name": "700720_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Ppo Hmo", "plan_name": "701720", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Ppo Hmo", "plan_name": "701720_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Ms State Emplo", "plan_name": "401457", "standard_charge_percentage": 0.80, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Ms State Emplo", "plan_name": "401457_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Basic Pl", "plan_name": "400100", "standard_charge_percentage": 0.85, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Basic Pl", "plan_name": "400100_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Federal", "plan_name": "400110", "standard_charge_percentage": 0.85, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Federal", "plan_name": "400110_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." } ] } ] }, { "description": "Enterectomy w/o taper cong", "code_information": [ { "code": "44126", "type": "CPT" } ], "standard_charges": [ { "gross_charge": 40260.27, "minimum": 32208.22, "maximum": 34221.23, "setting": "inpatient", "payers_information": [ { "payer_name": "Aetna", "plan_name": "700700", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna", "plan_name": "700700_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Miscellaneous", "plan_name": "700720", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Miscellaneous", "plan_name": "700720_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Ppo Hmo", "plan_name": "701720", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Ppo Hmo", "plan_name": "701720_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Ms State Emplo", "plan_name": "401457", "standard_charge_percentage": 0.80, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Ms State Emplo", "plan_name": "401457_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Basic Pl", "plan_name": "400100", "standard_charge_percentage": 0.85, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Basic Pl", "plan_name": "400100_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Federal", "plan_name": "400110", "standard_charge_percentage": 0.85, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Federal", "plan_name": "400110_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." } ] } ] }, { "description": "Enterectomy w/taper cong", "code_information": [ { "code": "44127", "type": "CPT" } ], "standard_charges": [ { "gross_charge": 40260.27, "minimum": 32208.22, "maximum": 34221.23, "setting": "inpatient", "payers_information": [ { "payer_name": "Aetna", "plan_name": "700700", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna", "plan_name": "700700_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Miscellaneous", "plan_name": "700720", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Miscellaneous", "plan_name": "700720_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Ppo Hmo", "plan_name": "701720", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Ppo Hmo", "plan_name": "701720_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Ms State Emplo", "plan_name": "401457", "standard_charge_percentage": 0.80, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Ms State Emplo", "plan_name": "401457_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Basic Pl", "plan_name": "400100", "standard_charge_percentage": 0.85, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Basic Pl", "plan_name": "400100_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Federal", "plan_name": "400110", "standard_charge_percentage": 0.85, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Federal", "plan_name": "400110_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." } ] } ] }, { "description": "Enterectomy cong add-on", "code_information": [ { "code": "44128", "type": "CPT" } ], "standard_charges": [ { "gross_charge": 40260.27, "minimum": 32208.22, "maximum": 34221.23, "setting": "inpatient", "payers_information": [ { "payer_name": "Aetna", "plan_name": "700700", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna", "plan_name": "700700_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Miscellaneous", "plan_name": "700720", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Miscellaneous", "plan_name": "700720_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Ppo Hmo", "plan_name": "701720", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Ppo Hmo", "plan_name": "701720_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Ms State Emplo", "plan_name": "401457", "standard_charge_percentage": 0.80, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Ms State Emplo", "plan_name": "401457_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Basic Pl", "plan_name": "400100", "standard_charge_percentage": 0.85, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Basic Pl", "plan_name": "400100_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Federal", "plan_name": "400110", "standard_charge_percentage": 0.85, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Federal", "plan_name": "400110_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." } ] } ] }, { "description": "Bowel to bowel fusion", "code_information": [ { "code": "44130", "type": "CPT" } ], "standard_charges": [ { "gross_charge": 40317.97, "minimum": 32254.38, "maximum": 34270.27, "setting": "inpatient", "payers_information": [ { "payer_name": "Aetna", "plan_name": "700700", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna", "plan_name": "700700_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Miscellaneous", "plan_name": "700720", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Miscellaneous", "plan_name": "700720_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Ppo Hmo", "plan_name": "701720", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Ppo Hmo", "plan_name": "701720_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Ms State Emplo", "plan_name": "401457", "standard_charge_percentage": 0.80, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Ms State Emplo", "plan_name": "401457_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Basic Pl", "plan_name": "400100", "standard_charge_percentage": 0.85, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Basic Pl", "plan_name": "400100_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Federal", "plan_name": "400110", "standard_charge_percentage": 0.85, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Federal", "plan_name": "400110_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." } ] } ] }, { "description": "Enterectomy cadaver donor", "code_information": [ { "code": "44132", "type": "CPT" } ], "standard_charges": [ { "gross_charge": 42409.26, "minimum": 33927.41, "maximum": 36047.87, "setting": "inpatient", "payers_information": [ { "payer_name": "Aetna", "plan_name": "700700", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna", "plan_name": "700700_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Miscellaneous", "plan_name": "700720", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Miscellaneous", "plan_name": "700720_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Ppo Hmo", "plan_name": "701720", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Ppo Hmo", "plan_name": "701720_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Ms State Emplo", "plan_name": "401457", "standard_charge_percentage": 0.80, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Ms State Emplo", "plan_name": "401457_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Basic Pl", "plan_name": "400100", "standard_charge_percentage": 0.85, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Basic Pl", "plan_name": "400100_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Federal", "plan_name": "400110", "standard_charge_percentage": 0.85, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Federal", "plan_name": "400110_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." } ] } ] }, { "description": "Enterectomy live donor", "code_information": [ { "code": "44133", "type": "CPT" } ], "standard_charges": [ { "gross_charge": 42409.26, "minimum": 33927.41, "maximum": 36047.87, "setting": "inpatient", "payers_information": [ { "payer_name": "Aetna", "plan_name": "700700", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna", "plan_name": "700700_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Miscellaneous", "plan_name": "700720", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Miscellaneous", "plan_name": "700720_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Ppo Hmo", "plan_name": "701720", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Ppo Hmo", "plan_name": "701720_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Ms State Emplo", "plan_name": "401457", "standard_charge_percentage": 0.80, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Ms State Emplo", "plan_name": "401457_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Basic Pl", "plan_name": "400100", "standard_charge_percentage": 0.85, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Basic Pl", "plan_name": "400100_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Federal", "plan_name": "400110", "standard_charge_percentage": 0.85, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Federal", "plan_name": "400110_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." } ] } ] }, { "description": "Remove intestinal allograft", "code_information": [ { "code": "44137", "type": "CPT" } ], "standard_charges": [ { "gross_charge": 35007.69, "minimum": 28006.15, "maximum": 29756.54, "setting": "inpatient", "payers_information": [ { "payer_name": "Aetna", "plan_name": "700700", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna", "plan_name": "700700_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Miscellaneous", "plan_name": "700720", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Miscellaneous", "plan_name": "700720_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Ppo Hmo", "plan_name": "701720", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Ppo Hmo", "plan_name": "701720_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Ms State Emplo", "plan_name": "401457", "standard_charge_percentage": 0.80, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Ms State Emplo", "plan_name": "401457_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Basic Pl", "plan_name": "400100", "standard_charge_percentage": 0.85, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Basic Pl", "plan_name": "400100_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Federal", "plan_name": "400110", "standard_charge_percentage": 0.85, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Federal", "plan_name": "400110_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." } ] } ] }, { "description": "Mobilization of colon", "code_information": [ { "code": "44139", "type": "CPT" } ], "standard_charges": [ { "gross_charge": 42840.63, "minimum": 34272.50, "maximum": 36414.54, "setting": "inpatient", "payers_information": [ { "payer_name": "Aetna", "plan_name": "700700", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna", "plan_name": "700700_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Miscellaneous", "plan_name": "700720", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Miscellaneous", "plan_name": "700720_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Ppo Hmo", "plan_name": "701720", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Ppo Hmo", "plan_name": "701720_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Ms State Emplo", "plan_name": "401457", "standard_charge_percentage": 0.80, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Ms State Emplo", "plan_name": "401457_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Basic Pl", "plan_name": "400100", "standard_charge_percentage": 0.85, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Basic Pl", "plan_name": "400100_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Federal", "plan_name": "400110", "standard_charge_percentage": 0.85, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Federal", "plan_name": "400110_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." } ] } ] }, { "description": "Partial removal of colon", "code_information": [ { "code": "44140", "type": "CPT" } ], "standard_charges": [ { "gross_charge": 42840.63, "minimum": 34272.50, "maximum": 36414.54, "setting": "inpatient", "payers_information": [ { "payer_name": "Aetna", "plan_name": "700700", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna", "plan_name": "700700_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Miscellaneous", "plan_name": "700720", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Miscellaneous", "plan_name": "700720_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Ppo Hmo", "plan_name": "701720", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Ppo Hmo", "plan_name": "701720_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Ms State Emplo", "plan_name": "401457", "standard_charge_percentage": 0.80, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Ms State Emplo", "plan_name": "401457_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Basic Pl", "plan_name": "400100", "standard_charge_percentage": 0.85, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Basic Pl", "plan_name": "400100_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Federal", "plan_name": "400110", "standard_charge_percentage": 0.85, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Federal", "plan_name": "400110_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." } ] } ] }, { "description": "Partial removal of colon", "code_information": [ { "code": "44141", "type": "CPT" } ], "standard_charges": [ { "gross_charge": 42183.08, "minimum": 33746.46, "maximum": 35855.62, "setting": "inpatient", "payers_information": [ { "payer_name": "Aetna", "plan_name": "700700", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna", "plan_name": "700700_1", 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"standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Ms State Emplo", "plan_name": "401457", "standard_charge_percentage": 0.80, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Ms State Emplo", "plan_name": "401457_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Basic Pl", "plan_name": "400100", "standard_charge_percentage": 0.85, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Basic Pl", "plan_name": "400100_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Federal", "plan_name": "400110", "standard_charge_percentage": 0.85, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Federal", "plan_name": "400110_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." } ] } ] }, { "description": "Partial removal of colon", "code_information": [ { "code": "44143", "type": "CPT" } ], "standard_charges": [ { "gross_charge": 42394.96, "minimum": 33915.97, "maximum": 36035.72, "setting": "inpatient", "payers_information": [ { "payer_name": "Aetna", "plan_name": "700700", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna", "plan_name": "700700_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Miscellaneous", "plan_name": "700720", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Miscellaneous", "plan_name": "700720_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Ppo Hmo", "plan_name": "701720", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Ppo Hmo", "plan_name": "701720_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Ms State Emplo", "plan_name": "401457", "standard_charge_percentage": 0.80, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Ms State Emplo", "plan_name": "401457_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Basic Pl", "plan_name": "400100", "standard_charge_percentage": 0.85, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Basic Pl", "plan_name": "400100_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Federal", "plan_name": "400110", "standard_charge_percentage": 0.85, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Federal", "plan_name": "400110_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." } ] } ] }, { "description": "Partial removal of colon", 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"standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Ppo Hmo", "plan_name": "701720", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Ppo Hmo", "plan_name": "701720_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Ms State Emplo", "plan_name": "401457", "standard_charge_percentage": 0.80, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Ms State Emplo", "plan_name": "401457_1", 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"standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." } ] } ] }, { "description": "Partial removal of colon", "code_information": [ { "code": "44145", "type": "CPT" } ], "standard_charges": [ { "gross_charge": 43481.26, "minimum": 34785.01, "maximum": 36959.07, "setting": "inpatient", "payers_information": [ { "payer_name": "Aetna", "plan_name": "700700", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna", "plan_name": "700700_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Miscellaneous", "plan_name": "700720", "standard_charge_percentage": 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"0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Federal", "plan_name": "400110_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." } ] } ] }, { "description": "Partial removal of colon", "code_information": [ { "code": "44146", "type": "CPT" } ], "standard_charges": [ { "gross_charge": 42674.57, "minimum": 34139.66, "maximum": 36273.38, "setting": "inpatient", "payers_information": [ { "payer_name": "Aetna", "plan_name": "700700", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna", "plan_name": "700700_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent 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charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Ms State Emplo", "plan_name": "401457", "standard_charge_percentage": 0.80, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Ms State Emplo", "plan_name": "401457_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Basic Pl", "plan_name": "400100", "standard_charge_percentage": 0.85, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Basic Pl", "plan_name": "400100_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Federal", "plan_name": "400110", "standard_charge_percentage": 0.85, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Federal", "plan_name": "400110_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." } ] } ] }, { "description": "Partial removal of colon", "code_information": [ { "code": "44147", "type": "CPT" } ], "standard_charges": [ { "gross_charge": 42840.63, "minimum": 34272.50, "maximum": 36414.54, "setting": "inpatient", "payers_information": [ { "payer_name": "Aetna", "plan_name": "700700", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna", "plan_name": "700700_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Miscellaneous", "plan_name": "700720", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Miscellaneous", "plan_name": "700720_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Ppo Hmo", "plan_name": "701720", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Ppo Hmo", "plan_name": "701720_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Ms State Emplo", "plan_name": "401457", "standard_charge_percentage": 0.80, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Ms State Emplo", "plan_name": "401457_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Basic Pl", "plan_name": "400100", "standard_charge_percentage": 0.85, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Basic Pl", "plan_name": "400100_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Federal", "plan_name": "400110", "standard_charge_percentage": 0.85, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Federal", "plan_name": "400110_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." } ] } ] }, { "description": "Removal of colon", "code_information": [ { "code": "44150", "type": "CPT" } ], "standard_charges": [ { "gross_charge": 61714.85, "minimum": 49371.88, "maximum": 52457.62, "setting": "inpatient", "payers_information": [ { "payer_name": "Aetna", "plan_name": "700700", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna", "plan_name": "700700_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Miscellaneous", "plan_name": "700720", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Miscellaneous", "plan_name": "700720_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Ppo Hmo", "plan_name": "701720", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Ppo Hmo", "plan_name": "701720_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Ms State Emplo", "plan_name": "401457", "standard_charge_percentage": 0.80, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Ms State Emplo", "plan_name": "401457_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Basic Pl", "plan_name": "400100", "standard_charge_percentage": 0.85, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Basic Pl", "plan_name": "400100_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Federal", "plan_name": "400110", "standard_charge_percentage": 0.85, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Federal", "plan_name": "400110_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." } ] } ] }, { "description": "Removal of colon/ileostomy", "code_information": [ { "code": "44151", "type": "CPT" } ], "standard_charges": [ { "gross_charge": 61714.85, "minimum": 49371.88, "maximum": 52457.62, "setting": "inpatient", "payers_information": [ { "payer_name": "Aetna", "plan_name": "700700", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna", "plan_name": "700700_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Miscellaneous", "plan_name": "700720", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Miscellaneous", "plan_name": "700720_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Ppo Hmo", "plan_name": "701720", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Ppo Hmo", "plan_name": "701720_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Ms State Emplo", "plan_name": "401457", "standard_charge_percentage": 0.80, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Ms State Emplo", "plan_name": "401457_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Basic Pl", "plan_name": "400100", "standard_charge_percentage": 0.85, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Basic Pl", "plan_name": "400100_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Federal", "plan_name": "400110", "standard_charge_percentage": 0.85, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Federal", "plan_name": "400110_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." } ] } ] }, { "description": "Removal of colon/ileostomy", "code_information": [ { "code": "44155", "type": "CPT" } ], "standard_charges": [ { "gross_charge": 34815.08, "minimum": 27852.06, "maximum": 29592.82, "setting": "inpatient", "payers_information": [ { "payer_name": "Aetna", "plan_name": "700700", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna", "plan_name": "700700_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Miscellaneous", "plan_name": "700720", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Miscellaneous", "plan_name": "700720_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Ppo Hmo", "plan_name": "701720", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Ppo Hmo", "plan_name": "701720_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Ms State Emplo", "plan_name": "401457", "standard_charge_percentage": 0.80, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Ms State Emplo", "plan_name": "401457_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Basic Pl", "plan_name": "400100", "standard_charge_percentage": 0.85, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Basic Pl", "plan_name": "400100_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Federal", "plan_name": "400110", "standard_charge_percentage": 0.85, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Federal", "plan_name": "400110_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." } ] } ] }, { "description": "Removal of colon/ileostomy", "code_information": [ { "code": "44156", "type": "CPT" } ], "standard_charges": [ { "gross_charge": 61714.85, "minimum": 49371.88, "maximum": 52457.62, "setting": "inpatient", "payers_information": [ { "payer_name": "Aetna", "plan_name": "700700", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna", "plan_name": "700700_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Miscellaneous", "plan_name": "700720", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Miscellaneous", "plan_name": "700720_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Ppo Hmo", "plan_name": "701720", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Ppo Hmo", "plan_name": "701720_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Ms State Emplo", "plan_name": "401457", "standard_charge_percentage": 0.80, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Ms State Emplo", "plan_name": "401457_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Basic Pl", "plan_name": "400100", "standard_charge_percentage": 0.85, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Basic Pl", "plan_name": "400100_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Federal", "plan_name": "400110", "standard_charge_percentage": 0.85, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Federal", "plan_name": "400110_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." } ] } ] }, { "description": "Colectomy w/ileoanal anast", "code_information": [ { "code": "44157", "type": "CPT" } ], "standard_charges": [ { "gross_charge": 61714.85, "minimum": 49371.88, "maximum": 52457.62, "setting": "inpatient", "payers_information": [ { "payer_name": "Aetna", "plan_name": "700700", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna", "plan_name": "700700_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Miscellaneous", "plan_name": "700720", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Miscellaneous", "plan_name": "700720_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Ppo Hmo", "plan_name": "701720", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Ppo Hmo", "plan_name": "701720_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Ms State Emplo", "plan_name": "401457", "standard_charge_percentage": 0.80, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Ms State Emplo", "plan_name": "401457_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Basic Pl", "plan_name": "400100", "standard_charge_percentage": 0.85, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Basic Pl", "plan_name": "400100_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Federal", "plan_name": "400110", "standard_charge_percentage": 0.85, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Federal", "plan_name": "400110_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." } ] } ] }, { "description": "Colectomy w/neo-rectum pouch", "code_information": [ { "code": "44158", "type": "CPT" } ], "standard_charges": [ { "gross_charge": 61714.85, "minimum": 49371.88, "maximum": 52457.62, "setting": "inpatient", "payers_information": [ { "payer_name": "Aetna", "plan_name": "700700", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna", "plan_name": "700700_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Miscellaneous", "plan_name": "700720", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Miscellaneous", "plan_name": "700720_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Ppo Hmo", "plan_name": "701720", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Ppo Hmo", "plan_name": "701720_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Ms State Emplo", "plan_name": "401457", "standard_charge_percentage": 0.80, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Ms State Emplo", "plan_name": "401457_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Basic Pl", "plan_name": "400100", "standard_charge_percentage": 0.85, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Basic Pl", "plan_name": "400100_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Federal", "plan_name": "400110", "standard_charge_percentage": 0.85, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Federal", "plan_name": "400110_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." } ] } ] }, { "description": "Removal of colon", "code_information": [ { "code": "44160", "type": "CPT" } ], "standard_charges": [ { "gross_charge": 39283.17, "minimum": 31426.54, "maximum": 33390.69, "setting": "inpatient", "payers_information": [ { "payer_name": "Aetna", "plan_name": "700700", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna", "plan_name": "700700_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Miscellaneous", "plan_name": "700720", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Miscellaneous", "plan_name": "700720_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Ppo Hmo", "plan_name": "701720", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Ppo Hmo", "plan_name": "701720_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Ms State Emplo", "plan_name": "401457", "standard_charge_percentage": 0.80, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Ms State Emplo", "plan_name": "401457_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Basic Pl", "plan_name": "400100", "standard_charge_percentage": 0.85, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Basic Pl", "plan_name": "400100_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Federal", "plan_name": "400110", "standard_charge_percentage": 0.85, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Federal", "plan_name": "400110_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." } ] } ] }, { "description": "Lap colostomy", "code_information": [ { "code": "44188", "type": "CPT" } ], "standard_charges": [ { "gross_charge": 38439.75, "minimum": 30751.80, "maximum": 32673.79, "setting": "inpatient", "payers_information": [ { "payer_name": "Aetna", "plan_name": "700700", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna", "plan_name": "700700_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Miscellaneous", "plan_name": "700720", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Miscellaneous", "plan_name": "700720_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Ppo Hmo", "plan_name": "701720", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Ppo Hmo", "plan_name": "701720_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Ms State Emplo", "plan_name": "401457", "standard_charge_percentage": 0.80, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Ms State Emplo", "plan_name": "401457_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Basic Pl", "plan_name": "400100", "standard_charge_percentage": 0.85, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Basic Pl", "plan_name": "400100_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Federal", "plan_name": "400110", "standard_charge_percentage": 0.85, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Federal", "plan_name": "400110_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." } ] } ] }, { "description": "Lap enterectomy", "code_information": [ { "code": "44202", "type": "CPT" } ], "standard_charges": [ { "gross_charge": 44001.58, "minimum": 35201.26, "maximum": 37401.34, "setting": "inpatient", "payers_information": [ { "payer_name": "Aetna", "plan_name": "700700", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna", "plan_name": "700700_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Miscellaneous", "plan_name": "700720", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Miscellaneous", "plan_name": "700720_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Ppo Hmo", "plan_name": "701720", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Ppo Hmo", "plan_name": "701720_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Ms State Emplo", "plan_name": "401457", "standard_charge_percentage": 0.80, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Ms State Emplo", "plan_name": "401457_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Basic Pl", "plan_name": "400100", "standard_charge_percentage": 0.85, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Basic Pl", "plan_name": "400100_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Federal", "plan_name": "400110", "standard_charge_percentage": 0.85, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Federal", "plan_name": "400110_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." } ] } ] }, { "description": "Lap resect s/intestine addl", "code_information": [ { "code": "44203", "type": "CPT" } ], "standard_charges": [ { "gross_charge": 44001.58, "minimum": 35201.26, "maximum": 37401.34, "setting": "inpatient", "payers_information": [ { "payer_name": "Aetna", "plan_name": "700700", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna", "plan_name": "700700_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Miscellaneous", "plan_name": "700720", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Miscellaneous", "plan_name": "700720_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Ppo Hmo", "plan_name": "701720", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Ppo Hmo", "plan_name": "701720_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Ms State Emplo", "plan_name": "401457", "standard_charge_percentage": 0.80, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Ms State Emplo", "plan_name": "401457_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Basic Pl", "plan_name": "400100", "standard_charge_percentage": 0.85, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Basic Pl", "plan_name": "400100_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Federal", "plan_name": "400110", "standard_charge_percentage": 0.85, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Federal", "plan_name": "400110_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." } ] } ] }, { "description": "Lap colectomy part w/ileum", "code_information": [ { "code": "44205", "type": "CPT" } ], "standard_charges": [ { "gross_charge": 44001.58, "minimum": 35201.26, "maximum": 37401.34, "setting": "inpatient", "payers_information": [ { "payer_name": "Aetna", "plan_name": "700700", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna", "plan_name": "700700_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Miscellaneous", "plan_name": "700720", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Miscellaneous", "plan_name": "700720_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Ppo Hmo", "plan_name": "701720", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Ppo Hmo", "plan_name": "701720_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Ms State Emplo", "plan_name": "401457", "standard_charge_percentage": 0.80, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Ms State Emplo", "plan_name": "401457_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Basic Pl", "plan_name": "400100", "standard_charge_percentage": 0.85, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Basic Pl", "plan_name": "400100_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Federal", "plan_name": "400110", "standard_charge_percentage": 0.85, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Federal", "plan_name": "400110_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." } ] } ] }, { "description": "Lap part colectomy w/stoma", "code_information": [ { "code": "44206", "type": "CPT" } ], "standard_charges": [ { "gross_charge": 38439.75, "minimum": 30751.80, "maximum": 32673.79, "setting": "inpatient", "payers_information": [ { "payer_name": "Aetna", "plan_name": "700700", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna", "plan_name": "700700_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Miscellaneous", "plan_name": "700720", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Miscellaneous", "plan_name": "700720_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Ppo Hmo", "plan_name": "701720", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Ppo Hmo", "plan_name": "701720_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Ms State Emplo", "plan_name": "401457", "standard_charge_percentage": 0.80, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Ms State Emplo", "plan_name": "401457_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Basic Pl", "plan_name": "400100", "standard_charge_percentage": 0.85, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Basic Pl", "plan_name": "400100_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Federal", "plan_name": "400110", "standard_charge_percentage": 0.85, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Federal", "plan_name": "400110_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." } ] } ] }, { "description": "L colectomy/coloproctostomy", "code_information": [ { "code": "44207", "type": "CPT" } ], "standard_charges": [ { "gross_charge": 38439.75, "minimum": 30751.80, "maximum": 32673.79, "setting": "inpatient", "payers_information": [ { "payer_name": "Aetna", "plan_name": "700700", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna", "plan_name": "700700_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Miscellaneous", "plan_name": "700720", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Miscellaneous", "plan_name": "700720_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Ppo Hmo", "plan_name": "701720", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Ppo Hmo", "plan_name": "701720_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Ms State Emplo", "plan_name": "401457", "standard_charge_percentage": 0.80, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Ms State Emplo", "plan_name": "401457_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Basic Pl", "plan_name": "400100", "standard_charge_percentage": 0.85, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Basic Pl", "plan_name": "400100_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Federal", "plan_name": "400110", "standard_charge_percentage": 0.85, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Federal", "plan_name": "400110_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." } ] } ] }, { "description": "L colectomy/coloproctostomy", "code_information": [ { "code": "44208", "type": "CPT" } ], "standard_charges": [ { "gross_charge": 38439.75, "minimum": 30751.80, "maximum": 32673.79, "setting": "inpatient", "payers_information": [ { "payer_name": "Aetna", "plan_name": "700700", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna", "plan_name": "700700_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Miscellaneous", "plan_name": "700720", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Miscellaneous", "plan_name": "700720_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Ppo Hmo", "plan_name": "701720", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Ppo Hmo", "plan_name": "701720_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Ms State Emplo", "plan_name": "401457", "standard_charge_percentage": 0.80, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Ms State Emplo", "plan_name": "401457_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Basic Pl", "plan_name": "400100", "standard_charge_percentage": 0.85, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Basic Pl", "plan_name": "400100_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Federal", "plan_name": "400110", "standard_charge_percentage": 0.85, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Federal", "plan_name": "400110_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." } ] } ] }, { "description": "Laparo total proctocolectomy", "code_information": [ { "code": "44210", "type": "CPT" } ], "standard_charges": [ { "gross_charge": 38439.75, "minimum": 30751.80, "maximum": 32673.79, "setting": "inpatient", "payers_information": [ { "payer_name": "Aetna", "plan_name": "700700", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna", "plan_name": "700700_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Miscellaneous", "plan_name": "700720", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Miscellaneous", "plan_name": "700720_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Ppo Hmo", "plan_name": "701720", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Ppo Hmo", "plan_name": "701720_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Ms State Emplo", "plan_name": "401457", "standard_charge_percentage": 0.80, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Ms State Emplo", "plan_name": "401457_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Basic Pl", "plan_name": "400100", "standard_charge_percentage": 0.85, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Basic Pl", "plan_name": "400100_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Federal", "plan_name": "400110", "standard_charge_percentage": 0.85, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Federal", "plan_name": "400110_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." } ] } ] }, { "description": "Lap close enterostomy", "code_information": [ { "code": "44227", "type": "CPT" } ], "standard_charges": [ { "gross_charge": 66807.43, "minimum": 53445.94, "maximum": 56786.32, "setting": "inpatient", "payers_information": [ { "payer_name": "Aetna", "plan_name": "700700", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna", "plan_name": "700700_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Miscellaneous", "plan_name": "700720", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Miscellaneous", "plan_name": "700720_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Ppo Hmo", "plan_name": "701720", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Ppo Hmo", "plan_name": "701720_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Ms State Emplo", "plan_name": "401457", "standard_charge_percentage": 0.80, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Ms State Emplo", "plan_name": "401457_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Basic Pl", "plan_name": "400100", "standard_charge_percentage": 0.85, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Basic Pl", "plan_name": "400100_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Federal", "plan_name": "400110", "standard_charge_percentage": 0.85, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Federal", "plan_name": "400110_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." } ] } ] }, { "description": "Laparoscope proc intestine", "code_information": [ { "code": "44238", "type": "CPT" } ], "standard_charges": [ { "gross_charge": 33732.94, "minimum": 5344.68, "maximum": 28673.00, "setting": "inpatient", "payers_information": [ { "payer_name": "Aarp", "plan_name": "500102", "standard_charge_dollar": 5344.68, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna", "plan_name": "700700", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna", "plan_name": "700700_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Mcare Ffs 6005", "plan_name": "700703", "standard_charge_dollar": 5344.68, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Miscellaneous", "plan_name": "700720", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Miscellaneous", "plan_name": "700720_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Ppo Hmo", "plan_name": "701720", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Ppo Hmo", "plan_name": "701720_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Ambetter 68069", "plan_name": "500516", "standard_charge_dollar": 5344.68, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Ms State Emplo", "plan_name": "401457", "standard_charge_percentage": 0.80, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Ms State Emplo", "plan_name": "401457_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Basic Pl", "plan_name": "400100", "standard_charge_percentage": 0.85, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Basic Pl", "plan_name": "400100_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Federal", "plan_name": "400110", "standard_charge_percentage": 0.85, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Federal", "plan_name": "400110_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Cigna Healthsprings Ffs", "plan_name": "500064", "standard_charge_dollar": 5344.68, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Conseco", "plan_name": "500302", "standard_charge_dollar": 5344.68, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Humana Ffs 61101", "plan_name": "500006", "standard_charge_dollar": 5344.68, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Medicare A", "plan_name": "100100", "standard_charge_dollar": 5344.68, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Medicare A", "plan_name": "100500", "standard_charge_dollar": 5344.68, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Medicare Part B Only", "plan_name": "100300", "standard_charge_dollar": 5344.68, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Medicare Railroad", "plan_name": "100103", "standard_charge_dollar": 5344.68, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Ms Physicians Care N", "plan_name": "714210", "standard_charge_dollar": 6680.85, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Peoples Hlth Ffs 72126", "plan_name": "500019", "standard_charge_dollar": 5344.68, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Uhc/Secure Horizons", "plan_name": "500449", "standard_charge_dollar": 5344.68, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "United Health Care/", "plan_name": "500292", "standard_charge_dollar": 6039.49, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "United Healthcare", "plan_name": "750104", "standard_charge_dollar": 6039.49, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "United Healthcare Ba", "plan_name": "750090", "standard_charge_dollar": 6039.49, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "United Healthcare Me", "plan_name": "501310", "standard_charge_dollar": 5344.68, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Windsor Mcare Extra", "plan_name": "500778", "standard_charge_dollar": 5344.68, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." } ] } ] }, { "description": "Colostomy", "code_information": [ { "code": "44320", "type": "CPT" } ], "standard_charges": [ { "gross_charge": 37661.55, "minimum": 30129.24, "maximum": 32012.32, "setting": "inpatient", "payers_information": [ { "payer_name": "Aetna", "plan_name": "700700", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna", "plan_name": "700700_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Miscellaneous", "plan_name": "700720", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Miscellaneous", "plan_name": "700720_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Ppo Hmo", "plan_name": "701720", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Ppo Hmo", "plan_name": "701720_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Ms State Emplo", "plan_name": "401457", "standard_charge_percentage": 0.80, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Ms State Emplo", "plan_name": "401457_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Basic Pl", "plan_name": "400100", "standard_charge_percentage": 0.85, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Basic Pl", "plan_name": "400100_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Federal", "plan_name": "400110", "standard_charge_percentage": 0.85, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Federal", "plan_name": "400110_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." } ] } ] }, { "description": "Colostomy with biopsies", "code_information": [ { "code": "44322", "type": "CPT" } ], "standard_charges": [ { "gross_charge": 42183.08, "minimum": 33746.46, "maximum": 35855.62, "setting": "inpatient", "payers_information": [ { "payer_name": "Aetna", "plan_name": "700700", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna", "plan_name": "700700_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Miscellaneous", "plan_name": "700720", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Miscellaneous", "plan_name": "700720_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Ppo Hmo", "plan_name": "701720", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Ppo Hmo", "plan_name": "701720_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Ms State Emplo", "plan_name": "401457", "standard_charge_percentage": 0.80, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Ms State Emplo", "plan_name": "401457_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Basic Pl", "plan_name": "400100", "standard_charge_percentage": 0.85, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Basic Pl", "plan_name": "400100_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Federal", "plan_name": "400110", "standard_charge_percentage": 0.85, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Federal", "plan_name": "400110_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." } ] } ] }, { "description": "Revision of colostomy", "code_information": [ { "code": "44345", "type": "CPT" } ], "standard_charges": [ { "gross_charge": 38116.53, "minimum": 30493.22, "maximum": 32399.05, "setting": "inpatient", "payers_information": [ { "payer_name": "Aetna", "plan_name": "700700", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna", "plan_name": "700700_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Miscellaneous", "plan_name": "700720", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Miscellaneous", "plan_name": "700720_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Ppo Hmo", "plan_name": "701720", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Ppo Hmo", "plan_name": "701720_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Ms State Emplo", "plan_name": "401457", "standard_charge_percentage": 0.80, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Ms State Emplo", "plan_name": "401457_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Basic Pl", "plan_name": "400100", "standard_charge_percentage": 0.85, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Basic Pl", "plan_name": "400100_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Federal", "plan_name": "400110", "standard_charge_percentage": 0.85, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Federal", "plan_name": "400110_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." } ] } ] }, { "description": "Revision of colostomy", "code_information": [ { "code": "44346", "type": "CPT" } ], "standard_charges": [ { "gross_charge": 38116.53, "minimum": 30493.22, "maximum": 32399.05, "setting": "inpatient", "payers_information": [ { "payer_name": "Aetna", "plan_name": "700700", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna", "plan_name": "700700_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Miscellaneous", "plan_name": "700720", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Miscellaneous", "plan_name": "700720_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Ppo Hmo", "plan_name": "701720", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Ppo Hmo", "plan_name": "701720_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Ms State Emplo", "plan_name": "401457", "standard_charge_percentage": 0.80, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Ms State Emplo", "plan_name": "401457_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Basic Pl", "plan_name": "400100", "standard_charge_percentage": 0.85, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Basic Pl", "plan_name": "400100_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Federal", "plan_name": "400110", "standard_charge_percentage": 0.85, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Federal", "plan_name": "400110_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." } ] } ] }, { "description": "Small bowel endoscopy", "code_information": [ { "code": "44360", "type": "CPT" } ], "standard_charges": [ { "gross_charge": 25703.80, "minimum": 1737.77, "maximum": 21848.23, "setting": "inpatient", "payers_information": [ { "payer_name": "Aarp", "plan_name": "500102", "standard_charge_dollar": 1737.77, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna", "plan_name": "700700", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna", "plan_name": "700700_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Mcare Ffs 6005", "plan_name": "700703", "standard_charge_dollar": 1737.77, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Miscellaneous", "plan_name": "700720", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Miscellaneous", "plan_name": "700720_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Ppo Hmo", "plan_name": "701720", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Ppo Hmo", "plan_name": "701720_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Ambetter 68069", "plan_name": "500516", "standard_charge_dollar": 1737.77, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Ms State Emplo", "plan_name": "401457", "standard_charge_percentage": 0.80, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Ms State Emplo", "plan_name": "401457_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Basic Pl", "plan_name": "400100", "standard_charge_percentage": 0.85, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Basic Pl", "plan_name": "400100_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Federal", "plan_name": "400110", "standard_charge_percentage": 0.85, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Federal", "plan_name": "400110_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Cigna Healthsprings Ffs", "plan_name": "500064", "standard_charge_dollar": 1737.77, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Conseco", "plan_name": "500302", "standard_charge_dollar": 1737.77, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Humana Ffs 61101", "plan_name": "500006", "standard_charge_dollar": 1737.77, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Medicare A", "plan_name": "100100", "standard_charge_dollar": 1737.77, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Medicare A", "plan_name": "100500", "standard_charge_dollar": 1737.77, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Medicare Part B Only", "plan_name": "100300", "standard_charge_dollar": 1737.77, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Medicare Railroad", "plan_name": "100103", "standard_charge_dollar": 1737.77, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Ms Physicians Care N", "plan_name": "714210", "standard_charge_dollar": 2172.22, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Peoples Hlth Ffs 72126", "plan_name": "500019", "standard_charge_dollar": 1737.77, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Uhc/Secure Horizons", "plan_name": "500449", "standard_charge_dollar": 1737.77, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "United Health Care/", "plan_name": "500292", "standard_charge_dollar": 1963.68, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "United Healthcare", "plan_name": "750104", "standard_charge_dollar": 1963.68, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "United Healthcare Ba", "plan_name": "750090", "standard_charge_dollar": 1963.68, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "United Healthcare Me", "plan_name": "501310", "standard_charge_dollar": 1737.77, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Windsor Mcare Extra", "plan_name": "500778", "standard_charge_dollar": 1737.77, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." } ] } ] }, { "description": "Small bowel endoscopy", "code_information": [ { "code": "44373", "type": "CPT" } ], "standard_charges": [ { "gross_charge": 19572.97, "minimum": 1737.77, "maximum": 16637.02, "setting": "inpatient", "payers_information": [ { "payer_name": "Aarp", "plan_name": "500102", "standard_charge_dollar": 1737.77, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna", "plan_name": "700700", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna", "plan_name": "700700_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Mcare Ffs 6005", "plan_name": "700703", "standard_charge_dollar": 1737.77, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Miscellaneous", "plan_name": "700720", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Miscellaneous", "plan_name": "700720_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Ppo Hmo", "plan_name": "701720", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Ppo Hmo", "plan_name": "701720_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Ambetter 68069", "plan_name": "500516", "standard_charge_dollar": 1737.77, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Ms State Emplo", "plan_name": "401457", "standard_charge_percentage": 0.80, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Ms State Emplo", "plan_name": "401457_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Basic Pl", "plan_name": "400100", "standard_charge_percentage": 0.85, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Basic Pl", "plan_name": "400100_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Federal", "plan_name": "400110", "standard_charge_percentage": 0.85, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Federal", "plan_name": "400110_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Cigna Healthsprings Ffs", "plan_name": "500064", "standard_charge_dollar": 1737.77, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Conseco", "plan_name": "500302", "standard_charge_dollar": 1737.77, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Humana Ffs 61101", "plan_name": "500006", "standard_charge_dollar": 1737.77, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Medicare A", "plan_name": "100100", "standard_charge_dollar": 1737.77, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Medicare A", "plan_name": "100500", "standard_charge_dollar": 1737.77, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Medicare Part B Only", "plan_name": "100300", "standard_charge_dollar": 1737.77, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Medicare Railroad", "plan_name": "100103", "standard_charge_dollar": 1737.77, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Ms Physicians Care N", "plan_name": "714210", "standard_charge_dollar": 2172.22, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Peoples Hlth Ffs 72126", "plan_name": "500019", "standard_charge_dollar": 1737.77, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Uhc/Secure Horizons", "plan_name": "500449", "standard_charge_dollar": 1737.77, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "United Health Care/", "plan_name": "500292", "standard_charge_dollar": 1963.68, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "United Healthcare", "plan_name": "750104", "standard_charge_dollar": 1963.68, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "United Healthcare Ba", "plan_name": "750090", "standard_charge_dollar": 1963.68, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "United Healthcare Me", "plan_name": "501310", "standard_charge_dollar": 1737.77, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Windsor Mcare Extra", "plan_name": "500778", "standard_charge_dollar": 1737.77, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." } ] } ] }, { "description": "Small bowel endoscopy", "code_information": [ { "code": "44376", "type": "CPT" } ], "standard_charges": [ { "gross_charge": 25364.12, "minimum": 1737.77, "maximum": 21559.50, "setting": "inpatient", "payers_information": [ { "payer_name": "Aarp", "plan_name": "500102", "standard_charge_dollar": 1737.77, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna", "plan_name": "700700", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna", "plan_name": "700700_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Mcare Ffs 6005", "plan_name": "700703", "standard_charge_dollar": 1737.77, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Miscellaneous", "plan_name": "700720", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Miscellaneous", "plan_name": "700720_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Ppo Hmo", "plan_name": "701720", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Ppo Hmo", "plan_name": "701720_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Ambetter 68069", "plan_name": "500516", "standard_charge_dollar": 1737.77, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Ms State Emplo", "plan_name": "401457", "standard_charge_percentage": 0.80, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Ms State Emplo", "plan_name": "401457_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Basic Pl", "plan_name": "400100", "standard_charge_percentage": 0.85, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Basic Pl", "plan_name": "400100_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Federal", "plan_name": "400110", "standard_charge_percentage": 0.85, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Federal", "plan_name": "400110_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Cigna Healthsprings Ffs", "plan_name": "500064", "standard_charge_dollar": 1737.77, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Conseco", "plan_name": "500302", "standard_charge_dollar": 1737.77, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Humana Ffs 61101", "plan_name": "500006", "standard_charge_dollar": 1737.77, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Medicare A", "plan_name": "100100", "standard_charge_dollar": 1737.77, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Medicare A", "plan_name": "100500", "standard_charge_dollar": 1737.77, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Medicare Part B Only", "plan_name": "100300", "standard_charge_dollar": 1737.77, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Medicare Railroad", "plan_name": "100103", "standard_charge_dollar": 1737.77, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Ms Physicians Care N", "plan_name": "714210", "standard_charge_dollar": 2172.22, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Peoples Hlth Ffs 72126", "plan_name": "500019", "standard_charge_dollar": 1737.77, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Uhc/Secure Horizons", "plan_name": "500449", "standard_charge_dollar": 1737.77, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "United Health Care/", "plan_name": "500292", "standard_charge_dollar": 1963.68, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "United Healthcare", "plan_name": "750104", "standard_charge_dollar": 1963.68, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "United Healthcare Ba", "plan_name": "750090", "standard_charge_dollar": 1963.68, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "United Healthcare Me", "plan_name": "501310", "standard_charge_dollar": 1737.77, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Windsor Mcare Extra", "plan_name": "500778", "standard_charge_dollar": 1737.77, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." } ] } ] }, { "description": "Small bowel endoscopy br/wa", "code_information": [ { "code": "44380", "type": "CPT" } ], "standard_charges": [ { "gross_charge": 25703.80, "minimum": 858.87, "maximum": 21848.23, "setting": "inpatient", "payers_information": [ { "payer_name": "Aarp", "plan_name": "500102", "standard_charge_dollar": 858.87, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna", "plan_name": "700700", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna", "plan_name": "700700_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Mcare Ffs 6005", "plan_name": "700703", "standard_charge_dollar": 858.87, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Miscellaneous", "plan_name": "700720", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Miscellaneous", "plan_name": "700720_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Ppo Hmo", "plan_name": "701720", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Ppo Hmo", "plan_name": "701720_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Ambetter 68069", "plan_name": "500516", "standard_charge_dollar": 858.87, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Ms State Emplo", "plan_name": "401457", "standard_charge_percentage": 0.80, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Ms State Emplo", "plan_name": "401457_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Basic Pl", "plan_name": "400100", "standard_charge_percentage": 0.85, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Basic Pl", "plan_name": "400100_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Federal", "plan_name": "400110", "standard_charge_percentage": 0.85, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Federal", "plan_name": "400110_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Cigna Healthsprings Ffs", "plan_name": "500064", "standard_charge_dollar": 858.87, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Conseco", "plan_name": "500302", "standard_charge_dollar": 858.87, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Humana Ffs 61101", "plan_name": "500006", "standard_charge_dollar": 858.87, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Medicare A", "plan_name": "100100", "standard_charge_dollar": 858.87, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Medicare A", "plan_name": "100500", "standard_charge_dollar": 858.87, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Medicare Part B Only", "plan_name": "100300", "standard_charge_dollar": 858.87, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Medicare Railroad", "plan_name": "100103", "standard_charge_dollar": 858.87, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Ms Physicians Care N", "plan_name": "714210", "standard_charge_dollar": 1073.59, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Peoples Hlth Ffs 72126", "plan_name": "500019", "standard_charge_dollar": 858.87, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Uhc/Secure Horizons", "plan_name": "500449", "standard_charge_dollar": 858.87, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "United Health Care/", "plan_name": "500292", "standard_charge_dollar": 970.52, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "United Healthcare", "plan_name": "750104", "standard_charge_dollar": 970.52, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "United Healthcare Ba", "plan_name": "750090", "standard_charge_dollar": 970.52, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "United Healthcare Me", "plan_name": "501310", "standard_charge_dollar": 858.87, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Windsor Mcare Extra", "plan_name": "500778", "standard_charge_dollar": 858.87, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." } ] } ] }, { "description": "Endoscopy of bowel pouch", "code_information": [ { "code": "44385", "type": "CPT" } ], "standard_charges": [ { "gross_charge": 25703.80, "minimum": 835.19, "maximum": 21848.23, "setting": "inpatient", "payers_information": [ { "payer_name": "Aarp", "plan_name": "500102", "standard_charge_dollar": 835.19, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna", "plan_name": "700700", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna", "plan_name": "700700_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Mcare Ffs 6005", "plan_name": "700703", "standard_charge_dollar": 835.19, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Miscellaneous", "plan_name": "700720", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Miscellaneous", "plan_name": "700720_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Ppo Hmo", "plan_name": "701720", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Ppo Hmo", "plan_name": "701720_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Ambetter 68069", "plan_name": "500516", "standard_charge_dollar": 835.19, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Ms State Emplo", "plan_name": "401457", "standard_charge_percentage": 0.80, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Ms State Emplo", "plan_name": "401457_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Basic Pl", "plan_name": "400100", "standard_charge_percentage": 0.85, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Basic Pl", "plan_name": "400100_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Federal", "plan_name": "400110", "standard_charge_percentage": 0.85, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Federal", "plan_name": "400110_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Cigna Healthsprings Ffs", "plan_name": "500064", "standard_charge_dollar": 835.19, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Conseco", "plan_name": "500302", "standard_charge_dollar": 835.19, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Humana Ffs 61101", "plan_name": "500006", "standard_charge_dollar": 835.19, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Medicare A", "plan_name": "100100", "standard_charge_dollar": 835.19, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Medicare A", "plan_name": "100500", "standard_charge_dollar": 835.19, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Medicare Part B Only", "plan_name": "100300", "standard_charge_dollar": 835.19, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Medicare Railroad", "plan_name": "100103", "standard_charge_dollar": 835.19, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Ms Physicians Care N", "plan_name": "714210", "standard_charge_dollar": 1043.99, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Peoples Hlth Ffs 72126", "plan_name": "500019", "standard_charge_dollar": 835.19, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Uhc/Secure Horizons", "plan_name": "500449", "standard_charge_dollar": 835.19, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "United Health Care/", "plan_name": "500292", "standard_charge_dollar": 943.76, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "United Healthcare", "plan_name": "750104", "standard_charge_dollar": 943.76, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "United Healthcare Ba", "plan_name": "750090", "standard_charge_dollar": 943.76, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "United Healthcare Me", "plan_name": "501310", "standard_charge_dollar": 835.19, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Windsor Mcare Extra", "plan_name": "500778", "standard_charge_dollar": 835.19, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." } ] } ] }, { "description": "Colonoscopy thru stoma spx", "code_information": [ { "code": "44388", "type": "CPT" } ], "standard_charges": [ { "gross_charge": 23731.77, "minimum": 835.19, "maximum": 20172.00, "setting": "inpatient", "payers_information": [ { "payer_name": "Aarp", "plan_name": "500102", "standard_charge_dollar": 835.19, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna", "plan_name": "700700", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna", "plan_name": "700700_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Mcare Ffs 6005", "plan_name": "700703", "standard_charge_dollar": 835.19, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Miscellaneous", "plan_name": "700720", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Miscellaneous", "plan_name": "700720_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Ppo Hmo", "plan_name": "701720", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Ppo Hmo", "plan_name": "701720_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Ambetter 68069", "plan_name": "500516", "standard_charge_dollar": 835.19, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Ms State Emplo", "plan_name": "401457", "standard_charge_percentage": 0.80, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Ms State Emplo", "plan_name": "401457_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Basic Pl", "plan_name": "400100", "standard_charge_percentage": 0.85, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Basic Pl", "plan_name": "400100_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Federal", "plan_name": "400110", "standard_charge_percentage": 0.85, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Federal", "plan_name": "400110_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Cigna Healthsprings Ffs", "plan_name": "500064", "standard_charge_dollar": 835.19, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Conseco", "plan_name": "500302", "standard_charge_dollar": 835.19, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Humana Ffs 61101", "plan_name": "500006", "standard_charge_dollar": 835.19, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Medicare A", "plan_name": "100100", "standard_charge_dollar": 835.19, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Medicare A", "plan_name": "100500", "standard_charge_dollar": 835.19, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Medicare Part B Only", "plan_name": "100300", "standard_charge_dollar": 835.19, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Medicare Railroad", "plan_name": "100103", "standard_charge_dollar": 835.19, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Ms Physicians Care N", "plan_name": "714210", "standard_charge_dollar": 1043.99, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Peoples Hlth Ffs 72126", "plan_name": "500019", "standard_charge_dollar": 835.19, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Uhc/Secure Horizons", "plan_name": "500449", "standard_charge_dollar": 835.19, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "United Health Care/", "plan_name": "500292", "standard_charge_dollar": 943.76, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "United Healthcare", "plan_name": "750104", "standard_charge_dollar": 943.76, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "United Healthcare Ba", "plan_name": "750090", "standard_charge_dollar": 943.76, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "United Healthcare Me", "plan_name": "501310", "standard_charge_dollar": 835.19, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Windsor Mcare Extra", "plan_name": "500778", "standard_charge_dollar": 835.19, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." } ] } ] }, { "description": "Colonoscopy with biopsy", "code_information": [ { "code": "44389", "type": "CPT" } ], "standard_charges": [ { "gross_charge": 33056.51, "minimum": 1080.12, "maximum": 28098.03, "setting": "inpatient", "payers_information": [ { "payer_name": "Aarp", "plan_name": "500102", "standard_charge_dollar": 1080.12, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna", "plan_name": "700700", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna", "plan_name": "700700_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Mcare Ffs 6005", "plan_name": "700703", "standard_charge_dollar": 1080.12, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Miscellaneous", "plan_name": "700720", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Miscellaneous", "plan_name": "700720_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Ppo Hmo", "plan_name": "701720", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Ppo Hmo", "plan_name": "701720_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Ambetter 68069", "plan_name": "500516", "standard_charge_dollar": 1080.12, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Ms State Emplo", "plan_name": "401457", "standard_charge_percentage": 0.80, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Ms State Emplo", "plan_name": "401457_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Basic Pl", "plan_name": "400100", "standard_charge_percentage": 0.85, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Basic Pl", "plan_name": "400100_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Federal", "plan_name": "400110", "standard_charge_percentage": 0.85, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Federal", "plan_name": "400110_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Cigna Healthsprings Ffs", "plan_name": "500064", "standard_charge_dollar": 1080.12, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Conseco", "plan_name": "500302", "standard_charge_dollar": 1080.12, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Humana Ffs 61101", "plan_name": "500006", "standard_charge_dollar": 1080.12, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Medicare A", "plan_name": "100100", "standard_charge_dollar": 1080.12, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Medicare A", "plan_name": "100500", "standard_charge_dollar": 1080.12, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Medicare Part B Only", "plan_name": "100300", "standard_charge_dollar": 1080.12, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Medicare Railroad", "plan_name": "100103", "standard_charge_dollar": 1080.12, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Ms Physicians Care N", "plan_name": "714210", "standard_charge_dollar": 1350.15, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Peoples Hlth Ffs 72126", "plan_name": "500019", "standard_charge_dollar": 1080.12, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Uhc/Secure Horizons", "plan_name": "500449", "standard_charge_dollar": 1080.12, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "United Health Care/", "plan_name": "500292", "standard_charge_dollar": 1220.53, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "United Healthcare", "plan_name": "750104", "standard_charge_dollar": 1220.53, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "United Healthcare Ba", "plan_name": "750090", "standard_charge_dollar": 1220.53, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "United Healthcare Me", "plan_name": "501310", "standard_charge_dollar": 1080.12, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Windsor Mcare Extra", "plan_name": "500778", "standard_charge_dollar": 1080.12, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." } ] } ] }, { "description": "Colonoscopy & polypectomy", "code_information": [ { "code": "44392", "type": "CPT" } ], "standard_charges": [ { "gross_charge": 25526.85, "minimum": 1080.12, "maximum": 21697.82, "setting": "inpatient", "payers_information": [ { "payer_name": "Aarp", "plan_name": "500102", "standard_charge_dollar": 1080.12, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna", "plan_name": "700700", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna", "plan_name": "700700_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Mcare Ffs 6005", "plan_name": "700703", "standard_charge_dollar": 1080.12, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Miscellaneous", "plan_name": "700720", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Miscellaneous", "plan_name": "700720_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Ppo Hmo", "plan_name": "701720", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Ppo Hmo", "plan_name": "701720_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Ambetter 68069", "plan_name": "500516", "standard_charge_dollar": 1080.12, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Ms State Emplo", "plan_name": "401457", "standard_charge_percentage": 0.80, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Ms State Emplo", "plan_name": "401457_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Basic Pl", "plan_name": "400100", "standard_charge_percentage": 0.85, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Basic Pl", "plan_name": "400100_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Federal", "plan_name": "400110", "standard_charge_percentage": 0.85, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Federal", "plan_name": "400110_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Cigna Healthsprings Ffs", "plan_name": "500064", "standard_charge_dollar": 1080.12, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Conseco", "plan_name": "500302", "standard_charge_dollar": 1080.12, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Humana Ffs 61101", "plan_name": "500006", "standard_charge_dollar": 1080.12, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Medicare A", "plan_name": "100100", "standard_charge_dollar": 1080.12, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Medicare A", "plan_name": "100500", "standard_charge_dollar": 1080.12, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Medicare Part B Only", "plan_name": "100300", "standard_charge_dollar": 1080.12, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Medicare Railroad", "plan_name": "100103", "standard_charge_dollar": 1080.12, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Ms Physicians Care N", "plan_name": "714210", "standard_charge_dollar": 1350.15, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Peoples Hlth Ffs 72126", "plan_name": "500019", "standard_charge_dollar": 1080.12, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Uhc/Secure Horizons", "plan_name": "500449", "standard_charge_dollar": 1080.12, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "United Health Care/", "plan_name": "500292", "standard_charge_dollar": 1220.53, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "United Healthcare", "plan_name": "750104", "standard_charge_dollar": 1220.53, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "United Healthcare Ba", "plan_name": "750090", "standard_charge_dollar": 1220.53, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "United Healthcare Me", "plan_name": "501310", "standard_charge_dollar": 1080.12, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Windsor Mcare Extra", "plan_name": "500778", "standard_charge_dollar": 1080.12, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." } ] } ] }, { "description": "Colonoscopy w/snare", "code_information": [ { "code": "44394", "type": "CPT" } ], "standard_charges": [ { "gross_charge": 25526.85, "minimum": 1080.12, "maximum": 21697.82, "setting": "inpatient", "payers_information": [ { "payer_name": "Aarp", "plan_name": "500102", "standard_charge_dollar": 1080.12, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna", "plan_name": "700700", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna", "plan_name": "700700_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Mcare Ffs 6005", "plan_name": "700703", "standard_charge_dollar": 1080.12, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Miscellaneous", "plan_name": "700720", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Miscellaneous", "plan_name": "700720_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Ppo Hmo", "plan_name": "701720", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Ppo Hmo", "plan_name": "701720_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Ambetter 68069", "plan_name": "500516", "standard_charge_dollar": 1080.12, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Ms State Emplo", "plan_name": "401457", "standard_charge_percentage": 0.80, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Ms State Emplo", "plan_name": "401457_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Basic Pl", "plan_name": "400100", "standard_charge_percentage": 0.85, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Basic Pl", "plan_name": "400100_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Federal", "plan_name": "400110", "standard_charge_percentage": 0.85, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Federal", "plan_name": "400110_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Cigna Healthsprings Ffs", "plan_name": "500064", "standard_charge_dollar": 1080.12, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Conseco", "plan_name": "500302", "standard_charge_dollar": 1080.12, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Humana Ffs 61101", "plan_name": "500006", "standard_charge_dollar": 1080.12, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Medicare A", "plan_name": "100100", "standard_charge_dollar": 1080.12, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Medicare A", "plan_name": "100500", "standard_charge_dollar": 1080.12, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Medicare Part B Only", "plan_name": "100300", "standard_charge_dollar": 1080.12, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Medicare Railroad", "plan_name": "100103", "standard_charge_dollar": 1080.12, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Ms Physicians Care N", "plan_name": "714210", "standard_charge_dollar": 1350.15, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Peoples Hlth Ffs 72126", "plan_name": "500019", "standard_charge_dollar": 1080.12, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Uhc/Secure Horizons", "plan_name": "500449", "standard_charge_dollar": 1080.12, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "United Health Care/", "plan_name": "500292", "standard_charge_dollar": 1220.53, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "United Healthcare", "plan_name": "750104", "standard_charge_dollar": 1220.53, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "United Healthcare Ba", "plan_name": "750090", "standard_charge_dollar": 1220.53, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "United Healthcare Me", "plan_name": "501310", "standard_charge_dollar": 1080.12, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Windsor Mcare Extra", "plan_name": "500778", "standard_charge_dollar": 1080.12, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." } ] } ] }, { "description": "Colonoscopy w/resection", "code_information": [ { "code": "44403", "type": "CPT" } ], "standard_charges": [ { "gross_charge": 25526.85, "minimum": 338.08, "maximum": 1350.15, "setting": "inpatient", "payers_information": [ { "payer_name": "Aarp", "plan_name": "500102", "standard_charge_dollar": 1080.12, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna", "plan_name": "700700", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna", "plan_name": "700700_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Mcare Ffs 6005", "plan_name": "700703", "standard_charge_dollar": 1080.12, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Miscellaneous", "plan_name": "700720", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Miscellaneous", "plan_name": "700720_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Ppo Hmo", "plan_name": "701720", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Ppo Hmo", "plan_name": "701720_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Ambetter 68069", "plan_name": "500516", "standard_charge_dollar": 1080.12, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Ms State Emplo", "plan_name": "401457", "standard_charge_dollar": 338.08, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Ms State Emplo", "plan_name": "401457_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Basic Pl", "plan_name": "400100", "standard_charge_dollar": 338.08, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Basic Pl", "plan_name": "400100_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Federal", "plan_name": "400110", "standard_charge_dollar": 338.08, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Federal", "plan_name": "400110_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Cigna Healthsprings Ffs", "plan_name": "500064", "standard_charge_dollar": 1080.12, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Conseco", "plan_name": "500302", "standard_charge_dollar": 1080.12, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Humana Ffs 61101", "plan_name": "500006", "standard_charge_dollar": 1080.12, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Medicare A", "plan_name": "100100", "standard_charge_dollar": 1080.12, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Medicare A", "plan_name": "100500", "standard_charge_dollar": 1080.12, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Medicare Part B Only", "plan_name": "100300", "standard_charge_dollar": 1080.12, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Medicare Railroad", "plan_name": "100103", "standard_charge_dollar": 1080.12, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Ms Physicians Care N", "plan_name": "714210", "standard_charge_dollar": 1350.15, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Peoples Hlth Ffs 72126", "plan_name": "500019", "standard_charge_dollar": 1080.12, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Uhc/Secure Horizons", "plan_name": "500449", "standard_charge_dollar": 1080.12, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "United Health Care/", "plan_name": "500292", "standard_charge_dollar": 1220.53, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "United Healthcare", "plan_name": "750104", "standard_charge_dollar": 1220.53, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "United Healthcare Ba", "plan_name": "750090", "standard_charge_dollar": 1220.53, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "United Healthcare Me", "plan_name": "501310", "standard_charge_dollar": 1080.12, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Windsor Mcare Extra", "plan_name": "500778", "standard_charge_dollar": 1080.12, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." } ] } ] }, { "description": "Colonoscopy w/ultrasound", "code_information": [ { "code": "44406", "type": "CPT" } ], "standard_charges": [ { "gross_charge": 23731.77, "minimum": 255.37, "maximum": 1350.15, "setting": "inpatient", "payers_information": [ { "payer_name": "Aarp", "plan_name": "500102", "standard_charge_dollar": 1080.12, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna", "plan_name": "700700", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna", "plan_name": "700700_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Mcare Ffs 6005", "plan_name": "700703", "standard_charge_dollar": 1080.12, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Miscellaneous", "plan_name": "700720", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Miscellaneous", "plan_name": "700720_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Ppo Hmo", "plan_name": "701720", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Ppo Hmo", "plan_name": "701720_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Ambetter 68069", "plan_name": "500516", "standard_charge_dollar": 1080.12, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Ms State Emplo", "plan_name": "401457", "standard_charge_dollar": 255.37, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Ms State Emplo", "plan_name": "401457_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Basic Pl", "plan_name": "400100", "standard_charge_dollar": 255.37, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Basic Pl", "plan_name": "400100_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Federal", "plan_name": "400110", "standard_charge_dollar": 255.37, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Federal", "plan_name": "400110_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Cigna Healthsprings Ffs", "plan_name": "500064", "standard_charge_dollar": 1080.12, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Conseco", "plan_name": "500302", "standard_charge_dollar": 1080.12, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Humana Ffs 61101", "plan_name": "500006", "standard_charge_dollar": 1080.12, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Medicare A", "plan_name": "100100", "standard_charge_dollar": 1080.12, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Medicare A", "plan_name": "100500", "standard_charge_dollar": 1080.12, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Medicare Part B Only", "plan_name": "100300", "standard_charge_dollar": 1080.12, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Medicare Railroad", "plan_name": "100103", "standard_charge_dollar": 1080.12, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Ms Physicians Care N", "plan_name": "714210", "standard_charge_dollar": 1350.15, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Peoples Hlth Ffs 72126", "plan_name": "500019", "standard_charge_dollar": 1080.12, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Uhc/Secure Horizons", "plan_name": "500449", "standard_charge_dollar": 1080.12, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "United Health Care/", "plan_name": "500292", "standard_charge_dollar": 1220.53, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "United Healthcare", "plan_name": "750104", "standard_charge_dollar": 1220.53, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "United Healthcare Ba", "plan_name": "750090", "standard_charge_dollar": 1220.53, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "United Healthcare Me", "plan_name": "501310", "standard_charge_dollar": 1080.12, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Windsor Mcare Extra", "plan_name": "500778", "standard_charge_dollar": 1080.12, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." } ] } ] }, { "description": "Suture small intestine", "code_information": [ { "code": "44602", "type": "CPT" } ], "standard_charges": [ { "gross_charge": 34905.53, "minimum": 27924.42, "maximum": 29669.70, "setting": "inpatient", "payers_information": [ { "payer_name": "Aetna", "plan_name": "700700", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna", "plan_name": "700700_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Miscellaneous", "plan_name": "700720", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Miscellaneous", "plan_name": "700720_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Ppo Hmo", "plan_name": "701720", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Ppo Hmo", "plan_name": "701720_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Ms State Emplo", "plan_name": "401457", "standard_charge_percentage": 0.80, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Ms State Emplo", "plan_name": "401457_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Basic Pl", "plan_name": "400100", "standard_charge_percentage": 0.85, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Basic Pl", "plan_name": "400100_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Federal", "plan_name": "400110", "standard_charge_percentage": 0.85, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Federal", "plan_name": "400110_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." } ] } ] }, { "description": "Suture small intestine", "code_information": [ { "code": "44603", "type": "CPT" } ], "standard_charges": [ { "gross_charge": 34905.53, "minimum": 27924.42, "maximum": 29669.70, "setting": "inpatient", "payers_information": [ { "payer_name": "Aetna", "plan_name": "700700", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna", "plan_name": "700700_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Miscellaneous", "plan_name": "700720", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Miscellaneous", "plan_name": "700720_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Ppo Hmo", "plan_name": "701720", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Ppo Hmo", "plan_name": "701720_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Ms State Emplo", "plan_name": "401457", "standard_charge_percentage": 0.80, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Ms State Emplo", "plan_name": "401457_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Basic Pl", "plan_name": "400100", "standard_charge_percentage": 0.85, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Basic Pl", "plan_name": "400100_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Federal", "plan_name": "400110", "standard_charge_percentage": 0.85, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Federal", "plan_name": "400110_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." } ] } ] }, { "description": "Repair of bowel lesion", "code_information": [ { "code": "44605", "type": "CPT" } ], "standard_charges": [ { "gross_charge": 38116.53, "minimum": 30493.22, "maximum": 32399.05, "setting": "inpatient", "payers_information": [ { "payer_name": "Aetna", "plan_name": "700700", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna", "plan_name": "700700_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Miscellaneous", "plan_name": "700720", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Miscellaneous", "plan_name": "700720_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Ppo Hmo", "plan_name": "701720", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Ppo Hmo", "plan_name": "701720_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Ms State Emplo", "plan_name": "401457", "standard_charge_percentage": 0.80, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Ms State Emplo", "plan_name": "401457_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Basic Pl", "plan_name": "400100", "standard_charge_percentage": 0.85, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Basic Pl", "plan_name": "400100_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Federal", "plan_name": "400110", "standard_charge_percentage": 0.85, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Federal", "plan_name": "400110_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." } ] } ] }, { "description": "Intestinal stricturoplasty", "code_information": [ { "code": "44615", "type": "CPT" } ], "standard_charges": [ { "gross_charge": 55699.22, "minimum": 44559.38, "maximum": 47344.34, "setting": "inpatient", "payers_information": [ { "payer_name": "Aetna", "plan_name": "700700", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna", "plan_name": "700700_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Miscellaneous", "plan_name": "700720", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Miscellaneous", "plan_name": "700720_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Ppo Hmo", "plan_name": "701720", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Ppo Hmo", "plan_name": "701720_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Ms State Emplo", "plan_name": "401457", "standard_charge_percentage": 0.80, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Ms State Emplo", "plan_name": "401457_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Basic Pl", "plan_name": "400100", "standard_charge_percentage": 0.85, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Basic Pl", "plan_name": "400100_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Federal", "plan_name": "400110", "standard_charge_percentage": 0.85, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Federal", "plan_name": "400110_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." } ] } ] }, { "description": "Repair bowel opening", "code_information": [ { "code": "44626", "type": "CPT" } ], "standard_charges": [ { "gross_charge": 42840.63, "minimum": 34272.50, "maximum": 36414.54, "setting": "inpatient", "payers_information": [ { "payer_name": "Aetna", "plan_name": "700700", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna", "plan_name": "700700_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Miscellaneous", "plan_name": "700720", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Miscellaneous", "plan_name": "700720_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Ppo Hmo", "plan_name": "701720", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Ppo Hmo", "plan_name": "701720_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Ms State Emplo", "plan_name": "401457", "standard_charge_percentage": 0.80, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Ms State Emplo", "plan_name": "401457_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Basic Pl", "plan_name": "400100", "standard_charge_percentage": 0.85, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Basic Pl", "plan_name": "400100_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Federal", "plan_name": "400110", "standard_charge_percentage": 0.85, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Federal", "plan_name": "400110_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." } ] } ] }, { "description": "Repair bowel-skin fistula", "code_information": [ { "code": "44640", "type": "CPT" } ], "standard_charges": [ { "gross_charge": 34905.53, "minimum": 27924.42, "maximum": 29669.70, "setting": "inpatient", "payers_information": [ { "payer_name": "Aetna", "plan_name": "700700", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna", "plan_name": "700700_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Miscellaneous", "plan_name": "700720", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Miscellaneous", "plan_name": "700720_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Ppo Hmo", "plan_name": "701720", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Ppo Hmo", "plan_name": "701720_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Ms State Emplo", "plan_name": "401457", "standard_charge_percentage": 0.80, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Ms State Emplo", "plan_name": "401457_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Basic Pl", "plan_name": "400100", "standard_charge_percentage": 0.85, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Basic Pl", "plan_name": "400100_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Federal", "plan_name": "400110", "standard_charge_percentage": 0.85, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Federal", "plan_name": "400110_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." } ] } ] }, { "description": "Repair bowel fistula", "code_information": [ { "code": "44650", "type": "CPT" } ], "standard_charges": [ { "gross_charge": 34905.53, "minimum": 27924.42, "maximum": 29669.70, "setting": "inpatient", "payers_information": [ { "payer_name": "Aetna", "plan_name": "700700", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna", "plan_name": "700700_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Miscellaneous", "plan_name": "700720", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Miscellaneous", "plan_name": "700720_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Ppo Hmo", "plan_name": "701720", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Ppo Hmo", "plan_name": "701720_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Ms State Emplo", "plan_name": "401457", "standard_charge_percentage": 0.80, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Ms State Emplo", "plan_name": "401457_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Basic Pl", "plan_name": "400100", "standard_charge_percentage": 0.85, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Basic Pl", "plan_name": "400100_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Federal", "plan_name": "400110", "standard_charge_percentage": 0.85, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Federal", "plan_name": "400110_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." } ] } ] }, { "description": "Repair bowel-bladder fistula", "code_information": [ { "code": "44660", "type": "CPT" } ], "standard_charges": [ { "gross_charge": 68896.77, "minimum": 55117.42, "maximum": 58562.25, "setting": "inpatient", "payers_information": [ { "payer_name": "Aetna", "plan_name": "700700", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna", "plan_name": "700700_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Miscellaneous", "plan_name": "700720", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Miscellaneous", "plan_name": "700720_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Ppo Hmo", "plan_name": "701720", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Ppo Hmo", "plan_name": "701720_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Ms State Emplo", "plan_name": "401457", "standard_charge_percentage": 0.80, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Ms State Emplo", "plan_name": "401457_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Basic Pl", "plan_name": "400100", "standard_charge_percentage": 0.85, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Basic Pl", "plan_name": "400100_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Federal", "plan_name": "400110", "standard_charge_percentage": 0.85, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Federal", "plan_name": "400110_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." } ] } ] }, { "description": "Repair bowel-bladder fistula", "code_information": [ { "code": "44661", "type": "CPT" } ], "standard_charges": [ { "gross_charge": 34905.53, "minimum": 27924.42, "maximum": 29669.70, "setting": "inpatient", "payers_information": [ { "payer_name": "Aetna", "plan_name": "700700", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna", "plan_name": "700700_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Miscellaneous", "plan_name": "700720", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Miscellaneous", "plan_name": "700720_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Ppo Hmo", "plan_name": "701720", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Ppo Hmo", "plan_name": "701720_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Ms State Emplo", "plan_name": "401457", "standard_charge_percentage": 0.80, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Ms State Emplo", "plan_name": "401457_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Basic Pl", "plan_name": "400100", "standard_charge_percentage": 0.85, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Basic Pl", "plan_name": "400100_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Federal", "plan_name": "400110", "standard_charge_percentage": 0.85, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Federal", "plan_name": "400110_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." } ] } ] }, { "description": "Suspend bowel w/prosthesis", "code_information": [ { "code": "44700", "type": "CPT" } ], "standard_charges": [ { "gross_charge": 51356.53, "minimum": 41085.22, "maximum": 43653.05, "setting": "inpatient", "payers_information": [ { "payer_name": "Aetna", "plan_name": "700700", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna", "plan_name": "700700_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Miscellaneous", "plan_name": "700720", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Miscellaneous", "plan_name": "700720_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Ppo Hmo", "plan_name": "701720", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Ppo Hmo", "plan_name": "701720_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Ms State Emplo", "plan_name": "401457", "standard_charge_percentage": 0.80, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Ms State Emplo", "plan_name": "401457_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Basic Pl", "plan_name": "400100", "standard_charge_percentage": 0.85, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Basic Pl", "plan_name": "400100_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Federal", "plan_name": "400110", "standard_charge_percentage": 0.85, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Federal", "plan_name": "400110_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." } ] } ] }, { "description": "Unlisted px small intestine", "code_information": [ { "code": "44799", "type": "CPT" } ], "standard_charges": [ { "gross_charge": 38909.44, "minimum": 858.87, "maximum": 33073.02, "setting": "inpatient", "payers_information": [ { "payer_name": "Aarp", "plan_name": "500102", "standard_charge_dollar": 858.87, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna", "plan_name": "700700", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna", "plan_name": "700700_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Mcare Ffs 6005", "plan_name": "700703", "standard_charge_dollar": 858.87, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Miscellaneous", "plan_name": "700720", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Miscellaneous", "plan_name": "700720_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Ppo Hmo", "plan_name": "701720", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Ppo Hmo", "plan_name": "701720_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Ambetter 68069", "plan_name": "500516", "standard_charge_dollar": 858.87, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Ms State Emplo", "plan_name": "401457", "standard_charge_percentage": 0.80, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Ms State Emplo", "plan_name": "401457_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Basic Pl", "plan_name": "400100", "standard_charge_percentage": 0.85, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Basic Pl", "plan_name": "400100_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Federal", "plan_name": "400110", "standard_charge_percentage": 0.85, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Federal", "plan_name": "400110_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Cigna Healthsprings Ffs", "plan_name": "500064", "standard_charge_dollar": 858.87, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Conseco", "plan_name": "500302", "standard_charge_dollar": 858.87, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Humana Ffs 61101", "plan_name": "500006", "standard_charge_dollar": 858.87, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Medicare A", "plan_name": "100100", "standard_charge_dollar": 858.87, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Medicare A", "plan_name": "100500", "standard_charge_dollar": 858.87, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Medicare Part B Only", "plan_name": "100300", "standard_charge_dollar": 858.87, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Medicare Railroad", "plan_name": "100103", "standard_charge_dollar": 858.87, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Ms Physicians Care N", "plan_name": "714210", "standard_charge_dollar": 1073.59, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Peoples Hlth Ffs 72126", "plan_name": "500019", "standard_charge_dollar": 858.87, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Uhc/Secure Horizons", "plan_name": "500449", "standard_charge_dollar": 858.87, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "United Health Care/", "plan_name": "500292", "standard_charge_dollar": 970.52, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "United Healthcare", "plan_name": "750104", "standard_charge_dollar": 970.52, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "United Healthcare Ba", "plan_name": "750090", "standard_charge_dollar": 970.52, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "United Healthcare Me", "plan_name": "501310", "standard_charge_dollar": 858.87, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Windsor Mcare Extra", "plan_name": "500778", "standard_charge_dollar": 858.87, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." } ] } ] }, { "description": "Excision of bowel pouch", "code_information": [ { "code": "44800", "type": "CPT" } ], "standard_charges": [ { "gross_charge": 33911.13, "minimum": 27128.90, "maximum": 28824.46, "setting": "inpatient", "payers_information": [ { "payer_name": "Aetna", "plan_name": "700700", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna", "plan_name": "700700_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Miscellaneous", "plan_name": "700720", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Miscellaneous", "plan_name": "700720_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Ppo Hmo", "plan_name": "701720", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Ppo Hmo", "plan_name": "701720_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Ms State Emplo", "plan_name": "401457", "standard_charge_percentage": 0.80, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Ms State Emplo", "plan_name": "401457_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Basic Pl", "plan_name": "400100", "standard_charge_percentage": 0.85, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Basic Pl", "plan_name": "400100_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Federal", "plan_name": "400110", "standard_charge_percentage": 0.85, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Federal", "plan_name": "400110_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." } ] } ] }, { "description": "Bowel surgery procedure", "code_information": [ { "code": "44899", "type": "CPT" } ], "standard_charges": [ { "gross_charge": 33911.13, "minimum": 27128.90, "maximum": 28824.46, "setting": "inpatient", "payers_information": [ { "payer_name": "Aetna", "plan_name": "700700", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna", "plan_name": "700700_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Miscellaneous", "plan_name": "700720", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Miscellaneous", "plan_name": "700720_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Ppo Hmo", "plan_name": "701720", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Ppo Hmo", "plan_name": "701720_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Ms State Emplo", "plan_name": "401457", "standard_charge_percentage": 0.80, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Ms State Emplo", "plan_name": "401457_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Basic Pl", "plan_name": "400100", "standard_charge_percentage": 0.85, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Basic Pl", "plan_name": "400100_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Federal", "plan_name": "400110", "standard_charge_percentage": 0.85, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Federal", "plan_name": "400110_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." } ] } ] }, { "description": "Appendectomy", "code_information": [ { "code": "44950", "type": "CPT" } ], "standard_charges": [ { "gross_charge": 46324.30, "minimum": 5716.04, "maximum": 39375.66, "setting": "inpatient", "payers_information": [ { "payer_name": "Aarp", "plan_name": "500102", "standard_charge_dollar": 5716.04, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna", "plan_name": "700700", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna", "plan_name": "700700_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Mcare Ffs 6005", "plan_name": "700703", "standard_charge_dollar": 5716.04, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Miscellaneous", "plan_name": "700720", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Miscellaneous", "plan_name": "700720_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Ppo Hmo", "plan_name": "701720", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Ppo Hmo", "plan_name": "701720_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Ambetter 68069", "plan_name": "500516", "standard_charge_dollar": 5716.04, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Ms State Emplo", "plan_name": "401457", "standard_charge_percentage": 0.80, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Ms State Emplo", "plan_name": "401457_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Basic Pl", "plan_name": "400100", "standard_charge_percentage": 0.85, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Basic Pl", "plan_name": "400100_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Federal", "plan_name": "400110", "standard_charge_percentage": 0.85, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Federal", "plan_name": "400110_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Cigna Healthsprings Ffs", "plan_name": "500064", "standard_charge_dollar": 5716.04, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Conseco", "plan_name": "500302", "standard_charge_dollar": 5716.04, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Humana Ffs 61101", "plan_name": "500006", "standard_charge_dollar": 5716.04, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Medicare A", "plan_name": "100100", "standard_charge_dollar": 5716.04, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Medicare A", "plan_name": "100500", "standard_charge_dollar": 5716.04, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Medicare Part B Only", "plan_name": "100300", "standard_charge_dollar": 5716.04, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Medicare Railroad", "plan_name": "100103", "standard_charge_dollar": 5716.04, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Ms Physicians Care N", "plan_name": "714210", "standard_charge_dollar": 7145.05, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Peoples Hlth Ffs 72126", "plan_name": "500019", "standard_charge_dollar": 5716.04, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Uhc/Secure Horizons", "plan_name": "500449", "standard_charge_dollar": 5716.04, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "United Health Care/", "plan_name": "500292", "standard_charge_dollar": 6459.13, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "United Healthcare", "plan_name": "750104", "standard_charge_dollar": 6459.13, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "United Healthcare Ba", "plan_name": "750090", "standard_charge_dollar": 6459.13, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "United Healthcare Me", "plan_name": "501310", "standard_charge_dollar": 5716.04, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Windsor Mcare Extra", "plan_name": "500778", "standard_charge_dollar": 5716.04, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." } ] } ] }, { "description": "Appendectomy add-on", "code_information": [ { "code": "44955", "type": "CPT" } ], "standard_charges": [ { "gross_charge": 46324.30, "minimum": 37059.44, "maximum": 39375.66, "setting": "inpatient", "payers_information": [ { "payer_name": "Aetna", "plan_name": "700700", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna", "plan_name": "700700_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Miscellaneous", "plan_name": "700720", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Miscellaneous", "plan_name": "700720_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Ppo Hmo", "plan_name": "701720", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Ppo Hmo", "plan_name": "701720_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Ms State Emplo", "plan_name": "401457", "standard_charge_percentage": 0.80, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Ms State Emplo", "plan_name": "401457_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Basic Pl", "plan_name": "400100", "standard_charge_percentage": 0.85, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Basic Pl", "plan_name": "400100_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Federal", "plan_name": "400110", "standard_charge_percentage": 0.85, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Federal", "plan_name": "400110_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." } ] } ] }, { "description": "Appendectomy", "code_information": [ { "code": "44960", "type": "CPT" } ], "standard_charges": [ { "gross_charge": 46324.30, "minimum": 37059.44, "maximum": 39375.66, "setting": "inpatient", "payers_information": [ { "payer_name": "Aetna", "plan_name": "700700", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna", "plan_name": "700700_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Miscellaneous", "plan_name": "700720", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Miscellaneous", "plan_name": "700720_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Ppo Hmo", "plan_name": "701720", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Ppo Hmo", "plan_name": "701720_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Ms State Emplo", "plan_name": "401457", "standard_charge_percentage": 0.80, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Ms State Emplo", "plan_name": "401457_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Basic Pl", "plan_name": "400100", "standard_charge_percentage": 0.85, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Basic Pl", "plan_name": "400100_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Federal", "plan_name": "400110", "standard_charge_percentage": 0.85, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Federal", "plan_name": "400110_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." } ] } ] }, { "description": "Laparoscopy appendectomy", "code_information": [ { "code": "44970", "type": "CPT" } ], "standard_charges": [ { "gross_charge": 27700.98, "minimum": 5344.68, "maximum": 23545.83, "setting": "inpatient", "payers_information": [ { "payer_name": "Aarp", "plan_name": "500102", "standard_charge_dollar": 5344.68, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna", "plan_name": "700700", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna", "plan_name": "700700_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Mcare Ffs 6005", "plan_name": "700703", "standard_charge_dollar": 5344.68, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Miscellaneous", "plan_name": "700720", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Miscellaneous", "plan_name": "700720_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Ppo Hmo", "plan_name": "701720", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Ppo Hmo", "plan_name": "701720_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Ambetter 68069", "plan_name": "500516", "standard_charge_dollar": 5344.68, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Ms State Emplo", "plan_name": "401457", "standard_charge_percentage": 0.80, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Ms State Emplo", "plan_name": "401457_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Basic Pl", "plan_name": "400100", "standard_charge_percentage": 0.85, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Basic Pl", "plan_name": "400100_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Federal", "plan_name": "400110", "standard_charge_percentage": 0.85, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Federal", "plan_name": "400110_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Cigna Healthsprings Ffs", "plan_name": "500064", "standard_charge_dollar": 5344.68, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Conseco", "plan_name": "500302", "standard_charge_dollar": 5344.68, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Humana Ffs 61101", "plan_name": "500006", "standard_charge_dollar": 5344.68, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Medicare A", "plan_name": "100100", "standard_charge_dollar": 5344.68, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Medicare A", "plan_name": "100500", "standard_charge_dollar": 5344.68, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Medicare Part B Only", "plan_name": "100300", "standard_charge_dollar": 5344.68, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Medicare Railroad", "plan_name": "100103", "standard_charge_dollar": 5344.68, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Ms Physicians Care N", "plan_name": "714210", "standard_charge_dollar": 6680.85, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Peoples Hlth Ffs 72126", "plan_name": "500019", "standard_charge_dollar": 5344.68, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Uhc/Secure Horizons", "plan_name": "500449", "standard_charge_dollar": 5344.68, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "United Health Care/", "plan_name": "500292", "standard_charge_dollar": 6039.49, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "United Healthcare", "plan_name": "750104", "standard_charge_dollar": 6039.49, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "United Healthcare Ba", "plan_name": "750090", "standard_charge_dollar": 6039.49, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "United Healthcare Me", "plan_name": "501310", "standard_charge_dollar": 5344.68, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Windsor Mcare Extra", "plan_name": "500778", "standard_charge_dollar": 5344.68, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." } ] } ] }, { "description": "Drainage of pelvic abscess", "code_information": [ { "code": "45000", "type": "CPT" } ], "standard_charges": [ { "gross_charge": 38397.45, "minimum": 1080.12, "maximum": 32637.83, "setting": "inpatient", "payers_information": [ { "payer_name": "Aarp", "plan_name": "500102", "standard_charge_dollar": 1080.12, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna", "plan_name": "700700", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna", "plan_name": "700700_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Mcare Ffs 6005", "plan_name": "700703", "standard_charge_dollar": 1080.12, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Miscellaneous", "plan_name": "700720", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Miscellaneous", "plan_name": "700720_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Ppo Hmo", "plan_name": "701720", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Ppo Hmo", "plan_name": "701720_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Ambetter 68069", "plan_name": "500516", "standard_charge_dollar": 1080.12, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Ms State Emplo", "plan_name": "401457", "standard_charge_percentage": 0.80, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Ms State Emplo", "plan_name": "401457_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Basic Pl", "plan_name": "400100", "standard_charge_percentage": 0.85, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Basic Pl", "plan_name": "400100_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Federal", "plan_name": "400110", "standard_charge_percentage": 0.85, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Federal", "plan_name": "400110_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Cigna Healthsprings Ffs", "plan_name": "500064", "standard_charge_dollar": 1080.12, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Conseco", "plan_name": "500302", "standard_charge_dollar": 1080.12, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Humana Ffs 61101", "plan_name": "500006", "standard_charge_dollar": 1080.12, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Medicare A", "plan_name": "100100", "standard_charge_dollar": 1080.12, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Medicare A", "plan_name": "100500", "standard_charge_dollar": 1080.12, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Medicare Part B Only", "plan_name": "100300", "standard_charge_dollar": 1080.12, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Medicare Railroad", "plan_name": "100103", "standard_charge_dollar": 1080.12, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Ms Physicians Care N", "plan_name": "714210", "standard_charge_dollar": 1350.15, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Peoples Hlth Ffs 72126", "plan_name": "500019", "standard_charge_dollar": 1080.12, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Uhc/Secure Horizons", "plan_name": "500449", "standard_charge_dollar": 1080.12, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "United Health Care/", "plan_name": "500292", "standard_charge_dollar": 1220.53, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "United Healthcare", "plan_name": "750104", "standard_charge_dollar": 1220.53, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "United Healthcare Ba", "plan_name": "750090", "standard_charge_dollar": 1220.53, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "United Healthcare Me", "plan_name": "501310", "standard_charge_dollar": 1080.12, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Windsor Mcare Extra", "plan_name": "500778", "standard_charge_dollar": 1080.12, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." } ] } ] }, { "description": "Drainage of rectal abscess", "code_information": [ { "code": "45005", "type": "CPT" } ], "standard_charges": [ { "gross_charge": 38397.45, "minimum": 1080.12, "maximum": 32637.83, "setting": "inpatient", "payers_information": [ { "payer_name": "Aarp", "plan_name": "500102", "standard_charge_dollar": 1080.12, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna", "plan_name": "700700", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna", "plan_name": "700700_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Mcare Ffs 6005", "plan_name": "700703", "standard_charge_dollar": 1080.12, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Miscellaneous", "plan_name": "700720", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Miscellaneous", "plan_name": "700720_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Ppo Hmo", "plan_name": "701720", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Ppo Hmo", "plan_name": "701720_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Ambetter 68069", "plan_name": "500516", "standard_charge_dollar": 1080.12, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Ms State Emplo", "plan_name": "401457", "standard_charge_percentage": 0.80, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Ms State Emplo", "plan_name": "401457_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Basic Pl", "plan_name": "400100", "standard_charge_percentage": 0.85, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Basic Pl", "plan_name": "400100_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Federal", "plan_name": "400110", "standard_charge_percentage": 0.85, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Federal", "plan_name": "400110_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Cigna Healthsprings Ffs", "plan_name": "500064", "standard_charge_dollar": 1080.12, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Conseco", "plan_name": "500302", "standard_charge_dollar": 1080.12, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Humana Ffs 61101", "plan_name": "500006", "standard_charge_dollar": 1080.12, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Medicare A", "plan_name": "100100", "standard_charge_dollar": 1080.12, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Medicare A", "plan_name": "100500", "standard_charge_dollar": 1080.12, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Medicare Part B Only", "plan_name": "100300", "standard_charge_dollar": 1080.12, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Medicare Railroad", "plan_name": "100103", "standard_charge_dollar": 1080.12, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Ms Physicians Care N", "plan_name": "714210", "standard_charge_dollar": 1350.15, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Peoples Hlth Ffs 72126", "plan_name": "500019", "standard_charge_dollar": 1080.12, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Uhc/Secure Horizons", "plan_name": "500449", "standard_charge_dollar": 1080.12, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "United Health Care/", "plan_name": "500292", "standard_charge_dollar": 1220.53, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "United Healthcare", "plan_name": "750104", "standard_charge_dollar": 1220.53, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "United Healthcare Ba", "plan_name": "750090", "standard_charge_dollar": 1220.53, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "United Healthcare Me", "plan_name": "501310", "standard_charge_dollar": 1080.12, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Windsor Mcare Extra", "plan_name": "500778", "standard_charge_dollar": 1080.12, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." } ] } ] }, { "description": "Drainage of rectal abscess", "code_information": [ { "code": "45020", "type": "CPT" } ], "standard_charges": [ { "gross_charge": 38397.45, "minimum": 2512.22, "maximum": 32637.83, "setting": "inpatient", "payers_information": [ { "payer_name": "Aarp", "plan_name": "500102", "standard_charge_dollar": 2512.22, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna", "plan_name": "700700", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna", "plan_name": "700700_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Mcare Ffs 6005", "plan_name": "700703", "standard_charge_dollar": 2512.22, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Miscellaneous", "plan_name": "700720", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Miscellaneous", "plan_name": "700720_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Ppo Hmo", "plan_name": "701720", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Ppo Hmo", "plan_name": "701720_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Ambetter 68069", "plan_name": "500516", "standard_charge_dollar": 2512.22, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Ms State Emplo", "plan_name": "401457", "standard_charge_percentage": 0.80, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Ms State Emplo", "plan_name": "401457_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Basic Pl", "plan_name": "400100", "standard_charge_percentage": 0.85, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Basic Pl", "plan_name": "400100_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Federal", "plan_name": "400110", "standard_charge_percentage": 0.85, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Federal", "plan_name": "400110_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Cigna Healthsprings Ffs", "plan_name": "500064", "standard_charge_dollar": 2512.22, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Conseco", "plan_name": "500302", "standard_charge_dollar": 2512.22, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Humana Ffs 61101", "plan_name": "500006", "standard_charge_dollar": 2512.22, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Medicare A", "plan_name": "100100", "standard_charge_dollar": 2512.22, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Medicare A", "plan_name": "100500", "standard_charge_dollar": 2512.22, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Medicare Part B Only", "plan_name": "100300", "standard_charge_dollar": 2512.22, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Medicare Railroad", "plan_name": "100103", "standard_charge_dollar": 2512.22, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Ms Physicians Care N", "plan_name": "714210", "standard_charge_dollar": 3140.27, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Peoples Hlth Ffs 72126", "plan_name": "500019", "standard_charge_dollar": 2512.22, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Uhc/Secure Horizons", "plan_name": "500449", "standard_charge_dollar": 2512.22, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "United Health Care/", "plan_name": "500292", "standard_charge_dollar": 2838.81, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "United Healthcare", "plan_name": "750104", "standard_charge_dollar": 2838.81, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "United Healthcare Ba", "plan_name": "750090", "standard_charge_dollar": 2838.81, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "United Healthcare Me", "plan_name": "501310", "standard_charge_dollar": 2512.22, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Windsor Mcare Extra", "plan_name": "500778", "standard_charge_dollar": 2512.22, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." } ] } ] }, { "description": "Biopsy of rectum", "code_information": [ { "code": "45100", "type": "CPT" } ], "standard_charges": [ { "gross_charge": 17380.19, "minimum": 2512.22, "maximum": 14773.16, "setting": "inpatient", "payers_information": [ { "payer_name": "Aarp", "plan_name": "500102", "standard_charge_dollar": 2512.22, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna", "plan_name": "700700", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna", "plan_name": "700700_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Mcare Ffs 6005", "plan_name": "700703", "standard_charge_dollar": 2512.22, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Miscellaneous", "plan_name": "700720", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Miscellaneous", "plan_name": "700720_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Ppo Hmo", "plan_name": "701720", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Ppo Hmo", "plan_name": "701720_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Ambetter 68069", "plan_name": "500516", "standard_charge_dollar": 2512.22, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Ms State Emplo", "plan_name": "401457", "standard_charge_percentage": 0.80, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Ms State Emplo", "plan_name": "401457_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Basic Pl", "plan_name": "400100", "standard_charge_percentage": 0.85, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Basic Pl", "plan_name": "400100_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Federal", "plan_name": "400110", "standard_charge_percentage": 0.85, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Federal", "plan_name": "400110_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Cigna Healthsprings Ffs", "plan_name": "500064", "standard_charge_dollar": 2512.22, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Conseco", "plan_name": "500302", "standard_charge_dollar": 2512.22, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Humana Ffs 61101", "plan_name": "500006", "standard_charge_dollar": 2512.22, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Medicare A", "plan_name": "100100", "standard_charge_dollar": 2512.22, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Medicare A", "plan_name": "100500", "standard_charge_dollar": 2512.22, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Medicare Part B Only", "plan_name": "100300", "standard_charge_dollar": 2512.22, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Medicare Railroad", "plan_name": "100103", "standard_charge_dollar": 2512.22, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Ms Physicians Care N", "plan_name": "714210", "standard_charge_dollar": 3140.27, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Peoples Hlth Ffs 72126", "plan_name": "500019", "standard_charge_dollar": 2512.22, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Uhc/Secure Horizons", "plan_name": "500449", "standard_charge_dollar": 2512.22, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "United Health Care/", "plan_name": "500292", "standard_charge_dollar": 2838.81, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "United Healthcare", "plan_name": "750104", "standard_charge_dollar": 2838.81, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "United Healthcare Ba", "plan_name": "750090", "standard_charge_dollar": 2838.81, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "United Healthcare Me", "plan_name": "501310", "standard_charge_dollar": 2512.22, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Windsor Mcare Extra", "plan_name": "500778", "standard_charge_dollar": 2512.22, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." } ] } ] }, { "description": "Removal of rectum", "code_information": [ { "code": "45110", "type": "CPT" } ], "standard_charges": [ { "gross_charge": 34473.25, "minimum": 27578.60, "maximum": 29302.26, "setting": "inpatient", "payers_information": [ { "payer_name": "Aetna", "plan_name": "700700", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna", "plan_name": "700700_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Miscellaneous", "plan_name": "700720", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Miscellaneous", "plan_name": "700720_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Ppo Hmo", "plan_name": "701720", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Ppo Hmo", "plan_name": "701720_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Ms State Emplo", "plan_name": "401457", "standard_charge_percentage": 0.80, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Ms State Emplo", "plan_name": "401457_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Basic Pl", "plan_name": "400100", "standard_charge_percentage": 0.85, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Basic Pl", "plan_name": "400100_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Federal", "plan_name": "400110", "standard_charge_percentage": 0.85, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Federal", "plan_name": "400110_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." } ] } ] }, { "description": "Remove rectum w/reservoir", "code_information": [ { "code": "45119", "type": "CPT" } ], "standard_charges": [ { "gross_charge": 40914.76, "minimum": 32731.81, "maximum": 34777.55, "setting": "inpatient", "payers_information": [ { "payer_name": "Aetna", "plan_name": "700700", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna", "plan_name": "700700_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Miscellaneous", "plan_name": "700720", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Miscellaneous", "plan_name": "700720_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Ppo Hmo", "plan_name": "701720", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Ppo Hmo", "plan_name": "701720_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Ms State Emplo", "plan_name": "401457", "standard_charge_percentage": 0.80, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Ms State Emplo", "plan_name": "401457_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Basic Pl", "plan_name": "400100", "standard_charge_percentage": 0.85, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Basic Pl", "plan_name": "400100_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Federal", "plan_name": "400110", "standard_charge_percentage": 0.85, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Federal", "plan_name": "400110_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." } ] } ] }, { "description": "Removal of rectum", "code_information": [ { "code": "45120", "type": "CPT" } ], "standard_charges": [ { "gross_charge": 34473.25, "minimum": 27578.60, "maximum": 29302.26, "setting": "inpatient", "payers_information": [ { "payer_name": "Aetna", "plan_name": "700700", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna", "plan_name": "700700_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Miscellaneous", "plan_name": "700720", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Miscellaneous", "plan_name": "700720_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Ppo Hmo", "plan_name": "701720", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Ppo Hmo", "plan_name": "701720_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Ms State Emplo", "plan_name": "401457", "standard_charge_percentage": 0.80, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Ms State Emplo", "plan_name": "401457_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Basic Pl", "plan_name": "400100", "standard_charge_percentage": 0.85, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Basic Pl", "plan_name": "400100_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Federal", "plan_name": "400110", "standard_charge_percentage": 0.85, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Federal", "plan_name": "400110_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." } ] } ] }, { "description": "Removal of rectum and colon", "code_information": [ { "code": "45121", "type": "CPT" } ], "standard_charges": [ { "gross_charge": 39548.51, "minimum": 31638.81, "maximum": 33616.23, "setting": "inpatient", "payers_information": [ { "payer_name": "Aetna", "plan_name": "700700", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna", "plan_name": "700700_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Miscellaneous", "plan_name": "700720", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Miscellaneous", "plan_name": "700720_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Ppo Hmo", "plan_name": "701720", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Ppo Hmo", "plan_name": "701720_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Ms State Emplo", "plan_name": "401457", "standard_charge_percentage": 0.80, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Ms State Emplo", "plan_name": "401457_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Basic Pl", "plan_name": "400100", "standard_charge_percentage": 0.85, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Basic Pl", "plan_name": "400100_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Federal", "plan_name": "400110", "standard_charge_percentage": 0.85, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Federal", "plan_name": "400110_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." } ] } ] }, { "description": "Pelvic exenteration", "code_information": [ { "code": "45126", "type": "CPT" } ], "standard_charges": [ { "gross_charge": 20135.04, "minimum": 16108.03, "maximum": 17114.78, "setting": "inpatient", "payers_information": [ { "payer_name": "Aetna", "plan_name": "700700", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna", "plan_name": "700700_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Miscellaneous", "plan_name": "700720", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Miscellaneous", "plan_name": "700720_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Ppo Hmo", "plan_name": "701720", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Ppo Hmo", "plan_name": "701720_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Ms State Emplo", "plan_name": "401457", "standard_charge_percentage": 0.80, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Ms State Emplo", "plan_name": "401457_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Basic Pl", "plan_name": "400100", "standard_charge_percentage": 0.85, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Basic Pl", "plan_name": "400100_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Federal", "plan_name": "400110", "standard_charge_percentage": 0.85, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Federal", "plan_name": "400110_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." } ] } ] }, { "description": "Excise ileoanal reservior", "code_information": [ { "code": "45136", "type": "CPT" } ], "standard_charges": [ { "gross_charge": 33911.13, "minimum": 27128.90, "maximum": 28824.46, "setting": "inpatient", "payers_information": [ { "payer_name": "Aetna", "plan_name": "700700", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna", "plan_name": "700700_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Miscellaneous", "plan_name": "700720", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Miscellaneous", "plan_name": "700720_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Ppo Hmo", "plan_name": "701720", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Ppo Hmo", "plan_name": "701720_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Ms State Emplo", "plan_name": "401457", "standard_charge_percentage": 0.80, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Ms State Emplo", "plan_name": "401457_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Basic Pl", "plan_name": "400100", "standard_charge_percentage": 0.85, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Basic Pl", "plan_name": "400100_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Federal", "plan_name": "400110", "standard_charge_percentage": 0.85, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Federal", "plan_name": "400110_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." } ] } ] }, { "description": "Proctosigmoidoscopy dx", "code_information": [ { "code": "45300", "type": "CPT" } ], "standard_charges": [ { "gross_charge": 23731.77, "minimum": 835.19, "maximum": 20172.00, "setting": "inpatient", "payers_information": [ { "payer_name": "Aarp", "plan_name": "500102", "standard_charge_dollar": 835.19, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna", "plan_name": "700700", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna", "plan_name": "700700_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Mcare Ffs 6005", "plan_name": "700703", "standard_charge_dollar": 835.19, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Miscellaneous", "plan_name": "700720", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Miscellaneous", "plan_name": "700720_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Ppo Hmo", "plan_name": "701720", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Ppo Hmo", "plan_name": "701720_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Ambetter 68069", "plan_name": "500516", "standard_charge_dollar": 835.19, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Ms State Emplo", "plan_name": "401457", "standard_charge_percentage": 0.80, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Ms State Emplo", "plan_name": "401457_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Basic Pl", "plan_name": "400100", "standard_charge_percentage": 0.85, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Basic Pl", "plan_name": "400100_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Federal", "plan_name": "400110", "standard_charge_percentage": 0.85, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Federal", "plan_name": "400110_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Cigna Healthsprings Ffs", "plan_name": "500064", "standard_charge_dollar": 835.19, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Conseco", "plan_name": "500302", "standard_charge_dollar": 835.19, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Humana Ffs 61101", "plan_name": "500006", "standard_charge_dollar": 835.19, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Medicare A", "plan_name": "100100", "standard_charge_dollar": 835.19, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Medicare A", "plan_name": "100500", "standard_charge_dollar": 835.19, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Medicare Part B Only", "plan_name": "100300", "standard_charge_dollar": 835.19, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Medicare Railroad", "plan_name": "100103", "standard_charge_dollar": 835.19, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Ms Physicians Care N", "plan_name": "714210", "standard_charge_dollar": 1043.99, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Peoples Hlth Ffs 72126", "plan_name": "500019", "standard_charge_dollar": 835.19, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Uhc/Secure Horizons", "plan_name": "500449", "standard_charge_dollar": 835.19, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "United Health Care/", "plan_name": "500292", "standard_charge_dollar": 943.76, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "United Healthcare", "plan_name": "750104", "standard_charge_dollar": 943.76, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "United Healthcare Ba", "plan_name": "750090", "standard_charge_dollar": 943.76, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "United Healthcare Me", "plan_name": "501310", "standard_charge_dollar": 835.19, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Windsor Mcare Extra", "plan_name": "500778", "standard_charge_dollar": 835.19, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." } ] } ] }, { "description": "Proctosigmoidoscopy w/bx", "code_information": [ { "code": "45305", "type": "CPT" } ], "standard_charges": [ { "gross_charge": 23731.77, "minimum": 1080.12, "maximum": 20172.00, "setting": "inpatient", "payers_information": [ { "payer_name": "Aarp", "plan_name": "500102", "standard_charge_dollar": 1080.12, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna", "plan_name": "700700", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna", "plan_name": "700700_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Mcare Ffs 6005", "plan_name": "700703", "standard_charge_dollar": 1080.12, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Miscellaneous", "plan_name": "700720", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Miscellaneous", "plan_name": "700720_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Ppo Hmo", "plan_name": "701720", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Ppo Hmo", "plan_name": "701720_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Ambetter 68069", "plan_name": "500516", "standard_charge_dollar": 1080.12, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Ms State Emplo", "plan_name": "401457", "standard_charge_percentage": 0.80, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Ms State Emplo", "plan_name": "401457_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Basic Pl", "plan_name": "400100", "standard_charge_percentage": 0.85, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Basic Pl", "plan_name": "400100_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Federal", "plan_name": "400110", "standard_charge_percentage": 0.85, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Federal", "plan_name": "400110_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Cigna Healthsprings Ffs", "plan_name": "500064", "standard_charge_dollar": 1080.12, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Conseco", "plan_name": "500302", "standard_charge_dollar": 1080.12, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Humana Ffs 61101", "plan_name": "500006", "standard_charge_dollar": 1080.12, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Medicare A", "plan_name": "100100", "standard_charge_dollar": 1080.12, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Medicare A", "plan_name": "100500", "standard_charge_dollar": 1080.12, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Medicare Part B Only", "plan_name": "100300", "standard_charge_dollar": 1080.12, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Medicare Railroad", "plan_name": "100103", "standard_charge_dollar": 1080.12, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Ms Physicians Care N", "plan_name": "714210", "standard_charge_dollar": 1350.15, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Peoples Hlth Ffs 72126", "plan_name": "500019", "standard_charge_dollar": 1080.12, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Uhc/Secure Horizons", "plan_name": "500449", "standard_charge_dollar": 1080.12, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "United Health Care/", "plan_name": "500292", "standard_charge_dollar": 1220.53, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "United Healthcare", "plan_name": "750104", "standard_charge_dollar": 1220.53, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "United Healthcare Ba", "plan_name": "750090", "standard_charge_dollar": 1220.53, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "United Healthcare Me", "plan_name": "501310", "standard_charge_dollar": 1080.12, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Windsor Mcare Extra", "plan_name": "500778", "standard_charge_dollar": 1080.12, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." } ] } ] }, { "description": "Diagnostic sigmoidoscopy", "code_information": [ { "code": "45330", "type": "CPT" } ], "standard_charges": [ { "gross_charge": 23731.77, "minimum": 835.19, "maximum": 20172.00, "setting": "inpatient", "payers_information": [ { "payer_name": "Aarp", "plan_name": "500102", "standard_charge_dollar": 835.19, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna", "plan_name": "700700", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna", "plan_name": "700700_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Mcare Ffs 6005", "plan_name": "700703", "standard_charge_dollar": 835.19, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Miscellaneous", "plan_name": "700720", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Miscellaneous", "plan_name": "700720_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Ppo Hmo", "plan_name": "701720", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Ppo Hmo", "plan_name": "701720_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Ambetter 68069", "plan_name": "500516", "standard_charge_dollar": 835.19, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Ms State Emplo", "plan_name": "401457", "standard_charge_percentage": 0.80, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Ms State Emplo", "plan_name": "401457_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Basic Pl", "plan_name": "400100", "standard_charge_percentage": 0.85, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Basic Pl", "plan_name": "400100_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Federal", "plan_name": "400110", "standard_charge_percentage": 0.85, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Federal", "plan_name": "400110_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Cigna Healthsprings Ffs", "plan_name": "500064", "standard_charge_dollar": 835.19, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Conseco", "plan_name": "500302", "standard_charge_dollar": 835.19, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Humana Ffs 61101", "plan_name": "500006", "standard_charge_dollar": 835.19, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Medicare A", "plan_name": "100100", "standard_charge_dollar": 835.19, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Medicare A", "plan_name": "100500", "standard_charge_dollar": 835.19, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Medicare Part B Only", "plan_name": "100300", "standard_charge_dollar": 835.19, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Medicare Railroad", "plan_name": "100103", "standard_charge_dollar": 835.19, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Ms Physicians Care N", "plan_name": "714210", "standard_charge_dollar": 1043.99, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Peoples Hlth Ffs 72126", "plan_name": "500019", "standard_charge_dollar": 835.19, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Uhc/Secure Horizons", "plan_name": "500449", "standard_charge_dollar": 835.19, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "United Health Care/", "plan_name": "500292", "standard_charge_dollar": 943.76, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "United Healthcare", "plan_name": "750104", "standard_charge_dollar": 943.76, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "United Healthcare Ba", "plan_name": "750090", "standard_charge_dollar": 943.76, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "United Healthcare Me", "plan_name": "501310", "standard_charge_dollar": 835.19, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Windsor Mcare Extra", "plan_name": "500778", "standard_charge_dollar": 835.19, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." } ] } ] }, { "description": "Sigmoidoscopy and biopsy", "code_information": [ { "code": "45331", "type": "CPT" } ], "standard_charges": [ { "gross_charge": 18448.04, "minimum": 835.19, "maximum": 15680.83, "setting": "inpatient", "payers_information": [ { "payer_name": "Aarp", "plan_name": "500102", "standard_charge_dollar": 835.19, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna", "plan_name": "700700", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna", "plan_name": "700700_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Mcare Ffs 6005", "plan_name": "700703", "standard_charge_dollar": 835.19, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Miscellaneous", "plan_name": "700720", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Miscellaneous", "plan_name": "700720_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Ppo Hmo", "plan_name": "701720", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Ppo Hmo", "plan_name": "701720_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Ambetter 68069", "plan_name": "500516", "standard_charge_dollar": 835.19, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Ms State Emplo", "plan_name": "401457", "standard_charge_percentage": 0.80, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Ms State Emplo", "plan_name": "401457_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Basic Pl", "plan_name": "400100", "standard_charge_percentage": 0.85, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Basic Pl", "plan_name": "400100_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Federal", "plan_name": "400110", "standard_charge_percentage": 0.85, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Federal", "plan_name": "400110_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Cigna Healthsprings Ffs", "plan_name": "500064", "standard_charge_dollar": 835.19, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Conseco", "plan_name": "500302", "standard_charge_dollar": 835.19, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Humana Ffs 61101", "plan_name": "500006", "standard_charge_dollar": 835.19, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Medicare A", "plan_name": "100100", "standard_charge_dollar": 835.19, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Medicare A", "plan_name": "100500", "standard_charge_dollar": 835.19, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Medicare Part B Only", "plan_name": "100300", "standard_charge_dollar": 835.19, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Medicare Railroad", "plan_name": "100103", "standard_charge_dollar": 835.19, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Ms Physicians Care N", "plan_name": "714210", "standard_charge_dollar": 1043.99, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Peoples Hlth Ffs 72126", "plan_name": "500019", "standard_charge_dollar": 835.19, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Uhc/Secure Horizons", "plan_name": "500449", "standard_charge_dollar": 835.19, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "United Health Care/", "plan_name": "500292", "standard_charge_dollar": 943.76, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "United Healthcare", "plan_name": "750104", "standard_charge_dollar": 943.76, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "United Healthcare Ba", "plan_name": "750090", "standard_charge_dollar": 943.76, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "United Healthcare Me", "plan_name": "501310", "standard_charge_dollar": 835.19, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Windsor Mcare Extra", "plan_name": "500778", "standard_charge_dollar": 835.19, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." } ] } ] }, { "description": "Sigmoidoscopy w/ultrasound", "code_information": [ { "code": "45341", "type": "CPT" } ], "standard_charges": [ { "gross_charge": 23731.77, "minimum": 835.19, "maximum": 20172.00, "setting": "inpatient", "payers_information": [ { "payer_name": "Aarp", "plan_name": "500102", "standard_charge_dollar": 835.19, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna", "plan_name": "700700", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna", "plan_name": "700700_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Mcare Ffs 6005", "plan_name": "700703", "standard_charge_dollar": 835.19, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Miscellaneous", "plan_name": "700720", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Miscellaneous", "plan_name": "700720_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Ppo Hmo", "plan_name": "701720", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Ppo Hmo", "plan_name": "701720_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Ambetter 68069", "plan_name": "500516", "standard_charge_dollar": 835.19, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Ms State Emplo", "plan_name": "401457", "standard_charge_percentage": 0.80, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Ms State Emplo", "plan_name": "401457_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Basic Pl", "plan_name": "400100", "standard_charge_percentage": 0.85, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Basic Pl", "plan_name": "400100_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Federal", "plan_name": "400110", "standard_charge_percentage": 0.85, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Federal", "plan_name": "400110_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Cigna Healthsprings Ffs", "plan_name": "500064", "standard_charge_dollar": 835.19, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Conseco", "plan_name": "500302", "standard_charge_dollar": 835.19, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Humana Ffs 61101", "plan_name": "500006", "standard_charge_dollar": 835.19, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Medicare A", "plan_name": "100100", "standard_charge_dollar": 835.19, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Medicare A", "plan_name": "100500", "standard_charge_dollar": 835.19, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Medicare Part B Only", "plan_name": "100300", "standard_charge_dollar": 835.19, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Medicare Railroad", "plan_name": "100103", "standard_charge_dollar": 835.19, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Ms Physicians Care N", "plan_name": "714210", "standard_charge_dollar": 1043.99, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Peoples Hlth Ffs 72126", "plan_name": "500019", "standard_charge_dollar": 835.19, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Uhc/Secure Horizons", "plan_name": "500449", "standard_charge_dollar": 835.19, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "United Health Care/", "plan_name": "500292", "standard_charge_dollar": 943.76, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "United Healthcare", "plan_name": "750104", "standard_charge_dollar": 943.76, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "United Healthcare Ba", "plan_name": "750090", "standard_charge_dollar": 943.76, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "United Healthcare Me", "plan_name": "501310", "standard_charge_dollar": 835.19, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Windsor Mcare Extra", "plan_name": "500778", "standard_charge_dollar": 835.19, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." } ] } ] }, { "description": "Sigmoidoscopy w/us guide bx", "code_information": [ { "code": "45342", "type": "CPT" } ], "standard_charges": [ { "gross_charge": 23256.79, "minimum": 1080.12, "maximum": 19768.27, "setting": "inpatient", "payers_information": [ { "payer_name": "Aarp", "plan_name": "500102", "standard_charge_dollar": 1080.12, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna", "plan_name": "700700", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna", "plan_name": "700700_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Mcare Ffs 6005", "plan_name": "700703", "standard_charge_dollar": 1080.12, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Miscellaneous", "plan_name": "700720", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Miscellaneous", "plan_name": "700720_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Ppo Hmo", "plan_name": "701720", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Ppo Hmo", "plan_name": "701720_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Ambetter 68069", "plan_name": "500516", "standard_charge_dollar": 1080.12, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Ms State Emplo", "plan_name": "401457", "standard_charge_percentage": 0.80, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Ms State Emplo", "plan_name": "401457_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Basic Pl", "plan_name": "400100", "standard_charge_percentage": 0.85, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Basic Pl", "plan_name": "400100_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Federal", "plan_name": "400110", "standard_charge_percentage": 0.85, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Federal", "plan_name": "400110_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Cigna Healthsprings Ffs", "plan_name": "500064", "standard_charge_dollar": 1080.12, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Conseco", "plan_name": "500302", "standard_charge_dollar": 1080.12, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Humana Ffs 61101", "plan_name": "500006", "standard_charge_dollar": 1080.12, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Medicare A", "plan_name": "100100", "standard_charge_dollar": 1080.12, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Medicare A", "plan_name": "100500", "standard_charge_dollar": 1080.12, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Medicare Part B Only", "plan_name": "100300", "standard_charge_dollar": 1080.12, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Medicare Railroad", "plan_name": "100103", "standard_charge_dollar": 1080.12, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Ms Physicians Care N", "plan_name": "714210", "standard_charge_dollar": 1350.15, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Peoples Hlth Ffs 72126", "plan_name": "500019", "standard_charge_dollar": 1080.12, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Uhc/Secure Horizons", "plan_name": "500449", "standard_charge_dollar": 1080.12, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "United Health Care/", "plan_name": "500292", "standard_charge_dollar": 1220.53, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "United Healthcare", "plan_name": "750104", "standard_charge_dollar": 1220.53, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "United Healthcare Ba", "plan_name": "750090", "standard_charge_dollar": 1220.53, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "United Healthcare Me", "plan_name": "501310", "standard_charge_dollar": 1080.12, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Windsor Mcare Extra", "plan_name": "500778", "standard_charge_dollar": 1080.12, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." } ] } ] }, { "description": "Diagnostic colonoscopy", "code_information": [ { "code": "45378", "type": "CPT" } ], "standard_charges": [ { "gross_charge": 23731.77, "minimum": 835.19, "maximum": 20172.00, "setting": "inpatient", "payers_information": [ { "payer_name": "Aarp", "plan_name": "500102", "standard_charge_dollar": 835.19, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna", "plan_name": "700700", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna", "plan_name": "700700_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Mcare Ffs 6005", "plan_name": "700703", "standard_charge_dollar": 835.19, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Miscellaneous", "plan_name": "700720", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Miscellaneous", "plan_name": "700720_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Ppo Hmo", "plan_name": "701720", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Ppo Hmo", "plan_name": "701720_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Ambetter 68069", "plan_name": "500516", "standard_charge_dollar": 835.19, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Ms State Emplo", "plan_name": "401457", "standard_charge_percentage": 0.80, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Ms State Emplo", "plan_name": "401457_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Basic Pl", "plan_name": "400100", "standard_charge_percentage": 0.85, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Basic Pl", "plan_name": "400100_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Federal", "plan_name": "400110", "standard_charge_percentage": 0.85, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Federal", "plan_name": "400110_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Cigna Healthsprings Ffs", "plan_name": "500064", "standard_charge_dollar": 835.19, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Conseco", "plan_name": "500302", "standard_charge_dollar": 835.19, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Humana Ffs 61101", "plan_name": "500006", "standard_charge_dollar": 835.19, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Medicare A", "plan_name": "100100", "standard_charge_dollar": 835.19, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Medicare A", "plan_name": "100500", "standard_charge_dollar": 835.19, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Medicare Part B Only", "plan_name": "100300", "standard_charge_dollar": 835.19, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Medicare Railroad", "plan_name": "100103", "standard_charge_dollar": 835.19, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Ms Physicians Care N", "plan_name": "714210", "standard_charge_dollar": 1043.99, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Peoples Hlth Ffs 72126", "plan_name": "500019", "standard_charge_dollar": 835.19, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Uhc/Secure Horizons", "plan_name": "500449", "standard_charge_dollar": 835.19, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "United Health Care/", "plan_name": "500292", "standard_charge_dollar": 943.76, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "United Healthcare", "plan_name": "750104", "standard_charge_dollar": 943.76, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "United Healthcare Ba", "plan_name": "750090", "standard_charge_dollar": 943.76, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "United Healthcare Me", "plan_name": "501310", "standard_charge_dollar": 835.19, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Windsor Mcare Extra", "plan_name": "500778", "standard_charge_dollar": 835.19, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." } ] } ] }, { "description": "Colonoscopy w/fb removal", "code_information": [ { "code": "45379", "type": "CPT" } ], "standard_charges": [ { "gross_charge": 23731.77, "minimum": 1080.12, "maximum": 20172.00, "setting": "inpatient", "payers_information": [ { "payer_name": "Aarp", "plan_name": "500102", "standard_charge_dollar": 1080.12, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna", "plan_name": "700700", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna", "plan_name": "700700_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Mcare Ffs 6005", "plan_name": "700703", "standard_charge_dollar": 1080.12, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Miscellaneous", "plan_name": "700720", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Miscellaneous", "plan_name": "700720_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Ppo Hmo", "plan_name": "701720", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Ppo Hmo", "plan_name": "701720_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Ambetter 68069", "plan_name": "500516", "standard_charge_dollar": 1080.12, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Ms State Emplo", "plan_name": "401457", "standard_charge_percentage": 0.80, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Ms State Emplo", "plan_name": "401457_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Basic Pl", "plan_name": "400100", "standard_charge_percentage": 0.85, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Basic Pl", "plan_name": "400100_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Federal", "plan_name": "400110", "standard_charge_percentage": 0.85, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Federal", "plan_name": "400110_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Cigna Healthsprings Ffs", "plan_name": "500064", "standard_charge_dollar": 1080.12, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Conseco", "plan_name": "500302", "standard_charge_dollar": 1080.12, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Humana Ffs 61101", "plan_name": "500006", "standard_charge_dollar": 1080.12, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Medicare A", "plan_name": "100100", "standard_charge_dollar": 1080.12, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Medicare A", "plan_name": "100500", "standard_charge_dollar": 1080.12, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Medicare Part B Only", "plan_name": "100300", "standard_charge_dollar": 1080.12, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Medicare Railroad", "plan_name": "100103", "standard_charge_dollar": 1080.12, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Ms Physicians Care N", "plan_name": "714210", "standard_charge_dollar": 1350.15, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Peoples Hlth Ffs 72126", "plan_name": "500019", "standard_charge_dollar": 1080.12, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Uhc/Secure Horizons", "plan_name": "500449", "standard_charge_dollar": 1080.12, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "United Health Care/", "plan_name": "500292", "standard_charge_dollar": 1220.53, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "United Healthcare", "plan_name": "750104", "standard_charge_dollar": 1220.53, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "United Healthcare Ba", "plan_name": "750090", "standard_charge_dollar": 1220.53, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "United Healthcare Me", "plan_name": "501310", "standard_charge_dollar": 1080.12, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Windsor Mcare Extra", "plan_name": "500778", "standard_charge_dollar": 1080.12, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." } ] } ] }, { "description": "Colonoscopy and biopsy", "code_information": [ { "code": "45380", "type": "CPT" } ], "standard_charges": [ { "gross_charge": 27572.17, "minimum": 1080.12, "maximum": 23436.34, "setting": "inpatient", "payers_information": [ { "payer_name": "Aarp", "plan_name": "500102", "standard_charge_dollar": 1080.12, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna", "plan_name": "700700", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna", "plan_name": "700700_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Mcare Ffs 6005", "plan_name": "700703", "standard_charge_dollar": 1080.12, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Miscellaneous", "plan_name": "700720", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Miscellaneous", "plan_name": "700720_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Ppo Hmo", "plan_name": "701720", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Ppo Hmo", "plan_name": "701720_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Ambetter 68069", "plan_name": "500516", "standard_charge_dollar": 1080.12, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Ms State Emplo", "plan_name": "401457", "standard_charge_percentage": 0.80, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Ms State Emplo", "plan_name": "401457_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Basic Pl", "plan_name": "400100", "standard_charge_percentage": 0.85, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Basic Pl", "plan_name": "400100_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Federal", "plan_name": "400110", "standard_charge_percentage": 0.85, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Federal", "plan_name": "400110_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Cigna Healthsprings Ffs", "plan_name": "500064", "standard_charge_dollar": 1080.12, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Conseco", "plan_name": "500302", "standard_charge_dollar": 1080.12, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Humana Ffs 61101", "plan_name": "500006", "standard_charge_dollar": 1080.12, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Medicare A", "plan_name": "100100", "standard_charge_dollar": 1080.12, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Medicare A", "plan_name": "100500", "standard_charge_dollar": 1080.12, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Medicare Part B Only", "plan_name": "100300", "standard_charge_dollar": 1080.12, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Medicare Railroad", "plan_name": "100103", "standard_charge_dollar": 1080.12, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Ms Physicians Care N", "plan_name": "714210", "standard_charge_dollar": 1350.15, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Peoples Hlth Ffs 72126", "plan_name": "500019", "standard_charge_dollar": 1080.12, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Uhc/Secure Horizons", "plan_name": "500449", "standard_charge_dollar": 1080.12, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "United Health Care/", "plan_name": "500292", "standard_charge_dollar": 1220.53, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "United Healthcare", "plan_name": "750104", "standard_charge_dollar": 1220.53, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "United Healthcare Ba", "plan_name": "750090", "standard_charge_dollar": 1220.53, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "United Healthcare Me", "plan_name": "501310", "standard_charge_dollar": 1080.12, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Windsor Mcare Extra", "plan_name": "500778", "standard_charge_dollar": 1080.12, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." } ] } ] }, { "description": "Colonoscopy w/lesion removal", "code_information": [ { "code": "45384", "type": "CPT" } ], "standard_charges": [ { "gross_charge": 25526.85, "minimum": 1080.12, "maximum": 21697.82, "setting": "inpatient", "payers_information": [ { "payer_name": "Aarp", "plan_name": "500102", "standard_charge_dollar": 1080.12, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna", "plan_name": "700700", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna", "plan_name": "700700_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Mcare Ffs 6005", "plan_name": "700703", "standard_charge_dollar": 1080.12, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Miscellaneous", "plan_name": "700720", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Miscellaneous", "plan_name": "700720_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Ppo Hmo", "plan_name": "701720", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Ppo Hmo", "plan_name": "701720_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Ambetter 68069", "plan_name": "500516", "standard_charge_dollar": 1080.12, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Ms State Emplo", "plan_name": "401457", "standard_charge_percentage": 0.80, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Ms State Emplo", "plan_name": "401457_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Basic Pl", "plan_name": "400100", "standard_charge_percentage": 0.85, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Basic Pl", "plan_name": "400100_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Federal", "plan_name": "400110", "standard_charge_percentage": 0.85, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Federal", "plan_name": "400110_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Cigna Healthsprings Ffs", "plan_name": "500064", "standard_charge_dollar": 1080.12, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Conseco", "plan_name": "500302", "standard_charge_dollar": 1080.12, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Humana Ffs 61101", "plan_name": "500006", "standard_charge_dollar": 1080.12, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Medicare A", "plan_name": "100100", "standard_charge_dollar": 1080.12, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Medicare A", "plan_name": "100500", "standard_charge_dollar": 1080.12, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Medicare Part B Only", "plan_name": "100300", "standard_charge_dollar": 1080.12, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Medicare Railroad", "plan_name": "100103", "standard_charge_dollar": 1080.12, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Ms Physicians Care N", "plan_name": "714210", "standard_charge_dollar": 1350.15, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Peoples Hlth Ffs 72126", "plan_name": "500019", "standard_charge_dollar": 1080.12, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Uhc/Secure Horizons", "plan_name": "500449", "standard_charge_dollar": 1080.12, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "United Health Care/", "plan_name": "500292", "standard_charge_dollar": 1220.53, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "United Healthcare", "plan_name": "750104", "standard_charge_dollar": 1220.53, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "United Healthcare Ba", "plan_name": "750090", "standard_charge_dollar": 1220.53, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "United Healthcare Me", "plan_name": "501310", "standard_charge_dollar": 1080.12, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Windsor Mcare Extra", "plan_name": "500778", "standard_charge_dollar": 1080.12, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." } ] } ] }, { "description": "Colonoscopy w/lesion removal", "code_information": [ { "code": "45385", "type": "CPT" } ], "standard_charges": [ { "gross_charge": 25526.85, "minimum": 1080.12, "maximum": 21697.82, "setting": "inpatient", "payers_information": [ { "payer_name": "Aarp", "plan_name": "500102", "standard_charge_dollar": 1080.12, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna", "plan_name": "700700", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna", "plan_name": "700700_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Mcare Ffs 6005", "plan_name": "700703", "standard_charge_dollar": 1080.12, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Miscellaneous", "plan_name": "700720", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Miscellaneous", "plan_name": "700720_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Ppo Hmo", "plan_name": "701720", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Ppo Hmo", "plan_name": "701720_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Ambetter 68069", "plan_name": "500516", "standard_charge_dollar": 1080.12, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Ms State Emplo", "plan_name": "401457", "standard_charge_percentage": 0.80, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Ms State Emplo", "plan_name": "401457_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Basic Pl", "plan_name": "400100", "standard_charge_percentage": 0.85, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Basic Pl", "plan_name": "400100_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Federal", "plan_name": "400110", "standard_charge_percentage": 0.85, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Federal", "plan_name": "400110_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Cigna Healthsprings Ffs", "plan_name": "500064", "standard_charge_dollar": 1080.12, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Conseco", "plan_name": "500302", "standard_charge_dollar": 1080.12, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Humana Ffs 61101", "plan_name": "500006", "standard_charge_dollar": 1080.12, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Medicare A", "plan_name": "100100", "standard_charge_dollar": 1080.12, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Medicare A", "plan_name": "100500", "standard_charge_dollar": 1080.12, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Medicare Part B Only", "plan_name": "100300", "standard_charge_dollar": 1080.12, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Medicare Railroad", "plan_name": "100103", "standard_charge_dollar": 1080.12, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Ms Physicians Care N", "plan_name": "714210", "standard_charge_dollar": 1350.15, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Peoples Hlth Ffs 72126", "plan_name": "500019", "standard_charge_dollar": 1080.12, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Uhc/Secure Horizons", "plan_name": "500449", "standard_charge_dollar": 1080.12, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "United Health Care/", "plan_name": "500292", "standard_charge_dollar": 1220.53, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "United Healthcare", "plan_name": "750104", "standard_charge_dollar": 1220.53, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "United Healthcare Ba", "plan_name": "750090", "standard_charge_dollar": 1220.53, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "United Healthcare Me", "plan_name": "501310", "standard_charge_dollar": 1080.12, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Windsor Mcare Extra", "plan_name": "500778", "standard_charge_dollar": 1080.12, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." } ] } ] }, { "description": "Colonoscopy w/resection", "code_information": [ { "code": "45390", "type": "CPT" } ], "standard_charges": [ { "gross_charge": 25526.85, "minimum": 370.37, "maximum": 3140.27, "setting": "inpatient", "payers_information": [ { "payer_name": "Aarp", "plan_name": "500102", "standard_charge_dollar": 2512.22, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna", "plan_name": "700700", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna", "plan_name": "700700_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Mcare Ffs 6005", "plan_name": "700703", "standard_charge_dollar": 2512.22, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Miscellaneous", "plan_name": "700720", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Miscellaneous", "plan_name": "700720_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Ppo Hmo", "plan_name": "701720", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Ppo Hmo", "plan_name": "701720_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Ambetter 68069", "plan_name": "500516", "standard_charge_dollar": 2512.22, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Ms State Emplo", "plan_name": "401457", "standard_charge_dollar": 370.37, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Ms State Emplo", "plan_name": "401457_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Basic Pl", "plan_name": "400100", "standard_charge_dollar": 370.37, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Basic Pl", "plan_name": "400100_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Federal", "plan_name": "400110", "standard_charge_dollar": 370.37, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Federal", "plan_name": "400110_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Cigna Healthsprings Ffs", "plan_name": "500064", "standard_charge_dollar": 2512.22, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Conseco", "plan_name": "500302", "standard_charge_dollar": 2512.22, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Humana Ffs 61101", "plan_name": "500006", "standard_charge_dollar": 2512.22, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Medicare A", "plan_name": "100100", "standard_charge_dollar": 2512.22, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Medicare A", "plan_name": "100500", "standard_charge_dollar": 2512.22, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Medicare Part B Only", "plan_name": "100300", "standard_charge_dollar": 2512.22, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Medicare Railroad", "plan_name": "100103", "standard_charge_dollar": 2512.22, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Ms Physicians Care N", "plan_name": "714210", "standard_charge_dollar": 3140.27, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Peoples Hlth Ffs 72126", "plan_name": "500019", "standard_charge_dollar": 2512.22, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Uhc/Secure Horizons", "plan_name": "500449", "standard_charge_dollar": 2512.22, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "United Health Care/", "plan_name": "500292", "standard_charge_dollar": 2838.81, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "United Healthcare", "plan_name": "750104", "standard_charge_dollar": 2838.81, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "United Healthcare Ba", "plan_name": "750090", "standard_charge_dollar": 2838.81, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "United Healthcare Me", "plan_name": "501310", "standard_charge_dollar": 2512.22, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Windsor Mcare Extra", "plan_name": "500778", "standard_charge_dollar": 2512.22, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." } ] } ] }, { "description": "Colonoscopy w/endoscope us", "code_information": [ { "code": "45391", "type": "CPT" } ], "standard_charges": [ { "gross_charge": 23731.77, "minimum": 1080.12, "maximum": 20172.00, "setting": "inpatient", "payers_information": [ { "payer_name": "Aarp", "plan_name": "500102", "standard_charge_dollar": 1080.12, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna", "plan_name": "700700", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna", "plan_name": "700700_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Mcare Ffs 6005", "plan_name": "700703", "standard_charge_dollar": 1080.12, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Miscellaneous", "plan_name": "700720", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Miscellaneous", "plan_name": "700720_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Ppo Hmo", "plan_name": "701720", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Ppo Hmo", "plan_name": "701720_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Ambetter 68069", "plan_name": "500516", "standard_charge_dollar": 1080.12, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Ms State Emplo", "plan_name": "401457", "standard_charge_percentage": 0.80, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Ms State Emplo", "plan_name": "401457_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Basic Pl", "plan_name": "400100", "standard_charge_percentage": 0.85, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Basic Pl", "plan_name": "400100_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Federal", "plan_name": "400110", "standard_charge_percentage": 0.85, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Federal", "plan_name": "400110_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Cigna Healthsprings Ffs", "plan_name": "500064", "standard_charge_dollar": 1080.12, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Conseco", "plan_name": "500302", "standard_charge_dollar": 1080.12, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Humana Ffs 61101", "plan_name": "500006", "standard_charge_dollar": 1080.12, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Medicare A", "plan_name": "100100", "standard_charge_dollar": 1080.12, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Medicare A", "plan_name": "100500", "standard_charge_dollar": 1080.12, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Medicare Part B Only", "plan_name": "100300", "standard_charge_dollar": 1080.12, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Medicare Railroad", "plan_name": "100103", "standard_charge_dollar": 1080.12, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Ms Physicians Care N", "plan_name": "714210", "standard_charge_dollar": 1350.15, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Peoples Hlth Ffs 72126", "plan_name": "500019", "standard_charge_dollar": 1080.12, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Uhc/Secure Horizons", "plan_name": "500449", "standard_charge_dollar": 1080.12, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "United Health Care/", "plan_name": "500292", "standard_charge_dollar": 1220.53, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "United Healthcare", "plan_name": "750104", "standard_charge_dollar": 1220.53, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "United Healthcare Ba", "plan_name": "750090", "standard_charge_dollar": 1220.53, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "United Healthcare Me", "plan_name": "501310", "standard_charge_dollar": 1080.12, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Windsor Mcare Extra", "plan_name": "500778", "standard_charge_dollar": 1080.12, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." } ] } ] }, { "description": "Lap removal of rectum", "code_information": [ { "code": "45395", "type": "CPT" } ], "standard_charges": [ { "gross_charge": 34473.25, "minimum": 27578.60, "maximum": 29302.26, "setting": "inpatient", "payers_information": [ { "payer_name": "Aetna", "plan_name": "700700", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna", "plan_name": "700700_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Miscellaneous", "plan_name": "700720", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Miscellaneous", "plan_name": "700720_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Ppo Hmo", "plan_name": "701720", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Ppo Hmo", "plan_name": "701720_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Ms State Emplo", "plan_name": "401457", "standard_charge_percentage": 0.80, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Ms State Emplo", "plan_name": "401457_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Basic Pl", "plan_name": "400100", "standard_charge_percentage": 0.85, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Basic Pl", "plan_name": "400100_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Federal", "plan_name": "400110", "standard_charge_percentage": 0.85, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Federal", "plan_name": "400110_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." } ] } ] }, { "description": "Lap remove rectum w/pouch", "code_information": [ { "code": "45397", "type": "CPT" } ], "standard_charges": [ { "gross_charge": 34473.25, "minimum": 27578.60, "maximum": 29302.26, "setting": "inpatient", "payers_information": [ { "payer_name": "Aetna", "plan_name": "700700", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna", "plan_name": "700700_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Miscellaneous", "plan_name": "700720", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Miscellaneous", "plan_name": "700720_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Ppo Hmo", "plan_name": "701720", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Ppo Hmo", "plan_name": "701720_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Ms State Emplo", "plan_name": "401457", "standard_charge_percentage": 0.80, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Ms State Emplo", "plan_name": "401457_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Basic Pl", "plan_name": "400100", "standard_charge_percentage": 0.85, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Basic Pl", "plan_name": "400100_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Federal", "plan_name": "400110", "standard_charge_percentage": 0.85, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Federal", "plan_name": "400110_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." } ] } ] }, { "description": "Unlisted procedure colon", "code_information": [ { "code": "45399", "type": "CPT" } ], "standard_charges": [ { "gross_charge": 52166.00, "minimum": 835.19, "maximum": 1043.99, "setting": "inpatient", "payers_information": [ { "payer_name": "Aarp", "plan_name": "500102", "standard_charge_dollar": 835.19, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna", "plan_name": "700700", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna", "plan_name": "700700_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Mcare Ffs 6005", "plan_name": "700703", "standard_charge_dollar": 835.19, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Miscellaneous", "plan_name": "700720", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Miscellaneous", "plan_name": "700720_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Ppo Hmo", "plan_name": "701720", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Ppo Hmo", "plan_name": "701720_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Ambetter 68069", "plan_name": "500516", "standard_charge_dollar": 835.19, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Ms State Emplo", "plan_name": "401457", "standard_charge_dollar": 908.34, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Ms State Emplo", "plan_name": "401457_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Basic Pl", "plan_name": "400100", "standard_charge_dollar": 908.34, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Basic Pl", "plan_name": "400100_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Federal", "plan_name": "400110", "standard_charge_dollar": 908.34, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Federal", "plan_name": "400110_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Cigna Healthsprings Ffs", "plan_name": "500064", "standard_charge_dollar": 835.19, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Conseco", "plan_name": "500302", "standard_charge_dollar": 835.19, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Humana Ffs 61101", "plan_name": "500006", "standard_charge_dollar": 835.19, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Medicare A", "plan_name": "100100", "standard_charge_dollar": 835.19, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Medicare A", "plan_name": "100500", "standard_charge_dollar": 835.19, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Medicare Part B Only", "plan_name": "100300", "standard_charge_dollar": 835.19, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Medicare Railroad", "plan_name": "100103", "standard_charge_dollar": 835.19, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Ms Physicians Care N", "plan_name": "714210", "standard_charge_dollar": 1043.99, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Peoples Hlth Ffs 72126", "plan_name": "500019", "standard_charge_dollar": 835.19, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Uhc/Secure Horizons", "plan_name": "500449", "standard_charge_dollar": 835.19, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "United Health Care/", "plan_name": "500292", "standard_charge_dollar": 943.76, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "United Healthcare", "plan_name": "750104", "standard_charge_dollar": 943.76, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "United Healthcare Ba", "plan_name": "750090", "standard_charge_dollar": 943.76, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "United Healthcare Me", "plan_name": "501310", "standard_charge_dollar": 835.19, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Windsor Mcare Extra", "plan_name": "500778", "standard_charge_dollar": 835.19, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." } ] } ] }, { "description": "Repair rectum/remove sigmoid", "code_information": [ { "code": "45550", "type": "CPT" } ], "standard_charges": [ { "gross_charge": 22932.33, "minimum": 18345.86, "maximum": 19492.48, "setting": "inpatient", "payers_information": [ { "payer_name": "Aetna", "plan_name": "700700", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna", "plan_name": "700700_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Miscellaneous", "plan_name": "700720", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Miscellaneous", "plan_name": "700720_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Ppo Hmo", "plan_name": "701720", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Ppo Hmo", "plan_name": "701720_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Ms State Emplo", "plan_name": "401457", "standard_charge_percentage": 0.80, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Ms State Emplo", "plan_name": "401457_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Basic Pl", "plan_name": "400100", "standard_charge_percentage": 0.85, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Basic Pl", "plan_name": "400100_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Federal", "plan_name": "400110", "standard_charge_percentage": 0.85, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Federal", "plan_name": "400110_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." } ] } ] }, { "description": "Exploration/repair of rectum", "code_information": [ { "code": "45562", "type": "CPT" } ], "standard_charges": [ { "gross_charge": 38550.01, "minimum": 30840.01, "maximum": 32767.51, "setting": "inpatient", "payers_information": [ { "payer_name": "Aetna", "plan_name": "700700", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna", "plan_name": "700700_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Miscellaneous", "plan_name": "700720", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Miscellaneous", "plan_name": "700720_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Ppo Hmo", "plan_name": "701720", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Ppo Hmo", "plan_name": "701720_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Ms State Emplo", "plan_name": "401457", "standard_charge_percentage": 0.80, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Ms State Emplo", "plan_name": "401457_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Basic Pl", "plan_name": "400100", "standard_charge_percentage": 0.85, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Basic Pl", "plan_name": "400100_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Federal", "plan_name": "400110", "standard_charge_percentage": 0.85, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Federal", "plan_name": "400110_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." } ] } ] }, { "description": "Exploration/repair of rectum", "code_information": [ { "code": "45563", "type": "CPT" } ], "standard_charges": [ { "gross_charge": 37440.82, "minimum": 29952.66, "maximum": 31824.70, "setting": "inpatient", "payers_information": [ { "payer_name": "Aetna", "plan_name": "700700", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna", "plan_name": "700700_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Miscellaneous", "plan_name": "700720", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Miscellaneous", "plan_name": "700720_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Ppo Hmo", "plan_name": "701720", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Ppo Hmo", "plan_name": "701720_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Ms State Emplo", "plan_name": "401457", "standard_charge_percentage": 0.80, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Ms State Emplo", "plan_name": "401457_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Basic Pl", "plan_name": "400100", "standard_charge_percentage": 0.85, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Basic Pl", "plan_name": "400100_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Federal", "plan_name": "400110", "standard_charge_percentage": 0.85, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Federal", "plan_name": "400110_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." } ] } ] }, { "description": "Repair rect/bladder fistula", "code_information": [ { "code": "45800", "type": "CPT" } ], "standard_charges": [ { "gross_charge": 68896.77, "minimum": 55117.42, "maximum": 58562.25, "setting": "inpatient", "payers_information": [ { "payer_name": "Aetna", "plan_name": "700700", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna", "plan_name": "700700_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Miscellaneous", "plan_name": "700720", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Miscellaneous", "plan_name": "700720_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Ppo Hmo", "plan_name": "701720", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Ppo Hmo", "plan_name": "701720_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Ms State Emplo", "plan_name": "401457", "standard_charge_percentage": 0.80, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Ms State Emplo", "plan_name": "401457_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Basic Pl", "plan_name": "400100", "standard_charge_percentage": 0.85, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Basic Pl", "plan_name": "400100_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Federal", "plan_name": "400110", "standard_charge_percentage": 0.85, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Federal", "plan_name": "400110_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." } ] } ] }, { "description": "Repair fistula w/colostomy", "code_information": [ { "code": "45805", "type": "CPT" } ], "standard_charges": [ { "gross_charge": 68896.77, "minimum": 55117.42, "maximum": 58562.25, "setting": "inpatient", "payers_information": [ { "payer_name": "Aetna", "plan_name": "700700", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna", "plan_name": "700700_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Miscellaneous", "plan_name": "700720", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Miscellaneous", "plan_name": "700720_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Ppo Hmo", "plan_name": "701720", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Ppo Hmo", "plan_name": "701720_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Ms State Emplo", "plan_name": "401457", "standard_charge_percentage": 0.80, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Ms State Emplo", "plan_name": "401457_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Basic Pl", "plan_name": "400100", "standard_charge_percentage": 0.85, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Basic Pl", "plan_name": "400100_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Federal", "plan_name": "400110", "standard_charge_percentage": 0.85, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Federal", "plan_name": "400110_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." } ] } ] }, { "description": "Repair fistula w/colostomy", "code_information": [ { "code": "45825", "type": "CPT" } ], "standard_charges": [ { "gross_charge": 34473.25, "minimum": 27578.60, "maximum": 29302.26, "setting": "inpatient", "payers_information": [ { "payer_name": "Aetna", "plan_name": "700700", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna", "plan_name": "700700_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Miscellaneous", "plan_name": "700720", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Miscellaneous", "plan_name": "700720_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Ppo Hmo", "plan_name": "701720", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Ppo Hmo", "plan_name": "701720_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Ms State Emplo", "plan_name": "401457", "standard_charge_percentage": 0.80, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Ms State Emplo", "plan_name": "401457_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Basic Pl", "plan_name": "400100", "standard_charge_percentage": 0.85, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Basic Pl", "plan_name": "400100_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Federal", "plan_name": "400110", "standard_charge_percentage": 0.85, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Federal", "plan_name": "400110_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." } ] } ] }, { "description": "Surg dx exam anorectal", "code_information": [ { "code": "45990", "type": "CPT" } ], "standard_charges": [ { "gross_charge": 23731.77, "minimum": 2512.22, "maximum": 20172.00, "setting": "inpatient", "payers_information": [ { "payer_name": "Aarp", "plan_name": "500102", "standard_charge_dollar": 2512.22, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna", "plan_name": "700700", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna", "plan_name": "700700_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Mcare Ffs 6005", "plan_name": "700703", "standard_charge_dollar": 2512.22, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Miscellaneous", "plan_name": "700720", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Miscellaneous", "plan_name": "700720_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Ppo Hmo", "plan_name": "701720", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Ppo Hmo", "plan_name": "701720_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Ambetter 68069", "plan_name": "500516", "standard_charge_dollar": 2512.22, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Ms State Emplo", "plan_name": "401457", "standard_charge_percentage": 0.80, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Ms State Emplo", "plan_name": "401457_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Basic Pl", "plan_name": "400100", "standard_charge_percentage": 0.85, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Basic Pl", "plan_name": "400100_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Federal", "plan_name": "400110", "standard_charge_percentage": 0.85, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Federal", "plan_name": "400110_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Cigna Healthsprings Ffs", "plan_name": "500064", "standard_charge_dollar": 2512.22, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Conseco", "plan_name": "500302", "standard_charge_dollar": 2512.22, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Humana Ffs 61101", "plan_name": "500006", "standard_charge_dollar": 2512.22, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Medicare A", "plan_name": "100100", "standard_charge_dollar": 2512.22, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Medicare A", "plan_name": "100500", "standard_charge_dollar": 2512.22, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Medicare Part B Only", "plan_name": "100300", "standard_charge_dollar": 2512.22, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Medicare Railroad", "plan_name": "100103", "standard_charge_dollar": 2512.22, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Ms Physicians Care N", "plan_name": "714210", "standard_charge_dollar": 3140.27, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Peoples Hlth Ffs 72126", "plan_name": "500019", "standard_charge_dollar": 2512.22, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Uhc/Secure Horizons", "plan_name": "500449", "standard_charge_dollar": 2512.22, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "United Health Care/", "plan_name": "500292", "standard_charge_dollar": 2838.81, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "United Healthcare", "plan_name": "750104", "standard_charge_dollar": 2838.81, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "United Healthcare Ba", "plan_name": "750090", "standard_charge_dollar": 2838.81, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "United Healthcare Me", "plan_name": "501310", "standard_charge_dollar": 2512.22, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Windsor Mcare Extra", "plan_name": "500778", "standard_charge_dollar": 2512.22, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." } ] } ] }, { "description": "Rectum surgery procedure", "code_information": [ { "code": "45999", "type": "CPT" } ], "standard_charges": [ { "gross_charge": 41795.31, "minimum": 835.19, "maximum": 35526.01, "setting": "inpatient", "payers_information": [ { "payer_name": "Aarp", "plan_name": "500102", "standard_charge_dollar": 835.19, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna", "plan_name": "700700", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna", "plan_name": "700700_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Mcare Ffs 6005", "plan_name": "700703", "standard_charge_dollar": 835.19, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Miscellaneous", "plan_name": "700720", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Miscellaneous", "plan_name": "700720_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Ppo Hmo", "plan_name": "701720", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Ppo Hmo", "plan_name": "701720_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Ambetter 68069", "plan_name": "500516", "standard_charge_dollar": 835.19, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Ms State Emplo", "plan_name": "401457", "standard_charge_percentage": 0.80, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Ms State Emplo", "plan_name": "401457_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Basic Pl", "plan_name": "400100", "standard_charge_percentage": 0.85, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Basic Pl", "plan_name": "400100_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Federal", "plan_name": "400110", "standard_charge_percentage": 0.85, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Federal", "plan_name": "400110_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Cigna Healthsprings Ffs", "plan_name": "500064", "standard_charge_dollar": 835.19, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Conseco", "plan_name": "500302", "standard_charge_dollar": 835.19, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Humana Ffs 61101", "plan_name": "500006", "standard_charge_dollar": 835.19, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Medicare A", "plan_name": "100100", "standard_charge_dollar": 835.19, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Medicare A", "plan_name": "100500", "standard_charge_dollar": 835.19, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Medicare Part B Only", "plan_name": "100300", "standard_charge_dollar": 835.19, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Medicare Railroad", "plan_name": "100103", "standard_charge_dollar": 835.19, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Ms Physicians Care N", "plan_name": "714210", "standard_charge_dollar": 1043.99, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Peoples Hlth Ffs 72126", "plan_name": "500019", "standard_charge_dollar": 835.19, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Uhc/Secure Horizons", "plan_name": "500449", "standard_charge_dollar": 835.19, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "United Health Care/", "plan_name": "500292", "standard_charge_dollar": 943.76, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "United Healthcare", "plan_name": "750104", "standard_charge_dollar": 943.76, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "United Healthcare Ba", "plan_name": "750090", "standard_charge_dollar": 943.76, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "United Healthcare Me", "plan_name": "501310", "standard_charge_dollar": 835.19, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Windsor Mcare Extra", "plan_name": "500778", "standard_charge_dollar": 835.19, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." } ] } ] }, { "description": "Incision of rectal abscess", "code_information": [ { "code": "46060", "type": "CPT" } ], "standard_charges": [ { "gross_charge": 36422.18, "minimum": 2512.22, "maximum": 30958.85, "setting": "inpatient", "payers_information": [ { "payer_name": "Aarp", "plan_name": "500102", "standard_charge_dollar": 2512.22, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna", "plan_name": "700700", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna", "plan_name": "700700_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Mcare Ffs 6005", "plan_name": "700703", "standard_charge_dollar": 2512.22, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Miscellaneous", "plan_name": "700720", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Miscellaneous", "plan_name": "700720_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Ppo Hmo", "plan_name": "701720", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Ppo Hmo", "plan_name": "701720_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Ambetter 68069", "plan_name": "500516", "standard_charge_dollar": 2512.22, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Ms State Emplo", "plan_name": "401457", "standard_charge_percentage": 0.80, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Ms State Emplo", "plan_name": "401457_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Basic Pl", "plan_name": "400100", "standard_charge_percentage": 0.85, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Basic Pl", "plan_name": "400100_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Federal", "plan_name": "400110", "standard_charge_percentage": 0.85, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Federal", "plan_name": "400110_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Cigna Healthsprings Ffs", "plan_name": "500064", "standard_charge_dollar": 2512.22, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Conseco", "plan_name": "500302", "standard_charge_dollar": 2512.22, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Humana Ffs 61101", "plan_name": "500006", "standard_charge_dollar": 2512.22, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Medicare A", "plan_name": "100100", "standard_charge_dollar": 2512.22, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Medicare A", "plan_name": "100500", "standard_charge_dollar": 2512.22, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Medicare Part B Only", "plan_name": "100300", "standard_charge_dollar": 2512.22, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Medicare Railroad", "plan_name": "100103", "standard_charge_dollar": 2512.22, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Ms Physicians Care N", "plan_name": "714210", "standard_charge_dollar": 3140.27, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Peoples Hlth Ffs 72126", "plan_name": "500019", "standard_charge_dollar": 2512.22, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Uhc/Secure Horizons", "plan_name": "500449", "standard_charge_dollar": 2512.22, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "United Health Care/", "plan_name": "500292", "standard_charge_dollar": 2838.81, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "United Healthcare", "plan_name": "750104", "standard_charge_dollar": 2838.81, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "United Healthcare Ba", "plan_name": "750090", "standard_charge_dollar": 2838.81, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "United Healthcare Me", "plan_name": "501310", "standard_charge_dollar": 2512.22, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Windsor Mcare Extra", "plan_name": "500778", "standard_charge_dollar": 2512.22, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." } ] } ] }, { "description": "Hc i & d thrombosed hemorrhoid ext", "code_information": [ { "code": "46083", "type": "CPT" } ], "standard_charges": [ { "gross_charge": 175.00, "minimum": 140.00, "maximum": 278.50, "setting": "both", "payers_information": [ { "payer_name": "Aarp", "plan_name": "500102", "standard_charge_dollar": 222.80, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna", "plan_name": "700700", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna", "plan_name": "700700_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Mcare Ffs 6005", "plan_name": "700703", "standard_charge_dollar": 222.80, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Miscellaneous", "plan_name": "700720", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Miscellaneous", "plan_name": "700720_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Ppo Hmo", "plan_name": "701720", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Ppo Hmo", "plan_name": "701720_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Ambetter 68069", "plan_name": "500516", "standard_charge_dollar": 222.80, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Ms State Emplo", "plan_name": "401457", "standard_charge_percentage": 0.80, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Ms State Emplo", "plan_name": "401457_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Basic Pl", "plan_name": "400100", "standard_charge_percentage": 0.85, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Basic Pl", "plan_name": "400100_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Federal", "plan_name": "400110", "standard_charge_percentage": 0.85, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Federal", "plan_name": "400110_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Cigna Healthsprings Ffs", "plan_name": "500064", "standard_charge_dollar": 222.80, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Conseco", "plan_name": "500302", "standard_charge_dollar": 222.80, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Humana Ffs 61101", "plan_name": "500006", "standard_charge_dollar": 222.80, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Medicare A", "plan_name": "100100", "standard_charge_dollar": 222.80, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Medicare A", "plan_name": "100500", "standard_charge_dollar": 222.80, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Medicare Part B Only", "plan_name": "100300", "standard_charge_dollar": 222.80, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Medicare Railroad", "plan_name": "100103", "standard_charge_dollar": 222.80, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Ms Physicians Care N", "plan_name": "714210", "standard_charge_dollar": 278.50, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Peoples Hlth Ffs 72126", "plan_name": "500019", "standard_charge_dollar": 222.80, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Uhc/Secure Horizons", "plan_name": "500449", "standard_charge_dollar": 222.80, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "United Health Care/", "plan_name": "500292", "standard_charge_dollar": 251.76, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "United Healthcare", "plan_name": "750104", "standard_charge_dollar": 251.76, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "United Healthcare Ba", "plan_name": "750090", "standard_charge_dollar": 251.76, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "United Healthcare Me", "plan_name": "501310", "standard_charge_dollar": 222.80, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Windsor Mcare Extra", "plan_name": "500778", "standard_charge_dollar": 222.80, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." } ] } ] }, { "description": "Incise external hemorrhoid", "code_information": [ { "code": "46083", "type": "CPT" } ], "standard_charges": [ { "gross_charge": 31483.82, "minimum": 222.80, "maximum": 26761.25, "setting": "inpatient", "payers_information": [ { "payer_name": "Aarp", "plan_name": "500102", "standard_charge_dollar": 222.80, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna", "plan_name": "700700", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna", "plan_name": "700700_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Mcare Ffs 6005", "plan_name": "700703", "standard_charge_dollar": 222.80, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Miscellaneous", "plan_name": "700720", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Miscellaneous", "plan_name": "700720_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Ppo Hmo", "plan_name": "701720", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Ppo Hmo", "plan_name": "701720_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Ambetter 68069", "plan_name": "500516", "standard_charge_dollar": 222.80, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Ms State Emplo", "plan_name": "401457", "standard_charge_percentage": 0.80, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Ms State Emplo", "plan_name": "401457_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Basic Pl", "plan_name": "400100", "standard_charge_percentage": 0.85, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Basic Pl", "plan_name": "400100_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Federal", "plan_name": "400110", "standard_charge_percentage": 0.85, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Federal", "plan_name": "400110_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Cigna Healthsprings Ffs", "plan_name": "500064", "standard_charge_dollar": 222.80, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Conseco", "plan_name": "500302", "standard_charge_dollar": 222.80, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Humana Ffs 61101", "plan_name": "500006", "standard_charge_dollar": 222.80, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Medicare A", "plan_name": "100100", "standard_charge_dollar": 222.80, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Medicare A", "plan_name": "100500", "standard_charge_dollar": 222.80, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Medicare Part B Only", "plan_name": "100300", "standard_charge_dollar": 222.80, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Medicare Railroad", "plan_name": "100103", "standard_charge_dollar": 222.80, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Ms Physicians Care N", "plan_name": "714210", "standard_charge_dollar": 278.50, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Peoples Hlth Ffs 72126", "plan_name": "500019", "standard_charge_dollar": 222.80, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Uhc/Secure Horizons", "plan_name": "500449", "standard_charge_dollar": 222.80, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "United Health Care/", "plan_name": "500292", "standard_charge_dollar": 251.76, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "United Healthcare", "plan_name": "750104", "standard_charge_dollar": 251.76, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "United Healthcare Ba", "plan_name": "750090", "standard_charge_dollar": 251.76, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "United Healthcare Me", "plan_name": "501310", "standard_charge_dollar": 222.80, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Windsor Mcare Extra", "plan_name": "500778", "standard_charge_dollar": 222.80, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." } ] } ] }, { "description": "Incise external hemorrhoid", "code_information": [ { "code": "46083", "type": "CPT" } ], "standard_charges": [ { "gross_charge": 175.00, "minimum": 140.00, "maximum": 278.50, "setting": "outpatient", "payers_information": [ { "payer_name": "Aarp", "plan_name": "500102", "standard_charge_dollar": 222.80, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna", "plan_name": "700700", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna", "plan_name": "700700_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Mcare Ffs 6005", "plan_name": "700703", "standard_charge_dollar": 222.80, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Miscellaneous", "plan_name": "700720", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Miscellaneous", "plan_name": "700720_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Ppo Hmo", "plan_name": "701720", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Ppo Hmo", "plan_name": "701720_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Ambetter 68069", "plan_name": "500516", "standard_charge_dollar": 222.80, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Ms State Emplo", "plan_name": "401457", "standard_charge_percentage": 0.80, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Ms State Emplo", "plan_name": "401457_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Basic Pl", "plan_name": "400100", "standard_charge_percentage": 0.85, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Basic Pl", "plan_name": "400100_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Federal", "plan_name": "400110", "standard_charge_percentage": 0.85, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Federal", "plan_name": "400110_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Cigna Healthsprings Ffs", "plan_name": "500064", "standard_charge_dollar": 222.80, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Conseco", "plan_name": "500302", "standard_charge_dollar": 222.80, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Humana Ffs 61101", "plan_name": "500006", "standard_charge_dollar": 222.80, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Medicare A", "plan_name": "100100", "standard_charge_dollar": 222.80, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Medicare A", "plan_name": "100500", "standard_charge_dollar": 222.80, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Medicare Part B Only", "plan_name": "100300", "standard_charge_dollar": 222.80, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Medicare Railroad", "plan_name": "100103", "standard_charge_dollar": 222.80, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Ms Physicians Care N", "plan_name": "714210", "standard_charge_dollar": 278.50, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Peoples Hlth Ffs 72126", "plan_name": "500019", "standard_charge_dollar": 222.80, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Uhc/Secure Horizons", "plan_name": "500449", "standard_charge_dollar": 222.80, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "United Health Care/", "plan_name": "500292", "standard_charge_dollar": 251.76, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "United Healthcare", "plan_name": "750104", "standard_charge_dollar": 251.76, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "United Healthcare Ba", "plan_name": "750090", "standard_charge_dollar": 251.76, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "United Healthcare Me", "plan_name": "501310", "standard_charge_dollar": 222.80, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Windsor Mcare Extra", "plan_name": "500778", "standard_charge_dollar": 222.80, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." } ] } ] }, { "description": "Remove int/ext hem 1 group", "code_information": [ { "code": "46255", "type": "CPT" } ], "standard_charges": [ { "gross_charge": 31483.82, "minimum": 2512.22, "maximum": 26761.25, "setting": "inpatient", "payers_information": [ { "payer_name": "Aarp", "plan_name": "500102", "standard_charge_dollar": 2512.22, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna", "plan_name": "700700", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna", "plan_name": "700700_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Mcare Ffs 6005", "plan_name": "700703", "standard_charge_dollar": 2512.22, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Miscellaneous", "plan_name": "700720", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Miscellaneous", "plan_name": "700720_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Ppo Hmo", "plan_name": "701720", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Ppo Hmo", "plan_name": "701720_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Ambetter 68069", "plan_name": "500516", "standard_charge_dollar": 2512.22, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Ms State Emplo", "plan_name": "401457", "standard_charge_percentage": 0.80, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Ms State Emplo", "plan_name": "401457_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Basic Pl", "plan_name": "400100", "standard_charge_percentage": 0.85, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Basic Pl", "plan_name": "400100_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Federal", "plan_name": "400110", "standard_charge_percentage": 0.85, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Federal", "plan_name": "400110_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Cigna Healthsprings Ffs", "plan_name": "500064", "standard_charge_dollar": 2512.22, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Conseco", "plan_name": "500302", "standard_charge_dollar": 2512.22, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Humana Ffs 61101", "plan_name": "500006", "standard_charge_dollar": 2512.22, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Medicare A", "plan_name": "100100", "standard_charge_dollar": 2512.22, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Medicare A", "plan_name": "100500", "standard_charge_dollar": 2512.22, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Medicare Part B Only", "plan_name": "100300", "standard_charge_dollar": 2512.22, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Medicare Railroad", "plan_name": "100103", "standard_charge_dollar": 2512.22, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Ms Physicians Care N", "plan_name": "714210", "standard_charge_dollar": 3140.27, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Peoples Hlth Ffs 72126", "plan_name": "500019", "standard_charge_dollar": 2512.22, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Uhc/Secure Horizons", "plan_name": "500449", "standard_charge_dollar": 2512.22, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "United Health Care/", "plan_name": "500292", "standard_charge_dollar": 2838.81, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "United Healthcare", "plan_name": "750104", "standard_charge_dollar": 2838.81, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "United Healthcare Ba", "plan_name": "750090", "standard_charge_dollar": 2838.81, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "United Healthcare Me", "plan_name": "501310", "standard_charge_dollar": 2512.22, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Windsor Mcare Extra", "plan_name": "500778", "standard_charge_dollar": 2512.22, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." } ] } ] }, { "description": "Remove in/ex hem grp & fiss", "code_information": [ { "code": "46257", "type": "CPT" } ], "standard_charges": [ { "gross_charge": 31483.82, "minimum": 2512.22, "maximum": 26761.25, "setting": "inpatient", "payers_information": [ { "payer_name": "Aarp", "plan_name": "500102", "standard_charge_dollar": 2512.22, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna", "plan_name": "700700", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna", "plan_name": "700700_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Mcare Ffs 6005", "plan_name": "700703", "standard_charge_dollar": 2512.22, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Miscellaneous", "plan_name": "700720", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Miscellaneous", "plan_name": "700720_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Ppo Hmo", "plan_name": "701720", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Ppo Hmo", "plan_name": "701720_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Ambetter 68069", "plan_name": "500516", "standard_charge_dollar": 2512.22, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Ms State Emplo", "plan_name": "401457", "standard_charge_percentage": 0.80, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Ms State Emplo", "plan_name": "401457_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Basic Pl", "plan_name": "400100", "standard_charge_percentage": 0.85, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Basic Pl", "plan_name": "400100_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Federal", "plan_name": "400110", "standard_charge_percentage": 0.85, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Federal", "plan_name": "400110_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Cigna Healthsprings Ffs", "plan_name": "500064", "standard_charge_dollar": 2512.22, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Conseco", "plan_name": "500302", "standard_charge_dollar": 2512.22, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Humana Ffs 61101", "plan_name": "500006", "standard_charge_dollar": 2512.22, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Medicare A", "plan_name": "100100", "standard_charge_dollar": 2512.22, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Medicare A", "plan_name": "100500", "standard_charge_dollar": 2512.22, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Medicare Part B Only", "plan_name": "100300", "standard_charge_dollar": 2512.22, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Medicare Railroad", "plan_name": "100103", "standard_charge_dollar": 2512.22, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Ms Physicians Care N", "plan_name": "714210", "standard_charge_dollar": 3140.27, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Peoples Hlth Ffs 72126", "plan_name": "500019", "standard_charge_dollar": 2512.22, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Uhc/Secure Horizons", "plan_name": "500449", "standard_charge_dollar": 2512.22, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "United Health Care/", "plan_name": "500292", "standard_charge_dollar": 2838.81, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "United Healthcare", "plan_name": "750104", "standard_charge_dollar": 2838.81, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "United Healthcare Ba", "plan_name": "750090", "standard_charge_dollar": 2838.81, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "United Healthcare Me", "plan_name": "501310", "standard_charge_dollar": 2512.22, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Windsor Mcare Extra", "plan_name": "500778", "standard_charge_dollar": 2512.22, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." } ] } ] }, { "description": "Remove in/ex hem grps w/fist", "code_information": [ { "code": "46262", "type": "CPT" } ], "standard_charges": [ { "gross_charge": 31483.82, "minimum": 2512.22, "maximum": 26761.25, "setting": "inpatient", "payers_information": [ { "payer_name": "Aarp", "plan_name": "500102", "standard_charge_dollar": 2512.22, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna", "plan_name": "700700", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna", "plan_name": "700700_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Mcare Ffs 6005", "plan_name": "700703", "standard_charge_dollar": 2512.22, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Miscellaneous", "plan_name": "700720", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Miscellaneous", "plan_name": "700720_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Ppo Hmo", "plan_name": "701720", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Ppo Hmo", "plan_name": "701720_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Ambetter 68069", "plan_name": "500516", "standard_charge_dollar": 2512.22, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Ms State Emplo", "plan_name": "401457", "standard_charge_percentage": 0.80, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Ms State Emplo", "plan_name": "401457_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Basic Pl", "plan_name": "400100", "standard_charge_percentage": 0.85, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Basic Pl", "plan_name": "400100_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Federal", "plan_name": "400110", "standard_charge_percentage": 0.85, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Federal", "plan_name": "400110_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Cigna Healthsprings Ffs", "plan_name": "500064", "standard_charge_dollar": 2512.22, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Conseco", "plan_name": "500302", "standard_charge_dollar": 2512.22, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Humana Ffs 61101", "plan_name": "500006", "standard_charge_dollar": 2512.22, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Medicare A", "plan_name": "100100", "standard_charge_dollar": 2512.22, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Medicare A", "plan_name": "100500", "standard_charge_dollar": 2512.22, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Medicare Part B Only", "plan_name": "100300", "standard_charge_dollar": 2512.22, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Medicare Railroad", "plan_name": "100103", "standard_charge_dollar": 2512.22, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Ms Physicians Care N", "plan_name": "714210", "standard_charge_dollar": 3140.27, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Peoples Hlth Ffs 72126", "plan_name": "500019", "standard_charge_dollar": 2512.22, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Uhc/Secure Horizons", "plan_name": "500449", "standard_charge_dollar": 2512.22, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "United Health Care/", "plan_name": "500292", "standard_charge_dollar": 2838.81, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "United Healthcare", "plan_name": "750104", "standard_charge_dollar": 2838.81, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "United Healthcare Ba", "plan_name": "750090", "standard_charge_dollar": 2838.81, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "United Healthcare Me", "plan_name": "501310", "standard_charge_dollar": 2512.22, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Windsor Mcare Extra", "plan_name": "500778", "standard_charge_dollar": 2512.22, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." } ] } ] }, { "description": "Removal of hemorrhoid clot", "code_information": [ { "code": "46320", "type": "CPT" } ], "standard_charges": [ { "gross_charge": 31483.82, "minimum": 1080.12, "maximum": 26761.25, "setting": "inpatient", "payers_information": [ { "payer_name": "Aarp", "plan_name": "500102", "standard_charge_dollar": 1080.12, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna", "plan_name": "700700", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna", "plan_name": "700700_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Mcare Ffs 6005", "plan_name": "700703", "standard_charge_dollar": 1080.12, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Miscellaneous", "plan_name": "700720", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Miscellaneous", "plan_name": "700720_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Ppo Hmo", "plan_name": "701720", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Ppo Hmo", "plan_name": "701720_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Ambetter 68069", "plan_name": "500516", "standard_charge_dollar": 1080.12, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Ms State Emplo", "plan_name": "401457", "standard_charge_percentage": 0.80, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Ms State Emplo", "plan_name": "401457_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Basic Pl", "plan_name": "400100", "standard_charge_percentage": 0.85, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Basic Pl", "plan_name": "400100_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Federal", "plan_name": "400110", "standard_charge_percentage": 0.85, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Federal", "plan_name": "400110_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Cigna Healthsprings Ffs", "plan_name": "500064", "standard_charge_dollar": 1080.12, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Conseco", "plan_name": "500302", "standard_charge_dollar": 1080.12, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Humana Ffs 61101", "plan_name": "500006", "standard_charge_dollar": 1080.12, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Medicare A", "plan_name": "100100", "standard_charge_dollar": 1080.12, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Medicare A", "plan_name": "100500", "standard_charge_dollar": 1080.12, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Medicare Part B Only", "plan_name": "100300", "standard_charge_dollar": 1080.12, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Medicare Railroad", "plan_name": "100103", "standard_charge_dollar": 1080.12, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Ms Physicians Care N", "plan_name": "714210", "standard_charge_dollar": 1350.15, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Peoples Hlth Ffs 72126", "plan_name": "500019", "standard_charge_dollar": 1080.12, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Uhc/Secure Horizons", "plan_name": "500449", "standard_charge_dollar": 1080.12, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "United Health Care/", "plan_name": "500292", "standard_charge_dollar": 1220.53, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "United Healthcare", "plan_name": "750104", "standard_charge_dollar": 1220.53, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "United Healthcare Ba", "plan_name": "750090", "standard_charge_dollar": 1220.53, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "United Healthcare Me", "plan_name": "501310", "standard_charge_dollar": 1080.12, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Windsor Mcare Extra", "plan_name": "500778", "standard_charge_dollar": 1080.12, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." } ] } ] }, { "description": "Diagnostic anoscopy spx", "code_information": [ { "code": "46600", "type": "CPT" } ], "standard_charges": [ { "gross_charge": 23731.77, "minimum": 118.08, "maximum": 149.97, "setting": "inpatient", "payers_information": [ { "payer_name": "Aarp", "plan_name": "500102", "standard_charge_dollar": 118.08, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna", "plan_name": "700700", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna", "plan_name": "700700_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Mcare Ffs 6005", "plan_name": "700703", "standard_charge_dollar": 118.08, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Miscellaneous", "plan_name": "700720", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Miscellaneous", "plan_name": "700720_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Ppo Hmo", "plan_name": "701720", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Ppo Hmo", "plan_name": "701720_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Ambetter 68069", "plan_name": "500516", "standard_charge_dollar": 118.08, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Ms State Emplo", "plan_name": "401457", "standard_charge_dollar": 149.97, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Ms State Emplo", "plan_name": "401457_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Basic Pl", "plan_name": "400100", "standard_charge_dollar": 149.97, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Basic Pl", "plan_name": "400100_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Federal", "plan_name": "400110", "standard_charge_dollar": 149.97, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Federal", "plan_name": "400110_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Cigna Healthsprings Ffs", "plan_name": "500064", "standard_charge_dollar": 118.08, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Conseco", "plan_name": "500302", "standard_charge_dollar": 118.08, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Humana Ffs 61101", "plan_name": "500006", "standard_charge_dollar": 118.08, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Medicare A", "plan_name": "100100", "standard_charge_dollar": 118.08, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Medicare A", "plan_name": "100500", "standard_charge_dollar": 118.08, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Medicare Part B Only", "plan_name": "100300", "standard_charge_dollar": 118.08, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Medicare Railroad", "plan_name": "100103", "standard_charge_dollar": 118.08, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Ms Physicians Care N", "plan_name": "714210", "standard_charge_dollar": 147.60, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Peoples Hlth Ffs 72126", "plan_name": "500019", "standard_charge_dollar": 118.08, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Uhc/Secure Horizons", "plan_name": "500449", "standard_charge_dollar": 118.08, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "United Health Care/", "plan_name": "500292", "standard_charge_dollar": 133.43, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "United Healthcare", "plan_name": "750104", "standard_charge_dollar": 133.43, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "United Healthcare Ba", "plan_name": "750090", "standard_charge_dollar": 133.43, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "United Healthcare Me", "plan_name": "501310", "standard_charge_dollar": 118.08, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Windsor Mcare Extra", "plan_name": "500778", "standard_charge_dollar": 118.08, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." } ] } ] }, { "description": "Diagnostic anoscopy", "code_information": [ { "code": "46601", "type": "CPT" } ], "standard_charges": [ { "gross_charge": 23731.77, "minimum": 81.80, "maximum": 456.94, "setting": "inpatient", "payers_information": [ { "payer_name": "Aarp", "plan_name": "500102", "standard_charge_dollar": 365.55, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna", "plan_name": "700700", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna", "plan_name": "700700_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Mcare Ffs 6005", "plan_name": "700703", "standard_charge_dollar": 365.55, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Miscellaneous", "plan_name": "700720", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Miscellaneous", "plan_name": "700720_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Ppo Hmo", "plan_name": "701720", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Ppo Hmo", "plan_name": "701720_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Ambetter 68069", "plan_name": "500516", "standard_charge_dollar": 365.55, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Ms State Emplo", "plan_name": "401457", "standard_charge_dollar": 81.80, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Ms State Emplo", "plan_name": "401457_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Basic Pl", "plan_name": "400100", "standard_charge_dollar": 81.80, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Basic Pl", "plan_name": "400100_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Federal", "plan_name": "400110", "standard_charge_dollar": 81.80, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Federal", "plan_name": "400110_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Cigna Healthsprings Ffs", "plan_name": "500064", "standard_charge_dollar": 365.55, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Conseco", "plan_name": "500302", "standard_charge_dollar": 365.55, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Humana Ffs 61101", "plan_name": "500006", "standard_charge_dollar": 365.55, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Medicare A", "plan_name": "100100", "standard_charge_dollar": 365.55, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Medicare A", "plan_name": "100500", "standard_charge_dollar": 365.55, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Medicare Part B Only", "plan_name": "100300", "standard_charge_dollar": 365.55, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Medicare Railroad", "plan_name": "100103", "standard_charge_dollar": 365.55, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Ms Physicians Care N", "plan_name": "714210", "standard_charge_dollar": 456.94, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Peoples Hlth Ffs 72126", "plan_name": "500019", "standard_charge_dollar": 365.55, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Uhc/Secure Horizons", "plan_name": "500449", "standard_charge_dollar": 365.55, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "United Health Care/", "plan_name": "500292", "standard_charge_dollar": 413.07, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "United Healthcare", "plan_name": "750104", "standard_charge_dollar": 413.07, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "United Healthcare Ba", "plan_name": "750090", "standard_charge_dollar": 413.07, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "United Healthcare Me", "plan_name": "501310", "standard_charge_dollar": 365.55, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Windsor Mcare Extra", "plan_name": "500778", "standard_charge_dollar": 365.55, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." } ] } ] }, { "description": "Anus surgery procedure", "code_information": [ { "code": "46999", "type": "CPT" } ], "standard_charges": [ { "gross_charge": 62630.45, "minimum": 835.19, "maximum": 53235.88, "setting": "inpatient", "payers_information": [ { "payer_name": "Aarp", "plan_name": "500102", "standard_charge_dollar": 835.19, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna", "plan_name": "700700", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna", "plan_name": "700700_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Mcare Ffs 6005", "plan_name": "700703", "standard_charge_dollar": 835.19, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Miscellaneous", "plan_name": "700720", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Miscellaneous", "plan_name": "700720_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Ppo Hmo", "plan_name": "701720", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Ppo Hmo", "plan_name": "701720_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Ambetter 68069", "plan_name": "500516", "standard_charge_dollar": 835.19, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Ms State Emplo", "plan_name": "401457", "standard_charge_percentage": 0.80, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Ms State Emplo", "plan_name": "401457_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Basic Pl", "plan_name": "400100", "standard_charge_percentage": 0.85, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Basic Pl", "plan_name": "400100_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Federal", "plan_name": "400110", "standard_charge_percentage": 0.85, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Federal", "plan_name": "400110_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Cigna Healthsprings Ffs", "plan_name": "500064", "standard_charge_dollar": 835.19, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Conseco", "plan_name": "500302", "standard_charge_dollar": 835.19, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Humana Ffs 61101", "plan_name": "500006", "standard_charge_dollar": 835.19, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Medicare A", "plan_name": "100100", "standard_charge_dollar": 835.19, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Medicare A", "plan_name": "100500", "standard_charge_dollar": 835.19, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Medicare Part B Only", "plan_name": "100300", "standard_charge_dollar": 835.19, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Medicare Railroad", "plan_name": "100103", "standard_charge_dollar": 835.19, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Ms Physicians Care N", "plan_name": "714210", "standard_charge_dollar": 1043.99, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Peoples Hlth Ffs 72126", "plan_name": "500019", "standard_charge_dollar": 835.19, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Uhc/Secure Horizons", "plan_name": "500449", "standard_charge_dollar": 835.19, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "United Health Care/", "plan_name": "500292", "standard_charge_dollar": 943.76, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "United Healthcare", "plan_name": "750104", "standard_charge_dollar": 943.76, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "United Healthcare Ba", "plan_name": "750090", "standard_charge_dollar": 943.76, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "United Healthcare Me", "plan_name": "501310", "standard_charge_dollar": 835.19, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Windsor Mcare Extra", "plan_name": "500778", "standard_charge_dollar": 835.19, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." } ] } ] }, { "description": "Liver surgery procedure", "code_information": [ { "code": "47399", "type": "CPT" } ], "standard_charges": [ { "gross_charge": 7051.76, "minimum": 644.54, "maximum": 5994.00, "setting": "inpatient", "payers_information": [ { "payer_name": "Aarp", "plan_name": "500102", "standard_charge_dollar": 644.54, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna", "plan_name": "700700", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna", "plan_name": "700700_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Mcare Ffs 6005", "plan_name": "700703", "standard_charge_dollar": 644.54, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Miscellaneous", "plan_name": "700720", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Miscellaneous", "plan_name": "700720_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Ppo Hmo", "plan_name": "701720", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Ppo Hmo", "plan_name": "701720_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Ambetter 68069", "plan_name": "500516", "standard_charge_dollar": 644.54, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Ms State Emplo", "plan_name": "401457", "standard_charge_percentage": 0.80, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Ms State Emplo", "plan_name": "401457_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Basic Pl", "plan_name": "400100", "standard_charge_percentage": 0.85, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Basic Pl", "plan_name": "400100_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Federal", "plan_name": "400110", "standard_charge_percentage": 0.85, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Federal", "plan_name": "400110_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Cigna Healthsprings Ffs", "plan_name": "500064", "standard_charge_dollar": 644.54, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Conseco", "plan_name": "500302", "standard_charge_dollar": 644.54, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Humana Ffs 61101", "plan_name": "500006", "standard_charge_dollar": 644.54, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Medicare A", "plan_name": "100100", "standard_charge_dollar": 644.54, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Medicare A", "plan_name": "100500", "standard_charge_dollar": 644.54, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Medicare Part B Only", "plan_name": "100300", "standard_charge_dollar": 644.54, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Medicare Railroad", "plan_name": "100103", "standard_charge_dollar": 644.54, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Ms Physicians Care N", "plan_name": "714210", "standard_charge_dollar": 805.67, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Peoples Hlth Ffs 72126", "plan_name": "500019", "standard_charge_dollar": 644.54, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Uhc/Secure Horizons", "plan_name": "500449", "standard_charge_dollar": 644.54, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "United Health Care/", "plan_name": "500292", "standard_charge_dollar": 728.33, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "United Healthcare", "plan_name": "750104", "standard_charge_dollar": 728.33, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "United Healthcare Ba", "plan_name": "750090", "standard_charge_dollar": 728.33, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "United Healthcare Me", "plan_name": "501310", "standard_charge_dollar": 644.54, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Windsor Mcare Extra", "plan_name": "500778", "standard_charge_dollar": 644.54, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." } ] } ] }, { "description": "Incision of bile duct", "code_information": [ { "code": "47420", "type": "CPT" } ], "standard_charges": [ { "gross_charge": 16391.22, "minimum": 13112.98, "maximum": 13932.54, "setting": "inpatient", "payers_information": [ { "payer_name": "Aetna", "plan_name": "700700", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna", "plan_name": "700700_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Miscellaneous", "plan_name": "700720", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Miscellaneous", "plan_name": "700720_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Ppo Hmo", "plan_name": "701720", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Ppo Hmo", "plan_name": "701720_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Ms State Emplo", "plan_name": "401457", "standard_charge_percentage": 0.80, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Ms State Emplo", "plan_name": "401457_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Basic Pl", "plan_name": "400100", "standard_charge_percentage": 0.85, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Basic Pl", "plan_name": "400100_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Federal", "plan_name": "400110", "standard_charge_percentage": 0.85, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Federal", "plan_name": "400110_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." } ] } ] }, { "description": "Incision of bile duct", "code_information": [ { "code": "47425", "type": "CPT" } ], "standard_charges": [ { "gross_charge": 16391.22, "minimum": 13112.98, "maximum": 13932.54, "setting": "inpatient", "payers_information": [ { "payer_name": "Aetna", "plan_name": "700700", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna", "plan_name": "700700_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Miscellaneous", "plan_name": "700720", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Miscellaneous", "plan_name": "700720_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Ppo Hmo", "plan_name": "701720", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Ppo Hmo", "plan_name": "701720_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Ms State Emplo", "plan_name": "401457", "standard_charge_percentage": 0.80, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Ms State Emplo", "plan_name": "401457_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Basic Pl", "plan_name": "400100", "standard_charge_percentage": 0.85, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Basic Pl", "plan_name": "400100_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Federal", "plan_name": "400110", "standard_charge_percentage": 0.85, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Federal", "plan_name": "400110_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." } ] } ] }, { "description": "Incision of gallbladder", "code_information": [ { "code": "47490", "type": "CPT" } ], "standard_charges": [ { "gross_charge": 20867.07, "minimum": 3232.86, "maximum": 17737.01, "setting": "inpatient", "payers_information": [ { "payer_name": "Aarp", "plan_name": "500102", "standard_charge_dollar": 3232.86, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna", "plan_name": "700700", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna", "plan_name": "700700_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Mcare Ffs 6005", "plan_name": "700703", "standard_charge_dollar": 3232.86, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Miscellaneous", "plan_name": "700720", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Miscellaneous", "plan_name": "700720_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Ppo Hmo", "plan_name": "701720", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Ppo Hmo", "plan_name": "701720_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Ambetter 68069", "plan_name": "500516", "standard_charge_dollar": 3232.86, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Ms State Emplo", "plan_name": "401457", "standard_charge_percentage": 0.80, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Ms State Emplo", "plan_name": "401457_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Basic Pl", "plan_name": "400100", "standard_charge_percentage": 0.85, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Basic Pl", "plan_name": "400100_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Federal", "plan_name": "400110", "standard_charge_percentage": 0.85, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Federal", "plan_name": "400110_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Cigna Healthsprings Ffs", "plan_name": "500064", "standard_charge_dollar": 3232.86, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Conseco", "plan_name": "500302", "standard_charge_dollar": 3232.86, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Humana Ffs 61101", "plan_name": "500006", "standard_charge_dollar": 3232.86, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Medicare A", "plan_name": "100100", "standard_charge_dollar": 3232.86, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Medicare A", "plan_name": "100500", "standard_charge_dollar": 3232.86, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Medicare Part B Only", "plan_name": "100300", "standard_charge_dollar": 3232.86, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Medicare Railroad", "plan_name": "100103", "standard_charge_dollar": 3232.86, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Ms Physicians Care N", "plan_name": "714210", "standard_charge_dollar": 4041.08, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Peoples Hlth Ffs 72126", "plan_name": "500019", "standard_charge_dollar": 3232.86, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Uhc/Secure Horizons", "plan_name": "500449", "standard_charge_dollar": 3232.86, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "United Health Care/", "plan_name": "500292", "standard_charge_dollar": 3653.14, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "United Healthcare", "plan_name": "750104", "standard_charge_dollar": 3653.14, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "United Healthcare Ba", "plan_name": "750090", "standard_charge_dollar": 3653.14, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "United Healthcare Me", "plan_name": "501310", "standard_charge_dollar": 3232.86, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Windsor Mcare Extra", "plan_name": "500778", "standard_charge_dollar": 3232.86, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." } ] } ] }, { "description": "Biliary endoscopy thru skin", "code_information": [ { "code": "47555", "type": "CPT" } ], "standard_charges": [ { "gross_charge": 16940.12, "minimum": 3232.86, "maximum": 14399.10, "setting": "inpatient", "payers_information": [ { "payer_name": "Aarp", "plan_name": "500102", "standard_charge_dollar": 3232.86, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna", "plan_name": "700700", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna", "plan_name": "700700_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Mcare Ffs 6005", "plan_name": "700703", "standard_charge_dollar": 3232.86, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Miscellaneous", "plan_name": "700720", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Miscellaneous", "plan_name": "700720_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Ppo Hmo", "plan_name": "701720", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Ppo Hmo", "plan_name": "701720_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Ambetter 68069", "plan_name": "500516", "standard_charge_dollar": 3232.86, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Ms State Emplo", "plan_name": "401457", "standard_charge_percentage": 0.80, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Ms State Emplo", "plan_name": "401457_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Basic Pl", "plan_name": "400100", "standard_charge_percentage": 0.85, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Basic Pl", "plan_name": "400100_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Federal", "plan_name": "400110", "standard_charge_percentage": 0.85, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Federal", "plan_name": "400110_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Cigna Healthsprings Ffs", "plan_name": "500064", "standard_charge_dollar": 3232.86, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Conseco", "plan_name": "500302", "standard_charge_dollar": 3232.86, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Humana Ffs 61101", "plan_name": "500006", "standard_charge_dollar": 3232.86, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Medicare A", "plan_name": "100100", "standard_charge_dollar": 3232.86, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Medicare A", "plan_name": "100500", "standard_charge_dollar": 3232.86, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Medicare Part B Only", "plan_name": "100300", "standard_charge_dollar": 3232.86, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Medicare Railroad", "plan_name": "100103", "standard_charge_dollar": 3232.86, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Ms Physicians Care N", "plan_name": "714210", "standard_charge_dollar": 4041.08, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Peoples Hlth Ffs 72126", "plan_name": "500019", "standard_charge_dollar": 3232.86, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Uhc/Secure Horizons", "plan_name": "500449", "standard_charge_dollar": 3232.86, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "United Health Care/", "plan_name": "500292", "standard_charge_dollar": 3653.14, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "United Healthcare", "plan_name": "750104", "standard_charge_dollar": 3653.14, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "United Healthcare Ba", "plan_name": "750090", "standard_charge_dollar": 3653.14, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "United Healthcare Me", "plan_name": "501310", "standard_charge_dollar": 3232.86, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Windsor Mcare Extra", "plan_name": "500778", "standard_charge_dollar": 3232.86, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." } ] } ] }, { "description": "Biliary endoscopy thru skin", "code_information": [ { "code": "47556", "type": "CPT" } ], "standard_charges": [ { "gross_charge": 16940.12, "minimum": 9537.40, "maximum": 14399.10, "setting": "inpatient", "payers_information": [ { "payer_name": "Aarp", "plan_name": "500102", "standard_charge_dollar": 9537.40, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna", "plan_name": "700700", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna", "plan_name": "700700_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Mcare Ffs 6005", "plan_name": "700703", "standard_charge_dollar": 9537.40, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Miscellaneous", "plan_name": "700720", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Miscellaneous", "plan_name": "700720_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Ppo Hmo", "plan_name": "701720", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Ppo Hmo", "plan_name": "701720_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Ambetter 68069", "plan_name": "500516", "standard_charge_dollar": 9537.40, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Ms State Emplo", "plan_name": "401457", "standard_charge_percentage": 0.80, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Ms State Emplo", "plan_name": "401457_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Basic Pl", "plan_name": "400100", "standard_charge_percentage": 0.85, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Basic Pl", "plan_name": "400100_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Federal", "plan_name": "400110", "standard_charge_percentage": 0.85, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Federal", "plan_name": "400110_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Cigna Healthsprings Ffs", "plan_name": "500064", "standard_charge_dollar": 9537.40, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Conseco", "plan_name": "500302", "standard_charge_dollar": 9537.40, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Humana Ffs 61101", "plan_name": "500006", "standard_charge_dollar": 9537.40, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Medicare A", "plan_name": "100100", "standard_charge_dollar": 9537.40, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Medicare A", "plan_name": "100500", "standard_charge_dollar": 9537.40, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Medicare Part B Only", "plan_name": "100300", "standard_charge_dollar": 9537.40, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Medicare Railroad", "plan_name": "100103", "standard_charge_dollar": 9537.40, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Ms Physicians Care N", "plan_name": "714210", "standard_charge_dollar": 11921.75, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Peoples Hlth Ffs 72126", "plan_name": "500019", "standard_charge_dollar": 9537.40, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Uhc/Secure Horizons", "plan_name": "500449", "standard_charge_dollar": 9537.40, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "United Health Care/", "plan_name": "500292", "standard_charge_dollar": 10777.26, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "United Healthcare", "plan_name": "750104", "standard_charge_dollar": 10777.26, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "United Healthcare Ba", "plan_name": "750090", "standard_charge_dollar": 10777.26, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "United Healthcare Me", "plan_name": "501310", "standard_charge_dollar": 9537.40, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Windsor Mcare Extra", "plan_name": "500778", "standard_charge_dollar": 9537.40, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." } ] } ] }, { "description": "Laparoscopic cholecystectomy", "code_information": [ { "code": "47562", "type": "CPT" } ], "standard_charges": [ { "gross_charge": 30289.47, "minimum": 5344.68, "maximum": 25746.05, "setting": "inpatient", "payers_information": [ { "payer_name": "Aarp", "plan_name": "500102", "standard_charge_dollar": 5344.68, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna", "plan_name": "700700", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna", "plan_name": "700700_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Mcare Ffs 6005", "plan_name": "700703", "standard_charge_dollar": 5344.68, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Miscellaneous", "plan_name": "700720", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Miscellaneous", "plan_name": "700720_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Ppo Hmo", "plan_name": "701720", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Ppo Hmo", "plan_name": "701720_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Ambetter 68069", "plan_name": "500516", "standard_charge_dollar": 5344.68, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Ms State Emplo", "plan_name": "401457", "standard_charge_percentage": 0.80, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Ms State Emplo", "plan_name": "401457_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Basic Pl", "plan_name": "400100", "standard_charge_percentage": 0.85, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Basic Pl", "plan_name": "400100_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Federal", "plan_name": "400110", "standard_charge_percentage": 0.85, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Federal", "plan_name": "400110_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Cigna Healthsprings Ffs", "plan_name": "500064", "standard_charge_dollar": 5344.68, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Conseco", "plan_name": "500302", "standard_charge_dollar": 5344.68, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Humana Ffs 61101", "plan_name": "500006", "standard_charge_dollar": 5344.68, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Medicare A", "plan_name": "100100", "standard_charge_dollar": 5344.68, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Medicare A", "plan_name": "100500", "standard_charge_dollar": 5344.68, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Medicare Part B Only", "plan_name": "100300", "standard_charge_dollar": 5344.68, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Medicare Railroad", "plan_name": "100103", "standard_charge_dollar": 5344.68, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Ms Physicians Care N", "plan_name": "714210", "standard_charge_dollar": 6680.85, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Peoples Hlth Ffs 72126", "plan_name": "500019", "standard_charge_dollar": 5344.68, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Uhc/Secure Horizons", "plan_name": "500449", "standard_charge_dollar": 5344.68, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "United Health Care/", "plan_name": "500292", "standard_charge_dollar": 6039.49, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "United Healthcare", "plan_name": "750104", "standard_charge_dollar": 6039.49, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "United Healthcare Ba", "plan_name": "750090", "standard_charge_dollar": 6039.49, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "United Healthcare Me", "plan_name": "501310", "standard_charge_dollar": 5344.68, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Windsor Mcare Extra", "plan_name": "500778", "standard_charge_dollar": 5344.68, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." } ] } ] }, { "description": "Laparo cholecystectomy/explr", "code_information": [ { "code": "47564", "type": "CPT" } ], "standard_charges": [ { "gross_charge": 30289.47, "minimum": 9537.40, "maximum": 25746.05, "setting": "inpatient", "payers_information": [ { "payer_name": "Aarp", "plan_name": "500102", "standard_charge_dollar": 9537.40, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna", "plan_name": "700700", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna", "plan_name": "700700_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Mcare Ffs 6005", "plan_name": "700703", "standard_charge_dollar": 9537.40, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Miscellaneous", "plan_name": "700720", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Miscellaneous", "plan_name": "700720_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Ppo Hmo", "plan_name": "701720", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Ppo Hmo", "plan_name": "701720_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Ambetter 68069", "plan_name": "500516", "standard_charge_dollar": 9537.40, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Ms State Emplo", "plan_name": "401457", "standard_charge_percentage": 0.80, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Ms State Emplo", "plan_name": "401457_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Basic Pl", "plan_name": "400100", "standard_charge_percentage": 0.85, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Basic Pl", "plan_name": "400100_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Federal", "plan_name": "400110", "standard_charge_percentage": 0.85, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Federal", "plan_name": "400110_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Cigna Healthsprings Ffs", "plan_name": "500064", "standard_charge_dollar": 9537.40, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Conseco", "plan_name": "500302", "standard_charge_dollar": 9537.40, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Humana Ffs 61101", "plan_name": "500006", "standard_charge_dollar": 9537.40, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Medicare A", "plan_name": "100100", "standard_charge_dollar": 9537.40, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Medicare A", "plan_name": "100500", "standard_charge_dollar": 9537.40, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Medicare Part B Only", "plan_name": "100300", "standard_charge_dollar": 9537.40, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Medicare Railroad", "plan_name": "100103", "standard_charge_dollar": 9537.40, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Ms Physicians Care N", "plan_name": "714210", "standard_charge_dollar": 11921.75, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Peoples Hlth Ffs 72126", "plan_name": "500019", "standard_charge_dollar": 9537.40, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Uhc/Secure Horizons", "plan_name": "500449", "standard_charge_dollar": 9537.40, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "United Health Care/", "plan_name": "500292", "standard_charge_dollar": 10777.26, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "United Healthcare", "plan_name": "750104", "standard_charge_dollar": 10777.26, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "United Healthcare Ba", "plan_name": "750090", "standard_charge_dollar": 10777.26, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "United Healthcare Me", "plan_name": "501310", "standard_charge_dollar": 9537.40, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Windsor Mcare Extra", "plan_name": "500778", "standard_charge_dollar": 9537.40, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." } ] } ] }, { "description": "Removal of gallbladder", "code_information": [ { "code": "47600", "type": "CPT" } ], "standard_charges": [ { "gross_charge": 28772.20, "minimum": 23017.76, "maximum": 24456.37, "setting": "inpatient", "payers_information": [ { "payer_name": "Aetna", "plan_name": "700700", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna", "plan_name": "700700_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Miscellaneous", "plan_name": "700720", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Miscellaneous", "plan_name": "700720_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Ppo Hmo", "plan_name": "701720", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Ppo Hmo", "plan_name": "701720_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Ms State Emplo", "plan_name": "401457", "standard_charge_percentage": 0.80, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Ms State Emplo", "plan_name": "401457_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Basic Pl", "plan_name": "400100", "standard_charge_percentage": 0.85, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Basic Pl", "plan_name": "400100_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Federal", "plan_name": "400110", "standard_charge_percentage": 0.85, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Federal", "plan_name": "400110_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." } ] } ] }, { "description": "Removal of gallbladder", "code_information": [ { "code": "47610", "type": "CPT" } ], "standard_charges": [ { "gross_charge": 27224.58, "minimum": 21779.66, "maximum": 23140.89, "setting": "inpatient", "payers_information": [ { "payer_name": "Aetna", "plan_name": "700700", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna", "plan_name": "700700_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Miscellaneous", "plan_name": "700720", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Miscellaneous", "plan_name": "700720_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Ppo Hmo", "plan_name": "701720", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Ppo Hmo", "plan_name": "701720_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Ms State Emplo", "plan_name": "401457", "standard_charge_percentage": 0.80, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Ms State Emplo", "plan_name": "401457_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Basic Pl", "plan_name": "400100", "standard_charge_percentage": 0.85, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Basic Pl", "plan_name": "400100_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Federal", "plan_name": "400110", "standard_charge_percentage": 0.85, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Federal", "plan_name": "400110_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." } ] } ] }, { "description": "Removal of gallbladder", "code_information": [ { "code": "47612", "type": "CPT" } ], "standard_charges": [ { "gross_charge": 27224.58, "minimum": 21779.66, "maximum": 23140.89, "setting": "inpatient", "payers_information": [ { "payer_name": "Aetna", "plan_name": "700700", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna", "plan_name": "700700_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Miscellaneous", "plan_name": "700720", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Miscellaneous", "plan_name": "700720_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Ppo Hmo", "plan_name": "701720", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Ppo Hmo", "plan_name": "701720_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Ms State Emplo", "plan_name": "401457", "standard_charge_percentage": 0.80, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Ms State Emplo", "plan_name": "401457_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Basic Pl", "plan_name": "400100", "standard_charge_percentage": 0.85, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Basic Pl", "plan_name": "400100_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Federal", "plan_name": "400110", "standard_charge_percentage": 0.85, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Federal", "plan_name": "400110_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." } ] } ] }, { "description": "Removal of gallbladder", "code_information": [ { "code": "47620", "type": "CPT" } ], "standard_charges": [ { "gross_charge": 27224.58, "minimum": 21779.66, "maximum": 23140.89, "setting": "inpatient", "payers_information": [ { "payer_name": "Aetna", "plan_name": "700700", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna", "plan_name": "700700_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Miscellaneous", "plan_name": "700720", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Miscellaneous", "plan_name": "700720_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Ppo Hmo", "plan_name": "701720", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Ppo Hmo", "plan_name": "701720_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Ms State Emplo", "plan_name": "401457", "standard_charge_percentage": 0.80, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Ms State Emplo", "plan_name": "401457_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Basic Pl", "plan_name": "400100", "standard_charge_percentage": 0.85, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Basic Pl", "plan_name": "400100_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Federal", "plan_name": "400110", "standard_charge_percentage": 0.85, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Federal", "plan_name": "400110_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." } ] } ] }, { "description": "Fuse upper gi structures", "code_information": [ { "code": "47721", "type": "CPT" } ], "standard_charges": [ { "gross_charge": 62580.64, "minimum": 50064.51, "maximum": 53193.54, "setting": "inpatient", "payers_information": [ { "payer_name": "Aetna", "plan_name": "700700", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna", "plan_name": "700700_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Miscellaneous", "plan_name": "700720", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Miscellaneous", "plan_name": "700720_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Ppo Hmo", "plan_name": "701720", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Ppo Hmo", "plan_name": "701720_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Ms State Emplo", "plan_name": "401457", "standard_charge_percentage": 0.80, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Ms State Emplo", "plan_name": "401457_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Basic Pl", "plan_name": "400100", "standard_charge_percentage": 0.85, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Basic Pl", "plan_name": "400100_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Federal", "plan_name": "400110", "standard_charge_percentage": 0.85, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Federal", "plan_name": "400110_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." } ] } ] }, { "description": "Fuse gallbladder & bowel", "code_information": [ { "code": "47740", "type": "CPT" } ], "standard_charges": [ { "gross_charge": 62580.64, "minimum": 50064.51, "maximum": 53193.54, "setting": "inpatient", "payers_information": [ { "payer_name": "Aetna", "plan_name": "700700", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna", "plan_name": "700700_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Miscellaneous", "plan_name": "700720", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Miscellaneous", "plan_name": "700720_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Ppo Hmo", "plan_name": "701720", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Ppo Hmo", "plan_name": "701720_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Ms State Emplo", "plan_name": "401457", "standard_charge_percentage": 0.80, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Ms State Emplo", "plan_name": "401457_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Basic Pl", "plan_name": "400100", "standard_charge_percentage": 0.85, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Basic Pl", "plan_name": "400100_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Federal", "plan_name": "400110", "standard_charge_percentage": 0.85, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Federal", "plan_name": "400110_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." } ] } ] }, { "description": "Fuse gallbladder & bowel", "code_information": [ { "code": "47741", "type": "CPT" } ], "standard_charges": [ { "gross_charge": 62580.64, "minimum": 50064.51, "maximum": 53193.54, "setting": "inpatient", "payers_information": [ { "payer_name": "Aetna", "plan_name": "700700", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna", "plan_name": "700700_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Miscellaneous", "plan_name": "700720", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Miscellaneous", "plan_name": "700720_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Ppo Hmo", "plan_name": "701720", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Ppo Hmo", "plan_name": "701720_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Ms State Emplo", "plan_name": "401457", "standard_charge_percentage": 0.80, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Ms State Emplo", "plan_name": "401457_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Basic Pl", "plan_name": "400100", "standard_charge_percentage": 0.85, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Basic Pl", "plan_name": "400100_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Federal", "plan_name": "400110", "standard_charge_percentage": 0.85, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Federal", "plan_name": "400110_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." } ] } ] }, { "description": "Placement bile duct support", "code_information": [ { "code": "47801", "type": "CPT" } ], "standard_charges": [ { "gross_charge": 16940.12, "minimum": 13552.10, "maximum": 14399.10, "setting": "inpatient", "payers_information": [ { "payer_name": "Aetna", "plan_name": "700700", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna", "plan_name": "700700_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Miscellaneous", "plan_name": "700720", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Miscellaneous", "plan_name": "700720_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Ppo Hmo", "plan_name": "701720", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Ppo Hmo", "plan_name": "701720_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Ms State Emplo", "plan_name": "401457", "standard_charge_percentage": 0.80, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Ms State Emplo", "plan_name": "401457_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Basic Pl", "plan_name": "400100", "standard_charge_percentage": 0.85, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Basic Pl", "plan_name": "400100_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Federal", "plan_name": "400110", "standard_charge_percentage": 0.85, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Federal", "plan_name": "400110_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." } ] } ] }, { "description": "Bile tract surgery procedure", "code_information": [ { "code": "47999", "type": "CPT" } ], "standard_charges": [ { "gross_charge": 66807.43, "minimum": 858.87, "maximum": 56786.32, "setting": "inpatient", "payers_information": [ { "payer_name": "Aarp", "plan_name": "500102", "standard_charge_dollar": 858.87, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna", "plan_name": "700700", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna", "plan_name": "700700_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Mcare Ffs 6005", "plan_name": "700703", "standard_charge_dollar": 858.87, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Miscellaneous", "plan_name": "700720", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Miscellaneous", "plan_name": "700720_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Ppo Hmo", "plan_name": "701720", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Ppo Hmo", "plan_name": "701720_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Ambetter 68069", "plan_name": "500516", "standard_charge_dollar": 858.87, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Ms State Emplo", "plan_name": "401457", "standard_charge_percentage": 0.80, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Ms State Emplo", "plan_name": "401457_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Basic Pl", "plan_name": "400100", "standard_charge_percentage": 0.85, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Basic Pl", "plan_name": "400100_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Federal", "plan_name": "400110", "standard_charge_percentage": 0.85, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Federal", "plan_name": "400110_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Cigna Healthsprings Ffs", "plan_name": "500064", "standard_charge_dollar": 858.87, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Conseco", "plan_name": "500302", "standard_charge_dollar": 858.87, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Humana Ffs 61101", "plan_name": "500006", "standard_charge_dollar": 858.87, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Medicare A", "plan_name": "100100", "standard_charge_dollar": 858.87, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Medicare A", "plan_name": "100500", "standard_charge_dollar": 858.87, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Medicare Part B Only", "plan_name": "100300", "standard_charge_dollar": 858.87, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Medicare Railroad", "plan_name": "100103", "standard_charge_dollar": 858.87, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Ms Physicians Care N", "plan_name": "714210", "standard_charge_dollar": 1073.59, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Peoples Hlth Ffs 72126", "plan_name": "500019", "standard_charge_dollar": 858.87, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Uhc/Secure Horizons", "plan_name": "500449", "standard_charge_dollar": 858.87, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "United Health Care/", "plan_name": "500292", "standard_charge_dollar": 970.52, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "United Healthcare", "plan_name": "750104", "standard_charge_dollar": 970.52, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "United Healthcare Ba", "plan_name": "750090", "standard_charge_dollar": 970.52, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "United Healthcare Me", "plan_name": "501310", "standard_charge_dollar": 858.87, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Windsor Mcare Extra", "plan_name": "500778", "standard_charge_dollar": 858.87, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." } ] } ] }, { "description": "Biopsy of pancreas open", "code_information": [ { "code": "48100", "type": "CPT" } ], "standard_charges": [ { "gross_charge": 24277.25, "minimum": 19421.80, "maximum": 20635.66, "setting": "inpatient", "payers_information": [ { "payer_name": "Aetna", "plan_name": "700700", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna", "plan_name": "700700_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Miscellaneous", "plan_name": "700720", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Miscellaneous", "plan_name": "700720_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Ppo Hmo", "plan_name": "701720", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Ppo Hmo", "plan_name": "701720_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Ms State Emplo", "plan_name": "401457", "standard_charge_percentage": 0.80, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Ms State Emplo", "plan_name": "401457_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Basic Pl", "plan_name": "400100", "standard_charge_percentage": 0.85, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Basic Pl", "plan_name": "400100_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Federal", "plan_name": "400110", "standard_charge_percentage": 0.85, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Federal", "plan_name": "400110_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." } ] } ] }, { "description": "Needle biopsy pancreas", "code_information": [ { "code": "48102", "type": "CPT" } ], "standard_charges": [ { "gross_charge": 24277.25, "minimum": 1484.25, "maximum": 20635.66, "setting": "inpatient", "payers_information": [ { "payer_name": "Aarp", "plan_name": "500102", "standard_charge_dollar": 1484.25, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna", "plan_name": "700700", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna", "plan_name": "700700_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Mcare Ffs 6005", "plan_name": "700703", "standard_charge_dollar": 1484.25, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Miscellaneous", "plan_name": "700720", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Miscellaneous", "plan_name": "700720_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Ppo Hmo", "plan_name": "701720", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Ppo Hmo", "plan_name": "701720_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Ambetter 68069", "plan_name": "500516", "standard_charge_dollar": 1484.25, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Ms State Emplo", "plan_name": "401457", "standard_charge_percentage": 0.80, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Ms State Emplo", "plan_name": "401457_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Basic Pl", "plan_name": "400100", "standard_charge_percentage": 0.85, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Basic Pl", "plan_name": "400100_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Federal", "plan_name": "400110", "standard_charge_percentage": 0.85, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Federal", "plan_name": "400110_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Cigna Healthsprings Ffs", "plan_name": "500064", "standard_charge_dollar": 1484.25, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Conseco", "plan_name": "500302", "standard_charge_dollar": 1484.25, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Humana Ffs 61101", "plan_name": "500006", "standard_charge_dollar": 1484.25, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Medicare A", "plan_name": "100100", "standard_charge_dollar": 1484.25, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Medicare A", "plan_name": "100500", "standard_charge_dollar": 1484.25, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Medicare Part B Only", "plan_name": "100300", "standard_charge_dollar": 1484.25, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Medicare Railroad", "plan_name": "100103", "standard_charge_dollar": 1484.25, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Ms Physicians Care N", "plan_name": "714210", "standard_charge_dollar": 1855.31, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Peoples Hlth Ffs 72126", "plan_name": "500019", "standard_charge_dollar": 1484.25, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Uhc/Secure Horizons", "plan_name": "500449", "standard_charge_dollar": 1484.25, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "United Health Care/", "plan_name": "500292", "standard_charge_dollar": 1677.20, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "United Healthcare", "plan_name": "750104", "standard_charge_dollar": 1677.20, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "United Healthcare Ba", "plan_name": "750090", "standard_charge_dollar": 1677.20, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "United Healthcare Me", "plan_name": "501310", "standard_charge_dollar": 1484.25, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Windsor Mcare Extra", "plan_name": "500778", "standard_charge_dollar": 1484.25, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." } ] } ] }, { "description": "Partial removal of pancreas", "code_information": [ { "code": "48140", "type": "CPT" } ], "standard_charges": [ { "gross_charge": 84640.63, "minimum": 67712.50, "maximum": 71944.54, "setting": "inpatient", "payers_information": [ { "payer_name": "Aetna", "plan_name": "700700", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna", "plan_name": "700700_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Miscellaneous", "plan_name": "700720", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Miscellaneous", "plan_name": "700720_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Ppo Hmo", "plan_name": "701720", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Ppo Hmo", "plan_name": "701720_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Ms State Emplo", "plan_name": "401457", "standard_charge_percentage": 0.80, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Ms State Emplo", "plan_name": "401457_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Basic Pl", "plan_name": "400100", "standard_charge_percentage": 0.85, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Basic Pl", "plan_name": "400100_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Federal", "plan_name": "400110", "standard_charge_percentage": 0.85, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Federal", "plan_name": "400110_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." } ] } ] }, { "description": "Partial removal of pancreas", "code_information": [ { "code": "48145", "type": "CPT" } ], "standard_charges": [ { "gross_charge": 84640.63, "minimum": 67712.50, "maximum": 71944.54, "setting": "inpatient", "payers_information": [ { "payer_name": "Aetna", "plan_name": "700700", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna", "plan_name": "700700_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Miscellaneous", "plan_name": "700720", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Miscellaneous", "plan_name": "700720_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Ppo Hmo", "plan_name": "701720", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Ppo Hmo", "plan_name": "701720_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Ms State Emplo", "plan_name": "401457", "standard_charge_percentage": 0.80, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Ms State Emplo", "plan_name": "401457_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Basic Pl", "plan_name": "400100", "standard_charge_percentage": 0.85, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Basic Pl", "plan_name": "400100_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Federal", "plan_name": "400110", "standard_charge_percentage": 0.85, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Federal", "plan_name": "400110_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." } ] } ] }, { "description": "Partial removal of pancreas", "code_information": [ { "code": "48150", "type": "CPT" } ], "standard_charges": [ { "gross_charge": 62580.64, "minimum": 50064.51, "maximum": 53193.54, "setting": "inpatient", "payers_information": [ { "payer_name": "Aetna", "plan_name": "700700", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna", "plan_name": "700700_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Miscellaneous", "plan_name": "700720", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Miscellaneous", "plan_name": "700720_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Ppo Hmo", "plan_name": "701720", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Ppo Hmo", "plan_name": "701720_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Ms State Emplo", "plan_name": "401457", "standard_charge_percentage": 0.80, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Ms State Emplo", "plan_name": "401457_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Basic Pl", "plan_name": "400100", "standard_charge_percentage": 0.85, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Basic Pl", "plan_name": "400100_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Federal", "plan_name": "400110", "standard_charge_percentage": 0.85, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Federal", "plan_name": "400110_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." } ] } ] }, { "description": "Pancreatectomy", "code_information": [ { "code": "48153", "type": "CPT" } ], "standard_charges": [ { "gross_charge": 62580.64, "minimum": 50064.51, "maximum": 53193.54, "setting": "inpatient", "payers_information": [ { "payer_name": "Aetna", "plan_name": "700700", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna", "plan_name": "700700_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Miscellaneous", "plan_name": "700720", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Miscellaneous", "plan_name": "700720_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Ppo Hmo", "plan_name": "701720", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Ppo Hmo", "plan_name": "701720_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Ms State Emplo", "plan_name": "401457", "standard_charge_percentage": 0.80, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Ms State Emplo", "plan_name": "401457_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Basic Pl", "plan_name": "400100", "standard_charge_percentage": 0.85, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Basic Pl", "plan_name": "400100_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Federal", "plan_name": "400110", "standard_charge_percentage": 0.85, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Federal", "plan_name": "400110_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." } ] } ] }, { "description": "Pancreatectomy", "code_information": [ { "code": "48154", "type": "CPT" } ], "standard_charges": [ { "gross_charge": 62580.64, "minimum": 50064.51, "maximum": 53193.54, "setting": "inpatient", "payers_information": [ { "payer_name": "Aetna", "plan_name": "700700", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna", "plan_name": "700700_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Miscellaneous", "plan_name": "700720", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Miscellaneous", "plan_name": "700720_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Ppo Hmo", "plan_name": "701720", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Ppo Hmo", "plan_name": "701720_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Ms State Emplo", "plan_name": "401457", "standard_charge_percentage": 0.80, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Ms State Emplo", "plan_name": "401457_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Basic Pl", "plan_name": "400100", "standard_charge_percentage": 0.85, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Basic Pl", "plan_name": "400100_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Federal", "plan_name": "400110", "standard_charge_percentage": 0.85, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Federal", "plan_name": "400110_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." } ] } ] }, { "description": "Duodenal exclusion", "code_information": [ { "code": "48547", "type": "CPT" } ], "standard_charges": [ { "gross_charge": 62580.64, "minimum": 50064.51, "maximum": 53193.54, "setting": "inpatient", "payers_information": [ { "payer_name": "Aetna", "plan_name": "700700", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna", "plan_name": "700700_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Miscellaneous", "plan_name": "700720", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Miscellaneous", "plan_name": "700720_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Ppo Hmo", "plan_name": "701720", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Ppo Hmo", "plan_name": "701720_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Ms State Emplo", "plan_name": "401457", "standard_charge_percentage": 0.80, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Ms State Emplo", "plan_name": "401457_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Basic Pl", "plan_name": "400100", "standard_charge_percentage": 0.85, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Basic Pl", "plan_name": "400100_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Federal", "plan_name": "400110", "standard_charge_percentage": 0.85, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Federal", "plan_name": "400110_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." } ] } ] }, { "description": "Pancreas surgery procedure", "code_information": [ { "code": "48999", "type": "CPT" } ], "standard_charges": [ { "gross_charge": 24277.25, "minimum": 644.54, "maximum": 20635.66, "setting": "inpatient", "payers_information": [ { "payer_name": "Aarp", "plan_name": "500102", "standard_charge_dollar": 644.54, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna", "plan_name": "700700", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna", "plan_name": "700700_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Mcare Ffs 6005", "plan_name": "700703", "standard_charge_dollar": 644.54, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Miscellaneous", "plan_name": "700720", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Miscellaneous", "plan_name": "700720_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Ppo Hmo", "plan_name": "701720", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Ppo Hmo", "plan_name": "701720_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Ambetter 68069", "plan_name": "500516", "standard_charge_dollar": 644.54, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Ms State Emplo", "plan_name": "401457", "standard_charge_percentage": 0.80, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Ms State Emplo", "plan_name": "401457_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Basic Pl", "plan_name": "400100", "standard_charge_percentage": 0.85, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Basic Pl", "plan_name": "400100_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Federal", "plan_name": "400110", "standard_charge_percentage": 0.85, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Federal", "plan_name": "400110_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Cigna Healthsprings Ffs", "plan_name": "500064", "standard_charge_dollar": 644.54, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Conseco", "plan_name": "500302", "standard_charge_dollar": 644.54, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Humana Ffs 61101", "plan_name": "500006", "standard_charge_dollar": 644.54, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Medicare A", "plan_name": "100100", "standard_charge_dollar": 644.54, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Medicare A", "plan_name": "100500", "standard_charge_dollar": 644.54, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Medicare Part B Only", "plan_name": "100300", "standard_charge_dollar": 644.54, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Medicare Railroad", "plan_name": "100103", "standard_charge_dollar": 644.54, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Ms Physicians Care N", "plan_name": "714210", "standard_charge_dollar": 805.67, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Peoples Hlth Ffs 72126", "plan_name": "500019", "standard_charge_dollar": 644.54, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Uhc/Secure Horizons", "plan_name": "500449", "standard_charge_dollar": 644.54, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "United Health Care/", "plan_name": "500292", "standard_charge_dollar": 728.33, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "United Healthcare", "plan_name": "750104", "standard_charge_dollar": 728.33, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "United Healthcare Ba", "plan_name": "750090", "standard_charge_dollar": 728.33, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "United Healthcare Me", "plan_name": "501310", "standard_charge_dollar": 644.54, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Windsor Mcare Extra", "plan_name": "500778", "standard_charge_dollar": 644.54, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." } ] } ] }, { "description": "Exploration of abdomen", "code_information": [ { "code": "49000", "type": "CPT" } ], "standard_charges": [ { "gross_charge": 44438.30, "minimum": 35550.64, "maximum": 37772.56, "setting": "inpatient", "payers_information": [ { "payer_name": "Aetna", "plan_name": "700700", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna", "plan_name": "700700_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Miscellaneous", "plan_name": "700720", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Miscellaneous", "plan_name": "700720_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Ppo Hmo", "plan_name": "701720", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Ppo Hmo", "plan_name": "701720_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Ms State Emplo", "plan_name": "401457", "standard_charge_percentage": 0.80, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Ms State Emplo", "plan_name": "401457_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Basic Pl", "plan_name": "400100", "standard_charge_percentage": 0.85, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Basic Pl", "plan_name": "400100_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Federal", "plan_name": "400110", "standard_charge_percentage": 0.85, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Federal", "plan_name": "400110_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." } ] } ] }, { "description": "Reopening of abdomen", "code_information": [ { "code": "49002", "type": "CPT" } ], "standard_charges": [ { "gross_charge": 44438.30, "minimum": 35550.64, "maximum": 37772.56, "setting": "inpatient", "payers_information": [ { "payer_name": "Aetna", "plan_name": "700700", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna", "plan_name": "700700_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Miscellaneous", "plan_name": "700720", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Miscellaneous", "plan_name": "700720_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Ppo Hmo", "plan_name": "701720", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Ppo Hmo", "plan_name": "701720_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Ms State Emplo", "plan_name": "401457", "standard_charge_percentage": 0.80, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Ms State Emplo", "plan_name": "401457_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Basic Pl", "plan_name": "400100", "standard_charge_percentage": 0.85, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Basic Pl", "plan_name": "400100_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Federal", "plan_name": "400110", "standard_charge_percentage": 0.85, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Federal", "plan_name": "400110_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." } ] } ] }, { "description": "Drainage abdom abscess open", "code_information": [ { "code": "49020", "type": "CPT" } ], "standard_charges": [ { "gross_charge": 30767.09, "minimum": 24613.67, "maximum": 26152.03, "setting": "inpatient", "payers_information": [ { "payer_name": "Aetna", "plan_name": "700700", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna", "plan_name": "700700_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Miscellaneous", "plan_name": "700720", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Miscellaneous", "plan_name": "700720_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Ppo Hmo", "plan_name": "701720", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Ppo Hmo", "plan_name": "701720_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Ms State Emplo", "plan_name": "401457", "standard_charge_percentage": 0.80, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Ms State Emplo", "plan_name": "401457_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Basic Pl", "plan_name": "400100", "standard_charge_percentage": 0.85, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Basic Pl", "plan_name": "400100_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Federal", "plan_name": "400110", "standard_charge_percentage": 0.85, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Federal", "plan_name": "400110_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." } ] } ] }, { "description": "Drain open abdom abscess", "code_information": [ { "code": "49040", "type": "CPT" } ], "standard_charges": [ { "gross_charge": 30767.09, "minimum": 24613.67, "maximum": 26152.03, "setting": "inpatient", "payers_information": [ { "payer_name": "Aetna", "plan_name": "700700", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna", "plan_name": "700700_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Miscellaneous", "plan_name": "700720", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Miscellaneous", "plan_name": "700720_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Ppo Hmo", "plan_name": "701720", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Ppo Hmo", "plan_name": "701720_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Ms State Emplo", "plan_name": "401457", "standard_charge_percentage": 0.80, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Ms State Emplo", "plan_name": "401457_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Basic Pl", "plan_name": "400100", "standard_charge_percentage": 0.85, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Basic Pl", "plan_name": "400100_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Federal", "plan_name": "400110", "standard_charge_percentage": 0.85, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Federal", "plan_name": "400110_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." } ] } ] }, { "description": "Drain open retroperi abscess", "code_information": [ { "code": "49060", "type": "CPT" } ], "standard_charges": [ { "gross_charge": 30767.09, "minimum": 24613.67, "maximum": 26152.03, "setting": "inpatient", "payers_information": [ { "payer_name": "Aetna", "plan_name": "700700", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna", "plan_name": "700700_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Miscellaneous", "plan_name": "700720", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Miscellaneous", "plan_name": "700720_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Ppo Hmo", "plan_name": "701720", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Ppo Hmo", "plan_name": "701720_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Ms State Emplo", "plan_name": "401457", "standard_charge_percentage": 0.80, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Ms State Emplo", "plan_name": "401457_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Basic Pl", "plan_name": "400100", "standard_charge_percentage": 0.85, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Basic Pl", "plan_name": "400100_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Federal", "plan_name": "400110", "standard_charge_percentage": 0.85, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Federal", "plan_name": "400110_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." } ] } ] }, { "description": "Abd paracentesis", "code_information": [ { "code": "49082", "type": "CPT" } ], "standard_charges": [ { "gross_charge": 38197.86, "minimum": 858.87, "maximum": 32468.18, "setting": "inpatient", "payers_information": [ { "payer_name": "Aarp", "plan_name": "500102", "standard_charge_dollar": 858.87, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna", "plan_name": "700700", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna", "plan_name": "700700_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Mcare Ffs 6005", "plan_name": "700703", "standard_charge_dollar": 858.87, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Miscellaneous", "plan_name": "700720", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Miscellaneous", "plan_name": "700720_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Ppo Hmo", "plan_name": "701720", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Ppo Hmo", "plan_name": "701720_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Ambetter 68069", "plan_name": "500516", "standard_charge_dollar": 858.87, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Ms State Emplo", "plan_name": "401457", "standard_charge_percentage": 0.80, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Ms State Emplo", "plan_name": "401457_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Basic Pl", "plan_name": "400100", "standard_charge_percentage": 0.85, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Basic Pl", "plan_name": "400100_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Federal", "plan_name": "400110", "standard_charge_percentage": 0.85, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Federal", "plan_name": "400110_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Cigna Healthsprings Ffs", "plan_name": "500064", "standard_charge_dollar": 858.87, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Conseco", "plan_name": "500302", "standard_charge_dollar": 858.87, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Humana Ffs 61101", "plan_name": "500006", "standard_charge_dollar": 858.87, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Medicare A", "plan_name": "100100", "standard_charge_dollar": 858.87, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Medicare A", "plan_name": "100500", "standard_charge_dollar": 858.87, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Medicare Part B Only", "plan_name": "100300", "standard_charge_dollar": 858.87, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Medicare Railroad", "plan_name": "100103", "standard_charge_dollar": 858.87, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Ms Physicians Care N", "plan_name": "714210", "standard_charge_dollar": 1073.59, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Peoples Hlth Ffs 72126", "plan_name": "500019", "standard_charge_dollar": 858.87, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Uhc/Secure Horizons", "plan_name": "500449", "standard_charge_dollar": 858.87, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "United Health Care/", "plan_name": "500292", "standard_charge_dollar": 970.52, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "United Healthcare", "plan_name": "750104", "standard_charge_dollar": 970.52, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "United Healthcare Ba", "plan_name": "750090", "standard_charge_dollar": 970.52, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "United Healthcare Me", "plan_name": "501310", "standard_charge_dollar": 858.87, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Windsor Mcare Extra", "plan_name": "500778", "standard_charge_dollar": 858.87, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." } ] } ] }, { "description": "Abd paracentesis w/imaging", "code_information": [ { "code": "49083", "type": "CPT" } ], "standard_charges": [ { "gross_charge": 38197.86, "minimum": 858.87, "maximum": 32468.18, "setting": "inpatient", "payers_information": [ { "payer_name": "Aarp", "plan_name": "500102", "standard_charge_dollar": 858.87, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna", "plan_name": "700700", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna", "plan_name": "700700_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Mcare Ffs 6005", "plan_name": "700703", "standard_charge_dollar": 858.87, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Miscellaneous", "plan_name": "700720", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Miscellaneous", "plan_name": "700720_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Ppo Hmo", "plan_name": "701720", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Ppo Hmo", "plan_name": "701720_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Ambetter 68069", "plan_name": "500516", "standard_charge_dollar": 858.87, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Ms State Emplo", "plan_name": "401457", "standard_charge_percentage": 0.80, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Ms State Emplo", "plan_name": "401457_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Basic Pl", "plan_name": "400100", "standard_charge_percentage": 0.85, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Basic Pl", "plan_name": "400100_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Federal", "plan_name": "400110", "standard_charge_percentage": 0.85, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Federal", "plan_name": "400110_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Cigna Healthsprings Ffs", "plan_name": "500064", "standard_charge_dollar": 858.87, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Conseco", "plan_name": "500302", "standard_charge_dollar": 858.87, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Humana Ffs 61101", "plan_name": "500006", "standard_charge_dollar": 858.87, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Medicare A", "plan_name": "100100", "standard_charge_dollar": 858.87, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Medicare A", "plan_name": "100500", "standard_charge_dollar": 858.87, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Medicare Part B Only", "plan_name": "100300", "standard_charge_dollar": 858.87, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Medicare Railroad", "plan_name": "100103", "standard_charge_dollar": 858.87, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Ms Physicians Care N", "plan_name": "714210", "standard_charge_dollar": 1073.59, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Peoples Hlth Ffs 72126", "plan_name": "500019", "standard_charge_dollar": 858.87, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Uhc/Secure Horizons", "plan_name": "500449", "standard_charge_dollar": 858.87, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "United Health Care/", "plan_name": "500292", "standard_charge_dollar": 970.52, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "United Healthcare", "plan_name": "750104", "standard_charge_dollar": 970.52, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "United Healthcare Ba", "plan_name": "750090", "standard_charge_dollar": 970.52, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "United Healthcare Me", "plan_name": "501310", "standard_charge_dollar": 858.87, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Windsor Mcare Extra", "plan_name": "500778", "standard_charge_dollar": 858.87, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." } ] } ] }, { "description": "Biopsy abdominal mass", "code_information": [ { "code": "49180", "type": "CPT" } ], "standard_charges": [ { "gross_charge": 17992.48, "minimum": 1484.25, "maximum": 15293.61, "setting": "inpatient", "payers_information": [ { "payer_name": "Aarp", "plan_name": "500102", "standard_charge_dollar": 1484.25, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna", "plan_name": "700700", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna", "plan_name": "700700_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Mcare Ffs 6005", "plan_name": "700703", "standard_charge_dollar": 1484.25, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Miscellaneous", "plan_name": "700720", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Miscellaneous", "plan_name": "700720_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Ppo Hmo", "plan_name": "701720", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Ppo Hmo", "plan_name": "701720_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Ambetter 68069", "plan_name": "500516", "standard_charge_dollar": 1484.25, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Ms State Emplo", "plan_name": "401457", "standard_charge_percentage": 0.80, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Ms State Emplo", "plan_name": "401457_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Basic Pl", "plan_name": "400100", "standard_charge_percentage": 0.85, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Basic Pl", "plan_name": "400100_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Federal", "plan_name": "400110", "standard_charge_percentage": 0.85, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Federal", "plan_name": "400110_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Cigna Healthsprings Ffs", "plan_name": "500064", "standard_charge_dollar": 1484.25, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Conseco", "plan_name": "500302", "standard_charge_dollar": 1484.25, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Humana Ffs 61101", "plan_name": "500006", "standard_charge_dollar": 1484.25, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Medicare A", "plan_name": "100100", "standard_charge_dollar": 1484.25, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Medicare A", "plan_name": "100500", "standard_charge_dollar": 1484.25, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Medicare Part B Only", "plan_name": "100300", "standard_charge_dollar": 1484.25, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Medicare Railroad", "plan_name": "100103", "standard_charge_dollar": 1484.25, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Ms Physicians Care N", "plan_name": "714210", "standard_charge_dollar": 1855.31, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Peoples Hlth Ffs 72126", "plan_name": "500019", "standard_charge_dollar": 1484.25, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Uhc/Secure Horizons", "plan_name": "500449", "standard_charge_dollar": 1484.25, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "United Health Care/", "plan_name": "500292", "standard_charge_dollar": 1677.20, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "United Healthcare", "plan_name": "750104", "standard_charge_dollar": 1677.20, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "United Healthcare Ba", "plan_name": "750090", "standard_charge_dollar": 1677.20, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "United Healthcare Me", "plan_name": "501310", "standard_charge_dollar": 1484.25, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Windsor Mcare Extra", "plan_name": "500778", "standard_charge_dollar": 1484.25, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." } ] } ] }, { "description": "Removal of omentum", "code_information": [ { "code": "49255", "type": "CPT" } ], "standard_charges": [ { "gross_charge": 26753.44, "minimum": 21402.75, "maximum": 22740.42, "setting": "inpatient", "payers_information": [ { "payer_name": "Aetna", "plan_name": "700700", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna", "plan_name": "700700_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Miscellaneous", "plan_name": "700720", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Miscellaneous", "plan_name": "700720_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Ppo Hmo", "plan_name": "701720", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Ppo Hmo", "plan_name": "701720_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Ms State Emplo", "plan_name": "401457", "standard_charge_percentage": 0.80, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Ms State Emplo", "plan_name": "401457_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Basic Pl", "plan_name": "400100", "standard_charge_percentage": 0.85, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Basic Pl", "plan_name": "400100_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Federal", "plan_name": "400110", "standard_charge_percentage": 0.85, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Federal", "plan_name": "400110_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." } ] } ] }, { "description": "Diag laparo separate proc", "code_information": [ { "code": "49320", "type": "CPT" } ], "standard_charges": [ { "gross_charge": 17782.39, "minimum": 5344.68, "maximum": 15115.03, "setting": "inpatient", "payers_information": [ { "payer_name": "Aarp", "plan_name": "500102", "standard_charge_dollar": 5344.68, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna", "plan_name": "700700", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna", "plan_name": "700700_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Mcare Ffs 6005", "plan_name": "700703", "standard_charge_dollar": 5344.68, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Miscellaneous", "plan_name": "700720", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Miscellaneous", "plan_name": "700720_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Ppo Hmo", "plan_name": "701720", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Ppo Hmo", "plan_name": "701720_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Ambetter 68069", "plan_name": "500516", "standard_charge_dollar": 5344.68, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Ms State Emplo", "plan_name": "401457", "standard_charge_percentage": 0.80, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Ms State Emplo", "plan_name": "401457_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Basic Pl", "plan_name": "400100", "standard_charge_percentage": 0.85, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Basic Pl", "plan_name": "400100_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Federal", "plan_name": "400110", "standard_charge_percentage": 0.85, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Federal", "plan_name": "400110_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Cigna Healthsprings Ffs", "plan_name": "500064", "standard_charge_dollar": 5344.68, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Conseco", "plan_name": "500302", "standard_charge_dollar": 5344.68, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Humana Ffs 61101", "plan_name": "500006", "standard_charge_dollar": 5344.68, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Medicare A", "plan_name": "100100", "standard_charge_dollar": 5344.68, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Medicare A", "plan_name": "100500", "standard_charge_dollar": 5344.68, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Medicare Part B Only", "plan_name": "100300", "standard_charge_dollar": 5344.68, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Medicare Railroad", "plan_name": "100103", "standard_charge_dollar": 5344.68, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Ms Physicians Care N", "plan_name": "714210", "standard_charge_dollar": 6680.85, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Peoples Hlth Ffs 72126", "plan_name": "500019", "standard_charge_dollar": 5344.68, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Uhc/Secure Horizons", "plan_name": "500449", "standard_charge_dollar": 5344.68, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "United Health Care/", "plan_name": "500292", "standard_charge_dollar": 6039.49, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "United Healthcare", "plan_name": "750104", "standard_charge_dollar": 6039.49, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "United Healthcare Ba", "plan_name": "750090", "standard_charge_dollar": 6039.49, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "United Healthcare Me", "plan_name": "501310", "standard_charge_dollar": 5344.68, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Windsor Mcare Extra", "plan_name": "500778", "standard_charge_dollar": 5344.68, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." } ] } ] }, { "description": "Lap revision perm ip cath", "code_information": [ { "code": "49325", "type": "CPT" } ], "standard_charges": [ { "gross_charge": 32534.83, "minimum": 5344.68, "maximum": 27654.61, "setting": "inpatient", "payers_information": [ { "payer_name": "Aarp", "plan_name": "500102", "standard_charge_dollar": 5344.68, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna", "plan_name": "700700", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna", "plan_name": "700700_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Mcare Ffs 6005", "plan_name": "700703", "standard_charge_dollar": 5344.68, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Miscellaneous", "plan_name": "700720", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Miscellaneous", "plan_name": "700720_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Ppo Hmo", "plan_name": "701720", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Ppo Hmo", "plan_name": "701720_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Ambetter 68069", "plan_name": "500516", "standard_charge_dollar": 5344.68, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Ms State Emplo", "plan_name": "401457", "standard_charge_percentage": 0.80, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Ms State Emplo", "plan_name": "401457_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Basic Pl", "plan_name": "400100", "standard_charge_percentage": 0.85, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Basic Pl", "plan_name": "400100_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Federal", "plan_name": "400110", "standard_charge_percentage": 0.85, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Federal", "plan_name": "400110_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Cigna Healthsprings Ffs", "plan_name": "500064", "standard_charge_dollar": 5344.68, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Conseco", "plan_name": "500302", "standard_charge_dollar": 5344.68, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Humana Ffs 61101", "plan_name": "500006", "standard_charge_dollar": 5344.68, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Medicare A", "plan_name": "100100", "standard_charge_dollar": 5344.68, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Medicare A", "plan_name": "100500", "standard_charge_dollar": 5344.68, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Medicare Part B Only", "plan_name": "100300", "standard_charge_dollar": 5344.68, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Medicare Railroad", "plan_name": "100103", "standard_charge_dollar": 5344.68, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Ms Physicians Care N", "plan_name": "714210", "standard_charge_dollar": 6680.85, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Peoples Hlth Ffs 72126", "plan_name": "500019", "standard_charge_dollar": 5344.68, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Uhc/Secure Horizons", "plan_name": "500449", "standard_charge_dollar": 5344.68, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "United Health Care/", "plan_name": "500292", "standard_charge_dollar": 6039.49, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "United Healthcare", "plan_name": "750104", "standard_charge_dollar": 6039.49, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "United Healthcare Ba", "plan_name": "750090", "standard_charge_dollar": 6039.49, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "United Healthcare Me", "plan_name": "501310", "standard_charge_dollar": 5344.68, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Windsor Mcare Extra", "plan_name": "500778", "standard_charge_dollar": 5344.68, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." } ] } ] }, { "description": "Image cath fluid colxn visc", "code_information": [ { "code": "49405", "type": "CPT" } ], "standard_charges": [ { "gross_charge": 35878.65, "minimum": 223.01, "maximum": 1855.31, "setting": "inpatient", "payers_information": [ { "payer_name": "Aarp", "plan_name": "500102", "standard_charge_dollar": 1484.25, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna", "plan_name": "700700", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna", "plan_name": "700700_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Mcare Ffs 6005", "plan_name": "700703", "standard_charge_dollar": 1484.25, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Miscellaneous", "plan_name": "700720", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Miscellaneous", "plan_name": "700720_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Ppo Hmo", "plan_name": "701720", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Ppo Hmo", "plan_name": "701720_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Ambetter 68069", "plan_name": "500516", "standard_charge_dollar": 1484.25, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Ms State Emplo", "plan_name": "401457", "standard_charge_dollar": 223.01, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Ms State Emplo", "plan_name": "401457_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Basic Pl", "plan_name": "400100", "standard_charge_dollar": 223.01, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Basic Pl", "plan_name": "400100_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Federal", "plan_name": "400110", "standard_charge_dollar": 223.01, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Federal", "plan_name": "400110_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Cigna Healthsprings Ffs", "plan_name": "500064", "standard_charge_dollar": 1484.25, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Conseco", "plan_name": "500302", "standard_charge_dollar": 1484.25, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Humana Ffs 61101", "plan_name": "500006", "standard_charge_dollar": 1484.25, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Medicare A", "plan_name": "100100", "standard_charge_dollar": 1484.25, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Medicare A", "plan_name": "100500", "standard_charge_dollar": 1484.25, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Medicare Part B Only", "plan_name": "100300", "standard_charge_dollar": 1484.25, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Medicare Railroad", "plan_name": "100103", "standard_charge_dollar": 1484.25, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Ms Physicians Care N", "plan_name": "714210", "standard_charge_dollar": 1855.31, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Peoples Hlth Ffs 72126", "plan_name": "500019", "standard_charge_dollar": 1484.25, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Uhc/Secure Horizons", "plan_name": "500449", "standard_charge_dollar": 1484.25, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "United Health Care/", "plan_name": "500292", "standard_charge_dollar": 1677.20, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "United Healthcare", "plan_name": "750104", "standard_charge_dollar": 1677.20, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "United Healthcare Ba", "plan_name": "750090", "standard_charge_dollar": 1677.20, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "United Healthcare Me", "plan_name": "501310", "standard_charge_dollar": 1484.25, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Windsor Mcare Extra", "plan_name": "500778", "standard_charge_dollar": 1484.25, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." } ] } ] }, { "description": "Image cath fluid peri/retro", "code_information": [ { "code": "49406", "type": "CPT" } ], "standard_charges": [ { "gross_charge": 30133.27, "minimum": 223.01, "maximum": 1855.31, "setting": "inpatient", "payers_information": [ { "payer_name": "Aarp", "plan_name": "500102", "standard_charge_dollar": 1484.25, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna", "plan_name": "700700", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna", "plan_name": "700700_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Mcare Ffs 6005", "plan_name": "700703", "standard_charge_dollar": 1484.25, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Miscellaneous", "plan_name": "700720", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Miscellaneous", "plan_name": "700720_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Ppo Hmo", "plan_name": "701720", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Ppo Hmo", "plan_name": "701720_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Ambetter 68069", "plan_name": "500516", "standard_charge_dollar": 1484.25, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Ms State Emplo", "plan_name": "401457", "standard_charge_dollar": 223.01, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Ms State Emplo", "plan_name": "401457_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Basic Pl", "plan_name": "400100", "standard_charge_dollar": 223.01, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Basic Pl", "plan_name": "400100_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Federal", "plan_name": "400110", "standard_charge_dollar": 223.01, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Federal", "plan_name": "400110_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Cigna Healthsprings Ffs", "plan_name": "500064", "standard_charge_dollar": 1484.25, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Conseco", "plan_name": "500302", "standard_charge_dollar": 1484.25, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Humana Ffs 61101", "plan_name": "500006", "standard_charge_dollar": 1484.25, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Medicare A", "plan_name": "100100", "standard_charge_dollar": 1484.25, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Medicare A", "plan_name": "100500", "standard_charge_dollar": 1484.25, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Medicare Part B Only", "plan_name": "100300", "standard_charge_dollar": 1484.25, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Medicare Railroad", "plan_name": "100103", "standard_charge_dollar": 1484.25, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Ms Physicians Care N", "plan_name": "714210", "standard_charge_dollar": 1855.31, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Peoples Hlth Ffs 72126", "plan_name": "500019", "standard_charge_dollar": 1484.25, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Uhc/Secure Horizons", "plan_name": "500449", "standard_charge_dollar": 1484.25, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "United Health Care/", "plan_name": "500292", "standard_charge_dollar": 1677.20, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "United Healthcare", "plan_name": "750104", "standard_charge_dollar": 1677.20, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "United Healthcare Ba", "plan_name": "750090", "standard_charge_dollar": 1677.20, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "United Healthcare Me", "plan_name": "501310", "standard_charge_dollar": 1484.25, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Windsor Mcare Extra", "plan_name": "500778", "standard_charge_dollar": 1484.25, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." } ] } ] }, { "description": "Ins device for rt guide open", "code_information": [ { "code": "49412", "type": "CPT" } ], "standard_charges": [ { "gross_charge": 39033.16, "minimum": 31226.53, "maximum": 33178.19, "setting": "inpatient", "payers_information": [ { "payer_name": "Aetna", "plan_name": "700700", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna", "plan_name": "700700_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Miscellaneous", "plan_name": "700720", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Miscellaneous", "plan_name": "700720_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Ppo Hmo", "plan_name": "701720", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Ppo Hmo", "plan_name": "701720_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Ms State Emplo", "plan_name": "401457", "standard_charge_percentage": 0.80, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Ms State Emplo", "plan_name": "401457_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Basic Pl", "plan_name": "400100", "standard_charge_percentage": 0.85, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Basic Pl", "plan_name": "400100_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Federal", "plan_name": "400110", "standard_charge_percentage": 0.85, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Federal", "plan_name": "400110_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." } ] } ] }, { "description": "Insert tun ip cath perc", "code_information": [ { "code": "49418", "type": "CPT" } ], "standard_charges": [ { "gross_charge": 47184.70, "minimum": 3232.86, "maximum": 40107.00, "setting": "inpatient", "payers_information": [ { "payer_name": "Aarp", "plan_name": "500102", "standard_charge_dollar": 3232.86, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna", "plan_name": "700700", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna", "plan_name": "700700_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Mcare Ffs 6005", "plan_name": "700703", "standard_charge_dollar": 3232.86, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Miscellaneous", "plan_name": "700720", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Miscellaneous", "plan_name": "700720_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Ppo Hmo", "plan_name": "701720", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Ppo Hmo", "plan_name": "701720_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Ambetter 68069", "plan_name": "500516", "standard_charge_dollar": 3232.86, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Ms State Emplo", "plan_name": "401457", "standard_charge_percentage": 0.80, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Ms State Emplo", "plan_name": "401457_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Basic Pl", "plan_name": "400100", "standard_charge_percentage": 0.85, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Basic Pl", "plan_name": "400100_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Federal", "plan_name": "400110", "standard_charge_percentage": 0.85, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Federal", "plan_name": "400110_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Cigna Healthsprings Ffs", "plan_name": "500064", "standard_charge_dollar": 3232.86, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Conseco", "plan_name": "500302", "standard_charge_dollar": 3232.86, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Humana Ffs 61101", "plan_name": "500006", "standard_charge_dollar": 3232.86, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Medicare A", "plan_name": "100100", "standard_charge_dollar": 3232.86, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Medicare A", "plan_name": "100500", "standard_charge_dollar": 3232.86, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Medicare Part B Only", "plan_name": "100300", "standard_charge_dollar": 3232.86, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Medicare Railroad", "plan_name": "100103", "standard_charge_dollar": 3232.86, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Ms Physicians Care N", "plan_name": "714210", "standard_charge_dollar": 4041.08, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Peoples Hlth Ffs 72126", "plan_name": "500019", "standard_charge_dollar": 3232.86, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Uhc/Secure Horizons", "plan_name": "500449", "standard_charge_dollar": 3232.86, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "United Health Care/", "plan_name": "500292", "standard_charge_dollar": 3653.14, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "United Healthcare", "plan_name": "750104", "standard_charge_dollar": 3653.14, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "United Healthcare Ba", "plan_name": "750090", "standard_charge_dollar": 3653.14, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "United Healthcare Me", "plan_name": "501310", "standard_charge_dollar": 3232.86, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Windsor Mcare Extra", "plan_name": "500778", "standard_charge_dollar": 3232.86, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." } ] } ] }, { "description": "Removal of shunt", "code_information": [ { "code": "49429", "type": "CPT" } ], "standard_charges": [ { "gross_charge": 32534.83, "minimum": 2883.33, "maximum": 3604.16, "setting": "inpatient", "payers_information": [ { "payer_name": "Aarp", "plan_name": "500102", "standard_charge_dollar": 2883.33, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna", "plan_name": "700700", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna", "plan_name": "700700_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Mcare Ffs 6005", "plan_name": "700703", "standard_charge_dollar": 2883.33, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Miscellaneous", "plan_name": "700720", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Miscellaneous", "plan_name": "700720_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Ppo Hmo", "plan_name": "701720", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Ppo Hmo", "plan_name": "701720_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Ambetter 68069", "plan_name": "500516", "standard_charge_dollar": 2883.33, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Ms State Emplo", "plan_name": "401457", "standard_charge_dollar": 3371.00, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Ms State Emplo", "plan_name": "401457_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Basic Pl", "plan_name": "400100", "standard_charge_dollar": 3371.00, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Basic Pl", "plan_name": "400100_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Federal", "plan_name": "400110", "standard_charge_dollar": 3371.00, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Federal", "plan_name": "400110_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Cigna Healthsprings Ffs", "plan_name": "500064", "standard_charge_dollar": 2883.33, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Conseco", "plan_name": "500302", "standard_charge_dollar": 2883.33, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Humana Ffs 61101", "plan_name": "500006", "standard_charge_dollar": 2883.33, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Medicare A", "plan_name": "100100", "standard_charge_dollar": 2883.33, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Medicare A", "plan_name": "100500", "standard_charge_dollar": 2883.33, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Medicare Part B Only", "plan_name": "100300", "standard_charge_dollar": 2883.33, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Medicare Railroad", "plan_name": "100103", "standard_charge_dollar": 2883.33, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Ms Physicians Care N", "plan_name": "714210", "standard_charge_dollar": 3604.16, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Peoples Hlth Ffs 72126", "plan_name": "500019", "standard_charge_dollar": 2883.33, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Uhc/Secure Horizons", "plan_name": "500449", "standard_charge_dollar": 2883.33, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "United Health Care/", "plan_name": "500292", "standard_charge_dollar": 3258.16, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "United Healthcare", "plan_name": "750104", "standard_charge_dollar": 3258.16, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "United Healthcare Ba", "plan_name": "750090", "standard_charge_dollar": 3258.16, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "United Healthcare Me", "plan_name": "501310", "standard_charge_dollar": 2883.33, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Windsor Mcare Extra", "plan_name": "500778", "standard_charge_dollar": 2883.33, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." } ] } ] }, { "description": "Embedded ip cath exit-site", "code_information": [ { "code": "49436", "type": "CPT" } ], "standard_charges": [ { "gross_charge": 32534.83, "minimum": 1737.77, "maximum": 27654.61, "setting": "inpatient", "payers_information": [ { "payer_name": "Aarp", "plan_name": "500102", "standard_charge_dollar": 1737.77, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna", "plan_name": "700700", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna", "plan_name": "700700_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Mcare Ffs 6005", "plan_name": "700703", "standard_charge_dollar": 1737.77, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Miscellaneous", "plan_name": "700720", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Miscellaneous", "plan_name": "700720_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Ppo Hmo", "plan_name": "701720", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Ppo Hmo", "plan_name": "701720_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Ambetter 68069", "plan_name": "500516", "standard_charge_dollar": 1737.77, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Ms State Emplo", "plan_name": "401457", "standard_charge_percentage": 0.80, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Ms State Emplo", "plan_name": "401457_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Basic Pl", "plan_name": "400100", "standard_charge_percentage": 0.85, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Basic Pl", "plan_name": "400100_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Federal", "plan_name": "400110", "standard_charge_percentage": 0.85, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Federal", "plan_name": "400110_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Cigna Healthsprings Ffs", "plan_name": "500064", "standard_charge_dollar": 1737.77, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Conseco", "plan_name": "500302", "standard_charge_dollar": 1737.77, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Humana Ffs 61101", "plan_name": "500006", "standard_charge_dollar": 1737.77, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Medicare A", "plan_name": "100100", "standard_charge_dollar": 1737.77, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Medicare A", "plan_name": "100500", "standard_charge_dollar": 1737.77, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Medicare Part B Only", "plan_name": "100300", "standard_charge_dollar": 1737.77, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Medicare Railroad", "plan_name": "100103", "standard_charge_dollar": 1737.77, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Ms Physicians Care N", "plan_name": "714210", "standard_charge_dollar": 2172.22, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Peoples Hlth Ffs 72126", "plan_name": "500019", "standard_charge_dollar": 1737.77, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Uhc/Secure Horizons", "plan_name": "500449", "standard_charge_dollar": 1737.77, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "United Health Care/", "plan_name": "500292", "standard_charge_dollar": 1963.68, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "United Healthcare", "plan_name": "750104", "standard_charge_dollar": 1963.68, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "United Healthcare Ba", "plan_name": "750090", "standard_charge_dollar": 1963.68, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "United Healthcare Me", "plan_name": "501310", "standard_charge_dollar": 1737.77, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Windsor Mcare Extra", "plan_name": "500778", "standard_charge_dollar": 1737.77, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." } ] } ] }, { "description": "Place gastrostomy tube perc", "code_information": [ { "code": "49440", "type": "CPT" } ], "standard_charges": [ { "gross_charge": 28690.88, "minimum": 1737.77, "maximum": 24387.25, "setting": "inpatient", "payers_information": [ { "payer_name": "Aarp", "plan_name": "500102", "standard_charge_dollar": 1737.77, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna", "plan_name": "700700", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna", "plan_name": "700700_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Mcare Ffs 6005", "plan_name": "700703", "standard_charge_dollar": 1737.77, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Miscellaneous", "plan_name": "700720", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Miscellaneous", "plan_name": "700720_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Ppo Hmo", "plan_name": "701720", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Ppo Hmo", "plan_name": "701720_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Ambetter 68069", "plan_name": "500516", "standard_charge_dollar": 1737.77, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Ms State Emplo", "plan_name": "401457", "standard_charge_percentage": 0.80, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Ms State Emplo", "plan_name": "401457_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Basic Pl", "plan_name": "400100", "standard_charge_percentage": 0.85, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Basic Pl", "plan_name": "400100_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Federal", "plan_name": "400110", "standard_charge_percentage": 0.85, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Federal", "plan_name": "400110_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Cigna Healthsprings Ffs", "plan_name": "500064", "standard_charge_dollar": 1737.77, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Conseco", "plan_name": "500302", "standard_charge_dollar": 1737.77, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Humana Ffs 61101", "plan_name": "500006", "standard_charge_dollar": 1737.77, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Medicare A", "plan_name": "100100", "standard_charge_dollar": 1737.77, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Medicare A", "plan_name": "100500", "standard_charge_dollar": 1737.77, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Medicare Part B Only", "plan_name": "100300", "standard_charge_dollar": 1737.77, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Medicare Railroad", "plan_name": "100103", "standard_charge_dollar": 1737.77, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Ms Physicians Care N", "plan_name": "714210", "standard_charge_dollar": 2172.22, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Peoples Hlth Ffs 72126", "plan_name": "500019", "standard_charge_dollar": 1737.77, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Uhc/Secure Horizons", "plan_name": "500449", "standard_charge_dollar": 1737.77, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "United Health Care/", "plan_name": "500292", "standard_charge_dollar": 1963.68, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "United Healthcare", "plan_name": "750104", "standard_charge_dollar": 1963.68, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "United Healthcare Ba", "plan_name": "750090", "standard_charge_dollar": 1963.68, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "United Healthcare Me", "plan_name": "501310", "standard_charge_dollar": 1737.77, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Windsor Mcare Extra", "plan_name": "500778", "standard_charge_dollar": 1737.77, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." } ] } ] }, { "description": "Replace g/c tube perc", "code_information": [ { "code": "49450", "type": "CPT" } ], "standard_charges": [ { "gross_charge": 18587.20, "minimum": 858.87, "maximum": 15799.12, "setting": "inpatient", "payers_information": [ { "payer_name": "Aarp", "plan_name": "500102", "standard_charge_dollar": 858.87, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna", "plan_name": "700700", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna", "plan_name": "700700_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Mcare Ffs 6005", "plan_name": "700703", "standard_charge_dollar": 858.87, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Miscellaneous", "plan_name": "700720", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Miscellaneous", "plan_name": "700720_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Ppo Hmo", "plan_name": "701720", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Ppo Hmo", "plan_name": "701720_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Ambetter 68069", "plan_name": "500516", "standard_charge_dollar": 858.87, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Ms State Emplo", "plan_name": "401457", "standard_charge_percentage": 0.80, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Ms State Emplo", "plan_name": "401457_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Basic Pl", "plan_name": "400100", "standard_charge_percentage": 0.85, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Basic Pl", "plan_name": "400100_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Federal", "plan_name": "400110", "standard_charge_percentage": 0.85, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Federal", "plan_name": "400110_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Cigna Healthsprings Ffs", "plan_name": "500064", "standard_charge_dollar": 858.87, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Conseco", "plan_name": "500302", "standard_charge_dollar": 858.87, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Humana Ffs 61101", "plan_name": "500006", "standard_charge_dollar": 858.87, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Medicare A", "plan_name": "100100", "standard_charge_dollar": 858.87, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Medicare A", "plan_name": "100500", "standard_charge_dollar": 858.87, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Medicare Part B Only", "plan_name": "100300", "standard_charge_dollar": 858.87, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Medicare Railroad", "plan_name": "100103", "standard_charge_dollar": 858.87, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Ms Physicians Care N", "plan_name": "714210", "standard_charge_dollar": 1073.59, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Peoples Hlth Ffs 72126", "plan_name": "500019", "standard_charge_dollar": 858.87, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Uhc/Secure Horizons", "plan_name": "500449", "standard_charge_dollar": 858.87, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "United Health Care/", "plan_name": "500292", "standard_charge_dollar": 970.52, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "United Healthcare", "plan_name": "750104", "standard_charge_dollar": 970.52, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "United Healthcare Ba", "plan_name": "750090", "standard_charge_dollar": 970.52, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "United Healthcare Me", "plan_name": "501310", "standard_charge_dollar": 858.87, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Windsor Mcare Extra", "plan_name": "500778", "standard_charge_dollar": 858.87, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." } ] } ] }, { "description": "Replace duod/jej tube perc", "code_information": [ { "code": "49451", "type": "CPT" } ], "standard_charges": [ { "gross_charge": 18587.20, "minimum": 858.87, "maximum": 15799.12, "setting": "inpatient", "payers_information": [ { "payer_name": "Aarp", "plan_name": "500102", "standard_charge_dollar": 858.87, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna", "plan_name": "700700", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna", "plan_name": "700700_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Mcare Ffs 6005", "plan_name": "700703", "standard_charge_dollar": 858.87, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Miscellaneous", "plan_name": "700720", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Miscellaneous", "plan_name": "700720_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Ppo Hmo", "plan_name": "701720", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Ppo Hmo", "plan_name": "701720_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Ambetter 68069", "plan_name": "500516", "standard_charge_dollar": 858.87, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Ms State Emplo", "plan_name": "401457", "standard_charge_percentage": 0.80, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Ms State Emplo", "plan_name": "401457_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Basic Pl", "plan_name": "400100", "standard_charge_percentage": 0.85, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Basic Pl", "plan_name": "400100_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Federal", "plan_name": "400110", "standard_charge_percentage": 0.85, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Federal", "plan_name": "400110_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Cigna Healthsprings Ffs", "plan_name": "500064", "standard_charge_dollar": 858.87, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Conseco", "plan_name": "500302", "standard_charge_dollar": 858.87, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Humana Ffs 61101", "plan_name": "500006", "standard_charge_dollar": 858.87, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Medicare A", "plan_name": "100100", "standard_charge_dollar": 858.87, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Medicare A", "plan_name": "100500", "standard_charge_dollar": 858.87, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Medicare Part B Only", "plan_name": "100300", "standard_charge_dollar": 858.87, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Medicare Railroad", "plan_name": "100103", "standard_charge_dollar": 858.87, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Ms Physicians Care N", "plan_name": "714210", "standard_charge_dollar": 1073.59, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Peoples Hlth Ffs 72126", "plan_name": "500019", "standard_charge_dollar": 858.87, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Uhc/Secure Horizons", "plan_name": "500449", "standard_charge_dollar": 858.87, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "United Health Care/", "plan_name": "500292", "standard_charge_dollar": 970.52, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "United Healthcare", "plan_name": "750104", "standard_charge_dollar": 970.52, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "United Healthcare Ba", "plan_name": "750090", "standard_charge_dollar": 970.52, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "United Healthcare Me", "plan_name": "501310", "standard_charge_dollar": 858.87, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Windsor Mcare Extra", "plan_name": "500778", "standard_charge_dollar": 858.87, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." } ] } ] }, { "description": "Replace g-j tube perc", "code_information": [ { "code": "49452", "type": "CPT" } ], "standard_charges": [ { "gross_charge": 18587.20, "minimum": 858.87, "maximum": 15799.12, "setting": "inpatient", "payers_information": [ { "payer_name": "Aarp", "plan_name": "500102", "standard_charge_dollar": 858.87, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna", "plan_name": "700700", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna", "plan_name": "700700_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Mcare Ffs 6005", "plan_name": "700703", "standard_charge_dollar": 858.87, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Miscellaneous", "plan_name": "700720", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Miscellaneous", "plan_name": "700720_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Ppo Hmo", "plan_name": "701720", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Ppo Hmo", "plan_name": "701720_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Ambetter 68069", "plan_name": "500516", "standard_charge_dollar": 858.87, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Ms State Emplo", "plan_name": "401457", "standard_charge_percentage": 0.80, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Ms State Emplo", "plan_name": "401457_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Basic Pl", "plan_name": "400100", "standard_charge_percentage": 0.85, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Basic Pl", "plan_name": "400100_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Federal", "plan_name": "400110", "standard_charge_percentage": 0.85, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Federal", "plan_name": "400110_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Cigna Healthsprings Ffs", "plan_name": "500064", "standard_charge_dollar": 858.87, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Conseco", "plan_name": "500302", "standard_charge_dollar": 858.87, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Humana Ffs 61101", "plan_name": "500006", "standard_charge_dollar": 858.87, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Medicare A", "plan_name": "100100", "standard_charge_dollar": 858.87, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Medicare A", "plan_name": "100500", "standard_charge_dollar": 858.87, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Medicare Part B Only", "plan_name": "100300", "standard_charge_dollar": 858.87, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Medicare Railroad", "plan_name": "100103", "standard_charge_dollar": 858.87, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Ms Physicians Care N", "plan_name": "714210", "standard_charge_dollar": 1073.59, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Peoples Hlth Ffs 72126", "plan_name": "500019", "standard_charge_dollar": 858.87, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Uhc/Secure Horizons", "plan_name": "500449", "standard_charge_dollar": 858.87, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "United Health Care/", "plan_name": "500292", "standard_charge_dollar": 970.52, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "United Healthcare", "plan_name": "750104", "standard_charge_dollar": 970.52, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "United Healthcare Ba", "plan_name": "750090", "standard_charge_dollar": 970.52, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "United Healthcare Me", "plan_name": "501310", "standard_charge_dollar": 858.87, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Windsor Mcare Extra", "plan_name": "500778", "standard_charge_dollar": 858.87, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." } ] } ] }, { "description": "Rpr hern preemie reduc", "code_information": [ { "code": "49491", "type": "CPT" } ], "standard_charges": [ { "gross_charge": 22937.92, "minimum": 5344.68, "maximum": 19497.23, "setting": "inpatient", "payers_information": [ { "payer_name": "Aarp", "plan_name": "500102", "standard_charge_dollar": 5344.68, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna", "plan_name": "700700", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna", "plan_name": "700700_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Mcare Ffs 6005", "plan_name": "700703", "standard_charge_dollar": 5344.68, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Miscellaneous", "plan_name": "700720", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Miscellaneous", "plan_name": "700720_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Ppo Hmo", "plan_name": "701720", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Ppo Hmo", "plan_name": "701720_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Ambetter 68069", "plan_name": "500516", "standard_charge_dollar": 5344.68, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Ms State Emplo", "plan_name": "401457", "standard_charge_percentage": 0.80, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Ms State Emplo", "plan_name": "401457_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Basic Pl", "plan_name": "400100", "standard_charge_percentage": 0.85, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Basic Pl", "plan_name": "400100_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Federal", "plan_name": "400110", "standard_charge_percentage": 0.85, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Federal", "plan_name": "400110_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Cigna Healthsprings Ffs", "plan_name": "500064", "standard_charge_dollar": 5344.68, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Conseco", "plan_name": "500302", "standard_charge_dollar": 5344.68, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Humana Ffs 61101", "plan_name": "500006", "standard_charge_dollar": 5344.68, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Medicare A", "plan_name": "100100", "standard_charge_dollar": 5344.68, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Medicare A", "plan_name": "100500", "standard_charge_dollar": 5344.68, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Medicare Part B Only", "plan_name": "100300", "standard_charge_dollar": 5344.68, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Medicare Railroad", "plan_name": "100103", "standard_charge_dollar": 5344.68, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Ms Physicians Care N", "plan_name": "714210", "standard_charge_dollar": 6680.85, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Peoples Hlth Ffs 72126", "plan_name": "500019", "standard_charge_dollar": 5344.68, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Uhc/Secure Horizons", "plan_name": "500449", "standard_charge_dollar": 5344.68, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "United Health Care/", "plan_name": "500292", "standard_charge_dollar": 6039.49, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "United Healthcare", "plan_name": "750104", "standard_charge_dollar": 6039.49, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "United Healthcare Ba", "plan_name": "750090", "standard_charge_dollar": 6039.49, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "United Healthcare Me", "plan_name": "501310", "standard_charge_dollar": 5344.68, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Windsor Mcare Extra", "plan_name": "500778", "standard_charge_dollar": 5344.68, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." } ] } ] }, { "description": "Rpr ing hern premie blocked", "code_information": [ { "code": "49492", "type": "CPT" } ], "standard_charges": [ { "gross_charge": 22937.92, "minimum": 3232.86, "maximum": 19497.23, "setting": "inpatient", "payers_information": [ { "payer_name": "Aarp", "plan_name": "500102", "standard_charge_dollar": 3232.86, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna", "plan_name": "700700", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna", "plan_name": "700700_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Mcare Ffs 6005", "plan_name": "700703", "standard_charge_dollar": 3232.86, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Miscellaneous", "plan_name": "700720", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Miscellaneous", "plan_name": "700720_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Ppo Hmo", "plan_name": "701720", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Ppo Hmo", "plan_name": "701720_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Ambetter 68069", "plan_name": "500516", "standard_charge_dollar": 3232.86, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Ms State Emplo", "plan_name": "401457", "standard_charge_percentage": 0.80, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Ms State Emplo", "plan_name": "401457_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Basic Pl", "plan_name": "400100", "standard_charge_percentage": 0.85, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Basic Pl", "plan_name": "400100_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Federal", "plan_name": "400110", "standard_charge_percentage": 0.85, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Federal", "plan_name": "400110_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Cigna Healthsprings Ffs", "plan_name": "500064", "standard_charge_dollar": 3232.86, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Conseco", "plan_name": "500302", "standard_charge_dollar": 3232.86, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Humana Ffs 61101", "plan_name": "500006", "standard_charge_dollar": 3232.86, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Medicare A", "plan_name": "100100", "standard_charge_dollar": 3232.86, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Medicare A", "plan_name": "100500", "standard_charge_dollar": 3232.86, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Medicare Part B Only", "plan_name": "100300", "standard_charge_dollar": 3232.86, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Medicare Railroad", "plan_name": "100103", "standard_charge_dollar": 3232.86, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Ms Physicians Care N", "plan_name": "714210", "standard_charge_dollar": 4041.08, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Peoples Hlth Ffs 72126", "plan_name": "500019", "standard_charge_dollar": 3232.86, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Uhc/Secure Horizons", "plan_name": "500449", "standard_charge_dollar": 3232.86, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "United Health Care/", "plan_name": "500292", "standard_charge_dollar": 3653.14, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "United Healthcare", "plan_name": "750104", "standard_charge_dollar": 3653.14, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "United Healthcare Ba", "plan_name": "750090", "standard_charge_dollar": 3653.14, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "United Healthcare Me", "plan_name": "501310", "standard_charge_dollar": 3232.86, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Windsor Mcare Extra", "plan_name": "500778", "standard_charge_dollar": 3232.86, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." } ] } ] }, { "description": "Rpr ing hernia baby reduc", "code_information": [ { "code": "49495", "type": "CPT" } ], "standard_charges": [ { "gross_charge": 22937.92, "minimum": 3232.86, "maximum": 19497.23, "setting": "inpatient", "payers_information": [ { "payer_name": "Aarp", "plan_name": "500102", "standard_charge_dollar": 3232.86, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna", "plan_name": "700700", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna", "plan_name": "700700_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Mcare Ffs 6005", "plan_name": "700703", "standard_charge_dollar": 3232.86, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Miscellaneous", "plan_name": "700720", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Miscellaneous", "plan_name": "700720_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Ppo Hmo", "plan_name": "701720", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Ppo Hmo", "plan_name": "701720_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Ambetter 68069", "plan_name": "500516", "standard_charge_dollar": 3232.86, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Ms State Emplo", "plan_name": "401457", "standard_charge_percentage": 0.80, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Ms State Emplo", "plan_name": "401457_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Basic Pl", "plan_name": "400100", "standard_charge_percentage": 0.85, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Basic Pl", "plan_name": "400100_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Federal", "plan_name": "400110", "standard_charge_percentage": 0.85, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Federal", "plan_name": "400110_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Cigna Healthsprings Ffs", "plan_name": "500064", "standard_charge_dollar": 3232.86, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Conseco", "plan_name": "500302", "standard_charge_dollar": 3232.86, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Humana Ffs 61101", "plan_name": "500006", "standard_charge_dollar": 3232.86, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Medicare A", "plan_name": "100100", "standard_charge_dollar": 3232.86, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Medicare A", "plan_name": "100500", "standard_charge_dollar": 3232.86, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Medicare Part B Only", "plan_name": "100300", "standard_charge_dollar": 3232.86, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Medicare Railroad", "plan_name": "100103", "standard_charge_dollar": 3232.86, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Ms Physicians Care N", "plan_name": "714210", "standard_charge_dollar": 4041.08, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Peoples Hlth Ffs 72126", "plan_name": "500019", "standard_charge_dollar": 3232.86, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Uhc/Secure Horizons", "plan_name": "500449", "standard_charge_dollar": 3232.86, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "United Health Care/", "plan_name": "500292", "standard_charge_dollar": 3653.14, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "United Healthcare", "plan_name": "750104", "standard_charge_dollar": 3653.14, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "United Healthcare Ba", "plan_name": "750090", "standard_charge_dollar": 3653.14, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "United Healthcare Me", "plan_name": "501310", "standard_charge_dollar": 3232.86, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Windsor Mcare Extra", "plan_name": "500778", "standard_charge_dollar": 3232.86, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." } ] } ] }, { "description": "Rpr ing hernia baby blocked", "code_information": [ { "code": "49496", "type": "CPT" } ], "standard_charges": [ { "gross_charge": 22937.92, "minimum": 3232.86, "maximum": 19497.23, "setting": "inpatient", "payers_information": [ { "payer_name": "Aarp", "plan_name": "500102", "standard_charge_dollar": 3232.86, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna", "plan_name": "700700", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna", "plan_name": "700700_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Mcare Ffs 6005", "plan_name": "700703", "standard_charge_dollar": 3232.86, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Miscellaneous", "plan_name": "700720", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Miscellaneous", "plan_name": "700720_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Ppo Hmo", "plan_name": "701720", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Ppo Hmo", "plan_name": "701720_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Ambetter 68069", "plan_name": "500516", "standard_charge_dollar": 3232.86, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Ms State Emplo", "plan_name": "401457", "standard_charge_percentage": 0.80, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Ms State Emplo", "plan_name": "401457_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Basic Pl", "plan_name": "400100", "standard_charge_percentage": 0.85, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Basic Pl", "plan_name": "400100_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Federal", "plan_name": "400110", "standard_charge_percentage": 0.85, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Federal", "plan_name": "400110_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Cigna Healthsprings Ffs", "plan_name": "500064", "standard_charge_dollar": 3232.86, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Conseco", "plan_name": "500302", "standard_charge_dollar": 3232.86, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Humana Ffs 61101", "plan_name": "500006", "standard_charge_dollar": 3232.86, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Medicare A", "plan_name": "100100", "standard_charge_dollar": 3232.86, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Medicare A", "plan_name": "100500", "standard_charge_dollar": 3232.86, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Medicare Part B Only", "plan_name": "100300", "standard_charge_dollar": 3232.86, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Medicare Railroad", "plan_name": "100103", "standard_charge_dollar": 3232.86, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Ms Physicians Care N", "plan_name": "714210", "standard_charge_dollar": 4041.08, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Peoples Hlth Ffs 72126", "plan_name": "500019", "standard_charge_dollar": 3232.86, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Uhc/Secure Horizons", "plan_name": "500449", "standard_charge_dollar": 3232.86, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "United Health Care/", "plan_name": "500292", "standard_charge_dollar": 3653.14, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "United Healthcare", "plan_name": "750104", "standard_charge_dollar": 3653.14, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "United Healthcare Ba", "plan_name": "750090", "standard_charge_dollar": 3653.14, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "United Healthcare Me", "plan_name": "501310", "standard_charge_dollar": 3232.86, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Windsor Mcare Extra", "plan_name": "500778", "standard_charge_dollar": 3232.86, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." } ] } ] }, { "description": "Rpr ing hernia init reduce", "code_information": [ { "code": "49500", "type": "CPT" } ], "standard_charges": [ { "gross_charge": 22937.92, "minimum": 5716.04, "maximum": 19497.23, "setting": "inpatient", "payers_information": [ { "payer_name": "Aarp", "plan_name": "500102", "standard_charge_dollar": 5716.04, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna", "plan_name": "700700", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna", "plan_name": "700700_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Mcare Ffs 6005", "plan_name": "700703", "standard_charge_dollar": 5716.04, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Miscellaneous", "plan_name": "700720", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Miscellaneous", "plan_name": "700720_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Ppo Hmo", "plan_name": "701720", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Ppo Hmo", "plan_name": "701720_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Ambetter 68069", "plan_name": "500516", "standard_charge_dollar": 5716.04, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Ms State Emplo", "plan_name": "401457", "standard_charge_percentage": 0.80, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Ms State Emplo", "plan_name": "401457_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Basic Pl", "plan_name": "400100", "standard_charge_percentage": 0.85, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Basic Pl", "plan_name": "400100_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Federal", "plan_name": "400110", "standard_charge_percentage": 0.85, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Federal", "plan_name": "400110_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Cigna Healthsprings Ffs", "plan_name": "500064", "standard_charge_dollar": 5716.04, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Conseco", "plan_name": "500302", "standard_charge_dollar": 5716.04, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Humana Ffs 61101", "plan_name": "500006", "standard_charge_dollar": 5716.04, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Medicare A", "plan_name": "100100", "standard_charge_dollar": 5716.04, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Medicare A", "plan_name": "100500", "standard_charge_dollar": 5716.04, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Medicare Part B Only", "plan_name": "100300", "standard_charge_dollar": 5716.04, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Medicare Railroad", "plan_name": "100103", "standard_charge_dollar": 5716.04, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Ms Physicians Care N", "plan_name": "714210", "standard_charge_dollar": 7145.05, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Peoples Hlth Ffs 72126", "plan_name": "500019", "standard_charge_dollar": 5716.04, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Uhc/Secure Horizons", "plan_name": "500449", "standard_charge_dollar": 5716.04, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "United Health Care/", "plan_name": "500292", "standard_charge_dollar": 6459.13, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "United Healthcare", "plan_name": "750104", "standard_charge_dollar": 6459.13, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "United Healthcare Ba", "plan_name": "750090", "standard_charge_dollar": 6459.13, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "United Healthcare Me", "plan_name": "501310", "standard_charge_dollar": 5716.04, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Windsor Mcare Extra", "plan_name": "500778", "standard_charge_dollar": 5716.04, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." } ] } ] }, { "description": "Rpr ing hernia init blocked", "code_information": [ { "code": "49501", "type": "CPT" } ], "standard_charges": [ { "gross_charge": 22937.92, "minimum": 3232.86, "maximum": 19497.23, "setting": "inpatient", "payers_information": [ { "payer_name": "Aarp", "plan_name": "500102", "standard_charge_dollar": 3232.86, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna", "plan_name": "700700", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna", "plan_name": "700700_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Mcare Ffs 6005", "plan_name": "700703", "standard_charge_dollar": 3232.86, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Miscellaneous", "plan_name": "700720", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Miscellaneous", "plan_name": "700720_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Ppo Hmo", "plan_name": "701720", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Ppo Hmo", "plan_name": "701720_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Ambetter 68069", "plan_name": "500516", "standard_charge_dollar": 3232.86, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Ms State Emplo", "plan_name": "401457", "standard_charge_percentage": 0.80, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Ms State Emplo", "plan_name": "401457_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Basic Pl", "plan_name": "400100", "standard_charge_percentage": 0.85, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Basic Pl", "plan_name": "400100_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Federal", "plan_name": "400110", "standard_charge_percentage": 0.85, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Federal", "plan_name": "400110_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Cigna Healthsprings Ffs", "plan_name": "500064", "standard_charge_dollar": 3232.86, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Conseco", "plan_name": "500302", "standard_charge_dollar": 3232.86, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Humana Ffs 61101", "plan_name": "500006", "standard_charge_dollar": 3232.86, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Medicare A", "plan_name": "100100", "standard_charge_dollar": 3232.86, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Medicare A", "plan_name": "100500", "standard_charge_dollar": 3232.86, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Medicare Part B Only", "plan_name": "100300", "standard_charge_dollar": 3232.86, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Medicare Railroad", "plan_name": "100103", "standard_charge_dollar": 3232.86, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Ms Physicians Care N", "plan_name": "714210", "standard_charge_dollar": 4041.08, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Peoples Hlth Ffs 72126", "plan_name": "500019", "standard_charge_dollar": 3232.86, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Uhc/Secure Horizons", "plan_name": "500449", "standard_charge_dollar": 3232.86, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "United Health Care/", "plan_name": "500292", "standard_charge_dollar": 3653.14, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "United Healthcare", "plan_name": "750104", "standard_charge_dollar": 3653.14, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "United Healthcare Ba", "plan_name": "750090", "standard_charge_dollar": 3653.14, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "United Healthcare Me", "plan_name": "501310", "standard_charge_dollar": 3232.86, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Windsor Mcare Extra", "plan_name": "500778", "standard_charge_dollar": 3232.86, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." } ] } ] }, { "description": "Prp i/hern init reduc >5 yr", "code_information": [ { "code": "49505", "type": "CPT" } ], "standard_charges": [ { "gross_charge": 22937.92, "minimum": 3232.86, "maximum": 19497.23, "setting": "inpatient", "payers_information": [ { "payer_name": "Aarp", "plan_name": "500102", "standard_charge_dollar": 3232.86, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna", "plan_name": "700700", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna", "plan_name": "700700_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Mcare Ffs 6005", "plan_name": "700703", "standard_charge_dollar": 3232.86, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Miscellaneous", "plan_name": "700720", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Miscellaneous", "plan_name": "700720_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Ppo Hmo", "plan_name": "701720", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Ppo Hmo", "plan_name": "701720_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Ambetter 68069", "plan_name": "500516", "standard_charge_dollar": 3232.86, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Ms State Emplo", "plan_name": "401457", "standard_charge_percentage": 0.80, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Ms State Emplo", "plan_name": "401457_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Basic Pl", "plan_name": "400100", "standard_charge_percentage": 0.85, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Basic Pl", "plan_name": "400100_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Federal", "plan_name": "400110", "standard_charge_percentage": 0.85, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Federal", "plan_name": "400110_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Cigna Healthsprings Ffs", "plan_name": "500064", "standard_charge_dollar": 3232.86, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Conseco", "plan_name": "500302", "standard_charge_dollar": 3232.86, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Humana Ffs 61101", "plan_name": "500006", "standard_charge_dollar": 3232.86, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Medicare A", "plan_name": "100100", "standard_charge_dollar": 3232.86, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Medicare A", "plan_name": "100500", "standard_charge_dollar": 3232.86, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Medicare Part B Only", "plan_name": "100300", "standard_charge_dollar": 3232.86, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Medicare Railroad", "plan_name": "100103", "standard_charge_dollar": 3232.86, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Ms Physicians Care N", "plan_name": "714210", "standard_charge_dollar": 4041.08, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Peoples Hlth Ffs 72126", "plan_name": "500019", "standard_charge_dollar": 3232.86, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Uhc/Secure Horizons", "plan_name": "500449", "standard_charge_dollar": 3232.86, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "United Health Care/", "plan_name": "500292", "standard_charge_dollar": 3653.14, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "United Healthcare", "plan_name": "750104", "standard_charge_dollar": 3653.14, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "United Healthcare Ba", "plan_name": "750090", "standard_charge_dollar": 3653.14, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "United Healthcare Me", "plan_name": "501310", "standard_charge_dollar": 3232.86, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Windsor Mcare Extra", "plan_name": "500778", "standard_charge_dollar": 3232.86, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." } ] } ] }, { "description": "Prp i/hern init block >5 yr", "code_information": [ { "code": "49507", "type": "CPT" } ], "standard_charges": [ { "gross_charge": 22937.92, "minimum": 3232.86, "maximum": 19497.23, "setting": "inpatient", "payers_information": [ { "payer_name": "Aarp", "plan_name": "500102", "standard_charge_dollar": 3232.86, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna", "plan_name": "700700", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna", "plan_name": "700700_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Mcare Ffs 6005", "plan_name": "700703", "standard_charge_dollar": 3232.86, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Miscellaneous", "plan_name": "700720", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Miscellaneous", "plan_name": "700720_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Ppo Hmo", "plan_name": "701720", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Ppo Hmo", "plan_name": "701720_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Ambetter 68069", "plan_name": "500516", "standard_charge_dollar": 3232.86, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Ms State Emplo", "plan_name": "401457", "standard_charge_percentage": 0.80, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Ms State Emplo", "plan_name": "401457_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Basic Pl", "plan_name": "400100", "standard_charge_percentage": 0.85, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Basic Pl", "plan_name": "400100_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Federal", "plan_name": "400110", "standard_charge_percentage": 0.85, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Federal", "plan_name": "400110_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Cigna Healthsprings Ffs", "plan_name": "500064", "standard_charge_dollar": 3232.86, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Conseco", "plan_name": "500302", "standard_charge_dollar": 3232.86, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Humana Ffs 61101", "plan_name": "500006", "standard_charge_dollar": 3232.86, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Medicare A", "plan_name": "100100", "standard_charge_dollar": 3232.86, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Medicare A", "plan_name": "100500", "standard_charge_dollar": 3232.86, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Medicare Part B Only", "plan_name": "100300", "standard_charge_dollar": 3232.86, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Medicare Railroad", "plan_name": "100103", "standard_charge_dollar": 3232.86, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Ms Physicians Care N", "plan_name": "714210", "standard_charge_dollar": 4041.08, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Peoples Hlth Ffs 72126", "plan_name": "500019", "standard_charge_dollar": 3232.86, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Uhc/Secure Horizons", "plan_name": "500449", "standard_charge_dollar": 3232.86, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "United Health Care/", "plan_name": "500292", "standard_charge_dollar": 3653.14, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "United Healthcare", "plan_name": "750104", "standard_charge_dollar": 3653.14, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "United Healthcare Ba", "plan_name": "750090", "standard_charge_dollar": 3653.14, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "United Healthcare Me", "plan_name": "501310", "standard_charge_dollar": 3232.86, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Windsor Mcare Extra", "plan_name": "500778", "standard_charge_dollar": 3232.86, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." } ] } ] }, { "description": "Rerepair ing hernia reduce", "code_information": [ { "code": "49520", "type": "CPT" } ], "standard_charges": [ { "gross_charge": 22937.92, "minimum": 3232.86, "maximum": 19497.23, "setting": "inpatient", "payers_information": [ { "payer_name": "Aarp", "plan_name": "500102", "standard_charge_dollar": 3232.86, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna", "plan_name": "700700", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna", "plan_name": "700700_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Mcare Ffs 6005", "plan_name": "700703", "standard_charge_dollar": 3232.86, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Miscellaneous", "plan_name": "700720", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Miscellaneous", "plan_name": "700720_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Ppo Hmo", "plan_name": "701720", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Ppo Hmo", "plan_name": "701720_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Ambetter 68069", "plan_name": "500516", "standard_charge_dollar": 3232.86, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Ms State Emplo", "plan_name": "401457", "standard_charge_percentage": 0.80, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Ms State Emplo", "plan_name": "401457_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Basic Pl", "plan_name": "400100", "standard_charge_percentage": 0.85, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Basic Pl", "plan_name": "400100_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Federal", "plan_name": "400110", "standard_charge_percentage": 0.85, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Federal", "plan_name": "400110_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Cigna Healthsprings Ffs", "plan_name": "500064", "standard_charge_dollar": 3232.86, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Conseco", "plan_name": "500302", "standard_charge_dollar": 3232.86, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Humana Ffs 61101", "plan_name": "500006", "standard_charge_dollar": 3232.86, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Medicare A", "plan_name": "100100", "standard_charge_dollar": 3232.86, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Medicare A", "plan_name": "100500", "standard_charge_dollar": 3232.86, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Medicare Part B Only", "plan_name": "100300", "standard_charge_dollar": 3232.86, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Medicare Railroad", "plan_name": "100103", "standard_charge_dollar": 3232.86, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Ms Physicians Care N", "plan_name": "714210", "standard_charge_dollar": 4041.08, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Peoples Hlth Ffs 72126", "plan_name": "500019", "standard_charge_dollar": 3232.86, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Uhc/Secure Horizons", "plan_name": "500449", "standard_charge_dollar": 3232.86, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "United Health Care/", "plan_name": "500292", "standard_charge_dollar": 3653.14, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "United Healthcare", "plan_name": "750104", "standard_charge_dollar": 3653.14, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "United Healthcare Ba", "plan_name": "750090", "standard_charge_dollar": 3653.14, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "United Healthcare Me", "plan_name": "501310", "standard_charge_dollar": 3232.86, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Windsor Mcare Extra", "plan_name": "500778", "standard_charge_dollar": 3232.86, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." } ] } ] }, { "description": "Rerepair ing hernia blocked", "code_information": [ { "code": "49521", "type": "CPT" } ], "standard_charges": [ { "gross_charge": 22937.92, "minimum": 5716.04, "maximum": 19497.23, "setting": "inpatient", "payers_information": [ { "payer_name": "Aarp", "plan_name": "500102", "standard_charge_dollar": 5716.04, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna", "plan_name": "700700", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna", "plan_name": "700700_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Mcare Ffs 6005", "plan_name": "700703", "standard_charge_dollar": 5716.04, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Miscellaneous", "plan_name": "700720", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Miscellaneous", "plan_name": "700720_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Ppo Hmo", "plan_name": "701720", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Ppo Hmo", "plan_name": "701720_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Ambetter 68069", "plan_name": "500516", "standard_charge_dollar": 5716.04, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Ms State Emplo", "plan_name": "401457", "standard_charge_percentage": 0.80, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Ms State Emplo", "plan_name": "401457_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Basic Pl", "plan_name": "400100", "standard_charge_percentage": 0.85, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Basic Pl", "plan_name": "400100_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Federal", "plan_name": "400110", "standard_charge_percentage": 0.85, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Federal", "plan_name": "400110_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Cigna Healthsprings Ffs", "plan_name": "500064", "standard_charge_dollar": 5716.04, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Conseco", "plan_name": "500302", "standard_charge_dollar": 5716.04, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Humana Ffs 61101", "plan_name": "500006", "standard_charge_dollar": 5716.04, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Medicare A", "plan_name": "100100", "standard_charge_dollar": 5716.04, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Medicare A", "plan_name": "100500", "standard_charge_dollar": 5716.04, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Medicare Part B Only", "plan_name": "100300", "standard_charge_dollar": 5716.04, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Medicare Railroad", "plan_name": "100103", "standard_charge_dollar": 5716.04, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Ms Physicians Care N", "plan_name": "714210", "standard_charge_dollar": 7145.05, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Peoples Hlth Ffs 72126", "plan_name": "500019", "standard_charge_dollar": 5716.04, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Uhc/Secure Horizons", "plan_name": "500449", "standard_charge_dollar": 5716.04, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "United Health Care/", "plan_name": "500292", "standard_charge_dollar": 6459.13, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "United Healthcare", "plan_name": "750104", "standard_charge_dollar": 6459.13, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "United Healthcare Ba", "plan_name": "750090", "standard_charge_dollar": 6459.13, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "United Healthcare Me", "plan_name": "501310", "standard_charge_dollar": 5716.04, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Windsor Mcare Extra", "plan_name": "500778", "standard_charge_dollar": 5716.04, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." } ] } ] }, { "description": "Repair ing hernia sliding", "code_information": [ { "code": "49525", "type": "CPT" } ], "standard_charges": [ { "gross_charge": 22937.92, "minimum": 3232.86, "maximum": 19497.23, "setting": "inpatient", "payers_information": [ { "payer_name": "Aarp", "plan_name": "500102", "standard_charge_dollar": 3232.86, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna", "plan_name": "700700", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna", "plan_name": "700700_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Mcare Ffs 6005", "plan_name": "700703", "standard_charge_dollar": 3232.86, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Miscellaneous", "plan_name": "700720", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Miscellaneous", "plan_name": "700720_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Ppo Hmo", "plan_name": "701720", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Ppo Hmo", "plan_name": "701720_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Ambetter 68069", "plan_name": "500516", "standard_charge_dollar": 3232.86, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Ms State Emplo", "plan_name": "401457", "standard_charge_percentage": 0.80, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Ms State Emplo", "plan_name": "401457_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Basic Pl", "plan_name": "400100", "standard_charge_percentage": 0.85, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Basic Pl", "plan_name": "400100_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Federal", "plan_name": "400110", "standard_charge_percentage": 0.85, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Federal", "plan_name": "400110_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Cigna Healthsprings Ffs", "plan_name": "500064", "standard_charge_dollar": 3232.86, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Conseco", "plan_name": "500302", "standard_charge_dollar": 3232.86, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Humana Ffs 61101", "plan_name": "500006", "standard_charge_dollar": 3232.86, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Medicare A", "plan_name": "100100", "standard_charge_dollar": 3232.86, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Medicare A", "plan_name": "100500", "standard_charge_dollar": 3232.86, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Medicare Part B Only", "plan_name": "100300", "standard_charge_dollar": 3232.86, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Medicare Railroad", "plan_name": "100103", "standard_charge_dollar": 3232.86, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Ms Physicians Care N", "plan_name": "714210", "standard_charge_dollar": 4041.08, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Peoples Hlth Ffs 72126", "plan_name": "500019", "standard_charge_dollar": 3232.86, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Uhc/Secure Horizons", "plan_name": "500449", "standard_charge_dollar": 3232.86, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "United Health Care/", "plan_name": "500292", "standard_charge_dollar": 3653.14, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "United Healthcare", "plan_name": "750104", "standard_charge_dollar": 3653.14, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "United Healthcare Ba", "plan_name": "750090", "standard_charge_dollar": 3653.14, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "United Healthcare Me", "plan_name": "501310", "standard_charge_dollar": 3232.86, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Windsor Mcare Extra", "plan_name": "500778", "standard_charge_dollar": 3232.86, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." } ] } ] }, { "description": "Rpr rem hernia init reduce", "code_information": [ { "code": "49550", "type": "CPT" } ], "standard_charges": [ { "gross_charge": 90582.19, "minimum": 3232.86, "maximum": 76994.86, "setting": "inpatient", "payers_information": [ { "payer_name": "Aarp", "plan_name": "500102", "standard_charge_dollar": 3232.86, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna", "plan_name": "700700", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna", "plan_name": "700700_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Mcare Ffs 6005", "plan_name": "700703", "standard_charge_dollar": 3232.86, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Miscellaneous", "plan_name": "700720", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Miscellaneous", "plan_name": "700720_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Ppo Hmo", "plan_name": "701720", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Ppo Hmo", "plan_name": "701720_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Ambetter 68069", "plan_name": "500516", "standard_charge_dollar": 3232.86, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Ms State Emplo", "plan_name": "401457", "standard_charge_percentage": 0.80, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Ms State Emplo", "plan_name": "401457_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Basic Pl", "plan_name": "400100", "standard_charge_percentage": 0.85, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Basic Pl", "plan_name": "400100_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Federal", "plan_name": "400110", "standard_charge_percentage": 0.85, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Federal", "plan_name": "400110_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Cigna Healthsprings Ffs", "plan_name": "500064", "standard_charge_dollar": 3232.86, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Conseco", "plan_name": "500302", "standard_charge_dollar": 3232.86, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Humana Ffs 61101", "plan_name": "500006", "standard_charge_dollar": 3232.86, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Medicare A", "plan_name": "100100", "standard_charge_dollar": 3232.86, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Medicare A", "plan_name": "100500", "standard_charge_dollar": 3232.86, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Medicare Part B Only", "plan_name": "100300", "standard_charge_dollar": 3232.86, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Medicare Railroad", "plan_name": "100103", "standard_charge_dollar": 3232.86, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Ms Physicians Care N", "plan_name": "714210", "standard_charge_dollar": 4041.08, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Peoples Hlth Ffs 72126", "plan_name": "500019", "standard_charge_dollar": 3232.86, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Uhc/Secure Horizons", "plan_name": "500449", "standard_charge_dollar": 3232.86, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "United Health Care/", "plan_name": "500292", "standard_charge_dollar": 3653.14, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "United Healthcare", "plan_name": "750104", "standard_charge_dollar": 3653.14, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "United Healthcare Ba", "plan_name": "750090", "standard_charge_dollar": 3653.14, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "United Healthcare Me", "plan_name": "501310", "standard_charge_dollar": 3232.86, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Windsor Mcare Extra", "plan_name": "500778", "standard_charge_dollar": 3232.86, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." } ] } ] }, { "description": "Rpr fem hernia init blocked", "code_information": [ { "code": "49553", "type": "CPT" } ], "standard_charges": [ { "gross_charge": 90582.19, "minimum": 3232.86, "maximum": 76994.86, "setting": "inpatient", "payers_information": [ { "payer_name": "Aarp", "plan_name": "500102", "standard_charge_dollar": 3232.86, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna", "plan_name": "700700", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna", "plan_name": "700700_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Mcare Ffs 6005", "plan_name": "700703", "standard_charge_dollar": 3232.86, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Miscellaneous", "plan_name": "700720", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Miscellaneous", "plan_name": "700720_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Ppo Hmo", "plan_name": "701720", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Ppo Hmo", "plan_name": "701720_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Ambetter 68069", "plan_name": "500516", "standard_charge_dollar": 3232.86, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Ms State Emplo", "plan_name": "401457", "standard_charge_percentage": 0.80, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Ms State Emplo", "plan_name": "401457_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Basic Pl", "plan_name": "400100", "standard_charge_percentage": 0.85, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Basic Pl", "plan_name": "400100_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Federal", "plan_name": "400110", "standard_charge_percentage": 0.85, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Federal", "plan_name": "400110_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Cigna Healthsprings Ffs", "plan_name": "500064", "standard_charge_dollar": 3232.86, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Conseco", "plan_name": "500302", "standard_charge_dollar": 3232.86, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Humana Ffs 61101", "plan_name": "500006", "standard_charge_dollar": 3232.86, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Medicare A", "plan_name": "100100", "standard_charge_dollar": 3232.86, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Medicare A", "plan_name": "100500", "standard_charge_dollar": 3232.86, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Medicare Part B Only", "plan_name": "100300", "standard_charge_dollar": 3232.86, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Medicare Railroad", "plan_name": "100103", "standard_charge_dollar": 3232.86, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Ms Physicians Care N", "plan_name": "714210", "standard_charge_dollar": 4041.08, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Peoples Hlth Ffs 72126", "plan_name": "500019", "standard_charge_dollar": 3232.86, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Uhc/Secure Horizons", "plan_name": "500449", "standard_charge_dollar": 3232.86, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "United Health Care/", "plan_name": "500292", "standard_charge_dollar": 3653.14, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "United Healthcare", "plan_name": "750104", "standard_charge_dollar": 3653.14, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "United Healthcare Ba", "plan_name": "750090", "standard_charge_dollar": 3653.14, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "United Healthcare Me", "plan_name": "501310", "standard_charge_dollar": 3232.86, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Windsor Mcare Extra", "plan_name": "500778", "standard_charge_dollar": 3232.86, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." } ] } ] }, { "description": "Rerepair fem hernia reduce", "code_information": [ { "code": "49555", "type": "CPT" } ], "standard_charges": [ { "gross_charge": 90582.19, "minimum": 3232.86, "maximum": 76994.86, "setting": "inpatient", "payers_information": [ { "payer_name": "Aarp", "plan_name": "500102", "standard_charge_dollar": 3232.86, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna", "plan_name": "700700", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna", "plan_name": "700700_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Mcare Ffs 6005", "plan_name": "700703", "standard_charge_dollar": 3232.86, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Miscellaneous", "plan_name": "700720", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Miscellaneous", "plan_name": "700720_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Ppo Hmo", "plan_name": "701720", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Ppo Hmo", "plan_name": "701720_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Ambetter 68069", "plan_name": "500516", "standard_charge_dollar": 3232.86, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Ms State Emplo", "plan_name": "401457", "standard_charge_percentage": 0.80, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Ms State Emplo", "plan_name": "401457_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Basic Pl", "plan_name": "400100", "standard_charge_percentage": 0.85, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Basic Pl", "plan_name": "400100_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Federal", "plan_name": "400110", "standard_charge_percentage": 0.85, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Federal", "plan_name": "400110_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Cigna Healthsprings Ffs", "plan_name": "500064", "standard_charge_dollar": 3232.86, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Conseco", "plan_name": "500302", "standard_charge_dollar": 3232.86, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Humana Ffs 61101", "plan_name": "500006", "standard_charge_dollar": 3232.86, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Medicare A", "plan_name": "100100", "standard_charge_dollar": 3232.86, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Medicare A", "plan_name": "100500", "standard_charge_dollar": 3232.86, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Medicare Part B Only", "plan_name": "100300", "standard_charge_dollar": 3232.86, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Medicare Railroad", "plan_name": "100103", "standard_charge_dollar": 3232.86, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Ms Physicians Care N", "plan_name": "714210", "standard_charge_dollar": 4041.08, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Peoples Hlth Ffs 72126", "plan_name": "500019", "standard_charge_dollar": 3232.86, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Uhc/Secure Horizons", "plan_name": "500449", "standard_charge_dollar": 3232.86, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "United Health Care/", "plan_name": "500292", "standard_charge_dollar": 3653.14, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "United Healthcare", "plan_name": "750104", "standard_charge_dollar": 3653.14, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "United Healthcare Ba", "plan_name": "750090", "standard_charge_dollar": 3653.14, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "United Healthcare Me", "plan_name": "501310", "standard_charge_dollar": 3232.86, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Windsor Mcare Extra", "plan_name": "500778", "standard_charge_dollar": 3232.86, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." } ] } ] }, { "description": "Repair umbilical lesion", "code_information": [ { "code": "49600", "type": "CPT" } ], "standard_charges": [ { "gross_charge": 32534.83, "minimum": 3232.86, "maximum": 27654.61, "setting": "inpatient", "payers_information": [ { "payer_name": "Aarp", "plan_name": "500102", "standard_charge_dollar": 3232.86, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna", "plan_name": "700700", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna", "plan_name": "700700_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Mcare Ffs 6005", "plan_name": "700703", "standard_charge_dollar": 3232.86, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Miscellaneous", "plan_name": "700720", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Miscellaneous", "plan_name": "700720_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Ppo Hmo", "plan_name": "701720", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Ppo Hmo", "plan_name": "701720_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Ambetter 68069", "plan_name": "500516", "standard_charge_dollar": 3232.86, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Ms State Emplo", "plan_name": "401457", "standard_charge_percentage": 0.80, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Ms State Emplo", "plan_name": "401457_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Basic Pl", "plan_name": "400100", "standard_charge_percentage": 0.85, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Basic Pl", "plan_name": "400100_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Federal", "plan_name": "400110", "standard_charge_percentage": 0.85, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Federal", "plan_name": "400110_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Cigna Healthsprings Ffs", "plan_name": "500064", "standard_charge_dollar": 3232.86, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Conseco", "plan_name": "500302", "standard_charge_dollar": 3232.86, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Humana Ffs 61101", "plan_name": "500006", "standard_charge_dollar": 3232.86, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Medicare A", "plan_name": "100100", "standard_charge_dollar": 3232.86, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Medicare A", "plan_name": "100500", "standard_charge_dollar": 3232.86, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Medicare Part B Only", "plan_name": "100300", "standard_charge_dollar": 3232.86, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Medicare Railroad", "plan_name": "100103", "standard_charge_dollar": 3232.86, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Ms Physicians Care N", "plan_name": "714210", "standard_charge_dollar": 4041.08, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Peoples Hlth Ffs 72126", "plan_name": "500019", "standard_charge_dollar": 3232.86, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Uhc/Secure Horizons", "plan_name": "500449", "standard_charge_dollar": 3232.86, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "United Health Care/", "plan_name": "500292", "standard_charge_dollar": 3653.14, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "United Healthcare", "plan_name": "750104", "standard_charge_dollar": 3653.14, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "United Healthcare Ba", "plan_name": "750090", "standard_charge_dollar": 3653.14, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "United Healthcare Me", "plan_name": "501310", "standard_charge_dollar": 3232.86, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Windsor Mcare Extra", "plan_name": "500778", "standard_charge_dollar": 3232.86, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." } ] } ] }, { "description": "Repair umbilical lesion", "code_information": [ { "code": "49605", "type": "CPT" } ], "standard_charges": [ { "gross_charge": 46365.90, "minimum": 37092.72, "maximum": 39411.02, "setting": "inpatient", "payers_information": [ { "payer_name": "Aetna", "plan_name": "700700", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna", "plan_name": "700700_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Miscellaneous", "plan_name": "700720", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Miscellaneous", "plan_name": "700720_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Ppo Hmo", "plan_name": "701720", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Ppo Hmo", "plan_name": "701720_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Ms State Emplo", "plan_name": "401457", "standard_charge_percentage": 0.80, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Ms State Emplo", "plan_name": "401457_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Basic Pl", "plan_name": "400100", "standard_charge_percentage": 0.85, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Basic Pl", "plan_name": "400100_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Federal", "plan_name": "400110", "standard_charge_percentage": 0.85, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Federal", "plan_name": "400110_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." } ] } ] }, { "description": "Repair umbilical lesion", "code_information": [ { "code": "49606", "type": "CPT" } ], "standard_charges": [ { "gross_charge": 46365.90, "minimum": 37092.72, "maximum": 39411.02, "setting": "inpatient", "payers_information": [ { "payer_name": "Aetna", "plan_name": "700700", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna", "plan_name": "700700_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Miscellaneous", "plan_name": "700720", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Miscellaneous", "plan_name": "700720_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Ppo Hmo", "plan_name": "701720", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Ppo Hmo", "plan_name": "701720_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Ms State Emplo", "plan_name": "401457", "standard_charge_percentage": 0.80, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Ms State Emplo", "plan_name": "401457_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Basic Pl", "plan_name": "400100", "standard_charge_percentage": 0.85, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Basic Pl", "plan_name": "400100_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Federal", "plan_name": "400110", "standard_charge_percentage": 0.85, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Federal", "plan_name": "400110_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." } ] } ] }, { "description": "Repair umbilical lesion", "code_information": [ { "code": "49610", "type": "CPT" } ], "standard_charges": [ { "gross_charge": 32534.83, "minimum": 26027.86, "maximum": 27654.61, "setting": "inpatient", "payers_information": [ { "payer_name": "Aetna", "plan_name": "700700", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna", "plan_name": "700700_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Miscellaneous", "plan_name": "700720", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Miscellaneous", "plan_name": "700720_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Ppo Hmo", "plan_name": "701720", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Ppo Hmo", "plan_name": "701720_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Ms State Emplo", "plan_name": "401457", "standard_charge_percentage": 0.80, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Ms State Emplo", "plan_name": "401457_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Basic Pl", "plan_name": "400100", "standard_charge_percentage": 0.85, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Basic Pl", "plan_name": "400100_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Federal", "plan_name": "400110", "standard_charge_percentage": 0.85, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Federal", "plan_name": "400110_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." } ] } ] }, { "description": "Repair umbilical lesion", "code_information": [ { "code": "49611", "type": "CPT" } ], "standard_charges": [ { "gross_charge": 32534.83, "minimum": 26027.86, "maximum": 27654.61, "setting": "inpatient", "payers_information": [ { "payer_name": "Aetna", "plan_name": "700700", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna", "plan_name": "700700_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Miscellaneous", "plan_name": "700720", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Miscellaneous", "plan_name": "700720_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Ppo Hmo", "plan_name": "701720", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Ppo Hmo", "plan_name": "701720_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Ms State Emplo", "plan_name": "401457", "standard_charge_percentage": 0.80, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Ms State Emplo", "plan_name": "401457_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Basic Pl", "plan_name": "400100", "standard_charge_percentage": 0.85, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Basic Pl", "plan_name": "400100_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Federal", "plan_name": "400110", "standard_charge_percentage": 0.85, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Federal", "plan_name": "400110_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." } ] } ] }, { "description": "Laparo proc hernia repair", "code_information": [ { "code": "49659", "type": "CPT" } ], "standard_charges": [ { "gross_charge": 61886.90, "minimum": 5344.68, "maximum": 52603.87, "setting": "inpatient", "payers_information": [ { "payer_name": "Aarp", "plan_name": "500102", "standard_charge_dollar": 5344.68, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna", "plan_name": "700700", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna", "plan_name": "700700_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Mcare Ffs 6005", "plan_name": "700703", "standard_charge_dollar": 5344.68, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Miscellaneous", "plan_name": "700720", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Miscellaneous", "plan_name": "700720_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Ppo Hmo", "plan_name": "701720", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Ppo Hmo", "plan_name": "701720_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Ambetter 68069", "plan_name": "500516", "standard_charge_dollar": 5344.68, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Ms State Emplo", "plan_name": "401457", "standard_charge_percentage": 0.80, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Ms State Emplo", "plan_name": "401457_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Basic Pl", "plan_name": "400100", "standard_charge_percentage": 0.85, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Basic Pl", "plan_name": "400100_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Federal", "plan_name": "400110", "standard_charge_percentage": 0.85, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Federal", "plan_name": "400110_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Cigna Healthsprings Ffs", "plan_name": "500064", "standard_charge_dollar": 5344.68, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Conseco", "plan_name": "500302", "standard_charge_dollar": 5344.68, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Humana Ffs 61101", "plan_name": "500006", "standard_charge_dollar": 5344.68, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Medicare A", "plan_name": "100100", "standard_charge_dollar": 5344.68, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Medicare A", "plan_name": "100500", "standard_charge_dollar": 5344.68, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Medicare Part B Only", "plan_name": "100300", "standard_charge_dollar": 5344.68, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Medicare Railroad", "plan_name": "100103", "standard_charge_dollar": 5344.68, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Ms Physicians Care N", "plan_name": "714210", "standard_charge_dollar": 6680.85, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Peoples Hlth Ffs 72126", "plan_name": "500019", "standard_charge_dollar": 5344.68, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Uhc/Secure Horizons", "plan_name": "500449", "standard_charge_dollar": 5344.68, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "United Health Care/", "plan_name": "500292", "standard_charge_dollar": 6039.49, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "United Healthcare", "plan_name": "750104", "standard_charge_dollar": 6039.49, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "United Healthcare Ba", "plan_name": "750090", "standard_charge_dollar": 6039.49, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "United Healthcare Me", "plan_name": "501310", "standard_charge_dollar": 5344.68, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Windsor Mcare Extra", "plan_name": "500778", "standard_charge_dollar": 5344.68, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." } ] } ] }, { "description": "Omental flap extra-abdom", "code_information": [ { "code": "49904", "type": "CPT" } ], "standard_charges": [ { "gross_charge": 14841.25, "minimum": 11873.00, "maximum": 12615.06, "setting": "inpatient", "payers_information": [ { "payer_name": "Aetna", "plan_name": "700700", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna", "plan_name": "700700_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Miscellaneous", "plan_name": "700720", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Miscellaneous", "plan_name": "700720_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Ppo Hmo", "plan_name": "701720", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Ppo Hmo", "plan_name": "701720_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Ms State Emplo", "plan_name": "401457", "standard_charge_percentage": 0.80, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Ms State Emplo", "plan_name": "401457_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Basic Pl", "plan_name": "400100", "standard_charge_percentage": 0.85, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Basic Pl", "plan_name": "400100_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Federal", "plan_name": "400110", "standard_charge_percentage": 0.85, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Federal", "plan_name": "400110_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." } ] } ] }, { "description": "Omental flap intra-abdom", "code_information": [ { "code": "49905", "type": "CPT" } ], "standard_charges": [ { "gross_charge": 32534.83, "minimum": 26027.86, "maximum": 27654.61, "setting": "inpatient", "payers_information": [ { "payer_name": "Aetna", "plan_name": "700700", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna", "plan_name": "700700_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Miscellaneous", "plan_name": "700720", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Miscellaneous", "plan_name": "700720_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Ppo Hmo", "plan_name": "701720", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Ppo Hmo", "plan_name": "701720_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Ms State Emplo", "plan_name": "401457", "standard_charge_percentage": 0.80, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Ms State Emplo", "plan_name": "401457_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Basic Pl", "plan_name": "400100", "standard_charge_percentage": 0.85, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Basic Pl", "plan_name": "400100_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Federal", "plan_name": "400110", "standard_charge_percentage": 0.85, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Federal", "plan_name": "400110_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." } ] } ] }, { "description": "Abdomen surgery procedure", "code_information": [ { "code": "49999", "type": "CPT" } ], "standard_charges": [ { "gross_charge": 13207.45, "minimum": 858.87, "maximum": 11226.33, "setting": "inpatient", "payers_information": [ { "payer_name": "Aarp", "plan_name": "500102", "standard_charge_dollar": 858.87, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna", "plan_name": "700700", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna", "plan_name": "700700_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Mcare Ffs 6005", "plan_name": "700703", "standard_charge_dollar": 858.87, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Miscellaneous", "plan_name": "700720", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Miscellaneous", "plan_name": "700720_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Ppo Hmo", "plan_name": "701720", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Ppo Hmo", "plan_name": "701720_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Ambetter 68069", "plan_name": "500516", "standard_charge_dollar": 858.87, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Ms State Emplo", "plan_name": "401457", "standard_charge_percentage": 0.80, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Ms State Emplo", "plan_name": "401457_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Basic Pl", "plan_name": "400100", "standard_charge_percentage": 0.85, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Basic Pl", "plan_name": "400100_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Federal", "plan_name": "400110", "standard_charge_percentage": 0.85, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Federal", "plan_name": "400110_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Cigna Healthsprings Ffs", "plan_name": "500064", "standard_charge_dollar": 858.87, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Conseco", "plan_name": "500302", "standard_charge_dollar": 858.87, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Humana Ffs 61101", "plan_name": "500006", "standard_charge_dollar": 858.87, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Medicare A", "plan_name": "100100", "standard_charge_dollar": 858.87, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Medicare A", "plan_name": "100500", "standard_charge_dollar": 858.87, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Medicare Part B Only", "plan_name": "100300", "standard_charge_dollar": 858.87, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Medicare Railroad", "plan_name": "100103", "standard_charge_dollar": 858.87, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Ms Physicians Care N", "plan_name": "714210", "standard_charge_dollar": 1073.59, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Peoples Hlth Ffs 72126", "plan_name": "500019", "standard_charge_dollar": 858.87, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Uhc/Secure Horizons", "plan_name": "500449", "standard_charge_dollar": 858.87, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "United Health Care/", "plan_name": "500292", "standard_charge_dollar": 970.52, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "United Healthcare", "plan_name": "750104", "standard_charge_dollar": 970.52, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "United Healthcare Ba", "plan_name": "750090", "standard_charge_dollar": 970.52, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "United Healthcare Me", "plan_name": "501310", "standard_charge_dollar": 858.87, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Windsor Mcare Extra", "plan_name": "500778", "standard_charge_dollar": 858.87, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." } ] } ] }, { "description": "Dilat xst trc ndurlgc px", "code_information": [ { "code": "50436", "type": "CPT" } ], "standard_charges": [ { "gross_charge": 22095.82, "minimum": 3159.49, "maximum": 18781.45, "setting": "inpatient", "payers_information": [ { "payer_name": "Aarp", "plan_name": "500102", "standard_charge_dollar": 3159.49, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna", "plan_name": "700700", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna", "plan_name": "700700_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Mcare Ffs 6005", "plan_name": "700703", "standard_charge_dollar": 3159.49, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Miscellaneous", "plan_name": "700720", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Miscellaneous", "plan_name": "700720_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Ppo Hmo", "plan_name": "701720", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Ppo Hmo", "plan_name": "701720_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Ambetter 68069", "plan_name": "500516", "standard_charge_dollar": 3159.49, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Ms State Emplo", "plan_name": "401457", "standard_charge_percentage": 0.80, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Ms State Emplo", "plan_name": "401457_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Basic Pl", "plan_name": "400100", "standard_charge_percentage": 0.85, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Basic Pl", "plan_name": "400100_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Federal", "plan_name": "400110", "standard_charge_percentage": 0.85, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Federal", "plan_name": "400110_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Cigna Healthsprings Ffs", "plan_name": "500064", "standard_charge_dollar": 3159.49, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Conseco", "plan_name": "500302", "standard_charge_dollar": 3159.49, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Humana Ffs 61101", "plan_name": "500006", "standard_charge_dollar": 3159.49, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Medicare A", "plan_name": "100100", "standard_charge_dollar": 3159.49, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Medicare A", "plan_name": "100500", "standard_charge_dollar": 3159.49, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Medicare Part B Only", "plan_name": "100300", "standard_charge_dollar": 3159.49, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Medicare Railroad", "plan_name": "100103", "standard_charge_dollar": 3159.49, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Ms Physicians Care N", "plan_name": "714210", "standard_charge_dollar": 3949.37, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Peoples Hlth Ffs 72126", "plan_name": "500019", "standard_charge_dollar": 3159.49, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Uhc/Secure Horizons", "plan_name": "500449", "standard_charge_dollar": 3159.49, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "United Health Care/", "plan_name": "500292", "standard_charge_dollar": 3570.23, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "United Healthcare", "plan_name": "750104", "standard_charge_dollar": 3570.23, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "United Healthcare Ba", "plan_name": "750090", "standard_charge_dollar": 3570.23, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "United Healthcare Me", "plan_name": "501310", "standard_charge_dollar": 3159.49, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Windsor Mcare Extra", "plan_name": "500778", "standard_charge_dollar": 3159.49, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." } ] } ] }, { "description": "Dilat xst trc new access rcs", "code_information": [ { "code": "50437", "type": "CPT" } ], "standard_charges": [ { "gross_charge": 21754.86, "minimum": 3159.49, "maximum": 18491.63, "setting": "inpatient", "payers_information": [ { "payer_name": "Aarp", "plan_name": "500102", "standard_charge_dollar": 3159.49, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna", "plan_name": "700700", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna", "plan_name": "700700_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Mcare Ffs 6005", "plan_name": "700703", "standard_charge_dollar": 3159.49, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Miscellaneous", "plan_name": "700720", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Miscellaneous", "plan_name": "700720_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Ppo Hmo", "plan_name": "701720", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Ppo Hmo", "plan_name": "701720_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Ambetter 68069", "plan_name": "500516", "standard_charge_dollar": 3159.49, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Ms State Emplo", "plan_name": "401457", "standard_charge_percentage": 0.80, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Ms State Emplo", "plan_name": "401457_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Basic Pl", "plan_name": "400100", "standard_charge_percentage": 0.85, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Basic Pl", "plan_name": "400100_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Federal", "plan_name": "400110", "standard_charge_percentage": 0.85, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Federal", "plan_name": "400110_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Cigna Healthsprings Ffs", "plan_name": "500064", "standard_charge_dollar": 3159.49, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Conseco", "plan_name": "500302", "standard_charge_dollar": 3159.49, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Humana Ffs 61101", "plan_name": "500006", "standard_charge_dollar": 3159.49, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Medicare A", "plan_name": "100100", "standard_charge_dollar": 3159.49, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Medicare A", "plan_name": "100500", "standard_charge_dollar": 3159.49, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Medicare Part B Only", "plan_name": "100300", "standard_charge_dollar": 3159.49, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Medicare Railroad", "plan_name": "100103", "standard_charge_dollar": 3159.49, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Ms Physicians Care N", "plan_name": "714210", "standard_charge_dollar": 3949.37, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Peoples Hlth Ffs 72126", "plan_name": "500019", "standard_charge_dollar": 3159.49, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Uhc/Secure Horizons", "plan_name": "500449", "standard_charge_dollar": 3159.49, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "United Health Care/", "plan_name": "500292", "standard_charge_dollar": 3570.23, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "United Healthcare", "plan_name": "750104", "standard_charge_dollar": 3570.23, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "United Healthcare Ba", "plan_name": "750090", "standard_charge_dollar": 3570.23, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "United Healthcare Me", "plan_name": "501310", "standard_charge_dollar": 3159.49, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Windsor Mcare Extra", "plan_name": "500778", "standard_charge_dollar": 3159.49, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." } ] } ] }, { "description": "Close nephrovisceral fistula", "code_information": [ { "code": "50526", "type": "CPT" } ], "standard_charges": [ { "gross_charge": 66807.43, "minimum": 53445.94, "maximum": 56786.32, "setting": "inpatient", "payers_information": [ { "payer_name": "Aetna", "plan_name": "700700", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna", "plan_name": "700700_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Miscellaneous", "plan_name": "700720", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Miscellaneous", "plan_name": "700720_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Ppo Hmo", "plan_name": "701720", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Ppo Hmo", "plan_name": "701720_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Ms State Emplo", "plan_name": "401457", "standard_charge_percentage": 0.80, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Ms State Emplo", "plan_name": "401457_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Basic Pl", "plan_name": "400100", "standard_charge_percentage": 0.85, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Basic Pl", "plan_name": "400100_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Federal", "plan_name": "400110", "standard_charge_percentage": 0.85, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Federal", "plan_name": "400110_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." } ] } ] }, { "description": "Kidney endoscopy", "code_information": [ { "code": "50551", "type": "CPT" } ], "standard_charges": [ { "gross_charge": 22095.82, "minimum": 4656.95, "maximum": 18781.45, "setting": "inpatient", "payers_information": [ { "payer_name": "Aarp", "plan_name": "500102", "standard_charge_dollar": 4656.95, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna", "plan_name": "700700", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna", "plan_name": "700700_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Mcare Ffs 6005", "plan_name": "700703", "standard_charge_dollar": 4656.95, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Miscellaneous", "plan_name": "700720", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Miscellaneous", "plan_name": "700720_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Ppo Hmo", "plan_name": "701720", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Ppo Hmo", "plan_name": "701720_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Ambetter 68069", "plan_name": "500516", "standard_charge_dollar": 4656.95, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Ms State Emplo", "plan_name": "401457", "standard_charge_percentage": 0.80, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Ms State Emplo", "plan_name": "401457_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Basic Pl", "plan_name": "400100", "standard_charge_percentage": 0.85, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Basic Pl", "plan_name": "400100_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Federal", "plan_name": "400110", "standard_charge_percentage": 0.85, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Federal", "plan_name": "400110_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Cigna Healthsprings Ffs", "plan_name": "500064", "standard_charge_dollar": 4656.95, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Conseco", "plan_name": "500302", "standard_charge_dollar": 4656.95, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Humana Ffs 61101", "plan_name": "500006", "standard_charge_dollar": 4656.95, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Medicare A", "plan_name": "100100", "standard_charge_dollar": 4656.95, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Medicare A", "plan_name": "100500", "standard_charge_dollar": 4656.95, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Medicare Part B Only", "plan_name": "100300", "standard_charge_dollar": 4656.95, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Medicare Railroad", "plan_name": "100103", "standard_charge_dollar": 4656.95, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Ms Physicians Care N", "plan_name": "714210", "standard_charge_dollar": 5821.18, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Peoples Hlth Ffs 72126", "plan_name": "500019", "standard_charge_dollar": 4656.95, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Uhc/Secure Horizons", "plan_name": "500449", "standard_charge_dollar": 4656.95, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "United Health Care/", "plan_name": "500292", "standard_charge_dollar": 5262.35, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "United Healthcare", "plan_name": "750104", "standard_charge_dollar": 5262.35, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "United Healthcare Ba", "plan_name": "750090", "standard_charge_dollar": 5262.35, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "United Healthcare Me", "plan_name": "501310", "standard_charge_dollar": 4656.95, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Windsor Mcare Extra", "plan_name": "500778", "standard_charge_dollar": 4656.95, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." } ] } ] }, { "description": "Kidney endoscopy", "code_information": [ { "code": "50553", "type": "CPT" } ], "standard_charges": [ { "gross_charge": 22095.82, "minimum": 4656.95, "maximum": 18781.45, "setting": "inpatient", "payers_information": [ { "payer_name": "Aarp", "plan_name": "500102", "standard_charge_dollar": 4656.95, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna", "plan_name": "700700", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna", "plan_name": "700700_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Mcare Ffs 6005", "plan_name": "700703", "standard_charge_dollar": 4656.95, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Miscellaneous", "plan_name": "700720", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Miscellaneous", "plan_name": "700720_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Ppo Hmo", "plan_name": "701720", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Ppo Hmo", "plan_name": "701720_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Ambetter 68069", "plan_name": "500516", "standard_charge_dollar": 4656.95, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Ms State Emplo", "plan_name": "401457", "standard_charge_percentage": 0.80, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Ms State Emplo", "plan_name": "401457_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Basic Pl", "plan_name": "400100", "standard_charge_percentage": 0.85, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Basic Pl", "plan_name": "400100_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Federal", "plan_name": "400110", "standard_charge_percentage": 0.85, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Federal", "plan_name": "400110_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Cigna Healthsprings Ffs", "plan_name": "500064", "standard_charge_dollar": 4656.95, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Conseco", "plan_name": "500302", "standard_charge_dollar": 4656.95, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Humana Ffs 61101", "plan_name": "500006", "standard_charge_dollar": 4656.95, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Medicare A", "plan_name": "100100", "standard_charge_dollar": 4656.95, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Medicare A", "plan_name": "100500", "standard_charge_dollar": 4656.95, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Medicare Part B Only", "plan_name": "100300", "standard_charge_dollar": 4656.95, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Medicare Railroad", "plan_name": "100103", "standard_charge_dollar": 4656.95, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Ms Physicians Care N", "plan_name": "714210", "standard_charge_dollar": 5821.18, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Peoples Hlth Ffs 72126", "plan_name": "500019", "standard_charge_dollar": 4656.95, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Uhc/Secure Horizons", "plan_name": "500449", "standard_charge_dollar": 4656.95, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "United Health Care/", "plan_name": "500292", "standard_charge_dollar": 5262.35, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "United Healthcare", "plan_name": "750104", "standard_charge_dollar": 5262.35, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "United Healthcare Ba", "plan_name": "750090", "standard_charge_dollar": 5262.35, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "United Healthcare Me", "plan_name": "501310", "standard_charge_dollar": 4656.95, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Windsor Mcare Extra", "plan_name": "500778", "standard_charge_dollar": 4656.95, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." } ] } ] }, { "description": "Kidney endoscopy", "code_information": [ { "code": "50572", "type": "CPT" } ], "standard_charges": [ { "gross_charge": 22095.82, "minimum": 611.45, "maximum": 18781.45, "setting": "inpatient", "payers_information": [ { "payer_name": "Aarp", "plan_name": "500102", "standard_charge_dollar": 611.45, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna", "plan_name": "700700", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna", "plan_name": "700700_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Mcare Ffs 6005", "plan_name": "700703", "standard_charge_dollar": 611.45, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Miscellaneous", "plan_name": "700720", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Miscellaneous", "plan_name": "700720_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Ppo Hmo", "plan_name": "701720", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Ppo Hmo", "plan_name": "701720_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Ambetter 68069", "plan_name": "500516", "standard_charge_dollar": 611.45, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Ms State Emplo", "plan_name": "401457", "standard_charge_percentage": 0.80, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Ms State Emplo", "plan_name": "401457_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Basic Pl", "plan_name": "400100", "standard_charge_percentage": 0.85, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Basic Pl", "plan_name": "400100_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Federal", "plan_name": "400110", "standard_charge_percentage": 0.85, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Federal", "plan_name": "400110_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Cigna Healthsprings Ffs", "plan_name": "500064", "standard_charge_dollar": 611.45, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Conseco", "plan_name": "500302", "standard_charge_dollar": 611.45, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Humana Ffs 61101", "plan_name": "500006", "standard_charge_dollar": 611.45, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Medicare A", "plan_name": "100100", "standard_charge_dollar": 611.45, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Medicare A", "plan_name": "100500", "standard_charge_dollar": 611.45, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Medicare Part B Only", "plan_name": "100300", "standard_charge_dollar": 611.45, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Medicare Railroad", "plan_name": "100103", "standard_charge_dollar": 611.45, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Ms Physicians Care N", "plan_name": "714210", "standard_charge_dollar": 764.31, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Peoples Hlth Ffs 72126", "plan_name": "500019", "standard_charge_dollar": 611.45, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Uhc/Secure Horizons", "plan_name": "500449", "standard_charge_dollar": 611.45, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "United Health Care/", "plan_name": "500292", "standard_charge_dollar": 690.94, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "United Healthcare", "plan_name": "750104", "standard_charge_dollar": 690.94, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "United Healthcare Ba", "plan_name": "750090", "standard_charge_dollar": 690.94, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "United Healthcare Me", "plan_name": "501310", "standard_charge_dollar": 611.45, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Windsor Mcare Extra", "plan_name": "500778", "standard_charge_dollar": 611.45, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." } ] } ] }, { "description": "Kidney endoscopy & treatment", "code_information": [ { "code": "50580", "type": "CPT" } ], "standard_charges": [ { "gross_charge": 19669.90, "minimum": 4656.95, "maximum": 16719.42, "setting": "inpatient", "payers_information": [ { "payer_name": "Aarp", "plan_name": "500102", "standard_charge_dollar": 4656.95, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna", "plan_name": "700700", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna", "plan_name": "700700_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Mcare Ffs 6005", "plan_name": "700703", "standard_charge_dollar": 4656.95, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Miscellaneous", "plan_name": "700720", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Miscellaneous", "plan_name": "700720_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Ppo Hmo", "plan_name": "701720", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Ppo Hmo", "plan_name": "701720_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Ambetter 68069", "plan_name": "500516", "standard_charge_dollar": 4656.95, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Ms State Emplo", "plan_name": "401457", "standard_charge_percentage": 0.80, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Ms State Emplo", "plan_name": "401457_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Basic Pl", "plan_name": "400100", "standard_charge_percentage": 0.85, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Basic Pl", "plan_name": "400100_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Federal", "plan_name": "400110", "standard_charge_percentage": 0.85, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Federal", "plan_name": "400110_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Cigna Healthsprings Ffs", "plan_name": "500064", "standard_charge_dollar": 4656.95, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Conseco", "plan_name": "500302", "standard_charge_dollar": 4656.95, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Humana Ffs 61101", "plan_name": "500006", "standard_charge_dollar": 4656.95, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Medicare A", "plan_name": "100100", "standard_charge_dollar": 4656.95, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Medicare A", "plan_name": "100500", "standard_charge_dollar": 4656.95, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Medicare Part B Only", "plan_name": "100300", "standard_charge_dollar": 4656.95, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Medicare Railroad", "plan_name": "100103", "standard_charge_dollar": 4656.95, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Ms Physicians Care N", "plan_name": "714210", "standard_charge_dollar": 5821.18, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Peoples Hlth Ffs 72126", "plan_name": "500019", "standard_charge_dollar": 4656.95, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Uhc/Secure Horizons", "plan_name": "500449", "standard_charge_dollar": 4656.95, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "United Health Care/", "plan_name": "500292", "standard_charge_dollar": 5262.35, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "United Healthcare", "plan_name": "750104", "standard_charge_dollar": 5262.35, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "United Healthcare Ba", "plan_name": "750090", "standard_charge_dollar": 5262.35, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "United Healthcare Me", "plan_name": "501310", "standard_charge_dollar": 4656.95, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Windsor Mcare Extra", "plan_name": "500778", "standard_charge_dollar": 4656.95, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." } ] } ] }, { "description": "Fragmenting of kidney stone", "code_information": [ { "code": "50590", "type": "CPT" } ], "standard_charges": [ { "gross_charge": 24824.21, "minimum": 3159.49, "maximum": 21100.58, "setting": "inpatient", "payers_information": [ { "payer_name": "Aarp", "plan_name": "500102", "standard_charge_dollar": 3159.49, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna", "plan_name": "700700", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna", "plan_name": "700700_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Mcare Ffs 6005", "plan_name": "700703", "standard_charge_dollar": 3159.49, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Miscellaneous", "plan_name": "700720", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Miscellaneous", "plan_name": "700720_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Ppo Hmo", "plan_name": "701720", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Ppo Hmo", "plan_name": "701720_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Ambetter 68069", "plan_name": "500516", "standard_charge_dollar": 3159.49, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Ms State Emplo", "plan_name": "401457", "standard_charge_percentage": 0.80, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Ms State Emplo", "plan_name": "401457_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Basic Pl", "plan_name": "400100", "standard_charge_percentage": 0.85, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Basic Pl", "plan_name": "400100_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Federal", "plan_name": "400110", "standard_charge_percentage": 0.85, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Federal", "plan_name": "400110_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Cigna Healthsprings Ffs", "plan_name": "500064", "standard_charge_dollar": 3159.49, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Conseco", "plan_name": "500302", "standard_charge_dollar": 3159.49, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Humana Ffs 61101", "plan_name": "500006", "standard_charge_dollar": 3159.49, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Medicare A", "plan_name": "100100", "standard_charge_dollar": 3159.49, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Medicare A", "plan_name": "100500", "standard_charge_dollar": 3159.49, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Medicare Part B Only", "plan_name": "100300", "standard_charge_dollar": 3159.49, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Medicare Railroad", "plan_name": "100103", "standard_charge_dollar": 3159.49, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Ms Physicians Care N", "plan_name": "714210", "standard_charge_dollar": 3949.37, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Peoples Hlth Ffs 72126", "plan_name": "500019", "standard_charge_dollar": 3159.49, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Uhc/Secure Horizons", "plan_name": "500449", "standard_charge_dollar": 3159.49, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "United Health Care/", "plan_name": "500292", "standard_charge_dollar": 3570.23, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "United Healthcare", "plan_name": "750104", "standard_charge_dollar": 3570.23, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "United Healthcare Ba", "plan_name": "750090", "standard_charge_dollar": 3570.23, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "United Healthcare Me", "plan_name": "501310", "standard_charge_dollar": 3159.49, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Windsor Mcare Extra", "plan_name": "500778", "standard_charge_dollar": 3159.49, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." } ] } ] }, { "description": "Injection for ureter x-ray", "code_information": [ { "code": "50690", "type": "CPT" } ], "standard_charges": [ { "gross_charge": 12766.73, "minimum": 10213.38, "maximum": 10851.72, "setting": "inpatient", "payers_information": [ { "payer_name": "Aetna", "plan_name": "700700", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna", "plan_name": "700700_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Miscellaneous", "plan_name": "700720", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Miscellaneous", "plan_name": "700720_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Ppo Hmo", "plan_name": "701720", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Ppo Hmo", "plan_name": "701720_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Ms State Emplo", "plan_name": "401457", "standard_charge_percentage": 0.80, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Ms State Emplo", "plan_name": "401457_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Basic Pl", "plan_name": "400100", "standard_charge_percentage": 0.85, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Basic Pl", "plan_name": "400100_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Federal", "plan_name": "400110", "standard_charge_percentage": 0.85, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Federal", "plan_name": "400110_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." } ] } ] }, { "description": "Balloon dilate urtrl strix", "code_information": [ { "code": "50706", "type": "CPT" } ], "standard_charges": [ { "gross_charge": 22095.82, "minimum": 17676.66, "maximum": 18781.45, "setting": "inpatient", "payers_information": [ { "payer_name": "Aetna", "plan_name": "700700", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna", "plan_name": "700700_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Miscellaneous", "plan_name": "700720", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Miscellaneous", "plan_name": "700720_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Ppo Hmo", "plan_name": "701720", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Ppo Hmo", "plan_name": "701720_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Ms State Emplo", "plan_name": "401457", "standard_charge_percentage": 0.80, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Ms State Emplo", "plan_name": "401457_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Basic Pl", "plan_name": "400100", "standard_charge_percentage": 0.85, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Basic Pl", "plan_name": "400100_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Federal", "plan_name": "400110", "standard_charge_percentage": 0.85, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Federal", "plan_name": "400110_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." } ] } ] }, { "description": "Revise urine flow", "code_information": [ { "code": "50830", "type": "CPT" } ], "standard_charges": [ { "gross_charge": 46170.56, "minimum": 36936.45, "maximum": 39244.98, "setting": "inpatient", "payers_information": [ { "payer_name": "Aetna", "plan_name": "700700", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna", "plan_name": "700700_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Miscellaneous", "plan_name": "700720", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Miscellaneous", "plan_name": "700720_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Ppo Hmo", "plan_name": "701720", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Ppo Hmo", "plan_name": "701720_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Ms State Emplo", "plan_name": "401457", "standard_charge_percentage": 0.80, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Ms State Emplo", "plan_name": "401457_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Basic Pl", "plan_name": "400100", "standard_charge_percentage": 0.85, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Basic Pl", "plan_name": "400100_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Federal", "plan_name": "400110", "standard_charge_percentage": 0.85, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Federal", "plan_name": "400110_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." } ] } ] }, { "description": "Closure ureter/bowel fistula", "code_information": [ { "code": "50930", "type": "CPT" } ], "standard_charges": [ { "gross_charge": 68896.77, "minimum": 55117.42, "maximum": 58562.25, "setting": "inpatient", "payers_information": [ { "payer_name": "Aetna", "plan_name": "700700", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna", "plan_name": "700700_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Miscellaneous", "plan_name": "700720", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Miscellaneous", "plan_name": "700720_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Ppo Hmo", "plan_name": "701720", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Ppo Hmo", "plan_name": "701720_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Ms State Emplo", "plan_name": "401457", "standard_charge_percentage": 0.80, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Ms State Emplo", "plan_name": "401457_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Basic Pl", "plan_name": "400100", "standard_charge_percentage": 0.85, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Basic Pl", "plan_name": "400100_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Federal", "plan_name": "400110", "standard_charge_percentage": 0.85, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Federal", "plan_name": "400110_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." } ] } ] }, { "description": "Endoscopy of ureter", "code_information": [ { "code": "50953", "type": "CPT" } ], "standard_charges": [ { "gross_charge": 22095.82, "minimum": 3159.49, "maximum": 18781.45, "setting": "inpatient", "payers_information": [ { "payer_name": "Aarp", "plan_name": "500102", "standard_charge_dollar": 3159.49, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna", "plan_name": "700700", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna", "plan_name": "700700_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Mcare Ffs 6005", "plan_name": "700703", "standard_charge_dollar": 3159.49, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Miscellaneous", "plan_name": "700720", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Miscellaneous", "plan_name": "700720_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Ppo Hmo", "plan_name": "701720", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Ppo Hmo", "plan_name": "701720_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Ambetter 68069", "plan_name": "500516", "standard_charge_dollar": 3159.49, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Ms State Emplo", "plan_name": "401457", "standard_charge_percentage": 0.80, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Ms State Emplo", "plan_name": "401457_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Basic Pl", "plan_name": "400100", "standard_charge_percentage": 0.85, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Basic Pl", "plan_name": "400100_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Federal", "plan_name": "400110", "standard_charge_percentage": 0.85, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Federal", "plan_name": "400110_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Cigna Healthsprings Ffs", "plan_name": "500064", "standard_charge_dollar": 3159.49, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Conseco", "plan_name": "500302", "standard_charge_dollar": 3159.49, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Humana Ffs 61101", "plan_name": "500006", "standard_charge_dollar": 3159.49, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Medicare A", "plan_name": "100100", "standard_charge_dollar": 3159.49, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Medicare A", "plan_name": "100500", "standard_charge_dollar": 3159.49, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Medicare Part B Only", "plan_name": "100300", "standard_charge_dollar": 3159.49, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Medicare Railroad", "plan_name": "100103", "standard_charge_dollar": 3159.49, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Ms Physicians Care N", "plan_name": "714210", "standard_charge_dollar": 3949.37, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Peoples Hlth Ffs 72126", "plan_name": "500019", "standard_charge_dollar": 3159.49, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Uhc/Secure Horizons", "plan_name": "500449", "standard_charge_dollar": 3159.49, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "United Health Care/", "plan_name": "500292", "standard_charge_dollar": 3570.23, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "United Healthcare", "plan_name": "750104", "standard_charge_dollar": 3570.23, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "United Healthcare Ba", "plan_name": "750090", "standard_charge_dollar": 3570.23, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "United Healthcare Me", "plan_name": "501310", "standard_charge_dollar": 3159.49, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Windsor Mcare Extra", "plan_name": "500778", "standard_charge_dollar": 3159.49, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." } ] } ] }, { "description": "Ureter endoscopy & treatment", "code_information": [ { "code": "50961", "type": "CPT" } ], "standard_charges": [ { "gross_charge": 16962.70, "minimum": 4656.95, "maximum": 14418.30, "setting": "inpatient", "payers_information": [ { "payer_name": "Aarp", "plan_name": "500102", "standard_charge_dollar": 4656.95, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna", "plan_name": "700700", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna", "plan_name": "700700_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Mcare Ffs 6005", "plan_name": "700703", "standard_charge_dollar": 4656.95, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Miscellaneous", "plan_name": "700720", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Miscellaneous", "plan_name": "700720_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Ppo Hmo", "plan_name": "701720", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Ppo Hmo", "plan_name": "701720_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Ambetter 68069", "plan_name": "500516", "standard_charge_dollar": 4656.95, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Ms State Emplo", "plan_name": "401457", "standard_charge_percentage": 0.80, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Ms State Emplo", "plan_name": "401457_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Basic Pl", "plan_name": "400100", "standard_charge_percentage": 0.85, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Basic Pl", "plan_name": "400100_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Federal", "plan_name": "400110", "standard_charge_percentage": 0.85, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Federal", "plan_name": "400110_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Cigna Healthsprings Ffs", "plan_name": "500064", "standard_charge_dollar": 4656.95, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Conseco", "plan_name": "500302", "standard_charge_dollar": 4656.95, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Humana Ffs 61101", "plan_name": "500006", "standard_charge_dollar": 4656.95, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Medicare A", "plan_name": "100100", "standard_charge_dollar": 4656.95, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Medicare A", "plan_name": "100500", "standard_charge_dollar": 4656.95, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Medicare Part B Only", "plan_name": "100300", "standard_charge_dollar": 4656.95, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Medicare Railroad", "plan_name": "100103", "standard_charge_dollar": 4656.95, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Ms Physicians Care N", "plan_name": "714210", "standard_charge_dollar": 5821.18, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Peoples Hlth Ffs 72126", "plan_name": "500019", "standard_charge_dollar": 4656.95, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Uhc/Secure Horizons", "plan_name": "500449", "standard_charge_dollar": 4656.95, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "United Health Care/", "plan_name": "500292", "standard_charge_dollar": 5262.35, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "United Healthcare", "plan_name": "750104", "standard_charge_dollar": 5262.35, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "United Healthcare Ba", "plan_name": "750090", "standard_charge_dollar": 5262.35, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "United Healthcare Me", "plan_name": "501310", "standard_charge_dollar": 4656.95, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Windsor Mcare Extra", "plan_name": "500778", "standard_charge_dollar": 4656.95, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." } ] } ] }, { "description": "Ureter endoscopy & catheter", "code_information": [ { "code": "50972", "type": "CPT" } ], "standard_charges": [ { "gross_charge": 22095.82, "minimum": 3159.49, "maximum": 18781.45, "setting": "inpatient", "payers_information": [ { "payer_name": "Aarp", "plan_name": "500102", "standard_charge_dollar": 3159.49, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna", "plan_name": "700700", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna", "plan_name": "700700_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Mcare Ffs 6005", "plan_name": "700703", "standard_charge_dollar": 3159.49, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Miscellaneous", "plan_name": "700720", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Miscellaneous", "plan_name": "700720_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Ppo Hmo", "plan_name": "701720", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Ppo Hmo", "plan_name": "701720_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Ambetter 68069", "plan_name": "500516", "standard_charge_dollar": 3159.49, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Ms State Emplo", "plan_name": "401457", "standard_charge_percentage": 0.80, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Ms State Emplo", "plan_name": "401457_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Basic Pl", "plan_name": "400100", "standard_charge_percentage": 0.85, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Basic Pl", "plan_name": "400100_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Federal", "plan_name": "400110", "standard_charge_percentage": 0.85, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Federal", "plan_name": "400110_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Cigna Healthsprings Ffs", "plan_name": "500064", "standard_charge_dollar": 3159.49, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Conseco", "plan_name": "500302", "standard_charge_dollar": 3159.49, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Humana Ffs 61101", "plan_name": "500006", "standard_charge_dollar": 3159.49, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Medicare A", "plan_name": "100100", "standard_charge_dollar": 3159.49, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Medicare A", "plan_name": "100500", "standard_charge_dollar": 3159.49, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Medicare Part B Only", "plan_name": "100300", "standard_charge_dollar": 3159.49, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Medicare Railroad", "plan_name": "100103", "standard_charge_dollar": 3159.49, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Ms Physicians Care N", "plan_name": "714210", "standard_charge_dollar": 3949.37, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Peoples Hlth Ffs 72126", "plan_name": "500019", "standard_charge_dollar": 3159.49, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Uhc/Secure Horizons", "plan_name": "500449", "standard_charge_dollar": 3159.49, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "United Health Care/", "plan_name": "500292", "standard_charge_dollar": 3570.23, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "United Healthcare", "plan_name": "750104", "standard_charge_dollar": 3570.23, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "United Healthcare Ba", "plan_name": "750090", "standard_charge_dollar": 3570.23, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "United Healthcare Me", "plan_name": "501310", "standard_charge_dollar": 3159.49, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Windsor Mcare Extra", "plan_name": "500778", "standard_charge_dollar": 3159.49, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." } ] } ] }, { "description": "Drain bl w/cath insertion", "code_information": [ { "code": "51102", "type": "CPT" } ], "standard_charges": [ { "gross_charge": 27479.36, "minimum": 1876.58, "maximum": 23357.46, "setting": "inpatient", "payers_information": [ { "payer_name": "Aarp", "plan_name": "500102", "standard_charge_dollar": 1876.58, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna", "plan_name": "700700", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna", "plan_name": "700700_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Mcare Ffs 6005", "plan_name": "700703", "standard_charge_dollar": 1876.58, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Miscellaneous", "plan_name": "700720", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Miscellaneous", "plan_name": "700720_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Ppo Hmo", "plan_name": "701720", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Ppo Hmo", "plan_name": "701720_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Ambetter 68069", "plan_name": "500516", "standard_charge_dollar": 1876.58, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Ms State Emplo", "plan_name": "401457", "standard_charge_percentage": 0.80, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Ms State Emplo", "plan_name": "401457_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Basic Pl", "plan_name": "400100", "standard_charge_percentage": 0.85, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Basic Pl", "plan_name": "400100_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Federal", "plan_name": "400110", "standard_charge_percentage": 0.85, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Federal", "plan_name": "400110_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Cigna Healthsprings Ffs", "plan_name": "500064", "standard_charge_dollar": 1876.58, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Conseco", "plan_name": "500302", "standard_charge_dollar": 1876.58, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Humana Ffs 61101", "plan_name": "500006", "standard_charge_dollar": 1876.58, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Medicare A", "plan_name": "100100", "standard_charge_dollar": 1876.58, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Medicare A", "plan_name": "100500", "standard_charge_dollar": 1876.58, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Medicare Part B Only", "plan_name": "100300", "standard_charge_dollar": 1876.58, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Medicare Railroad", "plan_name": "100103", "standard_charge_dollar": 1876.58, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Ms Physicians Care N", "plan_name": "714210", "standard_charge_dollar": 2345.72, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Peoples Hlth Ffs 72126", "plan_name": "500019", "standard_charge_dollar": 1876.58, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Uhc/Secure Horizons", "plan_name": "500449", "standard_charge_dollar": 1876.58, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "United Health Care/", "plan_name": "500292", "standard_charge_dollar": 2120.53, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "United Healthcare", "plan_name": "750104", "standard_charge_dollar": 2120.53, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "United Healthcare Ba", "plan_name": "750090", "standard_charge_dollar": 2120.53, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "United Healthcare Me", "plan_name": "501310", "standard_charge_dollar": 1876.58, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Windsor Mcare Extra", "plan_name": "500778", "standard_charge_dollar": 1876.58, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." } ] } ] }, { "description": "Removal of bladder cyst", "code_information": [ { "code": "51500", "type": "CPT" } ], "standard_charges": [ { "gross_charge": 46170.56, "minimum": 5344.68, "maximum": 39244.98, "setting": "inpatient", "payers_information": [ { "payer_name": "Aarp", "plan_name": "500102", "standard_charge_dollar": 5344.68, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna", "plan_name": "700700", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna", "plan_name": "700700_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Mcare Ffs 6005", "plan_name": "700703", "standard_charge_dollar": 5344.68, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Miscellaneous", "plan_name": "700720", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Miscellaneous", "plan_name": "700720_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Ppo Hmo", "plan_name": "701720", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Ppo Hmo", "plan_name": "701720_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Ambetter 68069", "plan_name": "500516", "standard_charge_dollar": 5344.68, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Ms State Emplo", "plan_name": "401457", "standard_charge_percentage": 0.80, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Ms State Emplo", "plan_name": "401457_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Basic Pl", "plan_name": "400100", "standard_charge_percentage": 0.85, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Basic Pl", "plan_name": "400100_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Federal", "plan_name": "400110", "standard_charge_percentage": 0.85, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Federal", "plan_name": "400110_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Cigna Healthsprings Ffs", "plan_name": "500064", "standard_charge_dollar": 5344.68, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Conseco", "plan_name": "500302", "standard_charge_dollar": 5344.68, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Humana Ffs 61101", "plan_name": "500006", "standard_charge_dollar": 5344.68, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Medicare A", "plan_name": "100100", "standard_charge_dollar": 5344.68, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Medicare A", "plan_name": "100500", "standard_charge_dollar": 5344.68, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Medicare Part B Only", "plan_name": "100300", "standard_charge_dollar": 5344.68, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Medicare Railroad", "plan_name": "100103", "standard_charge_dollar": 5344.68, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Ms Physicians Care N", "plan_name": "714210", "standard_charge_dollar": 6680.85, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Peoples Hlth Ffs 72126", "plan_name": "500019", "standard_charge_dollar": 5344.68, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Uhc/Secure Horizons", "plan_name": "500449", "standard_charge_dollar": 5344.68, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "United Health Care/", "plan_name": "500292", "standard_charge_dollar": 6039.49, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "United Healthcare", "plan_name": "750104", "standard_charge_dollar": 6039.49, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "United Healthcare Ba", "plan_name": "750090", "standard_charge_dollar": 6039.49, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "United Healthcare Me", "plan_name": "501310", "standard_charge_dollar": 5344.68, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Windsor Mcare Extra", "plan_name": "500778", "standard_charge_dollar": 5344.68, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." } ] } ] }, { "description": "Removal of pelvic structures", "code_information": [ { "code": "51597", "type": "CPT" } ], "standard_charges": [ { "gross_charge": 16663.01, "minimum": 13330.41, "maximum": 14163.56, "setting": "inpatient", "payers_information": [ { "payer_name": "Aetna", "plan_name": "700700", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna", "plan_name": "700700_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Miscellaneous", "plan_name": "700720", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Miscellaneous", "plan_name": "700720_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Ppo Hmo", "plan_name": "701720", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Ppo Hmo", "plan_name": "701720_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Ms State Emplo", "plan_name": "401457", "standard_charge_percentage": 0.80, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Ms State Emplo", "plan_name": "401457_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Basic Pl", "plan_name": "400100", "standard_charge_percentage": 0.85, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Basic Pl", "plan_name": "400100_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Federal", "plan_name": "400110", "standard_charge_percentage": 0.85, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Federal", "plan_name": "400110_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." } ] } ] }, { "description": "Irrigation of bladder", "code_information": [ { "code": "51700", "type": "CPT" } ], "standard_charges": [ { "gross_charge": 22480.65, "minimum": 222.80, "maximum": 19108.55, "setting": "inpatient", "payers_information": [ { "payer_name": "Aarp", "plan_name": "500102", "standard_charge_dollar": 222.80, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna", "plan_name": "700700", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna", "plan_name": "700700_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Mcare Ffs 6005", "plan_name": "700703", "standard_charge_dollar": 222.80, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Miscellaneous", "plan_name": "700720", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Miscellaneous", "plan_name": "700720_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Ppo Hmo", "plan_name": "701720", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Ppo Hmo", "plan_name": "701720_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Ambetter 68069", "plan_name": "500516", "standard_charge_dollar": 222.80, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Ms State Emplo", "plan_name": "401457", "standard_charge_percentage": 0.80, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Ms State Emplo", "plan_name": "401457_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Basic Pl", "plan_name": "400100", "standard_charge_percentage": 0.85, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Basic Pl", "plan_name": "400100_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Federal", "plan_name": "400110", "standard_charge_percentage": 0.85, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Federal", "plan_name": "400110_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Cigna Healthsprings Ffs", "plan_name": "500064", "standard_charge_dollar": 222.80, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Conseco", "plan_name": "500302", "standard_charge_dollar": 222.80, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Humana Ffs 61101", "plan_name": "500006", "standard_charge_dollar": 222.80, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Medicare A", "plan_name": "100100", "standard_charge_dollar": 222.80, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Medicare A", "plan_name": "100500", "standard_charge_dollar": 222.80, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Medicare Part B Only", "plan_name": "100300", "standard_charge_dollar": 222.80, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Medicare Railroad", "plan_name": "100103", "standard_charge_dollar": 222.80, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Ms Physicians Care N", "plan_name": "714210", "standard_charge_dollar": 278.50, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Peoples Hlth Ffs 72126", "plan_name": "500019", "standard_charge_dollar": 222.80, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Uhc/Secure Horizons", "plan_name": "500449", "standard_charge_dollar": 222.80, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "United Health Care/", "plan_name": "500292", "standard_charge_dollar": 251.76, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "United Healthcare", "plan_name": "750104", "standard_charge_dollar": 251.76, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "United Healthcare Ba", "plan_name": "750090", "standard_charge_dollar": 251.76, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "United Healthcare Me", "plan_name": "501310", "standard_charge_dollar": 222.80, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Windsor Mcare Extra", "plan_name": "500778", "standard_charge_dollar": 222.80, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." } ] } ] }, { "description": "Hc insert bladder catheter foley", "code_information": [ { "code": "51702", "type": "CPT" } ], "standard_charges": [ { "gross_charge": 110.00, "minimum": 118.08, "maximum": 149.97, "setting": "both", "payers_information": [ { "payer_name": "Aarp", "plan_name": "500102", "standard_charge_dollar": 118.08, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna", "plan_name": "700700", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna", "plan_name": "700700_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Mcare Ffs 6005", "plan_name": "700703", "standard_charge_dollar": 118.08, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Miscellaneous", "plan_name": "700720", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Miscellaneous", "plan_name": "700720_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Ppo Hmo", "plan_name": "701720", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Ppo Hmo", "plan_name": "701720_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Ambetter 68069", "plan_name": "500516", "standard_charge_dollar": 118.08, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Ms State Emplo", "plan_name": "401457", "standard_charge_dollar": 149.97, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Ms State Emplo", "plan_name": "401457_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Basic Pl", "plan_name": "400100", "standard_charge_dollar": 149.97, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Basic Pl", "plan_name": "400100_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Federal", "plan_name": "400110", "standard_charge_dollar": 149.97, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Federal", "plan_name": "400110_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Cigna Healthsprings Ffs", "plan_name": "500064", "standard_charge_dollar": 118.08, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Conseco", "plan_name": "500302", "standard_charge_dollar": 118.08, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Humana Ffs 61101", "plan_name": "500006", "standard_charge_dollar": 118.08, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Medicare A", "plan_name": "100100", "standard_charge_dollar": 118.08, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Medicare A", "plan_name": "100500", "standard_charge_dollar": 118.08, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Medicare Part B Only", "plan_name": "100300", "standard_charge_dollar": 118.08, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Medicare Railroad", "plan_name": "100103", "standard_charge_dollar": 118.08, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Ms Physicians Care N", "plan_name": "714210", "standard_charge_dollar": 147.60, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Peoples Hlth Ffs 72126", "plan_name": "500019", "standard_charge_dollar": 118.08, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Uhc/Secure Horizons", "plan_name": "500449", "standard_charge_dollar": 118.08, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "United Health Care/", "plan_name": "500292", "standard_charge_dollar": 133.43, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "United Healthcare", "plan_name": "750104", "standard_charge_dollar": 133.43, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "United Healthcare Ba", "plan_name": "750090", "standard_charge_dollar": 133.43, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "United Healthcare Me", "plan_name": "501310", "standard_charge_dollar": 118.08, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Windsor Mcare Extra", "plan_name": "500778", "standard_charge_dollar": 118.08, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." } ] } ] }, { "description": "Insert temp bladder cath", "code_information": [ { "code": "51702", "type": "CPT" } ], "standard_charges": [ { "gross_charge": 17841.83, "minimum": 118.08, "maximum": 149.97, "setting": "inpatient", "payers_information": [ { "payer_name": "Aarp", "plan_name": "500102", "standard_charge_dollar": 118.08, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna", "plan_name": "700700", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna", "plan_name": "700700_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Mcare Ffs 6005", "plan_name": "700703", "standard_charge_dollar": 118.08, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Miscellaneous", "plan_name": "700720", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Miscellaneous", "plan_name": "700720_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Ppo Hmo", "plan_name": "701720", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Ppo Hmo", "plan_name": "701720_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Ambetter 68069", "plan_name": "500516", "standard_charge_dollar": 118.08, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Ms State Emplo", "plan_name": "401457", "standard_charge_dollar": 149.97, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Ms State Emplo", "plan_name": "401457_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Basic Pl", "plan_name": "400100", "standard_charge_dollar": 149.97, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Basic Pl", "plan_name": "400100_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Federal", "plan_name": "400110", "standard_charge_dollar": 149.97, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Federal", "plan_name": "400110_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Cigna Healthsprings Ffs", "plan_name": "500064", "standard_charge_dollar": 118.08, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Conseco", "plan_name": "500302", "standard_charge_dollar": 118.08, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Humana Ffs 61101", "plan_name": "500006", "standard_charge_dollar": 118.08, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Medicare A", "plan_name": "100100", "standard_charge_dollar": 118.08, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Medicare A", "plan_name": "100500", "standard_charge_dollar": 118.08, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Medicare Part B Only", "plan_name": "100300", "standard_charge_dollar": 118.08, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Medicare Railroad", "plan_name": "100103", "standard_charge_dollar": 118.08, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Ms Physicians Care N", "plan_name": "714210", "standard_charge_dollar": 147.60, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Peoples Hlth Ffs 72126", "plan_name": "500019", "standard_charge_dollar": 118.08, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Uhc/Secure Horizons", "plan_name": "500449", "standard_charge_dollar": 118.08, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "United Health Care/", "plan_name": "500292", "standard_charge_dollar": 133.43, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "United Healthcare", "plan_name": "750104", "standard_charge_dollar": 133.43, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "United Healthcare Ba", "plan_name": "750090", "standard_charge_dollar": 133.43, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "United Healthcare Me", "plan_name": "501310", "standard_charge_dollar": 118.08, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Windsor Mcare Extra", "plan_name": "500778", "standard_charge_dollar": 118.08, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." } ] } ] }, { "description": "Insert temp bladder cath", "code_information": [ { "code": "51702", "type": "CPT" } ], "standard_charges": [ { "gross_charge": 110.00, "minimum": 118.08, "maximum": 149.97, "setting": "outpatient", "payers_information": [ { "payer_name": "Aarp", "plan_name": "500102", "standard_charge_dollar": 118.08, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna", "plan_name": "700700", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna", "plan_name": "700700_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Mcare Ffs 6005", "plan_name": "700703", "standard_charge_dollar": 118.08, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Miscellaneous", "plan_name": "700720", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Miscellaneous", "plan_name": "700720_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Ppo Hmo", "plan_name": "701720", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Ppo Hmo", "plan_name": "701720_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Ambetter 68069", "plan_name": "500516", "standard_charge_dollar": 118.08, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Ms State Emplo", "plan_name": "401457", "standard_charge_dollar": 149.97, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Ms State Emplo", "plan_name": "401457_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Basic Pl", "plan_name": "400100", "standard_charge_dollar": 149.97, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Basic Pl", "plan_name": "400100_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Federal", "plan_name": "400110", "standard_charge_dollar": 149.97, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Federal", "plan_name": "400110_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Cigna Healthsprings Ffs", "plan_name": "500064", "standard_charge_dollar": 118.08, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Conseco", "plan_name": "500302", "standard_charge_dollar": 118.08, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Humana Ffs 61101", "plan_name": "500006", "standard_charge_dollar": 118.08, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Medicare A", "plan_name": "100100", "standard_charge_dollar": 118.08, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Medicare A", "plan_name": "100500", "standard_charge_dollar": 118.08, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Medicare Part B Only", "plan_name": "100300", "standard_charge_dollar": 118.08, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Medicare Railroad", "plan_name": "100103", "standard_charge_dollar": 118.08, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Ms Physicians Care N", "plan_name": "714210", "standard_charge_dollar": 147.60, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Peoples Hlth Ffs 72126", "plan_name": "500019", "standard_charge_dollar": 118.08, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Uhc/Secure Horizons", "plan_name": "500449", "standard_charge_dollar": 118.08, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "United Health Care/", "plan_name": "500292", "standard_charge_dollar": 133.43, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "United Healthcare", "plan_name": "750104", "standard_charge_dollar": 133.43, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "United Healthcare Ba", "plan_name": "750090", "standard_charge_dollar": 133.43, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "United Healthcare Me", "plan_name": "501310", "standard_charge_dollar": 118.08, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Windsor Mcare Extra", "plan_name": "500778", "standard_charge_dollar": 118.08, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." } ] } ] }, { "description": "Insert bladder cath complex", "code_information": [ { "code": "51703", "type": "CPT" } ], "standard_charges": [ { "gross_charge": 22020.44, "minimum": 143.33, "maximum": 18717.37, "setting": "inpatient", "payers_information": [ { "payer_name": "Aarp", "plan_name": "500102", "standard_charge_dollar": 143.33, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna", "plan_name": "700700", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna", "plan_name": "700700_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Mcare Ffs 6005", "plan_name": "700703", "standard_charge_dollar": 143.33, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Miscellaneous", "plan_name": "700720", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Miscellaneous", "plan_name": "700720_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Ppo Hmo", "plan_name": "701720", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Ppo Hmo", "plan_name": "701720_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Ambetter 68069", "plan_name": "500516", "standard_charge_dollar": 143.33, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Ms State Emplo", "plan_name": "401457", "standard_charge_percentage": 0.80, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Ms State Emplo", "plan_name": "401457_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Basic Pl", "plan_name": "400100", "standard_charge_percentage": 0.85, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Basic Pl", "plan_name": "400100_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Federal", "plan_name": "400110", "standard_charge_percentage": 0.85, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Federal", "plan_name": "400110_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Cigna Healthsprings Ffs", "plan_name": "500064", "standard_charge_dollar": 143.33, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Conseco", "plan_name": "500302", "standard_charge_dollar": 143.33, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Humana Ffs 61101", "plan_name": "500006", "standard_charge_dollar": 143.33, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Medicare A", "plan_name": "100100", "standard_charge_dollar": 143.33, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Medicare A", "plan_name": "100500", "standard_charge_dollar": 143.33, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Medicare Part B Only", "plan_name": "100300", "standard_charge_dollar": 143.33, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Medicare Railroad", "plan_name": "100103", "standard_charge_dollar": 143.33, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Ms Physicians Care N", "plan_name": "714210", "standard_charge_dollar": 179.16, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Peoples Hlth Ffs 72126", "plan_name": "500019", "standard_charge_dollar": 143.33, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Uhc/Secure Horizons", "plan_name": "500449", "standard_charge_dollar": 143.33, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "United Health Care/", "plan_name": "500292", "standard_charge_dollar": 161.96, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "United Healthcare", "plan_name": "750104", "standard_charge_dollar": 161.96, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "United Healthcare Ba", "plan_name": "750090", "standard_charge_dollar": 161.96, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "United Healthcare Me", "plan_name": "501310", "standard_charge_dollar": 143.33, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Windsor Mcare Extra", "plan_name": "500778", "standard_charge_dollar": 143.33, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." } ] } ] }, { "description": "Change of bladder tube", "code_information": [ { "code": "51705", "type": "CPT" } ], "standard_charges": [ { "gross_charge": 26199.04, "minimum": 222.80, "maximum": 22269.18, "setting": "inpatient", "payers_information": [ { "payer_name": "Aarp", "plan_name": "500102", "standard_charge_dollar": 222.80, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna", "plan_name": "700700", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna", "plan_name": "700700_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Mcare Ffs 6005", "plan_name": "700703", "standard_charge_dollar": 222.80, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Miscellaneous", "plan_name": "700720", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Miscellaneous", "plan_name": "700720_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Ppo Hmo", "plan_name": "701720", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Ppo Hmo", "plan_name": "701720_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Ambetter 68069", "plan_name": "500516", "standard_charge_dollar": 222.80, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Ms State Emplo", "plan_name": "401457", "standard_charge_percentage": 0.80, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Ms State Emplo", "plan_name": "401457_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Basic Pl", "plan_name": "400100", "standard_charge_percentage": 0.85, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Basic Pl", "plan_name": "400100_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Federal", "plan_name": "400110", "standard_charge_percentage": 0.85, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Federal", "plan_name": "400110_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Cigna Healthsprings Ffs", "plan_name": "500064", "standard_charge_dollar": 222.80, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Conseco", "plan_name": "500302", "standard_charge_dollar": 222.80, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Humana Ffs 61101", "plan_name": "500006", "standard_charge_dollar": 222.80, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Medicare A", "plan_name": "100100", "standard_charge_dollar": 222.80, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Medicare A", "plan_name": "100500", "standard_charge_dollar": 222.80, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Medicare Part B Only", "plan_name": "100300", "standard_charge_dollar": 222.80, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Medicare Railroad", "plan_name": "100103", "standard_charge_dollar": 222.80, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Ms Physicians Care N", "plan_name": "714210", "standard_charge_dollar": 278.50, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Peoples Hlth Ffs 72126", "plan_name": "500019", "standard_charge_dollar": 222.80, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Uhc/Secure Horizons", "plan_name": "500449", "standard_charge_dollar": 222.80, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "United Health Care/", "plan_name": "500292", "standard_charge_dollar": 251.76, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "United Healthcare", "plan_name": "750104", "standard_charge_dollar": 251.76, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "United Healthcare Ba", "plan_name": "750090", "standard_charge_dollar": 251.76, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "United Healthcare Me", "plan_name": "501310", "standard_charge_dollar": 222.80, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Windsor Mcare Extra", "plan_name": "500778", "standard_charge_dollar": 222.80, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." } ] } ] }, { "description": "Change of bladder tube", "code_information": [ { "code": "51710", "type": "CPT" } ], "standard_charges": [ { "gross_charge": 26199.04, "minimum": 611.45, "maximum": 22269.18, "setting": "inpatient", "payers_information": [ { "payer_name": "Aarp", "plan_name": "500102", "standard_charge_dollar": 611.45, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna", "plan_name": "700700", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna", "plan_name": "700700_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Mcare Ffs 6005", "plan_name": "700703", "standard_charge_dollar": 611.45, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Miscellaneous", "plan_name": "700720", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Miscellaneous", "plan_name": "700720_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Ppo Hmo", "plan_name": "701720", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Ppo Hmo", "plan_name": "701720_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Ambetter 68069", "plan_name": "500516", "standard_charge_dollar": 611.45, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Ms State Emplo", "plan_name": "401457", "standard_charge_percentage": 0.80, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Ms State Emplo", "plan_name": "401457_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Basic Pl", "plan_name": "400100", "standard_charge_percentage": 0.85, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Basic Pl", "plan_name": "400100_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Federal", "plan_name": "400110", "standard_charge_percentage": 0.85, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Federal", "plan_name": "400110_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Cigna Healthsprings Ffs", "plan_name": "500064", "standard_charge_dollar": 611.45, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Conseco", "plan_name": "500302", "standard_charge_dollar": 611.45, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Humana Ffs 61101", "plan_name": "500006", "standard_charge_dollar": 611.45, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Medicare A", "plan_name": "100100", "standard_charge_dollar": 611.45, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Medicare A", "plan_name": "100500", "standard_charge_dollar": 611.45, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Medicare Part B Only", "plan_name": "100300", "standard_charge_dollar": 611.45, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Medicare Railroad", "plan_name": "100103", "standard_charge_dollar": 611.45, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Ms Physicians Care N", "plan_name": "714210", "standard_charge_dollar": 764.31, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Peoples Hlth Ffs 72126", "plan_name": "500019", "standard_charge_dollar": 611.45, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Uhc/Secure Horizons", "plan_name": "500449", "standard_charge_dollar": 611.45, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "United Health Care/", "plan_name": "500292", "standard_charge_dollar": 690.94, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "United Healthcare", "plan_name": "750104", "standard_charge_dollar": 690.94, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "United Healthcare Ba", "plan_name": "750090", "standard_charge_dollar": 690.94, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "United Healthcare Me", "plan_name": "501310", "standard_charge_dollar": 611.45, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Windsor Mcare Extra", "plan_name": "500778", "standard_charge_dollar": 611.45, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." } ] } ] }, { "description": "Revision of bladder/urethra", "code_information": [ { "code": "51800", "type": "CPT" } ], "standard_charges": [ { "gross_charge": 68896.77, "minimum": 55117.42, "maximum": 58562.25, "setting": "inpatient", "payers_information": [ { "payer_name": "Aetna", "plan_name": "700700", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna", "plan_name": "700700_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Miscellaneous", "plan_name": "700720", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Miscellaneous", "plan_name": "700720_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Ppo Hmo", "plan_name": "701720", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Ppo Hmo", "plan_name": "701720_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Ms State Emplo", "plan_name": "401457", "standard_charge_percentage": 0.80, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Ms State Emplo", "plan_name": "401457_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Basic Pl", "plan_name": "400100", "standard_charge_percentage": 0.85, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Basic Pl", "plan_name": "400100_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Federal", "plan_name": "400110", "standard_charge_percentage": 0.85, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Federal", "plan_name": "400110_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." } ] } ] }, { "description": "Revision of urinary tract", "code_information": [ { "code": "51820", "type": "CPT" } ], "standard_charges": [ { "gross_charge": 68896.77, "minimum": 55117.42, "maximum": 58562.25, "setting": "inpatient", "payers_information": [ { "payer_name": "Aetna", "plan_name": "700700", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna", "plan_name": "700700_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Miscellaneous", "plan_name": "700720", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Miscellaneous", "plan_name": "700720_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Ppo Hmo", "plan_name": "701720", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Ppo Hmo", "plan_name": "701720_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Ms State Emplo", "plan_name": "401457", "standard_charge_percentage": 0.80, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Ms State Emplo", "plan_name": "401457_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Basic Pl", "plan_name": "400100", "standard_charge_percentage": 0.85, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Basic Pl", "plan_name": "400100_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Federal", "plan_name": "400110", "standard_charge_percentage": 0.85, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Federal", "plan_name": "400110_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." } ] } ] }, { "description": "Repair of bladder wound", "code_information": [ { "code": "51860", "type": "CPT" } ], "standard_charges": [ { "gross_charge": 68896.77, "minimum": 8471.03, "maximum": 58562.25, "setting": "inpatient", "payers_information": [ { "payer_name": "Aarp", "plan_name": "500102", "standard_charge_dollar": 8471.03, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna", "plan_name": "700700", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna", "plan_name": "700700_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Mcare Ffs 6005", "plan_name": "700703", "standard_charge_dollar": 8471.03, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Miscellaneous", "plan_name": "700720", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Miscellaneous", "plan_name": "700720_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Ppo Hmo", "plan_name": "701720", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Ppo Hmo", "plan_name": "701720_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Ambetter 68069", "plan_name": "500516", "standard_charge_dollar": 8471.03, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Ms State Emplo", "plan_name": "401457", "standard_charge_percentage": 0.80, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Ms State Emplo", "plan_name": "401457_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Basic Pl", "plan_name": "400100", "standard_charge_percentage": 0.85, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Basic Pl", "plan_name": "400100_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Federal", "plan_name": "400110", "standard_charge_percentage": 0.85, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Federal", "plan_name": "400110_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Cigna Healthsprings Ffs", "plan_name": "500064", "standard_charge_dollar": 8471.03, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Conseco", "plan_name": "500302", "standard_charge_dollar": 8471.03, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Humana Ffs 61101", "plan_name": "500006", "standard_charge_dollar": 8471.03, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Medicare A", "plan_name": "100100", "standard_charge_dollar": 8471.03, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Medicare A", "plan_name": "100500", "standard_charge_dollar": 8471.03, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Medicare Part B Only", "plan_name": "100300", "standard_charge_dollar": 8471.03, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Medicare Railroad", "plan_name": "100103", "standard_charge_dollar": 8471.03, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Ms Physicians Care N", "plan_name": "714210", "standard_charge_dollar": 10588.79, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Peoples Hlth Ffs 72126", "plan_name": "500019", "standard_charge_dollar": 8471.03, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Uhc/Secure Horizons", "plan_name": "500449", "standard_charge_dollar": 8471.03, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "United Health Care/", "plan_name": "500292", "standard_charge_dollar": 9572.26, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "United Healthcare", "plan_name": "750104", "standard_charge_dollar": 9572.26, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "United Healthcare Ba", "plan_name": "750090", "standard_charge_dollar": 9572.26, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "United Healthcare Me", "plan_name": "501310", "standard_charge_dollar": 8471.03, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Windsor Mcare Extra", "plan_name": "500778", "standard_charge_dollar": 8471.03, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." } ] } ] }, { "description": "Repair of bladder wound", "code_information": [ { "code": "51865", "type": "CPT" } ], "standard_charges": [ { "gross_charge": 68896.77, "minimum": 55117.42, "maximum": 58562.25, "setting": "inpatient", "payers_information": [ { "payer_name": "Aetna", "plan_name": "700700", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna", "plan_name": "700700_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Miscellaneous", "plan_name": "700720", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Miscellaneous", "plan_name": "700720_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Ppo Hmo", "plan_name": "701720", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Ppo Hmo", "plan_name": "701720_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Ms State Emplo", "plan_name": "401457", "standard_charge_percentage": 0.80, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Ms State Emplo", "plan_name": "401457_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Basic Pl", "plan_name": "400100", "standard_charge_percentage": 0.85, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Basic Pl", "plan_name": "400100_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Federal", "plan_name": "400110", "standard_charge_percentage": 0.85, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Federal", "plan_name": "400110_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." } ] } ] }, { "description": "Repair of bladder opening", "code_information": [ { "code": "51880", "type": "CPT" } ], "standard_charges": [ { "gross_charge": 68896.77, "minimum": 3159.49, "maximum": 58562.25, "setting": "inpatient", "payers_information": [ { "payer_name": "Aarp", "plan_name": "500102", "standard_charge_dollar": 3159.49, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna", "plan_name": "700700", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna", "plan_name": "700700_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Mcare Ffs 6005", "plan_name": "700703", "standard_charge_dollar": 3159.49, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Miscellaneous", "plan_name": "700720", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Miscellaneous", "plan_name": "700720_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Ppo Hmo", "plan_name": "701720", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Ppo Hmo", "plan_name": "701720_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Ambetter 68069", "plan_name": "500516", "standard_charge_dollar": 3159.49, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Ms State Emplo", "plan_name": "401457", "standard_charge_percentage": 0.80, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Ms State Emplo", "plan_name": "401457_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Basic Pl", "plan_name": "400100", "standard_charge_percentage": 0.85, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Basic Pl", "plan_name": "400100_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Federal", "plan_name": "400110", "standard_charge_percentage": 0.85, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Federal", "plan_name": "400110_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Cigna Healthsprings Ffs", "plan_name": "500064", "standard_charge_dollar": 3159.49, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Conseco", "plan_name": "500302", "standard_charge_dollar": 3159.49, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Humana Ffs 61101", "plan_name": "500006", "standard_charge_dollar": 3159.49, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Medicare A", "plan_name": "100100", "standard_charge_dollar": 3159.49, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Medicare A", "plan_name": "100500", "standard_charge_dollar": 3159.49, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Medicare Part B Only", "plan_name": "100300", "standard_charge_dollar": 3159.49, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Medicare Railroad", "plan_name": "100103", "standard_charge_dollar": 3159.49, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Ms Physicians Care N", "plan_name": "714210", "standard_charge_dollar": 3949.37, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Peoples Hlth Ffs 72126", "plan_name": "500019", "standard_charge_dollar": 3159.49, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Uhc/Secure Horizons", "plan_name": "500449", "standard_charge_dollar": 3159.49, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "United Health Care/", "plan_name": "500292", "standard_charge_dollar": 3570.23, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "United Healthcare", "plan_name": "750104", "standard_charge_dollar": 3570.23, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "United Healthcare Ba", "plan_name": "750090", "standard_charge_dollar": 3570.23, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "United Healthcare Me", "plan_name": "501310", "standard_charge_dollar": 3159.49, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Windsor Mcare Extra", "plan_name": "500778", "standard_charge_dollar": 3159.49, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." } ] } ] }, { "description": "Repair bladder/vagina lesion", "code_information": [ { "code": "51900", "type": "CPT" } ], "standard_charges": [ { "gross_charge": 68896.77, "minimum": 55117.42, "maximum": 58562.25, "setting": "inpatient", "payers_information": [ { "payer_name": "Aetna", "plan_name": "700700", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna", "plan_name": "700700_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Miscellaneous", "plan_name": "700720", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Miscellaneous", "plan_name": "700720_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Ppo Hmo", "plan_name": "701720", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Ppo Hmo", "plan_name": "701720_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Ms State Emplo", "plan_name": "401457", "standard_charge_percentage": 0.80, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Ms State Emplo", "plan_name": "401457_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Basic Pl", "plan_name": "400100", "standard_charge_percentage": 0.85, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Basic Pl", "plan_name": "400100_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Federal", "plan_name": "400110", "standard_charge_percentage": 0.85, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Federal", "plan_name": "400110_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." } ] } ] }, { "description": "Close bladder-uterus fistula", "code_information": [ { "code": "51920", "type": "CPT" } ], "standard_charges": [ { "gross_charge": 68896.77, "minimum": 55117.42, "maximum": 58562.25, "setting": "inpatient", "payers_information": [ { "payer_name": "Aetna", "plan_name": "700700", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna", "plan_name": "700700_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Miscellaneous", "plan_name": "700720", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Miscellaneous", "plan_name": "700720_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Ppo Hmo", "plan_name": "701720", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Ppo Hmo", "plan_name": "701720_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Ms State Emplo", "plan_name": "401457", "standard_charge_percentage": 0.80, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Ms State Emplo", "plan_name": "401457_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Basic Pl", "plan_name": "400100", "standard_charge_percentage": 0.85, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Basic Pl", "plan_name": "400100_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Federal", "plan_name": "400110", "standard_charge_percentage": 0.85, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Federal", "plan_name": "400110_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." } ] } ] }, { "description": "Hysterectomy/bladder repair", "code_information": [ { "code": "51925", "type": "CPT" } ], "standard_charges": [ { "gross_charge": 68896.77, "minimum": 55117.42, "maximum": 58562.25, "setting": "inpatient", "payers_information": [ { "payer_name": "Aetna", "plan_name": "700700", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna", "plan_name": "700700_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Miscellaneous", "plan_name": "700720", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Miscellaneous", "plan_name": "700720_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Ppo Hmo", "plan_name": "701720", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Ppo Hmo", "plan_name": "701720_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Ms State Emplo", "plan_name": "401457", "standard_charge_percentage": 0.80, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Ms State Emplo", "plan_name": "401457_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Basic Pl", "plan_name": "400100", "standard_charge_percentage": 0.85, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Basic Pl", "plan_name": "400100_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Federal", "plan_name": "400110", "standard_charge_percentage": 0.85, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Federal", "plan_name": "400110_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." } ] } ] }, { "description": "Construct bladder opening", "code_information": [ { "code": "51980", "type": "CPT" } ], "standard_charges": [ { "gross_charge": 68896.77, "minimum": 55117.42, "maximum": 58562.25, "setting": "inpatient", "payers_information": [ { "payer_name": "Aetna", "plan_name": "700700", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna", "plan_name": "700700_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Miscellaneous", "plan_name": "700720", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Miscellaneous", "plan_name": "700720_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Ppo Hmo", "plan_name": "701720", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Ppo Hmo", "plan_name": "701720_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Ms State Emplo", "plan_name": "401457", "standard_charge_percentage": 0.80, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Ms State Emplo", "plan_name": "401457_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Basic Pl", "plan_name": "400100", "standard_charge_percentage": 0.85, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Basic Pl", "plan_name": "400100_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Federal", "plan_name": "400110", "standard_charge_percentage": 0.85, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Federal", "plan_name": "400110_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." } ] } ] }, { "description": "Cystoscopy removal of clots", "code_information": [ { "code": "52001", "type": "CPT" } ], "standard_charges": [ { "gross_charge": 27165.19, "minimum": 3159.49, "maximum": 23090.41, "setting": "inpatient", "payers_information": [ { "payer_name": "Aarp", "plan_name": "500102", "standard_charge_dollar": 3159.49, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna", "plan_name": "700700", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna", "plan_name": "700700_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Mcare Ffs 6005", "plan_name": "700703", "standard_charge_dollar": 3159.49, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Miscellaneous", "plan_name": "700720", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Miscellaneous", "plan_name": "700720_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Ppo Hmo", "plan_name": "701720", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Ppo Hmo", "plan_name": "701720_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Ambetter 68069", "plan_name": "500516", "standard_charge_dollar": 3159.49, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Ms State Emplo", "plan_name": "401457", "standard_charge_percentage": 0.80, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Ms State Emplo", "plan_name": "401457_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Basic Pl", "plan_name": "400100", "standard_charge_percentage": 0.85, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Basic Pl", "plan_name": "400100_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Federal", "plan_name": "400110", "standard_charge_percentage": 0.85, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Federal", "plan_name": "400110_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Cigna Healthsprings Ffs", "plan_name": "500064", "standard_charge_dollar": 3159.49, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Conseco", "plan_name": "500302", "standard_charge_dollar": 3159.49, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Humana Ffs 61101", "plan_name": "500006", "standard_charge_dollar": 3159.49, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Medicare A", "plan_name": "100100", "standard_charge_dollar": 3159.49, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Medicare A", "plan_name": "100500", "standard_charge_dollar": 3159.49, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Medicare Part B Only", "plan_name": "100300", "standard_charge_dollar": 3159.49, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Medicare Railroad", "plan_name": "100103", "standard_charge_dollar": 3159.49, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Ms Physicians Care N", "plan_name": "714210", "standard_charge_dollar": 3949.37, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Peoples Hlth Ffs 72126", "plan_name": "500019", "standard_charge_dollar": 3159.49, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Uhc/Secure Horizons", "plan_name": "500449", "standard_charge_dollar": 3159.49, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "United Health Care/", "plan_name": "500292", "standard_charge_dollar": 3570.23, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "United Healthcare", "plan_name": "750104", "standard_charge_dollar": 3570.23, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "United Healthcare Ba", "plan_name": "750090", "standard_charge_dollar": 3570.23, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "United Healthcare Me", "plan_name": "501310", "standard_charge_dollar": 3159.49, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Windsor Mcare Extra", "plan_name": "500778", "standard_charge_dollar": 3159.49, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." } ] } ] }, { "description": "Cystoscopy and treatment", "code_information": [ { "code": "52214", "type": "CPT" } ], "standard_charges": [ { "gross_charge": 17890.97, "minimum": 3159.49, "maximum": 15207.32, "setting": "inpatient", "payers_information": [ { "payer_name": "Aarp", "plan_name": "500102", "standard_charge_dollar": 3159.49, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna", "plan_name": "700700", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna", "plan_name": "700700_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Mcare Ffs 6005", "plan_name": "700703", "standard_charge_dollar": 3159.49, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Miscellaneous", "plan_name": "700720", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Miscellaneous", "plan_name": "700720_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Ppo Hmo", "plan_name": "701720", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Ppo Hmo", "plan_name": "701720_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Ambetter 68069", "plan_name": "500516", "standard_charge_dollar": 3159.49, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Ms State Emplo", "plan_name": "401457", "standard_charge_percentage": 0.80, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Ms State Emplo", "plan_name": "401457_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Basic Pl", "plan_name": "400100", "standard_charge_percentage": 0.85, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Basic Pl", "plan_name": "400100_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Federal", "plan_name": "400110", "standard_charge_percentage": 0.85, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Federal", "plan_name": "400110_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Cigna Healthsprings Ffs", "plan_name": "500064", "standard_charge_dollar": 3159.49, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Conseco", "plan_name": "500302", "standard_charge_dollar": 3159.49, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Humana Ffs 61101", "plan_name": "500006", "standard_charge_dollar": 3159.49, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Medicare A", "plan_name": "100100", "standard_charge_dollar": 3159.49, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Medicare A", "plan_name": "100500", "standard_charge_dollar": 3159.49, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Medicare Part B Only", "plan_name": "100300", "standard_charge_dollar": 3159.49, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Medicare Railroad", "plan_name": "100103", "standard_charge_dollar": 3159.49, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Ms Physicians Care N", "plan_name": "714210", "standard_charge_dollar": 3949.37, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Peoples Hlth Ffs 72126", "plan_name": "500019", "standard_charge_dollar": 3159.49, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Uhc/Secure Horizons", "plan_name": "500449", "standard_charge_dollar": 3159.49, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "United Health Care/", "plan_name": "500292", "standard_charge_dollar": 3570.23, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "United Healthcare", "plan_name": "750104", "standard_charge_dollar": 3570.23, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "United Healthcare Ba", "plan_name": "750090", "standard_charge_dollar": 3570.23, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "United Healthcare Me", "plan_name": "501310", "standard_charge_dollar": 3159.49, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Windsor Mcare Extra", "plan_name": "500778", "standard_charge_dollar": 3159.49, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." } ] } ] }, { "description": "Cystoscopy and radiotracer", "code_information": [ { "code": "52250", "type": "CPT" } ], "standard_charges": [ { "gross_charge": 24843.05, "minimum": 3159.49, "maximum": 21116.59, "setting": "inpatient", "payers_information": [ { "payer_name": "Aarp", "plan_name": "500102", "standard_charge_dollar": 3159.49, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna", "plan_name": "700700", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna", "plan_name": "700700_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Mcare Ffs 6005", "plan_name": "700703", "standard_charge_dollar": 3159.49, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Miscellaneous", "plan_name": "700720", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Miscellaneous", "plan_name": "700720_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Ppo Hmo", "plan_name": "701720", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Ppo Hmo", "plan_name": "701720_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Ambetter 68069", "plan_name": "500516", "standard_charge_dollar": 3159.49, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Ms State Emplo", "plan_name": "401457", "standard_charge_percentage": 0.80, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Ms State Emplo", "plan_name": "401457_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Basic Pl", "plan_name": "400100", "standard_charge_percentage": 0.85, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Basic Pl", "plan_name": "400100_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Federal", "plan_name": "400110", "standard_charge_percentage": 0.85, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Federal", "plan_name": "400110_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Cigna Healthsprings Ffs", "plan_name": "500064", "standard_charge_dollar": 3159.49, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Conseco", "plan_name": "500302", "standard_charge_dollar": 3159.49, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Humana Ffs 61101", "plan_name": "500006", "standard_charge_dollar": 3159.49, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Medicare A", "plan_name": "100100", "standard_charge_dollar": 3159.49, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Medicare A", "plan_name": "100500", "standard_charge_dollar": 3159.49, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Medicare Part B Only", "plan_name": "100300", "standard_charge_dollar": 3159.49, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Medicare Railroad", "plan_name": "100103", "standard_charge_dollar": 3159.49, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Ms Physicians Care N", "plan_name": "714210", "standard_charge_dollar": 3949.37, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Peoples Hlth Ffs 72126", "plan_name": "500019", "standard_charge_dollar": 3159.49, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Uhc/Secure Horizons", "plan_name": "500449", "standard_charge_dollar": 3159.49, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "United Health Care/", "plan_name": "500292", "standard_charge_dollar": 3570.23, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "United Healthcare", "plan_name": "750104", "standard_charge_dollar": 3570.23, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "United Healthcare Ba", "plan_name": "750090", "standard_charge_dollar": 3570.23, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "United Healthcare Me", "plan_name": "501310", "standard_charge_dollar": 3159.49, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Windsor Mcare Extra", "plan_name": "500778", "standard_charge_dollar": 3159.49, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." } ] } ] }, { "description": "Cystoscopy implant stent", "code_information": [ { "code": "52282", "type": "CPT" } ], "standard_charges": [ { "gross_charge": 20220.36, "minimum": 3159.49, "maximum": 17187.31, "setting": "inpatient", "payers_information": [ { "payer_name": "Aarp", "plan_name": "500102", "standard_charge_dollar": 3159.49, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna", "plan_name": "700700", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna", "plan_name": "700700_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Mcare Ffs 6005", "plan_name": "700703", "standard_charge_dollar": 3159.49, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Miscellaneous", "plan_name": "700720", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Miscellaneous", "plan_name": "700720_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Ppo Hmo", "plan_name": "701720", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Ppo Hmo", "plan_name": "701720_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Ambetter 68069", "plan_name": "500516", "standard_charge_dollar": 3159.49, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Ms State Emplo", "plan_name": "401457", "standard_charge_percentage": 0.80, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Ms State Emplo", "plan_name": "401457_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Basic Pl", "plan_name": "400100", "standard_charge_percentage": 0.85, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Basic Pl", "plan_name": "400100_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Federal", "plan_name": "400110", "standard_charge_percentage": 0.85, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Federal", "plan_name": "400110_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Cigna Healthsprings Ffs", "plan_name": "500064", "standard_charge_dollar": 3159.49, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Conseco", "plan_name": "500302", "standard_charge_dollar": 3159.49, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Humana Ffs 61101", "plan_name": "500006", "standard_charge_dollar": 3159.49, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Medicare A", "plan_name": "100100", "standard_charge_dollar": 3159.49, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Medicare A", "plan_name": "100500", "standard_charge_dollar": 3159.49, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Medicare Part B Only", "plan_name": "100300", "standard_charge_dollar": 3159.49, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Medicare Railroad", "plan_name": "100103", "standard_charge_dollar": 3159.49, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Ms Physicians Care N", "plan_name": "714210", "standard_charge_dollar": 3949.37, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Peoples Hlth Ffs 72126", "plan_name": "500019", "standard_charge_dollar": 3159.49, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Uhc/Secure Horizons", "plan_name": "500449", "standard_charge_dollar": 3159.49, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "United Health Care/", "plan_name": "500292", "standard_charge_dollar": 3570.23, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "United Healthcare", "plan_name": "750104", "standard_charge_dollar": 3570.23, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "United Healthcare Ba", "plan_name": "750090", "standard_charge_dollar": 3570.23, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "United Healthcare Me", "plan_name": "501310", "standard_charge_dollar": 3159.49, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Windsor Mcare Extra", "plan_name": "500778", "standard_charge_dollar": 3159.49, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." } ] } ] }, { "description": "Cystoscopy and treatment", "code_information": [ { "code": "52285", "type": "CPT" } ], "standard_charges": [ { "gross_charge": 17999.43, "minimum": 611.45, "maximum": 15299.52, "setting": "inpatient", "payers_information": [ { "payer_name": "Aarp", "plan_name": "500102", "standard_charge_dollar": 611.45, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna", "plan_name": "700700", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna", "plan_name": "700700_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Mcare Ffs 6005", "plan_name": "700703", "standard_charge_dollar": 611.45, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Miscellaneous", "plan_name": "700720", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Miscellaneous", "plan_name": "700720_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Ppo Hmo", "plan_name": "701720", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Ppo Hmo", "plan_name": "701720_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Ambetter 68069", "plan_name": "500516", "standard_charge_dollar": 611.45, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Ms State Emplo", "plan_name": "401457", "standard_charge_percentage": 0.80, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Ms State Emplo", "plan_name": "401457_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Basic Pl", "plan_name": "400100", "standard_charge_percentage": 0.85, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Basic Pl", "plan_name": "400100_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Federal", "plan_name": "400110", "standard_charge_percentage": 0.85, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Federal", "plan_name": "400110_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Cigna Healthsprings Ffs", "plan_name": "500064", "standard_charge_dollar": 611.45, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Conseco", "plan_name": "500302", "standard_charge_dollar": 611.45, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Humana Ffs 61101", "plan_name": "500006", "standard_charge_dollar": 611.45, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Medicare A", "plan_name": "100100", "standard_charge_dollar": 611.45, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Medicare A", "plan_name": "100500", "standard_charge_dollar": 611.45, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Medicare Part B Only", "plan_name": "100300", "standard_charge_dollar": 611.45, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Medicare Railroad", "plan_name": "100103", "standard_charge_dollar": 611.45, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Ms Physicians Care N", "plan_name": "714210", "standard_charge_dollar": 764.31, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Peoples Hlth Ffs 72126", "plan_name": "500019", "standard_charge_dollar": 611.45, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Uhc/Secure Horizons", "plan_name": "500449", "standard_charge_dollar": 611.45, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "United Health Care/", "plan_name": "500292", "standard_charge_dollar": 690.94, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "United Healthcare", "plan_name": "750104", "standard_charge_dollar": 690.94, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "United Healthcare Ba", "plan_name": "750090", "standard_charge_dollar": 690.94, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "United Healthcare Me", "plan_name": "501310", "standard_charge_dollar": 611.45, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Windsor Mcare Extra", "plan_name": "500778", "standard_charge_dollar": 611.45, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." } ] } ] }, { "description": "Cystoscopy and treatment", "code_information": [ { "code": "52310", "type": "CPT" } ], "standard_charges": [ { "gross_charge": 49092.37, "minimum": 1876.58, "maximum": 41728.51, "setting": "inpatient", "payers_information": [ { "payer_name": "Aarp", "plan_name": "500102", "standard_charge_dollar": 1876.58, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna", "plan_name": "700700", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna", "plan_name": "700700_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Mcare Ffs 6005", "plan_name": "700703", "standard_charge_dollar": 1876.58, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Miscellaneous", "plan_name": "700720", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Miscellaneous", "plan_name": "700720_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Ppo Hmo", "plan_name": "701720", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Ppo Hmo", "plan_name": "701720_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Ambetter 68069", "plan_name": "500516", "standard_charge_dollar": 1876.58, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Ms State Emplo", "plan_name": "401457", "standard_charge_percentage": 0.80, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Ms State Emplo", "plan_name": "401457_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Basic Pl", "plan_name": "400100", "standard_charge_percentage": 0.85, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Basic Pl", "plan_name": "400100_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Federal", "plan_name": "400110", "standard_charge_percentage": 0.85, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Federal", "plan_name": "400110_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Cigna Healthsprings Ffs", "plan_name": "500064", "standard_charge_dollar": 1876.58, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Conseco", "plan_name": "500302", "standard_charge_dollar": 1876.58, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Humana Ffs 61101", "plan_name": "500006", "standard_charge_dollar": 1876.58, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Medicare A", "plan_name": "100100", "standard_charge_dollar": 1876.58, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Medicare A", "plan_name": "100500", "standard_charge_dollar": 1876.58, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Medicare Part B Only", "plan_name": "100300", "standard_charge_dollar": 1876.58, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Medicare Railroad", "plan_name": "100103", "standard_charge_dollar": 1876.58, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Ms Physicians Care N", "plan_name": "714210", "standard_charge_dollar": 2345.72, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Peoples Hlth Ffs 72126", "plan_name": "500019", "standard_charge_dollar": 1876.58, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Uhc/Secure Horizons", "plan_name": "500449", "standard_charge_dollar": 1876.58, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "United Health Care/", "plan_name": "500292", "standard_charge_dollar": 2120.53, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "United Healthcare", "plan_name": "750104", "standard_charge_dollar": 2120.53, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "United Healthcare Ba", "plan_name": "750090", "standard_charge_dollar": 2120.53, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "United Healthcare Me", "plan_name": "501310", "standard_charge_dollar": 1876.58, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Windsor Mcare Extra", "plan_name": "500778", "standard_charge_dollar": 1876.58, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." } ] } ] }, { "description": "Cystoscopy and treatment", "code_information": [ { "code": "52315", "type": "CPT" } ], "standard_charges": [ { "gross_charge": 27165.19, "minimum": 1876.58, "maximum": 23090.41, "setting": "inpatient", "payers_information": [ { "payer_name": "Aarp", "plan_name": "500102", "standard_charge_dollar": 1876.58, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna", "plan_name": "700700", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna", "plan_name": "700700_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Mcare Ffs 6005", "plan_name": "700703", "standard_charge_dollar": 1876.58, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Miscellaneous", "plan_name": "700720", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Miscellaneous", "plan_name": "700720_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Ppo Hmo", "plan_name": "701720", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Ppo Hmo", "plan_name": "701720_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Ambetter 68069", "plan_name": "500516", "standard_charge_dollar": 1876.58, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Ms State Emplo", "plan_name": "401457", "standard_charge_percentage": 0.80, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Ms State Emplo", "plan_name": "401457_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Basic Pl", "plan_name": "400100", "standard_charge_percentage": 0.85, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Basic Pl", "plan_name": "400100_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Federal", "plan_name": "400110", "standard_charge_percentage": 0.85, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Federal", "plan_name": "400110_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Cigna Healthsprings Ffs", "plan_name": "500064", "standard_charge_dollar": 1876.58, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Conseco", "plan_name": "500302", "standard_charge_dollar": 1876.58, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Humana Ffs 61101", "plan_name": "500006", "standard_charge_dollar": 1876.58, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Medicare A", "plan_name": "100100", "standard_charge_dollar": 1876.58, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Medicare A", "plan_name": "100500", "standard_charge_dollar": 1876.58, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Medicare Part B Only", "plan_name": "100300", "standard_charge_dollar": 1876.58, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Medicare Railroad", "plan_name": "100103", "standard_charge_dollar": 1876.58, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Ms Physicians Care N", "plan_name": "714210", "standard_charge_dollar": 2345.72, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Peoples Hlth Ffs 72126", "plan_name": "500019", "standard_charge_dollar": 1876.58, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Uhc/Secure Horizons", "plan_name": "500449", "standard_charge_dollar": 1876.58, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "United Health Care/", "plan_name": "500292", "standard_charge_dollar": 2120.53, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "United Healthcare", "plan_name": "750104", "standard_charge_dollar": 2120.53, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "United Healthcare Ba", "plan_name": "750090", "standard_charge_dollar": 2120.53, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "United Healthcare Me", "plan_name": "501310", "standard_charge_dollar": 1876.58, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Windsor Mcare Extra", "plan_name": "500778", "standard_charge_dollar": 1876.58, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." } ] } ] }, { "description": "Remove bladder stone", "code_information": [ { "code": "52317", "type": "CPT" } ], "standard_charges": [ { "gross_charge": 25549.76, "minimum": 3159.49, "maximum": 21717.30, "setting": "inpatient", "payers_information": [ { "payer_name": "Aarp", "plan_name": "500102", "standard_charge_dollar": 3159.49, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna", "plan_name": "700700", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna", "plan_name": "700700_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Mcare Ffs 6005", "plan_name": "700703", "standard_charge_dollar": 3159.49, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Miscellaneous", "plan_name": "700720", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Miscellaneous", "plan_name": "700720_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Ppo Hmo", "plan_name": "701720", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Ppo Hmo", "plan_name": "701720_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Ambetter 68069", "plan_name": "500516", "standard_charge_dollar": 3159.49, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Ms State Emplo", "plan_name": "401457", "standard_charge_percentage": 0.80, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Ms State Emplo", "plan_name": "401457_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Basic Pl", "plan_name": "400100", "standard_charge_percentage": 0.85, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Basic Pl", "plan_name": "400100_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Federal", "plan_name": "400110", "standard_charge_percentage": 0.85, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Federal", "plan_name": "400110_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Cigna Healthsprings Ffs", "plan_name": "500064", "standard_charge_dollar": 3159.49, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Conseco", "plan_name": "500302", "standard_charge_dollar": 3159.49, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Humana Ffs 61101", "plan_name": "500006", "standard_charge_dollar": 3159.49, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Medicare A", "plan_name": "100100", "standard_charge_dollar": 3159.49, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Medicare A", "plan_name": "100500", "standard_charge_dollar": 3159.49, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Medicare Part B Only", "plan_name": "100300", "standard_charge_dollar": 3159.49, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Medicare Railroad", "plan_name": "100103", "standard_charge_dollar": 3159.49, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Ms Physicians Care N", "plan_name": "714210", "standard_charge_dollar": 3949.37, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Peoples Hlth Ffs 72126", "plan_name": "500019", "standard_charge_dollar": 3159.49, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Uhc/Secure Horizons", "plan_name": "500449", "standard_charge_dollar": 3159.49, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "United Health Care/", "plan_name": "500292", "standard_charge_dollar": 3570.23, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "United Healthcare", "plan_name": "750104", "standard_charge_dollar": 3570.23, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "United Healthcare Ba", "plan_name": "750090", "standard_charge_dollar": 3570.23, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "United Healthcare Me", "plan_name": "501310", "standard_charge_dollar": 3159.49, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Windsor Mcare Extra", "plan_name": "500778", "standard_charge_dollar": 3159.49, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." } ] } ] }, { "description": "Remove bladder stone", "code_information": [ { "code": "52318", "type": "CPT" } ], "standard_charges": [ { "gross_charge": 68896.77, "minimum": 3159.49, "maximum": 58562.25, "setting": "inpatient", "payers_information": [ { "payer_name": "Aarp", "plan_name": "500102", "standard_charge_dollar": 3159.49, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna", "plan_name": "700700", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna", "plan_name": "700700_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Mcare Ffs 6005", "plan_name": "700703", "standard_charge_dollar": 3159.49, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Miscellaneous", "plan_name": "700720", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Miscellaneous", "plan_name": "700720_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Ppo Hmo", "plan_name": "701720", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Ppo Hmo", "plan_name": "701720_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Ambetter 68069", "plan_name": "500516", "standard_charge_dollar": 3159.49, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Ms State Emplo", "plan_name": "401457", "standard_charge_percentage": 0.80, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Ms State Emplo", "plan_name": "401457_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Basic Pl", "plan_name": "400100", "standard_charge_percentage": 0.85, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Basic Pl", "plan_name": "400100_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Federal", "plan_name": "400110", "standard_charge_percentage": 0.85, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Federal", "plan_name": "400110_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Cigna Healthsprings Ffs", "plan_name": "500064", "standard_charge_dollar": 3159.49, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Conseco", "plan_name": "500302", "standard_charge_dollar": 3159.49, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Humana Ffs 61101", "plan_name": "500006", "standard_charge_dollar": 3159.49, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Medicare A", "plan_name": "100100", "standard_charge_dollar": 3159.49, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Medicare A", "plan_name": "100500", "standard_charge_dollar": 3159.49, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Medicare Part B Only", "plan_name": "100300", "standard_charge_dollar": 3159.49, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Medicare Railroad", "plan_name": "100103", "standard_charge_dollar": 3159.49, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Ms Physicians Care N", "plan_name": "714210", "standard_charge_dollar": 3949.37, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Peoples Hlth Ffs 72126", "plan_name": "500019", "standard_charge_dollar": 3159.49, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Uhc/Secure Horizons", "plan_name": "500449", "standard_charge_dollar": 3159.49, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "United Health Care/", "plan_name": "500292", "standard_charge_dollar": 3570.23, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "United Healthcare", "plan_name": "750104", "standard_charge_dollar": 3570.23, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "United Healthcare Ba", "plan_name": "750090", "standard_charge_dollar": 3570.23, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "United Healthcare Me", "plan_name": "501310", "standard_charge_dollar": 3159.49, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Windsor Mcare Extra", "plan_name": "500778", "standard_charge_dollar": 3159.49, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." } ] } ] }, { "description": "Cystoscopy and treatment", "code_information": [ { "code": "52320", "type": "CPT" } ], "standard_charges": [ { "gross_charge": 19669.90, "minimum": 3159.49, "maximum": 16719.42, "setting": "inpatient", "payers_information": [ { "payer_name": "Aarp", "plan_name": "500102", "standard_charge_dollar": 3159.49, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna", "plan_name": "700700", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna", "plan_name": "700700_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Mcare Ffs 6005", "plan_name": "700703", "standard_charge_dollar": 3159.49, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Miscellaneous", "plan_name": "700720", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Miscellaneous", "plan_name": "700720_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Ppo Hmo", "plan_name": "701720", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Ppo Hmo", "plan_name": "701720_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Ambetter 68069", "plan_name": "500516", "standard_charge_dollar": 3159.49, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Ms State Emplo", "plan_name": "401457", "standard_charge_percentage": 0.80, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Ms State Emplo", "plan_name": "401457_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Basic Pl", "plan_name": "400100", "standard_charge_percentage": 0.85, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Basic Pl", "plan_name": "400100_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Federal", "plan_name": "400110", "standard_charge_percentage": 0.85, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Federal", "plan_name": "400110_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Cigna Healthsprings Ffs", "plan_name": "500064", "standard_charge_dollar": 3159.49, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Conseco", "plan_name": "500302", "standard_charge_dollar": 3159.49, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Humana Ffs 61101", "plan_name": "500006", "standard_charge_dollar": 3159.49, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Medicare A", "plan_name": "100100", "standard_charge_dollar": 3159.49, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Medicare A", "plan_name": "100500", "standard_charge_dollar": 3159.49, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Medicare Part B Only", "plan_name": "100300", "standard_charge_dollar": 3159.49, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Medicare Railroad", "plan_name": "100103", "standard_charge_dollar": 3159.49, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Ms Physicians Care N", "plan_name": "714210", "standard_charge_dollar": 3949.37, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Peoples Hlth Ffs 72126", "plan_name": "500019", "standard_charge_dollar": 3159.49, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Uhc/Secure Horizons", "plan_name": "500449", "standard_charge_dollar": 3159.49, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "United Health Care/", "plan_name": "500292", "standard_charge_dollar": 3570.23, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "United Healthcare", "plan_name": "750104", "standard_charge_dollar": 3570.23, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "United Healthcare Ba", "plan_name": "750090", "standard_charge_dollar": 3570.23, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "United Healthcare Me", "plan_name": "501310", "standard_charge_dollar": 3159.49, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Windsor Mcare Extra", "plan_name": "500778", "standard_charge_dollar": 3159.49, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." } ] } ] }, { "description": "Cystoscopy stone removal", "code_information": [ { "code": "52325", "type": "CPT" } ], "standard_charges": [ { "gross_charge": 19669.90, "minimum": 4656.95, "maximum": 16719.42, "setting": "inpatient", "payers_information": [ { "payer_name": "Aarp", "plan_name": "500102", "standard_charge_dollar": 4656.95, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna", "plan_name": "700700", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna", "plan_name": "700700_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Mcare Ffs 6005", "plan_name": "700703", "standard_charge_dollar": 4656.95, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Miscellaneous", "plan_name": "700720", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Miscellaneous", "plan_name": "700720_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Ppo Hmo", "plan_name": "701720", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Ppo Hmo", "plan_name": "701720_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Ambetter 68069", "plan_name": "500516", "standard_charge_dollar": 4656.95, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Ms State Emplo", "plan_name": "401457", "standard_charge_percentage": 0.80, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Ms State Emplo", "plan_name": "401457_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Basic Pl", "plan_name": "400100", "standard_charge_percentage": 0.85, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Basic Pl", "plan_name": "400100_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Federal", "plan_name": "400110", "standard_charge_percentage": 0.85, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Federal", "plan_name": "400110_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Cigna Healthsprings Ffs", "plan_name": "500064", "standard_charge_dollar": 4656.95, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Conseco", "plan_name": "500302", "standard_charge_dollar": 4656.95, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Humana Ffs 61101", "plan_name": "500006", "standard_charge_dollar": 4656.95, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Medicare A", "plan_name": "100100", "standard_charge_dollar": 4656.95, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Medicare A", "plan_name": "100500", "standard_charge_dollar": 4656.95, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Medicare Part B Only", "plan_name": "100300", "standard_charge_dollar": 4656.95, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Medicare Railroad", "plan_name": "100103", "standard_charge_dollar": 4656.95, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Ms Physicians Care N", "plan_name": "714210", "standard_charge_dollar": 5821.18, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Peoples Hlth Ffs 72126", "plan_name": "500019", "standard_charge_dollar": 4656.95, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Uhc/Secure Horizons", "plan_name": "500449", "standard_charge_dollar": 4656.95, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "United Health Care/", "plan_name": "500292", "standard_charge_dollar": 5262.35, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "United Healthcare", "plan_name": "750104", "standard_charge_dollar": 5262.35, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "United Healthcare Ba", "plan_name": "750090", "standard_charge_dollar": 5262.35, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "United Healthcare Me", "plan_name": "501310", "standard_charge_dollar": 4656.95, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Windsor Mcare Extra", "plan_name": "500778", "standard_charge_dollar": 4656.95, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." } ] } ] }, { "description": "Cystoscopy and treatment", "code_information": [ { "code": "52330", "type": "CPT" } ], "standard_charges": [ { "gross_charge": 22095.82, "minimum": 3159.49, "maximum": 18781.45, "setting": "inpatient", "payers_information": [ { "payer_name": "Aarp", "plan_name": "500102", "standard_charge_dollar": 3159.49, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna", "plan_name": "700700", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna", "plan_name": "700700_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Mcare Ffs 6005", "plan_name": "700703", "standard_charge_dollar": 3159.49, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Miscellaneous", "plan_name": "700720", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Miscellaneous", "plan_name": "700720_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Ppo Hmo", "plan_name": "701720", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Ppo Hmo", "plan_name": "701720_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Ambetter 68069", "plan_name": "500516", "standard_charge_dollar": 3159.49, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Ms State Emplo", "plan_name": "401457", "standard_charge_percentage": 0.80, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Ms State Emplo", "plan_name": "401457_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Basic Pl", "plan_name": "400100", "standard_charge_percentage": 0.85, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Basic Pl", "plan_name": "400100_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Federal", "plan_name": "400110", "standard_charge_percentage": 0.85, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Federal", "plan_name": "400110_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Cigna Healthsprings Ffs", "plan_name": "500064", "standard_charge_dollar": 3159.49, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Conseco", "plan_name": "500302", "standard_charge_dollar": 3159.49, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Humana Ffs 61101", "plan_name": "500006", "standard_charge_dollar": 3159.49, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Medicare A", "plan_name": "100100", "standard_charge_dollar": 3159.49, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Medicare A", "plan_name": "100500", "standard_charge_dollar": 3159.49, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Medicare Part B Only", "plan_name": "100300", "standard_charge_dollar": 3159.49, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Medicare Railroad", "plan_name": "100103", "standard_charge_dollar": 3159.49, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Ms Physicians Care N", "plan_name": "714210", "standard_charge_dollar": 3949.37, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Peoples Hlth Ffs 72126", "plan_name": "500019", "standard_charge_dollar": 3159.49, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Uhc/Secure Horizons", "plan_name": "500449", "standard_charge_dollar": 3159.49, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "United Health Care/", "plan_name": "500292", "standard_charge_dollar": 3570.23, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "United Healthcare", "plan_name": "750104", "standard_charge_dollar": 3570.23, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "United Healthcare Ba", "plan_name": "750090", "standard_charge_dollar": 3570.23, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "United Healthcare Me", "plan_name": "501310", "standard_charge_dollar": 3159.49, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Windsor Mcare Extra", "plan_name": "500778", "standard_charge_dollar": 3159.49, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." } ] } ] }, { "description": "Cystoscopy and treatment", "code_information": [ { "code": "52332", "type": "CPT" } ], "standard_charges": [ { "gross_charge": 22028.84, "minimum": 3159.49, "maximum": 18724.51, "setting": "inpatient", "payers_information": [ { "payer_name": "Aarp", "plan_name": "500102", "standard_charge_dollar": 3159.49, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna", "plan_name": "700700", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna", "plan_name": "700700_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Mcare Ffs 6005", "plan_name": "700703", "standard_charge_dollar": 3159.49, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Miscellaneous", "plan_name": "700720", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Miscellaneous", "plan_name": "700720_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Ppo Hmo", "plan_name": "701720", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Ppo Hmo", "plan_name": "701720_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Ambetter 68069", "plan_name": "500516", "standard_charge_dollar": 3159.49, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Ms State Emplo", "plan_name": "401457", "standard_charge_percentage": 0.80, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Ms State Emplo", "plan_name": "401457_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Basic Pl", "plan_name": "400100", "standard_charge_percentage": 0.85, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Basic Pl", "plan_name": "400100_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Federal", "plan_name": "400110", "standard_charge_percentage": 0.85, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Federal", "plan_name": "400110_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Cigna Healthsprings Ffs", "plan_name": "500064", "standard_charge_dollar": 3159.49, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Conseco", "plan_name": "500302", "standard_charge_dollar": 3159.49, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Humana Ffs 61101", "plan_name": "500006", "standard_charge_dollar": 3159.49, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Medicare A", "plan_name": "100100", "standard_charge_dollar": 3159.49, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Medicare A", "plan_name": "100500", "standard_charge_dollar": 3159.49, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Medicare Part B Only", "plan_name": "100300", "standard_charge_dollar": 3159.49, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Medicare Railroad", "plan_name": "100103", "standard_charge_dollar": 3159.49, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Ms Physicians Care N", "plan_name": "714210", "standard_charge_dollar": 3949.37, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Peoples Hlth Ffs 72126", "plan_name": "500019", "standard_charge_dollar": 3159.49, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Uhc/Secure Horizons", "plan_name": "500449", "standard_charge_dollar": 3159.49, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "United Health Care/", "plan_name": "500292", "standard_charge_dollar": 3570.23, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "United Healthcare", "plan_name": "750104", "standard_charge_dollar": 3570.23, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "United Healthcare Ba", "plan_name": "750090", "standard_charge_dollar": 3570.23, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "United Healthcare Me", "plan_name": "501310", "standard_charge_dollar": 3159.49, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Windsor Mcare Extra", "plan_name": "500778", "standard_charge_dollar": 3159.49, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." } ] } ] }, { "description": "Create passage to kidney", "code_information": [ { "code": "52334", "type": "CPT" } ], "standard_charges": [ { "gross_charge": 22028.84, "minimum": 3159.49, "maximum": 18724.51, "setting": "inpatient", "payers_information": [ { "payer_name": "Aarp", "plan_name": "500102", "standard_charge_dollar": 3159.49, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna", "plan_name": "700700", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna", "plan_name": "700700_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Mcare Ffs 6005", "plan_name": "700703", "standard_charge_dollar": 3159.49, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Miscellaneous", "plan_name": "700720", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Miscellaneous", "plan_name": "700720_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Ppo Hmo", "plan_name": "701720", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Ppo Hmo", "plan_name": "701720_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Ambetter 68069", "plan_name": "500516", "standard_charge_dollar": 3159.49, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Ms State Emplo", "plan_name": "401457", "standard_charge_percentage": 0.80, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Ms State Emplo", "plan_name": "401457_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Basic Pl", "plan_name": "400100", "standard_charge_percentage": 0.85, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Basic Pl", "plan_name": "400100_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Federal", "plan_name": "400110", "standard_charge_percentage": 0.85, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Federal", "plan_name": "400110_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Cigna Healthsprings Ffs", "plan_name": "500064", "standard_charge_dollar": 3159.49, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Conseco", "plan_name": "500302", "standard_charge_dollar": 3159.49, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Humana Ffs 61101", "plan_name": "500006", "standard_charge_dollar": 3159.49, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Medicare A", "plan_name": "100100", "standard_charge_dollar": 3159.49, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Medicare A", "plan_name": "100500", "standard_charge_dollar": 3159.49, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Medicare Part B Only", "plan_name": "100300", "standard_charge_dollar": 3159.49, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Medicare Railroad", "plan_name": "100103", "standard_charge_dollar": 3159.49, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Ms Physicians Care N", "plan_name": "714210", "standard_charge_dollar": 3949.37, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Peoples Hlth Ffs 72126", "plan_name": "500019", "standard_charge_dollar": 3159.49, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Uhc/Secure Horizons", "plan_name": "500449", "standard_charge_dollar": 3159.49, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "United Health Care/", "plan_name": "500292", "standard_charge_dollar": 3570.23, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "United Healthcare", "plan_name": "750104", "standard_charge_dollar": 3570.23, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "United Healthcare Ba", "plan_name": "750090", "standard_charge_dollar": 3570.23, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "United Healthcare Me", "plan_name": "501310", "standard_charge_dollar": 3159.49, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Windsor Mcare Extra", "plan_name": "500778", "standard_charge_dollar": 3159.49, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." } ] } ] }, { "description": "Cysto w/ureter stricture tx", "code_information": [ { "code": "52341", "type": "CPT" } ], "standard_charges": [ { "gross_charge": 22095.82, "minimum": 3159.49, "maximum": 18781.45, "setting": "inpatient", "payers_information": [ { "payer_name": "Aarp", "plan_name": "500102", "standard_charge_dollar": 3159.49, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna", "plan_name": "700700", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna", "plan_name": "700700_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Mcare Ffs 6005", "plan_name": "700703", "standard_charge_dollar": 3159.49, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Miscellaneous", "plan_name": "700720", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Miscellaneous", "plan_name": "700720_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Ppo Hmo", "plan_name": "701720", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Ppo Hmo", "plan_name": "701720_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Ambetter 68069", "plan_name": "500516", "standard_charge_dollar": 3159.49, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Ms State Emplo", "plan_name": "401457", "standard_charge_percentage": 0.80, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Ms State Emplo", "plan_name": "401457_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Basic Pl", "plan_name": "400100", "standard_charge_percentage": 0.85, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Basic Pl", "plan_name": "400100_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Federal", "plan_name": "400110", "standard_charge_percentage": 0.85, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Federal", "plan_name": "400110_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Cigna Healthsprings Ffs", "plan_name": "500064", "standard_charge_dollar": 3159.49, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Conseco", "plan_name": "500302", "standard_charge_dollar": 3159.49, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Humana Ffs 61101", "plan_name": "500006", "standard_charge_dollar": 3159.49, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Medicare A", "plan_name": "100100", "standard_charge_dollar": 3159.49, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Medicare A", "plan_name": "100500", "standard_charge_dollar": 3159.49, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Medicare Part B Only", "plan_name": "100300", "standard_charge_dollar": 3159.49, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Medicare Railroad", "plan_name": "100103", "standard_charge_dollar": 3159.49, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Ms Physicians Care N", "plan_name": "714210", "standard_charge_dollar": 3949.37, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Peoples Hlth Ffs 72126", "plan_name": "500019", "standard_charge_dollar": 3159.49, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Uhc/Secure Horizons", "plan_name": "500449", "standard_charge_dollar": 3159.49, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "United Health Care/", "plan_name": "500292", "standard_charge_dollar": 3570.23, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "United Healthcare", "plan_name": "750104", "standard_charge_dollar": 3570.23, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "United Healthcare Ba", "plan_name": "750090", "standard_charge_dollar": 3570.23, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "United Healthcare Me", "plan_name": "501310", "standard_charge_dollar": 3159.49, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Windsor Mcare Extra", "plan_name": "500778", "standard_charge_dollar": 3159.49, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." } ] } ] }, { "description": "Cysto w/up stricture tx", "code_information": [ { "code": "52342", "type": "CPT" } ], "standard_charges": [ { "gross_charge": 22095.82, "minimum": 3159.49, "maximum": 18781.45, "setting": "inpatient", "payers_information": [ { "payer_name": "Aarp", "plan_name": "500102", "standard_charge_dollar": 3159.49, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna", "plan_name": "700700", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna", "plan_name": "700700_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Mcare Ffs 6005", "plan_name": "700703", "standard_charge_dollar": 3159.49, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Miscellaneous", "plan_name": "700720", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Miscellaneous", "plan_name": "700720_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Ppo Hmo", "plan_name": "701720", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Ppo Hmo", "plan_name": "701720_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Ambetter 68069", "plan_name": "500516", "standard_charge_dollar": 3159.49, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Ms State Emplo", "plan_name": "401457", "standard_charge_percentage": 0.80, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Ms State Emplo", "plan_name": "401457_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Basic Pl", "plan_name": "400100", "standard_charge_percentage": 0.85, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Basic Pl", "plan_name": "400100_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Federal", "plan_name": "400110", "standard_charge_percentage": 0.85, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Federal", "plan_name": "400110_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Cigna Healthsprings Ffs", "plan_name": "500064", "standard_charge_dollar": 3159.49, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Conseco", "plan_name": "500302", "standard_charge_dollar": 3159.49, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Humana Ffs 61101", "plan_name": "500006", "standard_charge_dollar": 3159.49, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Medicare A", "plan_name": "100100", "standard_charge_dollar": 3159.49, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Medicare A", "plan_name": "100500", "standard_charge_dollar": 3159.49, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Medicare Part B Only", "plan_name": "100300", "standard_charge_dollar": 3159.49, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Medicare Railroad", "plan_name": "100103", "standard_charge_dollar": 3159.49, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Ms Physicians Care N", "plan_name": "714210", "standard_charge_dollar": 3949.37, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Peoples Hlth Ffs 72126", "plan_name": "500019", "standard_charge_dollar": 3159.49, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Uhc/Secure Horizons", "plan_name": "500449", "standard_charge_dollar": 3159.49, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "United Health Care/", "plan_name": "500292", "standard_charge_dollar": 3570.23, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "United Healthcare", "plan_name": "750104", "standard_charge_dollar": 3570.23, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "United Healthcare Ba", "plan_name": "750090", "standard_charge_dollar": 3570.23, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "United Healthcare Me", "plan_name": "501310", "standard_charge_dollar": 3159.49, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Windsor Mcare Extra", "plan_name": "500778", "standard_charge_dollar": 3159.49, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." } ] } ] }, { "description": "Cysto w/renal stricture tx", "code_information": [ { "code": "52343", "type": "CPT" } ], "standard_charges": [ { "gross_charge": 17151.91, "minimum": 3159.49, "maximum": 14579.12, "setting": "inpatient", "payers_information": [ { "payer_name": "Aarp", "plan_name": "500102", "standard_charge_dollar": 3159.49, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna", "plan_name": "700700", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna", "plan_name": "700700_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Mcare Ffs 6005", "plan_name": "700703", "standard_charge_dollar": 3159.49, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Miscellaneous", "plan_name": "700720", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Miscellaneous", "plan_name": "700720_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Ppo Hmo", "plan_name": "701720", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Ppo Hmo", "plan_name": "701720_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Ambetter 68069", "plan_name": "500516", "standard_charge_dollar": 3159.49, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Ms State Emplo", "plan_name": "401457", "standard_charge_percentage": 0.80, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Ms State Emplo", "plan_name": "401457_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Basic Pl", "plan_name": "400100", "standard_charge_percentage": 0.85, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Basic Pl", "plan_name": "400100_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Federal", "plan_name": "400110", "standard_charge_percentage": 0.85, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Federal", "plan_name": "400110_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Cigna Healthsprings Ffs", "plan_name": "500064", "standard_charge_dollar": 3159.49, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Conseco", "plan_name": "500302", "standard_charge_dollar": 3159.49, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Humana Ffs 61101", "plan_name": "500006", "standard_charge_dollar": 3159.49, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Medicare A", "plan_name": "100100", "standard_charge_dollar": 3159.49, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Medicare A", "plan_name": "100500", "standard_charge_dollar": 3159.49, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Medicare Part B Only", "plan_name": "100300", "standard_charge_dollar": 3159.49, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Medicare Railroad", "plan_name": "100103", "standard_charge_dollar": 3159.49, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Ms Physicians Care N", "plan_name": "714210", "standard_charge_dollar": 3949.37, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Peoples Hlth Ffs 72126", "plan_name": "500019", "standard_charge_dollar": 3159.49, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Uhc/Secure Horizons", "plan_name": "500449", "standard_charge_dollar": 3159.49, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "United Health Care/", "plan_name": "500292", "standard_charge_dollar": 3570.23, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "United Healthcare", "plan_name": "750104", "standard_charge_dollar": 3570.23, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "United Healthcare Ba", "plan_name": "750090", "standard_charge_dollar": 3570.23, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "United Healthcare Me", "plan_name": "501310", "standard_charge_dollar": 3159.49, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Windsor Mcare Extra", "plan_name": "500778", "standard_charge_dollar": 3159.49, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." } ] } ] }, { "description": "Cysto/uretero stricture tx", "code_information": [ { "code": "52344", "type": "CPT" } ], "standard_charges": [ { "gross_charge": 22095.82, "minimum": 3159.49, "maximum": 18781.45, "setting": "inpatient", "payers_information": [ { "payer_name": "Aarp", "plan_name": "500102", "standard_charge_dollar": 3159.49, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna", "plan_name": "700700", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna", "plan_name": "700700_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Mcare Ffs 6005", "plan_name": "700703", "standard_charge_dollar": 3159.49, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Miscellaneous", "plan_name": "700720", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Miscellaneous", "plan_name": "700720_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Ppo Hmo", "plan_name": "701720", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Ppo Hmo", "plan_name": "701720_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Ambetter 68069", "plan_name": "500516", "standard_charge_dollar": 3159.49, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Ms State Emplo", "plan_name": "401457", "standard_charge_percentage": 0.80, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Ms State Emplo", "plan_name": "401457_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Basic Pl", "plan_name": "400100", "standard_charge_percentage": 0.85, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Basic Pl", "plan_name": "400100_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Federal", "plan_name": "400110", "standard_charge_percentage": 0.85, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Federal", "plan_name": "400110_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Cigna Healthsprings Ffs", "plan_name": "500064", "standard_charge_dollar": 3159.49, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Conseco", "plan_name": "500302", "standard_charge_dollar": 3159.49, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Humana Ffs 61101", "plan_name": "500006", "standard_charge_dollar": 3159.49, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Medicare A", "plan_name": "100100", "standard_charge_dollar": 3159.49, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Medicare A", "plan_name": "100500", "standard_charge_dollar": 3159.49, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Medicare Part B Only", "plan_name": "100300", "standard_charge_dollar": 3159.49, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Medicare Railroad", "plan_name": "100103", "standard_charge_dollar": 3159.49, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Ms Physicians Care N", "plan_name": "714210", "standard_charge_dollar": 3949.37, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Peoples Hlth Ffs 72126", "plan_name": "500019", "standard_charge_dollar": 3159.49, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Uhc/Secure Horizons", "plan_name": "500449", "standard_charge_dollar": 3159.49, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "United Health Care/", "plan_name": "500292", "standard_charge_dollar": 3570.23, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "United Healthcare", "plan_name": "750104", "standard_charge_dollar": 3570.23, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "United Healthcare Ba", "plan_name": "750090", "standard_charge_dollar": 3570.23, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "United Healthcare Me", "plan_name": "501310", "standard_charge_dollar": 3159.49, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Windsor Mcare Extra", "plan_name": "500778", "standard_charge_dollar": 3159.49, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." } ] } ] }, { "description": "Cysto/uretero w/up stricture", "code_information": [ { "code": "52345", "type": "CPT" } ], "standard_charges": [ { "gross_charge": 22095.82, "minimum": 3159.49, "maximum": 18781.45, "setting": "inpatient", "payers_information": [ { "payer_name": "Aarp", "plan_name": "500102", "standard_charge_dollar": 3159.49, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna", "plan_name": "700700", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna", "plan_name": "700700_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Mcare Ffs 6005", "plan_name": "700703", "standard_charge_dollar": 3159.49, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Miscellaneous", "plan_name": "700720", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Miscellaneous", "plan_name": "700720_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Ppo Hmo", "plan_name": "701720", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Ppo Hmo", "plan_name": "701720_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Ambetter 68069", "plan_name": "500516", "standard_charge_dollar": 3159.49, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Ms State Emplo", "plan_name": "401457", "standard_charge_percentage": 0.80, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Ms State Emplo", "plan_name": "401457_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Basic Pl", "plan_name": "400100", "standard_charge_percentage": 0.85, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Basic Pl", "plan_name": "400100_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Federal", "plan_name": "400110", "standard_charge_percentage": 0.85, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Federal", "plan_name": "400110_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Cigna Healthsprings Ffs", "plan_name": "500064", "standard_charge_dollar": 3159.49, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Conseco", "plan_name": "500302", "standard_charge_dollar": 3159.49, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Humana Ffs 61101", "plan_name": "500006", "standard_charge_dollar": 3159.49, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Medicare A", "plan_name": "100100", "standard_charge_dollar": 3159.49, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Medicare A", "plan_name": "100500", "standard_charge_dollar": 3159.49, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Medicare Part B Only", "plan_name": "100300", "standard_charge_dollar": 3159.49, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Medicare Railroad", "plan_name": "100103", "standard_charge_dollar": 3159.49, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Ms Physicians Care N", "plan_name": "714210", "standard_charge_dollar": 3949.37, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Peoples Hlth Ffs 72126", "plan_name": "500019", "standard_charge_dollar": 3159.49, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Uhc/Secure Horizons", "plan_name": "500449", "standard_charge_dollar": 3159.49, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "United Health Care/", "plan_name": "500292", "standard_charge_dollar": 3570.23, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "United Healthcare", "plan_name": "750104", "standard_charge_dollar": 3570.23, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "United Healthcare Ba", "plan_name": "750090", "standard_charge_dollar": 3570.23, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "United Healthcare Me", "plan_name": "501310", "standard_charge_dollar": 3159.49, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Windsor Mcare Extra", "plan_name": "500778", "standard_charge_dollar": 3159.49, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." } ] } ] }, { "description": "Cystouretero w/renal strict", "code_information": [ { "code": "52346", "type": "CPT" } ], "standard_charges": [ { "gross_charge": 22095.82, "minimum": 4656.95, "maximum": 18781.45, "setting": "inpatient", "payers_information": [ { "payer_name": "Aarp", "plan_name": "500102", "standard_charge_dollar": 4656.95, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna", "plan_name": "700700", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna", "plan_name": "700700_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Mcare Ffs 6005", "plan_name": "700703", "standard_charge_dollar": 4656.95, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Miscellaneous", "plan_name": "700720", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Miscellaneous", "plan_name": "700720_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Ppo Hmo", "plan_name": "701720", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Ppo Hmo", "plan_name": "701720_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Ambetter 68069", "plan_name": "500516", "standard_charge_dollar": 4656.95, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Ms State Emplo", "plan_name": "401457", "standard_charge_percentage": 0.80, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Ms State Emplo", "plan_name": "401457_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Basic Pl", "plan_name": "400100", "standard_charge_percentage": 0.85, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Basic Pl", "plan_name": "400100_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Federal", "plan_name": "400110", "standard_charge_percentage": 0.85, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Federal", "plan_name": "400110_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Cigna Healthsprings Ffs", "plan_name": "500064", "standard_charge_dollar": 4656.95, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Conseco", "plan_name": "500302", "standard_charge_dollar": 4656.95, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Humana Ffs 61101", "plan_name": "500006", "standard_charge_dollar": 4656.95, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Medicare A", "plan_name": "100100", "standard_charge_dollar": 4656.95, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Medicare A", "plan_name": "100500", "standard_charge_dollar": 4656.95, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Medicare Part B Only", "plan_name": "100300", "standard_charge_dollar": 4656.95, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Medicare Railroad", "plan_name": "100103", "standard_charge_dollar": 4656.95, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Ms Physicians Care N", "plan_name": "714210", "standard_charge_dollar": 5821.18, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Peoples Hlth Ffs 72126", "plan_name": "500019", "standard_charge_dollar": 4656.95, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Uhc/Secure Horizons", "plan_name": "500449", "standard_charge_dollar": 4656.95, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "United Health Care/", "plan_name": "500292", "standard_charge_dollar": 5262.35, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "United Healthcare", "plan_name": "750104", "standard_charge_dollar": 5262.35, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "United Healthcare Ba", "plan_name": "750090", "standard_charge_dollar": 5262.35, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "United Healthcare Me", "plan_name": "501310", "standard_charge_dollar": 4656.95, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Windsor Mcare Extra", "plan_name": "500778", "standard_charge_dollar": 4656.95, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." } ] } ] }, { "description": "Cystouretero w/stone remove", "code_information": [ { "code": "52352", "type": "CPT" } ], "standard_charges": [ { "gross_charge": 19669.90, "minimum": 3159.49, "maximum": 16719.42, "setting": "inpatient", "payers_information": [ { "payer_name": "Aarp", "plan_name": "500102", "standard_charge_dollar": 3159.49, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna", "plan_name": "700700", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna", "plan_name": "700700_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Mcare Ffs 6005", "plan_name": "700703", "standard_charge_dollar": 3159.49, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Miscellaneous", "plan_name": "700720", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Miscellaneous", "plan_name": "700720_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Ppo Hmo", "plan_name": "701720", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Ppo Hmo", "plan_name": "701720_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Ambetter 68069", "plan_name": "500516", "standard_charge_dollar": 3159.49, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Ms State Emplo", "plan_name": "401457", "standard_charge_percentage": 0.80, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Ms State Emplo", "plan_name": "401457_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Basic Pl", "plan_name": "400100", "standard_charge_percentage": 0.85, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Basic Pl", "plan_name": "400100_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Federal", "plan_name": "400110", "standard_charge_percentage": 0.85, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Federal", "plan_name": "400110_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Cigna Healthsprings Ffs", "plan_name": "500064", "standard_charge_dollar": 3159.49, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Conseco", "plan_name": "500302", "standard_charge_dollar": 3159.49, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Humana Ffs 61101", "plan_name": "500006", "standard_charge_dollar": 3159.49, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Medicare A", "plan_name": "100100", "standard_charge_dollar": 3159.49, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Medicare A", "plan_name": "100500", "standard_charge_dollar": 3159.49, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Medicare Part B Only", "plan_name": "100300", "standard_charge_dollar": 3159.49, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Medicare Railroad", "plan_name": "100103", "standard_charge_dollar": 3159.49, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Ms Physicians Care N", "plan_name": "714210", "standard_charge_dollar": 3949.37, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Peoples Hlth Ffs 72126", "plan_name": "500019", "standard_charge_dollar": 3159.49, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Uhc/Secure Horizons", "plan_name": "500449", "standard_charge_dollar": 3159.49, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "United Health Care/", "plan_name": "500292", "standard_charge_dollar": 3570.23, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "United Healthcare", "plan_name": "750104", "standard_charge_dollar": 3570.23, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "United Healthcare Ba", "plan_name": "750090", "standard_charge_dollar": 3570.23, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "United Healthcare Me", "plan_name": "501310", "standard_charge_dollar": 3159.49, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Windsor Mcare Extra", "plan_name": "500778", "standard_charge_dollar": 3159.49, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." } ] } ] }, { "description": "Cystouretero w/lithotripsy", "code_information": [ { "code": "52353", "type": "CPT" } ], "standard_charges": [ { "gross_charge": 23965.16, "minimum": 4656.95, "maximum": 20370.39, "setting": "inpatient", "payers_information": [ { "payer_name": "Aarp", "plan_name": "500102", "standard_charge_dollar": 4656.95, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna", "plan_name": "700700", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna", "plan_name": "700700_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Mcare Ffs 6005", "plan_name": "700703", "standard_charge_dollar": 4656.95, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Miscellaneous", "plan_name": "700720", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Miscellaneous", "plan_name": "700720_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Ppo Hmo", "plan_name": "701720", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Ppo Hmo", "plan_name": "701720_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Ambetter 68069", "plan_name": "500516", "standard_charge_dollar": 4656.95, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Ms State Emplo", "plan_name": "401457", "standard_charge_percentage": 0.80, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Ms State Emplo", "plan_name": "401457_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Basic Pl", "plan_name": "400100", "standard_charge_percentage": 0.85, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Basic Pl", "plan_name": "400100_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Federal", "plan_name": "400110", "standard_charge_percentage": 0.85, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Federal", "plan_name": "400110_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Cigna Healthsprings Ffs", "plan_name": "500064", "standard_charge_dollar": 4656.95, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Conseco", "plan_name": "500302", "standard_charge_dollar": 4656.95, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Humana Ffs 61101", "plan_name": "500006", "standard_charge_dollar": 4656.95, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Medicare A", "plan_name": "100100", "standard_charge_dollar": 4656.95, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Medicare A", "plan_name": "100500", "standard_charge_dollar": 4656.95, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Medicare Part B Only", "plan_name": "100300", "standard_charge_dollar": 4656.95, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Medicare Railroad", "plan_name": "100103", "standard_charge_dollar": 4656.95, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Ms Physicians Care N", "plan_name": "714210", "standard_charge_dollar": 5821.18, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Peoples Hlth Ffs 72126", "plan_name": "500019", "standard_charge_dollar": 4656.95, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Uhc/Secure Horizons", "plan_name": "500449", "standard_charge_dollar": 4656.95, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "United Health Care/", "plan_name": "500292", "standard_charge_dollar": 5262.35, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "United Healthcare", "plan_name": "750104", "standard_charge_dollar": 5262.35, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "United Healthcare Ba", "plan_name": "750090", "standard_charge_dollar": 5262.35, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "United Healthcare Me", "plan_name": "501310", "standard_charge_dollar": 4656.95, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Windsor Mcare Extra", "plan_name": "500778", "standard_charge_dollar": 4656.95, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." } ] } ] }, { "description": "Cysto/uretero w/lithotripsy", "code_information": [ { "code": "52356", "type": "CPT" } ], "standard_charges": [ { "gross_charge": 22441.22, "minimum": 461.12, "maximum": 5821.18, "setting": "inpatient", "payers_information": [ { "payer_name": "Aarp", "plan_name": "500102", "standard_charge_dollar": 4656.95, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna", "plan_name": "700700", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna", "plan_name": "700700_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Mcare Ffs 6005", "plan_name": "700703", "standard_charge_dollar": 4656.95, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Miscellaneous", "plan_name": "700720", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Miscellaneous", "plan_name": "700720_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Ppo Hmo", "plan_name": "701720", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Ppo Hmo", "plan_name": "701720_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Ambetter 68069", "plan_name": "500516", "standard_charge_dollar": 4656.95, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Ms State Emplo", "plan_name": "401457", "standard_charge_dollar": 461.12, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Ms State Emplo", "plan_name": "401457_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Basic Pl", "plan_name": "400100", "standard_charge_dollar": 461.12, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Basic Pl", "plan_name": "400100_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Federal", "plan_name": "400110", "standard_charge_dollar": 461.12, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Federal", "plan_name": "400110_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Cigna Healthsprings Ffs", "plan_name": "500064", "standard_charge_dollar": 4656.95, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Conseco", "plan_name": "500302", "standard_charge_dollar": 4656.95, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Humana Ffs 61101", "plan_name": "500006", "standard_charge_dollar": 4656.95, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Medicare A", "plan_name": "100100", "standard_charge_dollar": 4656.95, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Medicare A", "plan_name": "100500", "standard_charge_dollar": 4656.95, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Medicare Part B Only", "plan_name": "100300", "standard_charge_dollar": 4656.95, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Medicare Railroad", "plan_name": "100103", "standard_charge_dollar": 4656.95, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Ms Physicians Care N", "plan_name": "714210", "standard_charge_dollar": 5821.18, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Peoples Hlth Ffs 72126", "plan_name": "500019", "standard_charge_dollar": 4656.95, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Uhc/Secure Horizons", "plan_name": "500449", "standard_charge_dollar": 4656.95, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "United Health Care/", "plan_name": "500292", "standard_charge_dollar": 5262.35, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "United Healthcare", "plan_name": "750104", "standard_charge_dollar": 5262.35, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "United Healthcare Ba", "plan_name": "750090", "standard_charge_dollar": 5262.35, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "United Healthcare Me", "plan_name": "501310", "standard_charge_dollar": 4656.95, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Windsor Mcare Extra", "plan_name": "500778", "standard_charge_dollar": 4656.95, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." } ] } ] }, { "description": "Cystouretero w/congen repr", "code_information": [ { "code": "52400", "type": "CPT" } ], "standard_charges": [ { "gross_charge": 24395.53, "minimum": 3159.49, "maximum": 20736.20, "setting": "inpatient", "payers_information": [ { "payer_name": "Aarp", "plan_name": "500102", "standard_charge_dollar": 3159.49, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna", "plan_name": "700700", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna", "plan_name": "700700_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Mcare Ffs 6005", "plan_name": "700703", "standard_charge_dollar": 3159.49, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Miscellaneous", "plan_name": "700720", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Miscellaneous", "plan_name": "700720_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Ppo Hmo", "plan_name": "701720", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Ppo Hmo", "plan_name": "701720_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Ambetter 68069", "plan_name": "500516", "standard_charge_dollar": 3159.49, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Ms State Emplo", "plan_name": "401457", "standard_charge_percentage": 0.80, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Ms State Emplo", "plan_name": "401457_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Basic Pl", "plan_name": "400100", "standard_charge_percentage": 0.85, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Basic Pl", "plan_name": "400100_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Federal", "plan_name": "400110", "standard_charge_percentage": 0.85, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Federal", "plan_name": "400110_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Cigna Healthsprings Ffs", "plan_name": "500064", "standard_charge_dollar": 3159.49, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Conseco", "plan_name": "500302", "standard_charge_dollar": 3159.49, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Humana Ffs 61101", "plan_name": "500006", "standard_charge_dollar": 3159.49, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Medicare A", "plan_name": "100100", "standard_charge_dollar": 3159.49, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Medicare A", "plan_name": "100500", "standard_charge_dollar": 3159.49, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Medicare Part B Only", "plan_name": "100300", "standard_charge_dollar": 3159.49, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Medicare Railroad", "plan_name": "100103", "standard_charge_dollar": 3159.49, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Ms Physicians Care N", "plan_name": "714210", "standard_charge_dollar": 3949.37, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Peoples Hlth Ffs 72126", "plan_name": "500019", "standard_charge_dollar": 3159.49, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Uhc/Secure Horizons", "plan_name": "500449", "standard_charge_dollar": 3159.49, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "United Health Care/", "plan_name": "500292", "standard_charge_dollar": 3570.23, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "United Healthcare", "plan_name": "750104", "standard_charge_dollar": 3570.23, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "United Healthcare Ba", "plan_name": "750090", "standard_charge_dollar": 3570.23, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "United Healthcare Me", "plan_name": "501310", "standard_charge_dollar": 3159.49, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Windsor Mcare Extra", "plan_name": "500778", "standard_charge_dollar": 3159.49, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." } ] } ] }, { "description": "Incision of prostate", "code_information": [ { "code": "52450", "type": "CPT" } ], "standard_charges": [ { "gross_charge": 25634.85, "minimum": 3159.49, "maximum": 21789.62, "setting": "inpatient", "payers_information": [ { "payer_name": "Aarp", "plan_name": "500102", "standard_charge_dollar": 3159.49, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna", "plan_name": "700700", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna", "plan_name": "700700_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Mcare Ffs 6005", "plan_name": "700703", "standard_charge_dollar": 3159.49, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Miscellaneous", "plan_name": "700720", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Miscellaneous", "plan_name": "700720_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Ppo Hmo", "plan_name": "701720", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Ppo Hmo", "plan_name": "701720_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Ambetter 68069", "plan_name": "500516", "standard_charge_dollar": 3159.49, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Ms State Emplo", "plan_name": "401457", "standard_charge_percentage": 0.80, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Ms State Emplo", "plan_name": "401457_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Basic Pl", "plan_name": "400100", "standard_charge_percentage": 0.85, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Basic Pl", "plan_name": "400100_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Federal", "plan_name": "400110", "standard_charge_percentage": 0.85, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Federal", "plan_name": "400110_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Cigna Healthsprings Ffs", "plan_name": "500064", "standard_charge_dollar": 3159.49, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Conseco", "plan_name": "500302", "standard_charge_dollar": 3159.49, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Humana Ffs 61101", "plan_name": "500006", "standard_charge_dollar": 3159.49, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Medicare A", "plan_name": "100100", "standard_charge_dollar": 3159.49, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Medicare A", "plan_name": "100500", "standard_charge_dollar": 3159.49, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Medicare Part B Only", "plan_name": "100300", "standard_charge_dollar": 3159.49, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Medicare Railroad", "plan_name": "100103", "standard_charge_dollar": 3159.49, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Ms Physicians Care N", "plan_name": "714210", "standard_charge_dollar": 3949.37, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Peoples Hlth Ffs 72126", "plan_name": "500019", "standard_charge_dollar": 3159.49, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Uhc/Secure Horizons", "plan_name": "500449", "standard_charge_dollar": 3159.49, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "United Health Care/", "plan_name": "500292", "standard_charge_dollar": 3570.23, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "United Healthcare", "plan_name": "750104", "standard_charge_dollar": 3570.23, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "United Healthcare Ba", "plan_name": "750090", "standard_charge_dollar": 3570.23, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "United Healthcare Me", "plan_name": "501310", "standard_charge_dollar": 3159.49, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Windsor Mcare Extra", "plan_name": "500778", "standard_charge_dollar": 3159.49, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." } ] } ] }, { "description": "Revision of bladder neck", "code_information": [ { "code": "52500", "type": "CPT" } ], "standard_charges": [ { "gross_charge": 19835.41, "minimum": 3159.49, "maximum": 16860.10, "setting": "inpatient", "payers_information": [ { "payer_name": "Aarp", "plan_name": "500102", "standard_charge_dollar": 3159.49, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna", "plan_name": "700700", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna", "plan_name": "700700_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Mcare Ffs 6005", "plan_name": "700703", "standard_charge_dollar": 3159.49, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Miscellaneous", "plan_name": "700720", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Miscellaneous", "plan_name": "700720_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Ppo Hmo", "plan_name": "701720", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Ppo Hmo", "plan_name": "701720_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Ambetter 68069", "plan_name": "500516", "standard_charge_dollar": 3159.49, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Ms State Emplo", "plan_name": "401457", "standard_charge_percentage": 0.80, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Ms State Emplo", "plan_name": "401457_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Basic Pl", "plan_name": "400100", "standard_charge_percentage": 0.85, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Basic Pl", "plan_name": "400100_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Federal", "plan_name": "400110", "standard_charge_percentage": 0.85, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Federal", "plan_name": "400110_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Cigna Healthsprings Ffs", "plan_name": "500064", "standard_charge_dollar": 3159.49, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Conseco", "plan_name": "500302", "standard_charge_dollar": 3159.49, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Humana Ffs 61101", "plan_name": "500006", "standard_charge_dollar": 3159.49, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Medicare A", "plan_name": "100100", "standard_charge_dollar": 3159.49, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Medicare A", "plan_name": "100500", "standard_charge_dollar": 3159.49, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Medicare Part B Only", "plan_name": "100300", "standard_charge_dollar": 3159.49, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Medicare Railroad", "plan_name": "100103", "standard_charge_dollar": 3159.49, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Ms Physicians Care N", "plan_name": "714210", "standard_charge_dollar": 3949.37, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Peoples Hlth Ffs 72126", "plan_name": "500019", "standard_charge_dollar": 3159.49, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Uhc/Secure Horizons", "plan_name": "500449", "standard_charge_dollar": 3159.49, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "United Health Care/", "plan_name": "500292", "standard_charge_dollar": 3570.23, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "United Healthcare", "plan_name": "750104", "standard_charge_dollar": 3570.23, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "United Healthcare Ba", "plan_name": "750090", "standard_charge_dollar": 3570.23, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "United Healthcare Me", "plan_name": "501310", "standard_charge_dollar": 3159.49, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Windsor Mcare Extra", "plan_name": "500778", "standard_charge_dollar": 3159.49, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." } ] } ] }, { "description": "Prostatectomy (turp)", "code_information": [ { "code": "52601", "type": "CPT" } ], "standard_charges": [ { "gross_charge": 19746.45, "minimum": 4656.95, "maximum": 16784.48, "setting": "inpatient", "payers_information": [ { "payer_name": "Aarp", "plan_name": "500102", "standard_charge_dollar": 4656.95, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna", "plan_name": "700700", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna", "plan_name": "700700_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Mcare Ffs 6005", "plan_name": "700703", "standard_charge_dollar": 4656.95, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Miscellaneous", "plan_name": "700720", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Miscellaneous", "plan_name": "700720_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Ppo Hmo", "plan_name": "701720", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Ppo Hmo", "plan_name": "701720_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Ambetter 68069", "plan_name": "500516", "standard_charge_dollar": 4656.95, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Ms State Emplo", "plan_name": "401457", "standard_charge_percentage": 0.80, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Ms State Emplo", "plan_name": "401457_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Basic Pl", "plan_name": "400100", "standard_charge_percentage": 0.85, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Basic Pl", "plan_name": "400100_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Federal", "plan_name": "400110", "standard_charge_percentage": 0.85, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Federal", "plan_name": "400110_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Cigna Healthsprings Ffs", "plan_name": "500064", "standard_charge_dollar": 4656.95, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Conseco", "plan_name": "500302", "standard_charge_dollar": 4656.95, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Humana Ffs 61101", "plan_name": "500006", "standard_charge_dollar": 4656.95, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Medicare A", "plan_name": "100100", "standard_charge_dollar": 4656.95, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Medicare A", "plan_name": "100500", "standard_charge_dollar": 4656.95, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Medicare Part B Only", "plan_name": "100300", "standard_charge_dollar": 4656.95, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Medicare Railroad", "plan_name": "100103", "standard_charge_dollar": 4656.95, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Ms Physicians Care N", "plan_name": "714210", "standard_charge_dollar": 5821.18, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Peoples Hlth Ffs 72126", "plan_name": "500019", "standard_charge_dollar": 4656.95, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Uhc/Secure Horizons", "plan_name": "500449", "standard_charge_dollar": 4656.95, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "United Health Care/", "plan_name": "500292", "standard_charge_dollar": 5262.35, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "United Healthcare", "plan_name": "750104", "standard_charge_dollar": 5262.35, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "United Healthcare Ba", "plan_name": "750090", "standard_charge_dollar": 5262.35, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "United Healthcare Me", "plan_name": "501310", "standard_charge_dollar": 4656.95, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Windsor Mcare Extra", "plan_name": "500778", "standard_charge_dollar": 4656.95, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." } ] } ] }, { "description": "Remove prostate regrowth", "code_information": [ { "code": "52630", "type": "CPT" } ], "standard_charges": [ { "gross_charge": 19746.45, "minimum": 4656.95, "maximum": 16784.48, "setting": "inpatient", "payers_information": [ { "payer_name": "Aarp", "plan_name": "500102", "standard_charge_dollar": 4656.95, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna", "plan_name": "700700", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna", "plan_name": "700700_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Mcare Ffs 6005", "plan_name": "700703", "standard_charge_dollar": 4656.95, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Miscellaneous", "plan_name": "700720", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Miscellaneous", "plan_name": "700720_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Ppo Hmo", "plan_name": "701720", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Ppo Hmo", "plan_name": "701720_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Ambetter 68069", "plan_name": "500516", "standard_charge_dollar": 4656.95, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Ms State Emplo", "plan_name": "401457", "standard_charge_percentage": 0.80, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Ms State Emplo", "plan_name": "401457_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Basic Pl", "plan_name": "400100", "standard_charge_percentage": 0.85, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Basic Pl", "plan_name": "400100_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Federal", "plan_name": "400110", "standard_charge_percentage": 0.85, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Federal", "plan_name": "400110_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Cigna Healthsprings Ffs", "plan_name": "500064", "standard_charge_dollar": 4656.95, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Conseco", "plan_name": "500302", "standard_charge_dollar": 4656.95, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Humana Ffs 61101", "plan_name": "500006", "standard_charge_dollar": 4656.95, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Medicare A", "plan_name": "100100", "standard_charge_dollar": 4656.95, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Medicare A", "plan_name": "100500", "standard_charge_dollar": 4656.95, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Medicare Part B Only", "plan_name": "100300", "standard_charge_dollar": 4656.95, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Medicare Railroad", "plan_name": "100103", "standard_charge_dollar": 4656.95, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Ms Physicians Care N", "plan_name": "714210", "standard_charge_dollar": 5821.18, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Peoples Hlth Ffs 72126", "plan_name": "500019", "standard_charge_dollar": 4656.95, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Uhc/Secure Horizons", "plan_name": "500449", "standard_charge_dollar": 4656.95, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "United Health Care/", "plan_name": "500292", "standard_charge_dollar": 5262.35, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "United Healthcare", "plan_name": "750104", "standard_charge_dollar": 5262.35, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "United Healthcare Ba", "plan_name": "750090", "standard_charge_dollar": 5262.35, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "United Healthcare Me", "plan_name": "501310", "standard_charge_dollar": 4656.95, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Windsor Mcare Extra", "plan_name": "500778", "standard_charge_dollar": 4656.95, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." } ] } ] }, { "description": "Relieve bladder contracture", "code_information": [ { "code": "52640", "type": "CPT" } ], "standard_charges": [ { "gross_charge": 26225.67, "minimum": 3159.49, "maximum": 22291.82, "setting": "inpatient", "payers_information": [ { "payer_name": "Aarp", "plan_name": "500102", "standard_charge_dollar": 3159.49, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna", "plan_name": "700700", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna", "plan_name": "700700_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Mcare Ffs 6005", "plan_name": "700703", "standard_charge_dollar": 3159.49, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Miscellaneous", "plan_name": "700720", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Miscellaneous", "plan_name": "700720_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Ppo Hmo", "plan_name": "701720", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Ppo Hmo", "plan_name": "701720_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Ambetter 68069", "plan_name": "500516", "standard_charge_dollar": 3159.49, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Ms State Emplo", "plan_name": "401457", "standard_charge_percentage": 0.80, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Ms State Emplo", "plan_name": "401457_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Basic Pl", "plan_name": "400100", "standard_charge_percentage": 0.85, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Basic Pl", "plan_name": "400100_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Federal", "plan_name": "400110", "standard_charge_percentage": 0.85, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Federal", "plan_name": "400110_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Cigna Healthsprings Ffs", "plan_name": "500064", "standard_charge_dollar": 3159.49, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Conseco", "plan_name": "500302", "standard_charge_dollar": 3159.49, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Humana Ffs 61101", "plan_name": "500006", "standard_charge_dollar": 3159.49, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Medicare A", "plan_name": "100100", "standard_charge_dollar": 3159.49, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Medicare A", "plan_name": "100500", "standard_charge_dollar": 3159.49, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Medicare Part B Only", "plan_name": "100300", "standard_charge_dollar": 3159.49, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Medicare Railroad", "plan_name": "100103", "standard_charge_dollar": 3159.49, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Ms Physicians Care N", "plan_name": "714210", "standard_charge_dollar": 3949.37, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Peoples Hlth Ffs 72126", "plan_name": "500019", "standard_charge_dollar": 3159.49, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Uhc/Secure Horizons", "plan_name": "500449", "standard_charge_dollar": 3159.49, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "United Health Care/", "plan_name": "500292", "standard_charge_dollar": 3570.23, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "United Healthcare", "plan_name": "750104", "standard_charge_dollar": 3570.23, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "United Healthcare Ba", "plan_name": "750090", "standard_charge_dollar": 3570.23, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "United Healthcare Me", "plan_name": "501310", "standard_charge_dollar": 3159.49, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Windsor Mcare Extra", "plan_name": "500778", "standard_charge_dollar": 3159.49, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." } ] } ] }, { "description": "Laser surgery of prostate", "code_information": [ { "code": "52648", "type": "CPT" } ], "standard_charges": [ { "gross_charge": 16876.86, "minimum": 4656.95, "maximum": 14345.33, "setting": "inpatient", "payers_information": [ { "payer_name": "Aarp", "plan_name": "500102", "standard_charge_dollar": 4656.95, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna", "plan_name": "700700", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna", "plan_name": "700700_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Mcare Ffs 6005", "plan_name": "700703", "standard_charge_dollar": 4656.95, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Miscellaneous", "plan_name": "700720", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Miscellaneous", "plan_name": "700720_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Ppo Hmo", "plan_name": "701720", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Ppo Hmo", "plan_name": "701720_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Ambetter 68069", "plan_name": "500516", "standard_charge_dollar": 4656.95, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Ms State Emplo", "plan_name": "401457", "standard_charge_percentage": 0.80, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Ms State Emplo", "plan_name": "401457_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Basic Pl", "plan_name": "400100", "standard_charge_percentage": 0.85, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Basic Pl", "plan_name": "400100_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Federal", "plan_name": "400110", "standard_charge_percentage": 0.85, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Federal", "plan_name": "400110_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Cigna Healthsprings Ffs", "plan_name": "500064", "standard_charge_dollar": 4656.95, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Conseco", "plan_name": "500302", "standard_charge_dollar": 4656.95, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Humana Ffs 61101", "plan_name": "500006", "standard_charge_dollar": 4656.95, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Medicare A", "plan_name": "100100", "standard_charge_dollar": 4656.95, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Medicare A", "plan_name": "100500", "standard_charge_dollar": 4656.95, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Medicare Part B Only", "plan_name": "100300", "standard_charge_dollar": 4656.95, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Medicare Railroad", "plan_name": "100103", "standard_charge_dollar": 4656.95, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Ms Physicians Care N", "plan_name": "714210", "standard_charge_dollar": 5821.18, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Peoples Hlth Ffs 72126", "plan_name": "500019", "standard_charge_dollar": 4656.95, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Uhc/Secure Horizons", "plan_name": "500449", "standard_charge_dollar": 4656.95, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "United Health Care/", "plan_name": "500292", "standard_charge_dollar": 5262.35, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "United Healthcare", "plan_name": "750104", "standard_charge_dollar": 5262.35, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "United Healthcare Ba", "plan_name": "750090", "standard_charge_dollar": 5262.35, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "United Healthcare Me", "plan_name": "501310", "standard_charge_dollar": 4656.95, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Windsor Mcare Extra", "plan_name": "500778", "standard_charge_dollar": 4656.95, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." } ] } ] }, { "description": "Prostate laser enucleation", "code_information": [ { "code": "52649", "type": "CPT" } ], "standard_charges": [ { "gross_charge": 19541.48, "minimum": 4656.95, "maximum": 16610.26, "setting": "inpatient", "payers_information": [ { "payer_name": "Aarp", "plan_name": "500102", "standard_charge_dollar": 4656.95, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna", "plan_name": "700700", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna", "plan_name": "700700_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Mcare Ffs 6005", "plan_name": "700703", "standard_charge_dollar": 4656.95, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Miscellaneous", "plan_name": "700720", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Miscellaneous", "plan_name": "700720_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Ppo Hmo", "plan_name": "701720", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Ppo Hmo", "plan_name": "701720_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Ambetter 68069", "plan_name": "500516", "standard_charge_dollar": 4656.95, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Ms State Emplo", "plan_name": "401457", "standard_charge_percentage": 0.80, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Ms State Emplo", "plan_name": "401457_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Basic Pl", "plan_name": "400100", "standard_charge_percentage": 0.85, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Basic Pl", "plan_name": "400100_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Federal", "plan_name": "400110", "standard_charge_percentage": 0.85, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Federal", "plan_name": "400110_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Cigna Healthsprings Ffs", "plan_name": "500064", "standard_charge_dollar": 4656.95, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Conseco", "plan_name": "500302", "standard_charge_dollar": 4656.95, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Humana Ffs 61101", "plan_name": "500006", "standard_charge_dollar": 4656.95, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Medicare A", "plan_name": "100100", "standard_charge_dollar": 4656.95, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Medicare A", "plan_name": "100500", "standard_charge_dollar": 4656.95, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Medicare Part B Only", "plan_name": "100300", "standard_charge_dollar": 4656.95, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Medicare Railroad", "plan_name": "100103", "standard_charge_dollar": 4656.95, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Ms Physicians Care N", "plan_name": "714210", "standard_charge_dollar": 5821.18, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Peoples Hlth Ffs 72126", "plan_name": "500019", "standard_charge_dollar": 4656.95, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Uhc/Secure Horizons", "plan_name": "500449", "standard_charge_dollar": 4656.95, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "United Health Care/", "plan_name": "500292", "standard_charge_dollar": 5262.35, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "United Healthcare", "plan_name": "750104", "standard_charge_dollar": 5262.35, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "United Healthcare Ba", "plan_name": "750090", "standard_charge_dollar": 5262.35, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "United Healthcare Me", "plan_name": "501310", "standard_charge_dollar": 4656.95, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Windsor Mcare Extra", "plan_name": "500778", "standard_charge_dollar": 4656.95, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." } ] } ] }, { "description": "Drainage of prostate abscess", "code_information": [ { "code": "52700", "type": "CPT" } ], "standard_charges": [ { "gross_charge": 25634.85, "minimum": 3159.49, "maximum": 21789.62, "setting": "inpatient", "payers_information": [ { "payer_name": "Aarp", "plan_name": "500102", "standard_charge_dollar": 3159.49, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna", "plan_name": "700700", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna", "plan_name": "700700_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Mcare Ffs 6005", "plan_name": "700703", "standard_charge_dollar": 3159.49, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Miscellaneous", "plan_name": "700720", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Miscellaneous", "plan_name": "700720_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Ppo Hmo", "plan_name": "701720", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Ppo Hmo", "plan_name": "701720_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Ambetter 68069", "plan_name": "500516", "standard_charge_dollar": 3159.49, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Ms State Emplo", "plan_name": "401457", "standard_charge_percentage": 0.80, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Ms State Emplo", "plan_name": "401457_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Basic Pl", "plan_name": "400100", "standard_charge_percentage": 0.85, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Basic Pl", "plan_name": "400100_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Federal", "plan_name": "400110", "standard_charge_percentage": 0.85, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Federal", "plan_name": "400110_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Cigna Healthsprings Ffs", "plan_name": "500064", "standard_charge_dollar": 3159.49, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Conseco", "plan_name": "500302", "standard_charge_dollar": 3159.49, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Humana Ffs 61101", "plan_name": "500006", "standard_charge_dollar": 3159.49, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Medicare A", "plan_name": "100100", "standard_charge_dollar": 3159.49, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Medicare A", "plan_name": "100500", "standard_charge_dollar": 3159.49, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Medicare Part B Only", "plan_name": "100300", "standard_charge_dollar": 3159.49, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Medicare Railroad", "plan_name": "100103", "standard_charge_dollar": 3159.49, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Ms Physicians Care N", "plan_name": "714210", "standard_charge_dollar": 3949.37, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Peoples Hlth Ffs 72126", "plan_name": "500019", "standard_charge_dollar": 3159.49, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Uhc/Secure Horizons", "plan_name": "500449", "standard_charge_dollar": 3159.49, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "United Health Care/", "plan_name": "500292", "standard_charge_dollar": 3570.23, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "United Healthcare", "plan_name": "750104", "standard_charge_dollar": 3570.23, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "United Healthcare Ba", "plan_name": "750090", "standard_charge_dollar": 3570.23, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "United Healthcare Me", "plan_name": "501310", "standard_charge_dollar": 3159.49, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Windsor Mcare Extra", "plan_name": "500778", "standard_charge_dollar": 3159.49, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." } ] } ] }, { "description": "Incision of urethra", "code_information": [ { "code": "53020", "type": "CPT" } ], "standard_charges": [ { "gross_charge": 17546.60, "minimum": 1876.58, "maximum": 14914.61, "setting": "inpatient", "payers_information": [ { "payer_name": "Aarp", "plan_name": "500102", "standard_charge_dollar": 1876.58, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna", "plan_name": "700700", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna", "plan_name": "700700_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Mcare Ffs 6005", "plan_name": "700703", "standard_charge_dollar": 1876.58, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Miscellaneous", "plan_name": "700720", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Miscellaneous", "plan_name": "700720_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Ppo Hmo", "plan_name": "701720", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Ppo Hmo", "plan_name": "701720_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Ambetter 68069", "plan_name": "500516", "standard_charge_dollar": 1876.58, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Ms State Emplo", "plan_name": "401457", "standard_charge_percentage": 0.80, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Ms State Emplo", "plan_name": "401457_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Basic Pl", "plan_name": "400100", "standard_charge_percentage": 0.85, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Basic Pl", "plan_name": "400100_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Federal", "plan_name": "400110", "standard_charge_percentage": 0.85, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Federal", "plan_name": "400110_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Cigna Healthsprings Ffs", "plan_name": "500064", "standard_charge_dollar": 1876.58, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Conseco", "plan_name": "500302", "standard_charge_dollar": 1876.58, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Humana Ffs 61101", "plan_name": "500006", "standard_charge_dollar": 1876.58, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Medicare A", "plan_name": "100100", "standard_charge_dollar": 1876.58, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Medicare A", "plan_name": "100500", "standard_charge_dollar": 1876.58, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Medicare Part B Only", "plan_name": "100300", "standard_charge_dollar": 1876.58, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Medicare Railroad", "plan_name": "100103", "standard_charge_dollar": 1876.58, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Ms Physicians Care N", "plan_name": "714210", "standard_charge_dollar": 2345.72, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Peoples Hlth Ffs 72126", "plan_name": "500019", "standard_charge_dollar": 1876.58, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Uhc/Secure Horizons", "plan_name": "500449", "standard_charge_dollar": 1876.58, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "United Health Care/", "plan_name": "500292", "standard_charge_dollar": 2120.53, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "United Healthcare", "plan_name": "750104", "standard_charge_dollar": 2120.53, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "United Healthcare Ba", "plan_name": "750090", "standard_charge_dollar": 2120.53, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "United Healthcare Me", "plan_name": "501310", "standard_charge_dollar": 1876.58, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Windsor Mcare Extra", "plan_name": "500778", "standard_charge_dollar": 1876.58, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." } ] } ] }, { "description": "Incision of urethra", "code_information": [ { "code": "53025", "type": "CPT" } ], "standard_charges": [ { "gross_charge": 17546.60, "minimum": 1876.58, "maximum": 14914.61, "setting": "inpatient", "payers_information": [ { "payer_name": "Aarp", "plan_name": "500102", "standard_charge_dollar": 1876.58, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna", "plan_name": "700700", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna", "plan_name": "700700_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Mcare Ffs 6005", "plan_name": "700703", "standard_charge_dollar": 1876.58, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Miscellaneous", "plan_name": "700720", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Miscellaneous", "plan_name": "700720_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Ppo Hmo", "plan_name": "701720", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Ppo Hmo", "plan_name": "701720_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Ambetter 68069", "plan_name": "500516", "standard_charge_dollar": 1876.58, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Ms State Emplo", "plan_name": "401457", "standard_charge_percentage": 0.80, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Ms State Emplo", "plan_name": "401457_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Basic Pl", "plan_name": "400100", "standard_charge_percentage": 0.85, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Basic Pl", "plan_name": "400100_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Federal", "plan_name": "400110", "standard_charge_percentage": 0.85, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Federal", "plan_name": "400110_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Cigna Healthsprings Ffs", "plan_name": "500064", "standard_charge_dollar": 1876.58, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Conseco", "plan_name": "500302", "standard_charge_dollar": 1876.58, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Humana Ffs 61101", "plan_name": "500006", "standard_charge_dollar": 1876.58, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Medicare A", "plan_name": "100100", "standard_charge_dollar": 1876.58, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Medicare A", "plan_name": "100500", "standard_charge_dollar": 1876.58, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Medicare Part B Only", "plan_name": "100300", "standard_charge_dollar": 1876.58, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Medicare Railroad", "plan_name": "100103", "standard_charge_dollar": 1876.58, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Ms Physicians Care N", "plan_name": "714210", "standard_charge_dollar": 2345.72, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Peoples Hlth Ffs 72126", "plan_name": "500019", "standard_charge_dollar": 1876.58, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Uhc/Secure Horizons", "plan_name": "500449", "standard_charge_dollar": 1876.58, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "United Health Care/", "plan_name": "500292", "standard_charge_dollar": 2120.53, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "United Healthcare", "plan_name": "750104", "standard_charge_dollar": 2120.53, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "United Healthcare Ba", "plan_name": "750090", "standard_charge_dollar": 2120.53, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "United Healthcare Me", "plan_name": "501310", "standard_charge_dollar": 1876.58, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Windsor Mcare Extra", "plan_name": "500778", "standard_charge_dollar": 1876.58, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." } ] } ] }, { "description": "Drainage of urinary leakage", "code_information": [ { "code": "53080", "type": "CPT" } ], "standard_charges": [ { "gross_charge": 68896.77, "minimum": 611.45, "maximum": 58562.25, "setting": "inpatient", "payers_information": [ { "payer_name": "Aarp", "plan_name": "500102", "standard_charge_dollar": 611.45, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna", "plan_name": "700700", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna", "plan_name": "700700_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Mcare Ffs 6005", "plan_name": "700703", "standard_charge_dollar": 611.45, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Miscellaneous", "plan_name": "700720", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Miscellaneous", "plan_name": "700720_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Ppo Hmo", "plan_name": "701720", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Ppo Hmo", "plan_name": "701720_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Ambetter 68069", "plan_name": "500516", "standard_charge_dollar": 611.45, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Ms State Emplo", "plan_name": "401457", "standard_charge_percentage": 0.80, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Ms State Emplo", "plan_name": "401457_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Basic Pl", "plan_name": "400100", "standard_charge_percentage": 0.85, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Basic Pl", "plan_name": "400100_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Federal", "plan_name": "400110", "standard_charge_percentage": 0.85, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Federal", "plan_name": "400110_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Cigna Healthsprings Ffs", "plan_name": "500064", "standard_charge_dollar": 611.45, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Conseco", "plan_name": "500302", "standard_charge_dollar": 611.45, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Humana Ffs 61101", "plan_name": "500006", "standard_charge_dollar": 611.45, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Medicare A", "plan_name": "100100", "standard_charge_dollar": 611.45, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Medicare A", "plan_name": "100500", "standard_charge_dollar": 611.45, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Medicare Part B Only", "plan_name": "100300", "standard_charge_dollar": 611.45, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Medicare Railroad", "plan_name": "100103", "standard_charge_dollar": 611.45, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Ms Physicians Care N", "plan_name": "714210", "standard_charge_dollar": 764.31, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Peoples Hlth Ffs 72126", "plan_name": "500019", "standard_charge_dollar": 611.45, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Uhc/Secure Horizons", "plan_name": "500449", "standard_charge_dollar": 611.45, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "United Health Care/", "plan_name": "500292", "standard_charge_dollar": 690.94, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "United Healthcare", "plan_name": "750104", "standard_charge_dollar": 690.94, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "United Healthcare Ba", "plan_name": "750090", "standard_charge_dollar": 690.94, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "United Healthcare Me", "plan_name": "501310", "standard_charge_dollar": 611.45, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Windsor Mcare Extra", "plan_name": "500778", "standard_charge_dollar": 611.45, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." } ] } ] }, { "description": "Removal of urethra", "code_information": [ { "code": "53210", "type": "CPT" } ], "standard_charges": [ { "gross_charge": 18905.08, "minimum": 3159.49, "maximum": 16069.32, "setting": "inpatient", "payers_information": [ { "payer_name": "Aarp", "plan_name": "500102", "standard_charge_dollar": 3159.49, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna", "plan_name": "700700", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna", "plan_name": "700700_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Mcare Ffs 6005", "plan_name": "700703", "standard_charge_dollar": 3159.49, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Miscellaneous", "plan_name": "700720", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Miscellaneous", "plan_name": "700720_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Ppo Hmo", "plan_name": "701720", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Ppo Hmo", "plan_name": "701720_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Ambetter 68069", "plan_name": "500516", "standard_charge_dollar": 3159.49, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Ms State Emplo", "plan_name": "401457", "standard_charge_percentage": 0.80, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Ms State Emplo", "plan_name": "401457_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Basic Pl", "plan_name": "400100", "standard_charge_percentage": 0.85, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Basic Pl", "plan_name": "400100_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Federal", "plan_name": "400110", "standard_charge_percentage": 0.85, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Federal", "plan_name": "400110_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Cigna Healthsprings Ffs", "plan_name": "500064", "standard_charge_dollar": 3159.49, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Conseco", "plan_name": "500302", "standard_charge_dollar": 3159.49, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Humana Ffs 61101", "plan_name": "500006", "standard_charge_dollar": 3159.49, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Medicare A", "plan_name": "100100", "standard_charge_dollar": 3159.49, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Medicare A", "plan_name": "100500", "standard_charge_dollar": 3159.49, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Medicare Part B Only", "plan_name": "100300", "standard_charge_dollar": 3159.49, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Medicare Railroad", "plan_name": "100103", "standard_charge_dollar": 3159.49, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Ms Physicians Care N", "plan_name": "714210", "standard_charge_dollar": 3949.37, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Peoples Hlth Ffs 72126", "plan_name": "500019", "standard_charge_dollar": 3159.49, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Uhc/Secure Horizons", "plan_name": "500449", "standard_charge_dollar": 3159.49, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "United Health Care/", "plan_name": "500292", "standard_charge_dollar": 3570.23, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "United Healthcare", "plan_name": "750104", "standard_charge_dollar": 3570.23, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "United Healthcare Ba", "plan_name": "750090", "standard_charge_dollar": 3570.23, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "United Healthcare Me", "plan_name": "501310", "standard_charge_dollar": 3159.49, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Windsor Mcare Extra", "plan_name": "500778", "standard_charge_dollar": 3159.49, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." } ] } ] }, { "description": "Repair of urethra injury", "code_information": [ { "code": "53502", "type": "CPT" } ], "standard_charges": [ { "gross_charge": 68896.77, "minimum": 3159.49, "maximum": 58562.25, "setting": "inpatient", "payers_information": [ { "payer_name": "Aarp", "plan_name": "500102", "standard_charge_dollar": 3159.49, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna", "plan_name": "700700", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna", "plan_name": "700700_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Mcare Ffs 6005", "plan_name": "700703", "standard_charge_dollar": 3159.49, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Miscellaneous", "plan_name": "700720", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Miscellaneous", "plan_name": "700720_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Ppo Hmo", "plan_name": "701720", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Ppo Hmo", "plan_name": "701720_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Ambetter 68069", "plan_name": "500516", "standard_charge_dollar": 3159.49, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Ms State Emplo", "plan_name": "401457", "standard_charge_percentage": 0.80, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Ms State Emplo", "plan_name": "401457_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Basic Pl", "plan_name": "400100", "standard_charge_percentage": 0.85, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Basic Pl", "plan_name": "400100_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Federal", "plan_name": "400110", "standard_charge_percentage": 0.85, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Federal", "plan_name": "400110_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Cigna Healthsprings Ffs", "plan_name": "500064", "standard_charge_dollar": 3159.49, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Conseco", "plan_name": "500302", "standard_charge_dollar": 3159.49, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Humana Ffs 61101", "plan_name": "500006", "standard_charge_dollar": 3159.49, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Medicare A", "plan_name": "100100", "standard_charge_dollar": 3159.49, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Medicare A", "plan_name": "100500", "standard_charge_dollar": 3159.49, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Medicare Part B Only", "plan_name": "100300", "standard_charge_dollar": 3159.49, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Medicare Railroad", "plan_name": "100103", "standard_charge_dollar": 3159.49, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Ms Physicians Care N", "plan_name": "714210", "standard_charge_dollar": 3949.37, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Peoples Hlth Ffs 72126", "plan_name": "500019", "standard_charge_dollar": 3159.49, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Uhc/Secure Horizons", "plan_name": "500449", "standard_charge_dollar": 3159.49, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "United Health Care/", "plan_name": "500292", "standard_charge_dollar": 3570.23, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "United Healthcare", "plan_name": "750104", "standard_charge_dollar": 3570.23, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "United Healthcare Ba", "plan_name": "750090", "standard_charge_dollar": 3570.23, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "United Healthcare Me", "plan_name": "501310", "standard_charge_dollar": 3159.49, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Windsor Mcare Extra", "plan_name": "500778", "standard_charge_dollar": 3159.49, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." } ] } ] }, { "description": "Dilation of urethra", "code_information": [ { "code": "53660", "type": "CPT" } ], "standard_charges": [ { "gross_charge": 22480.65, "minimum": 143.33, "maximum": 19108.55, "setting": "inpatient", "payers_information": [ { "payer_name": "Aarp", "plan_name": "500102", "standard_charge_dollar": 143.33, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna", "plan_name": "700700", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna", "plan_name": "700700_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Mcare Ffs 6005", "plan_name": "700703", "standard_charge_dollar": 143.33, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Miscellaneous", "plan_name": "700720", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Miscellaneous", "plan_name": "700720_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Ppo Hmo", "plan_name": "701720", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Ppo Hmo", "plan_name": "701720_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Ambetter 68069", "plan_name": "500516", "standard_charge_dollar": 143.33, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Ms State Emplo", "plan_name": "401457", "standard_charge_percentage": 0.80, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Ms State Emplo", "plan_name": "401457_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Basic Pl", "plan_name": "400100", "standard_charge_percentage": 0.85, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Basic Pl", "plan_name": "400100_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Federal", "plan_name": "400110", "standard_charge_percentage": 0.85, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Federal", "plan_name": "400110_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Cigna Healthsprings Ffs", "plan_name": "500064", "standard_charge_dollar": 143.33, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Conseco", "plan_name": "500302", "standard_charge_dollar": 143.33, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Humana Ffs 61101", "plan_name": "500006", "standard_charge_dollar": 143.33, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Medicare A", "plan_name": "100100", "standard_charge_dollar": 143.33, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Medicare A", "plan_name": "100500", "standard_charge_dollar": 143.33, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Medicare Part B Only", "plan_name": "100300", "standard_charge_dollar": 143.33, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Medicare Railroad", "plan_name": "100103", "standard_charge_dollar": 143.33, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Ms Physicians Care N", "plan_name": "714210", "standard_charge_dollar": 179.16, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Peoples Hlth Ffs 72126", "plan_name": "500019", "standard_charge_dollar": 143.33, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Uhc/Secure Horizons", "plan_name": "500449", "standard_charge_dollar": 143.33, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "United Health Care/", "plan_name": "500292", "standard_charge_dollar": 161.96, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "United Healthcare", "plan_name": "750104", "standard_charge_dollar": 161.96, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "United Healthcare Ba", "plan_name": "750090", "standard_charge_dollar": 161.96, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "United Healthcare Me", "plan_name": "501310", "standard_charge_dollar": 143.33, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Windsor Mcare Extra", "plan_name": "500778", "standard_charge_dollar": 143.33, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." } ] } ] }, { "description": "Dilation of urethra", "code_information": [ { "code": "53661", "type": "CPT" } ], "standard_charges": [ { "gross_charge": 22480.65, "minimum": 118.08, "maximum": 149.97, "setting": "inpatient", "payers_information": [ { "payer_name": "Aarp", "plan_name": "500102", "standard_charge_dollar": 118.08, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna", "plan_name": "700700", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna", "plan_name": "700700_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Mcare Ffs 6005", "plan_name": "700703", "standard_charge_dollar": 118.08, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Miscellaneous", "plan_name": "700720", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Miscellaneous", "plan_name": "700720_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Ppo Hmo", "plan_name": "701720", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Ppo Hmo", "plan_name": "701720_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Ambetter 68069", "plan_name": "500516", "standard_charge_dollar": 118.08, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Ms State Emplo", "plan_name": "401457", "standard_charge_dollar": 149.97, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Ms State Emplo", "plan_name": "401457_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Basic Pl", "plan_name": "400100", "standard_charge_dollar": 149.97, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Basic Pl", "plan_name": "400100_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Federal", "plan_name": "400110", "standard_charge_dollar": 149.97, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Federal", "plan_name": "400110_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Cigna Healthsprings Ffs", "plan_name": "500064", "standard_charge_dollar": 118.08, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Conseco", "plan_name": "500302", "standard_charge_dollar": 118.08, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Humana Ffs 61101", "plan_name": "500006", "standard_charge_dollar": 118.08, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Medicare A", "plan_name": "100100", "standard_charge_dollar": 118.08, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Medicare A", "plan_name": "100500", "standard_charge_dollar": 118.08, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Medicare Part B Only", "plan_name": "100300", "standard_charge_dollar": 118.08, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Medicare Railroad", "plan_name": "100103", "standard_charge_dollar": 118.08, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Ms Physicians Care N", "plan_name": "714210", "standard_charge_dollar": 147.60, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Peoples Hlth Ffs 72126", "plan_name": "500019", "standard_charge_dollar": 118.08, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Uhc/Secure Horizons", "plan_name": "500449", "standard_charge_dollar": 118.08, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "United Health Care/", "plan_name": "500292", "standard_charge_dollar": 133.43, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "United Healthcare", "plan_name": "750104", "standard_charge_dollar": 133.43, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "United Healthcare Ba", "plan_name": "750090", "standard_charge_dollar": 133.43, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "United Healthcare Me", "plan_name": "501310", "standard_charge_dollar": 118.08, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Windsor Mcare Extra", "plan_name": "500778", "standard_charge_dollar": 118.08, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." } ] } ] }, { "description": "Prostatic microwave thermotx", "code_information": [ { "code": "53850", "type": "CPT" } ], "standard_charges": [ { "gross_charge": 19746.45, "minimum": 3159.49, "maximum": 16784.48, "setting": "inpatient", "payers_information": [ { "payer_name": "Aarp", "plan_name": "500102", "standard_charge_dollar": 3159.49, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna", "plan_name": "700700", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna", "plan_name": "700700_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Mcare Ffs 6005", "plan_name": "700703", "standard_charge_dollar": 3159.49, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Miscellaneous", "plan_name": "700720", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Miscellaneous", "plan_name": "700720_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Ppo Hmo", "plan_name": "701720", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Ppo Hmo", "plan_name": "701720_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Ambetter 68069", "plan_name": "500516", "standard_charge_dollar": 3159.49, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Ms State Emplo", "plan_name": "401457", "standard_charge_percentage": 0.80, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Ms State Emplo", "plan_name": "401457_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Basic Pl", "plan_name": "400100", "standard_charge_percentage": 0.85, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Basic Pl", "plan_name": "400100_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Federal", "plan_name": "400110", "standard_charge_percentage": 0.85, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Federal", "plan_name": "400110_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Cigna Healthsprings Ffs", "plan_name": "500064", "standard_charge_dollar": 3159.49, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Conseco", "plan_name": "500302", "standard_charge_dollar": 3159.49, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Humana Ffs 61101", "plan_name": "500006", "standard_charge_dollar": 3159.49, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Medicare A", "plan_name": "100100", "standard_charge_dollar": 3159.49, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Medicare A", "plan_name": "100500", "standard_charge_dollar": 3159.49, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Medicare Part B Only", "plan_name": "100300", "standard_charge_dollar": 3159.49, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Medicare Railroad", "plan_name": "100103", "standard_charge_dollar": 3159.49, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Ms Physicians Care N", "plan_name": "714210", "standard_charge_dollar": 3949.37, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Peoples Hlth Ffs 72126", "plan_name": "500019", "standard_charge_dollar": 3159.49, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Uhc/Secure Horizons", "plan_name": "500449", "standard_charge_dollar": 3159.49, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "United Health Care/", "plan_name": "500292", "standard_charge_dollar": 3570.23, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "United Healthcare", "plan_name": "750104", "standard_charge_dollar": 3570.23, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "United Healthcare Ba", "plan_name": "750090", "standard_charge_dollar": 3570.23, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "United Healthcare Me", "plan_name": "501310", "standard_charge_dollar": 3159.49, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Windsor Mcare Extra", "plan_name": "500778", "standard_charge_dollar": 3159.49, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." } ] } ] }, { "description": "Urology surgery procedure", "code_information": [ { "code": "53899", "type": "CPT" } ], "standard_charges": [ { "gross_charge": 46725.62, "minimum": 222.80, "maximum": 39716.78, "setting": "inpatient", "payers_information": [ { "payer_name": "Aarp", "plan_name": "500102", "standard_charge_dollar": 222.80, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna", "plan_name": "700700", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna", "plan_name": "700700_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Mcare Ffs 6005", "plan_name": "700703", "standard_charge_dollar": 222.80, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Miscellaneous", "plan_name": "700720", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Miscellaneous", "plan_name": "700720_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Ppo Hmo", "plan_name": "701720", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Ppo Hmo", "plan_name": "701720_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Ambetter 68069", "plan_name": "500516", "standard_charge_dollar": 222.80, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Ms State Emplo", "plan_name": "401457", "standard_charge_percentage": 0.80, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Ms State Emplo", "plan_name": "401457_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Basic Pl", "plan_name": "400100", "standard_charge_percentage": 0.85, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Basic Pl", "plan_name": "400100_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Federal", "plan_name": "400110", "standard_charge_percentage": 0.85, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Federal", "plan_name": "400110_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Cigna Healthsprings Ffs", "plan_name": "500064", "standard_charge_dollar": 222.80, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Conseco", "plan_name": "500302", "standard_charge_dollar": 222.80, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Humana Ffs 61101", "plan_name": "500006", "standard_charge_dollar": 222.80, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Medicare A", "plan_name": "100100", "standard_charge_dollar": 222.80, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Medicare A", "plan_name": "100500", "standard_charge_dollar": 222.80, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Medicare Part B Only", "plan_name": "100300", "standard_charge_dollar": 222.80, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Medicare Railroad", "plan_name": "100103", "standard_charge_dollar": 222.80, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Ms Physicians Care N", "plan_name": "714210", "standard_charge_dollar": 278.50, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Peoples Hlth Ffs 72126", "plan_name": "500019", "standard_charge_dollar": 222.80, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Uhc/Secure Horizons", "plan_name": "500449", "standard_charge_dollar": 222.80, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "United Health Care/", "plan_name": "500292", "standard_charge_dollar": 251.76, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "United Healthcare", "plan_name": "750104", "standard_charge_dollar": 251.76, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "United Healthcare Ba", "plan_name": "750090", "standard_charge_dollar": 251.76, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "United Healthcare Me", "plan_name": "501310", "standard_charge_dollar": 222.80, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Windsor Mcare Extra", "plan_name": "500778", "standard_charge_dollar": 222.80, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." } ] } ] }, { "description": "Treatment of penis lesion", "code_information": [ { "code": "54115", "type": "CPT" } ], "standard_charges": [ { "gross_charge": 95471.95, "minimum": 2621.84, "maximum": 81151.16, "setting": "inpatient", "payers_information": [ { "payer_name": "Aarp", "plan_name": "500102", "standard_charge_dollar": 2621.84, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna", "plan_name": "700700", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna", "plan_name": "700700_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Mcare Ffs 6005", "plan_name": "700703", "standard_charge_dollar": 2621.84, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Miscellaneous", "plan_name": "700720", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Miscellaneous", "plan_name": "700720_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Ppo Hmo", "plan_name": "701720", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Ppo Hmo", "plan_name": "701720_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Ambetter 68069", "plan_name": "500516", "standard_charge_dollar": 2621.84, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Ms State Emplo", "plan_name": "401457", "standard_charge_percentage": 0.80, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Ms State Emplo", "plan_name": "401457_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Basic Pl", "plan_name": "400100", "standard_charge_percentage": 0.85, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Basic Pl", "plan_name": "400100_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Federal", "plan_name": "400110", "standard_charge_percentage": 0.85, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Federal", "plan_name": "400110_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Cigna Healthsprings Ffs", "plan_name": "500064", "standard_charge_dollar": 2621.84, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Conseco", "plan_name": "500302", "standard_charge_dollar": 2621.84, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Humana Ffs 61101", "plan_name": "500006", "standard_charge_dollar": 2621.84, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Medicare A", "plan_name": "100100", "standard_charge_dollar": 2621.84, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Medicare A", "plan_name": "100500", "standard_charge_dollar": 2621.84, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Medicare Part B Only", "plan_name": "100300", "standard_charge_dollar": 2621.84, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Medicare Railroad", "plan_name": "100103", "standard_charge_dollar": 2621.84, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Ms Physicians Care N", "plan_name": "714210", "standard_charge_dollar": 3277.29, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Peoples Hlth Ffs 72126", "plan_name": "500019", "standard_charge_dollar": 2621.84, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Uhc/Secure Horizons", "plan_name": "500449", "standard_charge_dollar": 2621.84, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "United Health Care/", "plan_name": "500292", "standard_charge_dollar": 2962.67, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "United Healthcare", "plan_name": "750104", "standard_charge_dollar": 2962.67, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "United Healthcare Ba", "plan_name": "750090", "standard_charge_dollar": 2962.67, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "United Healthcare Me", "plan_name": "501310", "standard_charge_dollar": 2621.84, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Windsor Mcare Extra", "plan_name": "500778", "standard_charge_dollar": 2621.84, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." } ] } ] }, { "description": "Circumcision w/regionl block", "code_information": [ { "code": "54150", "type": "CPT" } ], "standard_charges": [ { "gross_charge": 6446.30, "minimum": 1876.58, "maximum": 5479.36, "setting": "inpatient", "payers_information": [ { "payer_name": "Aarp", "plan_name": "500102", "standard_charge_dollar": 1876.58, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna", "plan_name": "700700", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna", "plan_name": "700700_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Mcare Ffs 6005", "plan_name": "700703", "standard_charge_dollar": 1876.58, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Miscellaneous", "plan_name": "700720", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Miscellaneous", "plan_name": "700720_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Ppo Hmo", "plan_name": "701720", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Ppo Hmo", "plan_name": "701720_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Ambetter 68069", "plan_name": "500516", "standard_charge_dollar": 1876.58, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Ms State Emplo", "plan_name": "401457", "standard_charge_percentage": 0.80, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Ms State Emplo", "plan_name": "401457_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Basic Pl", "plan_name": "400100", "standard_charge_percentage": 0.85, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Basic Pl", "plan_name": "400100_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Federal", "plan_name": "400110", "standard_charge_percentage": 0.85, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Federal", "plan_name": "400110_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Cigna Healthsprings Ffs", "plan_name": "500064", "standard_charge_dollar": 1876.58, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Conseco", "plan_name": "500302", "standard_charge_dollar": 1876.58, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Humana Ffs 61101", "plan_name": "500006", "standard_charge_dollar": 1876.58, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Medicare A", "plan_name": "100100", "standard_charge_dollar": 1876.58, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Medicare A", "plan_name": "100500", "standard_charge_dollar": 1876.58, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Medicare Part B Only", "plan_name": "100300", "standard_charge_dollar": 1876.58, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Medicare Railroad", "plan_name": "100103", "standard_charge_dollar": 1876.58, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Ms Physicians Care N", "plan_name": "714210", "standard_charge_dollar": 2345.72, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Peoples Hlth Ffs 72126", "plan_name": "500019", "standard_charge_dollar": 1876.58, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Uhc/Secure Horizons", "plan_name": "500449", "standard_charge_dollar": 1876.58, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "United Health Care/", "plan_name": "500292", "standard_charge_dollar": 2120.53, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "United Healthcare", "plan_name": "750104", "standard_charge_dollar": 2120.53, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "United Healthcare Ba", "plan_name": "750090", "standard_charge_dollar": 2120.53, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "United Healthcare Me", "plan_name": "501310", "standard_charge_dollar": 1876.58, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Windsor Mcare Extra", "plan_name": "500778", "standard_charge_dollar": 1876.58, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." } ] } ] }, { "description": "Circumcision neonate", "code_information": [ { "code": "54160", "type": "CPT" } ], "standard_charges": [ { "gross_charge": 6446.30, "minimum": 611.45, "maximum": 5479.36, "setting": "inpatient", "payers_information": [ { "payer_name": "Aarp", "plan_name": "500102", "standard_charge_dollar": 611.45, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna", "plan_name": "700700", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna", "plan_name": "700700_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Mcare Ffs 6005", "plan_name": "700703", "standard_charge_dollar": 611.45, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Miscellaneous", "plan_name": "700720", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Miscellaneous", "plan_name": "700720_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Ppo Hmo", "plan_name": "701720", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Ppo Hmo", "plan_name": "701720_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Ambetter 68069", "plan_name": "500516", "standard_charge_dollar": 611.45, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Ms State Emplo", "plan_name": "401457", "standard_charge_percentage": 0.80, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Ms State Emplo", "plan_name": "401457_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Basic Pl", "plan_name": "400100", "standard_charge_percentage": 0.85, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Basic Pl", "plan_name": "400100_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Federal", "plan_name": "400110", "standard_charge_percentage": 0.85, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Federal", "plan_name": "400110_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Cigna Healthsprings Ffs", "plan_name": "500064", "standard_charge_dollar": 611.45, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Conseco", "plan_name": "500302", "standard_charge_dollar": 611.45, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Humana Ffs 61101", "plan_name": "500006", "standard_charge_dollar": 611.45, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Medicare A", "plan_name": "100100", "standard_charge_dollar": 611.45, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Medicare A", "plan_name": "100500", "standard_charge_dollar": 611.45, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Medicare Part B Only", "plan_name": "100300", "standard_charge_dollar": 611.45, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Medicare Railroad", "plan_name": "100103", "standard_charge_dollar": 611.45, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Ms Physicians Care N", "plan_name": "714210", "standard_charge_dollar": 764.31, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Peoples Hlth Ffs 72126", "plan_name": "500019", "standard_charge_dollar": 611.45, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Uhc/Secure Horizons", "plan_name": "500449", "standard_charge_dollar": 611.45, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "United Health Care/", "plan_name": "500292", "standard_charge_dollar": 690.94, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "United Healthcare", "plan_name": "750104", "standard_charge_dollar": 690.94, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "United Healthcare Ba", "plan_name": "750090", "standard_charge_dollar": 690.94, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "United Healthcare Me", "plan_name": "501310", "standard_charge_dollar": 611.45, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Windsor Mcare Extra", "plan_name": "500778", "standard_charge_dollar": 611.45, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." } ] } ] }, { "description": "Circum 28 days or older", "code_information": [ { "code": "54161", "type": "CPT" } ], "standard_charges": [ { "gross_charge": 6446.30, "minimum": 1876.58, "maximum": 5479.36, "setting": "inpatient", "payers_information": [ { "payer_name": "Aarp", "plan_name": "500102", "standard_charge_dollar": 1876.58, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna", "plan_name": "700700", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna", "plan_name": "700700_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Mcare Ffs 6005", "plan_name": "700703", "standard_charge_dollar": 1876.58, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Miscellaneous", "plan_name": "700720", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Miscellaneous", "plan_name": "700720_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Ppo Hmo", "plan_name": "701720", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Ppo Hmo", "plan_name": "701720_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Ambetter 68069", "plan_name": "500516", "standard_charge_dollar": 1876.58, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Ms State Emplo", "plan_name": "401457", "standard_charge_percentage": 0.80, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Ms State Emplo", "plan_name": "401457_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Basic Pl", "plan_name": "400100", "standard_charge_percentage": 0.85, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Basic Pl", "plan_name": "400100_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Federal", "plan_name": "400110", "standard_charge_percentage": 0.85, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Federal", "plan_name": "400110_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Cigna Healthsprings Ffs", "plan_name": "500064", "standard_charge_dollar": 1876.58, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Conseco", "plan_name": "500302", "standard_charge_dollar": 1876.58, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Humana Ffs 61101", "plan_name": "500006", "standard_charge_dollar": 1876.58, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Medicare A", "plan_name": "100100", "standard_charge_dollar": 1876.58, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Medicare A", "plan_name": "100500", "standard_charge_dollar": 1876.58, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Medicare Part B Only", "plan_name": "100300", "standard_charge_dollar": 1876.58, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Medicare Railroad", "plan_name": "100103", "standard_charge_dollar": 1876.58, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Ms Physicians Care N", "plan_name": "714210", "standard_charge_dollar": 2345.72, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Peoples Hlth Ffs 72126", "plan_name": "500019", "standard_charge_dollar": 1876.58, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Uhc/Secure Horizons", "plan_name": "500449", "standard_charge_dollar": 1876.58, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "United Health Care/", "plan_name": "500292", "standard_charge_dollar": 2120.53, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "United Healthcare", "plan_name": "750104", "standard_charge_dollar": 2120.53, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "United Healthcare Ba", "plan_name": "750090", "standard_charge_dollar": 2120.53, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "United Healthcare Me", "plan_name": "501310", "standard_charge_dollar": 1876.58, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Windsor Mcare Extra", "plan_name": "500778", "standard_charge_dollar": 1876.58, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." } ] } ] }, { "description": "Repair of circumcision", "code_information": [ { "code": "54163", "type": "CPT" } ], "standard_charges": [ { "gross_charge": 6446.30, "minimum": 1876.58, "maximum": 5479.36, "setting": "inpatient", "payers_information": [ { "payer_name": "Aarp", "plan_name": "500102", "standard_charge_dollar": 1876.58, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna", "plan_name": "700700", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna", "plan_name": "700700_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Mcare Ffs 6005", "plan_name": "700703", "standard_charge_dollar": 1876.58, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Miscellaneous", "plan_name": "700720", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Miscellaneous", "plan_name": "700720_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Ppo Hmo", "plan_name": "701720", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Ppo Hmo", "plan_name": "701720_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Ambetter 68069", "plan_name": "500516", "standard_charge_dollar": 1876.58, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Ms State Emplo", "plan_name": "401457", "standard_charge_percentage": 0.80, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Ms State Emplo", "plan_name": "401457_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Basic Pl", "plan_name": "400100", "standard_charge_percentage": 0.85, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Basic Pl", "plan_name": "400100_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Federal", "plan_name": "400110", "standard_charge_percentage": 0.85, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Federal", "plan_name": "400110_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Cigna Healthsprings Ffs", "plan_name": "500064", "standard_charge_dollar": 1876.58, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Conseco", "plan_name": "500302", "standard_charge_dollar": 1876.58, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Humana Ffs 61101", "plan_name": "500006", "standard_charge_dollar": 1876.58, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Medicare A", "plan_name": "100100", "standard_charge_dollar": 1876.58, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Medicare A", "plan_name": "100500", "standard_charge_dollar": 1876.58, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Medicare Part B Only", "plan_name": "100300", "standard_charge_dollar": 1876.58, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Medicare Railroad", "plan_name": "100103", "standard_charge_dollar": 1876.58, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Ms Physicians Care N", "plan_name": "714210", "standard_charge_dollar": 2345.72, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Peoples Hlth Ffs 72126", "plan_name": "500019", "standard_charge_dollar": 1876.58, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Uhc/Secure Horizons", "plan_name": "500449", "standard_charge_dollar": 1876.58, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "United Health Care/", "plan_name": "500292", "standard_charge_dollar": 2120.53, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "United Healthcare", "plan_name": "750104", "standard_charge_dollar": 2120.53, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "United Healthcare Ba", "plan_name": "750090", "standard_charge_dollar": 2120.53, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "United Healthcare Me", "plan_name": "501310", "standard_charge_dollar": 1876.58, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Windsor Mcare Extra", "plan_name": "500778", "standard_charge_dollar": 1876.58, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." } ] } ] }, { "description": "Secondary urethral surgery", "code_information": [ { "code": "54348", "type": "CPT" } ], "standard_charges": [ { "gross_charge": 17546.60, "minimum": 4656.95, "maximum": 14914.61, "setting": "inpatient", "payers_information": [ { "payer_name": "Aarp", "plan_name": "500102", "standard_charge_dollar": 4656.95, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna", "plan_name": "700700", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna", "plan_name": "700700_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Mcare Ffs 6005", "plan_name": "700703", "standard_charge_dollar": 4656.95, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Miscellaneous", "plan_name": "700720", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Miscellaneous", "plan_name": "700720_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Ppo Hmo", "plan_name": "701720", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Ppo Hmo", "plan_name": "701720_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Ambetter 68069", "plan_name": "500516", "standard_charge_dollar": 4656.95, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Ms State Emplo", "plan_name": "401457", "standard_charge_percentage": 0.80, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Ms State Emplo", "plan_name": "401457_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Basic Pl", "plan_name": "400100", "standard_charge_percentage": 0.85, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Basic Pl", "plan_name": "400100_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Federal", "plan_name": "400110", "standard_charge_percentage": 0.85, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Federal", "plan_name": "400110_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Cigna Healthsprings Ffs", "plan_name": "500064", "standard_charge_dollar": 4656.95, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Conseco", "plan_name": "500302", "standard_charge_dollar": 4656.95, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Humana Ffs 61101", "plan_name": "500006", "standard_charge_dollar": 4656.95, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Medicare A", "plan_name": "100100", "standard_charge_dollar": 4656.95, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Medicare A", "plan_name": "100500", "standard_charge_dollar": 4656.95, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Medicare Part B Only", "plan_name": "100300", "standard_charge_dollar": 4656.95, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Medicare Railroad", "plan_name": "100103", "standard_charge_dollar": 4656.95, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Ms Physicians Care N", "plan_name": "714210", "standard_charge_dollar": 5821.18, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Peoples Hlth Ffs 72126", "plan_name": "500019", "standard_charge_dollar": 4656.95, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Uhc/Secure Horizons", "plan_name": "500449", "standard_charge_dollar": 4656.95, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "United Health Care/", "plan_name": "500292", "standard_charge_dollar": 5262.35, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "United Healthcare", "plan_name": "750104", "standard_charge_dollar": 5262.35, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "United Healthcare Ba", "plan_name": "750090", "standard_charge_dollar": 5262.35, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "United Healthcare Me", "plan_name": "501310", "standard_charge_dollar": 4656.95, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Windsor Mcare Extra", "plan_name": "500778", "standard_charge_dollar": 4656.95, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." } ] } ] }, { "description": "Reconstruct urethra/penis", "code_information": [ { "code": "54352", "type": "CPT" } ], "standard_charges": [ { "gross_charge": 17546.60, "minimum": 4656.95, "maximum": 14914.61, "setting": "inpatient", "payers_information": [ { "payer_name": "Aarp", "plan_name": "500102", "standard_charge_dollar": 4656.95, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna", "plan_name": "700700", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna", "plan_name": "700700_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Mcare Ffs 6005", "plan_name": "700703", "standard_charge_dollar": 4656.95, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Miscellaneous", "plan_name": "700720", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Miscellaneous", "plan_name": "700720_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Ppo Hmo", "plan_name": "701720", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Ppo Hmo", "plan_name": "701720_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Ambetter 68069", "plan_name": "500516", "standard_charge_dollar": 4656.95, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Ms State Emplo", "plan_name": "401457", "standard_charge_percentage": 0.80, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Ms State Emplo", "plan_name": "401457_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Basic Pl", "plan_name": "400100", "standard_charge_percentage": 0.85, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Basic Pl", "plan_name": "400100_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Federal", "plan_name": "400110", "standard_charge_percentage": 0.85, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Federal", "plan_name": "400110_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Cigna Healthsprings Ffs", "plan_name": "500064", "standard_charge_dollar": 4656.95, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Conseco", "plan_name": "500302", "standard_charge_dollar": 4656.95, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Humana Ffs 61101", "plan_name": "500006", "standard_charge_dollar": 4656.95, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Medicare A", "plan_name": "100100", "standard_charge_dollar": 4656.95, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Medicare A", "plan_name": "100500", "standard_charge_dollar": 4656.95, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Medicare Part B Only", "plan_name": "100300", "standard_charge_dollar": 4656.95, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Medicare Railroad", "plan_name": "100103", "standard_charge_dollar": 4656.95, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Ms Physicians Care N", "plan_name": "714210", "standard_charge_dollar": 5821.18, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Peoples Hlth Ffs 72126", "plan_name": "500019", "standard_charge_dollar": 4656.95, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Uhc/Secure Horizons", "plan_name": "500449", "standard_charge_dollar": 4656.95, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "United Health Care/", "plan_name": "500292", "standard_charge_dollar": 5262.35, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "United Healthcare", "plan_name": "750104", "standard_charge_dollar": 5262.35, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "United Healthcare Ba", "plan_name": "750090", "standard_charge_dollar": 5262.35, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "United Healthcare Me", "plan_name": "501310", "standard_charge_dollar": 4656.95, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Windsor Mcare Extra", "plan_name": "500778", "standard_charge_dollar": 4656.95, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." } ] } ] }, { "description": "Repair penis and bladder", "code_information": [ { "code": "54390", "type": "CPT" } ], "standard_charges": [ { "gross_charge": 68896.77, "minimum": 55117.42, "maximum": 58562.25, "setting": "inpatient", "payers_information": [ { "payer_name": "Aetna", "plan_name": "700700", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna", "plan_name": "700700_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Miscellaneous", "plan_name": "700720", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Miscellaneous", "plan_name": "700720_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Ppo Hmo", "plan_name": "701720", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Ppo Hmo", "plan_name": "701720_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Ms State Emplo", "plan_name": "401457", "standard_charge_percentage": 0.80, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Ms State Emplo", "plan_name": "401457_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Basic Pl", "plan_name": "400100", "standard_charge_percentage": 0.85, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Basic Pl", "plan_name": "400100_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Federal", "plan_name": "400110", "standard_charge_percentage": 0.85, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Federal", "plan_name": "400110_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." } ] } ] }, { "description": "Remove muti-comp penis pros", "code_information": [ { "code": "54406", "type": "CPT" } ], "standard_charges": [ { "gross_charge": 95471.95, "minimum": 3159.49, "maximum": 3949.37, "setting": "inpatient", "payers_information": [ { "payer_name": "Aarp", "plan_name": "500102", "standard_charge_dollar": 3159.49, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna", "plan_name": "700700", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna", "plan_name": "700700_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Mcare Ffs 6005", "plan_name": "700703", "standard_charge_dollar": 3159.49, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Miscellaneous", "plan_name": "700720", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Miscellaneous", "plan_name": "700720_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Ppo Hmo", "plan_name": "701720", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Ppo Hmo", "plan_name": "701720_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Ambetter 68069", "plan_name": "500516", "standard_charge_dollar": 3159.49, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Ms State Emplo", "plan_name": "401457", "standard_charge_dollar": 3365.24, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Ms State Emplo", "plan_name": "401457_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Basic Pl", "plan_name": "400100", "standard_charge_dollar": 3365.24, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Basic Pl", "plan_name": "400100_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Federal", "plan_name": "400110", "standard_charge_dollar": 3365.24, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Federal", "plan_name": "400110_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Cigna Healthsprings Ffs", "plan_name": "500064", "standard_charge_dollar": 3159.49, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Conseco", "plan_name": "500302", "standard_charge_dollar": 3159.49, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Humana Ffs 61101", "plan_name": "500006", "standard_charge_dollar": 3159.49, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Medicare A", "plan_name": "100100", "standard_charge_dollar": 3159.49, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Medicare A", "plan_name": "100500", "standard_charge_dollar": 3159.49, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Medicare Part B Only", "plan_name": "100300", "standard_charge_dollar": 3159.49, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Medicare Railroad", "plan_name": "100103", "standard_charge_dollar": 3159.49, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Ms Physicians Care N", "plan_name": "714210", "standard_charge_dollar": 3949.37, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Peoples Hlth Ffs 72126", "plan_name": "500019", "standard_charge_dollar": 3159.49, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Uhc/Secure Horizons", "plan_name": "500449", "standard_charge_dollar": 3159.49, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "United Health Care/", "plan_name": "500292", "standard_charge_dollar": 3570.23, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "United Healthcare", "plan_name": "750104", "standard_charge_dollar": 3570.23, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "United Healthcare Ba", "plan_name": "750090", "standard_charge_dollar": 3570.23, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "United Healthcare Me", "plan_name": "501310", "standard_charge_dollar": 3159.49, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Windsor Mcare Extra", "plan_name": "500778", "standard_charge_dollar": 3159.49, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." } ] } ] }, { "description": "Remove/replace penis prosth", "code_information": [ { "code": "54410", "type": "CPT" } ], "standard_charges": [ { "gross_charge": 95471.95, "minimum": 18439.15, "maximum": 81151.16, "setting": "inpatient", "payers_information": [ { "payer_name": "Aarp", "plan_name": "500102", "standard_charge_dollar": 18439.15, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna", "plan_name": "700700", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna", "plan_name": "700700_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Mcare Ffs 6005", "plan_name": "700703", "standard_charge_dollar": 18439.15, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Miscellaneous", "plan_name": "700720", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Miscellaneous", "plan_name": "700720_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Ppo Hmo", "plan_name": "701720", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Ppo Hmo", "plan_name": "701720_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Ambetter 68069", "plan_name": "500516", "standard_charge_dollar": 18439.15, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Ms State Emplo", "plan_name": "401457", "standard_charge_percentage": 0.80, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Ms State Emplo", "plan_name": "401457_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Basic Pl", "plan_name": "400100", "standard_charge_percentage": 0.85, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Basic Pl", "plan_name": "400100_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Federal", "plan_name": "400110", "standard_charge_percentage": 0.85, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Federal", "plan_name": "400110_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Cigna Healthsprings Ffs", "plan_name": "500064", "standard_charge_dollar": 18439.15, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Conseco", "plan_name": "500302", "standard_charge_dollar": 18439.15, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Humana Ffs 61101", "plan_name": "500006", "standard_charge_dollar": 18439.15, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Medicare A", "plan_name": "100100", "standard_charge_dollar": 18439.15, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Medicare A", "plan_name": "100500", "standard_charge_dollar": 18439.15, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Medicare Part B Only", "plan_name": "100300", "standard_charge_dollar": 18439.15, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Medicare Railroad", "plan_name": "100103", "standard_charge_dollar": 18439.15, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Ms Physicians Care N", "plan_name": "714210", "standard_charge_dollar": 23048.94, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Peoples Hlth Ffs 72126", "plan_name": "500019", "standard_charge_dollar": 18439.15, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Uhc/Secure Horizons", "plan_name": "500449", "standard_charge_dollar": 18439.15, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "United Health Care/", "plan_name": "500292", "standard_charge_dollar": 20836.24, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "United Healthcare", "plan_name": "750104", "standard_charge_dollar": 20836.24, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "United Healthcare Ba", "plan_name": "750090", "standard_charge_dollar": 20836.24, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "United Healthcare Me", "plan_name": "501310", "standard_charge_dollar": 18439.15, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Windsor Mcare Extra", "plan_name": "500778", "standard_charge_dollar": 18439.15, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." } ] } ] }, { "description": "Remov/replc penis pros comp", "code_information": [ { "code": "54411", "type": "CPT" } ], "standard_charges": [ { "gross_charge": 50246.84, "minimum": 18439.15, "maximum": 42709.81, "setting": "inpatient", "payers_information": [ { "payer_name": "Aarp", "plan_name": "500102", "standard_charge_dollar": 18439.15, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna", "plan_name": "700700", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna", "plan_name": "700700_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Mcare Ffs 6005", "plan_name": "700703", "standard_charge_dollar": 18439.15, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Miscellaneous", "plan_name": "700720", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Miscellaneous", "plan_name": "700720_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Ppo Hmo", "plan_name": "701720", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Ppo Hmo", "plan_name": "701720_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Ambetter 68069", "plan_name": "500516", "standard_charge_dollar": 18439.15, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Ms State Emplo", "plan_name": "401457", "standard_charge_percentage": 0.80, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Ms State Emplo", "plan_name": "401457_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Basic Pl", "plan_name": "400100", "standard_charge_percentage": 0.85, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Basic Pl", "plan_name": "400100_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Federal", "plan_name": "400110", "standard_charge_percentage": 0.85, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Federal", "plan_name": "400110_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Cigna Healthsprings Ffs", "plan_name": "500064", "standard_charge_dollar": 18439.15, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Conseco", "plan_name": "500302", "standard_charge_dollar": 18439.15, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Humana Ffs 61101", "plan_name": "500006", "standard_charge_dollar": 18439.15, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Medicare A", "plan_name": "100100", "standard_charge_dollar": 18439.15, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Medicare A", "plan_name": "100500", "standard_charge_dollar": 18439.15, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Medicare Part B Only", "plan_name": "100300", "standard_charge_dollar": 18439.15, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Medicare Railroad", "plan_name": "100103", "standard_charge_dollar": 18439.15, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Ms Physicians Care N", "plan_name": "714210", "standard_charge_dollar": 23048.94, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Peoples Hlth Ffs 72126", "plan_name": "500019", "standard_charge_dollar": 18439.15, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Uhc/Secure Horizons", "plan_name": "500449", "standard_charge_dollar": 18439.15, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "United Health Care/", "plan_name": "500292", "standard_charge_dollar": 20836.24, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "United Healthcare", "plan_name": "750104", "standard_charge_dollar": 20836.24, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "United Healthcare Ba", "plan_name": "750090", "standard_charge_dollar": 20836.24, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "United Healthcare Me", "plan_name": "501310", "standard_charge_dollar": 18439.15, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Windsor Mcare Extra", "plan_name": "500778", "standard_charge_dollar": 18439.15, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." } ] } ] }, { "description": "Remove self-contd penis pros", "code_information": [ { "code": "54415", "type": "CPT" } ], "standard_charges": [ { "gross_charge": 95471.95, "minimum": 3159.49, "maximum": 3949.37, "setting": "inpatient", "payers_information": [ { "payer_name": "Aarp", "plan_name": "500102", "standard_charge_dollar": 3159.49, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna", "plan_name": "700700", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna", "plan_name": "700700_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Mcare Ffs 6005", "plan_name": "700703", "standard_charge_dollar": 3159.49, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Miscellaneous", "plan_name": "700720", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Miscellaneous", "plan_name": "700720_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Ppo Hmo", "plan_name": "701720", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Ppo Hmo", "plan_name": "701720_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Ambetter 68069", "plan_name": "500516", "standard_charge_dollar": 3159.49, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Ms State Emplo", "plan_name": "401457", "standard_charge_dollar": 3365.24, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Ms State Emplo", "plan_name": "401457_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Basic Pl", "plan_name": "400100", "standard_charge_dollar": 3365.24, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Basic Pl", "plan_name": "400100_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Federal", "plan_name": "400110", "standard_charge_dollar": 3365.24, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Federal", "plan_name": "400110_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Cigna Healthsprings Ffs", "plan_name": "500064", "standard_charge_dollar": 3159.49, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Conseco", "plan_name": "500302", "standard_charge_dollar": 3159.49, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Humana Ffs 61101", "plan_name": "500006", "standard_charge_dollar": 3159.49, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Medicare A", "plan_name": "100100", "standard_charge_dollar": 3159.49, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Medicare A", "plan_name": "100500", "standard_charge_dollar": 3159.49, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Medicare Part B Only", "plan_name": "100300", "standard_charge_dollar": 3159.49, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Medicare Railroad", "plan_name": "100103", "standard_charge_dollar": 3159.49, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Ms Physicians Care N", "plan_name": "714210", "standard_charge_dollar": 3949.37, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Peoples Hlth Ffs 72126", "plan_name": "500019", "standard_charge_dollar": 3159.49, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Uhc/Secure Horizons", "plan_name": "500449", "standard_charge_dollar": 3159.49, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "United Health Care/", "plan_name": "500292", "standard_charge_dollar": 3570.23, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "United Healthcare", "plan_name": "750104", "standard_charge_dollar": 3570.23, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "United Healthcare Ba", "plan_name": "750090", "standard_charge_dollar": 3570.23, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "United Healthcare Me", "plan_name": "501310", "standard_charge_dollar": 3159.49, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Windsor Mcare Extra", "plan_name": "500778", "standard_charge_dollar": 3159.49, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." } ] } ] }, { "description": "Remv/repl penis contain pros", "code_information": [ { "code": "54416", "type": "CPT" } ], "standard_charges": [ { "gross_charge": 95471.95, "minimum": 18439.15, "maximum": 81151.16, "setting": "inpatient", "payers_information": [ { "payer_name": "Aarp", "plan_name": "500102", "standard_charge_dollar": 18439.15, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna", "plan_name": "700700", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna", "plan_name": "700700_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Mcare Ffs 6005", "plan_name": "700703", "standard_charge_dollar": 18439.15, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Miscellaneous", "plan_name": "700720", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Miscellaneous", "plan_name": "700720_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Ppo Hmo", "plan_name": "701720", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Ppo Hmo", "plan_name": "701720_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Ambetter 68069", "plan_name": "500516", "standard_charge_dollar": 18439.15, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Ms State Emplo", "plan_name": "401457", "standard_charge_percentage": 0.80, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Ms State Emplo", "plan_name": "401457_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Basic Pl", "plan_name": "400100", "standard_charge_percentage": 0.85, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Basic Pl", "plan_name": "400100_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Federal", "plan_name": "400110", "standard_charge_percentage": 0.85, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Federal", "plan_name": "400110_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Cigna Healthsprings Ffs", "plan_name": "500064", "standard_charge_dollar": 18439.15, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Conseco", "plan_name": "500302", "standard_charge_dollar": 18439.15, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Humana Ffs 61101", "plan_name": "500006", "standard_charge_dollar": 18439.15, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Medicare A", "plan_name": "100100", "standard_charge_dollar": 18439.15, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Medicare A", "plan_name": "100500", "standard_charge_dollar": 18439.15, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Medicare Part B Only", "plan_name": "100300", "standard_charge_dollar": 18439.15, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Medicare Railroad", "plan_name": "100103", "standard_charge_dollar": 18439.15, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Ms Physicians Care N", "plan_name": "714210", "standard_charge_dollar": 23048.94, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Peoples Hlth Ffs 72126", "plan_name": "500019", "standard_charge_dollar": 18439.15, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Uhc/Secure Horizons", "plan_name": "500449", "standard_charge_dollar": 18439.15, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "United Health Care/", "plan_name": "500292", "standard_charge_dollar": 20836.24, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "United Healthcare", "plan_name": "750104", "standard_charge_dollar": 20836.24, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "United Healthcare Ba", "plan_name": "750090", "standard_charge_dollar": 20836.24, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "United Healthcare Me", "plan_name": "501310", "standard_charge_dollar": 18439.15, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Windsor Mcare Extra", "plan_name": "500778", "standard_charge_dollar": 18439.15, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." } ] } ] }, { "description": "Remv/replc penis pros compl", "code_information": [ { "code": "54417", "type": "CPT" } ], "standard_charges": [ { "gross_charge": 95471.95, "minimum": 11901.96, "maximum": 81151.16, "setting": "inpatient", "payers_information": [ { "payer_name": "Aarp", "plan_name": "500102", "standard_charge_dollar": 11901.96, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna", "plan_name": "700700", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna", "plan_name": "700700_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Mcare Ffs 6005", "plan_name": "700703", "standard_charge_dollar": 11901.96, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Miscellaneous", "plan_name": "700720", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Miscellaneous", "plan_name": "700720_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Ppo Hmo", "plan_name": "701720", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Ppo Hmo", "plan_name": "701720_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Ambetter 68069", "plan_name": "500516", "standard_charge_dollar": 11901.96, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Ms State Emplo", "plan_name": "401457", "standard_charge_percentage": 0.80, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Ms State Emplo", "plan_name": "401457_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Basic Pl", "plan_name": "400100", "standard_charge_percentage": 0.85, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Basic Pl", "plan_name": "400100_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Federal", "plan_name": "400110", "standard_charge_percentage": 0.85, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Federal", "plan_name": "400110_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Cigna Healthsprings Ffs", "plan_name": "500064", "standard_charge_dollar": 11901.96, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Conseco", "plan_name": "500302", "standard_charge_dollar": 11901.96, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Humana Ffs 61101", "plan_name": "500006", "standard_charge_dollar": 11901.96, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Medicare A", "plan_name": "100100", "standard_charge_dollar": 11901.96, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Medicare A", "plan_name": "100500", "standard_charge_dollar": 11901.96, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Medicare Part B Only", "plan_name": "100300", "standard_charge_dollar": 11901.96, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Medicare Railroad", "plan_name": "100103", "standard_charge_dollar": 11901.96, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Ms Physicians Care N", "plan_name": "714210", "standard_charge_dollar": 14877.44, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Peoples Hlth Ffs 72126", "plan_name": "500019", "standard_charge_dollar": 11901.96, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Uhc/Secure Horizons", "plan_name": "500449", "standard_charge_dollar": 11901.96, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "United Health Care/", "plan_name": "500292", "standard_charge_dollar": 13449.21, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "United Healthcare", "plan_name": "750104", "standard_charge_dollar": 13449.21, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "United Healthcare Ba", "plan_name": "750090", "standard_charge_dollar": 13449.21, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "United Healthcare Me", "plan_name": "501310", "standard_charge_dollar": 11901.96, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Windsor Mcare Extra", "plan_name": "500778", "standard_charge_dollar": 11901.96, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." } ] } ] }, { "description": "Drainage of scrotum", "code_information": [ { "code": "54700", "type": "CPT" } ], "standard_charges": [ { "gross_charge": 27279.78, "minimum": 1876.58, "maximum": 23187.81, "setting": "inpatient", "payers_information": [ { "payer_name": "Aarp", "plan_name": "500102", "standard_charge_dollar": 1876.58, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna", "plan_name": "700700", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna", "plan_name": "700700_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Mcare Ffs 6005", "plan_name": "700703", "standard_charge_dollar": 1876.58, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Miscellaneous", "plan_name": "700720", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Miscellaneous", "plan_name": "700720_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Ppo Hmo", "plan_name": "701720", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Ppo Hmo", "plan_name": "701720_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Ambetter 68069", "plan_name": "500516", "standard_charge_dollar": 1876.58, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Ms State Emplo", "plan_name": "401457", "standard_charge_percentage": 0.80, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Ms State Emplo", "plan_name": "401457_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Basic Pl", "plan_name": "400100", "standard_charge_percentage": 0.85, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Basic Pl", "plan_name": "400100_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Federal", "plan_name": "400110", "standard_charge_percentage": 0.85, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Federal", "plan_name": "400110_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Cigna Healthsprings Ffs", "plan_name": "500064", "standard_charge_dollar": 1876.58, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Conseco", "plan_name": "500302", "standard_charge_dollar": 1876.58, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Humana Ffs 61101", "plan_name": "500006", "standard_charge_dollar": 1876.58, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Medicare A", "plan_name": "100100", "standard_charge_dollar": 1876.58, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Medicare A", "plan_name": "100500", "standard_charge_dollar": 1876.58, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Medicare Part B Only", "plan_name": "100300", "standard_charge_dollar": 1876.58, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Medicare Railroad", "plan_name": "100103", "standard_charge_dollar": 1876.58, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Ms Physicians Care N", "plan_name": "714210", "standard_charge_dollar": 2345.72, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Peoples Hlth Ffs 72126", "plan_name": "500019", "standard_charge_dollar": 1876.58, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Uhc/Secure Horizons", "plan_name": "500449", "standard_charge_dollar": 1876.58, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "United Health Care/", "plan_name": "500292", "standard_charge_dollar": 2120.53, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "United Healthcare", "plan_name": "750104", "standard_charge_dollar": 2120.53, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "United Healthcare Ba", "plan_name": "750090", "standard_charge_dollar": 2120.53, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "United Healthcare Me", "plan_name": "501310", "standard_charge_dollar": 1876.58, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Windsor Mcare Extra", "plan_name": "500778", "standard_charge_dollar": 1876.58, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." } ] } ] }, { "description": "Drainage of scrotum abscess", "code_information": [ { "code": "55100", "type": "CPT" } ], "standard_charges": [ { "gross_charge": 27279.78, "minimum": 1484.25, "maximum": 23187.81, "setting": "inpatient", "payers_information": [ { "payer_name": "Aarp", "plan_name": "500102", "standard_charge_dollar": 1484.25, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna", "plan_name": "700700", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna", "plan_name": "700700_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Mcare Ffs 6005", "plan_name": "700703", "standard_charge_dollar": 1484.25, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Miscellaneous", "plan_name": "700720", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Miscellaneous", "plan_name": "700720_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Ppo Hmo", "plan_name": "701720", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Ppo Hmo", "plan_name": "701720_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Ambetter 68069", "plan_name": "500516", "standard_charge_dollar": 1484.25, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Ms State Emplo", "plan_name": "401457", "standard_charge_percentage": 0.80, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Ms State Emplo", "plan_name": "401457_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Basic Pl", "plan_name": "400100", "standard_charge_percentage": 0.85, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Basic Pl", "plan_name": "400100_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Federal", "plan_name": "400110", "standard_charge_percentage": 0.85, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Federal", "plan_name": "400110_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Cigna Healthsprings Ffs", "plan_name": "500064", "standard_charge_dollar": 1484.25, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Conseco", "plan_name": "500302", "standard_charge_dollar": 1484.25, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Humana Ffs 61101", "plan_name": "500006", "standard_charge_dollar": 1484.25, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Medicare A", "plan_name": "100100", "standard_charge_dollar": 1484.25, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Medicare A", "plan_name": "100500", "standard_charge_dollar": 1484.25, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Medicare Part B Only", "plan_name": "100300", "standard_charge_dollar": 1484.25, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Medicare Railroad", "plan_name": "100103", "standard_charge_dollar": 1484.25, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Ms Physicians Care N", "plan_name": "714210", "standard_charge_dollar": 1855.31, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Peoples Hlth Ffs 72126", "plan_name": "500019", "standard_charge_dollar": 1484.25, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Uhc/Secure Horizons", "plan_name": "500449", "standard_charge_dollar": 1484.25, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "United Health Care/", "plan_name": "500292", "standard_charge_dollar": 1677.20, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "United Healthcare", "plan_name": "750104", "standard_charge_dollar": 1677.20, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "United Healthcare Ba", "plan_name": "750090", "standard_charge_dollar": 1677.20, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "United Healthcare Me", "plan_name": "501310", "standard_charge_dollar": 1484.25, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Windsor Mcare Extra", "plan_name": "500778", "standard_charge_dollar": 1484.25, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." } ] } ] }, { "description": "Removal of prostate", "code_information": [ { "code": "55821", "type": "CPT" } ], "standard_charges": [ { "gross_charge": 17546.60, "minimum": 14037.28, "maximum": 14914.61, "setting": "inpatient", "payers_information": [ { "payer_name": "Aetna", "plan_name": "700700", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna", "plan_name": "700700_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Miscellaneous", "plan_name": "700720", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Miscellaneous", "plan_name": "700720_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Ppo Hmo", "plan_name": "701720", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Ppo Hmo", "plan_name": "701720_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Ms State Emplo", "plan_name": "401457", "standard_charge_percentage": 0.80, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Ms State Emplo", "plan_name": "401457_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Basic Pl", "plan_name": "400100", "standard_charge_percentage": 0.85, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Basic Pl", "plan_name": "400100_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Federal", "plan_name": "400110", "standard_charge_percentage": 0.85, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Federal", "plan_name": "400110_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." } ] } ] }, { "description": "Removal of prostate", "code_information": [ { "code": "55831", "type": "CPT" } ], "standard_charges": [ { "gross_charge": 17546.60, "minimum": 14037.28, "maximum": 14914.61, "setting": "inpatient", "payers_information": [ { "payer_name": "Aetna", "plan_name": "700700", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna", "plan_name": "700700_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Miscellaneous", "plan_name": "700720", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Miscellaneous", "plan_name": "700720_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Ppo Hmo", "plan_name": "701720", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Ppo Hmo", "plan_name": "701720_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Ms State Emplo", "plan_name": "401457", "standard_charge_percentage": 0.80, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Ms State Emplo", "plan_name": "401457_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Basic Pl", "plan_name": "400100", "standard_charge_percentage": 0.85, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Basic Pl", "plan_name": "400100_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Federal", "plan_name": "400110", "standard_charge_percentage": 0.85, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Federal", "plan_name": "400110_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." } ] } ] }, { "description": "Genital surgery procedure", "code_information": [ { "code": "55899", "type": "CPT" } ], "standard_charges": [ { "gross_charge": 19835.41, "minimum": 222.80, "maximum": 16860.10, "setting": "inpatient", "payers_information": [ { "payer_name": "Aarp", "plan_name": "500102", "standard_charge_dollar": 222.80, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna", "plan_name": "700700", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna", "plan_name": "700700_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Mcare Ffs 6005", "plan_name": "700703", "standard_charge_dollar": 222.80, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Miscellaneous", "plan_name": "700720", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Miscellaneous", "plan_name": "700720_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Ppo Hmo", "plan_name": "701720", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Ppo Hmo", "plan_name": "701720_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Ambetter 68069", "plan_name": "500516", "standard_charge_dollar": 222.80, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Ms State Emplo", "plan_name": "401457", "standard_charge_percentage": 0.80, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Ms State Emplo", "plan_name": "401457_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Basic Pl", "plan_name": "400100", "standard_charge_percentage": 0.85, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Basic Pl", "plan_name": "400100_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Federal", "plan_name": "400110", "standard_charge_percentage": 0.85, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Federal", "plan_name": "400110_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Cigna Healthsprings Ffs", "plan_name": "500064", "standard_charge_dollar": 222.80, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Conseco", "plan_name": "500302", "standard_charge_dollar": 222.80, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Humana Ffs 61101", "plan_name": "500006", "standard_charge_dollar": 222.80, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Medicare A", "plan_name": "100100", "standard_charge_dollar": 222.80, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Medicare A", "plan_name": "100500", "standard_charge_dollar": 222.80, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Medicare Part B Only", "plan_name": "100300", "standard_charge_dollar": 222.80, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Medicare Railroad", "plan_name": "100103", "standard_charge_dollar": 222.80, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Ms Physicians Care N", "plan_name": "714210", "standard_charge_dollar": 278.50, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Peoples Hlth Ffs 72126", "plan_name": "500019", "standard_charge_dollar": 222.80, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Uhc/Secure Horizons", "plan_name": "500449", "standard_charge_dollar": 222.80, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "United Health Care/", "plan_name": "500292", "standard_charge_dollar": 251.76, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "United Healthcare", "plan_name": "750104", "standard_charge_dollar": 251.76, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "United Healthcare Ba", "plan_name": "750090", "standard_charge_dollar": 251.76, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "United Healthcare Me", "plan_name": "501310", "standard_charge_dollar": 222.80, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Windsor Mcare Extra", "plan_name": "500778", "standard_charge_dollar": 222.80, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." } ] } ] }, { "description": "I & d of vulva/perineum", "code_information": [ { "code": "56405", "type": "CPT" } ], "standard_charges": [ { "gross_charge": 32540.30, "minimum": 278.66, "maximum": 27659.26, "setting": "inpatient", "payers_information": [ { "payer_name": "Aarp", "plan_name": "500102", "standard_charge_dollar": 278.66, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna", "plan_name": "700700", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna", "plan_name": "700700_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Mcare Ffs 6005", "plan_name": "700703", "standard_charge_dollar": 278.66, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Miscellaneous", "plan_name": "700720", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Miscellaneous", "plan_name": "700720_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Ppo Hmo", "plan_name": "701720", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Ppo Hmo", "plan_name": "701720_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Ambetter 68069", "plan_name": "500516", "standard_charge_dollar": 278.66, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Ms State Emplo", "plan_name": "401457", "standard_charge_percentage": 0.80, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Ms State Emplo", "plan_name": "401457_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Basic Pl", "plan_name": "400100", "standard_charge_percentage": 0.85, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Basic Pl", "plan_name": "400100_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Federal", "plan_name": "400110", "standard_charge_percentage": 0.85, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Federal", "plan_name": "400110_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Cigna Healthsprings Ffs", "plan_name": "500064", "standard_charge_dollar": 278.66, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Conseco", "plan_name": "500302", "standard_charge_dollar": 278.66, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Humana Ffs 61101", "plan_name": "500006", "standard_charge_dollar": 278.66, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Medicare A", "plan_name": "100100", "standard_charge_dollar": 278.66, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Medicare A", "plan_name": "100500", "standard_charge_dollar": 278.66, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Medicare Part B Only", "plan_name": "100300", "standard_charge_dollar": 278.66, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Medicare Railroad", "plan_name": "100103", "standard_charge_dollar": 278.66, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Ms Physicians Care N", "plan_name": "714210", "standard_charge_dollar": 348.32, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Peoples Hlth Ffs 72126", "plan_name": "500019", "standard_charge_dollar": 278.66, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Uhc/Secure Horizons", "plan_name": "500449", "standard_charge_dollar": 278.66, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "United Health Care/", "plan_name": "500292", "standard_charge_dollar": 314.88, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "United Healthcare", "plan_name": "750104", "standard_charge_dollar": 314.88, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "United Healthcare Ba", "plan_name": "750090", "standard_charge_dollar": 314.88, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "United Healthcare Me", "plan_name": "501310", "standard_charge_dollar": 278.66, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Windsor Mcare Extra", "plan_name": "500778", "standard_charge_dollar": 278.66, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." } ] } ] }, { "description": "Fistula repair & colostomy", "code_information": [ { "code": "57307", "type": "CPT" } ], "standard_charges": [ { "gross_charge": 38116.53, "minimum": 30493.22, "maximum": 32399.05, "setting": "inpatient", "payers_information": [ { "payer_name": "Aetna", "plan_name": "700700", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna", "plan_name": "700700_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Miscellaneous", "plan_name": "700720", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Miscellaneous", "plan_name": "700720_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Ppo Hmo", "plan_name": "701720", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Ppo Hmo", "plan_name": "701720_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Ms State Emplo", "plan_name": "401457", "standard_charge_percentage": 0.80, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Ms State Emplo", "plan_name": "401457_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Basic Pl", "plan_name": "400100", "standard_charge_percentage": 0.85, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Basic Pl", "plan_name": "400100_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Federal", "plan_name": "400110", "standard_charge_percentage": 0.85, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Federal", "plan_name": "400110_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." } ] } ] }, { "description": "Repair bladder-vagina lesion", "code_information": [ { "code": "57320", "type": "CPT" } ], "standard_charges": [ { "gross_charge": 68896.77, "minimum": 4522.13, "maximum": 58562.25, "setting": "inpatient", "payers_information": [ { "payer_name": "Aarp", "plan_name": "500102", "standard_charge_dollar": 4522.13, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna", "plan_name": "700700", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna", "plan_name": "700700_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Mcare Ffs 6005", "plan_name": "700703", "standard_charge_dollar": 4522.13, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Miscellaneous", "plan_name": "700720", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Miscellaneous", "plan_name": "700720_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Ppo Hmo", "plan_name": "701720", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Ppo Hmo", "plan_name": "701720_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Ambetter 68069", "plan_name": "500516", "standard_charge_dollar": 4522.13, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Ms State Emplo", "plan_name": "401457", "standard_charge_percentage": 0.80, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Ms State Emplo", "plan_name": "401457_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Basic Pl", "plan_name": "400100", "standard_charge_percentage": 0.85, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Basic Pl", "plan_name": "400100_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Federal", "plan_name": "400110", "standard_charge_percentage": 0.85, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Federal", "plan_name": "400110_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Cigna Healthsprings Ffs", "plan_name": "500064", "standard_charge_dollar": 4522.13, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Conseco", "plan_name": "500302", "standard_charge_dollar": 4522.13, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Humana Ffs 61101", "plan_name": "500006", "standard_charge_dollar": 4522.13, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Medicare A", "plan_name": "100100", "standard_charge_dollar": 4522.13, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Medicare A", "plan_name": "100500", "standard_charge_dollar": 4522.13, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Medicare Part B Only", "plan_name": "100300", "standard_charge_dollar": 4522.13, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Medicare Railroad", "plan_name": "100103", "standard_charge_dollar": 4522.13, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Ms Physicians Care N", "plan_name": "714210", "standard_charge_dollar": 5652.66, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Peoples Hlth Ffs 72126", "plan_name": "500019", "standard_charge_dollar": 4522.13, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Uhc/Secure Horizons", "plan_name": "500449", "standard_charge_dollar": 4522.13, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "United Health Care/", "plan_name": "500292", "standard_charge_dollar": 5110.01, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "United Healthcare", "plan_name": "750104", "standard_charge_dollar": 5110.01, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "United Healthcare Ba", "plan_name": "750090", "standard_charge_dollar": 5110.01, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "United Healthcare Me", "plan_name": "501310", "standard_charge_dollar": 4522.13, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Windsor Mcare Extra", "plan_name": "500778", "standard_charge_dollar": 4522.13, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." } ] } ] }, { "description": "Repair bladder-vagina lesion", "code_information": [ { "code": "57330", "type": "CPT" } ], "standard_charges": [ { "gross_charge": 68896.77, "minimum": 6774.16, "maximum": 58562.25, "setting": "inpatient", "payers_information": [ { "payer_name": "Aarp", "plan_name": "500102", "standard_charge_dollar": 6774.16, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna", "plan_name": "700700", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna", "plan_name": "700700_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Mcare Ffs 6005", "plan_name": "700703", "standard_charge_dollar": 6774.16, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Miscellaneous", "plan_name": "700720", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Miscellaneous", "plan_name": "700720_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Ppo Hmo", "plan_name": "701720", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Ppo Hmo", "plan_name": "701720_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Ambetter 68069", "plan_name": "500516", "standard_charge_dollar": 6774.16, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Ms State Emplo", "plan_name": "401457", "standard_charge_percentage": 0.80, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Ms State Emplo", "plan_name": "401457_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Basic Pl", "plan_name": "400100", "standard_charge_percentage": 0.85, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Basic Pl", "plan_name": "400100_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Federal", "plan_name": "400110", "standard_charge_percentage": 0.85, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Federal", "plan_name": "400110_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Cigna Healthsprings Ffs", "plan_name": "500064", "standard_charge_dollar": 6774.16, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Conseco", "plan_name": "500302", "standard_charge_dollar": 6774.16, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Humana Ffs 61101", "plan_name": "500006", "standard_charge_dollar": 6774.16, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Medicare A", "plan_name": "100100", "standard_charge_dollar": 6774.16, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Medicare A", "plan_name": "100500", "standard_charge_dollar": 6774.16, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Medicare Part B Only", "plan_name": "100300", "standard_charge_dollar": 6774.16, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Medicare Railroad", "plan_name": "100103", "standard_charge_dollar": 6774.16, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Ms Physicians Care N", "plan_name": "714210", "standard_charge_dollar": 8467.70, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Peoples Hlth Ffs 72126", "plan_name": "500019", "standard_charge_dollar": 6774.16, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Uhc/Secure Horizons", "plan_name": "500449", "standard_charge_dollar": 6774.16, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "United Health Care/", "plan_name": "500292", "standard_charge_dollar": 7654.80, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "United Healthcare", "plan_name": "750104", "standard_charge_dollar": 7654.80, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "United Healthcare Ba", "plan_name": "750090", "standard_charge_dollar": 7654.80, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "United Healthcare Me", "plan_name": "501310", "standard_charge_dollar": 6774.16, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Windsor Mcare Extra", "plan_name": "500778", "standard_charge_dollar": 6774.16, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." } ] } ] }, { "description": "Repair vagina", "code_information": [ { "code": "57335", "type": "CPT" } ], "standard_charges": [ { "gross_charge": 9832.34, "minimum": 4522.13, "maximum": 8357.49, "setting": "inpatient", "payers_information": [ { "payer_name": "Aarp", "plan_name": "500102", "standard_charge_dollar": 4522.13, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna", "plan_name": "700700", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna", "plan_name": "700700_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Mcare Ffs 6005", "plan_name": "700703", "standard_charge_dollar": 4522.13, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Miscellaneous", "plan_name": "700720", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Miscellaneous", "plan_name": "700720_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Ppo Hmo", "plan_name": "701720", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Ppo Hmo", "plan_name": "701720_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Ambetter 68069", "plan_name": "500516", "standard_charge_dollar": 4522.13, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Ms State Emplo", "plan_name": "401457", "standard_charge_percentage": 0.80, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Ms State Emplo", "plan_name": "401457_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Basic Pl", "plan_name": "400100", "standard_charge_percentage": 0.85, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Basic Pl", "plan_name": "400100_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Federal", "plan_name": "400110", "standard_charge_percentage": 0.85, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Federal", "plan_name": "400110_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Cigna Healthsprings Ffs", "plan_name": "500064", "standard_charge_dollar": 4522.13, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Conseco", "plan_name": "500302", "standard_charge_dollar": 4522.13, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Humana Ffs 61101", "plan_name": "500006", "standard_charge_dollar": 4522.13, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Medicare A", "plan_name": "100100", "standard_charge_dollar": 4522.13, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Medicare A", "plan_name": "100500", "standard_charge_dollar": 4522.13, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Medicare Part B Only", "plan_name": "100300", "standard_charge_dollar": 4522.13, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Medicare Railroad", "plan_name": "100103", "standard_charge_dollar": 4522.13, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Ms Physicians Care N", "plan_name": "714210", "standard_charge_dollar": 5652.66, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Peoples Hlth Ffs 72126", "plan_name": "500019", "standard_charge_dollar": 4522.13, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Uhc/Secure Horizons", "plan_name": "500449", "standard_charge_dollar": 4522.13, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "United Health Care/", "plan_name": "500292", "standard_charge_dollar": 5110.01, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "United Healthcare", "plan_name": "750104", "standard_charge_dollar": 5110.01, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "United Healthcare Ba", "plan_name": "750090", "standard_charge_dollar": 5110.01, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "United Healthcare Me", "plan_name": "501310", "standard_charge_dollar": 4522.13, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Windsor Mcare Extra", "plan_name": "500778", "standard_charge_dollar": 4522.13, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." } ] } ] }, { "description": "Cam cervix uteri drg colp", "code_information": [ { "code": "57465", "type": "CPT" } ], "standard_charges": [ { "gross_charge": 22407.08, "minimum": 17925.66, "maximum": 19046.02, "setting": "inpatient", "payers_information": [ { "payer_name": "Aetna", "plan_name": "700700", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna", "plan_name": "700700_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Miscellaneous", "plan_name": "700720", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Miscellaneous", "plan_name": "700720_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Ppo Hmo", "plan_name": "701720", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Ppo Hmo", "plan_name": "701720_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Ms State Emplo", "plan_name": "401457", "standard_charge_percentage": 0.80, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Ms State Emplo", "plan_name": "401457_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Basic Pl", "plan_name": "400100", "standard_charge_percentage": 0.85, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Basic Pl", "plan_name": "400100_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Federal", "plan_name": "400110", "standard_charge_percentage": 0.85, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Federal", "plan_name": "400110_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." } ] } ] }, { "description": "Remove cervix/repair pelvis", "code_information": [ { "code": "57545", "type": "CPT" } ], "standard_charges": [ { "gross_charge": 10608.44, "minimum": 8486.75, "maximum": 9017.17, "setting": "inpatient", "payers_information": [ { "payer_name": "Aetna", "plan_name": "700700", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna", "plan_name": "700700_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Miscellaneous", "plan_name": "700720", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Miscellaneous", "plan_name": "700720_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Ppo Hmo", "plan_name": "701720", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Ppo Hmo", "plan_name": "701720_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Ms State Emplo", "plan_name": "401457", "standard_charge_percentage": 0.80, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Ms State Emplo", "plan_name": "401457_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Basic Pl", "plan_name": "400100", "standard_charge_percentage": 0.85, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Basic Pl", "plan_name": "400100_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Federal", "plan_name": "400110", "standard_charge_percentage": 0.85, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Federal", "plan_name": "400110_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." } ] } ] }, { "description": "Total hysterectomy", "code_information": [ { "code": "58150", "type": "CPT" } ], "standard_charges": [ { "gross_charge": 17539.35, "minimum": 14031.48, "maximum": 14908.45, "setting": "inpatient", "payers_information": [ { "payer_name": "Aetna", "plan_name": "700700", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna", "plan_name": "700700_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Miscellaneous", "plan_name": "700720", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Miscellaneous", "plan_name": "700720_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Ppo Hmo", "plan_name": "701720", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Ppo Hmo", "plan_name": "701720_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Ms State Emplo", "plan_name": "401457", "standard_charge_percentage": 0.80, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Ms State Emplo", "plan_name": "401457_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Basic Pl", "plan_name": "400100", "standard_charge_percentage": 0.85, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Basic Pl", "plan_name": "400100_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Federal", "plan_name": "400110", "standard_charge_percentage": 0.85, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Federal", "plan_name": "400110_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." } ] } ] }, { "description": "Total hysterectomy", "code_information": [ { "code": "58152", "type": "CPT" } ], "standard_charges": [ { "gross_charge": 17410.57, "minimum": 13928.46, "maximum": 14798.98, "setting": "inpatient", "payers_information": [ { "payer_name": "Aetna", "plan_name": "700700", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna", "plan_name": "700700_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Miscellaneous", "plan_name": "700720", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Miscellaneous", "plan_name": "700720_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Ppo Hmo", "plan_name": "701720", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Ppo Hmo", "plan_name": "701720_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Ms State Emplo", "plan_name": "401457", "standard_charge_percentage": 0.80, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Ms State Emplo", "plan_name": "401457_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Basic Pl", "plan_name": "400100", "standard_charge_percentage": 0.85, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Basic Pl", "plan_name": "400100_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Federal", "plan_name": "400110", "standard_charge_percentage": 0.85, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Federal", "plan_name": "400110_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." } ] } ] }, { "description": "Partial hysterectomy", "code_information": [ { "code": "58180", "type": "CPT" } ], "standard_charges": [ { "gross_charge": 17539.35, "minimum": 14031.48, "maximum": 14908.45, "setting": "inpatient", "payers_information": [ { "payer_name": "Aetna", "plan_name": "700700", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna", "plan_name": "700700_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Miscellaneous", "plan_name": "700720", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Miscellaneous", "plan_name": "700720_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Ppo Hmo", "plan_name": "701720", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Ppo Hmo", "plan_name": "701720_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Ms State Emplo", "plan_name": "401457", "standard_charge_percentage": 0.80, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Ms State Emplo", "plan_name": "401457_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Basic Pl", "plan_name": "400100", "standard_charge_percentage": 0.85, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Basic Pl", "plan_name": "400100_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Federal", "plan_name": "400110", "standard_charge_percentage": 0.85, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Federal", "plan_name": "400110_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." } ] } ] }, { "description": "Extensive hysterectomy", "code_information": [ { "code": "58200", "type": "CPT" } ], "standard_charges": [ { "gross_charge": 17410.57, "minimum": 13928.46, "maximum": 14798.98, "setting": "inpatient", "payers_information": [ { "payer_name": "Aetna", "plan_name": "700700", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna", "plan_name": "700700_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Miscellaneous", "plan_name": "700720", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Miscellaneous", "plan_name": "700720_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Ppo Hmo", "plan_name": "701720", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Ppo Hmo", "plan_name": "701720_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Ms State Emplo", "plan_name": "401457", "standard_charge_percentage": 0.80, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Ms State Emplo", "plan_name": "401457_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Basic Pl", "plan_name": "400100", "standard_charge_percentage": 0.85, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Basic Pl", "plan_name": "400100_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Federal", "plan_name": "400110", "standard_charge_percentage": 0.85, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Federal", "plan_name": "400110_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." } ] } ] }, { "description": "Extensive hysterectomy", "code_information": [ { "code": "58210", "type": "CPT" } ], "standard_charges": [ { "gross_charge": 17410.57, "minimum": 13928.46, "maximum": 14798.98, "setting": "inpatient", "payers_information": [ { "payer_name": "Aetna", "plan_name": "700700", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna", "plan_name": "700700_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Miscellaneous", "plan_name": "700720", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Miscellaneous", "plan_name": "700720_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Ppo Hmo", "plan_name": "701720", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Ppo Hmo", "plan_name": "701720_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Ms State Emplo", "plan_name": "401457", "standard_charge_percentage": 0.80, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Ms State Emplo", "plan_name": "401457_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Basic Pl", "plan_name": "400100", "standard_charge_percentage": 0.85, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Basic Pl", "plan_name": "400100_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Federal", "plan_name": "400110", "standard_charge_percentage": 0.85, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Federal", "plan_name": "400110_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." } ] } ] }, { "description": "Removal of pelvis contents", "code_information": [ { "code": "58240", "type": "CPT" } ], "standard_charges": [ { "gross_charge": 20491.40, "minimum": 16393.12, "maximum": 17417.69, "setting": "inpatient", "payers_information": [ { "payer_name": "Aetna", "plan_name": "700700", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna", "plan_name": "700700_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Miscellaneous", "plan_name": "700720", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Miscellaneous", "plan_name": "700720_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Ppo Hmo", "plan_name": "701720", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Ppo Hmo", "plan_name": "701720_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Ms State Emplo", "plan_name": "401457", "standard_charge_percentage": 0.80, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Ms State Emplo", "plan_name": "401457_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Basic Pl", "plan_name": "400100", "standard_charge_percentage": 0.85, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Basic Pl", "plan_name": "400100_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Federal", "plan_name": "400110", "standard_charge_percentage": 0.85, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Federal", "plan_name": "400110_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." } ] } ] }, { "description": "Lsh uterus 250 g or less", "code_information": [ { "code": "58541", "type": "CPT" } ], "standard_charges": [ { "gross_charge": 16854.42, "minimum": 9537.40, "maximum": 14326.26, "setting": "inpatient", "payers_information": [ { "payer_name": "Aarp", "plan_name": "500102", "standard_charge_dollar": 9537.40, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna", "plan_name": "700700", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna", "plan_name": "700700_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Mcare Ffs 6005", "plan_name": "700703", "standard_charge_dollar": 9537.40, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Miscellaneous", "plan_name": "700720", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Miscellaneous", "plan_name": "700720_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Ppo Hmo", "plan_name": "701720", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Ppo Hmo", "plan_name": "701720_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Ambetter 68069", "plan_name": "500516", "standard_charge_dollar": 9537.40, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Ms State Emplo", "plan_name": "401457", "standard_charge_percentage": 0.80, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Ms State Emplo", "plan_name": "401457_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Basic Pl", "plan_name": "400100", "standard_charge_percentage": 0.85, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Basic Pl", "plan_name": "400100_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Federal", "plan_name": "400110", "standard_charge_percentage": 0.85, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Federal", "plan_name": "400110_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Cigna Healthsprings Ffs", "plan_name": "500064", "standard_charge_dollar": 9537.40, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Conseco", "plan_name": "500302", "standard_charge_dollar": 9537.40, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Humana Ffs 61101", "plan_name": "500006", "standard_charge_dollar": 9537.40, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Medicare A", "plan_name": "100100", "standard_charge_dollar": 9537.40, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Medicare A", "plan_name": "100500", "standard_charge_dollar": 9537.40, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Medicare Part B Only", "plan_name": "100300", "standard_charge_dollar": 9537.40, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Medicare Railroad", "plan_name": "100103", "standard_charge_dollar": 9537.40, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Ms Physicians Care N", "plan_name": "714210", "standard_charge_dollar": 11921.75, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Peoples Hlth Ffs 72126", "plan_name": "500019", "standard_charge_dollar": 9537.40, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Uhc/Secure Horizons", "plan_name": "500449", "standard_charge_dollar": 9537.40, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "United Health Care/", "plan_name": "500292", "standard_charge_dollar": 10777.26, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "United Healthcare", "plan_name": "750104", "standard_charge_dollar": 10777.26, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "United Healthcare Ba", "plan_name": "750090", "standard_charge_dollar": 10777.26, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "United Healthcare Me", "plan_name": "501310", "standard_charge_dollar": 9537.40, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Windsor Mcare Extra", "plan_name": "500778", "standard_charge_dollar": 9537.40, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." } ] } ] }, { "description": "Lsh w/t/o ut 250 g or less", "code_information": [ { "code": "58542", "type": "CPT" } ], "standard_charges": [ { "gross_charge": 24346.75, "minimum": 9537.40, "maximum": 20694.74, "setting": "inpatient", "payers_information": [ { "payer_name": "Aarp", "plan_name": "500102", "standard_charge_dollar": 9537.40, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna", "plan_name": "700700", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna", "plan_name": "700700_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Mcare Ffs 6005", "plan_name": "700703", "standard_charge_dollar": 9537.40, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Miscellaneous", "plan_name": "700720", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Miscellaneous", "plan_name": "700720_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Ppo Hmo", "plan_name": "701720", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Ppo Hmo", "plan_name": "701720_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Ambetter 68069", "plan_name": "500516", "standard_charge_dollar": 9537.40, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Ms State Emplo", "plan_name": "401457", "standard_charge_percentage": 0.80, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Ms State Emplo", "plan_name": "401457_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Basic Pl", "plan_name": "400100", "standard_charge_percentage": 0.85, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Basic Pl", "plan_name": "400100_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Federal", "plan_name": "400110", "standard_charge_percentage": 0.85, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Federal", "plan_name": "400110_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Cigna Healthsprings Ffs", "plan_name": "500064", "standard_charge_dollar": 9537.40, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Conseco", "plan_name": "500302", "standard_charge_dollar": 9537.40, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Humana Ffs 61101", "plan_name": "500006", "standard_charge_dollar": 9537.40, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Medicare A", "plan_name": "100100", "standard_charge_dollar": 9537.40, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Medicare A", "plan_name": "100500", "standard_charge_dollar": 9537.40, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Medicare Part B Only", "plan_name": "100300", "standard_charge_dollar": 9537.40, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Medicare Railroad", "plan_name": "100103", "standard_charge_dollar": 9537.40, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Ms Physicians Care N", "plan_name": "714210", "standard_charge_dollar": 11921.75, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Peoples Hlth Ffs 72126", "plan_name": "500019", "standard_charge_dollar": 9537.40, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Uhc/Secure Horizons", "plan_name": "500449", "standard_charge_dollar": 9537.40, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "United Health Care/", "plan_name": "500292", "standard_charge_dollar": 10777.26, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "United Healthcare", "plan_name": "750104", "standard_charge_dollar": 10777.26, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "United Healthcare Ba", "plan_name": "750090", "standard_charge_dollar": 10777.26, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "United Healthcare Me", "plan_name": "501310", "standard_charge_dollar": 9537.40, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Windsor Mcare Extra", "plan_name": "500778", "standard_charge_dollar": 9537.40, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." } ] } ] }, { "description": "Lsh uterus above 250 g", "code_information": [ { "code": "58543", "type": "CPT" } ], "standard_charges": [ { "gross_charge": 16854.42, "minimum": 9537.40, "maximum": 14326.26, "setting": "inpatient", "payers_information": [ { "payer_name": "Aarp", "plan_name": "500102", "standard_charge_dollar": 9537.40, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna", "plan_name": "700700", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna", "plan_name": "700700_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Mcare Ffs 6005", "plan_name": "700703", "standard_charge_dollar": 9537.40, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Miscellaneous", "plan_name": "700720", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Miscellaneous", "plan_name": "700720_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Ppo Hmo", "plan_name": "701720", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Ppo Hmo", "plan_name": "701720_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Ambetter 68069", "plan_name": "500516", "standard_charge_dollar": 9537.40, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Ms State Emplo", "plan_name": "401457", "standard_charge_percentage": 0.80, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Ms State Emplo", "plan_name": "401457_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Basic Pl", "plan_name": "400100", "standard_charge_percentage": 0.85, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Basic Pl", "plan_name": "400100_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Federal", "plan_name": "400110", "standard_charge_percentage": 0.85, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Federal", "plan_name": "400110_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Cigna Healthsprings Ffs", "plan_name": "500064", "standard_charge_dollar": 9537.40, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Conseco", "plan_name": "500302", "standard_charge_dollar": 9537.40, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Humana Ffs 61101", "plan_name": "500006", "standard_charge_dollar": 9537.40, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Medicare A", "plan_name": "100100", "standard_charge_dollar": 9537.40, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Medicare A", "plan_name": "100500", "standard_charge_dollar": 9537.40, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Medicare Part B Only", "plan_name": "100300", "standard_charge_dollar": 9537.40, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Medicare Railroad", "plan_name": "100103", "standard_charge_dollar": 9537.40, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Ms Physicians Care N", "plan_name": "714210", "standard_charge_dollar": 11921.75, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Peoples Hlth Ffs 72126", "plan_name": "500019", "standard_charge_dollar": 9537.40, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Uhc/Secure Horizons", "plan_name": "500449", "standard_charge_dollar": 9537.40, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "United Health Care/", "plan_name": "500292", "standard_charge_dollar": 10777.26, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "United Healthcare", "plan_name": "750104", "standard_charge_dollar": 10777.26, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "United Healthcare Ba", "plan_name": "750090", "standard_charge_dollar": 10777.26, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "United Healthcare Me", "plan_name": "501310", "standard_charge_dollar": 9537.40, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Windsor Mcare Extra", "plan_name": "500778", "standard_charge_dollar": 9537.40, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." } ] } ] }, { "description": "Lsh w/t/o uterus above 250 g", "code_information": [ { "code": "58544", "type": "CPT" } ], "standard_charges": [ { "gross_charge": 24346.75, "minimum": 9537.40, "maximum": 20694.74, "setting": "inpatient", "payers_information": [ { "payer_name": "Aarp", "plan_name": "500102", "standard_charge_dollar": 9537.40, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna", "plan_name": "700700", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna", "plan_name": "700700_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Mcare Ffs 6005", "plan_name": "700703", "standard_charge_dollar": 9537.40, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Miscellaneous", "plan_name": "700720", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Miscellaneous", "plan_name": "700720_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Ppo Hmo", "plan_name": "701720", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Ppo Hmo", "plan_name": "701720_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Ambetter 68069", "plan_name": "500516", "standard_charge_dollar": 9537.40, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Ms State Emplo", "plan_name": "401457", "standard_charge_percentage": 0.80, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Ms State Emplo", "plan_name": "401457_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Basic Pl", "plan_name": "400100", "standard_charge_percentage": 0.85, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Basic Pl", "plan_name": "400100_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Federal", "plan_name": "400110", "standard_charge_percentage": 0.85, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Federal", "plan_name": "400110_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Cigna Healthsprings Ffs", "plan_name": "500064", "standard_charge_dollar": 9537.40, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Conseco", "plan_name": "500302", "standard_charge_dollar": 9537.40, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Humana Ffs 61101", "plan_name": "500006", "standard_charge_dollar": 9537.40, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Medicare A", "plan_name": "100100", "standard_charge_dollar": 9537.40, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Medicare A", "plan_name": "100500", "standard_charge_dollar": 9537.40, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Medicare Part B Only", "plan_name": "100300", "standard_charge_dollar": 9537.40, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Medicare Railroad", "plan_name": "100103", "standard_charge_dollar": 9537.40, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Ms Physicians Care N", "plan_name": "714210", "standard_charge_dollar": 11921.75, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Peoples Hlth Ffs 72126", "plan_name": "500019", "standard_charge_dollar": 9537.40, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Uhc/Secure Horizons", "plan_name": "500449", "standard_charge_dollar": 9537.40, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "United Health Care/", "plan_name": "500292", "standard_charge_dollar": 10777.26, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "United Healthcare", "plan_name": "750104", "standard_charge_dollar": 10777.26, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "United Healthcare Ba", "plan_name": "750090", "standard_charge_dollar": 10777.26, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "United Healthcare Me", "plan_name": "501310", "standard_charge_dollar": 9537.40, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Windsor Mcare Extra", "plan_name": "500778", "standard_charge_dollar": 9537.40, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." } ] } ] }, { "description": "Lap radical hyst", "code_information": [ { "code": "58548", "type": "CPT" } ], "standard_charges": [ { "gross_charge": 24346.75, "minimum": 19477.40, "maximum": 20694.74, "setting": "inpatient", "payers_information": [ { "payer_name": "Aetna", "plan_name": "700700", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna", "plan_name": "700700_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Miscellaneous", "plan_name": "700720", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Miscellaneous", "plan_name": "700720_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Ppo Hmo", "plan_name": "701720", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Ppo Hmo", "plan_name": "701720_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Ms State Emplo", "plan_name": "401457", "standard_charge_percentage": 0.80, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Ms State Emplo", "plan_name": "401457_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Basic Pl", "plan_name": "400100", "standard_charge_percentage": 0.85, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Basic Pl", "plan_name": "400100_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Federal", "plan_name": "400110", "standard_charge_percentage": 0.85, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Federal", "plan_name": "400110_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." } ] } ] }, { "description": "Laparo-asst vag hysterectomy", "code_information": [ { "code": "58550", "type": "CPT" } ], "standard_charges": [ { "gross_charge": 16041.25, "minimum": 5344.68, "maximum": 13635.06, "setting": "inpatient", "payers_information": [ { "payer_name": "Aarp", "plan_name": "500102", "standard_charge_dollar": 5344.68, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna", "plan_name": "700700", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna", "plan_name": "700700_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Mcare Ffs 6005", "plan_name": "700703", "standard_charge_dollar": 5344.68, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Miscellaneous", "plan_name": "700720", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Miscellaneous", "plan_name": "700720_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Ppo Hmo", "plan_name": "701720", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Ppo Hmo", "plan_name": "701720_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Ambetter 68069", "plan_name": "500516", "standard_charge_dollar": 5344.68, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Ms State Emplo", "plan_name": "401457", "standard_charge_percentage": 0.80, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Ms State Emplo", "plan_name": "401457_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Basic Pl", "plan_name": "400100", "standard_charge_percentage": 0.85, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Basic Pl", "plan_name": "400100_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Federal", "plan_name": "400110", "standard_charge_percentage": 0.85, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Federal", "plan_name": "400110_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Cigna Healthsprings Ffs", "plan_name": "500064", "standard_charge_dollar": 5344.68, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Conseco", "plan_name": "500302", "standard_charge_dollar": 5344.68, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Humana Ffs 61101", "plan_name": "500006", "standard_charge_dollar": 5344.68, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Medicare A", "plan_name": "100100", "standard_charge_dollar": 5344.68, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Medicare A", "plan_name": "100500", "standard_charge_dollar": 5344.68, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Medicare Part B Only", "plan_name": "100300", "standard_charge_dollar": 5344.68, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Medicare Railroad", "plan_name": "100103", "standard_charge_dollar": 5344.68, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Ms Physicians Care N", "plan_name": "714210", "standard_charge_dollar": 6680.85, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Peoples Hlth Ffs 72126", "plan_name": "500019", "standard_charge_dollar": 5344.68, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Uhc/Secure Horizons", "plan_name": "500449", "standard_charge_dollar": 5344.68, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "United Health Care/", "plan_name": "500292", "standard_charge_dollar": 6039.49, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "United Healthcare", "plan_name": "750104", "standard_charge_dollar": 6039.49, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "United Healthcare Ba", "plan_name": "750090", "standard_charge_dollar": 6039.49, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "United Healthcare Me", "plan_name": "501310", "standard_charge_dollar": 5344.68, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Windsor Mcare Extra", "plan_name": "500778", "standard_charge_dollar": 5344.68, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." } ] } ] }, { "description": "Laparo-vag hyst complex", "code_information": [ { "code": "58553", "type": "CPT" } ], "standard_charges": [ { "gross_charge": 16041.25, "minimum": 9537.40, "maximum": 13635.06, "setting": "inpatient", "payers_information": [ { "payer_name": "Aarp", "plan_name": "500102", "standard_charge_dollar": 9537.40, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna", "plan_name": "700700", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna", "plan_name": "700700_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Mcare Ffs 6005", "plan_name": "700703", "standard_charge_dollar": 9537.40, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Miscellaneous", "plan_name": "700720", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Miscellaneous", "plan_name": "700720_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Ppo Hmo", "plan_name": "701720", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Ppo Hmo", "plan_name": "701720_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Ambetter 68069", "plan_name": "500516", "standard_charge_dollar": 9537.40, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Ms State Emplo", "plan_name": "401457", "standard_charge_percentage": 0.80, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Ms State Emplo", "plan_name": "401457_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Basic Pl", "plan_name": "400100", "standard_charge_percentage": 0.85, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Basic Pl", "plan_name": "400100_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Federal", "plan_name": "400110", "standard_charge_percentage": 0.85, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Federal", "plan_name": "400110_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Cigna Healthsprings Ffs", "plan_name": "500064", "standard_charge_dollar": 9537.40, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Conseco", "plan_name": "500302", "standard_charge_dollar": 9537.40, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Humana Ffs 61101", "plan_name": "500006", "standard_charge_dollar": 9537.40, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Medicare A", "plan_name": "100100", "standard_charge_dollar": 9537.40, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Medicare A", "plan_name": "100500", "standard_charge_dollar": 9537.40, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Medicare Part B Only", "plan_name": "100300", "standard_charge_dollar": 9537.40, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Medicare Railroad", "plan_name": "100103", "standard_charge_dollar": 9537.40, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Ms Physicians Care N", "plan_name": "714210", "standard_charge_dollar": 11921.75, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Peoples Hlth Ffs 72126", "plan_name": "500019", "standard_charge_dollar": 9537.40, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Uhc/Secure Horizons", "plan_name": "500449", "standard_charge_dollar": 9537.40, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "United Health Care/", "plan_name": "500292", "standard_charge_dollar": 10777.26, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "United Healthcare", "plan_name": "750104", "standard_charge_dollar": 10777.26, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "United Healthcare Ba", "plan_name": "750090", "standard_charge_dollar": 10777.26, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "United Healthcare Me", "plan_name": "501310", "standard_charge_dollar": 9537.40, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Windsor Mcare Extra", "plan_name": "500778", "standard_charge_dollar": 9537.40, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." } ] } ] }, { "description": "Tlh uterus 250 g or less", "code_information": [ { "code": "58570", "type": "CPT" } ], "standard_charges": [ { "gross_charge": 16854.42, "minimum": 9537.40, "maximum": 14326.26, "setting": "inpatient", "payers_information": [ { "payer_name": "Aarp", "plan_name": "500102", "standard_charge_dollar": 9537.40, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna", "plan_name": "700700", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna", "plan_name": "700700_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Mcare Ffs 6005", "plan_name": "700703", "standard_charge_dollar": 9537.40, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Miscellaneous", "plan_name": "700720", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Miscellaneous", "plan_name": "700720_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Ppo Hmo", "plan_name": "701720", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Ppo Hmo", "plan_name": "701720_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Ambetter 68069", "plan_name": "500516", "standard_charge_dollar": 9537.40, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Ms State Emplo", "plan_name": "401457", "standard_charge_percentage": 0.80, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Ms State Emplo", "plan_name": "401457_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Basic Pl", "plan_name": "400100", "standard_charge_percentage": 0.85, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Basic Pl", "plan_name": "400100_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Federal", "plan_name": "400110", "standard_charge_percentage": 0.85, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Federal", "plan_name": "400110_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Cigna Healthsprings Ffs", "plan_name": "500064", "standard_charge_dollar": 9537.40, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Conseco", "plan_name": "500302", "standard_charge_dollar": 9537.40, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Humana Ffs 61101", "plan_name": "500006", "standard_charge_dollar": 9537.40, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Medicare A", "plan_name": "100100", "standard_charge_dollar": 9537.40, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Medicare A", "plan_name": "100500", "standard_charge_dollar": 9537.40, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Medicare Part B Only", "plan_name": "100300", "standard_charge_dollar": 9537.40, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Medicare Railroad", "plan_name": "100103", "standard_charge_dollar": 9537.40, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Ms Physicians Care N", "plan_name": "714210", "standard_charge_dollar": 11921.75, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Peoples Hlth Ffs 72126", "plan_name": "500019", "standard_charge_dollar": 9537.40, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Uhc/Secure Horizons", "plan_name": "500449", "standard_charge_dollar": 9537.40, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "United Health Care/", "plan_name": "500292", "standard_charge_dollar": 10777.26, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "United Healthcare", "plan_name": "750104", "standard_charge_dollar": 10777.26, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "United Healthcare Ba", "plan_name": "750090", "standard_charge_dollar": 10777.26, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "United Healthcare Me", "plan_name": "501310", "standard_charge_dollar": 9537.40, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Windsor Mcare Extra", "plan_name": "500778", "standard_charge_dollar": 9537.40, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." } ] } ] }, { "description": "Tlh w/t/o 250 g or less", "code_information": [ { "code": "58571", "type": "CPT" } ], "standard_charges": [ { "gross_charge": 24346.75, "minimum": 9537.40, "maximum": 20694.74, "setting": "inpatient", "payers_information": [ { "payer_name": "Aarp", "plan_name": "500102", "standard_charge_dollar": 9537.40, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna", "plan_name": "700700", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna", "plan_name": "700700_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Mcare Ffs 6005", "plan_name": "700703", "standard_charge_dollar": 9537.40, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Miscellaneous", "plan_name": "700720", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Miscellaneous", "plan_name": "700720_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Ppo Hmo", "plan_name": "701720", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Ppo Hmo", "plan_name": "701720_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Ambetter 68069", "plan_name": "500516", "standard_charge_dollar": 9537.40, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Ms State Emplo", "plan_name": "401457", "standard_charge_percentage": 0.80, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Ms State Emplo", "plan_name": "401457_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Basic Pl", "plan_name": "400100", "standard_charge_percentage": 0.85, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Basic Pl", "plan_name": "400100_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Federal", "plan_name": "400110", "standard_charge_percentage": 0.85, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Federal", "plan_name": "400110_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Cigna Healthsprings Ffs", "plan_name": "500064", "standard_charge_dollar": 9537.40, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Conseco", "plan_name": "500302", "standard_charge_dollar": 9537.40, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Humana Ffs 61101", "plan_name": "500006", "standard_charge_dollar": 9537.40, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Medicare A", "plan_name": "100100", "standard_charge_dollar": 9537.40, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Medicare A", "plan_name": "100500", "standard_charge_dollar": 9537.40, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Medicare Part B Only", "plan_name": "100300", "standard_charge_dollar": 9537.40, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Medicare Railroad", "plan_name": "100103", "standard_charge_dollar": 9537.40, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Ms Physicians Care N", "plan_name": "714210", "standard_charge_dollar": 11921.75, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Peoples Hlth Ffs 72126", "plan_name": "500019", "standard_charge_dollar": 9537.40, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Uhc/Secure Horizons", "plan_name": "500449", "standard_charge_dollar": 9537.40, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "United Health Care/", "plan_name": "500292", "standard_charge_dollar": 10777.26, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "United Healthcare", "plan_name": "750104", "standard_charge_dollar": 10777.26, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "United Healthcare Ba", "plan_name": "750090", "standard_charge_dollar": 10777.26, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "United Healthcare Me", "plan_name": "501310", "standard_charge_dollar": 9537.40, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Windsor Mcare Extra", "plan_name": "500778", "standard_charge_dollar": 9537.40, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." } ] } ] }, { "description": "Tlh uterus over 250 g", "code_information": [ { "code": "58572", "type": "CPT" } ], "standard_charges": [ { "gross_charge": 16854.42, "minimum": 9537.40, "maximum": 14326.26, "setting": "inpatient", "payers_information": [ { "payer_name": "Aarp", "plan_name": "500102", "standard_charge_dollar": 9537.40, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna", "plan_name": "700700", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna", "plan_name": "700700_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Mcare Ffs 6005", "plan_name": "700703", "standard_charge_dollar": 9537.40, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Miscellaneous", "plan_name": "700720", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Miscellaneous", "plan_name": "700720_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Ppo Hmo", "plan_name": "701720", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Ppo Hmo", "plan_name": "701720_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Ambetter 68069", "plan_name": "500516", "standard_charge_dollar": 9537.40, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Ms State Emplo", "plan_name": "401457", "standard_charge_percentage": 0.80, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Ms State Emplo", "plan_name": "401457_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Basic Pl", "plan_name": "400100", "standard_charge_percentage": 0.85, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Basic Pl", "plan_name": "400100_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Federal", "plan_name": "400110", "standard_charge_percentage": 0.85, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Federal", "plan_name": "400110_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Cigna Healthsprings Ffs", "plan_name": "500064", "standard_charge_dollar": 9537.40, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Conseco", "plan_name": "500302", "standard_charge_dollar": 9537.40, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Humana Ffs 61101", "plan_name": "500006", "standard_charge_dollar": 9537.40, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Medicare A", "plan_name": "100100", "standard_charge_dollar": 9537.40, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Medicare A", "plan_name": "100500", "standard_charge_dollar": 9537.40, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Medicare Part B Only", "plan_name": "100300", "standard_charge_dollar": 9537.40, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Medicare Railroad", "plan_name": "100103", "standard_charge_dollar": 9537.40, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Ms Physicians Care N", "plan_name": "714210", "standard_charge_dollar": 11921.75, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Peoples Hlth Ffs 72126", "plan_name": "500019", "standard_charge_dollar": 9537.40, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Uhc/Secure Horizons", "plan_name": "500449", "standard_charge_dollar": 9537.40, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "United Health Care/", "plan_name": "500292", "standard_charge_dollar": 10777.26, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "United Healthcare", "plan_name": "750104", "standard_charge_dollar": 10777.26, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "United Healthcare Ba", "plan_name": "750090", "standard_charge_dollar": 10777.26, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "United Healthcare Me", "plan_name": "501310", "standard_charge_dollar": 9537.40, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Windsor Mcare Extra", "plan_name": "500778", "standard_charge_dollar": 9537.40, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." } ] } ] }, { "description": "Tlh w/t/o uterus over 250 g", "code_information": [ { "code": "58573", "type": "CPT" } ], "standard_charges": [ { "gross_charge": 24346.75, "minimum": 9537.40, "maximum": 20694.74, "setting": "inpatient", "payers_information": [ { "payer_name": "Aarp", "plan_name": "500102", "standard_charge_dollar": 9537.40, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna", "plan_name": "700700", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna", "plan_name": "700700_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Mcare Ffs 6005", "plan_name": "700703", "standard_charge_dollar": 9537.40, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Miscellaneous", "plan_name": "700720", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Miscellaneous", "plan_name": "700720_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Ppo Hmo", "plan_name": "701720", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Ppo Hmo", "plan_name": "701720_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Ambetter 68069", "plan_name": "500516", "standard_charge_dollar": 9537.40, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Ms State Emplo", "plan_name": "401457", "standard_charge_percentage": 0.80, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Ms State Emplo", "plan_name": "401457_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Basic Pl", "plan_name": "400100", "standard_charge_percentage": 0.85, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Basic Pl", "plan_name": "400100_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Federal", "plan_name": "400110", "standard_charge_percentage": 0.85, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Federal", "plan_name": "400110_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Cigna Healthsprings Ffs", "plan_name": "500064", "standard_charge_dollar": 9537.40, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Conseco", "plan_name": "500302", "standard_charge_dollar": 9537.40, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Humana Ffs 61101", "plan_name": "500006", "standard_charge_dollar": 9537.40, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Medicare A", "plan_name": "100100", "standard_charge_dollar": 9537.40, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Medicare A", "plan_name": "100500", "standard_charge_dollar": 9537.40, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Medicare Part B Only", "plan_name": "100300", "standard_charge_dollar": 9537.40, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Medicare Railroad", "plan_name": "100103", "standard_charge_dollar": 9537.40, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Ms Physicians Care N", "plan_name": "714210", "standard_charge_dollar": 11921.75, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Peoples Hlth Ffs 72126", "plan_name": "500019", "standard_charge_dollar": 9537.40, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Uhc/Secure Horizons", "plan_name": "500449", "standard_charge_dollar": 9537.40, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "United Health Care/", "plan_name": "500292", "standard_charge_dollar": 10777.26, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "United Healthcare", "plan_name": "750104", "standard_charge_dollar": 10777.26, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "United Healthcare Ba", "plan_name": "750090", "standard_charge_dollar": 10777.26, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "United Healthcare Me", "plan_name": "501310", "standard_charge_dollar": 9537.40, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Windsor Mcare Extra", "plan_name": "500778", "standard_charge_dollar": 9537.40, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." } ] } ] }, { "description": "Laps tot hyst resj mal", "code_information": [ { "code": "58575", "type": "CPT" } ], "standard_charges": [ { "gross_charge": 24346.75, "minimum": 19477.40, "maximum": 20694.74, "setting": "inpatient", "payers_information": [ { "payer_name": "Aetna", "plan_name": "700700", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna", "plan_name": "700700_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Miscellaneous", "plan_name": "700720", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Miscellaneous", "plan_name": "700720_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Ppo Hmo", "plan_name": "701720", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Ppo Hmo", "plan_name": "701720_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Ms State Emplo", "plan_name": "401457", "standard_charge_percentage": 0.80, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Ms State Emplo", "plan_name": "401457_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Basic Pl", "plan_name": "400100", "standard_charge_percentage": 0.85, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Basic Pl", "plan_name": "400100_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Federal", "plan_name": "400110", "standard_charge_percentage": 0.85, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Federal", "plan_name": "400110_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." } ] } ] }, { "description": "Laparoscopy remove adnexa", "code_information": [ { "code": "58661", "type": "CPT" } ], "standard_charges": [ { "gross_charge": 31839.07, "minimum": 5344.68, "maximum": 27063.21, "setting": "inpatient", "payers_information": [ { "payer_name": "Aarp", "plan_name": "500102", "standard_charge_dollar": 5344.68, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna", "plan_name": "700700", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna", "plan_name": "700700_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Mcare Ffs 6005", "plan_name": "700703", "standard_charge_dollar": 5344.68, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Miscellaneous", "plan_name": "700720", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Miscellaneous", "plan_name": "700720_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Ppo Hmo", "plan_name": "701720", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Ppo Hmo", "plan_name": "701720_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Ambetter 68069", "plan_name": "500516", "standard_charge_dollar": 5344.68, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Ms State Emplo", "plan_name": "401457", "standard_charge_percentage": 0.80, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Ms State Emplo", "plan_name": "401457_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Basic Pl", "plan_name": "400100", "standard_charge_percentage": 0.85, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Basic Pl", "plan_name": "400100_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Federal", "plan_name": "400110", "standard_charge_percentage": 0.85, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Federal", "plan_name": "400110_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Cigna Healthsprings Ffs", "plan_name": "500064", "standard_charge_dollar": 5344.68, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Conseco", "plan_name": "500302", "standard_charge_dollar": 5344.68, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Humana Ffs 61101", "plan_name": "500006", "standard_charge_dollar": 5344.68, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Medicare A", "plan_name": "100100", "standard_charge_dollar": 5344.68, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Medicare A", "plan_name": "100500", "standard_charge_dollar": 5344.68, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Medicare Part B Only", "plan_name": "100300", "standard_charge_dollar": 5344.68, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Medicare Railroad", "plan_name": "100103", "standard_charge_dollar": 5344.68, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Ms Physicians Care N", "plan_name": "714210", "standard_charge_dollar": 6680.85, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Peoples Hlth Ffs 72126", "plan_name": "500019", "standard_charge_dollar": 5344.68, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Uhc/Secure Horizons", "plan_name": "500449", "standard_charge_dollar": 5344.68, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "United Health Care/", "plan_name": "500292", "standard_charge_dollar": 6039.49, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "United Healthcare", "plan_name": "750104", "standard_charge_dollar": 6039.49, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "United Healthcare Ba", "plan_name": "750090", "standard_charge_dollar": 6039.49, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "United Healthcare Me", "plan_name": "501310", "standard_charge_dollar": 5344.68, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Windsor Mcare Extra", "plan_name": "500778", "standard_charge_dollar": 5344.68, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." } ] } ] }, { "description": "Removal of fallopian tube", "code_information": [ { "code": "58700", "type": "CPT" } ], "standard_charges": [ { "gross_charge": 17008.36, "minimum": 13606.69, "maximum": 14457.11, "setting": "inpatient", "payers_information": [ { "payer_name": "Aetna", "plan_name": "700700", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna", "plan_name": "700700_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Miscellaneous", "plan_name": "700720", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Miscellaneous", "plan_name": "700720_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Ppo Hmo", "plan_name": "701720", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Ppo Hmo", "plan_name": "701720_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Ms State Emplo", "plan_name": "401457", "standard_charge_percentage": 0.80, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Ms State Emplo", "plan_name": "401457_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Basic Pl", "plan_name": "400100", "standard_charge_percentage": 0.85, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Basic Pl", "plan_name": "400100_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Federal", "plan_name": "400110", "standard_charge_percentage": 0.85, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Federal", "plan_name": "400110_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." } ] } ] }, { "description": "Removal of ovary/tube(s)", "code_information": [ { "code": "58720", "type": "CPT" } ], "standard_charges": [ { "gross_charge": 19404.09, "minimum": 15523.27, "maximum": 16493.48, "setting": "inpatient", "payers_information": [ { "payer_name": "Aetna", "plan_name": "700700", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna", "plan_name": "700700_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Miscellaneous", "plan_name": "700720", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Miscellaneous", "plan_name": "700720_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Ppo Hmo", "plan_name": "701720", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Ppo Hmo", "plan_name": "701720_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Ms State Emplo", "plan_name": "401457", "standard_charge_percentage": 0.80, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Ms State Emplo", "plan_name": "401457_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Basic Pl", "plan_name": "400100", "standard_charge_percentage": 0.85, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Basic Pl", "plan_name": "400100_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Federal", "plan_name": "400110", "standard_charge_percentage": 0.85, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Federal", "plan_name": "400110_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." } ] } ] }, { "description": "Removal of ovary(s)", "code_information": [ { "code": "58940", "type": "CPT" } ], "standard_charges": [ { "gross_charge": 20088.58, "minimum": 16070.86, "maximum": 17075.29, "setting": "inpatient", "payers_information": [ { "payer_name": "Aetna", "plan_name": "700700", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna", "plan_name": "700700_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Miscellaneous", "plan_name": "700720", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Miscellaneous", "plan_name": "700720_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Ppo Hmo", "plan_name": "701720", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Ppo Hmo", "plan_name": "701720_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Ms State Emplo", "plan_name": "401457", "standard_charge_percentage": 0.80, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Ms State Emplo", "plan_name": "401457_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Basic Pl", "plan_name": "400100", "standard_charge_percentage": 0.85, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Basic Pl", "plan_name": "400100_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Federal", "plan_name": "400110", "standard_charge_percentage": 0.85, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Federal", "plan_name": "400110_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." } ] } ] }, { "description": "Removal of ovary(s)", "code_information": [ { "code": "58943", "type": "CPT" } ], "standard_charges": [ { "gross_charge": 19404.09, "minimum": 15523.27, "maximum": 16493.48, "setting": "inpatient", "payers_information": [ { "payer_name": "Aetna", "plan_name": "700700", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna", "plan_name": "700700_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Miscellaneous", "plan_name": "700720", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Miscellaneous", "plan_name": "700720_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Ppo Hmo", "plan_name": "701720", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Ppo Hmo", "plan_name": "701720_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Ms State Emplo", "plan_name": "401457", "standard_charge_percentage": 0.80, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Ms State Emplo", "plan_name": "401457_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Basic Pl", "plan_name": "400100", "standard_charge_percentage": 0.85, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Basic Pl", "plan_name": "400100_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Federal", "plan_name": "400110", "standard_charge_percentage": 0.85, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Federal", "plan_name": "400110_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." } ] } ] }, { "description": "Resect ovarian malignancy", "code_information": [ { "code": "58950", "type": "CPT" } ], "standard_charges": [ { "gross_charge": 20139.02, "minimum": 16111.22, "maximum": 17118.17, "setting": "inpatient", "payers_information": [ { "payer_name": "Aetna", "plan_name": "700700", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna", "plan_name": "700700_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Miscellaneous", "plan_name": "700720", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Miscellaneous", "plan_name": "700720_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Ppo Hmo", "plan_name": "701720", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Ppo Hmo", "plan_name": "701720_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Ms State Emplo", "plan_name": "401457", "standard_charge_percentage": 0.80, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Ms State Emplo", "plan_name": "401457_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Basic Pl", "plan_name": "400100", "standard_charge_percentage": 0.85, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Basic Pl", "plan_name": "400100_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Federal", "plan_name": "400110", "standard_charge_percentage": 0.85, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Federal", "plan_name": "400110_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." } ] } ] }, { "description": "Resect ovarian malignancy", "code_information": [ { "code": "58951", "type": "CPT" } ], "standard_charges": [ { "gross_charge": 17685.36, "minimum": 14148.29, "maximum": 15032.56, "setting": "inpatient", "payers_information": [ { "payer_name": "Aetna", "plan_name": "700700", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna", "plan_name": "700700_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Miscellaneous", "plan_name": "700720", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Miscellaneous", "plan_name": "700720_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Ppo Hmo", "plan_name": "701720", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Ppo Hmo", "plan_name": "701720_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Ms State Emplo", "plan_name": "401457", "standard_charge_percentage": 0.80, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Ms State Emplo", "plan_name": "401457_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Basic Pl", "plan_name": "400100", "standard_charge_percentage": 0.85, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Basic Pl", "plan_name": "400100_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Federal", "plan_name": "400110", "standard_charge_percentage": 0.85, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Federal", "plan_name": "400110_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." } ] } ] }, { "description": "Resect ovarian malignancy", "code_information": [ { "code": "58952", "type": "CPT" } ], "standard_charges": [ { "gross_charge": 17685.36, "minimum": 14148.29, "maximum": 15032.56, "setting": "inpatient", "payers_information": [ { "payer_name": "Aetna", "plan_name": "700700", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna", "plan_name": "700700_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Miscellaneous", "plan_name": "700720", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Miscellaneous", "plan_name": "700720_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Ppo Hmo", "plan_name": "701720", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Ppo Hmo", "plan_name": "701720_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Ms State Emplo", "plan_name": "401457", "standard_charge_percentage": 0.80, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Ms State Emplo", "plan_name": "401457_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Basic Pl", "plan_name": "400100", "standard_charge_percentage": 0.85, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Basic Pl", "plan_name": "400100_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Federal", "plan_name": "400110", "standard_charge_percentage": 0.85, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Federal", "plan_name": "400110_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." } ] } ] }, { "description": "Tah rad dissect for debulk", "code_information": [ { "code": "58953", "type": "CPT" } ], "standard_charges": [ { "gross_charge": 17410.57, "minimum": 13928.46, "maximum": 14798.98, "setting": "inpatient", "payers_information": [ { "payer_name": "Aetna", "plan_name": "700700", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna", "plan_name": "700700_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Miscellaneous", "plan_name": "700720", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Miscellaneous", "plan_name": "700720_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Ppo Hmo", "plan_name": "701720", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Ppo Hmo", "plan_name": "701720_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Ms State Emplo", "plan_name": "401457", "standard_charge_percentage": 0.80, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Ms State Emplo", "plan_name": "401457_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Basic Pl", "plan_name": "400100", "standard_charge_percentage": 0.85, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Basic Pl", "plan_name": "400100_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Federal", "plan_name": "400110", "standard_charge_percentage": 0.85, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Federal", "plan_name": "400110_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." } ] } ] }, { "description": "Tah rad debulk/lymph remove", "code_information": [ { "code": "58954", "type": "CPT" } ], "standard_charges": [ { "gross_charge": 17410.57, "minimum": 13928.46, "maximum": 14798.98, "setting": "inpatient", "payers_information": [ { "payer_name": "Aetna", "plan_name": "700700", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna", "plan_name": "700700_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Miscellaneous", "plan_name": "700720", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Miscellaneous", "plan_name": "700720_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Ppo Hmo", "plan_name": "701720", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Ppo Hmo", "plan_name": "701720_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Ms State Emplo", "plan_name": "401457", "standard_charge_percentage": 0.80, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Ms State Emplo", "plan_name": "401457_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Basic Pl", "plan_name": "400100", "standard_charge_percentage": 0.85, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Basic Pl", "plan_name": "400100_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Federal", "plan_name": "400110", "standard_charge_percentage": 0.85, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Federal", "plan_name": "400110_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." } ] } ] }, { "description": "Bso omentectomy w/tah", "code_information": [ { "code": "58956", "type": "CPT" } ], "standard_charges": [ { "gross_charge": 17410.57, "minimum": 13928.46, "maximum": 14798.98, "setting": "inpatient", "payers_information": [ { "payer_name": "Aetna", "plan_name": "700700", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna", "plan_name": "700700_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Miscellaneous", "plan_name": "700720", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Miscellaneous", "plan_name": "700720_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Ppo Hmo", "plan_name": "701720", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Ppo Hmo", "plan_name": "701720_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Ms State Emplo", "plan_name": "401457", "standard_charge_percentage": 0.80, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Ms State Emplo", "plan_name": "401457_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Basic Pl", "plan_name": "400100", "standard_charge_percentage": 0.85, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Basic Pl", "plan_name": "400100_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Federal", "plan_name": "400110", "standard_charge_percentage": 0.85, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Federal", "plan_name": "400110_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." } ] } ] }, { "description": "Resect recur gyn mal w/lym", "code_information": [ { "code": "58958", "type": "CPT" } ], "standard_charges": [ { "gross_charge": 17436.52, "minimum": 13949.22, "maximum": 14821.04, "setting": "inpatient", "payers_information": [ { "payer_name": "Aetna", "plan_name": "700700", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna", "plan_name": "700700_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Miscellaneous", "plan_name": "700720", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Miscellaneous", "plan_name": "700720_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Ppo Hmo", "plan_name": "701720", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Ppo Hmo", "plan_name": "701720_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Ms State Emplo", "plan_name": "401457", "standard_charge_percentage": 0.80, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Ms State Emplo", "plan_name": "401457_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Basic Pl", "plan_name": "400100", "standard_charge_percentage": 0.85, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Basic Pl", "plan_name": "400100_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Federal", "plan_name": "400110", "standard_charge_percentage": 0.85, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Federal", "plan_name": "400110_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." } ] } ] }, { "description": "Genital surgery procedure", "code_information": [ { "code": "58999", "type": "CPT" } ], "standard_charges": [ { "gross_charge": 22407.08, "minimum": 184.29, "maximum": 19046.02, "setting": "inpatient", "payers_information": [ { "payer_name": "Aarp", "plan_name": "500102", "standard_charge_dollar": 184.29, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna", "plan_name": "700700", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna", "plan_name": "700700_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Mcare Ffs 6005", "plan_name": "700703", "standard_charge_dollar": 184.29, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Miscellaneous", "plan_name": "700720", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Miscellaneous", "plan_name": "700720_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Ppo Hmo", "plan_name": "701720", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Ppo Hmo", "plan_name": "701720_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Ambetter 68069", "plan_name": "500516", "standard_charge_dollar": 184.29, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Ms State Emplo", "plan_name": "401457", "standard_charge_percentage": 0.80, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Ms State Emplo", "plan_name": "401457_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Basic Pl", "plan_name": "400100", "standard_charge_percentage": 0.85, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Basic Pl", "plan_name": "400100_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Federal", "plan_name": "400110", "standard_charge_percentage": 0.85, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Federal", "plan_name": "400110_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Cigna Healthsprings Ffs", "plan_name": "500064", "standard_charge_dollar": 184.29, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Conseco", "plan_name": "500302", "standard_charge_dollar": 184.29, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Humana Ffs 61101", "plan_name": "500006", "standard_charge_dollar": 184.29, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Medicare A", "plan_name": "100100", "standard_charge_dollar": 184.29, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Medicare A", "plan_name": "100500", "standard_charge_dollar": 184.29, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Medicare Part B Only", "plan_name": "100300", "standard_charge_dollar": 184.29, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Medicare Railroad", "plan_name": "100103", "standard_charge_dollar": 184.29, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Ms Physicians Care N", "plan_name": "714210", "standard_charge_dollar": 230.36, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Peoples Hlth Ffs 72126", "plan_name": "500019", "standard_charge_dollar": 184.29, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Uhc/Secure Horizons", "plan_name": "500449", "standard_charge_dollar": 184.29, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "United Health Care/", "plan_name": "500292", "standard_charge_dollar": 208.24, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "United Healthcare", "plan_name": "750104", "standard_charge_dollar": 208.24, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "United Healthcare Ba", "plan_name": "750090", "standard_charge_dollar": 208.24, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "United Healthcare Me", "plan_name": "501310", "standard_charge_dollar": 184.29, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Windsor Mcare Extra", "plan_name": "500778", "standard_charge_dollar": 184.29, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." } ] } ] }, { "description": "Treat ectopic pregnancy", "code_information": [ { "code": "59120", "type": "CPT" } ], "standard_charges": [ { "gross_charge": 19404.09, "minimum": 15523.27, "maximum": 16493.48, "setting": "inpatient", "payers_information": [ { "payer_name": "Aetna", "plan_name": "700700", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna", "plan_name": "700700_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Miscellaneous", "plan_name": "700720", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Miscellaneous", "plan_name": "700720_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Ppo Hmo", "plan_name": "701720", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Ppo Hmo", "plan_name": "701720_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Ms State Emplo", "plan_name": "401457", "standard_charge_percentage": 0.80, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Ms State Emplo", "plan_name": "401457_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Basic Pl", "plan_name": "400100", "standard_charge_percentage": 0.85, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Basic Pl", "plan_name": "400100_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Federal", "plan_name": "400110", "standard_charge_percentage": 0.85, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Federal", "plan_name": "400110_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." } ] } ] }, { "description": "Treat ectopic pregnancy", "code_information": [ { "code": "59121", "type": "CPT" } ], "standard_charges": [ { "gross_charge": 157135.20, "minimum": 125708.16, "maximum": 133564.92, "setting": "inpatient", "payers_information": [ { "payer_name": "Aetna", "plan_name": "700700", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna", "plan_name": "700700_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Miscellaneous", "plan_name": "700720", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Miscellaneous", "plan_name": "700720_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Ppo Hmo", "plan_name": "701720", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Ppo Hmo", "plan_name": "701720_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Ms State Emplo", "plan_name": "401457", "standard_charge_percentage": 0.80, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Ms State Emplo", "plan_name": "401457_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Basic Pl", "plan_name": "400100", "standard_charge_percentage": 0.85, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Basic Pl", "plan_name": "400100_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Federal", "plan_name": "400110", "standard_charge_percentage": 0.85, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Federal", "plan_name": "400110_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." } ] } ] }, { "description": "Treat ectopic pregnancy", "code_information": [ { "code": "59130", "type": "CPT" } ], "standard_charges": [ { "gross_charge": 157135.20, "minimum": 125708.16, "maximum": 133564.92, "setting": "inpatient", "payers_information": [ { "payer_name": "Aetna", "plan_name": "700700", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna", "plan_name": "700700_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Miscellaneous", "plan_name": "700720", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Miscellaneous", "plan_name": "700720_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Ppo Hmo", "plan_name": "701720", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Ppo Hmo", "plan_name": "701720_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Ms State Emplo", "plan_name": "401457", "standard_charge_percentage": 0.80, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Ms State Emplo", "plan_name": "401457_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Basic Pl", "plan_name": "400100", "standard_charge_percentage": 0.85, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Basic Pl", "plan_name": "400100_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Federal", "plan_name": "400110", "standard_charge_percentage": 0.85, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Federal", "plan_name": "400110_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." } ] } ] }, { "description": "Treat ectopic pregnancy", "code_information": [ { "code": "59136", "type": "CPT" } ], "standard_charges": [ { "gross_charge": 21788.89, "minimum": 17431.11, "maximum": 18520.56, "setting": "inpatient", "payers_information": [ { "payer_name": "Aetna", "plan_name": "700700", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna", "plan_name": "700700_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Miscellaneous", "plan_name": "700720", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Miscellaneous", "plan_name": "700720_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Ppo Hmo", "plan_name": "701720", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Ppo Hmo", "plan_name": "701720_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Ms State Emplo", "plan_name": "401457", "standard_charge_percentage": 0.80, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Ms State Emplo", "plan_name": "401457_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Basic Pl", "plan_name": "400100", "standard_charge_percentage": 0.85, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Basic Pl", "plan_name": "400100_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Federal", "plan_name": "400110", "standard_charge_percentage": 0.85, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Federal", "plan_name": "400110_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." } ] } ] }, { "description": "Treat ectopic pregnancy", "code_information": [ { "code": "59140", "type": "CPT" } ], "standard_charges": [ { "gross_charge": 16663.01, "minimum": 13330.41, "maximum": 14163.56, "setting": "inpatient", "payers_information": [ { "payer_name": "Aetna", "plan_name": "700700", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna", "plan_name": "700700_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Miscellaneous", "plan_name": "700720", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Miscellaneous", "plan_name": "700720_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Ppo Hmo", "plan_name": "701720", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Ppo Hmo", "plan_name": "701720_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Ms State Emplo", "plan_name": "401457", "standard_charge_percentage": 0.80, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Ms State Emplo", "plan_name": "401457_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Basic Pl", "plan_name": "400100", "standard_charge_percentage": 0.85, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Basic Pl", "plan_name": "400100_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Federal", "plan_name": "400110", "standard_charge_percentage": 0.85, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Federal", "plan_name": "400110_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." } ] } ] }, { "description": "Treat ectopic pregnancy", "code_information": [ { "code": "59151", "type": "CPT" } ], "standard_charges": [ { "gross_charge": 31839.07, "minimum": 5344.68, "maximum": 27063.21, "setting": "inpatient", "payers_information": [ { "payer_name": "Aarp", "plan_name": "500102", "standard_charge_dollar": 5344.68, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna", "plan_name": "700700", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna", "plan_name": "700700_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Mcare Ffs 6005", "plan_name": "700703", "standard_charge_dollar": 5344.68, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Miscellaneous", "plan_name": "700720", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Miscellaneous", "plan_name": "700720_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Ppo Hmo", "plan_name": "701720", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Ppo Hmo", "plan_name": "701720_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Ambetter 68069", "plan_name": "500516", "standard_charge_dollar": 5344.68, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Ms State Emplo", "plan_name": "401457", "standard_charge_percentage": 0.80, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Ms State Emplo", "plan_name": "401457_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Basic Pl", "plan_name": "400100", "standard_charge_percentage": 0.85, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Basic Pl", "plan_name": "400100_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Federal", "plan_name": "400110", "standard_charge_percentage": 0.85, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Federal", "plan_name": "400110_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Cigna Healthsprings Ffs", "plan_name": "500064", "standard_charge_dollar": 5344.68, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Conseco", "plan_name": "500302", "standard_charge_dollar": 5344.68, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Humana Ffs 61101", "plan_name": "500006", "standard_charge_dollar": 5344.68, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Medicare A", "plan_name": "100100", "standard_charge_dollar": 5344.68, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Medicare A", "plan_name": "100500", "standard_charge_dollar": 5344.68, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Medicare Part B Only", "plan_name": "100300", "standard_charge_dollar": 5344.68, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Medicare Railroad", "plan_name": "100103", "standard_charge_dollar": 5344.68, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Ms Physicians Care N", "plan_name": "714210", "standard_charge_dollar": 6680.85, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Peoples Hlth Ffs 72126", "plan_name": "500019", "standard_charge_dollar": 5344.68, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Uhc/Secure Horizons", "plan_name": "500449", "standard_charge_dollar": 5344.68, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "United Health Care/", "plan_name": "500292", "standard_charge_dollar": 6039.49, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "United Healthcare", "plan_name": "750104", "standard_charge_dollar": 6039.49, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "United Healthcare Ba", "plan_name": "750090", "standard_charge_dollar": 6039.49, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "United Healthcare Me", "plan_name": "501310", "standard_charge_dollar": 5344.68, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Windsor Mcare Extra", "plan_name": "500778", "standard_charge_dollar": 5344.68, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." } ] } ] }, { "description": "D & c after delivery", "code_information": [ { "code": "59160", "type": "CPT" } ], "standard_charges": [ { "gross_charge": 8131.79, "minimum": 2912.67, "maximum": 6912.02, "setting": "inpatient", "payers_information": [ { "payer_name": "Aarp", "plan_name": "500102", "standard_charge_dollar": 2912.67, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna", "plan_name": "700700", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna", "plan_name": "700700_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Mcare Ffs 6005", "plan_name": "700703", "standard_charge_dollar": 2912.67, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Miscellaneous", "plan_name": "700720", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Miscellaneous", "plan_name": "700720_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Ppo Hmo", "plan_name": "701720", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Ppo Hmo", "plan_name": "701720_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Ambetter 68069", "plan_name": "500516", "standard_charge_dollar": 2912.67, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Ms State Emplo", "plan_name": "401457", "standard_charge_percentage": 0.80, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Ms State Emplo", "plan_name": "401457_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Basic Pl", "plan_name": "400100", "standard_charge_percentage": 0.85, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Basic Pl", "plan_name": "400100_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Federal", "plan_name": "400110", "standard_charge_percentage": 0.85, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Federal", "plan_name": "400110_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Cigna Healthsprings Ffs", "plan_name": "500064", "standard_charge_dollar": 2912.67, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Conseco", "plan_name": "500302", "standard_charge_dollar": 2912.67, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Humana Ffs 61101", "plan_name": "500006", "standard_charge_dollar": 2912.67, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Medicare A", "plan_name": "100100", "standard_charge_dollar": 2912.67, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Medicare A", "plan_name": "100500", "standard_charge_dollar": 2912.67, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Medicare Part B Only", "plan_name": "100300", "standard_charge_dollar": 2912.67, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Medicare Railroad", "plan_name": "100103", "standard_charge_dollar": 2912.67, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Ms Physicians Care N", "plan_name": "714210", "standard_charge_dollar": 3640.84, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Peoples Hlth Ffs 72126", "plan_name": "500019", "standard_charge_dollar": 2912.67, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Uhc/Secure Horizons", "plan_name": "500449", "standard_charge_dollar": 2912.67, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "United Health Care/", "plan_name": "500292", "standard_charge_dollar": 3291.32, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "United Healthcare", "plan_name": "750104", "standard_charge_dollar": 3291.32, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "United Healthcare Ba", "plan_name": "750090", "standard_charge_dollar": 3291.32, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "United Healthcare Me", "plan_name": "501310", "standard_charge_dollar": 2912.67, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Windsor Mcare Extra", "plan_name": "500778", "standard_charge_dollar": 2912.67, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." } ] } ] }, { "description": "Insert cervical dilator", "code_information": [ { "code": "59200", "type": "CPT" } ], "standard_charges": [ { "gross_charge": 9832.34, "minimum": 278.66, "maximum": 8357.49, "setting": "inpatient", "payers_information": [ { "payer_name": "Aarp", "plan_name": "500102", "standard_charge_dollar": 278.66, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna", "plan_name": "700700", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna", "plan_name": "700700_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Mcare Ffs 6005", "plan_name": "700703", "standard_charge_dollar": 278.66, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Miscellaneous", "plan_name": "700720", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Miscellaneous", "plan_name": "700720_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Ppo Hmo", "plan_name": "701720", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Ppo Hmo", "plan_name": "701720_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Ambetter 68069", "plan_name": "500516", "standard_charge_dollar": 278.66, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Ms State Emplo", "plan_name": "401457", "standard_charge_percentage": 0.80, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Ms State Emplo", "plan_name": "401457_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Basic Pl", "plan_name": "400100", "standard_charge_percentage": 0.85, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Basic Pl", "plan_name": "400100_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Federal", "plan_name": "400110", "standard_charge_percentage": 0.85, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Federal", "plan_name": "400110_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Cigna Healthsprings Ffs", "plan_name": "500064", "standard_charge_dollar": 278.66, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Conseco", "plan_name": "500302", "standard_charge_dollar": 278.66, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Humana Ffs 61101", "plan_name": "500006", "standard_charge_dollar": 278.66, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Medicare A", "plan_name": "100100", "standard_charge_dollar": 278.66, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Medicare A", "plan_name": "100500", "standard_charge_dollar": 278.66, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Medicare Part B Only", "plan_name": "100300", "standard_charge_dollar": 278.66, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Medicare Railroad", "plan_name": "100103", "standard_charge_dollar": 278.66, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Ms Physicians Care N", "plan_name": "714210", "standard_charge_dollar": 348.32, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Peoples Hlth Ffs 72126", "plan_name": "500019", "standard_charge_dollar": 278.66, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Uhc/Secure Horizons", "plan_name": "500449", "standard_charge_dollar": 278.66, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "United Health Care/", "plan_name": "500292", "standard_charge_dollar": 314.88, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "United Healthcare", "plan_name": "750104", "standard_charge_dollar": 314.88, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "United Healthcare Ba", "plan_name": "750090", "standard_charge_dollar": 314.88, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "United Healthcare Me", "plan_name": "501310", "standard_charge_dollar": 278.66, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Windsor Mcare Extra", "plan_name": "500778", "standard_charge_dollar": 278.66, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." } ] } ] }, { "description": "Obstetrical care", "code_information": [ { "code": "59400", "type": "CPT" } ], "standard_charges": [ { "gross_charge": 7055.40, "minimum": 2214.50, "maximum": 2214.50, "setting": "inpatient", "payers_information": [ { "payer_name": "Aetna", "plan_name": "700700", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna", "plan_name": "700700_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Miscellaneous", "plan_name": "700720", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Miscellaneous", "plan_name": "700720_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Ppo Hmo", "plan_name": "701720", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Ppo Hmo", "plan_name": "701720_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Ms State Emplo", "plan_name": "401457", "standard_charge_dollar": 2214.50, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Ms State Emplo", "plan_name": "401457_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Basic Pl", "plan_name": "400100", "standard_charge_dollar": 2214.50, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Basic Pl", "plan_name": "400100_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Federal", "plan_name": "400110", "standard_charge_dollar": 2214.50, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Federal", "plan_name": "400110_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." } ] } ] }, { "description": "Obstetrical care", "code_information": [ { "code": "59409", "type": "CPT" } ], "standard_charges": [ { "gross_charge": 7198.68, "minimum": 2912.67, "maximum": 6118.88, "setting": "inpatient", "payers_information": [ { "payer_name": "Aarp", "plan_name": "500102", "standard_charge_dollar": 2912.67, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna", "plan_name": "700700", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna", "plan_name": "700700_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Mcare Ffs 6005", "plan_name": "700703", "standard_charge_dollar": 2912.67, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Miscellaneous", "plan_name": "700720", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Miscellaneous", "plan_name": "700720_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Ppo Hmo", "plan_name": "701720", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Ppo Hmo", "plan_name": "701720_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Ambetter 68069", "plan_name": "500516", "standard_charge_dollar": 2912.67, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Ms State Emplo", "plan_name": "401457", "standard_charge_percentage": 0.80, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Ms State Emplo", "plan_name": "401457_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Basic Pl", "plan_name": "400100", "standard_charge_percentage": 0.85, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Basic Pl", "plan_name": "400100_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Federal", "plan_name": "400110", "standard_charge_percentage": 0.85, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Federal", "plan_name": "400110_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Cigna Healthsprings Ffs", "plan_name": "500064", "standard_charge_dollar": 2912.67, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Conseco", "plan_name": "500302", "standard_charge_dollar": 2912.67, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Humana Ffs 61101", "plan_name": "500006", "standard_charge_dollar": 2912.67, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Medicare A", "plan_name": "100100", "standard_charge_dollar": 2912.67, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Medicare A", "plan_name": "100500", "standard_charge_dollar": 2912.67, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Medicare Part B Only", "plan_name": "100300", "standard_charge_dollar": 2912.67, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Medicare Railroad", "plan_name": "100103", "standard_charge_dollar": 2912.67, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Ms Physicians Care N", "plan_name": "714210", "standard_charge_dollar": 3640.84, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Peoples Hlth Ffs 72126", "plan_name": "500019", "standard_charge_dollar": 2912.67, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Uhc/Secure Horizons", "plan_name": "500449", "standard_charge_dollar": 2912.67, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "United Health Care/", "plan_name": "500292", "standard_charge_dollar": 3291.32, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "United Healthcare", "plan_name": "750104", "standard_charge_dollar": 3291.32, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "United Healthcare Ba", "plan_name": "750090", "standard_charge_dollar": 3291.32, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "United Healthcare Me", "plan_name": "501310", "standard_charge_dollar": 2912.67, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Windsor Mcare Extra", "plan_name": "500778", "standard_charge_dollar": 2912.67, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." } ] } ] }, { "description": "Obstetrical care", "code_information": [ { "code": "59410", "type": "CPT" } ], "standard_charges": [ { "gross_charge": 7198.68, "minimum": 1109.22, "maximum": 1109.22, "setting": "inpatient", "payers_information": [ { "payer_name": "Aetna", "plan_name": "700700", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna", "plan_name": "700700_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Miscellaneous", "plan_name": "700720", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Miscellaneous", "plan_name": "700720_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Ppo Hmo", "plan_name": "701720", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Ppo Hmo", "plan_name": "701720_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Ms State Emplo", "plan_name": "401457", "standard_charge_dollar": 1109.22, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Ms State Emplo", "plan_name": "401457_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Basic Pl", "plan_name": "400100", "standard_charge_dollar": 1109.22, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Basic Pl", "plan_name": "400100_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Federal", "plan_name": "400110", "standard_charge_dollar": 1109.22, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Federal", "plan_name": "400110_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." } ] } ] }, { "description": "Deliver placenta", "code_information": [ { "code": "59414", "type": "CPT" } ], "standard_charges": [ { "gross_charge": 11756.22, "minimum": 2912.67, "maximum": 9992.79, "setting": "inpatient", "payers_information": [ { "payer_name": "Aarp", "plan_name": "500102", "standard_charge_dollar": 2912.67, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna", "plan_name": "700700", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna", "plan_name": "700700_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Mcare Ffs 6005", "plan_name": "700703", "standard_charge_dollar": 2912.67, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Miscellaneous", "plan_name": "700720", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Miscellaneous", "plan_name": "700720_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Ppo Hmo", "plan_name": "701720", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Ppo Hmo", "plan_name": "701720_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Ambetter 68069", "plan_name": "500516", "standard_charge_dollar": 2912.67, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Ms State Emplo", "plan_name": "401457", "standard_charge_percentage": 0.80, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Ms State Emplo", "plan_name": "401457_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Basic Pl", "plan_name": "400100", "standard_charge_percentage": 0.85, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Basic Pl", "plan_name": "400100_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Federal", "plan_name": "400110", "standard_charge_percentage": 0.85, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Federal", "plan_name": "400110_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Cigna Healthsprings Ffs", "plan_name": "500064", "standard_charge_dollar": 2912.67, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Conseco", "plan_name": "500302", "standard_charge_dollar": 2912.67, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Humana Ffs 61101", "plan_name": "500006", "standard_charge_dollar": 2912.67, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Medicare A", "plan_name": "100100", "standard_charge_dollar": 2912.67, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Medicare A", "plan_name": "100500", "standard_charge_dollar": 2912.67, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Medicare Part B Only", "plan_name": "100300", "standard_charge_dollar": 2912.67, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Medicare Railroad", "plan_name": "100103", "standard_charge_dollar": 2912.67, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Ms Physicians Care N", "plan_name": "714210", "standard_charge_dollar": 3640.84, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Peoples Hlth Ffs 72126", "plan_name": "500019", "standard_charge_dollar": 2912.67, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Uhc/Secure Horizons", "plan_name": "500449", "standard_charge_dollar": 2912.67, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "United Health Care/", "plan_name": "500292", "standard_charge_dollar": 3291.32, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "United Healthcare", "plan_name": "750104", "standard_charge_dollar": 3291.32, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "United Healthcare Ba", "plan_name": "750090", "standard_charge_dollar": 3291.32, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "United Healthcare Me", "plan_name": "501310", "standard_charge_dollar": 2912.67, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Windsor Mcare Extra", "plan_name": "500778", "standard_charge_dollar": 2912.67, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." } ] } ] }, { "description": "Cesarean delivery", "code_information": [ { "code": "59510", "type": "CPT" } ], "standard_charges": [ { "gross_charge": 11477.61, "minimum": 2449.95, "maximum": 2449.95, "setting": "inpatient", "payers_information": [ { "payer_name": "Aetna", "plan_name": "700700", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna", "plan_name": "700700_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Miscellaneous", "plan_name": "700720", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Miscellaneous", "plan_name": "700720_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Ppo Hmo", "plan_name": "701720", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Ppo Hmo", "plan_name": "701720_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Ms State Emplo", "plan_name": "401457", "standard_charge_dollar": 2449.95, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Ms State Emplo", "plan_name": "401457_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Basic Pl", "plan_name": "400100", "standard_charge_dollar": 2449.95, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Basic Pl", "plan_name": "400100_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Federal", "plan_name": "400110", "standard_charge_dollar": 2449.95, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Federal", "plan_name": "400110_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." } ] } ] }, { "description": "Cesarean delivery only", "code_information": [ { "code": "59514", "type": "CPT" } ], "standard_charges": [ { "gross_charge": 11477.61, "minimum": 9182.09, "maximum": 9755.97, "setting": "inpatient", "payers_information": [ { "payer_name": "Aetna", "plan_name": "700700", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna", "plan_name": "700700_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Miscellaneous", "plan_name": "700720", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Miscellaneous", "plan_name": "700720_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Ppo Hmo", "plan_name": "701720", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Ppo Hmo", "plan_name": "701720_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Ms State Emplo", "plan_name": "401457", "standard_charge_percentage": 0.80, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Ms State Emplo", "plan_name": "401457_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Basic Pl", "plan_name": "400100", "standard_charge_percentage": 0.85, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Basic Pl", "plan_name": "400100_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Federal", "plan_name": "400110", "standard_charge_percentage": 0.85, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Federal", "plan_name": "400110_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." } ] } ] }, { "description": "Cesarean delivery", "code_information": [ { "code": "59515", "type": "CPT" } ], "standard_charges": [ { "gross_charge": 11477.61, "minimum": 1343.26, "maximum": 1343.26, "setting": "inpatient", "payers_information": [ { "payer_name": "Aetna", "plan_name": "700700", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna", "plan_name": "700700_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Miscellaneous", "plan_name": "700720", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Miscellaneous", "plan_name": "700720_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Ppo Hmo", "plan_name": "701720", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Ppo Hmo", "plan_name": "701720_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Ms State Emplo", "plan_name": "401457", "standard_charge_dollar": 1343.26, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Ms State Emplo", "plan_name": "401457_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Basic Pl", "plan_name": "400100", "standard_charge_dollar": 1343.26, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Basic Pl", "plan_name": "400100_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Federal", "plan_name": "400110", "standard_charge_dollar": 1343.26, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Federal", "plan_name": "400110_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." } ] } ] }, { "description": "Remove uterus after cesarean", "code_information": [ { "code": "59525", "type": "CPT" } ], "standard_charges": [ { "gross_charge": 16670.66, "minimum": 13336.53, "maximum": 14170.06, "setting": "inpatient", "payers_information": [ { "payer_name": "Aetna", "plan_name": "700700", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna", "plan_name": "700700_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Miscellaneous", "plan_name": "700720", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Miscellaneous", "plan_name": "700720_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Ppo Hmo", "plan_name": "701720", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Ppo Hmo", "plan_name": "701720_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Ms State Emplo", "plan_name": "401457", "standard_charge_percentage": 0.80, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Ms State Emplo", "plan_name": "401457_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Basic Pl", "plan_name": "400100", "standard_charge_percentage": 0.85, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Basic Pl", "plan_name": "400100_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Federal", "plan_name": "400110", "standard_charge_percentage": 0.85, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Federal", "plan_name": "400110_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." } ] } ] }, { "description": "Vbac delivery", "code_information": [ { "code": "59610", "type": "CPT" } ], "standard_charges": [ { "gross_charge": 7196.02, "minimum": 2321.84, "maximum": 2321.84, "setting": "inpatient", "payers_information": [ { "payer_name": "Aetna", "plan_name": "700700", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna", "plan_name": "700700_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Miscellaneous", "plan_name": "700720", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Miscellaneous", "plan_name": "700720_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Ppo Hmo", "plan_name": "701720", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Ppo Hmo", "plan_name": "701720_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Ms State Emplo", "plan_name": "401457", "standard_charge_dollar": 2321.84, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Ms State Emplo", "plan_name": "401457_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Basic Pl", "plan_name": "400100", "standard_charge_dollar": 2321.84, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Basic Pl", "plan_name": "400100_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Federal", "plan_name": "400110", "standard_charge_dollar": 2321.84, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Federal", "plan_name": "400110_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." } ] } ] }, { "description": "Vbac delivery only", "code_information": [ { "code": "59612", "type": "CPT" } ], "standard_charges": [ { "gross_charge": 7196.02, "minimum": 2912.67, "maximum": 6116.62, "setting": "inpatient", "payers_information": [ { "payer_name": "Aarp", "plan_name": "500102", "standard_charge_dollar": 2912.67, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna", "plan_name": "700700", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna", "plan_name": "700700_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Mcare Ffs 6005", "plan_name": "700703", "standard_charge_dollar": 2912.67, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Miscellaneous", "plan_name": "700720", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Miscellaneous", "plan_name": "700720_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Ppo Hmo", "plan_name": "701720", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Ppo Hmo", "plan_name": "701720_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Ambetter 68069", "plan_name": "500516", "standard_charge_dollar": 2912.67, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Ms State Emplo", "plan_name": "401457", "standard_charge_percentage": 0.80, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Ms State Emplo", "plan_name": "401457_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Basic Pl", "plan_name": "400100", "standard_charge_percentage": 0.85, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Basic Pl", "plan_name": "400100_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Federal", "plan_name": "400110", "standard_charge_percentage": 0.85, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Federal", "plan_name": "400110_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Cigna Healthsprings Ffs", "plan_name": "500064", "standard_charge_dollar": 2912.67, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Conseco", "plan_name": "500302", "standard_charge_dollar": 2912.67, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Humana Ffs 61101", "plan_name": "500006", "standard_charge_dollar": 2912.67, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Medicare A", "plan_name": "100100", "standard_charge_dollar": 2912.67, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Medicare A", "plan_name": "100500", "standard_charge_dollar": 2912.67, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Medicare Part B Only", "plan_name": "100300", "standard_charge_dollar": 2912.67, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Medicare Railroad", "plan_name": "100103", "standard_charge_dollar": 2912.67, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Ms Physicians Care N", "plan_name": "714210", "standard_charge_dollar": 3640.84, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Peoples Hlth Ffs 72126", "plan_name": "500019", "standard_charge_dollar": 2912.67, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Uhc/Secure Horizons", "plan_name": "500449", "standard_charge_dollar": 2912.67, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "United Health Care/", "plan_name": "500292", "standard_charge_dollar": 3291.32, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "United Healthcare", "plan_name": "750104", "standard_charge_dollar": 3291.32, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "United Healthcare Ba", "plan_name": "750090", "standard_charge_dollar": 3291.32, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "United Healthcare Me", "plan_name": "501310", "standard_charge_dollar": 2912.67, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Windsor Mcare Extra", "plan_name": "500778", "standard_charge_dollar": 2912.67, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." } ] } ] }, { "description": "Vbac care after delivery", "code_information": [ { "code": "59614", "type": "CPT" } ], "standard_charges": [ { "gross_charge": 7196.02, "minimum": 1214.04, "maximum": 1214.04, "setting": "inpatient", "payers_information": [ { "payer_name": "Aetna", "plan_name": "700700", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna", "plan_name": "700700_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Miscellaneous", "plan_name": "700720", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Miscellaneous", "plan_name": "700720_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Ppo Hmo", "plan_name": "701720", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Ppo Hmo", "plan_name": "701720_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Ms State Emplo", "plan_name": "401457", "standard_charge_dollar": 1214.04, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Ms State Emplo", "plan_name": "401457_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Basic Pl", "plan_name": "400100", "standard_charge_dollar": 1214.04, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Basic Pl", "plan_name": "400100_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Federal", "plan_name": "400110", "standard_charge_dollar": 1214.04, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Federal", "plan_name": "400110_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." } ] } ] }, { "description": "Attempted vbac delivery", "code_information": [ { "code": "59618", "type": "CPT" } ], "standard_charges": [ { "gross_charge": 11477.61, "minimum": 2481.45, "maximum": 2481.45, "setting": "inpatient", "payers_information": [ { "payer_name": "Aetna", "plan_name": "700700", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna", "plan_name": "700700_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Miscellaneous", "plan_name": "700720", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Miscellaneous", "plan_name": "700720_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Ppo Hmo", "plan_name": "701720", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Ppo Hmo", "plan_name": "701720_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Ms State Emplo", "plan_name": "401457", "standard_charge_dollar": 2481.45, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Ms State Emplo", "plan_name": "401457_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Basic Pl", "plan_name": "400100", "standard_charge_dollar": 2481.45, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Basic Pl", "plan_name": "400100_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Federal", "plan_name": "400110", "standard_charge_dollar": 2481.45, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Federal", "plan_name": "400110_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." } ] } ] }, { "description": "Attempted vbac delivery only", "code_information": [ { "code": "59620", "type": "CPT" } ], "standard_charges": [ { "gross_charge": 11477.61, "minimum": 9182.09, "maximum": 9755.97, "setting": "inpatient", "payers_information": [ { "payer_name": "Aetna", "plan_name": "700700", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna", "plan_name": "700700_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Miscellaneous", "plan_name": "700720", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Miscellaneous", "plan_name": "700720_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Ppo Hmo", "plan_name": "701720", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Ppo Hmo", "plan_name": "701720_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Ms State Emplo", "plan_name": "401457", "standard_charge_percentage": 0.80, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Ms State Emplo", "plan_name": "401457_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Basic Pl", "plan_name": "400100", "standard_charge_percentage": 0.85, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Basic Pl", "plan_name": "400100_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Federal", "plan_name": "400110", "standard_charge_percentage": 0.85, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Federal", "plan_name": "400110_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." } ] } ] }, { "description": "Attempted vbac after care", "code_information": [ { "code": "59622", "type": "CPT" } ], "standard_charges": [ { "gross_charge": 11477.61, "minimum": 1371.90, "maximum": 1371.90, "setting": "inpatient", "payers_information": [ { "payer_name": "Aetna", "plan_name": "700700", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna", "plan_name": "700700_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Miscellaneous", "plan_name": "700720", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Miscellaneous", "plan_name": "700720_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Ppo Hmo", "plan_name": "701720", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Ppo Hmo", "plan_name": "701720_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Ms State Emplo", "plan_name": "401457", "standard_charge_dollar": 1371.90, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Ms State Emplo", "plan_name": "401457_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Basic Pl", "plan_name": "400100", "standard_charge_dollar": 1371.90, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Basic Pl", "plan_name": "400100_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Federal", "plan_name": "400110", "standard_charge_dollar": 1371.90, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Federal", "plan_name": "400110_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." } ] } ] }, { "description": "Treatment of miscarriage", "code_information": [ { "code": "59812", "type": "CPT" } ], "standard_charges": [ { "gross_charge": 12964.37, "minimum": 2912.67, "maximum": 11019.71, "setting": "inpatient", "payers_information": [ { "payer_name": "Aarp", "plan_name": "500102", "standard_charge_dollar": 2912.67, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna", "plan_name": "700700", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna", "plan_name": "700700_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Mcare Ffs 6005", "plan_name": "700703", "standard_charge_dollar": 2912.67, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Miscellaneous", "plan_name": "700720", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Miscellaneous", "plan_name": "700720_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Ppo Hmo", "plan_name": "701720", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Ppo Hmo", "plan_name": "701720_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Ambetter 68069", "plan_name": "500516", "standard_charge_dollar": 2912.67, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Ms State Emplo", "plan_name": "401457", "standard_charge_percentage": 0.80, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Ms State Emplo", "plan_name": "401457_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Basic Pl", "plan_name": "400100", "standard_charge_percentage": 0.85, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Basic Pl", "plan_name": "400100_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Federal", "plan_name": "400110", "standard_charge_percentage": 0.85, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Federal", "plan_name": "400110_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Cigna Healthsprings Ffs", "plan_name": "500064", "standard_charge_dollar": 2912.67, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Conseco", "plan_name": "500302", "standard_charge_dollar": 2912.67, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Humana Ffs 61101", "plan_name": "500006", "standard_charge_dollar": 2912.67, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Medicare A", "plan_name": "100100", "standard_charge_dollar": 2912.67, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Medicare A", "plan_name": "100500", "standard_charge_dollar": 2912.67, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Medicare Part B Only", "plan_name": "100300", "standard_charge_dollar": 2912.67, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Medicare Railroad", "plan_name": "100103", "standard_charge_dollar": 2912.67, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Ms Physicians Care N", "plan_name": "714210", "standard_charge_dollar": 3640.84, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Peoples Hlth Ffs 72126", "plan_name": "500019", "standard_charge_dollar": 2912.67, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Uhc/Secure Horizons", "plan_name": "500449", "standard_charge_dollar": 2912.67, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "United Health Care/", "plan_name": "500292", "standard_charge_dollar": 3291.32, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "United Healthcare", "plan_name": "750104", "standard_charge_dollar": 3291.32, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "United Healthcare Ba", "plan_name": "750090", "standard_charge_dollar": 3291.32, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "United Healthcare Me", "plan_name": "501310", "standard_charge_dollar": 2912.67, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Windsor Mcare Extra", "plan_name": "500778", "standard_charge_dollar": 2912.67, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." } ] } ] }, { "description": "Care of miscarriage", "code_information": [ { "code": "59820", "type": "CPT" } ], "standard_charges": [ { "gross_charge": 12964.37, "minimum": 2912.67, "maximum": 11019.71, "setting": "inpatient", "payers_information": [ { "payer_name": "Aarp", "plan_name": "500102", "standard_charge_dollar": 2912.67, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna", "plan_name": "700700", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna", "plan_name": "700700_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Mcare Ffs 6005", "plan_name": "700703", "standard_charge_dollar": 2912.67, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Miscellaneous", "plan_name": "700720", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Miscellaneous", "plan_name": "700720_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Ppo Hmo", "plan_name": "701720", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Ppo Hmo", "plan_name": "701720_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Ambetter 68069", "plan_name": "500516", "standard_charge_dollar": 2912.67, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Ms State Emplo", "plan_name": "401457", "standard_charge_percentage": 0.80, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Ms State Emplo", "plan_name": "401457_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Basic Pl", "plan_name": "400100", "standard_charge_percentage": 0.85, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Basic Pl", "plan_name": "400100_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Federal", "plan_name": "400110", "standard_charge_percentage": 0.85, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Federal", "plan_name": "400110_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Cigna Healthsprings Ffs", "plan_name": "500064", "standard_charge_dollar": 2912.67, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Conseco", "plan_name": "500302", "standard_charge_dollar": 2912.67, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Humana Ffs 61101", "plan_name": "500006", "standard_charge_dollar": 2912.67, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Medicare A", "plan_name": "100100", "standard_charge_dollar": 2912.67, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Medicare A", "plan_name": "100500", "standard_charge_dollar": 2912.67, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Medicare Part B Only", "plan_name": "100300", "standard_charge_dollar": 2912.67, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Medicare Railroad", "plan_name": "100103", "standard_charge_dollar": 2912.67, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Ms Physicians Care N", "plan_name": "714210", "standard_charge_dollar": 3640.84, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Peoples Hlth Ffs 72126", "plan_name": "500019", "standard_charge_dollar": 2912.67, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Uhc/Secure Horizons", "plan_name": "500449", "standard_charge_dollar": 2912.67, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "United Health Care/", "plan_name": "500292", "standard_charge_dollar": 3291.32, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "United Healthcare", "plan_name": "750104", "standard_charge_dollar": 3291.32, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "United Healthcare Ba", "plan_name": "750090", "standard_charge_dollar": 3291.32, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "United Healthcare Me", "plan_name": "501310", "standard_charge_dollar": 2912.67, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Windsor Mcare Extra", "plan_name": "500778", "standard_charge_dollar": 2912.67, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." } ] } ] }, { "description": "Treatment of miscarriage", "code_information": [ { "code": "59821", "type": "CPT" } ], "standard_charges": [ { "gross_charge": 12964.37, "minimum": 2912.67, "maximum": 11019.71, "setting": "inpatient", "payers_information": [ { "payer_name": "Aarp", "plan_name": "500102", "standard_charge_dollar": 2912.67, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna", "plan_name": "700700", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna", "plan_name": "700700_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Mcare Ffs 6005", "plan_name": "700703", "standard_charge_dollar": 2912.67, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Miscellaneous", "plan_name": "700720", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Miscellaneous", "plan_name": "700720_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Ppo Hmo", "plan_name": "701720", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Ppo Hmo", "plan_name": "701720_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Ambetter 68069", "plan_name": "500516", "standard_charge_dollar": 2912.67, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Ms State Emplo", "plan_name": "401457", "standard_charge_percentage": 0.80, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Ms State Emplo", "plan_name": "401457_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Basic Pl", "plan_name": "400100", "standard_charge_percentage": 0.85, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Basic Pl", "plan_name": "400100_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Federal", "plan_name": "400110", "standard_charge_percentage": 0.85, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Federal", "plan_name": "400110_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Cigna Healthsprings Ffs", "plan_name": "500064", "standard_charge_dollar": 2912.67, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Conseco", "plan_name": "500302", "standard_charge_dollar": 2912.67, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Humana Ffs 61101", "plan_name": "500006", "standard_charge_dollar": 2912.67, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Medicare A", "plan_name": "100100", "standard_charge_dollar": 2912.67, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Medicare A", "plan_name": "100500", "standard_charge_dollar": 2912.67, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Medicare Part B Only", "plan_name": "100300", "standard_charge_dollar": 2912.67, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Medicare Railroad", "plan_name": "100103", "standard_charge_dollar": 2912.67, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Ms Physicians Care N", "plan_name": "714210", "standard_charge_dollar": 3640.84, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Peoples Hlth Ffs 72126", "plan_name": "500019", "standard_charge_dollar": 2912.67, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Uhc/Secure Horizons", "plan_name": "500449", "standard_charge_dollar": 2912.67, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "United Health Care/", "plan_name": "500292", "standard_charge_dollar": 3291.32, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "United Healthcare", "plan_name": "750104", "standard_charge_dollar": 3291.32, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "United Healthcare Ba", "plan_name": "750090", "standard_charge_dollar": 3291.32, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "United Healthcare Me", "plan_name": "501310", "standard_charge_dollar": 2912.67, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Windsor Mcare Extra", "plan_name": "500778", "standard_charge_dollar": 2912.67, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." } ] } ] }, { "description": "Treat uterus infection", "code_information": [ { "code": "59830", "type": "CPT" } ], "standard_charges": [ { "gross_charge": 12964.37, "minimum": 10371.50, "maximum": 11019.71, "setting": "inpatient", "payers_information": [ { "payer_name": "Aetna", "plan_name": "700700", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna", "plan_name": "700700_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Miscellaneous", "plan_name": "700720", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Miscellaneous", "plan_name": "700720_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Ppo Hmo", "plan_name": "701720", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Ppo Hmo", "plan_name": "701720_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Ms State Emplo", "plan_name": "401457", "standard_charge_percentage": 0.80, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Ms State Emplo", "plan_name": "401457_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Basic Pl", "plan_name": "400100", "standard_charge_percentage": 0.85, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Basic Pl", "plan_name": "400100_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Federal", "plan_name": "400110", "standard_charge_percentage": 0.85, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Federal", "plan_name": "400110_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." } ] } ] }, { "description": "Evacuate mole of uterus", "code_information": [ { "code": "59870", "type": "CPT" } ], "standard_charges": [ { "gross_charge": 12964.37, "minimum": 2912.67, "maximum": 11019.71, "setting": "inpatient", "payers_information": [ { "payer_name": "Aarp", "plan_name": "500102", "standard_charge_dollar": 2912.67, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna", "plan_name": "700700", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna", "plan_name": "700700_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Mcare Ffs 6005", "plan_name": "700703", "standard_charge_dollar": 2912.67, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Miscellaneous", "plan_name": "700720", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Miscellaneous", "plan_name": "700720_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Ppo Hmo", "plan_name": "701720", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Ppo Hmo", "plan_name": "701720_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Ambetter 68069", "plan_name": "500516", "standard_charge_dollar": 2912.67, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Ms State Emplo", "plan_name": "401457", "standard_charge_percentage": 0.80, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Ms State Emplo", "plan_name": "401457_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Basic Pl", "plan_name": "400100", "standard_charge_percentage": 0.85, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Basic Pl", "plan_name": "400100_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Federal", "plan_name": "400110", "standard_charge_percentage": 0.85, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Federal", "plan_name": "400110_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Cigna Healthsprings Ffs", "plan_name": "500064", "standard_charge_dollar": 2912.67, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Conseco", "plan_name": "500302", "standard_charge_dollar": 2912.67, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Humana Ffs 61101", "plan_name": "500006", "standard_charge_dollar": 2912.67, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Medicare A", "plan_name": "100100", "standard_charge_dollar": 2912.67, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Medicare A", "plan_name": "100500", "standard_charge_dollar": 2912.67, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Medicare Part B Only", "plan_name": "100300", "standard_charge_dollar": 2912.67, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Medicare Railroad", "plan_name": "100103", "standard_charge_dollar": 2912.67, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Ms Physicians Care N", "plan_name": "714210", "standard_charge_dollar": 3640.84, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Peoples Hlth Ffs 72126", "plan_name": "500019", "standard_charge_dollar": 2912.67, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Uhc/Secure Horizons", "plan_name": "500449", "standard_charge_dollar": 2912.67, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "United Health Care/", "plan_name": "500292", "standard_charge_dollar": 3291.32, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "United Healthcare", "plan_name": "750104", "standard_charge_dollar": 3291.32, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "United Healthcare Ba", "plan_name": "750090", "standard_charge_dollar": 3291.32, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "United Healthcare Me", "plan_name": "501310", "standard_charge_dollar": 2912.67, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Windsor Mcare Extra", "plan_name": "500778", "standard_charge_dollar": 2912.67, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." } ] } ] }, { "description": "Fetal invas px w/us", "code_information": [ { "code": "59897", "type": "CPT" } ], "standard_charges": [ { "gross_charge": 7051.76, "minimum": 184.29, "maximum": 5994.00, "setting": "inpatient", "payers_information": [ { "payer_name": "Aarp", "plan_name": "500102", "standard_charge_dollar": 184.29, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna", "plan_name": "700700", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna", "plan_name": "700700_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Mcare Ffs 6005", "plan_name": "700703", "standard_charge_dollar": 184.29, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Miscellaneous", "plan_name": "700720", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Miscellaneous", "plan_name": "700720_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Ppo Hmo", "plan_name": "701720", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Ppo Hmo", "plan_name": "701720_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Ambetter 68069", "plan_name": "500516", "standard_charge_dollar": 184.29, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Ms State Emplo", "plan_name": "401457", "standard_charge_percentage": 0.80, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Ms State Emplo", "plan_name": "401457_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Basic Pl", "plan_name": "400100", "standard_charge_percentage": 0.85, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Basic Pl", "plan_name": "400100_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Federal", "plan_name": "400110", "standard_charge_percentage": 0.85, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Federal", "plan_name": "400110_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Cigna Healthsprings Ffs", "plan_name": "500064", "standard_charge_dollar": 184.29, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Conseco", "plan_name": "500302", "standard_charge_dollar": 184.29, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Humana Ffs 61101", "plan_name": "500006", "standard_charge_dollar": 184.29, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Medicare A", "plan_name": "100100", "standard_charge_dollar": 184.29, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Medicare A", "plan_name": "100500", "standard_charge_dollar": 184.29, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Medicare Part B Only", "plan_name": "100300", "standard_charge_dollar": 184.29, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Medicare Railroad", "plan_name": "100103", "standard_charge_dollar": 184.29, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Ms Physicians Care N", "plan_name": "714210", "standard_charge_dollar": 230.36, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Peoples Hlth Ffs 72126", "plan_name": "500019", "standard_charge_dollar": 184.29, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Uhc/Secure Horizons", "plan_name": "500449", "standard_charge_dollar": 184.29, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "United Health Care/", "plan_name": "500292", "standard_charge_dollar": 208.24, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "United Healthcare", "plan_name": "750104", "standard_charge_dollar": 208.24, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "United Healthcare Ba", "plan_name": "750090", "standard_charge_dollar": 208.24, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "United Healthcare Me", "plan_name": "501310", "standard_charge_dollar": 184.29, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Windsor Mcare Extra", "plan_name": "500778", "standard_charge_dollar": 184.29, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." } ] } ] }, { "description": "Maternity care procedure", "code_information": [ { "code": "59899", "type": "CPT" } ], "standard_charges": [ { "gross_charge": 11477.61, "minimum": 184.29, "maximum": 9755.97, "setting": "inpatient", "payers_information": [ { "payer_name": "Aarp", "plan_name": "500102", "standard_charge_dollar": 184.29, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna", "plan_name": "700700", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna", "plan_name": "700700_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Mcare Ffs 6005", "plan_name": "700703", "standard_charge_dollar": 184.29, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Miscellaneous", "plan_name": "700720", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Miscellaneous", "plan_name": "700720_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Ppo Hmo", "plan_name": "701720", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Ppo Hmo", "plan_name": "701720_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Ambetter 68069", "plan_name": "500516", "standard_charge_dollar": 184.29, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Ms State Emplo", "plan_name": "401457", "standard_charge_percentage": 0.80, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Ms State Emplo", "plan_name": "401457_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Basic Pl", "plan_name": "400100", "standard_charge_percentage": 0.85, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Basic Pl", "plan_name": "400100_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Federal", "plan_name": "400110", "standard_charge_percentage": 0.85, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Federal", "plan_name": "400110_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Cigna Healthsprings Ffs", "plan_name": "500064", "standard_charge_dollar": 184.29, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Conseco", "plan_name": "500302", "standard_charge_dollar": 184.29, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Humana Ffs 61101", "plan_name": "500006", "standard_charge_dollar": 184.29, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Medicare A", "plan_name": "100100", "standard_charge_dollar": 184.29, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Medicare A", "plan_name": "100500", "standard_charge_dollar": 184.29, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Medicare Part B Only", "plan_name": "100300", "standard_charge_dollar": 184.29, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Medicare Railroad", "plan_name": "100103", "standard_charge_dollar": 184.29, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Ms Physicians Care N", "plan_name": "714210", "standard_charge_dollar": 230.36, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Peoples Hlth Ffs 72126", "plan_name": "500019", "standard_charge_dollar": 184.29, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Uhc/Secure Horizons", "plan_name": "500449", "standard_charge_dollar": 184.29, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "United Health Care/", "plan_name": "500292", "standard_charge_dollar": 208.24, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "United Healthcare", "plan_name": "750104", "standard_charge_dollar": 208.24, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "United Healthcare Ba", "plan_name": "750090", "standard_charge_dollar": 208.24, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "United Healthcare Me", "plan_name": "501310", "standard_charge_dollar": 184.29, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Windsor Mcare Extra", "plan_name": "500778", "standard_charge_dollar": 184.29, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." } ] } ] }, { "description": "Laparoscopy adrenalectomy", "code_information": [ { "code": "60650", "type": "CPT" } ], "standard_charges": [ { "gross_charge": 107384.23, "minimum": 85907.38, "maximum": 91276.60, "setting": "inpatient", "payers_information": [ { "payer_name": "Aetna", "plan_name": "700700", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna", "plan_name": "700700_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Miscellaneous", "plan_name": "700720", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Miscellaneous", "plan_name": "700720_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Ppo Hmo", "plan_name": "701720", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Ppo Hmo", "plan_name": "701720_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Ms State Emplo", "plan_name": "401457", "standard_charge_percentage": 0.80, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Ms State Emplo", "plan_name": "401457_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Basic Pl", "plan_name": "400100", "standard_charge_percentage": 0.85, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Basic Pl", "plan_name": "400100_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Federal", "plan_name": "400110", "standard_charge_percentage": 0.85, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Federal", "plan_name": "400110_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." } ] } ] }, { "description": "Perq art m-thrombect &/nfs", "code_information": [ { "code": "61645", "type": "CPT" } ], "standard_charges": [ { "gross_charge": 20954.60, "minimum": 848.67, "maximum": 848.67, "setting": "inpatient", "payers_information": [ { "payer_name": "Aetna", "plan_name": "700700", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna", "plan_name": "700700_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Miscellaneous", "plan_name": "700720", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Miscellaneous", "plan_name": "700720_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Ppo Hmo", "plan_name": "701720", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Ppo Hmo", "plan_name": "701720_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Ms State Emplo", "plan_name": "401457", "standard_charge_dollar": 848.67, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Ms State Emplo", "plan_name": "401457_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Basic Pl", "plan_name": "400100", "standard_charge_dollar": 848.67, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Basic Pl", "plan_name": "400100_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Federal", "plan_name": "400110", "standard_charge_dollar": 848.67, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Federal", "plan_name": "400110_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." } ] } ] }, { "description": "Dx lmbr spi pnxr", "code_information": [ { "code": "62270", "type": "CPT" } ], "standard_charges": [ { "gross_charge": 22993.20, "minimum": 634.40, "maximum": 19544.22, "setting": "inpatient", "payers_information": [ { "payer_name": "Aarp", "plan_name": "500102", "standard_charge_dollar": 634.40, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna", "plan_name": "700700", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna", "plan_name": "700700_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Mcare Ffs 6005", "plan_name": "700703", "standard_charge_dollar": 634.40, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Miscellaneous", "plan_name": "700720", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Miscellaneous", "plan_name": "700720_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Ppo Hmo", "plan_name": "701720", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Ppo Hmo", "plan_name": "701720_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Ambetter 68069", "plan_name": "500516", "standard_charge_dollar": 634.40, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Ms State Emplo", "plan_name": "401457", "standard_charge_percentage": 0.80, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Ms State Emplo", "plan_name": "401457_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Basic Pl", "plan_name": "400100", "standard_charge_percentage": 0.85, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Basic Pl", "plan_name": "400100_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Federal", "plan_name": "400110", "standard_charge_percentage": 0.85, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Federal", "plan_name": "400110_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Cigna Healthsprings Ffs", "plan_name": "500064", "standard_charge_dollar": 634.40, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Conseco", "plan_name": "500302", "standard_charge_dollar": 634.40, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Humana Ffs 61101", "plan_name": "500006", "standard_charge_dollar": 634.40, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Medicare A", "plan_name": "100100", "standard_charge_dollar": 634.40, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Medicare A", "plan_name": "100500", "standard_charge_dollar": 634.40, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Medicare Part B Only", "plan_name": "100300", "standard_charge_dollar": 634.40, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Medicare Railroad", "plan_name": "100103", "standard_charge_dollar": 634.40, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Ms Physicians Care N", "plan_name": "714210", "standard_charge_dollar": 793.00, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Peoples Hlth Ffs 72126", "plan_name": "500019", "standard_charge_dollar": 634.40, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Uhc/Secure Horizons", "plan_name": "500449", "standard_charge_dollar": 634.40, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "United Health Care/", "plan_name": "500292", "standard_charge_dollar": 716.87, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "United Healthcare", "plan_name": "750104", "standard_charge_dollar": 716.87, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "United Healthcare Ba", "plan_name": "750090", "standard_charge_dollar": 716.87, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "United Healthcare Me", "plan_name": "501310", "standard_charge_dollar": 634.40, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Windsor Mcare Extra", "plan_name": "500778", "standard_charge_dollar": 634.40, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." } ] } ] }, { "description": "Dx lmbr spi pnxr w/fluor/ct", "code_information": [ { "code": "62328", "type": "CPT" } ], "standard_charges": [ { "gross_charge": 22993.20, "minimum": 634.40, "maximum": 19544.22, "setting": "inpatient", "payers_information": [ { "payer_name": "Aarp", "plan_name": "500102", "standard_charge_dollar": 634.40, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna", "plan_name": "700700", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna", "plan_name": "700700_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Mcare Ffs 6005", "plan_name": "700703", "standard_charge_dollar": 634.40, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Miscellaneous", "plan_name": "700720", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Miscellaneous", "plan_name": "700720_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Ppo Hmo", "plan_name": "701720", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Ppo Hmo", "plan_name": "701720_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Ambetter 68069", "plan_name": "500516", "standard_charge_dollar": 634.40, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Ms State Emplo", "plan_name": "401457", "standard_charge_percentage": 0.80, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Ms State Emplo", "plan_name": "401457_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Basic Pl", "plan_name": "400100", "standard_charge_percentage": 0.85, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Basic Pl", "plan_name": "400100_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Federal", "plan_name": "400110", "standard_charge_percentage": 0.85, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Federal", "plan_name": "400110_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Cigna Healthsprings Ffs", "plan_name": "500064", "standard_charge_dollar": 634.40, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Conseco", "plan_name": "500302", "standard_charge_dollar": 634.40, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Humana Ffs 61101", "plan_name": "500006", "standard_charge_dollar": 634.40, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Medicare A", "plan_name": "100100", "standard_charge_dollar": 634.40, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Medicare A", "plan_name": "100500", "standard_charge_dollar": 634.40, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Medicare Part B Only", "plan_name": "100300", "standard_charge_dollar": 634.40, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Medicare Railroad", "plan_name": "100103", "standard_charge_dollar": 634.40, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Ms Physicians Care N", "plan_name": "714210", "standard_charge_dollar": 793.00, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Peoples Hlth Ffs 72126", "plan_name": "500019", "standard_charge_dollar": 634.40, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Uhc/Secure Horizons", "plan_name": "500449", "standard_charge_dollar": 634.40, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "United Health Care/", "plan_name": "500292", "standard_charge_dollar": 716.87, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "United Healthcare", "plan_name": "750104", "standard_charge_dollar": 716.87, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "United Healthcare Ba", "plan_name": "750090", "standard_charge_dollar": 716.87, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "United Healthcare Me", "plan_name": "501310", "standard_charge_dollar": 634.40, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Windsor Mcare Extra", "plan_name": "500778", "standard_charge_dollar": 634.40, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." } ] } ] }, { "description": "Insert spine infusion device", "code_information": [ { "code": "62360", "type": "CPT" } ], "standard_charges": [ { "gross_charge": 28531.24, "minimum": 16190.72, "maximum": 24251.55, "setting": "inpatient", "payers_information": [ { "payer_name": "Aarp", "plan_name": "500102", "standard_charge_dollar": 16190.72, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna", "plan_name": "700700", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna", "plan_name": "700700_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Mcare Ffs 6005", "plan_name": "700703", "standard_charge_dollar": 16190.72, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Miscellaneous", "plan_name": "700720", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Miscellaneous", "plan_name": "700720_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Ppo Hmo", "plan_name": "701720", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Ppo Hmo", "plan_name": "701720_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Ambetter 68069", "plan_name": "500516", "standard_charge_dollar": 16190.72, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Ms State Emplo", "plan_name": "401457", "standard_charge_percentage": 0.80, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Ms State Emplo", "plan_name": "401457_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Basic Pl", "plan_name": "400100", "standard_charge_percentage": 0.85, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Basic Pl", "plan_name": "400100_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Federal", "plan_name": "400110", "standard_charge_percentage": 0.85, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Federal", "plan_name": "400110_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Cigna Healthsprings Ffs", "plan_name": "500064", "standard_charge_dollar": 16190.72, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Conseco", "plan_name": "500302", "standard_charge_dollar": 16190.72, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Humana Ffs 61101", "plan_name": "500006", "standard_charge_dollar": 16190.72, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Medicare A", "plan_name": "100100", "standard_charge_dollar": 16190.72, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Medicare A", "plan_name": "100500", "standard_charge_dollar": 16190.72, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Medicare Part B Only", "plan_name": "100300", "standard_charge_dollar": 16190.72, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Medicare Railroad", "plan_name": "100103", "standard_charge_dollar": 16190.72, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Ms Physicians Care N", "plan_name": "714210", "standard_charge_dollar": 20238.39, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Peoples Hlth Ffs 72126", "plan_name": "500019", "standard_charge_dollar": 16190.72, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Uhc/Secure Horizons", "plan_name": "500449", "standard_charge_dollar": 16190.72, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "United Health Care/", "plan_name": "500292", "standard_charge_dollar": 18295.51, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "United Healthcare", "plan_name": "750104", "standard_charge_dollar": 18295.51, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "United Healthcare Ba", "plan_name": "750090", "standard_charge_dollar": 18295.51, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "United Healthcare Me", "plan_name": "501310", "standard_charge_dollar": 16190.72, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Windsor Mcare Extra", "plan_name": "500778", "standard_charge_dollar": 16190.72, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." } ] } ] }, { "description": "Remove spine infusion device", "code_information": [ { "code": "62365", "type": "CPT" } ], "standard_charges": [ { "gross_charge": 32126.15, "minimum": 5095.17, "maximum": 7333.21, "setting": "inpatient", "payers_information": [ { "payer_name": "Aarp", "plan_name": "500102", "standard_charge_dollar": 5866.57, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna", "plan_name": "700700", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna", "plan_name": "700700_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Mcare Ffs 6005", "plan_name": "700703", "standard_charge_dollar": 5866.57, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Miscellaneous", "plan_name": "700720", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Miscellaneous", "plan_name": "700720_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Ppo Hmo", "plan_name": "701720", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Ppo Hmo", "plan_name": "701720_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Ambetter 68069", "plan_name": "500516", "standard_charge_dollar": 5866.57, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Ms State Emplo", "plan_name": "401457", "standard_charge_dollar": 5095.17, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Ms State Emplo", "plan_name": "401457_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Basic Pl", "plan_name": "400100", "standard_charge_dollar": 5095.17, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Basic Pl", "plan_name": "400100_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Federal", "plan_name": "400110", "standard_charge_dollar": 5095.17, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Federal", "plan_name": "400110_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Cigna Healthsprings Ffs", "plan_name": "500064", "standard_charge_dollar": 5866.57, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Conseco", "plan_name": "500302", "standard_charge_dollar": 5866.57, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Humana Ffs 61101", "plan_name": "500006", "standard_charge_dollar": 5866.57, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Medicare A", "plan_name": "100100", "standard_charge_dollar": 5866.57, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Medicare A", "plan_name": "100500", "standard_charge_dollar": 5866.57, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Medicare Part B Only", "plan_name": "100300", "standard_charge_dollar": 5866.57, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Medicare Railroad", "plan_name": "100103", "standard_charge_dollar": 5866.57, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Ms Physicians Care N", "plan_name": "714210", "standard_charge_dollar": 7333.21, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Peoples Hlth Ffs 72126", "plan_name": "500019", "standard_charge_dollar": 5866.57, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Uhc/Secure Horizons", "plan_name": "500449", "standard_charge_dollar": 5866.57, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "United Health Care/", "plan_name": "500292", "standard_charge_dollar": 6629.23, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "United Healthcare", "plan_name": "750104", "standard_charge_dollar": 6629.23, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "United Healthcare Ba", "plan_name": "750090", "standard_charge_dollar": 6629.23, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "United Healthcare Me", "plan_name": "501310", "standard_charge_dollar": 5866.57, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Windsor Mcare Extra", "plan_name": "500778", "standard_charge_dollar": 5866.57, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." } ] } ] }, { "description": "Analyze spine infus pump", "code_information": [ { "code": "62367", "type": "CPT" } ], "standard_charges": [ { "gross_charge": 7199.69, "minimum": 274.74, "maximum": 6119.74, "setting": "inpatient", "payers_information": [ { "payer_name": "Aarp", "plan_name": "500102", "standard_charge_dollar": 274.74, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna", "plan_name": "700700", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna", "plan_name": "700700_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Mcare Ffs 6005", "plan_name": "700703", "standard_charge_dollar": 274.74, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Miscellaneous", "plan_name": "700720", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Miscellaneous", "plan_name": "700720_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Ppo Hmo", "plan_name": "701720", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Ppo Hmo", "plan_name": "701720_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Ambetter 68069", "plan_name": "500516", "standard_charge_dollar": 274.74, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Ms State Emplo", "plan_name": "401457", "standard_charge_percentage": 0.80, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Ms State Emplo", "plan_name": "401457_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Basic Pl", "plan_name": "400100", "standard_charge_percentage": 0.85, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Basic Pl", "plan_name": "400100_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Federal", "plan_name": "400110", "standard_charge_percentage": 0.85, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Federal", "plan_name": "400110_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Cigna Healthsprings Ffs", "plan_name": "500064", "standard_charge_dollar": 274.74, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Conseco", "plan_name": "500302", "standard_charge_dollar": 274.74, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Humana Ffs 61101", "plan_name": "500006", "standard_charge_dollar": 274.74, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Medicare A", "plan_name": "100100", "standard_charge_dollar": 274.74, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Medicare A", "plan_name": "100500", "standard_charge_dollar": 274.74, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Medicare Part B Only", "plan_name": "100300", "standard_charge_dollar": 274.74, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Medicare Railroad", "plan_name": "100103", "standard_charge_dollar": 274.74, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Ms Physicians Care N", "plan_name": "714210", "standard_charge_dollar": 343.42, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Peoples Hlth Ffs 72126", "plan_name": "500019", "standard_charge_dollar": 274.74, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Uhc/Secure Horizons", "plan_name": "500449", "standard_charge_dollar": 274.74, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "United Health Care/", "plan_name": "500292", "standard_charge_dollar": 310.45, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "United Healthcare", "plan_name": "750104", "standard_charge_dollar": 310.45, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "United Healthcare Ba", "plan_name": "750090", "standard_charge_dollar": 310.45, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "United Healthcare Me", "plan_name": "501310", "standard_charge_dollar": 274.74, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Windsor Mcare Extra", "plan_name": "500778", "standard_charge_dollar": 274.74, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." } ] } ] }, { "description": "Analyze sp inf pump w/reprog", "code_information": [ { "code": "62368", "type": "CPT" } ], "standard_charges": [ { "gross_charge": 7199.69, "minimum": 274.74, "maximum": 6119.74, "setting": "inpatient", "payers_information": [ { "payer_name": "Aarp", "plan_name": "500102", "standard_charge_dollar": 274.74, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna", "plan_name": "700700", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna", "plan_name": "700700_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Mcare Ffs 6005", "plan_name": "700703", "standard_charge_dollar": 274.74, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Miscellaneous", "plan_name": "700720", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Miscellaneous", "plan_name": "700720_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Ppo Hmo", "plan_name": "701720", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Ppo Hmo", "plan_name": "701720_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Ambetter 68069", "plan_name": "500516", "standard_charge_dollar": 274.74, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Ms State Emplo", "plan_name": "401457", "standard_charge_percentage": 0.80, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Ms State Emplo", "plan_name": "401457_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Basic Pl", "plan_name": "400100", "standard_charge_percentage": 0.85, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Basic Pl", "plan_name": "400100_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Federal", "plan_name": "400110", "standard_charge_percentage": 0.85, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Federal", "plan_name": "400110_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Cigna Healthsprings Ffs", "plan_name": "500064", "standard_charge_dollar": 274.74, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Conseco", "plan_name": "500302", "standard_charge_dollar": 274.74, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Humana Ffs 61101", "plan_name": "500006", "standard_charge_dollar": 274.74, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Medicare A", "plan_name": "100100", "standard_charge_dollar": 274.74, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Medicare A", "plan_name": "100500", "standard_charge_dollar": 274.74, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Medicare Part B Only", "plan_name": "100300", "standard_charge_dollar": 274.74, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Medicare Railroad", "plan_name": "100103", "standard_charge_dollar": 274.74, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Ms Physicians Care N", "plan_name": "714210", "standard_charge_dollar": 343.42, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Peoples Hlth Ffs 72126", "plan_name": "500019", "standard_charge_dollar": 274.74, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Uhc/Secure Horizons", "plan_name": "500449", "standard_charge_dollar": 274.74, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "United Health Care/", "plan_name": "500292", "standard_charge_dollar": 310.45, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "United Healthcare", "plan_name": "750104", "standard_charge_dollar": 310.45, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "United Healthcare Ba", "plan_name": "750090", "standard_charge_dollar": 310.45, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "United Healthcare Me", "plan_name": "501310", "standard_charge_dollar": 274.74, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Windsor Mcare Extra", "plan_name": "500778", "standard_charge_dollar": 274.74, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." } ] } ] }, { "description": "Anal sp inf pmp w/reprg&fill", "code_information": [ { "code": "62369", "type": "CPT" } ], "standard_charges": [ { "gross_charge": 7199.69, "minimum": 274.74, "maximum": 6119.74, "setting": "inpatient", "payers_information": [ { "payer_name": "Aarp", "plan_name": "500102", "standard_charge_dollar": 274.74, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna", "plan_name": "700700", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna", "plan_name": "700700_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Mcare Ffs 6005", "plan_name": "700703", "standard_charge_dollar": 274.74, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Miscellaneous", "plan_name": "700720", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Miscellaneous", "plan_name": "700720_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Ppo Hmo", "plan_name": "701720", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Ppo Hmo", "plan_name": "701720_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Ambetter 68069", "plan_name": "500516", "standard_charge_dollar": 274.74, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Ms State Emplo", "plan_name": "401457", "standard_charge_percentage": 0.80, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Ms State Emplo", "plan_name": "401457_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Basic Pl", "plan_name": "400100", "standard_charge_percentage": 0.85, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Basic Pl", "plan_name": "400100_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Federal", "plan_name": "400110", "standard_charge_percentage": 0.85, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Federal", "plan_name": "400110_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Cigna Healthsprings Ffs", "plan_name": "500064", "standard_charge_dollar": 274.74, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Conseco", "plan_name": "500302", "standard_charge_dollar": 274.74, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Humana Ffs 61101", "plan_name": "500006", "standard_charge_dollar": 274.74, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Medicare A", "plan_name": "100100", "standard_charge_dollar": 274.74, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Medicare A", "plan_name": "100500", "standard_charge_dollar": 274.74, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Medicare Part B Only", "plan_name": "100300", "standard_charge_dollar": 274.74, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Medicare Railroad", "plan_name": "100103", "standard_charge_dollar": 274.74, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Ms Physicians Care N", "plan_name": "714210", "standard_charge_dollar": 343.42, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Peoples Hlth Ffs 72126", "plan_name": "500019", "standard_charge_dollar": 274.74, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Uhc/Secure Horizons", "plan_name": "500449", "standard_charge_dollar": 274.74, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "United Health Care/", "plan_name": "500292", "standard_charge_dollar": 310.45, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "United Healthcare", "plan_name": "750104", "standard_charge_dollar": 310.45, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "United Healthcare Ba", "plan_name": "750090", "standard_charge_dollar": 310.45, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "United Healthcare Me", "plan_name": "501310", "standard_charge_dollar": 274.74, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Windsor Mcare Extra", "plan_name": "500778", "standard_charge_dollar": 274.74, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." } ] } ] }, { "description": "Anl sp inf pmp w/mdreprg&fil", "code_information": [ { "code": "62370", "type": "CPT" } ], "standard_charges": [ { "gross_charge": 7199.69, "minimum": 274.74, "maximum": 6119.74, "setting": "inpatient", "payers_information": [ { "payer_name": "Aarp", "plan_name": "500102", "standard_charge_dollar": 274.74, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna", "plan_name": "700700", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna", "plan_name": "700700_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Mcare Ffs 6005", "plan_name": "700703", "standard_charge_dollar": 274.74, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Miscellaneous", "plan_name": "700720", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Miscellaneous", "plan_name": "700720_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Ppo Hmo", "plan_name": "701720", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Ppo Hmo", "plan_name": "701720_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Ambetter 68069", "plan_name": "500516", "standard_charge_dollar": 274.74, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Ms State Emplo", "plan_name": "401457", "standard_charge_percentage": 0.80, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Ms State Emplo", "plan_name": "401457_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Basic Pl", "plan_name": "400100", "standard_charge_percentage": 0.85, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Basic Pl", "plan_name": "400100_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Federal", "plan_name": "400110", "standard_charge_percentage": 0.85, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Federal", "plan_name": "400110_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Cigna Healthsprings Ffs", "plan_name": "500064", "standard_charge_dollar": 274.74, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Conseco", "plan_name": "500302", "standard_charge_dollar": 274.74, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Humana Ffs 61101", "plan_name": "500006", "standard_charge_dollar": 274.74, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Medicare A", "plan_name": "100100", "standard_charge_dollar": 274.74, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Medicare A", "plan_name": "100500", "standard_charge_dollar": 274.74, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Medicare Part B Only", "plan_name": "100300", "standard_charge_dollar": 274.74, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Medicare Railroad", "plan_name": "100103", "standard_charge_dollar": 274.74, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Ms Physicians Care N", "plan_name": "714210", "standard_charge_dollar": 343.42, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Peoples Hlth Ffs 72126", "plan_name": "500019", "standard_charge_dollar": 274.74, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Uhc/Secure Horizons", "plan_name": "500449", "standard_charge_dollar": 274.74, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "United Health Care/", "plan_name": "500292", "standard_charge_dollar": 310.45, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "United Healthcare", "plan_name": "750104", "standard_charge_dollar": 310.45, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "United Healthcare Ba", "plan_name": "750090", "standard_charge_dollar": 310.45, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "United Healthcare Me", "plan_name": "501310", "standard_charge_dollar": 274.74, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Windsor Mcare Extra", "plan_name": "500778", "standard_charge_dollar": 274.74, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." } ] } ] }, { "description": "Hc digital nerve block perphieral", "code_information": [ { "code": "64450", "type": "CPT" } ], "standard_charges": [ { "gross_charge": 400.00, "minimum": 320.00, "maximum": 793.00, "setting": "both", "payers_information": [ { "payer_name": "Aarp", "plan_name": "500102", "standard_charge_dollar": 634.40, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna", "plan_name": "700700", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna", "plan_name": "700700_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Mcare Ffs 6005", "plan_name": "700703", "standard_charge_dollar": 634.40, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Miscellaneous", "plan_name": "700720", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Miscellaneous", "plan_name": "700720_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Ppo Hmo", "plan_name": "701720", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Ppo Hmo", "plan_name": "701720_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Ambetter 68069", "plan_name": "500516", "standard_charge_dollar": 634.40, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Ms State Emplo", "plan_name": "401457", "standard_charge_percentage": 0.80, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Ms State Emplo", "plan_name": "401457_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Basic Pl", "plan_name": "400100", "standard_charge_percentage": 0.85, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Basic Pl", "plan_name": "400100_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Federal", "plan_name": "400110", "standard_charge_percentage": 0.85, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Federal", "plan_name": "400110_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Cigna Healthsprings Ffs", "plan_name": "500064", "standard_charge_dollar": 634.40, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Conseco", "plan_name": "500302", "standard_charge_dollar": 634.40, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Humana Ffs 61101", "plan_name": "500006", "standard_charge_dollar": 634.40, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Medicare A", "plan_name": "100100", "standard_charge_dollar": 634.40, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Medicare A", "plan_name": "100500", "standard_charge_dollar": 634.40, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Medicare Part B Only", "plan_name": "100300", "standard_charge_dollar": 634.40, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Medicare Railroad", "plan_name": "100103", "standard_charge_dollar": 634.40, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Ms Physicians Care N", "plan_name": "714210", "standard_charge_dollar": 793.00, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Peoples Hlth Ffs 72126", "plan_name": "500019", "standard_charge_dollar": 634.40, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Uhc/Secure Horizons", "plan_name": "500449", "standard_charge_dollar": 634.40, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "United Health Care/", "plan_name": "500292", "standard_charge_dollar": 716.87, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "United Healthcare", "plan_name": "750104", "standard_charge_dollar": 716.87, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "United Healthcare Ba", "plan_name": "750090", "standard_charge_dollar": 716.87, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "United Healthcare Me", "plan_name": "501310", "standard_charge_dollar": 634.40, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Windsor Mcare Extra", "plan_name": "500778", "standard_charge_dollar": 634.40, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." } ] } ] }, { "description": "Njx aa&/strd other pn/branch", "code_information": [ { "code": "64450", "type": "CPT" } ], "standard_charges": [ { "gross_charge": 400.00, "minimum": 320.00, "maximum": 793.00, "setting": "both", "payers_information": [ { "payer_name": "Aarp", "plan_name": "500102", "standard_charge_dollar": 634.40, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna", "plan_name": "700700", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna", "plan_name": "700700_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Mcare Ffs 6005", "plan_name": "700703", "standard_charge_dollar": 634.40, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Miscellaneous", "plan_name": "700720", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Miscellaneous", "plan_name": "700720_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Ppo Hmo", "plan_name": "701720", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Ppo Hmo", "plan_name": "701720_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Ambetter 68069", "plan_name": "500516", "standard_charge_dollar": 634.40, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Ms State Emplo", "plan_name": "401457", "standard_charge_percentage": 0.80, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Ms State Emplo", "plan_name": "401457_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Basic Pl", "plan_name": "400100", "standard_charge_percentage": 0.85, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Basic Pl", "plan_name": "400100_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Federal", "plan_name": "400110", "standard_charge_percentage": 0.85, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Federal", "plan_name": "400110_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Cigna Healthsprings Ffs", "plan_name": "500064", "standard_charge_dollar": 634.40, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Conseco", "plan_name": "500302", "standard_charge_dollar": 634.40, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Humana Ffs 61101", "plan_name": "500006", "standard_charge_dollar": 634.40, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Medicare A", "plan_name": "100100", "standard_charge_dollar": 634.40, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Medicare A", "plan_name": "100500", "standard_charge_dollar": 634.40, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Medicare Part B Only", "plan_name": "100300", "standard_charge_dollar": 634.40, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Medicare Railroad", "plan_name": "100103", "standard_charge_dollar": 634.40, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Ms Physicians Care N", "plan_name": "714210", "standard_charge_dollar": 793.00, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Peoples Hlth Ffs 72126", "plan_name": "500019", "standard_charge_dollar": 634.40, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Uhc/Secure Horizons", "plan_name": "500449", "standard_charge_dollar": 634.40, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "United Health Care/", "plan_name": "500292", "standard_charge_dollar": 716.87, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "United Healthcare", "plan_name": "750104", "standard_charge_dollar": 716.87, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "United Healthcare Ba", "plan_name": "750090", "standard_charge_dollar": 716.87, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "United Healthcare Me", "plan_name": "501310", "standard_charge_dollar": 634.40, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Windsor Mcare Extra", "plan_name": "500778", "standard_charge_dollar": 634.40, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." } ] } ] }, { "description": "Inj paravert f jnt c/t 1 lev", "code_information": [ { "code": "64490", "type": "CPT" } ], "standard_charges": [ { "gross_charge": 12855.44, "minimum": 815.57, "maximum": 10927.12, "setting": "inpatient", "payers_information": [ { "payer_name": "Aarp", "plan_name": "500102", "standard_charge_dollar": 815.57, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna", "plan_name": "700700", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna", "plan_name": "700700_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Mcare Ffs 6005", "plan_name": "700703", "standard_charge_dollar": 815.57, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Miscellaneous", "plan_name": "700720", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Miscellaneous", "plan_name": "700720_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Ppo Hmo", "plan_name": "701720", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Ppo Hmo", "plan_name": "701720_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Ambetter 68069", "plan_name": "500516", "standard_charge_dollar": 815.57, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Ms State Emplo", "plan_name": "401457", "standard_charge_percentage": 0.80, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Ms State Emplo", "plan_name": "401457_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Basic Pl", "plan_name": "400100", "standard_charge_percentage": 0.85, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Basic Pl", "plan_name": "400100_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Federal", "plan_name": "400110", "standard_charge_percentage": 0.85, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Federal", "plan_name": "400110_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Cigna Healthsprings Ffs", "plan_name": "500064", "standard_charge_dollar": 815.57, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Conseco", "plan_name": "500302", "standard_charge_dollar": 815.57, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Humana Ffs 61101", "plan_name": "500006", "standard_charge_dollar": 815.57, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Medicare A", "plan_name": "100100", "standard_charge_dollar": 815.57, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Medicare A", "plan_name": "100500", "standard_charge_dollar": 815.57, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Medicare Part B Only", "plan_name": "100300", "standard_charge_dollar": 815.57, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Medicare Railroad", "plan_name": "100103", "standard_charge_dollar": 815.57, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Ms Physicians Care N", "plan_name": "714210", "standard_charge_dollar": 1019.46, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Peoples Hlth Ffs 72126", "plan_name": "500019", "standard_charge_dollar": 815.57, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Uhc/Secure Horizons", "plan_name": "500449", "standard_charge_dollar": 815.57, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "United Health Care/", "plan_name": "500292", "standard_charge_dollar": 921.59, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "United Healthcare", "plan_name": "750104", "standard_charge_dollar": 921.59, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "United Healthcare Ba", "plan_name": "750090", "standard_charge_dollar": 921.59, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "United Healthcare Me", "plan_name": "501310", "standard_charge_dollar": 815.57, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Windsor Mcare Extra", "plan_name": "500778", "standard_charge_dollar": 815.57, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." } ] } ] }, { "description": "Hc removal foreign body eye", "code_information": [ { "code": "65205", "type": "CPT" } ], "standard_charges": [ { "gross_charge": 126.00, "minimum": 118.08, "maximum": 149.97, "setting": "both", "payers_information": [ { "payer_name": "Aarp", "plan_name": "500102", "standard_charge_dollar": 118.08, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna", "plan_name": "700700", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna", "plan_name": "700700_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Mcare Ffs 6005", "plan_name": "700703", "standard_charge_dollar": 118.08, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Miscellaneous", "plan_name": "700720", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Miscellaneous", "plan_name": "700720_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Ppo Hmo", "plan_name": "701720", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Ppo Hmo", "plan_name": "701720_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Ambetter 68069", "plan_name": "500516", "standard_charge_dollar": 118.08, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Ms State Emplo", "plan_name": "401457", "standard_charge_dollar": 149.97, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Ms State Emplo", "plan_name": "401457_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Basic Pl", "plan_name": "400100", "standard_charge_dollar": 149.97, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Basic Pl", "plan_name": "400100_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Federal", "plan_name": "400110", "standard_charge_dollar": 149.97, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Federal", "plan_name": "400110_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Cigna Healthsprings Ffs", "plan_name": "500064", "standard_charge_dollar": 118.08, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Conseco", "plan_name": "500302", "standard_charge_dollar": 118.08, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Humana Ffs 61101", "plan_name": "500006", "standard_charge_dollar": 118.08, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Medicare A", "plan_name": "100100", "standard_charge_dollar": 118.08, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Medicare A", "plan_name": "100500", "standard_charge_dollar": 118.08, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Medicare Part B Only", "plan_name": "100300", "standard_charge_dollar": 118.08, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Medicare Railroad", "plan_name": "100103", "standard_charge_dollar": 118.08, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Ms Physicians Care N", "plan_name": "714210", "standard_charge_dollar": 147.60, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Peoples Hlth Ffs 72126", "plan_name": "500019", "standard_charge_dollar": 118.08, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Uhc/Secure Horizons", "plan_name": "500449", "standard_charge_dollar": 118.08, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "United Health Care/", "plan_name": "500292", "standard_charge_dollar": 133.43, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "United Healthcare", "plan_name": "750104", "standard_charge_dollar": 133.43, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "United Healthcare Ba", "plan_name": "750090", "standard_charge_dollar": 133.43, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "United Healthcare Me", "plan_name": "501310", "standard_charge_dollar": 118.08, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Windsor Mcare Extra", "plan_name": "500778", "standard_charge_dollar": 118.08, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." } ] } ] }, { "description": "Remove foreign body from eye", "code_information": [ { "code": "65205", "type": "CPT" } ], "standard_charges": [ { "gross_charge": 126.00, "minimum": 118.08, "maximum": 149.97, "setting": "both", "payers_information": [ { "payer_name": "Aarp", "plan_name": "500102", "standard_charge_dollar": 118.08, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna", "plan_name": "700700", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna", "plan_name": "700700_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Mcare Ffs 6005", "plan_name": "700703", "standard_charge_dollar": 118.08, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Miscellaneous", "plan_name": "700720", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Miscellaneous", "plan_name": "700720_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Ppo Hmo", "plan_name": "701720", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Ppo Hmo", "plan_name": "701720_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Ambetter 68069", "plan_name": "500516", "standard_charge_dollar": 118.08, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Ms State Emplo", "plan_name": "401457", "standard_charge_dollar": 149.97, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Ms State Emplo", "plan_name": "401457_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Basic Pl", "plan_name": "400100", "standard_charge_dollar": 149.97, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Basic Pl", "plan_name": "400100_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Federal", "plan_name": "400110", "standard_charge_dollar": 149.97, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Federal", "plan_name": "400110_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Cigna Healthsprings Ffs", "plan_name": "500064", "standard_charge_dollar": 118.08, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Conseco", "plan_name": "500302", "standard_charge_dollar": 118.08, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Humana Ffs 61101", "plan_name": "500006", "standard_charge_dollar": 118.08, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Medicare A", "plan_name": "100100", "standard_charge_dollar": 118.08, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Medicare A", "plan_name": "100500", "standard_charge_dollar": 118.08, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Medicare Part B Only", "plan_name": "100300", "standard_charge_dollar": 118.08, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Medicare Railroad", "plan_name": "100103", "standard_charge_dollar": 118.08, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Ms Physicians Care N", "plan_name": "714210", "standard_charge_dollar": 147.60, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Peoples Hlth Ffs 72126", "plan_name": "500019", "standard_charge_dollar": 118.08, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Uhc/Secure Horizons", "plan_name": "500449", "standard_charge_dollar": 118.08, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "United Health Care/", "plan_name": "500292", "standard_charge_dollar": 133.43, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "United Healthcare", "plan_name": "750104", "standard_charge_dollar": 133.43, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "United Healthcare Ba", "plan_name": "750090", "standard_charge_dollar": 133.43, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "United Healthcare Me", "plan_name": "501310", "standard_charge_dollar": 118.08, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Windsor Mcare Extra", "plan_name": "500778", "standard_charge_dollar": 118.08, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." } ] } ] }, { "description": "Hc removal f/b corneal w/o slit lamp", "code_information": [ { "code": "65220", "type": "CPT" } ], "standard_charges": [ { "gross_charge": 126.00, "minimum": 365.55, "maximum": 456.94, "setting": "both", "payers_information": [ { "payer_name": "Aarp", "plan_name": "500102", "standard_charge_dollar": 365.55, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna", "plan_name": "700700", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna", "plan_name": "700700_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Mcare Ffs 6005", "plan_name": "700703", "standard_charge_dollar": 365.55, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Miscellaneous", "plan_name": "700720", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Miscellaneous", "plan_name": "700720_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Ppo Hmo", "plan_name": "701720", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Ppo Hmo", "plan_name": "701720_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Ambetter 68069", "plan_name": "500516", "standard_charge_dollar": 365.55, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Ms State Emplo", "plan_name": "401457", "standard_charge_dollar": 395.24, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Ms State Emplo", "plan_name": "401457_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Basic Pl", "plan_name": "400100", "standard_charge_dollar": 395.24, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Basic Pl", "plan_name": "400100_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Federal", "plan_name": "400110", "standard_charge_dollar": 395.24, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Federal", "plan_name": "400110_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Cigna Healthsprings Ffs", "plan_name": "500064", "standard_charge_dollar": 365.55, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Conseco", "plan_name": "500302", "standard_charge_dollar": 365.55, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Humana Ffs 61101", "plan_name": "500006", "standard_charge_dollar": 365.55, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Medicare A", "plan_name": "100100", "standard_charge_dollar": 365.55, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Medicare A", "plan_name": "100500", "standard_charge_dollar": 365.55, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Medicare Part B Only", "plan_name": "100300", "standard_charge_dollar": 365.55, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Medicare Railroad", "plan_name": "100103", "standard_charge_dollar": 365.55, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Ms Physicians Care N", "plan_name": "714210", "standard_charge_dollar": 456.94, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Peoples Hlth Ffs 72126", "plan_name": "500019", "standard_charge_dollar": 365.55, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Uhc/Secure Horizons", "plan_name": "500449", "standard_charge_dollar": 365.55, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "United Health Care/", "plan_name": "500292", "standard_charge_dollar": 413.07, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "United Healthcare", "plan_name": "750104", "standard_charge_dollar": 413.07, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "United Healthcare Ba", "plan_name": "750090", "standard_charge_dollar": 413.07, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "United Healthcare Me", "plan_name": "501310", "standard_charge_dollar": 365.55, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Windsor Mcare Extra", "plan_name": "500778", "standard_charge_dollar": 365.55, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." } ] } ] }, { "description": "Remove foreign body from eye", "code_information": [ { "code": "65220", "type": "CPT" } ], "standard_charges": [ { "gross_charge": 126.00, "minimum": 365.55, "maximum": 456.94, "setting": "both", "payers_information": [ { "payer_name": "Aarp", "plan_name": "500102", "standard_charge_dollar": 365.55, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna", "plan_name": "700700", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna", "plan_name": "700700_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Mcare Ffs 6005", "plan_name": "700703", "standard_charge_dollar": 365.55, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Miscellaneous", "plan_name": "700720", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Miscellaneous", "plan_name": "700720_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Ppo Hmo", "plan_name": "701720", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Ppo Hmo", "plan_name": "701720_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Ambetter 68069", "plan_name": "500516", "standard_charge_dollar": 365.55, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Ms State Emplo", "plan_name": "401457", "standard_charge_dollar": 395.24, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Ms State Emplo", "plan_name": "401457_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Basic Pl", "plan_name": "400100", "standard_charge_dollar": 395.24, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Basic Pl", "plan_name": "400100_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Federal", "plan_name": "400110", "standard_charge_dollar": 395.24, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Federal", "plan_name": "400110_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Cigna Healthsprings Ffs", "plan_name": "500064", "standard_charge_dollar": 365.55, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Conseco", "plan_name": "500302", "standard_charge_dollar": 365.55, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Humana Ffs 61101", "plan_name": "500006", "standard_charge_dollar": 365.55, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Medicare A", "plan_name": "100100", "standard_charge_dollar": 365.55, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Medicare A", "plan_name": "100500", "standard_charge_dollar": 365.55, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Medicare Part B Only", "plan_name": "100300", "standard_charge_dollar": 365.55, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Medicare Railroad", "plan_name": "100103", "standard_charge_dollar": 365.55, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Ms Physicians Care N", "plan_name": "714210", "standard_charge_dollar": 456.94, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Peoples Hlth Ffs 72126", "plan_name": "500019", "standard_charge_dollar": 365.55, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Uhc/Secure Horizons", "plan_name": "500449", "standard_charge_dollar": 365.55, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "United Health Care/", "plan_name": "500292", "standard_charge_dollar": 413.07, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "United Healthcare", "plan_name": "750104", "standard_charge_dollar": 413.07, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "United Healthcare Ba", "plan_name": "750090", "standard_charge_dollar": 413.07, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "United Healthcare Me", "plan_name": "501310", "standard_charge_dollar": 365.55, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Windsor Mcare Extra", "plan_name": "500778", "standard_charge_dollar": 365.55, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." } ] } ] }, { "description": "Clear outer ear canal", "code_information": [ { "code": "69200", "type": "CPT" } ], "standard_charges": [ { "gross_charge": 136.50, "minimum": 118.08, "maximum": 149.97, "setting": "both", "payers_information": [ { "payer_name": "Aarp", "plan_name": "500102", "standard_charge_dollar": 118.08, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna", "plan_name": "700700", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna", "plan_name": "700700_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Mcare Ffs 6005", "plan_name": "700703", "standard_charge_dollar": 118.08, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Miscellaneous", "plan_name": "700720", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Miscellaneous", "plan_name": "700720_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Ppo Hmo", "plan_name": "701720", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Ppo Hmo", "plan_name": "701720_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Ambetter 68069", "plan_name": "500516", "standard_charge_dollar": 118.08, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Ms State Emplo", "plan_name": "401457", "standard_charge_dollar": 149.97, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Ms State Emplo", "plan_name": "401457_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Basic Pl", "plan_name": "400100", "standard_charge_dollar": 149.97, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Basic Pl", "plan_name": "400100_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Federal", "plan_name": "400110", "standard_charge_dollar": 149.97, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Federal", "plan_name": "400110_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Cigna Healthsprings Ffs", "plan_name": "500064", "standard_charge_dollar": 118.08, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Conseco", "plan_name": "500302", "standard_charge_dollar": 118.08, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Humana Ffs 61101", "plan_name": "500006", "standard_charge_dollar": 118.08, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Medicare A", "plan_name": "100100", "standard_charge_dollar": 118.08, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Medicare A", "plan_name": "100500", "standard_charge_dollar": 118.08, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Medicare Part B Only", "plan_name": "100300", "standard_charge_dollar": 118.08, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Medicare Railroad", "plan_name": "100103", "standard_charge_dollar": 118.08, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Ms Physicians Care N", "plan_name": "714210", "standard_charge_dollar": 147.60, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Peoples Hlth Ffs 72126", "plan_name": "500019", "standard_charge_dollar": 118.08, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Uhc/Secure Horizons", "plan_name": "500449", "standard_charge_dollar": 118.08, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "United Health Care/", "plan_name": "500292", "standard_charge_dollar": 133.43, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "United Healthcare", "plan_name": "750104", "standard_charge_dollar": 133.43, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "United Healthcare Ba", "plan_name": "750090", "standard_charge_dollar": 133.43, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "United Healthcare Me", "plan_name": "501310", "standard_charge_dollar": 118.08, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Windsor Mcare Extra", "plan_name": "500778", "standard_charge_dollar": 118.08, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." } ] } ] }, { "description": "Hc removal foreign body ear", "code_information": [ { "code": "69200", "type": "CPT" } ], "standard_charges": [ { "gross_charge": 136.50, "minimum": 118.08, "maximum": 149.97, "setting": "both", "payers_information": [ { "payer_name": "Aarp", "plan_name": "500102", "standard_charge_dollar": 118.08, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna", "plan_name": "700700", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna", "plan_name": "700700_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Mcare Ffs 6005", "plan_name": "700703", "standard_charge_dollar": 118.08, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Miscellaneous", "plan_name": "700720", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Miscellaneous", "plan_name": "700720_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Ppo Hmo", "plan_name": "701720", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Ppo Hmo", "plan_name": "701720_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Ambetter 68069", "plan_name": "500516", "standard_charge_dollar": 118.08, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Ms State Emplo", "plan_name": "401457", "standard_charge_dollar": 149.97, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Ms State Emplo", "plan_name": "401457_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Basic Pl", "plan_name": "400100", "standard_charge_dollar": 149.97, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Basic Pl", "plan_name": "400100_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Federal", "plan_name": "400110", "standard_charge_dollar": 149.97, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Federal", "plan_name": "400110_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Cigna Healthsprings Ffs", "plan_name": "500064", "standard_charge_dollar": 118.08, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Conseco", "plan_name": "500302", "standard_charge_dollar": 118.08, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Humana Ffs 61101", "plan_name": "500006", "standard_charge_dollar": 118.08, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Medicare A", "plan_name": "100100", "standard_charge_dollar": 118.08, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Medicare A", "plan_name": "100500", "standard_charge_dollar": 118.08, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Medicare Part B Only", "plan_name": "100300", "standard_charge_dollar": 118.08, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Medicare Railroad", "plan_name": "100103", "standard_charge_dollar": 118.08, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Ms Physicians Care N", "plan_name": "714210", "standard_charge_dollar": 147.60, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Peoples Hlth Ffs 72126", "plan_name": "500019", "standard_charge_dollar": 118.08, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Uhc/Secure Horizons", "plan_name": "500449", "standard_charge_dollar": 118.08, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "United Health Care/", "plan_name": "500292", "standard_charge_dollar": 133.43, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "United Healthcare", "plan_name": "750104", "standard_charge_dollar": 133.43, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "United Healthcare Ba", "plan_name": "750090", "standard_charge_dollar": 133.43, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "United Healthcare Me", "plan_name": "501310", "standard_charge_dollar": 118.08, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Windsor Mcare Extra", "plan_name": "500778", "standard_charge_dollar": 118.08, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." } ] } ] }, { "description": "Hc removal foreign body ear", "code_information": [ { "code": "69200", "type": "CPT" } ], "standard_charges": [ { "gross_charge": 136.50, "minimum": 109.20, "maximum": 147.60, "setting": "both", "payers_information": [ { "payer_name": "Aarp", "plan_name": "500102", "standard_charge_dollar": 118.08, "count": "0", "methodology": "fee schedule", "modifiers": "52", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna", "plan_name": "700700", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna", "plan_name": "700700_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Mcare Ffs 6005", "plan_name": "700703", "standard_charge_dollar": 118.08, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Miscellaneous", "plan_name": "700720", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Miscellaneous", "plan_name": "700720_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Ppo Hmo", "plan_name": "701720", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Ppo Hmo", "plan_name": "701720_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Ambetter 68069", "plan_name": "500516", "standard_charge_dollar": 118.08, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Ms State Emplo", "plan_name": "401457", "standard_charge_percentage": 0.80, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Ms State Emplo", "plan_name": "401457_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Basic Pl", "plan_name": "400100", "standard_charge_percentage": 0.85, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Basic Pl", "plan_name": "400100_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Federal", "plan_name": "400110", "standard_charge_percentage": 0.85, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Federal", "plan_name": "400110_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Cigna Healthsprings Ffs", "plan_name": "500064", "standard_charge_dollar": 118.08, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Conseco", "plan_name": "500302", "standard_charge_dollar": 118.08, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Humana Ffs 61101", "plan_name": "500006", "standard_charge_dollar": 118.08, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Medicare A", "plan_name": "100100", "standard_charge_dollar": 118.08, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Medicare A", "plan_name": "100500", "standard_charge_dollar": 118.08, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Medicare Part B Only", "plan_name": "100300", "standard_charge_dollar": 118.08, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Medicare Railroad", "plan_name": "100103", "standard_charge_dollar": 118.08, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Ms Physicians Care N", "plan_name": "714210", "standard_charge_dollar": 147.60, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Peoples Hlth Ffs 72126", "plan_name": "500019", "standard_charge_dollar": 118.08, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Uhc/Secure Horizons", "plan_name": "500449", "standard_charge_dollar": 118.08, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "United Health Care/", "plan_name": "500292", "standard_charge_dollar": 133.43, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "United Healthcare", "plan_name": "750104", "standard_charge_dollar": 133.43, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "United Healthcare Ba", "plan_name": "750090", "standard_charge_dollar": 133.43, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "United Healthcare Me", "plan_name": "501310", "standard_charge_dollar": 118.08, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Windsor Mcare Extra", "plan_name": "500778", "standard_charge_dollar": 118.08, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." } ] } ] }, { "description": "Hc rmvl impct ear wax uni w/irig", "code_information": [ { "code": "69209", "type": "CPT" } ], "standard_charges": [ { "gross_charge": 110.00, "minimum": 54.41, "maximum": 81.80, "setting": "both", "payers_information": [ { "payer_name": "Aarp", "plan_name": "500102", "standard_charge_dollar": 54.41, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna", "plan_name": "700700", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna", "plan_name": "700700_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Mcare Ffs 6005", "plan_name": "700703", "standard_charge_dollar": 54.41, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Miscellaneous", "plan_name": "700720", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Miscellaneous", "plan_name": "700720_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Ppo Hmo", "plan_name": "701720", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Ppo Hmo", "plan_name": "701720_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Ambetter 68069", "plan_name": "500516", "standard_charge_dollar": 54.41, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Ms State Emplo", "plan_name": "401457", "standard_charge_dollar": 81.80, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Ms State Emplo", "plan_name": "401457_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Basic Pl", "plan_name": "400100", "standard_charge_dollar": 81.80, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Basic Pl", "plan_name": "400100_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Federal", "plan_name": "400110", "standard_charge_dollar": 81.80, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Federal", "plan_name": "400110_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Cigna Healthsprings Ffs", "plan_name": "500064", "standard_charge_dollar": 54.41, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Conseco", "plan_name": "500302", "standard_charge_dollar": 54.41, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Humana Ffs 61101", "plan_name": "500006", "standard_charge_dollar": 54.41, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Medicare A", "plan_name": "100100", "standard_charge_dollar": 54.41, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Medicare A", "plan_name": "100500", "standard_charge_dollar": 54.41, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Medicare Part B Only", "plan_name": "100300", "standard_charge_dollar": 54.41, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Medicare Railroad", "plan_name": "100103", "standard_charge_dollar": 54.41, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Ms Physicians Care N", "plan_name": "714210", "standard_charge_dollar": 68.02, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Peoples Hlth Ffs 72126", "plan_name": "500019", "standard_charge_dollar": 54.41, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Uhc/Secure Horizons", "plan_name": "500449", "standard_charge_dollar": 54.41, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "United Health Care/", "plan_name": "500292", "standard_charge_dollar": 61.49, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "United Healthcare", "plan_name": "750104", "standard_charge_dollar": 61.49, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "United Healthcare Ba", "plan_name": "750090", "standard_charge_dollar": 61.49, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "United Healthcare Me", "plan_name": "501310", "standard_charge_dollar": 54.41, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Windsor Mcare Extra", "plan_name": "500778", "standard_charge_dollar": 54.41, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." } ] } ] }, { "description": "Remove impacted ear wax uni", "code_information": [ { "code": "69209", "type": "CPT" } ], "standard_charges": [ { "gross_charge": 110.00, "minimum": 54.41, "maximum": 81.80, "setting": "both", "payers_information": [ { "payer_name": "Aarp", "plan_name": "500102", "standard_charge_dollar": 54.41, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna", "plan_name": "700700", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna", "plan_name": "700700_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Mcare Ffs 6005", "plan_name": "700703", "standard_charge_dollar": 54.41, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Miscellaneous", "plan_name": "700720", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Miscellaneous", "plan_name": "700720_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Ppo Hmo", "plan_name": "701720", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Ppo Hmo", "plan_name": "701720_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Ambetter 68069", "plan_name": "500516", "standard_charge_dollar": 54.41, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Ms State Emplo", "plan_name": "401457", "standard_charge_dollar": 81.80, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Ms State Emplo", "plan_name": "401457_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Basic Pl", "plan_name": "400100", "standard_charge_dollar": 81.80, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Basic Pl", "plan_name": "400100_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Federal", "plan_name": "400110", "standard_charge_dollar": 81.80, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Federal", "plan_name": "400110_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Cigna Healthsprings Ffs", "plan_name": "500064", "standard_charge_dollar": 54.41, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Conseco", "plan_name": "500302", "standard_charge_dollar": 54.41, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Humana Ffs 61101", "plan_name": "500006", "standard_charge_dollar": 54.41, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Medicare A", "plan_name": "100100", "standard_charge_dollar": 54.41, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Medicare A", "plan_name": "100500", "standard_charge_dollar": 54.41, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Medicare Part B Only", "plan_name": "100300", "standard_charge_dollar": 54.41, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Medicare Railroad", "plan_name": "100103", "standard_charge_dollar": 54.41, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Ms Physicians Care N", "plan_name": "714210", "standard_charge_dollar": 68.02, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Peoples Hlth Ffs 72126", "plan_name": "500019", "standard_charge_dollar": 54.41, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Uhc/Secure Horizons", "plan_name": "500449", "standard_charge_dollar": 54.41, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "United Health Care/", "plan_name": "500292", "standard_charge_dollar": 61.49, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "United Healthcare", "plan_name": "750104", "standard_charge_dollar": 61.49, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "United Healthcare Ba", "plan_name": "750090", "standard_charge_dollar": 61.49, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "United Healthcare Me", "plan_name": "501310", "standard_charge_dollar": 54.41, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Windsor Mcare Extra", "plan_name": "500778", "standard_charge_dollar": 54.41, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." } ] } ] }, { "description": "Hc rmvl impct ear wax uni w/irig", "code_information": [ { "code": "69209", "type": "CPT" } ], "standard_charges": [ { "gross_charge": 440.00, "minimum": 54.41, "maximum": 374.00, "setting": "both", "payers_information": [ { "payer_name": "Aarp", "plan_name": "500102", "standard_charge_dollar": 54.41, "count": "0", "methodology": "fee schedule", "modifiers": "50", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna", "plan_name": "700700", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna", "plan_name": "700700_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Mcare Ffs 6005", "plan_name": "700703", "standard_charge_dollar": 54.41, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Miscellaneous", "plan_name": "700720", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Miscellaneous", "plan_name": "700720_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Ppo Hmo", "plan_name": "701720", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Ppo Hmo", "plan_name": "701720_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Ambetter 68069", "plan_name": "500516", "standard_charge_dollar": 54.41, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Ms State Emplo", "plan_name": "401457", "standard_charge_percentage": 0.80, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Ms State Emplo", "plan_name": "401457_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Basic Pl", "plan_name": "400100", "standard_charge_percentage": 0.85, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Basic Pl", "plan_name": "400100_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Federal", "plan_name": "400110", "standard_charge_percentage": 0.85, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Federal", "plan_name": "400110_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Cigna Healthsprings Ffs", "plan_name": "500064", "standard_charge_dollar": 54.41, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Conseco", "plan_name": "500302", "standard_charge_dollar": 54.41, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Humana Ffs 61101", "plan_name": "500006", "standard_charge_dollar": 54.41, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Medicare A", "plan_name": "100100", "standard_charge_dollar": 54.41, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Medicare A", "plan_name": "100500", "standard_charge_dollar": 54.41, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Medicare Part B Only", "plan_name": "100300", "standard_charge_dollar": 54.41, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Medicare Railroad", "plan_name": "100103", "standard_charge_dollar": 54.41, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Ms Physicians Care N", "plan_name": "714210", "standard_charge_dollar": 68.02, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Peoples Hlth Ffs 72126", "plan_name": "500019", "standard_charge_dollar": 54.41, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Uhc/Secure Horizons", "plan_name": "500449", "standard_charge_dollar": 54.41, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "United Health Care/", "plan_name": "500292", "standard_charge_dollar": 61.49, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "United Healthcare", "plan_name": "750104", "standard_charge_dollar": 61.49, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "United Healthcare Ba", "plan_name": "750090", "standard_charge_dollar": 61.49, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "United Healthcare Me", "plan_name": "501310", "standard_charge_dollar": 54.41, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Windsor Mcare Extra", "plan_name": "500778", "standard_charge_dollar": 54.41, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." } ] } ] }, { "description": "Hc removal cerumen impaction", "code_information": [ { "code": "69210", "type": "CPT" } ], "standard_charges": [ { "gross_charge": 94.50, "minimum": 54.41, "maximum": 81.80, "setting": "both", "payers_information": [ { "payer_name": "Aarp", "plan_name": "500102", "standard_charge_dollar": 54.41, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna", "plan_name": "700700", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna", "plan_name": "700700_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Mcare Ffs 6005", "plan_name": "700703", "standard_charge_dollar": 54.41, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Miscellaneous", "plan_name": "700720", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Miscellaneous", "plan_name": "700720_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Ppo Hmo", "plan_name": "701720", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Ppo Hmo", "plan_name": "701720_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Ambetter 68069", "plan_name": "500516", "standard_charge_dollar": 54.41, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Ms State Emplo", "plan_name": "401457", "standard_charge_dollar": 81.80, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Ms State Emplo", "plan_name": "401457_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Basic Pl", "plan_name": "400100", "standard_charge_dollar": 81.80, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Basic Pl", "plan_name": "400100_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Federal", "plan_name": "400110", "standard_charge_dollar": 81.80, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Federal", "plan_name": "400110_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Cigna Healthsprings Ffs", "plan_name": "500064", "standard_charge_dollar": 54.41, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Conseco", "plan_name": "500302", "standard_charge_dollar": 54.41, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Humana Ffs 61101", "plan_name": "500006", "standard_charge_dollar": 54.41, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Medicare A", "plan_name": "100100", "standard_charge_dollar": 54.41, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Medicare A", "plan_name": "100500", "standard_charge_dollar": 54.41, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Medicare Part B Only", "plan_name": "100300", "standard_charge_dollar": 54.41, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Medicare Railroad", "plan_name": "100103", "standard_charge_dollar": 54.41, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Ms Physicians Care N", "plan_name": "714210", "standard_charge_dollar": 68.02, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Peoples Hlth Ffs 72126", "plan_name": "500019", "standard_charge_dollar": 54.41, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Uhc/Secure Horizons", "plan_name": "500449", "standard_charge_dollar": 54.41, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "United Health Care/", "plan_name": "500292", "standard_charge_dollar": 61.49, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "United Healthcare", "plan_name": "750104", "standard_charge_dollar": 61.49, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "United Healthcare Ba", "plan_name": "750090", "standard_charge_dollar": 61.49, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "United Healthcare Me", "plan_name": "501310", "standard_charge_dollar": 54.41, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Windsor Mcare Extra", "plan_name": "500778", "standard_charge_dollar": 54.41, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." } ] } ] }, { "description": "Remove impacted ear wax uni", "code_information": [ { "code": "69210", "type": "CPT" } ], "standard_charges": [ { "gross_charge": 94.50, "minimum": 54.41, "maximum": 81.80, "setting": "both", "payers_information": [ { "payer_name": "Aarp", "plan_name": "500102", "standard_charge_dollar": 54.41, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna", "plan_name": "700700", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna", "plan_name": "700700_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Mcare Ffs 6005", "plan_name": "700703", "standard_charge_dollar": 54.41, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Miscellaneous", "plan_name": "700720", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Miscellaneous", "plan_name": "700720_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Ppo Hmo", "plan_name": "701720", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Ppo Hmo", "plan_name": "701720_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Ambetter 68069", "plan_name": "500516", "standard_charge_dollar": 54.41, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Ms State Emplo", "plan_name": "401457", "standard_charge_dollar": 81.80, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Ms State Emplo", "plan_name": "401457_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Basic Pl", "plan_name": "400100", "standard_charge_dollar": 81.80, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Basic Pl", "plan_name": "400100_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Federal", "plan_name": "400110", "standard_charge_dollar": 81.80, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Federal", "plan_name": "400110_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Cigna Healthsprings Ffs", "plan_name": "500064", "standard_charge_dollar": 54.41, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Conseco", "plan_name": "500302", "standard_charge_dollar": 54.41, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Humana Ffs 61101", "plan_name": "500006", "standard_charge_dollar": 54.41, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Medicare A", "plan_name": "100100", "standard_charge_dollar": 54.41, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Medicare A", "plan_name": "100500", "standard_charge_dollar": 54.41, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Medicare Part B Only", "plan_name": "100300", "standard_charge_dollar": 54.41, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Medicare Railroad", "plan_name": "100103", "standard_charge_dollar": 54.41, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Ms Physicians Care N", "plan_name": "714210", "standard_charge_dollar": 68.02, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Peoples Hlth Ffs 72126", "plan_name": "500019", "standard_charge_dollar": 54.41, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Uhc/Secure Horizons", "plan_name": "500449", "standard_charge_dollar": 54.41, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "United Health Care/", "plan_name": "500292", "standard_charge_dollar": 61.49, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "United Healthcare", "plan_name": "750104", "standard_charge_dollar": 61.49, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "United Healthcare Ba", "plan_name": "750090", "standard_charge_dollar": 61.49, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "United Healthcare Me", "plan_name": "501310", "standard_charge_dollar": 54.41, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Windsor Mcare Extra", "plan_name": "500778", "standard_charge_dollar": 54.41, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." } ] } ] }, { "description": "Hc mandible complete min 4 view", "code_information": [ { "code": "70110", "type": "CPT" } ], "standard_charges": [ { "gross_charge": 208.64, "minimum": 97.41, "maximum": 151.04, "setting": "both", "payers_information": [ { "payer_name": "Aarp", "plan_name": "500102", "standard_charge_dollar": 97.41, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna", "plan_name": "700700", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna", "plan_name": "700700_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Mcare Ffs 6005", "plan_name": "700703", "standard_charge_dollar": 97.41, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Miscellaneous", "plan_name": "700720", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Miscellaneous", "plan_name": "700720_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Ppo Hmo", "plan_name": "701720", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Ppo Hmo", "plan_name": "701720_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Ambetter 68069", "plan_name": "500516", "standard_charge_dollar": 97.41, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Ms State Emplo", "plan_name": "401457", "standard_charge_dollar": 151.04, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Ms State Emplo", "plan_name": "401457_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Basic Pl", "plan_name": "400100", "standard_charge_dollar": 151.04, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Basic Pl", "plan_name": "400100_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Federal", "plan_name": "400110", "standard_charge_dollar": 151.04, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Federal", "plan_name": "400110_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Cigna Healthsprings Ffs", "plan_name": "500064", "standard_charge_dollar": 97.41, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Conseco", "plan_name": "500302", "standard_charge_dollar": 97.41, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Humana Ffs 61101", "plan_name": "500006", "standard_charge_dollar": 97.41, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Medicare A", "plan_name": "100100", "standard_charge_dollar": 97.41, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Medicare A", "plan_name": "100500", "standard_charge_dollar": 97.41, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Medicare Part B Only", "plan_name": "100300", "standard_charge_dollar": 97.41, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Medicare Railroad", "plan_name": "100103", "standard_charge_dollar": 97.41, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Ms Physicians Care N", "plan_name": "714210", "standard_charge_dollar": 121.77, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Peoples Hlth Ffs 72126", "plan_name": "500019", "standard_charge_dollar": 97.41, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Uhc/Secure Horizons", "plan_name": "500449", "standard_charge_dollar": 97.41, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "United Health Care/", "plan_name": "500292", "standard_charge_dollar": 110.08, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "United Healthcare", "plan_name": "750104", "standard_charge_dollar": 110.08, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "United Healthcare Ba", "plan_name": "750090", "standard_charge_dollar": 110.08, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "United Healthcare Me", "plan_name": "501310", "standard_charge_dollar": 97.41, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Windsor Mcare Extra", "plan_name": "500778", "standard_charge_dollar": 97.41, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." } ] } ] }, { "description": "X-ray exam of jaw 4/> views", "code_information": [ { "code": "70110", "type": "CPT" } ], "standard_charges": [ { "gross_charge": 208.64, "minimum": 97.41, "maximum": 151.04, "setting": "both", "payers_information": [ { "payer_name": "Aarp", "plan_name": "500102", "standard_charge_dollar": 97.41, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna", "plan_name": "700700", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna", "plan_name": "700700_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Mcare Ffs 6005", "plan_name": "700703", "standard_charge_dollar": 97.41, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Miscellaneous", "plan_name": "700720", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Miscellaneous", "plan_name": "700720_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Ppo Hmo", "plan_name": "701720", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Ppo Hmo", "plan_name": "701720_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Ambetter 68069", "plan_name": "500516", "standard_charge_dollar": 97.41, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Ms State Emplo", "plan_name": "401457", "standard_charge_dollar": 151.04, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Ms State Emplo", "plan_name": "401457_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Basic Pl", "plan_name": "400100", "standard_charge_dollar": 151.04, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Basic Pl", "plan_name": "400100_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Federal", "plan_name": "400110", "standard_charge_dollar": 151.04, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Federal", "plan_name": "400110_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Cigna Healthsprings Ffs", "plan_name": "500064", "standard_charge_dollar": 97.41, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Conseco", "plan_name": "500302", "standard_charge_dollar": 97.41, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Humana Ffs 61101", "plan_name": "500006", "standard_charge_dollar": 97.41, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Medicare A", "plan_name": "100100", "standard_charge_dollar": 97.41, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Medicare A", "plan_name": "100500", "standard_charge_dollar": 97.41, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Medicare Part B Only", "plan_name": "100300", "standard_charge_dollar": 97.41, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Medicare Railroad", "plan_name": "100103", "standard_charge_dollar": 97.41, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Ms Physicians Care N", "plan_name": "714210", "standard_charge_dollar": 121.77, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Peoples Hlth Ffs 72126", "plan_name": "500019", "standard_charge_dollar": 97.41, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Uhc/Secure Horizons", "plan_name": "500449", "standard_charge_dollar": 97.41, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "United Health Care/", "plan_name": "500292", "standard_charge_dollar": 110.08, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "United Healthcare", "plan_name": "750104", "standard_charge_dollar": 110.08, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "United Healthcare Ba", "plan_name": "750090", "standard_charge_dollar": 110.08, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "United Healthcare Me", "plan_name": "501310", "standard_charge_dollar": 97.41, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Windsor Mcare Extra", "plan_name": "500778", "standard_charge_dollar": 97.41, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." } ] } ] }, { "description": "Hc facial bones comp min 3 views", "code_information": [ { "code": "70150", "type": "CPT" } ], "standard_charges": [ { "gross_charge": 239.35, "minimum": 97.41, "maximum": 151.04, "setting": "both", "payers_information": [ { "payer_name": "Aarp", "plan_name": "500102", "standard_charge_dollar": 97.41, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna", "plan_name": "700700", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna", "plan_name": "700700_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Mcare Ffs 6005", "plan_name": "700703", "standard_charge_dollar": 97.41, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Miscellaneous", "plan_name": "700720", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Miscellaneous", "plan_name": "700720_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Ppo Hmo", "plan_name": "701720", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Ppo Hmo", "plan_name": "701720_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Ambetter 68069", "plan_name": "500516", "standard_charge_dollar": 97.41, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Ms State Emplo", "plan_name": "401457", "standard_charge_dollar": 151.04, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Ms State Emplo", "plan_name": "401457_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Basic Pl", "plan_name": "400100", "standard_charge_dollar": 151.04, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Basic Pl", "plan_name": "400100_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Federal", "plan_name": "400110", "standard_charge_dollar": 151.04, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Federal", "plan_name": "400110_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Cigna Healthsprings Ffs", "plan_name": "500064", "standard_charge_dollar": 97.41, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Conseco", "plan_name": "500302", "standard_charge_dollar": 97.41, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Humana Ffs 61101", "plan_name": "500006", "standard_charge_dollar": 97.41, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Medicare A", "plan_name": "100100", "standard_charge_dollar": 97.41, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Medicare A", "plan_name": "100500", "standard_charge_dollar": 97.41, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Medicare Part B Only", "plan_name": "100300", "standard_charge_dollar": 97.41, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Medicare Railroad", "plan_name": "100103", "standard_charge_dollar": 97.41, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Ms Physicians Care N", "plan_name": "714210", "standard_charge_dollar": 121.77, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Peoples Hlth Ffs 72126", "plan_name": "500019", "standard_charge_dollar": 97.41, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Uhc/Secure Horizons", "plan_name": "500449", "standard_charge_dollar": 97.41, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "United Health Care/", "plan_name": "500292", "standard_charge_dollar": 110.08, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "United Healthcare", "plan_name": "750104", "standard_charge_dollar": 110.08, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "United Healthcare Ba", "plan_name": "750090", "standard_charge_dollar": 110.08, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "United Healthcare Me", "plan_name": "501310", "standard_charge_dollar": 97.41, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Windsor Mcare Extra", "plan_name": "500778", "standard_charge_dollar": 97.41, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." } ] } ] }, { "description": "X-ray exam of facial bones", "code_information": [ { "code": "70150", "type": "CPT" } ], "standard_charges": [ { "gross_charge": 239.35, "minimum": 97.41, "maximum": 151.04, "setting": "both", "payers_information": [ { "payer_name": "Aarp", "plan_name": "500102", "standard_charge_dollar": 97.41, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna", "plan_name": "700700", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna", "plan_name": "700700_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Mcare Ffs 6005", "plan_name": "700703", "standard_charge_dollar": 97.41, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Miscellaneous", "plan_name": "700720", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Miscellaneous", "plan_name": "700720_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Ppo Hmo", "plan_name": "701720", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Ppo Hmo", "plan_name": "701720_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Ambetter 68069", "plan_name": "500516", "standard_charge_dollar": 97.41, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Ms State Emplo", "plan_name": "401457", "standard_charge_dollar": 151.04, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Ms State Emplo", "plan_name": "401457_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Basic Pl", "plan_name": "400100", "standard_charge_dollar": 151.04, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Basic Pl", "plan_name": "400100_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Federal", "plan_name": "400110", "standard_charge_dollar": 151.04, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Federal", "plan_name": "400110_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Cigna Healthsprings Ffs", "plan_name": "500064", "standard_charge_dollar": 97.41, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Conseco", "plan_name": "500302", "standard_charge_dollar": 97.41, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Humana Ffs 61101", "plan_name": "500006", "standard_charge_dollar": 97.41, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Medicare A", "plan_name": "100100", "standard_charge_dollar": 97.41, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Medicare A", "plan_name": "100500", "standard_charge_dollar": 97.41, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Medicare Part B Only", "plan_name": "100300", "standard_charge_dollar": 97.41, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Medicare Railroad", "plan_name": "100103", "standard_charge_dollar": 97.41, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Ms Physicians Care N", "plan_name": "714210", "standard_charge_dollar": 121.77, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Peoples Hlth Ffs 72126", "plan_name": "500019", "standard_charge_dollar": 97.41, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Uhc/Secure Horizons", "plan_name": "500449", "standard_charge_dollar": 97.41, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "United Health Care/", "plan_name": "500292", "standard_charge_dollar": 110.08, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "United Healthcare", "plan_name": "750104", "standard_charge_dollar": 110.08, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "United Healthcare Ba", "plan_name": "750090", "standard_charge_dollar": 110.08, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "United Healthcare Me", "plan_name": "501310", "standard_charge_dollar": 97.41, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Windsor Mcare Extra", "plan_name": "500778", "standard_charge_dollar": 97.41, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." } ] } ] }, { "description": "Hc nasal complete min 3 views", "code_information": [ { "code": "70160", "type": "CPT" } ], "standard_charges": [ { "gross_charge": 174.20, "minimum": 80.66, "maximum": 100.82, "setting": "both", "payers_information": [ { "payer_name": "Aarp", "plan_name": "500102", "standard_charge_dollar": 80.66, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna", "plan_name": "700700", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna", "plan_name": "700700_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Mcare Ffs 6005", "plan_name": "700703", "standard_charge_dollar": 80.66, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Miscellaneous", "plan_name": "700720", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Miscellaneous", "plan_name": "700720_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Ppo Hmo", "plan_name": "701720", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Ppo Hmo", "plan_name": "701720_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Ambetter 68069", "plan_name": "500516", "standard_charge_dollar": 80.66, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Ms State Emplo", "plan_name": "401457", "standard_charge_dollar": 91.20, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Ms State Emplo", "plan_name": "401457_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Basic Pl", "plan_name": "400100", "standard_charge_dollar": 91.20, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Basic Pl", "plan_name": "400100_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Federal", "plan_name": "400110", "standard_charge_dollar": 91.20, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Federal", "plan_name": "400110_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Cigna Healthsprings Ffs", "plan_name": "500064", "standard_charge_dollar": 80.66, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Conseco", "plan_name": "500302", "standard_charge_dollar": 80.66, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Humana Ffs 61101", "plan_name": "500006", "standard_charge_dollar": 80.66, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Medicare A", "plan_name": "100100", "standard_charge_dollar": 80.66, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Medicare A", "plan_name": "100500", "standard_charge_dollar": 80.66, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Medicare Part B Only", "plan_name": "100300", "standard_charge_dollar": 80.66, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Medicare Railroad", "plan_name": "100103", "standard_charge_dollar": 80.66, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Ms Physicians Care N", "plan_name": "714210", "standard_charge_dollar": 100.82, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Peoples Hlth Ffs 72126", "plan_name": "500019", "standard_charge_dollar": 80.66, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Uhc/Secure Horizons", "plan_name": "500449", "standard_charge_dollar": 80.66, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "United Health Care/", "plan_name": "500292", "standard_charge_dollar": 91.15, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "United Healthcare", "plan_name": "750104", "standard_charge_dollar": 91.15, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "United Healthcare Ba", "plan_name": "750090", "standard_charge_dollar": 91.15, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "United Healthcare Me", "plan_name": "501310", "standard_charge_dollar": 80.66, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Windsor Mcare Extra", "plan_name": "500778", "standard_charge_dollar": 80.66, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." } ] } ] }, { "description": "X-ray exam of nasal bones", "code_information": [ { "code": "70160", "type": "CPT" } ], "standard_charges": [ { "gross_charge": 174.20, "minimum": 80.66, "maximum": 100.82, "setting": "both", "payers_information": [ { "payer_name": "Aarp", "plan_name": "500102", "standard_charge_dollar": 80.66, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna", "plan_name": "700700", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna", "plan_name": "700700_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Mcare Ffs 6005", "plan_name": "700703", "standard_charge_dollar": 80.66, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Miscellaneous", "plan_name": "700720", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Miscellaneous", "plan_name": "700720_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Ppo Hmo", "plan_name": "701720", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Ppo Hmo", "plan_name": "701720_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Ambetter 68069", "plan_name": "500516", "standard_charge_dollar": 80.66, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Ms State Emplo", "plan_name": "401457", "standard_charge_dollar": 91.20, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Ms State Emplo", "plan_name": "401457_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Basic Pl", "plan_name": "400100", "standard_charge_dollar": 91.20, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Basic Pl", "plan_name": "400100_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Federal", "plan_name": "400110", "standard_charge_dollar": 91.20, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Federal", "plan_name": "400110_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Cigna Healthsprings Ffs", "plan_name": "500064", "standard_charge_dollar": 80.66, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Conseco", "plan_name": "500302", "standard_charge_dollar": 80.66, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Humana Ffs 61101", "plan_name": "500006", "standard_charge_dollar": 80.66, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Medicare A", "plan_name": "100100", "standard_charge_dollar": 80.66, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Medicare A", "plan_name": "100500", "standard_charge_dollar": 80.66, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Medicare Part B Only", "plan_name": "100300", "standard_charge_dollar": 80.66, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Medicare Railroad", "plan_name": "100103", "standard_charge_dollar": 80.66, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Ms Physicians Care N", "plan_name": "714210", "standard_charge_dollar": 100.82, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Peoples Hlth Ffs 72126", "plan_name": "500019", "standard_charge_dollar": 80.66, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Uhc/Secure Horizons", "plan_name": "500449", "standard_charge_dollar": 80.66, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "United Health Care/", "plan_name": "500292", "standard_charge_dollar": 91.15, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "United Healthcare", "plan_name": "750104", "standard_charge_dollar": 91.15, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "United Healthcare Ba", "plan_name": "750090", "standard_charge_dollar": 91.15, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "United Healthcare Me", "plan_name": "501310", "standard_charge_dollar": 80.66, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Windsor Mcare Extra", "plan_name": "500778", "standard_charge_dollar": 80.66, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." } ] } ] }, { "description": "Hc sinuses paransl comp min 3 view", "code_information": [ { "code": "70220", "type": "CPT" } ], "standard_charges": [ { "gross_charge": 250.00, "minimum": 80.66, "maximum": 100.82, "setting": "both", "payers_information": [ { "payer_name": "Aarp", "plan_name": "500102", "standard_charge_dollar": 80.66, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna", "plan_name": "700700", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna", "plan_name": "700700_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Mcare Ffs 6005", "plan_name": "700703", "standard_charge_dollar": 80.66, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Miscellaneous", "plan_name": "700720", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Miscellaneous", "plan_name": "700720_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Ppo Hmo", "plan_name": "701720", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Ppo Hmo", "plan_name": "701720_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Ambetter 68069", "plan_name": "500516", "standard_charge_dollar": 80.66, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Ms State Emplo", "plan_name": "401457", "standard_charge_dollar": 91.20, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Ms State Emplo", "plan_name": "401457_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Basic Pl", "plan_name": "400100", "standard_charge_dollar": 91.20, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Basic Pl", "plan_name": "400100_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Federal", "plan_name": "400110", "standard_charge_dollar": 91.20, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Federal", "plan_name": "400110_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Cigna Healthsprings Ffs", "plan_name": "500064", "standard_charge_dollar": 80.66, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Conseco", "plan_name": "500302", "standard_charge_dollar": 80.66, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Humana Ffs 61101", "plan_name": "500006", "standard_charge_dollar": 80.66, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Medicare A", "plan_name": "100100", "standard_charge_dollar": 80.66, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Medicare A", "plan_name": "100500", "standard_charge_dollar": 80.66, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Medicare Part B Only", "plan_name": "100300", "standard_charge_dollar": 80.66, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Medicare Railroad", "plan_name": "100103", "standard_charge_dollar": 80.66, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Ms Physicians Care N", "plan_name": "714210", "standard_charge_dollar": 100.82, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Peoples Hlth Ffs 72126", "plan_name": "500019", "standard_charge_dollar": 80.66, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Uhc/Secure Horizons", "plan_name": "500449", "standard_charge_dollar": 80.66, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "United Health Care/", "plan_name": "500292", "standard_charge_dollar": 91.15, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "United Healthcare", "plan_name": "750104", "standard_charge_dollar": 91.15, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "United Healthcare Ba", "plan_name": "750090", "standard_charge_dollar": 91.15, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "United Healthcare Me", "plan_name": "501310", "standard_charge_dollar": 80.66, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Windsor Mcare Extra", "plan_name": "500778", "standard_charge_dollar": 80.66, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." } ] } ] }, { "description": "X-ray exam of sinuses", "code_information": [ { "code": "70220", "type": "CPT" } ], "standard_charges": [ { "gross_charge": 250.00, "minimum": 80.66, "maximum": 100.82, "setting": "both", "payers_information": [ { "payer_name": "Aarp", "plan_name": "500102", "standard_charge_dollar": 80.66, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna", "plan_name": "700700", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna", "plan_name": "700700_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Mcare Ffs 6005", "plan_name": "700703", "standard_charge_dollar": 80.66, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Miscellaneous", "plan_name": "700720", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Miscellaneous", "plan_name": "700720_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Ppo Hmo", "plan_name": "701720", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Ppo Hmo", "plan_name": "701720_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Ambetter 68069", "plan_name": "500516", "standard_charge_dollar": 80.66, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Ms State Emplo", "plan_name": "401457", "standard_charge_dollar": 91.20, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Ms State Emplo", "plan_name": "401457_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Basic Pl", "plan_name": "400100", "standard_charge_dollar": 91.20, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Basic Pl", "plan_name": "400100_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Federal", "plan_name": "400110", "standard_charge_dollar": 91.20, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Federal", "plan_name": "400110_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Cigna Healthsprings Ffs", "plan_name": "500064", "standard_charge_dollar": 80.66, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Conseco", "plan_name": "500302", "standard_charge_dollar": 80.66, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Humana Ffs 61101", "plan_name": "500006", "standard_charge_dollar": 80.66, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Medicare A", "plan_name": "100100", "standard_charge_dollar": 80.66, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Medicare A", "plan_name": "100500", "standard_charge_dollar": 80.66, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Medicare Part B Only", "plan_name": "100300", "standard_charge_dollar": 80.66, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Medicare Railroad", "plan_name": "100103", "standard_charge_dollar": 80.66, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Ms Physicians Care N", "plan_name": "714210", "standard_charge_dollar": 100.82, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Peoples Hlth Ffs 72126", "plan_name": "500019", "standard_charge_dollar": 80.66, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Uhc/Secure Horizons", "plan_name": "500449", "standard_charge_dollar": 80.66, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "United Health Care/", "plan_name": "500292", "standard_charge_dollar": 91.15, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "United Healthcare", "plan_name": "750104", "standard_charge_dollar": 91.15, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "United Healthcare Ba", "plan_name": "750090", "standard_charge_dollar": 91.15, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "United Healthcare Me", "plan_name": "501310", "standard_charge_dollar": 80.66, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Windsor Mcare Extra", "plan_name": "500778", "standard_charge_dollar": 80.66, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." } ] } ] }, { "description": "Hc skull complete min 4 view", "code_information": [ { "code": "70260", "type": "CPT" } ], "standard_charges": [ { "gross_charge": 266.00, "minimum": 97.41, "maximum": 151.04, "setting": "both", "payers_information": [ { "payer_name": "Aarp", "plan_name": "500102", "standard_charge_dollar": 97.41, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna", "plan_name": "700700", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna", "plan_name": "700700_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Mcare Ffs 6005", "plan_name": "700703", "standard_charge_dollar": 97.41, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Miscellaneous", "plan_name": "700720", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Miscellaneous", "plan_name": "700720_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Ppo Hmo", "plan_name": "701720", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Ppo Hmo", "plan_name": "701720_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Ambetter 68069", "plan_name": "500516", "standard_charge_dollar": 97.41, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Ms State Emplo", "plan_name": "401457", "standard_charge_dollar": 151.04, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Ms State Emplo", "plan_name": "401457_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Basic Pl", "plan_name": "400100", "standard_charge_dollar": 151.04, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Basic Pl", "plan_name": "400100_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Federal", "plan_name": "400110", "standard_charge_dollar": 151.04, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Federal", "plan_name": "400110_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Cigna Healthsprings Ffs", "plan_name": "500064", "standard_charge_dollar": 97.41, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Conseco", "plan_name": "500302", "standard_charge_dollar": 97.41, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Humana Ffs 61101", "plan_name": "500006", "standard_charge_dollar": 97.41, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Medicare A", "plan_name": "100100", "standard_charge_dollar": 97.41, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Medicare A", "plan_name": "100500", "standard_charge_dollar": 97.41, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Medicare Part B Only", "plan_name": "100300", "standard_charge_dollar": 97.41, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Medicare Railroad", "plan_name": "100103", "standard_charge_dollar": 97.41, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Ms Physicians Care N", "plan_name": "714210", "standard_charge_dollar": 121.77, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Peoples Hlth Ffs 72126", "plan_name": "500019", "standard_charge_dollar": 97.41, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Uhc/Secure Horizons", "plan_name": "500449", "standard_charge_dollar": 97.41, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "United Health Care/", "plan_name": "500292", "standard_charge_dollar": 110.08, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "United Healthcare", "plan_name": "750104", "standard_charge_dollar": 110.08, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "United Healthcare Ba", "plan_name": "750090", "standard_charge_dollar": 110.08, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "United Healthcare Me", "plan_name": "501310", "standard_charge_dollar": 97.41, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Windsor Mcare Extra", "plan_name": "500778", "standard_charge_dollar": 97.41, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." } ] } ] }, { "description": "X-ray exam of skull", "code_information": [ { "code": "70260", "type": "CPT" } ], "standard_charges": [ { "gross_charge": 266.00, "minimum": 97.41, "maximum": 151.04, "setting": "both", "payers_information": [ { "payer_name": "Aarp", "plan_name": "500102", "standard_charge_dollar": 97.41, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna", "plan_name": "700700", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna", "plan_name": "700700_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Mcare Ffs 6005", "plan_name": "700703", "standard_charge_dollar": 97.41, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Miscellaneous", "plan_name": "700720", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Miscellaneous", "plan_name": "700720_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Ppo Hmo", "plan_name": "701720", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Ppo Hmo", "plan_name": "701720_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Ambetter 68069", "plan_name": "500516", "standard_charge_dollar": 97.41, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Ms State Emplo", "plan_name": "401457", "standard_charge_dollar": 151.04, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Ms State Emplo", "plan_name": "401457_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Basic Pl", "plan_name": "400100", "standard_charge_dollar": 151.04, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Basic Pl", "plan_name": "400100_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Federal", "plan_name": "400110", "standard_charge_dollar": 151.04, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Federal", "plan_name": "400110_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Cigna Healthsprings Ffs", "plan_name": "500064", "standard_charge_dollar": 97.41, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Conseco", "plan_name": "500302", "standard_charge_dollar": 97.41, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Humana Ffs 61101", "plan_name": "500006", "standard_charge_dollar": 97.41, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Medicare A", "plan_name": "100100", "standard_charge_dollar": 97.41, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Medicare A", "plan_name": "100500", "standard_charge_dollar": 97.41, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Medicare Part B Only", "plan_name": "100300", "standard_charge_dollar": 97.41, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Medicare Railroad", "plan_name": "100103", "standard_charge_dollar": 97.41, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Ms Physicians Care N", "plan_name": "714210", "standard_charge_dollar": 121.77, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Peoples Hlth Ffs 72126", "plan_name": "500019", "standard_charge_dollar": 97.41, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Uhc/Secure Horizons", "plan_name": "500449", "standard_charge_dollar": 97.41, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "United Health Care/", "plan_name": "500292", "standard_charge_dollar": 110.08, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "United Healthcare", "plan_name": "750104", "standard_charge_dollar": 110.08, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "United Healthcare Ba", "plan_name": "750090", "standard_charge_dollar": 110.08, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "United Healthcare Me", "plan_name": "501310", "standard_charge_dollar": 97.41, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Windsor Mcare Extra", "plan_name": "500778", "standard_charge_dollar": 97.41, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." } ] } ] }, { "description": "Hc neck soft tissue", "code_information": [ { "code": "70360", "type": "CPT" } ], "standard_charges": [ { "gross_charge": 150.00, "minimum": 80.66, "maximum": 100.82, "setting": "both", "payers_information": [ { "payer_name": "Aarp", "plan_name": "500102", "standard_charge_dollar": 80.66, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna", "plan_name": "700700", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna", "plan_name": "700700_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Mcare Ffs 6005", "plan_name": "700703", "standard_charge_dollar": 80.66, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Miscellaneous", "plan_name": "700720", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Miscellaneous", "plan_name": "700720_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Ppo Hmo", "plan_name": "701720", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Ppo Hmo", "plan_name": "701720_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Ambetter 68069", "plan_name": "500516", "standard_charge_dollar": 80.66, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Ms State Emplo", "plan_name": "401457", "standard_charge_dollar": 91.20, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Ms State Emplo", "plan_name": "401457_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Basic Pl", "plan_name": "400100", "standard_charge_dollar": 91.20, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Basic Pl", "plan_name": "400100_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Federal", "plan_name": "400110", "standard_charge_dollar": 91.20, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Federal", "plan_name": "400110_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Cigna Healthsprings Ffs", "plan_name": "500064", "standard_charge_dollar": 80.66, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Conseco", "plan_name": "500302", "standard_charge_dollar": 80.66, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Humana Ffs 61101", "plan_name": "500006", "standard_charge_dollar": 80.66, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Medicare A", "plan_name": "100100", "standard_charge_dollar": 80.66, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Medicare A", "plan_name": "100500", "standard_charge_dollar": 80.66, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Medicare Part B Only", "plan_name": "100300", "standard_charge_dollar": 80.66, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Medicare Railroad", "plan_name": "100103", "standard_charge_dollar": 80.66, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Ms Physicians Care N", "plan_name": "714210", "standard_charge_dollar": 100.82, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Peoples Hlth Ffs 72126", "plan_name": "500019", "standard_charge_dollar": 80.66, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Uhc/Secure Horizons", "plan_name": "500449", "standard_charge_dollar": 80.66, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "United Health Care/", "plan_name": "500292", "standard_charge_dollar": 91.15, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "United Healthcare", "plan_name": "750104", "standard_charge_dollar": 91.15, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "United Healthcare Ba", "plan_name": "750090", "standard_charge_dollar": 91.15, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "United Healthcare Me", "plan_name": "501310", "standard_charge_dollar": 80.66, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Windsor Mcare Extra", "plan_name": "500778", "standard_charge_dollar": 80.66, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." } ] } ] }, { "description": "X-ray exam of neck", "code_information": [ { "code": "70360", "type": "CPT" } ], "standard_charges": [ { "gross_charge": 150.00, "minimum": 80.66, "maximum": 100.82, "setting": "both", "payers_information": [ { "payer_name": "Aarp", "plan_name": "500102", "standard_charge_dollar": 80.66, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna", "plan_name": "700700", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna", "plan_name": "700700_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Mcare Ffs 6005", "plan_name": "700703", "standard_charge_dollar": 80.66, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Miscellaneous", "plan_name": "700720", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Miscellaneous", "plan_name": "700720_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Ppo Hmo", "plan_name": "701720", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Ppo Hmo", "plan_name": "701720_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Ambetter 68069", "plan_name": "500516", "standard_charge_dollar": 80.66, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Ms State Emplo", "plan_name": "401457", "standard_charge_dollar": 91.20, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Ms State Emplo", "plan_name": "401457_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Basic Pl", "plan_name": "400100", "standard_charge_dollar": 91.20, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Basic Pl", "plan_name": "400100_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Federal", "plan_name": "400110", "standard_charge_dollar": 91.20, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Federal", "plan_name": "400110_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Cigna Healthsprings Ffs", "plan_name": "500064", "standard_charge_dollar": 80.66, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Conseco", "plan_name": "500302", "standard_charge_dollar": 80.66, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Humana Ffs 61101", "plan_name": "500006", "standard_charge_dollar": 80.66, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Medicare A", "plan_name": "100100", "standard_charge_dollar": 80.66, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Medicare A", "plan_name": "100500", "standard_charge_dollar": 80.66, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Medicare Part B Only", "plan_name": "100300", "standard_charge_dollar": 80.66, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Medicare Railroad", "plan_name": "100103", "standard_charge_dollar": 80.66, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Ms Physicians Care N", "plan_name": "714210", "standard_charge_dollar": 100.82, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Peoples Hlth Ffs 72126", "plan_name": "500019", "standard_charge_dollar": 80.66, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Uhc/Secure Horizons", "plan_name": "500449", "standard_charge_dollar": 80.66, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "United Health Care/", "plan_name": "500292", "standard_charge_dollar": 91.15, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "United Healthcare", "plan_name": "750104", "standard_charge_dollar": 91.15, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "United Healthcare Ba", "plan_name": "750090", "standard_charge_dollar": 91.15, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "United Healthcare Me", "plan_name": "501310", "standard_charge_dollar": 80.66, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Windsor Mcare Extra", "plan_name": "500778", "standard_charge_dollar": 80.66, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." } ] } ] }, { "description": "Ct head/brain w/o dye", "code_information": [ { "code": "70450", "type": "CPT" } ], "standard_charges": [ { "gross_charge": 950.00, "minimum": 168.74, "maximum": 257.13, "setting": "both", "payers_information": [ { "payer_name": "Aarp", "plan_name": "500102", "standard_charge_dollar": 205.70, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna", "plan_name": "700700", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna", "plan_name": "700700_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Mcare Ffs 6005", "plan_name": "700703", "standard_charge_dollar": 205.70, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Miscellaneous", "plan_name": "700720", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Miscellaneous", "plan_name": "700720_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Ppo Hmo", "plan_name": "701720", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Ppo Hmo", "plan_name": "701720_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Ambetter 68069", "plan_name": "500516", "standard_charge_dollar": 205.70, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Ms State Emplo", "plan_name": "401457", "standard_charge_dollar": 168.74, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Ms State Emplo", "plan_name": "401457_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Basic Pl", "plan_name": "400100", "standard_charge_dollar": 168.74, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Basic Pl", "plan_name": "400100_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Federal", "plan_name": "400110", "standard_charge_dollar": 168.74, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Federal", "plan_name": "400110_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Cigna Healthsprings Ffs", "plan_name": "500064", "standard_charge_dollar": 205.70, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Conseco", "plan_name": "500302", "standard_charge_dollar": 205.70, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Humana Ffs 61101", "plan_name": "500006", "standard_charge_dollar": 205.70, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Medicare A", "plan_name": "100100", "standard_charge_dollar": 205.70, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Medicare A", "plan_name": "100500", "standard_charge_dollar": 205.70, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Medicare Part B Only", "plan_name": "100300", "standard_charge_dollar": 205.70, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Medicare Railroad", "plan_name": "100103", "standard_charge_dollar": 205.70, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Ms Physicians Care N", "plan_name": "714210", "standard_charge_dollar": 257.13, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Peoples Hlth Ffs 72126", "plan_name": "500019", "standard_charge_dollar": 205.70, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Uhc/Secure Horizons", "plan_name": "500449", "standard_charge_dollar": 205.70, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "United Health Care/", "plan_name": "500292", "standard_charge_dollar": 232.44, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "United Healthcare", "plan_name": "750104", "standard_charge_dollar": 232.44, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "United Healthcare Ba", "plan_name": "750090", "standard_charge_dollar": 232.44, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "United Healthcare Me", "plan_name": "501310", "standard_charge_dollar": 205.70, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Windsor Mcare Extra", "plan_name": "500778", "standard_charge_dollar": 205.70, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." } ] } ] }, { "description": "Hc ct head w/o contrast", "code_information": [ { "code": "70450", "type": "CPT" } ], "standard_charges": [ { "gross_charge": 950.00, "minimum": 168.74, "maximum": 257.13, "setting": "both", "payers_information": [ { "payer_name": "Aarp", "plan_name": "500102", "standard_charge_dollar": 205.70, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna", "plan_name": "700700", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna", "plan_name": "700700_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Mcare Ffs 6005", "plan_name": "700703", "standard_charge_dollar": 205.70, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Miscellaneous", "plan_name": "700720", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Miscellaneous", "plan_name": "700720_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Ppo Hmo", "plan_name": "701720", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Ppo Hmo", "plan_name": "701720_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Ambetter 68069", "plan_name": "500516", "standard_charge_dollar": 205.70, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Ms State Emplo", "plan_name": "401457", "standard_charge_dollar": 168.74, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Ms State Emplo", "plan_name": "401457_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Basic Pl", "plan_name": "400100", "standard_charge_dollar": 168.74, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Basic Pl", "plan_name": "400100_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Federal", "plan_name": "400110", "standard_charge_dollar": 168.74, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Federal", "plan_name": "400110_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Cigna Healthsprings Ffs", "plan_name": "500064", "standard_charge_dollar": 205.70, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Conseco", "plan_name": "500302", "standard_charge_dollar": 205.70, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Humana Ffs 61101", "plan_name": "500006", "standard_charge_dollar": 205.70, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Medicare A", "plan_name": "100100", "standard_charge_dollar": 205.70, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Medicare A", "plan_name": "100500", "standard_charge_dollar": 205.70, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Medicare Part B Only", "plan_name": "100300", "standard_charge_dollar": 205.70, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Medicare Railroad", "plan_name": "100103", "standard_charge_dollar": 205.70, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Ms Physicians Care N", "plan_name": "714210", "standard_charge_dollar": 257.13, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Peoples Hlth Ffs 72126", "plan_name": "500019", "standard_charge_dollar": 205.70, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Uhc/Secure Horizons", "plan_name": "500449", "standard_charge_dollar": 205.70, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "United Health Care/", "plan_name": "500292", "standard_charge_dollar": 232.44, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "United Healthcare", "plan_name": "750104", "standard_charge_dollar": 232.44, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "United Healthcare Ba", "plan_name": "750090", "standard_charge_dollar": 232.44, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "United Healthcare Me", "plan_name": "501310", "standard_charge_dollar": 205.70, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Windsor Mcare Extra", "plan_name": "500778", "standard_charge_dollar": 205.70, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." } ] } ] }, { "description": "Ct head/brain w/dye", "code_information": [ { "code": "70460", "type": "CPT" } ], "standard_charges": [ { "gross_charge": 1279.43, "minimum": 355.29, "maximum": 498.25, "setting": "both", "payers_information": [ { "payer_name": "Aarp", "plan_name": "500102", "standard_charge_dollar": 398.60, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna", "plan_name": "700700", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna", "plan_name": "700700_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Mcare Ffs 6005", "plan_name": "700703", "standard_charge_dollar": 398.60, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Miscellaneous", "plan_name": "700720", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Miscellaneous", "plan_name": "700720_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Ppo Hmo", "plan_name": "701720", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Ppo Hmo", "plan_name": "701720_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Ambetter 68069", "plan_name": "500516", "standard_charge_dollar": 398.60, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Ms State Emplo", "plan_name": "401457", "standard_charge_dollar": 355.29, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Ms State Emplo", "plan_name": "401457_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Basic Pl", "plan_name": "400100", "standard_charge_dollar": 355.29, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Basic Pl", "plan_name": "400100_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Federal", "plan_name": "400110", "standard_charge_dollar": 355.29, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Federal", "plan_name": "400110_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Cigna Healthsprings Ffs", "plan_name": "500064", "standard_charge_dollar": 398.60, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Conseco", "plan_name": "500302", "standard_charge_dollar": 398.60, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Humana Ffs 61101", "plan_name": "500006", "standard_charge_dollar": 398.60, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Medicare A", "plan_name": "100100", "standard_charge_dollar": 398.60, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Medicare A", "plan_name": "100500", "standard_charge_dollar": 398.60, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Medicare Part B Only", "plan_name": "100300", "standard_charge_dollar": 398.60, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Medicare Railroad", "plan_name": "100103", "standard_charge_dollar": 398.60, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Ms Physicians Care N", "plan_name": "714210", "standard_charge_dollar": 498.25, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Peoples Hlth Ffs 72126", "plan_name": "500019", "standard_charge_dollar": 398.60, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Uhc/Secure Horizons", "plan_name": "500449", "standard_charge_dollar": 398.60, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "United Health Care/", "plan_name": "500292", "standard_charge_dollar": 450.42, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "United Healthcare", "plan_name": "750104", "standard_charge_dollar": 450.42, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "United Healthcare Ba", "plan_name": "750090", "standard_charge_dollar": 450.42, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "United Healthcare Me", "plan_name": "501310", "standard_charge_dollar": 398.60, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Windsor Mcare Extra", "plan_name": "500778", "standard_charge_dollar": 398.60, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." } ] } ] }, { "description": "Hc ct head w/contrast", "code_information": [ { "code": "70460", "type": "CPT" } ], "standard_charges": [ { "gross_charge": 1279.43, "minimum": 355.29, "maximum": 498.25, "setting": "both", "payers_information": [ { "payer_name": "Aarp", "plan_name": "500102", "standard_charge_dollar": 398.60, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna", "plan_name": "700700", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna", "plan_name": "700700_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Mcare Ffs 6005", "plan_name": "700703", "standard_charge_dollar": 398.60, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Miscellaneous", "plan_name": "700720", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Miscellaneous", "plan_name": "700720_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Ppo Hmo", "plan_name": "701720", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Ppo Hmo", "plan_name": "701720_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Ambetter 68069", "plan_name": "500516", "standard_charge_dollar": 398.60, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Ms State Emplo", "plan_name": "401457", "standard_charge_dollar": 355.29, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Ms State Emplo", "plan_name": "401457_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Basic Pl", "plan_name": "400100", "standard_charge_dollar": 355.29, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Basic Pl", "plan_name": "400100_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Federal", "plan_name": "400110", "standard_charge_dollar": 355.29, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Federal", "plan_name": "400110_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Cigna Healthsprings Ffs", "plan_name": "500064", "standard_charge_dollar": 398.60, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Conseco", "plan_name": "500302", "standard_charge_dollar": 398.60, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Humana Ffs 61101", "plan_name": "500006", "standard_charge_dollar": 398.60, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Medicare A", "plan_name": "100100", "standard_charge_dollar": 398.60, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Medicare A", "plan_name": "100500", "standard_charge_dollar": 398.60, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Medicare Part B Only", "plan_name": "100300", "standard_charge_dollar": 398.60, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Medicare Railroad", "plan_name": "100103", "standard_charge_dollar": 398.60, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Ms Physicians Care N", "plan_name": "714210", "standard_charge_dollar": 498.25, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Peoples Hlth Ffs 72126", "plan_name": "500019", "standard_charge_dollar": 398.60, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Uhc/Secure Horizons", "plan_name": "500449", "standard_charge_dollar": 398.60, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "United Health Care/", "plan_name": "500292", "standard_charge_dollar": 450.42, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "United Healthcare", "plan_name": "750104", "standard_charge_dollar": 450.42, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "United Healthcare Ba", "plan_name": "750090", "standard_charge_dollar": 450.42, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "United Healthcare Me", "plan_name": "501310", "standard_charge_dollar": 398.60, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Windsor Mcare Extra", "plan_name": "500778", "standard_charge_dollar": 398.60, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." } ] } ] }, { "description": "Ct head/brain w/o & w/dye", "code_information": [ { "code": "70470", "type": "CPT" } ], "standard_charges": [ { "gross_charge": 1400.00, "minimum": 355.29, "maximum": 498.25, "setting": "both", "payers_information": [ { "payer_name": "Aarp", "plan_name": "500102", "standard_charge_dollar": 398.60, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna", "plan_name": "700700", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna", "plan_name": "700700_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Mcare Ffs 6005", "plan_name": "700703", "standard_charge_dollar": 398.60, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Miscellaneous", "plan_name": "700720", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Miscellaneous", "plan_name": "700720_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Ppo Hmo", "plan_name": "701720", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Ppo Hmo", "plan_name": "701720_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Ambetter 68069", "plan_name": "500516", "standard_charge_dollar": 398.60, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Ms State Emplo", "plan_name": "401457", "standard_charge_dollar": 355.29, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Ms State Emplo", "plan_name": "401457_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Basic Pl", "plan_name": "400100", "standard_charge_dollar": 355.29, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Basic Pl", "plan_name": "400100_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Federal", "plan_name": "400110", "standard_charge_dollar": 355.29, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Federal", "plan_name": "400110_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Cigna Healthsprings Ffs", "plan_name": "500064", "standard_charge_dollar": 398.60, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Conseco", "plan_name": "500302", "standard_charge_dollar": 398.60, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Humana Ffs 61101", "plan_name": "500006", "standard_charge_dollar": 398.60, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Medicare A", "plan_name": "100100", "standard_charge_dollar": 398.60, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Medicare A", "plan_name": "100500", "standard_charge_dollar": 398.60, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Medicare Part B Only", "plan_name": "100300", "standard_charge_dollar": 398.60, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Medicare Railroad", "plan_name": "100103", "standard_charge_dollar": 398.60, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Ms Physicians Care N", "plan_name": "714210", "standard_charge_dollar": 498.25, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Peoples Hlth Ffs 72126", "plan_name": "500019", "standard_charge_dollar": 398.60, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Uhc/Secure Horizons", "plan_name": "500449", "standard_charge_dollar": 398.60, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "United Health Care/", "plan_name": "500292", "standard_charge_dollar": 450.42, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "United Healthcare", "plan_name": "750104", "standard_charge_dollar": 450.42, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "United Healthcare Ba", "plan_name": "750090", "standard_charge_dollar": 450.42, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "United Healthcare Me", "plan_name": "501310", "standard_charge_dollar": 398.60, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Windsor Mcare Extra", "plan_name": "500778", "standard_charge_dollar": 398.60, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." } ] } ] }, { "description": "Hc ct head w/ wo contrast", "code_information": [ { "code": "70470", "type": "CPT" } ], "standard_charges": [ { "gross_charge": 1400.00, "minimum": 355.29, "maximum": 498.25, "setting": "both", "payers_information": [ { "payer_name": "Aarp", "plan_name": "500102", "standard_charge_dollar": 398.60, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna", "plan_name": "700700", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna", "plan_name": "700700_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Mcare Ffs 6005", "plan_name": "700703", "standard_charge_dollar": 398.60, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Miscellaneous", "plan_name": "700720", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Miscellaneous", "plan_name": "700720_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Ppo Hmo", "plan_name": "701720", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Ppo Hmo", "plan_name": "701720_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Ambetter 68069", "plan_name": "500516", "standard_charge_dollar": 398.60, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Ms State Emplo", "plan_name": "401457", "standard_charge_dollar": 355.29, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Ms State Emplo", "plan_name": "401457_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Basic Pl", "plan_name": "400100", "standard_charge_dollar": 355.29, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Basic Pl", "plan_name": "400100_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Federal", "plan_name": "400110", "standard_charge_dollar": 355.29, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Federal", "plan_name": "400110_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Cigna Healthsprings Ffs", "plan_name": "500064", "standard_charge_dollar": 398.60, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Conseco", "plan_name": "500302", "standard_charge_dollar": 398.60, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Humana Ffs 61101", "plan_name": "500006", "standard_charge_dollar": 398.60, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Medicare A", "plan_name": "100100", "standard_charge_dollar": 398.60, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Medicare A", "plan_name": "100500", "standard_charge_dollar": 398.60, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Medicare Part B Only", "plan_name": "100300", "standard_charge_dollar": 398.60, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Medicare Railroad", "plan_name": "100103", "standard_charge_dollar": 398.60, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Ms Physicians Care N", "plan_name": "714210", "standard_charge_dollar": 498.25, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Peoples Hlth Ffs 72126", "plan_name": "500019", "standard_charge_dollar": 398.60, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Uhc/Secure Horizons", "plan_name": "500449", "standard_charge_dollar": 398.60, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "United Health Care/", "plan_name": "500292", "standard_charge_dollar": 450.42, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "United Healthcare", "plan_name": "750104", "standard_charge_dollar": 450.42, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "United Healthcare Ba", "plan_name": "750090", "standard_charge_dollar": 450.42, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "United Healthcare Me", "plan_name": "501310", "standard_charge_dollar": 398.60, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Windsor Mcare Extra", "plan_name": "500778", "standard_charge_dollar": 398.60, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." } ] } ] }, { "description": "Ct orbit/ear/fossa w/o dye", "code_information": [ { "code": "70480", "type": "CPT" } ], "standard_charges": [ { "gross_charge": 1142.00, "minimum": 168.74, "maximum": 257.13, "setting": "both", "payers_information": [ { "payer_name": "Aarp", "plan_name": "500102", "standard_charge_dollar": 205.70, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna", "plan_name": "700700", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna", "plan_name": "700700_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Mcare Ffs 6005", "plan_name": "700703", "standard_charge_dollar": 205.70, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Miscellaneous", "plan_name": "700720", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Miscellaneous", "plan_name": "700720_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Ppo Hmo", "plan_name": "701720", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Ppo Hmo", "plan_name": "701720_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Ambetter 68069", "plan_name": "500516", "standard_charge_dollar": 205.70, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Ms State Emplo", "plan_name": "401457", "standard_charge_dollar": 168.74, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Ms State Emplo", "plan_name": "401457_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Basic Pl", "plan_name": "400100", "standard_charge_dollar": 168.74, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Basic Pl", "plan_name": "400100_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Federal", "plan_name": "400110", "standard_charge_dollar": 168.74, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Federal", "plan_name": "400110_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Cigna Healthsprings Ffs", "plan_name": "500064", "standard_charge_dollar": 205.70, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Conseco", "plan_name": "500302", "standard_charge_dollar": 205.70, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Humana Ffs 61101", "plan_name": "500006", "standard_charge_dollar": 205.70, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Medicare A", "plan_name": "100100", "standard_charge_dollar": 205.70, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Medicare A", "plan_name": "100500", "standard_charge_dollar": 205.70, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Medicare Part B Only", "plan_name": "100300", "standard_charge_dollar": 205.70, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Medicare Railroad", "plan_name": "100103", "standard_charge_dollar": 205.70, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Ms Physicians Care N", "plan_name": "714210", "standard_charge_dollar": 257.13, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Peoples Hlth Ffs 72126", "plan_name": "500019", "standard_charge_dollar": 205.70, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Uhc/Secure Horizons", "plan_name": "500449", "standard_charge_dollar": 205.70, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "United Health Care/", "plan_name": "500292", "standard_charge_dollar": 232.44, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "United Healthcare", "plan_name": "750104", "standard_charge_dollar": 232.44, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "United Healthcare Ba", "plan_name": "750090", "standard_charge_dollar": 232.44, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "United Healthcare Me", "plan_name": "501310", "standard_charge_dollar": 205.70, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Windsor Mcare Extra", "plan_name": "500778", "standard_charge_dollar": 205.70, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." } ] } ] }, { "description": "Hc ct orbit/sella/ear w/o contrast", "code_information": [ { "code": "70480", "type": "CPT" } ], "standard_charges": [ { "gross_charge": 1142.00, "minimum": 168.74, "maximum": 257.13, "setting": "both", "payers_information": [ { "payer_name": "Aarp", "plan_name": "500102", "standard_charge_dollar": 205.70, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna", "plan_name": "700700", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna", "plan_name": "700700_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Mcare Ffs 6005", "plan_name": "700703", "standard_charge_dollar": 205.70, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Miscellaneous", "plan_name": "700720", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Miscellaneous", "plan_name": "700720_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Ppo Hmo", "plan_name": "701720", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Ppo Hmo", "plan_name": "701720_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Ambetter 68069", "plan_name": "500516", "standard_charge_dollar": 205.70, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Ms State Emplo", "plan_name": "401457", "standard_charge_dollar": 168.74, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Ms State Emplo", "plan_name": "401457_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Basic Pl", "plan_name": "400100", "standard_charge_dollar": 168.74, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Basic Pl", "plan_name": "400100_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Federal", "plan_name": "400110", "standard_charge_dollar": 168.74, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Federal", "plan_name": "400110_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Cigna Healthsprings Ffs", "plan_name": "500064", "standard_charge_dollar": 205.70, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Conseco", "plan_name": "500302", "standard_charge_dollar": 205.70, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Humana Ffs 61101", "plan_name": "500006", "standard_charge_dollar": 205.70, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Medicare A", "plan_name": "100100", "standard_charge_dollar": 205.70, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Medicare A", "plan_name": "100500", "standard_charge_dollar": 205.70, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Medicare Part B Only", "plan_name": "100300", "standard_charge_dollar": 205.70, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Medicare Railroad", "plan_name": "100103", "standard_charge_dollar": 205.70, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Ms Physicians Care N", "plan_name": "714210", "standard_charge_dollar": 257.13, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Peoples Hlth Ffs 72126", "plan_name": "500019", "standard_charge_dollar": 205.70, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Uhc/Secure Horizons", "plan_name": "500449", "standard_charge_dollar": 205.70, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "United Health Care/", "plan_name": "500292", "standard_charge_dollar": 232.44, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "United Healthcare", "plan_name": "750104", "standard_charge_dollar": 232.44, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "United Healthcare Ba", "plan_name": "750090", "standard_charge_dollar": 232.44, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "United Healthcare Me", "plan_name": "501310", "standard_charge_dollar": 205.70, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Windsor Mcare Extra", "plan_name": "500778", "standard_charge_dollar": 205.70, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." } ] } ] }, { "description": "Ct orbit/ear/fossa w/dye", "code_information": [ { "code": "70481", "type": "CPT" } ], "standard_charges": [ { "gross_charge": 1142.00, "minimum": 355.29, "maximum": 498.25, "setting": "both", "payers_information": [ { "payer_name": "Aarp", "plan_name": "500102", "standard_charge_dollar": 398.60, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna", "plan_name": "700700", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna", "plan_name": "700700_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Mcare Ffs 6005", "plan_name": "700703", "standard_charge_dollar": 398.60, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Miscellaneous", "plan_name": "700720", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Miscellaneous", "plan_name": "700720_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Ppo Hmo", "plan_name": "701720", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Ppo Hmo", "plan_name": "701720_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Ambetter 68069", "plan_name": "500516", "standard_charge_dollar": 398.60, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Ms State Emplo", "plan_name": "401457", "standard_charge_dollar": 355.29, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Ms State Emplo", "plan_name": "401457_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Basic Pl", "plan_name": "400100", "standard_charge_dollar": 355.29, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Basic Pl", "plan_name": "400100_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Federal", "plan_name": "400110", "standard_charge_dollar": 355.29, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Federal", "plan_name": "400110_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Cigna Healthsprings Ffs", "plan_name": "500064", "standard_charge_dollar": 398.60, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Conseco", "plan_name": "500302", "standard_charge_dollar": 398.60, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Humana Ffs 61101", "plan_name": "500006", "standard_charge_dollar": 398.60, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Medicare A", "plan_name": "100100", "standard_charge_dollar": 398.60, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Medicare A", "plan_name": "100500", "standard_charge_dollar": 398.60, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Medicare Part B Only", "plan_name": "100300", "standard_charge_dollar": 398.60, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Medicare Railroad", "plan_name": "100103", "standard_charge_dollar": 398.60, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Ms Physicians Care N", "plan_name": "714210", "standard_charge_dollar": 498.25, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Peoples Hlth Ffs 72126", "plan_name": "500019", "standard_charge_dollar": 398.60, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Uhc/Secure Horizons", "plan_name": "500449", "standard_charge_dollar": 398.60, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "United Health Care/", "plan_name": "500292", "standard_charge_dollar": 450.42, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "United Healthcare", "plan_name": "750104", "standard_charge_dollar": 450.42, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "United Healthcare Ba", "plan_name": "750090", "standard_charge_dollar": 450.42, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "United Healthcare Me", "plan_name": "501310", "standard_charge_dollar": 398.60, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Windsor Mcare Extra", "plan_name": "500778", "standard_charge_dollar": 398.60, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." } ] } ] }, { "description": "Hc ct orbit/sella/ear w/contrast", "code_information": [ { "code": "70481", "type": "CPT" } ], "standard_charges": [ { "gross_charge": 1142.00, "minimum": 355.29, "maximum": 498.25, "setting": "both", "payers_information": [ { "payer_name": "Aarp", "plan_name": "500102", "standard_charge_dollar": 398.60, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna", "plan_name": "700700", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna", "plan_name": "700700_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Mcare Ffs 6005", "plan_name": "700703", "standard_charge_dollar": 398.60, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Miscellaneous", "plan_name": "700720", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Miscellaneous", "plan_name": "700720_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Ppo Hmo", "plan_name": "701720", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Ppo Hmo", "plan_name": "701720_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Ambetter 68069", "plan_name": "500516", "standard_charge_dollar": 398.60, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Ms State Emplo", "plan_name": "401457", "standard_charge_dollar": 355.29, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Ms State Emplo", "plan_name": "401457_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Basic Pl", "plan_name": "400100", "standard_charge_dollar": 355.29, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Basic Pl", "plan_name": "400100_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Federal", "plan_name": "400110", "standard_charge_dollar": 355.29, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Federal", "plan_name": "400110_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Cigna Healthsprings Ffs", "plan_name": "500064", "standard_charge_dollar": 398.60, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Conseco", "plan_name": "500302", "standard_charge_dollar": 398.60, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Humana Ffs 61101", "plan_name": "500006", "standard_charge_dollar": 398.60, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Medicare A", "plan_name": "100100", "standard_charge_dollar": 398.60, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Medicare A", "plan_name": "100500", "standard_charge_dollar": 398.60, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Medicare Part B Only", "plan_name": "100300", "standard_charge_dollar": 398.60, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Medicare Railroad", "plan_name": "100103", "standard_charge_dollar": 398.60, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Ms Physicians Care N", "plan_name": "714210", "standard_charge_dollar": 498.25, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Peoples Hlth Ffs 72126", "plan_name": "500019", "standard_charge_dollar": 398.60, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Uhc/Secure Horizons", "plan_name": "500449", "standard_charge_dollar": 398.60, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "United Health Care/", "plan_name": "500292", "standard_charge_dollar": 450.42, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "United Healthcare", "plan_name": "750104", "standard_charge_dollar": 450.42, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "United Healthcare Ba", "plan_name": "750090", "standard_charge_dollar": 450.42, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "United Healthcare Me", "plan_name": "501310", "standard_charge_dollar": 398.60, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Windsor Mcare Extra", "plan_name": "500778", "standard_charge_dollar": 398.60, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." } ] } ] }, { "description": "Ct maxillofacial w/o dye", "code_information": [ { "code": "70486", "type": "CPT" } ], "standard_charges": [ { "gross_charge": 875.00, "minimum": 168.74, "maximum": 257.13, "setting": "both", "payers_information": [ { "payer_name": "Aarp", "plan_name": "500102", "standard_charge_dollar": 205.70, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna", "plan_name": "700700", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna", "plan_name": "700700_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Mcare Ffs 6005", "plan_name": "700703", "standard_charge_dollar": 205.70, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Miscellaneous", "plan_name": "700720", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Miscellaneous", "plan_name": "700720_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Ppo Hmo", "plan_name": "701720", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Ppo Hmo", "plan_name": "701720_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Ambetter 68069", "plan_name": "500516", "standard_charge_dollar": 205.70, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Ms State Emplo", "plan_name": "401457", "standard_charge_dollar": 168.74, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Ms State Emplo", "plan_name": "401457_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Basic Pl", "plan_name": "400100", "standard_charge_dollar": 168.74, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Basic Pl", "plan_name": "400100_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Federal", "plan_name": "400110", "standard_charge_dollar": 168.74, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Federal", "plan_name": "400110_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Cigna Healthsprings Ffs", "plan_name": "500064", "standard_charge_dollar": 205.70, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Conseco", "plan_name": "500302", "standard_charge_dollar": 205.70, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Humana Ffs 61101", "plan_name": "500006", "standard_charge_dollar": 205.70, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Medicare A", "plan_name": "100100", "standard_charge_dollar": 205.70, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Medicare A", "plan_name": "100500", "standard_charge_dollar": 205.70, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Medicare Part B Only", "plan_name": "100300", "standard_charge_dollar": 205.70, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Medicare Railroad", "plan_name": "100103", "standard_charge_dollar": 205.70, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Ms Physicians Care N", "plan_name": "714210", "standard_charge_dollar": 257.13, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Peoples Hlth Ffs 72126", "plan_name": "500019", "standard_charge_dollar": 205.70, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Uhc/Secure Horizons", "plan_name": "500449", "standard_charge_dollar": 205.70, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "United Health Care/", "plan_name": "500292", "standard_charge_dollar": 232.44, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "United Healthcare", "plan_name": "750104", "standard_charge_dollar": 232.44, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "United Healthcare Ba", "plan_name": "750090", "standard_charge_dollar": 232.44, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "United Healthcare Me", "plan_name": "501310", "standard_charge_dollar": 205.70, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Windsor Mcare Extra", "plan_name": "500778", "standard_charge_dollar": 205.70, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." } ] } ] }, { "description": "Hc ct maxillofacial w/o contrast", "code_information": [ { "code": "70486", "type": "CPT" } ], "standard_charges": [ { "gross_charge": 875.00, "minimum": 168.74, "maximum": 257.13, "setting": "both", "payers_information": [ { "payer_name": "Aarp", "plan_name": "500102", "standard_charge_dollar": 205.70, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna", "plan_name": "700700", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna", "plan_name": "700700_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Mcare Ffs 6005", "plan_name": "700703", "standard_charge_dollar": 205.70, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Miscellaneous", "plan_name": "700720", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Miscellaneous", "plan_name": "700720_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Ppo Hmo", "plan_name": "701720", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Ppo Hmo", "plan_name": "701720_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Ambetter 68069", "plan_name": "500516", "standard_charge_dollar": 205.70, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Ms State Emplo", "plan_name": "401457", "standard_charge_dollar": 168.74, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Ms State Emplo", "plan_name": "401457_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Basic Pl", "plan_name": "400100", "standard_charge_dollar": 168.74, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Basic Pl", "plan_name": "400100_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Federal", "plan_name": "400110", "standard_charge_dollar": 168.74, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Federal", "plan_name": "400110_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Cigna Healthsprings Ffs", "plan_name": "500064", "standard_charge_dollar": 205.70, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Conseco", "plan_name": "500302", "standard_charge_dollar": 205.70, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Humana Ffs 61101", "plan_name": "500006", "standard_charge_dollar": 205.70, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Medicare A", "plan_name": "100100", "standard_charge_dollar": 205.70, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Medicare A", "plan_name": "100500", "standard_charge_dollar": 205.70, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Medicare Part B Only", "plan_name": "100300", "standard_charge_dollar": 205.70, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Medicare Railroad", "plan_name": "100103", "standard_charge_dollar": 205.70, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Ms Physicians Care N", "plan_name": "714210", "standard_charge_dollar": 257.13, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Peoples Hlth Ffs 72126", "plan_name": "500019", "standard_charge_dollar": 205.70, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Uhc/Secure Horizons", "plan_name": "500449", "standard_charge_dollar": 205.70, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "United Health Care/", "plan_name": "500292", "standard_charge_dollar": 232.44, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "United Healthcare", "plan_name": "750104", "standard_charge_dollar": 232.44, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "United Healthcare Ba", "plan_name": "750090", "standard_charge_dollar": 232.44, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "United Healthcare Me", "plan_name": "501310", "standard_charge_dollar": 205.70, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Windsor Mcare Extra", "plan_name": "500778", "standard_charge_dollar": 205.70, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." } ] } ] }, { "description": "Ct maxillofacial w/dye", "code_information": [ { "code": "70487", "type": "CPT" } ], "standard_charges": [ { "gross_charge": 1150.00, "minimum": 355.29, "maximum": 498.25, "setting": "both", "payers_information": [ { "payer_name": "Aarp", "plan_name": "500102", "standard_charge_dollar": 398.60, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna", "plan_name": "700700", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna", "plan_name": "700700_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Mcare Ffs 6005", "plan_name": "700703", "standard_charge_dollar": 398.60, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Miscellaneous", "plan_name": "700720", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Miscellaneous", "plan_name": "700720_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Ppo Hmo", "plan_name": "701720", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Ppo Hmo", "plan_name": "701720_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Ambetter 68069", "plan_name": "500516", "standard_charge_dollar": 398.60, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Ms State Emplo", "plan_name": "401457", "standard_charge_dollar": 355.29, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Ms State Emplo", "plan_name": "401457_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Basic Pl", "plan_name": "400100", "standard_charge_dollar": 355.29, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Basic Pl", "plan_name": "400100_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Federal", "plan_name": "400110", "standard_charge_dollar": 355.29, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Federal", "plan_name": "400110_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Cigna Healthsprings Ffs", "plan_name": "500064", "standard_charge_dollar": 398.60, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Conseco", "plan_name": "500302", "standard_charge_dollar": 398.60, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Humana Ffs 61101", "plan_name": "500006", "standard_charge_dollar": 398.60, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Medicare A", "plan_name": "100100", "standard_charge_dollar": 398.60, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Medicare A", "plan_name": "100500", "standard_charge_dollar": 398.60, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Medicare Part B Only", "plan_name": "100300", "standard_charge_dollar": 398.60, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Medicare Railroad", "plan_name": "100103", "standard_charge_dollar": 398.60, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Ms Physicians Care N", "plan_name": "714210", "standard_charge_dollar": 498.25, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Peoples Hlth Ffs 72126", "plan_name": "500019", "standard_charge_dollar": 398.60, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Uhc/Secure Horizons", "plan_name": "500449", "standard_charge_dollar": 398.60, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "United Health Care/", "plan_name": "500292", "standard_charge_dollar": 450.42, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "United Healthcare", "plan_name": "750104", "standard_charge_dollar": 450.42, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "United Healthcare Ba", "plan_name": "750090", "standard_charge_dollar": 450.42, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "United Healthcare Me", "plan_name": "501310", "standard_charge_dollar": 398.60, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Windsor Mcare Extra", "plan_name": "500778", "standard_charge_dollar": 398.60, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." } ] } ] }, { "description": "Hc ct maxillofacial w/contrast", "code_information": [ { "code": "70487", "type": "CPT" } ], "standard_charges": [ { "gross_charge": 1150.00, "minimum": 355.29, "maximum": 498.25, "setting": "both", "payers_information": [ { "payer_name": "Aarp", "plan_name": "500102", "standard_charge_dollar": 398.60, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna", "plan_name": "700700", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna", "plan_name": "700700_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Mcare Ffs 6005", "plan_name": "700703", "standard_charge_dollar": 398.60, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Miscellaneous", "plan_name": "700720", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Miscellaneous", "plan_name": "700720_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Ppo Hmo", "plan_name": "701720", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Ppo Hmo", "plan_name": "701720_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Ambetter 68069", "plan_name": "500516", "standard_charge_dollar": 398.60, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Ms State Emplo", "plan_name": "401457", "standard_charge_dollar": 355.29, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Ms State Emplo", "plan_name": "401457_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Basic Pl", "plan_name": "400100", "standard_charge_dollar": 355.29, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Basic Pl", "plan_name": "400100_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Federal", "plan_name": "400110", "standard_charge_dollar": 355.29, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Federal", "plan_name": "400110_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Cigna Healthsprings Ffs", "plan_name": "500064", "standard_charge_dollar": 398.60, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Conseco", "plan_name": "500302", "standard_charge_dollar": 398.60, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Humana Ffs 61101", "plan_name": "500006", "standard_charge_dollar": 398.60, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Medicare A", "plan_name": "100100", "standard_charge_dollar": 398.60, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Medicare A", "plan_name": "100500", "standard_charge_dollar": 398.60, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Medicare Part B Only", "plan_name": "100300", "standard_charge_dollar": 398.60, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Medicare Railroad", "plan_name": "100103", "standard_charge_dollar": 398.60, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Ms Physicians Care N", "plan_name": "714210", "standard_charge_dollar": 498.25, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Peoples Hlth Ffs 72126", "plan_name": "500019", "standard_charge_dollar": 398.60, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Uhc/Secure Horizons", "plan_name": "500449", "standard_charge_dollar": 398.60, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "United Health Care/", "plan_name": "500292", "standard_charge_dollar": 450.42, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "United Healthcare", "plan_name": "750104", "standard_charge_dollar": 450.42, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "United Healthcare Ba", "plan_name": "750090", "standard_charge_dollar": 450.42, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "United Healthcare Me", "plan_name": "501310", "standard_charge_dollar": 398.60, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Windsor Mcare Extra", "plan_name": "500778", "standard_charge_dollar": 398.60, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." } ] } ] }, { "description": "Ct soft tissue neck w/o dye", "code_information": [ { "code": "70490", "type": "CPT" } ], "standard_charges": [ { "gross_charge": 859.79, "minimum": 168.74, "maximum": 257.13, "setting": "both", "payers_information": [ { "payer_name": "Aarp", "plan_name": "500102", "standard_charge_dollar": 205.70, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna", "plan_name": "700700", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna", "plan_name": "700700_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Mcare Ffs 6005", "plan_name": "700703", "standard_charge_dollar": 205.70, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Miscellaneous", "plan_name": "700720", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Miscellaneous", "plan_name": "700720_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Ppo Hmo", "plan_name": "701720", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Ppo Hmo", "plan_name": "701720_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Ambetter 68069", "plan_name": "500516", "standard_charge_dollar": 205.70, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Ms State Emplo", "plan_name": "401457", "standard_charge_dollar": 168.74, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Ms State Emplo", "plan_name": "401457_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Basic Pl", "plan_name": "400100", "standard_charge_dollar": 168.74, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Basic Pl", "plan_name": "400100_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Federal", "plan_name": "400110", "standard_charge_dollar": 168.74, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Federal", "plan_name": "400110_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Cigna Healthsprings Ffs", "plan_name": "500064", "standard_charge_dollar": 205.70, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Conseco", "plan_name": "500302", "standard_charge_dollar": 205.70, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Humana Ffs 61101", "plan_name": "500006", "standard_charge_dollar": 205.70, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Medicare A", "plan_name": "100100", "standard_charge_dollar": 205.70, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Medicare A", "plan_name": "100500", "standard_charge_dollar": 205.70, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Medicare Part B Only", "plan_name": "100300", "standard_charge_dollar": 205.70, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Medicare Railroad", "plan_name": "100103", "standard_charge_dollar": 205.70, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Ms Physicians Care N", "plan_name": "714210", "standard_charge_dollar": 257.13, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Peoples Hlth Ffs 72126", "plan_name": "500019", "standard_charge_dollar": 205.70, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Uhc/Secure Horizons", "plan_name": "500449", "standard_charge_dollar": 205.70, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "United Health Care/", "plan_name": "500292", "standard_charge_dollar": 232.44, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "United Healthcare", "plan_name": "750104", "standard_charge_dollar": 232.44, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "United Healthcare Ba", "plan_name": "750090", "standard_charge_dollar": 232.44, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "United Healthcare Me", "plan_name": "501310", "standard_charge_dollar": 205.70, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Windsor Mcare Extra", "plan_name": "500778", "standard_charge_dollar": 205.70, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." } ] } ] }, { "description": "Hc ct neck w/o contrast", "code_information": [ { "code": "70490", "type": "CPT" } ], "standard_charges": [ { "gross_charge": 859.79, "minimum": 168.74, "maximum": 257.13, "setting": "both", "payers_information": [ { "payer_name": "Aarp", "plan_name": "500102", "standard_charge_dollar": 205.70, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna", "plan_name": "700700", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna", "plan_name": "700700_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Mcare Ffs 6005", "plan_name": "700703", "standard_charge_dollar": 205.70, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Miscellaneous", "plan_name": "700720", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Miscellaneous", "plan_name": "700720_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Ppo Hmo", "plan_name": "701720", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Ppo Hmo", "plan_name": "701720_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Ambetter 68069", "plan_name": "500516", "standard_charge_dollar": 205.70, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Ms State Emplo", "plan_name": "401457", "standard_charge_dollar": 168.74, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Ms State Emplo", "plan_name": "401457_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Basic Pl", "plan_name": "400100", "standard_charge_dollar": 168.74, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Basic Pl", "plan_name": "400100_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Federal", "plan_name": "400110", "standard_charge_dollar": 168.74, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Federal", "plan_name": "400110_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Cigna Healthsprings Ffs", "plan_name": "500064", "standard_charge_dollar": 205.70, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Conseco", "plan_name": "500302", "standard_charge_dollar": 205.70, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Humana Ffs 61101", "plan_name": "500006", "standard_charge_dollar": 205.70, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Medicare A", "plan_name": "100100", "standard_charge_dollar": 205.70, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Medicare A", "plan_name": "100500", "standard_charge_dollar": 205.70, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Medicare Part B Only", "plan_name": "100300", "standard_charge_dollar": 205.70, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Medicare Railroad", "plan_name": "100103", "standard_charge_dollar": 205.70, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Ms Physicians Care N", "plan_name": "714210", "standard_charge_dollar": 257.13, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Peoples Hlth Ffs 72126", "plan_name": "500019", "standard_charge_dollar": 205.70, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Uhc/Secure Horizons", "plan_name": "500449", "standard_charge_dollar": 205.70, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "United Health Care/", "plan_name": "500292", "standard_charge_dollar": 232.44, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "United Healthcare", "plan_name": "750104", "standard_charge_dollar": 232.44, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "United Healthcare Ba", "plan_name": "750090", "standard_charge_dollar": 232.44, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "United Healthcare Me", "plan_name": "501310", "standard_charge_dollar": 205.70, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Windsor Mcare Extra", "plan_name": "500778", "standard_charge_dollar": 205.70, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." } ] } ] }, { "description": "Ct soft tissue neck w/dye", "code_information": [ { "code": "70491", "type": "CPT" } ], "standard_charges": [ { "gross_charge": 1252.39, "minimum": 355.29, "maximum": 498.25, "setting": "both", "payers_information": [ { "payer_name": "Aarp", "plan_name": "500102", "standard_charge_dollar": 398.60, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna", "plan_name": "700700", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna", "plan_name": "700700_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Mcare Ffs 6005", "plan_name": "700703", "standard_charge_dollar": 398.60, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Miscellaneous", "plan_name": "700720", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Miscellaneous", "plan_name": "700720_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Ppo Hmo", "plan_name": "701720", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Ppo Hmo", "plan_name": "701720_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Ambetter 68069", "plan_name": "500516", "standard_charge_dollar": 398.60, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Ms State Emplo", "plan_name": "401457", "standard_charge_dollar": 355.29, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Ms State Emplo", "plan_name": "401457_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Basic Pl", "plan_name": "400100", "standard_charge_dollar": 355.29, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Basic Pl", "plan_name": "400100_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Federal", "plan_name": "400110", "standard_charge_dollar": 355.29, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Federal", "plan_name": "400110_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Cigna Healthsprings Ffs", "plan_name": "500064", "standard_charge_dollar": 398.60, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Conseco", "plan_name": "500302", "standard_charge_dollar": 398.60, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Humana Ffs 61101", "plan_name": "500006", "standard_charge_dollar": 398.60, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Medicare A", "plan_name": "100100", "standard_charge_dollar": 398.60, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Medicare A", "plan_name": "100500", "standard_charge_dollar": 398.60, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Medicare Part B Only", "plan_name": "100300", "standard_charge_dollar": 398.60, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Medicare Railroad", "plan_name": "100103", "standard_charge_dollar": 398.60, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Ms Physicians Care N", "plan_name": "714210", "standard_charge_dollar": 498.25, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Peoples Hlth Ffs 72126", "plan_name": "500019", "standard_charge_dollar": 398.60, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Uhc/Secure Horizons", "plan_name": "500449", "standard_charge_dollar": 398.60, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "United Health Care/", "plan_name": "500292", "standard_charge_dollar": 450.42, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "United Healthcare", "plan_name": "750104", "standard_charge_dollar": 450.42, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "United Healthcare Ba", "plan_name": "750090", "standard_charge_dollar": 450.42, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "United Healthcare Me", "plan_name": "501310", "standard_charge_dollar": 398.60, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Windsor Mcare Extra", "plan_name": "500778", "standard_charge_dollar": 398.60, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." } ] } ] }, { "description": "Hc ct neck w/contrast", "code_information": [ { "code": "70491", "type": "CPT" } ], "standard_charges": [ { "gross_charge": 1252.39, "minimum": 355.29, "maximum": 498.25, "setting": "both", "payers_information": [ { "payer_name": "Aarp", "plan_name": "500102", "standard_charge_dollar": 398.60, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna", "plan_name": "700700", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna", "plan_name": "700700_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Mcare Ffs 6005", "plan_name": "700703", "standard_charge_dollar": 398.60, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Miscellaneous", "plan_name": "700720", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Miscellaneous", "plan_name": "700720_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Ppo Hmo", "plan_name": "701720", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Ppo Hmo", "plan_name": "701720_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Ambetter 68069", "plan_name": "500516", "standard_charge_dollar": 398.60, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Ms State Emplo", "plan_name": "401457", "standard_charge_dollar": 355.29, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Ms State Emplo", "plan_name": "401457_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Basic Pl", "plan_name": "400100", "standard_charge_dollar": 355.29, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Basic Pl", "plan_name": "400100_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Federal", "plan_name": "400110", "standard_charge_dollar": 355.29, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Federal", "plan_name": "400110_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Cigna Healthsprings Ffs", "plan_name": "500064", "standard_charge_dollar": 398.60, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Conseco", "plan_name": "500302", "standard_charge_dollar": 398.60, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Humana Ffs 61101", "plan_name": "500006", "standard_charge_dollar": 398.60, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Medicare A", "plan_name": "100100", "standard_charge_dollar": 398.60, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Medicare A", "plan_name": "100500", "standard_charge_dollar": 398.60, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Medicare Part B Only", "plan_name": "100300", "standard_charge_dollar": 398.60, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Medicare Railroad", "plan_name": "100103", "standard_charge_dollar": 398.60, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Ms Physicians Care N", "plan_name": "714210", "standard_charge_dollar": 498.25, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Peoples Hlth Ffs 72126", "plan_name": "500019", "standard_charge_dollar": 398.60, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Uhc/Secure Horizons", "plan_name": "500449", "standard_charge_dollar": 398.60, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "United Health Care/", "plan_name": "500292", "standard_charge_dollar": 450.42, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "United Healthcare", "plan_name": "750104", "standard_charge_dollar": 450.42, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "United Healthcare Ba", "plan_name": "750090", "standard_charge_dollar": 450.42, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "United Healthcare Me", "plan_name": "501310", "standard_charge_dollar": 398.60, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Windsor Mcare Extra", "plan_name": "500778", "standard_charge_dollar": 398.60, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." } ] } ] }, { "description": "Ct angiography head", "code_information": [ { "code": "70496", "type": "CPT" } ], "standard_charges": [ { "gross_charge": 1746.00, "minimum": 355.29, "maximum": 498.25, "setting": "both", "payers_information": [ { "payer_name": "Aarp", "plan_name": "500102", "standard_charge_dollar": 398.60, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna", "plan_name": "700700", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna", "plan_name": "700700_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Mcare Ffs 6005", "plan_name": "700703", "standard_charge_dollar": 398.60, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Miscellaneous", "plan_name": "700720", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Miscellaneous", "plan_name": "700720_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Ppo Hmo", "plan_name": "701720", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Ppo Hmo", "plan_name": "701720_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Ambetter 68069", "plan_name": "500516", "standard_charge_dollar": 398.60, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Ms State Emplo", "plan_name": "401457", "standard_charge_dollar": 355.29, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Ms State Emplo", "plan_name": "401457_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Basic Pl", "plan_name": "400100", "standard_charge_dollar": 355.29, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Basic Pl", "plan_name": "400100_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Federal", "plan_name": "400110", "standard_charge_dollar": 355.29, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Federal", "plan_name": "400110_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Cigna Healthsprings Ffs", "plan_name": "500064", "standard_charge_dollar": 398.60, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Conseco", "plan_name": "500302", "standard_charge_dollar": 398.60, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Humana Ffs 61101", "plan_name": "500006", "standard_charge_dollar": 398.60, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Medicare A", "plan_name": "100100", "standard_charge_dollar": 398.60, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Medicare A", "plan_name": "100500", "standard_charge_dollar": 398.60, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Medicare Part B Only", "plan_name": "100300", "standard_charge_dollar": 398.60, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Medicare Railroad", "plan_name": "100103", "standard_charge_dollar": 398.60, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Ms Physicians Care N", "plan_name": "714210", "standard_charge_dollar": 498.25, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Peoples Hlth Ffs 72126", "plan_name": "500019", "standard_charge_dollar": 398.60, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Uhc/Secure Horizons", "plan_name": "500449", "standard_charge_dollar": 398.60, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "United Health Care/", "plan_name": "500292", "standard_charge_dollar": 450.42, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "United Healthcare", "plan_name": "750104", "standard_charge_dollar": 450.42, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "United Healthcare Ba", "plan_name": "750090", "standard_charge_dollar": 450.42, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "United Healthcare Me", "plan_name": "501310", "standard_charge_dollar": 398.60, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Windsor Mcare Extra", "plan_name": "500778", "standard_charge_dollar": 398.60, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." } ] } ] }, { "description": "Hc ct head angiography", "code_information": [ { "code": "70496", "type": "CPT" } ], "standard_charges": [ { "gross_charge": 1746.00, "minimum": 355.29, "maximum": 498.25, "setting": "both", "payers_information": [ { "payer_name": "Aarp", "plan_name": "500102", "standard_charge_dollar": 398.60, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna", "plan_name": "700700", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna", "plan_name": "700700_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Mcare Ffs 6005", "plan_name": "700703", "standard_charge_dollar": 398.60, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Miscellaneous", "plan_name": "700720", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Miscellaneous", "plan_name": "700720_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Ppo Hmo", "plan_name": "701720", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Ppo Hmo", "plan_name": "701720_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Ambetter 68069", "plan_name": "500516", "standard_charge_dollar": 398.60, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Ms State Emplo", "plan_name": "401457", "standard_charge_dollar": 355.29, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Ms State Emplo", "plan_name": "401457_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Basic Pl", "plan_name": "400100", "standard_charge_dollar": 355.29, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Basic Pl", "plan_name": "400100_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Federal", "plan_name": "400110", "standard_charge_dollar": 355.29, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Federal", "plan_name": "400110_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Cigna Healthsprings Ffs", "plan_name": "500064", "standard_charge_dollar": 398.60, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Conseco", "plan_name": "500302", "standard_charge_dollar": 398.60, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Humana Ffs 61101", "plan_name": "500006", "standard_charge_dollar": 398.60, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Medicare A", "plan_name": "100100", "standard_charge_dollar": 398.60, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Medicare A", "plan_name": "100500", "standard_charge_dollar": 398.60, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Medicare Part B Only", "plan_name": "100300", "standard_charge_dollar": 398.60, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Medicare Railroad", "plan_name": "100103", "standard_charge_dollar": 398.60, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Ms Physicians Care N", "plan_name": "714210", "standard_charge_dollar": 498.25, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Peoples Hlth Ffs 72126", "plan_name": "500019", "standard_charge_dollar": 398.60, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Uhc/Secure Horizons", "plan_name": "500449", "standard_charge_dollar": 398.60, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "United Health Care/", "plan_name": "500292", "standard_charge_dollar": 450.42, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "United Healthcare", "plan_name": "750104", "standard_charge_dollar": 450.42, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "United Healthcare Ba", "plan_name": "750090", "standard_charge_dollar": 450.42, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "United Healthcare Me", "plan_name": "501310", "standard_charge_dollar": 398.60, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Windsor Mcare Extra", "plan_name": "500778", "standard_charge_dollar": 398.60, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." } ] } ] }, { "description": "Ct angiography neck", "code_information": [ { "code": "70498", "type": "CPT" } ], "standard_charges": [ { "gross_charge": 1863.50, "minimum": 355.29, "maximum": 498.25, "setting": "both", "payers_information": [ { "payer_name": "Aarp", "plan_name": "500102", "standard_charge_dollar": 398.60, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna", "plan_name": "700700", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna", "plan_name": "700700_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Mcare Ffs 6005", "plan_name": "700703", "standard_charge_dollar": 398.60, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Miscellaneous", "plan_name": "700720", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Miscellaneous", "plan_name": "700720_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Ppo Hmo", "plan_name": "701720", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Ppo Hmo", "plan_name": "701720_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Ambetter 68069", "plan_name": "500516", "standard_charge_dollar": 398.60, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Ms State Emplo", "plan_name": "401457", "standard_charge_dollar": 355.29, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Ms State Emplo", "plan_name": "401457_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Basic Pl", "plan_name": "400100", "standard_charge_dollar": 355.29, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Basic Pl", "plan_name": "400100_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Federal", "plan_name": "400110", "standard_charge_dollar": 355.29, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Federal", "plan_name": "400110_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Cigna Healthsprings Ffs", "plan_name": "500064", "standard_charge_dollar": 398.60, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Conseco", "plan_name": "500302", "standard_charge_dollar": 398.60, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Humana Ffs 61101", "plan_name": "500006", "standard_charge_dollar": 398.60, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Medicare A", "plan_name": "100100", "standard_charge_dollar": 398.60, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Medicare A", "plan_name": "100500", "standard_charge_dollar": 398.60, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Medicare Part B Only", "plan_name": "100300", "standard_charge_dollar": 398.60, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Medicare Railroad", "plan_name": "100103", "standard_charge_dollar": 398.60, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Ms Physicians Care N", "plan_name": "714210", "standard_charge_dollar": 498.25, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Peoples Hlth Ffs 72126", "plan_name": "500019", "standard_charge_dollar": 398.60, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Uhc/Secure Horizons", "plan_name": "500449", "standard_charge_dollar": 398.60, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "United Health Care/", "plan_name": "500292", "standard_charge_dollar": 450.42, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "United Healthcare", "plan_name": "750104", "standard_charge_dollar": 450.42, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "United Healthcare Ba", "plan_name": "750090", "standard_charge_dollar": 450.42, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "United Healthcare Me", "plan_name": "501310", "standard_charge_dollar": 398.60, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Windsor Mcare Extra", "plan_name": "500778", "standard_charge_dollar": 398.60, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." } ] } ] }, { "description": "Hc cta neck w/ wo contrast", "code_information": [ { "code": "70498", "type": "CPT" } ], "standard_charges": [ { "gross_charge": 1863.50, "minimum": 355.29, "maximum": 498.25, "setting": "both", "payers_information": [ { "payer_name": "Aarp", "plan_name": "500102", "standard_charge_dollar": 398.60, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna", "plan_name": "700700", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna", "plan_name": "700700_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Mcare Ffs 6005", "plan_name": "700703", "standard_charge_dollar": 398.60, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Miscellaneous", "plan_name": "700720", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Miscellaneous", "plan_name": "700720_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Ppo Hmo", "plan_name": "701720", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Ppo Hmo", "plan_name": "701720_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Ambetter 68069", "plan_name": "500516", "standard_charge_dollar": 398.60, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Ms State Emplo", "plan_name": "401457", "standard_charge_dollar": 355.29, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Ms State Emplo", "plan_name": "401457_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Basic Pl", "plan_name": "400100", "standard_charge_dollar": 355.29, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Basic Pl", "plan_name": "400100_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Federal", "plan_name": "400110", "standard_charge_dollar": 355.29, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Federal", "plan_name": "400110_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Cigna Healthsprings Ffs", "plan_name": "500064", "standard_charge_dollar": 398.60, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Conseco", "plan_name": "500302", "standard_charge_dollar": 398.60, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Humana Ffs 61101", "plan_name": "500006", "standard_charge_dollar": 398.60, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Medicare A", "plan_name": "100100", "standard_charge_dollar": 398.60, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Medicare A", "plan_name": "100500", "standard_charge_dollar": 398.60, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Medicare Part B Only", "plan_name": "100300", "standard_charge_dollar": 398.60, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Medicare Railroad", "plan_name": "100103", "standard_charge_dollar": 398.60, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Ms Physicians Care N", "plan_name": "714210", "standard_charge_dollar": 498.25, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Peoples Hlth Ffs 72126", "plan_name": "500019", "standard_charge_dollar": 398.60, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Uhc/Secure Horizons", "plan_name": "500449", "standard_charge_dollar": 398.60, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "United Health Care/", "plan_name": "500292", "standard_charge_dollar": 450.42, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "United Healthcare", "plan_name": "750104", "standard_charge_dollar": 450.42, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "United Healthcare Ba", "plan_name": "750090", "standard_charge_dollar": 450.42, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "United Healthcare Me", "plan_name": "501310", "standard_charge_dollar": 398.60, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Windsor Mcare Extra", "plan_name": "500778", "standard_charge_dollar": 398.60, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." } ] } ] }, { "description": "Hc xray chest 1 view", "code_information": [ { "code": "71045", "type": "CPT" } ], "standard_charges": [ { "gross_charge": 100.00, "minimum": 91.20, "maximum": 964.86, "setting": "both", "payers_information": [ { "payer_name": "Aarp", "plan_name": "500102", "standard_charge_dollar": 771.89, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna", "plan_name": "700700", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna", "plan_name": "700700_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Mcare Ffs 6005", "plan_name": "700703", "standard_charge_dollar": 771.89, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Miscellaneous", "plan_name": "700720", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Miscellaneous", "plan_name": "700720_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Ppo Hmo", "plan_name": "701720", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Ppo Hmo", "plan_name": "701720_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Ambetter 68069", "plan_name": "500516", "standard_charge_dollar": 771.89, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Ms State Emplo", "plan_name": "401457", "standard_charge_dollar": 91.20, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Ms State Emplo", "plan_name": "401457_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Basic Pl", "plan_name": "400100", "standard_charge_dollar": 91.20, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Basic Pl", "plan_name": "400100_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Federal", "plan_name": "400110", "standard_charge_dollar": 91.20, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Federal", "plan_name": "400110_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Cigna Healthsprings Ffs", "plan_name": "500064", "standard_charge_dollar": 771.89, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Conseco", "plan_name": "500302", "standard_charge_dollar": 771.89, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Humana Ffs 61101", "plan_name": "500006", "standard_charge_dollar": 771.89, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Medicare A", "plan_name": "100100", "standard_charge_dollar": 771.89, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Medicare A", "plan_name": "100500", "standard_charge_dollar": 771.89, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Medicare Part B Only", "plan_name": "100300", "standard_charge_dollar": 771.89, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Medicare Railroad", "plan_name": "100103", "standard_charge_dollar": 771.89, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Ms Physicians Care N", "plan_name": "714210", "standard_charge_dollar": 964.86, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Peoples Hlth Ffs 72126", "plan_name": "500019", "standard_charge_dollar": 771.89, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Uhc/Secure Horizons", "plan_name": "500449", "standard_charge_dollar": 771.89, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "United Health Care/", "plan_name": "500292", "standard_charge_dollar": 872.23, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "United Healthcare", "plan_name": "750104", "standard_charge_dollar": 872.23, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "United Healthcare Ba", "plan_name": "750090", "standard_charge_dollar": 872.23, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "United Healthcare Me", "plan_name": "501310", "standard_charge_dollar": 771.89, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Windsor Mcare Extra", "plan_name": "500778", "standard_charge_dollar": 771.89, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." } ] } ] }, { "description": "X-ray exam chest 1 view", "code_information": [ { "code": "71045", "type": "CPT" } ], "standard_charges": [ { "gross_charge": 100.00, "minimum": 91.20, "maximum": 964.86, "setting": "both", "payers_information": [ { "payer_name": "Aarp", "plan_name": "500102", "standard_charge_dollar": 771.89, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna", "plan_name": "700700", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna", "plan_name": "700700_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Mcare Ffs 6005", "plan_name": "700703", "standard_charge_dollar": 771.89, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Miscellaneous", "plan_name": "700720", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Miscellaneous", "plan_name": "700720_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Ppo Hmo", "plan_name": "701720", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Ppo Hmo", "plan_name": "701720_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Ambetter 68069", "plan_name": "500516", "standard_charge_dollar": 771.89, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Ms State Emplo", "plan_name": "401457", "standard_charge_dollar": 91.20, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Ms State Emplo", "plan_name": "401457_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Basic Pl", "plan_name": "400100", "standard_charge_dollar": 91.20, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Basic Pl", "plan_name": "400100_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Federal", "plan_name": "400110", "standard_charge_dollar": 91.20, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Federal", "plan_name": "400110_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Cigna Healthsprings Ffs", "plan_name": "500064", "standard_charge_dollar": 771.89, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Conseco", "plan_name": "500302", "standard_charge_dollar": 771.89, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Humana Ffs 61101", "plan_name": "500006", "standard_charge_dollar": 771.89, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Medicare A", "plan_name": "100100", "standard_charge_dollar": 771.89, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Medicare A", "plan_name": "100500", "standard_charge_dollar": 771.89, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Medicare Part B Only", "plan_name": "100300", "standard_charge_dollar": 771.89, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Medicare Railroad", "plan_name": "100103", "standard_charge_dollar": 771.89, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Ms Physicians Care N", "plan_name": "714210", "standard_charge_dollar": 964.86, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Peoples Hlth Ffs 72126", "plan_name": "500019", "standard_charge_dollar": 771.89, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Uhc/Secure Horizons", "plan_name": "500449", "standard_charge_dollar": 771.89, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "United Health Care/", "plan_name": "500292", "standard_charge_dollar": 872.23, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "United Healthcare", "plan_name": "750104", "standard_charge_dollar": 872.23, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "United Healthcare Ba", "plan_name": "750090", "standard_charge_dollar": 872.23, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "United Healthcare Me", "plan_name": "501310", "standard_charge_dollar": 771.89, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Windsor Mcare Extra", "plan_name": "500778", "standard_charge_dollar": 771.89, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." } ] } ] }, { "description": "Hc xray chest 2 views", "code_information": [ { "code": "71046", "type": "CPT" } ], "standard_charges": [ { "gross_charge": 150.00, "minimum": 91.20, "maximum": 964.86, "setting": "both", "payers_information": [ { "payer_name": "Aarp", "plan_name": "500102", "standard_charge_dollar": 771.89, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna", "plan_name": "700700", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna", "plan_name": "700700_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Mcare Ffs 6005", "plan_name": "700703", "standard_charge_dollar": 771.89, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Miscellaneous", "plan_name": "700720", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Miscellaneous", "plan_name": "700720_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Ppo Hmo", "plan_name": "701720", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Ppo Hmo", "plan_name": "701720_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Ambetter 68069", "plan_name": "500516", "standard_charge_dollar": 771.89, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Ms State Emplo", "plan_name": "401457", "standard_charge_dollar": 91.20, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Ms State Emplo", "plan_name": "401457_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Basic Pl", "plan_name": "400100", "standard_charge_dollar": 91.20, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Basic Pl", "plan_name": "400100_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Federal", "plan_name": "400110", "standard_charge_dollar": 91.20, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Federal", "plan_name": "400110_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Cigna Healthsprings Ffs", "plan_name": "500064", "standard_charge_dollar": 771.89, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Conseco", "plan_name": "500302", "standard_charge_dollar": 771.89, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Humana Ffs 61101", "plan_name": "500006", "standard_charge_dollar": 771.89, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Medicare A", "plan_name": "100100", "standard_charge_dollar": 771.89, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Medicare A", "plan_name": "100500", "standard_charge_dollar": 771.89, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Medicare Part B Only", "plan_name": "100300", "standard_charge_dollar": 771.89, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Medicare Railroad", "plan_name": "100103", "standard_charge_dollar": 771.89, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Ms Physicians Care N", "plan_name": "714210", "standard_charge_dollar": 964.86, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Peoples Hlth Ffs 72126", "plan_name": "500019", "standard_charge_dollar": 771.89, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Uhc/Secure Horizons", "plan_name": "500449", "standard_charge_dollar": 771.89, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "United Health Care/", "plan_name": "500292", "standard_charge_dollar": 872.23, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "United Healthcare", "plan_name": "750104", "standard_charge_dollar": 872.23, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "United Healthcare Ba", "plan_name": "750090", "standard_charge_dollar": 872.23, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "United Healthcare Me", "plan_name": "501310", "standard_charge_dollar": 771.89, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Windsor Mcare Extra", "plan_name": "500778", "standard_charge_dollar": 771.89, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." } ] } ] }, { "description": "X-ray exam chest 2 views", "code_information": [ { "code": "71046", "type": "CPT" } ], "standard_charges": [ { "gross_charge": 150.00, "minimum": 91.20, "maximum": 964.86, "setting": "both", "payers_information": [ { "payer_name": "Aarp", "plan_name": "500102", "standard_charge_dollar": 771.89, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna", "plan_name": "700700", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna", "plan_name": "700700_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Mcare Ffs 6005", "plan_name": "700703", "standard_charge_dollar": 771.89, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Miscellaneous", "plan_name": "700720", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Miscellaneous", "plan_name": "700720_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Ppo Hmo", "plan_name": "701720", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Ppo Hmo", "plan_name": "701720_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Ambetter 68069", "plan_name": "500516", "standard_charge_dollar": 771.89, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Ms State Emplo", "plan_name": "401457", "standard_charge_dollar": 91.20, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Ms State Emplo", "plan_name": "401457_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Basic Pl", "plan_name": "400100", "standard_charge_dollar": 91.20, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Basic Pl", "plan_name": "400100_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Federal", "plan_name": "400110", "standard_charge_dollar": 91.20, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Federal", "plan_name": "400110_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Cigna Healthsprings Ffs", "plan_name": "500064", "standard_charge_dollar": 771.89, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Conseco", "plan_name": "500302", "standard_charge_dollar": 771.89, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Humana Ffs 61101", "plan_name": "500006", "standard_charge_dollar": 771.89, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Medicare A", "plan_name": "100100", "standard_charge_dollar": 771.89, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Medicare A", "plan_name": "100500", "standard_charge_dollar": 771.89, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Medicare Part B Only", "plan_name": "100300", "standard_charge_dollar": 771.89, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Medicare Railroad", "plan_name": "100103", "standard_charge_dollar": 771.89, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Ms Physicians Care N", "plan_name": "714210", "standard_charge_dollar": 964.86, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Peoples Hlth Ffs 72126", "plan_name": "500019", "standard_charge_dollar": 771.89, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Uhc/Secure Horizons", "plan_name": "500449", "standard_charge_dollar": 771.89, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "United Health Care/", "plan_name": "500292", "standard_charge_dollar": 872.23, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "United Healthcare", "plan_name": "750104", "standard_charge_dollar": 872.23, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "United Healthcare Ba", "plan_name": "750090", "standard_charge_dollar": 872.23, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "United Healthcare Me", "plan_name": "501310", "standard_charge_dollar": 771.89, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Windsor Mcare Extra", "plan_name": "500778", "standard_charge_dollar": 771.89, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." } ] } ] }, { "description": "Hc xray chest 2 views", "code_information": [ { "code": "71046", "type": "CPT" } ], "standard_charges": [ { "gross_charge": 150.00, "minimum": 120.00, "maximum": 964.86, "setting": "both", "payers_information": [ { "payer_name": "Aarp", "plan_name": "500102", "standard_charge_dollar": 771.89, "count": "0", "methodology": "fee schedule", "modifiers": "TC", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna", "plan_name": "700700", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna", "plan_name": "700700_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Mcare Ffs 6005", "plan_name": "700703", "standard_charge_dollar": 771.89, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Miscellaneous", "plan_name": "700720", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Miscellaneous", "plan_name": "700720_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Ppo Hmo", "plan_name": "701720", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Ppo Hmo", "plan_name": "701720_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Ambetter 68069", "plan_name": "500516", "standard_charge_dollar": 771.89, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Ms State Emplo", "plan_name": "401457", "standard_charge_percentage": 0.80, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Ms State Emplo", "plan_name": "401457_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Basic Pl", "plan_name": "400100", "standard_charge_percentage": 0.85, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Basic Pl", "plan_name": "400100_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Federal", "plan_name": "400110", "standard_charge_percentage": 0.85, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Federal", "plan_name": "400110_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Cigna Healthsprings Ffs", "plan_name": "500064", "standard_charge_dollar": 771.89, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Conseco", "plan_name": "500302", "standard_charge_dollar": 771.89, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Humana Ffs 61101", "plan_name": "500006", "standard_charge_dollar": 771.89, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Medicare A", "plan_name": "100100", "standard_charge_dollar": 771.89, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Medicare A", "plan_name": "100500", "standard_charge_dollar": 771.89, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Medicare Part B Only", "plan_name": "100300", "standard_charge_dollar": 771.89, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Medicare Railroad", "plan_name": "100103", "standard_charge_dollar": 771.89, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Ms Physicians Care N", "plan_name": "714210", "standard_charge_dollar": 964.86, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Peoples Hlth Ffs 72126", "plan_name": "500019", "standard_charge_dollar": 771.89, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Uhc/Secure Horizons", "plan_name": "500449", "standard_charge_dollar": 771.89, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "United Health Care/", "plan_name": "500292", "standard_charge_dollar": 872.23, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "United Healthcare", "plan_name": "750104", "standard_charge_dollar": 872.23, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "United Healthcare Ba", "plan_name": "750090", "standard_charge_dollar": 872.23, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "United Healthcare Me", "plan_name": "501310", "standard_charge_dollar": 771.89, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Windsor Mcare Extra", "plan_name": "500778", "standard_charge_dollar": 771.89, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." } ] } ] }, { "description": "Hc xray chest 3 views", "code_information": [ { "code": "71047", "type": "CPT" } ], "standard_charges": [ { "gross_charge": 162.75, "minimum": 80.66, "maximum": 100.82, "setting": "both", "payers_information": [ { "payer_name": "Aarp", "plan_name": "500102", "standard_charge_dollar": 80.66, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna", "plan_name": "700700", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna", "plan_name": "700700_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Mcare Ffs 6005", "plan_name": "700703", "standard_charge_dollar": 80.66, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Miscellaneous", "plan_name": "700720", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Miscellaneous", "plan_name": "700720_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Ppo Hmo", "plan_name": "701720", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Ppo Hmo", "plan_name": "701720_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Ambetter 68069", "plan_name": "500516", "standard_charge_dollar": 80.66, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Ms State Emplo", "plan_name": "401457", "standard_charge_dollar": 91.20, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Ms State Emplo", "plan_name": "401457_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Basic Pl", "plan_name": "400100", "standard_charge_dollar": 91.20, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Basic Pl", "plan_name": "400100_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Federal", "plan_name": "400110", "standard_charge_dollar": 91.20, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Federal", "plan_name": "400110_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Cigna Healthsprings Ffs", "plan_name": "500064", "standard_charge_dollar": 80.66, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Conseco", "plan_name": "500302", "standard_charge_dollar": 80.66, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Humana Ffs 61101", "plan_name": "500006", "standard_charge_dollar": 80.66, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Medicare A", "plan_name": "100100", "standard_charge_dollar": 80.66, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Medicare A", "plan_name": "100500", "standard_charge_dollar": 80.66, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Medicare Part B Only", "plan_name": "100300", "standard_charge_dollar": 80.66, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Medicare Railroad", "plan_name": "100103", "standard_charge_dollar": 80.66, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Ms Physicians Care N", "plan_name": "714210", "standard_charge_dollar": 100.82, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Peoples Hlth Ffs 72126", "plan_name": "500019", "standard_charge_dollar": 80.66, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Uhc/Secure Horizons", "plan_name": "500449", "standard_charge_dollar": 80.66, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "United Health Care/", "plan_name": "500292", "standard_charge_dollar": 91.15, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "United Healthcare", "plan_name": "750104", "standard_charge_dollar": 91.15, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "United Healthcare Ba", "plan_name": "750090", "standard_charge_dollar": 91.15, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "United Healthcare Me", "plan_name": "501310", "standard_charge_dollar": 80.66, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Windsor Mcare Extra", "plan_name": "500778", "standard_charge_dollar": 80.66, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." } ] } ] }, { "description": "X-ray exam chest 3 views", "code_information": [ { "code": "71047", "type": "CPT" } ], "standard_charges": [ { "gross_charge": 162.75, "minimum": 80.66, "maximum": 100.82, "setting": "both", "payers_information": [ { "payer_name": "Aarp", "plan_name": "500102", "standard_charge_dollar": 80.66, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna", "plan_name": "700700", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna", "plan_name": "700700_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Mcare Ffs 6005", "plan_name": "700703", "standard_charge_dollar": 80.66, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Miscellaneous", "plan_name": "700720", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Miscellaneous", "plan_name": "700720_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Ppo Hmo", "plan_name": "701720", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Ppo Hmo", "plan_name": "701720_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Ambetter 68069", "plan_name": "500516", "standard_charge_dollar": 80.66, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Ms State Emplo", "plan_name": "401457", "standard_charge_dollar": 91.20, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Ms State Emplo", "plan_name": "401457_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Basic Pl", "plan_name": "400100", "standard_charge_dollar": 91.20, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Basic Pl", "plan_name": "400100_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Federal", "plan_name": "400110", "standard_charge_dollar": 91.20, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Federal", "plan_name": "400110_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Cigna Healthsprings Ffs", "plan_name": "500064", "standard_charge_dollar": 80.66, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Conseco", "plan_name": "500302", "standard_charge_dollar": 80.66, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Humana Ffs 61101", "plan_name": "500006", "standard_charge_dollar": 80.66, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Medicare A", "plan_name": "100100", "standard_charge_dollar": 80.66, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Medicare A", "plan_name": "100500", "standard_charge_dollar": 80.66, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Medicare Part B Only", "plan_name": "100300", "standard_charge_dollar": 80.66, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Medicare Railroad", "plan_name": "100103", "standard_charge_dollar": 80.66, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Ms Physicians Care N", "plan_name": "714210", "standard_charge_dollar": 100.82, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Peoples Hlth Ffs 72126", "plan_name": "500019", "standard_charge_dollar": 80.66, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Uhc/Secure Horizons", "plan_name": "500449", "standard_charge_dollar": 80.66, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "United Health Care/", "plan_name": "500292", "standard_charge_dollar": 91.15, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "United Healthcare", "plan_name": "750104", "standard_charge_dollar": 91.15, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "United Healthcare Ba", "plan_name": "750090", "standard_charge_dollar": 91.15, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "United Healthcare Me", "plan_name": "501310", "standard_charge_dollar": 80.66, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Windsor Mcare Extra", "plan_name": "500778", "standard_charge_dollar": 80.66, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." } ] } ] }, { "description": "Hc xray chest min 4 views", "code_information": [ { "code": "71048", "type": "CPT" } ], "standard_charges": [ { "gross_charge": 174.50, "minimum": 91.20, "maximum": 121.77, "setting": "both", "payers_information": [ { "payer_name": "Aarp", "plan_name": "500102", "standard_charge_dollar": 97.41, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna", "plan_name": "700700", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna", "plan_name": "700700_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Mcare Ffs 6005", "plan_name": "700703", "standard_charge_dollar": 97.41, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Miscellaneous", "plan_name": "700720", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Miscellaneous", "plan_name": "700720_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Ppo Hmo", "plan_name": "701720", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Ppo Hmo", "plan_name": "701720_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Ambetter 68069", "plan_name": "500516", "standard_charge_dollar": 97.41, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Ms State Emplo", "plan_name": "401457", "standard_charge_dollar": 91.20, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Ms State Emplo", "plan_name": "401457_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Basic Pl", "plan_name": "400100", "standard_charge_dollar": 91.20, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Basic Pl", "plan_name": "400100_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Federal", "plan_name": "400110", "standard_charge_dollar": 91.20, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Federal", "plan_name": "400110_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Cigna Healthsprings Ffs", "plan_name": "500064", "standard_charge_dollar": 97.41, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Conseco", "plan_name": "500302", "standard_charge_dollar": 97.41, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Humana Ffs 61101", "plan_name": "500006", "standard_charge_dollar": 97.41, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Medicare A", "plan_name": "100100", "standard_charge_dollar": 97.41, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Medicare A", "plan_name": "100500", "standard_charge_dollar": 97.41, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Medicare Part B Only", "plan_name": "100300", "standard_charge_dollar": 97.41, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Medicare Railroad", "plan_name": "100103", "standard_charge_dollar": 97.41, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Ms Physicians Care N", "plan_name": "714210", "standard_charge_dollar": 121.77, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Peoples Hlth Ffs 72126", "plan_name": "500019", "standard_charge_dollar": 97.41, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Uhc/Secure Horizons", "plan_name": "500449", "standard_charge_dollar": 97.41, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "United Health Care/", "plan_name": "500292", "standard_charge_dollar": 110.08, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "United Healthcare", "plan_name": "750104", "standard_charge_dollar": 110.08, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "United Healthcare Ba", "plan_name": "750090", "standard_charge_dollar": 110.08, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "United Healthcare Me", "plan_name": "501310", "standard_charge_dollar": 97.41, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Windsor Mcare Extra", "plan_name": "500778", "standard_charge_dollar": 97.41, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." } ] } ] }, { "description": "X-ray exam chest 4+ views", "code_information": [ { "code": "71048", "type": "CPT" } ], "standard_charges": [ { "gross_charge": 174.50, "minimum": 91.20, "maximum": 121.77, "setting": "both", "payers_information": [ { "payer_name": "Aarp", "plan_name": "500102", "standard_charge_dollar": 97.41, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna", "plan_name": "700700", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna", "plan_name": "700700_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Mcare Ffs 6005", "plan_name": "700703", "standard_charge_dollar": 97.41, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Miscellaneous", "plan_name": "700720", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Miscellaneous", "plan_name": "700720_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Ppo Hmo", "plan_name": "701720", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Ppo Hmo", "plan_name": "701720_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Ambetter 68069", "plan_name": "500516", "standard_charge_dollar": 97.41, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Ms State Emplo", "plan_name": "401457", "standard_charge_dollar": 91.20, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Ms State Emplo", "plan_name": "401457_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Basic Pl", "plan_name": "400100", "standard_charge_dollar": 91.20, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Basic Pl", "plan_name": "400100_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Federal", "plan_name": "400110", "standard_charge_dollar": 91.20, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Federal", "plan_name": "400110_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Cigna Healthsprings Ffs", "plan_name": "500064", "standard_charge_dollar": 97.41, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Conseco", "plan_name": "500302", "standard_charge_dollar": 97.41, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Humana Ffs 61101", "plan_name": "500006", "standard_charge_dollar": 97.41, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Medicare A", "plan_name": "100100", "standard_charge_dollar": 97.41, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Medicare A", "plan_name": "100500", "standard_charge_dollar": 97.41, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Medicare Part B Only", "plan_name": "100300", "standard_charge_dollar": 97.41, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Medicare Railroad", "plan_name": "100103", "standard_charge_dollar": 97.41, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Ms Physicians Care N", "plan_name": "714210", "standard_charge_dollar": 121.77, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Peoples Hlth Ffs 72126", "plan_name": "500019", "standard_charge_dollar": 97.41, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Uhc/Secure Horizons", "plan_name": "500449", "standard_charge_dollar": 97.41, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "United Health Care/", "plan_name": "500292", "standard_charge_dollar": 110.08, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "United Healthcare", "plan_name": "750104", "standard_charge_dollar": 110.08, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "United Healthcare Ba", "plan_name": "750090", "standard_charge_dollar": 110.08, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "United Healthcare Me", "plan_name": "501310", "standard_charge_dollar": 97.41, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Windsor Mcare Extra", "plan_name": "500778", "standard_charge_dollar": 97.41, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." } ] } ] }, { "description": "Hc ribs unilateral 2 view", "code_information": [ { "code": "71100", "type": "CPT" } ], "standard_charges": [ { "gross_charge": 175.00, "minimum": 80.66, "maximum": 100.82, "setting": "both", "payers_information": [ { "payer_name": "Aarp", "plan_name": "500102", "standard_charge_dollar": 80.66, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna", "plan_name": "700700", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna", "plan_name": "700700_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Mcare Ffs 6005", "plan_name": "700703", "standard_charge_dollar": 80.66, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Miscellaneous", "plan_name": "700720", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Miscellaneous", "plan_name": "700720_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Ppo Hmo", "plan_name": "701720", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Ppo Hmo", "plan_name": "701720_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Ambetter 68069", "plan_name": "500516", "standard_charge_dollar": 80.66, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Ms State Emplo", "plan_name": "401457", "standard_charge_dollar": 91.20, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Ms State Emplo", "plan_name": "401457_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Basic Pl", "plan_name": "400100", "standard_charge_dollar": 91.20, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Basic Pl", "plan_name": "400100_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Federal", "plan_name": "400110", "standard_charge_dollar": 91.20, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Federal", "plan_name": "400110_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Cigna Healthsprings Ffs", "plan_name": "500064", "standard_charge_dollar": 80.66, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Conseco", "plan_name": "500302", "standard_charge_dollar": 80.66, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Humana Ffs 61101", "plan_name": "500006", "standard_charge_dollar": 80.66, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Medicare A", "plan_name": "100100", "standard_charge_dollar": 80.66, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Medicare A", "plan_name": "100500", "standard_charge_dollar": 80.66, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Medicare Part B Only", "plan_name": "100300", "standard_charge_dollar": 80.66, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Medicare Railroad", "plan_name": "100103", "standard_charge_dollar": 80.66, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Ms Physicians Care N", "plan_name": "714210", "standard_charge_dollar": 100.82, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Peoples Hlth Ffs 72126", "plan_name": "500019", "standard_charge_dollar": 80.66, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Uhc/Secure Horizons", "plan_name": "500449", "standard_charge_dollar": 80.66, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "United Health Care/", "plan_name": "500292", "standard_charge_dollar": 91.15, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "United Healthcare", "plan_name": "750104", "standard_charge_dollar": 91.15, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "United Healthcare Ba", "plan_name": "750090", "standard_charge_dollar": 91.15, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "United Healthcare Me", "plan_name": "501310", "standard_charge_dollar": 80.66, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Windsor Mcare Extra", "plan_name": "500778", "standard_charge_dollar": 80.66, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." } ] } ] }, { "description": "X-ray exam ribs uni 2 views", "code_information": [ { "code": "71100", "type": "CPT" } ], "standard_charges": [ { "gross_charge": 175.00, "minimum": 80.66, "maximum": 100.82, "setting": "both", "payers_information": [ { "payer_name": "Aarp", "plan_name": "500102", "standard_charge_dollar": 80.66, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna", "plan_name": "700700", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna", "plan_name": "700700_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Mcare Ffs 6005", "plan_name": "700703", "standard_charge_dollar": 80.66, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Miscellaneous", "plan_name": "700720", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Miscellaneous", "plan_name": "700720_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Ppo Hmo", "plan_name": "701720", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Ppo Hmo", "plan_name": "701720_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Ambetter 68069", "plan_name": "500516", "standard_charge_dollar": 80.66, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Ms State Emplo", "plan_name": "401457", "standard_charge_dollar": 91.20, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Ms State Emplo", "plan_name": "401457_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Basic Pl", "plan_name": "400100", "standard_charge_dollar": 91.20, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Basic Pl", "plan_name": "400100_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Federal", "plan_name": "400110", "standard_charge_dollar": 91.20, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Federal", "plan_name": "400110_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Cigna Healthsprings Ffs", "plan_name": "500064", "standard_charge_dollar": 80.66, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Conseco", "plan_name": "500302", "standard_charge_dollar": 80.66, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Humana Ffs 61101", "plan_name": "500006", "standard_charge_dollar": 80.66, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Medicare A", "plan_name": "100100", "standard_charge_dollar": 80.66, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Medicare A", "plan_name": "100500", "standard_charge_dollar": 80.66, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Medicare Part B Only", "plan_name": "100300", "standard_charge_dollar": 80.66, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Medicare Railroad", "plan_name": "100103", "standard_charge_dollar": 80.66, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Ms Physicians Care N", "plan_name": "714210", "standard_charge_dollar": 100.82, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Peoples Hlth Ffs 72126", "plan_name": "500019", "standard_charge_dollar": 80.66, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Uhc/Secure Horizons", "plan_name": "500449", "standard_charge_dollar": 80.66, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "United Health Care/", "plan_name": "500292", "standard_charge_dollar": 91.15, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "United Healthcare", "plan_name": "750104", "standard_charge_dollar": 91.15, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "United Healthcare Ba", "plan_name": "750090", "standard_charge_dollar": 91.15, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "United Healthcare Me", "plan_name": "501310", "standard_charge_dollar": 80.66, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Windsor Mcare Extra", "plan_name": "500778", "standard_charge_dollar": 80.66, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." } ] } ] }, { "description": "Hc ribs bilateral 3 view", "code_information": [ { "code": "71110", "type": "CPT" } ], "standard_charges": [ { "gross_charge": 275.00, "minimum": 97.41, "maximum": 151.04, "setting": "both", "payers_information": [ { "payer_name": "Aarp", "plan_name": "500102", "standard_charge_dollar": 97.41, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna", "plan_name": "700700", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna", "plan_name": "700700_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Mcare Ffs 6005", "plan_name": "700703", "standard_charge_dollar": 97.41, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Miscellaneous", "plan_name": "700720", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Miscellaneous", "plan_name": "700720_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Ppo Hmo", "plan_name": "701720", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Ppo Hmo", "plan_name": "701720_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Ambetter 68069", "plan_name": "500516", "standard_charge_dollar": 97.41, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Ms State Emplo", "plan_name": "401457", "standard_charge_dollar": 151.04, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Ms State Emplo", "plan_name": "401457_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Basic Pl", "plan_name": "400100", "standard_charge_dollar": 151.04, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Basic Pl", "plan_name": "400100_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Federal", "plan_name": "400110", "standard_charge_dollar": 151.04, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Federal", "plan_name": "400110_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Cigna Healthsprings Ffs", "plan_name": "500064", "standard_charge_dollar": 97.41, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Conseco", "plan_name": "500302", "standard_charge_dollar": 97.41, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Humana Ffs 61101", "plan_name": "500006", "standard_charge_dollar": 97.41, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Medicare A", "plan_name": "100100", "standard_charge_dollar": 97.41, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Medicare A", "plan_name": "100500", "standard_charge_dollar": 97.41, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Medicare Part B Only", "plan_name": "100300", "standard_charge_dollar": 97.41, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Medicare Railroad", "plan_name": "100103", "standard_charge_dollar": 97.41, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Ms Physicians Care N", "plan_name": "714210", "standard_charge_dollar": 121.77, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Peoples Hlth Ffs 72126", "plan_name": "500019", "standard_charge_dollar": 97.41, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Uhc/Secure Horizons", "plan_name": "500449", "standard_charge_dollar": 97.41, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "United Health Care/", "plan_name": "500292", "standard_charge_dollar": 110.08, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "United Healthcare", "plan_name": "750104", "standard_charge_dollar": 110.08, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "United Healthcare Ba", "plan_name": "750090", "standard_charge_dollar": 110.08, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "United Healthcare Me", "plan_name": "501310", "standard_charge_dollar": 97.41, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Windsor Mcare Extra", "plan_name": "500778", "standard_charge_dollar": 97.41, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." } ] } ] }, { "description": "X-ray exam ribs bil 3 views", "code_information": [ { "code": "71110", "type": "CPT" } ], "standard_charges": [ { "gross_charge": 275.00, "minimum": 97.41, "maximum": 151.04, "setting": "both", "payers_information": [ { "payer_name": "Aarp", "plan_name": "500102", "standard_charge_dollar": 97.41, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna", "plan_name": "700700", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna", "plan_name": "700700_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Mcare Ffs 6005", "plan_name": "700703", "standard_charge_dollar": 97.41, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Miscellaneous", "plan_name": "700720", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Miscellaneous", "plan_name": "700720_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Ppo Hmo", "plan_name": "701720", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Ppo Hmo", "plan_name": "701720_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Ambetter 68069", "plan_name": "500516", "standard_charge_dollar": 97.41, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Ms State Emplo", "plan_name": "401457", "standard_charge_dollar": 151.04, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Ms State Emplo", "plan_name": "401457_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Basic Pl", "plan_name": "400100", "standard_charge_dollar": 151.04, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Basic Pl", "plan_name": "400100_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Federal", "plan_name": "400110", "standard_charge_dollar": 151.04, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Federal", "plan_name": "400110_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Cigna Healthsprings Ffs", "plan_name": "500064", "standard_charge_dollar": 97.41, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Conseco", "plan_name": "500302", "standard_charge_dollar": 97.41, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Humana Ffs 61101", "plan_name": "500006", "standard_charge_dollar": 97.41, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Medicare A", "plan_name": "100100", "standard_charge_dollar": 97.41, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Medicare A", "plan_name": "100500", "standard_charge_dollar": 97.41, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Medicare Part B Only", "plan_name": "100300", "standard_charge_dollar": 97.41, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Medicare Railroad", "plan_name": "100103", "standard_charge_dollar": 97.41, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Ms Physicians Care N", "plan_name": "714210", "standard_charge_dollar": 121.77, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Peoples Hlth Ffs 72126", "plan_name": "500019", "standard_charge_dollar": 97.41, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Uhc/Secure Horizons", "plan_name": "500449", "standard_charge_dollar": 97.41, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "United Health Care/", "plan_name": "500292", "standard_charge_dollar": 110.08, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "United Healthcare", "plan_name": "750104", "standard_charge_dollar": 110.08, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "United Healthcare Ba", "plan_name": "750090", "standard_charge_dollar": 110.08, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "United Healthcare Me", "plan_name": "501310", "standard_charge_dollar": 97.41, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Windsor Mcare Extra", "plan_name": "500778", "standard_charge_dollar": 97.41, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." } ] } ] }, { "description": "Ct thorax w/o dye", "code_information": [ { "code": "71250", "type": "CPT" } ], "standard_charges": [ { "gross_charge": 1021.50, "minimum": 168.74, "maximum": 257.13, "setting": "both", "payers_information": [ { "payer_name": "Aarp", "plan_name": "500102", "standard_charge_dollar": 205.70, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna", "plan_name": "700700", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna", "plan_name": "700700_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Mcare Ffs 6005", "plan_name": "700703", "standard_charge_dollar": 205.70, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Miscellaneous", "plan_name": "700720", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Miscellaneous", "plan_name": "700720_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Ppo Hmo", "plan_name": "701720", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Ppo Hmo", "plan_name": "701720_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Ambetter 68069", "plan_name": "500516", "standard_charge_dollar": 205.70, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Ms State Emplo", "plan_name": "401457", "standard_charge_dollar": 168.74, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Ms State Emplo", "plan_name": "401457_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Basic Pl", "plan_name": "400100", "standard_charge_dollar": 168.74, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Basic Pl", "plan_name": "400100_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Federal", "plan_name": "400110", "standard_charge_dollar": 168.74, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Federal", "plan_name": "400110_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Cigna Healthsprings Ffs", "plan_name": "500064", "standard_charge_dollar": 205.70, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Conseco", "plan_name": "500302", "standard_charge_dollar": 205.70, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Humana Ffs 61101", "plan_name": "500006", "standard_charge_dollar": 205.70, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Medicare A", "plan_name": "100100", "standard_charge_dollar": 205.70, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Medicare A", "plan_name": "100500", "standard_charge_dollar": 205.70, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Medicare Part B Only", "plan_name": "100300", "standard_charge_dollar": 205.70, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Medicare Railroad", "plan_name": "100103", "standard_charge_dollar": 205.70, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Ms Physicians Care N", "plan_name": "714210", "standard_charge_dollar": 257.13, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Peoples Hlth Ffs 72126", "plan_name": "500019", "standard_charge_dollar": 205.70, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Uhc/Secure Horizons", "plan_name": "500449", "standard_charge_dollar": 205.70, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "United Health Care/", "plan_name": "500292", "standard_charge_dollar": 232.44, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "United Healthcare", "plan_name": "750104", "standard_charge_dollar": 232.44, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "United Healthcare Ba", "plan_name": "750090", "standard_charge_dollar": 232.44, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "United Healthcare Me", "plan_name": "501310", "standard_charge_dollar": 205.70, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Windsor Mcare Extra", "plan_name": "500778", "standard_charge_dollar": 205.70, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." } ] } ] }, { "description": "Hc ct thorax w/o contrast", "code_information": [ { "code": "71250", "type": "CPT" } ], "standard_charges": [ { "gross_charge": 1021.50, "minimum": 168.74, "maximum": 257.13, "setting": "both", "payers_information": [ { "payer_name": "Aarp", "plan_name": "500102", "standard_charge_dollar": 205.70, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna", "plan_name": "700700", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna", "plan_name": "700700_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Mcare Ffs 6005", "plan_name": "700703", "standard_charge_dollar": 205.70, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Miscellaneous", "plan_name": "700720", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Miscellaneous", "plan_name": "700720_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Ppo Hmo", "plan_name": "701720", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Ppo Hmo", "plan_name": "701720_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Ambetter 68069", "plan_name": "500516", "standard_charge_dollar": 205.70, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Ms State Emplo", "plan_name": "401457", "standard_charge_dollar": 168.74, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Ms State Emplo", "plan_name": "401457_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Basic Pl", "plan_name": "400100", "standard_charge_dollar": 168.74, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Basic Pl", "plan_name": "400100_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Federal", "plan_name": "400110", "standard_charge_dollar": 168.74, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Federal", "plan_name": "400110_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Cigna Healthsprings Ffs", "plan_name": "500064", "standard_charge_dollar": 205.70, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Conseco", "plan_name": "500302", "standard_charge_dollar": 205.70, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Humana Ffs 61101", "plan_name": "500006", "standard_charge_dollar": 205.70, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Medicare A", "plan_name": "100100", "standard_charge_dollar": 205.70, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Medicare A", "plan_name": "100500", "standard_charge_dollar": 205.70, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Medicare Part B Only", "plan_name": "100300", "standard_charge_dollar": 205.70, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Medicare Railroad", "plan_name": "100103", "standard_charge_dollar": 205.70, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Ms Physicians Care N", "plan_name": "714210", "standard_charge_dollar": 257.13, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Peoples Hlth Ffs 72126", "plan_name": "500019", "standard_charge_dollar": 205.70, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Uhc/Secure Horizons", "plan_name": "500449", "standard_charge_dollar": 205.70, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "United Health Care/", "plan_name": "500292", "standard_charge_dollar": 232.44, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "United Healthcare", "plan_name": "750104", "standard_charge_dollar": 232.44, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "United Healthcare Ba", "plan_name": "750090", "standard_charge_dollar": 232.44, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "United Healthcare Me", "plan_name": "501310", "standard_charge_dollar": 205.70, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Windsor Mcare Extra", "plan_name": "500778", "standard_charge_dollar": 205.70, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." } ] } ] }, { "description": "Ct thorax w/dye", "code_information": [ { "code": "71260", "type": "CPT" } ], "standard_charges": [ { "gross_charge": 1450.00, "minimum": 355.29, "maximum": 498.25, "setting": "both", "payers_information": [ { "payer_name": "Aarp", "plan_name": "500102", "standard_charge_dollar": 398.60, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna", "plan_name": "700700", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna", "plan_name": "700700_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Mcare Ffs 6005", "plan_name": "700703", "standard_charge_dollar": 398.60, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Miscellaneous", "plan_name": "700720", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Miscellaneous", "plan_name": "700720_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Ppo Hmo", "plan_name": "701720", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Ppo Hmo", "plan_name": "701720_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Ambetter 68069", "plan_name": "500516", "standard_charge_dollar": 398.60, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Ms State Emplo", "plan_name": "401457", "standard_charge_dollar": 355.29, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Ms State Emplo", "plan_name": "401457_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Basic Pl", "plan_name": "400100", "standard_charge_dollar": 355.29, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Basic Pl", "plan_name": "400100_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Federal", "plan_name": "400110", "standard_charge_dollar": 355.29, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Federal", "plan_name": "400110_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Cigna Healthsprings Ffs", "plan_name": "500064", "standard_charge_dollar": 398.60, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Conseco", "plan_name": "500302", "standard_charge_dollar": 398.60, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Humana Ffs 61101", "plan_name": "500006", "standard_charge_dollar": 398.60, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Medicare A", "plan_name": "100100", "standard_charge_dollar": 398.60, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Medicare A", "plan_name": "100500", "standard_charge_dollar": 398.60, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Medicare Part B Only", "plan_name": "100300", "standard_charge_dollar": 398.60, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Medicare Railroad", "plan_name": "100103", "standard_charge_dollar": 398.60, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Ms Physicians Care N", "plan_name": "714210", "standard_charge_dollar": 498.25, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Peoples Hlth Ffs 72126", "plan_name": "500019", "standard_charge_dollar": 398.60, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Uhc/Secure Horizons", "plan_name": "500449", "standard_charge_dollar": 398.60, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "United Health Care/", "plan_name": "500292", "standard_charge_dollar": 450.42, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "United Healthcare", "plan_name": "750104", "standard_charge_dollar": 450.42, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "United Healthcare Ba", "plan_name": "750090", "standard_charge_dollar": 450.42, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "United Healthcare Me", "plan_name": "501310", "standard_charge_dollar": 398.60, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Windsor Mcare Extra", "plan_name": "500778", "standard_charge_dollar": 398.60, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." } ] } ] }, { "description": "Hc ct thorax w/contrast", "code_information": [ { "code": "71260", "type": "CPT" } ], "standard_charges": [ { "gross_charge": 1450.00, "minimum": 355.29, "maximum": 498.25, "setting": "both", "payers_information": [ { "payer_name": "Aarp", "plan_name": "500102", "standard_charge_dollar": 398.60, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna", "plan_name": "700700", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna", "plan_name": "700700_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Mcare Ffs 6005", "plan_name": "700703", "standard_charge_dollar": 398.60, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Miscellaneous", "plan_name": "700720", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Miscellaneous", "plan_name": "700720_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Ppo Hmo", "plan_name": "701720", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Ppo Hmo", "plan_name": "701720_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Ambetter 68069", "plan_name": "500516", "standard_charge_dollar": 398.60, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Ms State Emplo", "plan_name": "401457", "standard_charge_dollar": 355.29, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Ms State Emplo", "plan_name": "401457_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Basic Pl", "plan_name": "400100", "standard_charge_dollar": 355.29, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Basic Pl", "plan_name": "400100_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Federal", "plan_name": "400110", "standard_charge_dollar": 355.29, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Federal", "plan_name": "400110_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Cigna Healthsprings Ffs", "plan_name": "500064", "standard_charge_dollar": 398.60, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Conseco", "plan_name": "500302", "standard_charge_dollar": 398.60, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Humana Ffs 61101", "plan_name": "500006", "standard_charge_dollar": 398.60, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Medicare A", "plan_name": "100100", "standard_charge_dollar": 398.60, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Medicare A", "plan_name": "100500", "standard_charge_dollar": 398.60, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Medicare Part B Only", "plan_name": "100300", "standard_charge_dollar": 398.60, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Medicare Railroad", "plan_name": "100103", "standard_charge_dollar": 398.60, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Ms Physicians Care N", "plan_name": "714210", "standard_charge_dollar": 498.25, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Peoples Hlth Ffs 72126", "plan_name": "500019", "standard_charge_dollar": 398.60, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Uhc/Secure Horizons", "plan_name": "500449", "standard_charge_dollar": 398.60, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "United Health Care/", "plan_name": "500292", "standard_charge_dollar": 450.42, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "United Healthcare", "plan_name": "750104", "standard_charge_dollar": 450.42, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "United Healthcare Ba", "plan_name": "750090", "standard_charge_dollar": 450.42, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "United Healthcare Me", "plan_name": "501310", "standard_charge_dollar": 398.60, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Windsor Mcare Extra", "plan_name": "500778", "standard_charge_dollar": 398.60, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." } ] } ] }, { "description": "Ct angiography chest", "code_information": [ { "code": "71275", "type": "CPT" } ], "standard_charges": [ { "gross_charge": 1450.00, "minimum": 355.29, "maximum": 498.25, "setting": "both", "payers_information": [ { "payer_name": "Aarp", "plan_name": "500102", "standard_charge_dollar": 398.60, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna", "plan_name": "700700", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna", "plan_name": "700700_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Mcare Ffs 6005", "plan_name": "700703", "standard_charge_dollar": 398.60, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Miscellaneous", "plan_name": "700720", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Miscellaneous", "plan_name": "700720_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Ppo Hmo", "plan_name": "701720", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Ppo Hmo", "plan_name": "701720_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Ambetter 68069", "plan_name": "500516", "standard_charge_dollar": 398.60, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Ms State Emplo", "plan_name": "401457", "standard_charge_dollar": 355.29, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Ms State Emplo", "plan_name": "401457_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Basic Pl", "plan_name": "400100", "standard_charge_dollar": 355.29, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Basic Pl", "plan_name": "400100_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Federal", "plan_name": "400110", "standard_charge_dollar": 355.29, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Federal", "plan_name": "400110_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Cigna Healthsprings Ffs", "plan_name": "500064", "standard_charge_dollar": 398.60, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Conseco", "plan_name": "500302", "standard_charge_dollar": 398.60, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Humana Ffs 61101", "plan_name": "500006", "standard_charge_dollar": 398.60, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Medicare A", "plan_name": "100100", "standard_charge_dollar": 398.60, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Medicare A", "plan_name": "100500", "standard_charge_dollar": 398.60, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Medicare Part B Only", "plan_name": "100300", "standard_charge_dollar": 398.60, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Medicare Railroad", "plan_name": "100103", "standard_charge_dollar": 398.60, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Ms Physicians Care N", "plan_name": "714210", "standard_charge_dollar": 498.25, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Peoples Hlth Ffs 72126", "plan_name": "500019", "standard_charge_dollar": 398.60, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Uhc/Secure Horizons", "plan_name": "500449", "standard_charge_dollar": 398.60, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "United Health Care/", "plan_name": "500292", "standard_charge_dollar": 450.42, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "United Healthcare", "plan_name": "750104", "standard_charge_dollar": 450.42, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "United Healthcare Ba", "plan_name": "750090", "standard_charge_dollar": 450.42, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "United Healthcare Me", "plan_name": "501310", "standard_charge_dollar": 398.60, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Windsor Mcare Extra", "plan_name": "500778", "standard_charge_dollar": 398.60, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." } ] } ] }, { "description": "Hc ct chest angiography", "code_information": [ { "code": "71275", "type": "CPT" } ], "standard_charges": [ { "gross_charge": 1450.00, "minimum": 355.29, "maximum": 498.25, "setting": "both", "payers_information": [ { "payer_name": "Aarp", "plan_name": "500102", "standard_charge_dollar": 398.60, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna", "plan_name": "700700", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna", "plan_name": "700700_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Mcare Ffs 6005", "plan_name": "700703", "standard_charge_dollar": 398.60, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Miscellaneous", "plan_name": "700720", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Miscellaneous", "plan_name": "700720_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Ppo Hmo", "plan_name": "701720", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Ppo Hmo", "plan_name": "701720_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Ambetter 68069", "plan_name": "500516", "standard_charge_dollar": 398.60, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Ms State Emplo", "plan_name": "401457", "standard_charge_dollar": 355.29, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Ms State Emplo", "plan_name": "401457_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Basic Pl", "plan_name": "400100", "standard_charge_dollar": 355.29, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Basic Pl", "plan_name": "400100_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Federal", "plan_name": "400110", "standard_charge_dollar": 355.29, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Federal", "plan_name": "400110_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Cigna Healthsprings Ffs", "plan_name": "500064", "standard_charge_dollar": 398.60, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Conseco", "plan_name": "500302", "standard_charge_dollar": 398.60, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Humana Ffs 61101", "plan_name": "500006", "standard_charge_dollar": 398.60, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Medicare A", "plan_name": "100100", "standard_charge_dollar": 398.60, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Medicare A", "plan_name": "100500", "standard_charge_dollar": 398.60, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Medicare Part B Only", "plan_name": "100300", "standard_charge_dollar": 398.60, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Medicare Railroad", "plan_name": "100103", "standard_charge_dollar": 398.60, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Ms Physicians Care N", "plan_name": "714210", "standard_charge_dollar": 498.25, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Peoples Hlth Ffs 72126", "plan_name": "500019", "standard_charge_dollar": 398.60, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Uhc/Secure Horizons", "plan_name": "500449", "standard_charge_dollar": 398.60, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "United Health Care/", "plan_name": "500292", "standard_charge_dollar": 450.42, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "United Healthcare", "plan_name": "750104", "standard_charge_dollar": 450.42, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "United Healthcare Ba", "plan_name": "750090", "standard_charge_dollar": 450.42, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "United Healthcare Me", "plan_name": "501310", "standard_charge_dollar": 398.60, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Windsor Mcare Extra", "plan_name": "500778", "standard_charge_dollar": 398.60, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." } ] } ] }, { "description": "Hc spine single view", "code_information": [ { "code": "72020", "type": "CPT" } ], "standard_charges": [ { "gross_charge": 185.00, "minimum": 80.66, "maximum": 100.82, "setting": "both", "payers_information": [ { "payer_name": "Aarp", "plan_name": "500102", "standard_charge_dollar": 80.66, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna", "plan_name": "700700", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna", "plan_name": "700700_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Mcare Ffs 6005", "plan_name": "700703", "standard_charge_dollar": 80.66, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Miscellaneous", "plan_name": "700720", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Miscellaneous", "plan_name": "700720_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Ppo Hmo", "plan_name": "701720", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Ppo Hmo", "plan_name": "701720_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Ambetter 68069", "plan_name": "500516", "standard_charge_dollar": 80.66, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Ms State Emplo", "plan_name": "401457", "standard_charge_dollar": 91.20, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Ms State Emplo", "plan_name": "401457_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Basic Pl", "plan_name": "400100", "standard_charge_dollar": 91.20, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Basic Pl", "plan_name": "400100_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Federal", "plan_name": "400110", "standard_charge_dollar": 91.20, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Federal", "plan_name": "400110_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Cigna Healthsprings Ffs", "plan_name": "500064", "standard_charge_dollar": 80.66, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Conseco", "plan_name": "500302", "standard_charge_dollar": 80.66, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Humana Ffs 61101", "plan_name": "500006", "standard_charge_dollar": 80.66, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Medicare A", "plan_name": "100100", "standard_charge_dollar": 80.66, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Medicare A", "plan_name": "100500", "standard_charge_dollar": 80.66, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Medicare Part B Only", "plan_name": "100300", "standard_charge_dollar": 80.66, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Medicare Railroad", "plan_name": "100103", "standard_charge_dollar": 80.66, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Ms Physicians Care N", "plan_name": "714210", "standard_charge_dollar": 100.82, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Peoples Hlth Ffs 72126", "plan_name": "500019", "standard_charge_dollar": 80.66, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Uhc/Secure Horizons", "plan_name": "500449", "standard_charge_dollar": 80.66, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "United Health Care/", "plan_name": "500292", "standard_charge_dollar": 91.15, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "United Healthcare", "plan_name": "750104", "standard_charge_dollar": 91.15, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "United Healthcare Ba", "plan_name": "750090", "standard_charge_dollar": 91.15, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "United Healthcare Me", "plan_name": "501310", "standard_charge_dollar": 80.66, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Windsor Mcare Extra", "plan_name": "500778", "standard_charge_dollar": 80.66, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." } ] } ] }, { "description": "X-ray exam of spine 1 view", "code_information": [ { "code": "72020", "type": "CPT" } ], "standard_charges": [ { "gross_charge": 185.00, "minimum": 80.66, "maximum": 100.82, "setting": "both", "payers_information": [ { "payer_name": "Aarp", "plan_name": "500102", "standard_charge_dollar": 80.66, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna", "plan_name": "700700", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna", "plan_name": "700700_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Mcare Ffs 6005", "plan_name": "700703", "standard_charge_dollar": 80.66, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Miscellaneous", "plan_name": "700720", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Miscellaneous", "plan_name": "700720_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Ppo Hmo", "plan_name": "701720", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Ppo Hmo", "plan_name": "701720_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Ambetter 68069", "plan_name": "500516", "standard_charge_dollar": 80.66, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Ms State Emplo", "plan_name": "401457", "standard_charge_dollar": 91.20, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Ms State Emplo", "plan_name": "401457_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Basic Pl", "plan_name": "400100", "standard_charge_dollar": 91.20, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Basic Pl", "plan_name": "400100_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Federal", "plan_name": "400110", "standard_charge_dollar": 91.20, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Federal", "plan_name": "400110_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Cigna Healthsprings Ffs", "plan_name": "500064", "standard_charge_dollar": 80.66, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Conseco", "plan_name": "500302", "standard_charge_dollar": 80.66, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Humana Ffs 61101", "plan_name": "500006", "standard_charge_dollar": 80.66, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Medicare A", "plan_name": "100100", "standard_charge_dollar": 80.66, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Medicare A", "plan_name": "100500", "standard_charge_dollar": 80.66, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Medicare Part B Only", "plan_name": "100300", "standard_charge_dollar": 80.66, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Medicare Railroad", "plan_name": "100103", "standard_charge_dollar": 80.66, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Ms Physicians Care N", "plan_name": "714210", "standard_charge_dollar": 100.82, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Peoples Hlth Ffs 72126", "plan_name": "500019", "standard_charge_dollar": 80.66, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Uhc/Secure Horizons", "plan_name": "500449", "standard_charge_dollar": 80.66, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "United Health Care/", "plan_name": "500292", "standard_charge_dollar": 91.15, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "United Healthcare", "plan_name": "750104", "standard_charge_dollar": 91.15, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "United Healthcare Ba", "plan_name": "750090", "standard_charge_dollar": 91.15, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "United Healthcare Me", "plan_name": "501310", "standard_charge_dollar": 80.66, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Windsor Mcare Extra", "plan_name": "500778", "standard_charge_dollar": 80.66, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." } ] } ] }, { "description": "Hc spine cervical 2 or 3 view", "code_information": [ { "code": "72040", "type": "CPT" } ], "standard_charges": [ { "gross_charge": 275.00, "minimum": 80.66, "maximum": 151.04, "setting": "both", "payers_information": [ { "payer_name": "Aarp", "plan_name": "500102", "standard_charge_dollar": 80.66, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna", "plan_name": "700700", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna", "plan_name": "700700_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Mcare Ffs 6005", "plan_name": "700703", "standard_charge_dollar": 80.66, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Miscellaneous", "plan_name": "700720", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Miscellaneous", "plan_name": "700720_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Ppo Hmo", "plan_name": "701720", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Ppo Hmo", "plan_name": "701720_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Ambetter 68069", "plan_name": "500516", "standard_charge_dollar": 80.66, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Ms State Emplo", "plan_name": "401457", "standard_charge_dollar": 151.04, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Ms State Emplo", "plan_name": "401457_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Basic Pl", "plan_name": "400100", "standard_charge_dollar": 151.04, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Basic Pl", "plan_name": "400100_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Federal", "plan_name": "400110", "standard_charge_dollar": 151.04, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Federal", "plan_name": "400110_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Cigna Healthsprings Ffs", "plan_name": "500064", "standard_charge_dollar": 80.66, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Conseco", "plan_name": "500302", "standard_charge_dollar": 80.66, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Humana Ffs 61101", "plan_name": "500006", "standard_charge_dollar": 80.66, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Medicare A", "plan_name": "100100", "standard_charge_dollar": 80.66, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Medicare A", "plan_name": "100500", "standard_charge_dollar": 80.66, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Medicare Part B Only", "plan_name": "100300", "standard_charge_dollar": 80.66, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Medicare Railroad", "plan_name": "100103", "standard_charge_dollar": 80.66, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Ms Physicians Care N", "plan_name": "714210", "standard_charge_dollar": 100.82, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Peoples Hlth Ffs 72126", "plan_name": "500019", "standard_charge_dollar": 80.66, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Uhc/Secure Horizons", "plan_name": "500449", "standard_charge_dollar": 80.66, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "United Health Care/", "plan_name": "500292", "standard_charge_dollar": 91.15, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "United Healthcare", "plan_name": "750104", "standard_charge_dollar": 91.15, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "United Healthcare Ba", "plan_name": "750090", "standard_charge_dollar": 91.15, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "United Healthcare Me", "plan_name": "501310", "standard_charge_dollar": 80.66, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Windsor Mcare Extra", "plan_name": "500778", "standard_charge_dollar": 80.66, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." } ] } ] }, { "description": "X-ray exam neck spine 2-3 vw", "code_information": [ { "code": "72040", "type": "CPT" } ], "standard_charges": [ { "gross_charge": 275.00, "minimum": 80.66, "maximum": 151.04, "setting": "both", "payers_information": [ { "payer_name": "Aarp", "plan_name": "500102", "standard_charge_dollar": 80.66, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna", "plan_name": "700700", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna", "plan_name": "700700_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Mcare Ffs 6005", "plan_name": "700703", "standard_charge_dollar": 80.66, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Miscellaneous", "plan_name": "700720", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Miscellaneous", "plan_name": "700720_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Ppo Hmo", "plan_name": "701720", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Ppo Hmo", "plan_name": "701720_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Ambetter 68069", "plan_name": "500516", "standard_charge_dollar": 80.66, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Ms State Emplo", "plan_name": "401457", "standard_charge_dollar": 151.04, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Ms State Emplo", "plan_name": "401457_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Basic Pl", "plan_name": "400100", "standard_charge_dollar": 151.04, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Basic Pl", "plan_name": "400100_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Federal", "plan_name": "400110", "standard_charge_dollar": 151.04, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Federal", "plan_name": "400110_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Cigna Healthsprings Ffs", "plan_name": "500064", "standard_charge_dollar": 80.66, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Conseco", "plan_name": "500302", "standard_charge_dollar": 80.66, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Humana Ffs 61101", "plan_name": "500006", "standard_charge_dollar": 80.66, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Medicare A", "plan_name": "100100", "standard_charge_dollar": 80.66, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Medicare A", "plan_name": "100500", "standard_charge_dollar": 80.66, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Medicare Part B Only", "plan_name": "100300", "standard_charge_dollar": 80.66, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Medicare Railroad", "plan_name": "100103", "standard_charge_dollar": 80.66, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Ms Physicians Care N", "plan_name": "714210", "standard_charge_dollar": 100.82, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Peoples Hlth Ffs 72126", "plan_name": "500019", "standard_charge_dollar": 80.66, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Uhc/Secure Horizons", "plan_name": "500449", "standard_charge_dollar": 80.66, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "United Health Care/", "plan_name": "500292", "standard_charge_dollar": 91.15, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "United Healthcare", "plan_name": "750104", "standard_charge_dollar": 91.15, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "United Healthcare Ba", "plan_name": "750090", "standard_charge_dollar": 91.15, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "United Healthcare Me", "plan_name": "501310", "standard_charge_dollar": 80.66, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Windsor Mcare Extra", "plan_name": "500778", "standard_charge_dollar": 80.66, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." } ] } ] }, { "description": "Hc spine cervical 4 or 5 view", "code_information": [ { "code": "72050", "type": "CPT" } ], "standard_charges": [ { "gross_charge": 275.00, "minimum": 97.41, "maximum": 151.04, "setting": "both", "payers_information": [ { "payer_name": "Aarp", "plan_name": "500102", "standard_charge_dollar": 97.41, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna", "plan_name": "700700", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna", "plan_name": "700700_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Mcare Ffs 6005", "plan_name": "700703", "standard_charge_dollar": 97.41, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Miscellaneous", "plan_name": "700720", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Miscellaneous", "plan_name": "700720_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Ppo Hmo", "plan_name": "701720", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Ppo Hmo", "plan_name": "701720_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Ambetter 68069", "plan_name": "500516", "standard_charge_dollar": 97.41, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Ms State Emplo", "plan_name": "401457", "standard_charge_dollar": 151.04, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Ms State Emplo", "plan_name": "401457_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Basic Pl", "plan_name": "400100", "standard_charge_dollar": 151.04, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Basic Pl", "plan_name": "400100_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Federal", "plan_name": "400110", "standard_charge_dollar": 151.04, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Federal", "plan_name": "400110_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Cigna Healthsprings Ffs", "plan_name": "500064", "standard_charge_dollar": 97.41, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Conseco", "plan_name": "500302", "standard_charge_dollar": 97.41, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Humana Ffs 61101", "plan_name": "500006", "standard_charge_dollar": 97.41, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Medicare A", "plan_name": "100100", "standard_charge_dollar": 97.41, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Medicare A", "plan_name": "100500", "standard_charge_dollar": 97.41, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Medicare Part B Only", "plan_name": "100300", "standard_charge_dollar": 97.41, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Medicare Railroad", "plan_name": "100103", "standard_charge_dollar": 97.41, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Ms Physicians Care N", "plan_name": "714210", "standard_charge_dollar": 121.77, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Peoples Hlth Ffs 72126", "plan_name": "500019", "standard_charge_dollar": 97.41, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Uhc/Secure Horizons", "plan_name": "500449", "standard_charge_dollar": 97.41, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "United Health Care/", "plan_name": "500292", "standard_charge_dollar": 110.08, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "United Healthcare", "plan_name": "750104", "standard_charge_dollar": 110.08, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "United Healthcare Ba", "plan_name": "750090", "standard_charge_dollar": 110.08, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "United Healthcare Me", "plan_name": "501310", "standard_charge_dollar": 97.41, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Windsor Mcare Extra", "plan_name": "500778", "standard_charge_dollar": 97.41, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." } ] } ] }, { "description": "X-ray exam neck spine 4/5vws", "code_information": [ { "code": "72050", "type": "CPT" } ], "standard_charges": [ { "gross_charge": 275.00, "minimum": 97.41, "maximum": 151.04, "setting": "both", "payers_information": [ { "payer_name": "Aarp", "plan_name": "500102", "standard_charge_dollar": 97.41, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna", "plan_name": "700700", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna", "plan_name": "700700_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Mcare Ffs 6005", "plan_name": "700703", "standard_charge_dollar": 97.41, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Miscellaneous", "plan_name": "700720", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Miscellaneous", "plan_name": "700720_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Ppo Hmo", "plan_name": "701720", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Ppo Hmo", "plan_name": "701720_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Ambetter 68069", "plan_name": "500516", "standard_charge_dollar": 97.41, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Ms State Emplo", "plan_name": "401457", "standard_charge_dollar": 151.04, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Ms State Emplo", "plan_name": "401457_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Basic Pl", "plan_name": "400100", "standard_charge_dollar": 151.04, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Basic Pl", "plan_name": "400100_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Federal", "plan_name": "400110", "standard_charge_dollar": 151.04, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Federal", "plan_name": "400110_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Cigna Healthsprings Ffs", "plan_name": "500064", "standard_charge_dollar": 97.41, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Conseco", "plan_name": "500302", "standard_charge_dollar": 97.41, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Humana Ffs 61101", "plan_name": "500006", "standard_charge_dollar": 97.41, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Medicare A", "plan_name": "100100", "standard_charge_dollar": 97.41, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Medicare A", "plan_name": "100500", "standard_charge_dollar": 97.41, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Medicare Part B Only", "plan_name": "100300", "standard_charge_dollar": 97.41, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Medicare Railroad", "plan_name": "100103", "standard_charge_dollar": 97.41, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Ms Physicians Care N", "plan_name": "714210", "standard_charge_dollar": 121.77, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Peoples Hlth Ffs 72126", "plan_name": "500019", "standard_charge_dollar": 97.41, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Uhc/Secure Horizons", "plan_name": "500449", "standard_charge_dollar": 97.41, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "United Health Care/", "plan_name": "500292", "standard_charge_dollar": 110.08, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "United Healthcare", "plan_name": "750104", "standard_charge_dollar": 110.08, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "United Healthcare Ba", "plan_name": "750090", "standard_charge_dollar": 110.08, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "United Healthcare Me", "plan_name": "501310", "standard_charge_dollar": 97.41, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Windsor Mcare Extra", "plan_name": "500778", "standard_charge_dollar": 97.41, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." } ] } ] }, { "description": "Hc spine cervical series w/flex 6 or more view", "code_information": [ { "code": "72052", "type": "CPT" } ], "standard_charges": [ { "gross_charge": 297.41, "minimum": 97.41, "maximum": 151.04, "setting": "both", "payers_information": [ { "payer_name": "Aarp", "plan_name": "500102", "standard_charge_dollar": 97.41, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna", "plan_name": "700700", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna", "plan_name": "700700_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Mcare Ffs 6005", "plan_name": "700703", "standard_charge_dollar": 97.41, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Miscellaneous", "plan_name": "700720", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Miscellaneous", "plan_name": "700720_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Ppo Hmo", "plan_name": "701720", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Ppo Hmo", "plan_name": "701720_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Ambetter 68069", "plan_name": "500516", "standard_charge_dollar": 97.41, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Ms State Emplo", "plan_name": "401457", "standard_charge_dollar": 151.04, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Ms State Emplo", "plan_name": "401457_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Basic Pl", "plan_name": "400100", "standard_charge_dollar": 151.04, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Basic Pl", "plan_name": "400100_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Federal", "plan_name": "400110", "standard_charge_dollar": 151.04, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Federal", "plan_name": "400110_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Cigna Healthsprings Ffs", "plan_name": "500064", "standard_charge_dollar": 97.41, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Conseco", "plan_name": "500302", "standard_charge_dollar": 97.41, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Humana Ffs 61101", "plan_name": "500006", "standard_charge_dollar": 97.41, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Medicare A", "plan_name": "100100", "standard_charge_dollar": 97.41, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Medicare A", "plan_name": "100500", "standard_charge_dollar": 97.41, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Medicare Part B Only", "plan_name": "100300", "standard_charge_dollar": 97.41, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Medicare Railroad", "plan_name": "100103", "standard_charge_dollar": 97.41, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Ms Physicians Care N", "plan_name": "714210", "standard_charge_dollar": 121.77, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Peoples Hlth Ffs 72126", "plan_name": "500019", "standard_charge_dollar": 97.41, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Uhc/Secure Horizons", "plan_name": "500449", "standard_charge_dollar": 97.41, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "United Health Care/", "plan_name": "500292", "standard_charge_dollar": 110.08, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "United Healthcare", "plan_name": "750104", "standard_charge_dollar": 110.08, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "United Healthcare Ba", "plan_name": "750090", "standard_charge_dollar": 110.08, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "United Healthcare Me", "plan_name": "501310", "standard_charge_dollar": 97.41, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Windsor Mcare Extra", "plan_name": "500778", "standard_charge_dollar": 97.41, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." } ] } ] }, { "description": "X-ray exam neck spine 6/>vws", "code_information": [ { "code": "72052", "type": "CPT" } ], "standard_charges": [ { "gross_charge": 297.41, "minimum": 97.41, "maximum": 151.04, "setting": "both", "payers_information": [ { "payer_name": "Aarp", "plan_name": "500102", "standard_charge_dollar": 97.41, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna", "plan_name": "700700", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna", "plan_name": "700700_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Mcare Ffs 6005", "plan_name": "700703", "standard_charge_dollar": 97.41, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Miscellaneous", "plan_name": "700720", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Miscellaneous", "plan_name": "700720_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Ppo Hmo", "plan_name": "701720", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Ppo Hmo", "plan_name": "701720_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Ambetter 68069", "plan_name": "500516", "standard_charge_dollar": 97.41, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Ms State Emplo", "plan_name": "401457", "standard_charge_dollar": 151.04, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Ms State Emplo", "plan_name": "401457_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Basic Pl", "plan_name": "400100", "standard_charge_dollar": 151.04, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Basic Pl", "plan_name": "400100_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Federal", "plan_name": "400110", "standard_charge_dollar": 151.04, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Federal", "plan_name": "400110_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Cigna Healthsprings Ffs", "plan_name": "500064", "standard_charge_dollar": 97.41, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Conseco", "plan_name": "500302", "standard_charge_dollar": 97.41, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Humana Ffs 61101", "plan_name": "500006", "standard_charge_dollar": 97.41, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Medicare A", "plan_name": "100100", "standard_charge_dollar": 97.41, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Medicare A", "plan_name": "100500", "standard_charge_dollar": 97.41, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Medicare Part B Only", "plan_name": "100300", "standard_charge_dollar": 97.41, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Medicare Railroad", "plan_name": "100103", "standard_charge_dollar": 97.41, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Ms Physicians Care N", "plan_name": "714210", "standard_charge_dollar": 121.77, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Peoples Hlth Ffs 72126", "plan_name": "500019", "standard_charge_dollar": 97.41, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Uhc/Secure Horizons", "plan_name": "500449", "standard_charge_dollar": 97.41, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "United Health Care/", "plan_name": "500292", "standard_charge_dollar": 110.08, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "United Healthcare", "plan_name": "750104", "standard_charge_dollar": 110.08, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "United Healthcare Ba", "plan_name": "750090", "standard_charge_dollar": 110.08, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "United Healthcare Me", "plan_name": "501310", "standard_charge_dollar": 97.41, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Windsor Mcare Extra", "plan_name": "500778", "standard_charge_dollar": 97.41, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." } ] } ] }, { "description": "Hc spine thoracic 2 view", "code_information": [ { "code": "72070", "type": "CPT" } ], "standard_charges": [ { "gross_charge": 230.00, "minimum": 97.41, "maximum": 151.04, "setting": "both", "payers_information": [ { "payer_name": "Aarp", "plan_name": "500102", "standard_charge_dollar": 97.41, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna", "plan_name": "700700", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna", "plan_name": "700700_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Mcare Ffs 6005", "plan_name": "700703", "standard_charge_dollar": 97.41, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Miscellaneous", "plan_name": "700720", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Miscellaneous", "plan_name": "700720_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Ppo Hmo", "plan_name": "701720", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Ppo Hmo", "plan_name": "701720_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Ambetter 68069", "plan_name": "500516", "standard_charge_dollar": 97.41, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Ms State Emplo", "plan_name": "401457", "standard_charge_dollar": 151.04, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Ms State Emplo", "plan_name": "401457_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Basic Pl", "plan_name": "400100", "standard_charge_dollar": 151.04, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Basic Pl", "plan_name": "400100_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Federal", "plan_name": "400110", "standard_charge_dollar": 151.04, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Federal", "plan_name": "400110_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Cigna Healthsprings Ffs", "plan_name": "500064", "standard_charge_dollar": 97.41, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Conseco", "plan_name": "500302", "standard_charge_dollar": 97.41, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Humana Ffs 61101", "plan_name": "500006", "standard_charge_dollar": 97.41, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Medicare A", "plan_name": "100100", "standard_charge_dollar": 97.41, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Medicare A", "plan_name": "100500", "standard_charge_dollar": 97.41, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Medicare Part B Only", "plan_name": "100300", "standard_charge_dollar": 97.41, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Medicare Railroad", "plan_name": "100103", "standard_charge_dollar": 97.41, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Ms Physicians Care N", "plan_name": "714210", "standard_charge_dollar": 121.77, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Peoples Hlth Ffs 72126", "plan_name": "500019", "standard_charge_dollar": 97.41, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Uhc/Secure Horizons", "plan_name": "500449", "standard_charge_dollar": 97.41, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "United Health Care/", "plan_name": "500292", "standard_charge_dollar": 110.08, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "United Healthcare", "plan_name": "750104", "standard_charge_dollar": 110.08, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "United Healthcare Ba", "plan_name": "750090", "standard_charge_dollar": 110.08, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "United Healthcare Me", "plan_name": "501310", "standard_charge_dollar": 97.41, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Windsor Mcare Extra", "plan_name": "500778", "standard_charge_dollar": 97.41, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." } ] } ] }, { "description": "X-ray exam thorac spine 2vws", "code_information": [ { "code": "72070", "type": "CPT" } ], "standard_charges": [ { "gross_charge": 230.00, "minimum": 97.41, "maximum": 151.04, "setting": "both", "payers_information": [ { "payer_name": "Aarp", "plan_name": "500102", "standard_charge_dollar": 97.41, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna", "plan_name": "700700", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna", "plan_name": "700700_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Mcare Ffs 6005", "plan_name": "700703", "standard_charge_dollar": 97.41, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Miscellaneous", "plan_name": "700720", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Miscellaneous", "plan_name": "700720_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Ppo Hmo", "plan_name": "701720", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Ppo Hmo", "plan_name": "701720_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Ambetter 68069", "plan_name": "500516", "standard_charge_dollar": 97.41, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Ms State Emplo", "plan_name": "401457", "standard_charge_dollar": 151.04, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Ms State Emplo", "plan_name": "401457_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Basic Pl", "plan_name": "400100", "standard_charge_dollar": 151.04, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Basic Pl", "plan_name": "400100_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Federal", "plan_name": "400110", "standard_charge_dollar": 151.04, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Federal", "plan_name": "400110_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Cigna Healthsprings Ffs", "plan_name": "500064", "standard_charge_dollar": 97.41, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Conseco", "plan_name": "500302", "standard_charge_dollar": 97.41, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Humana Ffs 61101", "plan_name": "500006", "standard_charge_dollar": 97.41, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Medicare A", "plan_name": "100100", "standard_charge_dollar": 97.41, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Medicare A", "plan_name": "100500", "standard_charge_dollar": 97.41, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Medicare Part B Only", "plan_name": "100300", "standard_charge_dollar": 97.41, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Medicare Railroad", "plan_name": "100103", "standard_charge_dollar": 97.41, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Ms Physicians Care N", "plan_name": "714210", "standard_charge_dollar": 121.77, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Peoples Hlth Ffs 72126", "plan_name": "500019", "standard_charge_dollar": 97.41, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Uhc/Secure Horizons", "plan_name": "500449", "standard_charge_dollar": 97.41, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "United Health Care/", "plan_name": "500292", "standard_charge_dollar": 110.08, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "United Healthcare", "plan_name": "750104", "standard_charge_dollar": 110.08, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "United Healthcare Ba", "plan_name": "750090", "standard_charge_dollar": 110.08, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "United Healthcare Me", "plan_name": "501310", "standard_charge_dollar": 97.41, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Windsor Mcare Extra", "plan_name": "500778", "standard_charge_dollar": 97.41, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." } ] } ] }, { "description": "Hc spine thoracic 3 view", "code_information": [ { "code": "72072", "type": "CPT" } ], "standard_charges": [ { "gross_charge": 230.00, "minimum": 97.41, "maximum": 151.04, "setting": "both", "payers_information": [ { "payer_name": "Aarp", "plan_name": "500102", "standard_charge_dollar": 97.41, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna", "plan_name": "700700", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna", "plan_name": "700700_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Mcare Ffs 6005", "plan_name": "700703", "standard_charge_dollar": 97.41, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Miscellaneous", "plan_name": "700720", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Miscellaneous", "plan_name": "700720_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Ppo Hmo", "plan_name": "701720", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Ppo Hmo", "plan_name": "701720_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Ambetter 68069", "plan_name": "500516", "standard_charge_dollar": 97.41, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Ms State Emplo", "plan_name": "401457", "standard_charge_dollar": 151.04, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Ms State Emplo", "plan_name": "401457_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Basic Pl", "plan_name": "400100", "standard_charge_dollar": 151.04, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Basic Pl", "plan_name": "400100_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Federal", "plan_name": "400110", "standard_charge_dollar": 151.04, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Federal", "plan_name": "400110_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Cigna Healthsprings Ffs", "plan_name": "500064", "standard_charge_dollar": 97.41, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Conseco", "plan_name": "500302", "standard_charge_dollar": 97.41, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Humana Ffs 61101", "plan_name": "500006", "standard_charge_dollar": 97.41, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Medicare A", "plan_name": "100100", "standard_charge_dollar": 97.41, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Medicare A", "plan_name": "100500", "standard_charge_dollar": 97.41, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Medicare Part B Only", "plan_name": "100300", "standard_charge_dollar": 97.41, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Medicare Railroad", "plan_name": "100103", "standard_charge_dollar": 97.41, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Ms Physicians Care N", "plan_name": "714210", "standard_charge_dollar": 121.77, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Peoples Hlth Ffs 72126", "plan_name": "500019", "standard_charge_dollar": 97.41, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Uhc/Secure Horizons", "plan_name": "500449", "standard_charge_dollar": 97.41, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "United Health Care/", "plan_name": "500292", "standard_charge_dollar": 110.08, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "United Healthcare", "plan_name": "750104", "standard_charge_dollar": 110.08, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "United Healthcare Ba", "plan_name": "750090", "standard_charge_dollar": 110.08, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "United Healthcare Me", "plan_name": "501310", "standard_charge_dollar": 97.41, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Windsor Mcare Extra", "plan_name": "500778", "standard_charge_dollar": 97.41, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." } ] } ] }, { "description": "X-ray exam thorac spine 3vws", "code_information": [ { "code": "72072", "type": "CPT" } ], "standard_charges": [ { "gross_charge": 230.00, "minimum": 97.41, "maximum": 151.04, "setting": "both", "payers_information": [ { "payer_name": "Aarp", "plan_name": "500102", "standard_charge_dollar": 97.41, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna", "plan_name": "700700", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna", "plan_name": "700700_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Mcare Ffs 6005", "plan_name": "700703", "standard_charge_dollar": 97.41, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Miscellaneous", "plan_name": "700720", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Miscellaneous", "plan_name": "700720_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Ppo Hmo", "plan_name": "701720", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Ppo Hmo", "plan_name": "701720_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Ambetter 68069", "plan_name": "500516", "standard_charge_dollar": 97.41, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Ms State Emplo", "plan_name": "401457", "standard_charge_dollar": 151.04, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Ms State Emplo", "plan_name": "401457_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Basic Pl", "plan_name": "400100", "standard_charge_dollar": 151.04, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Basic Pl", "plan_name": "400100_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Federal", "plan_name": "400110", "standard_charge_dollar": 151.04, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Federal", "plan_name": "400110_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Cigna Healthsprings Ffs", "plan_name": "500064", "standard_charge_dollar": 97.41, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Conseco", "plan_name": "500302", "standard_charge_dollar": 97.41, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Humana Ffs 61101", "plan_name": "500006", "standard_charge_dollar": 97.41, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Medicare A", "plan_name": "100100", "standard_charge_dollar": 97.41, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Medicare A", "plan_name": "100500", "standard_charge_dollar": 97.41, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Medicare Part B Only", "plan_name": "100300", "standard_charge_dollar": 97.41, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Medicare Railroad", "plan_name": "100103", "standard_charge_dollar": 97.41, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Ms Physicians Care N", "plan_name": "714210", "standard_charge_dollar": 121.77, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Peoples Hlth Ffs 72126", "plan_name": "500019", "standard_charge_dollar": 97.41, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Uhc/Secure Horizons", "plan_name": "500449", "standard_charge_dollar": 97.41, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "United Health Care/", "plan_name": "500292", "standard_charge_dollar": 110.08, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "United Healthcare", "plan_name": "750104", "standard_charge_dollar": 110.08, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "United Healthcare Ba", "plan_name": "750090", "standard_charge_dollar": 110.08, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "United Healthcare Me", "plan_name": "501310", "standard_charge_dollar": 97.41, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Windsor Mcare Extra", "plan_name": "500778", "standard_charge_dollar": 97.41, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." } ] } ] }, { "description": "Hc xray entire spine 2-3 views", "code_information": [ { "code": "72082", "type": "CPT" } ], "standard_charges": [ { "gross_charge": 275.00, "minimum": 97.41, "maximum": 151.04, "setting": "both", "payers_information": [ { "payer_name": "Aarp", "plan_name": "500102", "standard_charge_dollar": 97.41, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna", "plan_name": "700700", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna", "plan_name": "700700_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Mcare Ffs 6005", "plan_name": "700703", "standard_charge_dollar": 97.41, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Miscellaneous", "plan_name": "700720", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Miscellaneous", "plan_name": "700720_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Ppo Hmo", "plan_name": "701720", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Ppo Hmo", "plan_name": "701720_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Ambetter 68069", "plan_name": "500516", "standard_charge_dollar": 97.41, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Ms State Emplo", "plan_name": "401457", "standard_charge_dollar": 151.04, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Ms State Emplo", "plan_name": "401457_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Basic Pl", "plan_name": "400100", "standard_charge_dollar": 151.04, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Basic Pl", "plan_name": "400100_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Federal", "plan_name": "400110", "standard_charge_dollar": 151.04, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Federal", "plan_name": "400110_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Cigna Healthsprings Ffs", "plan_name": "500064", "standard_charge_dollar": 97.41, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Conseco", "plan_name": "500302", "standard_charge_dollar": 97.41, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Humana Ffs 61101", "plan_name": "500006", "standard_charge_dollar": 97.41, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Medicare A", "plan_name": "100100", "standard_charge_dollar": 97.41, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Medicare A", "plan_name": "100500", "standard_charge_dollar": 97.41, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Medicare Part B Only", "plan_name": "100300", "standard_charge_dollar": 97.41, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Medicare Railroad", "plan_name": "100103", "standard_charge_dollar": 97.41, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Ms Physicians Care N", "plan_name": "714210", "standard_charge_dollar": 121.77, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Peoples Hlth Ffs 72126", "plan_name": "500019", "standard_charge_dollar": 97.41, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Uhc/Secure Horizons", "plan_name": "500449", "standard_charge_dollar": 97.41, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "United Health Care/", "plan_name": "500292", "standard_charge_dollar": 110.08, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "United Healthcare", "plan_name": "750104", "standard_charge_dollar": 110.08, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "United Healthcare Ba", "plan_name": "750090", "standard_charge_dollar": 110.08, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "United Healthcare Me", "plan_name": "501310", "standard_charge_dollar": 97.41, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Windsor Mcare Extra", "plan_name": "500778", "standard_charge_dollar": 97.41, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." } ] } ] }, { "description": "X-ray exam entire spi 2/3 vw", "code_information": [ { "code": "72082", "type": "CPT" } ], "standard_charges": [ { "gross_charge": 275.00, "minimum": 97.41, "maximum": 151.04, "setting": "both", "payers_information": [ { "payer_name": "Aarp", "plan_name": "500102", "standard_charge_dollar": 97.41, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna", "plan_name": "700700", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna", "plan_name": "700700_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Mcare Ffs 6005", "plan_name": "700703", "standard_charge_dollar": 97.41, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Miscellaneous", "plan_name": "700720", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Miscellaneous", "plan_name": "700720_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Ppo Hmo", "plan_name": "701720", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Ppo Hmo", "plan_name": "701720_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Ambetter 68069", "plan_name": "500516", "standard_charge_dollar": 97.41, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Ms State Emplo", "plan_name": "401457", "standard_charge_dollar": 151.04, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Ms State Emplo", "plan_name": "401457_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Basic Pl", "plan_name": "400100", "standard_charge_dollar": 151.04, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Basic Pl", "plan_name": "400100_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Federal", "plan_name": "400110", "standard_charge_dollar": 151.04, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Federal", "plan_name": "400110_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Cigna Healthsprings Ffs", "plan_name": "500064", "standard_charge_dollar": 97.41, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Conseco", "plan_name": "500302", "standard_charge_dollar": 97.41, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Humana Ffs 61101", "plan_name": "500006", "standard_charge_dollar": 97.41, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Medicare A", "plan_name": "100100", "standard_charge_dollar": 97.41, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Medicare A", "plan_name": "100500", "standard_charge_dollar": 97.41, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Medicare Part B Only", "plan_name": "100300", "standard_charge_dollar": 97.41, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Medicare Railroad", "plan_name": "100103", "standard_charge_dollar": 97.41, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Ms Physicians Care N", "plan_name": "714210", "standard_charge_dollar": 121.77, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Peoples Hlth Ffs 72126", "plan_name": "500019", "standard_charge_dollar": 97.41, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Uhc/Secure Horizons", "plan_name": "500449", "standard_charge_dollar": 97.41, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "United Health Care/", "plan_name": "500292", "standard_charge_dollar": 110.08, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "United Healthcare", "plan_name": "750104", "standard_charge_dollar": 110.08, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "United Healthcare Ba", "plan_name": "750090", "standard_charge_dollar": 110.08, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "United Healthcare Me", "plan_name": "501310", "standard_charge_dollar": 97.41, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Windsor Mcare Extra", "plan_name": "500778", "standard_charge_dollar": 97.41, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." } ] } ] }, { "description": "Hc spine lumbosacral 2 or 3 view", "code_information": [ { "code": "72100", "type": "CPT" } ], "standard_charges": [ { "gross_charge": 223.00, "minimum": 97.41, "maximum": 151.04, "setting": "both", "payers_information": [ { "payer_name": "Aarp", "plan_name": "500102", "standard_charge_dollar": 97.41, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna", "plan_name": "700700", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna", "plan_name": "700700_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Mcare Ffs 6005", "plan_name": "700703", "standard_charge_dollar": 97.41, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Miscellaneous", "plan_name": "700720", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Miscellaneous", "plan_name": "700720_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Ppo Hmo", "plan_name": "701720", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Ppo Hmo", "plan_name": "701720_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Ambetter 68069", "plan_name": "500516", "standard_charge_dollar": 97.41, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Ms State Emplo", "plan_name": "401457", "standard_charge_dollar": 151.04, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Ms State Emplo", "plan_name": "401457_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Basic Pl", "plan_name": "400100", "standard_charge_dollar": 151.04, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Basic Pl", "plan_name": "400100_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Federal", "plan_name": "400110", "standard_charge_dollar": 151.04, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Federal", "plan_name": "400110_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Cigna Healthsprings Ffs", "plan_name": "500064", "standard_charge_dollar": 97.41, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Conseco", "plan_name": "500302", "standard_charge_dollar": 97.41, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Humana Ffs 61101", "plan_name": "500006", "standard_charge_dollar": 97.41, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Medicare A", "plan_name": "100100", "standard_charge_dollar": 97.41, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Medicare A", "plan_name": "100500", "standard_charge_dollar": 97.41, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Medicare Part B Only", "plan_name": "100300", "standard_charge_dollar": 97.41, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Medicare Railroad", "plan_name": "100103", "standard_charge_dollar": 97.41, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Ms Physicians Care N", "plan_name": "714210", "standard_charge_dollar": 121.77, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Peoples Hlth Ffs 72126", "plan_name": "500019", "standard_charge_dollar": 97.41, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Uhc/Secure Horizons", "plan_name": "500449", "standard_charge_dollar": 97.41, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "United Health Care/", "plan_name": "500292", "standard_charge_dollar": 110.08, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "United Healthcare", "plan_name": "750104", "standard_charge_dollar": 110.08, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "United Healthcare Ba", "plan_name": "750090", "standard_charge_dollar": 110.08, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "United Healthcare Me", "plan_name": "501310", "standard_charge_dollar": 97.41, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Windsor Mcare Extra", "plan_name": "500778", "standard_charge_dollar": 97.41, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." } ] } ] }, { "description": "X-ray exam l-s spine 2/3 vws", "code_information": [ { "code": "72100", "type": "CPT" } ], "standard_charges": [ { "gross_charge": 223.00, "minimum": 97.41, "maximum": 151.04, "setting": "both", "payers_information": [ { "payer_name": "Aarp", "plan_name": "500102", "standard_charge_dollar": 97.41, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna", "plan_name": "700700", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna", "plan_name": "700700_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Mcare Ffs 6005", "plan_name": "700703", "standard_charge_dollar": 97.41, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Miscellaneous", "plan_name": "700720", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Miscellaneous", "plan_name": "700720_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Ppo Hmo", "plan_name": "701720", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Ppo Hmo", "plan_name": "701720_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Ambetter 68069", "plan_name": "500516", "standard_charge_dollar": 97.41, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Ms State Emplo", "plan_name": "401457", "standard_charge_dollar": 151.04, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Ms State Emplo", "plan_name": "401457_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Basic Pl", "plan_name": "400100", "standard_charge_dollar": 151.04, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Basic Pl", "plan_name": "400100_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Federal", "plan_name": "400110", "standard_charge_dollar": 151.04, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Federal", "plan_name": "400110_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Cigna Healthsprings Ffs", "plan_name": "500064", "standard_charge_dollar": 97.41, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Conseco", "plan_name": "500302", "standard_charge_dollar": 97.41, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Humana Ffs 61101", "plan_name": "500006", "standard_charge_dollar": 97.41, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Medicare A", "plan_name": "100100", "standard_charge_dollar": 97.41, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Medicare A", "plan_name": "100500", "standard_charge_dollar": 97.41, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Medicare Part B Only", "plan_name": "100300", "standard_charge_dollar": 97.41, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Medicare Railroad", "plan_name": "100103", "standard_charge_dollar": 97.41, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Ms Physicians Care N", "plan_name": "714210", "standard_charge_dollar": 121.77, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Peoples Hlth Ffs 72126", "plan_name": "500019", "standard_charge_dollar": 97.41, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Uhc/Secure Horizons", "plan_name": "500449", "standard_charge_dollar": 97.41, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "United Health Care/", "plan_name": "500292", "standard_charge_dollar": 110.08, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "United Healthcare", "plan_name": "750104", "standard_charge_dollar": 110.08, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "United Healthcare Ba", "plan_name": "750090", "standard_charge_dollar": 110.08, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "United Healthcare Me", "plan_name": "501310", "standard_charge_dollar": 97.41, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Windsor Mcare Extra", "plan_name": "500778", "standard_charge_dollar": 97.41, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." } ] } ] }, { "description": "Hc spine lumbosacral min 4 view", "code_information": [ { "code": "72110", "type": "CPT" } ], "standard_charges": [ { "gross_charge": 223.00, "minimum": 97.41, "maximum": 151.04, "setting": "both", "payers_information": [ { "payer_name": "Aarp", "plan_name": "500102", "standard_charge_dollar": 97.41, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna", "plan_name": "700700", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna", "plan_name": "700700_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Mcare Ffs 6005", "plan_name": "700703", "standard_charge_dollar": 97.41, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Miscellaneous", "plan_name": "700720", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Miscellaneous", "plan_name": "700720_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Ppo Hmo", "plan_name": "701720", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Ppo Hmo", "plan_name": "701720_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Ambetter 68069", "plan_name": "500516", "standard_charge_dollar": 97.41, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Ms State Emplo", "plan_name": "401457", "standard_charge_dollar": 151.04, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Ms State Emplo", "plan_name": "401457_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Basic Pl", "plan_name": "400100", "standard_charge_dollar": 151.04, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Basic Pl", "plan_name": "400100_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Federal", "plan_name": "400110", "standard_charge_dollar": 151.04, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Federal", "plan_name": "400110_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Cigna Healthsprings Ffs", "plan_name": "500064", "standard_charge_dollar": 97.41, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Conseco", "plan_name": "500302", "standard_charge_dollar": 97.41, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Humana Ffs 61101", "plan_name": "500006", "standard_charge_dollar": 97.41, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Medicare A", "plan_name": "100100", "standard_charge_dollar": 97.41, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Medicare A", "plan_name": "100500", "standard_charge_dollar": 97.41, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Medicare Part B Only", "plan_name": "100300", "standard_charge_dollar": 97.41, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Medicare Railroad", "plan_name": "100103", "standard_charge_dollar": 97.41, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Ms Physicians Care N", "plan_name": "714210", "standard_charge_dollar": 121.77, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Peoples Hlth Ffs 72126", "plan_name": "500019", "standard_charge_dollar": 97.41, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Uhc/Secure Horizons", "plan_name": "500449", "standard_charge_dollar": 97.41, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "United Health Care/", "plan_name": "500292", "standard_charge_dollar": 110.08, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "United Healthcare", "plan_name": "750104", "standard_charge_dollar": 110.08, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "United Healthcare Ba", "plan_name": "750090", "standard_charge_dollar": 110.08, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "United Healthcare Me", "plan_name": "501310", "standard_charge_dollar": 97.41, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Windsor Mcare Extra", "plan_name": "500778", "standard_charge_dollar": 97.41, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." } ] } ] }, { "description": "X-ray exam l-2 spine 4/>vws", "code_information": [ { "code": "72110", "type": "CPT" } ], "standard_charges": [ { "gross_charge": 223.00, "minimum": 97.41, "maximum": 151.04, "setting": "both", "payers_information": [ { "payer_name": "Aarp", "plan_name": "500102", "standard_charge_dollar": 97.41, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna", "plan_name": "700700", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna", "plan_name": "700700_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Mcare Ffs 6005", "plan_name": "700703", "standard_charge_dollar": 97.41, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Miscellaneous", "plan_name": "700720", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Miscellaneous", "plan_name": "700720_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Ppo Hmo", "plan_name": "701720", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Ppo Hmo", "plan_name": "701720_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Ambetter 68069", "plan_name": "500516", "standard_charge_dollar": 97.41, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Ms State Emplo", "plan_name": "401457", "standard_charge_dollar": 151.04, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Ms State Emplo", "plan_name": "401457_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Basic Pl", "plan_name": "400100", "standard_charge_dollar": 151.04, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Basic Pl", "plan_name": "400100_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Federal", "plan_name": "400110", "standard_charge_dollar": 151.04, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Federal", "plan_name": "400110_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Cigna Healthsprings Ffs", "plan_name": "500064", "standard_charge_dollar": 97.41, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Conseco", "plan_name": "500302", "standard_charge_dollar": 97.41, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Humana Ffs 61101", "plan_name": "500006", "standard_charge_dollar": 97.41, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Medicare A", "plan_name": "100100", "standard_charge_dollar": 97.41, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Medicare A", "plan_name": "100500", "standard_charge_dollar": 97.41, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Medicare Part B Only", "plan_name": "100300", "standard_charge_dollar": 97.41, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Medicare Railroad", "plan_name": "100103", "standard_charge_dollar": 97.41, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Ms Physicians Care N", "plan_name": "714210", "standard_charge_dollar": 121.77, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Peoples Hlth Ffs 72126", "plan_name": "500019", "standard_charge_dollar": 97.41, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Uhc/Secure Horizons", "plan_name": "500449", "standard_charge_dollar": 97.41, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "United Health Care/", "plan_name": "500292", "standard_charge_dollar": 110.08, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "United Healthcare", "plan_name": "750104", "standard_charge_dollar": 110.08, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "United Healthcare Ba", "plan_name": "750090", "standard_charge_dollar": 110.08, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "United Healthcare Me", "plan_name": "501310", "standard_charge_dollar": 97.41, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Windsor Mcare Extra", "plan_name": "500778", "standard_charge_dollar": 97.41, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." } ] } ] }, { "description": "Hc spine lumbaosac complete inc bending", "code_information": [ { "code": "72114", "type": "CPT" } ], "standard_charges": [ { "gross_charge": 223.00, "minimum": 97.41, "maximum": 151.04, "setting": "both", "payers_information": [ { "payer_name": "Aarp", "plan_name": "500102", "standard_charge_dollar": 97.41, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna", "plan_name": "700700", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna", "plan_name": "700700_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Mcare Ffs 6005", "plan_name": "700703", "standard_charge_dollar": 97.41, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Miscellaneous", "plan_name": "700720", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Miscellaneous", "plan_name": "700720_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Ppo Hmo", "plan_name": "701720", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Ppo Hmo", "plan_name": "701720_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Ambetter 68069", "plan_name": "500516", "standard_charge_dollar": 97.41, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Ms State Emplo", "plan_name": "401457", "standard_charge_dollar": 151.04, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Ms State Emplo", "plan_name": "401457_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Basic Pl", "plan_name": "400100", "standard_charge_dollar": 151.04, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Basic Pl", "plan_name": "400100_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Federal", "plan_name": "400110", "standard_charge_dollar": 151.04, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Federal", "plan_name": "400110_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Cigna Healthsprings Ffs", "plan_name": "500064", "standard_charge_dollar": 97.41, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Conseco", "plan_name": "500302", "standard_charge_dollar": 97.41, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Humana Ffs 61101", "plan_name": "500006", "standard_charge_dollar": 97.41, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Medicare A", "plan_name": "100100", "standard_charge_dollar": 97.41, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Medicare A", "plan_name": "100500", "standard_charge_dollar": 97.41, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Medicare Part B Only", "plan_name": "100300", "standard_charge_dollar": 97.41, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Medicare Railroad", "plan_name": "100103", "standard_charge_dollar": 97.41, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Ms Physicians Care N", "plan_name": "714210", "standard_charge_dollar": 121.77, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Peoples Hlth Ffs 72126", "plan_name": "500019", "standard_charge_dollar": 97.41, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Uhc/Secure Horizons", "plan_name": "500449", "standard_charge_dollar": 97.41, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "United Health Care/", "plan_name": "500292", "standard_charge_dollar": 110.08, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "United Healthcare", "plan_name": "750104", "standard_charge_dollar": 110.08, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "United Healthcare Ba", "plan_name": "750090", "standard_charge_dollar": 110.08, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "United Healthcare Me", "plan_name": "501310", "standard_charge_dollar": 97.41, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Windsor Mcare Extra", "plan_name": "500778", "standard_charge_dollar": 97.41, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." } ] } ] }, { "description": "X-ray exam l-s spine bending", "code_information": [ { "code": "72114", "type": "CPT" } ], "standard_charges": [ { "gross_charge": 223.00, "minimum": 97.41, "maximum": 151.04, "setting": "both", "payers_information": [ { "payer_name": "Aarp", "plan_name": "500102", "standard_charge_dollar": 97.41, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna", "plan_name": "700700", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna", "plan_name": "700700_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Mcare Ffs 6005", "plan_name": "700703", "standard_charge_dollar": 97.41, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Miscellaneous", "plan_name": "700720", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Miscellaneous", "plan_name": "700720_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Ppo Hmo", "plan_name": "701720", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Ppo Hmo", "plan_name": "701720_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Ambetter 68069", "plan_name": "500516", "standard_charge_dollar": 97.41, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Ms State Emplo", "plan_name": "401457", "standard_charge_dollar": 151.04, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Ms State Emplo", "plan_name": "401457_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Basic Pl", "plan_name": "400100", "standard_charge_dollar": 151.04, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Basic Pl", "plan_name": "400100_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Federal", "plan_name": "400110", "standard_charge_dollar": 151.04, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Federal", "plan_name": "400110_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Cigna Healthsprings Ffs", "plan_name": "500064", "standard_charge_dollar": 97.41, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Conseco", "plan_name": "500302", "standard_charge_dollar": 97.41, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Humana Ffs 61101", "plan_name": "500006", "standard_charge_dollar": 97.41, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Medicare A", "plan_name": "100100", "standard_charge_dollar": 97.41, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Medicare A", "plan_name": "100500", "standard_charge_dollar": 97.41, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Medicare Part B Only", "plan_name": "100300", "standard_charge_dollar": 97.41, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Medicare Railroad", "plan_name": "100103", "standard_charge_dollar": 97.41, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Ms Physicians Care N", "plan_name": "714210", "standard_charge_dollar": 121.77, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Peoples Hlth Ffs 72126", "plan_name": "500019", "standard_charge_dollar": 97.41, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Uhc/Secure Horizons", "plan_name": "500449", "standard_charge_dollar": 97.41, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "United Health Care/", "plan_name": "500292", "standard_charge_dollar": 110.08, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "United Healthcare", "plan_name": "750104", "standard_charge_dollar": 110.08, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "United Healthcare Ba", "plan_name": "750090", "standard_charge_dollar": 110.08, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "United Healthcare Me", "plan_name": "501310", "standard_charge_dollar": 97.41, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Windsor Mcare Extra", "plan_name": "500778", "standard_charge_dollar": 97.41, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." } ] } ] }, { "description": "Ct neck spine w/o dye", "code_information": [ { "code": "72125", "type": "CPT" } ], "standard_charges": [ { "gross_charge": 1250.00, "minimum": 168.74, "maximum": 257.13, "setting": "both", "payers_information": [ { "payer_name": "Aarp", "plan_name": "500102", "standard_charge_dollar": 205.70, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna", "plan_name": "700700", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna", "plan_name": "700700_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Mcare Ffs 6005", "plan_name": "700703", "standard_charge_dollar": 205.70, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Miscellaneous", "plan_name": "700720", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Miscellaneous", "plan_name": "700720_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Ppo Hmo", "plan_name": "701720", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Ppo Hmo", "plan_name": "701720_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Ambetter 68069", "plan_name": "500516", "standard_charge_dollar": 205.70, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Ms State Emplo", "plan_name": "401457", "standard_charge_dollar": 168.74, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Ms State Emplo", "plan_name": "401457_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Basic Pl", "plan_name": "400100", "standard_charge_dollar": 168.74, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Basic Pl", "plan_name": "400100_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Federal", "plan_name": "400110", "standard_charge_dollar": 168.74, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Federal", "plan_name": "400110_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Cigna Healthsprings Ffs", "plan_name": "500064", "standard_charge_dollar": 205.70, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Conseco", "plan_name": "500302", "standard_charge_dollar": 205.70, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Humana Ffs 61101", "plan_name": "500006", "standard_charge_dollar": 205.70, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Medicare A", "plan_name": "100100", "standard_charge_dollar": 205.70, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Medicare A", "plan_name": "100500", "standard_charge_dollar": 205.70, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Medicare Part B Only", "plan_name": "100300", "standard_charge_dollar": 205.70, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Medicare Railroad", "plan_name": "100103", "standard_charge_dollar": 205.70, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Ms Physicians Care N", "plan_name": "714210", "standard_charge_dollar": 257.13, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Peoples Hlth Ffs 72126", "plan_name": "500019", "standard_charge_dollar": 205.70, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Uhc/Secure Horizons", "plan_name": "500449", "standard_charge_dollar": 205.70, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "United Health Care/", "plan_name": "500292", "standard_charge_dollar": 232.44, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "United Healthcare", "plan_name": "750104", "standard_charge_dollar": 232.44, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "United Healthcare Ba", "plan_name": "750090", "standard_charge_dollar": 232.44, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "United Healthcare Me", "plan_name": "501310", "standard_charge_dollar": 205.70, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Windsor Mcare Extra", "plan_name": "500778", "standard_charge_dollar": 205.70, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." } ] } ] }, { "description": "Hc ct spine cervical w/o contrast", "code_information": [ { "code": "72125", "type": "CPT" } ], "standard_charges": [ { "gross_charge": 1250.00, "minimum": 168.74, "maximum": 257.13, "setting": "both", "payers_information": [ { "payer_name": "Aarp", "plan_name": "500102", "standard_charge_dollar": 205.70, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna", "plan_name": "700700", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna", "plan_name": "700700_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Mcare Ffs 6005", "plan_name": "700703", "standard_charge_dollar": 205.70, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Miscellaneous", "plan_name": "700720", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Miscellaneous", "plan_name": "700720_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Ppo Hmo", "plan_name": "701720", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Ppo Hmo", "plan_name": "701720_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Ambetter 68069", "plan_name": "500516", "standard_charge_dollar": 205.70, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Ms State Emplo", "plan_name": "401457", "standard_charge_dollar": 168.74, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Ms State Emplo", "plan_name": "401457_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Basic Pl", "plan_name": "400100", "standard_charge_dollar": 168.74, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Basic Pl", "plan_name": "400100_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Federal", "plan_name": "400110", "standard_charge_dollar": 168.74, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Federal", "plan_name": "400110_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Cigna Healthsprings Ffs", "plan_name": "500064", "standard_charge_dollar": 205.70, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Conseco", "plan_name": "500302", "standard_charge_dollar": 205.70, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Humana Ffs 61101", "plan_name": "500006", "standard_charge_dollar": 205.70, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Medicare A", "plan_name": "100100", "standard_charge_dollar": 205.70, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Medicare A", "plan_name": "100500", "standard_charge_dollar": 205.70, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Medicare Part B Only", "plan_name": "100300", "standard_charge_dollar": 205.70, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Medicare Railroad", "plan_name": "100103", "standard_charge_dollar": 205.70, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Ms Physicians Care N", "plan_name": "714210", "standard_charge_dollar": 257.13, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Peoples Hlth Ffs 72126", "plan_name": "500019", "standard_charge_dollar": 205.70, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Uhc/Secure Horizons", "plan_name": "500449", "standard_charge_dollar": 205.70, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "United Health Care/", "plan_name": "500292", "standard_charge_dollar": 232.44, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "United Healthcare", "plan_name": "750104", "standard_charge_dollar": 232.44, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "United Healthcare Ba", "plan_name": "750090", "standard_charge_dollar": 232.44, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "United Healthcare Me", "plan_name": "501310", "standard_charge_dollar": 205.70, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Windsor Mcare Extra", "plan_name": "500778", "standard_charge_dollar": 205.70, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." } ] } ] }, { "description": "Ct neck spine w/dye", "code_information": [ { "code": "72126", "type": "CPT" } ], "standard_charges": [ { "gross_charge": 1350.00, "minimum": 398.60, "maximum": 521.58, "setting": "both", "payers_information": [ { "payer_name": "Aarp", "plan_name": "500102", "standard_charge_dollar": 398.60, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna", "plan_name": "700700", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna", "plan_name": "700700_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Mcare Ffs 6005", "plan_name": "700703", "standard_charge_dollar": 398.60, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Miscellaneous", "plan_name": "700720", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Miscellaneous", "plan_name": "700720_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Ppo Hmo", "plan_name": "701720", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Ppo Hmo", "plan_name": "701720_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Ambetter 68069", "plan_name": "500516", "standard_charge_dollar": 398.60, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Ms State Emplo", "plan_name": "401457", "standard_charge_dollar": 521.58, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Ms State Emplo", "plan_name": "401457_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Basic Pl", "plan_name": "400100", "standard_charge_dollar": 521.58, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Basic Pl", "plan_name": "400100_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Federal", "plan_name": "400110", "standard_charge_dollar": 521.58, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Federal", "plan_name": "400110_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Cigna Healthsprings Ffs", "plan_name": "500064", "standard_charge_dollar": 398.60, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Conseco", "plan_name": "500302", "standard_charge_dollar": 398.60, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Humana Ffs 61101", "plan_name": "500006", "standard_charge_dollar": 398.60, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Medicare A", "plan_name": "100100", "standard_charge_dollar": 398.60, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Medicare A", "plan_name": "100500", "standard_charge_dollar": 398.60, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Medicare Part B Only", "plan_name": "100300", "standard_charge_dollar": 398.60, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Medicare Railroad", "plan_name": "100103", "standard_charge_dollar": 398.60, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Ms Physicians Care N", "plan_name": "714210", "standard_charge_dollar": 498.25, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Peoples Hlth Ffs 72126", "plan_name": "500019", "standard_charge_dollar": 398.60, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Uhc/Secure Horizons", "plan_name": "500449", "standard_charge_dollar": 398.60, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "United Health Care/", "plan_name": "500292", "standard_charge_dollar": 450.42, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "United Healthcare", "plan_name": "750104", "standard_charge_dollar": 450.42, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "United Healthcare Ba", "plan_name": "750090", "standard_charge_dollar": 450.42, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "United Healthcare Me", "plan_name": "501310", "standard_charge_dollar": 398.60, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Windsor Mcare Extra", "plan_name": "500778", "standard_charge_dollar": 398.60, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." } ] } ] }, { "description": "Hc ct spine cervical w/contrast", "code_information": [ { "code": "72126", "type": "CPT" } ], "standard_charges": [ { "gross_charge": 1350.00, "minimum": 398.60, "maximum": 521.58, "setting": "both", "payers_information": [ { "payer_name": "Aarp", "plan_name": "500102", "standard_charge_dollar": 398.60, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna", "plan_name": "700700", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna", "plan_name": "700700_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Mcare Ffs 6005", "plan_name": "700703", "standard_charge_dollar": 398.60, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Miscellaneous", "plan_name": "700720", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Miscellaneous", "plan_name": "700720_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Ppo Hmo", "plan_name": "701720", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Ppo Hmo", "plan_name": "701720_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Ambetter 68069", "plan_name": "500516", "standard_charge_dollar": 398.60, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Ms State Emplo", "plan_name": "401457", "standard_charge_dollar": 521.58, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Ms State Emplo", "plan_name": "401457_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Basic Pl", "plan_name": "400100", "standard_charge_dollar": 521.58, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Basic Pl", "plan_name": "400100_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Federal", "plan_name": "400110", "standard_charge_dollar": 521.58, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Federal", "plan_name": "400110_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Cigna Healthsprings Ffs", "plan_name": "500064", "standard_charge_dollar": 398.60, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Conseco", "plan_name": "500302", "standard_charge_dollar": 398.60, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Humana Ffs 61101", "plan_name": "500006", "standard_charge_dollar": 398.60, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Medicare A", "plan_name": "100100", "standard_charge_dollar": 398.60, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Medicare A", "plan_name": "100500", "standard_charge_dollar": 398.60, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Medicare Part B Only", "plan_name": "100300", "standard_charge_dollar": 398.60, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Medicare Railroad", "plan_name": "100103", "standard_charge_dollar": 398.60, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Ms Physicians Care N", "plan_name": "714210", "standard_charge_dollar": 498.25, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Peoples Hlth Ffs 72126", "plan_name": "500019", "standard_charge_dollar": 398.60, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Uhc/Secure Horizons", "plan_name": "500449", "standard_charge_dollar": 398.60, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "United Health Care/", "plan_name": "500292", "standard_charge_dollar": 450.42, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "United Healthcare", "plan_name": "750104", "standard_charge_dollar": 450.42, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "United Healthcare Ba", "plan_name": "750090", "standard_charge_dollar": 450.42, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "United Healthcare Me", "plan_name": "501310", "standard_charge_dollar": 398.60, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Windsor Mcare Extra", "plan_name": "500778", "standard_charge_dollar": 398.60, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." } ] } ] }, { "description": "Ct neck spine w/o & w/dye", "code_information": [ { "code": "72127", "type": "CPT" } ], "standard_charges": [ { "gross_charge": 1322.00, "minimum": 355.29, "maximum": 498.25, "setting": "both", "payers_information": [ { "payer_name": "Aarp", "plan_name": "500102", "standard_charge_dollar": 398.60, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna", "plan_name": "700700", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna", "plan_name": "700700_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Mcare Ffs 6005", "plan_name": "700703", "standard_charge_dollar": 398.60, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Miscellaneous", "plan_name": "700720", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Miscellaneous", "plan_name": "700720_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Ppo Hmo", "plan_name": "701720", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Ppo Hmo", "plan_name": "701720_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Ambetter 68069", "plan_name": "500516", "standard_charge_dollar": 398.60, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Ms State Emplo", "plan_name": "401457", "standard_charge_dollar": 355.29, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Ms State Emplo", "plan_name": "401457_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Basic Pl", "plan_name": "400100", "standard_charge_dollar": 355.29, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Basic Pl", "plan_name": "400100_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Federal", "plan_name": "400110", "standard_charge_dollar": 355.29, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Federal", "plan_name": "400110_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Cigna Healthsprings Ffs", "plan_name": "500064", "standard_charge_dollar": 398.60, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Conseco", "plan_name": "500302", "standard_charge_dollar": 398.60, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Humana Ffs 61101", "plan_name": "500006", "standard_charge_dollar": 398.60, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Medicare A", "plan_name": "100100", "standard_charge_dollar": 398.60, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Medicare A", "plan_name": "100500", "standard_charge_dollar": 398.60, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Medicare Part B Only", "plan_name": "100300", "standard_charge_dollar": 398.60, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Medicare Railroad", "plan_name": "100103", "standard_charge_dollar": 398.60, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Ms Physicians Care N", "plan_name": "714210", "standard_charge_dollar": 498.25, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Peoples Hlth Ffs 72126", "plan_name": "500019", "standard_charge_dollar": 398.60, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Uhc/Secure Horizons", "plan_name": "500449", "standard_charge_dollar": 398.60, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "United Health Care/", "plan_name": "500292", "standard_charge_dollar": 450.42, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "United Healthcare", "plan_name": "750104", "standard_charge_dollar": 450.42, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "United Healthcare Ba", "plan_name": "750090", "standard_charge_dollar": 450.42, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "United Healthcare Me", "plan_name": "501310", "standard_charge_dollar": 398.60, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Windsor Mcare Extra", "plan_name": "500778", "standard_charge_dollar": 398.60, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." } ] } ] }, { "description": "Hc ct spine cervical w/ wo contrast", "code_information": [ { "code": "72127", "type": "CPT" } ], "standard_charges": [ { "gross_charge": 1322.00, "minimum": 355.29, "maximum": 498.25, "setting": "both", "payers_information": [ { "payer_name": "Aarp", "plan_name": "500102", "standard_charge_dollar": 398.60, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna", "plan_name": "700700", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna", "plan_name": "700700_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Mcare Ffs 6005", "plan_name": "700703", "standard_charge_dollar": 398.60, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Miscellaneous", "plan_name": "700720", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Miscellaneous", "plan_name": "700720_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Ppo Hmo", "plan_name": "701720", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Ppo Hmo", "plan_name": "701720_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Ambetter 68069", "plan_name": "500516", "standard_charge_dollar": 398.60, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Ms State Emplo", "plan_name": "401457", "standard_charge_dollar": 355.29, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Ms State Emplo", "plan_name": "401457_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Basic Pl", "plan_name": "400100", "standard_charge_dollar": 355.29, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Basic Pl", "plan_name": "400100_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Federal", "plan_name": "400110", "standard_charge_dollar": 355.29, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Federal", "plan_name": "400110_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Cigna Healthsprings Ffs", "plan_name": "500064", "standard_charge_dollar": 398.60, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Conseco", "plan_name": "500302", "standard_charge_dollar": 398.60, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Humana Ffs 61101", "plan_name": "500006", "standard_charge_dollar": 398.60, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Medicare A", "plan_name": "100100", "standard_charge_dollar": 398.60, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Medicare A", "plan_name": "100500", "standard_charge_dollar": 398.60, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Medicare Part B Only", "plan_name": "100300", "standard_charge_dollar": 398.60, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Medicare Railroad", "plan_name": "100103", "standard_charge_dollar": 398.60, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Ms Physicians Care N", "plan_name": "714210", "standard_charge_dollar": 498.25, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Peoples Hlth Ffs 72126", "plan_name": "500019", "standard_charge_dollar": 398.60, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Uhc/Secure Horizons", "plan_name": "500449", "standard_charge_dollar": 398.60, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "United Health Care/", "plan_name": "500292", "standard_charge_dollar": 450.42, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "United Healthcare", "plan_name": "750104", "standard_charge_dollar": 450.42, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "United Healthcare Ba", "plan_name": "750090", "standard_charge_dollar": 450.42, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "United Healthcare Me", "plan_name": "501310", "standard_charge_dollar": 398.60, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Windsor Mcare Extra", "plan_name": "500778", "standard_charge_dollar": 398.60, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." } ] } ] }, { "description": "Ct chest spine w/o dye", "code_information": [ { "code": "72128", "type": "CPT" } ], "standard_charges": [ { "gross_charge": 991.50, "minimum": 168.74, "maximum": 257.13, "setting": "both", "payers_information": [ { "payer_name": "Aarp", "plan_name": "500102", "standard_charge_dollar": 205.70, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna", "plan_name": "700700", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna", "plan_name": "700700_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Mcare Ffs 6005", "plan_name": "700703", "standard_charge_dollar": 205.70, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Miscellaneous", "plan_name": "700720", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Miscellaneous", "plan_name": "700720_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Ppo Hmo", "plan_name": "701720", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Ppo Hmo", "plan_name": "701720_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Ambetter 68069", "plan_name": "500516", "standard_charge_dollar": 205.70, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Ms State Emplo", "plan_name": "401457", "standard_charge_dollar": 168.74, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Ms State Emplo", "plan_name": "401457_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Basic Pl", "plan_name": "400100", "standard_charge_dollar": 168.74, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Basic Pl", "plan_name": "400100_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Federal", "plan_name": "400110", "standard_charge_dollar": 168.74, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Federal", "plan_name": "400110_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Cigna Healthsprings Ffs", "plan_name": "500064", "standard_charge_dollar": 205.70, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Conseco", "plan_name": "500302", "standard_charge_dollar": 205.70, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Humana Ffs 61101", "plan_name": "500006", "standard_charge_dollar": 205.70, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Medicare A", "plan_name": "100100", "standard_charge_dollar": 205.70, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Medicare A", "plan_name": "100500", "standard_charge_dollar": 205.70, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Medicare Part B Only", "plan_name": "100300", "standard_charge_dollar": 205.70, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Medicare Railroad", "plan_name": "100103", "standard_charge_dollar": 205.70, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Ms Physicians Care N", "plan_name": "714210", "standard_charge_dollar": 257.13, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Peoples Hlth Ffs 72126", "plan_name": "500019", "standard_charge_dollar": 205.70, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Uhc/Secure Horizons", "plan_name": "500449", "standard_charge_dollar": 205.70, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "United Health Care/", "plan_name": "500292", "standard_charge_dollar": 232.44, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "United Healthcare", "plan_name": "750104", "standard_charge_dollar": 232.44, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "United Healthcare Ba", "plan_name": "750090", "standard_charge_dollar": 232.44, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "United Healthcare Me", "plan_name": "501310", "standard_charge_dollar": 205.70, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Windsor Mcare Extra", "plan_name": "500778", "standard_charge_dollar": 205.70, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." } ] } ] }, { "description": "Hc ct spine thoracic w/o contrast", "code_information": [ { "code": "72128", "type": "CPT" } ], "standard_charges": [ { "gross_charge": 991.50, "minimum": 168.74, "maximum": 257.13, "setting": "both", "payers_information": [ { "payer_name": "Aarp", "plan_name": "500102", "standard_charge_dollar": 205.70, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna", "plan_name": "700700", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna", "plan_name": "700700_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Mcare Ffs 6005", "plan_name": "700703", "standard_charge_dollar": 205.70, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Miscellaneous", "plan_name": "700720", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Miscellaneous", "plan_name": "700720_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Ppo Hmo", "plan_name": "701720", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Ppo Hmo", "plan_name": "701720_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Ambetter 68069", "plan_name": "500516", "standard_charge_dollar": 205.70, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Ms State Emplo", "plan_name": "401457", "standard_charge_dollar": 168.74, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Ms State Emplo", "plan_name": "401457_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Basic Pl", "plan_name": "400100", "standard_charge_dollar": 168.74, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Basic Pl", "plan_name": "400100_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Federal", "plan_name": "400110", "standard_charge_dollar": 168.74, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Federal", "plan_name": "400110_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Cigna Healthsprings Ffs", "plan_name": "500064", "standard_charge_dollar": 205.70, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Conseco", "plan_name": "500302", "standard_charge_dollar": 205.70, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Humana Ffs 61101", "plan_name": "500006", "standard_charge_dollar": 205.70, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Medicare A", "plan_name": "100100", "standard_charge_dollar": 205.70, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Medicare A", "plan_name": "100500", "standard_charge_dollar": 205.70, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Medicare Part B Only", "plan_name": "100300", "standard_charge_dollar": 205.70, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Medicare Railroad", "plan_name": "100103", "standard_charge_dollar": 205.70, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Ms Physicians Care N", "plan_name": "714210", "standard_charge_dollar": 257.13, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Peoples Hlth Ffs 72126", "plan_name": "500019", "standard_charge_dollar": 205.70, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Uhc/Secure Horizons", "plan_name": "500449", "standard_charge_dollar": 205.70, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "United Health Care/", "plan_name": "500292", "standard_charge_dollar": 232.44, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "United Healthcare", "plan_name": "750104", "standard_charge_dollar": 232.44, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "United Healthcare Ba", "plan_name": "750090", "standard_charge_dollar": 232.44, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "United Healthcare Me", "plan_name": "501310", "standard_charge_dollar": 205.70, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Windsor Mcare Extra", "plan_name": "500778", "standard_charge_dollar": 205.70, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." } ] } ] }, { "description": "Ct lumbar spine w/o dye", "code_information": [ { "code": "72131", "type": "CPT" } ], "standard_charges": [ { "gross_charge": 991.50, "minimum": 168.74, "maximum": 257.13, "setting": "both", "payers_information": [ { "payer_name": "Aarp", "plan_name": "500102", "standard_charge_dollar": 205.70, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna", "plan_name": "700700", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna", "plan_name": "700700_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Mcare Ffs 6005", "plan_name": "700703", "standard_charge_dollar": 205.70, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Miscellaneous", "plan_name": "700720", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Miscellaneous", "plan_name": "700720_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Ppo Hmo", "plan_name": "701720", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Ppo Hmo", "plan_name": "701720_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Ambetter 68069", "plan_name": "500516", "standard_charge_dollar": 205.70, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Ms State Emplo", "plan_name": "401457", "standard_charge_dollar": 168.74, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Ms State Emplo", "plan_name": "401457_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Basic Pl", "plan_name": "400100", "standard_charge_dollar": 168.74, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Basic Pl", "plan_name": "400100_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Federal", "plan_name": "400110", "standard_charge_dollar": 168.74, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Federal", "plan_name": "400110_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Cigna Healthsprings Ffs", "plan_name": "500064", "standard_charge_dollar": 205.70, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Conseco", "plan_name": "500302", "standard_charge_dollar": 205.70, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Humana Ffs 61101", "plan_name": "500006", "standard_charge_dollar": 205.70, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Medicare A", "plan_name": "100100", "standard_charge_dollar": 205.70, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Medicare A", "plan_name": "100500", "standard_charge_dollar": 205.70, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Medicare Part B Only", "plan_name": "100300", "standard_charge_dollar": 205.70, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Medicare Railroad", "plan_name": "100103", "standard_charge_dollar": 205.70, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Ms Physicians Care N", "plan_name": "714210", "standard_charge_dollar": 257.13, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Peoples Hlth Ffs 72126", "plan_name": "500019", "standard_charge_dollar": 205.70, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Uhc/Secure Horizons", "plan_name": "500449", "standard_charge_dollar": 205.70, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "United Health Care/", "plan_name": "500292", "standard_charge_dollar": 232.44, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "United Healthcare", "plan_name": "750104", "standard_charge_dollar": 232.44, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "United Healthcare Ba", "plan_name": "750090", "standard_charge_dollar": 232.44, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "United Healthcare Me", "plan_name": "501310", "standard_charge_dollar": 205.70, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Windsor Mcare Extra", "plan_name": "500778", "standard_charge_dollar": 205.70, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." } ] } ] }, { "description": "Hc ct spine lumbar w/o contrast", "code_information": [ { "code": "72131", "type": "CPT" } ], "standard_charges": [ { "gross_charge": 991.50, "minimum": 168.74, "maximum": 257.13, "setting": "both", "payers_information": [ { "payer_name": "Aarp", "plan_name": "500102", "standard_charge_dollar": 205.70, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna", "plan_name": "700700", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna", "plan_name": "700700_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Mcare Ffs 6005", "plan_name": "700703", "standard_charge_dollar": 205.70, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Miscellaneous", "plan_name": "700720", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Miscellaneous", "plan_name": "700720_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Ppo Hmo", "plan_name": "701720", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Ppo Hmo", "plan_name": "701720_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Ambetter 68069", "plan_name": "500516", "standard_charge_dollar": 205.70, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Ms State Emplo", "plan_name": "401457", "standard_charge_dollar": 168.74, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Ms State Emplo", "plan_name": "401457_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Basic Pl", "plan_name": "400100", "standard_charge_dollar": 168.74, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Basic Pl", "plan_name": "400100_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Federal", "plan_name": "400110", "standard_charge_dollar": 168.74, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Federal", "plan_name": "400110_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Cigna Healthsprings Ffs", "plan_name": "500064", "standard_charge_dollar": 205.70, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Conseco", "plan_name": "500302", "standard_charge_dollar": 205.70, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Humana Ffs 61101", "plan_name": "500006", "standard_charge_dollar": 205.70, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Medicare A", "plan_name": "100100", "standard_charge_dollar": 205.70, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Medicare A", "plan_name": "100500", "standard_charge_dollar": 205.70, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Medicare Part B Only", "plan_name": "100300", "standard_charge_dollar": 205.70, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Medicare Railroad", "plan_name": "100103", "standard_charge_dollar": 205.70, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Ms Physicians Care N", "plan_name": "714210", "standard_charge_dollar": 257.13, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Peoples Hlth Ffs 72126", "plan_name": "500019", "standard_charge_dollar": 205.70, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Uhc/Secure Horizons", "plan_name": "500449", "standard_charge_dollar": 205.70, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "United Health Care/", "plan_name": "500292", "standard_charge_dollar": 232.44, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "United Healthcare", "plan_name": "750104", "standard_charge_dollar": 232.44, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "United Healthcare Ba", "plan_name": "750090", "standard_charge_dollar": 232.44, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "United Healthcare Me", "plan_name": "501310", "standard_charge_dollar": 205.70, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Windsor Mcare Extra", "plan_name": "500778", "standard_charge_dollar": 205.70, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." } ] } ] }, { "description": "Hc pelvis 1 or 2 view", "code_information": [ { "code": "72170", "type": "CPT" } ], "standard_charges": [ { "gross_charge": 150.00, "minimum": 97.41, "maximum": 151.04, "setting": "both", "payers_information": [ { "payer_name": "Aarp", "plan_name": "500102", "standard_charge_dollar": 97.41, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna", "plan_name": "700700", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna", "plan_name": "700700_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Mcare Ffs 6005", "plan_name": "700703", "standard_charge_dollar": 97.41, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Miscellaneous", "plan_name": "700720", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Miscellaneous", "plan_name": "700720_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Ppo Hmo", "plan_name": "701720", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Ppo Hmo", "plan_name": "701720_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Ambetter 68069", "plan_name": "500516", "standard_charge_dollar": 97.41, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Ms State Emplo", "plan_name": "401457", "standard_charge_dollar": 151.04, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Ms State Emplo", "plan_name": "401457_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Basic Pl", "plan_name": "400100", "standard_charge_dollar": 151.04, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Basic Pl", "plan_name": "400100_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Federal", "plan_name": "400110", "standard_charge_dollar": 151.04, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Federal", "plan_name": "400110_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Cigna Healthsprings Ffs", "plan_name": "500064", "standard_charge_dollar": 97.41, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Conseco", "plan_name": "500302", "standard_charge_dollar": 97.41, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Humana Ffs 61101", "plan_name": "500006", "standard_charge_dollar": 97.41, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Medicare A", "plan_name": "100100", "standard_charge_dollar": 97.41, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Medicare A", "plan_name": "100500", "standard_charge_dollar": 97.41, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Medicare Part B Only", "plan_name": "100300", "standard_charge_dollar": 97.41, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Medicare Railroad", "plan_name": "100103", "standard_charge_dollar": 97.41, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Ms Physicians Care N", "plan_name": "714210", "standard_charge_dollar": 121.77, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Peoples Hlth Ffs 72126", "plan_name": "500019", "standard_charge_dollar": 97.41, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Uhc/Secure Horizons", "plan_name": "500449", "standard_charge_dollar": 97.41, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "United Health Care/", "plan_name": "500292", "standard_charge_dollar": 110.08, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "United Healthcare", "plan_name": "750104", "standard_charge_dollar": 110.08, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "United Healthcare Ba", "plan_name": "750090", "standard_charge_dollar": 110.08, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "United Healthcare Me", "plan_name": "501310", "standard_charge_dollar": 97.41, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Windsor Mcare Extra", "plan_name": "500778", "standard_charge_dollar": 97.41, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." } ] } ] }, { "description": "X-ray exam of pelvis", "code_information": [ { "code": "72170", "type": "CPT" } ], "standard_charges": [ { "gross_charge": 150.00, "minimum": 97.41, "maximum": 151.04, "setting": "both", "payers_information": [ { "payer_name": "Aarp", "plan_name": "500102", "standard_charge_dollar": 97.41, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna", "plan_name": "700700", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna", "plan_name": "700700_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Mcare Ffs 6005", "plan_name": "700703", "standard_charge_dollar": 97.41, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Miscellaneous", "plan_name": "700720", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Miscellaneous", "plan_name": "700720_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Ppo Hmo", "plan_name": "701720", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Ppo Hmo", "plan_name": "701720_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Ambetter 68069", "plan_name": "500516", "standard_charge_dollar": 97.41, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Ms State Emplo", "plan_name": "401457", "standard_charge_dollar": 151.04, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Ms State Emplo", "plan_name": "401457_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Basic Pl", "plan_name": "400100", "standard_charge_dollar": 151.04, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Basic Pl", "plan_name": "400100_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Federal", "plan_name": "400110", "standard_charge_dollar": 151.04, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Federal", "plan_name": "400110_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Cigna Healthsprings Ffs", "plan_name": "500064", "standard_charge_dollar": 97.41, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Conseco", "plan_name": "500302", "standard_charge_dollar": 97.41, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Humana Ffs 61101", "plan_name": "500006", "standard_charge_dollar": 97.41, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Medicare A", "plan_name": "100100", "standard_charge_dollar": 97.41, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Medicare A", "plan_name": "100500", "standard_charge_dollar": 97.41, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Medicare Part B Only", "plan_name": "100300", "standard_charge_dollar": 97.41, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Medicare Railroad", "plan_name": "100103", "standard_charge_dollar": 97.41, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Ms Physicians Care N", "plan_name": "714210", "standard_charge_dollar": 121.77, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Peoples Hlth Ffs 72126", "plan_name": "500019", "standard_charge_dollar": 97.41, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Uhc/Secure Horizons", "plan_name": "500449", "standard_charge_dollar": 97.41, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "United Health Care/", "plan_name": "500292", "standard_charge_dollar": 110.08, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "United Healthcare", "plan_name": "750104", "standard_charge_dollar": 110.08, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "United Healthcare Ba", "plan_name": "750090", "standard_charge_dollar": 110.08, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "United Healthcare Me", "plan_name": "501310", "standard_charge_dollar": 97.41, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Windsor Mcare Extra", "plan_name": "500778", "standard_charge_dollar": 97.41, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." } ] } ] }, { "description": "Hc pelvis 1 or 2 view", "code_information": [ { "code": "72170", "type": "CPT" } ], "standard_charges": [ { "gross_charge": 600.00, "minimum": 97.41, "maximum": 510.00, "setting": "both", "payers_information": [ { "payer_name": "Aarp", "plan_name": "500102", "standard_charge_dollar": 97.41, "count": "0", "methodology": "fee schedule", "modifiers": "50", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna", "plan_name": "700700", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna", "plan_name": "700700_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Mcare Ffs 6005", "plan_name": "700703", "standard_charge_dollar": 97.41, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Miscellaneous", "plan_name": "700720", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Miscellaneous", "plan_name": "700720_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Ppo Hmo", "plan_name": "701720", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Ppo Hmo", "plan_name": "701720_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Ambetter 68069", "plan_name": "500516", "standard_charge_dollar": 97.41, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Ms State Emplo", "plan_name": "401457", "standard_charge_percentage": 0.80, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Ms State Emplo", "plan_name": "401457_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Basic Pl", "plan_name": "400100", "standard_charge_percentage": 0.85, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Basic Pl", "plan_name": "400100_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Federal", "plan_name": "400110", "standard_charge_percentage": 0.85, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Federal", "plan_name": "400110_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Cigna Healthsprings Ffs", "plan_name": "500064", "standard_charge_dollar": 97.41, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Conseco", "plan_name": "500302", "standard_charge_dollar": 97.41, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Humana Ffs 61101", "plan_name": "500006", "standard_charge_dollar": 97.41, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Medicare A", "plan_name": "100100", "standard_charge_dollar": 97.41, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Medicare A", "plan_name": "100500", "standard_charge_dollar": 97.41, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Medicare Part B Only", "plan_name": "100300", "standard_charge_dollar": 97.41, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Medicare Railroad", "plan_name": "100103", "standard_charge_dollar": 97.41, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Ms Physicians Care N", "plan_name": "714210", "standard_charge_dollar": 121.77, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Peoples Hlth Ffs 72126", "plan_name": "500019", "standard_charge_dollar": 97.41, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Uhc/Secure Horizons", "plan_name": "500449", "standard_charge_dollar": 97.41, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "United Health Care/", "plan_name": "500292", "standard_charge_dollar": 110.08, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "United Healthcare", "plan_name": "750104", "standard_charge_dollar": 110.08, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "United Healthcare Ba", "plan_name": "750090", "standard_charge_dollar": 110.08, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "United Healthcare Me", "plan_name": "501310", "standard_charge_dollar": 97.41, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Windsor Mcare Extra", "plan_name": "500778", "standard_charge_dollar": 97.41, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." } ] } ] }, { "description": "Ct pelvis w/o dye", "code_information": [ { "code": "72192", "type": "CPT" } ], "standard_charges": [ { "gross_charge": 1000.39, "minimum": 168.74, "maximum": 257.13, "setting": "both", "payers_information": [ { "payer_name": "Aarp", "plan_name": "500102", "standard_charge_dollar": 205.70, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna", "plan_name": "700700", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna", "plan_name": "700700_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Mcare Ffs 6005", "plan_name": "700703", "standard_charge_dollar": 205.70, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Miscellaneous", "plan_name": "700720", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Miscellaneous", "plan_name": "700720_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Ppo Hmo", "plan_name": "701720", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Ppo Hmo", "plan_name": "701720_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Ambetter 68069", "plan_name": "500516", "standard_charge_dollar": 205.70, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Ms State Emplo", "plan_name": "401457", "standard_charge_dollar": 168.74, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Ms State Emplo", "plan_name": "401457_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Basic Pl", "plan_name": "400100", "standard_charge_dollar": 168.74, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Basic Pl", "plan_name": "400100_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Federal", "plan_name": "400110", "standard_charge_dollar": 168.74, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Federal", "plan_name": "400110_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Cigna Healthsprings Ffs", "plan_name": "500064", "standard_charge_dollar": 205.70, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Conseco", "plan_name": "500302", "standard_charge_dollar": 205.70, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Humana Ffs 61101", "plan_name": "500006", "standard_charge_dollar": 205.70, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Medicare A", "plan_name": "100100", "standard_charge_dollar": 205.70, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Medicare A", "plan_name": "100500", "standard_charge_dollar": 205.70, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Medicare Part B Only", "plan_name": "100300", "standard_charge_dollar": 205.70, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Medicare Railroad", "plan_name": "100103", "standard_charge_dollar": 205.70, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Ms Physicians Care N", "plan_name": "714210", "standard_charge_dollar": 257.13, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Peoples Hlth Ffs 72126", "plan_name": "500019", "standard_charge_dollar": 205.70, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Uhc/Secure Horizons", "plan_name": "500449", "standard_charge_dollar": 205.70, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "United Health Care/", "plan_name": "500292", "standard_charge_dollar": 232.44, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "United Healthcare", "plan_name": "750104", "standard_charge_dollar": 232.44, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "United Healthcare Ba", "plan_name": "750090", "standard_charge_dollar": 232.44, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "United Healthcare Me", "plan_name": "501310", "standard_charge_dollar": 205.70, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Windsor Mcare Extra", "plan_name": "500778", "standard_charge_dollar": 205.70, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." } ] } ] }, { "description": "Hc ct pelvis w/o contrast", "code_information": [ { "code": "72192", "type": "CPT" } ], "standard_charges": [ { "gross_charge": 1000.39, "minimum": 168.74, "maximum": 257.13, "setting": "both", "payers_information": [ { "payer_name": "Aarp", "plan_name": "500102", "standard_charge_dollar": 205.70, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna", "plan_name": "700700", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna", "plan_name": "700700_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Mcare Ffs 6005", "plan_name": "700703", "standard_charge_dollar": 205.70, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Miscellaneous", "plan_name": "700720", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Miscellaneous", "plan_name": "700720_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Ppo Hmo", "plan_name": "701720", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Ppo Hmo", "plan_name": "701720_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Ambetter 68069", "plan_name": "500516", "standard_charge_dollar": 205.70, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Ms State Emplo", "plan_name": "401457", "standard_charge_dollar": 168.74, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Ms State Emplo", "plan_name": "401457_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Basic Pl", "plan_name": "400100", "standard_charge_dollar": 168.74, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Basic Pl", "plan_name": "400100_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Federal", "plan_name": "400110", "standard_charge_dollar": 168.74, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Federal", "plan_name": "400110_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Cigna Healthsprings Ffs", "plan_name": "500064", "standard_charge_dollar": 205.70, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Conseco", "plan_name": "500302", "standard_charge_dollar": 205.70, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Humana Ffs 61101", "plan_name": "500006", "standard_charge_dollar": 205.70, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Medicare A", "plan_name": "100100", "standard_charge_dollar": 205.70, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Medicare A", "plan_name": "100500", "standard_charge_dollar": 205.70, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Medicare Part B Only", "plan_name": "100300", "standard_charge_dollar": 205.70, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Medicare Railroad", "plan_name": "100103", "standard_charge_dollar": 205.70, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Ms Physicians Care N", "plan_name": "714210", "standard_charge_dollar": 257.13, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Peoples Hlth Ffs 72126", "plan_name": "500019", "standard_charge_dollar": 205.70, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Uhc/Secure Horizons", "plan_name": "500449", "standard_charge_dollar": 205.70, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "United Health Care/", "plan_name": "500292", "standard_charge_dollar": 232.44, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "United Healthcare", "plan_name": "750104", "standard_charge_dollar": 232.44, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "United Healthcare Ba", "plan_name": "750090", "standard_charge_dollar": 232.44, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "United Healthcare Me", "plan_name": "501310", "standard_charge_dollar": 205.70, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Windsor Mcare Extra", "plan_name": "500778", "standard_charge_dollar": 205.70, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." } ] } ] }, { "description": "Ct pelvis w/dye", "code_information": [ { "code": "72193", "type": "CPT" } ], "standard_charges": [ { "gross_charge": 1400.00, "minimum": 355.29, "maximum": 498.25, "setting": "both", "payers_information": [ { "payer_name": "Aarp", "plan_name": "500102", "standard_charge_dollar": 398.60, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna", "plan_name": "700700", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna", "plan_name": "700700_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Mcare Ffs 6005", "plan_name": "700703", "standard_charge_dollar": 398.60, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Miscellaneous", "plan_name": "700720", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Miscellaneous", "plan_name": "700720_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Ppo Hmo", "plan_name": "701720", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Ppo Hmo", "plan_name": "701720_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Ambetter 68069", "plan_name": "500516", "standard_charge_dollar": 398.60, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Ms State Emplo", "plan_name": "401457", "standard_charge_dollar": 355.29, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Ms State Emplo", "plan_name": "401457_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Basic Pl", "plan_name": "400100", "standard_charge_dollar": 355.29, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Basic Pl", "plan_name": "400100_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Federal", "plan_name": "400110", "standard_charge_dollar": 355.29, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Federal", "plan_name": "400110_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Cigna Healthsprings Ffs", "plan_name": "500064", "standard_charge_dollar": 398.60, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Conseco", "plan_name": "500302", "standard_charge_dollar": 398.60, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Humana Ffs 61101", "plan_name": "500006", "standard_charge_dollar": 398.60, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Medicare A", "plan_name": "100100", "standard_charge_dollar": 398.60, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Medicare A", "plan_name": "100500", "standard_charge_dollar": 398.60, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Medicare Part B Only", "plan_name": "100300", "standard_charge_dollar": 398.60, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Medicare Railroad", "plan_name": "100103", "standard_charge_dollar": 398.60, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Ms Physicians Care N", "plan_name": "714210", "standard_charge_dollar": 498.25, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Peoples Hlth Ffs 72126", "plan_name": "500019", "standard_charge_dollar": 398.60, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Uhc/Secure Horizons", "plan_name": "500449", "standard_charge_dollar": 398.60, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "United Health Care/", "plan_name": "500292", "standard_charge_dollar": 450.42, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "United Healthcare", "plan_name": "750104", "standard_charge_dollar": 450.42, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "United Healthcare Ba", "plan_name": "750090", "standard_charge_dollar": 450.42, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "United Healthcare Me", "plan_name": "501310", "standard_charge_dollar": 398.60, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Windsor Mcare Extra", "plan_name": "500778", "standard_charge_dollar": 398.60, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." } ] } ] }, { "description": "Hc ct pelvis w/contrast", "code_information": [ { "code": "72193", "type": "CPT" } ], "standard_charges": [ { "gross_charge": 1400.00, "minimum": 355.29, "maximum": 498.25, "setting": "both", "payers_information": [ { "payer_name": "Aarp", "plan_name": "500102", "standard_charge_dollar": 398.60, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna", "plan_name": "700700", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna", "plan_name": "700700_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Mcare Ffs 6005", "plan_name": "700703", "standard_charge_dollar": 398.60, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Miscellaneous", "plan_name": "700720", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Miscellaneous", "plan_name": "700720_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Ppo Hmo", "plan_name": "701720", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Ppo Hmo", "plan_name": "701720_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Ambetter 68069", "plan_name": "500516", "standard_charge_dollar": 398.60, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Ms State Emplo", "plan_name": "401457", "standard_charge_dollar": 355.29, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Ms State Emplo", "plan_name": "401457_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Basic Pl", "plan_name": "400100", "standard_charge_dollar": 355.29, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Basic Pl", "plan_name": "400100_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Federal", "plan_name": "400110", "standard_charge_dollar": 355.29, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Federal", "plan_name": "400110_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Cigna Healthsprings Ffs", "plan_name": "500064", "standard_charge_dollar": 398.60, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Conseco", "plan_name": "500302", "standard_charge_dollar": 398.60, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Humana Ffs 61101", "plan_name": "500006", "standard_charge_dollar": 398.60, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Medicare A", "plan_name": "100100", "standard_charge_dollar": 398.60, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Medicare A", "plan_name": "100500", "standard_charge_dollar": 398.60, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Medicare Part B Only", "plan_name": "100300", "standard_charge_dollar": 398.60, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Medicare Railroad", "plan_name": "100103", "standard_charge_dollar": 398.60, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Ms Physicians Care N", "plan_name": "714210", "standard_charge_dollar": 498.25, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Peoples Hlth Ffs 72126", "plan_name": "500019", "standard_charge_dollar": 398.60, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Uhc/Secure Horizons", "plan_name": "500449", "standard_charge_dollar": 398.60, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "United Health Care/", "plan_name": "500292", "standard_charge_dollar": 450.42, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "United Healthcare", "plan_name": "750104", "standard_charge_dollar": 450.42, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "United Healthcare Ba", "plan_name": "750090", "standard_charge_dollar": 450.42, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "United Healthcare Me", "plan_name": "501310", "standard_charge_dollar": 398.60, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Windsor Mcare Extra", "plan_name": "500778", "standard_charge_dollar": 398.60, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." } ] } ] }, { "description": "Ct pelvis w/o & w/dye", "code_information": [ { "code": "72194", "type": "CPT" } ], "standard_charges": [ { "gross_charge": 1500.00, "minimum": 355.29, "maximum": 498.25, "setting": "both", "payers_information": [ { "payer_name": "Aarp", "plan_name": "500102", "standard_charge_dollar": 398.60, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna", "plan_name": "700700", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna", "plan_name": "700700_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Mcare Ffs 6005", "plan_name": "700703", "standard_charge_dollar": 398.60, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Miscellaneous", "plan_name": "700720", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Miscellaneous", "plan_name": "700720_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Ppo Hmo", "plan_name": "701720", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Ppo Hmo", "plan_name": "701720_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Ambetter 68069", "plan_name": "500516", "standard_charge_dollar": 398.60, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Ms State Emplo", "plan_name": "401457", "standard_charge_dollar": 355.29, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Ms State Emplo", "plan_name": "401457_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Basic Pl", "plan_name": "400100", "standard_charge_dollar": 355.29, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Basic Pl", "plan_name": "400100_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Federal", "plan_name": "400110", "standard_charge_dollar": 355.29, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Federal", "plan_name": "400110_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Cigna Healthsprings Ffs", "plan_name": "500064", "standard_charge_dollar": 398.60, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Conseco", "plan_name": "500302", "standard_charge_dollar": 398.60, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Humana Ffs 61101", "plan_name": "500006", "standard_charge_dollar": 398.60, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Medicare A", "plan_name": "100100", "standard_charge_dollar": 398.60, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Medicare A", "plan_name": "100500", "standard_charge_dollar": 398.60, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Medicare Part B Only", "plan_name": "100300", "standard_charge_dollar": 398.60, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Medicare Railroad", "plan_name": "100103", "standard_charge_dollar": 398.60, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Ms Physicians Care N", "plan_name": "714210", "standard_charge_dollar": 498.25, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Peoples Hlth Ffs 72126", "plan_name": "500019", "standard_charge_dollar": 398.60, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Uhc/Secure Horizons", "plan_name": "500449", "standard_charge_dollar": 398.60, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "United Health Care/", "plan_name": "500292", "standard_charge_dollar": 450.42, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "United Healthcare", "plan_name": "750104", "standard_charge_dollar": 450.42, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "United Healthcare Ba", "plan_name": "750090", "standard_charge_dollar": 450.42, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "United Healthcare Me", "plan_name": "501310", "standard_charge_dollar": 398.60, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Windsor Mcare Extra", "plan_name": "500778", "standard_charge_dollar": 398.60, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." } ] } ] }, { "description": "Hc ct pelvis w/wo contrast", "code_information": [ { "code": "72194", "type": "CPT" } ], "standard_charges": [ { "gross_charge": 1500.00, "minimum": 355.29, "maximum": 498.25, "setting": "both", "payers_information": [ { "payer_name": "Aarp", "plan_name": "500102", "standard_charge_dollar": 398.60, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna", "plan_name": "700700", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna", "plan_name": "700700_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Mcare Ffs 6005", "plan_name": "700703", "standard_charge_dollar": 398.60, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Miscellaneous", "plan_name": "700720", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Miscellaneous", "plan_name": "700720_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Ppo Hmo", "plan_name": "701720", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Ppo Hmo", "plan_name": "701720_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Ambetter 68069", "plan_name": "500516", "standard_charge_dollar": 398.60, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Ms State Emplo", "plan_name": "401457", "standard_charge_dollar": 355.29, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Ms State Emplo", "plan_name": "401457_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Basic Pl", "plan_name": "400100", "standard_charge_dollar": 355.29, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Basic Pl", "plan_name": "400100_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Federal", "plan_name": "400110", "standard_charge_dollar": 355.29, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Federal", "plan_name": "400110_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Cigna Healthsprings Ffs", "plan_name": "500064", "standard_charge_dollar": 398.60, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Conseco", "plan_name": "500302", "standard_charge_dollar": 398.60, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Humana Ffs 61101", "plan_name": "500006", "standard_charge_dollar": 398.60, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Medicare A", "plan_name": "100100", "standard_charge_dollar": 398.60, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Medicare A", "plan_name": "100500", "standard_charge_dollar": 398.60, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Medicare Part B Only", "plan_name": "100300", "standard_charge_dollar": 398.60, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Medicare Railroad", "plan_name": "100103", "standard_charge_dollar": 398.60, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Ms Physicians Care N", "plan_name": "714210", "standard_charge_dollar": 498.25, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Peoples Hlth Ffs 72126", "plan_name": "500019", "standard_charge_dollar": 398.60, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Uhc/Secure Horizons", "plan_name": "500449", "standard_charge_dollar": 398.60, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "United Health Care/", "plan_name": "500292", "standard_charge_dollar": 450.42, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "United Healthcare", "plan_name": "750104", "standard_charge_dollar": 450.42, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "United Healthcare Ba", "plan_name": "750090", "standard_charge_dollar": 450.42, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "United Healthcare Me", "plan_name": "501310", "standard_charge_dollar": 398.60, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Windsor Mcare Extra", "plan_name": "500778", "standard_charge_dollar": 398.60, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." } ] } ] }, { "description": "Hc sacroiliac joints < 3 view", "code_information": [ { "code": "72200", "type": "CPT" } ], "standard_charges": [ { "gross_charge": 191.00, "minimum": 97.41, "maximum": 151.04, "setting": "both", "payers_information": [ { "payer_name": "Aarp", "plan_name": "500102", "standard_charge_dollar": 97.41, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna", "plan_name": "700700", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna", "plan_name": "700700_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Mcare Ffs 6005", "plan_name": "700703", "standard_charge_dollar": 97.41, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Miscellaneous", "plan_name": "700720", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Miscellaneous", "plan_name": "700720_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Ppo Hmo", "plan_name": "701720", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Ppo Hmo", "plan_name": "701720_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Ambetter 68069", "plan_name": "500516", "standard_charge_dollar": 97.41, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Ms State Emplo", "plan_name": "401457", "standard_charge_dollar": 151.04, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Ms State Emplo", "plan_name": "401457_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Basic Pl", "plan_name": "400100", "standard_charge_dollar": 151.04, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Basic Pl", "plan_name": "400100_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Federal", "plan_name": "400110", "standard_charge_dollar": 151.04, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Federal", "plan_name": "400110_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Cigna Healthsprings Ffs", "plan_name": "500064", "standard_charge_dollar": 97.41, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Conseco", "plan_name": "500302", "standard_charge_dollar": 97.41, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Humana Ffs 61101", "plan_name": "500006", "standard_charge_dollar": 97.41, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Medicare A", "plan_name": "100100", "standard_charge_dollar": 97.41, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Medicare A", "plan_name": "100500", "standard_charge_dollar": 97.41, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Medicare Part B Only", "plan_name": "100300", "standard_charge_dollar": 97.41, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Medicare Railroad", "plan_name": "100103", "standard_charge_dollar": 97.41, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Ms Physicians Care N", "plan_name": "714210", "standard_charge_dollar": 121.77, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Peoples Hlth Ffs 72126", "plan_name": "500019", "standard_charge_dollar": 97.41, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Uhc/Secure Horizons", "plan_name": "500449", "standard_charge_dollar": 97.41, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "United Health Care/", "plan_name": "500292", "standard_charge_dollar": 110.08, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "United Healthcare", "plan_name": "750104", "standard_charge_dollar": 110.08, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "United Healthcare Ba", "plan_name": "750090", "standard_charge_dollar": 110.08, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "United Healthcare Me", "plan_name": "501310", "standard_charge_dollar": 97.41, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Windsor Mcare Extra", "plan_name": "500778", "standard_charge_dollar": 97.41, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." } ] } ] }, { "description": "X-ray exam si joints", "code_information": [ { "code": "72200", "type": "CPT" } ], "standard_charges": [ { "gross_charge": 191.00, "minimum": 97.41, "maximum": 151.04, "setting": "both", "payers_information": [ { "payer_name": "Aarp", "plan_name": "500102", "standard_charge_dollar": 97.41, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna", "plan_name": "700700", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna", "plan_name": "700700_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Mcare Ffs 6005", "plan_name": "700703", "standard_charge_dollar": 97.41, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Miscellaneous", "plan_name": "700720", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Miscellaneous", "plan_name": "700720_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Ppo Hmo", "plan_name": "701720", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Ppo Hmo", "plan_name": "701720_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Ambetter 68069", "plan_name": "500516", "standard_charge_dollar": 97.41, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Ms State Emplo", "plan_name": "401457", "standard_charge_dollar": 151.04, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Ms State Emplo", "plan_name": "401457_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Basic Pl", "plan_name": "400100", "standard_charge_dollar": 151.04, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Basic Pl", "plan_name": "400100_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Federal", "plan_name": "400110", "standard_charge_dollar": 151.04, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Federal", "plan_name": "400110_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Cigna Healthsprings Ffs", "plan_name": "500064", "standard_charge_dollar": 97.41, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Conseco", "plan_name": "500302", "standard_charge_dollar": 97.41, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Humana Ffs 61101", "plan_name": "500006", "standard_charge_dollar": 97.41, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Medicare A", "plan_name": "100100", "standard_charge_dollar": 97.41, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Medicare A", "plan_name": "100500", "standard_charge_dollar": 97.41, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Medicare Part B Only", "plan_name": "100300", "standard_charge_dollar": 97.41, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Medicare Railroad", "plan_name": "100103", "standard_charge_dollar": 97.41, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Ms Physicians Care N", "plan_name": "714210", "standard_charge_dollar": 121.77, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Peoples Hlth Ffs 72126", "plan_name": "500019", "standard_charge_dollar": 97.41, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Uhc/Secure Horizons", "plan_name": "500449", "standard_charge_dollar": 97.41, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "United Health Care/", "plan_name": "500292", "standard_charge_dollar": 110.08, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "United Healthcare", "plan_name": "750104", "standard_charge_dollar": 110.08, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "United Healthcare Ba", "plan_name": "750090", "standard_charge_dollar": 110.08, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "United Healthcare Me", "plan_name": "501310", "standard_charge_dollar": 97.41, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Windsor Mcare Extra", "plan_name": "500778", "standard_charge_dollar": 97.41, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." } ] } ] }, { "description": "Hc sacroiliac joints min 3 view", "code_information": [ { "code": "72202", "type": "CPT" } ], "standard_charges": [ { "gross_charge": 228.00, "minimum": 97.41, "maximum": 151.04, "setting": "both", "payers_information": [ { "payer_name": "Aarp", "plan_name": "500102", "standard_charge_dollar": 97.41, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna", "plan_name": "700700", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna", "plan_name": "700700_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Mcare Ffs 6005", "plan_name": "700703", "standard_charge_dollar": 97.41, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Miscellaneous", "plan_name": "700720", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Miscellaneous", "plan_name": "700720_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Ppo Hmo", "plan_name": "701720", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Ppo Hmo", "plan_name": "701720_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Ambetter 68069", "plan_name": "500516", "standard_charge_dollar": 97.41, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Ms State Emplo", "plan_name": "401457", "standard_charge_dollar": 151.04, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Ms State Emplo", "plan_name": "401457_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Basic Pl", "plan_name": "400100", "standard_charge_dollar": 151.04, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Basic Pl", "plan_name": "400100_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Federal", "plan_name": "400110", "standard_charge_dollar": 151.04, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Federal", "plan_name": "400110_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Cigna Healthsprings Ffs", "plan_name": "500064", "standard_charge_dollar": 97.41, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Conseco", "plan_name": "500302", "standard_charge_dollar": 97.41, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Humana Ffs 61101", "plan_name": "500006", "standard_charge_dollar": 97.41, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Medicare A", "plan_name": "100100", "standard_charge_dollar": 97.41, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Medicare A", "plan_name": "100500", "standard_charge_dollar": 97.41, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Medicare Part B Only", "plan_name": "100300", "standard_charge_dollar": 97.41, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Medicare Railroad", "plan_name": "100103", "standard_charge_dollar": 97.41, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Ms Physicians Care N", "plan_name": "714210", "standard_charge_dollar": 121.77, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Peoples Hlth Ffs 72126", "plan_name": "500019", "standard_charge_dollar": 97.41, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Uhc/Secure Horizons", "plan_name": "500449", "standard_charge_dollar": 97.41, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "United Health Care/", "plan_name": "500292", "standard_charge_dollar": 110.08, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "United Healthcare", "plan_name": "750104", "standard_charge_dollar": 110.08, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "United Healthcare Ba", "plan_name": "750090", "standard_charge_dollar": 110.08, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "United Healthcare Me", "plan_name": "501310", "standard_charge_dollar": 97.41, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Windsor Mcare Extra", "plan_name": "500778", "standard_charge_dollar": 97.41, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." } ] } ] }, { "description": "X-ray exam si joints 3/> vws", "code_information": [ { "code": "72202", "type": "CPT" } ], "standard_charges": [ { "gross_charge": 228.00, "minimum": 97.41, "maximum": 151.04, "setting": "both", "payers_information": [ { "payer_name": "Aarp", "plan_name": "500102", "standard_charge_dollar": 97.41, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna", "plan_name": "700700", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna", "plan_name": "700700_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Mcare Ffs 6005", "plan_name": "700703", "standard_charge_dollar": 97.41, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Miscellaneous", "plan_name": "700720", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Miscellaneous", "plan_name": "700720_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Ppo Hmo", "plan_name": "701720", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Ppo Hmo", "plan_name": "701720_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Ambetter 68069", "plan_name": "500516", "standard_charge_dollar": 97.41, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Ms State Emplo", "plan_name": "401457", "standard_charge_dollar": 151.04, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Ms State Emplo", "plan_name": "401457_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Basic Pl", "plan_name": "400100", "standard_charge_dollar": 151.04, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Basic Pl", "plan_name": "400100_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Federal", "plan_name": "400110", "standard_charge_dollar": 151.04, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Federal", "plan_name": "400110_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Cigna Healthsprings Ffs", "plan_name": "500064", "standard_charge_dollar": 97.41, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Conseco", "plan_name": "500302", "standard_charge_dollar": 97.41, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Humana Ffs 61101", "plan_name": "500006", "standard_charge_dollar": 97.41, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Medicare A", "plan_name": "100100", "standard_charge_dollar": 97.41, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Medicare A", "plan_name": "100500", "standard_charge_dollar": 97.41, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Medicare Part B Only", "plan_name": "100300", "standard_charge_dollar": 97.41, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Medicare Railroad", "plan_name": "100103", "standard_charge_dollar": 97.41, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Ms Physicians Care N", "plan_name": "714210", "standard_charge_dollar": 121.77, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Peoples Hlth Ffs 72126", "plan_name": "500019", "standard_charge_dollar": 97.41, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Uhc/Secure Horizons", "plan_name": "500449", "standard_charge_dollar": 97.41, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "United Health Care/", "plan_name": "500292", "standard_charge_dollar": 110.08, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "United Healthcare", "plan_name": "750104", "standard_charge_dollar": 110.08, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "United Healthcare Ba", "plan_name": "750090", "standard_charge_dollar": 110.08, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "United Healthcare Me", "plan_name": "501310", "standard_charge_dollar": 97.41, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Windsor Mcare Extra", "plan_name": "500778", "standard_charge_dollar": 97.41, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." } ] } ] }, { "description": "Hc sacrum coccyx min 2 view", "code_information": [ { "code": "72220", "type": "CPT" } ], "standard_charges": [ { "gross_charge": 168.84, "minimum": 80.66, "maximum": 100.82, "setting": "both", "payers_information": [ { "payer_name": "Aarp", "plan_name": "500102", "standard_charge_dollar": 80.66, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna", "plan_name": "700700", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna", "plan_name": "700700_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Mcare Ffs 6005", "plan_name": "700703", "standard_charge_dollar": 80.66, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Miscellaneous", "plan_name": "700720", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Miscellaneous", "plan_name": "700720_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Ppo Hmo", "plan_name": "701720", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Ppo Hmo", "plan_name": "701720_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Ambetter 68069", "plan_name": "500516", "standard_charge_dollar": 80.66, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Ms State Emplo", "plan_name": "401457", "standard_charge_dollar": 91.20, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Ms State Emplo", "plan_name": "401457_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Basic Pl", "plan_name": "400100", "standard_charge_dollar": 91.20, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Basic Pl", "plan_name": "400100_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Federal", "plan_name": "400110", "standard_charge_dollar": 91.20, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Federal", "plan_name": "400110_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Cigna Healthsprings Ffs", "plan_name": "500064", "standard_charge_dollar": 80.66, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Conseco", "plan_name": "500302", "standard_charge_dollar": 80.66, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Humana Ffs 61101", "plan_name": "500006", "standard_charge_dollar": 80.66, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Medicare A", "plan_name": "100100", "standard_charge_dollar": 80.66, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Medicare A", "plan_name": "100500", "standard_charge_dollar": 80.66, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Medicare Part B Only", "plan_name": "100300", "standard_charge_dollar": 80.66, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Medicare Railroad", "plan_name": "100103", "standard_charge_dollar": 80.66, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Ms Physicians Care N", "plan_name": "714210", "standard_charge_dollar": 100.82, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Peoples Hlth Ffs 72126", "plan_name": "500019", "standard_charge_dollar": 80.66, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Uhc/Secure Horizons", "plan_name": "500449", "standard_charge_dollar": 80.66, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "United Health Care/", "plan_name": "500292", "standard_charge_dollar": 91.15, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "United Healthcare", "plan_name": "750104", "standard_charge_dollar": 91.15, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "United Healthcare Ba", "plan_name": "750090", "standard_charge_dollar": 91.15, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "United Healthcare Me", "plan_name": "501310", "standard_charge_dollar": 80.66, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Windsor Mcare Extra", "plan_name": "500778", "standard_charge_dollar": 80.66, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." } ] } ] }, { "description": "X-ray exam sacrum tailbone", "code_information": [ { "code": "72220", "type": "CPT" } ], "standard_charges": [ { "gross_charge": 168.84, "minimum": 80.66, "maximum": 100.82, "setting": "both", "payers_information": [ { "payer_name": "Aarp", "plan_name": "500102", "standard_charge_dollar": 80.66, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna", "plan_name": "700700", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna", "plan_name": "700700_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Mcare Ffs 6005", "plan_name": "700703", "standard_charge_dollar": 80.66, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Miscellaneous", "plan_name": "700720", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Miscellaneous", "plan_name": "700720_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Ppo Hmo", "plan_name": "701720", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Ppo Hmo", "plan_name": "701720_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Ambetter 68069", "plan_name": "500516", "standard_charge_dollar": 80.66, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Ms State Emplo", "plan_name": "401457", "standard_charge_dollar": 91.20, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Ms State Emplo", "plan_name": "401457_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Basic Pl", "plan_name": "400100", "standard_charge_dollar": 91.20, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Basic Pl", "plan_name": "400100_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Federal", "plan_name": "400110", "standard_charge_dollar": 91.20, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Federal", "plan_name": "400110_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Cigna Healthsprings Ffs", "plan_name": "500064", "standard_charge_dollar": 80.66, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Conseco", "plan_name": "500302", "standard_charge_dollar": 80.66, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Humana Ffs 61101", "plan_name": "500006", "standard_charge_dollar": 80.66, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Medicare A", "plan_name": "100100", "standard_charge_dollar": 80.66, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Medicare A", "plan_name": "100500", "standard_charge_dollar": 80.66, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Medicare Part B Only", "plan_name": "100300", "standard_charge_dollar": 80.66, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Medicare Railroad", "plan_name": "100103", "standard_charge_dollar": 80.66, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Ms Physicians Care N", "plan_name": "714210", "standard_charge_dollar": 100.82, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Peoples Hlth Ffs 72126", "plan_name": "500019", "standard_charge_dollar": 80.66, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Uhc/Secure Horizons", "plan_name": "500449", "standard_charge_dollar": 80.66, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "United Health Care/", "plan_name": "500292", "standard_charge_dollar": 91.15, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "United Healthcare", "plan_name": "750104", "standard_charge_dollar": 91.15, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "United Healthcare Ba", "plan_name": "750090", "standard_charge_dollar": 91.15, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "United Healthcare Me", "plan_name": "501310", "standard_charge_dollar": 80.66, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Windsor Mcare Extra", "plan_name": "500778", "standard_charge_dollar": 80.66, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." } ] } ] }, { "description": "Hc clavicle complete", "code_information": [ { "code": "73000", "type": "CPT" } ], "standard_charges": [ { "gross_charge": 163.33, "minimum": 80.66, "maximum": 100.82, "setting": "both", "payers_information": [ { "payer_name": "Aarp", "plan_name": "500102", "standard_charge_dollar": 80.66, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna", "plan_name": "700700", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna", "plan_name": "700700_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Mcare Ffs 6005", "plan_name": "700703", "standard_charge_dollar": 80.66, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Miscellaneous", "plan_name": "700720", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Miscellaneous", "plan_name": "700720_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Ppo Hmo", "plan_name": "701720", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Ppo Hmo", "plan_name": "701720_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Ambetter 68069", "plan_name": "500516", "standard_charge_dollar": 80.66, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Ms State Emplo", "plan_name": "401457", "standard_charge_dollar": 91.20, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Ms State Emplo", "plan_name": "401457_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Basic Pl", "plan_name": "400100", "standard_charge_dollar": 91.20, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Basic Pl", "plan_name": "400100_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Federal", "plan_name": "400110", "standard_charge_dollar": 91.20, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Federal", "plan_name": "400110_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Cigna Healthsprings Ffs", "plan_name": "500064", "standard_charge_dollar": 80.66, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Conseco", "plan_name": "500302", "standard_charge_dollar": 80.66, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Humana Ffs 61101", "plan_name": "500006", "standard_charge_dollar": 80.66, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Medicare A", "plan_name": "100100", "standard_charge_dollar": 80.66, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Medicare A", "plan_name": "100500", "standard_charge_dollar": 80.66, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Medicare Part B Only", "plan_name": "100300", "standard_charge_dollar": 80.66, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Medicare Railroad", "plan_name": "100103", "standard_charge_dollar": 80.66, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Ms Physicians Care N", "plan_name": "714210", "standard_charge_dollar": 100.82, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Peoples Hlth Ffs 72126", "plan_name": "500019", "standard_charge_dollar": 80.66, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Uhc/Secure Horizons", "plan_name": "500449", "standard_charge_dollar": 80.66, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "United Health Care/", "plan_name": "500292", "standard_charge_dollar": 91.15, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "United Healthcare", "plan_name": "750104", "standard_charge_dollar": 91.15, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "United Healthcare Ba", "plan_name": "750090", "standard_charge_dollar": 91.15, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "United Healthcare Me", "plan_name": "501310", "standard_charge_dollar": 80.66, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Windsor Mcare Extra", "plan_name": "500778", "standard_charge_dollar": 80.66, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." } ] } ] }, { "description": "X-ray exam of collar bone", "code_information": [ { "code": "73000", "type": "CPT" } ], "standard_charges": [ { "gross_charge": 163.33, "minimum": 80.66, "maximum": 100.82, "setting": "both", "payers_information": [ { "payer_name": "Aarp", "plan_name": "500102", "standard_charge_dollar": 80.66, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna", "plan_name": "700700", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna", "plan_name": "700700_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Mcare Ffs 6005", "plan_name": "700703", "standard_charge_dollar": 80.66, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Miscellaneous", "plan_name": "700720", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Miscellaneous", "plan_name": "700720_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Ppo Hmo", "plan_name": "701720", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Ppo Hmo", "plan_name": "701720_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Ambetter 68069", "plan_name": "500516", "standard_charge_dollar": 80.66, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Ms State Emplo", "plan_name": "401457", "standard_charge_dollar": 91.20, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Ms State Emplo", "plan_name": "401457_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Basic Pl", "plan_name": "400100", "standard_charge_dollar": 91.20, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Basic Pl", "plan_name": "400100_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Federal", "plan_name": "400110", "standard_charge_dollar": 91.20, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Federal", "plan_name": "400110_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Cigna Healthsprings Ffs", "plan_name": "500064", "standard_charge_dollar": 80.66, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Conseco", "plan_name": "500302", "standard_charge_dollar": 80.66, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Humana Ffs 61101", "plan_name": "500006", "standard_charge_dollar": 80.66, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Medicare A", "plan_name": "100100", "standard_charge_dollar": 80.66, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Medicare A", "plan_name": "100500", "standard_charge_dollar": 80.66, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Medicare Part B Only", "plan_name": "100300", "standard_charge_dollar": 80.66, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Medicare Railroad", "plan_name": "100103", "standard_charge_dollar": 80.66, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Ms Physicians Care N", "plan_name": "714210", "standard_charge_dollar": 100.82, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Peoples Hlth Ffs 72126", "plan_name": "500019", "standard_charge_dollar": 80.66, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Uhc/Secure Horizons", "plan_name": "500449", "standard_charge_dollar": 80.66, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "United Health Care/", "plan_name": "500292", "standard_charge_dollar": 91.15, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "United Healthcare", "plan_name": "750104", "standard_charge_dollar": 91.15, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "United Healthcare Ba", "plan_name": "750090", "standard_charge_dollar": 91.15, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "United Healthcare Me", "plan_name": "501310", "standard_charge_dollar": 80.66, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Windsor Mcare Extra", "plan_name": "500778", "standard_charge_dollar": 80.66, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." } ] } ] }, { "description": "Hc clavicle complete", "code_information": [ { "code": "73000", "type": "CPT" } ], "standard_charges": [ { "gross_charge": 653.32, "minimum": 80.66, "maximum": 555.32, "setting": "both", "payers_information": [ { "payer_name": "Aarp", "plan_name": "500102", "standard_charge_dollar": 80.66, "count": "0", "methodology": "fee schedule", "modifiers": "50", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna", "plan_name": "700700", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna", "plan_name": "700700_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Mcare Ffs 6005", "plan_name": "700703", "standard_charge_dollar": 80.66, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Miscellaneous", "plan_name": "700720", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Miscellaneous", "plan_name": "700720_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Ppo Hmo", "plan_name": "701720", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Ppo Hmo", "plan_name": "701720_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Ambetter 68069", "plan_name": "500516", "standard_charge_dollar": 80.66, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Ms State Emplo", "plan_name": "401457", "standard_charge_percentage": 0.80, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Ms State Emplo", "plan_name": "401457_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Basic Pl", "plan_name": "400100", "standard_charge_percentage": 0.85, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Basic Pl", "plan_name": "400100_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Federal", "plan_name": "400110", "standard_charge_percentage": 0.85, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Federal", "plan_name": "400110_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Cigna Healthsprings Ffs", "plan_name": "500064", "standard_charge_dollar": 80.66, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Conseco", "plan_name": "500302", "standard_charge_dollar": 80.66, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Humana Ffs 61101", "plan_name": "500006", "standard_charge_dollar": 80.66, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Medicare A", "plan_name": "100100", "standard_charge_dollar": 80.66, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Medicare A", "plan_name": "100500", "standard_charge_dollar": 80.66, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Medicare Part B Only", "plan_name": "100300", "standard_charge_dollar": 80.66, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Medicare Railroad", "plan_name": "100103", "standard_charge_dollar": 80.66, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Ms Physicians Care N", "plan_name": "714210", "standard_charge_dollar": 100.82, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Peoples Hlth Ffs 72126", "plan_name": "500019", "standard_charge_dollar": 80.66, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Uhc/Secure Horizons", "plan_name": "500449", "standard_charge_dollar": 80.66, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "United Health Care/", "plan_name": "500292", "standard_charge_dollar": 91.15, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "United Healthcare", "plan_name": "750104", "standard_charge_dollar": 91.15, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "United Healthcare Ba", "plan_name": "750090", "standard_charge_dollar": 91.15, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "United Healthcare Me", "plan_name": "501310", "standard_charge_dollar": 80.66, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Windsor Mcare Extra", "plan_name": "500778", "standard_charge_dollar": 80.66, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." } ] } ] }, { "description": "Hc scapula complete", "code_information": [ { "code": "73010", "type": "CPT" } ], "standard_charges": [ { "gross_charge": 175.00, "minimum": 91.20, "maximum": 121.77, "setting": "both", "payers_information": [ { "payer_name": "Aarp", "plan_name": "500102", "standard_charge_dollar": 97.41, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna", "plan_name": "700700", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna", "plan_name": "700700_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Mcare Ffs 6005", "plan_name": "700703", "standard_charge_dollar": 97.41, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Miscellaneous", "plan_name": "700720", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Miscellaneous", "plan_name": "700720_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Ppo Hmo", "plan_name": "701720", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Ppo Hmo", "plan_name": "701720_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Ambetter 68069", "plan_name": "500516", "standard_charge_dollar": 97.41, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Ms State Emplo", "plan_name": "401457", "standard_charge_dollar": 91.20, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Ms State Emplo", "plan_name": "401457_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Basic Pl", "plan_name": "400100", "standard_charge_dollar": 91.20, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Basic Pl", "plan_name": "400100_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Federal", "plan_name": "400110", "standard_charge_dollar": 91.20, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Federal", "plan_name": "400110_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Cigna Healthsprings Ffs", "plan_name": "500064", "standard_charge_dollar": 97.41, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Conseco", "plan_name": "500302", "standard_charge_dollar": 97.41, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Humana Ffs 61101", "plan_name": "500006", "standard_charge_dollar": 97.41, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Medicare A", "plan_name": "100100", "standard_charge_dollar": 97.41, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Medicare A", "plan_name": "100500", "standard_charge_dollar": 97.41, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Medicare Part B Only", "plan_name": "100300", "standard_charge_dollar": 97.41, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Medicare Railroad", "plan_name": "100103", "standard_charge_dollar": 97.41, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Ms Physicians Care N", "plan_name": "714210", "standard_charge_dollar": 121.77, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Peoples Hlth Ffs 72126", "plan_name": "500019", "standard_charge_dollar": 97.41, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Uhc/Secure Horizons", "plan_name": "500449", "standard_charge_dollar": 97.41, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "United Health Care/", "plan_name": "500292", "standard_charge_dollar": 110.08, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "United Healthcare", "plan_name": "750104", "standard_charge_dollar": 110.08, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "United Healthcare Ba", "plan_name": "750090", "standard_charge_dollar": 110.08, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "United Healthcare Me", "plan_name": "501310", "standard_charge_dollar": 97.41, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Windsor Mcare Extra", "plan_name": "500778", "standard_charge_dollar": 97.41, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." } ] } ] }, { "description": "X-ray exam of shoulder blade", "code_information": [ { "code": "73010", "type": "CPT" } ], "standard_charges": [ { "gross_charge": 175.00, "minimum": 91.20, "maximum": 121.77, "setting": "both", "payers_information": [ { "payer_name": "Aarp", "plan_name": "500102", "standard_charge_dollar": 97.41, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna", "plan_name": "700700", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna", "plan_name": "700700_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Mcare Ffs 6005", "plan_name": "700703", "standard_charge_dollar": 97.41, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Miscellaneous", "plan_name": "700720", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Miscellaneous", "plan_name": "700720_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Ppo Hmo", "plan_name": "701720", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Ppo Hmo", "plan_name": "701720_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Ambetter 68069", "plan_name": "500516", "standard_charge_dollar": 97.41, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Ms State Emplo", "plan_name": "401457", "standard_charge_dollar": 91.20, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Ms State Emplo", "plan_name": "401457_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Basic Pl", "plan_name": "400100", "standard_charge_dollar": 91.20, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Basic Pl", "plan_name": "400100_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Federal", "plan_name": "400110", "standard_charge_dollar": 91.20, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Federal", "plan_name": "400110_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Cigna Healthsprings Ffs", "plan_name": "500064", "standard_charge_dollar": 97.41, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Conseco", "plan_name": "500302", "standard_charge_dollar": 97.41, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Humana Ffs 61101", "plan_name": "500006", "standard_charge_dollar": 97.41, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Medicare A", "plan_name": "100100", "standard_charge_dollar": 97.41, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Medicare A", "plan_name": "100500", "standard_charge_dollar": 97.41, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Medicare Part B Only", "plan_name": "100300", "standard_charge_dollar": 97.41, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Medicare Railroad", "plan_name": "100103", "standard_charge_dollar": 97.41, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Ms Physicians Care N", "plan_name": "714210", "standard_charge_dollar": 121.77, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Peoples Hlth Ffs 72126", "plan_name": "500019", "standard_charge_dollar": 97.41, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Uhc/Secure Horizons", "plan_name": "500449", "standard_charge_dollar": 97.41, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "United Health Care/", "plan_name": "500292", "standard_charge_dollar": 110.08, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "United Healthcare", "plan_name": "750104", "standard_charge_dollar": 110.08, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "United Healthcare Ba", "plan_name": "750090", "standard_charge_dollar": 110.08, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "United Healthcare Me", "plan_name": "501310", "standard_charge_dollar": 97.41, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Windsor Mcare Extra", "plan_name": "500778", "standard_charge_dollar": 97.41, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." } ] } ] }, { "description": "Hc shoulder 1 view", "code_information": [ { "code": "73020", "type": "CPT" } ], "standard_charges": [ { "gross_charge": 91.93, "minimum": 80.66, "maximum": 100.82, "setting": "both", "payers_information": [ { "payer_name": "Aarp", "plan_name": "500102", "standard_charge_dollar": 80.66, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna", "plan_name": "700700", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna", "plan_name": "700700_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Mcare Ffs 6005", "plan_name": "700703", "standard_charge_dollar": 80.66, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Miscellaneous", "plan_name": "700720", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Miscellaneous", "plan_name": "700720_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Ppo Hmo", "plan_name": "701720", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Ppo Hmo", "plan_name": "701720_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Ambetter 68069", "plan_name": "500516", "standard_charge_dollar": 80.66, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Ms State Emplo", "plan_name": "401457", "standard_charge_dollar": 91.20, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Ms State Emplo", "plan_name": "401457_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Basic Pl", "plan_name": "400100", "standard_charge_dollar": 91.20, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Basic Pl", "plan_name": "400100_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Federal", "plan_name": "400110", "standard_charge_dollar": 91.20, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Federal", "plan_name": "400110_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Cigna Healthsprings Ffs", "plan_name": "500064", "standard_charge_dollar": 80.66, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Conseco", "plan_name": "500302", "standard_charge_dollar": 80.66, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Humana Ffs 61101", "plan_name": "500006", "standard_charge_dollar": 80.66, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Medicare A", "plan_name": "100100", "standard_charge_dollar": 80.66, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Medicare A", "plan_name": "100500", "standard_charge_dollar": 80.66, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Medicare Part B Only", "plan_name": "100300", "standard_charge_dollar": 80.66, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Medicare Railroad", "plan_name": "100103", "standard_charge_dollar": 80.66, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Ms Physicians Care N", "plan_name": "714210", "standard_charge_dollar": 100.82, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Peoples Hlth Ffs 72126", "plan_name": "500019", "standard_charge_dollar": 80.66, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Uhc/Secure Horizons", "plan_name": "500449", "standard_charge_dollar": 80.66, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "United Health Care/", "plan_name": "500292", "standard_charge_dollar": 91.15, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "United Healthcare", "plan_name": "750104", "standard_charge_dollar": 91.15, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "United Healthcare Ba", "plan_name": "750090", "standard_charge_dollar": 91.15, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "United Healthcare Me", "plan_name": "501310", "standard_charge_dollar": 80.66, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Windsor Mcare Extra", "plan_name": "500778", "standard_charge_dollar": 80.66, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." } ] } ] }, { "description": "X-ray exam of shoulder", "code_information": [ { "code": "73020", "type": "CPT" } ], "standard_charges": [ { "gross_charge": 91.93, "minimum": 80.66, "maximum": 100.82, "setting": "both", "payers_information": [ { "payer_name": "Aarp", "plan_name": "500102", "standard_charge_dollar": 80.66, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna", "plan_name": "700700", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna", "plan_name": "700700_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Mcare Ffs 6005", "plan_name": "700703", "standard_charge_dollar": 80.66, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Miscellaneous", "plan_name": "700720", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Miscellaneous", "plan_name": "700720_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Ppo Hmo", "plan_name": "701720", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Ppo Hmo", "plan_name": "701720_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Ambetter 68069", "plan_name": "500516", "standard_charge_dollar": 80.66, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Ms State Emplo", "plan_name": "401457", "standard_charge_dollar": 91.20, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Ms State Emplo", "plan_name": "401457_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Basic Pl", "plan_name": "400100", "standard_charge_dollar": 91.20, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Basic Pl", "plan_name": "400100_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Federal", "plan_name": "400110", "standard_charge_dollar": 91.20, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Federal", "plan_name": "400110_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Cigna Healthsprings Ffs", "plan_name": "500064", "standard_charge_dollar": 80.66, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Conseco", "plan_name": "500302", "standard_charge_dollar": 80.66, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Humana Ffs 61101", "plan_name": "500006", "standard_charge_dollar": 80.66, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Medicare A", "plan_name": "100100", "standard_charge_dollar": 80.66, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Medicare A", "plan_name": "100500", "standard_charge_dollar": 80.66, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Medicare Part B Only", "plan_name": "100300", "standard_charge_dollar": 80.66, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Medicare Railroad", "plan_name": "100103", "standard_charge_dollar": 80.66, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Ms Physicians Care N", "plan_name": "714210", "standard_charge_dollar": 100.82, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Peoples Hlth Ffs 72126", "plan_name": "500019", "standard_charge_dollar": 80.66, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Uhc/Secure Horizons", "plan_name": "500449", "standard_charge_dollar": 80.66, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "United Health Care/", "plan_name": "500292", "standard_charge_dollar": 91.15, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "United Healthcare", "plan_name": "750104", "standard_charge_dollar": 91.15, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "United Healthcare Ba", "plan_name": "750090", "standard_charge_dollar": 91.15, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "United Healthcare Me", "plan_name": "501310", "standard_charge_dollar": 80.66, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Windsor Mcare Extra", "plan_name": "500778", "standard_charge_dollar": 80.66, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." } ] } ] }, { "description": "Hc shoulder complete min 2 view", "code_information": [ { "code": "73030", "type": "CPT" } ], "standard_charges": [ { "gross_charge": 175.00, "minimum": 80.66, "maximum": 100.82, "setting": "both", "payers_information": [ { "payer_name": "Aarp", "plan_name": "500102", "standard_charge_dollar": 80.66, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna", "plan_name": "700700", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna", "plan_name": "700700_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Mcare Ffs 6005", "plan_name": "700703", "standard_charge_dollar": 80.66, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Miscellaneous", "plan_name": "700720", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Miscellaneous", "plan_name": "700720_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Ppo Hmo", "plan_name": "701720", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Ppo Hmo", "plan_name": "701720_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Ambetter 68069", "plan_name": "500516", "standard_charge_dollar": 80.66, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Ms State Emplo", "plan_name": "401457", "standard_charge_dollar": 91.20, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Ms State Emplo", "plan_name": "401457_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Basic Pl", "plan_name": "400100", "standard_charge_dollar": 91.20, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Basic Pl", "plan_name": "400100_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Federal", "plan_name": "400110", "standard_charge_dollar": 91.20, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Federal", "plan_name": "400110_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Cigna Healthsprings Ffs", "plan_name": "500064", "standard_charge_dollar": 80.66, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Conseco", "plan_name": "500302", "standard_charge_dollar": 80.66, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Humana Ffs 61101", "plan_name": "500006", "standard_charge_dollar": 80.66, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Medicare A", "plan_name": "100100", "standard_charge_dollar": 80.66, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Medicare A", "plan_name": "100500", "standard_charge_dollar": 80.66, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Medicare Part B Only", "plan_name": "100300", "standard_charge_dollar": 80.66, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Medicare Railroad", "plan_name": "100103", "standard_charge_dollar": 80.66, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Ms Physicians Care N", "plan_name": "714210", "standard_charge_dollar": 100.82, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Peoples Hlth Ffs 72126", "plan_name": "500019", "standard_charge_dollar": 80.66, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Uhc/Secure Horizons", "plan_name": "500449", "standard_charge_dollar": 80.66, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "United Health Care/", "plan_name": "500292", "standard_charge_dollar": 91.15, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "United Healthcare", "plan_name": "750104", "standard_charge_dollar": 91.15, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "United Healthcare Ba", "plan_name": "750090", "standard_charge_dollar": 91.15, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "United Healthcare Me", "plan_name": "501310", "standard_charge_dollar": 80.66, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Windsor Mcare Extra", "plan_name": "500778", "standard_charge_dollar": 80.66, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." } ] } ] }, { "description": "X-ray exam of shoulder", "code_information": [ { "code": "73030", "type": "CPT" } ], "standard_charges": [ { "gross_charge": 175.00, "minimum": 80.66, "maximum": 100.82, "setting": "both", "payers_information": [ { "payer_name": "Aarp", "plan_name": "500102", "standard_charge_dollar": 80.66, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna", "plan_name": "700700", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna", "plan_name": "700700_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Mcare Ffs 6005", "plan_name": "700703", "standard_charge_dollar": 80.66, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Miscellaneous", "plan_name": "700720", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Miscellaneous", "plan_name": "700720_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Ppo Hmo", "plan_name": "701720", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Ppo Hmo", "plan_name": "701720_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Ambetter 68069", "plan_name": "500516", "standard_charge_dollar": 80.66, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Ms State Emplo", "plan_name": "401457", "standard_charge_dollar": 91.20, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Ms State Emplo", "plan_name": "401457_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Basic Pl", "plan_name": "400100", "standard_charge_dollar": 91.20, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Basic Pl", "plan_name": "400100_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Federal", "plan_name": "400110", "standard_charge_dollar": 91.20, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Federal", "plan_name": "400110_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Cigna Healthsprings Ffs", "plan_name": "500064", "standard_charge_dollar": 80.66, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Conseco", "plan_name": "500302", "standard_charge_dollar": 80.66, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Humana Ffs 61101", "plan_name": "500006", "standard_charge_dollar": 80.66, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Medicare A", "plan_name": "100100", "standard_charge_dollar": 80.66, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Medicare A", "plan_name": "100500", "standard_charge_dollar": 80.66, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Medicare Part B Only", "plan_name": "100300", "standard_charge_dollar": 80.66, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Medicare Railroad", "plan_name": "100103", "standard_charge_dollar": 80.66, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Ms Physicians Care N", "plan_name": "714210", "standard_charge_dollar": 100.82, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Peoples Hlth Ffs 72126", "plan_name": "500019", "standard_charge_dollar": 80.66, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Uhc/Secure Horizons", "plan_name": "500449", "standard_charge_dollar": 80.66, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "United Health Care/", "plan_name": "500292", "standard_charge_dollar": 91.15, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "United Healthcare", "plan_name": "750104", "standard_charge_dollar": 91.15, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "United Healthcare Ba", "plan_name": "750090", "standard_charge_dollar": 91.15, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "United Healthcare Me", "plan_name": "501310", "standard_charge_dollar": 80.66, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Windsor Mcare Extra", "plan_name": "500778", "standard_charge_dollar": 80.66, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." } ] } ] }, { "description": "Hc shoulder complete min 2 view", "code_information": [ { "code": "73030", "type": "CPT" } ], "standard_charges": [ { "gross_charge": 700.00, "minimum": 80.66, "maximum": 595.00, "setting": "both", "payers_information": [ { "payer_name": "Aarp", "plan_name": "500102", "standard_charge_dollar": 80.66, "count": "0", "methodology": "fee schedule", "modifiers": "50", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna", "plan_name": "700700", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna", "plan_name": "700700_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Mcare Ffs 6005", "plan_name": "700703", "standard_charge_dollar": 80.66, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Miscellaneous", "plan_name": "700720", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Miscellaneous", "plan_name": "700720_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Ppo Hmo", "plan_name": "701720", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Ppo Hmo", "plan_name": "701720_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Ambetter 68069", "plan_name": "500516", "standard_charge_dollar": 80.66, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Ms State Emplo", "plan_name": "401457", "standard_charge_percentage": 0.80, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Ms State Emplo", "plan_name": "401457_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Basic Pl", "plan_name": "400100", "standard_charge_percentage": 0.85, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Basic Pl", "plan_name": "400100_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Federal", "plan_name": "400110", "standard_charge_percentage": 0.85, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Federal", "plan_name": "400110_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Cigna Healthsprings Ffs", "plan_name": "500064", "standard_charge_dollar": 80.66, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Conseco", "plan_name": "500302", "standard_charge_dollar": 80.66, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Humana Ffs 61101", "plan_name": "500006", "standard_charge_dollar": 80.66, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Medicare A", "plan_name": "100100", "standard_charge_dollar": 80.66, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Medicare A", "plan_name": "100500", "standard_charge_dollar": 80.66, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Medicare Part B Only", "plan_name": "100300", "standard_charge_dollar": 80.66, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Medicare Railroad", "plan_name": "100103", "standard_charge_dollar": 80.66, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Ms Physicians Care N", "plan_name": "714210", "standard_charge_dollar": 100.82, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Peoples Hlth Ffs 72126", "plan_name": "500019", "standard_charge_dollar": 80.66, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Uhc/Secure Horizons", "plan_name": "500449", "standard_charge_dollar": 80.66, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "United Health Care/", "plan_name": "500292", "standard_charge_dollar": 91.15, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "United Healthcare", "plan_name": "750104", "standard_charge_dollar": 91.15, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "United Healthcare Ba", "plan_name": "750090", "standard_charge_dollar": 91.15, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "United Healthcare Me", "plan_name": "501310", "standard_charge_dollar": 80.66, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Windsor Mcare Extra", "plan_name": "500778", "standard_charge_dollar": 80.66, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." } ] } ] }, { "description": "Hc humerus min 2 view", "code_information": [ { "code": "73060", "type": "CPT" } ], "standard_charges": [ { "gross_charge": 150.00, "minimum": 80.66, "maximum": 100.82, "setting": "both", "payers_information": [ { "payer_name": "Aarp", "plan_name": "500102", "standard_charge_dollar": 80.66, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna", "plan_name": "700700", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna", "plan_name": "700700_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Mcare Ffs 6005", "plan_name": "700703", "standard_charge_dollar": 80.66, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Miscellaneous", "plan_name": "700720", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Miscellaneous", "plan_name": "700720_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Ppo Hmo", "plan_name": "701720", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Ppo Hmo", "plan_name": "701720_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Ambetter 68069", "plan_name": "500516", "standard_charge_dollar": 80.66, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Ms State Emplo", "plan_name": "401457", "standard_charge_dollar": 91.20, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Ms State Emplo", "plan_name": "401457_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Basic Pl", "plan_name": "400100", "standard_charge_dollar": 91.20, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Basic Pl", "plan_name": "400100_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Federal", "plan_name": "400110", "standard_charge_dollar": 91.20, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Federal", "plan_name": "400110_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Cigna Healthsprings Ffs", "plan_name": "500064", "standard_charge_dollar": 80.66, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Conseco", "plan_name": "500302", "standard_charge_dollar": 80.66, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Humana Ffs 61101", "plan_name": "500006", "standard_charge_dollar": 80.66, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Medicare A", "plan_name": "100100", "standard_charge_dollar": 80.66, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Medicare A", "plan_name": "100500", "standard_charge_dollar": 80.66, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Medicare Part B Only", "plan_name": "100300", "standard_charge_dollar": 80.66, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Medicare Railroad", "plan_name": "100103", "standard_charge_dollar": 80.66, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Ms Physicians Care N", "plan_name": "714210", "standard_charge_dollar": 100.82, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Peoples Hlth Ffs 72126", "plan_name": "500019", "standard_charge_dollar": 80.66, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Uhc/Secure Horizons", "plan_name": "500449", "standard_charge_dollar": 80.66, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "United Health Care/", "plan_name": "500292", "standard_charge_dollar": 91.15, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "United Healthcare", "plan_name": "750104", "standard_charge_dollar": 91.15, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "United Healthcare Ba", "plan_name": "750090", "standard_charge_dollar": 91.15, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "United Healthcare Me", "plan_name": "501310", "standard_charge_dollar": 80.66, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Windsor Mcare Extra", "plan_name": "500778", "standard_charge_dollar": 80.66, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." } ] } ] }, { "description": "X-ray exam of humerus", "code_information": [ { "code": "73060", "type": "CPT" } ], "standard_charges": [ { "gross_charge": 150.00, "minimum": 80.66, "maximum": 100.82, "setting": "both", "payers_information": [ { "payer_name": "Aarp", "plan_name": "500102", "standard_charge_dollar": 80.66, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna", "plan_name": "700700", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna", "plan_name": "700700_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Mcare Ffs 6005", "plan_name": "700703", "standard_charge_dollar": 80.66, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Miscellaneous", "plan_name": "700720", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Miscellaneous", "plan_name": "700720_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Ppo Hmo", "plan_name": "701720", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Ppo Hmo", "plan_name": "701720_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Ambetter 68069", "plan_name": "500516", "standard_charge_dollar": 80.66, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Ms State Emplo", "plan_name": "401457", "standard_charge_dollar": 91.20, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Ms State Emplo", "plan_name": "401457_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Basic Pl", "plan_name": "400100", "standard_charge_dollar": 91.20, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Basic Pl", "plan_name": "400100_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Federal", "plan_name": "400110", "standard_charge_dollar": 91.20, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Federal", "plan_name": "400110_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Cigna Healthsprings Ffs", "plan_name": "500064", "standard_charge_dollar": 80.66, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Conseco", "plan_name": "500302", "standard_charge_dollar": 80.66, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Humana Ffs 61101", "plan_name": "500006", "standard_charge_dollar": 80.66, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Medicare A", "plan_name": "100100", "standard_charge_dollar": 80.66, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Medicare A", "plan_name": "100500", "standard_charge_dollar": 80.66, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Medicare Part B Only", "plan_name": "100300", "standard_charge_dollar": 80.66, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Medicare Railroad", "plan_name": "100103", "standard_charge_dollar": 80.66, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Ms Physicians Care N", "plan_name": "714210", "standard_charge_dollar": 100.82, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Peoples Hlth Ffs 72126", "plan_name": "500019", "standard_charge_dollar": 80.66, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Uhc/Secure Horizons", "plan_name": "500449", "standard_charge_dollar": 80.66, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "United Health Care/", "plan_name": "500292", "standard_charge_dollar": 91.15, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "United Healthcare", "plan_name": "750104", "standard_charge_dollar": 91.15, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "United Healthcare Ba", "plan_name": "750090", "standard_charge_dollar": 91.15, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "United Healthcare Me", "plan_name": "501310", "standard_charge_dollar": 80.66, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Windsor Mcare Extra", "plan_name": "500778", "standard_charge_dollar": 80.66, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." } ] } ] }, { "description": "Hc humerus min 2 view", "code_information": [ { "code": "73060", "type": "CPT" } ], "standard_charges": [ { "gross_charge": 600.00, "minimum": 80.66, "maximum": 510.00, "setting": "both", "payers_information": [ { "payer_name": "Aarp", "plan_name": "500102", "standard_charge_dollar": 80.66, "count": "0", "methodology": "fee schedule", "modifiers": "50", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna", "plan_name": "700700", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna", "plan_name": "700700_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Mcare Ffs 6005", "plan_name": "700703", "standard_charge_dollar": 80.66, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Miscellaneous", "plan_name": "700720", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Miscellaneous", "plan_name": "700720_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Ppo Hmo", "plan_name": "701720", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Ppo Hmo", "plan_name": "701720_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Ambetter 68069", "plan_name": "500516", "standard_charge_dollar": 80.66, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Ms State Emplo", "plan_name": "401457", "standard_charge_percentage": 0.80, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Ms State Emplo", "plan_name": "401457_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Basic Pl", "plan_name": "400100", "standard_charge_percentage": 0.85, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Basic Pl", "plan_name": "400100_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Federal", "plan_name": "400110", "standard_charge_percentage": 0.85, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Federal", "plan_name": "400110_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Cigna Healthsprings Ffs", "plan_name": "500064", "standard_charge_dollar": 80.66, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Conseco", "plan_name": "500302", "standard_charge_dollar": 80.66, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Humana Ffs 61101", "plan_name": "500006", "standard_charge_dollar": 80.66, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Medicare A", "plan_name": "100100", "standard_charge_dollar": 80.66, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Medicare A", "plan_name": "100500", "standard_charge_dollar": 80.66, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Medicare Part B Only", "plan_name": "100300", "standard_charge_dollar": 80.66, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Medicare Railroad", "plan_name": "100103", "standard_charge_dollar": 80.66, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Ms Physicians Care N", "plan_name": "714210", "standard_charge_dollar": 100.82, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Peoples Hlth Ffs 72126", "plan_name": "500019", "standard_charge_dollar": 80.66, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Uhc/Secure Horizons", "plan_name": "500449", "standard_charge_dollar": 80.66, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "United Health Care/", "plan_name": "500292", "standard_charge_dollar": 91.15, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "United Healthcare", "plan_name": "750104", "standard_charge_dollar": 91.15, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "United Healthcare Ba", "plan_name": "750090", "standard_charge_dollar": 91.15, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "United Healthcare Me", "plan_name": "501310", "standard_charge_dollar": 80.66, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Windsor Mcare Extra", "plan_name": "500778", "standard_charge_dollar": 80.66, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." } ] } ] }, { "description": "Hc elbow 2 view", "code_information": [ { "code": "73070", "type": "CPT" } ], "standard_charges": [ { "gross_charge": 150.00, "minimum": 80.66, "maximum": 100.82, "setting": "both", "payers_information": [ { "payer_name": "Aarp", "plan_name": "500102", "standard_charge_dollar": 80.66, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna", "plan_name": "700700", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna", "plan_name": "700700_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Mcare Ffs 6005", "plan_name": "700703", "standard_charge_dollar": 80.66, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Miscellaneous", "plan_name": "700720", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Miscellaneous", "plan_name": "700720_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Ppo Hmo", "plan_name": "701720", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Ppo Hmo", "plan_name": "701720_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Ambetter 68069", "plan_name": "500516", "standard_charge_dollar": 80.66, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Ms State Emplo", "plan_name": "401457", "standard_charge_dollar": 91.20, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Ms State Emplo", "plan_name": "401457_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Basic Pl", "plan_name": "400100", "standard_charge_dollar": 91.20, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Basic Pl", "plan_name": "400100_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Federal", "plan_name": "400110", "standard_charge_dollar": 91.20, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Federal", "plan_name": "400110_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Cigna Healthsprings Ffs", "plan_name": "500064", "standard_charge_dollar": 80.66, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Conseco", "plan_name": "500302", "standard_charge_dollar": 80.66, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Humana Ffs 61101", "plan_name": "500006", "standard_charge_dollar": 80.66, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Medicare A", "plan_name": "100100", "standard_charge_dollar": 80.66, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Medicare A", "plan_name": "100500", "standard_charge_dollar": 80.66, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Medicare Part B Only", "plan_name": "100300", "standard_charge_dollar": 80.66, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Medicare Railroad", "plan_name": "100103", "standard_charge_dollar": 80.66, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Ms Physicians Care N", "plan_name": "714210", "standard_charge_dollar": 100.82, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Peoples Hlth Ffs 72126", "plan_name": "500019", "standard_charge_dollar": 80.66, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Uhc/Secure Horizons", "plan_name": "500449", "standard_charge_dollar": 80.66, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "United Health Care/", "plan_name": "500292", "standard_charge_dollar": 91.15, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "United Healthcare", "plan_name": "750104", "standard_charge_dollar": 91.15, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "United Healthcare Ba", "plan_name": "750090", "standard_charge_dollar": 91.15, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "United Healthcare Me", "plan_name": "501310", "standard_charge_dollar": 80.66, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Windsor Mcare Extra", "plan_name": "500778", "standard_charge_dollar": 80.66, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." } ] } ] }, { "description": "X-ray exam of elbow", "code_information": [ { "code": "73070", "type": "CPT" } ], "standard_charges": [ { "gross_charge": 150.00, "minimum": 80.66, "maximum": 100.82, "setting": "both", "payers_information": [ { "payer_name": "Aarp", "plan_name": "500102", "standard_charge_dollar": 80.66, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna", "plan_name": "700700", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna", "plan_name": "700700_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Mcare Ffs 6005", "plan_name": "700703", "standard_charge_dollar": 80.66, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Miscellaneous", "plan_name": "700720", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Miscellaneous", "plan_name": "700720_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Ppo Hmo", "plan_name": "701720", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Ppo Hmo", "plan_name": "701720_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Ambetter 68069", "plan_name": "500516", "standard_charge_dollar": 80.66, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Ms State Emplo", "plan_name": "401457", "standard_charge_dollar": 91.20, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Ms State Emplo", "plan_name": "401457_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Basic Pl", "plan_name": "400100", "standard_charge_dollar": 91.20, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Basic Pl", "plan_name": "400100_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Federal", "plan_name": "400110", "standard_charge_dollar": 91.20, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Federal", "plan_name": "400110_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Cigna Healthsprings Ffs", "plan_name": "500064", "standard_charge_dollar": 80.66, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Conseco", "plan_name": "500302", "standard_charge_dollar": 80.66, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Humana Ffs 61101", "plan_name": "500006", "standard_charge_dollar": 80.66, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Medicare A", "plan_name": "100100", "standard_charge_dollar": 80.66, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Medicare A", "plan_name": "100500", "standard_charge_dollar": 80.66, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Medicare Part B Only", "plan_name": "100300", "standard_charge_dollar": 80.66, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Medicare Railroad", "plan_name": "100103", "standard_charge_dollar": 80.66, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Ms Physicians Care N", "plan_name": "714210", "standard_charge_dollar": 100.82, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Peoples Hlth Ffs 72126", "plan_name": "500019", "standard_charge_dollar": 80.66, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Uhc/Secure Horizons", "plan_name": "500449", "standard_charge_dollar": 80.66, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "United Health Care/", "plan_name": "500292", "standard_charge_dollar": 91.15, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "United Healthcare", "plan_name": "750104", "standard_charge_dollar": 91.15, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "United Healthcare Ba", "plan_name": "750090", "standard_charge_dollar": 91.15, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "United Healthcare Me", "plan_name": "501310", "standard_charge_dollar": 80.66, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Windsor Mcare Extra", "plan_name": "500778", "standard_charge_dollar": 80.66, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." } ] } ] }, { "description": "Hc elbow 2 view", "code_information": [ { "code": "73070", "type": "CPT" } ], "standard_charges": [ { "gross_charge": 600.00, "minimum": 80.66, "maximum": 510.00, "setting": "both", "payers_information": [ { "payer_name": "Aarp", "plan_name": "500102", "standard_charge_dollar": 80.66, "count": "0", "methodology": "fee schedule", "modifiers": "50", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna", "plan_name": "700700", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna", "plan_name": "700700_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Mcare Ffs 6005", "plan_name": "700703", "standard_charge_dollar": 80.66, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Miscellaneous", "plan_name": "700720", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Miscellaneous", "plan_name": "700720_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Ppo Hmo", "plan_name": "701720", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Ppo Hmo", "plan_name": "701720_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Ambetter 68069", "plan_name": "500516", "standard_charge_dollar": 80.66, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Ms State Emplo", "plan_name": "401457", "standard_charge_percentage": 0.80, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Ms State Emplo", "plan_name": "401457_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Basic Pl", "plan_name": "400100", "standard_charge_percentage": 0.85, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Basic Pl", "plan_name": "400100_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Federal", "plan_name": "400110", "standard_charge_percentage": 0.85, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Federal", "plan_name": "400110_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Cigna Healthsprings Ffs", "plan_name": "500064", "standard_charge_dollar": 80.66, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Conseco", "plan_name": "500302", "standard_charge_dollar": 80.66, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Humana Ffs 61101", "plan_name": "500006", "standard_charge_dollar": 80.66, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Medicare A", "plan_name": "100100", "standard_charge_dollar": 80.66, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Medicare A", "plan_name": "100500", "standard_charge_dollar": 80.66, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Medicare Part B Only", "plan_name": "100300", "standard_charge_dollar": 80.66, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Medicare Railroad", "plan_name": "100103", "standard_charge_dollar": 80.66, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Ms Physicians Care N", "plan_name": "714210", "standard_charge_dollar": 100.82, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Peoples Hlth Ffs 72126", "plan_name": "500019", "standard_charge_dollar": 80.66, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Uhc/Secure Horizons", "plan_name": "500449", "standard_charge_dollar": 80.66, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "United Health Care/", "plan_name": "500292", "standard_charge_dollar": 91.15, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "United Healthcare", "plan_name": "750104", "standard_charge_dollar": 91.15, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "United Healthcare Ba", "plan_name": "750090", "standard_charge_dollar": 91.15, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "United Healthcare Me", "plan_name": "501310", "standard_charge_dollar": 80.66, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Windsor Mcare Extra", "plan_name": "500778", "standard_charge_dollar": 80.66, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." } ] } ] }, { "description": "Hc elbow 2 view", "code_information": [ { "code": "73070", "type": "CPT" } ], "standard_charges": [ { "gross_charge": 150.00, "minimum": 80.66, "maximum": 127.50, "setting": "both", "payers_information": [ { "payer_name": "Aarp", "plan_name": "500102", "standard_charge_dollar": 80.66, "count": "0", "methodology": "fee schedule", "modifiers": "TC", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna", "plan_name": "700700", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna", "plan_name": "700700_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Mcare Ffs 6005", "plan_name": "700703", "standard_charge_dollar": 80.66, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Miscellaneous", "plan_name": "700720", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Miscellaneous", "plan_name": "700720_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Ppo Hmo", "plan_name": "701720", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Ppo Hmo", "plan_name": "701720_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Ambetter 68069", "plan_name": "500516", "standard_charge_dollar": 80.66, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Ms State Emplo", "plan_name": "401457", "standard_charge_percentage": 0.80, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Ms State Emplo", "plan_name": "401457_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Basic Pl", "plan_name": "400100", "standard_charge_percentage": 0.85, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Basic Pl", "plan_name": "400100_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Federal", "plan_name": "400110", "standard_charge_percentage": 0.85, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Federal", "plan_name": "400110_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Cigna Healthsprings Ffs", "plan_name": "500064", "standard_charge_dollar": 80.66, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Conseco", "plan_name": "500302", "standard_charge_dollar": 80.66, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Humana Ffs 61101", "plan_name": "500006", "standard_charge_dollar": 80.66, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Medicare A", "plan_name": "100100", "standard_charge_dollar": 80.66, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Medicare A", "plan_name": "100500", "standard_charge_dollar": 80.66, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Medicare Part B Only", "plan_name": "100300", "standard_charge_dollar": 80.66, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Medicare Railroad", "plan_name": "100103", "standard_charge_dollar": 80.66, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Ms Physicians Care N", "plan_name": "714210", "standard_charge_dollar": 100.82, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Peoples Hlth Ffs 72126", "plan_name": "500019", "standard_charge_dollar": 80.66, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Uhc/Secure Horizons", "plan_name": "500449", "standard_charge_dollar": 80.66, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "United Health Care/", "plan_name": "500292", "standard_charge_dollar": 91.15, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "United Healthcare", "plan_name": "750104", "standard_charge_dollar": 91.15, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "United Healthcare Ba", "plan_name": "750090", "standard_charge_dollar": 91.15, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "United Healthcare Me", "plan_name": "501310", "standard_charge_dollar": 80.66, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Windsor Mcare Extra", "plan_name": "500778", "standard_charge_dollar": 80.66, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." } ] } ] }, { "description": "Hc forearm 2 view", "code_information": [ { "code": "73090", "type": "CPT" } ], "standard_charges": [ { "gross_charge": 150.00, "minimum": 80.66, "maximum": 100.82, "setting": "both", "payers_information": [ { "payer_name": "Aarp", "plan_name": "500102", "standard_charge_dollar": 80.66, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna", "plan_name": "700700", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna", "plan_name": "700700_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Mcare Ffs 6005", "plan_name": "700703", "standard_charge_dollar": 80.66, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Miscellaneous", "plan_name": "700720", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Miscellaneous", "plan_name": "700720_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Ppo Hmo", "plan_name": "701720", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Ppo Hmo", "plan_name": "701720_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Ambetter 68069", "plan_name": "500516", "standard_charge_dollar": 80.66, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Ms State Emplo", "plan_name": "401457", "standard_charge_dollar": 91.20, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Ms State Emplo", "plan_name": "401457_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Basic Pl", "plan_name": "400100", "standard_charge_dollar": 91.20, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Basic Pl", "plan_name": "400100_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Federal", "plan_name": "400110", "standard_charge_dollar": 91.20, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Federal", "plan_name": "400110_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Cigna Healthsprings Ffs", "plan_name": "500064", "standard_charge_dollar": 80.66, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Conseco", "plan_name": "500302", "standard_charge_dollar": 80.66, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Humana Ffs 61101", "plan_name": "500006", "standard_charge_dollar": 80.66, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Medicare A", "plan_name": "100100", "standard_charge_dollar": 80.66, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Medicare A", "plan_name": "100500", "standard_charge_dollar": 80.66, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Medicare Part B Only", "plan_name": "100300", "standard_charge_dollar": 80.66, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Medicare Railroad", "plan_name": "100103", "standard_charge_dollar": 80.66, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Ms Physicians Care N", "plan_name": "714210", "standard_charge_dollar": 100.82, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Peoples Hlth Ffs 72126", "plan_name": "500019", "standard_charge_dollar": 80.66, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Uhc/Secure Horizons", "plan_name": "500449", "standard_charge_dollar": 80.66, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "United Health Care/", "plan_name": "500292", "standard_charge_dollar": 91.15, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "United Healthcare", "plan_name": "750104", "standard_charge_dollar": 91.15, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "United Healthcare Ba", "plan_name": "750090", "standard_charge_dollar": 91.15, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "United Healthcare Me", "plan_name": "501310", "standard_charge_dollar": 80.66, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Windsor Mcare Extra", "plan_name": "500778", "standard_charge_dollar": 80.66, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." } ] } ] }, { "description": "X-ray exam of forearm", "code_information": [ { "code": "73090", "type": "CPT" } ], "standard_charges": [ { "gross_charge": 150.00, "minimum": 80.66, "maximum": 100.82, "setting": "both", "payers_information": [ { "payer_name": "Aarp", "plan_name": "500102", "standard_charge_dollar": 80.66, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna", "plan_name": "700700", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna", "plan_name": "700700_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Mcare Ffs 6005", "plan_name": "700703", "standard_charge_dollar": 80.66, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Miscellaneous", "plan_name": "700720", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Miscellaneous", "plan_name": "700720_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Ppo Hmo", "plan_name": "701720", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Ppo Hmo", "plan_name": "701720_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Ambetter 68069", "plan_name": "500516", "standard_charge_dollar": 80.66, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Ms State Emplo", "plan_name": "401457", "standard_charge_dollar": 91.20, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Ms State Emplo", "plan_name": "401457_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Basic Pl", "plan_name": "400100", "standard_charge_dollar": 91.20, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Basic Pl", "plan_name": "400100_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Federal", "plan_name": "400110", "standard_charge_dollar": 91.20, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Federal", "plan_name": "400110_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Cigna Healthsprings Ffs", "plan_name": "500064", "standard_charge_dollar": 80.66, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Conseco", "plan_name": "500302", "standard_charge_dollar": 80.66, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Humana Ffs 61101", "plan_name": "500006", "standard_charge_dollar": 80.66, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Medicare A", "plan_name": "100100", "standard_charge_dollar": 80.66, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Medicare A", "plan_name": "100500", "standard_charge_dollar": 80.66, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Medicare Part B Only", "plan_name": "100300", "standard_charge_dollar": 80.66, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Medicare Railroad", "plan_name": "100103", "standard_charge_dollar": 80.66, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Ms Physicians Care N", "plan_name": "714210", "standard_charge_dollar": 100.82, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Peoples Hlth Ffs 72126", "plan_name": "500019", "standard_charge_dollar": 80.66, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Uhc/Secure Horizons", "plan_name": "500449", "standard_charge_dollar": 80.66, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "United Health Care/", "plan_name": "500292", "standard_charge_dollar": 91.15, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "United Healthcare", "plan_name": "750104", "standard_charge_dollar": 91.15, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "United Healthcare Ba", "plan_name": "750090", "standard_charge_dollar": 91.15, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "United Healthcare Me", "plan_name": "501310", "standard_charge_dollar": 80.66, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Windsor Mcare Extra", "plan_name": "500778", "standard_charge_dollar": 80.66, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." } ] } ] }, { "description": "Hc forearm 2 view", "code_information": [ { "code": "73090", "type": "CPT" } ], "standard_charges": [ { "gross_charge": 600.00, "minimum": 80.66, "maximum": 510.00, "setting": "both", "payers_information": [ { "payer_name": "Aarp", "plan_name": "500102", "standard_charge_dollar": 80.66, "count": "0", "methodology": "fee schedule", "modifiers": "50", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna", "plan_name": "700700", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna", "plan_name": "700700_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Mcare Ffs 6005", "plan_name": "700703", "standard_charge_dollar": 80.66, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Miscellaneous", "plan_name": "700720", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Miscellaneous", "plan_name": "700720_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Ppo Hmo", "plan_name": "701720", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Ppo Hmo", "plan_name": "701720_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Ambetter 68069", "plan_name": "500516", "standard_charge_dollar": 80.66, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Ms State Emplo", "plan_name": "401457", "standard_charge_percentage": 0.80, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Ms State Emplo", "plan_name": "401457_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Basic Pl", "plan_name": "400100", "standard_charge_percentage": 0.85, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Basic Pl", "plan_name": "400100_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Federal", "plan_name": "400110", "standard_charge_percentage": 0.85, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Federal", "plan_name": "400110_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Cigna Healthsprings Ffs", "plan_name": "500064", "standard_charge_dollar": 80.66, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Conseco", "plan_name": "500302", "standard_charge_dollar": 80.66, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Humana Ffs 61101", "plan_name": "500006", "standard_charge_dollar": 80.66, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Medicare A", "plan_name": "100100", "standard_charge_dollar": 80.66, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Medicare A", "plan_name": "100500", "standard_charge_dollar": 80.66, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Medicare Part B Only", "plan_name": "100300", "standard_charge_dollar": 80.66, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Medicare Railroad", "plan_name": "100103", "standard_charge_dollar": 80.66, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Ms Physicians Care N", "plan_name": "714210", "standard_charge_dollar": 100.82, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Peoples Hlth Ffs 72126", "plan_name": "500019", "standard_charge_dollar": 80.66, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Uhc/Secure Horizons", "plan_name": "500449", "standard_charge_dollar": 80.66, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "United Health Care/", "plan_name": "500292", "standard_charge_dollar": 91.15, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "United Healthcare", "plan_name": "750104", "standard_charge_dollar": 91.15, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "United Healthcare Ba", "plan_name": "750090", "standard_charge_dollar": 91.15, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "United Healthcare Me", "plan_name": "501310", "standard_charge_dollar": 80.66, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Windsor Mcare Extra", "plan_name": "500778", "standard_charge_dollar": 80.66, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." } ] } ] }, { "description": "Hc forearm 2 view", "code_information": [ { "code": "73090", "type": "CPT" } ], "standard_charges": [ { "gross_charge": 150.00, "minimum": 80.66, "maximum": 127.50, "setting": "both", "payers_information": [ { "payer_name": "Aarp", "plan_name": "500102", "standard_charge_dollar": 80.66, "count": "0", "methodology": "fee schedule", "modifiers": "TC", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna", "plan_name": "700700", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna", "plan_name": "700700_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Mcare Ffs 6005", "plan_name": "700703", "standard_charge_dollar": 80.66, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Miscellaneous", "plan_name": "700720", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Miscellaneous", "plan_name": "700720_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Ppo Hmo", "plan_name": "701720", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Ppo Hmo", "plan_name": "701720_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Ambetter 68069", "plan_name": "500516", "standard_charge_dollar": 80.66, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Ms State Emplo", "plan_name": "401457", "standard_charge_percentage": 0.80, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Ms State Emplo", "plan_name": "401457_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Basic Pl", "plan_name": "400100", "standard_charge_percentage": 0.85, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Basic Pl", "plan_name": "400100_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Federal", "plan_name": "400110", "standard_charge_percentage": 0.85, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Federal", "plan_name": "400110_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Cigna Healthsprings Ffs", "plan_name": "500064", "standard_charge_dollar": 80.66, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Conseco", "plan_name": "500302", "standard_charge_dollar": 80.66, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Humana Ffs 61101", "plan_name": "500006", "standard_charge_dollar": 80.66, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Medicare A", "plan_name": "100100", "standard_charge_dollar": 80.66, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Medicare A", "plan_name": "100500", "standard_charge_dollar": 80.66, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Medicare Part B Only", "plan_name": "100300", "standard_charge_dollar": 80.66, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Medicare Railroad", "plan_name": "100103", "standard_charge_dollar": 80.66, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Ms Physicians Care N", "plan_name": "714210", "standard_charge_dollar": 100.82, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Peoples Hlth Ffs 72126", "plan_name": "500019", "standard_charge_dollar": 80.66, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Uhc/Secure Horizons", "plan_name": "500449", "standard_charge_dollar": 80.66, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "United Health Care/", "plan_name": "500292", "standard_charge_dollar": 91.15, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "United Healthcare", "plan_name": "750104", "standard_charge_dollar": 91.15, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "United Healthcare Ba", "plan_name": "750090", "standard_charge_dollar": 91.15, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "United Healthcare Me", "plan_name": "501310", "standard_charge_dollar": 80.66, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Windsor Mcare Extra", "plan_name": "500778", "standard_charge_dollar": 80.66, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." } ] } ] }, { "description": "Hc wrist complete min 3 view", "code_information": [ { "code": "73110", "type": "CPT" } ], "standard_charges": [ { "gross_charge": 150.00, "minimum": 80.66, "maximum": 100.82, "setting": "both", "payers_information": [ { "payer_name": "Aarp", "plan_name": "500102", "standard_charge_dollar": 80.66, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna", "plan_name": "700700", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna", "plan_name": "700700_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Mcare Ffs 6005", "plan_name": "700703", "standard_charge_dollar": 80.66, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Miscellaneous", "plan_name": "700720", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Miscellaneous", "plan_name": "700720_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Ppo Hmo", "plan_name": "701720", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Ppo Hmo", "plan_name": "701720_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Ambetter 68069", "plan_name": "500516", "standard_charge_dollar": 80.66, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Ms State Emplo", "plan_name": "401457", "standard_charge_dollar": 91.20, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Ms State Emplo", "plan_name": "401457_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Basic Pl", "plan_name": "400100", "standard_charge_dollar": 91.20, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Basic Pl", "plan_name": "400100_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Federal", "plan_name": "400110", "standard_charge_dollar": 91.20, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Federal", "plan_name": "400110_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Cigna Healthsprings Ffs", "plan_name": "500064", "standard_charge_dollar": 80.66, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Conseco", "plan_name": "500302", "standard_charge_dollar": 80.66, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Humana Ffs 61101", "plan_name": "500006", "standard_charge_dollar": 80.66, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Medicare A", "plan_name": "100100", "standard_charge_dollar": 80.66, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Medicare A", "plan_name": "100500", "standard_charge_dollar": 80.66, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Medicare Part B Only", "plan_name": "100300", "standard_charge_dollar": 80.66, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Medicare Railroad", "plan_name": "100103", "standard_charge_dollar": 80.66, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Ms Physicians Care N", "plan_name": "714210", "standard_charge_dollar": 100.82, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Peoples Hlth Ffs 72126", "plan_name": "500019", "standard_charge_dollar": 80.66, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Uhc/Secure Horizons", "plan_name": "500449", "standard_charge_dollar": 80.66, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "United Health Care/", "plan_name": "500292", "standard_charge_dollar": 91.15, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "United Healthcare", "plan_name": "750104", "standard_charge_dollar": 91.15, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "United Healthcare Ba", "plan_name": "750090", "standard_charge_dollar": 91.15, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "United Healthcare Me", "plan_name": "501310", "standard_charge_dollar": 80.66, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Windsor Mcare Extra", "plan_name": "500778", "standard_charge_dollar": 80.66, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." } ] } ] }, { "description": "X-ray exam of wrist", "code_information": [ { "code": "73110", "type": "CPT" } ], "standard_charges": [ { "gross_charge": 150.00, "minimum": 80.66, "maximum": 100.82, "setting": "both", "payers_information": [ { "payer_name": "Aarp", "plan_name": "500102", "standard_charge_dollar": 80.66, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna", "plan_name": "700700", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna", "plan_name": "700700_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Mcare Ffs 6005", "plan_name": "700703", "standard_charge_dollar": 80.66, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Miscellaneous", "plan_name": "700720", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Miscellaneous", "plan_name": "700720_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Ppo Hmo", "plan_name": "701720", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Ppo Hmo", "plan_name": "701720_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Ambetter 68069", "plan_name": "500516", "standard_charge_dollar": 80.66, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Ms State Emplo", "plan_name": "401457", "standard_charge_dollar": 91.20, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Ms State Emplo", "plan_name": "401457_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Basic Pl", "plan_name": "400100", "standard_charge_dollar": 91.20, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Basic Pl", "plan_name": "400100_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Federal", "plan_name": "400110", "standard_charge_dollar": 91.20, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Federal", "plan_name": "400110_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Cigna Healthsprings Ffs", "plan_name": "500064", "standard_charge_dollar": 80.66, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Conseco", "plan_name": "500302", "standard_charge_dollar": 80.66, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Humana Ffs 61101", "plan_name": "500006", "standard_charge_dollar": 80.66, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Medicare A", "plan_name": "100100", "standard_charge_dollar": 80.66, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Medicare A", "plan_name": "100500", "standard_charge_dollar": 80.66, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Medicare Part B Only", "plan_name": "100300", "standard_charge_dollar": 80.66, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Medicare Railroad", "plan_name": "100103", "standard_charge_dollar": 80.66, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Ms Physicians Care N", "plan_name": "714210", "standard_charge_dollar": 100.82, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Peoples Hlth Ffs 72126", "plan_name": "500019", "standard_charge_dollar": 80.66, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Uhc/Secure Horizons", "plan_name": "500449", "standard_charge_dollar": 80.66, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "United Health Care/", "plan_name": "500292", "standard_charge_dollar": 91.15, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "United Healthcare", "plan_name": "750104", "standard_charge_dollar": 91.15, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "United Healthcare Ba", "plan_name": "750090", "standard_charge_dollar": 91.15, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "United Healthcare Me", "plan_name": "501310", "standard_charge_dollar": 80.66, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Windsor Mcare Extra", "plan_name": "500778", "standard_charge_dollar": 80.66, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." } ] } ] }, { "description": "Hc wrist complete min 3 view", "code_information": [ { "code": "73110", "type": "CPT" } ], "standard_charges": [ { "gross_charge": 600.00, "minimum": 80.66, "maximum": 510.00, "setting": "both", "payers_information": [ { "payer_name": "Aarp", "plan_name": "500102", "standard_charge_dollar": 80.66, "count": "0", "methodology": "fee schedule", "modifiers": "50", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna", "plan_name": "700700", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna", "plan_name": "700700_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Mcare Ffs 6005", "plan_name": "700703", "standard_charge_dollar": 80.66, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Miscellaneous", "plan_name": "700720", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Miscellaneous", "plan_name": "700720_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Ppo Hmo", "plan_name": "701720", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Ppo Hmo", "plan_name": "701720_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Ambetter 68069", "plan_name": "500516", "standard_charge_dollar": 80.66, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Ms State Emplo", "plan_name": "401457", "standard_charge_percentage": 0.80, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Ms State Emplo", "plan_name": "401457_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Basic Pl", "plan_name": "400100", "standard_charge_percentage": 0.85, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Basic Pl", "plan_name": "400100_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Federal", "plan_name": "400110", "standard_charge_percentage": 0.85, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Federal", "plan_name": "400110_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Cigna Healthsprings Ffs", "plan_name": "500064", "standard_charge_dollar": 80.66, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Conseco", "plan_name": "500302", "standard_charge_dollar": 80.66, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Humana Ffs 61101", "plan_name": "500006", "standard_charge_dollar": 80.66, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Medicare A", "plan_name": "100100", "standard_charge_dollar": 80.66, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Medicare A", "plan_name": "100500", "standard_charge_dollar": 80.66, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Medicare Part B Only", "plan_name": "100300", "standard_charge_dollar": 80.66, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Medicare Railroad", "plan_name": "100103", "standard_charge_dollar": 80.66, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Ms Physicians Care N", "plan_name": "714210", "standard_charge_dollar": 100.82, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Peoples Hlth Ffs 72126", "plan_name": "500019", "standard_charge_dollar": 80.66, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Uhc/Secure Horizons", "plan_name": "500449", "standard_charge_dollar": 80.66, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "United Health Care/", "plan_name": "500292", "standard_charge_dollar": 91.15, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "United Healthcare", "plan_name": "750104", "standard_charge_dollar": 91.15, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "United Healthcare Ba", "plan_name": "750090", "standard_charge_dollar": 91.15, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "United Healthcare Me", "plan_name": "501310", "standard_charge_dollar": 80.66, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Windsor Mcare Extra", "plan_name": "500778", "standard_charge_dollar": 80.66, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." } ] } ] }, { "description": "Hc wrist complete min 3 view", "code_information": [ { "code": "73110", "type": "CPT" } ], "standard_charges": [ { "gross_charge": 150.00, "minimum": 80.66, "maximum": 127.50, "setting": "both", "payers_information": [ { "payer_name": "Aarp", "plan_name": "500102", "standard_charge_dollar": 80.66, "count": "0", "methodology": "fee schedule", "modifiers": "TC", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna", "plan_name": "700700", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna", "plan_name": "700700_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Mcare Ffs 6005", "plan_name": "700703", "standard_charge_dollar": 80.66, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Miscellaneous", "plan_name": "700720", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Miscellaneous", "plan_name": "700720_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Ppo Hmo", "plan_name": "701720", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Ppo Hmo", "plan_name": "701720_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Ambetter 68069", "plan_name": "500516", "standard_charge_dollar": 80.66, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Ms State Emplo", "plan_name": "401457", "standard_charge_percentage": 0.80, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Ms State Emplo", "plan_name": "401457_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Basic Pl", "plan_name": "400100", "standard_charge_percentage": 0.85, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Basic Pl", "plan_name": "400100_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Federal", "plan_name": "400110", "standard_charge_percentage": 0.85, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Federal", "plan_name": "400110_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Cigna Healthsprings Ffs", "plan_name": "500064", "standard_charge_dollar": 80.66, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Conseco", "plan_name": "500302", "standard_charge_dollar": 80.66, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Humana Ffs 61101", "plan_name": "500006", "standard_charge_dollar": 80.66, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Medicare A", "plan_name": "100100", "standard_charge_dollar": 80.66, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Medicare A", "plan_name": "100500", "standard_charge_dollar": 80.66, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Medicare Part B Only", "plan_name": "100300", "standard_charge_dollar": 80.66, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Medicare Railroad", "plan_name": "100103", "standard_charge_dollar": 80.66, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Ms Physicians Care N", "plan_name": "714210", "standard_charge_dollar": 100.82, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Peoples Hlth Ffs 72126", "plan_name": "500019", "standard_charge_dollar": 80.66, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Uhc/Secure Horizons", "plan_name": "500449", "standard_charge_dollar": 80.66, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "United Health Care/", "plan_name": "500292", "standard_charge_dollar": 91.15, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "United Healthcare", "plan_name": "750104", "standard_charge_dollar": 91.15, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "United Healthcare Ba", "plan_name": "750090", "standard_charge_dollar": 91.15, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "United Healthcare Me", "plan_name": "501310", "standard_charge_dollar": 80.66, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Windsor Mcare Extra", "plan_name": "500778", "standard_charge_dollar": 80.66, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." } ] } ] }, { "description": "Hc hand min 3 view", "code_information": [ { "code": "73130", "type": "CPT" } ], "standard_charges": [ { "gross_charge": 150.00, "minimum": 80.66, "maximum": 100.82, "setting": "both", "payers_information": [ { "payer_name": "Aarp", "plan_name": "500102", "standard_charge_dollar": 80.66, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna", "plan_name": "700700", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna", "plan_name": "700700_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Mcare Ffs 6005", "plan_name": "700703", "standard_charge_dollar": 80.66, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Miscellaneous", "plan_name": "700720", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Miscellaneous", "plan_name": "700720_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Ppo Hmo", "plan_name": "701720", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Ppo Hmo", "plan_name": "701720_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Ambetter 68069", "plan_name": "500516", "standard_charge_dollar": 80.66, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Ms State Emplo", "plan_name": "401457", "standard_charge_dollar": 91.20, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Ms State Emplo", "plan_name": "401457_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Basic Pl", "plan_name": "400100", "standard_charge_dollar": 91.20, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Basic Pl", "plan_name": "400100_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Federal", "plan_name": "400110", "standard_charge_dollar": 91.20, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Federal", "plan_name": "400110_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Cigna Healthsprings Ffs", "plan_name": "500064", "standard_charge_dollar": 80.66, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Conseco", "plan_name": "500302", "standard_charge_dollar": 80.66, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Humana Ffs 61101", "plan_name": "500006", "standard_charge_dollar": 80.66, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Medicare A", "plan_name": "100100", "standard_charge_dollar": 80.66, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Medicare A", "plan_name": "100500", "standard_charge_dollar": 80.66, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Medicare Part B Only", "plan_name": "100300", "standard_charge_dollar": 80.66, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Medicare Railroad", "plan_name": "100103", "standard_charge_dollar": 80.66, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Ms Physicians Care N", "plan_name": "714210", "standard_charge_dollar": 100.82, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Peoples Hlth Ffs 72126", "plan_name": "500019", "standard_charge_dollar": 80.66, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Uhc/Secure Horizons", "plan_name": "500449", "standard_charge_dollar": 80.66, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "United Health Care/", "plan_name": "500292", "standard_charge_dollar": 91.15, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "United Healthcare", "plan_name": "750104", "standard_charge_dollar": 91.15, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "United Healthcare Ba", "plan_name": "750090", "standard_charge_dollar": 91.15, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "United Healthcare Me", "plan_name": "501310", "standard_charge_dollar": 80.66, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Windsor Mcare Extra", "plan_name": "500778", "standard_charge_dollar": 80.66, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." } ] } ] }, { "description": "X-ray exam of hand", "code_information": [ { "code": "73130", "type": "CPT" } ], "standard_charges": [ { "gross_charge": 150.00, "minimum": 80.66, "maximum": 100.82, "setting": "both", "payers_information": [ { "payer_name": "Aarp", "plan_name": "500102", "standard_charge_dollar": 80.66, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna", "plan_name": "700700", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna", "plan_name": "700700_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Mcare Ffs 6005", "plan_name": "700703", "standard_charge_dollar": 80.66, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Miscellaneous", "plan_name": "700720", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Miscellaneous", "plan_name": "700720_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Ppo Hmo", "plan_name": "701720", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Ppo Hmo", "plan_name": "701720_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Ambetter 68069", "plan_name": "500516", "standard_charge_dollar": 80.66, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Ms State Emplo", "plan_name": "401457", "standard_charge_dollar": 91.20, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Ms State Emplo", "plan_name": "401457_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Basic Pl", "plan_name": "400100", "standard_charge_dollar": 91.20, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Basic Pl", "plan_name": "400100_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Federal", "plan_name": "400110", "standard_charge_dollar": 91.20, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Federal", "plan_name": "400110_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Cigna Healthsprings Ffs", "plan_name": "500064", "standard_charge_dollar": 80.66, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Conseco", "plan_name": "500302", "standard_charge_dollar": 80.66, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Humana Ffs 61101", "plan_name": "500006", "standard_charge_dollar": 80.66, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Medicare A", "plan_name": "100100", "standard_charge_dollar": 80.66, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Medicare A", "plan_name": "100500", "standard_charge_dollar": 80.66, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Medicare Part B Only", "plan_name": "100300", "standard_charge_dollar": 80.66, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Medicare Railroad", "plan_name": "100103", "standard_charge_dollar": 80.66, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Ms Physicians Care N", "plan_name": "714210", "standard_charge_dollar": 100.82, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Peoples Hlth Ffs 72126", "plan_name": "500019", "standard_charge_dollar": 80.66, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Uhc/Secure Horizons", "plan_name": "500449", "standard_charge_dollar": 80.66, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "United Health Care/", "plan_name": "500292", "standard_charge_dollar": 91.15, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "United Healthcare", "plan_name": "750104", "standard_charge_dollar": 91.15, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "United Healthcare Ba", "plan_name": "750090", "standard_charge_dollar": 91.15, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "United Healthcare Me", "plan_name": "501310", "standard_charge_dollar": 80.66, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Windsor Mcare Extra", "plan_name": "500778", "standard_charge_dollar": 80.66, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." } ] } ] }, { "description": "Hc hand min 3 view", "code_information": [ { "code": "73130", "type": "CPT" } ], "standard_charges": [ { "gross_charge": 600.00, "minimum": 80.66, "maximum": 510.00, "setting": "both", "payers_information": [ { "payer_name": "Aarp", "plan_name": "500102", "standard_charge_dollar": 80.66, "count": "0", "methodology": "fee schedule", "modifiers": "50", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna", "plan_name": "700700", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna", "plan_name": "700700_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Mcare Ffs 6005", "plan_name": "700703", "standard_charge_dollar": 80.66, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Miscellaneous", "plan_name": "700720", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Miscellaneous", "plan_name": "700720_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Ppo Hmo", "plan_name": "701720", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Ppo Hmo", "plan_name": "701720_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Ambetter 68069", "plan_name": "500516", "standard_charge_dollar": 80.66, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Ms State Emplo", "plan_name": "401457", "standard_charge_percentage": 0.80, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Ms State Emplo", "plan_name": "401457_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Basic Pl", "plan_name": "400100", "standard_charge_percentage": 0.85, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Basic Pl", "plan_name": "400100_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Federal", "plan_name": "400110", "standard_charge_percentage": 0.85, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Federal", "plan_name": "400110_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Cigna Healthsprings Ffs", "plan_name": "500064", "standard_charge_dollar": 80.66, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Conseco", "plan_name": "500302", "standard_charge_dollar": 80.66, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Humana Ffs 61101", "plan_name": "500006", "standard_charge_dollar": 80.66, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Medicare A", "plan_name": "100100", "standard_charge_dollar": 80.66, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Medicare A", "plan_name": "100500", "standard_charge_dollar": 80.66, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Medicare Part B Only", "plan_name": "100300", "standard_charge_dollar": 80.66, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Medicare Railroad", "plan_name": "100103", "standard_charge_dollar": 80.66, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Ms Physicians Care N", "plan_name": "714210", "standard_charge_dollar": 100.82, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Peoples Hlth Ffs 72126", "plan_name": "500019", "standard_charge_dollar": 80.66, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Uhc/Secure Horizons", "plan_name": "500449", "standard_charge_dollar": 80.66, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "United Health Care/", "plan_name": "500292", "standard_charge_dollar": 91.15, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "United Healthcare", "plan_name": "750104", "standard_charge_dollar": 91.15, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "United Healthcare Ba", "plan_name": "750090", "standard_charge_dollar": 91.15, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "United Healthcare Me", "plan_name": "501310", "standard_charge_dollar": 80.66, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Windsor Mcare Extra", "plan_name": "500778", "standard_charge_dollar": 80.66, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." } ] } ] }, { "description": "Hc hand min 3 view", "code_information": [ { "code": "73130", "type": "CPT" } ], "standard_charges": [ { "gross_charge": 150.00, "minimum": 80.66, "maximum": 127.50, "setting": "both", "payers_information": [ { "payer_name": "Aarp", "plan_name": "500102", "standard_charge_dollar": 80.66, "count": "0", "methodology": "fee schedule", "modifiers": "TC", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna", "plan_name": "700700", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna", "plan_name": "700700_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Mcare Ffs 6005", "plan_name": "700703", "standard_charge_dollar": 80.66, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Miscellaneous", "plan_name": "700720", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Miscellaneous", "plan_name": "700720_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Ppo Hmo", "plan_name": "701720", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Ppo Hmo", "plan_name": "701720_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Ambetter 68069", "plan_name": "500516", "standard_charge_dollar": 80.66, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Ms State Emplo", "plan_name": "401457", "standard_charge_percentage": 0.80, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Ms State Emplo", "plan_name": "401457_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Basic Pl", "plan_name": "400100", "standard_charge_percentage": 0.85, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Basic Pl", "plan_name": "400100_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Federal", "plan_name": "400110", "standard_charge_percentage": 0.85, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Federal", "plan_name": "400110_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Cigna Healthsprings Ffs", "plan_name": "500064", "standard_charge_dollar": 80.66, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Conseco", "plan_name": "500302", "standard_charge_dollar": 80.66, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Humana Ffs 61101", "plan_name": "500006", "standard_charge_dollar": 80.66, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Medicare A", "plan_name": "100100", "standard_charge_dollar": 80.66, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Medicare A", "plan_name": "100500", "standard_charge_dollar": 80.66, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Medicare Part B Only", "plan_name": "100300", "standard_charge_dollar": 80.66, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Medicare Railroad", "plan_name": "100103", "standard_charge_dollar": 80.66, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Ms Physicians Care N", "plan_name": "714210", "standard_charge_dollar": 100.82, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Peoples Hlth Ffs 72126", "plan_name": "500019", "standard_charge_dollar": 80.66, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Uhc/Secure Horizons", "plan_name": "500449", "standard_charge_dollar": 80.66, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "United Health Care/", "plan_name": "500292", "standard_charge_dollar": 91.15, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "United Healthcare", "plan_name": "750104", "standard_charge_dollar": 91.15, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "United Healthcare Ba", "plan_name": "750090", "standard_charge_dollar": 91.15, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "United Healthcare Me", "plan_name": "501310", "standard_charge_dollar": 80.66, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Windsor Mcare Extra", "plan_name": "500778", "standard_charge_dollar": 80.66, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." } ] } ] }, { "description": "Hc finger min 2 view", "code_information": [ { "code": "73140", "type": "CPT" } ], "standard_charges": [ { "gross_charge": 150.00, "minimum": 80.66, "maximum": 100.82, "setting": "both", "payers_information": [ { "payer_name": "Aarp", "plan_name": "500102", "standard_charge_dollar": 80.66, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna", "plan_name": "700700", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna", "plan_name": "700700_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Mcare Ffs 6005", "plan_name": "700703", "standard_charge_dollar": 80.66, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Miscellaneous", "plan_name": "700720", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Miscellaneous", "plan_name": "700720_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Ppo Hmo", "plan_name": "701720", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Ppo Hmo", "plan_name": "701720_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Ambetter 68069", "plan_name": "500516", "standard_charge_dollar": 80.66, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Ms State Emplo", "plan_name": "401457", "standard_charge_dollar": 91.20, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Ms State Emplo", "plan_name": "401457_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Basic Pl", "plan_name": "400100", "standard_charge_dollar": 91.20, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Basic Pl", "plan_name": "400100_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Federal", "plan_name": "400110", "standard_charge_dollar": 91.20, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Federal", "plan_name": "400110_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Cigna Healthsprings Ffs", "plan_name": "500064", "standard_charge_dollar": 80.66, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Conseco", "plan_name": "500302", "standard_charge_dollar": 80.66, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Humana Ffs 61101", "plan_name": "500006", "standard_charge_dollar": 80.66, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Medicare A", "plan_name": "100100", "standard_charge_dollar": 80.66, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Medicare A", "plan_name": "100500", "standard_charge_dollar": 80.66, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Medicare Part B Only", "plan_name": "100300", "standard_charge_dollar": 80.66, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Medicare Railroad", "plan_name": "100103", "standard_charge_dollar": 80.66, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Ms Physicians Care N", "plan_name": "714210", "standard_charge_dollar": 100.82, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Peoples Hlth Ffs 72126", "plan_name": "500019", "standard_charge_dollar": 80.66, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Uhc/Secure Horizons", "plan_name": "500449", "standard_charge_dollar": 80.66, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "United Health Care/", "plan_name": "500292", "standard_charge_dollar": 91.15, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "United Healthcare", "plan_name": "750104", "standard_charge_dollar": 91.15, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "United Healthcare Ba", "plan_name": "750090", "standard_charge_dollar": 91.15, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "United Healthcare Me", "plan_name": "501310", "standard_charge_dollar": 80.66, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Windsor Mcare Extra", "plan_name": "500778", "standard_charge_dollar": 80.66, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." } ] } ] }, { "description": "X-ray exam of finger(s)", "code_information": [ { "code": "73140", "type": "CPT" } ], "standard_charges": [ { "gross_charge": 150.00, "minimum": 80.66, "maximum": 100.82, "setting": "both", "payers_information": [ { "payer_name": "Aarp", "plan_name": "500102", "standard_charge_dollar": 80.66, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna", "plan_name": "700700", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna", "plan_name": "700700_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Mcare Ffs 6005", "plan_name": "700703", "standard_charge_dollar": 80.66, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Miscellaneous", "plan_name": "700720", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Miscellaneous", "plan_name": "700720_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Ppo Hmo", "plan_name": "701720", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Ppo Hmo", "plan_name": "701720_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Ambetter 68069", "plan_name": "500516", "standard_charge_dollar": 80.66, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Ms State Emplo", "plan_name": "401457", "standard_charge_dollar": 91.20, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Ms State Emplo", "plan_name": "401457_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Basic Pl", "plan_name": "400100", "standard_charge_dollar": 91.20, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Basic Pl", "plan_name": "400100_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Federal", "plan_name": "400110", "standard_charge_dollar": 91.20, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Federal", "plan_name": "400110_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Cigna Healthsprings Ffs", "plan_name": "500064", "standard_charge_dollar": 80.66, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Conseco", "plan_name": "500302", "standard_charge_dollar": 80.66, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Humana Ffs 61101", "plan_name": "500006", "standard_charge_dollar": 80.66, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Medicare A", "plan_name": "100100", "standard_charge_dollar": 80.66, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Medicare A", "plan_name": "100500", "standard_charge_dollar": 80.66, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Medicare Part B Only", "plan_name": "100300", "standard_charge_dollar": 80.66, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Medicare Railroad", "plan_name": "100103", "standard_charge_dollar": 80.66, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Ms Physicians Care N", "plan_name": "714210", "standard_charge_dollar": 100.82, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Peoples Hlth Ffs 72126", "plan_name": "500019", "standard_charge_dollar": 80.66, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Uhc/Secure Horizons", "plan_name": "500449", "standard_charge_dollar": 80.66, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "United Health Care/", "plan_name": "500292", "standard_charge_dollar": 91.15, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "United Healthcare", "plan_name": "750104", "standard_charge_dollar": 91.15, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "United Healthcare Ba", "plan_name": "750090", "standard_charge_dollar": 91.15, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "United Healthcare Me", "plan_name": "501310", "standard_charge_dollar": 80.66, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Windsor Mcare Extra", "plan_name": "500778", "standard_charge_dollar": 80.66, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." } ] } ] }, { "description": "Hc finger min 2 view", "code_information": [ { "code": "73140", "type": "CPT" } ], "standard_charges": [ { "gross_charge": 600.00, "minimum": 80.66, "maximum": 510.00, "setting": "both", "payers_information": [ { "payer_name": "Aarp", "plan_name": "500102", "standard_charge_dollar": 80.66, "count": "0", "methodology": "fee schedule", "modifiers": "50", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna", "plan_name": "700700", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna", "plan_name": "700700_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Mcare Ffs 6005", "plan_name": "700703", "standard_charge_dollar": 80.66, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Miscellaneous", "plan_name": "700720", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Miscellaneous", "plan_name": "700720_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Ppo Hmo", "plan_name": "701720", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Ppo Hmo", "plan_name": "701720_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Ambetter 68069", "plan_name": "500516", "standard_charge_dollar": 80.66, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Ms State Emplo", "plan_name": "401457", "standard_charge_percentage": 0.80, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Ms State Emplo", "plan_name": "401457_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Basic Pl", "plan_name": "400100", "standard_charge_percentage": 0.85, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Basic Pl", "plan_name": "400100_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Federal", "plan_name": "400110", "standard_charge_percentage": 0.85, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Federal", "plan_name": "400110_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Cigna Healthsprings Ffs", "plan_name": "500064", "standard_charge_dollar": 80.66, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Conseco", "plan_name": "500302", "standard_charge_dollar": 80.66, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Humana Ffs 61101", "plan_name": "500006", "standard_charge_dollar": 80.66, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Medicare A", "plan_name": "100100", "standard_charge_dollar": 80.66, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Medicare A", "plan_name": "100500", "standard_charge_dollar": 80.66, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Medicare Part B Only", "plan_name": "100300", "standard_charge_dollar": 80.66, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Medicare Railroad", "plan_name": "100103", "standard_charge_dollar": 80.66, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Ms Physicians Care N", "plan_name": "714210", "standard_charge_dollar": 100.82, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Peoples Hlth Ffs 72126", "plan_name": "500019", "standard_charge_dollar": 80.66, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Uhc/Secure Horizons", "plan_name": "500449", "standard_charge_dollar": 80.66, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "United Health Care/", "plan_name": "500292", "standard_charge_dollar": 91.15, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "United Healthcare", "plan_name": "750104", "standard_charge_dollar": 91.15, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "United Healthcare Ba", "plan_name": "750090", "standard_charge_dollar": 91.15, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "United Healthcare Me", "plan_name": "501310", "standard_charge_dollar": 80.66, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Windsor Mcare Extra", "plan_name": "500778", "standard_charge_dollar": 80.66, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." } ] } ] }, { "description": "Hc finger min 2 view", "code_information": [ { "code": "73140", "type": "CPT" } ], "standard_charges": [ { "gross_charge": 150.00, "minimum": 80.66, "maximum": 127.50, "setting": "both", "payers_information": [ { "payer_name": "Aarp", "plan_name": "500102", "standard_charge_dollar": 80.66, "count": "0", "methodology": "fee schedule", "modifiers": "TC", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna", "plan_name": "700700", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna", "plan_name": "700700_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Mcare Ffs 6005", "plan_name": "700703", "standard_charge_dollar": 80.66, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Miscellaneous", "plan_name": "700720", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Miscellaneous", "plan_name": "700720_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Ppo Hmo", "plan_name": "701720", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Ppo Hmo", "plan_name": "701720_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Ambetter 68069", "plan_name": "500516", "standard_charge_dollar": 80.66, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Ms State Emplo", "plan_name": "401457", "standard_charge_percentage": 0.80, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Ms State Emplo", "plan_name": "401457_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Basic Pl", "plan_name": "400100", "standard_charge_percentage": 0.85, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Basic Pl", "plan_name": "400100_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Federal", "plan_name": "400110", "standard_charge_percentage": 0.85, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Federal", "plan_name": "400110_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Cigna Healthsprings Ffs", "plan_name": "500064", "standard_charge_dollar": 80.66, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Conseco", "plan_name": "500302", "standard_charge_dollar": 80.66, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Humana Ffs 61101", "plan_name": "500006", "standard_charge_dollar": 80.66, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Medicare A", "plan_name": "100100", "standard_charge_dollar": 80.66, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Medicare A", "plan_name": "100500", "standard_charge_dollar": 80.66, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Medicare Part B Only", "plan_name": "100300", "standard_charge_dollar": 80.66, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Medicare Railroad", "plan_name": "100103", "standard_charge_dollar": 80.66, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Ms Physicians Care N", "plan_name": "714210", "standard_charge_dollar": 100.82, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Peoples Hlth Ffs 72126", "plan_name": "500019", "standard_charge_dollar": 80.66, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Uhc/Secure Horizons", "plan_name": "500449", "standard_charge_dollar": 80.66, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "United Health Care/", "plan_name": "500292", "standard_charge_dollar": 91.15, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "United Healthcare", "plan_name": "750104", "standard_charge_dollar": 91.15, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "United Healthcare Ba", "plan_name": "750090", "standard_charge_dollar": 91.15, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "United Healthcare Me", "plan_name": "501310", "standard_charge_dollar": 80.66, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Windsor Mcare Extra", "plan_name": "500778", "standard_charge_dollar": 80.66, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." } ] } ] }, { "description": "Ct upper extremity w/o dye", "code_information": [ { "code": "73200", "type": "CPT" } ], "standard_charges": [ { "gross_charge": 513.71, "minimum": 168.74, "maximum": 257.13, "setting": "both", "payers_information": [ { "payer_name": "Aarp", "plan_name": "500102", "standard_charge_dollar": 205.70, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna", "plan_name": "700700", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna", "plan_name": "700700_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Mcare Ffs 6005", "plan_name": "700703", "standard_charge_dollar": 205.70, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Miscellaneous", "plan_name": "700720", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Miscellaneous", "plan_name": "700720_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Ppo Hmo", "plan_name": "701720", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Ppo Hmo", "plan_name": "701720_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Ambetter 68069", "plan_name": "500516", "standard_charge_dollar": 205.70, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Ms State Emplo", "plan_name": "401457", "standard_charge_dollar": 168.74, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Ms State Emplo", "plan_name": "401457_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Basic Pl", "plan_name": "400100", "standard_charge_dollar": 168.74, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Basic Pl", "plan_name": "400100_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Federal", "plan_name": "400110", "standard_charge_dollar": 168.74, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Federal", "plan_name": "400110_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Cigna Healthsprings Ffs", "plan_name": "500064", "standard_charge_dollar": 205.70, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Conseco", "plan_name": "500302", "standard_charge_dollar": 205.70, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Humana Ffs 61101", "plan_name": "500006", "standard_charge_dollar": 205.70, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Medicare A", "plan_name": "100100", "standard_charge_dollar": 205.70, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Medicare A", "plan_name": "100500", "standard_charge_dollar": 205.70, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Medicare Part B Only", "plan_name": "100300", "standard_charge_dollar": 205.70, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Medicare Railroad", "plan_name": "100103", "standard_charge_dollar": 205.70, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Ms Physicians Care N", "plan_name": "714210", "standard_charge_dollar": 257.13, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Peoples Hlth Ffs 72126", "plan_name": "500019", "standard_charge_dollar": 205.70, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Uhc/Secure Horizons", "plan_name": "500449", "standard_charge_dollar": 205.70, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "United Health Care/", "plan_name": "500292", "standard_charge_dollar": 232.44, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "United Healthcare", "plan_name": "750104", "standard_charge_dollar": 232.44, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "United Healthcare Ba", "plan_name": "750090", "standard_charge_dollar": 232.44, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "United Healthcare Me", "plan_name": "501310", "standard_charge_dollar": 205.70, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Windsor Mcare Extra", "plan_name": "500778", "standard_charge_dollar": 205.70, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." } ] } ] }, { "description": "Hc ct upper extremity w/o contrast", "code_information": [ { "code": "73200", "type": "CPT" } ], "standard_charges": [ { "gross_charge": 513.71, "minimum": 168.74, "maximum": 257.13, "setting": "both", "payers_information": [ { "payer_name": "Aarp", "plan_name": "500102", "standard_charge_dollar": 205.70, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna", "plan_name": "700700", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna", "plan_name": "700700_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Mcare Ffs 6005", "plan_name": "700703", "standard_charge_dollar": 205.70, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Miscellaneous", "plan_name": "700720", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Miscellaneous", "plan_name": "700720_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Ppo Hmo", "plan_name": "701720", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Ppo Hmo", "plan_name": "701720_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Ambetter 68069", "plan_name": "500516", "standard_charge_dollar": 205.70, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Ms State Emplo", "plan_name": "401457", "standard_charge_dollar": 168.74, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Ms State Emplo", "plan_name": "401457_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Basic Pl", "plan_name": "400100", "standard_charge_dollar": 168.74, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Basic Pl", "plan_name": "400100_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Federal", "plan_name": "400110", "standard_charge_dollar": 168.74, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Federal", "plan_name": "400110_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Cigna Healthsprings Ffs", "plan_name": "500064", "standard_charge_dollar": 205.70, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Conseco", "plan_name": "500302", "standard_charge_dollar": 205.70, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Humana Ffs 61101", "plan_name": "500006", "standard_charge_dollar": 205.70, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Medicare A", "plan_name": "100100", "standard_charge_dollar": 205.70, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Medicare A", "plan_name": "100500", "standard_charge_dollar": 205.70, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Medicare Part B Only", "plan_name": "100300", "standard_charge_dollar": 205.70, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Medicare Railroad", "plan_name": "100103", "standard_charge_dollar": 205.70, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Ms Physicians Care N", "plan_name": "714210", "standard_charge_dollar": 257.13, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Peoples Hlth Ffs 72126", "plan_name": "500019", "standard_charge_dollar": 205.70, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Uhc/Secure Horizons", "plan_name": "500449", "standard_charge_dollar": 205.70, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "United Health Care/", "plan_name": "500292", "standard_charge_dollar": 232.44, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "United Healthcare", "plan_name": "750104", "standard_charge_dollar": 232.44, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "United Healthcare Ba", "plan_name": "750090", "standard_charge_dollar": 232.44, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "United Healthcare Me", "plan_name": "501310", "standard_charge_dollar": 205.70, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Windsor Mcare Extra", "plan_name": "500778", "standard_charge_dollar": 205.70, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." } ] } ] }, { "description": "Hc ct upper extremity w/o contrast", "code_information": [ { "code": "73200", "type": "CPT" } ], "standard_charges": [ { "gross_charge": 2054.84, "minimum": 205.70, "maximum": 1746.61, "setting": "both", "payers_information": [ { "payer_name": "Aarp", "plan_name": "500102", "standard_charge_dollar": 205.70, "count": "0", "methodology": "fee schedule", "modifiers": "50", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna", "plan_name": "700700", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna", "plan_name": "700700_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Mcare Ffs 6005", "plan_name": "700703", "standard_charge_dollar": 205.70, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Miscellaneous", "plan_name": "700720", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Miscellaneous", "plan_name": "700720_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Ppo Hmo", "plan_name": "701720", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Ppo Hmo", "plan_name": "701720_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Ambetter 68069", "plan_name": "500516", "standard_charge_dollar": 205.70, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Ms State Emplo", "plan_name": "401457", "standard_charge_percentage": 0.80, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Ms State Emplo", "plan_name": "401457_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Basic Pl", "plan_name": "400100", "standard_charge_percentage": 0.85, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Basic Pl", "plan_name": "400100_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Federal", "plan_name": "400110", "standard_charge_percentage": 0.85, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Federal", "plan_name": "400110_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Cigna Healthsprings Ffs", "plan_name": "500064", "standard_charge_dollar": 205.70, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Conseco", "plan_name": "500302", "standard_charge_dollar": 205.70, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Humana Ffs 61101", "plan_name": "500006", "standard_charge_dollar": 205.70, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Medicare A", "plan_name": "100100", "standard_charge_dollar": 205.70, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Medicare A", "plan_name": "100500", "standard_charge_dollar": 205.70, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Medicare Part B Only", "plan_name": "100300", "standard_charge_dollar": 205.70, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Medicare Railroad", "plan_name": "100103", "standard_charge_dollar": 205.70, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Ms Physicians Care N", "plan_name": "714210", "standard_charge_dollar": 257.13, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Peoples Hlth Ffs 72126", "plan_name": "500019", "standard_charge_dollar": 205.70, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Uhc/Secure Horizons", "plan_name": "500449", "standard_charge_dollar": 205.70, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "United Health Care/", "plan_name": "500292", "standard_charge_dollar": 232.44, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "United Healthcare", "plan_name": "750104", "standard_charge_dollar": 232.44, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "United Healthcare Ba", "plan_name": "750090", "standard_charge_dollar": 232.44, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "United Healthcare Me", "plan_name": "501310", "standard_charge_dollar": 205.70, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Windsor Mcare Extra", "plan_name": "500778", "standard_charge_dollar": 205.70, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." } ] } ] }, { "description": "Ct upper extremity w/dye", "code_information": [ { "code": "73201", "type": "CPT" } ], "standard_charges": [ { "gross_charge": 784.00, "minimum": 398.60, "maximum": 521.58, "setting": "both", "payers_information": [ { "payer_name": "Aarp", "plan_name": "500102", "standard_charge_dollar": 398.60, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna", "plan_name": "700700", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna", "plan_name": "700700_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Mcare Ffs 6005", "plan_name": "700703", "standard_charge_dollar": 398.60, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Miscellaneous", "plan_name": "700720", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Miscellaneous", "plan_name": "700720_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Ppo Hmo", "plan_name": "701720", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Ppo Hmo", "plan_name": "701720_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Ambetter 68069", "plan_name": "500516", "standard_charge_dollar": 398.60, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Ms State Emplo", "plan_name": "401457", "standard_charge_dollar": 521.58, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Ms State Emplo", "plan_name": "401457_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Basic Pl", "plan_name": "400100", "standard_charge_dollar": 521.58, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Basic Pl", "plan_name": "400100_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Federal", "plan_name": "400110", "standard_charge_dollar": 521.58, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Federal", "plan_name": "400110_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Cigna Healthsprings Ffs", "plan_name": "500064", "standard_charge_dollar": 398.60, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Conseco", "plan_name": "500302", "standard_charge_dollar": 398.60, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Humana Ffs 61101", "plan_name": "500006", "standard_charge_dollar": 398.60, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Medicare A", "plan_name": "100100", "standard_charge_dollar": 398.60, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Medicare A", "plan_name": "100500", "standard_charge_dollar": 398.60, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Medicare Part B Only", "plan_name": "100300", "standard_charge_dollar": 398.60, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Medicare Railroad", "plan_name": "100103", "standard_charge_dollar": 398.60, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Ms Physicians Care N", "plan_name": "714210", "standard_charge_dollar": 498.25, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Peoples Hlth Ffs 72126", "plan_name": "500019", "standard_charge_dollar": 398.60, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Uhc/Secure Horizons", "plan_name": "500449", "standard_charge_dollar": 398.60, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "United Health Care/", "plan_name": "500292", "standard_charge_dollar": 450.42, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "United Healthcare", "plan_name": "750104", "standard_charge_dollar": 450.42, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "United Healthcare Ba", "plan_name": "750090", "standard_charge_dollar": 450.42, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "United Healthcare Me", "plan_name": "501310", "standard_charge_dollar": 398.60, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Windsor Mcare Extra", "plan_name": "500778", "standard_charge_dollar": 398.60, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." } ] } ] }, { "description": "Hc ct upper extremity w contrast", "code_information": [ { "code": "73201", "type": "CPT" } ], "standard_charges": [ { "gross_charge": 784.00, "minimum": 398.60, "maximum": 521.58, "setting": "both", "payers_information": [ { "payer_name": "Aarp", "plan_name": "500102", "standard_charge_dollar": 398.60, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna", "plan_name": "700700", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna", "plan_name": "700700_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Mcare Ffs 6005", "plan_name": "700703", "standard_charge_dollar": 398.60, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Miscellaneous", "plan_name": "700720", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Miscellaneous", "plan_name": "700720_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Ppo Hmo", "plan_name": "701720", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Ppo Hmo", "plan_name": "701720_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Ambetter 68069", "plan_name": "500516", "standard_charge_dollar": 398.60, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Ms State Emplo", "plan_name": "401457", "standard_charge_dollar": 521.58, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Ms State Emplo", "plan_name": "401457_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Basic Pl", "plan_name": "400100", "standard_charge_dollar": 521.58, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Basic Pl", "plan_name": "400100_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Federal", "plan_name": "400110", "standard_charge_dollar": 521.58, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Federal", "plan_name": "400110_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Cigna Healthsprings Ffs", "plan_name": "500064", "standard_charge_dollar": 398.60, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Conseco", "plan_name": "500302", "standard_charge_dollar": 398.60, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Humana Ffs 61101", "plan_name": "500006", "standard_charge_dollar": 398.60, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Medicare A", "plan_name": "100100", "standard_charge_dollar": 398.60, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Medicare A", "plan_name": "100500", "standard_charge_dollar": 398.60, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Medicare Part B Only", "plan_name": "100300", "standard_charge_dollar": 398.60, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Medicare Railroad", "plan_name": "100103", "standard_charge_dollar": 398.60, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Ms Physicians Care N", "plan_name": "714210", "standard_charge_dollar": 498.25, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Peoples Hlth Ffs 72126", "plan_name": "500019", "standard_charge_dollar": 398.60, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Uhc/Secure Horizons", "plan_name": "500449", "standard_charge_dollar": 398.60, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "United Health Care/", "plan_name": "500292", "standard_charge_dollar": 450.42, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "United Healthcare", "plan_name": "750104", "standard_charge_dollar": 450.42, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "United Healthcare Ba", "plan_name": "750090", "standard_charge_dollar": 450.42, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "United Healthcare Me", "plan_name": "501310", "standard_charge_dollar": 398.60, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Windsor Mcare Extra", "plan_name": "500778", "standard_charge_dollar": 398.60, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." } ] } ] }, { "description": "Ct angio upr extrm w/o&w/dye", "code_information": [ { "code": "73206", "type": "CPT" } ], "standard_charges": [ { "gross_charge": 1668.50, "minimum": 355.29, "maximum": 498.25, "setting": "both", "payers_information": [ { "payer_name": "Aarp", "plan_name": "500102", "standard_charge_dollar": 398.60, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna", "plan_name": "700700", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna", "plan_name": "700700_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Mcare Ffs 6005", "plan_name": "700703", "standard_charge_dollar": 398.60, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Miscellaneous", "plan_name": "700720", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Miscellaneous", "plan_name": "700720_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Ppo Hmo", "plan_name": "701720", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Ppo Hmo", "plan_name": "701720_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Ambetter 68069", "plan_name": "500516", "standard_charge_dollar": 398.60, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Ms State Emplo", "plan_name": "401457", "standard_charge_dollar": 355.29, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Ms State Emplo", "plan_name": "401457_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Basic Pl", "plan_name": "400100", "standard_charge_dollar": 355.29, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Basic Pl", "plan_name": "400100_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Federal", "plan_name": "400110", "standard_charge_dollar": 355.29, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Federal", "plan_name": "400110_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Cigna Healthsprings Ffs", "plan_name": "500064", "standard_charge_dollar": 398.60, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Conseco", "plan_name": "500302", "standard_charge_dollar": 398.60, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Humana Ffs 61101", "plan_name": "500006", "standard_charge_dollar": 398.60, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Medicare A", "plan_name": "100100", "standard_charge_dollar": 398.60, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Medicare A", "plan_name": "100500", "standard_charge_dollar": 398.60, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Medicare Part B Only", "plan_name": "100300", "standard_charge_dollar": 398.60, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Medicare Railroad", "plan_name": "100103", "standard_charge_dollar": 398.60, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Ms Physicians Care N", "plan_name": "714210", "standard_charge_dollar": 498.25, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Peoples Hlth Ffs 72126", "plan_name": "500019", "standard_charge_dollar": 398.60, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Uhc/Secure Horizons", "plan_name": "500449", "standard_charge_dollar": 398.60, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "United Health Care/", "plan_name": "500292", "standard_charge_dollar": 450.42, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "United Healthcare", "plan_name": "750104", "standard_charge_dollar": 450.42, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "United Healthcare Ba", "plan_name": "750090", "standard_charge_dollar": 450.42, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "United Healthcare Me", "plan_name": "501310", "standard_charge_dollar": 398.60, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Windsor Mcare Extra", "plan_name": "500778", "standard_charge_dollar": 398.60, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." } ] } ] }, { "description": "Hc cta upper extremity w contrast", "code_information": [ { "code": "73206", "type": "CPT" } ], "standard_charges": [ { "gross_charge": 1668.50, "minimum": 355.29, "maximum": 498.25, "setting": "both", "payers_information": [ { "payer_name": "Aarp", "plan_name": "500102", "standard_charge_dollar": 398.60, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna", "plan_name": "700700", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna", "plan_name": "700700_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Mcare Ffs 6005", "plan_name": "700703", "standard_charge_dollar": 398.60, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Miscellaneous", "plan_name": "700720", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Miscellaneous", "plan_name": "700720_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Ppo Hmo", "plan_name": "701720", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Ppo Hmo", "plan_name": "701720_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Ambetter 68069", "plan_name": "500516", "standard_charge_dollar": 398.60, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Ms State Emplo", "plan_name": "401457", "standard_charge_dollar": 355.29, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Ms State Emplo", "plan_name": "401457_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Basic Pl", "plan_name": "400100", "standard_charge_dollar": 355.29, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Basic Pl", "plan_name": "400100_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Federal", "plan_name": "400110", "standard_charge_dollar": 355.29, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Federal", "plan_name": "400110_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Cigna Healthsprings Ffs", "plan_name": "500064", "standard_charge_dollar": 398.60, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Conseco", "plan_name": "500302", "standard_charge_dollar": 398.60, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Humana Ffs 61101", "plan_name": "500006", "standard_charge_dollar": 398.60, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Medicare A", "plan_name": "100100", "standard_charge_dollar": 398.60, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Medicare A", "plan_name": "100500", "standard_charge_dollar": 398.60, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Medicare Part B Only", "plan_name": "100300", "standard_charge_dollar": 398.60, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Medicare Railroad", "plan_name": "100103", "standard_charge_dollar": 398.60, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Ms Physicians Care N", "plan_name": "714210", "standard_charge_dollar": 498.25, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Peoples Hlth Ffs 72126", "plan_name": "500019", "standard_charge_dollar": 398.60, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Uhc/Secure Horizons", "plan_name": "500449", "standard_charge_dollar": 398.60, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "United Health Care/", "plan_name": "500292", "standard_charge_dollar": 450.42, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "United Healthcare", "plan_name": "750104", "standard_charge_dollar": 450.42, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "United Healthcare Ba", "plan_name": "750090", "standard_charge_dollar": 450.42, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "United Healthcare Me", "plan_name": "501310", "standard_charge_dollar": 398.60, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Windsor Mcare Extra", "plan_name": "500778", "standard_charge_dollar": 398.60, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." } ] } ] }, { "description": "Hc xray hip unil 2-3 views", "code_information": [ { "code": "73502", "type": "CPT" } ], "standard_charges": [ { "gross_charge": 200.00, "minimum": 80.66, "maximum": 100.82, "setting": "both", "payers_information": [ { "payer_name": "Aarp", "plan_name": "500102", "standard_charge_dollar": 80.66, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna", "plan_name": "700700", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna", "plan_name": "700700_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Mcare Ffs 6005", "plan_name": "700703", "standard_charge_dollar": 80.66, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Miscellaneous", "plan_name": "700720", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Miscellaneous", "plan_name": "700720_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Ppo Hmo", "plan_name": "701720", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Ppo Hmo", "plan_name": "701720_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Ambetter 68069", "plan_name": "500516", "standard_charge_dollar": 80.66, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Ms State Emplo", "plan_name": "401457", "standard_charge_dollar": 91.20, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Ms State Emplo", "plan_name": "401457_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Basic Pl", "plan_name": "400100", "standard_charge_dollar": 91.20, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Basic Pl", "plan_name": "400100_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Federal", "plan_name": "400110", "standard_charge_dollar": 91.20, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Federal", "plan_name": "400110_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Cigna Healthsprings Ffs", "plan_name": "500064", "standard_charge_dollar": 80.66, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Conseco", "plan_name": "500302", "standard_charge_dollar": 80.66, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Humana Ffs 61101", "plan_name": "500006", "standard_charge_dollar": 80.66, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Medicare A", "plan_name": "100100", "standard_charge_dollar": 80.66, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Medicare A", "plan_name": "100500", "standard_charge_dollar": 80.66, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Medicare Part B Only", "plan_name": "100300", "standard_charge_dollar": 80.66, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Medicare Railroad", "plan_name": "100103", "standard_charge_dollar": 80.66, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Ms Physicians Care N", "plan_name": "714210", "standard_charge_dollar": 100.82, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Peoples Hlth Ffs 72126", "plan_name": "500019", "standard_charge_dollar": 80.66, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Uhc/Secure Horizons", "plan_name": "500449", "standard_charge_dollar": 80.66, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "United Health Care/", "plan_name": "500292", "standard_charge_dollar": 91.15, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "United Healthcare", "plan_name": "750104", "standard_charge_dollar": 91.15, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "United Healthcare Ba", "plan_name": "750090", "standard_charge_dollar": 91.15, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "United Healthcare Me", "plan_name": "501310", "standard_charge_dollar": 80.66, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Windsor Mcare Extra", "plan_name": "500778", "standard_charge_dollar": 80.66, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." } ] } ] }, { "description": "X-ray exam hip uni 2-3 views", "code_information": [ { "code": "73502", "type": "CPT" } ], "standard_charges": [ { "gross_charge": 200.00, "minimum": 80.66, "maximum": 100.82, "setting": "both", "payers_information": [ { "payer_name": "Aarp", "plan_name": "500102", "standard_charge_dollar": 80.66, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna", "plan_name": "700700", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna", "plan_name": "700700_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Mcare Ffs 6005", "plan_name": "700703", "standard_charge_dollar": 80.66, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Miscellaneous", "plan_name": "700720", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Miscellaneous", "plan_name": "700720_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Ppo Hmo", "plan_name": "701720", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Ppo Hmo", "plan_name": "701720_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Ambetter 68069", "plan_name": "500516", "standard_charge_dollar": 80.66, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Ms State Emplo", "plan_name": "401457", "standard_charge_dollar": 91.20, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Ms State Emplo", "plan_name": "401457_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Basic Pl", "plan_name": "400100", "standard_charge_dollar": 91.20, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Basic Pl", "plan_name": "400100_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Federal", "plan_name": "400110", "standard_charge_dollar": 91.20, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Federal", "plan_name": "400110_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Cigna Healthsprings Ffs", "plan_name": "500064", "standard_charge_dollar": 80.66, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Conseco", "plan_name": "500302", "standard_charge_dollar": 80.66, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Humana Ffs 61101", "plan_name": "500006", "standard_charge_dollar": 80.66, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Medicare A", "plan_name": "100100", "standard_charge_dollar": 80.66, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Medicare A", "plan_name": "100500", "standard_charge_dollar": 80.66, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Medicare Part B Only", "plan_name": "100300", "standard_charge_dollar": 80.66, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Medicare Railroad", "plan_name": "100103", "standard_charge_dollar": 80.66, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Ms Physicians Care N", "plan_name": "714210", "standard_charge_dollar": 100.82, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Peoples Hlth Ffs 72126", "plan_name": "500019", "standard_charge_dollar": 80.66, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Uhc/Secure Horizons", "plan_name": "500449", "standard_charge_dollar": 80.66, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "United Health Care/", "plan_name": "500292", "standard_charge_dollar": 91.15, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "United Healthcare", "plan_name": "750104", "standard_charge_dollar": 91.15, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "United Healthcare Ba", "plan_name": "750090", "standard_charge_dollar": 91.15, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "United Healthcare Me", "plan_name": "501310", "standard_charge_dollar": 80.66, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Windsor Mcare Extra", "plan_name": "500778", "standard_charge_dollar": 80.66, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." } ] } ] }, { "description": "Hc xray hip bilat 2 views", "code_information": [ { "code": "73521", "type": "CPT" } ], "standard_charges": [ { "gross_charge": 250.00, "minimum": 97.41, "maximum": 151.04, "setting": "both", "payers_information": [ { "payer_name": "Aarp", "plan_name": "500102", "standard_charge_dollar": 97.41, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna", "plan_name": "700700", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna", "plan_name": "700700_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Mcare Ffs 6005", "plan_name": "700703", "standard_charge_dollar": 97.41, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Miscellaneous", "plan_name": "700720", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Miscellaneous", "plan_name": "700720_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Ppo Hmo", "plan_name": "701720", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Ppo Hmo", "plan_name": "701720_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Ambetter 68069", "plan_name": "500516", "standard_charge_dollar": 97.41, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Ms State Emplo", "plan_name": "401457", "standard_charge_dollar": 151.04, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Ms State Emplo", "plan_name": "401457_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Basic Pl", "plan_name": "400100", "standard_charge_dollar": 151.04, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Basic Pl", "plan_name": "400100_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Federal", "plan_name": "400110", "standard_charge_dollar": 151.04, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Federal", "plan_name": "400110_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Cigna Healthsprings Ffs", "plan_name": "500064", "standard_charge_dollar": 97.41, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Conseco", "plan_name": "500302", "standard_charge_dollar": 97.41, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Humana Ffs 61101", "plan_name": "500006", "standard_charge_dollar": 97.41, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Medicare A", "plan_name": "100100", "standard_charge_dollar": 97.41, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Medicare A", "plan_name": "100500", "standard_charge_dollar": 97.41, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Medicare Part B Only", "plan_name": "100300", "standard_charge_dollar": 97.41, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Medicare Railroad", "plan_name": "100103", "standard_charge_dollar": 97.41, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Ms Physicians Care N", "plan_name": "714210", "standard_charge_dollar": 121.77, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Peoples Hlth Ffs 72126", "plan_name": "500019", "standard_charge_dollar": 97.41, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Uhc/Secure Horizons", "plan_name": "500449", "standard_charge_dollar": 97.41, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "United Health Care/", "plan_name": "500292", "standard_charge_dollar": 110.08, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "United Healthcare", "plan_name": "750104", "standard_charge_dollar": 110.08, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "United Healthcare Ba", "plan_name": "750090", "standard_charge_dollar": 110.08, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "United Healthcare Me", "plan_name": "501310", "standard_charge_dollar": 97.41, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Windsor Mcare Extra", "plan_name": "500778", "standard_charge_dollar": 97.41, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." } ] } ] }, { "description": "X-ray exam hips bi 2 views", "code_information": [ { "code": "73521", "type": "CPT" } ], "standard_charges": [ { "gross_charge": 250.00, "minimum": 97.41, "maximum": 151.04, "setting": "both", "payers_information": [ { "payer_name": "Aarp", "plan_name": "500102", "standard_charge_dollar": 97.41, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna", "plan_name": "700700", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna", "plan_name": "700700_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Mcare Ffs 6005", "plan_name": "700703", "standard_charge_dollar": 97.41, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Miscellaneous", "plan_name": "700720", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Miscellaneous", "plan_name": "700720_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Ppo Hmo", "plan_name": "701720", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Ppo Hmo", "plan_name": "701720_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Ambetter 68069", "plan_name": "500516", "standard_charge_dollar": 97.41, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Ms State Emplo", "plan_name": "401457", "standard_charge_dollar": 151.04, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Ms State Emplo", "plan_name": "401457_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Basic Pl", "plan_name": "400100", "standard_charge_dollar": 151.04, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Basic Pl", "plan_name": "400100_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Federal", "plan_name": "400110", "standard_charge_dollar": 151.04, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Federal", "plan_name": "400110_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Cigna Healthsprings Ffs", "plan_name": "500064", "standard_charge_dollar": 97.41, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Conseco", "plan_name": "500302", "standard_charge_dollar": 97.41, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Humana Ffs 61101", "plan_name": "500006", "standard_charge_dollar": 97.41, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Medicare A", "plan_name": "100100", "standard_charge_dollar": 97.41, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Medicare A", "plan_name": "100500", "standard_charge_dollar": 97.41, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Medicare Part B Only", "plan_name": "100300", "standard_charge_dollar": 97.41, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Medicare Railroad", "plan_name": "100103", "standard_charge_dollar": 97.41, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Ms Physicians Care N", "plan_name": "714210", "standard_charge_dollar": 121.77, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Peoples Hlth Ffs 72126", "plan_name": "500019", "standard_charge_dollar": 97.41, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Uhc/Secure Horizons", "plan_name": "500449", "standard_charge_dollar": 97.41, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "United Health Care/", "plan_name": "500292", "standard_charge_dollar": 110.08, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "United Healthcare", "plan_name": "750104", "standard_charge_dollar": 110.08, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "United Healthcare Ba", "plan_name": "750090", "standard_charge_dollar": 110.08, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "United Healthcare Me", "plan_name": "501310", "standard_charge_dollar": 97.41, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Windsor Mcare Extra", "plan_name": "500778", "standard_charge_dollar": 97.41, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." } ] } ] }, { "description": "Hc xray femur min 2 views", "code_information": [ { "code": "73552", "type": "CPT" } ], "standard_charges": [ { "gross_charge": 200.00, "minimum": 80.66, "maximum": 100.82, "setting": "both", "payers_information": [ { "payer_name": "Aarp", "plan_name": "500102", "standard_charge_dollar": 80.66, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna", "plan_name": "700700", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna", "plan_name": "700700_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Mcare Ffs 6005", "plan_name": "700703", "standard_charge_dollar": 80.66, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Miscellaneous", "plan_name": "700720", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Miscellaneous", "plan_name": "700720_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Ppo Hmo", "plan_name": "701720", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Ppo Hmo", "plan_name": "701720_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Ambetter 68069", "plan_name": "500516", "standard_charge_dollar": 80.66, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Ms State Emplo", "plan_name": "401457", "standard_charge_dollar": 91.20, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Ms State Emplo", "plan_name": "401457_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Basic Pl", "plan_name": "400100", "standard_charge_dollar": 91.20, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Basic Pl", "plan_name": "400100_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Federal", "plan_name": "400110", "standard_charge_dollar": 91.20, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Federal", "plan_name": "400110_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Cigna Healthsprings Ffs", "plan_name": "500064", "standard_charge_dollar": 80.66, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Conseco", "plan_name": "500302", "standard_charge_dollar": 80.66, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Humana Ffs 61101", "plan_name": "500006", "standard_charge_dollar": 80.66, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Medicare A", "plan_name": "100100", "standard_charge_dollar": 80.66, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Medicare A", "plan_name": "100500", "standard_charge_dollar": 80.66, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Medicare Part B Only", "plan_name": "100300", "standard_charge_dollar": 80.66, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Medicare Railroad", "plan_name": "100103", "standard_charge_dollar": 80.66, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Ms Physicians Care N", "plan_name": "714210", "standard_charge_dollar": 100.82, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Peoples Hlth Ffs 72126", "plan_name": "500019", "standard_charge_dollar": 80.66, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Uhc/Secure Horizons", "plan_name": "500449", "standard_charge_dollar": 80.66, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "United Health Care/", "plan_name": "500292", "standard_charge_dollar": 91.15, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "United Healthcare", "plan_name": "750104", "standard_charge_dollar": 91.15, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "United Healthcare Ba", "plan_name": "750090", "standard_charge_dollar": 91.15, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "United Healthcare Me", "plan_name": "501310", "standard_charge_dollar": 80.66, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Windsor Mcare Extra", "plan_name": "500778", "standard_charge_dollar": 80.66, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." } ] } ] }, { "description": "X-ray exam of femur 2/>", "code_information": [ { "code": "73552", "type": "CPT" } ], "standard_charges": [ { "gross_charge": 200.00, "minimum": 80.66, "maximum": 100.82, "setting": "both", "payers_information": [ { "payer_name": "Aarp", "plan_name": "500102", "standard_charge_dollar": 80.66, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna", "plan_name": "700700", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna", "plan_name": "700700_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Mcare Ffs 6005", "plan_name": "700703", "standard_charge_dollar": 80.66, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Miscellaneous", "plan_name": "700720", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Miscellaneous", "plan_name": "700720_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Ppo Hmo", "plan_name": "701720", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Ppo Hmo", "plan_name": "701720_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Ambetter 68069", "plan_name": "500516", "standard_charge_dollar": 80.66, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Ms State Emplo", "plan_name": "401457", "standard_charge_dollar": 91.20, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Ms State Emplo", "plan_name": "401457_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Basic Pl", "plan_name": "400100", "standard_charge_dollar": 91.20, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Basic Pl", "plan_name": "400100_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Federal", "plan_name": "400110", "standard_charge_dollar": 91.20, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Federal", "plan_name": "400110_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Cigna Healthsprings Ffs", "plan_name": "500064", "standard_charge_dollar": 80.66, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Conseco", "plan_name": "500302", "standard_charge_dollar": 80.66, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Humana Ffs 61101", "plan_name": "500006", "standard_charge_dollar": 80.66, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Medicare A", "plan_name": "100100", "standard_charge_dollar": 80.66, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Medicare A", "plan_name": "100500", "standard_charge_dollar": 80.66, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Medicare Part B Only", "plan_name": "100300", "standard_charge_dollar": 80.66, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Medicare Railroad", "plan_name": "100103", "standard_charge_dollar": 80.66, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Ms Physicians Care N", "plan_name": "714210", "standard_charge_dollar": 100.82, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Peoples Hlth Ffs 72126", "plan_name": "500019", "standard_charge_dollar": 80.66, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Uhc/Secure Horizons", "plan_name": "500449", "standard_charge_dollar": 80.66, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "United Health Care/", "plan_name": "500292", "standard_charge_dollar": 91.15, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "United Healthcare", "plan_name": "750104", "standard_charge_dollar": 91.15, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "United Healthcare Ba", "plan_name": "750090", "standard_charge_dollar": 91.15, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "United Healthcare Me", "plan_name": "501310", "standard_charge_dollar": 80.66, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Windsor Mcare Extra", "plan_name": "500778", "standard_charge_dollar": 80.66, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." } ] } ] }, { "description": "Hc xray femur min 2 views", "code_information": [ { "code": "73552", "type": "CPT" } ], "standard_charges": [ { "gross_charge": 800.00, "minimum": 80.66, "maximum": 680.00, "setting": "both", "payers_information": [ { "payer_name": "Aarp", "plan_name": "500102", "standard_charge_dollar": 80.66, "count": "0", "methodology": "fee schedule", "modifiers": "50", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna", "plan_name": "700700", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna", "plan_name": "700700_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Mcare Ffs 6005", "plan_name": "700703", "standard_charge_dollar": 80.66, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Miscellaneous", "plan_name": "700720", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Miscellaneous", "plan_name": "700720_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Ppo Hmo", "plan_name": "701720", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Ppo Hmo", "plan_name": "701720_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Ambetter 68069", "plan_name": "500516", "standard_charge_dollar": 80.66, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Ms State Emplo", "plan_name": "401457", "standard_charge_percentage": 0.80, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Ms State Emplo", "plan_name": "401457_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Basic Pl", "plan_name": "400100", "standard_charge_percentage": 0.85, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Basic Pl", "plan_name": "400100_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Federal", "plan_name": "400110", "standard_charge_percentage": 0.85, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Federal", "plan_name": "400110_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Cigna Healthsprings Ffs", "plan_name": "500064", "standard_charge_dollar": 80.66, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Conseco", "plan_name": "500302", "standard_charge_dollar": 80.66, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Humana Ffs 61101", "plan_name": "500006", "standard_charge_dollar": 80.66, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Medicare A", "plan_name": "100100", "standard_charge_dollar": 80.66, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Medicare A", "plan_name": "100500", "standard_charge_dollar": 80.66, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Medicare Part B Only", "plan_name": "100300", "standard_charge_dollar": 80.66, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Medicare Railroad", "plan_name": "100103", "standard_charge_dollar": 80.66, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Ms Physicians Care N", "plan_name": "714210", "standard_charge_dollar": 100.82, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Peoples Hlth Ffs 72126", "plan_name": "500019", "standard_charge_dollar": 80.66, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Uhc/Secure Horizons", "plan_name": "500449", "standard_charge_dollar": 80.66, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "United Health Care/", "plan_name": "500292", "standard_charge_dollar": 91.15, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "United Healthcare", "plan_name": "750104", "standard_charge_dollar": 91.15, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "United Healthcare Ba", "plan_name": "750090", "standard_charge_dollar": 91.15, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "United Healthcare Me", "plan_name": "501310", "standard_charge_dollar": 80.66, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Windsor Mcare Extra", "plan_name": "500778", "standard_charge_dollar": 80.66, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." } ] } ] }, { "description": "Hc knee 1 or 2 view", "code_information": [ { "code": "73560", "type": "CPT" } ], "standard_charges": [ { "gross_charge": 200.00, "minimum": 80.66, "maximum": 100.82, "setting": "both", "payers_information": [ { "payer_name": "Aarp", "plan_name": "500102", "standard_charge_dollar": 80.66, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna", "plan_name": "700700", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna", "plan_name": "700700_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Mcare Ffs 6005", "plan_name": "700703", "standard_charge_dollar": 80.66, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Miscellaneous", "plan_name": "700720", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Miscellaneous", "plan_name": "700720_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Ppo Hmo", "plan_name": "701720", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Ppo Hmo", "plan_name": "701720_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Ambetter 68069", "plan_name": "500516", "standard_charge_dollar": 80.66, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Ms State Emplo", "plan_name": "401457", "standard_charge_dollar": 91.20, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Ms State Emplo", "plan_name": "401457_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Basic Pl", "plan_name": "400100", "standard_charge_dollar": 91.20, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Basic Pl", "plan_name": "400100_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Federal", "plan_name": "400110", "standard_charge_dollar": 91.20, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Federal", "plan_name": "400110_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Cigna Healthsprings Ffs", "plan_name": "500064", "standard_charge_dollar": 80.66, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Conseco", "plan_name": "500302", "standard_charge_dollar": 80.66, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Humana Ffs 61101", "plan_name": "500006", "standard_charge_dollar": 80.66, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Medicare A", "plan_name": "100100", "standard_charge_dollar": 80.66, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Medicare A", "plan_name": "100500", "standard_charge_dollar": 80.66, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Medicare Part B Only", "plan_name": "100300", "standard_charge_dollar": 80.66, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Medicare Railroad", "plan_name": "100103", "standard_charge_dollar": 80.66, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Ms Physicians Care N", "plan_name": "714210", "standard_charge_dollar": 100.82, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Peoples Hlth Ffs 72126", "plan_name": "500019", "standard_charge_dollar": 80.66, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Uhc/Secure Horizons", "plan_name": "500449", "standard_charge_dollar": 80.66, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "United Health Care/", "plan_name": "500292", "standard_charge_dollar": 91.15, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "United Healthcare", "plan_name": "750104", "standard_charge_dollar": 91.15, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "United Healthcare Ba", "plan_name": "750090", "standard_charge_dollar": 91.15, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "United Healthcare Me", "plan_name": "501310", "standard_charge_dollar": 80.66, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Windsor Mcare Extra", "plan_name": "500778", "standard_charge_dollar": 80.66, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." } ] } ] }, { "description": "X-ray exam of knee 1 or 2", "code_information": [ { "code": "73560", "type": "CPT" } ], "standard_charges": [ { "gross_charge": 200.00, "minimum": 80.66, "maximum": 100.82, "setting": "both", "payers_information": [ { "payer_name": "Aarp", "plan_name": "500102", "standard_charge_dollar": 80.66, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna", "plan_name": "700700", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna", "plan_name": "700700_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Mcare Ffs 6005", "plan_name": "700703", "standard_charge_dollar": 80.66, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Miscellaneous", "plan_name": "700720", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Miscellaneous", "plan_name": "700720_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Ppo Hmo", "plan_name": "701720", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Ppo Hmo", "plan_name": "701720_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Ambetter 68069", "plan_name": "500516", "standard_charge_dollar": 80.66, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Ms State Emplo", "plan_name": "401457", "standard_charge_dollar": 91.20, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Ms State Emplo", "plan_name": "401457_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Basic Pl", "plan_name": "400100", "standard_charge_dollar": 91.20, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Basic Pl", "plan_name": "400100_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Federal", "plan_name": "400110", "standard_charge_dollar": 91.20, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Federal", "plan_name": "400110_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Cigna Healthsprings Ffs", "plan_name": "500064", "standard_charge_dollar": 80.66, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Conseco", "plan_name": "500302", "standard_charge_dollar": 80.66, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Humana Ffs 61101", "plan_name": "500006", "standard_charge_dollar": 80.66, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Medicare A", "plan_name": "100100", "standard_charge_dollar": 80.66, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Medicare A", "plan_name": "100500", "standard_charge_dollar": 80.66, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Medicare Part B Only", "plan_name": "100300", "standard_charge_dollar": 80.66, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Medicare Railroad", "plan_name": "100103", "standard_charge_dollar": 80.66, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Ms Physicians Care N", "plan_name": "714210", "standard_charge_dollar": 100.82, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Peoples Hlth Ffs 72126", "plan_name": "500019", "standard_charge_dollar": 80.66, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Uhc/Secure Horizons", "plan_name": "500449", "standard_charge_dollar": 80.66, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "United Health Care/", "plan_name": "500292", "standard_charge_dollar": 91.15, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "United Healthcare", "plan_name": "750104", "standard_charge_dollar": 91.15, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "United Healthcare Ba", "plan_name": "750090", "standard_charge_dollar": 91.15, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "United Healthcare Me", "plan_name": "501310", "standard_charge_dollar": 80.66, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Windsor Mcare Extra", "plan_name": "500778", "standard_charge_dollar": 80.66, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." } ] } ] }, { "description": "Hc knee 1 or 2 view", "code_information": [ { "code": "73560", "type": "CPT" } ], "standard_charges": [ { "gross_charge": 800.00, "minimum": 80.66, "maximum": 680.00, "setting": "both", "payers_information": [ { "payer_name": "Aarp", "plan_name": "500102", "standard_charge_dollar": 80.66, "count": "0", "methodology": "fee schedule", "modifiers": "50", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna", "plan_name": "700700", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna", "plan_name": "700700_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Mcare Ffs 6005", "plan_name": "700703", "standard_charge_dollar": 80.66, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Miscellaneous", "plan_name": "700720", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Miscellaneous", "plan_name": "700720_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Ppo Hmo", "plan_name": "701720", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Ppo Hmo", "plan_name": "701720_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Ambetter 68069", "plan_name": "500516", "standard_charge_dollar": 80.66, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Ms State Emplo", "plan_name": "401457", "standard_charge_percentage": 0.80, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Ms State Emplo", "plan_name": "401457_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Basic Pl", "plan_name": "400100", "standard_charge_percentage": 0.85, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Basic Pl", "plan_name": "400100_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Federal", "plan_name": "400110", "standard_charge_percentage": 0.85, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Federal", "plan_name": "400110_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Cigna Healthsprings Ffs", "plan_name": "500064", "standard_charge_dollar": 80.66, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Conseco", "plan_name": "500302", "standard_charge_dollar": 80.66, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Humana Ffs 61101", "plan_name": "500006", "standard_charge_dollar": 80.66, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Medicare A", "plan_name": "100100", "standard_charge_dollar": 80.66, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Medicare A", "plan_name": "100500", "standard_charge_dollar": 80.66, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Medicare Part B Only", "plan_name": "100300", "standard_charge_dollar": 80.66, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Medicare Railroad", "plan_name": "100103", "standard_charge_dollar": 80.66, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Ms Physicians Care N", "plan_name": "714210", "standard_charge_dollar": 100.82, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Peoples Hlth Ffs 72126", "plan_name": "500019", "standard_charge_dollar": 80.66, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Uhc/Secure Horizons", "plan_name": "500449", "standard_charge_dollar": 80.66, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "United Health Care/", "plan_name": "500292", "standard_charge_dollar": 91.15, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "United Healthcare", "plan_name": "750104", "standard_charge_dollar": 91.15, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "United Healthcare Ba", "plan_name": "750090", "standard_charge_dollar": 91.15, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "United Healthcare Me", "plan_name": "501310", "standard_charge_dollar": 80.66, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Windsor Mcare Extra", "plan_name": "500778", "standard_charge_dollar": 80.66, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." } ] } ] }, { "description": "Hc knee 3 view", "code_information": [ { "code": "73562", "type": "CPT" } ], "standard_charges": [ { "gross_charge": 200.00, "minimum": 80.66, "maximum": 100.82, "setting": "both", "payers_information": [ { "payer_name": "Aarp", "plan_name": "500102", "standard_charge_dollar": 80.66, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna", "plan_name": "700700", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna", "plan_name": "700700_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Mcare Ffs 6005", "plan_name": "700703", "standard_charge_dollar": 80.66, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Miscellaneous", "plan_name": "700720", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Miscellaneous", "plan_name": "700720_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Ppo Hmo", "plan_name": "701720", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Ppo Hmo", "plan_name": "701720_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Ambetter 68069", "plan_name": "500516", "standard_charge_dollar": 80.66, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Ms State Emplo", "plan_name": "401457", "standard_charge_dollar": 91.20, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Ms State Emplo", "plan_name": "401457_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Basic Pl", "plan_name": "400100", "standard_charge_dollar": 91.20, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Basic Pl", "plan_name": "400100_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Federal", "plan_name": "400110", "standard_charge_dollar": 91.20, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Federal", "plan_name": "400110_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Cigna Healthsprings Ffs", "plan_name": "500064", "standard_charge_dollar": 80.66, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Conseco", "plan_name": "500302", "standard_charge_dollar": 80.66, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Humana Ffs 61101", "plan_name": "500006", "standard_charge_dollar": 80.66, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Medicare A", "plan_name": "100100", "standard_charge_dollar": 80.66, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Medicare A", "plan_name": "100500", "standard_charge_dollar": 80.66, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Medicare Part B Only", "plan_name": "100300", "standard_charge_dollar": 80.66, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Medicare Railroad", "plan_name": "100103", "standard_charge_dollar": 80.66, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Ms Physicians Care N", "plan_name": "714210", "standard_charge_dollar": 100.82, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Peoples Hlth Ffs 72126", "plan_name": "500019", "standard_charge_dollar": 80.66, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Uhc/Secure Horizons", "plan_name": "500449", "standard_charge_dollar": 80.66, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "United Health Care/", "plan_name": "500292", "standard_charge_dollar": 91.15, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "United Healthcare", "plan_name": "750104", "standard_charge_dollar": 91.15, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "United Healthcare Ba", "plan_name": "750090", "standard_charge_dollar": 91.15, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "United Healthcare Me", "plan_name": "501310", "standard_charge_dollar": 80.66, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Windsor Mcare Extra", "plan_name": "500778", "standard_charge_dollar": 80.66, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." } ] } ] }, { "description": "X-ray exam of knee 3", "code_information": [ { "code": "73562", "type": "CPT" } ], "standard_charges": [ { "gross_charge": 200.00, "minimum": 80.66, "maximum": 100.82, "setting": "both", "payers_information": [ { "payer_name": "Aarp", "plan_name": "500102", "standard_charge_dollar": 80.66, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna", "plan_name": "700700", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna", "plan_name": "700700_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Mcare Ffs 6005", "plan_name": "700703", "standard_charge_dollar": 80.66, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Miscellaneous", "plan_name": "700720", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Miscellaneous", "plan_name": "700720_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Ppo Hmo", "plan_name": "701720", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Ppo Hmo", "plan_name": "701720_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Ambetter 68069", "plan_name": "500516", "standard_charge_dollar": 80.66, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Ms State Emplo", "plan_name": "401457", "standard_charge_dollar": 91.20, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Ms State Emplo", "plan_name": "401457_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Basic Pl", "plan_name": "400100", "standard_charge_dollar": 91.20, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Basic Pl", "plan_name": "400100_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Federal", "plan_name": "400110", "standard_charge_dollar": 91.20, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Federal", "plan_name": "400110_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Cigna Healthsprings Ffs", "plan_name": "500064", "standard_charge_dollar": 80.66, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Conseco", "plan_name": "500302", "standard_charge_dollar": 80.66, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Humana Ffs 61101", "plan_name": "500006", "standard_charge_dollar": 80.66, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Medicare A", "plan_name": "100100", "standard_charge_dollar": 80.66, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Medicare A", "plan_name": "100500", "standard_charge_dollar": 80.66, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Medicare Part B Only", "plan_name": "100300", "standard_charge_dollar": 80.66, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Medicare Railroad", "plan_name": "100103", "standard_charge_dollar": 80.66, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Ms Physicians Care N", "plan_name": "714210", "standard_charge_dollar": 100.82, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Peoples Hlth Ffs 72126", "plan_name": "500019", "standard_charge_dollar": 80.66, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Uhc/Secure Horizons", "plan_name": "500449", "standard_charge_dollar": 80.66, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "United Health Care/", "plan_name": "500292", "standard_charge_dollar": 91.15, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "United Healthcare", "plan_name": "750104", "standard_charge_dollar": 91.15, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "United Healthcare Ba", "plan_name": "750090", "standard_charge_dollar": 91.15, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "United Healthcare Me", "plan_name": "501310", "standard_charge_dollar": 80.66, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Windsor Mcare Extra", "plan_name": "500778", "standard_charge_dollar": 80.66, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." } ] } ] }, { "description": "Hc knee 3 view", "code_information": [ { "code": "73562", "type": "CPT" } ], "standard_charges": [ { "gross_charge": 800.00, "minimum": 80.66, "maximum": 680.00, "setting": "both", "payers_information": [ { "payer_name": "Aarp", "plan_name": "500102", "standard_charge_dollar": 80.66, "count": "0", "methodology": "fee schedule", "modifiers": "50", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna", "plan_name": "700700", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna", "plan_name": "700700_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Mcare Ffs 6005", "plan_name": "700703", "standard_charge_dollar": 80.66, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Miscellaneous", "plan_name": "700720", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Miscellaneous", "plan_name": "700720_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Ppo Hmo", "plan_name": "701720", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Ppo Hmo", "plan_name": "701720_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Ambetter 68069", "plan_name": "500516", "standard_charge_dollar": 80.66, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Ms State Emplo", "plan_name": "401457", "standard_charge_percentage": 0.80, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Ms State Emplo", "plan_name": "401457_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Basic Pl", "plan_name": "400100", "standard_charge_percentage": 0.85, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Basic Pl", "plan_name": "400100_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Federal", "plan_name": "400110", "standard_charge_percentage": 0.85, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Federal", "plan_name": "400110_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Cigna Healthsprings Ffs", "plan_name": "500064", "standard_charge_dollar": 80.66, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Conseco", "plan_name": "500302", "standard_charge_dollar": 80.66, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Humana Ffs 61101", "plan_name": "500006", "standard_charge_dollar": 80.66, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Medicare A", "plan_name": "100100", "standard_charge_dollar": 80.66, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Medicare A", "plan_name": "100500", "standard_charge_dollar": 80.66, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Medicare Part B Only", "plan_name": "100300", "standard_charge_dollar": 80.66, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Medicare Railroad", "plan_name": "100103", "standard_charge_dollar": 80.66, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Ms Physicians Care N", "plan_name": "714210", "standard_charge_dollar": 100.82, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Peoples Hlth Ffs 72126", "plan_name": "500019", "standard_charge_dollar": 80.66, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Uhc/Secure Horizons", "plan_name": "500449", "standard_charge_dollar": 80.66, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "United Health Care/", "plan_name": "500292", "standard_charge_dollar": 91.15, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "United Healthcare", "plan_name": "750104", "standard_charge_dollar": 91.15, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "United Healthcare Ba", "plan_name": "750090", "standard_charge_dollar": 91.15, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "United Healthcare Me", "plan_name": "501310", "standard_charge_dollar": 80.66, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Windsor Mcare Extra", "plan_name": "500778", "standard_charge_dollar": 80.66, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." } ] } ] }, { "description": "Hc knee complete min 4 view", "code_information": [ { "code": "73564", "type": "CPT" } ], "standard_charges": [ { "gross_charge": 250.00, "minimum": 97.41, "maximum": 151.04, "setting": "both", "payers_information": [ { "payer_name": "Aarp", "plan_name": "500102", "standard_charge_dollar": 97.41, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna", "plan_name": "700700", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna", "plan_name": "700700_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Mcare Ffs 6005", "plan_name": "700703", "standard_charge_dollar": 97.41, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Miscellaneous", "plan_name": "700720", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Miscellaneous", "plan_name": "700720_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Ppo Hmo", "plan_name": "701720", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Ppo Hmo", "plan_name": "701720_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Ambetter 68069", "plan_name": "500516", "standard_charge_dollar": 97.41, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Ms State Emplo", "plan_name": "401457", "standard_charge_dollar": 151.04, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Ms State Emplo", "plan_name": "401457_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Basic Pl", "plan_name": "400100", "standard_charge_dollar": 151.04, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Basic Pl", "plan_name": "400100_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Federal", "plan_name": "400110", "standard_charge_dollar": 151.04, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Federal", "plan_name": "400110_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Cigna Healthsprings Ffs", "plan_name": "500064", "standard_charge_dollar": 97.41, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Conseco", "plan_name": "500302", "standard_charge_dollar": 97.41, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Humana Ffs 61101", "plan_name": "500006", "standard_charge_dollar": 97.41, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Medicare A", "plan_name": "100100", "standard_charge_dollar": 97.41, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Medicare A", "plan_name": "100500", "standard_charge_dollar": 97.41, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Medicare Part B Only", "plan_name": "100300", "standard_charge_dollar": 97.41, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Medicare Railroad", "plan_name": "100103", "standard_charge_dollar": 97.41, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Ms Physicians Care N", "plan_name": "714210", "standard_charge_dollar": 121.77, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Peoples Hlth Ffs 72126", "plan_name": "500019", "standard_charge_dollar": 97.41, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Uhc/Secure Horizons", "plan_name": "500449", "standard_charge_dollar": 97.41, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "United Health Care/", "plan_name": "500292", "standard_charge_dollar": 110.08, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "United Healthcare", "plan_name": "750104", "standard_charge_dollar": 110.08, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "United Healthcare Ba", "plan_name": "750090", "standard_charge_dollar": 110.08, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "United Healthcare Me", "plan_name": "501310", "standard_charge_dollar": 97.41, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Windsor Mcare Extra", "plan_name": "500778", "standard_charge_dollar": 97.41, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." } ] } ] }, { "description": "X-ray exam knee 4 or more", "code_information": [ { "code": "73564", "type": "CPT" } ], "standard_charges": [ { "gross_charge": 250.00, "minimum": 97.41, "maximum": 151.04, "setting": "both", "payers_information": [ { "payer_name": "Aarp", "plan_name": "500102", "standard_charge_dollar": 97.41, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna", "plan_name": "700700", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna", "plan_name": "700700_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Mcare Ffs 6005", "plan_name": "700703", "standard_charge_dollar": 97.41, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Miscellaneous", "plan_name": "700720", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Miscellaneous", "plan_name": "700720_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Ppo Hmo", "plan_name": "701720", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Ppo Hmo", "plan_name": "701720_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Ambetter 68069", "plan_name": "500516", "standard_charge_dollar": 97.41, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Ms State Emplo", "plan_name": "401457", "standard_charge_dollar": 151.04, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Ms State Emplo", "plan_name": "401457_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Basic Pl", "plan_name": "400100", "standard_charge_dollar": 151.04, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Basic Pl", "plan_name": "400100_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Federal", "plan_name": "400110", "standard_charge_dollar": 151.04, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Federal", "plan_name": "400110_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Cigna Healthsprings Ffs", "plan_name": "500064", "standard_charge_dollar": 97.41, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Conseco", "plan_name": "500302", "standard_charge_dollar": 97.41, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Humana Ffs 61101", "plan_name": "500006", "standard_charge_dollar": 97.41, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Medicare A", "plan_name": "100100", "standard_charge_dollar": 97.41, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Medicare A", "plan_name": "100500", "standard_charge_dollar": 97.41, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Medicare Part B Only", "plan_name": "100300", "standard_charge_dollar": 97.41, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Medicare Railroad", "plan_name": "100103", "standard_charge_dollar": 97.41, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Ms Physicians Care N", "plan_name": "714210", "standard_charge_dollar": 121.77, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Peoples Hlth Ffs 72126", "plan_name": "500019", "standard_charge_dollar": 97.41, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Uhc/Secure Horizons", "plan_name": "500449", "standard_charge_dollar": 97.41, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "United Health Care/", "plan_name": "500292", "standard_charge_dollar": 110.08, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "United Healthcare", "plan_name": "750104", "standard_charge_dollar": 110.08, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "United Healthcare Ba", "plan_name": "750090", "standard_charge_dollar": 110.08, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "United Healthcare Me", "plan_name": "501310", "standard_charge_dollar": 97.41, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Windsor Mcare Extra", "plan_name": "500778", "standard_charge_dollar": 97.41, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." } ] } ] }, { "description": "Hc knees bilateral standing ap", "code_information": [ { "code": "73565", "type": "CPT" } ], "standard_charges": [ { "gross_charge": 185.00, "minimum": 80.66, "maximum": 100.82, "setting": "both", "payers_information": [ { "payer_name": "Aarp", "plan_name": "500102", "standard_charge_dollar": 80.66, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna", "plan_name": "700700", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna", "plan_name": "700700_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Mcare Ffs 6005", "plan_name": "700703", "standard_charge_dollar": 80.66, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Miscellaneous", "plan_name": "700720", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Miscellaneous", "plan_name": "700720_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Ppo Hmo", "plan_name": "701720", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Ppo Hmo", "plan_name": "701720_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Ambetter 68069", "plan_name": "500516", "standard_charge_dollar": 80.66, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Ms State Emplo", "plan_name": "401457", "standard_charge_dollar": 91.20, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Ms State Emplo", "plan_name": "401457_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Basic Pl", "plan_name": "400100", "standard_charge_dollar": 91.20, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Basic Pl", "plan_name": "400100_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Federal", "plan_name": "400110", "standard_charge_dollar": 91.20, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Federal", "plan_name": "400110_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Cigna Healthsprings Ffs", "plan_name": "500064", "standard_charge_dollar": 80.66, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Conseco", "plan_name": "500302", "standard_charge_dollar": 80.66, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Humana Ffs 61101", "plan_name": "500006", "standard_charge_dollar": 80.66, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Medicare A", "plan_name": "100100", "standard_charge_dollar": 80.66, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Medicare A", "plan_name": "100500", "standard_charge_dollar": 80.66, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Medicare Part B Only", "plan_name": "100300", "standard_charge_dollar": 80.66, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Medicare Railroad", "plan_name": "100103", "standard_charge_dollar": 80.66, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Ms Physicians Care N", "plan_name": "714210", "standard_charge_dollar": 100.82, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Peoples Hlth Ffs 72126", "plan_name": "500019", "standard_charge_dollar": 80.66, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Uhc/Secure Horizons", "plan_name": "500449", "standard_charge_dollar": 80.66, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "United Health Care/", "plan_name": "500292", "standard_charge_dollar": 91.15, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "United Healthcare", "plan_name": "750104", "standard_charge_dollar": 91.15, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "United Healthcare Ba", "plan_name": "750090", "standard_charge_dollar": 91.15, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "United Healthcare Me", "plan_name": "501310", "standard_charge_dollar": 80.66, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Windsor Mcare Extra", "plan_name": "500778", "standard_charge_dollar": 80.66, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." } ] } ] }, { "description": "X-ray exam of knees", "code_information": [ { "code": "73565", "type": "CPT" } ], "standard_charges": [ { "gross_charge": 185.00, "minimum": 80.66, "maximum": 100.82, "setting": "both", "payers_information": [ { "payer_name": "Aarp", "plan_name": "500102", "standard_charge_dollar": 80.66, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna", "plan_name": "700700", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna", "plan_name": "700700_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Mcare Ffs 6005", "plan_name": "700703", "standard_charge_dollar": 80.66, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Miscellaneous", "plan_name": "700720", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Miscellaneous", "plan_name": "700720_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Ppo Hmo", "plan_name": "701720", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Ppo Hmo", "plan_name": "701720_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Ambetter 68069", "plan_name": "500516", "standard_charge_dollar": 80.66, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Ms State Emplo", "plan_name": "401457", "standard_charge_dollar": 91.20, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Ms State Emplo", "plan_name": "401457_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Basic Pl", "plan_name": "400100", "standard_charge_dollar": 91.20, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Basic Pl", "plan_name": "400100_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Federal", "plan_name": "400110", "standard_charge_dollar": 91.20, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Federal", "plan_name": "400110_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Cigna Healthsprings Ffs", "plan_name": "500064", "standard_charge_dollar": 80.66, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Conseco", "plan_name": "500302", "standard_charge_dollar": 80.66, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Humana Ffs 61101", "plan_name": "500006", "standard_charge_dollar": 80.66, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Medicare A", "plan_name": "100100", "standard_charge_dollar": 80.66, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Medicare A", "plan_name": "100500", "standard_charge_dollar": 80.66, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Medicare Part B Only", "plan_name": "100300", "standard_charge_dollar": 80.66, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Medicare Railroad", "plan_name": "100103", "standard_charge_dollar": 80.66, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Ms Physicians Care N", "plan_name": "714210", "standard_charge_dollar": 100.82, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Peoples Hlth Ffs 72126", "plan_name": "500019", "standard_charge_dollar": 80.66, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Uhc/Secure Horizons", "plan_name": "500449", "standard_charge_dollar": 80.66, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "United Health Care/", "plan_name": "500292", "standard_charge_dollar": 91.15, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "United Healthcare", "plan_name": "750104", "standard_charge_dollar": 91.15, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "United Healthcare Ba", "plan_name": "750090", "standard_charge_dollar": 91.15, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "United Healthcare Me", "plan_name": "501310", "standard_charge_dollar": 80.66, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Windsor Mcare Extra", "plan_name": "500778", "standard_charge_dollar": 80.66, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." } ] } ] }, { "description": "Hc tibia and fibula 2 view", "code_information": [ { "code": "73590", "type": "CPT" } ], "standard_charges": [ { "gross_charge": 200.00, "minimum": 80.66, "maximum": 100.82, "setting": "both", "payers_information": [ { "payer_name": "Aarp", "plan_name": "500102", "standard_charge_dollar": 80.66, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna", "plan_name": "700700", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna", "plan_name": "700700_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Mcare Ffs 6005", "plan_name": "700703", "standard_charge_dollar": 80.66, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Miscellaneous", "plan_name": "700720", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Miscellaneous", "plan_name": "700720_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Ppo Hmo", "plan_name": "701720", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Ppo Hmo", "plan_name": "701720_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Ambetter 68069", "plan_name": "500516", "standard_charge_dollar": 80.66, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Ms State Emplo", "plan_name": "401457", "standard_charge_dollar": 91.20, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Ms State Emplo", "plan_name": "401457_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Basic Pl", "plan_name": "400100", "standard_charge_dollar": 91.20, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Basic Pl", "plan_name": "400100_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Federal", "plan_name": "400110", "standard_charge_dollar": 91.20, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Federal", "plan_name": "400110_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Cigna Healthsprings Ffs", "plan_name": "500064", "standard_charge_dollar": 80.66, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Conseco", "plan_name": "500302", "standard_charge_dollar": 80.66, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Humana Ffs 61101", "plan_name": "500006", "standard_charge_dollar": 80.66, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Medicare A", "plan_name": "100100", "standard_charge_dollar": 80.66, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Medicare A", "plan_name": "100500", "standard_charge_dollar": 80.66, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Medicare Part B Only", "plan_name": "100300", "standard_charge_dollar": 80.66, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Medicare Railroad", "plan_name": "100103", "standard_charge_dollar": 80.66, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Ms Physicians Care N", "plan_name": "714210", "standard_charge_dollar": 100.82, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Peoples Hlth Ffs 72126", "plan_name": "500019", "standard_charge_dollar": 80.66, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Uhc/Secure Horizons", "plan_name": "500449", "standard_charge_dollar": 80.66, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "United Health Care/", "plan_name": "500292", "standard_charge_dollar": 91.15, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "United Healthcare", "plan_name": "750104", "standard_charge_dollar": 91.15, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "United Healthcare Ba", "plan_name": "750090", "standard_charge_dollar": 91.15, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "United Healthcare Me", "plan_name": "501310", "standard_charge_dollar": 80.66, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Windsor Mcare Extra", "plan_name": "500778", "standard_charge_dollar": 80.66, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." } ] } ] }, { "description": "X-ray exam of lower leg", "code_information": [ { "code": "73590", "type": "CPT" } ], "standard_charges": [ { "gross_charge": 200.00, "minimum": 80.66, "maximum": 100.82, "setting": "both", "payers_information": [ { "payer_name": "Aarp", "plan_name": "500102", "standard_charge_dollar": 80.66, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna", "plan_name": "700700", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna", "plan_name": "700700_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Mcare Ffs 6005", "plan_name": "700703", "standard_charge_dollar": 80.66, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Miscellaneous", "plan_name": "700720", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Miscellaneous", "plan_name": "700720_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Ppo Hmo", "plan_name": "701720", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Ppo Hmo", "plan_name": "701720_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Ambetter 68069", "plan_name": "500516", "standard_charge_dollar": 80.66, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Ms State Emplo", "plan_name": "401457", "standard_charge_dollar": 91.20, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Ms State Emplo", "plan_name": "401457_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Basic Pl", "plan_name": "400100", "standard_charge_dollar": 91.20, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Basic Pl", "plan_name": "400100_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Federal", "plan_name": "400110", "standard_charge_dollar": 91.20, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Federal", "plan_name": "400110_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Cigna Healthsprings Ffs", "plan_name": "500064", "standard_charge_dollar": 80.66, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Conseco", "plan_name": "500302", "standard_charge_dollar": 80.66, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Humana Ffs 61101", "plan_name": "500006", "standard_charge_dollar": 80.66, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Medicare A", "plan_name": "100100", "standard_charge_dollar": 80.66, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Medicare A", "plan_name": "100500", "standard_charge_dollar": 80.66, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Medicare Part B Only", "plan_name": "100300", "standard_charge_dollar": 80.66, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Medicare Railroad", "plan_name": "100103", "standard_charge_dollar": 80.66, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Ms Physicians Care N", "plan_name": "714210", "standard_charge_dollar": 100.82, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Peoples Hlth Ffs 72126", "plan_name": "500019", "standard_charge_dollar": 80.66, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Uhc/Secure Horizons", "plan_name": "500449", "standard_charge_dollar": 80.66, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "United Health Care/", "plan_name": "500292", "standard_charge_dollar": 91.15, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "United Healthcare", "plan_name": "750104", "standard_charge_dollar": 91.15, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "United Healthcare Ba", "plan_name": "750090", "standard_charge_dollar": 91.15, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "United Healthcare Me", "plan_name": "501310", "standard_charge_dollar": 80.66, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Windsor Mcare Extra", "plan_name": "500778", "standard_charge_dollar": 80.66, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." } ] } ] }, { "description": "Hc tibia and fibula 2 view", "code_information": [ { "code": "73590", "type": "CPT" } ], "standard_charges": [ { "gross_charge": 800.00, "minimum": 80.66, "maximum": 680.00, "setting": "both", "payers_information": [ { "payer_name": "Aarp", "plan_name": "500102", "standard_charge_dollar": 80.66, "count": "0", "methodology": "fee schedule", "modifiers": "50", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna", "plan_name": "700700", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna", "plan_name": "700700_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Mcare Ffs 6005", "plan_name": "700703", "standard_charge_dollar": 80.66, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Miscellaneous", "plan_name": "700720", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Miscellaneous", "plan_name": "700720_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Ppo Hmo", "plan_name": "701720", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Ppo Hmo", "plan_name": "701720_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Ambetter 68069", "plan_name": "500516", "standard_charge_dollar": 80.66, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Ms State Emplo", "plan_name": "401457", "standard_charge_percentage": 0.80, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Ms State Emplo", "plan_name": "401457_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Basic Pl", "plan_name": "400100", "standard_charge_percentage": 0.85, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Basic Pl", "plan_name": "400100_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Federal", "plan_name": "400110", "standard_charge_percentage": 0.85, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Federal", "plan_name": "400110_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Cigna Healthsprings Ffs", "plan_name": "500064", "standard_charge_dollar": 80.66, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Conseco", "plan_name": "500302", "standard_charge_dollar": 80.66, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Humana Ffs 61101", "plan_name": "500006", "standard_charge_dollar": 80.66, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Medicare A", "plan_name": "100100", "standard_charge_dollar": 80.66, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Medicare A", "plan_name": "100500", "standard_charge_dollar": 80.66, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Medicare Part B Only", "plan_name": "100300", "standard_charge_dollar": 80.66, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Medicare Railroad", "plan_name": "100103", "standard_charge_dollar": 80.66, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Ms Physicians Care N", "plan_name": "714210", "standard_charge_dollar": 100.82, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Peoples Hlth Ffs 72126", "plan_name": "500019", "standard_charge_dollar": 80.66, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Uhc/Secure Horizons", "plan_name": "500449", "standard_charge_dollar": 80.66, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "United Health Care/", "plan_name": "500292", "standard_charge_dollar": 91.15, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "United Healthcare", "plan_name": "750104", "standard_charge_dollar": 91.15, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "United Healthcare Ba", "plan_name": "750090", "standard_charge_dollar": 91.15, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "United Healthcare Me", "plan_name": "501310", "standard_charge_dollar": 80.66, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Windsor Mcare Extra", "plan_name": "500778", "standard_charge_dollar": 80.66, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." } ] } ] }, { "description": "Hc ankle complete min 3 view", "code_information": [ { "code": "73610", "type": "CPT" } ], "standard_charges": [ { "gross_charge": 200.00, "minimum": 80.66, "maximum": 100.82, "setting": "both", "payers_information": [ { "payer_name": "Aarp", "plan_name": "500102", "standard_charge_dollar": 80.66, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna", "plan_name": "700700", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna", "plan_name": "700700_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Mcare Ffs 6005", "plan_name": "700703", "standard_charge_dollar": 80.66, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Miscellaneous", "plan_name": "700720", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Miscellaneous", "plan_name": "700720_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Ppo Hmo", "plan_name": "701720", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Ppo Hmo", "plan_name": "701720_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Ambetter 68069", "plan_name": "500516", "standard_charge_dollar": 80.66, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Ms State Emplo", "plan_name": "401457", "standard_charge_dollar": 91.20, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Ms State Emplo", "plan_name": "401457_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Basic Pl", "plan_name": "400100", "standard_charge_dollar": 91.20, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Basic Pl", "plan_name": "400100_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Federal", "plan_name": "400110", "standard_charge_dollar": 91.20, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Federal", "plan_name": "400110_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Cigna Healthsprings Ffs", "plan_name": "500064", "standard_charge_dollar": 80.66, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Conseco", "plan_name": "500302", "standard_charge_dollar": 80.66, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Humana Ffs 61101", "plan_name": "500006", "standard_charge_dollar": 80.66, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Medicare A", "plan_name": "100100", "standard_charge_dollar": 80.66, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Medicare A", "plan_name": "100500", "standard_charge_dollar": 80.66, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Medicare Part B Only", "plan_name": "100300", "standard_charge_dollar": 80.66, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Medicare Railroad", "plan_name": "100103", "standard_charge_dollar": 80.66, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Ms Physicians Care N", "plan_name": "714210", "standard_charge_dollar": 100.82, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Peoples Hlth Ffs 72126", "plan_name": "500019", "standard_charge_dollar": 80.66, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Uhc/Secure Horizons", "plan_name": "500449", "standard_charge_dollar": 80.66, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "United Health Care/", "plan_name": "500292", "standard_charge_dollar": 91.15, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "United Healthcare", "plan_name": "750104", "standard_charge_dollar": 91.15, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "United Healthcare Ba", "plan_name": "750090", "standard_charge_dollar": 91.15, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "United Healthcare Me", "plan_name": "501310", "standard_charge_dollar": 80.66, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Windsor Mcare Extra", "plan_name": "500778", "standard_charge_dollar": 80.66, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." } ] } ] }, { "description": "X-ray exam of ankle", "code_information": [ { "code": "73610", "type": "CPT" } ], "standard_charges": [ { "gross_charge": 200.00, "minimum": 80.66, "maximum": 100.82, "setting": "both", "payers_information": [ { "payer_name": "Aarp", "plan_name": "500102", "standard_charge_dollar": 80.66, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna", "plan_name": "700700", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna", "plan_name": "700700_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Mcare Ffs 6005", "plan_name": "700703", "standard_charge_dollar": 80.66, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Miscellaneous", "plan_name": "700720", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Miscellaneous", "plan_name": "700720_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Ppo Hmo", "plan_name": "701720", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Ppo Hmo", "plan_name": "701720_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Ambetter 68069", "plan_name": "500516", "standard_charge_dollar": 80.66, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Ms State Emplo", "plan_name": "401457", "standard_charge_dollar": 91.20, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Ms State Emplo", "plan_name": "401457_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Basic Pl", "plan_name": "400100", "standard_charge_dollar": 91.20, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Basic Pl", "plan_name": "400100_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Federal", "plan_name": "400110", "standard_charge_dollar": 91.20, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Federal", "plan_name": "400110_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Cigna Healthsprings Ffs", "plan_name": "500064", "standard_charge_dollar": 80.66, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Conseco", "plan_name": "500302", "standard_charge_dollar": 80.66, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Humana Ffs 61101", "plan_name": "500006", "standard_charge_dollar": 80.66, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Medicare A", "plan_name": "100100", "standard_charge_dollar": 80.66, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Medicare A", "plan_name": "100500", "standard_charge_dollar": 80.66, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Medicare Part B Only", "plan_name": "100300", "standard_charge_dollar": 80.66, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Medicare Railroad", "plan_name": "100103", "standard_charge_dollar": 80.66, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Ms Physicians Care N", "plan_name": "714210", "standard_charge_dollar": 100.82, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Peoples Hlth Ffs 72126", "plan_name": "500019", "standard_charge_dollar": 80.66, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Uhc/Secure Horizons", "plan_name": "500449", "standard_charge_dollar": 80.66, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "United Health Care/", "plan_name": "500292", "standard_charge_dollar": 91.15, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "United Healthcare", "plan_name": "750104", "standard_charge_dollar": 91.15, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "United Healthcare Ba", "plan_name": "750090", "standard_charge_dollar": 91.15, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "United Healthcare Me", "plan_name": "501310", "standard_charge_dollar": 80.66, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Windsor Mcare Extra", "plan_name": "500778", "standard_charge_dollar": 80.66, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." } ] } ] }, { "description": "Hc ankle complete min 3 view", "code_information": [ { "code": "73610", "type": "CPT" } ], "standard_charges": [ { "gross_charge": 800.00, "minimum": 80.66, "maximum": 680.00, "setting": "both", "payers_information": [ { "payer_name": "Aarp", "plan_name": "500102", "standard_charge_dollar": 80.66, "count": "0", "methodology": "fee schedule", "modifiers": "50", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna", "plan_name": "700700", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna", "plan_name": "700700_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Mcare Ffs 6005", "plan_name": "700703", "standard_charge_dollar": 80.66, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Miscellaneous", "plan_name": "700720", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Miscellaneous", "plan_name": "700720_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Ppo Hmo", "plan_name": "701720", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Ppo Hmo", "plan_name": "701720_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Ambetter 68069", "plan_name": "500516", "standard_charge_dollar": 80.66, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Ms State Emplo", "plan_name": "401457", "standard_charge_percentage": 0.80, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Ms State Emplo", "plan_name": "401457_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Basic Pl", "plan_name": "400100", "standard_charge_percentage": 0.85, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Basic Pl", "plan_name": "400100_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Federal", "plan_name": "400110", "standard_charge_percentage": 0.85, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Federal", "plan_name": "400110_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Cigna Healthsprings Ffs", "plan_name": "500064", "standard_charge_dollar": 80.66, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Conseco", "plan_name": "500302", "standard_charge_dollar": 80.66, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Humana Ffs 61101", "plan_name": "500006", "standard_charge_dollar": 80.66, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Medicare A", "plan_name": "100100", "standard_charge_dollar": 80.66, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Medicare A", "plan_name": "100500", "standard_charge_dollar": 80.66, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Medicare Part B Only", "plan_name": "100300", "standard_charge_dollar": 80.66, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Medicare Railroad", "plan_name": "100103", "standard_charge_dollar": 80.66, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Ms Physicians Care N", "plan_name": "714210", "standard_charge_dollar": 100.82, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Peoples Hlth Ffs 72126", "plan_name": "500019", "standard_charge_dollar": 80.66, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Uhc/Secure Horizons", "plan_name": "500449", "standard_charge_dollar": 80.66, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "United Health Care/", "plan_name": "500292", "standard_charge_dollar": 91.15, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "United Healthcare", "plan_name": "750104", "standard_charge_dollar": 91.15, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "United Healthcare Ba", "plan_name": "750090", "standard_charge_dollar": 91.15, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "United Healthcare Me", "plan_name": "501310", "standard_charge_dollar": 80.66, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Windsor Mcare Extra", "plan_name": "500778", "standard_charge_dollar": 80.66, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." } ] } ] }, { "description": "Hc foot complete min 3 view", "code_information": [ { "code": "73630", "type": "CPT" } ], "standard_charges": [ { "gross_charge": 200.00, "minimum": 80.66, "maximum": 100.82, "setting": "both", "payers_information": [ { "payer_name": "Aarp", "plan_name": "500102", "standard_charge_dollar": 80.66, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna", "plan_name": "700700", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna", "plan_name": "700700_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Mcare Ffs 6005", "plan_name": "700703", "standard_charge_dollar": 80.66, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Miscellaneous", "plan_name": "700720", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Miscellaneous", "plan_name": "700720_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Ppo Hmo", "plan_name": "701720", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Ppo Hmo", "plan_name": "701720_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Ambetter 68069", "plan_name": "500516", "standard_charge_dollar": 80.66, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Ms State Emplo", "plan_name": "401457", "standard_charge_dollar": 91.20, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Ms State Emplo", "plan_name": "401457_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Basic Pl", "plan_name": "400100", "standard_charge_dollar": 91.20, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Basic Pl", "plan_name": "400100_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Federal", "plan_name": "400110", "standard_charge_dollar": 91.20, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Federal", "plan_name": "400110_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Cigna Healthsprings Ffs", "plan_name": "500064", "standard_charge_dollar": 80.66, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Conseco", "plan_name": "500302", "standard_charge_dollar": 80.66, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Humana Ffs 61101", "plan_name": "500006", "standard_charge_dollar": 80.66, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Medicare A", "plan_name": "100100", "standard_charge_dollar": 80.66, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Medicare A", "plan_name": "100500", "standard_charge_dollar": 80.66, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Medicare Part B Only", "plan_name": "100300", "standard_charge_dollar": 80.66, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Medicare Railroad", "plan_name": "100103", "standard_charge_dollar": 80.66, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Ms Physicians Care N", "plan_name": "714210", "standard_charge_dollar": 100.82, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Peoples Hlth Ffs 72126", "plan_name": "500019", "standard_charge_dollar": 80.66, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Uhc/Secure Horizons", "plan_name": "500449", "standard_charge_dollar": 80.66, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "United Health Care/", "plan_name": "500292", "standard_charge_dollar": 91.15, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "United Healthcare", "plan_name": "750104", "standard_charge_dollar": 91.15, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "United Healthcare Ba", "plan_name": "750090", "standard_charge_dollar": 91.15, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "United Healthcare Me", "plan_name": "501310", "standard_charge_dollar": 80.66, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Windsor Mcare Extra", "plan_name": "500778", "standard_charge_dollar": 80.66, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." } ] } ] }, { "description": "X-ray exam of foot", "code_information": [ { "code": "73630", "type": "CPT" } ], "standard_charges": [ { "gross_charge": 200.00, "minimum": 80.66, "maximum": 100.82, "setting": "both", "payers_information": [ { "payer_name": "Aarp", "plan_name": "500102", "standard_charge_dollar": 80.66, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna", "plan_name": "700700", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna", "plan_name": "700700_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Mcare Ffs 6005", "plan_name": "700703", "standard_charge_dollar": 80.66, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Miscellaneous", "plan_name": "700720", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Miscellaneous", "plan_name": "700720_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Ppo Hmo", "plan_name": "701720", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Ppo Hmo", "plan_name": "701720_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Ambetter 68069", "plan_name": "500516", "standard_charge_dollar": 80.66, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Ms State Emplo", "plan_name": "401457", "standard_charge_dollar": 91.20, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Ms State Emplo", "plan_name": "401457_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Basic Pl", "plan_name": "400100", "standard_charge_dollar": 91.20, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Basic Pl", "plan_name": "400100_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Federal", "plan_name": "400110", "standard_charge_dollar": 91.20, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Federal", "plan_name": "400110_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Cigna Healthsprings Ffs", "plan_name": "500064", "standard_charge_dollar": 80.66, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Conseco", "plan_name": "500302", "standard_charge_dollar": 80.66, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Humana Ffs 61101", "plan_name": "500006", "standard_charge_dollar": 80.66, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Medicare A", "plan_name": "100100", "standard_charge_dollar": 80.66, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Medicare A", "plan_name": "100500", "standard_charge_dollar": 80.66, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Medicare Part B Only", "plan_name": "100300", "standard_charge_dollar": 80.66, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Medicare Railroad", "plan_name": "100103", "standard_charge_dollar": 80.66, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Ms Physicians Care N", "plan_name": "714210", "standard_charge_dollar": 100.82, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Peoples Hlth Ffs 72126", "plan_name": "500019", "standard_charge_dollar": 80.66, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Uhc/Secure Horizons", "plan_name": "500449", "standard_charge_dollar": 80.66, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "United Health Care/", "plan_name": "500292", "standard_charge_dollar": 91.15, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "United Healthcare", "plan_name": "750104", "standard_charge_dollar": 91.15, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "United Healthcare Ba", "plan_name": "750090", "standard_charge_dollar": 91.15, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "United Healthcare Me", "plan_name": "501310", "standard_charge_dollar": 80.66, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Windsor Mcare Extra", "plan_name": "500778", "standard_charge_dollar": 80.66, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." } ] } ] }, { "description": "Hc foot complete min 3 view", "code_information": [ { "code": "73630", "type": "CPT" } ], "standard_charges": [ { "gross_charge": 800.00, "minimum": 80.66, "maximum": 680.00, "setting": "both", "payers_information": [ { "payer_name": "Aarp", "plan_name": "500102", "standard_charge_dollar": 80.66, "count": "0", "methodology": "fee schedule", "modifiers": "50", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna", "plan_name": "700700", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna", "plan_name": "700700_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Mcare Ffs 6005", "plan_name": "700703", "standard_charge_dollar": 80.66, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Miscellaneous", "plan_name": "700720", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Miscellaneous", "plan_name": "700720_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Ppo Hmo", "plan_name": "701720", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Ppo Hmo", "plan_name": "701720_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Ambetter 68069", "plan_name": "500516", "standard_charge_dollar": 80.66, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Ms State Emplo", "plan_name": "401457", "standard_charge_percentage": 0.80, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Ms State Emplo", "plan_name": "401457_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Basic Pl", "plan_name": "400100", "standard_charge_percentage": 0.85, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Basic Pl", "plan_name": "400100_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Federal", "plan_name": "400110", "standard_charge_percentage": 0.85, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Federal", "plan_name": "400110_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Cigna Healthsprings Ffs", "plan_name": "500064", "standard_charge_dollar": 80.66, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Conseco", "plan_name": "500302", "standard_charge_dollar": 80.66, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Humana Ffs 61101", "plan_name": "500006", "standard_charge_dollar": 80.66, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Medicare A", "plan_name": "100100", "standard_charge_dollar": 80.66, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Medicare A", "plan_name": "100500", "standard_charge_dollar": 80.66, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Medicare Part B Only", "plan_name": "100300", "standard_charge_dollar": 80.66, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Medicare Railroad", "plan_name": "100103", "standard_charge_dollar": 80.66, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Ms Physicians Care N", "plan_name": "714210", "standard_charge_dollar": 100.82, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Peoples Hlth Ffs 72126", "plan_name": "500019", "standard_charge_dollar": 80.66, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Uhc/Secure Horizons", "plan_name": "500449", "standard_charge_dollar": 80.66, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "United Health Care/", "plan_name": "500292", "standard_charge_dollar": 91.15, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "United Healthcare", "plan_name": "750104", "standard_charge_dollar": 91.15, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "United Healthcare Ba", "plan_name": "750090", "standard_charge_dollar": 91.15, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "United Healthcare Me", "plan_name": "501310", "standard_charge_dollar": 80.66, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Windsor Mcare Extra", "plan_name": "500778", "standard_charge_dollar": 80.66, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." } ] } ] }, { "description": "Hc calcaneus min 2 view", "code_information": [ { "code": "73650", "type": "CPT" } ], "standard_charges": [ { "gross_charge": 200.00, "minimum": 80.66, "maximum": 100.82, "setting": "both", "payers_information": [ { "payer_name": "Aarp", "plan_name": "500102", "standard_charge_dollar": 80.66, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna", "plan_name": "700700", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna", "plan_name": "700700_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Mcare Ffs 6005", "plan_name": "700703", "standard_charge_dollar": 80.66, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Miscellaneous", "plan_name": "700720", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Miscellaneous", "plan_name": "700720_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Ppo Hmo", "plan_name": "701720", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Ppo Hmo", "plan_name": "701720_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Ambetter 68069", "plan_name": "500516", "standard_charge_dollar": 80.66, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Ms State Emplo", "plan_name": "401457", "standard_charge_dollar": 91.20, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Ms State Emplo", "plan_name": "401457_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Basic Pl", "plan_name": "400100", "standard_charge_dollar": 91.20, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Basic Pl", "plan_name": "400100_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Federal", "plan_name": "400110", "standard_charge_dollar": 91.20, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Federal", "plan_name": "400110_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Cigna Healthsprings Ffs", "plan_name": "500064", "standard_charge_dollar": 80.66, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Conseco", "plan_name": "500302", "standard_charge_dollar": 80.66, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Humana Ffs 61101", "plan_name": "500006", "standard_charge_dollar": 80.66, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Medicare A", "plan_name": "100100", "standard_charge_dollar": 80.66, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Medicare A", "plan_name": "100500", "standard_charge_dollar": 80.66, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Medicare Part B Only", "plan_name": "100300", "standard_charge_dollar": 80.66, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Medicare Railroad", "plan_name": "100103", "standard_charge_dollar": 80.66, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Ms Physicians Care N", "plan_name": "714210", "standard_charge_dollar": 100.82, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Peoples Hlth Ffs 72126", "plan_name": "500019", "standard_charge_dollar": 80.66, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Uhc/Secure Horizons", "plan_name": "500449", "standard_charge_dollar": 80.66, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "United Health Care/", "plan_name": "500292", "standard_charge_dollar": 91.15, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "United Healthcare", "plan_name": "750104", "standard_charge_dollar": 91.15, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "United Healthcare Ba", "plan_name": "750090", "standard_charge_dollar": 91.15, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "United Healthcare Me", "plan_name": "501310", "standard_charge_dollar": 80.66, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Windsor Mcare Extra", "plan_name": "500778", "standard_charge_dollar": 80.66, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." } ] } ] }, { "description": "X-ray exam of heel", "code_information": [ { "code": "73650", "type": "CPT" } ], "standard_charges": [ { "gross_charge": 200.00, "minimum": 80.66, "maximum": 100.82, "setting": "both", "payers_information": [ { "payer_name": "Aarp", "plan_name": "500102", "standard_charge_dollar": 80.66, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna", "plan_name": "700700", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna", "plan_name": "700700_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Mcare Ffs 6005", "plan_name": "700703", "standard_charge_dollar": 80.66, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Miscellaneous", "plan_name": "700720", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Miscellaneous", "plan_name": "700720_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Ppo Hmo", "plan_name": "701720", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Ppo Hmo", "plan_name": "701720_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Ambetter 68069", "plan_name": "500516", "standard_charge_dollar": 80.66, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Ms State Emplo", "plan_name": "401457", "standard_charge_dollar": 91.20, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Ms State Emplo", "plan_name": "401457_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Basic Pl", "plan_name": "400100", "standard_charge_dollar": 91.20, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Basic Pl", "plan_name": "400100_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Federal", "plan_name": "400110", "standard_charge_dollar": 91.20, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Federal", "plan_name": "400110_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Cigna Healthsprings Ffs", "plan_name": "500064", "standard_charge_dollar": 80.66, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Conseco", "plan_name": "500302", "standard_charge_dollar": 80.66, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Humana Ffs 61101", "plan_name": "500006", "standard_charge_dollar": 80.66, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Medicare A", "plan_name": "100100", "standard_charge_dollar": 80.66, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Medicare A", "plan_name": "100500", "standard_charge_dollar": 80.66, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Medicare Part B Only", "plan_name": "100300", "standard_charge_dollar": 80.66, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Medicare Railroad", "plan_name": "100103", "standard_charge_dollar": 80.66, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Ms Physicians Care N", "plan_name": "714210", "standard_charge_dollar": 100.82, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Peoples Hlth Ffs 72126", "plan_name": "500019", "standard_charge_dollar": 80.66, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Uhc/Secure Horizons", "plan_name": "500449", "standard_charge_dollar": 80.66, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "United Health Care/", "plan_name": "500292", "standard_charge_dollar": 91.15, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "United Healthcare", "plan_name": "750104", "standard_charge_dollar": 91.15, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "United Healthcare Ba", "plan_name": "750090", "standard_charge_dollar": 91.15, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "United Healthcare Me", "plan_name": "501310", "standard_charge_dollar": 80.66, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Windsor Mcare Extra", "plan_name": "500778", "standard_charge_dollar": 80.66, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." } ] } ] }, { "description": "Hc toe min 2 view", "code_information": [ { "code": "73660", "type": "CPT" } ], "standard_charges": [ { "gross_charge": 200.00, "minimum": 80.66, "maximum": 100.82, "setting": "both", "payers_information": [ { "payer_name": "Aarp", "plan_name": "500102", "standard_charge_dollar": 80.66, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna", "plan_name": "700700", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna", "plan_name": "700700_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Mcare Ffs 6005", "plan_name": "700703", "standard_charge_dollar": 80.66, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Miscellaneous", "plan_name": "700720", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Miscellaneous", "plan_name": "700720_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Ppo Hmo", "plan_name": "701720", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Ppo Hmo", "plan_name": "701720_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Ambetter 68069", "plan_name": "500516", "standard_charge_dollar": 80.66, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Ms State Emplo", "plan_name": "401457", "standard_charge_dollar": 91.20, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Ms State Emplo", "plan_name": "401457_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Basic Pl", "plan_name": "400100", "standard_charge_dollar": 91.20, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Basic Pl", "plan_name": "400100_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Federal", "plan_name": "400110", "standard_charge_dollar": 91.20, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Federal", "plan_name": "400110_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Cigna Healthsprings Ffs", "plan_name": "500064", "standard_charge_dollar": 80.66, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Conseco", "plan_name": "500302", "standard_charge_dollar": 80.66, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Humana Ffs 61101", "plan_name": "500006", "standard_charge_dollar": 80.66, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Medicare A", "plan_name": "100100", "standard_charge_dollar": 80.66, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Medicare A", "plan_name": "100500", "standard_charge_dollar": 80.66, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Medicare Part B Only", "plan_name": "100300", "standard_charge_dollar": 80.66, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Medicare Railroad", "plan_name": "100103", "standard_charge_dollar": 80.66, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Ms Physicians Care N", "plan_name": "714210", "standard_charge_dollar": 100.82, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Peoples Hlth Ffs 72126", "plan_name": "500019", "standard_charge_dollar": 80.66, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Uhc/Secure Horizons", "plan_name": "500449", "standard_charge_dollar": 80.66, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "United Health Care/", "plan_name": "500292", "standard_charge_dollar": 91.15, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "United Healthcare", "plan_name": "750104", "standard_charge_dollar": 91.15, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "United Healthcare Ba", "plan_name": "750090", "standard_charge_dollar": 91.15, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "United Healthcare Me", "plan_name": "501310", "standard_charge_dollar": 80.66, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Windsor Mcare Extra", "plan_name": "500778", "standard_charge_dollar": 80.66, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." } ] } ] }, { "description": "X-ray exam of toe(s)", "code_information": [ { "code": "73660", "type": "CPT" } ], "standard_charges": [ { "gross_charge": 200.00, "minimum": 80.66, "maximum": 100.82, "setting": "both", "payers_information": [ { "payer_name": "Aarp", "plan_name": "500102", "standard_charge_dollar": 80.66, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna", "plan_name": "700700", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna", "plan_name": "700700_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Mcare Ffs 6005", "plan_name": "700703", "standard_charge_dollar": 80.66, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Miscellaneous", "plan_name": "700720", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Miscellaneous", "plan_name": "700720_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Ppo Hmo", "plan_name": "701720", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Ppo Hmo", "plan_name": "701720_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Ambetter 68069", "plan_name": "500516", "standard_charge_dollar": 80.66, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Ms State Emplo", "plan_name": "401457", "standard_charge_dollar": 91.20, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Ms State Emplo", "plan_name": "401457_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Basic Pl", "plan_name": "400100", "standard_charge_dollar": 91.20, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Basic Pl", "plan_name": "400100_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Federal", "plan_name": "400110", "standard_charge_dollar": 91.20, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Federal", "plan_name": "400110_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Cigna Healthsprings Ffs", "plan_name": "500064", "standard_charge_dollar": 80.66, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Conseco", "plan_name": "500302", "standard_charge_dollar": 80.66, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Humana Ffs 61101", "plan_name": "500006", "standard_charge_dollar": 80.66, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Medicare A", "plan_name": "100100", "standard_charge_dollar": 80.66, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Medicare A", "plan_name": "100500", "standard_charge_dollar": 80.66, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Medicare Part B Only", "plan_name": "100300", "standard_charge_dollar": 80.66, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Medicare Railroad", "plan_name": "100103", "standard_charge_dollar": 80.66, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Ms Physicians Care N", "plan_name": "714210", "standard_charge_dollar": 100.82, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Peoples Hlth Ffs 72126", "plan_name": "500019", "standard_charge_dollar": 80.66, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Uhc/Secure Horizons", "plan_name": "500449", "standard_charge_dollar": 80.66, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "United Health Care/", "plan_name": "500292", "standard_charge_dollar": 91.15, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "United Healthcare", "plan_name": "750104", "standard_charge_dollar": 91.15, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "United Healthcare Ba", "plan_name": "750090", "standard_charge_dollar": 91.15, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "United Healthcare Me", "plan_name": "501310", "standard_charge_dollar": 80.66, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Windsor Mcare Extra", "plan_name": "500778", "standard_charge_dollar": 80.66, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." } ] } ] }, { "description": "Ct lower extremity w/o dye", "code_information": [ { "code": "73700", "type": "CPT" } ], "standard_charges": [ { "gross_charge": 589.00, "minimum": 168.74, "maximum": 257.13, "setting": "both", "payers_information": [ { "payer_name": "Aarp", "plan_name": "500102", "standard_charge_dollar": 205.70, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna", "plan_name": "700700", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna", "plan_name": "700700_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Mcare Ffs 6005", "plan_name": "700703", "standard_charge_dollar": 205.70, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Miscellaneous", "plan_name": "700720", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Miscellaneous", "plan_name": "700720_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Ppo Hmo", "plan_name": "701720", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Ppo Hmo", "plan_name": "701720_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Ambetter 68069", "plan_name": "500516", "standard_charge_dollar": 205.70, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Ms State Emplo", "plan_name": "401457", "standard_charge_dollar": 168.74, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Ms State Emplo", "plan_name": "401457_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Basic Pl", "plan_name": "400100", "standard_charge_dollar": 168.74, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Basic Pl", "plan_name": "400100_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Federal", "plan_name": "400110", "standard_charge_dollar": 168.74, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Federal", "plan_name": "400110_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Cigna Healthsprings Ffs", "plan_name": "500064", "standard_charge_dollar": 205.70, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Conseco", "plan_name": "500302", "standard_charge_dollar": 205.70, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Humana Ffs 61101", "plan_name": "500006", "standard_charge_dollar": 205.70, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Medicare A", "plan_name": "100100", "standard_charge_dollar": 205.70, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Medicare A", "plan_name": "100500", "standard_charge_dollar": 205.70, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Medicare Part B Only", "plan_name": "100300", "standard_charge_dollar": 205.70, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Medicare Railroad", "plan_name": "100103", "standard_charge_dollar": 205.70, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Ms Physicians Care N", "plan_name": "714210", "standard_charge_dollar": 257.13, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Peoples Hlth Ffs 72126", "plan_name": "500019", "standard_charge_dollar": 205.70, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Uhc/Secure Horizons", "plan_name": "500449", "standard_charge_dollar": 205.70, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "United Health Care/", "plan_name": "500292", "standard_charge_dollar": 232.44, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "United Healthcare", "plan_name": "750104", "standard_charge_dollar": 232.44, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "United Healthcare Ba", "plan_name": "750090", "standard_charge_dollar": 232.44, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "United Healthcare Me", "plan_name": "501310", "standard_charge_dollar": 205.70, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Windsor Mcare Extra", "plan_name": "500778", "standard_charge_dollar": 205.70, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." } ] } ] }, { "description": "Hc ct extrem lower w/o contrast", "code_information": [ { "code": "73700", "type": "CPT" } ], "standard_charges": [ { "gross_charge": 589.00, "minimum": 168.74, "maximum": 257.13, "setting": "both", "payers_information": [ { "payer_name": "Aarp", "plan_name": "500102", "standard_charge_dollar": 205.70, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna", "plan_name": "700700", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna", "plan_name": "700700_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Mcare Ffs 6005", "plan_name": "700703", "standard_charge_dollar": 205.70, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Miscellaneous", "plan_name": "700720", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Miscellaneous", "plan_name": "700720_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Ppo Hmo", "plan_name": "701720", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Ppo Hmo", "plan_name": "701720_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Ambetter 68069", "plan_name": "500516", "standard_charge_dollar": 205.70, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Ms State Emplo", "plan_name": "401457", "standard_charge_dollar": 168.74, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Ms State Emplo", "plan_name": "401457_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Basic Pl", "plan_name": "400100", "standard_charge_dollar": 168.74, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Basic Pl", "plan_name": "400100_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Federal", "plan_name": "400110", "standard_charge_dollar": 168.74, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Federal", "plan_name": "400110_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Cigna Healthsprings Ffs", "plan_name": "500064", "standard_charge_dollar": 205.70, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Conseco", "plan_name": "500302", "standard_charge_dollar": 205.70, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Humana Ffs 61101", "plan_name": "500006", "standard_charge_dollar": 205.70, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Medicare A", "plan_name": "100100", "standard_charge_dollar": 205.70, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Medicare A", "plan_name": "100500", "standard_charge_dollar": 205.70, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Medicare Part B Only", "plan_name": "100300", "standard_charge_dollar": 205.70, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Medicare Railroad", "plan_name": "100103", "standard_charge_dollar": 205.70, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Ms Physicians Care N", "plan_name": "714210", "standard_charge_dollar": 257.13, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Peoples Hlth Ffs 72126", "plan_name": "500019", "standard_charge_dollar": 205.70, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Uhc/Secure Horizons", "plan_name": "500449", "standard_charge_dollar": 205.70, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "United Health Care/", "plan_name": "500292", "standard_charge_dollar": 232.44, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "United Healthcare", "plan_name": "750104", "standard_charge_dollar": 232.44, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "United Healthcare Ba", "plan_name": "750090", "standard_charge_dollar": 232.44, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "United Healthcare Me", "plan_name": "501310", "standard_charge_dollar": 205.70, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Windsor Mcare Extra", "plan_name": "500778", "standard_charge_dollar": 205.70, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." } ] } ] }, { "description": "Ct lower extremity w/dye", "code_information": [ { "code": "73701", "type": "CPT" } ], "standard_charges": [ { "gross_charge": 1200.00, "minimum": 355.29, "maximum": 498.25, "setting": "both", "payers_information": [ { "payer_name": "Aarp", "plan_name": "500102", "standard_charge_dollar": 398.60, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna", "plan_name": "700700", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna", "plan_name": "700700_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Mcare Ffs 6005", "plan_name": "700703", "standard_charge_dollar": 398.60, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Miscellaneous", "plan_name": "700720", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Miscellaneous", "plan_name": "700720_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Ppo Hmo", "plan_name": "701720", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Ppo Hmo", "plan_name": "701720_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Ambetter 68069", "plan_name": "500516", "standard_charge_dollar": 398.60, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Ms State Emplo", "plan_name": "401457", "standard_charge_dollar": 355.29, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Ms State Emplo", "plan_name": "401457_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Basic Pl", "plan_name": "400100", "standard_charge_dollar": 355.29, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Basic Pl", "plan_name": "400100_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Federal", "plan_name": "400110", "standard_charge_dollar": 355.29, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Federal", "plan_name": "400110_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Cigna Healthsprings Ffs", "plan_name": "500064", "standard_charge_dollar": 398.60, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Conseco", "plan_name": "500302", "standard_charge_dollar": 398.60, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Humana Ffs 61101", "plan_name": "500006", "standard_charge_dollar": 398.60, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Medicare A", "plan_name": "100100", "standard_charge_dollar": 398.60, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Medicare A", "plan_name": "100500", "standard_charge_dollar": 398.60, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Medicare Part B Only", "plan_name": "100300", "standard_charge_dollar": 398.60, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Medicare Railroad", "plan_name": "100103", "standard_charge_dollar": 398.60, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Ms Physicians Care N", "plan_name": "714210", "standard_charge_dollar": 498.25, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Peoples Hlth Ffs 72126", "plan_name": "500019", "standard_charge_dollar": 398.60, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Uhc/Secure Horizons", "plan_name": "500449", "standard_charge_dollar": 398.60, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "United Health Care/", "plan_name": "500292", "standard_charge_dollar": 450.42, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "United Healthcare", "plan_name": "750104", "standard_charge_dollar": 450.42, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "United Healthcare Ba", "plan_name": "750090", "standard_charge_dollar": 450.42, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "United Healthcare Me", "plan_name": "501310", "standard_charge_dollar": 398.60, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Windsor Mcare Extra", "plan_name": "500778", "standard_charge_dollar": 398.60, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." } ] } ] }, { "description": "Hc ct extrem lower w/contrast", "code_information": [ { "code": "73701", "type": "CPT" } ], "standard_charges": [ { "gross_charge": 1200.00, "minimum": 355.29, "maximum": 498.25, "setting": "both", "payers_information": [ { "payer_name": "Aarp", "plan_name": "500102", "standard_charge_dollar": 398.60, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna", "plan_name": "700700", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna", "plan_name": "700700_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Mcare Ffs 6005", "plan_name": "700703", "standard_charge_dollar": 398.60, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Miscellaneous", "plan_name": "700720", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Miscellaneous", "plan_name": "700720_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Ppo Hmo", "plan_name": "701720", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Ppo Hmo", "plan_name": "701720_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Ambetter 68069", "plan_name": "500516", "standard_charge_dollar": 398.60, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Ms State Emplo", "plan_name": "401457", "standard_charge_dollar": 355.29, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Ms State Emplo", "plan_name": "401457_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Basic Pl", "plan_name": "400100", "standard_charge_dollar": 355.29, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Basic Pl", "plan_name": "400100_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Federal", "plan_name": "400110", "standard_charge_dollar": 355.29, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Federal", "plan_name": "400110_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Cigna Healthsprings Ffs", "plan_name": "500064", "standard_charge_dollar": 398.60, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Conseco", "plan_name": "500302", "standard_charge_dollar": 398.60, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Humana Ffs 61101", "plan_name": "500006", "standard_charge_dollar": 398.60, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Medicare A", "plan_name": "100100", "standard_charge_dollar": 398.60, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Medicare A", "plan_name": "100500", "standard_charge_dollar": 398.60, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Medicare Part B Only", "plan_name": "100300", "standard_charge_dollar": 398.60, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Medicare Railroad", "plan_name": "100103", "standard_charge_dollar": 398.60, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Ms Physicians Care N", "plan_name": "714210", "standard_charge_dollar": 498.25, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Peoples Hlth Ffs 72126", "plan_name": "500019", "standard_charge_dollar": 398.60, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Uhc/Secure Horizons", "plan_name": "500449", "standard_charge_dollar": 398.60, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "United Health Care/", "plan_name": "500292", "standard_charge_dollar": 450.42, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "United Healthcare", "plan_name": "750104", "standard_charge_dollar": 450.42, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "United Healthcare Ba", "plan_name": "750090", "standard_charge_dollar": 450.42, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "United Healthcare Me", "plan_name": "501310", "standard_charge_dollar": 398.60, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Windsor Mcare Extra", "plan_name": "500778", "standard_charge_dollar": 398.60, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." } ] } ] }, { "description": "Ct angio lwr extr w/o&w/dye", "code_information": [ { "code": "73706", "type": "CPT" } ], "standard_charges": [ { "gross_charge": 1400.00, "minimum": 355.29, "maximum": 498.25, "setting": "both", "payers_information": [ { "payer_name": "Aarp", "plan_name": "500102", "standard_charge_dollar": 398.60, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna", "plan_name": "700700", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna", "plan_name": "700700_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Mcare Ffs 6005", "plan_name": "700703", "standard_charge_dollar": 398.60, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Miscellaneous", "plan_name": "700720", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Miscellaneous", "plan_name": "700720_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Ppo Hmo", "plan_name": "701720", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Ppo Hmo", "plan_name": "701720_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Ambetter 68069", "plan_name": "500516", "standard_charge_dollar": 398.60, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Ms State Emplo", "plan_name": "401457", "standard_charge_dollar": 355.29, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Ms State Emplo", "plan_name": "401457_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Basic Pl", "plan_name": "400100", "standard_charge_dollar": 355.29, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Basic Pl", "plan_name": "400100_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Federal", "plan_name": "400110", "standard_charge_dollar": 355.29, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Federal", "plan_name": "400110_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Cigna Healthsprings Ffs", "plan_name": "500064", "standard_charge_dollar": 398.60, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Conseco", "plan_name": "500302", "standard_charge_dollar": 398.60, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Humana Ffs 61101", "plan_name": "500006", "standard_charge_dollar": 398.60, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Medicare A", "plan_name": "100100", "standard_charge_dollar": 398.60, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Medicare A", "plan_name": "100500", "standard_charge_dollar": 398.60, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Medicare Part B Only", "plan_name": "100300", "standard_charge_dollar": 398.60, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Medicare Railroad", "plan_name": "100103", "standard_charge_dollar": 398.60, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Ms Physicians Care N", "plan_name": "714210", "standard_charge_dollar": 498.25, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Peoples Hlth Ffs 72126", "plan_name": "500019", "standard_charge_dollar": 398.60, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Uhc/Secure Horizons", "plan_name": "500449", "standard_charge_dollar": 398.60, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "United Health Care/", "plan_name": "500292", "standard_charge_dollar": 450.42, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "United Healthcare", "plan_name": "750104", "standard_charge_dollar": 450.42, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "United Healthcare Ba", "plan_name": "750090", "standard_charge_dollar": 450.42, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "United Healthcare Me", "plan_name": "501310", "standard_charge_dollar": 398.60, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Windsor Mcare Extra", "plan_name": "500778", "standard_charge_dollar": 398.60, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." } ] } ] }, { "description": "Hc cta extremity lower", "code_information": [ { "code": "73706", "type": "CPT" } ], "standard_charges": [ { "gross_charge": 1400.00, "minimum": 355.29, "maximum": 498.25, "setting": "both", "payers_information": [ { "payer_name": "Aarp", "plan_name": "500102", "standard_charge_dollar": 398.60, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna", "plan_name": "700700", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna", "plan_name": "700700_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Mcare Ffs 6005", "plan_name": "700703", "standard_charge_dollar": 398.60, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Miscellaneous", "plan_name": "700720", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Miscellaneous", "plan_name": "700720_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Ppo Hmo", "plan_name": "701720", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Ppo Hmo", "plan_name": "701720_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Ambetter 68069", "plan_name": "500516", "standard_charge_dollar": 398.60, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Ms State Emplo", "plan_name": "401457", "standard_charge_dollar": 355.29, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Ms State Emplo", "plan_name": "401457_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Basic Pl", "plan_name": "400100", "standard_charge_dollar": 355.29, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Basic Pl", "plan_name": "400100_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Federal", "plan_name": "400110", "standard_charge_dollar": 355.29, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Federal", "plan_name": "400110_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Cigna Healthsprings Ffs", "plan_name": "500064", "standard_charge_dollar": 398.60, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Conseco", "plan_name": "500302", "standard_charge_dollar": 398.60, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Humana Ffs 61101", "plan_name": "500006", "standard_charge_dollar": 398.60, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Medicare A", "plan_name": "100100", "standard_charge_dollar": 398.60, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Medicare A", "plan_name": "100500", "standard_charge_dollar": 398.60, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Medicare Part B Only", "plan_name": "100300", "standard_charge_dollar": 398.60, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Medicare Railroad", "plan_name": "100103", "standard_charge_dollar": 398.60, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Ms Physicians Care N", "plan_name": "714210", "standard_charge_dollar": 498.25, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Peoples Hlth Ffs 72126", "plan_name": "500019", "standard_charge_dollar": 398.60, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Uhc/Secure Horizons", "plan_name": "500449", "standard_charge_dollar": 398.60, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "United Health Care/", "plan_name": "500292", "standard_charge_dollar": 450.42, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "United Healthcare", "plan_name": "750104", "standard_charge_dollar": 450.42, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "United Healthcare Ba", "plan_name": "750090", "standard_charge_dollar": 450.42, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "United Healthcare Me", "plan_name": "501310", "standard_charge_dollar": 398.60, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Windsor Mcare Extra", "plan_name": "500778", "standard_charge_dollar": 398.60, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." } ] } ] }, { "description": "Hc cta extremity lower", "code_information": [ { "code": "73706", "type": "CPT" } ], "standard_charges": [ { "gross_charge": 5600.00, "minimum": 398.60, "maximum": 4760.00, "setting": "both", "payers_information": [ { "payer_name": "Aarp", "plan_name": "500102", "standard_charge_dollar": 398.60, "count": "0", "methodology": "fee schedule", "modifiers": "50", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna", "plan_name": "700700", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna", "plan_name": "700700_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Mcare Ffs 6005", "plan_name": "700703", "standard_charge_dollar": 398.60, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Miscellaneous", "plan_name": "700720", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Miscellaneous", "plan_name": "700720_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Ppo Hmo", "plan_name": "701720", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Ppo Hmo", "plan_name": "701720_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Ambetter 68069", "plan_name": "500516", "standard_charge_dollar": 398.60, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Ms State Emplo", "plan_name": "401457", "standard_charge_percentage": 0.80, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Ms State Emplo", "plan_name": "401457_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Basic Pl", "plan_name": "400100", "standard_charge_percentage": 0.85, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Basic Pl", "plan_name": "400100_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Federal", "plan_name": "400110", "standard_charge_percentage": 0.85, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Federal", "plan_name": "400110_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Cigna Healthsprings Ffs", "plan_name": "500064", "standard_charge_dollar": 398.60, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Conseco", "plan_name": "500302", "standard_charge_dollar": 398.60, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Humana Ffs 61101", "plan_name": "500006", "standard_charge_dollar": 398.60, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Medicare A", "plan_name": "100100", "standard_charge_dollar": 398.60, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Medicare A", "plan_name": "100500", "standard_charge_dollar": 398.60, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Medicare Part B Only", "plan_name": "100300", "standard_charge_dollar": 398.60, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Medicare Railroad", "plan_name": "100103", "standard_charge_dollar": 398.60, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Ms Physicians Care N", "plan_name": "714210", "standard_charge_dollar": 498.25, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Peoples Hlth Ffs 72126", "plan_name": "500019", "standard_charge_dollar": 398.60, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Uhc/Secure Horizons", "plan_name": "500449", "standard_charge_dollar": 398.60, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "United Health Care/", "plan_name": "500292", "standard_charge_dollar": 450.42, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "United Healthcare", "plan_name": "750104", "standard_charge_dollar": 450.42, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "United Healthcare Ba", "plan_name": "750090", "standard_charge_dollar": 450.42, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "United Healthcare Me", "plan_name": "501310", "standard_charge_dollar": 398.60, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Windsor Mcare Extra", "plan_name": "500778", "standard_charge_dollar": 398.60, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." } ] } ] }, { "description": "Hc xray abdomen 1 view", "code_information": [ { "code": "74018", "type": "CPT" } ], "standard_charges": [ { "gross_charge": 175.00, "minimum": 80.66, "maximum": 100.82, "setting": "both", "payers_information": [ { "payer_name": "Aarp", "plan_name": "500102", "standard_charge_dollar": 80.66, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna", "plan_name": "700700", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna", "plan_name": "700700_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Mcare Ffs 6005", "plan_name": "700703", "standard_charge_dollar": 80.66, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Miscellaneous", "plan_name": "700720", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Miscellaneous", "plan_name": "700720_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Ppo Hmo", "plan_name": "701720", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Ppo Hmo", "plan_name": "701720_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Ambetter 68069", "plan_name": "500516", "standard_charge_dollar": 80.66, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Ms State Emplo", "plan_name": "401457", "standard_charge_dollar": 91.20, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Ms State Emplo", "plan_name": "401457_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Basic Pl", "plan_name": "400100", "standard_charge_dollar": 91.20, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Basic Pl", "plan_name": "400100_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Federal", "plan_name": "400110", "standard_charge_dollar": 91.20, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Federal", "plan_name": "400110_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Cigna Healthsprings Ffs", "plan_name": "500064", "standard_charge_dollar": 80.66, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Conseco", "plan_name": "500302", "standard_charge_dollar": 80.66, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Humana Ffs 61101", "plan_name": "500006", "standard_charge_dollar": 80.66, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Medicare A", "plan_name": "100100", "standard_charge_dollar": 80.66, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Medicare A", "plan_name": "100500", "standard_charge_dollar": 80.66, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Medicare Part B Only", "plan_name": "100300", "standard_charge_dollar": 80.66, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Medicare Railroad", "plan_name": "100103", "standard_charge_dollar": 80.66, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Ms Physicians Care N", "plan_name": "714210", "standard_charge_dollar": 100.82, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Peoples Hlth Ffs 72126", "plan_name": "500019", "standard_charge_dollar": 80.66, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Uhc/Secure Horizons", "plan_name": "500449", "standard_charge_dollar": 80.66, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "United Health Care/", "plan_name": "500292", "standard_charge_dollar": 91.15, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "United Healthcare", "plan_name": "750104", "standard_charge_dollar": 91.15, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "United Healthcare Ba", "plan_name": "750090", "standard_charge_dollar": 91.15, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "United Healthcare Me", "plan_name": "501310", "standard_charge_dollar": 80.66, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Windsor Mcare Extra", "plan_name": "500778", "standard_charge_dollar": 80.66, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." } ] } ] }, { "description": "X-ray exam abdomen 1 view", "code_information": [ { "code": "74018", "type": "CPT" } ], "standard_charges": [ { "gross_charge": 175.00, "minimum": 80.66, "maximum": 100.82, "setting": "both", "payers_information": [ { "payer_name": "Aarp", "plan_name": "500102", "standard_charge_dollar": 80.66, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna", "plan_name": "700700", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna", "plan_name": "700700_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Mcare Ffs 6005", "plan_name": "700703", "standard_charge_dollar": 80.66, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Miscellaneous", "plan_name": "700720", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Miscellaneous", "plan_name": "700720_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Ppo Hmo", "plan_name": "701720", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Ppo Hmo", "plan_name": "701720_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Ambetter 68069", "plan_name": "500516", "standard_charge_dollar": 80.66, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Ms State Emplo", "plan_name": "401457", "standard_charge_dollar": 91.20, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Ms State Emplo", "plan_name": "401457_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Basic Pl", "plan_name": "400100", "standard_charge_dollar": 91.20, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Basic Pl", "plan_name": "400100_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Federal", "plan_name": "400110", "standard_charge_dollar": 91.20, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Federal", "plan_name": "400110_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Cigna Healthsprings Ffs", "plan_name": "500064", "standard_charge_dollar": 80.66, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Conseco", "plan_name": "500302", "standard_charge_dollar": 80.66, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Humana Ffs 61101", "plan_name": "500006", "standard_charge_dollar": 80.66, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Medicare A", "plan_name": "100100", "standard_charge_dollar": 80.66, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Medicare A", "plan_name": "100500", "standard_charge_dollar": 80.66, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Medicare Part B Only", "plan_name": "100300", "standard_charge_dollar": 80.66, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Medicare Railroad", "plan_name": "100103", "standard_charge_dollar": 80.66, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Ms Physicians Care N", "plan_name": "714210", "standard_charge_dollar": 100.82, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Peoples Hlth Ffs 72126", "plan_name": "500019", "standard_charge_dollar": 80.66, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Uhc/Secure Horizons", "plan_name": "500449", "standard_charge_dollar": 80.66, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "United Health Care/", "plan_name": "500292", "standard_charge_dollar": 91.15, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "United Healthcare", "plan_name": "750104", "standard_charge_dollar": 91.15, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "United Healthcare Ba", "plan_name": "750090", "standard_charge_dollar": 91.15, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "United Healthcare Me", "plan_name": "501310", "standard_charge_dollar": 80.66, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Windsor Mcare Extra", "plan_name": "500778", "standard_charge_dollar": 80.66, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." } ] } ] }, { "description": "Hc xr abdomen 2 views", "code_information": [ { "code": "74019", "type": "CPT" } ], "standard_charges": [ { "gross_charge": 218.00, "minimum": 91.20, "maximum": 121.77, "setting": "both", "payers_information": [ { "payer_name": "Aarp", "plan_name": "500102", "standard_charge_dollar": 97.41, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna", "plan_name": "700700", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna", "plan_name": "700700_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Mcare Ffs 6005", "plan_name": "700703", "standard_charge_dollar": 97.41, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Miscellaneous", "plan_name": "700720", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Miscellaneous", "plan_name": "700720_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Ppo Hmo", "plan_name": "701720", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Ppo Hmo", "plan_name": "701720_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Ambetter 68069", "plan_name": "500516", "standard_charge_dollar": 97.41, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Ms State Emplo", "plan_name": "401457", "standard_charge_dollar": 91.20, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Ms State Emplo", "plan_name": "401457_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Basic Pl", "plan_name": "400100", "standard_charge_dollar": 91.20, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Basic Pl", "plan_name": "400100_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Federal", "plan_name": "400110", "standard_charge_dollar": 91.20, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Federal", "plan_name": "400110_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Cigna Healthsprings Ffs", "plan_name": "500064", "standard_charge_dollar": 97.41, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Conseco", "plan_name": "500302", "standard_charge_dollar": 97.41, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Humana Ffs 61101", "plan_name": "500006", "standard_charge_dollar": 97.41, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Medicare A", "plan_name": "100100", "standard_charge_dollar": 97.41, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Medicare A", "plan_name": "100500", "standard_charge_dollar": 97.41, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Medicare Part B Only", "plan_name": "100300", "standard_charge_dollar": 97.41, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Medicare Railroad", "plan_name": "100103", "standard_charge_dollar": 97.41, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Ms Physicians Care N", "plan_name": "714210", "standard_charge_dollar": 121.77, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Peoples Hlth Ffs 72126", "plan_name": "500019", "standard_charge_dollar": 97.41, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Uhc/Secure Horizons", "plan_name": "500449", "standard_charge_dollar": 97.41, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "United Health Care/", "plan_name": "500292", "standard_charge_dollar": 110.08, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "United Healthcare", "plan_name": "750104", "standard_charge_dollar": 110.08, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "United Healthcare Ba", "plan_name": "750090", "standard_charge_dollar": 110.08, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "United Healthcare Me", "plan_name": "501310", "standard_charge_dollar": 97.41, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Windsor Mcare Extra", "plan_name": "500778", "standard_charge_dollar": 97.41, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." } ] } ] }, { "description": "X-ray exam abdomen 2 views", "code_information": [ { "code": "74019", "type": "CPT" } ], "standard_charges": [ { "gross_charge": 218.00, "minimum": 91.20, "maximum": 121.77, "setting": "both", "payers_information": [ { "payer_name": "Aarp", "plan_name": "500102", "standard_charge_dollar": 97.41, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna", "plan_name": "700700", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna", "plan_name": "700700_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Mcare Ffs 6005", "plan_name": "700703", "standard_charge_dollar": 97.41, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Miscellaneous", "plan_name": "700720", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Miscellaneous", "plan_name": "700720_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Ppo Hmo", "plan_name": "701720", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Ppo Hmo", "plan_name": "701720_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Ambetter 68069", "plan_name": "500516", "standard_charge_dollar": 97.41, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Ms State Emplo", "plan_name": "401457", "standard_charge_dollar": 91.20, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Ms State Emplo", "plan_name": "401457_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Basic Pl", "plan_name": "400100", "standard_charge_dollar": 91.20, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Basic Pl", "plan_name": "400100_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Federal", "plan_name": "400110", "standard_charge_dollar": 91.20, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Federal", "plan_name": "400110_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Cigna Healthsprings Ffs", "plan_name": "500064", "standard_charge_dollar": 97.41, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Conseco", "plan_name": "500302", "standard_charge_dollar": 97.41, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Humana Ffs 61101", "plan_name": "500006", "standard_charge_dollar": 97.41, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Medicare A", "plan_name": "100100", "standard_charge_dollar": 97.41, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Medicare A", "plan_name": "100500", "standard_charge_dollar": 97.41, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Medicare Part B Only", "plan_name": "100300", "standard_charge_dollar": 97.41, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Medicare Railroad", "plan_name": "100103", "standard_charge_dollar": 97.41, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Ms Physicians Care N", "plan_name": "714210", "standard_charge_dollar": 121.77, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Peoples Hlth Ffs 72126", "plan_name": "500019", "standard_charge_dollar": 97.41, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Uhc/Secure Horizons", "plan_name": "500449", "standard_charge_dollar": 97.41, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "United Health Care/", "plan_name": "500292", "standard_charge_dollar": 110.08, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "United Healthcare", "plan_name": "750104", "standard_charge_dollar": 110.08, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "United Healthcare Ba", "plan_name": "750090", "standard_charge_dollar": 110.08, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "United Healthcare Me", "plan_name": "501310", "standard_charge_dollar": 97.41, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Windsor Mcare Extra", "plan_name": "500778", "standard_charge_dollar": 97.41, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." } ] } ] }, { "description": "Ct abdomen w/o dye", "code_information": [ { "code": "74150", "type": "CPT" } ], "standard_charges": [ { "gross_charge": 1100.00, "minimum": 168.74, "maximum": 257.13, "setting": "both", "payers_information": [ { "payer_name": "Aarp", "plan_name": "500102", "standard_charge_dollar": 205.70, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna", "plan_name": "700700", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna", "plan_name": "700700_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Mcare Ffs 6005", "plan_name": "700703", "standard_charge_dollar": 205.70, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Miscellaneous", "plan_name": "700720", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Miscellaneous", "plan_name": "700720_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Ppo Hmo", "plan_name": "701720", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Ppo Hmo", "plan_name": "701720_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Ambetter 68069", "plan_name": "500516", "standard_charge_dollar": 205.70, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Ms State Emplo", "plan_name": "401457", "standard_charge_dollar": 168.74, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Ms State Emplo", "plan_name": "401457_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Basic Pl", "plan_name": "400100", "standard_charge_dollar": 168.74, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Basic Pl", "plan_name": "400100_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Federal", "plan_name": "400110", "standard_charge_dollar": 168.74, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Federal", "plan_name": "400110_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Cigna Healthsprings Ffs", "plan_name": "500064", "standard_charge_dollar": 205.70, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Conseco", "plan_name": "500302", "standard_charge_dollar": 205.70, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Humana Ffs 61101", "plan_name": "500006", "standard_charge_dollar": 205.70, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Medicare A", "plan_name": "100100", "standard_charge_dollar": 205.70, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Medicare A", "plan_name": "100500", "standard_charge_dollar": 205.70, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Medicare Part B Only", "plan_name": "100300", "standard_charge_dollar": 205.70, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Medicare Railroad", "plan_name": "100103", "standard_charge_dollar": 205.70, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Ms Physicians Care N", "plan_name": "714210", "standard_charge_dollar": 257.13, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Peoples Hlth Ffs 72126", "plan_name": "500019", "standard_charge_dollar": 205.70, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Uhc/Secure Horizons", "plan_name": "500449", "standard_charge_dollar": 205.70, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "United Health Care/", "plan_name": "500292", "standard_charge_dollar": 232.44, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "United Healthcare", "plan_name": "750104", "standard_charge_dollar": 232.44, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "United Healthcare Ba", "plan_name": "750090", "standard_charge_dollar": 232.44, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "United Healthcare Me", "plan_name": "501310", "standard_charge_dollar": 205.70, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Windsor Mcare Extra", "plan_name": "500778", "standard_charge_dollar": 205.70, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." } ] } ] }, { "description": "Hc ct abdomen w/o contrast", "code_information": [ { "code": "74150", "type": "CPT" } ], "standard_charges": [ { "gross_charge": 1100.00, "minimum": 168.74, "maximum": 257.13, "setting": "both", "payers_information": [ { "payer_name": "Aarp", "plan_name": "500102", "standard_charge_dollar": 205.70, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna", "plan_name": "700700", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna", "plan_name": "700700_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Mcare Ffs 6005", "plan_name": "700703", "standard_charge_dollar": 205.70, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Miscellaneous", "plan_name": "700720", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Miscellaneous", "plan_name": "700720_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Ppo Hmo", "plan_name": "701720", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Ppo Hmo", "plan_name": "701720_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Ambetter 68069", "plan_name": "500516", "standard_charge_dollar": 205.70, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Ms State Emplo", "plan_name": "401457", "standard_charge_dollar": 168.74, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Ms State Emplo", "plan_name": "401457_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Basic Pl", "plan_name": "400100", "standard_charge_dollar": 168.74, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Basic Pl", "plan_name": "400100_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Federal", "plan_name": "400110", "standard_charge_dollar": 168.74, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Federal", "plan_name": "400110_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Cigna Healthsprings Ffs", "plan_name": "500064", "standard_charge_dollar": 205.70, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Conseco", "plan_name": "500302", "standard_charge_dollar": 205.70, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Humana Ffs 61101", "plan_name": "500006", "standard_charge_dollar": 205.70, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Medicare A", "plan_name": "100100", "standard_charge_dollar": 205.70, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Medicare A", "plan_name": "100500", "standard_charge_dollar": 205.70, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Medicare Part B Only", "plan_name": "100300", "standard_charge_dollar": 205.70, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Medicare Railroad", "plan_name": "100103", "standard_charge_dollar": 205.70, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Ms Physicians Care N", "plan_name": "714210", "standard_charge_dollar": 257.13, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Peoples Hlth Ffs 72126", "plan_name": "500019", "standard_charge_dollar": 205.70, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Uhc/Secure Horizons", "plan_name": "500449", "standard_charge_dollar": 205.70, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "United Health Care/", "plan_name": "500292", "standard_charge_dollar": 232.44, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "United Healthcare", "plan_name": "750104", "standard_charge_dollar": 232.44, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "United Healthcare Ba", "plan_name": "750090", "standard_charge_dollar": 232.44, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "United Healthcare Me", "plan_name": "501310", "standard_charge_dollar": 205.70, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Windsor Mcare Extra", "plan_name": "500778", "standard_charge_dollar": 205.70, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." } ] } ] }, { "description": "Ct abdomen w/dye", "code_information": [ { "code": "74160", "type": "CPT" } ], "standard_charges": [ { "gross_charge": 1450.00, "minimum": 355.29, "maximum": 498.25, "setting": "both", "payers_information": [ { "payer_name": "Aarp", "plan_name": "500102", "standard_charge_dollar": 398.60, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna", "plan_name": "700700", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna", "plan_name": "700700_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Mcare Ffs 6005", "plan_name": "700703", "standard_charge_dollar": 398.60, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Miscellaneous", "plan_name": "700720", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Miscellaneous", "plan_name": "700720_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Ppo Hmo", "plan_name": "701720", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Ppo Hmo", "plan_name": "701720_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Ambetter 68069", "plan_name": "500516", "standard_charge_dollar": 398.60, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Ms State Emplo", "plan_name": "401457", "standard_charge_dollar": 355.29, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Ms State Emplo", "plan_name": "401457_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Basic Pl", "plan_name": "400100", "standard_charge_dollar": 355.29, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Basic Pl", "plan_name": "400100_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Federal", "plan_name": "400110", "standard_charge_dollar": 355.29, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Federal", "plan_name": "400110_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Cigna Healthsprings Ffs", "plan_name": "500064", "standard_charge_dollar": 398.60, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Conseco", "plan_name": "500302", "standard_charge_dollar": 398.60, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Humana Ffs 61101", "plan_name": "500006", "standard_charge_dollar": 398.60, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Medicare A", "plan_name": "100100", "standard_charge_dollar": 398.60, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Medicare A", "plan_name": "100500", "standard_charge_dollar": 398.60, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Medicare Part B Only", "plan_name": "100300", "standard_charge_dollar": 398.60, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Medicare Railroad", "plan_name": "100103", "standard_charge_dollar": 398.60, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Ms Physicians Care N", "plan_name": "714210", "standard_charge_dollar": 498.25, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Peoples Hlth Ffs 72126", "plan_name": "500019", "standard_charge_dollar": 398.60, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Uhc/Secure Horizons", "plan_name": "500449", "standard_charge_dollar": 398.60, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "United Health Care/", "plan_name": "500292", "standard_charge_dollar": 450.42, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "United Healthcare", "plan_name": "750104", "standard_charge_dollar": 450.42, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "United Healthcare Ba", "plan_name": "750090", "standard_charge_dollar": 450.42, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "United Healthcare Me", "plan_name": "501310", "standard_charge_dollar": 398.60, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Windsor Mcare Extra", "plan_name": "500778", "standard_charge_dollar": 398.60, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." } ] } ] }, { "description": "Hc ct abdomen w/contrast", "code_information": [ { "code": "74160", "type": "CPT" } ], "standard_charges": [ { "gross_charge": 1450.00, "minimum": 355.29, "maximum": 498.25, "setting": "both", "payers_information": [ { "payer_name": "Aarp", "plan_name": "500102", "standard_charge_dollar": 398.60, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna", "plan_name": "700700", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna", "plan_name": "700700_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Mcare Ffs 6005", "plan_name": "700703", "standard_charge_dollar": 398.60, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Miscellaneous", "plan_name": "700720", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Miscellaneous", "plan_name": "700720_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Ppo Hmo", "plan_name": "701720", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Ppo Hmo", "plan_name": "701720_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Ambetter 68069", "plan_name": "500516", "standard_charge_dollar": 398.60, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Ms State Emplo", "plan_name": "401457", "standard_charge_dollar": 355.29, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Ms State Emplo", "plan_name": "401457_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Basic Pl", "plan_name": "400100", "standard_charge_dollar": 355.29, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Basic Pl", "plan_name": "400100_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Federal", "plan_name": "400110", "standard_charge_dollar": 355.29, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Federal", "plan_name": "400110_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Cigna Healthsprings Ffs", "plan_name": "500064", "standard_charge_dollar": 398.60, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Conseco", "plan_name": "500302", "standard_charge_dollar": 398.60, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Humana Ffs 61101", "plan_name": "500006", "standard_charge_dollar": 398.60, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Medicare A", "plan_name": "100100", "standard_charge_dollar": 398.60, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Medicare A", "plan_name": "100500", "standard_charge_dollar": 398.60, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Medicare Part B Only", "plan_name": "100300", "standard_charge_dollar": 398.60, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Medicare Railroad", "plan_name": "100103", "standard_charge_dollar": 398.60, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Ms Physicians Care N", "plan_name": "714210", "standard_charge_dollar": 498.25, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Peoples Hlth Ffs 72126", "plan_name": "500019", "standard_charge_dollar": 398.60, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Uhc/Secure Horizons", "plan_name": "500449", "standard_charge_dollar": 398.60, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "United Health Care/", "plan_name": "500292", "standard_charge_dollar": 450.42, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "United Healthcare", "plan_name": "750104", "standard_charge_dollar": 450.42, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "United Healthcare Ba", "plan_name": "750090", "standard_charge_dollar": 450.42, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "United Healthcare Me", "plan_name": "501310", "standard_charge_dollar": 398.60, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Windsor Mcare Extra", "plan_name": "500778", "standard_charge_dollar": 398.60, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." } ] } ] }, { "description": "Ct abdomen w/o & w/dye", "code_information": [ { "code": "74170", "type": "CPT" } ], "standard_charges": [ { "gross_charge": 1550.00, "minimum": 355.29, "maximum": 498.25, "setting": "both", "payers_information": [ { "payer_name": "Aarp", "plan_name": "500102", "standard_charge_dollar": 398.60, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna", "plan_name": "700700", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna", "plan_name": "700700_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Mcare Ffs 6005", "plan_name": "700703", "standard_charge_dollar": 398.60, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Miscellaneous", "plan_name": "700720", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Miscellaneous", "plan_name": "700720_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Ppo Hmo", "plan_name": "701720", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Ppo Hmo", "plan_name": "701720_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Ambetter 68069", "plan_name": "500516", "standard_charge_dollar": 398.60, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Ms State Emplo", "plan_name": "401457", "standard_charge_dollar": 355.29, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Ms State Emplo", "plan_name": "401457_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Basic Pl", "plan_name": "400100", "standard_charge_dollar": 355.29, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Basic Pl", "plan_name": "400100_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Federal", "plan_name": "400110", "standard_charge_dollar": 355.29, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Federal", "plan_name": "400110_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Cigna Healthsprings Ffs", "plan_name": "500064", "standard_charge_dollar": 398.60, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Conseco", "plan_name": "500302", "standard_charge_dollar": 398.60, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Humana Ffs 61101", "plan_name": "500006", "standard_charge_dollar": 398.60, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Medicare A", "plan_name": "100100", "standard_charge_dollar": 398.60, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Medicare A", "plan_name": "100500", "standard_charge_dollar": 398.60, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Medicare Part B Only", "plan_name": "100300", "standard_charge_dollar": 398.60, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Medicare Railroad", "plan_name": "100103", "standard_charge_dollar": 398.60, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Ms Physicians Care N", "plan_name": "714210", "standard_charge_dollar": 498.25, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Peoples Hlth Ffs 72126", "plan_name": "500019", "standard_charge_dollar": 398.60, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Uhc/Secure Horizons", "plan_name": "500449", "standard_charge_dollar": 398.60, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "United Health Care/", "plan_name": "500292", "standard_charge_dollar": 450.42, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "United Healthcare", "plan_name": "750104", "standard_charge_dollar": 450.42, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "United Healthcare Ba", "plan_name": "750090", "standard_charge_dollar": 450.42, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "United Healthcare Me", "plan_name": "501310", "standard_charge_dollar": 398.60, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Windsor Mcare Extra", "plan_name": "500778", "standard_charge_dollar": 398.60, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." } ] } ] }, { "description": "Hc ct abdomen w/ wo contrast", "code_information": [ { "code": "74170", "type": "CPT" } ], "standard_charges": [ { "gross_charge": 1550.00, "minimum": 355.29, "maximum": 498.25, "setting": "both", "payers_information": [ { "payer_name": "Aarp", "plan_name": "500102", "standard_charge_dollar": 398.60, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna", "plan_name": "700700", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna", "plan_name": "700700_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Mcare Ffs 6005", "plan_name": "700703", "standard_charge_dollar": 398.60, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Miscellaneous", "plan_name": "700720", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Miscellaneous", "plan_name": "700720_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Ppo Hmo", "plan_name": "701720", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Ppo Hmo", "plan_name": "701720_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Ambetter 68069", "plan_name": "500516", "standard_charge_dollar": 398.60, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Ms State Emplo", "plan_name": "401457", "standard_charge_dollar": 355.29, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Ms State Emplo", "plan_name": "401457_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Basic Pl", "plan_name": "400100", "standard_charge_dollar": 355.29, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Basic Pl", "plan_name": "400100_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Federal", "plan_name": "400110", "standard_charge_dollar": 355.29, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Federal", "plan_name": "400110_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Cigna Healthsprings Ffs", "plan_name": "500064", "standard_charge_dollar": 398.60, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Conseco", "plan_name": "500302", "standard_charge_dollar": 398.60, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Humana Ffs 61101", "plan_name": "500006", "standard_charge_dollar": 398.60, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Medicare A", "plan_name": "100100", "standard_charge_dollar": 398.60, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Medicare A", "plan_name": "100500", "standard_charge_dollar": 398.60, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Medicare Part B Only", "plan_name": "100300", "standard_charge_dollar": 398.60, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Medicare Railroad", "plan_name": "100103", "standard_charge_dollar": 398.60, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Ms Physicians Care N", "plan_name": "714210", "standard_charge_dollar": 498.25, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Peoples Hlth Ffs 72126", "plan_name": "500019", "standard_charge_dollar": 398.60, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Uhc/Secure Horizons", "plan_name": "500449", "standard_charge_dollar": 398.60, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "United Health Care/", "plan_name": "500292", "standard_charge_dollar": 450.42, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "United Healthcare", "plan_name": "750104", "standard_charge_dollar": 450.42, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "United Healthcare Ba", "plan_name": "750090", "standard_charge_dollar": 450.42, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "United Healthcare Me", "plan_name": "501310", "standard_charge_dollar": 398.60, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Windsor Mcare Extra", "plan_name": "500778", "standard_charge_dollar": 398.60, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." } ] } ] }, { "description": "Ct angio abd&pelv w/o&w/dye", "code_information": [ { "code": "74174", "type": "CPT" } ], "standard_charges": [ { "gross_charge": 1878.00, "minimum": 327.16, "maximum": 1596.30, "setting": "both", "payers_information": [ { "payer_name": "Aarp", "plan_name": "500102", "standard_charge_dollar": 327.16, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna", "plan_name": "700700", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna", "plan_name": "700700_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Mcare Ffs 6005", "plan_name": "700703", "standard_charge_dollar": 327.16, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Miscellaneous", "plan_name": "700720", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Miscellaneous", "plan_name": "700720_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Ppo Hmo", "plan_name": "701720", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Ppo Hmo", "plan_name": "701720_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Ambetter 68069", "plan_name": "500516", "standard_charge_dollar": 327.16, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Ms State Emplo", "plan_name": "401457", "standard_charge_percentage": 0.80, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Ms State Emplo", "plan_name": "401457_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Basic Pl", "plan_name": "400100", "standard_charge_percentage": 0.85, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Basic Pl", "plan_name": "400100_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Federal", "plan_name": "400110", "standard_charge_percentage": 0.85, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Federal", "plan_name": "400110_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Cigna Healthsprings Ffs", "plan_name": "500064", "standard_charge_dollar": 327.16, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Conseco", "plan_name": "500302", "standard_charge_dollar": 327.16, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Humana Ffs 61101", "plan_name": "500006", "standard_charge_dollar": 327.16, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Medicare A", "plan_name": "100100", "standard_charge_dollar": 327.16, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Medicare A", "plan_name": "100500", "standard_charge_dollar": 327.16, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Medicare Part B Only", "plan_name": "100300", "standard_charge_dollar": 327.16, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Medicare Railroad", "plan_name": "100103", "standard_charge_dollar": 327.16, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Ms Physicians Care N", "plan_name": "714210", "standard_charge_dollar": 408.94, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Peoples Hlth Ffs 72126", "plan_name": "500019", "standard_charge_dollar": 327.16, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Uhc/Secure Horizons", "plan_name": "500449", "standard_charge_dollar": 327.16, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "United Health Care/", "plan_name": "500292", "standard_charge_dollar": 369.69, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "United Healthcare", "plan_name": "750104", "standard_charge_dollar": 369.69, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "United Healthcare Ba", "plan_name": "750090", "standard_charge_dollar": 369.69, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "United Healthcare Me", "plan_name": "501310", "standard_charge_dollar": 327.16, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Windsor Mcare Extra", "plan_name": "500778", "standard_charge_dollar": 327.16, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." } ] } ] }, { "description": "Hc cta abd pelvis w/wo contrast", "code_information": [ { "code": "74174", "type": "CPT" } ], "standard_charges": [ { "gross_charge": 1878.00, "minimum": 327.16, "maximum": 1596.30, "setting": "both", "payers_information": [ { "payer_name": "Aarp", "plan_name": "500102", "standard_charge_dollar": 327.16, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna", "plan_name": "700700", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna", "plan_name": "700700_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Mcare Ffs 6005", "plan_name": "700703", "standard_charge_dollar": 327.16, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Miscellaneous", "plan_name": "700720", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Miscellaneous", "plan_name": "700720_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Ppo Hmo", "plan_name": "701720", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Ppo Hmo", "plan_name": "701720_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Ambetter 68069", "plan_name": "500516", "standard_charge_dollar": 327.16, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Ms State Emplo", "plan_name": "401457", "standard_charge_percentage": 0.80, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Ms State Emplo", "plan_name": "401457_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Basic Pl", "plan_name": "400100", "standard_charge_percentage": 0.85, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Basic Pl", "plan_name": "400100_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Federal", "plan_name": "400110", "standard_charge_percentage": 0.85, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Federal", "plan_name": "400110_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Cigna Healthsprings Ffs", "plan_name": "500064", "standard_charge_dollar": 327.16, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Conseco", "plan_name": "500302", "standard_charge_dollar": 327.16, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Humana Ffs 61101", "plan_name": "500006", "standard_charge_dollar": 327.16, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Medicare A", "plan_name": "100100", "standard_charge_dollar": 327.16, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Medicare A", "plan_name": "100500", "standard_charge_dollar": 327.16, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Medicare Part B Only", "plan_name": "100300", "standard_charge_dollar": 327.16, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Medicare Railroad", "plan_name": "100103", "standard_charge_dollar": 327.16, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Ms Physicians Care N", "plan_name": "714210", "standard_charge_dollar": 408.94, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Peoples Hlth Ffs 72126", "plan_name": "500019", "standard_charge_dollar": 327.16, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Uhc/Secure Horizons", "plan_name": "500449", "standard_charge_dollar": 327.16, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "United Health Care/", "plan_name": "500292", "standard_charge_dollar": 369.69, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "United Healthcare", "plan_name": "750104", "standard_charge_dollar": 369.69, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "United Healthcare Ba", "plan_name": "750090", "standard_charge_dollar": 369.69, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "United Healthcare Me", "plan_name": "501310", "standard_charge_dollar": 327.16, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Windsor Mcare Extra", "plan_name": "500778", "standard_charge_dollar": 327.16, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." } ] } ] }, { "description": "Ct angio abdom w/o & w/dye", "code_information": [ { "code": "74175", "type": "CPT" } ], "standard_charges": [ { "gross_charge": 1650.00, "minimum": 355.29, "maximum": 498.25, "setting": "both", "payers_information": [ { "payer_name": "Aarp", "plan_name": "500102", "standard_charge_dollar": 398.60, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna", "plan_name": "700700", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna", "plan_name": "700700_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Mcare Ffs 6005", "plan_name": "700703", "standard_charge_dollar": 398.60, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Miscellaneous", "plan_name": "700720", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Miscellaneous", "plan_name": "700720_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Ppo Hmo", "plan_name": "701720", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Ppo Hmo", "plan_name": "701720_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Ambetter 68069", "plan_name": "500516", "standard_charge_dollar": 398.60, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Ms State Emplo", "plan_name": "401457", "standard_charge_dollar": 355.29, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Ms State Emplo", "plan_name": "401457_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Basic Pl", "plan_name": "400100", "standard_charge_dollar": 355.29, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Basic Pl", "plan_name": "400100_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Federal", "plan_name": "400110", "standard_charge_dollar": 355.29, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Federal", "plan_name": "400110_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Cigna Healthsprings Ffs", "plan_name": "500064", "standard_charge_dollar": 398.60, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Conseco", "plan_name": "500302", "standard_charge_dollar": 398.60, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Humana Ffs 61101", "plan_name": "500006", "standard_charge_dollar": 398.60, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Medicare A", "plan_name": "100100", "standard_charge_dollar": 398.60, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Medicare A", "plan_name": "100500", "standard_charge_dollar": 398.60, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Medicare Part B Only", "plan_name": "100300", "standard_charge_dollar": 398.60, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Medicare Railroad", "plan_name": "100103", "standard_charge_dollar": 398.60, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Ms Physicians Care N", "plan_name": "714210", "standard_charge_dollar": 498.25, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Peoples Hlth Ffs 72126", "plan_name": "500019", "standard_charge_dollar": 398.60, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Uhc/Secure Horizons", "plan_name": "500449", "standard_charge_dollar": 398.60, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "United Health Care/", "plan_name": "500292", "standard_charge_dollar": 450.42, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "United Healthcare", "plan_name": "750104", "standard_charge_dollar": 450.42, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "United Healthcare Ba", "plan_name": "750090", "standard_charge_dollar": 450.42, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "United Healthcare Me", "plan_name": "501310", "standard_charge_dollar": 398.60, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Windsor Mcare Extra", "plan_name": "500778", "standard_charge_dollar": 398.60, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." } ] } ] }, { "description": "Hc cta abdomen w/wo contrast", "code_information": [ { "code": "74175", "type": "CPT" } ], "standard_charges": [ { "gross_charge": 1650.00, "minimum": 355.29, "maximum": 498.25, "setting": "both", "payers_information": [ { "payer_name": "Aarp", "plan_name": "500102", "standard_charge_dollar": 398.60, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna", "plan_name": "700700", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna", "plan_name": "700700_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Mcare Ffs 6005", "plan_name": "700703", "standard_charge_dollar": 398.60, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Miscellaneous", "plan_name": "700720", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Miscellaneous", "plan_name": "700720_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Ppo Hmo", "plan_name": "701720", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Ppo Hmo", "plan_name": "701720_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Ambetter 68069", "plan_name": "500516", "standard_charge_dollar": 398.60, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Ms State Emplo", "plan_name": "401457", "standard_charge_dollar": 355.29, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Ms State Emplo", "plan_name": "401457_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Basic Pl", "plan_name": "400100", "standard_charge_dollar": 355.29, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Basic Pl", "plan_name": "400100_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Federal", "plan_name": "400110", "standard_charge_dollar": 355.29, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Federal", "plan_name": "400110_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Cigna Healthsprings Ffs", "plan_name": "500064", "standard_charge_dollar": 398.60, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Conseco", "plan_name": "500302", "standard_charge_dollar": 398.60, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Humana Ffs 61101", "plan_name": "500006", "standard_charge_dollar": 398.60, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Medicare A", "plan_name": "100100", "standard_charge_dollar": 398.60, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Medicare A", "plan_name": "100500", "standard_charge_dollar": 398.60, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Medicare Part B Only", "plan_name": "100300", "standard_charge_dollar": 398.60, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Medicare Railroad", "plan_name": "100103", "standard_charge_dollar": 398.60, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Ms Physicians Care N", "plan_name": "714210", "standard_charge_dollar": 498.25, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Peoples Hlth Ffs 72126", "plan_name": "500019", "standard_charge_dollar": 398.60, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Uhc/Secure Horizons", "plan_name": "500449", "standard_charge_dollar": 398.60, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "United Health Care/", "plan_name": "500292", "standard_charge_dollar": 450.42, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "United Healthcare", "plan_name": "750104", "standard_charge_dollar": 450.42, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "United Healthcare Ba", "plan_name": "750090", "standard_charge_dollar": 450.42, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "United Healthcare Me", "plan_name": "501310", "standard_charge_dollar": 398.60, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Windsor Mcare Extra", "plan_name": "500778", "standard_charge_dollar": 398.60, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." } ] } ] }, { "description": "Ct abd & pelvis w/o contrast", "code_information": [ { "code": "74176", "type": "CPT" } ], "standard_charges": [ { "gross_charge": 2072.50, "minimum": 205.70, "maximum": 287.96, "setting": "both", "payers_information": [ { "payer_name": "Aarp", "plan_name": "500102", "standard_charge_dollar": 205.70, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna", "plan_name": "700700", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna", "plan_name": "700700_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Mcare Ffs 6005", "plan_name": "700703", "standard_charge_dollar": 205.70, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Miscellaneous", "plan_name": "700720", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Miscellaneous", "plan_name": "700720_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Ppo Hmo", "plan_name": "701720", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Ppo Hmo", "plan_name": "701720_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Ambetter 68069", "plan_name": "500516", "standard_charge_dollar": 205.70, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Ms State Emplo", "plan_name": "401457", "standard_charge_dollar": 287.96, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Ms State Emplo", "plan_name": "401457_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Basic Pl", "plan_name": "400100", "standard_charge_dollar": 287.96, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Basic Pl", "plan_name": "400100_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Federal", "plan_name": "400110", "standard_charge_dollar": 287.96, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Federal", "plan_name": "400110_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Cigna Healthsprings Ffs", "plan_name": "500064", "standard_charge_dollar": 205.70, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Conseco", "plan_name": "500302", "standard_charge_dollar": 205.70, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Humana Ffs 61101", "plan_name": "500006", "standard_charge_dollar": 205.70, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Medicare A", "plan_name": "100100", "standard_charge_dollar": 205.70, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Medicare A", "plan_name": "100500", "standard_charge_dollar": 205.70, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Medicare Part B Only", "plan_name": "100300", "standard_charge_dollar": 205.70, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Medicare Railroad", "plan_name": "100103", "standard_charge_dollar": 205.70, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Ms Physicians Care N", "plan_name": "714210", "standard_charge_dollar": 257.13, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Peoples Hlth Ffs 72126", "plan_name": "500019", "standard_charge_dollar": 205.70, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Uhc/Secure Horizons", "plan_name": "500449", "standard_charge_dollar": 205.70, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "United Health Care/", "plan_name": "500292", "standard_charge_dollar": 232.44, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "United Healthcare", "plan_name": "750104", "standard_charge_dollar": 232.44, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "United Healthcare Ba", "plan_name": "750090", "standard_charge_dollar": 232.44, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "United Healthcare Me", "plan_name": "501310", "standard_charge_dollar": 205.70, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Windsor Mcare Extra", "plan_name": "500778", "standard_charge_dollar": 205.70, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." } ] } ] }, { "description": "Hc ct abd pelvis w/o contrast", "code_information": [ { "code": "74176", "type": "CPT" } ], "standard_charges": [ { "gross_charge": 2072.50, "minimum": 205.70, "maximum": 287.96, "setting": "both", "payers_information": [ { "payer_name": "Aarp", "plan_name": "500102", "standard_charge_dollar": 205.70, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna", "plan_name": "700700", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna", "plan_name": "700700_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Mcare Ffs 6005", "plan_name": "700703", "standard_charge_dollar": 205.70, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Miscellaneous", "plan_name": "700720", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Miscellaneous", "plan_name": "700720_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Ppo Hmo", "plan_name": "701720", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Ppo Hmo", "plan_name": "701720_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Ambetter 68069", "plan_name": "500516", "standard_charge_dollar": 205.70, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Ms State Emplo", "plan_name": "401457", "standard_charge_dollar": 287.96, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Ms State Emplo", "plan_name": "401457_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Basic Pl", "plan_name": "400100", "standard_charge_dollar": 287.96, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Basic Pl", "plan_name": "400100_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Federal", "plan_name": "400110", "standard_charge_dollar": 287.96, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Federal", "plan_name": "400110_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Cigna Healthsprings Ffs", "plan_name": "500064", "standard_charge_dollar": 205.70, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Conseco", "plan_name": "500302", "standard_charge_dollar": 205.70, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Humana Ffs 61101", "plan_name": "500006", "standard_charge_dollar": 205.70, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Medicare A", "plan_name": "100100", "standard_charge_dollar": 205.70, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Medicare A", "plan_name": "100500", "standard_charge_dollar": 205.70, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Medicare Part B Only", "plan_name": "100300", "standard_charge_dollar": 205.70, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Medicare Railroad", "plan_name": "100103", "standard_charge_dollar": 205.70, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Ms Physicians Care N", "plan_name": "714210", "standard_charge_dollar": 257.13, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Peoples Hlth Ffs 72126", "plan_name": "500019", "standard_charge_dollar": 205.70, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Uhc/Secure Horizons", "plan_name": "500449", "standard_charge_dollar": 205.70, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "United Health Care/", "plan_name": "500292", "standard_charge_dollar": 232.44, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "United Healthcare", "plan_name": "750104", "standard_charge_dollar": 232.44, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "United Healthcare Ba", "plan_name": "750090", "standard_charge_dollar": 232.44, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "United Healthcare Me", "plan_name": "501310", "standard_charge_dollar": 205.70, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Windsor Mcare Extra", "plan_name": "500778", "standard_charge_dollar": 205.70, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." } ] } ] }, { "description": "Hc ct abd pelvis w/o contrast", "code_information": [ { "code": "74176", "type": "CPT" } ], "standard_charges": [ { "gross_charge": 2072.50, "minimum": 205.70, "maximum": 1761.63, "setting": "both", "payers_information": [ { "payer_name": "Aarp", "plan_name": "500102", "standard_charge_dollar": 205.70, "count": "0", "methodology": "fee schedule", "modifiers": "TC", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna", "plan_name": "700700", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna", "plan_name": "700700_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Mcare Ffs 6005", "plan_name": "700703", "standard_charge_dollar": 205.70, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Miscellaneous", "plan_name": "700720", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Miscellaneous", "plan_name": "700720_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Ppo Hmo", "plan_name": "701720", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Ppo Hmo", "plan_name": "701720_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Ambetter 68069", "plan_name": "500516", "standard_charge_dollar": 205.70, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Ms State Emplo", "plan_name": "401457", "standard_charge_percentage": 0.80, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Ms State Emplo", "plan_name": "401457_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Basic Pl", "plan_name": "400100", "standard_charge_percentage": 0.85, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Basic Pl", "plan_name": "400100_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Federal", "plan_name": "400110", "standard_charge_percentage": 0.85, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Federal", "plan_name": "400110_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Cigna Healthsprings Ffs", "plan_name": "500064", "standard_charge_dollar": 205.70, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Conseco", "plan_name": "500302", "standard_charge_dollar": 205.70, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Humana Ffs 61101", "plan_name": "500006", "standard_charge_dollar": 205.70, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Medicare A", "plan_name": "100100", "standard_charge_dollar": 205.70, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Medicare A", "plan_name": "100500", "standard_charge_dollar": 205.70, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Medicare Part B Only", "plan_name": "100300", "standard_charge_dollar": 205.70, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Medicare Railroad", "plan_name": "100103", "standard_charge_dollar": 205.70, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Ms Physicians Care N", "plan_name": "714210", "standard_charge_dollar": 257.13, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Peoples Hlth Ffs 72126", "plan_name": "500019", "standard_charge_dollar": 205.70, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Uhc/Secure Horizons", "plan_name": "500449", "standard_charge_dollar": 205.70, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "United Health Care/", "plan_name": "500292", "standard_charge_dollar": 232.44, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "United Healthcare", "plan_name": "750104", "standard_charge_dollar": 232.44, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "United Healthcare Ba", "plan_name": "750090", "standard_charge_dollar": 232.44, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "United Healthcare Me", "plan_name": "501310", "standard_charge_dollar": 205.70, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Windsor Mcare Extra", "plan_name": "500778", "standard_charge_dollar": 205.70, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." } ] } ] }, { "description": "Ct abd & pelv w/contrast", "code_information": [ { "code": "74177", "type": "CPT" } ], "standard_charges": [ { "gross_charge": 2300.00, "minimum": 398.60, "maximum": 521.58, "setting": "both", "payers_information": [ { "payer_name": "Aarp", "plan_name": "500102", "standard_charge_dollar": 398.60, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna", "plan_name": "700700", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna", "plan_name": "700700_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Mcare Ffs 6005", "plan_name": "700703", "standard_charge_dollar": 398.60, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Miscellaneous", "plan_name": "700720", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Miscellaneous", "plan_name": "700720_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Ppo Hmo", "plan_name": "701720", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Ppo Hmo", "plan_name": "701720_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Ambetter 68069", "plan_name": "500516", "standard_charge_dollar": 398.60, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Ms State Emplo", "plan_name": "401457", "standard_charge_dollar": 521.58, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Ms State Emplo", "plan_name": "401457_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Basic Pl", "plan_name": "400100", "standard_charge_dollar": 521.58, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Basic Pl", "plan_name": "400100_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Federal", "plan_name": "400110", "standard_charge_dollar": 521.58, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Federal", "plan_name": "400110_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Cigna Healthsprings Ffs", "plan_name": "500064", "standard_charge_dollar": 398.60, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Conseco", "plan_name": "500302", "standard_charge_dollar": 398.60, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Humana Ffs 61101", "plan_name": "500006", "standard_charge_dollar": 398.60, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Medicare A", "plan_name": "100100", "standard_charge_dollar": 398.60, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Medicare A", "plan_name": "100500", "standard_charge_dollar": 398.60, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Medicare Part B Only", "plan_name": "100300", "standard_charge_dollar": 398.60, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Medicare Railroad", "plan_name": "100103", "standard_charge_dollar": 398.60, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Ms Physicians Care N", "plan_name": "714210", "standard_charge_dollar": 498.25, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Peoples Hlth Ffs 72126", "plan_name": "500019", "standard_charge_dollar": 398.60, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Uhc/Secure Horizons", "plan_name": "500449", "standard_charge_dollar": 398.60, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "United Health Care/", "plan_name": "500292", "standard_charge_dollar": 450.42, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "United Healthcare", "plan_name": "750104", "standard_charge_dollar": 450.42, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "United Healthcare Ba", "plan_name": "750090", "standard_charge_dollar": 450.42, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "United Healthcare Me", "plan_name": "501310", "standard_charge_dollar": 398.60, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Windsor Mcare Extra", "plan_name": "500778", "standard_charge_dollar": 398.60, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." } ] } ] }, { "description": "Hc ct abd pelvis w/contrast", "code_information": [ { "code": "74177", "type": "CPT" } ], "standard_charges": [ { "gross_charge": 2300.00, "minimum": 398.60, "maximum": 521.58, "setting": "both", "payers_information": [ { "payer_name": "Aarp", "plan_name": "500102", "standard_charge_dollar": 398.60, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna", "plan_name": "700700", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna", "plan_name": "700700_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Mcare Ffs 6005", "plan_name": "700703", "standard_charge_dollar": 398.60, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Miscellaneous", "plan_name": "700720", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Miscellaneous", "plan_name": "700720_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Ppo Hmo", "plan_name": "701720", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Ppo Hmo", "plan_name": "701720_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Ambetter 68069", "plan_name": "500516", "standard_charge_dollar": 398.60, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Ms State Emplo", "plan_name": "401457", "standard_charge_dollar": 521.58, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Ms State Emplo", "plan_name": "401457_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Basic Pl", "plan_name": "400100", "standard_charge_dollar": 521.58, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Basic Pl", "plan_name": "400100_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Federal", "plan_name": "400110", "standard_charge_dollar": 521.58, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Federal", "plan_name": "400110_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Cigna Healthsprings Ffs", "plan_name": "500064", "standard_charge_dollar": 398.60, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Conseco", "plan_name": "500302", "standard_charge_dollar": 398.60, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Humana Ffs 61101", "plan_name": "500006", "standard_charge_dollar": 398.60, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Medicare A", "plan_name": "100100", "standard_charge_dollar": 398.60, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Medicare A", "plan_name": "100500", "standard_charge_dollar": 398.60, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Medicare Part B Only", "plan_name": "100300", "standard_charge_dollar": 398.60, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Medicare Railroad", "plan_name": "100103", "standard_charge_dollar": 398.60, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Ms Physicians Care N", "plan_name": "714210", "standard_charge_dollar": 498.25, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Peoples Hlth Ffs 72126", "plan_name": "500019", "standard_charge_dollar": 398.60, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Uhc/Secure Horizons", "plan_name": "500449", "standard_charge_dollar": 398.60, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "United Health Care/", "plan_name": "500292", "standard_charge_dollar": 450.42, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "United Healthcare", "plan_name": "750104", "standard_charge_dollar": 450.42, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "United Healthcare Ba", "plan_name": "750090", "standard_charge_dollar": 450.42, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "United Healthcare Me", "plan_name": "501310", "standard_charge_dollar": 398.60, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Windsor Mcare Extra", "plan_name": "500778", "standard_charge_dollar": 398.60, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." } ] } ] }, { "description": "Ct abd & pelv 1/> regns", "code_information": [ { "code": "74178", "type": "CPT" } ], "standard_charges": [ { "gross_charge": 2400.50, "minimum": 398.60, "maximum": 521.58, "setting": "both", "payers_information": [ { "payer_name": "Aarp", "plan_name": "500102", "standard_charge_dollar": 398.60, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna", "plan_name": "700700", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna", "plan_name": "700700_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Mcare Ffs 6005", "plan_name": "700703", "standard_charge_dollar": 398.60, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Miscellaneous", "plan_name": "700720", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Miscellaneous", "plan_name": "700720_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Ppo Hmo", "plan_name": "701720", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Ppo Hmo", "plan_name": "701720_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Ambetter 68069", "plan_name": "500516", "standard_charge_dollar": 398.60, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Ms State Emplo", "plan_name": "401457", "standard_charge_dollar": 521.58, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Ms State Emplo", "plan_name": "401457_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Basic Pl", "plan_name": "400100", "standard_charge_dollar": 521.58, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Basic Pl", "plan_name": "400100_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Federal", "plan_name": "400110", "standard_charge_dollar": 521.58, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Federal", "plan_name": "400110_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Cigna Healthsprings Ffs", "plan_name": "500064", "standard_charge_dollar": 398.60, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Conseco", "plan_name": "500302", "standard_charge_dollar": 398.60, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Humana Ffs 61101", "plan_name": "500006", "standard_charge_dollar": 398.60, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Medicare A", "plan_name": "100100", "standard_charge_dollar": 398.60, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Medicare A", "plan_name": "100500", "standard_charge_dollar": 398.60, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Medicare Part B Only", "plan_name": "100300", "standard_charge_dollar": 398.60, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Medicare Railroad", "plan_name": "100103", "standard_charge_dollar": 398.60, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Ms Physicians Care N", "plan_name": "714210", "standard_charge_dollar": 498.25, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Peoples Hlth Ffs 72126", "plan_name": "500019", "standard_charge_dollar": 398.60, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Uhc/Secure Horizons", "plan_name": "500449", "standard_charge_dollar": 398.60, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "United Health Care/", "plan_name": "500292", "standard_charge_dollar": 450.42, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "United Healthcare", "plan_name": "750104", "standard_charge_dollar": 450.42, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "United Healthcare Ba", "plan_name": "750090", "standard_charge_dollar": 450.42, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "United Healthcare Me", "plan_name": "501310", "standard_charge_dollar": 398.60, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Windsor Mcare Extra", "plan_name": "500778", "standard_charge_dollar": 398.60, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." } ] } ] }, { "description": "Hc ct abd pelvis w/wo contrast", "code_information": [ { "code": "74178", "type": "CPT" } ], "standard_charges": [ { "gross_charge": 2400.50, "minimum": 398.60, "maximum": 521.58, "setting": "both", "payers_information": [ { "payer_name": "Aarp", "plan_name": "500102", "standard_charge_dollar": 398.60, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna", "plan_name": "700700", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna", "plan_name": "700700_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Mcare Ffs 6005", "plan_name": "700703", "standard_charge_dollar": 398.60, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Miscellaneous", "plan_name": "700720", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Miscellaneous", "plan_name": "700720_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Ppo Hmo", "plan_name": "701720", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Ppo Hmo", "plan_name": "701720_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Ambetter 68069", "plan_name": "500516", "standard_charge_dollar": 398.60, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Ms State Emplo", "plan_name": "401457", "standard_charge_dollar": 521.58, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Ms State Emplo", "plan_name": "401457_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Basic Pl", "plan_name": "400100", "standard_charge_dollar": 521.58, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Basic Pl", "plan_name": "400100_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Federal", "plan_name": "400110", "standard_charge_dollar": 521.58, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Federal", "plan_name": "400110_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Cigna Healthsprings Ffs", "plan_name": "500064", "standard_charge_dollar": 398.60, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Conseco", "plan_name": "500302", "standard_charge_dollar": 398.60, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Humana Ffs 61101", "plan_name": "500006", "standard_charge_dollar": 398.60, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Medicare A", "plan_name": "100100", "standard_charge_dollar": 398.60, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Medicare A", "plan_name": "100500", "standard_charge_dollar": 398.60, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Medicare Part B Only", "plan_name": "100300", "standard_charge_dollar": 398.60, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Medicare Railroad", "plan_name": "100103", "standard_charge_dollar": 398.60, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Ms Physicians Care N", "plan_name": "714210", "standard_charge_dollar": 498.25, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Peoples Hlth Ffs 72126", "plan_name": "500019", "standard_charge_dollar": 398.60, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Uhc/Secure Horizons", "plan_name": "500449", "standard_charge_dollar": 398.60, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "United Health Care/", "plan_name": "500292", "standard_charge_dollar": 450.42, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "United Healthcare", "plan_name": "750104", "standard_charge_dollar": 450.42, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "United Healthcare Ba", "plan_name": "750090", "standard_charge_dollar": 450.42, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "United Healthcare Me", "plan_name": "501310", "standard_charge_dollar": 398.60, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Windsor Mcare Extra", "plan_name": "500778", "standard_charge_dollar": 398.60, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." } ] } ] }, { "description": "Contrst x-ray urinary tract", "code_information": [ { "code": "74400", "type": "CPT" } ], "standard_charges": [ { "gross_charge": 450.00, "minimum": 163.08, "maximum": 382.50, "setting": "both", "payers_information": [ { "payer_name": "Aarp", "plan_name": "500102", "standard_charge_dollar": 163.08, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna", "plan_name": "700700", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna", "plan_name": "700700_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Mcare Ffs 6005", "plan_name": "700703", "standard_charge_dollar": 163.08, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Miscellaneous", "plan_name": "700720", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Miscellaneous", "plan_name": "700720_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Ppo Hmo", "plan_name": "701720", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Ppo Hmo", "plan_name": "701720_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Ambetter 68069", "plan_name": "500516", "standard_charge_dollar": 163.08, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Ms State Emplo", "plan_name": "401457", "standard_charge_percentage": 0.80, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Ms State Emplo", "plan_name": "401457_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Basic Pl", "plan_name": "400100", "standard_charge_percentage": 0.85, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Basic Pl", "plan_name": "400100_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Federal", "plan_name": "400110", "standard_charge_percentage": 0.85, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Federal", "plan_name": "400110_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Cigna Healthsprings Ffs", "plan_name": "500064", "standard_charge_dollar": 163.08, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Conseco", "plan_name": "500302", "standard_charge_dollar": 163.08, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Humana Ffs 61101", "plan_name": "500006", "standard_charge_dollar": 163.08, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Medicare A", "plan_name": "100100", "standard_charge_dollar": 163.08, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Medicare A", "plan_name": "100500", "standard_charge_dollar": 163.08, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Medicare Part B Only", "plan_name": "100300", "standard_charge_dollar": 163.08, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Medicare Railroad", "plan_name": "100103", "standard_charge_dollar": 163.08, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Ms Physicians Care N", "plan_name": "714210", "standard_charge_dollar": 203.85, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Peoples Hlth Ffs 72126", "plan_name": "500019", "standard_charge_dollar": 163.08, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Uhc/Secure Horizons", "plan_name": "500449", "standard_charge_dollar": 163.08, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "United Health Care/", "plan_name": "500292", "standard_charge_dollar": 184.28, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "United Healthcare", "plan_name": "750104", "standard_charge_dollar": 184.28, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "United Healthcare Ba", "plan_name": "750090", "standard_charge_dollar": 184.28, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "United Healthcare Me", "plan_name": "501310", "standard_charge_dollar": 163.08, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Windsor Mcare Extra", "plan_name": "500778", "standard_charge_dollar": 163.08, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." } ] } ] }, { "description": "Hc iv pyelogram w/wo kub", "code_information": [ { "code": "74400", "type": "CPT" } ], "standard_charges": [ { "gross_charge": 450.00, "minimum": 163.08, "maximum": 382.50, "setting": "both", "payers_information": [ { "payer_name": "Aarp", "plan_name": "500102", "standard_charge_dollar": 163.08, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna", "plan_name": "700700", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna", "plan_name": "700700_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Mcare Ffs 6005", "plan_name": "700703", "standard_charge_dollar": 163.08, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Miscellaneous", "plan_name": "700720", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Miscellaneous", "plan_name": "700720_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Ppo Hmo", "plan_name": "701720", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Ppo Hmo", "plan_name": "701720_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Ambetter 68069", "plan_name": "500516", "standard_charge_dollar": 163.08, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Ms State Emplo", "plan_name": "401457", "standard_charge_percentage": 0.80, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Ms State Emplo", "plan_name": "401457_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Basic Pl", "plan_name": "400100", "standard_charge_percentage": 0.85, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Basic Pl", "plan_name": "400100_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Federal", "plan_name": "400110", "standard_charge_percentage": 0.85, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Federal", "plan_name": "400110_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Cigna Healthsprings Ffs", "plan_name": "500064", "standard_charge_dollar": 163.08, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Conseco", "plan_name": "500302", "standard_charge_dollar": 163.08, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Humana Ffs 61101", "plan_name": "500006", "standard_charge_dollar": 163.08, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Medicare A", "plan_name": "100100", "standard_charge_dollar": 163.08, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Medicare A", "plan_name": "100500", "standard_charge_dollar": 163.08, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Medicare Part B Only", "plan_name": "100300", "standard_charge_dollar": 163.08, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Medicare Railroad", "plan_name": "100103", "standard_charge_dollar": 163.08, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Ms Physicians Care N", "plan_name": "714210", "standard_charge_dollar": 203.85, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Peoples Hlth Ffs 72126", "plan_name": "500019", "standard_charge_dollar": 163.08, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Uhc/Secure Horizons", "plan_name": "500449", "standard_charge_dollar": 163.08, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "United Health Care/", "plan_name": "500292", "standard_charge_dollar": 184.28, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "United Healthcare", "plan_name": "750104", "standard_charge_dollar": 184.28, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "United Healthcare Ba", "plan_name": "750090", "standard_charge_dollar": 184.28, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "United Healthcare Me", "plan_name": "501310", "standard_charge_dollar": 163.08, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Windsor Mcare Extra", "plan_name": "500778", "standard_charge_dollar": 163.08, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." } ] } ] }, { "description": "Ct hrt w/o dye w/ca test", "code_information": [ { "code": "75571", "type": "CPT" } ], "standard_charges": [ { "gross_charge": 99.00, "minimum": 19.05, "maximum": 100.82, "setting": "both", "payers_information": [ { "payer_name": "Aarp", "plan_name": "500102", "standard_charge_dollar": 80.66, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna", "plan_name": "700700", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna", "plan_name": "700700_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Mcare Ffs 6005", "plan_name": "700703", "standard_charge_dollar": 80.66, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Miscellaneous", "plan_name": "700720", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Miscellaneous", "plan_name": "700720_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Ppo Hmo", "plan_name": "701720", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Ppo Hmo", "plan_name": "701720_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Ambetter 68069", "plan_name": "500516", "standard_charge_dollar": 80.66, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Ms State Emplo", "plan_name": "401457", "standard_charge_dollar": 19.05, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Ms State Emplo", "plan_name": "401457_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Basic Pl", "plan_name": "400100", "standard_charge_dollar": 19.05, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Basic Pl", "plan_name": "400100_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Federal", "plan_name": "400110", "standard_charge_dollar": 19.05, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Federal", "plan_name": "400110_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Cigna Healthsprings Ffs", "plan_name": "500064", "standard_charge_dollar": 80.66, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Conseco", "plan_name": "500302", "standard_charge_dollar": 80.66, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Humana Ffs 61101", "plan_name": "500006", "standard_charge_dollar": 80.66, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Medicare A", "plan_name": "100100", "standard_charge_dollar": 80.66, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Medicare A", "plan_name": "100500", "standard_charge_dollar": 80.66, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Medicare Part B Only", "plan_name": "100300", "standard_charge_dollar": 80.66, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Medicare Railroad", "plan_name": "100103", "standard_charge_dollar": 80.66, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Ms Physicians Care N", "plan_name": "714210", "standard_charge_dollar": 100.82, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Peoples Hlth Ffs 72126", "plan_name": "500019", "standard_charge_dollar": 80.66, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Uhc/Secure Horizons", "plan_name": "500449", "standard_charge_dollar": 80.66, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "United Health Care/", "plan_name": "500292", "standard_charge_dollar": 91.15, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "United Healthcare", "plan_name": "750104", "standard_charge_dollar": 91.15, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "United Healthcare Ba", "plan_name": "750090", "standard_charge_dollar": 91.15, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "United Healthcare Me", "plan_name": "501310", "standard_charge_dollar": 80.66, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Windsor Mcare Extra", "plan_name": "500778", "standard_charge_dollar": 80.66, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." } ] } ] }, { "description": "Hc ct heart w/o cntrst w/ca score", "code_information": [ { "code": "75571", "type": "CPT" } ], "standard_charges": [ { "gross_charge": 99.00, "minimum": 19.05, "maximum": 100.82, "setting": "both", "payers_information": [ { "payer_name": "Aarp", "plan_name": "500102", "standard_charge_dollar": 80.66, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna", "plan_name": "700700", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna", "plan_name": "700700_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Mcare Ffs 6005", "plan_name": "700703", "standard_charge_dollar": 80.66, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Miscellaneous", "plan_name": "700720", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Miscellaneous", "plan_name": "700720_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Ppo Hmo", "plan_name": "701720", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Ppo Hmo", "plan_name": "701720_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Ambetter 68069", "plan_name": "500516", "standard_charge_dollar": 80.66, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Ms State Emplo", "plan_name": "401457", "standard_charge_dollar": 19.05, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Ms State Emplo", "plan_name": "401457_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Basic Pl", "plan_name": "400100", "standard_charge_dollar": 19.05, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Basic Pl", "plan_name": "400100_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Federal", "plan_name": "400110", "standard_charge_dollar": 19.05, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Federal", "plan_name": "400110_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Cigna Healthsprings Ffs", "plan_name": "500064", "standard_charge_dollar": 80.66, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Conseco", "plan_name": "500302", "standard_charge_dollar": 80.66, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Humana Ffs 61101", "plan_name": "500006", "standard_charge_dollar": 80.66, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Medicare A", "plan_name": "100100", "standard_charge_dollar": 80.66, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Medicare A", "plan_name": "100500", "standard_charge_dollar": 80.66, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Medicare Part B Only", "plan_name": "100300", "standard_charge_dollar": 80.66, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Medicare Railroad", "plan_name": "100103", "standard_charge_dollar": 80.66, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Ms Physicians Care N", "plan_name": "714210", "standard_charge_dollar": 100.82, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Peoples Hlth Ffs 72126", "plan_name": "500019", "standard_charge_dollar": 80.66, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Uhc/Secure Horizons", "plan_name": "500449", "standard_charge_dollar": 80.66, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "United Health Care/", "plan_name": "500292", "standard_charge_dollar": 91.15, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "United Healthcare", "plan_name": "750104", "standard_charge_dollar": 91.15, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "United Healthcare Ba", "plan_name": "750090", "standard_charge_dollar": 91.15, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "United Healthcare Me", "plan_name": "501310", "standard_charge_dollar": 80.66, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Windsor Mcare Extra", "plan_name": "500778", "standard_charge_dollar": 80.66, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." } ] } ] }, { "description": "Ct angio abdominal arteries", "code_information": [ { "code": "75635", "type": "CPT" } ], "standard_charges": [ { "gross_charge": 1750.00, "minimum": 163.08, "maximum": 355.29, "setting": "both", "payers_information": [ { "payer_name": "Aarp", "plan_name": "500102", "standard_charge_dollar": 163.08, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna", "plan_name": "700700", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna", "plan_name": "700700_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Mcare Ffs 6005", "plan_name": "700703", "standard_charge_dollar": 163.08, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Miscellaneous", "plan_name": "700720", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Miscellaneous", "plan_name": "700720_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Ppo Hmo", "plan_name": "701720", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Ppo Hmo", "plan_name": "701720_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Ambetter 68069", "plan_name": "500516", "standard_charge_dollar": 163.08, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Ms State Emplo", "plan_name": "401457", "standard_charge_dollar": 355.29, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Ms State Emplo", "plan_name": "401457_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Basic Pl", "plan_name": "400100", "standard_charge_dollar": 355.29, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Basic Pl", "plan_name": "400100_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Federal", "plan_name": "400110", "standard_charge_dollar": 355.29, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Federal", "plan_name": "400110_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Cigna Healthsprings Ffs", "plan_name": "500064", "standard_charge_dollar": 163.08, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Conseco", "plan_name": "500302", "standard_charge_dollar": 163.08, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Humana Ffs 61101", "plan_name": "500006", "standard_charge_dollar": 163.08, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Medicare A", "plan_name": "100100", "standard_charge_dollar": 163.08, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Medicare A", "plan_name": "100500", "standard_charge_dollar": 163.08, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Medicare Part B Only", "plan_name": "100300", "standard_charge_dollar": 163.08, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Medicare Railroad", "plan_name": "100103", "standard_charge_dollar": 163.08, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Ms Physicians Care N", "plan_name": "714210", "standard_charge_dollar": 203.85, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Peoples Hlth Ffs 72126", "plan_name": "500019", "standard_charge_dollar": 163.08, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Uhc/Secure Horizons", "plan_name": "500449", "standard_charge_dollar": 163.08, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "United Health Care/", "plan_name": "500292", "standard_charge_dollar": 184.28, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "United Healthcare", "plan_name": "750104", "standard_charge_dollar": 184.28, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "United Healthcare Ba", "plan_name": "750090", "standard_charge_dollar": 184.28, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "United Healthcare Me", "plan_name": "501310", "standard_charge_dollar": 163.08, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Windsor Mcare Extra", "plan_name": "500778", "standard_charge_dollar": 163.08, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." } ] } ] }, { "description": "Hc cta abdominal aorta with runoff", "code_information": [ { "code": "75635", "type": "CPT" } ], "standard_charges": [ { "gross_charge": 1750.00, "minimum": 163.08, "maximum": 355.29, "setting": "both", "payers_information": [ { "payer_name": "Aarp", "plan_name": "500102", "standard_charge_dollar": 163.08, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna", "plan_name": "700700", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna", "plan_name": "700700_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Mcare Ffs 6005", "plan_name": "700703", "standard_charge_dollar": 163.08, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Miscellaneous", "plan_name": "700720", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Miscellaneous", "plan_name": "700720_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Ppo Hmo", "plan_name": "701720", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Ppo Hmo", "plan_name": "701720_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Ambetter 68069", "plan_name": "500516", "standard_charge_dollar": 163.08, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Ms State Emplo", "plan_name": "401457", "standard_charge_dollar": 355.29, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Ms State Emplo", "plan_name": "401457_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Basic Pl", "plan_name": "400100", "standard_charge_dollar": 355.29, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Basic Pl", "plan_name": "400100_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Federal", "plan_name": "400110", "standard_charge_dollar": 355.29, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Federal", "plan_name": "400110_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Cigna Healthsprings Ffs", "plan_name": "500064", "standard_charge_dollar": 163.08, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Conseco", "plan_name": "500302", "standard_charge_dollar": 163.08, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Humana Ffs 61101", "plan_name": "500006", "standard_charge_dollar": 163.08, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Medicare A", "plan_name": "100100", "standard_charge_dollar": 163.08, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Medicare A", "plan_name": "100500", "standard_charge_dollar": 163.08, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Medicare Part B Only", "plan_name": "100300", "standard_charge_dollar": 163.08, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Medicare Railroad", "plan_name": "100103", "standard_charge_dollar": 163.08, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Ms Physicians Care N", "plan_name": "714210", "standard_charge_dollar": 203.85, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Peoples Hlth Ffs 72126", "plan_name": "500019", "standard_charge_dollar": 163.08, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Uhc/Secure Horizons", "plan_name": "500449", "standard_charge_dollar": 163.08, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "United Health Care/", "plan_name": "500292", "standard_charge_dollar": 184.28, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "United Healthcare", "plan_name": "750104", "standard_charge_dollar": 184.28, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "United Healthcare Ba", "plan_name": "750090", "standard_charge_dollar": 184.28, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "United Healthcare Me", "plan_name": "501310", "standard_charge_dollar": 163.08, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Windsor Mcare Extra", "plan_name": "500778", "standard_charge_dollar": 163.08, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." } ] } ] }, { "description": "Hc neck/trunk foreign body child", "code_information": [ { "code": "76010", "type": "CPT" } ], "standard_charges": [ { "gross_charge": 118.91, "minimum": 80.66, "maximum": 287.96, "setting": "both", "payers_information": [ { "payer_name": "Aarp", "plan_name": "500102", "standard_charge_dollar": 80.66, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna", "plan_name": "700700", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna", "plan_name": "700700_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Mcare Ffs 6005", "plan_name": "700703", "standard_charge_dollar": 80.66, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Miscellaneous", "plan_name": "700720", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Miscellaneous", "plan_name": "700720_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Ppo Hmo", "plan_name": "701720", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Ppo Hmo", "plan_name": "701720_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Ambetter 68069", "plan_name": "500516", "standard_charge_dollar": 80.66, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Ms State Emplo", "plan_name": "401457", "standard_charge_dollar": 287.96, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Ms State Emplo", "plan_name": "401457_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Basic Pl", "plan_name": "400100", "standard_charge_dollar": 287.96, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Basic Pl", "plan_name": "400100_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Federal", "plan_name": "400110", "standard_charge_dollar": 287.96, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Federal", "plan_name": "400110_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Cigna Healthsprings Ffs", "plan_name": "500064", "standard_charge_dollar": 80.66, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Conseco", "plan_name": "500302", "standard_charge_dollar": 80.66, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Humana Ffs 61101", "plan_name": "500006", "standard_charge_dollar": 80.66, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Medicare A", "plan_name": "100100", "standard_charge_dollar": 80.66, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Medicare A", "plan_name": "100500", "standard_charge_dollar": 80.66, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Medicare Part B Only", "plan_name": "100300", "standard_charge_dollar": 80.66, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Medicare Railroad", "plan_name": "100103", "standard_charge_dollar": 80.66, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Ms Physicians Care N", "plan_name": "714210", "standard_charge_dollar": 100.82, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Peoples Hlth Ffs 72126", "plan_name": "500019", "standard_charge_dollar": 80.66, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Uhc/Secure Horizons", "plan_name": "500449", "standard_charge_dollar": 80.66, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "United Health Care/", "plan_name": "500292", "standard_charge_dollar": 91.15, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "United Healthcare", "plan_name": "750104", "standard_charge_dollar": 91.15, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "United Healthcare Ba", "plan_name": "750090", "standard_charge_dollar": 91.15, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "United Healthcare Me", "plan_name": "501310", "standard_charge_dollar": 80.66, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Windsor Mcare Extra", "plan_name": "500778", "standard_charge_dollar": 80.66, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." } ] } ] }, { "description": "X-ray nose to rectum", "code_information": [ { "code": "76010", "type": "CPT" } ], "standard_charges": [ { "gross_charge": 118.91, "minimum": 80.66, "maximum": 287.96, "setting": "both", "payers_information": [ { "payer_name": "Aarp", "plan_name": "500102", "standard_charge_dollar": 80.66, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna", "plan_name": "700700", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna", "plan_name": "700700_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Mcare Ffs 6005", "plan_name": "700703", "standard_charge_dollar": 80.66, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Miscellaneous", "plan_name": "700720", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Miscellaneous", "plan_name": "700720_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Ppo Hmo", "plan_name": "701720", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Ppo Hmo", "plan_name": "701720_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Ambetter 68069", "plan_name": "500516", "standard_charge_dollar": 80.66, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Ms State Emplo", "plan_name": "401457", "standard_charge_dollar": 287.96, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Ms State Emplo", "plan_name": "401457_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Basic Pl", "plan_name": "400100", "standard_charge_dollar": 287.96, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Basic Pl", "plan_name": "400100_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Federal", "plan_name": "400110", "standard_charge_dollar": 287.96, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Federal", "plan_name": "400110_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Cigna Healthsprings Ffs", "plan_name": "500064", "standard_charge_dollar": 80.66, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Conseco", "plan_name": "500302", "standard_charge_dollar": 80.66, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Humana Ffs 61101", "plan_name": "500006", "standard_charge_dollar": 80.66, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Medicare A", "plan_name": "100100", "standard_charge_dollar": 80.66, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Medicare A", "plan_name": "100500", "standard_charge_dollar": 80.66, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Medicare Part B Only", "plan_name": "100300", "standard_charge_dollar": 80.66, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Medicare Railroad", "plan_name": "100103", "standard_charge_dollar": 80.66, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Ms Physicians Care N", "plan_name": "714210", "standard_charge_dollar": 100.82, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Peoples Hlth Ffs 72126", "plan_name": "500019", "standard_charge_dollar": 80.66, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Uhc/Secure Horizons", "plan_name": "500449", "standard_charge_dollar": 80.66, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "United Health Care/", "plan_name": "500292", "standard_charge_dollar": 91.15, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "United Healthcare", "plan_name": "750104", "standard_charge_dollar": 91.15, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "United Healthcare Ba", "plan_name": "750090", "standard_charge_dollar": 91.15, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "United Healthcare Me", "plan_name": "501310", "standard_charge_dollar": 80.66, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Windsor Mcare Extra", "plan_name": "500778", "standard_charge_dollar": 80.66, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." } ] } ] }, { "description": "Hc us soft tissue head/neck/thyroid", "code_information": [ { "code": "76536", "type": "CPT" } ], "standard_charges": [ { "gross_charge": 350.00, "minimum": 97.41, "maximum": 230.37, "setting": "both", "payers_information": [ { "payer_name": "Aarp", "plan_name": "500102", "standard_charge_dollar": 97.41, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna", "plan_name": "700700", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna", "plan_name": "700700_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Mcare Ffs 6005", "plan_name": "700703", "standard_charge_dollar": 97.41, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Miscellaneous", "plan_name": "700720", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Miscellaneous", "plan_name": "700720_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Ppo Hmo", "plan_name": "701720", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Ppo Hmo", "plan_name": "701720_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Ambetter 68069", "plan_name": "500516", "standard_charge_dollar": 97.41, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Ms State Emplo", "plan_name": "401457", "standard_charge_dollar": 230.37, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Ms State Emplo", "plan_name": "401457_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Basic Pl", "plan_name": "400100", "standard_charge_dollar": 230.37, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Basic Pl", "plan_name": "400100_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Federal", "plan_name": "400110", "standard_charge_dollar": 230.37, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Federal", "plan_name": "400110_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Cigna Healthsprings Ffs", "plan_name": "500064", "standard_charge_dollar": 97.41, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Conseco", "plan_name": "500302", "standard_charge_dollar": 97.41, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Humana Ffs 61101", "plan_name": "500006", "standard_charge_dollar": 97.41, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Medicare A", "plan_name": "100100", "standard_charge_dollar": 97.41, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Medicare A", "plan_name": "100500", "standard_charge_dollar": 97.41, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Medicare Part B Only", "plan_name": "100300", "standard_charge_dollar": 97.41, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Medicare Railroad", "plan_name": "100103", "standard_charge_dollar": 97.41, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Ms Physicians Care N", "plan_name": "714210", "standard_charge_dollar": 121.77, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Peoples Hlth Ffs 72126", "plan_name": "500019", "standard_charge_dollar": 97.41, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Uhc/Secure Horizons", "plan_name": "500449", "standard_charge_dollar": 97.41, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "United Health Care/", "plan_name": "500292", "standard_charge_dollar": 110.08, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "United Healthcare", "plan_name": "750104", "standard_charge_dollar": 110.08, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "United Healthcare Ba", "plan_name": "750090", "standard_charge_dollar": 110.08, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "United Healthcare Me", "plan_name": "501310", "standard_charge_dollar": 97.41, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Windsor Mcare Extra", "plan_name": "500778", "standard_charge_dollar": 97.41, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." } ] } ] }, { "description": "Us exam of head and neck", "code_information": [ { "code": "76536", "type": "CPT" } ], "standard_charges": [ { "gross_charge": 350.00, "minimum": 97.41, "maximum": 230.37, "setting": "both", "payers_information": [ { "payer_name": "Aarp", "plan_name": "500102", "standard_charge_dollar": 97.41, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna", "plan_name": "700700", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna", "plan_name": "700700_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Mcare Ffs 6005", "plan_name": "700703", "standard_charge_dollar": 97.41, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Miscellaneous", "plan_name": "700720", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Miscellaneous", "plan_name": "700720_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Ppo Hmo", "plan_name": "701720", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Ppo Hmo", "plan_name": "701720_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Ambetter 68069", "plan_name": "500516", "standard_charge_dollar": 97.41, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Ms State Emplo", "plan_name": "401457", "standard_charge_dollar": 230.37, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Ms State Emplo", "plan_name": "401457_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Basic Pl", "plan_name": "400100", "standard_charge_dollar": 230.37, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Basic Pl", "plan_name": "400100_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Federal", "plan_name": "400110", "standard_charge_dollar": 230.37, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Federal", "plan_name": "400110_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Cigna Healthsprings Ffs", "plan_name": "500064", "standard_charge_dollar": 97.41, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Conseco", "plan_name": "500302", "standard_charge_dollar": 97.41, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Humana Ffs 61101", "plan_name": "500006", "standard_charge_dollar": 97.41, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Medicare A", "plan_name": "100100", "standard_charge_dollar": 97.41, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Medicare A", "plan_name": "100500", "standard_charge_dollar": 97.41, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Medicare Part B Only", "plan_name": "100300", "standard_charge_dollar": 97.41, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Medicare Railroad", "plan_name": "100103", "standard_charge_dollar": 97.41, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Ms Physicians Care N", "plan_name": "714210", "standard_charge_dollar": 121.77, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Peoples Hlth Ffs 72126", "plan_name": "500019", "standard_charge_dollar": 97.41, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Uhc/Secure Horizons", "plan_name": "500449", "standard_charge_dollar": 97.41, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "United Health Care/", "plan_name": "500292", "standard_charge_dollar": 110.08, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "United Healthcare", "plan_name": "750104", "standard_charge_dollar": 110.08, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "United Healthcare Ba", "plan_name": "750090", "standard_charge_dollar": 110.08, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "United Healthcare Me", "plan_name": "501310", "standard_charge_dollar": 97.41, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Windsor Mcare Extra", "plan_name": "500778", "standard_charge_dollar": 97.41, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." } ] } ] }, { "description": "Hc us chest", "code_information": [ { "code": "76604", "type": "CPT" } ], "standard_charges": [ { "gross_charge": 223.00, "minimum": 97.41, "maximum": 138.11, "setting": "both", "payers_information": [ { "payer_name": "Aarp", "plan_name": "500102", "standard_charge_dollar": 97.41, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna", "plan_name": "700700", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna", "plan_name": "700700_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Mcare Ffs 6005", "plan_name": "700703", "standard_charge_dollar": 97.41, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Miscellaneous", "plan_name": "700720", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Miscellaneous", "plan_name": "700720_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Ppo Hmo", "plan_name": "701720", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Ppo Hmo", "plan_name": "701720_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Ambetter 68069", "plan_name": "500516", "standard_charge_dollar": 97.41, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Ms State Emplo", "plan_name": "401457", "standard_charge_dollar": 138.11, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Ms State Emplo", "plan_name": "401457_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Basic Pl", "plan_name": "400100", "standard_charge_dollar": 138.11, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Basic Pl", "plan_name": "400100_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Federal", "plan_name": "400110", "standard_charge_dollar": 138.11, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Federal", "plan_name": "400110_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Cigna Healthsprings Ffs", "plan_name": "500064", "standard_charge_dollar": 97.41, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Conseco", "plan_name": "500302", "standard_charge_dollar": 97.41, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Humana Ffs 61101", "plan_name": "500006", "standard_charge_dollar": 97.41, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Medicare A", "plan_name": "100100", "standard_charge_dollar": 97.41, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Medicare A", "plan_name": "100500", "standard_charge_dollar": 97.41, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Medicare Part B Only", "plan_name": "100300", "standard_charge_dollar": 97.41, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Medicare Railroad", "plan_name": "100103", "standard_charge_dollar": 97.41, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Ms Physicians Care N", "plan_name": "714210", "standard_charge_dollar": 121.77, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Peoples Hlth Ffs 72126", "plan_name": "500019", "standard_charge_dollar": 97.41, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Uhc/Secure Horizons", "plan_name": "500449", "standard_charge_dollar": 97.41, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "United Health Care/", "plan_name": "500292", "standard_charge_dollar": 110.08, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "United Healthcare", "plan_name": "750104", "standard_charge_dollar": 110.08, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "United Healthcare Ba", "plan_name": "750090", "standard_charge_dollar": 110.08, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "United Healthcare Me", "plan_name": "501310", "standard_charge_dollar": 97.41, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Windsor Mcare Extra", "plan_name": "500778", "standard_charge_dollar": 97.41, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." } ] } ] }, { "description": "Us exam chest", "code_information": [ { "code": "76604", "type": "CPT" } ], "standard_charges": [ { "gross_charge": 223.00, "minimum": 97.41, "maximum": 138.11, "setting": "both", "payers_information": [ { "payer_name": "Aarp", "plan_name": "500102", "standard_charge_dollar": 97.41, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna", "plan_name": "700700", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna", "plan_name": "700700_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Mcare Ffs 6005", "plan_name": "700703", "standard_charge_dollar": 97.41, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Miscellaneous", "plan_name": "700720", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Miscellaneous", "plan_name": "700720_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Ppo Hmo", "plan_name": "701720", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Ppo Hmo", "plan_name": "701720_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Ambetter 68069", "plan_name": "500516", "standard_charge_dollar": 97.41, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Ms State Emplo", "plan_name": "401457", "standard_charge_dollar": 138.11, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Ms State Emplo", "plan_name": "401457_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Basic Pl", "plan_name": "400100", "standard_charge_dollar": 138.11, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Basic Pl", "plan_name": "400100_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Federal", "plan_name": "400110", "standard_charge_dollar": 138.11, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Federal", "plan_name": "400110_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Cigna Healthsprings Ffs", "plan_name": "500064", "standard_charge_dollar": 97.41, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Conseco", "plan_name": "500302", "standard_charge_dollar": 97.41, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Humana Ffs 61101", "plan_name": "500006", "standard_charge_dollar": 97.41, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Medicare A", "plan_name": "100100", "standard_charge_dollar": 97.41, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Medicare A", "plan_name": "100500", "standard_charge_dollar": 97.41, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Medicare Part B Only", "plan_name": "100300", "standard_charge_dollar": 97.41, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Medicare Railroad", "plan_name": "100103", "standard_charge_dollar": 97.41, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Ms Physicians Care N", "plan_name": "714210", "standard_charge_dollar": 121.77, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Peoples Hlth Ffs 72126", "plan_name": "500019", "standard_charge_dollar": 97.41, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Uhc/Secure Horizons", "plan_name": "500449", "standard_charge_dollar": 97.41, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "United Health Care/", "plan_name": "500292", "standard_charge_dollar": 110.08, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "United Healthcare", "plan_name": "750104", "standard_charge_dollar": 110.08, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "United Healthcare Ba", "plan_name": "750090", "standard_charge_dollar": 110.08, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "United Healthcare Me", "plan_name": "501310", "standard_charge_dollar": 97.41, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Windsor Mcare Extra", "plan_name": "500778", "standard_charge_dollar": 97.41, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." } ] } ] }, { "description": "Hs us addomen complete", "code_information": [ { "code": "76700", "type": "CPT" } ], "standard_charges": [ { "gross_charge": 500.00, "minimum": 230.37, "maximum": 350.97, "setting": "both", "payers_information": [ { "payer_name": "Aarp", "plan_name": "500102", "standard_charge_dollar": 280.78, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna", "plan_name": "700700", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna", "plan_name": "700700_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Mcare Ffs 6005", "plan_name": "700703", "standard_charge_dollar": 280.78, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Miscellaneous", "plan_name": "700720", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Miscellaneous", "plan_name": "700720_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Ppo Hmo", "plan_name": "701720", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Ppo Hmo", "plan_name": "701720_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Ambetter 68069", "plan_name": "500516", "standard_charge_dollar": 280.78, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Ms State Emplo", "plan_name": "401457", "standard_charge_dollar": 230.37, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Ms State Emplo", "plan_name": "401457_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Basic Pl", "plan_name": "400100", "standard_charge_dollar": 230.37, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Basic Pl", "plan_name": "400100_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Federal", "plan_name": "400110", "standard_charge_dollar": 230.37, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Federal", "plan_name": "400110_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Cigna Healthsprings Ffs", "plan_name": "500064", "standard_charge_dollar": 280.78, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Conseco", "plan_name": "500302", "standard_charge_dollar": 280.78, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Humana Ffs 61101", "plan_name": "500006", "standard_charge_dollar": 280.78, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Medicare A", "plan_name": "100100", "standard_charge_dollar": 280.78, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Medicare A", "plan_name": "100500", "standard_charge_dollar": 280.78, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Medicare Part B Only", "plan_name": "100300", "standard_charge_dollar": 280.78, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Medicare Railroad", "plan_name": "100103", "standard_charge_dollar": 280.78, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Ms Physicians Care N", "plan_name": "714210", "standard_charge_dollar": 350.97, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Peoples Hlth Ffs 72126", "plan_name": "500019", "standard_charge_dollar": 280.78, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Uhc/Secure Horizons", "plan_name": "500449", "standard_charge_dollar": 280.78, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "United Health Care/", "plan_name": "500292", "standard_charge_dollar": 317.28, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "United Healthcare", "plan_name": "750104", "standard_charge_dollar": 317.28, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "United Healthcare Ba", "plan_name": "750090", "standard_charge_dollar": 317.28, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "United Healthcare Me", "plan_name": "501310", "standard_charge_dollar": 280.78, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Windsor Mcare Extra", "plan_name": "500778", "standard_charge_dollar": 280.78, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." } ] } ] }, { "description": "Us exam abdom complete", "code_information": [ { "code": "76700", "type": "CPT" } ], "standard_charges": [ { "gross_charge": 500.00, "minimum": 230.37, "maximum": 350.97, "setting": "both", "payers_information": [ { "payer_name": "Aarp", "plan_name": "500102", "standard_charge_dollar": 280.78, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna", "plan_name": "700700", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna", "plan_name": "700700_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Mcare Ffs 6005", "plan_name": "700703", "standard_charge_dollar": 280.78, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Miscellaneous", "plan_name": "700720", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Miscellaneous", "plan_name": "700720_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Ppo Hmo", "plan_name": "701720", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Ppo Hmo", "plan_name": "701720_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Ambetter 68069", "plan_name": "500516", "standard_charge_dollar": 280.78, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Ms State Emplo", "plan_name": "401457", "standard_charge_dollar": 230.37, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Ms State Emplo", "plan_name": "401457_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Basic Pl", "plan_name": "400100", "standard_charge_dollar": 230.37, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Basic Pl", "plan_name": "400100_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Federal", "plan_name": "400110", "standard_charge_dollar": 230.37, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Federal", "plan_name": "400110_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Cigna Healthsprings Ffs", "plan_name": "500064", "standard_charge_dollar": 280.78, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Conseco", "plan_name": "500302", "standard_charge_dollar": 280.78, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Humana Ffs 61101", "plan_name": "500006", "standard_charge_dollar": 280.78, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Medicare A", "plan_name": "100100", "standard_charge_dollar": 280.78, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Medicare A", "plan_name": "100500", "standard_charge_dollar": 280.78, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Medicare Part B Only", "plan_name": "100300", "standard_charge_dollar": 280.78, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Medicare Railroad", "plan_name": "100103", "standard_charge_dollar": 280.78, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Ms Physicians Care N", "plan_name": "714210", "standard_charge_dollar": 350.97, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Peoples Hlth Ffs 72126", "plan_name": "500019", "standard_charge_dollar": 280.78, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Uhc/Secure Horizons", "plan_name": "500449", "standard_charge_dollar": 280.78, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "United Health Care/", "plan_name": "500292", "standard_charge_dollar": 317.28, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "United Healthcare", "plan_name": "750104", "standard_charge_dollar": 317.28, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "United Healthcare Ba", "plan_name": "750090", "standard_charge_dollar": 317.28, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "United Healthcare Me", "plan_name": "501310", "standard_charge_dollar": 280.78, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Windsor Mcare Extra", "plan_name": "500778", "standard_charge_dollar": 280.78, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." } ] } ] }, { "description": "Echo exam of abdomen", "code_information": [ { "code": "76705", "type": "CPT" } ], "standard_charges": [ { "gross_charge": 375.00, "minimum": 230.37, "maximum": 350.97, "setting": "both", "payers_information": [ { "payer_name": "Aarp", "plan_name": "500102", "standard_charge_dollar": 280.78, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna", "plan_name": "700700", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna", "plan_name": "700700_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Mcare Ffs 6005", "plan_name": "700703", "standard_charge_dollar": 280.78, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Miscellaneous", "plan_name": "700720", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Miscellaneous", "plan_name": "700720_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Ppo Hmo", "plan_name": "701720", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Ppo Hmo", "plan_name": "701720_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Ambetter 68069", "plan_name": "500516", "standard_charge_dollar": 280.78, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Ms State Emplo", "plan_name": "401457", "standard_charge_dollar": 230.37, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Ms State Emplo", "plan_name": "401457_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Basic Pl", "plan_name": "400100", "standard_charge_dollar": 230.37, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Basic Pl", "plan_name": "400100_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Federal", "plan_name": "400110", "standard_charge_dollar": 230.37, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Federal", "plan_name": "400110_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Cigna Healthsprings Ffs", "plan_name": "500064", "standard_charge_dollar": 280.78, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Conseco", "plan_name": "500302", "standard_charge_dollar": 280.78, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Humana Ffs 61101", "plan_name": "500006", "standard_charge_dollar": 280.78, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Medicare A", "plan_name": "100100", "standard_charge_dollar": 280.78, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Medicare A", "plan_name": "100500", "standard_charge_dollar": 280.78, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Medicare Part B Only", "plan_name": "100300", "standard_charge_dollar": 280.78, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Medicare Railroad", "plan_name": "100103", "standard_charge_dollar": 280.78, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Ms Physicians Care N", "plan_name": "714210", "standard_charge_dollar": 350.97, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Peoples Hlth Ffs 72126", "plan_name": "500019", "standard_charge_dollar": 280.78, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Uhc/Secure Horizons", "plan_name": "500449", "standard_charge_dollar": 280.78, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "United Health Care/", "plan_name": "500292", "standard_charge_dollar": 317.28, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "United Healthcare", "plan_name": "750104", "standard_charge_dollar": 317.28, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "United Healthcare Ba", "plan_name": "750090", "standard_charge_dollar": 317.28, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "United Healthcare Me", "plan_name": "501310", "standard_charge_dollar": 280.78, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Windsor Mcare Extra", "plan_name": "500778", "standard_charge_dollar": 280.78, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." } ] } ] }, { "description": "Hc us abdomen limited", "code_information": [ { "code": "76705", "type": "CPT" } ], "standard_charges": [ { "gross_charge": 375.00, "minimum": 230.37, "maximum": 350.97, "setting": "both", "payers_information": [ { "payer_name": "Aarp", "plan_name": "500102", "standard_charge_dollar": 280.78, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna", "plan_name": "700700", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna", "plan_name": "700700_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Mcare Ffs 6005", "plan_name": "700703", "standard_charge_dollar": 280.78, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Miscellaneous", "plan_name": "700720", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Miscellaneous", "plan_name": "700720_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Ppo Hmo", "plan_name": "701720", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Ppo Hmo", "plan_name": "701720_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Ambetter 68069", "plan_name": "500516", "standard_charge_dollar": 280.78, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Ms State Emplo", "plan_name": "401457", "standard_charge_dollar": 230.37, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Ms State Emplo", "plan_name": "401457_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Basic Pl", "plan_name": "400100", "standard_charge_dollar": 230.37, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Basic Pl", "plan_name": "400100_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Federal", "plan_name": "400110", "standard_charge_dollar": 230.37, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Federal", "plan_name": "400110_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Cigna Healthsprings Ffs", "plan_name": "500064", "standard_charge_dollar": 280.78, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Conseco", "plan_name": "500302", "standard_charge_dollar": 280.78, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Humana Ffs 61101", "plan_name": "500006", "standard_charge_dollar": 280.78, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Medicare A", "plan_name": "100100", "standard_charge_dollar": 280.78, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Medicare A", "plan_name": "100500", "standard_charge_dollar": 280.78, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Medicare Part B Only", "plan_name": "100300", "standard_charge_dollar": 280.78, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Medicare Railroad", "plan_name": "100103", "standard_charge_dollar": 280.78, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Ms Physicians Care N", "plan_name": "714210", "standard_charge_dollar": 350.97, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Peoples Hlth Ffs 72126", "plan_name": "500019", "standard_charge_dollar": 280.78, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Uhc/Secure Horizons", "plan_name": "500449", "standard_charge_dollar": 280.78, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "United Health Care/", "plan_name": "500292", "standard_charge_dollar": 317.28, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "United Healthcare", "plan_name": "750104", "standard_charge_dollar": 317.28, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "United Healthcare Ba", "plan_name": "750090", "standard_charge_dollar": 317.28, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "United Healthcare Me", "plan_name": "501310", "standard_charge_dollar": 280.78, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Windsor Mcare Extra", "plan_name": "500778", "standard_charge_dollar": 280.78, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." } ] } ] }, { "description": "Hc us retroperitoneal complete", "code_information": [ { "code": "76770", "type": "CPT" } ], "standard_charges": [ { "gross_charge": 550.00, "minimum": 230.37, "maximum": 350.97, "setting": "both", "payers_information": [ { "payer_name": "Aarp", "plan_name": "500102", "standard_charge_dollar": 280.78, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna", "plan_name": "700700", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna", "plan_name": "700700_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Mcare Ffs 6005", "plan_name": "700703", "standard_charge_dollar": 280.78, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Miscellaneous", "plan_name": "700720", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Miscellaneous", "plan_name": "700720_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Ppo Hmo", "plan_name": "701720", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Ppo Hmo", "plan_name": "701720_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Ambetter 68069", "plan_name": "500516", "standard_charge_dollar": 280.78, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Ms State Emplo", "plan_name": "401457", "standard_charge_dollar": 230.37, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Ms State Emplo", "plan_name": "401457_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Basic Pl", "plan_name": "400100", "standard_charge_dollar": 230.37, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Basic Pl", "plan_name": "400100_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Federal", "plan_name": "400110", "standard_charge_dollar": 230.37, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Federal", "plan_name": "400110_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Cigna Healthsprings Ffs", "plan_name": "500064", "standard_charge_dollar": 280.78, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Conseco", "plan_name": "500302", "standard_charge_dollar": 280.78, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Humana Ffs 61101", "plan_name": "500006", "standard_charge_dollar": 280.78, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Medicare A", "plan_name": "100100", "standard_charge_dollar": 280.78, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Medicare A", "plan_name": "100500", "standard_charge_dollar": 280.78, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Medicare Part B Only", "plan_name": "100300", "standard_charge_dollar": 280.78, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Medicare Railroad", "plan_name": "100103", "standard_charge_dollar": 280.78, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Ms Physicians Care N", "plan_name": "714210", "standard_charge_dollar": 350.97, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Peoples Hlth Ffs 72126", "plan_name": "500019", "standard_charge_dollar": 280.78, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Uhc/Secure Horizons", "plan_name": "500449", "standard_charge_dollar": 280.78, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "United Health Care/", "plan_name": "500292", "standard_charge_dollar": 317.28, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "United Healthcare", "plan_name": "750104", "standard_charge_dollar": 317.28, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "United Healthcare Ba", "plan_name": "750090", "standard_charge_dollar": 317.28, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "United Healthcare Me", "plan_name": "501310", "standard_charge_dollar": 280.78, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Windsor Mcare Extra", "plan_name": "500778", "standard_charge_dollar": 280.78, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." } ] } ] }, { "description": "Us exam abdo back wall comp", "code_information": [ { "code": "76770", "type": "CPT" } ], "standard_charges": [ { "gross_charge": 550.00, "minimum": 230.37, "maximum": 350.97, "setting": "both", "payers_information": [ { "payer_name": "Aarp", "plan_name": "500102", "standard_charge_dollar": 280.78, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna", "plan_name": "700700", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna", "plan_name": "700700_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Mcare Ffs 6005", "plan_name": "700703", "standard_charge_dollar": 280.78, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Miscellaneous", "plan_name": "700720", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Miscellaneous", "plan_name": "700720_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Ppo Hmo", "plan_name": "701720", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Ppo Hmo", "plan_name": "701720_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Ambetter 68069", "plan_name": "500516", "standard_charge_dollar": 280.78, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Ms State Emplo", "plan_name": "401457", "standard_charge_dollar": 230.37, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Ms State Emplo", "plan_name": "401457_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Basic Pl", "plan_name": "400100", "standard_charge_dollar": 230.37, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Basic Pl", "plan_name": "400100_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Federal", "plan_name": "400110", "standard_charge_dollar": 230.37, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Federal", "plan_name": "400110_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Cigna Healthsprings Ffs", "plan_name": "500064", "standard_charge_dollar": 280.78, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Conseco", "plan_name": "500302", "standard_charge_dollar": 280.78, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Humana Ffs 61101", "plan_name": "500006", "standard_charge_dollar": 280.78, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Medicare A", "plan_name": "100100", "standard_charge_dollar": 280.78, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Medicare A", "plan_name": "100500", "standard_charge_dollar": 280.78, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Medicare Part B Only", "plan_name": "100300", "standard_charge_dollar": 280.78, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Medicare Railroad", "plan_name": "100103", "standard_charge_dollar": 280.78, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Ms Physicians Care N", "plan_name": "714210", "standard_charge_dollar": 350.97, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Peoples Hlth Ffs 72126", "plan_name": "500019", "standard_charge_dollar": 280.78, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Uhc/Secure Horizons", "plan_name": "500449", "standard_charge_dollar": 280.78, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "United Health Care/", "plan_name": "500292", "standard_charge_dollar": 317.28, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "United Healthcare", "plan_name": "750104", "standard_charge_dollar": 317.28, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "United Healthcare Ba", "plan_name": "750090", "standard_charge_dollar": 317.28, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "United Healthcare Me", "plan_name": "501310", "standard_charge_dollar": 280.78, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Windsor Mcare Extra", "plan_name": "500778", "standard_charge_dollar": 280.78, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." } ] } ] }, { "description": "Hc us retroperitoneal limited", "code_information": [ { "code": "76775", "type": "CPT" } ], "standard_charges": [ { "gross_charge": 450.00, "minimum": 97.41, "maximum": 230.37, "setting": "both", "payers_information": [ { "payer_name": "Aarp", "plan_name": "500102", "standard_charge_dollar": 97.41, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna", "plan_name": "700700", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna", "plan_name": "700700_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Mcare Ffs 6005", "plan_name": "700703", "standard_charge_dollar": 97.41, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Miscellaneous", "plan_name": "700720", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Miscellaneous", "plan_name": "700720_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Ppo Hmo", "plan_name": "701720", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Ppo Hmo", "plan_name": "701720_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Ambetter 68069", "plan_name": "500516", "standard_charge_dollar": 97.41, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Ms State Emplo", "plan_name": "401457", "standard_charge_dollar": 230.37, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Ms State Emplo", "plan_name": "401457_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Basic Pl", "plan_name": "400100", "standard_charge_dollar": 230.37, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Basic Pl", "plan_name": "400100_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Federal", "plan_name": "400110", "standard_charge_dollar": 230.37, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Federal", "plan_name": "400110_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Cigna Healthsprings Ffs", "plan_name": "500064", "standard_charge_dollar": 97.41, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Conseco", "plan_name": "500302", "standard_charge_dollar": 97.41, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Humana Ffs 61101", "plan_name": "500006", "standard_charge_dollar": 97.41, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Medicare A", "plan_name": "100100", "standard_charge_dollar": 97.41, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Medicare A", "plan_name": "100500", "standard_charge_dollar": 97.41, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Medicare Part B Only", "plan_name": "100300", "standard_charge_dollar": 97.41, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Medicare Railroad", "plan_name": "100103", "standard_charge_dollar": 97.41, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Ms Physicians Care N", "plan_name": "714210", "standard_charge_dollar": 121.77, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Peoples Hlth Ffs 72126", "plan_name": "500019", "standard_charge_dollar": 97.41, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Uhc/Secure Horizons", "plan_name": "500449", "standard_charge_dollar": 97.41, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "United Health Care/", "plan_name": "500292", "standard_charge_dollar": 110.08, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "United Healthcare", "plan_name": "750104", "standard_charge_dollar": 110.08, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "United Healthcare Ba", "plan_name": "750090", "standard_charge_dollar": 110.08, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "United Healthcare Me", "plan_name": "501310", "standard_charge_dollar": 97.41, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Windsor Mcare Extra", "plan_name": "500778", "standard_charge_dollar": 97.41, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." } ] } ] }, { "description": "Us exam abdo back wall lim", "code_information": [ { "code": "76775", "type": "CPT" } ], "standard_charges": [ { "gross_charge": 450.00, "minimum": 97.41, "maximum": 230.37, "setting": "both", "payers_information": [ { "payer_name": "Aarp", "plan_name": "500102", "standard_charge_dollar": 97.41, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna", "plan_name": "700700", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna", "plan_name": "700700_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Mcare Ffs 6005", "plan_name": "700703", "standard_charge_dollar": 97.41, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Miscellaneous", "plan_name": "700720", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Miscellaneous", "plan_name": "700720_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Ppo Hmo", "plan_name": "701720", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Ppo Hmo", "plan_name": "701720_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Ambetter 68069", "plan_name": "500516", "standard_charge_dollar": 97.41, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Ms State Emplo", "plan_name": "401457", "standard_charge_dollar": 230.37, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Ms State Emplo", "plan_name": "401457_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Basic Pl", "plan_name": "400100", "standard_charge_dollar": 230.37, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Basic Pl", "plan_name": "400100_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Federal", "plan_name": "400110", "standard_charge_dollar": 230.37, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Federal", "plan_name": "400110_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Cigna Healthsprings Ffs", "plan_name": "500064", "standard_charge_dollar": 97.41, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Conseco", "plan_name": "500302", "standard_charge_dollar": 97.41, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Humana Ffs 61101", "plan_name": "500006", "standard_charge_dollar": 97.41, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Medicare A", "plan_name": "100100", "standard_charge_dollar": 97.41, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Medicare A", "plan_name": "100500", "standard_charge_dollar": 97.41, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Medicare Part B Only", "plan_name": "100300", "standard_charge_dollar": 97.41, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Medicare Railroad", "plan_name": "100103", "standard_charge_dollar": 97.41, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Ms Physicians Care N", "plan_name": "714210", "standard_charge_dollar": 121.77, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Peoples Hlth Ffs 72126", "plan_name": "500019", "standard_charge_dollar": 97.41, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Uhc/Secure Horizons", "plan_name": "500449", "standard_charge_dollar": 97.41, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "United Health Care/", "plan_name": "500292", "standard_charge_dollar": 110.08, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "United Healthcare", "plan_name": "750104", "standard_charge_dollar": 110.08, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "United Healthcare Ba", "plan_name": "750090", "standard_charge_dollar": 110.08, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "United Healthcare Me", "plan_name": "501310", "standard_charge_dollar": 97.41, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Windsor Mcare Extra", "plan_name": "500778", "standard_charge_dollar": 97.41, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." } ] } ] }, { "description": "Hc us ob <14 wks single fetus", "code_information": [ { "code": "76801", "type": "CPT" } ], "standard_charges": [ { "gross_charge": 350.00, "minimum": 97.41, "maximum": 297.50, "setting": "both", "payers_information": [ { "payer_name": "Aarp", "plan_name": "500102", "standard_charge_dollar": 97.41, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna", "plan_name": "700700", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna", "plan_name": "700700_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Mcare Ffs 6005", "plan_name": "700703", "standard_charge_dollar": 97.41, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Miscellaneous", "plan_name": "700720", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Miscellaneous", "plan_name": "700720_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Ppo Hmo", "plan_name": "701720", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Ppo Hmo", "plan_name": "701720_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Ambetter 68069", "plan_name": "500516", "standard_charge_dollar": 97.41, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Ms State Emplo", "plan_name": "401457", "standard_charge_percentage": 0.80, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Ms State Emplo", "plan_name": "401457_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Basic Pl", "plan_name": "400100", "standard_charge_percentage": 0.85, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Basic Pl", "plan_name": "400100_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Federal", "plan_name": "400110", "standard_charge_percentage": 0.85, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Federal", "plan_name": "400110_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Cigna Healthsprings Ffs", "plan_name": "500064", "standard_charge_dollar": 97.41, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Conseco", "plan_name": "500302", "standard_charge_dollar": 97.41, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Humana Ffs 61101", "plan_name": "500006", "standard_charge_dollar": 97.41, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Medicare A", "plan_name": "100100", "standard_charge_dollar": 97.41, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Medicare A", "plan_name": "100500", "standard_charge_dollar": 97.41, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Medicare Part B Only", "plan_name": "100300", "standard_charge_dollar": 97.41, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Medicare Railroad", "plan_name": "100103", "standard_charge_dollar": 97.41, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Ms Physicians Care N", "plan_name": "714210", "standard_charge_dollar": 121.77, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Peoples Hlth Ffs 72126", "plan_name": "500019", "standard_charge_dollar": 97.41, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Uhc/Secure Horizons", "plan_name": "500449", "standard_charge_dollar": 97.41, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "United Health Care/", "plan_name": "500292", "standard_charge_dollar": 110.08, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "United Healthcare", "plan_name": "750104", "standard_charge_dollar": 110.08, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "United Healthcare Ba", "plan_name": "750090", "standard_charge_dollar": 110.08, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "United Healthcare Me", "plan_name": "501310", "standard_charge_dollar": 97.41, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Windsor Mcare Extra", "plan_name": "500778", "standard_charge_dollar": 97.41, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." } ] } ] }, { "description": "Ob us < 14 wks single fetus", "code_information": [ { "code": "76801", "type": "CPT" } ], "standard_charges": [ { "gross_charge": 350.00, "minimum": 97.41, "maximum": 297.50, "setting": "both", "payers_information": [ { "payer_name": "Aarp", "plan_name": "500102", "standard_charge_dollar": 97.41, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna", "plan_name": "700700", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna", "plan_name": "700700_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Mcare Ffs 6005", "plan_name": "700703", "standard_charge_dollar": 97.41, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Miscellaneous", "plan_name": "700720", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Miscellaneous", "plan_name": "700720_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Ppo Hmo", "plan_name": "701720", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Ppo Hmo", "plan_name": "701720_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Ambetter 68069", "plan_name": "500516", "standard_charge_dollar": 97.41, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Ms State Emplo", "plan_name": "401457", "standard_charge_percentage": 0.80, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Ms State Emplo", "plan_name": "401457_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Basic Pl", "plan_name": "400100", "standard_charge_percentage": 0.85, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Basic Pl", "plan_name": "400100_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Federal", "plan_name": "400110", "standard_charge_percentage": 0.85, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Federal", "plan_name": "400110_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Cigna Healthsprings Ffs", "plan_name": "500064", "standard_charge_dollar": 97.41, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Conseco", "plan_name": "500302", "standard_charge_dollar": 97.41, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Humana Ffs 61101", "plan_name": "500006", "standard_charge_dollar": 97.41, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Medicare A", "plan_name": "100100", "standard_charge_dollar": 97.41, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Medicare A", "plan_name": "100500", "standard_charge_dollar": 97.41, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Medicare Part B Only", "plan_name": "100300", "standard_charge_dollar": 97.41, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Medicare Railroad", "plan_name": "100103", "standard_charge_dollar": 97.41, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Ms Physicians Care N", "plan_name": "714210", "standard_charge_dollar": 121.77, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Peoples Hlth Ffs 72126", "plan_name": "500019", "standard_charge_dollar": 97.41, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Uhc/Secure Horizons", "plan_name": "500449", "standard_charge_dollar": 97.41, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "United Health Care/", "plan_name": "500292", "standard_charge_dollar": 110.08, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "United Healthcare", "plan_name": "750104", "standard_charge_dollar": 110.08, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "United Healthcare Ba", "plan_name": "750090", "standard_charge_dollar": 110.08, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "United Healthcare Me", "plan_name": "501310", "standard_charge_dollar": 97.41, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Windsor Mcare Extra", "plan_name": "500778", "standard_charge_dollar": 97.41, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." } ] } ] }, { "description": "Hc us ob >14 wks single fetus", "code_information": [ { "code": "76805", "type": "CPT" } ], "standard_charges": [ { "gross_charge": 350.00, "minimum": 97.41, "maximum": 297.50, "setting": "both", "payers_information": [ { "payer_name": "Aarp", "plan_name": "500102", "standard_charge_dollar": 97.41, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna", "plan_name": "700700", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna", "plan_name": "700700_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Mcare Ffs 6005", "plan_name": "700703", "standard_charge_dollar": 97.41, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Miscellaneous", "plan_name": "700720", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Miscellaneous", "plan_name": "700720_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Ppo Hmo", "plan_name": "701720", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Ppo Hmo", "plan_name": "701720_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Ambetter 68069", "plan_name": "500516", "standard_charge_dollar": 97.41, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Ms State Emplo", "plan_name": "401457", "standard_charge_percentage": 0.80, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Ms State Emplo", "plan_name": "401457_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Basic Pl", "plan_name": "400100", "standard_charge_percentage": 0.85, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Basic Pl", "plan_name": "400100_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Federal", "plan_name": "400110", "standard_charge_percentage": 0.85, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Federal", "plan_name": "400110_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Cigna Healthsprings Ffs", "plan_name": "500064", "standard_charge_dollar": 97.41, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Conseco", "plan_name": "500302", "standard_charge_dollar": 97.41, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Humana Ffs 61101", "plan_name": "500006", "standard_charge_dollar": 97.41, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Medicare A", "plan_name": "100100", "standard_charge_dollar": 97.41, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Medicare A", "plan_name": "100500", "standard_charge_dollar": 97.41, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Medicare Part B Only", "plan_name": "100300", "standard_charge_dollar": 97.41, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Medicare Railroad", "plan_name": "100103", "standard_charge_dollar": 97.41, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Ms Physicians Care N", "plan_name": "714210", "standard_charge_dollar": 121.77, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Peoples Hlth Ffs 72126", "plan_name": "500019", "standard_charge_dollar": 97.41, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Uhc/Secure Horizons", "plan_name": "500449", "standard_charge_dollar": 97.41, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "United Health Care/", "plan_name": "500292", "standard_charge_dollar": 110.08, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "United Healthcare", "plan_name": "750104", "standard_charge_dollar": 110.08, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "United Healthcare Ba", "plan_name": "750090", "standard_charge_dollar": 110.08, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "United Healthcare Me", "plan_name": "501310", "standard_charge_dollar": 97.41, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Windsor Mcare Extra", "plan_name": "500778", "standard_charge_dollar": 97.41, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." } ] } ] }, { "description": "Ob us >= 14 wks sngl fetus", "code_information": [ { "code": "76805", "type": "CPT" } ], "standard_charges": [ { "gross_charge": 350.00, "minimum": 97.41, "maximum": 297.50, "setting": "both", "payers_information": [ { "payer_name": "Aarp", "plan_name": "500102", "standard_charge_dollar": 97.41, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna", "plan_name": "700700", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna", "plan_name": "700700_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Mcare Ffs 6005", "plan_name": "700703", "standard_charge_dollar": 97.41, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Miscellaneous", "plan_name": "700720", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Miscellaneous", "plan_name": "700720_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Ppo Hmo", "plan_name": "701720", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Ppo Hmo", "plan_name": "701720_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Ambetter 68069", "plan_name": "500516", "standard_charge_dollar": 97.41, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Ms State Emplo", "plan_name": "401457", "standard_charge_percentage": 0.80, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Ms State Emplo", "plan_name": "401457_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Basic Pl", "plan_name": "400100", "standard_charge_percentage": 0.85, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Basic Pl", "plan_name": "400100_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Federal", "plan_name": "400110", "standard_charge_percentage": 0.85, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Federal", "plan_name": "400110_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Cigna Healthsprings Ffs", "plan_name": "500064", "standard_charge_dollar": 97.41, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Conseco", "plan_name": "500302", "standard_charge_dollar": 97.41, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Humana Ffs 61101", "plan_name": "500006", "standard_charge_dollar": 97.41, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Medicare A", "plan_name": "100100", "standard_charge_dollar": 97.41, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Medicare A", "plan_name": "100500", "standard_charge_dollar": 97.41, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Medicare Part B Only", "plan_name": "100300", "standard_charge_dollar": 97.41, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Medicare Railroad", "plan_name": "100103", "standard_charge_dollar": 97.41, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Ms Physicians Care N", "plan_name": "714210", "standard_charge_dollar": 121.77, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Peoples Hlth Ffs 72126", "plan_name": "500019", "standard_charge_dollar": 97.41, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Uhc/Secure Horizons", "plan_name": "500449", "standard_charge_dollar": 97.41, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "United Health Care/", "plan_name": "500292", "standard_charge_dollar": 110.08, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "United Healthcare", "plan_name": "750104", "standard_charge_dollar": 110.08, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "United Healthcare Ba", "plan_name": "750090", "standard_charge_dollar": 110.08, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "United Healthcare Me", "plan_name": "501310", "standard_charge_dollar": 97.41, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Windsor Mcare Extra", "plan_name": "500778", "standard_charge_dollar": 97.41, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." } ] } ] }, { "description": "Hc us ob follow up", "code_information": [ { "code": "76816", "type": "CPT" } ], "standard_charges": [ { "gross_charge": 236.72, "minimum": 97.41, "maximum": 138.11, "setting": "both", "payers_information": [ { "payer_name": "Aarp", "plan_name": "500102", "standard_charge_dollar": 97.41, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna", "plan_name": "700700", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna", "plan_name": "700700_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Mcare Ffs 6005", "plan_name": "700703", "standard_charge_dollar": 97.41, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Miscellaneous", "plan_name": "700720", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Miscellaneous", "plan_name": "700720_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Ppo Hmo", "plan_name": "701720", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Ppo Hmo", "plan_name": "701720_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Ambetter 68069", "plan_name": "500516", "standard_charge_dollar": 97.41, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Ms State Emplo", "plan_name": "401457", "standard_charge_dollar": 138.11, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Ms State Emplo", "plan_name": "401457_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Basic Pl", "plan_name": "400100", "standard_charge_dollar": 138.11, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Basic Pl", "plan_name": "400100_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Federal", "plan_name": "400110", "standard_charge_dollar": 138.11, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Federal", "plan_name": "400110_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Cigna Healthsprings Ffs", "plan_name": "500064", "standard_charge_dollar": 97.41, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Conseco", "plan_name": "500302", "standard_charge_dollar": 97.41, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Humana Ffs 61101", "plan_name": "500006", "standard_charge_dollar": 97.41, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Medicare A", "plan_name": "100100", "standard_charge_dollar": 97.41, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Medicare A", "plan_name": "100500", "standard_charge_dollar": 97.41, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Medicare Part B Only", "plan_name": "100300", "standard_charge_dollar": 97.41, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Medicare Railroad", "plan_name": "100103", "standard_charge_dollar": 97.41, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Ms Physicians Care N", "plan_name": "714210", "standard_charge_dollar": 121.77, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Peoples Hlth Ffs 72126", "plan_name": "500019", "standard_charge_dollar": 97.41, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Uhc/Secure Horizons", "plan_name": "500449", "standard_charge_dollar": 97.41, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "United Health Care/", "plan_name": "500292", "standard_charge_dollar": 110.08, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "United Healthcare", "plan_name": "750104", "standard_charge_dollar": 110.08, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "United Healthcare Ba", "plan_name": "750090", "standard_charge_dollar": 110.08, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "United Healthcare Me", "plan_name": "501310", "standard_charge_dollar": 97.41, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Windsor Mcare Extra", "plan_name": "500778", "standard_charge_dollar": 97.41, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." } ] } ] }, { "description": "Ob us follow-up per fetus", "code_information": [ { "code": "76816", "type": "CPT" } ], "standard_charges": [ { "gross_charge": 236.72, "minimum": 97.41, "maximum": 138.11, "setting": "both", "payers_information": [ { "payer_name": "Aarp", "plan_name": "500102", "standard_charge_dollar": 97.41, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna", "plan_name": "700700", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna", "plan_name": "700700_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Mcare Ffs 6005", "plan_name": "700703", "standard_charge_dollar": 97.41, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Miscellaneous", "plan_name": "700720", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Miscellaneous", "plan_name": "700720_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Ppo Hmo", "plan_name": "701720", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Ppo Hmo", "plan_name": "701720_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Ambetter 68069", "plan_name": "500516", "standard_charge_dollar": 97.41, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Ms State Emplo", "plan_name": "401457", "standard_charge_dollar": 138.11, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Ms State Emplo", "plan_name": "401457_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Basic Pl", "plan_name": "400100", "standard_charge_dollar": 138.11, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Basic Pl", "plan_name": "400100_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Federal", "plan_name": "400110", "standard_charge_dollar": 138.11, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Federal", "plan_name": "400110_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Cigna Healthsprings Ffs", "plan_name": "500064", "standard_charge_dollar": 97.41, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Conseco", "plan_name": "500302", "standard_charge_dollar": 97.41, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Humana Ffs 61101", "plan_name": "500006", "standard_charge_dollar": 97.41, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Medicare A", "plan_name": "100100", "standard_charge_dollar": 97.41, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Medicare A", "plan_name": "100500", "standard_charge_dollar": 97.41, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Medicare Part B Only", "plan_name": "100300", "standard_charge_dollar": 97.41, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Medicare Railroad", "plan_name": "100103", "standard_charge_dollar": 97.41, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Ms Physicians Care N", "plan_name": "714210", "standard_charge_dollar": 121.77, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Peoples Hlth Ffs 72126", "plan_name": "500019", "standard_charge_dollar": 97.41, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Uhc/Secure Horizons", "plan_name": "500449", "standard_charge_dollar": 97.41, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "United Health Care/", "plan_name": "500292", "standard_charge_dollar": 110.08, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "United Healthcare", "plan_name": "750104", "standard_charge_dollar": 110.08, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "United Healthcare Ba", "plan_name": "750090", "standard_charge_dollar": 110.08, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "United Healthcare Me", "plan_name": "501310", "standard_charge_dollar": 97.41, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Windsor Mcare Extra", "plan_name": "500778", "standard_charge_dollar": 97.41, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." } ] } ] }, { "description": "Hc us ob transvaginal", "code_information": [ { "code": "76817", "type": "CPT" } ], "standard_charges": [ { "gross_charge": 350.00, "minimum": 97.41, "maximum": 230.37, "setting": "both", "payers_information": [ { "payer_name": "Aarp", "plan_name": "500102", "standard_charge_dollar": 97.41, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna", "plan_name": "700700", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna", "plan_name": "700700_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Mcare Ffs 6005", "plan_name": "700703", "standard_charge_dollar": 97.41, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Miscellaneous", "plan_name": "700720", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Miscellaneous", "plan_name": "700720_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Ppo Hmo", "plan_name": "701720", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Ppo Hmo", "plan_name": "701720_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Ambetter 68069", "plan_name": "500516", "standard_charge_dollar": 97.41, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Ms State Emplo", "plan_name": "401457", "standard_charge_dollar": 230.37, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Ms State Emplo", "plan_name": "401457_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Basic Pl", "plan_name": "400100", "standard_charge_dollar": 230.37, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Basic Pl", "plan_name": "400100_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Federal", "plan_name": "400110", "standard_charge_dollar": 230.37, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Federal", "plan_name": "400110_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Cigna Healthsprings Ffs", "plan_name": "500064", "standard_charge_dollar": 97.41, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Conseco", "plan_name": "500302", "standard_charge_dollar": 97.41, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Humana Ffs 61101", "plan_name": "500006", "standard_charge_dollar": 97.41, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Medicare A", "plan_name": "100100", "standard_charge_dollar": 97.41, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Medicare A", "plan_name": "100500", "standard_charge_dollar": 97.41, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Medicare Part B Only", "plan_name": "100300", "standard_charge_dollar": 97.41, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Medicare Railroad", "plan_name": "100103", "standard_charge_dollar": 97.41, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Ms Physicians Care N", "plan_name": "714210", "standard_charge_dollar": 121.77, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Peoples Hlth Ffs 72126", "plan_name": "500019", "standard_charge_dollar": 97.41, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Uhc/Secure Horizons", "plan_name": "500449", "standard_charge_dollar": 97.41, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "United Health Care/", "plan_name": "500292", "standard_charge_dollar": 110.08, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "United Healthcare", "plan_name": "750104", "standard_charge_dollar": 110.08, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "United Healthcare Ba", "plan_name": "750090", "standard_charge_dollar": 110.08, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "United Healthcare Me", "plan_name": "501310", "standard_charge_dollar": 97.41, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Windsor Mcare Extra", "plan_name": "500778", "standard_charge_dollar": 97.41, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." } ] } ] }, { "description": "Transvaginal us obstetric", "code_information": [ { "code": "76817", "type": "CPT" } ], "standard_charges": [ { "gross_charge": 350.00, "minimum": 97.41, "maximum": 230.37, "setting": "both", "payers_information": [ { "payer_name": "Aarp", "plan_name": "500102", "standard_charge_dollar": 97.41, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna", "plan_name": "700700", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna", "plan_name": "700700_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Mcare Ffs 6005", "plan_name": "700703", "standard_charge_dollar": 97.41, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Miscellaneous", "plan_name": "700720", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Miscellaneous", "plan_name": "700720_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Ppo Hmo", "plan_name": "701720", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Ppo Hmo", "plan_name": "701720_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Ambetter 68069", "plan_name": "500516", "standard_charge_dollar": 97.41, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Ms State Emplo", "plan_name": "401457", "standard_charge_dollar": 230.37, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Ms State Emplo", "plan_name": "401457_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Basic Pl", "plan_name": "400100", "standard_charge_dollar": 230.37, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Basic Pl", "plan_name": "400100_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Federal", "plan_name": "400110", "standard_charge_dollar": 230.37, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Federal", "plan_name": "400110_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Cigna Healthsprings Ffs", "plan_name": "500064", "standard_charge_dollar": 97.41, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Conseco", "plan_name": "500302", "standard_charge_dollar": 97.41, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Humana Ffs 61101", "plan_name": "500006", "standard_charge_dollar": 97.41, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Medicare A", "plan_name": "100100", "standard_charge_dollar": 97.41, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Medicare A", "plan_name": "100500", "standard_charge_dollar": 97.41, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Medicare Part B Only", "plan_name": "100300", "standard_charge_dollar": 97.41, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Medicare Railroad", "plan_name": "100103", "standard_charge_dollar": 97.41, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Ms Physicians Care N", "plan_name": "714210", "standard_charge_dollar": 121.77, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Peoples Hlth Ffs 72126", "plan_name": "500019", "standard_charge_dollar": 97.41, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Uhc/Secure Horizons", "plan_name": "500449", "standard_charge_dollar": 97.41, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "United Health Care/", "plan_name": "500292", "standard_charge_dollar": 110.08, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "United Healthcare", "plan_name": "750104", "standard_charge_dollar": 110.08, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "United Healthcare Ba", "plan_name": "750090", "standard_charge_dollar": 110.08, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "United Healthcare Me", "plan_name": "501310", "standard_charge_dollar": 97.41, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Windsor Mcare Extra", "plan_name": "500778", "standard_charge_dollar": 97.41, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." } ] } ] }, { "description": "Hc us transvaginal", "code_information": [ { "code": "76830", "type": "CPT" } ], "standard_charges": [ { "gross_charge": 372.50, "minimum": 97.41, "maximum": 316.63, "setting": "both", "payers_information": [ { "payer_name": "Aarp", "plan_name": "500102", "standard_charge_dollar": 97.41, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna", "plan_name": "700700", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna", "plan_name": "700700_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Mcare Ffs 6005", "plan_name": "700703", "standard_charge_dollar": 97.41, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Miscellaneous", "plan_name": "700720", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Miscellaneous", "plan_name": "700720_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Ppo Hmo", "plan_name": "701720", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Ppo Hmo", "plan_name": "701720_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Ambetter 68069", "plan_name": "500516", "standard_charge_dollar": 97.41, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Ms State Emplo", "plan_name": "401457", "standard_charge_percentage": 0.80, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Ms State Emplo", "plan_name": "401457_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Basic Pl", "plan_name": "400100", "standard_charge_percentage": 0.85, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Basic Pl", "plan_name": "400100_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Federal", "plan_name": "400110", "standard_charge_percentage": 0.85, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Federal", "plan_name": "400110_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Cigna Healthsprings Ffs", "plan_name": "500064", "standard_charge_dollar": 97.41, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Conseco", "plan_name": "500302", "standard_charge_dollar": 97.41, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Humana Ffs 61101", "plan_name": "500006", "standard_charge_dollar": 97.41, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Medicare A", "plan_name": "100100", "standard_charge_dollar": 97.41, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Medicare A", "plan_name": "100500", "standard_charge_dollar": 97.41, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Medicare Part B Only", "plan_name": "100300", "standard_charge_dollar": 97.41, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Medicare Railroad", "plan_name": "100103", "standard_charge_dollar": 97.41, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Ms Physicians Care N", "plan_name": "714210", "standard_charge_dollar": 121.77, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Peoples Hlth Ffs 72126", "plan_name": "500019", "standard_charge_dollar": 97.41, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Uhc/Secure Horizons", "plan_name": "500449", "standard_charge_dollar": 97.41, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "United Health Care/", "plan_name": "500292", "standard_charge_dollar": 110.08, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "United Healthcare", "plan_name": "750104", "standard_charge_dollar": 110.08, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "United Healthcare Ba", "plan_name": "750090", "standard_charge_dollar": 110.08, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "United Healthcare Me", "plan_name": "501310", "standard_charge_dollar": 97.41, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Windsor Mcare Extra", "plan_name": "500778", "standard_charge_dollar": 97.41, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." } ] } ] }, { "description": "Transvaginal us non-ob", "code_information": [ { "code": "76830", "type": "CPT" } ], "standard_charges": [ { "gross_charge": 372.50, "minimum": 97.41, "maximum": 316.63, "setting": "both", "payers_information": [ { "payer_name": "Aarp", "plan_name": "500102", "standard_charge_dollar": 97.41, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna", "plan_name": "700700", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna", "plan_name": "700700_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Mcare Ffs 6005", "plan_name": "700703", "standard_charge_dollar": 97.41, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Miscellaneous", "plan_name": "700720", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Miscellaneous", "plan_name": "700720_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Ppo Hmo", "plan_name": "701720", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Ppo Hmo", "plan_name": "701720_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Ambetter 68069", "plan_name": "500516", "standard_charge_dollar": 97.41, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Ms State Emplo", "plan_name": "401457", "standard_charge_percentage": 0.80, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Ms State Emplo", "plan_name": "401457_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Basic Pl", "plan_name": "400100", "standard_charge_percentage": 0.85, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Basic Pl", "plan_name": "400100_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Federal", "plan_name": "400110", "standard_charge_percentage": 0.85, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Federal", "plan_name": "400110_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Cigna Healthsprings Ffs", "plan_name": "500064", "standard_charge_dollar": 97.41, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Conseco", "plan_name": "500302", "standard_charge_dollar": 97.41, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Humana Ffs 61101", "plan_name": "500006", "standard_charge_dollar": 97.41, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Medicare A", "plan_name": "100100", "standard_charge_dollar": 97.41, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Medicare A", "plan_name": "100500", "standard_charge_dollar": 97.41, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Medicare Part B Only", "plan_name": "100300", "standard_charge_dollar": 97.41, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Medicare Railroad", "plan_name": "100103", "standard_charge_dollar": 97.41, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Ms Physicians Care N", "plan_name": "714210", "standard_charge_dollar": 121.77, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Peoples Hlth Ffs 72126", "plan_name": "500019", "standard_charge_dollar": 97.41, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Uhc/Secure Horizons", "plan_name": "500449", "standard_charge_dollar": 97.41, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "United Health Care/", "plan_name": "500292", "standard_charge_dollar": 110.08, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "United Healthcare", "plan_name": "750104", "standard_charge_dollar": 110.08, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "United Healthcare Ba", "plan_name": "750090", "standard_charge_dollar": 110.08, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "United Healthcare Me", "plan_name": "501310", "standard_charge_dollar": 97.41, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Windsor Mcare Extra", "plan_name": "500778", "standard_charge_dollar": 97.41, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." } ] } ] }, { "description": "Hc us pelvic complete", "code_information": [ { "code": "76856", "type": "CPT" } ], "standard_charges": [ { "gross_charge": 372.50, "minimum": 230.37, "maximum": 350.97, "setting": "both", "payers_information": [ { "payer_name": "Aarp", "plan_name": "500102", "standard_charge_dollar": 280.78, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna", "plan_name": "700700", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna", "plan_name": "700700_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Mcare Ffs 6005", "plan_name": "700703", "standard_charge_dollar": 280.78, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Miscellaneous", "plan_name": "700720", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Miscellaneous", "plan_name": "700720_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Ppo Hmo", "plan_name": "701720", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Ppo Hmo", "plan_name": "701720_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Ambetter 68069", "plan_name": "500516", "standard_charge_dollar": 280.78, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Ms State Emplo", "plan_name": "401457", "standard_charge_dollar": 230.37, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Ms State Emplo", "plan_name": "401457_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Basic Pl", "plan_name": "400100", "standard_charge_dollar": 230.37, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Basic Pl", "plan_name": "400100_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Federal", "plan_name": "400110", "standard_charge_dollar": 230.37, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Federal", "plan_name": "400110_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Cigna Healthsprings Ffs", "plan_name": "500064", "standard_charge_dollar": 280.78, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Conseco", "plan_name": "500302", "standard_charge_dollar": 280.78, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Humana Ffs 61101", "plan_name": "500006", "standard_charge_dollar": 280.78, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Medicare A", "plan_name": "100100", "standard_charge_dollar": 280.78, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Medicare A", "plan_name": "100500", "standard_charge_dollar": 280.78, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Medicare Part B Only", "plan_name": "100300", "standard_charge_dollar": 280.78, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Medicare Railroad", "plan_name": "100103", "standard_charge_dollar": 280.78, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Ms Physicians Care N", "plan_name": "714210", "standard_charge_dollar": 350.97, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Peoples Hlth Ffs 72126", "plan_name": "500019", "standard_charge_dollar": 280.78, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Uhc/Secure Horizons", "plan_name": "500449", "standard_charge_dollar": 280.78, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "United Health Care/", "plan_name": "500292", "standard_charge_dollar": 317.28, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "United Healthcare", "plan_name": "750104", "standard_charge_dollar": 317.28, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "United Healthcare Ba", "plan_name": "750090", "standard_charge_dollar": 317.28, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "United Healthcare Me", "plan_name": "501310", "standard_charge_dollar": 280.78, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Windsor Mcare Extra", "plan_name": "500778", "standard_charge_dollar": 280.78, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." } ] } ] }, { "description": "Us exam pelvic complete", "code_information": [ { "code": "76856", "type": "CPT" } ], "standard_charges": [ { "gross_charge": 372.50, "minimum": 230.37, "maximum": 350.97, "setting": "both", "payers_information": [ { "payer_name": "Aarp", "plan_name": "500102", "standard_charge_dollar": 280.78, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna", "plan_name": "700700", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna", "plan_name": "700700_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Mcare Ffs 6005", "plan_name": "700703", "standard_charge_dollar": 280.78, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Miscellaneous", "plan_name": "700720", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Miscellaneous", "plan_name": "700720_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Ppo Hmo", "plan_name": "701720", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Ppo Hmo", "plan_name": "701720_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Ambetter 68069", "plan_name": "500516", "standard_charge_dollar": 280.78, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Ms State Emplo", "plan_name": "401457", "standard_charge_dollar": 230.37, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Ms State Emplo", "plan_name": "401457_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Basic Pl", "plan_name": "400100", "standard_charge_dollar": 230.37, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Basic Pl", "plan_name": "400100_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Federal", "plan_name": "400110", "standard_charge_dollar": 230.37, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Federal", "plan_name": "400110_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Cigna Healthsprings Ffs", "plan_name": "500064", "standard_charge_dollar": 280.78, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Conseco", "plan_name": "500302", "standard_charge_dollar": 280.78, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Humana Ffs 61101", "plan_name": "500006", "standard_charge_dollar": 280.78, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Medicare A", "plan_name": "100100", "standard_charge_dollar": 280.78, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Medicare A", "plan_name": "100500", "standard_charge_dollar": 280.78, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Medicare Part B Only", "plan_name": "100300", "standard_charge_dollar": 280.78, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Medicare Railroad", "plan_name": "100103", "standard_charge_dollar": 280.78, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Ms Physicians Care N", "plan_name": "714210", "standard_charge_dollar": 350.97, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Peoples Hlth Ffs 72126", "plan_name": "500019", "standard_charge_dollar": 280.78, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Uhc/Secure Horizons", "plan_name": "500449", "standard_charge_dollar": 280.78, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "United Health Care/", "plan_name": "500292", "standard_charge_dollar": 317.28, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "United Healthcare", "plan_name": "750104", "standard_charge_dollar": 317.28, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "United Healthcare Ba", "plan_name": "750090", "standard_charge_dollar": 317.28, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "United Healthcare Me", "plan_name": "501310", "standard_charge_dollar": 280.78, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Windsor Mcare Extra", "plan_name": "500778", "standard_charge_dollar": 280.78, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." } ] } ] }, { "description": "Hc us pelvic limited", "code_information": [ { "code": "76857", "type": "CPT" } ], "standard_charges": [ { "gross_charge": 245.00, "minimum": 138.11, "maximum": 350.97, "setting": "both", "payers_information": [ { "payer_name": "Aarp", "plan_name": "500102", "standard_charge_dollar": 280.78, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna", "plan_name": "700700", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna", "plan_name": "700700_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Mcare Ffs 6005", "plan_name": "700703", "standard_charge_dollar": 280.78, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Miscellaneous", "plan_name": "700720", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Miscellaneous", "plan_name": "700720_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Ppo Hmo", "plan_name": "701720", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Ppo Hmo", "plan_name": "701720_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Ambetter 68069", "plan_name": "500516", "standard_charge_dollar": 280.78, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Ms State Emplo", "plan_name": "401457", "standard_charge_dollar": 138.11, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Ms State Emplo", "plan_name": "401457_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Basic Pl", "plan_name": "400100", "standard_charge_dollar": 138.11, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Basic Pl", "plan_name": "400100_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Federal", "plan_name": "400110", "standard_charge_dollar": 138.11, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Federal", "plan_name": "400110_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Cigna Healthsprings Ffs", "plan_name": "500064", "standard_charge_dollar": 280.78, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Conseco", "plan_name": "500302", "standard_charge_dollar": 280.78, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Humana Ffs 61101", "plan_name": "500006", "standard_charge_dollar": 280.78, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Medicare A", "plan_name": "100100", "standard_charge_dollar": 280.78, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Medicare A", "plan_name": "100500", "standard_charge_dollar": 280.78, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Medicare Part B Only", "plan_name": "100300", "standard_charge_dollar": 280.78, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Medicare Railroad", "plan_name": "100103", "standard_charge_dollar": 280.78, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Ms Physicians Care N", "plan_name": "714210", "standard_charge_dollar": 350.97, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Peoples Hlth Ffs 72126", "plan_name": "500019", "standard_charge_dollar": 280.78, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Uhc/Secure Horizons", "plan_name": "500449", "standard_charge_dollar": 280.78, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "United Health Care/", "plan_name": "500292", "standard_charge_dollar": 317.28, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "United Healthcare", "plan_name": "750104", "standard_charge_dollar": 317.28, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "United Healthcare Ba", "plan_name": "750090", "standard_charge_dollar": 317.28, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "United Healthcare Me", "plan_name": "501310", "standard_charge_dollar": 280.78, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Windsor Mcare Extra", "plan_name": "500778", "standard_charge_dollar": 280.78, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." } ] } ] }, { "description": "Us exam pelvic limited", "code_information": [ { "code": "76857", "type": "CPT" } ], "standard_charges": [ { "gross_charge": 245.00, "minimum": 138.11, "maximum": 350.97, "setting": "both", "payers_information": [ { "payer_name": "Aarp", "plan_name": "500102", "standard_charge_dollar": 280.78, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna", "plan_name": "700700", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna", "plan_name": "700700_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Mcare Ffs 6005", "plan_name": "700703", "standard_charge_dollar": 280.78, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Miscellaneous", "plan_name": "700720", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Miscellaneous", "plan_name": "700720_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Ppo Hmo", "plan_name": "701720", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Ppo Hmo", "plan_name": "701720_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Ambetter 68069", "plan_name": "500516", "standard_charge_dollar": 280.78, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Ms State Emplo", "plan_name": "401457", "standard_charge_dollar": 138.11, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Ms State Emplo", "plan_name": "401457_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Basic Pl", "plan_name": "400100", "standard_charge_dollar": 138.11, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Basic Pl", "plan_name": "400100_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Federal", "plan_name": "400110", "standard_charge_dollar": 138.11, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Federal", "plan_name": "400110_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Cigna Healthsprings Ffs", "plan_name": "500064", "standard_charge_dollar": 280.78, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Conseco", "plan_name": "500302", "standard_charge_dollar": 280.78, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Humana Ffs 61101", "plan_name": "500006", "standard_charge_dollar": 280.78, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Medicare A", "plan_name": "100100", "standard_charge_dollar": 280.78, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Medicare A", "plan_name": "100500", "standard_charge_dollar": 280.78, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Medicare Part B Only", "plan_name": "100300", "standard_charge_dollar": 280.78, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Medicare Railroad", "plan_name": "100103", "standard_charge_dollar": 280.78, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Ms Physicians Care N", "plan_name": "714210", "standard_charge_dollar": 350.97, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Peoples Hlth Ffs 72126", "plan_name": "500019", "standard_charge_dollar": 280.78, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Uhc/Secure Horizons", "plan_name": "500449", "standard_charge_dollar": 280.78, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "United Health Care/", "plan_name": "500292", "standard_charge_dollar": 317.28, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "United Healthcare", "plan_name": "750104", "standard_charge_dollar": 317.28, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "United Healthcare Ba", "plan_name": "750090", "standard_charge_dollar": 317.28, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "United Healthcare Me", "plan_name": "501310", "standard_charge_dollar": 280.78, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Windsor Mcare Extra", "plan_name": "500778", "standard_charge_dollar": 280.78, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." } ] } ] }, { "description": "Hc us scrotum", "code_information": [ { "code": "76870", "type": "CPT" } ], "standard_charges": [ { "gross_charge": 255.00, "minimum": 97.41, "maximum": 230.37, "setting": "both", "payers_information": [ { "payer_name": "Aarp", "plan_name": "500102", "standard_charge_dollar": 97.41, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna", "plan_name": "700700", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna", "plan_name": "700700_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Mcare Ffs 6005", "plan_name": "700703", "standard_charge_dollar": 97.41, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Miscellaneous", "plan_name": "700720", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Miscellaneous", "plan_name": "700720_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Ppo Hmo", "plan_name": "701720", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Ppo Hmo", "plan_name": "701720_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Ambetter 68069", "plan_name": "500516", "standard_charge_dollar": 97.41, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Ms State Emplo", "plan_name": "401457", "standard_charge_dollar": 230.37, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Ms State Emplo", "plan_name": "401457_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Basic Pl", "plan_name": "400100", "standard_charge_dollar": 230.37, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Basic Pl", "plan_name": "400100_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Federal", "plan_name": "400110", "standard_charge_dollar": 230.37, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Federal", "plan_name": "400110_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Cigna Healthsprings Ffs", "plan_name": "500064", "standard_charge_dollar": 97.41, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Conseco", "plan_name": "500302", "standard_charge_dollar": 97.41, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Humana Ffs 61101", "plan_name": "500006", "standard_charge_dollar": 97.41, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Medicare A", "plan_name": "100100", "standard_charge_dollar": 97.41, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Medicare A", "plan_name": "100500", "standard_charge_dollar": 97.41, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Medicare Part B Only", "plan_name": "100300", "standard_charge_dollar": 97.41, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Medicare Railroad", "plan_name": "100103", "standard_charge_dollar": 97.41, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Ms Physicians Care N", "plan_name": "714210", "standard_charge_dollar": 121.77, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Peoples Hlth Ffs 72126", "plan_name": "500019", "standard_charge_dollar": 97.41, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Uhc/Secure Horizons", "plan_name": "500449", "standard_charge_dollar": 97.41, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "United Health Care/", "plan_name": "500292", "standard_charge_dollar": 110.08, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "United Healthcare", "plan_name": "750104", "standard_charge_dollar": 110.08, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "United Healthcare Ba", "plan_name": "750090", "standard_charge_dollar": 110.08, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "United Healthcare Me", "plan_name": "501310", "standard_charge_dollar": 97.41, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Windsor Mcare Extra", "plan_name": "500778", "standard_charge_dollar": 97.41, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." } ] } ] }, { "description": "Us exam scrotum", "code_information": [ { "code": "76870", "type": "CPT" } ], "standard_charges": [ { "gross_charge": 255.00, "minimum": 97.41, "maximum": 230.37, "setting": "both", "payers_information": [ { "payer_name": "Aarp", "plan_name": "500102", "standard_charge_dollar": 97.41, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna", "plan_name": "700700", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna", "plan_name": "700700_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Mcare Ffs 6005", "plan_name": "700703", "standard_charge_dollar": 97.41, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Miscellaneous", "plan_name": "700720", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Miscellaneous", "plan_name": "700720_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Ppo Hmo", "plan_name": "701720", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Ppo Hmo", "plan_name": "701720_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Ambetter 68069", "plan_name": "500516", "standard_charge_dollar": 97.41, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Ms State Emplo", "plan_name": "401457", "standard_charge_dollar": 230.37, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Ms State Emplo", "plan_name": "401457_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Basic Pl", "plan_name": "400100", "standard_charge_dollar": 230.37, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Basic Pl", "plan_name": "400100_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Federal", "plan_name": "400110", "standard_charge_dollar": 230.37, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Federal", "plan_name": "400110_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Cigna Healthsprings Ffs", "plan_name": "500064", "standard_charge_dollar": 97.41, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Conseco", "plan_name": "500302", "standard_charge_dollar": 97.41, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Humana Ffs 61101", "plan_name": "500006", "standard_charge_dollar": 97.41, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Medicare A", "plan_name": "100100", "standard_charge_dollar": 97.41, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Medicare A", "plan_name": "100500", "standard_charge_dollar": 97.41, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Medicare Part B Only", "plan_name": "100300", "standard_charge_dollar": 97.41, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Medicare Railroad", "plan_name": "100103", "standard_charge_dollar": 97.41, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Ms Physicians Care N", "plan_name": "714210", "standard_charge_dollar": 121.77, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Peoples Hlth Ffs 72126", "plan_name": "500019", "standard_charge_dollar": 97.41, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Uhc/Secure Horizons", "plan_name": "500449", "standard_charge_dollar": 97.41, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "United Health Care/", "plan_name": "500292", "standard_charge_dollar": 110.08, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "United Healthcare", "plan_name": "750104", "standard_charge_dollar": 110.08, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "United Healthcare Ba", "plan_name": "750090", "standard_charge_dollar": 110.08, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "United Healthcare Me", "plan_name": "501310", "standard_charge_dollar": 97.41, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Windsor Mcare Extra", "plan_name": "500778", "standard_charge_dollar": 97.41, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." } ] } ] }, { "description": "Hc us extremity nonvas complete", "code_information": [ { "code": "76881", "type": "CPT" } ], "standard_charges": [ { "gross_charge": 279.47, "minimum": 97.41, "maximum": 237.55, "setting": "both", "payers_information": [ { "payer_name": "Aarp", "plan_name": "500102", "standard_charge_dollar": 97.41, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna", "plan_name": "700700", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna", "plan_name": "700700_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Mcare Ffs 6005", "plan_name": "700703", "standard_charge_dollar": 97.41, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Miscellaneous", "plan_name": "700720", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Miscellaneous", "plan_name": "700720_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Ppo Hmo", "plan_name": "701720", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Ppo Hmo", "plan_name": "701720_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Ambetter 68069", "plan_name": "500516", "standard_charge_dollar": 97.41, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Ms State Emplo", "plan_name": "401457", "standard_charge_percentage": 0.80, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Ms State Emplo", "plan_name": "401457_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Basic Pl", "plan_name": "400100", "standard_charge_percentage": 0.85, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Basic Pl", "plan_name": "400100_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Federal", "plan_name": "400110", "standard_charge_percentage": 0.85, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Federal", "plan_name": "400110_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Cigna Healthsprings Ffs", "plan_name": "500064", "standard_charge_dollar": 97.41, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Conseco", "plan_name": "500302", "standard_charge_dollar": 97.41, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Humana Ffs 61101", "plan_name": "500006", "standard_charge_dollar": 97.41, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Medicare A", "plan_name": "100100", "standard_charge_dollar": 97.41, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Medicare A", "plan_name": "100500", "standard_charge_dollar": 97.41, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Medicare Part B Only", "plan_name": "100300", "standard_charge_dollar": 97.41, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Medicare Railroad", "plan_name": "100103", "standard_charge_dollar": 97.41, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Ms Physicians Care N", "plan_name": "714210", "standard_charge_dollar": 121.77, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Peoples Hlth Ffs 72126", "plan_name": "500019", "standard_charge_dollar": 97.41, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Uhc/Secure Horizons", "plan_name": "500449", "standard_charge_dollar": 97.41, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "United Health Care/", "plan_name": "500292", "standard_charge_dollar": 110.08, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "United Healthcare", "plan_name": "750104", "standard_charge_dollar": 110.08, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "United Healthcare Ba", "plan_name": "750090", "standard_charge_dollar": 110.08, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "United Healthcare Me", "plan_name": "501310", "standard_charge_dollar": 97.41, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Windsor Mcare Extra", "plan_name": "500778", "standard_charge_dollar": 97.41, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." } ] } ] }, { "description": "Us compl joint r-t w/img", "code_information": [ { "code": "76881", "type": "CPT" } ], "standard_charges": [ { "gross_charge": 279.47, "minimum": 97.41, "maximum": 237.55, "setting": "both", "payers_information": [ { "payer_name": "Aarp", "plan_name": "500102", "standard_charge_dollar": 97.41, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna", "plan_name": "700700", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna", "plan_name": "700700_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Mcare Ffs 6005", "plan_name": "700703", "standard_charge_dollar": 97.41, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Miscellaneous", "plan_name": "700720", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Miscellaneous", "plan_name": "700720_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Ppo Hmo", "plan_name": "701720", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Ppo Hmo", "plan_name": "701720_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Ambetter 68069", "plan_name": "500516", "standard_charge_dollar": 97.41, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Ms State Emplo", "plan_name": "401457", "standard_charge_percentage": 0.80, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Ms State Emplo", "plan_name": "401457_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Basic Pl", "plan_name": "400100", "standard_charge_percentage": 0.85, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Basic Pl", "plan_name": "400100_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Federal", "plan_name": "400110", "standard_charge_percentage": 0.85, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Federal", "plan_name": "400110_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Cigna Healthsprings Ffs", "plan_name": "500064", "standard_charge_dollar": 97.41, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Conseco", "plan_name": "500302", "standard_charge_dollar": 97.41, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Humana Ffs 61101", "plan_name": "500006", "standard_charge_dollar": 97.41, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Medicare A", "plan_name": "100100", "standard_charge_dollar": 97.41, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Medicare A", "plan_name": "100500", "standard_charge_dollar": 97.41, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Medicare Part B Only", "plan_name": "100300", "standard_charge_dollar": 97.41, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Medicare Railroad", "plan_name": "100103", "standard_charge_dollar": 97.41, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Ms Physicians Care N", "plan_name": "714210", "standard_charge_dollar": 121.77, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Peoples Hlth Ffs 72126", "plan_name": "500019", "standard_charge_dollar": 97.41, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Uhc/Secure Horizons", "plan_name": "500449", "standard_charge_dollar": 97.41, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "United Health Care/", "plan_name": "500292", "standard_charge_dollar": 110.08, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "United Healthcare", "plan_name": "750104", "standard_charge_dollar": 110.08, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "United Healthcare Ba", "plan_name": "750090", "standard_charge_dollar": 110.08, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "United Healthcare Me", "plan_name": "501310", "standard_charge_dollar": 97.41, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Windsor Mcare Extra", "plan_name": "500778", "standard_charge_dollar": 97.41, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." } ] } ] }, { "description": "Hc us extremity nonvas limited", "code_information": [ { "code": "76882", "type": "CPT" } ], "standard_charges": [ { "gross_charge": 250.00, "minimum": 97.41, "maximum": 138.11, "setting": "both", "payers_information": [ { "payer_name": "Aarp", "plan_name": "500102", "standard_charge_dollar": 97.41, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna", "plan_name": "700700", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna", "plan_name": "700700_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Mcare Ffs 6005", "plan_name": "700703", "standard_charge_dollar": 97.41, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Miscellaneous", "plan_name": "700720", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Miscellaneous", "plan_name": "700720_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Ppo Hmo", "plan_name": "701720", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Ppo Hmo", "plan_name": "701720_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Ambetter 68069", "plan_name": "500516", "standard_charge_dollar": 97.41, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Ms State Emplo", "plan_name": "401457", "standard_charge_dollar": 138.11, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Ms State Emplo", "plan_name": "401457_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Basic Pl", "plan_name": "400100", "standard_charge_dollar": 138.11, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Basic Pl", "plan_name": "400100_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Federal", "plan_name": "400110", "standard_charge_dollar": 138.11, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Federal", "plan_name": "400110_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Cigna Healthsprings Ffs", "plan_name": "500064", "standard_charge_dollar": 97.41, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Conseco", "plan_name": "500302", "standard_charge_dollar": 97.41, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Humana Ffs 61101", "plan_name": "500006", "standard_charge_dollar": 97.41, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Medicare A", "plan_name": "100100", "standard_charge_dollar": 97.41, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Medicare A", "plan_name": "100500", "standard_charge_dollar": 97.41, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Medicare Part B Only", "plan_name": "100300", "standard_charge_dollar": 97.41, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Medicare Railroad", "plan_name": "100103", "standard_charge_dollar": 97.41, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Ms Physicians Care N", "plan_name": "714210", "standard_charge_dollar": 121.77, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Peoples Hlth Ffs 72126", "plan_name": "500019", "standard_charge_dollar": 97.41, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Uhc/Secure Horizons", "plan_name": "500449", "standard_charge_dollar": 97.41, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "United Health Care/", "plan_name": "500292", "standard_charge_dollar": 110.08, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "United Healthcare", "plan_name": "750104", "standard_charge_dollar": 110.08, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "United Healthcare Ba", "plan_name": "750090", "standard_charge_dollar": 110.08, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "United Healthcare Me", "plan_name": "501310", "standard_charge_dollar": 97.41, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Windsor Mcare Extra", "plan_name": "500778", "standard_charge_dollar": 97.41, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." } ] } ] }, { "description": "Us lmtd jt/nonvasc xtr strux", "code_information": [ { "code": "76882", "type": "CPT" } ], "standard_charges": [ { "gross_charge": 250.00, "minimum": 97.41, "maximum": 138.11, "setting": "both", "payers_information": [ { "payer_name": "Aarp", "plan_name": "500102", "standard_charge_dollar": 97.41, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna", "plan_name": "700700", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna", "plan_name": "700700_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Mcare Ffs 6005", "plan_name": "700703", "standard_charge_dollar": 97.41, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Miscellaneous", "plan_name": "700720", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Miscellaneous", "plan_name": "700720_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Ppo Hmo", "plan_name": "701720", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Ppo Hmo", "plan_name": "701720_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Ambetter 68069", "plan_name": "500516", "standard_charge_dollar": 97.41, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Ms State Emplo", "plan_name": "401457", "standard_charge_dollar": 138.11, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Ms State Emplo", "plan_name": "401457_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Basic Pl", "plan_name": "400100", "standard_charge_dollar": 138.11, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Basic Pl", "plan_name": "400100_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Federal", "plan_name": "400110", "standard_charge_dollar": 138.11, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Federal", "plan_name": "400110_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Cigna Healthsprings Ffs", "plan_name": "500064", "standard_charge_dollar": 97.41, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Conseco", "plan_name": "500302", "standard_charge_dollar": 97.41, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Humana Ffs 61101", "plan_name": "500006", "standard_charge_dollar": 97.41, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Medicare A", "plan_name": "100100", "standard_charge_dollar": 97.41, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Medicare A", "plan_name": "100500", "standard_charge_dollar": 97.41, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Medicare Part B Only", "plan_name": "100300", "standard_charge_dollar": 97.41, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Medicare Railroad", "plan_name": "100103", "standard_charge_dollar": 97.41, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Ms Physicians Care N", "plan_name": "714210", "standard_charge_dollar": 121.77, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Peoples Hlth Ffs 72126", "plan_name": "500019", "standard_charge_dollar": 97.41, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Uhc/Secure Horizons", "plan_name": "500449", "standard_charge_dollar": 97.41, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "United Health Care/", "plan_name": "500292", "standard_charge_dollar": 110.08, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "United Healthcare", "plan_name": "750104", "standard_charge_dollar": 110.08, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "United Healthcare Ba", "plan_name": "750090", "standard_charge_dollar": 110.08, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "United Healthcare Me", "plan_name": "501310", "standard_charge_dollar": 97.41, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Windsor Mcare Extra", "plan_name": "500778", "standard_charge_dollar": 97.41, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." } ] } ] }, { "description": "Hc ultrasound elastogram of organ tissue", "code_information": [ { "code": "76981", "type": "CPT" } ], "standard_charges": [ { "gross_charge": 178.00, "minimum": 142.40, "maximum": 350.97, "setting": "both", "payers_information": [ { "payer_name": "Aarp", "plan_name": "500102", "standard_charge_dollar": 280.78, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna", "plan_name": "700700", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna", "plan_name": "700700_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Mcare Ffs 6005", "plan_name": "700703", "standard_charge_dollar": 280.78, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Miscellaneous", "plan_name": "700720", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Miscellaneous", "plan_name": "700720_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Ppo Hmo", "plan_name": "701720", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Ppo Hmo", "plan_name": "701720_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Ambetter 68069", "plan_name": "500516", "standard_charge_dollar": 280.78, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Ms State Emplo", "plan_name": "401457", "standard_charge_percentage": 0.80, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Ms State Emplo", "plan_name": "401457_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Basic Pl", "plan_name": "400100", "standard_charge_percentage": 0.85, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Basic Pl", "plan_name": "400100_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Federal", "plan_name": "400110", "standard_charge_percentage": 0.85, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Federal", "plan_name": "400110_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Cigna Healthsprings Ffs", "plan_name": "500064", "standard_charge_dollar": 280.78, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Conseco", "plan_name": "500302", "standard_charge_dollar": 280.78, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Humana Ffs 61101", "plan_name": "500006", "standard_charge_dollar": 280.78, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Medicare A", "plan_name": "100100", "standard_charge_dollar": 280.78, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Medicare A", "plan_name": "100500", "standard_charge_dollar": 280.78, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Medicare Part B Only", "plan_name": "100300", "standard_charge_dollar": 280.78, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Medicare Railroad", "plan_name": "100103", "standard_charge_dollar": 280.78, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Ms Physicians Care N", "plan_name": "714210", "standard_charge_dollar": 350.97, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Peoples Hlth Ffs 72126", "plan_name": "500019", "standard_charge_dollar": 280.78, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Uhc/Secure Horizons", "plan_name": "500449", "standard_charge_dollar": 280.78, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "United Health Care/", "plan_name": "500292", "standard_charge_dollar": 317.28, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "United Healthcare", "plan_name": "750104", "standard_charge_dollar": 317.28, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "United Healthcare Ba", "plan_name": "750090", "standard_charge_dollar": 317.28, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "United Healthcare Me", "plan_name": "501310", "standard_charge_dollar": 280.78, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Windsor Mcare Extra", "plan_name": "500778", "standard_charge_dollar": 280.78, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." } ] } ] }, { "description": "Use parenchyma", "code_information": [ { "code": "76981", "type": "CPT" } ], "standard_charges": [ { "gross_charge": 178.00, "minimum": 142.40, "maximum": 350.97, "setting": "both", "payers_information": [ { "payer_name": "Aarp", "plan_name": "500102", "standard_charge_dollar": 280.78, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna", "plan_name": "700700", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna", "plan_name": "700700_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Mcare Ffs 6005", "plan_name": "700703", "standard_charge_dollar": 280.78, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Miscellaneous", "plan_name": "700720", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Miscellaneous", "plan_name": "700720_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Ppo Hmo", "plan_name": "701720", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Ppo Hmo", "plan_name": "701720_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Ambetter 68069", "plan_name": "500516", "standard_charge_dollar": 280.78, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Ms State Emplo", "plan_name": "401457", "standard_charge_percentage": 0.80, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Ms State Emplo", "plan_name": "401457_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Basic Pl", "plan_name": "400100", "standard_charge_percentage": 0.85, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Basic Pl", "plan_name": "400100_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Federal", "plan_name": "400110", "standard_charge_percentage": 0.85, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Federal", "plan_name": "400110_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Cigna Healthsprings Ffs", "plan_name": "500064", "standard_charge_dollar": 280.78, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Conseco", "plan_name": "500302", "standard_charge_dollar": 280.78, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Humana Ffs 61101", "plan_name": "500006", "standard_charge_dollar": 280.78, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Medicare A", "plan_name": "100100", "standard_charge_dollar": 280.78, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Medicare A", "plan_name": "100500", "standard_charge_dollar": 280.78, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Medicare Part B Only", "plan_name": "100300", "standard_charge_dollar": 280.78, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Medicare Railroad", "plan_name": "100103", "standard_charge_dollar": 280.78, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Ms Physicians Care N", "plan_name": "714210", "standard_charge_dollar": 350.97, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Peoples Hlth Ffs 72126", "plan_name": "500019", "standard_charge_dollar": 280.78, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Uhc/Secure Horizons", "plan_name": "500449", "standard_charge_dollar": 280.78, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "United Health Care/", "plan_name": "500292", "standard_charge_dollar": 317.28, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "United Healthcare", "plan_name": "750104", "standard_charge_dollar": 317.28, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "United Healthcare Ba", "plan_name": "750090", "standard_charge_dollar": 317.28, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "United Healthcare Me", "plan_name": "501310", "standard_charge_dollar": 280.78, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Windsor Mcare Extra", "plan_name": "500778", "standard_charge_dollar": 280.78, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." } ] } ] }, { "description": "Hc screen mammo incl cad", "code_information": [ { "code": "77067", "type": "CPT" } ], "standard_charges": [ { "gross_charge": 373.00, "minimum": 100.04, "maximum": 137.01, "setting": "both", "payers_information": [ { "payer_name": "Aarp", "plan_name": "500102", "standard_charge_dollar": 109.61, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna", "plan_name": "700700", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna", "plan_name": "700700_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Mcare Ffs 6005", "plan_name": "700703", "standard_charge_dollar": 109.61, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Miscellaneous", "plan_name": "700720", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Miscellaneous", "plan_name": "700720_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Ppo Hmo", "plan_name": "701720", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Ppo Hmo", "plan_name": "701720_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Ambetter 68069", "plan_name": "500516", "standard_charge_dollar": 109.61, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Ms State Emplo", "plan_name": "401457", "standard_charge_dollar": 100.04, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Ms State Emplo", "plan_name": "401457_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Basic Pl", "plan_name": "400100", "standard_charge_dollar": 100.04, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Basic Pl", "plan_name": "400100_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Federal", "plan_name": "400110", "standard_charge_dollar": 100.04, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Federal", "plan_name": "400110_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Cigna Healthsprings Ffs", "plan_name": "500064", "standard_charge_dollar": 109.61, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Conseco", "plan_name": "500302", "standard_charge_dollar": 109.61, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Humana Ffs 61101", "plan_name": "500006", "standard_charge_dollar": 109.61, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Medicare A", "plan_name": "100100", "standard_charge_dollar": 109.61, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Medicare A", "plan_name": "100500", "standard_charge_dollar": 109.61, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Medicare Part B Only", "plan_name": "100300", "standard_charge_dollar": 109.61, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Medicare Railroad", "plan_name": "100103", "standard_charge_dollar": 109.61, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Ms Physicians Care N", "plan_name": "714210", "standard_charge_dollar": 137.01, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Peoples Hlth Ffs 72126", "plan_name": "500019", "standard_charge_dollar": 109.61, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Uhc/Secure Horizons", "plan_name": "500449", "standard_charge_dollar": 109.61, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "United Health Care/", "plan_name": "500292", "standard_charge_dollar": 123.86, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "United Healthcare", "plan_name": "750104", "standard_charge_dollar": 123.86, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "United Healthcare Ba", "plan_name": "750090", "standard_charge_dollar": 123.86, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "United Healthcare Me", "plan_name": "501310", "standard_charge_dollar": 109.61, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Windsor Mcare Extra", "plan_name": "500778", "standard_charge_dollar": 109.61, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." } ] } ] }, { "description": "Scr mammo bi incl cad", "code_information": [ { "code": "77067", "type": "CPT" } ], "standard_charges": [ { "gross_charge": 373.00, "minimum": 100.04, "maximum": 137.01, "setting": "both", "payers_information": [ { "payer_name": "Aarp", "plan_name": "500102", "standard_charge_dollar": 109.61, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna", "plan_name": "700700", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna", "plan_name": "700700_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Mcare Ffs 6005", "plan_name": "700703", "standard_charge_dollar": 109.61, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Miscellaneous", "plan_name": "700720", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Miscellaneous", "plan_name": "700720_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Ppo Hmo", "plan_name": "701720", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Ppo Hmo", "plan_name": "701720_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Ambetter 68069", "plan_name": "500516", "standard_charge_dollar": 109.61, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Ms State Emplo", "plan_name": "401457", "standard_charge_dollar": 100.04, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Ms State Emplo", "plan_name": "401457_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Basic Pl", "plan_name": "400100", "standard_charge_dollar": 100.04, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Basic Pl", "plan_name": "400100_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Federal", "plan_name": "400110", "standard_charge_dollar": 100.04, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Federal", "plan_name": "400110_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Cigna Healthsprings Ffs", "plan_name": "500064", "standard_charge_dollar": 109.61, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Conseco", "plan_name": "500302", "standard_charge_dollar": 109.61, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Humana Ffs 61101", "plan_name": "500006", "standard_charge_dollar": 109.61, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Medicare A", "plan_name": "100100", "standard_charge_dollar": 109.61, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Medicare A", "plan_name": "100500", "standard_charge_dollar": 109.61, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Medicare Part B Only", "plan_name": "100300", "standard_charge_dollar": 109.61, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Medicare Railroad", "plan_name": "100103", "standard_charge_dollar": 109.61, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Ms Physicians Care N", "plan_name": "714210", "standard_charge_dollar": 137.01, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Peoples Hlth Ffs 72126", "plan_name": "500019", "standard_charge_dollar": 109.61, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Uhc/Secure Horizons", "plan_name": "500449", "standard_charge_dollar": 109.61, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "United Health Care/", "plan_name": "500292", "standard_charge_dollar": 123.86, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "United Healthcare", "plan_name": "750104", "standard_charge_dollar": 123.86, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "United Healthcare Ba", "plan_name": "750090", "standard_charge_dollar": 123.86, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "United Healthcare Me", "plan_name": "501310", "standard_charge_dollar": 109.61, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Windsor Mcare Extra", "plan_name": "500778", "standard_charge_dollar": 109.61, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." } ] } ] }, { "description": "Hc bone age study", "code_information": [ { "code": "77072", "type": "CPT" } ], "standard_charges": [ { "gross_charge": 150.00, "minimum": 97.41, "maximum": 151.04, "setting": "both", "payers_information": [ { "payer_name": "Aarp", "plan_name": "500102", "standard_charge_dollar": 97.41, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna", "plan_name": "700700", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna", "plan_name": "700700_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Mcare Ffs 6005", "plan_name": "700703", "standard_charge_dollar": 97.41, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Miscellaneous", "plan_name": "700720", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Miscellaneous", "plan_name": "700720_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Ppo Hmo", "plan_name": "701720", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Ppo Hmo", "plan_name": "701720_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Ambetter 68069", "plan_name": "500516", "standard_charge_dollar": 97.41, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Ms State Emplo", "plan_name": "401457", "standard_charge_dollar": 151.04, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Ms State Emplo", "plan_name": "401457_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Basic Pl", "plan_name": "400100", "standard_charge_dollar": 151.04, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Basic Pl", "plan_name": "400100_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Federal", "plan_name": "400110", "standard_charge_dollar": 151.04, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Federal", "plan_name": "400110_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Cigna Healthsprings Ffs", "plan_name": "500064", "standard_charge_dollar": 97.41, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Conseco", "plan_name": "500302", "standard_charge_dollar": 97.41, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Humana Ffs 61101", "plan_name": "500006", "standard_charge_dollar": 97.41, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Medicare A", "plan_name": "100100", "standard_charge_dollar": 97.41, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Medicare A", "plan_name": "100500", "standard_charge_dollar": 97.41, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Medicare Part B Only", "plan_name": "100300", "standard_charge_dollar": 97.41, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Medicare Railroad", "plan_name": "100103", "standard_charge_dollar": 97.41, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Ms Physicians Care N", "plan_name": "714210", "standard_charge_dollar": 121.77, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Peoples Hlth Ffs 72126", "plan_name": "500019", "standard_charge_dollar": 97.41, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Uhc/Secure Horizons", "plan_name": "500449", "standard_charge_dollar": 97.41, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "United Health Care/", "plan_name": "500292", "standard_charge_dollar": 110.08, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "United Healthcare", "plan_name": "750104", "standard_charge_dollar": 110.08, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "United Healthcare Ba", "plan_name": "750090", "standard_charge_dollar": 110.08, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "United Healthcare Me", "plan_name": "501310", "standard_charge_dollar": 97.41, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Windsor Mcare Extra", "plan_name": "500778", "standard_charge_dollar": 97.41, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." } ] } ] }, { "description": "X-rays for bone age", "code_information": [ { "code": "77072", "type": "CPT" } ], "standard_charges": [ { "gross_charge": 150.00, "minimum": 97.41, "maximum": 151.04, "setting": "both", "payers_information": [ { "payer_name": "Aarp", "plan_name": "500102", "standard_charge_dollar": 97.41, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna", "plan_name": "700700", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna", "plan_name": "700700_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Mcare Ffs 6005", "plan_name": "700703", "standard_charge_dollar": 97.41, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Miscellaneous", "plan_name": "700720", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Miscellaneous", "plan_name": "700720_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Ppo Hmo", "plan_name": "701720", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Ppo Hmo", "plan_name": "701720_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Ambetter 68069", "plan_name": "500516", "standard_charge_dollar": 97.41, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Ms State Emplo", "plan_name": "401457", "standard_charge_dollar": 151.04, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Ms State Emplo", "plan_name": "401457_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Basic Pl", "plan_name": "400100", "standard_charge_dollar": 151.04, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Basic Pl", "plan_name": "400100_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Federal", "plan_name": "400110", "standard_charge_dollar": 151.04, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Federal", "plan_name": "400110_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Cigna Healthsprings Ffs", "plan_name": "500064", "standard_charge_dollar": 97.41, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Conseco", "plan_name": "500302", "standard_charge_dollar": 97.41, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Humana Ffs 61101", "plan_name": "500006", "standard_charge_dollar": 97.41, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Medicare A", "plan_name": "100100", "standard_charge_dollar": 97.41, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Medicare A", "plan_name": "100500", "standard_charge_dollar": 97.41, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Medicare Part B Only", "plan_name": "100300", "standard_charge_dollar": 97.41, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Medicare Railroad", "plan_name": "100103", "standard_charge_dollar": 97.41, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Ms Physicians Care N", "plan_name": "714210", "standard_charge_dollar": 121.77, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Peoples Hlth Ffs 72126", "plan_name": "500019", "standard_charge_dollar": 97.41, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Uhc/Secure Horizons", "plan_name": "500449", "standard_charge_dollar": 97.41, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "United Health Care/", "plan_name": "500292", "standard_charge_dollar": 110.08, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "United Healthcare", "plan_name": "750104", "standard_charge_dollar": 110.08, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "United Healthcare Ba", "plan_name": "750090", "standard_charge_dollar": 110.08, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "United Healthcare Me", "plan_name": "501310", "standard_charge_dollar": 97.41, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Windsor Mcare Extra", "plan_name": "500778", "standard_charge_dollar": 97.41, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." } ] } ] }, { "description": "Hc bone length study scanogram", "code_information": [ { "code": "77073", "type": "CPT" } ], "standard_charges": [ { "gross_charge": 332.50, "minimum": 91.20, "maximum": 121.77, "setting": "both", "payers_information": [ { "payer_name": "Aarp", "plan_name": "500102", "standard_charge_dollar": 97.41, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna", "plan_name": "700700", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna", "plan_name": "700700_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Mcare Ffs 6005", "plan_name": "700703", "standard_charge_dollar": 97.41, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Miscellaneous", "plan_name": "700720", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Miscellaneous", "plan_name": "700720_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Ppo Hmo", "plan_name": "701720", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Ppo Hmo", "plan_name": "701720_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Ambetter 68069", "plan_name": "500516", "standard_charge_dollar": 97.41, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Ms State Emplo", "plan_name": "401457", "standard_charge_dollar": 91.20, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Ms State Emplo", "plan_name": "401457_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Basic Pl", "plan_name": "400100", "standard_charge_dollar": 91.20, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Basic Pl", "plan_name": "400100_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Federal", "plan_name": "400110", "standard_charge_dollar": 91.20, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Federal", "plan_name": "400110_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Cigna Healthsprings Ffs", "plan_name": "500064", "standard_charge_dollar": 97.41, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Conseco", "plan_name": "500302", "standard_charge_dollar": 97.41, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Humana Ffs 61101", "plan_name": "500006", "standard_charge_dollar": 97.41, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Medicare A", "plan_name": "100100", "standard_charge_dollar": 97.41, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Medicare A", "plan_name": "100500", "standard_charge_dollar": 97.41, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Medicare Part B Only", "plan_name": "100300", "standard_charge_dollar": 97.41, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Medicare Railroad", "plan_name": "100103", "standard_charge_dollar": 97.41, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Ms Physicians Care N", "plan_name": "714210", "standard_charge_dollar": 121.77, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Peoples Hlth Ffs 72126", "plan_name": "500019", "standard_charge_dollar": 97.41, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Uhc/Secure Horizons", "plan_name": "500449", "standard_charge_dollar": 97.41, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "United Health Care/", "plan_name": "500292", "standard_charge_dollar": 110.08, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "United Healthcare", "plan_name": "750104", "standard_charge_dollar": 110.08, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "United Healthcare Ba", "plan_name": "750090", "standard_charge_dollar": 110.08, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "United Healthcare Me", "plan_name": "501310", "standard_charge_dollar": 97.41, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Windsor Mcare Extra", "plan_name": "500778", "standard_charge_dollar": 97.41, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." } ] } ] }, { "description": "X-rays bone length studies", "code_information": [ { "code": "77073", "type": "CPT" } ], "standard_charges": [ { "gross_charge": 332.50, "minimum": 91.20, "maximum": 121.77, "setting": "both", "payers_information": [ { "payer_name": "Aarp", "plan_name": "500102", "standard_charge_dollar": 97.41, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna", "plan_name": "700700", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna", "plan_name": "700700_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Mcare Ffs 6005", "plan_name": "700703", "standard_charge_dollar": 97.41, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Miscellaneous", "plan_name": "700720", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Miscellaneous", "plan_name": "700720_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Ppo Hmo", "plan_name": "701720", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Ppo Hmo", "plan_name": "701720_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Ambetter 68069", "plan_name": "500516", "standard_charge_dollar": 97.41, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Ms State Emplo", "plan_name": "401457", "standard_charge_dollar": 91.20, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Ms State Emplo", "plan_name": "401457_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Basic Pl", "plan_name": "400100", "standard_charge_dollar": 91.20, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Basic Pl", "plan_name": "400100_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Federal", "plan_name": "400110", "standard_charge_dollar": 91.20, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Federal", "plan_name": "400110_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Cigna Healthsprings Ffs", "plan_name": "500064", "standard_charge_dollar": 97.41, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Conseco", "plan_name": "500302", "standard_charge_dollar": 97.41, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Humana Ffs 61101", "plan_name": "500006", "standard_charge_dollar": 97.41, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Medicare A", "plan_name": "100100", "standard_charge_dollar": 97.41, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Medicare A", "plan_name": "100500", "standard_charge_dollar": 97.41, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Medicare Part B Only", "plan_name": "100300", "standard_charge_dollar": 97.41, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Medicare Railroad", "plan_name": "100103", "standard_charge_dollar": 97.41, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Ms Physicians Care N", "plan_name": "714210", "standard_charge_dollar": 121.77, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Peoples Hlth Ffs 72126", "plan_name": "500019", "standard_charge_dollar": 97.41, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Uhc/Secure Horizons", "plan_name": "500449", "standard_charge_dollar": 97.41, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "United Health Care/", "plan_name": "500292", "standard_charge_dollar": 110.08, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "United Healthcare", "plan_name": "750104", "standard_charge_dollar": 110.08, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "United Healthcare Ba", "plan_name": "750090", "standard_charge_dollar": 110.08, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "United Healthcare Me", "plan_name": "501310", "standard_charge_dollar": 97.41, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Windsor Mcare Extra", "plan_name": "500778", "standard_charge_dollar": 97.41, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." } ] } ] }, { "description": "Hc osseous survey limited", "code_information": [ { "code": "77074", "type": "CPT" } ], "standard_charges": [ { "gross_charge": 386.00, "minimum": 97.41, "maximum": 151.04, "setting": "both", "payers_information": [ { "payer_name": "Aarp", "plan_name": "500102", "standard_charge_dollar": 97.41, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna", "plan_name": "700700", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna", "plan_name": "700700_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Mcare Ffs 6005", "plan_name": "700703", "standard_charge_dollar": 97.41, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Miscellaneous", "plan_name": "700720", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Miscellaneous", "plan_name": "700720_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Ppo Hmo", "plan_name": "701720", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Ppo Hmo", "plan_name": "701720_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Ambetter 68069", "plan_name": "500516", "standard_charge_dollar": 97.41, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Ms State Emplo", "plan_name": "401457", "standard_charge_dollar": 151.04, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Ms State Emplo", "plan_name": "401457_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Basic Pl", "plan_name": "400100", "standard_charge_dollar": 151.04, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Basic Pl", "plan_name": "400100_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Federal", "plan_name": "400110", "standard_charge_dollar": 151.04, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Federal", "plan_name": "400110_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Cigna Healthsprings Ffs", "plan_name": "500064", "standard_charge_dollar": 97.41, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Conseco", "plan_name": "500302", "standard_charge_dollar": 97.41, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Humana Ffs 61101", "plan_name": "500006", "standard_charge_dollar": 97.41, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Medicare A", "plan_name": "100100", "standard_charge_dollar": 97.41, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Medicare A", "plan_name": "100500", "standard_charge_dollar": 97.41, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Medicare Part B Only", "plan_name": "100300", "standard_charge_dollar": 97.41, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Medicare Railroad", "plan_name": "100103", "standard_charge_dollar": 97.41, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Ms Physicians Care N", "plan_name": "714210", "standard_charge_dollar": 121.77, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Peoples Hlth Ffs 72126", "plan_name": "500019", "standard_charge_dollar": 97.41, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Uhc/Secure Horizons", "plan_name": "500449", "standard_charge_dollar": 97.41, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "United Health Care/", "plan_name": "500292", "standard_charge_dollar": 110.08, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "United Healthcare", "plan_name": "750104", "standard_charge_dollar": 110.08, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "United Healthcare Ba", "plan_name": "750090", "standard_charge_dollar": 110.08, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "United Healthcare Me", "plan_name": "501310", "standard_charge_dollar": 97.41, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Windsor Mcare Extra", "plan_name": "500778", "standard_charge_dollar": 97.41, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." } ] } ] }, { "description": "X-rays bone survey limited", "code_information": [ { "code": "77074", "type": "CPT" } ], "standard_charges": [ { "gross_charge": 386.00, "minimum": 97.41, "maximum": 151.04, "setting": "both", "payers_information": [ { "payer_name": "Aarp", "plan_name": "500102", "standard_charge_dollar": 97.41, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna", "plan_name": "700700", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna", "plan_name": "700700_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Mcare Ffs 6005", "plan_name": "700703", "standard_charge_dollar": 97.41, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Miscellaneous", "plan_name": "700720", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Miscellaneous", "plan_name": "700720_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Ppo Hmo", "plan_name": "701720", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Ppo Hmo", "plan_name": "701720_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Ambetter 68069", "plan_name": "500516", "standard_charge_dollar": 97.41, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Ms State Emplo", "plan_name": "401457", "standard_charge_dollar": 151.04, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Ms State Emplo", "plan_name": "401457_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Basic Pl", "plan_name": "400100", "standard_charge_dollar": 151.04, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Basic Pl", "plan_name": "400100_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Federal", "plan_name": "400110", "standard_charge_dollar": 151.04, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Federal", "plan_name": "400110_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Cigna Healthsprings Ffs", "plan_name": "500064", "standard_charge_dollar": 97.41, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Conseco", "plan_name": "500302", "standard_charge_dollar": 97.41, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Humana Ffs 61101", "plan_name": "500006", "standard_charge_dollar": 97.41, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Medicare A", "plan_name": "100100", "standard_charge_dollar": 97.41, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Medicare A", "plan_name": "100500", "standard_charge_dollar": 97.41, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Medicare Part B Only", "plan_name": "100300", "standard_charge_dollar": 97.41, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Medicare Railroad", "plan_name": "100103", "standard_charge_dollar": 97.41, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Ms Physicians Care N", "plan_name": "714210", "standard_charge_dollar": 121.77, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Peoples Hlth Ffs 72126", "plan_name": "500019", "standard_charge_dollar": 97.41, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Uhc/Secure Horizons", "plan_name": "500449", "standard_charge_dollar": 97.41, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "United Health Care/", "plan_name": "500292", "standard_charge_dollar": 110.08, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "United Healthcare", "plan_name": "750104", "standard_charge_dollar": 110.08, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "United Healthcare Ba", "plan_name": "750090", "standard_charge_dollar": 110.08, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "United Healthcare Me", "plan_name": "501310", "standard_charge_dollar": 97.41, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Windsor Mcare Extra", "plan_name": "500778", "standard_charge_dollar": 97.41, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." } ] } ] }, { "description": "Hc osseous survey complete", "code_information": [ { "code": "77075", "type": "CPT" } ], "standard_charges": [ { "gross_charge": 288.75, "minimum": 97.41, "maximum": 151.04, "setting": "both", "payers_information": [ { "payer_name": "Aarp", "plan_name": "500102", "standard_charge_dollar": 97.41, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna", "plan_name": "700700", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna", "plan_name": "700700_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Mcare Ffs 6005", "plan_name": "700703", "standard_charge_dollar": 97.41, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Miscellaneous", "plan_name": "700720", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Miscellaneous", "plan_name": "700720_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Ppo Hmo", "plan_name": "701720", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Ppo Hmo", "plan_name": "701720_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Ambetter 68069", "plan_name": "500516", "standard_charge_dollar": 97.41, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Ms State Emplo", "plan_name": "401457", "standard_charge_dollar": 151.04, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Ms State Emplo", "plan_name": "401457_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Basic Pl", "plan_name": "400100", "standard_charge_dollar": 151.04, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Basic Pl", "plan_name": "400100_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Federal", "plan_name": "400110", "standard_charge_dollar": 151.04, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Federal", "plan_name": "400110_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Cigna Healthsprings Ffs", "plan_name": "500064", "standard_charge_dollar": 97.41, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Conseco", "plan_name": "500302", "standard_charge_dollar": 97.41, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Humana Ffs 61101", "plan_name": "500006", "standard_charge_dollar": 97.41, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Medicare A", "plan_name": "100100", "standard_charge_dollar": 97.41, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Medicare A", "plan_name": "100500", "standard_charge_dollar": 97.41, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Medicare Part B Only", "plan_name": "100300", "standard_charge_dollar": 97.41, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Medicare Railroad", "plan_name": "100103", "standard_charge_dollar": 97.41, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Ms Physicians Care N", "plan_name": "714210", "standard_charge_dollar": 121.77, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Peoples Hlth Ffs 72126", "plan_name": "500019", "standard_charge_dollar": 97.41, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Uhc/Secure Horizons", "plan_name": "500449", "standard_charge_dollar": 97.41, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "United Health Care/", "plan_name": "500292", "standard_charge_dollar": 110.08, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "United Healthcare", "plan_name": "750104", "standard_charge_dollar": 110.08, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "United Healthcare Ba", "plan_name": "750090", "standard_charge_dollar": 110.08, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "United Healthcare Me", "plan_name": "501310", "standard_charge_dollar": 97.41, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Windsor Mcare Extra", "plan_name": "500778", "standard_charge_dollar": 97.41, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." } ] } ] }, { "description": "X-rays bone survey complete", "code_information": [ { "code": "77075", "type": "CPT" } ], "standard_charges": [ { "gross_charge": 288.75, "minimum": 97.41, "maximum": 151.04, "setting": "both", "payers_information": [ { "payer_name": "Aarp", "plan_name": "500102", "standard_charge_dollar": 97.41, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna", "plan_name": "700700", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna", "plan_name": "700700_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Mcare Ffs 6005", "plan_name": "700703", "standard_charge_dollar": 97.41, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Miscellaneous", "plan_name": "700720", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Miscellaneous", "plan_name": "700720_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Ppo Hmo", "plan_name": "701720", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Ppo Hmo", "plan_name": "701720_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Ambetter 68069", "plan_name": "500516", "standard_charge_dollar": 97.41, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Ms State Emplo", "plan_name": "401457", "standard_charge_dollar": 151.04, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Ms State Emplo", "plan_name": "401457_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Basic Pl", "plan_name": "400100", "standard_charge_dollar": 151.04, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Basic Pl", "plan_name": "400100_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Federal", "plan_name": "400110", "standard_charge_dollar": 151.04, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Federal", "plan_name": "400110_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Cigna Healthsprings Ffs", "plan_name": "500064", "standard_charge_dollar": 97.41, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Conseco", "plan_name": "500302", "standard_charge_dollar": 97.41, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Humana Ffs 61101", "plan_name": "500006", "standard_charge_dollar": 97.41, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Medicare A", "plan_name": "100100", "standard_charge_dollar": 97.41, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Medicare A", "plan_name": "100500", "standard_charge_dollar": 97.41, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Medicare Part B Only", "plan_name": "100300", "standard_charge_dollar": 97.41, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Medicare Railroad", "plan_name": "100103", "standard_charge_dollar": 97.41, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Ms Physicians Care N", "plan_name": "714210", "standard_charge_dollar": 121.77, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Peoples Hlth Ffs 72126", "plan_name": "500019", "standard_charge_dollar": 97.41, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Uhc/Secure Horizons", "plan_name": "500449", "standard_charge_dollar": 97.41, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "United Health Care/", "plan_name": "500292", "standard_charge_dollar": 110.08, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "United Healthcare", "plan_name": "750104", "standard_charge_dollar": 110.08, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "United Healthcare Ba", "plan_name": "750090", "standard_charge_dollar": 110.08, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "United Healthcare Me", "plan_name": "501310", "standard_charge_dollar": 97.41, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Windsor Mcare Extra", "plan_name": "500778", "standard_charge_dollar": 97.41, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." } ] } ] }, { "description": "Hc basic metabolic panel", "code_information": [ { "code": "80048", "type": "CPT" } ], "standard_charges": [ { "gross_charge": 175.00, "minimum": 12.67, "maximum": 12.67, "setting": "both", "payers_information": [ { "payer_name": "Aetna", "plan_name": "700700", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna", "plan_name": "700700_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Miscellaneous", "plan_name": "700720", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Miscellaneous", "plan_name": "700720_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Ppo Hmo", "plan_name": "701720", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Ppo Hmo", "plan_name": "701720_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Ms State Emplo", "plan_name": "401457", "standard_charge_dollar": 12.67, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Ms State Emplo", "plan_name": "401457_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Basic Pl", "plan_name": "400100", "standard_charge_dollar": 12.67, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Basic Pl", "plan_name": "400100_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Federal", "plan_name": "400110", "standard_charge_dollar": 12.67, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Federal", "plan_name": "400110_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." } ] } ] }, { "description": "Metabolic panel total ca", "code_information": [ { "code": "80048", "type": "CPT" } ], "standard_charges": [ { "gross_charge": 175.00, "minimum": 12.67, "maximum": 12.67, "setting": "both", "payers_information": [ { "payer_name": "Aetna", "plan_name": "700700", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna", "plan_name": "700700_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Miscellaneous", "plan_name": "700720", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Miscellaneous", "plan_name": "700720_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Ppo Hmo", "plan_name": "701720", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Ppo Hmo", "plan_name": "701720_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Ms State Emplo", "plan_name": "401457", "standard_charge_dollar": 12.67, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Ms State Emplo", "plan_name": "401457_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Basic Pl", "plan_name": "400100", "standard_charge_dollar": 12.67, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Basic Pl", "plan_name": "400100_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Federal", "plan_name": "400110", "standard_charge_dollar": 12.67, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Federal", "plan_name": "400110_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." } ] } ] }, { "description": "Electrolyte panel", "code_information": [ { "code": "80051", "type": "CPT" } ], "standard_charges": [ { "gross_charge": 175.00, "minimum": 10.51, "maximum": 10.51, "setting": "both", "payers_information": [ { "payer_name": "Aetna", "plan_name": "700700", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna", "plan_name": "700700_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Miscellaneous", "plan_name": "700720", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Miscellaneous", "plan_name": "700720_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Ppo Hmo", "plan_name": "701720", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Ppo Hmo", "plan_name": "701720_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Ms State Emplo", "plan_name": "401457", "standard_charge_dollar": 10.51, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Ms State Emplo", "plan_name": "401457_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Basic Pl", "plan_name": "400100", "standard_charge_dollar": 10.51, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Basic Pl", "plan_name": "400100_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Federal", "plan_name": "400110", "standard_charge_dollar": 10.51, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Federal", "plan_name": "400110_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." } ] } ] }, { "description": "Hc electrolyte panel", "code_information": [ { "code": "80051", "type": "CPT" } ], "standard_charges": [ { "gross_charge": 175.00, "minimum": 10.51, "maximum": 10.51, "setting": "both", "payers_information": [ { "payer_name": "Aetna", "plan_name": "700700", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna", "plan_name": "700700_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Miscellaneous", "plan_name": "700720", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Miscellaneous", "plan_name": "700720_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Ppo Hmo", "plan_name": "701720", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Ppo Hmo", "plan_name": "701720_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Ms State Emplo", "plan_name": "401457", "standard_charge_dollar": 10.51, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Ms State Emplo", "plan_name": "401457_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Basic Pl", "plan_name": "400100", "standard_charge_dollar": 10.51, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Basic Pl", "plan_name": "400100_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Federal", "plan_name": "400110", "standard_charge_dollar": 10.51, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Federal", "plan_name": "400110_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." } ] } ] }, { "description": "Comprehen metabolic panel", "code_information": [ { "code": "80053", "type": "CPT" } ], "standard_charges": [ { "gross_charge": 185.00, "minimum": 15.83, "maximum": 15.83, "setting": "both", "payers_information": [ { "payer_name": "Aetna", "plan_name": "700700", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna", "plan_name": "700700_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Miscellaneous", "plan_name": "700720", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Miscellaneous", "plan_name": "700720_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Ppo Hmo", "plan_name": "701720", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Ppo Hmo", "plan_name": "701720_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Ms State Emplo", "plan_name": "401457", "standard_charge_dollar": 15.83, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Ms State Emplo", "plan_name": "401457_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Basic Pl", "plan_name": "400100", "standard_charge_dollar": 15.83, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Basic Pl", "plan_name": "400100_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Federal", "plan_name": "400110", "standard_charge_dollar": 15.83, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Federal", "plan_name": "400110_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." } ] } ] }, { "description": "Hc comprehensv metabolic panel", "code_information": [ { "code": "80053", "type": "CPT" } ], "standard_charges": [ { "gross_charge": 185.00, "minimum": 15.83, "maximum": 15.83, "setting": "both", "payers_information": [ { "payer_name": "Aetna", "plan_name": "700700", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna", "plan_name": "700700_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Miscellaneous", "plan_name": "700720", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Miscellaneous", "plan_name": "700720_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Ppo Hmo", "plan_name": "701720", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Ppo Hmo", "plan_name": "701720_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Ms State Emplo", "plan_name": "401457", "standard_charge_dollar": 15.83, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Ms State Emplo", "plan_name": "401457_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Basic Pl", "plan_name": "400100", "standard_charge_dollar": 15.83, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Basic Pl", "plan_name": "400100_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Federal", "plan_name": "400110", "standard_charge_dollar": 15.83, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Federal", "plan_name": "400110_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." } ] } ] }, { "description": "Hc lipid panel", "code_information": [ { "code": "80061", "type": "CPT" } ], "standard_charges": [ { "gross_charge": 150.00, "minimum": 13.39, "maximum": 20.06, "setting": "both", "payers_information": [ { "payer_name": "Aarp", "plan_name": "500102", "standard_charge_dollar": 13.39, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna", "plan_name": "700700", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna", "plan_name": "700700_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Mcare Ffs 6005", "plan_name": "700703", "standard_charge_dollar": 13.39, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Miscellaneous", "plan_name": "700720", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Miscellaneous", "plan_name": "700720_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Ppo Hmo", "plan_name": "701720", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Ppo Hmo", "plan_name": "701720_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Ambetter 68069", "plan_name": "500516", "standard_charge_dollar": 13.39, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Ms State Emplo", "plan_name": "401457", "standard_charge_dollar": 20.06, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Ms State Emplo", "plan_name": "401457_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Basic Pl", "plan_name": "400100", "standard_charge_dollar": 20.06, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Basic Pl", "plan_name": "400100_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Federal", "plan_name": "400110", "standard_charge_dollar": 20.06, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Federal", "plan_name": "400110_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Cigna Healthsprings Ffs", "plan_name": "500064", "standard_charge_dollar": 13.39, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Conseco", "plan_name": "500302", "standard_charge_dollar": 13.39, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Humana Ffs 61101", "plan_name": "500006", "standard_charge_dollar": 13.39, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Medicare A", "plan_name": "100100", "standard_charge_dollar": 13.39, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Medicare A", "plan_name": "100500", "standard_charge_dollar": 13.39, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Medicare Part B Only", "plan_name": "100300", "standard_charge_dollar": 13.39, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Medicare Railroad", "plan_name": "100103", "standard_charge_dollar": 13.39, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Ms Physicians Care N", "plan_name": "714210", "standard_charge_dollar": 16.74, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Peoples Hlth Ffs 72126", "plan_name": "500019", "standard_charge_dollar": 13.39, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Uhc/Secure Horizons", "plan_name": "500449", "standard_charge_dollar": 13.39, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "United Health Care/", "plan_name": "500292", "standard_charge_dollar": 15.13, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "United Healthcare", "plan_name": "750104", "standard_charge_dollar": 15.13, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "United Healthcare Ba", "plan_name": "750090", "standard_charge_dollar": 15.13, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "United Healthcare Me", "plan_name": "501310", "standard_charge_dollar": 13.39, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Windsor Mcare Extra", "plan_name": "500778", "standard_charge_dollar": 13.39, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." } ] } ] }, { "description": "Lipid panel", "code_information": [ { "code": "80061", "type": "CPT" } ], "standard_charges": [ { "gross_charge": 150.00, "minimum": 13.39, "maximum": 20.06, "setting": "both", "payers_information": [ { "payer_name": "Aarp", "plan_name": "500102", "standard_charge_dollar": 13.39, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna", "plan_name": "700700", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna", "plan_name": "700700_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Mcare Ffs 6005", "plan_name": "700703", "standard_charge_dollar": 13.39, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Miscellaneous", "plan_name": "700720", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Miscellaneous", "plan_name": "700720_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Ppo Hmo", "plan_name": "701720", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Ppo Hmo", "plan_name": "701720_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Ambetter 68069", "plan_name": "500516", "standard_charge_dollar": 13.39, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Ms State Emplo", "plan_name": "401457", "standard_charge_dollar": 20.06, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Ms State Emplo", "plan_name": "401457_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Basic Pl", "plan_name": "400100", "standard_charge_dollar": 20.06, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Basic Pl", "plan_name": "400100_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Federal", "plan_name": "400110", "standard_charge_dollar": 20.06, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Federal", "plan_name": "400110_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Cigna Healthsprings Ffs", "plan_name": "500064", "standard_charge_dollar": 13.39, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Conseco", "plan_name": "500302", "standard_charge_dollar": 13.39, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Humana Ffs 61101", "plan_name": "500006", "standard_charge_dollar": 13.39, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Medicare A", "plan_name": "100100", "standard_charge_dollar": 13.39, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Medicare A", "plan_name": "100500", "standard_charge_dollar": 13.39, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Medicare Part B Only", "plan_name": "100300", "standard_charge_dollar": 13.39, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Medicare Railroad", "plan_name": "100103", "standard_charge_dollar": 13.39, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Ms Physicians Care N", "plan_name": "714210", "standard_charge_dollar": 16.74, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Peoples Hlth Ffs 72126", "plan_name": "500019", "standard_charge_dollar": 13.39, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Uhc/Secure Horizons", "plan_name": "500449", "standard_charge_dollar": 13.39, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "United Health Care/", "plan_name": "500292", "standard_charge_dollar": 15.13, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "United Healthcare", "plan_name": "750104", "standard_charge_dollar": 15.13, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "United Healthcare Ba", "plan_name": "750090", "standard_charge_dollar": 15.13, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "United Healthcare Me", "plan_name": "501310", "standard_charge_dollar": 13.39, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Windsor Mcare Extra", "plan_name": "500778", "standard_charge_dollar": 13.39, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." } ] } ] }, { "description": "Hc renal function panel", "code_information": [ { "code": "80069", "type": "CPT" } ], "standard_charges": [ { "gross_charge": 175.00, "minimum": 13.01, "maximum": 13.01, "setting": "both", "payers_information": [ { "payer_name": "Aetna", "plan_name": "700700", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna", "plan_name": "700700_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Miscellaneous", "plan_name": "700720", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Miscellaneous", "plan_name": "700720_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Ppo Hmo", "plan_name": "701720", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Ppo Hmo", "plan_name": "701720_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Ms State Emplo", "plan_name": "401457", "standard_charge_dollar": 13.01, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Ms State Emplo", "plan_name": "401457_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Basic Pl", "plan_name": "400100", "standard_charge_dollar": 13.01, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Basic Pl", "plan_name": "400100_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Federal", "plan_name": "400110", "standard_charge_dollar": 13.01, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Federal", "plan_name": "400110_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." } ] } ] }, { "description": "Renal function panel", "code_information": [ { "code": "80069", "type": "CPT" } ], "standard_charges": [ { "gross_charge": 175.00, "minimum": 13.01, "maximum": 13.01, "setting": "both", "payers_information": [ { "payer_name": "Aetna", "plan_name": "700700", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna", "plan_name": "700700_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Miscellaneous", "plan_name": "700720", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Miscellaneous", "plan_name": "700720_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Ppo Hmo", "plan_name": "701720", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Ppo Hmo", "plan_name": "701720_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Ms State Emplo", "plan_name": "401457", "standard_charge_dollar": 13.01, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Ms State Emplo", "plan_name": "401457_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Basic Pl", "plan_name": "400100", "standard_charge_dollar": 13.01, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Basic Pl", "plan_name": "400100_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Federal", "plan_name": "400110", "standard_charge_dollar": 13.01, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Federal", "plan_name": "400110_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." } ] } ] }, { "description": "Acute hepatitis panel", "code_information": [ { "code": "80074", "type": "CPT" } ], "standard_charges": [ { "gross_charge": 175.00, "minimum": 61.69, "maximum": 61.69, "setting": "both", "payers_information": [ { "payer_name": "Aetna", "plan_name": "700700", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna", "plan_name": "700700_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Miscellaneous", "plan_name": "700720", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Miscellaneous", "plan_name": "700720_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Ppo Hmo", "plan_name": "701720", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Ppo Hmo", "plan_name": "701720_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Ms State Emplo", "plan_name": "401457", "standard_charge_dollar": 61.69, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Ms State Emplo", "plan_name": "401457_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Basic Pl", "plan_name": "400100", "standard_charge_dollar": 61.69, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Basic Pl", "plan_name": "400100_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Federal", "plan_name": "400110", "standard_charge_dollar": 61.69, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Federal", "plan_name": "400110_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." } ] } ] }, { "description": "Hc acute hepatitis panel", "code_information": [ { "code": "80074", "type": "CPT" } ], "standard_charges": [ { "gross_charge": 175.00, "minimum": 61.69, "maximum": 61.69, "setting": "both", "payers_information": [ { "payer_name": "Aetna", "plan_name": "700700", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna", "plan_name": "700700_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Miscellaneous", "plan_name": "700720", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Miscellaneous", "plan_name": "700720_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Ppo Hmo", "plan_name": "701720", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Ppo Hmo", "plan_name": "701720_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Ms State Emplo", "plan_name": "401457", "standard_charge_dollar": 61.69, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Ms State Emplo", "plan_name": "401457_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Basic Pl", "plan_name": "400100", "standard_charge_dollar": 61.69, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Basic Pl", "plan_name": "400100_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Federal", "plan_name": "400110", "standard_charge_dollar": 61.69, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Federal", "plan_name": "400110_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." } ] } ] }, { "description": "Hc hepatic function panel", "code_information": [ { "code": "80076", "type": "CPT" } ], "standard_charges": [ { "gross_charge": 175.00, "minimum": 12.24, "maximum": 12.24, "setting": "both", "payers_information": [ { "payer_name": "Aetna", "plan_name": "700700", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna", "plan_name": "700700_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Miscellaneous", "plan_name": "700720", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Miscellaneous", "plan_name": "700720_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Ppo Hmo", "plan_name": "701720", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Ppo Hmo", "plan_name": "701720_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Ms State Emplo", "plan_name": "401457", "standard_charge_dollar": 12.24, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Ms State Emplo", "plan_name": "401457_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Basic Pl", "plan_name": "400100", "standard_charge_dollar": 12.24, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Basic Pl", "plan_name": "400100_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Federal", "plan_name": "400110", "standard_charge_dollar": 12.24, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Federal", "plan_name": "400110_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." } ] } ] }, { "description": "Hepatic function panel", "code_information": [ { "code": "80076", "type": "CPT" } ], "standard_charges": [ { "gross_charge": 175.00, "minimum": 12.24, "maximum": 12.24, "setting": "both", "payers_information": [ { "payer_name": "Aetna", "plan_name": "700700", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna", "plan_name": "700700_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Miscellaneous", "plan_name": "700720", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Miscellaneous", "plan_name": "700720_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Ppo Hmo", "plan_name": "701720", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Ppo Hmo", "plan_name": "701720_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Ms State Emplo", "plan_name": "401457", "standard_charge_dollar": 12.24, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Ms State Emplo", "plan_name": "401457_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Basic Pl", "plan_name": "400100", "standard_charge_dollar": 12.24, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Basic Pl", "plan_name": "400100_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Federal", "plan_name": "400110", "standard_charge_dollar": 12.24, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Federal", "plan_name": "400110_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." } ] } ] }, { "description": "Drug assay acetaminophen", "code_information": [ { "code": "80143", "type": "CPT" } ], "standard_charges": [ { "gross_charge": 115.00, "minimum": 92.00, "maximum": 97.75, "setting": "both", "payers_information": [ { "payer_name": "Aetna", "plan_name": "700700", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna", "plan_name": "700700_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Miscellaneous", "plan_name": "700720", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Miscellaneous", "plan_name": "700720_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Ppo Hmo", "plan_name": "701720", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Ppo Hmo", "plan_name": "701720_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Ms State Emplo", "plan_name": "401457", "standard_charge_percentage": 0.80, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Ms State Emplo", "plan_name": "401457_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Basic Pl", "plan_name": "400100", "standard_charge_percentage": 0.85, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Basic Pl", "plan_name": "400100_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Federal", "plan_name": "400110", "standard_charge_percentage": 0.85, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Federal", "plan_name": "400110_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." } ] } ] }, { "description": "Hc drug assay acetaminophen", "code_information": [ { "code": "80143", "type": "CPT" } ], "standard_charges": [ { "gross_charge": 115.00, "minimum": 92.00, "maximum": 97.75, "setting": "both", "payers_information": [ { "payer_name": "Aetna", "plan_name": "700700", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna", "plan_name": "700700_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Miscellaneous", "plan_name": "700720", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Miscellaneous", "plan_name": "700720_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Ppo Hmo", "plan_name": "701720", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Ppo Hmo", "plan_name": "701720_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Ms State Emplo", "plan_name": "401457", "standard_charge_percentage": 0.80, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Ms State Emplo", "plan_name": "401457_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Basic Pl", "plan_name": "400100", "standard_charge_percentage": 0.85, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Basic Pl", "plan_name": "400100_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Federal", "plan_name": "400110", "standard_charge_percentage": 0.85, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Federal", "plan_name": "400110_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." } ] } ] }, { "description": "Drug assay adalimumab", "code_information": [ { "code": "80145", "type": "CPT" } ], "standard_charges": [ { "gross_charge": 533.10, "minimum": 426.48, "maximum": 453.14, "setting": "both", "payers_information": [ { "payer_name": "Aetna", "plan_name": "700700", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna", "plan_name": "700700_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Miscellaneous", "plan_name": "700720", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Miscellaneous", "plan_name": "700720_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Ppo Hmo", "plan_name": "701720", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Ppo Hmo", "plan_name": "701720_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Ms State Emplo", "plan_name": "401457", "standard_charge_percentage": 0.80, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Ms State Emplo", "plan_name": "401457_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Basic Pl", "plan_name": "400100", "standard_charge_percentage": 0.85, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Basic Pl", "plan_name": "400100_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Federal", "plan_name": "400110", "standard_charge_percentage": 0.85, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Federal", "plan_name": "400110_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." } ] } ] }, { "description": "Hc adalimumab quantitative with reflex to antibody", "code_information": [ { "code": "80145", "type": "CPT" } ], "standard_charges": [ { "gross_charge": 533.10, "minimum": 426.48, "maximum": 453.14, "setting": "both", "payers_information": [ { "payer_name": "Aetna", "plan_name": "700700", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna", "plan_name": "700700_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Miscellaneous", "plan_name": "700720", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Miscellaneous", "plan_name": "700720_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Ppo Hmo", "plan_name": "701720", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Ppo Hmo", "plan_name": "701720_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Ms State Emplo", "plan_name": "401457", "standard_charge_percentage": 0.80, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Ms State Emplo", "plan_name": "401457_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Basic Pl", "plan_name": "400100", "standard_charge_percentage": 0.85, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Basic Pl", "plan_name": "400100_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Federal", "plan_name": "400110", "standard_charge_percentage": 0.85, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Federal", "plan_name": "400110_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." } ] } ] }, { "description": "Assay of amikacin", "code_information": [ { "code": "80150", "type": "CPT" } ], "standard_charges": [ { "gross_charge": 100.00, "minimum": 22.59, "maximum": 22.59, "setting": "both", "payers_information": [ { "payer_name": "Aetna", "plan_name": "700700", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna", "plan_name": "700700_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Miscellaneous", "plan_name": "700720", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Miscellaneous", "plan_name": "700720_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Ppo Hmo", "plan_name": "701720", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Ppo Hmo", "plan_name": "701720_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Ms State Emplo", "plan_name": "401457", "standard_charge_dollar": 22.59, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Ms State Emplo", "plan_name": "401457_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Basic Pl", "plan_name": "400100", "standard_charge_dollar": 22.59, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Basic Pl", "plan_name": "400100_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Federal", "plan_name": "400110", "standard_charge_dollar": 22.59, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Federal", "plan_name": "400110_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." } ] } ] }, { "description": "Hc amikacin", "code_information": [ { "code": "80150", "type": "CPT" } ], "standard_charges": [ { "gross_charge": 100.00, "minimum": 22.59, "maximum": 22.59, "setting": "both", "payers_information": [ { "payer_name": "Aetna", "plan_name": "700700", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna", "plan_name": "700700_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Miscellaneous", "plan_name": "700720", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Miscellaneous", "plan_name": "700720_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Ppo Hmo", "plan_name": "701720", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Ppo Hmo", "plan_name": "701720_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Ms State Emplo", "plan_name": "401457", "standard_charge_dollar": 22.59, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Ms State Emplo", "plan_name": "401457_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Basic Pl", "plan_name": "400100", "standard_charge_dollar": 22.59, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Basic Pl", "plan_name": "400100_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Federal", "plan_name": "400110", "standard_charge_dollar": 22.59, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Federal", "plan_name": "400110_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." } ] } ] }, { "description": "Drug assay amiodarone", "code_information": [ { "code": "80151", "type": "CPT" } ], "standard_charges": [ { "gross_charge": 48.18, "minimum": 38.54, "maximum": 40.95, "setting": "both", "payers_information": [ { "payer_name": "Aetna", "plan_name": "700700", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna", "plan_name": "700700_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Miscellaneous", "plan_name": "700720", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Miscellaneous", "plan_name": "700720_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Ppo Hmo", "plan_name": "701720", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Ppo Hmo", "plan_name": "701720_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Ms State Emplo", "plan_name": "401457", "standard_charge_percentage": 0.80, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Ms State Emplo", "plan_name": "401457_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Basic Pl", "plan_name": "400100", "standard_charge_percentage": 0.85, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Basic Pl", "plan_name": "400100_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Federal", "plan_name": "400110", "standard_charge_percentage": 0.85, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Federal", "plan_name": "400110_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." } ] } ] }, { "description": "Hc measurement of amiodarone", "code_information": [ { "code": "80151", "type": "CPT" } ], "standard_charges": [ { "gross_charge": 48.18, "minimum": 38.54, "maximum": 40.95, "setting": "both", "payers_information": [ { "payer_name": "Aetna", "plan_name": "700700", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna", "plan_name": "700700_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Miscellaneous", "plan_name": "700720", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Miscellaneous", "plan_name": "700720_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Ppo Hmo", "plan_name": "701720", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Ppo Hmo", "plan_name": "701720_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Ms State Emplo", "plan_name": "401457", "standard_charge_percentage": 0.80, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Ms State Emplo", "plan_name": "401457_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Basic Pl", "plan_name": "400100", "standard_charge_percentage": 0.85, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Basic Pl", "plan_name": "400100_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Federal", "plan_name": "400110", "standard_charge_percentage": 0.85, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Federal", "plan_name": "400110_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." } ] } ] }, { "description": "Assay carbamazepine total", "code_information": [ { "code": "80156", "type": "CPT" } ], "standard_charges": [ { "gross_charge": 121.25, "minimum": 21.82, "maximum": 21.82, "setting": "both", "payers_information": [ { "payer_name": "Aetna", "plan_name": "700700", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna", "plan_name": "700700_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Miscellaneous", "plan_name": "700720", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Miscellaneous", "plan_name": "700720_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Ppo Hmo", "plan_name": "701720", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Ppo Hmo", "plan_name": "701720_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Ms State Emplo", "plan_name": "401457", "standard_charge_dollar": 21.82, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Ms State Emplo", "plan_name": "401457_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Basic Pl", "plan_name": "400100", "standard_charge_dollar": 21.82, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Basic Pl", "plan_name": "400100_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Federal", "plan_name": "400110", "standard_charge_dollar": 21.82, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Federal", "plan_name": "400110_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." } ] } ] }, { "description": "Hc carbamazepine total", "code_information": [ { "code": "80156", "type": "CPT" } ], "standard_charges": [ { "gross_charge": 121.25, "minimum": 21.82, "maximum": 21.82, "setting": "both", "payers_information": [ { "payer_name": "Aetna", "plan_name": "700700", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna", "plan_name": "700700_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Miscellaneous", "plan_name": "700720", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Miscellaneous", "plan_name": "700720_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Ppo Hmo", "plan_name": "701720", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Ppo Hmo", "plan_name": "701720_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Ms State Emplo", "plan_name": "401457", "standard_charge_dollar": 21.82, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Ms State Emplo", "plan_name": "401457_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Basic Pl", "plan_name": "400100", "standard_charge_dollar": 21.82, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Basic Pl", "plan_name": "400100_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Federal", "plan_name": "400110", "standard_charge_dollar": 21.82, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Federal", "plan_name": "400110_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." } ] } ] }, { "description": "Assay of digoxin total", "code_information": [ { "code": "80162", "type": "CPT" } ], "standard_charges": [ { "gross_charge": 100.00, "minimum": 19.90, "maximum": 19.90, "setting": "both", "payers_information": [ { "payer_name": "Aetna", "plan_name": "700700", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna", "plan_name": "700700_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Miscellaneous", "plan_name": "700720", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Miscellaneous", "plan_name": "700720_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Ppo Hmo", "plan_name": "701720", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Ppo Hmo", "plan_name": "701720_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Ms State Emplo", "plan_name": "401457", "standard_charge_dollar": 19.90, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Ms State Emplo", "plan_name": "401457_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Basic Pl", "plan_name": "400100", "standard_charge_dollar": 19.90, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Basic Pl", "plan_name": "400100_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Federal", "plan_name": "400110", "standard_charge_dollar": 19.90, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Federal", "plan_name": "400110_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." } ] } ] }, { "description": "Hc digoxin", "code_information": [ { "code": "80162", "type": "CPT" } ], "standard_charges": [ { "gross_charge": 100.00, "minimum": 19.90, "maximum": 19.90, "setting": "both", "payers_information": [ { "payer_name": "Aetna", "plan_name": "700700", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna", "plan_name": "700700_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Miscellaneous", "plan_name": "700720", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Miscellaneous", "plan_name": "700720_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Ppo Hmo", "plan_name": "701720", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Ppo Hmo", "plan_name": "701720_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Ms State Emplo", "plan_name": "401457", "standard_charge_dollar": 19.90, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Ms State Emplo", "plan_name": "401457_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Basic Pl", "plan_name": "400100", "standard_charge_dollar": 19.90, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Basic Pl", "plan_name": "400100_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Federal", "plan_name": "400110", "standard_charge_dollar": 19.90, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Federal", "plan_name": "400110_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." } ] } ] }, { "description": "Assay dipropylacetic acd tot", "code_information": [ { "code": "80164", "type": "CPT" } ], "standard_charges": [ { "gross_charge": 100.00, "minimum": 20.31, "maximum": 20.31, "setting": "both", "payers_information": [ { "payer_name": "Aetna", "plan_name": "700700", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna", "plan_name": "700700_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Miscellaneous", "plan_name": "700720", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Miscellaneous", "plan_name": "700720_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Ppo Hmo", "plan_name": "701720", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Ppo Hmo", "plan_name": "701720_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Ms State Emplo", "plan_name": "401457", "standard_charge_dollar": 20.31, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Ms State Emplo", "plan_name": "401457_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Basic Pl", "plan_name": "400100", "standard_charge_dollar": 20.31, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Basic Pl", "plan_name": "400100_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Federal", "plan_name": "400110", "standard_charge_dollar": 20.31, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Federal", "plan_name": "400110_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." } ] } ] }, { "description": "Hc depakene (valproic acid)", "code_information": [ { "code": "80164", "type": "CPT" } ], "standard_charges": [ { "gross_charge": 100.00, "minimum": 20.31, "maximum": 20.31, "setting": "both", "payers_information": [ { "payer_name": "Aetna", "plan_name": "700700", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna", "plan_name": "700700_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Miscellaneous", "plan_name": "700720", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Miscellaneous", "plan_name": "700720_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Ppo Hmo", "plan_name": "701720", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Ppo Hmo", "plan_name": "701720_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Ms State Emplo", "plan_name": "401457", "standard_charge_dollar": 20.31, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Ms State Emplo", "plan_name": "401457_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Basic Pl", "plan_name": "400100", "standard_charge_dollar": 20.31, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Basic Pl", "plan_name": "400100_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Federal", "plan_name": "400110", "standard_charge_dollar": 20.31, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Federal", "plan_name": "400110_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." } ] } ] }, { "description": "Assay of ethosuximide", "code_information": [ { "code": "80168", "type": "CPT" } ], "standard_charges": [ { "gross_charge": 85.22, "minimum": 22.64, "maximum": 22.64, "setting": "both", "payers_information": [ { "payer_name": "Aetna", "plan_name": "700700", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna", "plan_name": "700700_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Miscellaneous", "plan_name": "700720", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Miscellaneous", "plan_name": "700720_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Ppo Hmo", "plan_name": "701720", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Ppo Hmo", "plan_name": "701720_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Ms State Emplo", "plan_name": "401457", "standard_charge_dollar": 22.64, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Ms State Emplo", "plan_name": "401457_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Basic Pl", "plan_name": "400100", "standard_charge_dollar": 22.64, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Basic Pl", "plan_name": "400100_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Federal", "plan_name": "400110", "standard_charge_dollar": 22.64, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Federal", "plan_name": "400110_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." } ] } ] }, { "description": "Hc zarontin ethosuzimide", "code_information": [ { "code": "80168", "type": "CPT" } ], "standard_charges": [ { "gross_charge": 85.22, "minimum": 22.64, "maximum": 22.64, "setting": "both", "payers_information": [ { "payer_name": "Aetna", "plan_name": "700700", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna", "plan_name": "700700_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Miscellaneous", "plan_name": "700720", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Miscellaneous", "plan_name": "700720_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Ppo Hmo", "plan_name": "701720", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Ppo Hmo", "plan_name": "701720_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Ms State Emplo", "plan_name": "401457", "standard_charge_dollar": 22.64, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Ms State Emplo", "plan_name": "401457_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Basic Pl", "plan_name": "400100", "standard_charge_dollar": 22.64, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Basic Pl", "plan_name": "400100_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Federal", "plan_name": "400110", "standard_charge_dollar": 22.64, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Federal", "plan_name": "400110_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." } ] } ] }, { "description": "Assay of gentamicin", "code_information": [ { "code": "80170", "type": "CPT" } ], "standard_charges": [ { "gross_charge": 150.00, "minimum": 20.61, "maximum": 20.61, "setting": "both", "payers_information": [ { "payer_name": "Aetna", "plan_name": "700700", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna", "plan_name": "700700_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Miscellaneous", "plan_name": "700720", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Miscellaneous", "plan_name": "700720_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Ppo Hmo", "plan_name": "701720", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Ppo Hmo", "plan_name": "701720_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Ms State Emplo", "plan_name": "401457", "standard_charge_dollar": 20.61, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Ms State Emplo", "plan_name": "401457_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Basic Pl", "plan_name": "400100", "standard_charge_dollar": 20.61, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Basic Pl", "plan_name": "400100_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Federal", "plan_name": "400110", "standard_charge_dollar": 20.61, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Federal", "plan_name": "400110_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." } ] } ] }, { "description": "Hc gentamicin", "code_information": [ { "code": "80170", "type": "CPT" } ], "standard_charges": [ { "gross_charge": 150.00, "minimum": 20.61, "maximum": 20.61, "setting": "both", "payers_information": [ { "payer_name": "Aetna", "plan_name": "700700", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna", "plan_name": "700700_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Miscellaneous", "plan_name": "700720", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Miscellaneous", "plan_name": "700720_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Ppo Hmo", "plan_name": "701720", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Ppo Hmo", "plan_name": "701720_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Ms State Emplo", "plan_name": "401457", "standard_charge_dollar": 20.61, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Ms State Emplo", "plan_name": "401457_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Basic Pl", "plan_name": "400100", "standard_charge_dollar": 20.61, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Basic Pl", "plan_name": "400100_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Federal", "plan_name": "400110", "standard_charge_dollar": 20.61, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Federal", "plan_name": "400110_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." } ] } ] }, { "description": "Assay of haloperidol", "code_information": [ { "code": "80173", "type": "CPT" } ], "standard_charges": [ { "gross_charge": 127.86, "minimum": 21.82, "maximum": 21.82, "setting": "both", "payers_information": [ { "payer_name": "Aetna", "plan_name": "700700", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna", "plan_name": "700700_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Miscellaneous", "plan_name": "700720", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Miscellaneous", "plan_name": "700720_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Ppo Hmo", "plan_name": "701720", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Ppo Hmo", "plan_name": "701720_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Ms State Emplo", "plan_name": "401457", "standard_charge_dollar": 21.82, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Ms State Emplo", "plan_name": "401457_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Basic Pl", "plan_name": "400100", "standard_charge_dollar": 21.82, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Basic Pl", "plan_name": "400100_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Federal", "plan_name": "400110", "standard_charge_dollar": 21.82, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Federal", "plan_name": "400110_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." } ] } ] }, { "description": "Hc haloperidol", "code_information": [ { "code": "80173", "type": "CPT" } ], "standard_charges": [ { "gross_charge": 127.86, "minimum": 21.82, "maximum": 21.82, "setting": "both", "payers_information": [ { "payer_name": "Aetna", "plan_name": "700700", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna", "plan_name": "700700_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Miscellaneous", "plan_name": "700720", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Miscellaneous", "plan_name": "700720_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Ppo Hmo", "plan_name": "701720", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Ppo Hmo", "plan_name": "701720_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Ms State Emplo", "plan_name": "401457", "standard_charge_dollar": 21.82, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Ms State Emplo", "plan_name": "401457_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Basic Pl", "plan_name": "400100", "standard_charge_dollar": 21.82, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Basic Pl", "plan_name": "400100_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Federal", "plan_name": "400110", "standard_charge_dollar": 21.82, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Federal", "plan_name": "400110_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." } ] } ] }, { "description": "Drug screen quan lamotrigine", "code_information": [ { "code": "80175", "type": "CPT" } ], "standard_charges": [ { "gross_charge": 157.00, "minimum": 19.87, "maximum": 19.87, "setting": "both", "payers_information": [ { "payer_name": "Aetna", "plan_name": "700700", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna", "plan_name": "700700_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Miscellaneous", "plan_name": "700720", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Miscellaneous", "plan_name": "700720_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Ppo Hmo", "plan_name": "701720", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Ppo Hmo", "plan_name": "701720_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Ms State Emplo", "plan_name": "401457", "standard_charge_dollar": 19.87, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Ms State Emplo", "plan_name": "401457_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Basic Pl", "plan_name": "400100", "standard_charge_dollar": 19.87, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Basic Pl", "plan_name": "400100_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Federal", "plan_name": "400110", "standard_charge_dollar": 19.87, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Federal", "plan_name": "400110_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." } ] } ] }, { "description": "Hc lamotrigine", "code_information": [ { "code": "80175", "type": "CPT" } ], "standard_charges": [ { "gross_charge": 157.00, "minimum": 19.87, "maximum": 19.87, "setting": "both", "payers_information": [ { "payer_name": "Aetna", "plan_name": "700700", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna", "plan_name": "700700_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Miscellaneous", "plan_name": "700720", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Miscellaneous", "plan_name": "700720_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Ppo Hmo", "plan_name": "701720", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Ppo Hmo", "plan_name": "701720_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Ms State Emplo", "plan_name": "401457", "standard_charge_dollar": 19.87, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Ms State Emplo", "plan_name": "401457_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Basic Pl", "plan_name": "400100", "standard_charge_dollar": 19.87, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Basic Pl", "plan_name": "400100_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Federal", "plan_name": "400110", "standard_charge_dollar": 19.87, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Federal", "plan_name": "400110_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." } ] } ] }, { "description": "Drug scrn quan levetiracetam", "code_information": [ { "code": "80177", "type": "CPT" } ], "standard_charges": [ { "gross_charge": 100.00, "minimum": 19.87, "maximum": 19.87, "setting": "both", "payers_information": [ { "payer_name": "Aetna", "plan_name": "700700", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna", "plan_name": "700700_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Miscellaneous", "plan_name": "700720", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Miscellaneous", "plan_name": "700720_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Ppo Hmo", "plan_name": "701720", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Ppo Hmo", "plan_name": "701720_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Ms State Emplo", "plan_name": "401457", "standard_charge_dollar": 19.87, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Ms State Emplo", "plan_name": "401457_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Basic Pl", "plan_name": "400100", "standard_charge_dollar": 19.87, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Basic Pl", "plan_name": "400100_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Federal", "plan_name": "400110", "standard_charge_dollar": 19.87, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Federal", "plan_name": "400110_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." } ] } ] }, { "description": "Hc levetiracetam", "code_information": [ { "code": "80177", "type": "CPT" } ], "standard_charges": [ { "gross_charge": 100.00, "minimum": 19.87, "maximum": 19.87, "setting": "both", "payers_information": [ { "payer_name": "Aetna", "plan_name": "700700", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna", "plan_name": "700700_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Miscellaneous", "plan_name": "700720", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Miscellaneous", "plan_name": "700720_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Ppo Hmo", "plan_name": "701720", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Ppo Hmo", "plan_name": "701720_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Ms State Emplo", "plan_name": "401457", "standard_charge_dollar": 19.87, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Ms State Emplo", "plan_name": "401457_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Basic Pl", "plan_name": "400100", "standard_charge_dollar": 19.87, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Basic Pl", "plan_name": "400100_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Federal", "plan_name": "400110", "standard_charge_dollar": 19.87, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Federal", "plan_name": "400110_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." } ] } ] }, { "description": "Assay of lithium", "code_information": [ { "code": "80178", "type": "CPT" } ], "standard_charges": [ { "gross_charge": 65.00, "minimum": 9.91, "maximum": 9.91, "setting": "both", "payers_information": [ { "payer_name": "Aetna", "plan_name": "700700", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna", "plan_name": "700700_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Miscellaneous", "plan_name": "700720", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Miscellaneous", "plan_name": "700720_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Ppo Hmo", "plan_name": "701720", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Ppo Hmo", "plan_name": "701720_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Ms State Emplo", "plan_name": "401457", "standard_charge_dollar": 9.91, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Ms State Emplo", "plan_name": "401457_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Basic Pl", "plan_name": "400100", "standard_charge_dollar": 9.91, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Basic Pl", "plan_name": "400100_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Federal", "plan_name": "400110", "standard_charge_dollar": 9.91, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Federal", "plan_name": "400110_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." } ] } ] }, { "description": "Hc lithium", "code_information": [ { "code": "80178", "type": "CPT" } ], "standard_charges": [ { "gross_charge": 65.00, "minimum": 9.91, "maximum": 9.91, "setting": "both", "payers_information": [ { "payer_name": "Aetna", "plan_name": "700700", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna", "plan_name": "700700_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Miscellaneous", "plan_name": "700720", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Miscellaneous", "plan_name": "700720_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Ppo Hmo", "plan_name": "701720", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Ppo Hmo", "plan_name": "701720_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Ms State Emplo", "plan_name": "401457", "standard_charge_dollar": 9.91, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Ms State Emplo", "plan_name": "401457_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Basic Pl", "plan_name": "400100", "standard_charge_dollar": 9.91, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Basic Pl", "plan_name": "400100_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Federal", "plan_name": "400110", "standard_charge_dollar": 9.91, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Federal", "plan_name": "400110_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." } ] } ] }, { "description": "Drug assay salicylate", "code_information": [ { "code": "80179", "type": "CPT" } ], "standard_charges": [ { "gross_charge": 115.00, "minimum": 92.00, "maximum": 97.75, "setting": "both", "payers_information": [ { "payer_name": "Aetna", "plan_name": "700700", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna", "plan_name": "700700_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Miscellaneous", "plan_name": "700720", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Miscellaneous", "plan_name": "700720_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Ppo Hmo", "plan_name": "701720", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Ppo Hmo", "plan_name": "701720_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Ms State Emplo", "plan_name": "401457", "standard_charge_percentage": 0.80, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Ms State Emplo", "plan_name": "401457_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Basic Pl", "plan_name": "400100", "standard_charge_percentage": 0.85, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Basic Pl", "plan_name": "400100_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Federal", "plan_name": "400110", "standard_charge_percentage": 0.85, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Federal", "plan_name": "400110_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." } ] } ] }, { "description": "Hc drug assay salicylate", "code_information": [ { "code": "80179", "type": "CPT" } ], "standard_charges": [ { "gross_charge": 115.00, "minimum": 92.00, "maximum": 97.75, "setting": "both", "payers_information": [ { "payer_name": "Aetna", "plan_name": "700700", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna", "plan_name": "700700_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Miscellaneous", "plan_name": "700720", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Miscellaneous", "plan_name": "700720_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Ppo Hmo", "plan_name": "701720", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Ppo Hmo", "plan_name": "701720_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Ms State Emplo", "plan_name": "401457", "standard_charge_percentage": 0.80, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Ms State Emplo", "plan_name": "401457_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Basic Pl", "plan_name": "400100", "standard_charge_percentage": 0.85, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Basic Pl", "plan_name": "400100_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Federal", "plan_name": "400110", "standard_charge_percentage": 0.85, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Federal", "plan_name": "400110_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." } ] } ] }, { "description": "Drug scrn quan mycophenolate", "code_information": [ { "code": "80180", "type": "CPT" } ], "standard_charges": [ { "gross_charge": 62.38, "minimum": 27.05, "maximum": 27.05, "setting": "both", "payers_information": [ { "payer_name": "Aetna", "plan_name": "700700", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna", "plan_name": "700700_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Miscellaneous", "plan_name": "700720", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Miscellaneous", "plan_name": "700720_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Ppo Hmo", "plan_name": "701720", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Ppo Hmo", "plan_name": "701720_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Ms State Emplo", "plan_name": "401457", "standard_charge_dollar": 27.05, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Ms State Emplo", "plan_name": "401457_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Basic Pl", "plan_name": "400100", "standard_charge_dollar": 27.05, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Basic Pl", "plan_name": "400100_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Federal", "plan_name": "400110", "standard_charge_dollar": 27.05, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Federal", "plan_name": "400110_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." } ] } ] }, { "description": "Hc mycophenolic acid", "code_information": [ { "code": "80180", "type": "CPT" } ], "standard_charges": [ { "gross_charge": 62.38, "minimum": 27.05, "maximum": 27.05, "setting": "both", "payers_information": [ { "payer_name": "Aetna", "plan_name": "700700", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna", "plan_name": "700700_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Miscellaneous", "plan_name": "700720", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Miscellaneous", "plan_name": "700720_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Ppo Hmo", "plan_name": "701720", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Ppo Hmo", "plan_name": "701720_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Ms State Emplo", "plan_name": "401457", "standard_charge_dollar": 27.05, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Ms State Emplo", "plan_name": "401457_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Basic Pl", "plan_name": "400100", "standard_charge_dollar": 27.05, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Basic Pl", "plan_name": "400100_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Federal", "plan_name": "400110", "standard_charge_dollar": 27.05, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Federal", "plan_name": "400110_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." } ] } ] }, { "description": "Drug scrn quant oxcarbazepin", "code_information": [ { "code": "80183", "type": "CPT" } ], "standard_charges": [ { "gross_charge": 94.50, "minimum": 19.87, "maximum": 19.87, "setting": "both", "payers_information": [ { "payer_name": "Aetna", "plan_name": "700700", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna", "plan_name": "700700_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Miscellaneous", "plan_name": "700720", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Miscellaneous", "plan_name": "700720_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Ppo Hmo", "plan_name": "701720", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Ppo Hmo", "plan_name": "701720_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Ms State Emplo", "plan_name": "401457", "standard_charge_dollar": 19.87, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Ms State Emplo", "plan_name": "401457_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Basic Pl", "plan_name": "400100", "standard_charge_dollar": 19.87, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Basic Pl", "plan_name": "400100_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Federal", "plan_name": "400110", "standard_charge_dollar": 19.87, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Federal", "plan_name": "400110_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." } ] } ] }, { "description": "Hc trileptal", "code_information": [ { "code": "80183", "type": "CPT" } ], "standard_charges": [ { "gross_charge": 94.50, "minimum": 19.87, "maximum": 19.87, "setting": "both", "payers_information": [ { "payer_name": "Aetna", "plan_name": "700700", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna", "plan_name": "700700_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Miscellaneous", "plan_name": "700720", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Miscellaneous", "plan_name": "700720_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Ppo Hmo", "plan_name": "701720", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Ppo Hmo", "plan_name": "701720_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Ms State Emplo", "plan_name": "401457", "standard_charge_dollar": 19.87, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Ms State Emplo", "plan_name": "401457_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Basic Pl", "plan_name": "400100", "standard_charge_dollar": 19.87, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Basic Pl", "plan_name": "400100_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Federal", "plan_name": "400110", "standard_charge_dollar": 19.87, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Federal", "plan_name": "400110_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." } ] } ] }, { "description": "Assay of phenobarbital", "code_information": [ { "code": "80184", "type": "CPT" } ], "standard_charges": [ { "gross_charge": 50.00, "minimum": 12.22, "maximum": 12.22, "setting": "both", "payers_information": [ { "payer_name": "Aetna", "plan_name": "700700", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna", "plan_name": "700700_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Miscellaneous", "plan_name": "700720", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Miscellaneous", "plan_name": "700720_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Ppo Hmo", "plan_name": "701720", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Ppo Hmo", "plan_name": "701720_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Ms State Emplo", "plan_name": "401457", "standard_charge_dollar": 12.22, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Ms State Emplo", "plan_name": "401457_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Basic Pl", "plan_name": "400100", "standard_charge_dollar": 12.22, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Basic Pl", "plan_name": "400100_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Federal", "plan_name": "400110", "standard_charge_dollar": 12.22, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Federal", "plan_name": "400110_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." } ] } ] }, { "description": "Hc phenobarbital", "code_information": [ { "code": "80184", "type": "CPT" } ], "standard_charges": [ { "gross_charge": 50.00, "minimum": 12.22, "maximum": 12.22, "setting": "both", "payers_information": [ { "payer_name": "Aetna", "plan_name": "700700", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna", "plan_name": "700700_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Miscellaneous", "plan_name": "700720", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Miscellaneous", "plan_name": "700720_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Ppo Hmo", "plan_name": "701720", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Ppo Hmo", "plan_name": "701720_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Ms State Emplo", "plan_name": "401457", "standard_charge_dollar": 12.22, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Ms State Emplo", "plan_name": "401457_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Basic Pl", "plan_name": "400100", "standard_charge_dollar": 12.22, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Basic Pl", "plan_name": "400100_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Federal", "plan_name": "400110", "standard_charge_dollar": 12.22, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Federal", "plan_name": "400110_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." } ] } ] }, { "description": "Assay of phenytoin total", "code_information": [ { "code": "80185", "type": "CPT" } ], "standard_charges": [ { "gross_charge": 125.00, "minimum": 19.87, "maximum": 19.87, "setting": "both", "payers_information": [ { "payer_name": "Aetna", "plan_name": "700700", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna", "plan_name": "700700_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Miscellaneous", "plan_name": "700720", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Miscellaneous", "plan_name": "700720_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Ppo Hmo", "plan_name": "701720", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Ppo Hmo", "plan_name": "701720_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Ms State Emplo", "plan_name": "401457", "standard_charge_dollar": 19.87, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Ms State Emplo", "plan_name": "401457_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Basic Pl", "plan_name": "400100", "standard_charge_dollar": 19.87, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Basic Pl", "plan_name": "400100_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Federal", "plan_name": "400110", "standard_charge_dollar": 19.87, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Federal", "plan_name": "400110_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." } ] } ] }, { "description": "Hc phenytoin", "code_information": [ { "code": "80185", "type": "CPT" } ], "standard_charges": [ { "gross_charge": 125.00, "minimum": 19.87, "maximum": 19.87, "setting": "both", "payers_information": [ { "payer_name": "Aetna", "plan_name": "700700", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna", "plan_name": "700700_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Miscellaneous", "plan_name": "700720", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Miscellaneous", "plan_name": "700720_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Ppo Hmo", "plan_name": "701720", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Ppo Hmo", "plan_name": "701720_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Ms State Emplo", "plan_name": "401457", "standard_charge_dollar": 19.87, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Ms State Emplo", "plan_name": "401457_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Basic Pl", "plan_name": "400100", "standard_charge_dollar": 19.87, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Basic Pl", "plan_name": "400100_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Federal", "plan_name": "400110", "standard_charge_dollar": 19.87, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Federal", "plan_name": "400110_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." } ] } ] }, { "description": "Assay of tacrolimus", "code_information": [ { "code": "80197", "type": "CPT" } ], "standard_charges": [ { "gross_charge": 150.00, "minimum": 20.58, "maximum": 20.58, "setting": "both", "payers_information": [ { "payer_name": "Aetna", "plan_name": "700700", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna", "plan_name": "700700_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Miscellaneous", "plan_name": "700720", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Miscellaneous", "plan_name": "700720_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Ppo Hmo", "plan_name": "701720", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Ppo Hmo", "plan_name": "701720_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Ms State Emplo", "plan_name": "401457", "standard_charge_dollar": 20.58, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Ms State Emplo", "plan_name": "401457_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Basic Pl", "plan_name": "400100", "standard_charge_dollar": 20.58, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Basic Pl", "plan_name": "400100_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Federal", "plan_name": "400110", "standard_charge_dollar": 20.58, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Federal", "plan_name": "400110_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." } ] } ] }, { "description": "Hc tacrolimus", "code_information": [ { "code": "80197", "type": "CPT" } ], "standard_charges": [ { "gross_charge": 150.00, "minimum": 20.58, "maximum": 20.58, "setting": "both", "payers_information": [ { "payer_name": "Aetna", "plan_name": "700700", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna", "plan_name": "700700_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Miscellaneous", "plan_name": "700720", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Miscellaneous", "plan_name": "700720_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Ppo Hmo", "plan_name": "701720", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Ppo Hmo", "plan_name": "701720_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Ms State Emplo", "plan_name": "401457", "standard_charge_dollar": 20.58, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Ms State Emplo", "plan_name": "401457_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Basic Pl", "plan_name": "400100", "standard_charge_dollar": 20.58, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Basic Pl", "plan_name": "400100_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Federal", "plan_name": "400110", "standard_charge_dollar": 20.58, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Federal", "plan_name": "400110_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." } ] } ] }, { "description": "Assay of theophylline", "code_information": [ { "code": "80198", "type": "CPT" } ], "standard_charges": [ { "gross_charge": 100.00, "minimum": 21.20, "maximum": 21.20, "setting": "both", "payers_information": [ { "payer_name": "Aetna", "plan_name": "700700", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna", "plan_name": "700700_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Miscellaneous", "plan_name": "700720", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Miscellaneous", "plan_name": "700720_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Ppo Hmo", "plan_name": "701720", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Ppo Hmo", "plan_name": "701720_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Ms State Emplo", "plan_name": "401457", "standard_charge_dollar": 21.20, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Ms State Emplo", "plan_name": "401457_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Basic Pl", "plan_name": "400100", "standard_charge_dollar": 21.20, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Basic Pl", "plan_name": "400100_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Federal", "plan_name": "400110", "standard_charge_dollar": 21.20, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Federal", "plan_name": "400110_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." } ] } ] }, { "description": "Hc theophylline", "code_information": [ { "code": "80198", "type": "CPT" } ], "standard_charges": [ { "gross_charge": 100.00, "minimum": 21.20, "maximum": 21.20, "setting": "both", "payers_information": [ { "payer_name": "Aetna", "plan_name": "700700", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna", "plan_name": "700700_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Miscellaneous", "plan_name": "700720", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Miscellaneous", "plan_name": "700720_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Ppo Hmo", "plan_name": "701720", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Ppo Hmo", "plan_name": "701720_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Ms State Emplo", "plan_name": "401457", "standard_charge_dollar": 21.20, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Ms State Emplo", "plan_name": "401457_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Basic Pl", "plan_name": "400100", "standard_charge_dollar": 21.20, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Basic Pl", "plan_name": "400100_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Federal", "plan_name": "400110", "standard_charge_dollar": 21.20, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Federal", "plan_name": "400110_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." } ] } ] }, { "description": "Assay of tobramycin", "code_information": [ { "code": "80200", "type": "CPT" } ], "standard_charges": [ { "gross_charge": 82.42, "minimum": 22.64, "maximum": 22.64, "setting": "both", "payers_information": [ { "payer_name": "Aetna", "plan_name": "700700", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna", "plan_name": "700700_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Miscellaneous", "plan_name": "700720", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Miscellaneous", "plan_name": "700720_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Ppo Hmo", "plan_name": "701720", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Ppo Hmo", "plan_name": "701720_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Ms State Emplo", "plan_name": "401457", "standard_charge_dollar": 22.64, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Ms State Emplo", "plan_name": "401457_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Basic Pl", "plan_name": "400100", "standard_charge_dollar": 22.64, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Basic Pl", "plan_name": "400100_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Federal", "plan_name": "400110", "standard_charge_dollar": 22.64, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Federal", "plan_name": "400110_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." } ] } ] }, { "description": "Hc tobramycin", "code_information": [ { "code": "80200", "type": "CPT" } ], "standard_charges": [ { "gross_charge": 82.42, "minimum": 22.64, "maximum": 22.64, "setting": "both", "payers_information": [ { "payer_name": "Aetna", "plan_name": "700700", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna", "plan_name": "700700_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Miscellaneous", "plan_name": "700720", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Miscellaneous", "plan_name": "700720_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Ppo Hmo", "plan_name": "701720", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Ppo Hmo", "plan_name": "701720_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Ms State Emplo", "plan_name": "401457", "standard_charge_dollar": 22.64, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Ms State Emplo", "plan_name": "401457_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Basic Pl", "plan_name": "400100", "standard_charge_dollar": 22.64, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Basic Pl", "plan_name": "400100_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Federal", "plan_name": "400110", "standard_charge_dollar": 22.64, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Federal", "plan_name": "400110_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." } ] } ] }, { "description": "Assay of topiramate", "code_information": [ { "code": "80201", "type": "CPT" } ], "standard_charges": [ { "gross_charge": 101.50, "minimum": 17.86, "maximum": 17.86, "setting": "both", "payers_information": [ { "payer_name": "Aetna", "plan_name": "700700", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna", "plan_name": "700700_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Miscellaneous", "plan_name": "700720", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Miscellaneous", "plan_name": "700720_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Ppo Hmo", "plan_name": "701720", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Ppo Hmo", "plan_name": "701720_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Ms State Emplo", "plan_name": "401457", "standard_charge_dollar": 17.86, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Ms State Emplo", "plan_name": "401457_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Basic Pl", "plan_name": "400100", "standard_charge_dollar": 17.86, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Basic Pl", "plan_name": "400100_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Federal", "plan_name": "400110", "standard_charge_dollar": 17.86, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Federal", "plan_name": "400110_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." } ] } ] }, { "description": "Hc topiramate ser", "code_information": [ { "code": "80201", "type": "CPT" } ], "standard_charges": [ { "gross_charge": 101.50, "minimum": 17.86, "maximum": 17.86, "setting": "both", "payers_information": [ { "payer_name": "Aetna", "plan_name": "700700", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna", "plan_name": "700700_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Miscellaneous", "plan_name": "700720", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Miscellaneous", "plan_name": "700720_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Ppo Hmo", "plan_name": "701720", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Ppo Hmo", "plan_name": "701720_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Ms State Emplo", "plan_name": "401457", "standard_charge_dollar": 17.86, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Ms State Emplo", "plan_name": "401457_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Basic Pl", "plan_name": "400100", "standard_charge_dollar": 17.86, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Basic Pl", "plan_name": "400100_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Federal", "plan_name": "400110", "standard_charge_dollar": 17.86, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Federal", "plan_name": "400110_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." } ] } ] }, { "description": "Assay of vancomycin", "code_information": [ { "code": "80202", "type": "CPT" } ], "standard_charges": [ { "gross_charge": 175.00, "minimum": 20.31, "maximum": 20.31, "setting": "both", "payers_information": [ { "payer_name": "Aetna", "plan_name": "700700", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna", "plan_name": "700700_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Miscellaneous", "plan_name": "700720", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Miscellaneous", "plan_name": "700720_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Ppo Hmo", "plan_name": "701720", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Ppo Hmo", "plan_name": "701720_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Ms State Emplo", "plan_name": "401457", "standard_charge_dollar": 20.31, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Ms State Emplo", "plan_name": "401457_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Basic Pl", "plan_name": "400100", "standard_charge_dollar": 20.31, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Basic Pl", "plan_name": "400100_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Federal", "plan_name": "400110", "standard_charge_dollar": 20.31, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Federal", "plan_name": "400110_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." } ] } ] }, { "description": "Hc vancomycin", "code_information": [ { "code": "80202", "type": "CPT" } ], "standard_charges": [ { "gross_charge": 175.00, "minimum": 20.31, "maximum": 20.31, "setting": "both", "payers_information": [ { "payer_name": "Aetna", "plan_name": "700700", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna", "plan_name": "700700_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Miscellaneous", "plan_name": "700720", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Miscellaneous", "plan_name": "700720_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Ppo Hmo", "plan_name": "701720", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Ppo Hmo", "plan_name": "701720_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Ms State Emplo", "plan_name": "401457", "standard_charge_dollar": 20.31, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Ms State Emplo", "plan_name": "401457_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Basic Pl", "plan_name": "400100", "standard_charge_dollar": 20.31, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Basic Pl", "plan_name": "400100_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Federal", "plan_name": "400110", "standard_charge_dollar": 20.31, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Federal", "plan_name": "400110_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." } ] } ] }, { "description": "Drug assay rufinamide", "code_information": [ { "code": "80210", "type": "CPT" } ], "standard_charges": [ { "gross_charge": 177.60, "minimum": 142.08, "maximum": 150.96, "setting": "both", "payers_information": [ { "payer_name": "Aetna", "plan_name": "700700", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna", "plan_name": "700700_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Miscellaneous", "plan_name": "700720", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Miscellaneous", "plan_name": "700720_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Ppo Hmo", "plan_name": "701720", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Ppo Hmo", "plan_name": "701720_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Ms State Emplo", "plan_name": "401457", "standard_charge_percentage": 0.80, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Ms State Emplo", "plan_name": "401457_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Basic Pl", "plan_name": "400100", "standard_charge_percentage": 0.85, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Basic Pl", "plan_name": "400100_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Federal", "plan_name": "400110", "standard_charge_percentage": 0.85, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Federal", "plan_name": "400110_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." } ] } ] }, { "description": "Hc rufinamide s (mayo)", "code_information": [ { "code": "80210", "type": "CPT" } ], "standard_charges": [ { "gross_charge": 177.60, "minimum": 142.08, "maximum": 150.96, "setting": "both", "payers_information": [ { "payer_name": "Aetna", "plan_name": "700700", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna", "plan_name": "700700_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Miscellaneous", "plan_name": "700720", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Miscellaneous", "plan_name": "700720_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Ppo Hmo", "plan_name": "701720", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Ppo Hmo", "plan_name": "701720_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Ms State Emplo", "plan_name": "401457", "standard_charge_percentage": 0.80, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Ms State Emplo", "plan_name": "401457_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Basic Pl", "plan_name": "400100", "standard_charge_percentage": 0.85, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Basic Pl", "plan_name": "400100_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Federal", "plan_name": "400110", "standard_charge_percentage": 0.85, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Federal", "plan_name": "400110_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." } ] } ] }, { "description": "Drug assay lacosamide", "code_information": [ { "code": "80235", "type": "CPT" } ], "standard_charges": [ { "gross_charge": 221.70, "minimum": 177.36, "maximum": 188.45, "setting": "both", "payers_information": [ { "payer_name": "Aetna", "plan_name": "700700", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna", "plan_name": "700700_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Miscellaneous", "plan_name": "700720", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Miscellaneous", "plan_name": "700720_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Ppo Hmo", "plan_name": "701720", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Ppo Hmo", "plan_name": "701720_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Ms State Emplo", "plan_name": "401457", "standard_charge_percentage": 0.80, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Ms State Emplo", "plan_name": "401457_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Basic Pl", "plan_name": "400100", "standard_charge_percentage": 0.85, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Basic Pl", "plan_name": "400100_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Federal", "plan_name": "400110", "standard_charge_percentage": 0.85, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Federal", "plan_name": "400110_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." } ] } ] }, { "description": "Hc lacosamide (vimpat)", "code_information": [ { "code": "80235", "type": "CPT" } ], "standard_charges": [ { "gross_charge": 221.70, "minimum": 177.36, "maximum": 188.45, "setting": "both", "payers_information": [ { "payer_name": "Aetna", "plan_name": "700700", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna", "plan_name": "700700_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Miscellaneous", "plan_name": "700720", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Miscellaneous", "plan_name": "700720_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Ppo Hmo", "plan_name": "701720", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Ppo Hmo", "plan_name": "701720_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Ms State Emplo", "plan_name": "401457", "standard_charge_percentage": 0.80, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Ms State Emplo", "plan_name": "401457_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Basic Pl", "plan_name": "400100", "standard_charge_percentage": 0.85, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Basic Pl", "plan_name": "400100_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Federal", "plan_name": "400110", "standard_charge_percentage": 0.85, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Federal", "plan_name": "400110_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." } ] } ] }, { "description": "Hc ustekinumab qt (mayo)", "code_information": [ { "code": "80299", "type": "CPT" } ], "standard_charges": [ { "gross_charge": 262.62, "minimum": 20.53, "maximum": 20.53, "setting": "both", "payers_information": [ { "payer_name": "Aetna", "plan_name": "700700", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna", "plan_name": "700700_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Miscellaneous", "plan_name": "700720", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Miscellaneous", "plan_name": "700720_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Ppo Hmo", "plan_name": "701720", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Ppo Hmo", "plan_name": "701720_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Ms State Emplo", "plan_name": "401457", "standard_charge_dollar": 20.53, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Ms State Emplo", "plan_name": "401457_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Basic Pl", "plan_name": "400100", "standard_charge_dollar": 20.53, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Basic Pl", "plan_name": "400100_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Federal", "plan_name": "400110", "standard_charge_dollar": 20.53, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Federal", "plan_name": "400110_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." } ] } ] }, { "description": "Quantitative assay drug", "code_information": [ { "code": "80299", "type": "CPT" } ], "standard_charges": [ { "gross_charge": 262.62, "minimum": 20.53, "maximum": 20.53, "setting": "both", "payers_information": [ { "payer_name": "Aetna", "plan_name": "700700", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna", "plan_name": "700700_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Miscellaneous", "plan_name": "700720", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Miscellaneous", "plan_name": "700720_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Ppo Hmo", "plan_name": "701720", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Ppo Hmo", "plan_name": "701720_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Ms State Emplo", "plan_name": "401457", "standard_charge_dollar": 20.53, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Ms State Emplo", "plan_name": "401457_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Basic Pl", "plan_name": "400100", "standard_charge_dollar": 20.53, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Basic Pl", "plan_name": "400100_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Federal", "plan_name": "400110", "standard_charge_dollar": 20.53, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Federal", "plan_name": "400110_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." } ] } ] }, { "description": "Drug test prsmv dir opt obs", "code_information": [ { "code": "80305", "type": "CPT" } ], "standard_charges": [ { "gross_charge": 75.00, "minimum": 16.46, "maximum": 16.46, "setting": "both", "payers_information": [ { "payer_name": "Aetna", "plan_name": "700700", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna", "plan_name": "700700_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Miscellaneous", "plan_name": "700720", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Miscellaneous", "plan_name": "700720_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Ppo Hmo", "plan_name": "701720", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Ppo Hmo", "plan_name": "701720_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Ms State Emplo", "plan_name": "401457", "standard_charge_dollar": 16.46, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Ms State Emplo", "plan_name": "401457_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Basic Pl", "plan_name": "400100", "standard_charge_dollar": 16.46, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Basic Pl", "plan_name": "400100_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Federal", "plan_name": "400110", "standard_charge_dollar": 16.46, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Federal", "plan_name": "400110_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." } ] } ] }, { "description": "Hc drug test prsmv dir opt obs", "code_information": [ { "code": "80305", "type": "CPT" } ], "standard_charges": [ { "gross_charge": 75.00, "minimum": 16.46, "maximum": 16.46, "setting": "both", "payers_information": [ { "payer_name": "Aetna", "plan_name": "700700", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna", "plan_name": "700700_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Miscellaneous", "plan_name": "700720", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Miscellaneous", "plan_name": "700720_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Ppo Hmo", "plan_name": "701720", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Ppo Hmo", "plan_name": "701720_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Ms State Emplo", "plan_name": "401457", "standard_charge_dollar": 16.46, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Ms State Emplo", "plan_name": "401457_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Basic Pl", "plan_name": "400100", "standard_charge_dollar": 16.46, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Basic Pl", "plan_name": "400100_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Federal", "plan_name": "400110", "standard_charge_dollar": 16.46, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Federal", "plan_name": "400110_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." } ] } ] }, { "description": "Drug test prsmv instrmnt", "code_information": [ { "code": "80306", "type": "CPT" } ], "standard_charges": [ { "gross_charge": 100.00, "minimum": 21.95, "maximum": 21.95, "setting": "both", "payers_information": [ { "payer_name": "Aetna", "plan_name": "700700", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna", "plan_name": "700700_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Miscellaneous", "plan_name": "700720", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Miscellaneous", "plan_name": "700720_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Ppo Hmo", "plan_name": "701720", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Ppo Hmo", "plan_name": "701720_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Ms State Emplo", "plan_name": "401457", "standard_charge_dollar": 21.95, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Ms State Emplo", "plan_name": "401457_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Basic Pl", "plan_name": "400100", "standard_charge_dollar": 21.95, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Basic Pl", "plan_name": "400100_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Federal", "plan_name": "400110", "standard_charge_dollar": 21.95, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Federal", "plan_name": "400110_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." } ] } ] }, { "description": "Hc urine drug screen w/cc (lch 9 test)", "code_information": [ { "code": "80306", "type": "CPT" } ], "standard_charges": [ { "gross_charge": 100.00, "minimum": 21.95, "maximum": 21.95, "setting": "both", "payers_information": [ { "payer_name": "Aetna", "plan_name": "700700", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna", "plan_name": "700700_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Miscellaneous", "plan_name": "700720", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Miscellaneous", "plan_name": "700720_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Ppo Hmo", "plan_name": "701720", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Ppo Hmo", "plan_name": "701720_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Ms State Emplo", "plan_name": "401457", "standard_charge_dollar": 21.95, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Ms State Emplo", "plan_name": "401457_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Basic Pl", "plan_name": "400100", "standard_charge_dollar": 21.95, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Basic Pl", "plan_name": "400100_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Federal", "plan_name": "400110", "standard_charge_dollar": 21.95, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Federal", "plan_name": "400110_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." } ] } ] }, { "description": "Drug test prsmv chem anlyzr", "code_information": [ { "code": "80307", "type": "CPT" } ], "standard_charges": [ { "gross_charge": 320.00, "minimum": 87.79, "maximum": 87.79, "setting": "both", "payers_information": [ { "payer_name": "Aetna", "plan_name": "700700", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna", "plan_name": "700700_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Miscellaneous", "plan_name": "700720", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Miscellaneous", "plan_name": "700720_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Ppo Hmo", "plan_name": "701720", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Ppo Hmo", "plan_name": "701720_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Ms State Emplo", "plan_name": "401457", "standard_charge_dollar": 87.79, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Ms State Emplo", "plan_name": "401457_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Basic Pl", "plan_name": "400100", "standard_charge_dollar": 87.79, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Basic Pl", "plan_name": "400100_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Federal", "plan_name": "400110", "standard_charge_dollar": 87.79, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Federal", "plan_name": "400110_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." } ] } ] }, { "description": "Hc fentanyl screen urine", "code_information": [ { "code": "80307", "type": "CPT" } ], "standard_charges": [ { "gross_charge": 320.00, "minimum": 87.79, "maximum": 87.79, "setting": "both", "payers_information": [ { "payer_name": "Aetna", "plan_name": "700700", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna", "plan_name": "700700_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Miscellaneous", "plan_name": "700720", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Miscellaneous", "plan_name": "700720_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Ppo Hmo", "plan_name": "701720", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Ppo Hmo", "plan_name": "701720_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Ms State Emplo", "plan_name": "401457", "standard_charge_dollar": 87.79, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Ms State Emplo", "plan_name": "401457_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Basic Pl", "plan_name": "400100", "standard_charge_dollar": 87.79, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Basic Pl", "plan_name": "400100_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Federal", "plan_name": "400110", "standard_charge_dollar": 87.79, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Federal", "plan_name": "400110_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." } ] } ] }, { "description": "Hc fentanyl screen urine", "code_information": [ { "code": "80307", "type": "CPT" } ], "standard_charges": [ { "gross_charge": 320.00, "minimum": 256.00, "maximum": 272.00, "setting": "both", "payers_information": [ { "payer_name": "Aetna", "plan_name": "700700", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "modifiers": "QW", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna", "plan_name": "700700_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Miscellaneous", "plan_name": "700720", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Miscellaneous", "plan_name": "700720_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Ppo Hmo", "plan_name": "701720", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Ppo Hmo", "plan_name": "701720_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Ms State Emplo", "plan_name": "401457", "standard_charge_percentage": 0.80, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Ms State Emplo", "plan_name": "401457_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Basic Pl", "plan_name": "400100", "standard_charge_percentage": 0.85, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Basic Pl", "plan_name": "400100_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Federal", "plan_name": "400110", "standard_charge_percentage": 0.85, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Federal", "plan_name": "400110_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." } ] } ] }, { "description": "Drug screen quantalcohols", "code_information": [ { "code": "80320", "type": "CPT" } ], "standard_charges": [ { "gross_charge": 157.18, "minimum": 25.50, "maximum": 25.50, "setting": "both", "payers_information": [ { "payer_name": "Aetna", "plan_name": "700700", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna", "plan_name": "700700_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Miscellaneous", "plan_name": "700720", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Miscellaneous", "plan_name": "700720_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Ppo Hmo", "plan_name": "701720", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Ppo Hmo", "plan_name": "701720_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Ms State Emplo", "plan_name": "401457", "standard_charge_dollar": 25.50, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Ms State Emplo", "plan_name": "401457_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Basic Pl", "plan_name": "400100", "standard_charge_dollar": 25.50, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Basic Pl", "plan_name": "400100_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Federal", "plan_name": "400110", "standard_charge_dollar": 25.50, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Federal", "plan_name": "400110_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." } ] } ] }, { "description": "Hc ethylene glycol (etgl)", "code_information": [ { "code": "80320", "type": "CPT" } ], "standard_charges": [ { "gross_charge": 157.18, "minimum": 25.50, "maximum": 25.50, "setting": "both", "payers_information": [ { "payer_name": "Aetna", "plan_name": "700700", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna", "plan_name": "700700_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Miscellaneous", "plan_name": "700720", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Miscellaneous", "plan_name": "700720_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Ppo Hmo", "plan_name": "701720", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Ppo Hmo", "plan_name": "701720_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Ms State Emplo", "plan_name": "401457", "standard_charge_dollar": 25.50, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Ms State Emplo", "plan_name": "401457_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Basic Pl", "plan_name": "400100", "standard_charge_dollar": 25.50, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Basic Pl", "plan_name": "400100_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Federal", "plan_name": "400110", "standard_charge_dollar": 25.50, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Federal", "plan_name": "400110_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." } ] } ] }, { "description": "Alkaloids nos", "code_information": [ { "code": "80323", "type": "CPT" } ], "standard_charges": [ { "gross_charge": 117.62, "minimum": 66.00, "maximum": 66.00, "setting": "both", "payers_information": [ { "payer_name": "Aetna", "plan_name": "700700", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna", "plan_name": "700700_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Miscellaneous", "plan_name": "700720", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Miscellaneous", "plan_name": "700720_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Ppo Hmo", "plan_name": "701720", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Ppo Hmo", "plan_name": "701720_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Ms State Emplo", "plan_name": "401457", "standard_charge_dollar": 66.00, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Ms State Emplo", "plan_name": "401457_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Basic Pl", "plan_name": "400100", "standard_charge_dollar": 66.00, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Basic Pl", "plan_name": "400100_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Federal", "plan_name": "400110", "standard_charge_dollar": 66.00, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Federal", "plan_name": "400110_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." } ] } ] }, { "description": "Hc nicotine and metabolies s", "code_information": [ { "code": "80323", "type": "CPT" } ], "standard_charges": [ { "gross_charge": 117.62, "minimum": 66.00, "maximum": 66.00, "setting": "both", "payers_information": [ { "payer_name": "Aetna", "plan_name": "700700", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna", "plan_name": "700700_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Miscellaneous", "plan_name": "700720", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Miscellaneous", "plan_name": "700720_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Ppo Hmo", "plan_name": "701720", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Ppo Hmo", "plan_name": "701720_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Ms State Emplo", "plan_name": "401457", "standard_charge_dollar": 66.00, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Ms State Emplo", "plan_name": "401457_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Basic Pl", "plan_name": "400100", "standard_charge_dollar": 66.00, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Basic Pl", "plan_name": "400100_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Federal", "plan_name": "400110", "standard_charge_dollar": 66.00, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Federal", "plan_name": "400110_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." } ] } ] }, { "description": "Amphetamines 3or 4", "code_information": [ { "code": "80325", "type": "CPT" } ], "standard_charges": [ { "gross_charge": 126.66, "minimum": 42.00, "maximum": 42.00, "setting": "both", "payers_information": [ { "payer_name": "Aetna", "plan_name": "700700", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna", "plan_name": "700700_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Miscellaneous", "plan_name": "700720", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Miscellaneous", "plan_name": "700720_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Ppo Hmo", "plan_name": "701720", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Ppo Hmo", "plan_name": "701720_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Ms State Emplo", "plan_name": "401457", "standard_charge_dollar": 42.00, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Ms State Emplo", "plan_name": "401457_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Basic Pl", "plan_name": "400100", "standard_charge_dollar": 42.00, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Basic Pl", "plan_name": "400100_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Federal", "plan_name": "400110", "standard_charge_dollar": 42.00, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Federal", "plan_name": "400110_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." } ] } ] }, { "description": "Hc amphetamine urine", "code_information": [ { "code": "80325", "type": "CPT" } ], "standard_charges": [ { "gross_charge": 126.66, "minimum": 42.00, "maximum": 42.00, "setting": "both", "payers_information": [ { "payer_name": "Aetna", "plan_name": "700700", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna", "plan_name": "700700_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Miscellaneous", "plan_name": "700720", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Miscellaneous", "plan_name": "700720_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Ppo Hmo", "plan_name": "701720", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Ppo Hmo", "plan_name": "701720_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Ms State Emplo", "plan_name": "401457", "standard_charge_dollar": 42.00, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Ms State Emplo", "plan_name": "401457_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Basic Pl", "plan_name": "400100", "standard_charge_dollar": 42.00, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Basic Pl", "plan_name": "400100_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Federal", "plan_name": "400110", "standard_charge_dollar": 42.00, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Federal", "plan_name": "400110_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." } ] } ] }, { "description": "Amphetamines 5 or more", "code_information": [ { "code": "80326", "type": "CPT" } ], "standard_charges": [ { "gross_charge": 108.76, "minimum": 42.00, "maximum": 42.00, "setting": "both", "payers_information": [ { "payer_name": "Aetna", "plan_name": "700700", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna", "plan_name": "700700_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Miscellaneous", "plan_name": "700720", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Miscellaneous", "plan_name": "700720_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Ppo Hmo", "plan_name": "701720", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Ppo Hmo", "plan_name": "701720_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Ms State Emplo", "plan_name": "401457", "standard_charge_dollar": 42.00, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Ms State Emplo", "plan_name": "401457_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Basic Pl", "plan_name": "400100", "standard_charge_dollar": 42.00, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Basic Pl", "plan_name": "400100_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Federal", "plan_name": "400110", "standard_charge_dollar": 42.00, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Federal", "plan_name": "400110_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." } ] } ] }, { "description": "Hc amphetamines", "code_information": [ { "code": "80326", "type": "CPT" } ], "standard_charges": [ { "gross_charge": 108.76, "minimum": 42.00, "maximum": 42.00, "setting": "both", "payers_information": [ { "payer_name": "Aetna", "plan_name": "700700", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna", "plan_name": "700700_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Miscellaneous", "plan_name": "700720", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Miscellaneous", "plan_name": "700720_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Ppo Hmo", "plan_name": "701720", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Ppo Hmo", "plan_name": "701720_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Ms State Emplo", "plan_name": "401457", "standard_charge_dollar": 42.00, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Ms State Emplo", "plan_name": "401457_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Basic Pl", "plan_name": "400100", "standard_charge_dollar": 42.00, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Basic Pl", "plan_name": "400100_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Federal", "plan_name": "400110", "standard_charge_dollar": 42.00, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Federal", "plan_name": "400110_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." } ] } ] }, { "description": "Antidepressant tricyclic 1/2", "code_information": [ { "code": "80335", "type": "CPT" } ], "standard_charges": [ { "gross_charge": 228.86, "minimum": 35.25, "maximum": 35.25, "setting": "both", "payers_information": [ { "payer_name": "Aetna", "plan_name": "700700", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna", "plan_name": "700700_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Miscellaneous", "plan_name": "700720", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Miscellaneous", "plan_name": "700720_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Ppo Hmo", "plan_name": "701720", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Ppo Hmo", "plan_name": "701720_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Ms State Emplo", "plan_name": "401457", "standard_charge_dollar": 35.25, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Ms State Emplo", "plan_name": "401457_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Basic Pl", "plan_name": "400100", "standard_charge_dollar": 35.25, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Basic Pl", "plan_name": "400100_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Federal", "plan_name": "400110", "standard_charge_dollar": 35.25, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Federal", "plan_name": "400110_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." } ] } ] }, { "description": "Hc amitriptyline part nortriptyline", "code_information": [ { "code": "80335", "type": "CPT" } ], "standard_charges": [ { "gross_charge": 228.86, "minimum": 35.25, "maximum": 35.25, "setting": "both", "payers_information": [ { "payer_name": "Aetna", "plan_name": "700700", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna", "plan_name": "700700_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Miscellaneous", "plan_name": "700720", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Miscellaneous", "plan_name": "700720_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Ppo Hmo", "plan_name": "701720", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Ppo Hmo", "plan_name": "701720_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Ms State Emplo", "plan_name": "401457", "standard_charge_dollar": 35.25, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Ms State Emplo", "plan_name": "401457_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Basic Pl", "plan_name": "400100", "standard_charge_dollar": 35.25, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Basic Pl", "plan_name": "400100_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Federal", "plan_name": "400110", "standard_charge_dollar": 35.25, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Federal", "plan_name": "400110_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." } ] } ] }, { "description": "Benzodiazepines1-12", "code_information": [ { "code": "80346", "type": "CPT" } ], "standard_charges": [ { "gross_charge": 206.00, "minimum": 37.70, "maximum": 37.70, "setting": "both", "payers_information": [ { "payer_name": "Aetna", "plan_name": "700700", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna", "plan_name": "700700_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Miscellaneous", "plan_name": "700720", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Miscellaneous", "plan_name": "700720_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Ppo Hmo", "plan_name": "701720", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Ppo Hmo", "plan_name": "701720_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Ms State Emplo", "plan_name": "401457", "standard_charge_dollar": 37.70, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Ms State Emplo", "plan_name": "401457_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Basic Pl", "plan_name": "400100", "standard_charge_dollar": 37.70, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Basic Pl", "plan_name": "400100_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Federal", "plan_name": "400110", "standard_charge_dollar": 37.70, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Federal", "plan_name": "400110_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." } ] } ] }, { "description": "Hc clonazepam and metabolite (mayo)", "code_information": [ { "code": "80346", "type": "CPT" } ], "standard_charges": [ { "gross_charge": 206.00, "minimum": 37.70, "maximum": 37.70, "setting": "both", "payers_information": [ { "payer_name": "Aetna", "plan_name": "700700", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna", "plan_name": "700700_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Miscellaneous", "plan_name": "700720", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Miscellaneous", "plan_name": "700720_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Ppo Hmo", "plan_name": "701720", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Ppo Hmo", "plan_name": "701720_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Ms State Emplo", "plan_name": "401457", "standard_charge_dollar": 37.70, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Ms State Emplo", "plan_name": "401457_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Basic Pl", "plan_name": "400100", "standard_charge_dollar": 37.70, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Basic Pl", "plan_name": "400100_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Federal", "plan_name": "400110", "standard_charge_dollar": 37.70, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Federal", "plan_name": "400110_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." } ] } ] }, { "description": "Hc methylenedioxyamphetamines (famcs)", "code_information": [ { "code": "80359", "type": "CPT" } ], "standard_charges": [ { "gross_charge": 119.24, "minimum": 42.00, "maximum": 42.00, "setting": "both", "payers_information": [ { "payer_name": "Aetna", "plan_name": "700700", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna", "plan_name": "700700_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Miscellaneous", "plan_name": "700720", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Miscellaneous", "plan_name": "700720_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Ppo Hmo", "plan_name": "701720", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Ppo Hmo", "plan_name": "701720_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Ms State Emplo", "plan_name": "401457", "standard_charge_dollar": 42.00, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Ms State Emplo", "plan_name": "401457_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Basic Pl", "plan_name": "400100", "standard_charge_dollar": 42.00, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Basic Pl", "plan_name": "400100_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Federal", "plan_name": "400110", "standard_charge_dollar": 42.00, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Federal", "plan_name": "400110_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." } ] } ] }, { "description": "Methylenedioxyamphetamines", "code_information": [ { "code": "80359", "type": "CPT" } ], "standard_charges": [ { "gross_charge": 119.24, "minimum": 42.00, "maximum": 42.00, "setting": "both", "payers_information": [ { "payer_name": "Aetna", "plan_name": "700700", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna", "plan_name": "700700_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Miscellaneous", "plan_name": "700720", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Miscellaneous", "plan_name": "700720_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Ppo Hmo", "plan_name": "701720", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Ppo Hmo", "plan_name": "701720_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Ms State Emplo", "plan_name": "401457", "standard_charge_dollar": 42.00, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Ms State Emplo", "plan_name": "401457_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Basic Pl", "plan_name": "400100", "standard_charge_dollar": 42.00, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Basic Pl", "plan_name": "400100_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Federal", "plan_name": "400110", "standard_charge_dollar": 42.00, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Federal", "plan_name": "400110_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." } ] } ] }, { "description": "Hc drug screening opioids and opiate analogs 1 or 2", "code_information": [ { "code": "80362", "type": "CPT" } ], "standard_charges": [ { "gross_charge": 117.62, "minimum": 40.11, "maximum": 40.11, "setting": "both", "payers_information": [ { "payer_name": "Aetna", "plan_name": "700700", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna", "plan_name": "700700_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Miscellaneous", "plan_name": "700720", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Miscellaneous", "plan_name": "700720_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Ppo Hmo", "plan_name": "701720", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Ppo Hmo", "plan_name": "701720_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Ms State Emplo", "plan_name": "401457", "standard_charge_dollar": 40.11, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Ms State Emplo", "plan_name": "401457_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Basic Pl", "plan_name": "400100", "standard_charge_dollar": 40.11, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Basic Pl", "plan_name": "400100_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Federal", "plan_name": "400110", "standard_charge_dollar": 40.11, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Federal", "plan_name": "400110_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." } ] } ] }, { "description": "Opioids & opiate analogs 1/2", "code_information": [ { "code": "80362", "type": "CPT" } ], "standard_charges": [ { "gross_charge": 117.62, "minimum": 40.11, "maximum": 40.11, "setting": "both", "payers_information": [ { "payer_name": "Aetna", "plan_name": "700700", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna", "plan_name": "700700_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate 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}, { "payer_name": "Bc/Bs Ms State Emplo", "plan_name": "401457", "standard_charge_dollar": 40.11, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Ms State Emplo", "plan_name": "401457_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Basic Pl", "plan_name": "400100", "standard_charge_dollar": 40.11, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Basic Pl", "plan_name": "400100_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Federal", "plan_name": "400110", "standard_charge_dollar": 40.11, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Federal", "plan_name": "400110_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." } ] } ] }, { "description": "Hc targeted opioid screen", "code_information": [ { "code": "80364", "type": "CPT" } ], "standard_charges": [ { "gross_charge": 377.70, "minimum": 40.11, "maximum": 40.11, "setting": "both", "payers_information": [ { "payer_name": "Aetna", "plan_name": "700700", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna", "plan_name": "700700_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Miscellaneous", "plan_name": "700720", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Miscellaneous", "plan_name": "700720_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Ppo Hmo", "plan_name": "701720", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Ppo Hmo", "plan_name": "701720_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Ms State Emplo", "plan_name": "401457", "standard_charge_dollar": 40.11, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Ms State Emplo", "plan_name": "401457_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Basic Pl", "plan_name": "400100", "standard_charge_dollar": 40.11, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Basic Pl", "plan_name": "400100_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Federal", "plan_name": "400110", "standard_charge_dollar": 40.11, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Federal", "plan_name": "400110_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." } ] } ] }, { "description": "Opioid &opiate analog 5/more", "code_information": [ { "code": "80364", "type": "CPT" } ], "standard_charges": [ { "gross_charge": 377.70, "minimum": 40.11, "maximum": 40.11, "setting": "both", "payers_information": [ { "payer_name": "Aetna", "plan_name": "700700", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna", "plan_name": "700700_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Miscellaneous", "plan_name": "700720", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Miscellaneous", "plan_name": "700720_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Ppo Hmo", "plan_name": "701720", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data 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"Bc/Bs Of Ms Basic Pl", "plan_name": "400100_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Federal", "plan_name": "400110", "standard_charge_dollar": 40.11, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Federal", "plan_name": "400110_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." } ] } ] }, { "description": "Hc urinalysis with micro", "code_information": [ { "code": "81001", "type": "CPT" } ], "standard_charges": [ { "gross_charge": 55.00, "minimum": 4.75, "maximum": 4.75, "setting": "both", "payers_information": [ { "payer_name": "Aetna", "plan_name": "700700", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna", "plan_name": "700700_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Miscellaneous", "plan_name": "700720", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Miscellaneous", "plan_name": "700720_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Ppo Hmo", "plan_name": "701720", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Ppo Hmo", "plan_name": "701720_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Ms State Emplo", "plan_name": "401457", "standard_charge_dollar": 4.75, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Ms State Emplo", "plan_name": "401457_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Basic Pl", "plan_name": "400100", "standard_charge_dollar": 4.75, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Basic Pl", "plan_name": "400100_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Federal", "plan_name": "400110", "standard_charge_dollar": 4.75, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Federal", "plan_name": "400110_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." } ] } ] }, { "description": "Urinalysis auto w/scope", "code_information": [ { "code": "81001", "type": "CPT" } ], "standard_charges": [ { "gross_charge": 55.00, "minimum": 4.75, "maximum": 4.75, "setting": "both", "payers_information": [ { "payer_name": "Aetna", "plan_name": "700700", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna", "plan_name": "700700_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Miscellaneous", "plan_name": "700720", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Miscellaneous", "plan_name": "700720_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Ppo Hmo", "plan_name": "701720", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Ppo Hmo", "plan_name": "701720_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Ms State Emplo", "plan_name": "401457", "standard_charge_dollar": 4.75, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Ms State Emplo", "plan_name": "401457_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Basic Pl", "plan_name": "400100", "standard_charge_dollar": 4.75, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Basic Pl", "plan_name": "400100_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Federal", "plan_name": "400110", "standard_charge_dollar": 4.75, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Federal", "plan_name": "400110_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." } ] } ] }, { "description": "Hc urinalysis with micro", "code_information": [ { "code": "81001", "type": "CPT" } ], "standard_charges": [ { "gross_charge": 55.00, "minimum": 44.00, "maximum": 46.75, "setting": "both", "payers_information": [ { "payer_name": "Aetna", "plan_name": "700700", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "modifiers": "54", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna", "plan_name": "700700_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Miscellaneous", "plan_name": "700720", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Miscellaneous", "plan_name": "700720_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Ppo Hmo", "plan_name": "701720", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Ppo Hmo", "plan_name": "701720_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Ms State Emplo", "plan_name": "401457", "standard_charge_percentage": 0.80, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Ms State Emplo", "plan_name": "401457_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Basic Pl", "plan_name": "400100", "standard_charge_percentage": 0.85, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Basic Pl", "plan_name": "400100_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Federal", "plan_name": "400110", "standard_charge_percentage": 0.85, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Federal", "plan_name": "400110_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." } ] } ] }, { "description": "Hc urinalysis with micro", "code_information": [ { "code": "81001", "type": "CPT" } ], "standard_charges": [ { "gross_charge": 55.00, "minimum": 44.00, "maximum": 46.75, "setting": "both", "payers_information": [ { "payer_name": "Aetna", "plan_name": "700700", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "modifiers": "QW", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna", "plan_name": "700700_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Miscellaneous", "plan_name": "700720", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Miscellaneous", "plan_name": "700720_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Ppo Hmo", "plan_name": "701720", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Ppo Hmo", "plan_name": "701720_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Ms State Emplo", "plan_name": "401457", 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"plan_name": "400100_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Federal", "plan_name": "400110", "standard_charge_dollar": 3.37, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Federal", "plan_name": "400110_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." } ] } ] }, { "description": "Hc urinalysis automat w/o micro", "code_information": [ { "code": "81003", "type": "CPT" } ], "standard_charges": [ { "gross_charge": 7.35, "minimum": 5.88, "maximum": 6.25, "setting": "both", "payers_information": [ { "payer_name": "Aetna", "plan_name": "700700", 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"standard_charge_percentage": 0.85, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Basic Pl", "plan_name": "400100_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Federal", "plan_name": "400110", "standard_charge_percentage": 0.85, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Federal", "plan_name": "400110_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." } ] } ] }, { "description": "Hc urinalysis microscopic", 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"additional_payer_notes": "Insufficient remit data to calculate allowed amounts." } ] } ] }, { "description": "Microscopic exam of urine", "code_information": [ { "code": "81015", "type": "CPT" } ], "standard_charges": [ { "gross_charge": 7.35, "minimum": 4.57, "maximum": 4.57, "setting": "both", "payers_information": [ { "payer_name": "Aetna", "plan_name": "700700", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna", "plan_name": "700700_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Miscellaneous", "plan_name": "700720", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit 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"payer_name": "Bc/Bs Ms State Emplo", "plan_name": "401457_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Basic Pl", "plan_name": "400100", "standard_charge_dollar": 4.57, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Basic Pl", "plan_name": "400100_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Federal", "plan_name": "400110", "standard_charge_dollar": 4.57, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Federal", "plan_name": "400110_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." } ] } ] }, { "description": "Hc pregnancy test urine", "code_information": [ { "code": "81025", "type": "CPT" } ], "standard_charges": [ { "gross_charge": 65.00, "minimum": 9.47, "maximum": 9.47, "setting": "both", "payers_information": [ { "payer_name": "Aetna", "plan_name": "700700", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna", "plan_name": "700700_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Miscellaneous", "plan_name": "700720", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Miscellaneous", "plan_name": "700720_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Ppo Hmo", "plan_name": "701720", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Ppo Hmo", "plan_name": "701720_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Ms State Emplo", "plan_name": "401457", "standard_charge_dollar": 9.47, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Ms State Emplo", "plan_name": "401457_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Basic Pl", "plan_name": "400100", "standard_charge_dollar": 9.47, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Basic Pl", "plan_name": "400100_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Federal", "plan_name": "400110", "standard_charge_dollar": 9.47, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Federal", "plan_name": "400110_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." } ] } ] }, { "description": "Urine pregnancy test", "code_information": [ { "code": "81025", "type": "CPT" } ], "standard_charges": [ { "gross_charge": 65.00, "minimum": 9.47, "maximum": 9.47, "setting": "both", "payers_information": [ { "payer_name": "Aetna", "plan_name": "700700", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna", "plan_name": "700700_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Miscellaneous", "plan_name": "700720", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Miscellaneous", "plan_name": "700720_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Ppo Hmo", "plan_name": "701720", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Ppo Hmo", "plan_name": "701720_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Ms State Emplo", "plan_name": "401457", "standard_charge_dollar": 9.47, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Ms State Emplo", "plan_name": "401457_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Basic Pl", "plan_name": "400100", "standard_charge_dollar": 9.47, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Basic Pl", "plan_name": "400100_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Federal", "plan_name": "400110", "standard_charge_dollar": 9.47, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Federal", "plan_name": "400110_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." } ] } ] }, { "description": "Hc pregnancy test urine", "code_information": [ { "code": "81025", "type": "CPT" } ], "standard_charges": [ { "gross_charge": 22.00, "minimum": 17.60, "maximum": 18.70, "setting": "both", "payers_information": [ { "payer_name": "Aetna", "plan_name": "700700", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "modifiers": "QW", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna", "plan_name": "700700_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Miscellaneous", "plan_name": "700720", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Miscellaneous", "plan_name": "700720_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Ppo Hmo", "plan_name": "701720", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Ppo Hmo", "plan_name": "701720_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Ms State Emplo", "plan_name": "401457", "standard_charge_percentage": 0.80, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Ms State Emplo", "plan_name": "401457_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Basic Pl", "plan_name": "400100", "standard_charge_percentage": 0.85, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Basic Pl", "plan_name": "400100_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Federal", "plan_name": "400110", "standard_charge_percentage": 0.85, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Federal", "plan_name": "400110_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." } ] } ] }, { "description": "Hc volume measure timed coll", "code_information": [ { "code": "81050", "type": "CPT" } ], "standard_charges": [ { "gross_charge": 9.10, "minimum": 4.50, "maximum": 4.50, "setting": "both", "payers_information": [ { "payer_name": "Aetna", "plan_name": "700700", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna", "plan_name": "700700_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Miscellaneous", "plan_name": "700720", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Miscellaneous", "plan_name": "700720_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Ppo Hmo", "plan_name": "701720", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Ppo Hmo", "plan_name": "701720_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Ms State Emplo", "plan_name": "401457", "standard_charge_dollar": 4.50, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Ms State Emplo", "plan_name": "401457_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Basic Pl", "plan_name": "400100", "standard_charge_dollar": 4.50, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Basic Pl", "plan_name": "400100_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Federal", "plan_name": "400110", "standard_charge_dollar": 4.50, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Federal", "plan_name": "400110_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." } ] } ] }, { "description": "Urinalysis volume measure", "code_information": [ { "code": "81050", "type": "CPT" } ], "standard_charges": [ { "gross_charge": 9.10, "minimum": 4.50, "maximum": 4.50, "setting": "both", "payers_information": [ { "payer_name": "Aetna", "plan_name": "700700", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna", "plan_name": "700700_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Miscellaneous", "plan_name": "700720", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Miscellaneous", "plan_name": "700720_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Ppo Hmo", "plan_name": "701720", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Ppo Hmo", "plan_name": "701720_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Ms State Emplo", "plan_name": "401457", "standard_charge_dollar": 4.50, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Ms State Emplo", "plan_name": "401457_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Basic Pl", "plan_name": "400100", "standard_charge_dollar": 4.50, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Basic Pl", "plan_name": "400100_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Federal", "plan_name": "400110", "standard_charge_dollar": 4.50, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Federal", "plan_name": "400110_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." } ] } ] }, { "description": "Cytogen m array copy no&snp", "code_information": [ { "code": "81229", "type": "CPT" } ], "standard_charges": [ { "gross_charge": 2775.00, "minimum": 667.90, "maximum": 1450.00, "setting": "both", "payers_information": [ { "payer_name": "Aarp", "plan_name": "500102", "standard_charge_dollar": 1160.00, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna", "plan_name": "700700", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna", "plan_name": "700700_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Mcare Ffs 6005", "plan_name": "700703", "standard_charge_dollar": 1160.00, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Miscellaneous", "plan_name": "700720", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Miscellaneous", "plan_name": "700720_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Ppo Hmo", "plan_name": "701720", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Ppo Hmo", "plan_name": "701720_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Ambetter 68069", "plan_name": "500516", "standard_charge_dollar": 1160.00, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Ms State Emplo", "plan_name": "401457", "standard_charge_dollar": 667.90, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Ms State Emplo", "plan_name": "401457_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Basic Pl", "plan_name": "400100", "standard_charge_dollar": 667.90, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Basic Pl", "plan_name": "400100_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Federal", "plan_name": "400110", "standard_charge_dollar": 667.90, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Federal", "plan_name": "400110_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Cigna Healthsprings Ffs", "plan_name": "500064", "standard_charge_dollar": 1160.00, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Conseco", "plan_name": "500302", "standard_charge_dollar": 1160.00, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Humana Ffs 61101", "plan_name": "500006", "standard_charge_dollar": 1160.00, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Medicare A", "plan_name": "100100", "standard_charge_dollar": 1160.00, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Medicare A", "plan_name": "100500", "standard_charge_dollar": 1160.00, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Medicare Part B Only", "plan_name": "100300", "standard_charge_dollar": 1160.00, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Medicare Railroad", "plan_name": "100103", "standard_charge_dollar": 1160.00, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Ms Physicians Care N", "plan_name": "714210", "standard_charge_dollar": 1450.00, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Peoples Hlth Ffs 72126", "plan_name": "500019", "standard_charge_dollar": 1160.00, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Uhc/Secure Horizons", "plan_name": "500449", "standard_charge_dollar": 1160.00, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "United Health Care/", "plan_name": "500292", "standard_charge_dollar": 1310.80, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "United Healthcare", "plan_name": "750104", "standard_charge_dollar": 1310.80, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "United Healthcare Ba", "plan_name": "750090", "standard_charge_dollar": 1310.80, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "United Healthcare Me", "plan_name": "501310", "standard_charge_dollar": 1160.00, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Windsor Mcare Extra", "plan_name": "500778", "standard_charge_dollar": 1160.00, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." } ] } ] }, { "description": "Hc chromosomal microarray poc (mcmapc)", "code_information": [ { "code": "81229", "type": "CPT" } ], "standard_charges": [ { "gross_charge": 2775.00, "minimum": 667.90, "maximum": 1450.00, "setting": "both", "payers_information": [ { "payer_name": "Aarp", "plan_name": "500102", "standard_charge_dollar": 1160.00, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna", "plan_name": "700700", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna", "plan_name": "700700_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Mcare Ffs 6005", "plan_name": "700703", "standard_charge_dollar": 1160.00, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Miscellaneous", "plan_name": "700720", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Miscellaneous", "plan_name": "700720_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Ppo Hmo", "plan_name": "701720", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Ppo Hmo", "plan_name": "701720_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Ambetter 68069", "plan_name": "500516", "standard_charge_dollar": 1160.00, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Ms State Emplo", "plan_name": "401457", "standard_charge_dollar": 667.90, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Ms State Emplo", "plan_name": "401457_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Basic Pl", "plan_name": "400100", "standard_charge_dollar": 667.90, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Basic Pl", "plan_name": "400100_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Federal", "plan_name": "400110", "standard_charge_dollar": 667.90, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Federal", "plan_name": "400110_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Cigna Healthsprings Ffs", "plan_name": "500064", "standard_charge_dollar": 1160.00, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Conseco", "plan_name": "500302", "standard_charge_dollar": 1160.00, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Humana Ffs 61101", "plan_name": "500006", "standard_charge_dollar": 1160.00, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Medicare A", "plan_name": "100100", "standard_charge_dollar": 1160.00, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Medicare A", "plan_name": "100500", "standard_charge_dollar": 1160.00, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Medicare Part B Only", "plan_name": "100300", "standard_charge_dollar": 1160.00, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Medicare Railroad", "plan_name": "100103", "standard_charge_dollar": 1160.00, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Ms Physicians Care N", "plan_name": "714210", "standard_charge_dollar": 1450.00, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Peoples Hlth Ffs 72126", "plan_name": "500019", "standard_charge_dollar": 1160.00, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Uhc/Secure Horizons", "plan_name": "500449", "standard_charge_dollar": 1160.00, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "United Health Care/", "plan_name": "500292", "standard_charge_dollar": 1310.80, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "United Healthcare", "plan_name": "750104", "standard_charge_dollar": 1310.80, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "United Healthcare Ba", "plan_name": "750090", "standard_charge_dollar": 1310.80, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "United Healthcare Me", "plan_name": "501310", "standard_charge_dollar": 1160.00, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Windsor Mcare Extra", "plan_name": "500778", "standard_charge_dollar": 1160.00, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." } ] } ] }, { "description": "F2 gene", "code_information": [ { "code": "81240", "type": "CPT" } ], "standard_charges": [ { "gross_charge": 361.52, "minimum": 65.69, "maximum": 82.11, "setting": "both", "payers_information": [ { "payer_name": "Aarp", "plan_name": "500102", "standard_charge_dollar": 65.69, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna", "plan_name": "700700", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna", "plan_name": "700700_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Mcare Ffs 6005", "plan_name": "700703", "standard_charge_dollar": 65.69, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Miscellaneous", "plan_name": "700720", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Miscellaneous", "plan_name": "700720_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Ppo Hmo", "plan_name": "701720", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Ppo Hmo", "plan_name": "701720_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Ambetter 68069", "plan_name": "500516", "standard_charge_dollar": 65.69, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Ms State Emplo", "plan_name": "401457", "standard_charge_dollar": 73.73, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Ms State Emplo", "plan_name": "401457_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Basic Pl", "plan_name": "400100", "standard_charge_dollar": 73.73, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Basic Pl", "plan_name": "400100_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Federal", "plan_name": "400110", "standard_charge_dollar": 73.73, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Federal", "plan_name": "400110_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Cigna Healthsprings Ffs", "plan_name": "500064", "standard_charge_dollar": 65.69, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Conseco", "plan_name": "500302", "standard_charge_dollar": 65.69, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Humana Ffs 61101", "plan_name": "500006", "standard_charge_dollar": 65.69, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Medicare A", "plan_name": "100100", "standard_charge_dollar": 65.69, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Medicare A", "plan_name": "100500", "standard_charge_dollar": 65.69, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Medicare Part B Only", "plan_name": "100300", "standard_charge_dollar": 65.69, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Medicare Railroad", "plan_name": "100103", "standard_charge_dollar": 65.69, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Ms Physicians Care N", "plan_name": "714210", "standard_charge_dollar": 82.11, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Peoples Hlth Ffs 72126", "plan_name": "500019", "standard_charge_dollar": 65.69, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Uhc/Secure Horizons", "plan_name": "500449", "standard_charge_dollar": 65.69, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "United Health Care/", "plan_name": "500292", "standard_charge_dollar": 74.23, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "United Healthcare", "plan_name": "750104", "standard_charge_dollar": 74.23, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "United Healthcare Ba", "plan_name": "750090", "standard_charge_dollar": 74.23, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "United Healthcare Me", "plan_name": "501310", "standard_charge_dollar": 65.69, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Windsor Mcare Extra", "plan_name": "500778", "standard_charge_dollar": 65.69, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." } ] } ] }, { "description": "Hc prothrombin nucleotide by pcr", "code_information": [ { "code": "81240", "type": "CPT" } ], "standard_charges": [ { "gross_charge": 361.52, "minimum": 65.69, "maximum": 82.11, "setting": "both", "payers_information": [ { "payer_name": "Aarp", "plan_name": "500102", "standard_charge_dollar": 65.69, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna", "plan_name": "700700", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna", "plan_name": "700700_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Mcare Ffs 6005", "plan_name": "700703", "standard_charge_dollar": 65.69, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Miscellaneous", "plan_name": "700720", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Miscellaneous", "plan_name": "700720_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Ppo Hmo", "plan_name": "701720", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Ppo Hmo", "plan_name": "701720_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Ambetter 68069", "plan_name": "500516", "standard_charge_dollar": 65.69, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Ms State Emplo", "plan_name": "401457", "standard_charge_dollar": 73.73, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Ms State Emplo", "plan_name": "401457_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Basic Pl", "plan_name": "400100", "standard_charge_dollar": 73.73, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Basic Pl", "plan_name": "400100_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Federal", "plan_name": "400110", "standard_charge_dollar": 73.73, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Federal", "plan_name": "400110_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Cigna Healthsprings Ffs", "plan_name": "500064", "standard_charge_dollar": 65.69, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Conseco", "plan_name": "500302", "standard_charge_dollar": 65.69, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Humana Ffs 61101", "plan_name": "500006", "standard_charge_dollar": 65.69, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Medicare A", "plan_name": "100100", "standard_charge_dollar": 65.69, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Medicare A", "plan_name": "100500", "standard_charge_dollar": 65.69, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Medicare Part B Only", "plan_name": "100300", "standard_charge_dollar": 65.69, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Medicare Railroad", "plan_name": "100103", "standard_charge_dollar": 65.69, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Ms Physicians Care N", "plan_name": "714210", "standard_charge_dollar": 82.11, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Peoples Hlth Ffs 72126", "plan_name": "500019", "standard_charge_dollar": 65.69, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Uhc/Secure Horizons", "plan_name": "500449", "standard_charge_dollar": 65.69, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "United Health Care/", "plan_name": "500292", "standard_charge_dollar": 74.23, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "United Healthcare", "plan_name": "750104", "standard_charge_dollar": 74.23, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "United Healthcare Ba", "plan_name": "750090", "standard_charge_dollar": 74.23, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "United Healthcare Me", "plan_name": "501310", "standard_charge_dollar": 65.69, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Windsor Mcare Extra", "plan_name": "500778", "standard_charge_dollar": 65.69, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." } ] } ] }, { "description": "F5 gene", "code_information": [ { "code": "81241", "type": "CPT" } ], "standard_charges": [ { "gross_charge": 226.00, "minimum": 73.37, "maximum": 91.71, "setting": "both", "payers_information": [ { "payer_name": "Aarp", "plan_name": "500102", "standard_charge_dollar": 73.37, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna", "plan_name": "700700", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna", "plan_name": "700700_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Mcare Ffs 6005", "plan_name": "700703", "standard_charge_dollar": 73.37, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Miscellaneous", "plan_name": "700720", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Miscellaneous", "plan_name": "700720_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Ppo Hmo", "plan_name": "701720", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Ppo Hmo", "plan_name": "701720_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Ambetter 68069", "plan_name": "500516", "standard_charge_dollar": 73.37, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Ms State Emplo", "plan_name": "401457", "standard_charge_dollar": 91.56, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Ms State Emplo", "plan_name": "401457_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Basic Pl", "plan_name": "400100", "standard_charge_dollar": 91.56, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Basic Pl", "plan_name": "400100_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Federal", "plan_name": "400110", "standard_charge_dollar": 91.56, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Federal", "plan_name": "400110_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Cigna Healthsprings Ffs", "plan_name": "500064", "standard_charge_dollar": 73.37, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Conseco", "plan_name": "500302", "standard_charge_dollar": 73.37, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Humana Ffs 61101", "plan_name": "500006", "standard_charge_dollar": 73.37, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Medicare A", "plan_name": "100100", "standard_charge_dollar": 73.37, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Medicare A", "plan_name": "100500", "standard_charge_dollar": 73.37, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Medicare Part B Only", "plan_name": "100300", "standard_charge_dollar": 73.37, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Medicare Railroad", "plan_name": "100103", "standard_charge_dollar": 73.37, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Ms Physicians Care N", "plan_name": "714210", "standard_charge_dollar": 91.71, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Peoples Hlth Ffs 72126", "plan_name": "500019", "standard_charge_dollar": 73.37, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Uhc/Secure Horizons", "plan_name": "500449", "standard_charge_dollar": 73.37, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "United Health Care/", "plan_name": "500292", "standard_charge_dollar": 82.91, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "United Healthcare", "plan_name": "750104", "standard_charge_dollar": 82.91, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "United Healthcare Ba", "plan_name": "750090", "standard_charge_dollar": 82.91, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "United Healthcare Me", "plan_name": "501310", "standard_charge_dollar": 73.37, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Windsor Mcare Extra", "plan_name": "500778", "standard_charge_dollar": 73.37, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." } ] } ] }, { "description": "Hc f5 gene (factor v leiden)", "code_information": [ { "code": "81241", "type": "CPT" } ], "standard_charges": [ { "gross_charge": 226.00, "minimum": 73.37, "maximum": 91.71, "setting": "both", "payers_information": [ { "payer_name": "Aarp", "plan_name": "500102", "standard_charge_dollar": 73.37, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna", "plan_name": "700700", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna", "plan_name": "700700_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Mcare Ffs 6005", "plan_name": "700703", "standard_charge_dollar": 73.37, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Miscellaneous", "plan_name": "700720", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Miscellaneous", "plan_name": "700720_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Ppo Hmo", "plan_name": "701720", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Ppo Hmo", "plan_name": "701720_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Ambetter 68069", "plan_name": "500516", "standard_charge_dollar": 73.37, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Ms State Emplo", "plan_name": "401457", "standard_charge_dollar": 91.56, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Ms State Emplo", "plan_name": "401457_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Basic Pl", "plan_name": "400100", "standard_charge_dollar": 91.56, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Basic Pl", "plan_name": "400100_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Federal", "plan_name": "400110", "standard_charge_dollar": 91.56, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Federal", "plan_name": "400110_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Cigna Healthsprings Ffs", "plan_name": "500064", "standard_charge_dollar": 73.37, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Conseco", "plan_name": "500302", "standard_charge_dollar": 73.37, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Humana Ffs 61101", "plan_name": "500006", "standard_charge_dollar": 73.37, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Medicare A", "plan_name": "100100", "standard_charge_dollar": 73.37, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Medicare A", "plan_name": "100500", "standard_charge_dollar": 73.37, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Medicare Part B Only", "plan_name": "100300", "standard_charge_dollar": 73.37, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Medicare Railroad", "plan_name": "100103", "standard_charge_dollar": 73.37, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Ms Physicians Care N", "plan_name": "714210", "standard_charge_dollar": 91.71, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Peoples Hlth Ffs 72126", "plan_name": "500019", "standard_charge_dollar": 73.37, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Uhc/Secure Horizons", "plan_name": "500449", "standard_charge_dollar": 73.37, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "United Health Care/", "plan_name": "500292", "standard_charge_dollar": 82.91, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "United Healthcare", "plan_name": "750104", "standard_charge_dollar": 82.91, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "United Healthcare Ba", "plan_name": "750090", "standard_charge_dollar": 82.91, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "United Healthcare Me", "plan_name": "501310", "standard_charge_dollar": 73.37, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Windsor Mcare Extra", "plan_name": "500778", "standard_charge_dollar": 73.37, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." } ] } ] }, { "description": "Hc jak2 gene", "code_information": [ { "code": "81270", "type": "CPT" } ], "standard_charges": [ { "gross_charge": 375.00, "minimum": 91.66, "maximum": 137.36, "setting": "both", "payers_information": [ { "payer_name": "Aarp", "plan_name": "500102", "standard_charge_dollar": 91.66, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna", "plan_name": "700700", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna", "plan_name": "700700_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Mcare Ffs 6005", "plan_name": "700703", "standard_charge_dollar": 91.66, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Miscellaneous", "plan_name": "700720", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Miscellaneous", "plan_name": "700720_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Ppo Hmo", "plan_name": "701720", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Ppo Hmo", "plan_name": "701720_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Ambetter 68069", "plan_name": "500516", "standard_charge_dollar": 91.66, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Ms State Emplo", "plan_name": "401457", "standard_charge_dollar": 137.36, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Ms State Emplo", "plan_name": "401457_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Basic Pl", "plan_name": "400100", "standard_charge_dollar": 137.36, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Basic Pl", "plan_name": "400100_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Federal", "plan_name": "400110", "standard_charge_dollar": 137.36, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Federal", "plan_name": "400110_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Cigna Healthsprings Ffs", "plan_name": "500064", "standard_charge_dollar": 91.66, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Conseco", "plan_name": "500302", "standard_charge_dollar": 91.66, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Humana Ffs 61101", "plan_name": "500006", "standard_charge_dollar": 91.66, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Medicare A", "plan_name": "100100", "standard_charge_dollar": 91.66, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Medicare A", "plan_name": "100500", "standard_charge_dollar": 91.66, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Medicare Part B Only", "plan_name": "100300", "standard_charge_dollar": 91.66, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Medicare Railroad", "plan_name": "100103", "standard_charge_dollar": 91.66, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Ms Physicians Care N", "plan_name": "714210", "standard_charge_dollar": 114.58, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Peoples Hlth Ffs 72126", "plan_name": "500019", "standard_charge_dollar": 91.66, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Uhc/Secure Horizons", "plan_name": "500449", "standard_charge_dollar": 91.66, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "United Health Care/", "plan_name": "500292", "standard_charge_dollar": 103.58, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "United Healthcare", "plan_name": "750104", "standard_charge_dollar": 103.58, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "United Healthcare Ba", "plan_name": "750090", "standard_charge_dollar": 103.58, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "United Healthcare Me", "plan_name": "501310", "standard_charge_dollar": 91.66, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Windsor Mcare Extra", "plan_name": "500778", "standard_charge_dollar": 91.66, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." } ] } ] }, { "description": "Jak2 gene", "code_information": [ { "code": "81270", "type": "CPT" } ], "standard_charges": [ { "gross_charge": 375.00, "minimum": 91.66, "maximum": 137.36, "setting": "both", "payers_information": [ { "payer_name": "Aarp", "plan_name": "500102", "standard_charge_dollar": 91.66, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna", "plan_name": "700700", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna", "plan_name": "700700_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Mcare Ffs 6005", "plan_name": "700703", "standard_charge_dollar": 91.66, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Miscellaneous", "plan_name": "700720", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Miscellaneous", "plan_name": "700720_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Ppo Hmo", "plan_name": "701720", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Ppo Hmo", "plan_name": "701720_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Ambetter 68069", "plan_name": "500516", "standard_charge_dollar": 91.66, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Ms State Emplo", "plan_name": "401457", "standard_charge_dollar": 137.36, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Ms State Emplo", "plan_name": "401457_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Basic Pl", "plan_name": "400100", "standard_charge_dollar": 137.36, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Basic Pl", "plan_name": "400100_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Federal", "plan_name": "400110", "standard_charge_dollar": 137.36, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Federal", "plan_name": "400110_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Cigna Healthsprings Ffs", "plan_name": "500064", "standard_charge_dollar": 91.66, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Conseco", "plan_name": "500302", "standard_charge_dollar": 91.66, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Humana Ffs 61101", "plan_name": "500006", "standard_charge_dollar": 91.66, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Medicare A", "plan_name": "100100", "standard_charge_dollar": 91.66, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Medicare A", "plan_name": "100500", "standard_charge_dollar": 91.66, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Medicare Part B Only", "plan_name": "100300", "standard_charge_dollar": 91.66, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Medicare Railroad", "plan_name": "100103", "standard_charge_dollar": 91.66, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Ms Physicians Care N", "plan_name": "714210", "standard_charge_dollar": 114.58, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Peoples Hlth Ffs 72126", "plan_name": "500019", "standard_charge_dollar": 91.66, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Uhc/Secure Horizons", "plan_name": "500449", "standard_charge_dollar": 91.66, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "United Health Care/", "plan_name": "500292", "standard_charge_dollar": 103.58, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "United Healthcare", "plan_name": "750104", "standard_charge_dollar": 103.58, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "United Healthcare Ba", "plan_name": "750090", "standard_charge_dollar": 103.58, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "United Healthcare Me", "plan_name": "501310", "standard_charge_dollar": 91.66, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Windsor Mcare Extra", "plan_name": "500778", "standard_charge_dollar": 91.66, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." } ] } ] }, { "description": "Hc prader-willi molecular analvaries(pwas)", "code_information": [ { "code": "81331", "type": "CPT" } ], "standard_charges": [ { "gross_charge": 574.47, "minimum": 51.07, "maximum": 64.52, "setting": "both", "payers_information": [ { "payer_name": "Aarp", "plan_name": "500102", "standard_charge_dollar": 51.07, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna", "plan_name": "700700", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna", "plan_name": "700700_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Mcare Ffs 6005", "plan_name": "700703", "standard_charge_dollar": 51.07, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Miscellaneous", "plan_name": "700720", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Miscellaneous", "plan_name": "700720_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Ppo Hmo", "plan_name": "701720", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Ppo Hmo", "plan_name": "701720_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Ambetter 68069", "plan_name": "500516", "standard_charge_dollar": 51.07, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Ms State Emplo", "plan_name": "401457", "standard_charge_dollar": 64.52, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Ms State Emplo", "plan_name": "401457_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Basic Pl", "plan_name": "400100", "standard_charge_dollar": 64.52, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Basic Pl", "plan_name": "400100_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Federal", "plan_name": "400110", "standard_charge_dollar": 64.52, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Federal", "plan_name": "400110_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Cigna Healthsprings Ffs", "plan_name": "500064", "standard_charge_dollar": 51.07, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Conseco", "plan_name": "500302", "standard_charge_dollar": 51.07, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Humana Ffs 61101", "plan_name": "500006", "standard_charge_dollar": 51.07, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Medicare A", "plan_name": "100100", "standard_charge_dollar": 51.07, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Medicare A", "plan_name": "100500", "standard_charge_dollar": 51.07, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Medicare Part B Only", "plan_name": "100300", "standard_charge_dollar": 51.07, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Medicare Railroad", "plan_name": "100103", "standard_charge_dollar": 51.07, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Ms Physicians Care N", "plan_name": "714210", "standard_charge_dollar": 63.84, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Peoples Hlth Ffs 72126", "plan_name": "500019", "standard_charge_dollar": 51.07, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Uhc/Secure Horizons", "plan_name": "500449", "standard_charge_dollar": 51.07, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "United Health Care/", "plan_name": "500292", "standard_charge_dollar": 57.71, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "United Healthcare", "plan_name": "750104", "standard_charge_dollar": 57.71, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "United Healthcare Ba", "plan_name": "750090", "standard_charge_dollar": 57.71, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "United Healthcare Me", "plan_name": "501310", "standard_charge_dollar": 51.07, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Windsor Mcare Extra", "plan_name": "500778", "standard_charge_dollar": 51.07, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." } ] } ] }, { "description": "Snrpn/ube3a gene", "code_information": [ { "code": "81331", "type": "CPT" } ], "standard_charges": [ { "gross_charge": 574.47, "minimum": 51.07, "maximum": 64.52, "setting": "both", "payers_information": [ { "payer_name": "Aarp", "plan_name": "500102", "standard_charge_dollar": 51.07, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna", "plan_name": "700700", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna", "plan_name": "700700_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Mcare Ffs 6005", "plan_name": "700703", "standard_charge_dollar": 51.07, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Miscellaneous", "plan_name": "700720", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Miscellaneous", "plan_name": "700720_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Ppo Hmo", "plan_name": "701720", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Ppo Hmo", "plan_name": "701720_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Ambetter 68069", "plan_name": "500516", "standard_charge_dollar": 51.07, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Ms State Emplo", "plan_name": "401457", "standard_charge_dollar": 64.52, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Ms State Emplo", "plan_name": "401457_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Basic Pl", "plan_name": "400100", "standard_charge_dollar": 64.52, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Basic Pl", "plan_name": "400100_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Federal", "plan_name": "400110", "standard_charge_dollar": 64.52, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Federal", "plan_name": "400110_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Cigna Healthsprings Ffs", "plan_name": "500064", "standard_charge_dollar": 51.07, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Conseco", "plan_name": "500302", "standard_charge_dollar": 51.07, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Humana Ffs 61101", "plan_name": "500006", "standard_charge_dollar": 51.07, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Medicare A", "plan_name": "100100", "standard_charge_dollar": 51.07, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Medicare A", "plan_name": "100500", "standard_charge_dollar": 51.07, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Medicare Part B Only", "plan_name": "100300", "standard_charge_dollar": 51.07, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Medicare Railroad", "plan_name": "100103", "standard_charge_dollar": 51.07, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Ms Physicians Care N", "plan_name": "714210", "standard_charge_dollar": 63.84, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Peoples Hlth Ffs 72126", "plan_name": "500019", "standard_charge_dollar": 51.07, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Uhc/Secure Horizons", "plan_name": "500449", "standard_charge_dollar": 51.07, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "United Health Care/", "plan_name": "500292", "standard_charge_dollar": 57.71, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "United Healthcare", "plan_name": "750104", "standard_charge_dollar": 57.71, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "United Healthcare Ba", "plan_name": "750090", "standard_charge_dollar": 57.71, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "United Healthcare Me", "plan_name": "501310", "standard_charge_dollar": 51.07, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Windsor Mcare Extra", "plan_name": "500778", "standard_charge_dollar": 51.07, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." } ] } ] }, { "description": "Hbb full gene sequence", "code_information": [ { "code": "81364", "type": "CPT" } ], "standard_charges": [ { "gross_charge": 567.30, "minimum": 324.58, "maximum": 482.21, "setting": "both", "payers_information": [ { "payer_name": "Aarp", "plan_name": "500102", "standard_charge_dollar": 324.58, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna", "plan_name": "700700", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna", "plan_name": "700700_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Mcare Ffs 6005", "plan_name": "700703", "standard_charge_dollar": 324.58, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Miscellaneous", "plan_name": "700720", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Miscellaneous", "plan_name": "700720_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Ppo Hmo", "plan_name": "701720", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Ppo Hmo", "plan_name": "701720_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Ambetter 68069", "plan_name": "500516", "standard_charge_dollar": 324.58, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Ms State Emplo", "plan_name": "401457", "standard_charge_percentage": 0.80, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Ms State Emplo", "plan_name": "401457_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Basic Pl", "plan_name": "400100", "standard_charge_percentage": 0.85, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Basic Pl", "plan_name": "400100_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Federal", "plan_name": "400110", "standard_charge_percentage": 0.85, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Federal", "plan_name": "400110_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Cigna Healthsprings Ffs", "plan_name": "500064", "standard_charge_dollar": 324.58, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Conseco", "plan_name": "500302", "standard_charge_dollar": 324.58, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Humana Ffs 61101", "plan_name": "500006", "standard_charge_dollar": 324.58, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Medicare A", "plan_name": "100100", "standard_charge_dollar": 324.58, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Medicare A", "plan_name": "100500", "standard_charge_dollar": 324.58, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Medicare Part B Only", "plan_name": "100300", "standard_charge_dollar": 324.58, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Medicare Railroad", "plan_name": "100103", "standard_charge_dollar": 324.58, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Ms Physicians Care N", "plan_name": "714210", "standard_charge_dollar": 405.73, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Peoples Hlth Ffs 72126", "plan_name": "500019", "standard_charge_dollar": 324.58, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Uhc/Secure Horizons", "plan_name": "500449", "standard_charge_dollar": 324.58, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "United Health Care/", "plan_name": "500292", "standard_charge_dollar": 366.78, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "United Healthcare", "plan_name": "750104", "standard_charge_dollar": 366.78, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "United Healthcare Ba", "plan_name": "750090", "standard_charge_dollar": 366.78, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "United Healthcare Me", "plan_name": "501310", "standard_charge_dollar": 324.58, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Windsor Mcare Extra", "plan_name": "500778", "standard_charge_dollar": 324.58, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." } ] } ] }, { "description": "Hc beta globin gene seq (wbsqr)", "code_information": [ { "code": "81364", "type": "CPT" } ], "standard_charges": [ { "gross_charge": 567.30, "minimum": 324.58, "maximum": 482.21, "setting": "both", "payers_information": [ { "payer_name": "Aarp", "plan_name": "500102", "standard_charge_dollar": 324.58, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna", "plan_name": "700700", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna", "plan_name": "700700_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Mcare Ffs 6005", "plan_name": "700703", "standard_charge_dollar": 324.58, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Miscellaneous", "plan_name": "700720", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Miscellaneous", "plan_name": "700720_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Ppo Hmo", "plan_name": "701720", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Ppo Hmo", "plan_name": "701720_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Ambetter 68069", "plan_name": "500516", "standard_charge_dollar": 324.58, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Ms State Emplo", "plan_name": "401457", "standard_charge_percentage": 0.80, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Ms State Emplo", "plan_name": "401457_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Basic Pl", "plan_name": "400100", "standard_charge_percentage": 0.85, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Basic Pl", "plan_name": "400100_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Federal", "plan_name": "400110", "standard_charge_percentage": 0.85, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Federal", "plan_name": "400110_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Cigna Healthsprings Ffs", "plan_name": "500064", "standard_charge_dollar": 324.58, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Conseco", "plan_name": "500302", "standard_charge_dollar": 324.58, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Humana Ffs 61101", "plan_name": "500006", "standard_charge_dollar": 324.58, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Medicare A", "plan_name": "100100", "standard_charge_dollar": 324.58, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Medicare A", "plan_name": "100500", "standard_charge_dollar": 324.58, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Medicare Part B Only", "plan_name": "100300", "standard_charge_dollar": 324.58, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Medicare Railroad", "plan_name": "100103", "standard_charge_dollar": 324.58, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Ms Physicians Care N", "plan_name": "714210", "standard_charge_dollar": 405.73, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Peoples Hlth Ffs 72126", "plan_name": "500019", "standard_charge_dollar": 324.58, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Uhc/Secure Horizons", "plan_name": "500449", "standard_charge_dollar": 324.58, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "United Health Care/", "plan_name": "500292", "standard_charge_dollar": 366.78, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "United Healthcare", "plan_name": "750104", "standard_charge_dollar": 366.78, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "United Healthcare Ba", "plan_name": "750090", "standard_charge_dollar": 366.78, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "United Healthcare Me", "plan_name": "501310", "standard_charge_dollar": 324.58, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Windsor Mcare Extra", "plan_name": "500778", "standard_charge_dollar": 324.58, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." } ] } ] }, { "description": "Hc hla class ii typing low resolution one locus ea", "code_information": [ { "code": "81376", "type": "CPT" } ], "standard_charges": [ { "gross_charge": 249.67, "minimum": 122.22, "maximum": 183.14, "setting": "both", "payers_information": [ { "payer_name": "Aarp", "plan_name": "500102", "standard_charge_dollar": 122.22, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna", "plan_name": "700700", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna", "plan_name": "700700_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Mcare Ffs 6005", "plan_name": "700703", "standard_charge_dollar": 122.22, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Miscellaneous", "plan_name": "700720", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Miscellaneous", "plan_name": "700720_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Ppo Hmo", "plan_name": "701720", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Ppo Hmo", "plan_name": "701720_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Ambetter 68069", "plan_name": "500516", "standard_charge_dollar": 122.22, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Ms State Emplo", "plan_name": "401457", "standard_charge_dollar": 183.14, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Ms State Emplo", "plan_name": "401457_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total 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"payer_name": "United Healthcare Me", "plan_name": "501310", "standard_charge_dollar": 122.22, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Windsor Mcare Extra", "plan_name": "500778", "standard_charge_dollar": 122.22, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." } ] } ] }, { "description": "Hla ii typing 1 locus lr", "code_information": [ { "code": "81376", "type": "CPT" } ], "standard_charges": [ { "gross_charge": 249.67, "minimum": 122.22, "maximum": 183.14, "setting": "both", "payers_information": [ { "payer_name": "Aarp", "plan_name": "500102", "standard_charge_dollar": 122.22, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna", "plan_name": "700700", "standard_charge_percentage": 80.0, "count": 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billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Ppo Hmo", "plan_name": "701720", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Ppo Hmo", "plan_name": "701720_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Ambetter 68069", "plan_name": "500516", "standard_charge_dollar": 122.22, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Ms State Emplo", "plan_name": "401457", "standard_charge_dollar": 183.14, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Ms State Emplo", "plan_name": "401457_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Basic Pl", "plan_name": "400100", "standard_charge_dollar": 183.14, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Basic Pl", "plan_name": "400100_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Federal", "plan_name": "400110", "standard_charge_dollar": 183.14, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Federal", "plan_name": "400110_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Cigna Healthsprings Ffs", "plan_name": "500064", "standard_charge_dollar": 122.22, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Conseco", "plan_name": "500302", "standard_charge_dollar": 122.22, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Humana Ffs 61101", "plan_name": "500006", "standard_charge_dollar": 122.22, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Medicare A", "plan_name": "100100", "standard_charge_dollar": 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to calculate allowed amounts." }, { "payer_name": "Peoples Hlth Ffs 72126", "plan_name": "500019", "standard_charge_dollar": 122.22, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Uhc/Secure Horizons", "plan_name": "500449", "standard_charge_dollar": 122.22, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "United Health Care/", "plan_name": "500292", "standard_charge_dollar": 138.11, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "United Healthcare", "plan_name": "750104", "standard_charge_dollar": 138.11, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "United Healthcare Ba", "plan_name": "750090", "standard_charge_dollar": 138.11, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "United Healthcare Me", "plan_name": "501310", "standard_charge_dollar": 122.22, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Windsor Mcare Extra", "plan_name": "500778", "standard_charge_dollar": 122.22, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." } ] } ] }, { "description": "Hc mg microarray (ls98012)-chg only (charge code 031081479)", "code_information": [ { "code": "81479", "type": "CPT" } ], "standard_charges": [ { "gross_charge": 450.00, "minimum": 678.13, "maximum": 678.13, "setting": "both", "payers_information": [ { "payer_name": "Aetna", "plan_name": "700700", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna", "plan_name": "700700_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Miscellaneous", "plan_name": "700720", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Miscellaneous", "plan_name": "700720_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Ppo Hmo", "plan_name": "701720", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Ppo Hmo", "plan_name": "701720_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Ms State Emplo", "plan_name": "401457", "standard_charge_dollar": 678.13, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Ms State Emplo", "plan_name": "401457_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Basic Pl", "plan_name": "400100", "standard_charge_dollar": 678.13, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Basic Pl", "plan_name": "400100_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Federal", "plan_name": "400110", "standard_charge_dollar": 678.13, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Federal", "plan_name": "400110_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." } ] } ] }, { "description": "Unlisted molecular pathology", "code_information": [ { "code": "81479", "type": "CPT" } ], "standard_charges": [ { "gross_charge": 450.00, "minimum": 678.13, "maximum": 678.13, "setting": "both", "payers_information": [ { "payer_name": "Aetna", "plan_name": "700700", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna", "plan_name": "700700_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Miscellaneous", "plan_name": "700720", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Miscellaneous", "plan_name": "700720_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Ppo Hmo", "plan_name": "701720", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Ppo Hmo", "plan_name": "701720_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Ms State Emplo", "plan_name": "401457", "standard_charge_dollar": 678.13, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Ms State Emplo", "plan_name": "401457_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Basic Pl", "plan_name": "400100", "standard_charge_dollar": 678.13, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Basic Pl", "plan_name": "400100_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Federal", "plan_name": "400110", "standard_charge_dollar": 678.13, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Federal", "plan_name": "400110_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." } ] } ] }, { "description": "Hc fibro test-acti test s", "code_information": [ { "code": "81596", "type": "CPT" } ], "standard_charges": [ { "gross_charge": 513.00, "minimum": 72.19, "maximum": 436.05, "setting": "both", "payers_information": [ { "payer_name": "Aarp", "plan_name": "500102", "standard_charge_dollar": 72.19, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna", "plan_name": "700700", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna", "plan_name": "700700_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Mcare Ffs 6005", "plan_name": "700703", "standard_charge_dollar": 72.19, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Miscellaneous", "plan_name": "700720", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Miscellaneous", "plan_name": "700720_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Ppo Hmo", "plan_name": "701720", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Ppo Hmo", "plan_name": "701720_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Ambetter 68069", "plan_name": "500516", "standard_charge_dollar": 72.19, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Ms State Emplo", "plan_name": "401457", "standard_charge_percentage": 0.80, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Ms State Emplo", "plan_name": "401457_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Basic Pl", "plan_name": "400100", "standard_charge_percentage": 0.85, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Basic Pl", "plan_name": "400100_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Federal", "plan_name": "400110", "standard_charge_percentage": 0.85, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Federal", "plan_name": "400110_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Cigna Healthsprings Ffs", "plan_name": "500064", "standard_charge_dollar": 72.19, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Conseco", "plan_name": "500302", "standard_charge_dollar": 72.19, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Humana Ffs 61101", "plan_name": "500006", "standard_charge_dollar": 72.19, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Medicare A", "plan_name": "100100", "standard_charge_dollar": 72.19, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Medicare A", "plan_name": "100500", "standard_charge_dollar": 72.19, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Medicare Part B Only", "plan_name": "100300", "standard_charge_dollar": 72.19, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Medicare Railroad", "plan_name": "100103", "standard_charge_dollar": 72.19, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Ms Physicians Care N", "plan_name": "714210", "standard_charge_dollar": 90.24, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Peoples Hlth Ffs 72126", "plan_name": "500019", "standard_charge_dollar": 72.19, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Uhc/Secure Horizons", "plan_name": "500449", "standard_charge_dollar": 72.19, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "United Health Care/", "plan_name": "500292", "standard_charge_dollar": 81.57, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "United Healthcare", "plan_name": "750104", "standard_charge_dollar": 81.57, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "United Healthcare Ba", "plan_name": "750090", "standard_charge_dollar": 81.57, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "United Healthcare Me", "plan_name": "501310", "standard_charge_dollar": 72.19, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Windsor Mcare Extra", "plan_name": "500778", "standard_charge_dollar": 72.19, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." } ] } ] }, { "description": "Nfct ds chrnc hcv 6 assays", "code_information": [ { "code": "81596", "type": "CPT" } ], "standard_charges": [ { "gross_charge": 513.00, "minimum": 72.19, "maximum": 436.05, "setting": "both", "payers_information": [ { "payer_name": "Aarp", "plan_name": "500102", "standard_charge_dollar": 72.19, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna", "plan_name": "700700", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna", "plan_name": "700700_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Mcare Ffs 6005", "plan_name": "700703", "standard_charge_dollar": 72.19, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Miscellaneous", "plan_name": "700720", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Miscellaneous", "plan_name": "700720_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Ppo Hmo", "plan_name": "701720", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Ppo Hmo", "plan_name": "701720_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Ambetter 68069", "plan_name": "500516", "standard_charge_dollar": 72.19, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Ms State Emplo", "plan_name": "401457", "standard_charge_percentage": 0.80, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Ms State Emplo", "plan_name": "401457_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Basic Pl", "plan_name": "400100", "standard_charge_percentage": 0.85, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Basic Pl", "plan_name": "400100_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Federal", "plan_name": "400110", "standard_charge_percentage": 0.85, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Federal", "plan_name": "400110_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Cigna Healthsprings Ffs", "plan_name": "500064", "standard_charge_dollar": 72.19, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Conseco", "plan_name": "500302", "standard_charge_dollar": 72.19, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Humana Ffs 61101", "plan_name": "500006", "standard_charge_dollar": 72.19, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Medicare A", "plan_name": "100100", "standard_charge_dollar": 72.19, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Medicare A", "plan_name": "100500", "standard_charge_dollar": 72.19, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Medicare Part B Only", "plan_name": "100300", "standard_charge_dollar": 72.19, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Medicare Railroad", "plan_name": "100103", "standard_charge_dollar": 72.19, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Ms Physicians Care N", "plan_name": "714210", "standard_charge_dollar": 90.24, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Peoples Hlth Ffs 72126", "plan_name": "500019", "standard_charge_dollar": 72.19, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Uhc/Secure Horizons", "plan_name": "500449", "standard_charge_dollar": 72.19, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "United Health Care/", "plan_name": "500292", "standard_charge_dollar": 81.57, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "United Healthcare", "plan_name": "750104", "standard_charge_dollar": 81.57, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "United Healthcare Ba", "plan_name": "750090", "standard_charge_dollar": 81.57, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "United Healthcare Me", "plan_name": "501310", "standard_charge_dollar": 72.19, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Windsor Mcare Extra", "plan_name": "500778", "standard_charge_dollar": 72.19, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." } ] } ] }, { "description": "Hc acetone/ketone serum", "code_information": [ { "code": "82009", "type": "CPT" } ], "standard_charges": [ { "gross_charge": 40.00, "minimum": 6.78, "maximum": 6.78, "setting": "both", "payers_information": [ { "payer_name": "Aetna", "plan_name": "700700", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna", "plan_name": "700700_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Miscellaneous", "plan_name": "700720", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Miscellaneous", "plan_name": "700720_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Ppo Hmo", "plan_name": "701720", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Ppo Hmo", "plan_name": "701720_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Ms State Emplo", "plan_name": "401457", "standard_charge_dollar": 6.78, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Ms State Emplo", "plan_name": "401457_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Basic Pl", "plan_name": "400100", "standard_charge_dollar": 6.78, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Basic Pl", "plan_name": "400100_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Federal", "plan_name": "400110", "standard_charge_dollar": 6.78, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Federal", "plan_name": "400110_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." } ] } ] }, { "description": "Test for acetone/ketones", "code_information": [ { "code": "82009", "type": "CPT" } ], "standard_charges": [ { "gross_charge": 40.00, "minimum": 6.78, "maximum": 6.78, "setting": "both", "payers_information": [ { "payer_name": "Aetna", "plan_name": "700700", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna", "plan_name": "700700_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Miscellaneous", "plan_name": "700720", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Miscellaneous", "plan_name": "700720_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Ppo Hmo", "plan_name": "701720", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Ppo Hmo", "plan_name": "701720_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Ms State Emplo", "plan_name": "401457", "standard_charge_dollar": 6.78, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Ms State Emplo", "plan_name": "401457_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Basic Pl", "plan_name": "400100", "standard_charge_dollar": 6.78, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Basic Pl", "plan_name": "400100_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Federal", "plan_name": "400110", "standard_charge_dollar": 6.78, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Federal", "plan_name": "400110_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." } ] } ] }, { "description": "Acetone assay", "code_information": [ { "code": "82010", "type": "CPT" } ], "standard_charges": [ { "gross_charge": 60.00, "minimum": 12.24, "maximum": 12.24, "setting": "both", "payers_information": [ { "payer_name": "Aetna", "plan_name": "700700", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna", "plan_name": "700700_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Miscellaneous", "plan_name": "700720", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Miscellaneous", "plan_name": "700720_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Ppo Hmo", "plan_name": "701720", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Ppo Hmo", "plan_name": "701720_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Ms State Emplo", "plan_name": "401457", "standard_charge_dollar": 12.24, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Ms State Emplo", "plan_name": "401457_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Basic Pl", "plan_name": "400100", "standard_charge_dollar": 12.24, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Basic Pl", "plan_name": "400100_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Federal", "plan_name": "400110", "standard_charge_dollar": 12.24, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Federal", "plan_name": "400110_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." } ] } ] }, { "description": "Hc beta hydrobutyrate", "code_information": [ { "code": "82010", "type": "CPT" } ], "standard_charges": [ { "gross_charge": 60.00, "minimum": 12.24, "maximum": 12.24, "setting": "both", "payers_information": [ { "payer_name": "Aetna", "plan_name": "700700", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna", "plan_name": "700700_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Miscellaneous", "plan_name": "700720", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Miscellaneous", "plan_name": "700720_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Ppo Hmo", "plan_name": "701720", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Ppo Hmo", "plan_name": "701720_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Ms State Emplo", "plan_name": "401457", "standard_charge_dollar": 12.24, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Ms State Emplo", "plan_name": "401457_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Basic Pl", "plan_name": "400100", "standard_charge_dollar": 12.24, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Basic Pl", "plan_name": "400100_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Federal", "plan_name": "400110", "standard_charge_dollar": 12.24, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Federal", "plan_name": "400110_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." } ] } ] }, { "description": "Acylcarnitines quant", "code_information": [ { "code": "82017", "type": "CPT" } ], "standard_charges": [ { "gross_charge": 116.66, "minimum": 25.27, "maximum": 25.27, "setting": "both", "payers_information": [ { "payer_name": "Aetna", "plan_name": "700700", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna", "plan_name": "700700_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Miscellaneous", "plan_name": "700720", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Miscellaneous", "plan_name": "700720_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Ppo Hmo", "plan_name": "701720", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Ppo Hmo", "plan_name": "701720_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Ms State Emplo", "plan_name": "401457", "standard_charge_dollar": 25.27, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Ms State Emplo", "plan_name": "401457_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Basic Pl", "plan_name": "400100", "standard_charge_dollar": 25.27, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Basic Pl", "plan_name": "400100_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Federal", "plan_name": "400110", "standard_charge_dollar": 25.27, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Federal", "plan_name": "400110_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." } ] } ] }, { "description": "Hc acylcarnitines quant", "code_information": [ { "code": "82017", "type": "CPT" } ], "standard_charges": [ { "gross_charge": 116.66, "minimum": 25.27, "maximum": 25.27, "setting": "both", "payers_information": [ { "payer_name": "Aetna", "plan_name": "700700", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna", "plan_name": "700700_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Miscellaneous", "plan_name": "700720", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Miscellaneous", "plan_name": "700720_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Ppo Hmo", "plan_name": "701720", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Ppo Hmo", "plan_name": "701720_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Ms State Emplo", "plan_name": "401457", "standard_charge_dollar": 25.27, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Ms State Emplo", "plan_name": "401457_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Basic Pl", "plan_name": "400100", "standard_charge_dollar": 25.27, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Basic Pl", "plan_name": "400100_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Federal", "plan_name": "400110", "standard_charge_dollar": 25.27, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Federal", "plan_name": "400110_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." } ] } ] }, { "description": "Assay of acth", "code_information": [ { "code": "82024", "type": "CPT" } ], "standard_charges": [ { "gross_charge": 185.00, "minimum": 57.87, "maximum": 57.87, "setting": "both", "payers_information": [ { "payer_name": "Aetna", "plan_name": "700700", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna", "plan_name": "700700_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Miscellaneous", "plan_name": "700720", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Miscellaneous", "plan_name": "700720_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Ppo Hmo", "plan_name": "701720", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Ppo Hmo", "plan_name": "701720_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Ms State Emplo", "plan_name": "401457", "standard_charge_dollar": 57.87, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Ms State Emplo", "plan_name": "401457_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Basic Pl", "plan_name": "400100", "standard_charge_dollar": 57.87, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Basic Pl", "plan_name": "400100_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Federal", "plan_name": "400110", "standard_charge_dollar": 57.87, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Federal", "plan_name": "400110_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." } ] } ] }, { "description": "Hc acth", "code_information": [ { "code": "82024", "type": "CPT" } ], "standard_charges": [ { "gross_charge": 185.00, "minimum": 57.87, "maximum": 57.87, "setting": "both", "payers_information": [ { "payer_name": "Aetna", "plan_name": "700700", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna", "plan_name": "700700_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Miscellaneous", "plan_name": "700720", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Miscellaneous", "plan_name": "700720_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Ppo Hmo", "plan_name": "701720", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Ppo Hmo", "plan_name": "701720_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Ms State Emplo", "plan_name": "401457", "standard_charge_dollar": 57.87, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Ms State Emplo", "plan_name": "401457_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Basic Pl", "plan_name": "400100", "standard_charge_dollar": 57.87, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Basic Pl", "plan_name": "400100_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Federal", "plan_name": "400110", "standard_charge_dollar": 57.87, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Federal", "plan_name": "400110_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." } ] } ] }, { "description": "Assay of serum albumin", "code_information": [ { "code": "82040", "type": "CPT" } ], "standard_charges": [ { "gross_charge": 39.00, "minimum": 7.41, "maximum": 7.41, "setting": "both", "payers_information": [ { "payer_name": "Aetna", "plan_name": "700700", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna", "plan_name": "700700_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Miscellaneous", "plan_name": "700720", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Miscellaneous", "plan_name": "700720_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Ppo Hmo", "plan_name": "701720", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Ppo Hmo", "plan_name": "701720_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Ms State Emplo", "plan_name": "401457", "standard_charge_dollar": 7.41, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Ms State Emplo", "plan_name": "401457_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Basic Pl", "plan_name": "400100", "standard_charge_dollar": 7.41, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Basic Pl", "plan_name": "400100_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Federal", "plan_name": "400110", "standard_charge_dollar": 7.41, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Federal", "plan_name": "400110_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." } ] } ] }, { "description": "Hc albumin serum/plasma/wb", "code_information": [ { "code": "82040", "type": "CPT" } ], "standard_charges": [ { "gross_charge": 39.00, "minimum": 7.41, "maximum": 7.41, "setting": "both", "payers_information": [ { "payer_name": "Aetna", "plan_name": "700700", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna", "plan_name": "700700_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Miscellaneous", "plan_name": "700720", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Miscellaneous", "plan_name": "700720_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Ppo Hmo", "plan_name": "701720", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Ppo Hmo", "plan_name": "701720_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Ms State Emplo", "plan_name": "401457", "standard_charge_dollar": 7.41, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Ms State Emplo", "plan_name": "401457_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Basic Pl", "plan_name": "400100", "standard_charge_dollar": 7.41, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Basic Pl", "plan_name": "400100_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Federal", "plan_name": "400110", "standard_charge_dollar": 7.41, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Federal", "plan_name": "400110_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." } ] } ] }, { "description": "Hc albumin microalbumin", "code_information": [ { "code": "82043", "type": "CPT" } ], "standard_charges": [ { "gross_charge": 100.00, "minimum": 8.66, "maximum": 8.66, "setting": "both", "payers_information": [ { "payer_name": "Aetna", "plan_name": "700700", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna", "plan_name": "700700_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Miscellaneous", "plan_name": "700720", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Miscellaneous", "plan_name": "700720_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Ppo Hmo", "plan_name": "701720", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Ppo Hmo", "plan_name": "701720_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Ms State Emplo", "plan_name": "401457", "standard_charge_dollar": 8.66, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Ms State Emplo", "plan_name": "401457_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Basic Pl", "plan_name": "400100", "standard_charge_dollar": 8.66, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Basic Pl", "plan_name": "400100_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Federal", "plan_name": "400110", "standard_charge_dollar": 8.66, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Federal", "plan_name": "400110_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." } ] } ] }, { "description": "Ur albumin quantitative", "code_information": [ { "code": "82043", "type": "CPT" } ], "standard_charges": [ { "gross_charge": 100.00, "minimum": 8.66, "maximum": 8.66, "setting": "both", "payers_information": [ { "payer_name": "Aetna", "plan_name": "700700", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna", "plan_name": "700700_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Miscellaneous", "plan_name": "700720", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Miscellaneous", "plan_name": "700720_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Ppo Hmo", "plan_name": "701720", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Ppo Hmo", "plan_name": "701720_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Ms State Emplo", "plan_name": "401457", "standard_charge_dollar": 8.66, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Ms State Emplo", "plan_name": "401457_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Basic Pl", "plan_name": "400100", "standard_charge_dollar": 8.66, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Basic Pl", "plan_name": "400100_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Federal", "plan_name": "400110", "standard_charge_dollar": 8.66, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Federal", "plan_name": "400110_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." } ] } ] }, { "description": "Assay spec xcp ur&breath ia", "code_information": [ { "code": "82077", "type": "CPT" } ], "standard_charges": [ { "gross_charge": 54.60, "minimum": 43.68, "maximum": 46.41, "setting": "both", "payers_information": [ { "payer_name": "Aetna", "plan_name": "700700", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna", "plan_name": "700700_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Miscellaneous", "plan_name": "700720", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Miscellaneous", "plan_name": "700720_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Ppo Hmo", "plan_name": "701720", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Ppo Hmo", "plan_name": "701720_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Ms State Emplo", "plan_name": "401457", "standard_charge_percentage": 0.80, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Ms State Emplo", "plan_name": "401457_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Basic Pl", "plan_name": "400100", "standard_charge_percentage": 0.85, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Basic Pl", "plan_name": "400100_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Federal", "plan_name": "400110", "standard_charge_percentage": 0.85, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Federal", "plan_name": "400110_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." } ] } ] }, { "description": "Hc alcohol (ethanol)", "code_information": [ { "code": "82077", "type": "CPT" } ], "standard_charges": [ { "gross_charge": 54.60, "minimum": 43.68, "maximum": 46.41, "setting": "both", "payers_information": [ { "payer_name": "Aetna", "plan_name": "700700", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna", "plan_name": "700700_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Miscellaneous", "plan_name": "700720", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Miscellaneous", "plan_name": "700720_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Ppo Hmo", "plan_name": "701720", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Ppo Hmo", "plan_name": "701720_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Ms State Emplo", "plan_name": "401457", "standard_charge_percentage": 0.80, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Ms State Emplo", "plan_name": "401457_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Basic Pl", "plan_name": "400100", "standard_charge_percentage": 0.85, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Basic Pl", "plan_name": "400100_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Federal", "plan_name": "400110", "standard_charge_percentage": 0.85, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Federal", "plan_name": "400110_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." } ] } ] }, { "description": "Assay of aldolase", "code_information": [ { "code": "82085", "type": "CPT" } ], "standard_charges": [ { "gross_charge": 64.50, "minimum": 14.54, "maximum": 14.54, "setting": "both", "payers_information": [ { "payer_name": "Aetna", "plan_name": "700700", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna", "plan_name": "700700_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Miscellaneous", "plan_name": "700720", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Miscellaneous", "plan_name": "700720_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Ppo Hmo", "plan_name": "701720", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Ppo Hmo", "plan_name": "701720_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Ms State Emplo", "plan_name": "401457", "standard_charge_dollar": 14.54, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Ms State Emplo", "plan_name": "401457_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Basic Pl", "plan_name": "400100", "standard_charge_dollar": 14.54, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Basic Pl", "plan_name": "400100_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Federal", "plan_name": "400110", "standard_charge_dollar": 14.54, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Federal", "plan_name": "400110_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." } ] } ] }, { "description": "Hc aldolase", "code_information": [ { "code": "82085", "type": "CPT" } ], "standard_charges": [ { "gross_charge": 64.50, "minimum": 14.54, "maximum": 14.54, "setting": "both", "payers_information": [ { "payer_name": "Aetna", "plan_name": "700700", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna", "plan_name": "700700_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Miscellaneous", "plan_name": "700720", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Miscellaneous", "plan_name": "700720_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Ppo Hmo", "plan_name": "701720", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Ppo Hmo", "plan_name": "701720_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Ms State Emplo", "plan_name": "401457", "standard_charge_dollar": 14.54, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Ms State Emplo", "plan_name": "401457_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Basic Pl", "plan_name": "400100", "standard_charge_dollar": 14.54, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Basic Pl", "plan_name": "400100_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Federal", "plan_name": "400110", "standard_charge_dollar": 14.54, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Federal", "plan_name": "400110_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." } ] } ] }, { "description": "Assay of aldosterone", "code_information": [ { "code": "82088", "type": "CPT" } ], "standard_charges": [ { "gross_charge": 204.00, "minimum": 61.06, "maximum": 61.06, "setting": "both", "payers_information": [ { "payer_name": "Aetna", "plan_name": "700700", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna", "plan_name": "700700_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Miscellaneous", "plan_name": "700720", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Miscellaneous", "plan_name": "700720_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Ppo Hmo", "plan_name": "701720", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Ppo Hmo", "plan_name": "701720_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Ms State Emplo", "plan_name": "401457", "standard_charge_dollar": 61.06, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Ms State Emplo", "plan_name": "401457_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Basic Pl", "plan_name": "400100", "standard_charge_dollar": 61.06, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Basic Pl", "plan_name": "400100_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Federal", "plan_name": "400110", "standard_charge_dollar": 61.06, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Federal", "plan_name": "400110_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." } ] } ] }, { "description": "Hc adosterone urine", "code_information": [ { "code": "82088", "type": "CPT" } ], "standard_charges": [ { "gross_charge": 204.00, "minimum": 61.06, "maximum": 61.06, "setting": "both", "payers_information": [ { "payer_name": "Aetna", "plan_name": "700700", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna", "plan_name": "700700_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Miscellaneous", "plan_name": "700720", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Miscellaneous", "plan_name": "700720_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Ppo Hmo", "plan_name": "701720", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Ppo Hmo", "plan_name": "701720_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Ms State Emplo", "plan_name": "401457", "standard_charge_dollar": 61.06, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Ms State Emplo", "plan_name": "401457_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Basic Pl", "plan_name": "400100", "standard_charge_dollar": 61.06, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Basic Pl", "plan_name": "400100_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Federal", "plan_name": "400110", "standard_charge_dollar": 61.06, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Federal", "plan_name": "400110_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." } ] } ] }, { "description": "Alpha-1-antitrypsin total", "code_information": [ { "code": "82103", "type": "CPT" } ], "standard_charges": [ { "gross_charge": 77.00, "minimum": 15.96, "maximum": 15.96, "setting": "both", "payers_information": [ { "payer_name": "Aetna", "plan_name": "700700", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna", "plan_name": "700700_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Miscellaneous", "plan_name": "700720", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Miscellaneous", "plan_name": "700720_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Ppo Hmo", "plan_name": "701720", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Ppo Hmo", "plan_name": "701720_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Ms State Emplo", "plan_name": "401457", "standard_charge_dollar": 15.96, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Ms State Emplo", "plan_name": "401457_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Basic Pl", "plan_name": "400100", "standard_charge_dollar": 15.96, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Basic Pl", "plan_name": "400100_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Federal", "plan_name": "400110", "standard_charge_dollar": 15.96, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Federal", "plan_name": "400110_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." } ] } ] }, { "description": "Hc alpha 1 antitrypsin total", "code_information": [ { "code": "82103", "type": "CPT" } ], "standard_charges": [ { "gross_charge": 77.00, "minimum": 15.96, "maximum": 15.96, "setting": "both", "payers_information": [ { "payer_name": "Aetna", "plan_name": "700700", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna", "plan_name": "700700_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Miscellaneous", "plan_name": "700720", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Miscellaneous", "plan_name": "700720_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Ppo Hmo", "plan_name": "701720", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Ppo Hmo", "plan_name": "701720_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Ms State Emplo", "plan_name": "401457", "standard_charge_dollar": 15.96, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Ms State Emplo", "plan_name": "401457_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Basic Pl", "plan_name": "400100", "standard_charge_dollar": 15.96, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Basic Pl", "plan_name": "400100_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Federal", "plan_name": "400110", "standard_charge_dollar": 15.96, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Federal", "plan_name": "400110_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." } ] } ] }, { "description": "Alpha-1-antitrypsin pheno", "code_information": [ { "code": "82104", "type": "CPT" } ], "standard_charges": [ { "gross_charge": 106.00, "minimum": 21.67, "maximum": 21.67, "setting": "both", "payers_information": [ { "payer_name": "Aetna", "plan_name": "700700", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna", "plan_name": "700700_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Miscellaneous", "plan_name": "700720", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Miscellaneous", "plan_name": "700720_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Ppo Hmo", "plan_name": "701720", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Ppo Hmo", "plan_name": "701720_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Ms State Emplo", "plan_name": "401457", "standard_charge_dollar": 21.67, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Ms State Emplo", "plan_name": "401457_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Basic Pl", "plan_name": "400100", "standard_charge_dollar": 21.67, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Basic Pl", "plan_name": "400100_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Federal", "plan_name": "400110", "standard_charge_dollar": 21.67, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Federal", "plan_name": "400110_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." } ] } ] }, { "description": "Hc alpha 1 antitrypsin phenotype", "code_information": [ { "code": "82104", "type": "CPT" } ], "standard_charges": [ { "gross_charge": 106.00, "minimum": 21.67, "maximum": 21.67, "setting": "both", "payers_information": [ { "payer_name": "Aetna", "plan_name": "700700", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna", "plan_name": "700700_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Miscellaneous", "plan_name": "700720", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Miscellaneous", "plan_name": "700720_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Ppo Hmo", "plan_name": "701720", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Ppo Hmo", "plan_name": "701720_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Ms State Emplo", "plan_name": "401457", "standard_charge_dollar": 21.67, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Ms State Emplo", "plan_name": "401457_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Basic Pl", "plan_name": "400100", "standard_charge_dollar": 21.67, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Basic Pl", "plan_name": "400100_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Federal", "plan_name": "400110", "standard_charge_dollar": 21.67, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Federal", "plan_name": "400110_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." } ] } ] }, { "description": "Alpha-fetoprotein serum", "code_information": [ { "code": "82105", "type": "CPT" } ], "standard_charges": [ { "gross_charge": 65.10, "minimum": 8.99, "maximum": 8.99, "setting": "both", "payers_information": [ { "payer_name": "Aetna", "plan_name": "700700", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna", "plan_name": "700700_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Miscellaneous", "plan_name": "700720", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Miscellaneous", "plan_name": "700720_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Ppo Hmo", "plan_name": "701720", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Ppo Hmo", "plan_name": "701720_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Ms State Emplo", "plan_name": "401457", "standard_charge_dollar": 8.99, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Ms State Emplo", "plan_name": "401457_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Basic Pl", "plan_name": "400100", "standard_charge_dollar": 8.99, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Basic Pl", "plan_name": "400100_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Federal", "plan_name": "400110", "standard_charge_dollar": 8.99, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Federal", "plan_name": "400110_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." } ] } ] }, { "description": "Hc alpha feto protein serum", "code_information": [ { "code": "82105", "type": "CPT" } ], "standard_charges": [ { "gross_charge": 65.10, "minimum": 8.99, "maximum": 8.99, "setting": "both", "payers_information": [ { "payer_name": "Aetna", "plan_name": "700700", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna", "plan_name": "700700_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Miscellaneous", "plan_name": "700720", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Miscellaneous", "plan_name": "700720_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Ppo Hmo", "plan_name": "701720", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Ppo Hmo", "plan_name": "701720_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Ms State Emplo", "plan_name": "401457", "standard_charge_dollar": 8.99, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Ms State Emplo", "plan_name": "401457_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Basic Pl", "plan_name": "400100", "standard_charge_dollar": 8.99, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Basic Pl", "plan_name": "400100_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Federal", "plan_name": "400110", "standard_charge_dollar": 8.99, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Federal", "plan_name": "400110_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." } ] } ] }, { "description": "Amino acids quan 6 or more", "code_information": [ { "code": "82139", "type": "CPT" } ], "standard_charges": [ { "gross_charge": 290.30, "minimum": 25.27, "maximum": 25.27, "setting": "both", "payers_information": [ { "payer_name": "Aetna", "plan_name": "700700", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna", "plan_name": "700700_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Miscellaneous", "plan_name": "700720", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Miscellaneous", "plan_name": "700720_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Ppo Hmo", "plan_name": "701720", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Ppo Hmo", "plan_name": "701720_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Ms State Emplo", "plan_name": "401457", "standard_charge_dollar": 25.27, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Ms State Emplo", "plan_name": "401457_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Basic Pl", "plan_name": "400100", "standard_charge_dollar": 25.27, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Basic Pl", "plan_name": "400100_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Federal", "plan_name": "400110", "standard_charge_dollar": 25.27, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Federal", "plan_name": "400110_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." } ] } ] }, { "description": "Hc amino acid 6 or > quan blood", "code_information": [ { "code": "82139", "type": "CPT" } ], "standard_charges": [ { "gross_charge": 290.30, "minimum": 25.27, "maximum": 25.27, "setting": "both", "payers_information": [ { "payer_name": "Aetna", "plan_name": "700700", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna", "plan_name": "700700_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Miscellaneous", "plan_name": "700720", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Miscellaneous", "plan_name": "700720_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Ppo Hmo", "plan_name": "701720", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Ppo Hmo", "plan_name": "701720_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Ms State Emplo", "plan_name": "401457", "standard_charge_dollar": 25.27, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Ms State Emplo", "plan_name": "401457_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Basic Pl", "plan_name": "400100", "standard_charge_dollar": 25.27, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Basic Pl", "plan_name": "400100_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Federal", "plan_name": "400110", "standard_charge_dollar": 25.27, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Federal", "plan_name": "400110_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." } ] } ] }, { "description": "Assay of ammonia", "code_information": [ { "code": "82140", "type": "CPT" } ], "standard_charges": [ { "gross_charge": 263.27, "minimum": 18.29, "maximum": 18.29, "setting": "both", "payers_information": [ { "payer_name": "Aetna", "plan_name": "700700", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna", "plan_name": "700700_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Miscellaneous", "plan_name": "700720", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Miscellaneous", "plan_name": "700720_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Ppo Hmo", "plan_name": "701720", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Ppo Hmo", "plan_name": "701720_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Ms State Emplo", "plan_name": "401457", "standard_charge_dollar": 18.29, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Ms State Emplo", "plan_name": "401457_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Basic Pl", "plan_name": "400100", "standard_charge_dollar": 18.29, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Basic Pl", "plan_name": "400100_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Federal", "plan_name": "400110", "standard_charge_dollar": 18.29, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Federal", "plan_name": "400110_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." } ] } ] }, { "description": "Hc ammonia (mayo)", "code_information": [ { "code": "82140", "type": "CPT" } ], "standard_charges": [ { "gross_charge": 263.27, "minimum": 18.29, "maximum": 18.29, "setting": "both", "payers_information": [ { "payer_name": "Aetna", "plan_name": "700700", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna", "plan_name": "700700_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Miscellaneous", "plan_name": "700720", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Miscellaneous", "plan_name": "700720_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Ppo Hmo", "plan_name": "701720", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Ppo Hmo", "plan_name": "701720_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Ms State Emplo", "plan_name": "401457", "standard_charge_dollar": 18.29, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Ms State Emplo", "plan_name": "401457_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Basic Pl", "plan_name": "400100", "standard_charge_dollar": 18.29, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Basic Pl", "plan_name": "400100_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Federal", "plan_name": "400110", "standard_charge_dollar": 18.29, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Federal", "plan_name": "400110_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." } ] } ] }, { "description": "Assay of amylase", "code_information": [ { "code": "82150", "type": "CPT" } ], "standard_charges": [ { "gross_charge": 100.00, "minimum": 9.71, "maximum": 9.71, "setting": "both", "payers_information": [ { "payer_name": "Aetna", "plan_name": "700700", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna", "plan_name": "700700_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Miscellaneous", "plan_name": "700720", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Miscellaneous", "plan_name": "700720_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Ppo Hmo", "plan_name": "701720", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Ppo Hmo", "plan_name": "701720_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Ms State Emplo", "plan_name": "401457", "standard_charge_dollar": 9.71, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Ms State Emplo", "plan_name": "401457_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Basic Pl", "plan_name": "400100", "standard_charge_dollar": 9.71, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Basic Pl", "plan_name": "400100_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Federal", "plan_name": "400110", "standard_charge_dollar": 9.71, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Federal", "plan_name": "400110_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." } ] } ] }, { "description": "Hc amylase serum", "code_information": [ { "code": "82150", "type": "CPT" } ], "standard_charges": [ { "gross_charge": 100.00, "minimum": 9.71, "maximum": 9.71, "setting": "both", "payers_information": [ { "payer_name": "Aetna", "plan_name": "700700", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna", "plan_name": "700700_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Miscellaneous", "plan_name": "700720", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Miscellaneous", "plan_name": "700720_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Ppo Hmo", "plan_name": "701720", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Ppo Hmo", "plan_name": "701720_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Ms State Emplo", "plan_name": "401457", "standard_charge_dollar": 9.71, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Ms State Emplo", "plan_name": "401457_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Basic Pl", "plan_name": "400100", "standard_charge_dollar": 9.71, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Basic Pl", "plan_name": "400100_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Federal", "plan_name": "400110", "standard_charge_dollar": 9.71, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Federal", "plan_name": "400110_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." } ] } ] }, { "description": "Assay of androstenedione", "code_information": [ { "code": "82157", "type": "CPT" } ], "standard_charges": [ { "gross_charge": 71.84, "minimum": 43.87, "maximum": 43.87, "setting": "both", "payers_information": [ { "payer_name": "Aetna", "plan_name": "700700", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna", "plan_name": "700700_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Miscellaneous", "plan_name": "700720", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Miscellaneous", "plan_name": "700720_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Ppo Hmo", "plan_name": "701720", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Ppo Hmo", "plan_name": "701720_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Ms State Emplo", "plan_name": "401457", "standard_charge_dollar": 43.87, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Ms State Emplo", "plan_name": "401457_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Basic Pl", "plan_name": "400100", "standard_charge_dollar": 43.87, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Basic Pl", "plan_name": "400100_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Federal", "plan_name": "400110", "standard_charge_dollar": 43.87, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Federal", "plan_name": "400110_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." } ] } ] }, { "description": "Hc androstenedione", "code_information": [ { "code": "82157", "type": "CPT" } ], "standard_charges": [ { "gross_charge": 71.84, "minimum": 43.87, "maximum": 43.87, "setting": "both", "payers_information": [ { "payer_name": "Aetna", "plan_name": "700700", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna", "plan_name": "700700_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Miscellaneous", "plan_name": "700720", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Miscellaneous", "plan_name": "700720_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Ppo Hmo", "plan_name": "701720", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Ppo Hmo", "plan_name": "701720_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Ms State Emplo", "plan_name": "401457", "standard_charge_dollar": 43.87, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Ms State Emplo", "plan_name": "401457_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Basic Pl", "plan_name": "400100", "standard_charge_dollar": 43.87, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Basic Pl", "plan_name": "400100_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Federal", "plan_name": "400110", "standard_charge_dollar": 43.87, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Federal", "plan_name": "400110_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." } ] } ] }, { "description": "Angiotensin i enzyme test", "code_information": [ { "code": "82164", "type": "CPT" } ], "standard_charges": [ { "gross_charge": 84.36, "minimum": 17.00, "maximum": 17.00, "setting": "both", "payers_information": [ { "payer_name": "Aetna", "plan_name": "700700", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna", "plan_name": "700700_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Miscellaneous", "plan_name": "700720", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Miscellaneous", "plan_name": "700720_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Ppo Hmo", "plan_name": "701720", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Ppo Hmo", "plan_name": "701720_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Ms State Emplo", "plan_name": "401457", "standard_charge_dollar": 17.00, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Ms State Emplo", "plan_name": "401457_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Basic Pl", "plan_name": "400100", "standard_charge_dollar": 17.00, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Basic Pl", "plan_name": "400100_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Federal", "plan_name": "400110", "standard_charge_dollar": 17.00, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Federal", "plan_name": "400110_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." } ] } ] }, { "description": "Hc angiotension convert enzyme", "code_information": [ { "code": "82164", "type": "CPT" } ], "standard_charges": [ { "gross_charge": 84.36, "minimum": 17.00, "maximum": 17.00, "setting": "both", "payers_information": [ { "payer_name": "Aetna", "plan_name": "700700", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna", "plan_name": "700700_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Miscellaneous", "plan_name": "700720", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Miscellaneous", "plan_name": "700720_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Ppo Hmo", "plan_name": "701720", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Ppo Hmo", "plan_name": "701720_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Ms State Emplo", "plan_name": "401457", "standard_charge_dollar": 17.00, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Ms State Emplo", "plan_name": "401457_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Basic Pl", "plan_name": "400100", "standard_charge_dollar": 17.00, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Basic Pl", "plan_name": "400100_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Federal", "plan_name": "400110", "standard_charge_dollar": 17.00, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Federal", "plan_name": "400110_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." } ] } ] }, { "description": "Assay anti-mullerian horm", "code_information": [ { "code": "82166", "type": "CPT" } ], "standard_charges": [ { "gross_charge": 219.72, "minimum": 175.78, "maximum": 186.76, "setting": "both", "payers_information": [ { "payer_name": "Aetna", "plan_name": "700700", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna", "plan_name": "700700_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Miscellaneous", "plan_name": "700720", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Miscellaneous", "plan_name": "700720_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Ppo Hmo", "plan_name": "701720", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Ppo Hmo", "plan_name": "701720_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Ms State Emplo", "plan_name": "401457", "standard_charge_percentage": 0.80, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Ms State Emplo", "plan_name": "401457_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Basic Pl", "plan_name": "400100", "standard_charge_percentage": 0.85, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Basic Pl", "plan_name": "400100_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Federal", "plan_name": "400110", "standard_charge_percentage": 0.85, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Federal", "plan_name": "400110_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." } ] } ] }, { "description": "Hc assay of anti-mullerian hormone", "code_information": [ { "code": "82166", "type": "CPT" } ], "standard_charges": [ { "gross_charge": 219.72, "minimum": 175.78, "maximum": 186.76, "setting": "both", "payers_information": [ { "payer_name": "Aetna", "plan_name": "700700", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna", "plan_name": "700700_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Miscellaneous", "plan_name": "700720", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Miscellaneous", "plan_name": "700720_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Ppo Hmo", "plan_name": "701720", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Ppo Hmo", "plan_name": "701720_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Ms State Emplo", "plan_name": "401457", "standard_charge_percentage": 0.80, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Ms State Emplo", "plan_name": "401457_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Basic Pl", "plan_name": "400100", "standard_charge_percentage": 0.85, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Basic Pl", "plan_name": "400100_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Federal", "plan_name": "400110", "standard_charge_percentage": 0.85, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Federal", "plan_name": "400110_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." } ] } ] }, { "description": "Assay of arsenic", "code_information": [ { "code": "82175", "type": "CPT" } ], "standard_charges": [ { "gross_charge": 106.00, "minimum": 18.03, "maximum": 18.03, "setting": "both", "payers_information": [ { "payer_name": "Aetna", "plan_name": "700700", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna", "plan_name": "700700_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Miscellaneous", "plan_name": "700720", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Miscellaneous", "plan_name": "700720_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Ppo Hmo", "plan_name": "701720", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Ppo Hmo", "plan_name": "701720_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Ms State Emplo", "plan_name": "401457", "standard_charge_dollar": 18.03, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Ms State Emplo", "plan_name": "401457_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Basic Pl", "plan_name": "400100", "standard_charge_dollar": 18.03, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Basic Pl", "plan_name": "400100_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Federal", "plan_name": "400110", "standard_charge_dollar": 18.03, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Federal", "plan_name": "400110_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." } ] } ] }, { "description": "Hc arsenic level urine random", "code_information": [ { "code": "82175", "type": "CPT" } ], "standard_charges": [ { "gross_charge": 106.00, "minimum": 18.03, "maximum": 18.03, "setting": "both", "payers_information": [ { "payer_name": "Aetna", "plan_name": "700700", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna", "plan_name": "700700_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Miscellaneous", "plan_name": "700720", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Miscellaneous", "plan_name": "700720_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Ppo Hmo", "plan_name": "701720", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Ppo Hmo", "plan_name": "701720_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Ms State Emplo", "plan_name": "401457", "standard_charge_dollar": 18.03, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Ms State Emplo", "plan_name": "401457_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Basic Pl", "plan_name": "400100", "standard_charge_dollar": 18.03, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Basic Pl", "plan_name": "400100_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Federal", "plan_name": "400110", "standard_charge_dollar": 18.03, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Federal", "plan_name": "400110_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." } ] } ] }, { "description": "Assay of ascorbic acid", "code_information": [ { "code": "82180", "type": "CPT" } ], "standard_charges": [ { "gross_charge": 80.00, "minimum": 14.81, "maximum": 14.81, "setting": "both", "payers_information": [ { "payer_name": "Aetna", "plan_name": "700700", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna", "plan_name": "700700_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Miscellaneous", "plan_name": "700720", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Miscellaneous", "plan_name": "700720_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Ppo Hmo", "plan_name": "701720", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Ppo Hmo", "plan_name": "701720_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Ms State Emplo", "plan_name": "401457", "standard_charge_dollar": 14.81, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Ms State Emplo", "plan_name": "401457_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Basic Pl", "plan_name": "400100", "standard_charge_dollar": 14.81, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Basic Pl", "plan_name": "400100_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Federal", "plan_name": "400110", "standard_charge_dollar": 14.81, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Federal", "plan_name": "400110_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." } ] } ] }, { "description": "Hc ascorbic acid vit c", "code_information": [ { "code": "82180", "type": "CPT" } ], "standard_charges": [ { "gross_charge": 80.00, "minimum": 14.81, "maximum": 14.81, "setting": "both", "payers_information": [ { "payer_name": "Aetna", "plan_name": "700700", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna", "plan_name": "700700_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Miscellaneous", "plan_name": "700720", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Miscellaneous", "plan_name": "700720_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Ppo Hmo", "plan_name": "701720", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Ppo Hmo", "plan_name": "701720_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Ms State Emplo", "plan_name": "401457", "standard_charge_dollar": 14.81, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Ms State Emplo", "plan_name": "401457_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Basic Pl", "plan_name": "400100", "standard_charge_dollar": 14.81, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Basic Pl", "plan_name": "400100_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Federal", "plan_name": "400110", "standard_charge_dollar": 14.81, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Federal", "plan_name": "400110_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." } ] } ] }, { "description": "Assay of beta-2 protein", "code_information": [ { "code": "82232", "type": "CPT" } ], "standard_charges": [ { "gross_charge": 93.03, "minimum": 21.91, "maximum": 21.91, "setting": "both", "payers_information": [ { "payer_name": "Aetna", "plan_name": "700700", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna", "plan_name": "700700_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Miscellaneous", "plan_name": "700720", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Miscellaneous", "plan_name": "700720_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Ppo Hmo", "plan_name": "701720", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Ppo Hmo", "plan_name": "701720_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Ms State Emplo", "plan_name": "401457", "standard_charge_dollar": 21.91, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Ms State Emplo", "plan_name": "401457_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Basic Pl", "plan_name": "400100", "standard_charge_dollar": 21.91, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Basic Pl", "plan_name": "400100_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Federal", "plan_name": "400110", "standard_charge_dollar": 21.91, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Federal", "plan_name": "400110_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." } ] } ] }, { "description": "Hc beta 2 microglobulin", "code_information": [ { "code": "82232", "type": "CPT" } ], "standard_charges": [ { "gross_charge": 93.03, "minimum": 21.91, "maximum": 21.91, "setting": "both", "payers_information": [ { "payer_name": "Aetna", "plan_name": "700700", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna", "plan_name": "700700_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Miscellaneous", "plan_name": "700720", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Miscellaneous", "plan_name": "700720_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Ppo Hmo", "plan_name": "701720", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Ppo Hmo", "plan_name": "701720_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Ms State Emplo", "plan_name": "401457", "standard_charge_dollar": 21.91, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Ms State Emplo", "plan_name": "401457_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Basic Pl", "plan_name": "400100", "standard_charge_dollar": 21.91, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Basic Pl", "plan_name": "400100_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Federal", "plan_name": "400110", "standard_charge_dollar": 21.91, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Federal", "plan_name": "400110_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." } ] } ] }, { "description": "Bilirubin total", "code_information": [ { "code": "82247", "type": "CPT" } ], "standard_charges": [ { "gross_charge": 44.00, "minimum": 7.51, "maximum": 7.51, "setting": "both", "payers_information": [ { "payer_name": "Aetna", "plan_name": "700700", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna", "plan_name": "700700_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Miscellaneous", "plan_name": "700720", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Miscellaneous", "plan_name": "700720_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Ppo Hmo", "plan_name": "701720", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Ppo Hmo", "plan_name": "701720_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Ms State Emplo", "plan_name": "401457", "standard_charge_dollar": 7.51, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Ms State Emplo", "plan_name": "401457_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Basic Pl", "plan_name": "400100", "standard_charge_dollar": 7.51, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Basic Pl", "plan_name": "400100_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Federal", "plan_name": "400110", "standard_charge_dollar": 7.51, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Federal", "plan_name": "400110_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." } ] } ] }, { "description": "Hc bilirubin total", "code_information": [ { "code": "82247", "type": "CPT" } ], "standard_charges": [ { "gross_charge": 44.00, "minimum": 7.51, "maximum": 7.51, "setting": "both", "payers_information": [ { "payer_name": "Aetna", "plan_name": "700700", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna", "plan_name": "700700_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Miscellaneous", "plan_name": "700720", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Miscellaneous", "plan_name": "700720_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Ppo Hmo", "plan_name": "701720", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Ppo Hmo", "plan_name": "701720_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Ms State Emplo", "plan_name": "401457", "standard_charge_dollar": 7.51, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Ms State Emplo", "plan_name": "401457_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Basic Pl", "plan_name": "400100", "standard_charge_dollar": 7.51, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Basic Pl", "plan_name": "400100_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Federal", "plan_name": "400110", "standard_charge_dollar": 7.51, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Federal", "plan_name": "400110_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." } ] } ] }, { "description": "Bilirubin direct", "code_information": [ { "code": "82248", "type": "CPT" } ], "standard_charges": [ { "gross_charge": 44.00, "minimum": 7.51, "maximum": 7.51, "setting": "both", "payers_information": [ { "payer_name": "Aetna", "plan_name": "700700", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna", "plan_name": "700700_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Miscellaneous", "plan_name": "700720", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Miscellaneous", "plan_name": "700720_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Ppo Hmo", "plan_name": "701720", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Ppo Hmo", "plan_name": "701720_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Ms State Emplo", "plan_name": "401457", "standard_charge_dollar": 7.51, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Ms State Emplo", "plan_name": "401457_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Basic Pl", "plan_name": "400100", "standard_charge_dollar": 7.51, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Basic Pl", "plan_name": "400100_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Federal", "plan_name": "400110", "standard_charge_dollar": 7.51, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Federal", "plan_name": "400110_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." } ] } ] }, { "description": "Hc bilirubin direct", "code_information": [ { "code": "82248", "type": "CPT" } ], "standard_charges": [ { "gross_charge": 44.00, "minimum": 7.51, "maximum": 7.51, "setting": "both", "payers_information": [ { "payer_name": "Aetna", "plan_name": "700700", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna", "plan_name": "700700_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Miscellaneous", "plan_name": "700720", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Miscellaneous", "plan_name": "700720_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Ppo Hmo", "plan_name": "701720", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Ppo Hmo", "plan_name": "701720_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Ms State Emplo", "plan_name": "401457", "standard_charge_dollar": 7.51, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Ms State Emplo", "plan_name": "401457_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Basic Pl", "plan_name": "400100", "standard_charge_dollar": 7.51, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Basic Pl", "plan_name": "400100_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Federal", "plan_name": "400110", "standard_charge_dollar": 7.51, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Federal", "plan_name": "400110_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." } ] } ] }, { "description": "Hc occult blood feces", "code_information": [ { "code": "82270", "type": "CPT" } ], "standard_charges": [ { "gross_charge": 49.00, "minimum": 4.38, "maximum": 5.48, "setting": "both", "payers_information": [ { "payer_name": "Aarp", "plan_name": "500102", "standard_charge_dollar": 4.38, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna", "plan_name": "700700", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna", "plan_name": "700700_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Mcare Ffs 6005", "plan_name": "700703", "standard_charge_dollar": 4.38, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Miscellaneous", "plan_name": "700720", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Miscellaneous", "plan_name": "700720_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Ppo Hmo", "plan_name": "701720", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Ppo Hmo", "plan_name": "701720_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Ambetter 68069", "plan_name": "500516", "standard_charge_dollar": 4.38, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Ms State Emplo", "plan_name": "401457", "standard_charge_dollar": 4.87, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Ms State Emplo", "plan_name": "401457_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Basic Pl", "plan_name": "400100", "standard_charge_dollar": 4.87, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Basic Pl", "plan_name": "400100_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Federal", "plan_name": "400110", "standard_charge_dollar": 4.87, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Federal", "plan_name": "400110_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Cigna Healthsprings Ffs", "plan_name": "500064", "standard_charge_dollar": 4.38, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Conseco", "plan_name": "500302", "standard_charge_dollar": 4.38, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Humana Ffs 61101", "plan_name": "500006", "standard_charge_dollar": 4.38, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Medicare A", "plan_name": "100100", "standard_charge_dollar": 4.38, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Medicare A", "plan_name": "100500", "standard_charge_dollar": 4.38, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Medicare Part B Only", "plan_name": "100300", "standard_charge_dollar": 4.38, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Medicare Railroad", "plan_name": "100103", "standard_charge_dollar": 4.38, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Ms Physicians Care N", "plan_name": "714210", "standard_charge_dollar": 5.48, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Peoples Hlth Ffs 72126", "plan_name": "500019", "standard_charge_dollar": 4.38, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Uhc/Secure Horizons", "plan_name": "500449", "standard_charge_dollar": 4.38, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "United Health Care/", "plan_name": "500292", "standard_charge_dollar": 4.95, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "United Healthcare", "plan_name": "750104", "standard_charge_dollar": 4.95, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "United Healthcare Ba", "plan_name": "750090", "standard_charge_dollar": 4.95, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "United Healthcare Me", "plan_name": "501310", "standard_charge_dollar": 4.38, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Windsor Mcare Extra", "plan_name": "500778", "standard_charge_dollar": 4.38, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." } ] } ] }, { "description": "Occult blood feces", "code_information": [ { "code": "82270", "type": "CPT" } ], "standard_charges": [ { "gross_charge": 49.00, "minimum": 4.38, "maximum": 5.48, "setting": "both", "payers_information": [ { "payer_name": "Aarp", "plan_name": "500102", "standard_charge_dollar": 4.38, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna", "plan_name": "700700", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna", "plan_name": "700700_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Mcare Ffs 6005", "plan_name": "700703", "standard_charge_dollar": 4.38, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Miscellaneous", "plan_name": "700720", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Miscellaneous", "plan_name": "700720_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Ppo Hmo", "plan_name": "701720", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Ppo Hmo", "plan_name": "701720_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Ambetter 68069", "plan_name": "500516", "standard_charge_dollar": 4.38, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Ms State Emplo", "plan_name": "401457", "standard_charge_dollar": 4.87, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Ms State Emplo", "plan_name": "401457_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Basic Pl", "plan_name": "400100", "standard_charge_dollar": 4.87, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Basic Pl", "plan_name": "400100_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Federal", "plan_name": "400110", "standard_charge_dollar": 4.87, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Federal", "plan_name": "400110_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Cigna Healthsprings Ffs", "plan_name": "500064", "standard_charge_dollar": 4.38, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Conseco", "plan_name": "500302", "standard_charge_dollar": 4.38, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Humana Ffs 61101", "plan_name": "500006", "standard_charge_dollar": 4.38, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Medicare A", "plan_name": "100100", "standard_charge_dollar": 4.38, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Medicare A", "plan_name": "100500", "standard_charge_dollar": 4.38, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Medicare Part B Only", "plan_name": "100300", "standard_charge_dollar": 4.38, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Medicare Railroad", "plan_name": "100103", "standard_charge_dollar": 4.38, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Ms Physicians Care N", "plan_name": "714210", "standard_charge_dollar": 5.48, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Peoples Hlth Ffs 72126", "plan_name": "500019", "standard_charge_dollar": 4.38, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Uhc/Secure Horizons", "plan_name": "500449", "standard_charge_dollar": 4.38, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "United Health Care/", "plan_name": "500292", "standard_charge_dollar": 4.95, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "United Healthcare", "plan_name": "750104", "standard_charge_dollar": 4.95, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "United Healthcare Ba", "plan_name": "750090", "standard_charge_dollar": 4.95, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "United Healthcare Me", "plan_name": "501310", "standard_charge_dollar": 4.38, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Windsor Mcare Extra", "plan_name": "500778", "standard_charge_dollar": 4.38, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." } ] } ] }, { "description": "Hc occult blood  gastric fluid", "code_information": [ { "code": "82271", "type": "CPT" } ], "standard_charges": [ { "gross_charge": 31.50, "minimum": 4.87, "maximum": 4.87, "setting": "both", "payers_information": [ { "payer_name": "Aetna", "plan_name": "700700", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna", "plan_name": "700700_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Miscellaneous", "plan_name": "700720", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Miscellaneous", "plan_name": "700720_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Ppo Hmo", "plan_name": "701720", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Ppo Hmo", "plan_name": "701720_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Ms State Emplo", "plan_name": "401457", "standard_charge_dollar": 4.87, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Ms State Emplo", "plan_name": "401457_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Basic Pl", "plan_name": "400100", "standard_charge_dollar": 4.87, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Basic Pl", "plan_name": "400100_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Federal", "plan_name": "400110", "standard_charge_dollar": 4.87, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Federal", "plan_name": "400110_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." } ] } ] }, { "description": "Occult blood other sources", "code_information": [ { "code": "82271", "type": "CPT" } ], "standard_charges": [ { "gross_charge": 31.50, "minimum": 4.87, "maximum": 4.87, "setting": "both", "payers_information": [ { "payer_name": "Aetna", "plan_name": "700700", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna", "plan_name": "700700_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Miscellaneous", "plan_name": "700720", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Miscellaneous", "plan_name": "700720_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Ppo Hmo", "plan_name": "701720", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Ppo Hmo", "plan_name": "701720_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Ms State Emplo", "plan_name": "401457", "standard_charge_dollar": 4.87, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Ms State Emplo", "plan_name": "401457_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Basic Pl", "plan_name": "400100", "standard_charge_dollar": 4.87, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Basic Pl", "plan_name": "400100_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Federal", "plan_name": "400110", "standard_charge_dollar": 4.87, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Federal", "plan_name": "400110_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." } ] } ] }, { "description": "Hc occult blood feces 1-3 tests", "code_information": [ { "code": "82272", "type": "CPT" } ], "standard_charges": [ { "gross_charge": 50.00, "minimum": 4.87, "maximum": 4.87, "setting": "both", "payers_information": [ { "payer_name": "Aetna", "plan_name": "700700", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna", "plan_name": "700700_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Miscellaneous", "plan_name": "700720", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Miscellaneous", "plan_name": "700720_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Ppo Hmo", "plan_name": "701720", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Ppo Hmo", "plan_name": "701720_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Ms State Emplo", "plan_name": "401457", "standard_charge_dollar": 4.87, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Ms State Emplo", "plan_name": "401457_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Basic Pl", "plan_name": "400100", "standard_charge_dollar": 4.87, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Basic Pl", "plan_name": "400100_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Federal", "plan_name": "400110", "standard_charge_dollar": 4.87, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Federal", "plan_name": "400110_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." } ] } ] }, { "description": "Occult bld feces 1-3 tests", "code_information": [ { "code": "82272", "type": "CPT" } ], "standard_charges": [ { "gross_charge": 50.00, "minimum": 4.87, "maximum": 4.87, "setting": "both", "payers_information": [ { "payer_name": "Aetna", "plan_name": "700700", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna", "plan_name": "700700_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Miscellaneous", "plan_name": "700720", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Miscellaneous", "plan_name": "700720_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Ppo Hmo", "plan_name": "701720", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Ppo Hmo", "plan_name": "701720_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Ms State Emplo", "plan_name": "401457", "standard_charge_dollar": 4.87, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Ms State Emplo", "plan_name": "401457_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Basic Pl", "plan_name": "400100", "standard_charge_dollar": 4.87, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Basic Pl", "plan_name": "400100_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Federal", "plan_name": "400110", "standard_charge_dollar": 4.87, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Federal", "plan_name": "400110_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." } ] } ] }, { "description": "Assay test for blood fecal", "code_information": [ { "code": "82274", "type": "CPT" } ], "standard_charges": [ { "gross_charge": 47.76, "minimum": 13.50, "maximum": 13.50, "setting": "both", "payers_information": [ { "payer_name": "Aetna", "plan_name": "700700", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna", "plan_name": "700700_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Miscellaneous", "plan_name": "700720", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Miscellaneous", "plan_name": "700720_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Ppo Hmo", "plan_name": "701720", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Ppo Hmo", "plan_name": "701720_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Ms State Emplo", "plan_name": "401457", "standard_charge_dollar": 13.50, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Ms State Emplo", "plan_name": "401457_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Basic Pl", "plan_name": "400100", "standard_charge_dollar": 13.50, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Basic Pl", "plan_name": "400100_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Federal", "plan_name": "400110", "standard_charge_dollar": 13.50, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Federal", "plan_name": "400110_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." } ] } ] }, { "description": "Hc occult blood fhg qual 1-3", "code_information": [ { "code": "82274", "type": "CPT" } ], "standard_charges": [ { "gross_charge": 47.76, "minimum": 13.50, "maximum": 13.50, "setting": "both", "payers_information": [ { "payer_name": "Aetna", "plan_name": "700700", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna", "plan_name": "700700_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Miscellaneous", "plan_name": "700720", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Miscellaneous", "plan_name": "700720_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Ppo Hmo", "plan_name": "701720", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Ppo Hmo", "plan_name": "701720_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Ms State Emplo", "plan_name": "401457", "standard_charge_dollar": 13.50, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Ms State Emplo", "plan_name": "401457_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Basic Pl", "plan_name": "400100", "standard_charge_dollar": 13.50, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Basic Pl", "plan_name": "400100_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Federal", "plan_name": "400110", "standard_charge_dollar": 13.50, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Federal", "plan_name": "400110_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." } ] } ] }, { "description": "Assay of cadmium", "code_information": [ { "code": "82300", "type": "CPT" } ], "standard_charges": [ { "gross_charge": 102.50, "minimum": 30.49, "maximum": 30.49, "setting": "both", "payers_information": [ { "payer_name": "Aetna", "plan_name": "700700", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna", "plan_name": "700700_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Miscellaneous", "plan_name": "700720", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Miscellaneous", "plan_name": "700720_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Ppo Hmo", "plan_name": "701720", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Ppo Hmo", "plan_name": "701720_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Ms State Emplo", "plan_name": "401457", "standard_charge_dollar": 30.49, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Ms State Emplo", "plan_name": "401457_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Basic Pl", "plan_name": "400100", "standard_charge_dollar": 30.49, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Basic Pl", "plan_name": "400100_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Federal", "plan_name": "400110", "standard_charge_dollar": 30.49, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Federal", "plan_name": "400110_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." } ] } ] }, { "description": "Hc cadmium urine random", "code_information": [ { "code": "82300", "type": "CPT" } ], "standard_charges": [ { "gross_charge": 102.50, "minimum": 30.49, "maximum": 30.49, "setting": "both", "payers_information": [ { "payer_name": "Aetna", "plan_name": "700700", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna", "plan_name": "700700_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Miscellaneous", "plan_name": "700720", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Miscellaneous", "plan_name": "700720_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Ppo Hmo", "plan_name": "701720", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Ppo Hmo", "plan_name": "701720_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Ms State Emplo", "plan_name": "401457", "standard_charge_dollar": 30.49, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Ms State Emplo", "plan_name": "401457_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total 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"Insufficient remit data to calculate allowed amounts." } ] } ] }, { "description": "Hc hydroxyvitamin d2 and d3 serum", "code_information": [ { "code": "82306", "type": "CPT" } ], "standard_charges": [ { "gross_charge": 150.00, "minimum": 44.36, "maximum": 44.36, "setting": "both", "payers_information": [ { "payer_name": "Aetna", "plan_name": "700700", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna", "plan_name": "700700_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Miscellaneous", "plan_name": "700720", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Miscellaneous", "plan_name": "700720_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Ppo Hmo", "plan_name": "701720", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Ppo Hmo", "plan_name": "701720_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Ms State Emplo", "plan_name": "401457", "standard_charge_dollar": 44.36, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Ms State Emplo", "plan_name": "401457_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Basic Pl", "plan_name": "400100", "standard_charge_dollar": 44.36, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Basic Pl", "plan_name": "400100_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Federal", "plan_name": "400110", "standard_charge_dollar": 44.36, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Federal", "plan_name": "400110_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." } ] } ] }, { "description": "Vitamin d 25 hydroxy", "code_information": [ { "code": "82306", "type": "CPT" } ], "standard_charges": [ { "gross_charge": 150.00, "minimum": 44.36, "maximum": 44.36, "setting": "both", "payers_information": [ { "payer_name": "Aetna", "plan_name": "700700", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna", "plan_name": "700700_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Miscellaneous", "plan_name": "700720", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Miscellaneous", "plan_name": "700720_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Ppo Hmo", "plan_name": "701720", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Ppo Hmo", "plan_name": "701720_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Ms State Emplo", "plan_name": "401457", "standard_charge_dollar": 44.36, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Ms State Emplo", "plan_name": "401457_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Basic Pl", "plan_name": "400100", "standard_charge_dollar": 44.36, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Basic Pl", "plan_name": "400100_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Federal", "plan_name": "400110", "standard_charge_dollar": 44.36, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Federal", "plan_name": "400110_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." } ] } ] }, { "description": "Assay of calcium", "code_information": [ { "code": "82310", "type": "CPT" } ], "standard_charges": [ { "gross_charge": 38.85, "minimum": 7.73, "maximum": 7.73, "setting": "both", "payers_information": [ { "payer_name": "Aetna", "plan_name": "700700", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna", "plan_name": "700700_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Miscellaneous", "plan_name": "700720", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Miscellaneous", "plan_name": "700720_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Ppo Hmo", "plan_name": "701720", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Ppo Hmo", "plan_name": "701720_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Ms State Emplo", "plan_name": "401457", "standard_charge_dollar": 7.73, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Ms State Emplo", "plan_name": "401457_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Basic Pl", "plan_name": "400100", "standard_charge_dollar": 7.73, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Basic Pl", "plan_name": "400100_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Federal", "plan_name": "400110", "standard_charge_dollar": 7.73, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Federal", "plan_name": "400110_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." } ] } ] }, { "description": "Hc calcium serum", "code_information": [ { "code": "82310", "type": "CPT" } ], "standard_charges": [ { "gross_charge": 38.85, "minimum": 7.73, "maximum": 7.73, "setting": "both", "payers_information": [ { "payer_name": "Aetna", "plan_name": "700700", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna", "plan_name": "700700_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Miscellaneous", "plan_name": "700720", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Miscellaneous", "plan_name": "700720_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Ppo Hmo", "plan_name": "701720", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Ppo Hmo", "plan_name": "701720_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Ms State Emplo", "plan_name": "401457", "standard_charge_dollar": 7.73, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Ms State Emplo", "plan_name": "401457_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Basic Pl", "plan_name": "400100", "standard_charge_dollar": 7.73, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Basic Pl", "plan_name": "400100_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Federal", "plan_name": "400110", "standard_charge_dollar": 7.73, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Federal", "plan_name": "400110_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." } ] } ] }, { "description": "Assay of calcium in urine", "code_information": [ { "code": "82340", "type": "CPT" } ], "standard_charges": [ { "gross_charge": 38.85, "minimum": 9.03, "maximum": 9.03, "setting": "both", "payers_information": [ { "payer_name": "Aetna", "plan_name": "700700", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna", "plan_name": "700700_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Miscellaneous", "plan_name": "700720", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Miscellaneous", "plan_name": "700720_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Ppo Hmo", "plan_name": "701720", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Ppo Hmo", "plan_name": "701720_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Ms State Emplo", "plan_name": "401457", "standard_charge_dollar": 9.03, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Ms State Emplo", "plan_name": "401457_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Basic Pl", "plan_name": "400100", "standard_charge_dollar": 9.03, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Basic Pl", "plan_name": "400100_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Federal", "plan_name": "400110", "standard_charge_dollar": 9.03, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Federal", "plan_name": "400110_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." } ] } ] }, { "description": "Hc urine ca 24hr", "code_information": [ { "code": "82340", "type": "CPT" } ], "standard_charges": [ { "gross_charge": 38.85, "minimum": 9.03, "maximum": 9.03, "setting": "both", "payers_information": [ { "payer_name": "Aetna", "plan_name": "700700", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna", "plan_name": "700700_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Miscellaneous", "plan_name": "700720", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Miscellaneous", "plan_name": "700720_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Ppo Hmo", "plan_name": "701720", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Ppo Hmo", "plan_name": "701720_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Ms State Emplo", "plan_name": "401457", "standard_charge_dollar": 9.03, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Ms State Emplo", "plan_name": "401457_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Basic Pl", "plan_name": "400100", "standard_charge_dollar": 9.03, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Basic Pl", "plan_name": "400100_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Federal", "plan_name": "400110", "standard_charge_dollar": 9.03, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Federal", "plan_name": "400110_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." } ] } ] }, { "description": "Assay blood carbon dioxide", "code_information": [ { "code": "82374", "type": "CPT" } ], "standard_charges": [ { "gross_charge": 35.54, "minimum": 6.96, "maximum": 6.96, "setting": "both", "payers_information": [ { "payer_name": "Aetna", "plan_name": "700700", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna", "plan_name": "700700_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Miscellaneous", "plan_name": "700720", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Miscellaneous", "plan_name": "700720_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Ppo Hmo", "plan_name": "701720", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Ppo Hmo", "plan_name": "701720_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Ms State Emplo", "plan_name": "401457", "standard_charge_dollar": 6.96, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Ms State Emplo", "plan_name": "401457_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Basic Pl", "plan_name": "400100", "standard_charge_dollar": 6.96, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Basic Pl", "plan_name": "400100_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Federal", "plan_name": "400110", "standard_charge_dollar": 6.96, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Federal", "plan_name": "400110_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." } ] } ] }, { "description": "Hc carbon dioxide", "code_information": [ { "code": "82374", "type": "CPT" } ], "standard_charges": [ { "gross_charge": 35.54, "minimum": 6.96, "maximum": 6.96, "setting": "both", "payers_information": [ { "payer_name": "Aetna", "plan_name": "700700", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna", "plan_name": "700700_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Miscellaneous", "plan_name": "700720", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Miscellaneous", "plan_name": "700720_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Ppo Hmo", "plan_name": "701720", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Ppo Hmo", "plan_name": "701720_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Ms State Emplo", "plan_name": "401457", "standard_charge_dollar": 6.96, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Ms State Emplo", "plan_name": "401457_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Basic Pl", "plan_name": "400100", "standard_charge_dollar": 6.96, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Basic Pl", "plan_name": "400100_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Federal", "plan_name": "400110", "standard_charge_dollar": 6.96, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Federal", "plan_name": "400110_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." } ] } ] }, { "description": "Assay carboxyhb quant", "code_information": [ { "code": "82375", "type": "CPT" } ], "standard_charges": [ { "gross_charge": 87.80, "minimum": 18.29, "maximum": 18.29, "setting": "both", "payers_information": [ { "payer_name": "Aetna", "plan_name": "700700", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna", "plan_name": "700700_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Miscellaneous", "plan_name": "700720", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Miscellaneous", "plan_name": "700720_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Ppo Hmo", "plan_name": "701720", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Ppo Hmo", "plan_name": "701720_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Ms State Emplo", "plan_name": "401457", "standard_charge_dollar": 18.29, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Ms State Emplo", "plan_name": "401457_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Basic Pl", "plan_name": "400100", "standard_charge_dollar": 18.29, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Basic Pl", "plan_name": "400100_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Federal", "plan_name": "400110", "standard_charge_dollar": 18.29, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Federal", "plan_name": "400110_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." } ] } ] }, { "description": "Hc carbon monoxide", "code_information": [ { "code": "82375", "type": "CPT" } ], "standard_charges": [ { "gross_charge": 87.80, "minimum": 18.29, "maximum": 18.29, "setting": "both", "payers_information": [ { "payer_name": "Aetna", "plan_name": "700700", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna", "plan_name": "700700_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Miscellaneous", "plan_name": "700720", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Miscellaneous", "plan_name": "700720_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Ppo Hmo", "plan_name": "701720", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Ppo Hmo", "plan_name": "701720_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Ms State Emplo", "plan_name": "401457", "standard_charge_dollar": 18.29, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Ms State Emplo", "plan_name": "401457_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Basic Pl", "plan_name": "400100", "standard_charge_dollar": 18.29, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Basic Pl", "plan_name": "400100_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Federal", "plan_name": "400110", "standard_charge_dollar": 18.29, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Federal", "plan_name": "400110_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." } ] } ] }, { "description": "Carcinoembryonic antigen", "code_information": [ { "code": "82378", "type": "CPT" } ], "standard_charges": [ { "gross_charge": 83.26, "minimum": 28.42, "maximum": 28.42, "setting": "both", "payers_information": [ { "payer_name": "Aetna", "plan_name": "700700", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna", "plan_name": "700700_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Miscellaneous", "plan_name": "700720", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Miscellaneous", "plan_name": "700720_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Ppo Hmo", "plan_name": "701720", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Ppo Hmo", "plan_name": "701720_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Ms State Emplo", "plan_name": "401457", "standard_charge_dollar": 28.42, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Ms State Emplo", "plan_name": "401457_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Basic Pl", "plan_name": "400100", "standard_charge_dollar": 28.42, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Basic Pl", "plan_name": "400100_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Federal", "plan_name": "400110", "standard_charge_dollar": 28.42, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Federal", "plan_name": "400110_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." } ] } ] }, { "description": "Hc cea plasma", "code_information": [ { "code": "82378", "type": "CPT" } ], "standard_charges": [ { "gross_charge": 83.26, "minimum": 28.42, "maximum": 28.42, "setting": "both", "payers_information": [ { "payer_name": "Aetna", "plan_name": "700700", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna", "plan_name": "700700_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Miscellaneous", "plan_name": "700720", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Miscellaneous", "plan_name": "700720_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Ppo Hmo", "plan_name": "701720", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Ppo Hmo", "plan_name": "701720_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Ms State Emplo", "plan_name": "401457", "standard_charge_dollar": 28.42, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Ms State Emplo", "plan_name": "401457_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Basic Pl", "plan_name": "400100", "standard_charge_dollar": 28.42, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Basic Pl", "plan_name": "400100_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Federal", "plan_name": "400110", "standard_charge_dollar": 28.42, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Federal", "plan_name": "400110_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." } ] } ] }, { "description": "Assay of carnitine", "code_information": [ { "code": "82379", "type": "CPT" } ], "standard_charges": [ { "gross_charge": 67.48, "minimum": 25.27, "maximum": 25.27, "setting": "both", "payers_information": [ { "payer_name": "Aetna", "plan_name": "700700", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna", "plan_name": "700700_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Miscellaneous", "plan_name": "700720", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Miscellaneous", "plan_name": "700720_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Ppo Hmo", "plan_name": "701720", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Ppo Hmo", "plan_name": "701720_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Ms State Emplo", "plan_name": "401457", "standard_charge_dollar": 25.27, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Ms State Emplo", "plan_name": "401457_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Basic Pl", "plan_name": "400100", "standard_charge_dollar": 25.27, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Basic Pl", "plan_name": "400100_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Federal", "plan_name": "400110", "standard_charge_dollar": 25.27, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Federal", "plan_name": "400110_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." } ] } ] }, { "description": "Hc carnitine quan ea", "code_information": [ { "code": "82379", "type": "CPT" } ], "standard_charges": [ { "gross_charge": 67.48, "minimum": 25.27, "maximum": 25.27, "setting": "both", "payers_information": [ { "payer_name": "Aetna", "plan_name": "700700", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna", "plan_name": "700700_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Miscellaneous", "plan_name": "700720", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Miscellaneous", "plan_name": "700720_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Ppo Hmo", "plan_name": "701720", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Ppo Hmo", "plan_name": "701720_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Ms State Emplo", "plan_name": "401457", "standard_charge_dollar": 25.27, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Ms State Emplo", "plan_name": "401457_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Basic Pl", "plan_name": "400100", "standard_charge_dollar": 25.27, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Basic Pl", "plan_name": "400100_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Federal", "plan_name": "400110", "standard_charge_dollar": 25.27, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Federal", "plan_name": "400110_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." } ] } ] }, { "description": "Assay of ceruloplasmin", "code_information": [ { "code": "82390", "type": "CPT" } ], "standard_charges": [ { "gross_charge": 59.50, "minimum": 16.09, "maximum": 16.09, "setting": "both", "payers_information": [ { "payer_name": "Aetna", "plan_name": "700700", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna", "plan_name": "700700_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Miscellaneous", "plan_name": "700720", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Miscellaneous", "plan_name": "700720_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Ppo Hmo", "plan_name": "701720", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Ppo Hmo", "plan_name": "701720_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Ms State Emplo", "plan_name": "401457", "standard_charge_dollar": 16.09, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Ms State Emplo", "plan_name": "401457_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Basic Pl", "plan_name": "400100", "standard_charge_dollar": 16.09, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Basic Pl", "plan_name": "400100_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Federal", "plan_name": "400110", "standard_charge_dollar": 16.09, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Federal", "plan_name": "400110_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." } ] } ] }, { "description": "Hc ceruloplasmin", "code_information": [ { "code": "82390", "type": "CPT" } ], "standard_charges": [ { "gross_charge": 59.50, "minimum": 16.09, "maximum": 16.09, "setting": "both", "payers_information": [ { "payer_name": "Aetna", "plan_name": "700700", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna", "plan_name": "700700_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Miscellaneous", "plan_name": "700720", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Miscellaneous", "plan_name": "700720_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Ppo Hmo", "plan_name": "701720", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Ppo Hmo", "plan_name": "701720_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Ms State Emplo", "plan_name": "401457", "standard_charge_dollar": 16.09, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Ms State Emplo", "plan_name": "401457_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Basic Pl", "plan_name": "400100", "standard_charge_dollar": 16.09, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Basic Pl", "plan_name": "400100_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Federal", "plan_name": "400110", "standard_charge_dollar": 16.09, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Federal", "plan_name": "400110_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." } ] } ] }, { "description": "Chemiluminescent assay", "code_information": [ { "code": "82397", "type": "CPT" } ], "standard_charges": [ { "gross_charge": 125.00, "minimum": 18.25, "maximum": 18.25, "setting": "both", "payers_information": [ { "payer_name": "Aetna", "plan_name": "700700", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna", "plan_name": "700700_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Miscellaneous", "plan_name": "700720", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Miscellaneous", "plan_name": "700720_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Ppo Hmo", "plan_name": "701720", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Ppo Hmo", "plan_name": "701720_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Ms State Emplo", "plan_name": "401457", "standard_charge_dollar": 18.25, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Ms State Emplo", "plan_name": "401457_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Basic Pl", "plan_name": "400100", "standard_charge_dollar": 18.25, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Basic Pl", "plan_name": "400100_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Federal", "plan_name": "400110", "standard_charge_dollar": 18.25, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Federal", "plan_name": "400110_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." } ] } ] }, { "description": "Hc pth related peptide", "code_information": [ { "code": "82397", "type": "CPT" } ], "standard_charges": [ { "gross_charge": 125.00, "minimum": 18.25, "maximum": 18.25, "setting": "both", "payers_information": [ { "payer_name": "Aetna", "plan_name": "700700", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna", "plan_name": "700700_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Miscellaneous", "plan_name": "700720", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Miscellaneous", "plan_name": "700720_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Ppo Hmo", "plan_name": "701720", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Ppo Hmo", "plan_name": "701720_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Ms State Emplo", "plan_name": "401457", "standard_charge_dollar": 18.25, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Ms State Emplo", "plan_name": "401457_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Basic Pl", "plan_name": "400100", "standard_charge_dollar": 18.25, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Basic Pl", "plan_name": "400100_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Federal", "plan_name": "400110", "standard_charge_dollar": 18.25, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Federal", "plan_name": "400110_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." } ] } ] }, { "description": "Assay of blood chloride", "code_information": [ { "code": "82435", "type": "CPT" } ], "standard_charges": [ { "gross_charge": 35.00, "minimum": 6.89, "maximum": 6.89, "setting": "both", "payers_information": [ { "payer_name": "Aetna", "plan_name": "700700", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna", "plan_name": "700700_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Miscellaneous", "plan_name": "700720", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Miscellaneous", "plan_name": "700720_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Ppo Hmo", "plan_name": "701720", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Ppo Hmo", "plan_name": "701720_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Ms State Emplo", "plan_name": "401457", "standard_charge_dollar": 6.89, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Ms State Emplo", "plan_name": "401457_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Basic Pl", "plan_name": "400100", "standard_charge_dollar": 6.89, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Basic Pl", "plan_name": "400100_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Federal", "plan_name": "400110", "standard_charge_dollar": 6.89, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Federal", "plan_name": "400110_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." } ] } ] }, { "description": "Hc chloride blood", "code_information": [ { "code": "82435", "type": "CPT" } ], "standard_charges": [ { "gross_charge": 35.00, "minimum": 6.89, "maximum": 6.89, "setting": "both", "payers_information": [ { "payer_name": "Aetna", "plan_name": "700700", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna", "plan_name": "700700_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Miscellaneous", "plan_name": "700720", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Miscellaneous", "plan_name": "700720_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Ppo Hmo", "plan_name": "701720", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Ppo Hmo", "plan_name": "701720_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Ms State Emplo", "plan_name": "401457", "standard_charge_dollar": 6.89, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Ms State Emplo", "plan_name": "401457_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Basic Pl", "plan_name": "400100", "standard_charge_dollar": 6.89, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Basic Pl", "plan_name": "400100_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Federal", "plan_name": "400110", "standard_charge_dollar": 6.89, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Federal", "plan_name": "400110_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." } ] } ] }, { "description": "Assay of urine chloride", "code_information": [ { "code": "82436", "type": "CPT" } ], "standard_charges": [ { "gross_charge": 37.85, "minimum": 7.54, "maximum": 7.54, "setting": "both", "payers_information": [ { "payer_name": "Aetna", "plan_name": "700700", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna", "plan_name": "700700_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Miscellaneous", "plan_name": "700720", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Miscellaneous", "plan_name": "700720_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Ppo Hmo", "plan_name": "701720", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Ppo Hmo", "plan_name": "701720_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Ms State Emplo", "plan_name": "401457", "standard_charge_dollar": 7.54, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Ms State Emplo", "plan_name": "401457_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Basic Pl", "plan_name": "400100", "standard_charge_dollar": 7.54, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Basic Pl", "plan_name": "400100_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Federal", "plan_name": "400110", "standard_charge_dollar": 7.54, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Federal", "plan_name": "400110_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." } ] } ] }, { "description": "Hc chloride urine", "code_information": [ { "code": "82436", "type": "CPT" } ], "standard_charges": [ { "gross_charge": 37.85, "minimum": 7.54, "maximum": 7.54, "setting": "both", "payers_information": [ { "payer_name": "Aetna", "plan_name": "700700", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna", "plan_name": "700700_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Miscellaneous", "plan_name": "700720", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Miscellaneous", "plan_name": "700720_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Ppo Hmo", "plan_name": "701720", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Ppo Hmo", "plan_name": "701720_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Ms State Emplo", "plan_name": "401457", "standard_charge_dollar": 7.54, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Ms State Emplo", "plan_name": "401457_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Basic Pl", "plan_name": "400100", "standard_charge_dollar": 7.54, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Basic Pl", "plan_name": "400100_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Federal", "plan_name": "400110", "standard_charge_dollar": 7.54, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Federal", "plan_name": "400110_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." } ] } ] }, { "description": "Assay other fluid chlorides", "code_information": [ { "code": "82438", "type": "CPT" } ], "standard_charges": [ { "gross_charge": 57.56, "minimum": 6.96, "maximum": 6.96, "setting": "both", "payers_information": [ { "payer_name": "Aetna", "plan_name": "700700", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna", "plan_name": "700700_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Miscellaneous", "plan_name": "700720", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Miscellaneous", "plan_name": "700720_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Ppo Hmo", "plan_name": "701720", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Ppo Hmo", "plan_name": "701720_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Ms State Emplo", "plan_name": "401457", "standard_charge_dollar": 6.96, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Ms State Emplo", "plan_name": "401457_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Basic Pl", "plan_name": "400100", "standard_charge_dollar": 6.96, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Basic Pl", "plan_name": "400100_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Federal", "plan_name": "400110", "standard_charge_dollar": 6.96, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Federal", "plan_name": "400110_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." } ] } ] }, { "description": "Hc chloride other source stool", "code_information": [ { "code": "82438", "type": "CPT" } ], "standard_charges": [ { "gross_charge": 57.56, "minimum": 6.96, "maximum": 6.96, "setting": "both", "payers_information": [ { "payer_name": "Aetna", "plan_name": "700700", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna", "plan_name": "700700_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Miscellaneous", "plan_name": "700720", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Miscellaneous", "plan_name": "700720_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Ppo Hmo", "plan_name": "701720", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Ppo Hmo", "plan_name": "701720_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Ms State Emplo", "plan_name": "401457", "standard_charge_dollar": 6.96, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Ms State Emplo", "plan_name": "401457_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Basic Pl", "plan_name": "400100", "standard_charge_dollar": 6.96, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Basic Pl", "plan_name": "400100_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Federal", "plan_name": "400110", "standard_charge_dollar": 6.96, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Federal", "plan_name": "400110_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." } ] } ] }, { "description": "Assay bld/serum cholesterol", "code_information": [ { "code": "82465", "type": "CPT" } ], "standard_charges": [ { "gross_charge": 39.63, "minimum": 4.35, "maximum": 6.51, "setting": "both", "payers_information": [ { "payer_name": "Aarp", "plan_name": "500102", "standard_charge_dollar": 4.35, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna", "plan_name": "700700", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna", "plan_name": "700700_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Mcare Ffs 6005", "plan_name": "700703", "standard_charge_dollar": 4.35, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Miscellaneous", "plan_name": "700720", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Miscellaneous", "plan_name": "700720_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Ppo Hmo", "plan_name": "701720", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Ppo Hmo", "plan_name": "701720_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Ambetter 68069", "plan_name": "500516", "standard_charge_dollar": 4.35, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Ms State Emplo", "plan_name": "401457", "standard_charge_dollar": 6.51, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Ms State Emplo", "plan_name": "401457_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Basic Pl", "plan_name": "400100", "standard_charge_dollar": 6.51, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Basic Pl", "plan_name": "400100_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Federal", "plan_name": "400110", "standard_charge_dollar": 6.51, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Federal", "plan_name": "400110_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Cigna Healthsprings Ffs", "plan_name": "500064", "standard_charge_dollar": 4.35, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Conseco", "plan_name": "500302", "standard_charge_dollar": 4.35, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Humana Ffs 61101", "plan_name": "500006", "standard_charge_dollar": 4.35, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Medicare A", "plan_name": "100100", "standard_charge_dollar": 4.35, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Medicare A", "plan_name": "100500", "standard_charge_dollar": 4.35, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Medicare Part B Only", "plan_name": "100300", "standard_charge_dollar": 4.35, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Medicare Railroad", "plan_name": "100103", "standard_charge_dollar": 4.35, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Ms Physicians Care N", "plan_name": "714210", "standard_charge_dollar": 5.44, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Peoples Hlth Ffs 72126", "plan_name": "500019", "standard_charge_dollar": 4.35, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Uhc/Secure Horizons", "plan_name": "500449", "standard_charge_dollar": 4.35, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "United Health Care/", "plan_name": "500292", "standard_charge_dollar": 4.92, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "United Healthcare", "plan_name": "750104", "standard_charge_dollar": 4.92, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "United Healthcare Ba", "plan_name": "750090", "standard_charge_dollar": 4.92, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "United Healthcare Me", "plan_name": "501310", "standard_charge_dollar": 4.35, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Windsor Mcare Extra", "plan_name": "500778", "standard_charge_dollar": 4.35, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." } ] } ] }, { "description": "Hc cholesterol total", "code_information": [ { "code": "82465", "type": "CPT" } ], "standard_charges": [ { "gross_charge": 39.63, "minimum": 4.35, "maximum": 6.51, "setting": "both", "payers_information": [ { "payer_name": "Aarp", "plan_name": "500102", "standard_charge_dollar": 4.35, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna", "plan_name": "700700", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna", "plan_name": "700700_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Mcare Ffs 6005", "plan_name": "700703", "standard_charge_dollar": 4.35, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Miscellaneous", "plan_name": "700720", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Miscellaneous", "plan_name": "700720_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Ppo Hmo", "plan_name": "701720", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Ppo Hmo", "plan_name": "701720_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Ambetter 68069", "plan_name": "500516", "standard_charge_dollar": 4.35, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Ms State Emplo", "plan_name": "401457", "standard_charge_dollar": 6.51, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Ms State Emplo", "plan_name": "401457_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Basic Pl", "plan_name": "400100", "standard_charge_dollar": 6.51, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Basic Pl", "plan_name": "400100_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Federal", "plan_name": "400110", "standard_charge_dollar": 6.51, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Federal", "plan_name": "400110_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Cigna Healthsprings Ffs", "plan_name": "500064", "standard_charge_dollar": 4.35, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Conseco", "plan_name": "500302", "standard_charge_dollar": 4.35, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Humana Ffs 61101", "plan_name": "500006", "standard_charge_dollar": 4.35, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Medicare A", "plan_name": "100100", "standard_charge_dollar": 4.35, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Medicare A", "plan_name": "100500", "standard_charge_dollar": 4.35, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Medicare Part B Only", "plan_name": "100300", "standard_charge_dollar": 4.35, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Medicare Railroad", "plan_name": "100103", "standard_charge_dollar": 4.35, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Ms Physicians Care N", "plan_name": "714210", "standard_charge_dollar": 5.44, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Peoples Hlth Ffs 72126", "plan_name": "500019", "standard_charge_dollar": 4.35, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Uhc/Secure Horizons", "plan_name": "500449", "standard_charge_dollar": 4.35, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "United Health Care/", "plan_name": "500292", "standard_charge_dollar": 4.92, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "United Healthcare", "plan_name": "750104", "standard_charge_dollar": 4.92, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "United Healthcare Ba", "plan_name": "750090", "standard_charge_dollar": 4.92, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "United Healthcare Me", "plan_name": "501310", "standard_charge_dollar": 4.35, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Windsor Mcare Extra", "plan_name": "500778", "standard_charge_dollar": 4.35, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." } ] } ] }, { "description": "Assay of copper", "code_information": [ { "code": "82525", "type": "CPT" } ], "standard_charges": [ { "gross_charge": 85.38, "minimum": 18.59, "maximum": 18.59, "setting": "both", "payers_information": [ { "payer_name": "Aetna", "plan_name": "700700", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna", "plan_name": "700700_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Miscellaneous", "plan_name": "700720", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Miscellaneous", "plan_name": "700720_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Ppo Hmo", "plan_name": "701720", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Ppo Hmo", "plan_name": "701720_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Ms State Emplo", "plan_name": "401457", "standard_charge_dollar": 18.59, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Ms State Emplo", "plan_name": "401457_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Basic Pl", "plan_name": "400100", "standard_charge_dollar": 18.59, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Basic Pl", "plan_name": "400100_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Federal", "plan_name": "400110", "standard_charge_dollar": 18.59, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Federal", "plan_name": "400110_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." } ] } ] }, { "description": "Hc copper urine", "code_information": [ { "code": "82525", "type": "CPT" } ], "standard_charges": [ { "gross_charge": 85.38, "minimum": 18.59, "maximum": 18.59, "setting": "both", "payers_information": [ { "payer_name": "Aetna", "plan_name": "700700", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna", "plan_name": "700700_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Miscellaneous", "plan_name": "700720", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Miscellaneous", "plan_name": "700720_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Ppo Hmo", "plan_name": "701720", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Ppo Hmo", "plan_name": "701720_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Ms State Emplo", "plan_name": "401457", "standard_charge_dollar": 18.59, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Ms State Emplo", "plan_name": "401457_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Basic Pl", "plan_name": "400100", "standard_charge_dollar": 18.59, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Basic Pl", "plan_name": "400100_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Federal", "plan_name": "400110", "standard_charge_dollar": 18.59, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Federal", "plan_name": "400110_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." } ] } ] }, { "description": "Cortisol free", "code_information": [ { "code": "82530", "type": "CPT" } ], "standard_charges": [ { "gross_charge": 250.00, "minimum": 25.04, "maximum": 25.04, "setting": "both", "payers_information": [ { "payer_name": "Aetna", "plan_name": "700700", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna", "plan_name": "700700_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Miscellaneous", "plan_name": "700720", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Miscellaneous", "plan_name": "700720_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Ppo Hmo", "plan_name": "701720", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Ppo Hmo", "plan_name": "701720_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Ms State Emplo", "plan_name": "401457", "standard_charge_dollar": 25.04, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Ms State Emplo", "plan_name": "401457_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Basic Pl", "plan_name": "400100", "standard_charge_dollar": 25.04, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Basic Pl", "plan_name": "400100_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Federal", "plan_name": "400110", "standard_charge_dollar": 25.04, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Federal", "plan_name": "400110_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." } ] } ] }, { "description": "Hc cortisol free urine", "code_information": [ { "code": "82530", "type": "CPT" } ], "standard_charges": [ { "gross_charge": 250.00, "minimum": 25.04, "maximum": 25.04, "setting": "both", "payers_information": [ { "payer_name": "Aetna", "plan_name": "700700", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna", "plan_name": "700700_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Miscellaneous", "plan_name": "700720", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Miscellaneous", "plan_name": "700720_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Ppo Hmo", "plan_name": "701720", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Ppo Hmo", "plan_name": "701720_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Ms State Emplo", "plan_name": "401457", "standard_charge_dollar": 25.04, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Ms State Emplo", "plan_name": "401457_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Basic Pl", "plan_name": "400100", "standard_charge_dollar": 25.04, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Basic Pl", "plan_name": "400100_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Federal", "plan_name": "400110", "standard_charge_dollar": 25.04, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Federal", "plan_name": "400110_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." } ] } ] }, { "description": "Hc cortisol 60 min post dose", "code_information": [ { "code": "82533", "type": "CPT" } ], "standard_charges": [ { "gross_charge": 205.00, "minimum": 24.43, "maximum": 24.43, "setting": "both", "payers_information": [ { "payer_name": "Aetna", "plan_name": "700700", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna", "plan_name": "700700_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Miscellaneous", "plan_name": "700720", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Miscellaneous", "plan_name": "700720_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Ppo Hmo", "plan_name": "701720", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Ppo Hmo", "plan_name": "701720_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Ms State Emplo", "plan_name": "401457", "standard_charge_dollar": 24.43, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Ms State Emplo", "plan_name": "401457_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Basic Pl", "plan_name": "400100", "standard_charge_dollar": 24.43, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Basic Pl", "plan_name": "400100_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Federal", "plan_name": "400110", "standard_charge_dollar": 24.43, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Federal", "plan_name": "400110_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." } ] } ] }, { "description": "Total cortisol", "code_information": [ { "code": "82533", "type": "CPT" } ], "standard_charges": [ { "gross_charge": 205.00, "minimum": 24.43, "maximum": 24.43, "setting": "both", "payers_information": [ { "payer_name": "Aetna", "plan_name": "700700", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna", "plan_name": "700700_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Miscellaneous", "plan_name": "700720", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Miscellaneous", "plan_name": "700720_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Ppo Hmo", "plan_name": "701720", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Ppo Hmo", "plan_name": "701720_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Ms State Emplo", "plan_name": "401457", "standard_charge_dollar": 24.43, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Ms State Emplo", "plan_name": "401457_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Basic Pl", "plan_name": "400100", "standard_charge_dollar": 24.43, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Basic Pl", "plan_name": "400100_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Federal", "plan_name": "400110", "standard_charge_dollar": 24.43, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Federal", "plan_name": "400110_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." } ] } ] }, { "description": "Col chromotography qual/quan", "code_information": [ { "code": "82542", "type": "CPT" } ], "standard_charges": [ { "gross_charge": 517.43, "minimum": 27.06, "maximum": 27.06, "setting": "both", "payers_information": [ { "payer_name": "Aetna", "plan_name": "700700", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna", "plan_name": "700700_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Miscellaneous", "plan_name": "700720", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Miscellaneous", "plan_name": "700720_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Ppo Hmo", "plan_name": "701720", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Ppo Hmo", "plan_name": "701720_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Ms State Emplo", "plan_name": "401457", "standard_charge_dollar": 27.06, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Ms State Emplo", "plan_name": "401457_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Basic Pl", "plan_name": "400100", "standard_charge_dollar": 27.06, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Basic Pl", "plan_name": "400100_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Federal", "plan_name": "400110", "standard_charge_dollar": 27.06, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Federal", "plan_name": "400110_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." } ] } ] }, { "description": "Hc col chrom qual/quan (baps)", "code_information": [ { "code": "82542", "type": "CPT" } ], "standard_charges": [ { "gross_charge": 517.43, "minimum": 27.06, "maximum": 27.06, "setting": "both", "payers_information": [ { "payer_name": "Aetna", "plan_name": "700700", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna", "plan_name": "700700_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Miscellaneous", "plan_name": "700720", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Miscellaneous", "plan_name": "700720_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Ppo Hmo", "plan_name": "701720", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Ppo Hmo", "plan_name": "701720_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Ms State Emplo", "plan_name": "401457", "standard_charge_dollar": 27.06, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Ms State Emplo", "plan_name": "401457_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Basic Pl", "plan_name": "400100", "standard_charge_dollar": 27.06, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Basic Pl", "plan_name": "400100_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Federal", "plan_name": "400110", "standard_charge_dollar": 27.06, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Federal", "plan_name": "400110_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." } ] } ] }, { "description": "Assay of ck (cpk)", "code_information": [ { "code": "82550", "type": "CPT" } ], "standard_charges": [ { "gross_charge": 75.00, "minimum": 9.76, "maximum": 9.76, "setting": "both", "payers_information": [ { "payer_name": "Aetna", "plan_name": "700700", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna", "plan_name": "700700_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Miscellaneous", "plan_name": "700720", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Miscellaneous", "plan_name": "700720_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Ppo Hmo", "plan_name": "701720", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Ppo Hmo", "plan_name": "701720_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Ms State Emplo", "plan_name": "401457", "standard_charge_dollar": 9.76, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Ms State Emplo", "plan_name": "401457_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Basic Pl", "plan_name": "400100", "standard_charge_dollar": 9.76, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Basic Pl", "plan_name": "400100_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Federal", "plan_name": "400110", "standard_charge_dollar": 9.76, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Federal", "plan_name": "400110_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." } ] } ] }, { "description": "Hc cpk", "code_information": [ { "code": "82550", "type": "CPT" } ], "standard_charges": [ { "gross_charge": 75.00, "minimum": 9.76, "maximum": 9.76, "setting": "both", "payers_information": [ { "payer_name": "Aetna", "plan_name": "700700", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna", "plan_name": "700700_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Miscellaneous", "plan_name": "700720", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Miscellaneous", "plan_name": "700720_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Ppo Hmo", "plan_name": "701720", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Ppo Hmo", "plan_name": "701720_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Ms State Emplo", "plan_name": "401457", "standard_charge_dollar": 9.76, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Ms State Emplo", "plan_name": "401457_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Basic Pl", "plan_name": "400100", "standard_charge_dollar": 9.76, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Basic Pl", "plan_name": "400100_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Federal", "plan_name": "400110", "standard_charge_dollar": 9.76, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Federal", "plan_name": "400110_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." } ] } ] }, { "description": "Creatine mb fraction", "code_information": [ { "code": "82553", "type": "CPT" } ], "standard_charges": [ { "gross_charge": 125.00, "minimum": 15.22, "maximum": 15.22, "setting": "both", "payers_information": [ { "payer_name": "Aetna", "plan_name": "700700", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna", "plan_name": "700700_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Miscellaneous", "plan_name": "700720", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Miscellaneous", "plan_name": "700720_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Ppo Hmo", "plan_name": "701720", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Ppo Hmo", "plan_name": "701720_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Ms State Emplo", "plan_name": "401457", "standard_charge_dollar": 15.22, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Ms State Emplo", "plan_name": "401457_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Basic Pl", "plan_name": "400100", "standard_charge_dollar": 15.22, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Basic Pl", "plan_name": "400100_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Federal", "plan_name": "400110", "standard_charge_dollar": 15.22, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Federal", "plan_name": "400110_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." } ] } ] }, { "description": "Hc cpk mb panel", "code_information": [ { "code": "82553", "type": "CPT" } ], "standard_charges": [ { "gross_charge": 125.00, "minimum": 15.22, "maximum": 15.22, "setting": "both", "payers_information": [ { "payer_name": "Aetna", "plan_name": "700700", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna", "plan_name": "700700_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Miscellaneous", "plan_name": "700720", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Miscellaneous", "plan_name": "700720_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Ppo Hmo", "plan_name": "701720", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Ppo Hmo", "plan_name": "701720_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Ms State Emplo", "plan_name": "401457", "standard_charge_dollar": 15.22, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Ms State Emplo", "plan_name": "401457_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Basic Pl", "plan_name": "400100", "standard_charge_dollar": 15.22, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Basic Pl", "plan_name": "400100_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Federal", "plan_name": "400110", "standard_charge_dollar": 15.22, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Federal", "plan_name": "400110_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." } ] } ] }, { "description": "Assay of creatinine", "code_information": [ { "code": "82565", "type": "CPT" } ], "standard_charges": [ { "gross_charge": 65.00, "minimum": 7.68, "maximum": 7.68, "setting": "both", "payers_information": [ { "payer_name": "Aetna", "plan_name": "700700", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna", "plan_name": "700700_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Miscellaneous", "plan_name": "700720", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Miscellaneous", "plan_name": "700720_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Ppo Hmo", "plan_name": "701720", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Ppo Hmo", "plan_name": "701720_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Ms State Emplo", "plan_name": "401457", "standard_charge_dollar": 7.68, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Ms State Emplo", "plan_name": "401457_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Basic Pl", "plan_name": "400100", "standard_charge_dollar": 7.68, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Basic Pl", "plan_name": "400100_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Federal", "plan_name": "400110", "standard_charge_dollar": 7.68, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Federal", "plan_name": "400110_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." } ] } ] }, { "description": "Hc creatinine serum", "code_information": [ { "code": "82565", "type": "CPT" } ], "standard_charges": [ { "gross_charge": 65.00, "minimum": 7.68, "maximum": 7.68, "setting": "both", "payers_information": [ { "payer_name": "Aetna", "plan_name": "700700", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna", "plan_name": "700700_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Miscellaneous", "plan_name": "700720", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Miscellaneous", "plan_name": "700720_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Ppo Hmo", "plan_name": "701720", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Ppo Hmo", "plan_name": "701720_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Ms State Emplo", "plan_name": "401457", "standard_charge_dollar": 7.68, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Ms State Emplo", "plan_name": "401457_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Basic Pl", "plan_name": "400100", "standard_charge_dollar": 7.68, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Basic Pl", "plan_name": "400100_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Federal", "plan_name": "400110", "standard_charge_dollar": 7.68, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Federal", "plan_name": "400110_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." } ] } ] }, { "description": "Assay of urine creatinine", "code_information": [ { "code": "82570", "type": "CPT" } ], "standard_charges": [ { "gross_charge": 75.00, "minimum": 6.96, "maximum": 6.96, "setting": "both", "payers_information": [ { "payer_name": "Aetna", "plan_name": "700700", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna", "plan_name": "700700_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Miscellaneous", "plan_name": "700720", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Miscellaneous", "plan_name": "700720_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Ppo Hmo", "plan_name": "701720", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Ppo Hmo", "plan_name": "701720_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Ms State Emplo", "plan_name": "401457", "standard_charge_dollar": 6.96, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Ms State Emplo", "plan_name": "401457_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Basic Pl", "plan_name": "400100", "standard_charge_dollar": 6.96, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Basic Pl", "plan_name": "400100_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Federal", "plan_name": "400110", "standard_charge_dollar": 6.96, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Federal", "plan_name": "400110_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." } ] } ] }, { "description": "Hc creatinine urine 24 hr", "code_information": [ { "code": "82570", "type": "CPT" } ], "standard_charges": [ { "gross_charge": 75.00, "minimum": 6.96, "maximum": 6.96, "setting": "both", "payers_information": [ { "payer_name": "Aetna", "plan_name": "700700", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna", "plan_name": "700700_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Miscellaneous", "plan_name": "700720", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Miscellaneous", "plan_name": "700720_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Ppo Hmo", "plan_name": "701720", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Ppo Hmo", "plan_name": "701720_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Ms State Emplo", "plan_name": "401457", "standard_charge_dollar": 6.96, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Ms State Emplo", "plan_name": "401457_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Basic Pl", "plan_name": "400100", "standard_charge_dollar": 6.96, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Basic Pl", "plan_name": "400100_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Federal", "plan_name": "400110", "standard_charge_dollar": 6.96, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Federal", "plan_name": "400110_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." } ] } ] }, { "description": "Creatinine clearance test", "code_information": [ { "code": "82575", "type": "CPT" } ], "standard_charges": [ { "gross_charge": 83.47, "minimum": 14.17, "maximum": 14.17, "setting": "both", "payers_information": [ { "payer_name": "Aetna", "plan_name": "700700", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna", "plan_name": "700700_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Miscellaneous", "plan_name": "700720", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Miscellaneous", "plan_name": "700720_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Ppo Hmo", "plan_name": "701720", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Ppo Hmo", "plan_name": "701720_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Ms State Emplo", "plan_name": "401457", "standard_charge_dollar": 14.17, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Ms State Emplo", "plan_name": "401457_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Basic Pl", "plan_name": "400100", "standard_charge_dollar": 14.17, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Basic Pl", "plan_name": "400100_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Federal", "plan_name": "400110", "standard_charge_dollar": 14.17, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Federal", "plan_name": "400110_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." } ] } ] }, { "description": "Hc creatinine clearance", "code_information": [ { "code": "82575", "type": "CPT" } ], "standard_charges": [ { "gross_charge": 83.47, "minimum": 14.17, "maximum": 14.17, "setting": "both", "payers_information": [ { "payer_name": "Aetna", "plan_name": "700700", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna", "plan_name": "700700_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Miscellaneous", "plan_name": "700720", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Miscellaneous", "plan_name": "700720_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Ppo Hmo", "plan_name": "701720", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Ppo Hmo", "plan_name": "701720_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Ms State Emplo", "plan_name": "401457", "standard_charge_dollar": 14.17, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Ms State Emplo", "plan_name": "401457_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Basic Pl", "plan_name": "400100", "standard_charge_dollar": 14.17, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Basic Pl", "plan_name": "400100_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Federal", "plan_name": "400110", "standard_charge_dollar": 14.17, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Federal", "plan_name": "400110_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." } ] } ] }, { "description": "Hc vitamin b-12 level", "code_information": [ { "code": "82607", "type": "CPT" } ], "standard_charges": [ { "gross_charge": 125.00, "minimum": 22.59, "maximum": 22.59, "setting": "both", "payers_information": [ { "payer_name": "Aetna", "plan_name": "700700", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna", "plan_name": "700700_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Miscellaneous", "plan_name": "700720", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Miscellaneous", "plan_name": "700720_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Ppo Hmo", "plan_name": "701720", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Ppo Hmo", "plan_name": "701720_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Ms State Emplo", "plan_name": "401457", "standard_charge_dollar": 22.59, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Ms State Emplo", "plan_name": "401457_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Basic Pl", "plan_name": "400100", "standard_charge_dollar": 22.59, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Basic Pl", "plan_name": "400100_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Federal", "plan_name": "400110", "standard_charge_dollar": 22.59, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Federal", "plan_name": "400110_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." } ] } ] }, { "description": "Vitamin b-12", "code_information": [ { "code": "82607", "type": "CPT" } ], "standard_charges": [ { "gross_charge": 125.00, "minimum": 22.59, "maximum": 22.59, "setting": "both", "payers_information": [ { "payer_name": "Aetna", "plan_name": "700700", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna", "plan_name": "700700_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Miscellaneous", "plan_name": "700720", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Miscellaneous", "plan_name": "700720_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Ppo Hmo", "plan_name": "701720", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Ppo Hmo", "plan_name": "701720_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Ms State Emplo", "plan_name": "401457", "standard_charge_dollar": 22.59, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Ms State Emplo", "plan_name": "401457_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Basic Pl", "plan_name": "400100", "standard_charge_dollar": 22.59, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Basic Pl", "plan_name": "400100_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Federal", "plan_name": "400110", "standard_charge_dollar": 22.59, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Federal", "plan_name": "400110_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." } ] } ] }, { "description": "Cystatin c", "code_information": [ { "code": "82610", "type": "CPT" } ], "standard_charges": [ { "gross_charge": 91.22, "minimum": 20.37, "maximum": 20.37, "setting": "both", "payers_information": [ { "payer_name": "Aetna", "plan_name": "700700", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna", "plan_name": "700700_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Miscellaneous", "plan_name": "700720", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Miscellaneous", "plan_name": "700720_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Ppo Hmo", "plan_name": "701720", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Ppo Hmo", "plan_name": "701720_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Ms State Emplo", "plan_name": "401457", "standard_charge_dollar": 20.37, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Ms State Emplo", "plan_name": "401457_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Basic Pl", "plan_name": "400100", "standard_charge_dollar": 20.37, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Basic Pl", "plan_name": "400100_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Federal", "plan_name": "400110", "standard_charge_dollar": 20.37, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Federal", "plan_name": "400110_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." } ] } ] }, { "description": "Hc cystatin c", "code_information": [ { "code": "82610", "type": "CPT" } ], "standard_charges": [ { "gross_charge": 91.22, "minimum": 20.37, "maximum": 20.37, "setting": "both", "payers_information": [ { "payer_name": "Aetna", "plan_name": "700700", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna", "plan_name": "700700_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Miscellaneous", "plan_name": "700720", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Miscellaneous", "plan_name": "700720_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Ppo Hmo", "plan_name": "701720", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Ppo Hmo", "plan_name": "701720_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Ms State Emplo", "plan_name": "401457", "standard_charge_dollar": 20.37, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Ms State Emplo", "plan_name": "401457_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Basic Pl", "plan_name": "400100", "standard_charge_dollar": 20.37, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Basic Pl", "plan_name": "400100_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Federal", "plan_name": "400110", "standard_charge_dollar": 20.37, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Federal", "plan_name": "400110_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." } ] } ] }, { "description": "Dehydroepiandrosterone", "code_information": [ { "code": "82626", "type": "CPT" } ], "standard_charges": [ { "gross_charge": 109.25, "minimum": 37.86, "maximum": 37.86, "setting": "both", "payers_information": [ { "payer_name": "Aetna", "plan_name": "700700", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna", "plan_name": "700700_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Miscellaneous", "plan_name": "700720", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Miscellaneous", "plan_name": "700720_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Ppo Hmo", "plan_name": "701720", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Ppo Hmo", "plan_name": "701720_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Ms State Emplo", "plan_name": "401457", "standard_charge_dollar": 37.86, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Ms State Emplo", "plan_name": "401457_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Basic Pl", "plan_name": "400100", "standard_charge_dollar": 37.86, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Basic Pl", "plan_name": "400100_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Federal", "plan_name": "400110", "standard_charge_dollar": 37.86, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Federal", "plan_name": "400110_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." } ] } ] }, { "description": "Hc dhea", "code_information": [ { "code": "82626", "type": "CPT" } ], "standard_charges": [ { "gross_charge": 109.25, "minimum": 37.86, "maximum": 37.86, "setting": "both", "payers_information": [ { "payer_name": "Aetna", "plan_name": "700700", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna", "plan_name": "700700_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Miscellaneous", "plan_name": "700720", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Miscellaneous", "plan_name": "700720_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Ppo Hmo", "plan_name": "701720", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Ppo Hmo", "plan_name": "701720_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Ms State Emplo", "plan_name": "401457", "standard_charge_dollar": 37.86, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Ms State Emplo", "plan_name": "401457_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Basic Pl", "plan_name": "400100", "standard_charge_dollar": 37.86, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Basic Pl", "plan_name": "400100_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Federal", "plan_name": "400110", "standard_charge_dollar": 37.86, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Federal", "plan_name": "400110_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." } ] } ] }, { "description": "Hc vitamin d1 25 dihydroxy", "code_information": [ { "code": "82652", "type": "CPT" } ], "standard_charges": [ { "gross_charge": 270.00, "minimum": 57.68, "maximum": 57.68, "setting": "both", "payers_information": [ { "payer_name": "Aetna", "plan_name": "700700", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna", "plan_name": "700700_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Miscellaneous", "plan_name": "700720", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Miscellaneous", "plan_name": "700720_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Ppo Hmo", "plan_name": "701720", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Ppo Hmo", "plan_name": "701720_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Ms State Emplo", "plan_name": "401457", "standard_charge_dollar": 57.68, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Ms State Emplo", "plan_name": "401457_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Basic Pl", "plan_name": "400100", "standard_charge_dollar": 57.68, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Basic Pl", "plan_name": "400100_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Federal", "plan_name": "400110", "standard_charge_dollar": 57.68, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Federal", "plan_name": "400110_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." } ] } ] }, { "description": "Vit d 1 25-dihydroxy", "code_information": [ { "code": "82652", "type": "CPT" } ], "standard_charges": [ { "gross_charge": 270.00, "minimum": 57.68, "maximum": 57.68, "setting": "both", "payers_information": [ { 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"plan_name": "701720", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Ppo Hmo", "plan_name": "701720_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Ms State Emplo", "plan_name": "401457", "standard_charge_dollar": 57.68, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Ms State Emplo", "plan_name": "401457_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Basic Pl", "plan_name": "400100", "standard_charge_dollar": 57.68, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Basic Pl", "plan_name": "400100_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Federal", "plan_name": "400110", "standard_charge_dollar": 57.68, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Federal", "plan_name": "400110_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." } ] } ] }, { "description": "El-1 fecal quantitative", "code_information": [ { "code": "82653", "type": "CPT" } ], 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charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Ppo Hmo", "plan_name": "701720", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Ppo Hmo", "plan_name": "701720_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Ms State Emplo", "plan_name": "401457", "standard_charge_percentage": 0.80, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Ms State Emplo", "plan_name": "401457_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Basic Pl", "plan_name": "400100", "standard_charge_percentage": 0.85, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Basic Pl", "plan_name": "400100_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Federal", "plan_name": "400110", "standard_charge_percentage": 0.85, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Federal", "plan_name": "400110_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." } ] } ] }, { "description": "Hc elastase pancreatic fecal quantitative", "code_information": [ { "code": "82653", "type": "CPT" } ], "standard_charges": [ { "gross_charge": 180.00, "minimum": 144.00, "maximum": 153.00, "setting": "both", "payers_information": [ { "payer_name": "Aetna", "plan_name": "700700", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna", "plan_name": "700700_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Miscellaneous", "plan_name": "700720", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": 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remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Federal", "plan_name": "400110_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." } ] } ] }, { "description": "Enzyme cell activity", "code_information": [ { "code": "82657", "type": "CPT" } ], "standard_charges": [ { "gross_charge": 190.40, "minimum": 27.06, "maximum": 27.06, "setting": "both", "payers_information": [ { "payer_name": "Aetna", "plan_name": "700700", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna", "plan_name": "700700_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Miscellaneous", "plan_name": "700720", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Miscellaneous", "plan_name": "700720_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Ppo Hmo", "plan_name": "701720", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Ppo Hmo", "plan_name": "701720_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Ms State Emplo", "plan_name": "401457", "standard_charge_dollar": 27.06, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Ms State Emplo", "plan_name": "401457_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Basic Pl", "plan_name": "400100", "standard_charge_dollar": 27.06, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Basic Pl", "plan_name": "400100_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Federal", "plan_name": "400110", "standard_charge_dollar": 27.06, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Federal", "plan_name": "400110_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." } ] } ] }, { "description": "Hc cytochrome b5 reductase b (mayo)", "code_information": [ { "code": "82657", "type": "CPT" } ], "standard_charges": [ { "gross_charge": 190.40, "minimum": 27.06, "maximum": 27.06, "setting": "both", "payers_information": [ { "payer_name": "Aetna", "plan_name": "700700", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna", "plan_name": "700700_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Miscellaneous", "plan_name": "700720", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Miscellaneous", "plan_name": "700720_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Ppo Hmo", "plan_name": "701720", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Ppo Hmo", "plan_name": "701720_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Ms State Emplo", "plan_name": "401457", "standard_charge_dollar": 27.06, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Ms State Emplo", "plan_name": "401457_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Basic Pl", "plan_name": "400100", "standard_charge_dollar": 27.06, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Basic Pl", "plan_name": "400100_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Federal", "plan_name": "400110", "standard_charge_dollar": 27.06, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Federal", "plan_name": "400110_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." } ] } ] }, { "description": "Assay of estradiol", "code_information": [ { "code": "82670", "type": "CPT" } ], "standard_charges": [ { "gross_charge": 136.58, "minimum": 41.87, "maximum": 41.87, "setting": "both", "payers_information": [ { "payer_name": "Aetna", "plan_name": "700700", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna", "plan_name": "700700_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Miscellaneous", "plan_name": "700720", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Miscellaneous", "plan_name": "700720_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Ppo Hmo", "plan_name": "701720", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Ppo Hmo", "plan_name": "701720_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Ms State Emplo", "plan_name": "401457", "standard_charge_dollar": 41.87, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Ms State Emplo", "plan_name": "401457_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Basic Pl", "plan_name": "400100", "standard_charge_dollar": 41.87, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Basic Pl", "plan_name": "400100_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Federal", "plan_name": "400110", "standard_charge_dollar": 41.87, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Federal", "plan_name": "400110_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." } ] } ] }, { "description": "Hc estradiol", "code_information": [ { "code": "82670", "type": "CPT" } ], "standard_charges": [ { "gross_charge": 136.58, "minimum": 41.87, "maximum": 41.87, "setting": "both", "payers_information": [ { "payer_name": "Aetna", "plan_name": "700700", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna", "plan_name": "700700_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Miscellaneous", "plan_name": "700720", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Miscellaneous", "plan_name": "700720_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Ppo Hmo", "plan_name": "701720", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Ppo Hmo", "plan_name": "701720_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Ms State Emplo", "plan_name": "401457", "standard_charge_dollar": 41.87, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Ms State Emplo", "plan_name": "401457_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Basic Pl", "plan_name": "400100", "standard_charge_dollar": 41.87, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Basic Pl", "plan_name": "400100_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Federal", "plan_name": "400110", "standard_charge_dollar": 41.87, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Federal", "plan_name": "400110_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." } ] } ] }, { "description": "Assay of estrogens", "code_information": [ { "code": "82671", "type": "CPT" } ], "standard_charges": [ { "gross_charge": 130.00, "minimum": 38.31, "maximum": 38.31, "setting": "both", "payers_information": [ { "payer_name": "Aetna", "plan_name": "700700", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna", "plan_name": "700700_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Miscellaneous", "plan_name": "700720", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Miscellaneous", "plan_name": "700720_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Ppo Hmo", "plan_name": "701720", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Ppo Hmo", "plan_name": "701720_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Ms State Emplo", "plan_name": "401457", "standard_charge_dollar": 38.31, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Ms State Emplo", "plan_name": "401457_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Basic Pl", "plan_name": "400100", "standard_charge_dollar": 38.31, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Basic Pl", "plan_name": "400100_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Federal", "plan_name": "400110", "standard_charge_dollar": 38.31, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Federal", "plan_name": "400110_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." } ] } ] }, { "description": "Hc assay of estrogens fractionated", "code_information": [ { "code": "82671", "type": "CPT" } ], "standard_charges": [ { "gross_charge": 130.00, "minimum": 38.31, "maximum": 38.31, "setting": "both", "payers_information": [ { "payer_name": "Aetna", "plan_name": "700700", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna", "plan_name": "700700_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Miscellaneous", "plan_name": "700720", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Miscellaneous", "plan_name": "700720_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Ppo Hmo", "plan_name": "701720", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Ppo Hmo", "plan_name": "701720_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Ms State Emplo", "plan_name": "401457", "standard_charge_dollar": 38.31, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Ms State Emplo", "plan_name": "401457_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Basic Pl", "plan_name": "400100", "standard_charge_dollar": 38.31, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Basic Pl", "plan_name": "400100_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Federal", "plan_name": "400110", "standard_charge_dollar": 38.31, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Federal", "plan_name": "400110_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." } ] } ] }, { "description": "Assay of estrone", "code_information": [ { "code": "82679", "type": "CPT" } ], "standard_charges": [ { "gross_charge": 175.00, "minimum": 37.40, "maximum": 37.40, "setting": "both", "payers_information": [ { "payer_name": "Aetna", "plan_name": "700700", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna", "plan_name": "700700_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Miscellaneous", "plan_name": "700720", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Miscellaneous", "plan_name": "700720_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Ppo Hmo", "plan_name": "701720", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Ppo Hmo", "plan_name": "701720_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Ms State Emplo", "plan_name": "401457", "standard_charge_dollar": 37.40, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Ms State Emplo", "plan_name": "401457_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Basic Pl", "plan_name": "400100", "standard_charge_dollar": 37.40, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Basic Pl", "plan_name": "400100_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Federal", "plan_name": "400110", "standard_charge_dollar": 37.40, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Federal", "plan_name": "400110_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." } ] } ] }, { "description": "Hc estrone", "code_information": [ { "code": "82679", "type": "CPT" } ], "standard_charges": [ { "gross_charge": 175.00, "minimum": 37.40, "maximum": 37.40, "setting": "both", "payers_information": [ { "payer_name": "Aetna", "plan_name": "700700", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna", "plan_name": "700700_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Miscellaneous", "plan_name": "700720", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Miscellaneous", "plan_name": "700720_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Ppo Hmo", "plan_name": "701720", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Ppo Hmo", "plan_name": "701720_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Ms State Emplo", "plan_name": "401457", "standard_charge_dollar": 37.40, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Ms State Emplo", "plan_name": "401457_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Basic Pl", "plan_name": "400100", "standard_charge_dollar": 37.40, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Basic Pl", "plan_name": "400100_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Federal", "plan_name": "400110", "standard_charge_dollar": 37.40, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Federal", "plan_name": "400110_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." } ] } ] }, { "description": "Fats/lipids feces quant", "code_information": [ { "code": "82710", "type": "CPT" } ], "standard_charges": [ { "gross_charge": 87.34, "minimum": 25.18, "maximum": 25.18, "setting": "both", "payers_information": [ { "payer_name": "Aetna", "plan_name": "700700", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna", "plan_name": "700700_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Miscellaneous", "plan_name": "700720", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Miscellaneous", "plan_name": "700720_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Ppo Hmo", "plan_name": "701720", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Ppo Hmo", "plan_name": "701720_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Ms State Emplo", "plan_name": "401457", "standard_charge_dollar": 25.18, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Ms State Emplo", "plan_name": "401457_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Basic Pl", "plan_name": "400100", "standard_charge_dollar": 25.18, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Basic Pl", "plan_name": "400100_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Federal", "plan_name": "400110", "standard_charge_dollar": 25.18, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Federal", "plan_name": "400110_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." } ] } ] }, { "description": "Hc fat or lipids feces quan", "code_information": [ { "code": "82710", "type": "CPT" } ], "standard_charges": [ { "gross_charge": 87.34, "minimum": 25.18, "maximum": 25.18, "setting": "both", "payers_information": [ { "payer_name": "Aetna", "plan_name": "700700", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna", "plan_name": "700700_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Miscellaneous", "plan_name": "700720", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Miscellaneous", "plan_name": "700720_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Ppo Hmo", "plan_name": "701720", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Ppo Hmo", "plan_name": "701720_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Ms State Emplo", "plan_name": "401457", "standard_charge_dollar": 25.18, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Ms State Emplo", "plan_name": "401457_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Basic Pl", "plan_name": "400100", "standard_charge_dollar": 25.18, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Basic Pl", "plan_name": "400100_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Federal", "plan_name": "400110", "standard_charge_dollar": 25.18, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Federal", "plan_name": "400110_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." } ] } ] }, { "description": "Assay of ferritin", "code_information": [ { "code": "82728", "type": "CPT" } ], "standard_charges": [ { "gross_charge": 100.00, "minimum": 20.43, "maximum": 20.43, "setting": "both", "payers_information": [ { "payer_name": "Aetna", "plan_name": "700700", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna", "plan_name": "700700_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Miscellaneous", "plan_name": "700720", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Miscellaneous", "plan_name": "700720_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Ppo Hmo", "plan_name": "701720", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Ppo Hmo", "plan_name": "701720_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Ms State Emplo", "plan_name": "401457", "standard_charge_dollar": 20.43, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Ms State Emplo", "plan_name": "401457_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Basic Pl", "plan_name": "400100", "standard_charge_dollar": 20.43, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Basic Pl", "plan_name": "400100_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Federal", "plan_name": "400110", "standard_charge_dollar": 20.43, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Federal", "plan_name": "400110_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." } ] } ] }, { "description": "Hc ferritin", "code_information": [ { "code": "82728", "type": "CPT" } ], "standard_charges": [ { "gross_charge": 100.00, "minimum": 20.43, "maximum": 20.43, "setting": "both", "payers_information": [ { "payer_name": "Aetna", "plan_name": "700700", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna", "plan_name": "700700_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Miscellaneous", "plan_name": "700720", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Miscellaneous", "plan_name": "700720_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Ppo Hmo", "plan_name": "701720", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Ppo Hmo", "plan_name": "701720_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Ms State Emplo", "plan_name": "401457", "standard_charge_dollar": 20.43, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Ms State Emplo", "plan_name": "401457_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Basic Pl", "plan_name": "400100", "standard_charge_dollar": 20.43, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Basic Pl", "plan_name": "400100_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Federal", "plan_name": "400110", "standard_charge_dollar": 20.43, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Federal", "plan_name": "400110_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." } ] } ] }, { "description": "Assay of folic acid serum", "code_information": [ { "code": "82746", "type": "CPT" } ], "standard_charges": [ { "gross_charge": 100.00, "minimum": 18.73, "maximum": 18.73, "setting": "both", "payers_information": [ { "payer_name": "Aetna", "plan_name": "700700", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna", "plan_name": "700700_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Miscellaneous", "plan_name": "700720", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Miscellaneous", "plan_name": "700720_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Ppo Hmo", "plan_name": "701720", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Ppo Hmo", "plan_name": "701720_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Ms State Emplo", "plan_name": "401457", "standard_charge_dollar": 18.73, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Ms State Emplo", "plan_name": "401457_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Basic Pl", "plan_name": "400100", "standard_charge_dollar": 18.73, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Basic Pl", "plan_name": "400100_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Federal", "plan_name": "400110", "standard_charge_dollar": 18.73, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Federal", "plan_name": "400110_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." } ] } ] }, { "description": "Hc folic acid", "code_information": [ { "code": "82746", "type": "CPT" } ], "standard_charges": [ { "gross_charge": 100.00, "minimum": 18.73, "maximum": 18.73, "setting": "both", "payers_information": [ { "payer_name": "Aetna", "plan_name": "700700", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna", "plan_name": "700700_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Miscellaneous", "plan_name": "700720", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Miscellaneous", "plan_name": "700720_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Ppo Hmo", "plan_name": "701720", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Ppo Hmo", "plan_name": "701720_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Ms State Emplo", "plan_name": "401457", "standard_charge_dollar": 18.73, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Ms State Emplo", "plan_name": "401457_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Basic Pl", "plan_name": "400100", "standard_charge_dollar": 18.73, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Basic Pl", "plan_name": "400100_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Federal", "plan_name": "400110", "standard_charge_dollar": 18.73, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Federal", "plan_name": "400110_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." } ] } ] }, { "description": "Assay iga/igd/igg/igm each", "code_information": [ { "code": "82784", "type": "CPT" } ], "standard_charges": [ { "gross_charge": 90.36, "minimum": 13.94, "maximum": 13.94, "setting": "both", "payers_information": [ { "payer_name": "Aetna", "plan_name": "700700", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna", "plan_name": "700700_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Miscellaneous", "plan_name": "700720", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Miscellaneous", "plan_name": "700720_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Ppo Hmo", "plan_name": "701720", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Ppo Hmo", "plan_name": "701720_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Ms State Emplo", "plan_name": "401457", "standard_charge_dollar": 13.94, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Ms State Emplo", "plan_name": "401457_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Basic Pl", "plan_name": "400100", "standard_charge_dollar": 13.94, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Basic Pl", "plan_name": "400100_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Federal", "plan_name": "400110", "standard_charge_dollar": 13.94, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Federal", "plan_name": "400110_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." } ] } ] }, { "description": "Hc immunoglobulin d s (igd)", "code_information": [ { "code": "82784", "type": "CPT" } ], "standard_charges": [ { "gross_charge": 90.36, "minimum": 13.94, "maximum": 13.94, "setting": "both", "payers_information": [ { "payer_name": "Aetna", "plan_name": "700700", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna", "plan_name": "700700_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Miscellaneous", "plan_name": "700720", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Miscellaneous", "plan_name": "700720_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Ppo Hmo", "plan_name": "701720", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Ppo Hmo", "plan_name": "701720_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Ms State Emplo", "plan_name": "401457", "standard_charge_dollar": 13.94, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Ms State Emplo", "plan_name": "401457_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Basic Pl", "plan_name": "400100", "standard_charge_dollar": 13.94, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Basic Pl", "plan_name": "400100_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Federal", "plan_name": "400110", "standard_charge_dollar": 13.94, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Federal", "plan_name": "400110_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." } ] } ] }, { "description": "Assay of ige", "code_information": [ { "code": "82785", "type": "CPT" } ], "standard_charges": [ { "gross_charge": 67.04, "minimum": 21.76, "maximum": 21.76, "setting": "both", "payers_information": [ { "payer_name": "Aetna", "plan_name": "700700", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna", "plan_name": "700700_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Miscellaneous", "plan_name": "700720", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Miscellaneous", "plan_name": "700720_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Ppo Hmo", "plan_name": "701720", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Ppo Hmo", "plan_name": "701720_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Ms State Emplo", "plan_name": "401457", "standard_charge_dollar": 21.76, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Ms State Emplo", "plan_name": "401457_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Basic Pl", "plan_name": "400100", "standard_charge_dollar": 21.76, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Basic Pl", "plan_name": "400100_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Federal", "plan_name": "400110", "standard_charge_dollar": 21.76, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Federal", "plan_name": "400110_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." } ] } ] }, { "description": "Hc immunoglobulin e (ige)", "code_information": [ { "code": "82785", "type": "CPT" } ], "standard_charges": [ { "gross_charge": 67.04, "minimum": 21.76, "maximum": 21.76, "setting": "both", "payers_information": [ { "payer_name": "Aetna", "plan_name": "700700", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna", "plan_name": "700700_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Miscellaneous", "plan_name": "700720", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Miscellaneous", "plan_name": "700720_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Ppo Hmo", "plan_name": "701720", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Ppo Hmo", "plan_name": "701720_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Ms State Emplo", "plan_name": "401457", "standard_charge_dollar": 21.76, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Ms State Emplo", "plan_name": "401457_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Basic Pl", "plan_name": "400100", "standard_charge_dollar": 21.76, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Basic Pl", "plan_name": "400100_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Federal", "plan_name": "400110", "standard_charge_dollar": 21.76, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Federal", "plan_name": "400110_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." } ] } ] }, { "description": "Blood ph", "code_information": [ { "code": "82800", "type": "CPT" } ], "standard_charges": [ { "gross_charge": 96.81, "minimum": 12.68, "maximum": 12.68, "setting": "both", "payers_information": [ { "payer_name": "Aetna", "plan_name": "700700", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna", "plan_name": "700700_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Miscellaneous", "plan_name": "700720", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Miscellaneous", "plan_name": "700720_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Ppo Hmo", "plan_name": "701720", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Ppo Hmo", "plan_name": "701720_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Ms State Emplo", "plan_name": "401457", "standard_charge_dollar": 12.68, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Ms State Emplo", "plan_name": "401457_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Basic Pl", "plan_name": "400100", "standard_charge_dollar": 12.68, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Basic Pl", "plan_name": "400100_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Federal", "plan_name": "400110", "standard_charge_dollar": 12.68, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Federal", "plan_name": "400110_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." } ] } ] }, { "description": "Hc blood gas ph only", "code_information": [ { "code": "82800", "type": "CPT" } ], "standard_charges": [ { "gross_charge": 96.81, "minimum": 12.68, "maximum": 12.68, "setting": "both", "payers_information": [ { "payer_name": "Aetna", "plan_name": "700700", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna", "plan_name": "700700_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Miscellaneous", "plan_name": "700720", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Miscellaneous", "plan_name": "700720_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Ppo Hmo", "plan_name": "701720", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Ppo Hmo", "plan_name": "701720_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Ms State Emplo", "plan_name": "401457", "standard_charge_dollar": 12.68, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Ms State Emplo", "plan_name": "401457_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Basic Pl", "plan_name": "400100", "standard_charge_dollar": 12.68, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Basic Pl", "plan_name": "400100_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Federal", "plan_name": "400110", "standard_charge_dollar": 12.68, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Federal", "plan_name": "400110_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." } ] } ] }, { "description": "Blood gases any combination", "code_information": [ { "code": "82803", "type": "CPT" } ], "standard_charges": [ { "gross_charge": 225.00, "minimum": 29.00, "maximum": 29.00, "setting": "both", "payers_information": [ { "payer_name": "Aetna", "plan_name": "700700", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna", "plan_name": "700700_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Miscellaneous", "plan_name": "700720", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Miscellaneous", "plan_name": "700720_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Ppo Hmo", "plan_name": "701720", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Ppo Hmo", "plan_name": "701720_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Ms State Emplo", "plan_name": "401457", "standard_charge_dollar": 29.00, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Ms State Emplo", "plan_name": "401457_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Basic Pl", "plan_name": "400100", "standard_charge_dollar": 29.00, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Basic Pl", "plan_name": "400100_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Federal", "plan_name": "400110", "standard_charge_dollar": 29.00, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Federal", "plan_name": "400110_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." } ] } ] }, { "description": "Hc blood gases mixed w/o o2 sat", "code_information": [ { "code": "82803", "type": "CPT" } ], "standard_charges": [ { "gross_charge": 225.00, "minimum": 29.00, "maximum": 29.00, "setting": "both", "payers_information": [ { "payer_name": "Aetna", "plan_name": "700700", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna", "plan_name": "700700_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Miscellaneous", "plan_name": "700720", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Miscellaneous", "plan_name": "700720_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Ppo Hmo", "plan_name": "701720", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Ppo Hmo", "plan_name": "701720_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Ms State Emplo", "plan_name": "401457", "standard_charge_dollar": 29.00, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Ms State Emplo", "plan_name": "401457_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Basic Pl", "plan_name": "400100", "standard_charge_dollar": 29.00, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Basic Pl", "plan_name": "400100_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Federal", "plan_name": "400110", "standard_charge_dollar": 29.00, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Federal", "plan_name": "400110_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." } ] } ] }, { "description": "Assay glucose blood quant", "code_information": [ { "code": "82947", "type": "CPT" } ], "standard_charges": [ { "gross_charge": 40.00, "minimum": 3.93, "maximum": 5.89, "setting": "both", "payers_information": [ { "payer_name": "Aarp", "plan_name": "500102", "standard_charge_dollar": 3.93, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna", "plan_name": "700700", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna", "plan_name": "700700_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Mcare Ffs 6005", "plan_name": "700703", "standard_charge_dollar": 3.93, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Miscellaneous", "plan_name": "700720", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Miscellaneous", "plan_name": "700720_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Ppo Hmo", "plan_name": "701720", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Ppo Hmo", "plan_name": "701720_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Ambetter 68069", "plan_name": "500516", "standard_charge_dollar": 3.93, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Ms State Emplo", "plan_name": "401457", "standard_charge_dollar": 5.89, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Ms State Emplo", "plan_name": "401457_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Basic Pl", "plan_name": "400100", "standard_charge_dollar": 5.89, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Basic Pl", "plan_name": "400100_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Federal", "plan_name": "400110", "standard_charge_dollar": 5.89, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Federal", "plan_name": "400110_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Cigna Healthsprings Ffs", "plan_name": "500064", "standard_charge_dollar": 3.93, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Conseco", "plan_name": "500302", "standard_charge_dollar": 3.93, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Humana Ffs 61101", "plan_name": "500006", "standard_charge_dollar": 3.93, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Medicare A", "plan_name": "100100", "standard_charge_dollar": 3.93, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Medicare A", "plan_name": "100500", "standard_charge_dollar": 3.93, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Medicare Part B Only", "plan_name": "100300", "standard_charge_dollar": 3.93, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Medicare Railroad", "plan_name": "100103", "standard_charge_dollar": 3.93, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Ms Physicians Care N", "plan_name": "714210", "standard_charge_dollar": 4.91, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Peoples Hlth Ffs 72126", "plan_name": "500019", "standard_charge_dollar": 3.93, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Uhc/Secure Horizons", "plan_name": "500449", "standard_charge_dollar": 3.93, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "United Health Care/", "plan_name": "500292", "standard_charge_dollar": 4.44, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "United Healthcare", "plan_name": "750104", "standard_charge_dollar": 4.44, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "United Healthcare Ba", "plan_name": "750090", "standard_charge_dollar": 4.44, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "United Healthcare Me", "plan_name": "501310", "standard_charge_dollar": 3.93, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Windsor Mcare Extra", "plan_name": "500778", "standard_charge_dollar": 3.93, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." } ] } ] }, { "description": "Hc glucose blood quan", "code_information": [ { "code": "82947", "type": "CPT" } ], "standard_charges": [ { "gross_charge": 40.00, "minimum": 3.93, "maximum": 5.89, "setting": "both", "payers_information": [ { "payer_name": "Aarp", "plan_name": "500102", "standard_charge_dollar": 3.93, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna", "plan_name": "700700", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna", "plan_name": "700700_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Mcare Ffs 6005", "plan_name": "700703", "standard_charge_dollar": 3.93, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Miscellaneous", "plan_name": "700720", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Miscellaneous", "plan_name": "700720_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Ppo Hmo", "plan_name": "701720", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Ppo Hmo", "plan_name": "701720_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Ambetter 68069", "plan_name": "500516", "standard_charge_dollar": 3.93, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Ms State Emplo", "plan_name": "401457", "standard_charge_dollar": 5.89, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Ms State Emplo", "plan_name": "401457_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Basic Pl", "plan_name": "400100", "standard_charge_dollar": 5.89, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Basic Pl", "plan_name": "400100_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Federal", "plan_name": "400110", "standard_charge_dollar": 5.89, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Federal", "plan_name": "400110_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Cigna Healthsprings Ffs", "plan_name": "500064", "standard_charge_dollar": 3.93, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Conseco", "plan_name": "500302", "standard_charge_dollar": 3.93, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Humana Ffs 61101", "plan_name": "500006", "standard_charge_dollar": 3.93, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Medicare A", "plan_name": "100100", "standard_charge_dollar": 3.93, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Medicare A", "plan_name": "100500", "standard_charge_dollar": 3.93, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Medicare Part B Only", "plan_name": "100300", "standard_charge_dollar": 3.93, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Medicare Railroad", "plan_name": "100103", "standard_charge_dollar": 3.93, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Ms Physicians Care N", "plan_name": "714210", "standard_charge_dollar": 4.91, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Peoples Hlth Ffs 72126", "plan_name": "500019", "standard_charge_dollar": 3.93, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Uhc/Secure Horizons", "plan_name": "500449", "standard_charge_dollar": 3.93, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "United Health Care/", "plan_name": "500292", "standard_charge_dollar": 4.44, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "United Healthcare", "plan_name": "750104", "standard_charge_dollar": 4.44, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "United Healthcare Ba", "plan_name": "750090", "standard_charge_dollar": 4.44, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "United Healthcare Me", "plan_name": "501310", "standard_charge_dollar": 3.93, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Windsor Mcare Extra", "plan_name": "500778", "standard_charge_dollar": 3.93, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." } ] } ] }, { "description": "Hc glucose blood reagent strip", "code_information": [ { "code": "82948", "type": "CPT" } ], "standard_charges": [ { "gross_charge": 30.00, "minimum": 4.75, "maximum": 4.75, "setting": "both", "payers_information": [ { "payer_name": "Aetna", "plan_name": "700700", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna", "plan_name": "700700_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Miscellaneous", "plan_name": "700720", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Miscellaneous", "plan_name": "700720_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Ppo Hmo", "plan_name": "701720", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Ppo Hmo", "plan_name": "701720_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Ms State Emplo", "plan_name": "401457", "standard_charge_dollar": 4.75, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Ms State Emplo", "plan_name": "401457_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Basic Pl", "plan_name": "400100", "standard_charge_dollar": 4.75, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Basic Pl", "plan_name": "400100_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Federal", "plan_name": "400110", "standard_charge_dollar": 4.75, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Federal", "plan_name": "400110_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." } ] } ] }, { "description": "Reagent strip/blood glucose", "code_information": [ { "code": "82948", "type": "CPT" } ], "standard_charges": [ { "gross_charge": 30.00, "minimum": 4.75, "maximum": 4.75, "setting": "both", "payers_information": [ { "payer_name": "Aetna", "plan_name": "700700", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna", "plan_name": "700700_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Miscellaneous", "plan_name": "700720", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Miscellaneous", "plan_name": "700720_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Ppo Hmo", "plan_name": "701720", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Ppo Hmo", "plan_name": "701720_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Ms State Emplo", "plan_name": "401457", "standard_charge_dollar": 4.75, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Ms State Emplo", "plan_name": "401457_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Basic Pl", "plan_name": "400100", "standard_charge_dollar": 4.75, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Basic Pl", "plan_name": "400100_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Federal", "plan_name": "400110", "standard_charge_dollar": 4.75, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Federal", "plan_name": "400110_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." } ] } ] }, { "description": "Glucose test", "code_information": [ { "code": "82950", "type": "CPT" } ], "standard_charges": [ { "gross_charge": 31.50, "minimum": 4.75, "maximum": 7.12, "setting": "both", "payers_information": [ { "payer_name": "Aarp", "plan_name": "500102", "standard_charge_dollar": 4.75, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna", "plan_name": "700700", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna", "plan_name": "700700_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Mcare Ffs 6005", "plan_name": "700703", "standard_charge_dollar": 4.75, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Miscellaneous", "plan_name": "700720", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Miscellaneous", "plan_name": "700720_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Ppo Hmo", "plan_name": "701720", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Ppo Hmo", "plan_name": "701720_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Ambetter 68069", "plan_name": "500516", "standard_charge_dollar": 4.75, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Ms State Emplo", "plan_name": "401457", "standard_charge_dollar": 7.12, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Ms State Emplo", "plan_name": "401457_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Basic Pl", "plan_name": "400100", "standard_charge_dollar": 7.12, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Basic Pl", "plan_name": "400100_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Federal", "plan_name": "400110", "standard_charge_dollar": 7.12, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Federal", "plan_name": "400110_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Cigna Healthsprings Ffs", "plan_name": "500064", "standard_charge_dollar": 4.75, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Conseco", "plan_name": "500302", "standard_charge_dollar": 4.75, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Humana Ffs 61101", "plan_name": "500006", "standard_charge_dollar": 4.75, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Medicare A", "plan_name": "100100", "standard_charge_dollar": 4.75, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Medicare A", "plan_name": "100500", "standard_charge_dollar": 4.75, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Medicare Part B Only", "plan_name": "100300", "standard_charge_dollar": 4.75, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Medicare Railroad", "plan_name": "100103", "standard_charge_dollar": 4.75, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Ms Physicians Care N", "plan_name": "714210", "standard_charge_dollar": 5.94, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Peoples Hlth Ffs 72126", "plan_name": "500019", "standard_charge_dollar": 4.75, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Uhc/Secure Horizons", "plan_name": "500449", "standard_charge_dollar": 4.75, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "United Health Care/", "plan_name": "500292", "standard_charge_dollar": 5.37, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "United Healthcare", "plan_name": "750104", "standard_charge_dollar": 5.37, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "United Healthcare Ba", "plan_name": "750090", "standard_charge_dollar": 5.37, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "United Healthcare Me", "plan_name": "501310", "standard_charge_dollar": 4.75, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Windsor Mcare Extra", "plan_name": "500778", "standard_charge_dollar": 4.75, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." } ] } ] }, { "description": "Hc glucose 2 hr post prandial", "code_information": [ { "code": "82950", "type": "CPT" } ], "standard_charges": [ { "gross_charge": 31.50, "minimum": 4.75, "maximum": 7.12, "setting": "both", "payers_information": [ { "payer_name": "Aarp", "plan_name": "500102", "standard_charge_dollar": 4.75, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna", "plan_name": "700700", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna", "plan_name": "700700_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Mcare Ffs 6005", "plan_name": "700703", "standard_charge_dollar": 4.75, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Miscellaneous", "plan_name": "700720", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Miscellaneous", "plan_name": "700720_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Ppo Hmo", "plan_name": "701720", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Ppo Hmo", "plan_name": "701720_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Ambetter 68069", "plan_name": "500516", "standard_charge_dollar": 4.75, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Ms State Emplo", "plan_name": "401457", "standard_charge_dollar": 7.12, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Ms State Emplo", "plan_name": "401457_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Basic Pl", "plan_name": "400100", "standard_charge_dollar": 7.12, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Basic Pl", "plan_name": "400100_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Federal", "plan_name": "400110", "standard_charge_dollar": 7.12, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Federal", "plan_name": "400110_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Cigna Healthsprings Ffs", "plan_name": "500064", "standard_charge_dollar": 4.75, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Conseco", "plan_name": "500302", "standard_charge_dollar": 4.75, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Humana Ffs 61101", "plan_name": "500006", "standard_charge_dollar": 4.75, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Medicare A", "plan_name": "100100", "standard_charge_dollar": 4.75, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Medicare A", "plan_name": "100500", "standard_charge_dollar": 4.75, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Medicare Part B Only", "plan_name": "100300", "standard_charge_dollar": 4.75, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Medicare Railroad", "plan_name": "100103", "standard_charge_dollar": 4.75, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Ms Physicians Care N", "plan_name": "714210", "standard_charge_dollar": 5.94, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Peoples Hlth Ffs 72126", "plan_name": "500019", "standard_charge_dollar": 4.75, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Uhc/Secure Horizons", "plan_name": "500449", "standard_charge_dollar": 4.75, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "United Health Care/", "plan_name": "500292", "standard_charge_dollar": 5.37, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "United Healthcare", "plan_name": "750104", "standard_charge_dollar": 5.37, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "United Healthcare Ba", "plan_name": "750090", "standard_charge_dollar": 5.37, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "United Healthcare Me", "plan_name": "501310", "standard_charge_dollar": 4.75, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Windsor Mcare Extra", "plan_name": "500778", "standard_charge_dollar": 4.75, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." } ] } ] }, { "description": "Hc glucose 2 hr post prandial", "code_information": [ { "code": "82950", "type": "CPT" } ], "standard_charges": [ { "gross_charge": 31.50, "minimum": 4.75, "maximum": 26.78, "setting": "both", "payers_information": [ { "payer_name": "Aarp", "plan_name": "500102", "standard_charge_dollar": 4.75, "count": "0", "methodology": "fee schedule", "modifiers": "QW", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna", "plan_name": "700700", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna", "plan_name": "700700_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Mcare Ffs 6005", "plan_name": "700703", "standard_charge_dollar": 4.75, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Miscellaneous", "plan_name": "700720", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Miscellaneous", "plan_name": "700720_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Ppo Hmo", "plan_name": "701720", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Ppo Hmo", "plan_name": "701720_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Ambetter 68069", "plan_name": "500516", "standard_charge_dollar": 4.75, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Ms State Emplo", "plan_name": "401457", "standard_charge_percentage": 0.80, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Ms State Emplo", "plan_name": "401457_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Basic Pl", "plan_name": "400100", "standard_charge_percentage": 0.85, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Basic Pl", "plan_name": "400100_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Federal", "plan_name": "400110", "standard_charge_percentage": 0.85, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Federal", "plan_name": "400110_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Cigna Healthsprings Ffs", "plan_name": "500064", "standard_charge_dollar": 4.75, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Conseco", "plan_name": "500302", "standard_charge_dollar": 4.75, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Humana Ffs 61101", "plan_name": "500006", "standard_charge_dollar": 4.75, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Medicare A", "plan_name": "100100", "standard_charge_dollar": 4.75, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Medicare A", "plan_name": "100500", "standard_charge_dollar": 4.75, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Medicare Part B Only", "plan_name": "100300", "standard_charge_dollar": 4.75, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Medicare Railroad", "plan_name": "100103", "standard_charge_dollar": 4.75, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Ms Physicians Care N", "plan_name": "714210", "standard_charge_dollar": 5.94, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Peoples Hlth Ffs 72126", "plan_name": "500019", "standard_charge_dollar": 4.75, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Uhc/Secure Horizons", "plan_name": "500449", "standard_charge_dollar": 4.75, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "United Health Care/", "plan_name": "500292", "standard_charge_dollar": 5.37, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "United Healthcare", "plan_name": "750104", "standard_charge_dollar": 5.37, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "United Healthcare Ba", "plan_name": "750090", "standard_charge_dollar": 5.37, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "United Healthcare Me", "plan_name": "501310", "standard_charge_dollar": 4.75, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Windsor Mcare Extra", "plan_name": "500778", "standard_charge_dollar": 4.75, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." } ] } ] }, { "description": "Glucose tolerance test (gtt)", "code_information": [ { "code": "82951", "type": "CPT" } ], "standard_charges": [ { "gross_charge": 90.00, "minimum": 12.87, "maximum": 19.28, "setting": "both", "payers_information": [ { "payer_name": "Aarp", "plan_name": "500102", "standard_charge_dollar": 12.87, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna", "plan_name": "700700", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna", "plan_name": "700700_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Mcare Ffs 6005", "plan_name": "700703", "standard_charge_dollar": 12.87, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Miscellaneous", "plan_name": "700720", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Miscellaneous", "plan_name": "700720_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Ppo Hmo", "plan_name": "701720", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Ppo Hmo", "plan_name": "701720_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Ambetter 68069", "plan_name": "500516", "standard_charge_dollar": 12.87, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Ms State Emplo", "plan_name": "401457", "standard_charge_dollar": 19.28, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Ms State Emplo", "plan_name": "401457_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Basic Pl", "plan_name": "400100", "standard_charge_dollar": 19.28, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Basic Pl", "plan_name": "400100_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Federal", "plan_name": "400110", "standard_charge_dollar": 19.28, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Federal", "plan_name": "400110_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Cigna Healthsprings Ffs", "plan_name": "500064", "standard_charge_dollar": 12.87, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Conseco", "plan_name": "500302", "standard_charge_dollar": 12.87, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Humana Ffs 61101", "plan_name": "500006", "standard_charge_dollar": 12.87, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Medicare A", "plan_name": "100100", "standard_charge_dollar": 12.87, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Medicare A", "plan_name": "100500", "standard_charge_dollar": 12.87, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Medicare Part B Only", "plan_name": "100300", "standard_charge_dollar": 12.87, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Medicare Railroad", "plan_name": "100103", "standard_charge_dollar": 12.87, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Ms Physicians Care N", "plan_name": "714210", "standard_charge_dollar": 16.09, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Peoples Hlth Ffs 72126", "plan_name": "500019", "standard_charge_dollar": 12.87, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Uhc/Secure Horizons", "plan_name": "500449", "standard_charge_dollar": 12.87, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "United Health Care/", "plan_name": "500292", "standard_charge_dollar": 14.54, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "United Healthcare", "plan_name": "750104", "standard_charge_dollar": 14.54, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "United Healthcare Ba", "plan_name": "750090", "standard_charge_dollar": 14.54, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "United Healthcare Me", "plan_name": "501310", "standard_charge_dollar": 12.87, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Windsor Mcare Extra", "plan_name": "500778", "standard_charge_dollar": 12.87, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." } ] } ] }, { "description": "Hc gtt 1st three specimens", "code_information": [ { "code": "82951", "type": "CPT" } ], "standard_charges": [ { "gross_charge": 90.00, "minimum": 12.87, "maximum": 19.28, "setting": "both", "payers_information": [ { "payer_name": "Aarp", "plan_name": "500102", "standard_charge_dollar": 12.87, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna", "plan_name": "700700", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna", "plan_name": "700700_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Mcare Ffs 6005", "plan_name": "700703", "standard_charge_dollar": 12.87, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Miscellaneous", "plan_name": "700720", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Miscellaneous", "plan_name": "700720_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Ppo Hmo", "plan_name": "701720", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Ppo Hmo", "plan_name": "701720_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Ambetter 68069", "plan_name": "500516", "standard_charge_dollar": 12.87, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Ms State Emplo", "plan_name": "401457", "standard_charge_dollar": 19.28, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Ms State Emplo", "plan_name": "401457_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Basic Pl", "plan_name": "400100", "standard_charge_dollar": 19.28, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Basic Pl", "plan_name": "400100_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Federal", "plan_name": "400110", "standard_charge_dollar": 19.28, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Federal", "plan_name": "400110_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Cigna Healthsprings Ffs", "plan_name": "500064", "standard_charge_dollar": 12.87, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Conseco", "plan_name": "500302", "standard_charge_dollar": 12.87, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Humana Ffs 61101", "plan_name": "500006", "standard_charge_dollar": 12.87, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Medicare A", "plan_name": "100100", "standard_charge_dollar": 12.87, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Medicare A", "plan_name": "100500", "standard_charge_dollar": 12.87, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Medicare Part B Only", "plan_name": "100300", "standard_charge_dollar": 12.87, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Medicare Railroad", "plan_name": "100103", "standard_charge_dollar": 12.87, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Ms Physicians Care N", "plan_name": "714210", "standard_charge_dollar": 16.09, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Peoples Hlth Ffs 72126", "plan_name": "500019", "standard_charge_dollar": 12.87, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Uhc/Secure Horizons", "plan_name": "500449", "standard_charge_dollar": 12.87, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "United Health Care/", "plan_name": "500292", "standard_charge_dollar": 14.54, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "United Healthcare", "plan_name": "750104", "standard_charge_dollar": 14.54, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "United Healthcare Ba", "plan_name": "750090", "standard_charge_dollar": 14.54, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "United Healthcare Me", "plan_name": "501310", "standard_charge_dollar": 12.87, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Windsor Mcare Extra", "plan_name": "500778", "standard_charge_dollar": 12.87, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." } ] } ] }, { "description": "Hc gtt 3 specimens", "code_information": [ { "code": "82951", "type": "CPT" } ], "standard_charges": [ { "gross_charge": 90.00, "minimum": 12.87, "maximum": 76.50, "setting": "both", "payers_information": [ { "payer_name": "Aarp", "plan_name": "500102", "standard_charge_dollar": 12.87, "count": "0", "methodology": "fee schedule", "modifiers": "QW", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna", "plan_name": "700700", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna", "plan_name": "700700_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Mcare Ffs 6005", "plan_name": "700703", "standard_charge_dollar": 12.87, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Miscellaneous", "plan_name": "700720", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Miscellaneous", "plan_name": "700720_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Ppo Hmo", "plan_name": "701720", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Ppo Hmo", "plan_name": "701720_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Ambetter 68069", "plan_name": "500516", "standard_charge_dollar": 12.87, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Ms State Emplo", "plan_name": "401457", "standard_charge_percentage": 0.80, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Ms State Emplo", "plan_name": "401457_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Basic Pl", "plan_name": "400100", "standard_charge_percentage": 0.85, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Basic Pl", "plan_name": "400100_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Federal", "plan_name": "400110", "standard_charge_percentage": 0.85, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Federal", "plan_name": "400110_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Cigna Healthsprings Ffs", "plan_name": "500064", "standard_charge_dollar": 12.87, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Conseco", "plan_name": "500302", "standard_charge_dollar": 12.87, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Humana Ffs 61101", "plan_name": "500006", "standard_charge_dollar": 12.87, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Medicare A", "plan_name": "100100", "standard_charge_dollar": 12.87, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Medicare A", "plan_name": "100500", "standard_charge_dollar": 12.87, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Medicare Part B Only", "plan_name": "100300", "standard_charge_dollar": 12.87, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Medicare Railroad", "plan_name": "100103", "standard_charge_dollar": 12.87, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Ms Physicians Care N", "plan_name": "714210", "standard_charge_dollar": 16.09, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Peoples Hlth Ffs 72126", "plan_name": "500019", "standard_charge_dollar": 12.87, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Uhc/Secure Horizons", "plan_name": "500449", "standard_charge_dollar": 12.87, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "United Health Care/", "plan_name": "500292", "standard_charge_dollar": 14.54, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "United Healthcare", "plan_name": "750104", "standard_charge_dollar": 14.54, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "United Healthcare Ba", "plan_name": "750090", "standard_charge_dollar": 14.54, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "United Healthcare Me", "plan_name": "501310", "standard_charge_dollar": 12.87, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Windsor Mcare Extra", "plan_name": "500778", "standard_charge_dollar": 12.87, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." } ] } ] }, { "description": "Gtt-added samples", "code_information": [ { "code": "82952", "type": "CPT" } ], "standard_charges": [ { "gross_charge": 30.00, "minimum": 5.03, "maximum": 5.03, "setting": "both", "payers_information": [ { "payer_name": "Aetna", "plan_name": "700700", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna", "plan_name": "700700_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Miscellaneous", "plan_name": "700720", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Miscellaneous", "plan_name": "700720_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Ppo Hmo", "plan_name": "701720", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Ppo Hmo", "plan_name": "701720_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Ms State Emplo", "plan_name": "401457", "standard_charge_dollar": 5.03, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Ms State Emplo", "plan_name": "401457_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Basic Pl", "plan_name": "400100", "standard_charge_dollar": 5.03, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Basic Pl", "plan_name": "400100_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Federal", "plan_name": "400110", "standard_charge_dollar": 5.03, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Federal", "plan_name": "400110_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." } ] } ] }, { "description": "Hc gtt additional specimen", "code_information": [ { "code": "82952", "type": "CPT" } ], "standard_charges": [ { "gross_charge": 30.00, "minimum": 5.03, "maximum": 5.03, "setting": "both", "payers_information": [ { "payer_name": "Aetna", "plan_name": "700700", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna", "plan_name": "700700_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Miscellaneous", "plan_name": "700720", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Miscellaneous", "plan_name": "700720_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Ppo Hmo", "plan_name": "701720", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Ppo Hmo", "plan_name": "701720_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Ms State Emplo", "plan_name": "401457", "standard_charge_dollar": 5.03, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Ms State Emplo", "plan_name": "401457_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Basic Pl", "plan_name": "400100", "standard_charge_dollar": 5.03, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Basic Pl", "plan_name": "400100_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Federal", "plan_name": "400110", "standard_charge_dollar": 5.03, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Federal", "plan_name": "400110_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." } ] } ] }, { "description": "Glucose blood test", "code_information": [ { "code": "82962", "type": "CPT" } ], "standard_charges": [ { "gross_charge": 40.00, "minimum": 3.51, "maximum": 3.51, "setting": "both", "payers_information": [ { "payer_name": "Aetna", "plan_name": "700700", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna", "plan_name": "700700_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Miscellaneous", "plan_name": "700720", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Miscellaneous", "plan_name": "700720_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Ppo Hmo", "plan_name": "701720", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Ppo Hmo", "plan_name": "701720_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Ms State Emplo", "plan_name": "401457", "standard_charge_dollar": 3.51, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Ms State Emplo", "plan_name": "401457_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Basic Pl", "plan_name": "400100", "standard_charge_dollar": 3.51, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Basic Pl", "plan_name": "400100_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Federal", "plan_name": "400110", "standard_charge_dollar": 3.51, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Federal", "plan_name": "400110_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." } ] } ] }, { "description": "Hc glucose by monitor device", "code_information": [ { "code": "82962", "type": "CPT" } ], "standard_charges": [ { "gross_charge": 40.00, "minimum": 3.51, "maximum": 3.51, "setting": "both", "payers_information": [ { "payer_name": "Aetna", "plan_name": "700700", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna", "plan_name": "700700_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Miscellaneous", "plan_name": "700720", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Miscellaneous", "plan_name": "700720_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Ppo Hmo", "plan_name": "701720", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Ppo Hmo", "plan_name": "701720_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Ms State Emplo", "plan_name": "401457", "standard_charge_dollar": 3.51, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Ms State Emplo", "plan_name": "401457_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Basic Pl", "plan_name": "400100", "standard_charge_dollar": 3.51, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Basic Pl", "plan_name": "400100_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Federal", "plan_name": "400110", "standard_charge_dollar": 3.51, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Federal", "plan_name": "400110_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." } ] } ] }, { "description": "Assay of ggt", "code_information": [ { "code": "82977", "type": "CPT" } ], "standard_charges": [ { "gross_charge": 45.00, "minimum": 10.79, "maximum": 10.79, "setting": "both", "payers_information": [ { "payer_name": "Aetna", "plan_name": "700700", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna", "plan_name": "700700_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Miscellaneous", "plan_name": "700720", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Miscellaneous", "plan_name": "700720_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Ppo Hmo", "plan_name": "701720", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Ppo Hmo", "plan_name": "701720_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Ms State Emplo", "plan_name": "401457", "standard_charge_dollar": 10.79, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Ms State Emplo", "plan_name": "401457_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Basic Pl", "plan_name": "400100", "standard_charge_dollar": 10.79, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Basic Pl", "plan_name": "400100_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Federal", "plan_name": "400110", "standard_charge_dollar": 10.79, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Federal", "plan_name": "400110_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." } ] } ] }, { "description": "Hc ggt", "code_information": [ { "code": "82977", "type": "CPT" } ], "standard_charges": [ { "gross_charge": 45.00, "minimum": 10.79, "maximum": 10.79, "setting": "both", "payers_information": [ { "payer_name": "Aetna", "plan_name": "700700", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna", "plan_name": "700700_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Miscellaneous", "plan_name": "700720", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Miscellaneous", "plan_name": "700720_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Ppo Hmo", "plan_name": "701720", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Ppo Hmo", "plan_name": "701720_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Ms State Emplo", "plan_name": "401457", "standard_charge_dollar": 10.79, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Ms State Emplo", "plan_name": "401457_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Basic Pl", "plan_name": "400100", "standard_charge_dollar": 10.79, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Basic Pl", "plan_name": "400100_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Federal", "plan_name": "400110", "standard_charge_dollar": 10.79, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Federal", "plan_name": "400110_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." } ] } ] }, { "description": "Assay of gonadotropin (fsh)", "code_information": [ { "code": "83001", "type": "CPT" } ], "standard_charges": [ { "gross_charge": 180.00, "minimum": 27.84, "maximum": 27.84, "setting": "both", "payers_information": [ { "payer_name": "Aetna", "plan_name": "700700", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna", "plan_name": "700700_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Miscellaneous", "plan_name": "700720", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Miscellaneous", "plan_name": "700720_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Ppo Hmo", "plan_name": "701720", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Ppo Hmo", "plan_name": "701720_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Ms State Emplo", "plan_name": "401457", "standard_charge_dollar": 27.84, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Ms State Emplo", "plan_name": "401457_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Basic Pl", "plan_name": "400100", "standard_charge_dollar": 27.84, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Basic Pl", "plan_name": "400100_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Federal", "plan_name": "400110", "standard_charge_dollar": 27.84, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Federal", "plan_name": "400110_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." } ] } ] }, { "description": "Hc gonadotropin fsh", "code_information": [ { "code": "83001", "type": "CPT" } ], "standard_charges": [ { "gross_charge": 180.00, "minimum": 27.84, "maximum": 27.84, "setting": "both", "payers_information": [ { "payer_name": "Aetna", "plan_name": "700700", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna", "plan_name": "700700_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Miscellaneous", "plan_name": "700720", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Miscellaneous", "plan_name": "700720_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Ppo Hmo", "plan_name": "701720", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Ppo Hmo", "plan_name": "701720_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Ms State Emplo", "plan_name": "401457", "standard_charge_dollar": 27.84, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Ms State Emplo", "plan_name": "401457_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Basic Pl", "plan_name": "400100", "standard_charge_dollar": 27.84, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Basic Pl", "plan_name": "400100_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Federal", "plan_name": "400110", "standard_charge_dollar": 27.84, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Federal", "plan_name": "400110_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." } ] } ] }, { "description": "Assay of gonadotropin (lh)", "code_information": [ { "code": "83002", "type": "CPT" } ], "standard_charges": [ { "gross_charge": 78.96, "minimum": 27.74, "maximum": 27.74, "setting": "both", "payers_information": [ { "payer_name": "Aetna", "plan_name": "700700", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna", "plan_name": "700700_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Miscellaneous", "plan_name": "700720", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Miscellaneous", "plan_name": "700720_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Ppo Hmo", "plan_name": "701720", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Ppo Hmo", "plan_name": "701720_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Ms State Emplo", "plan_name": "401457", "standard_charge_dollar": 27.74, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Ms State Emplo", "plan_name": "401457_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Basic Pl", "plan_name": "400100", "standard_charge_dollar": 27.74, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Basic Pl", "plan_name": "400100_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Federal", "plan_name": "400110", "standard_charge_dollar": 27.74, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Federal", "plan_name": "400110_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." } ] } ] }, { "description": "Hc gonadotropin lh", "code_information": [ { "code": "83002", "type": "CPT" } ], "standard_charges": [ { "gross_charge": 78.96, "minimum": 27.74, "maximum": 27.74, "setting": "both", "payers_information": [ { "payer_name": "Aetna", "plan_name": "700700", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna", "plan_name": "700700_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Miscellaneous", "plan_name": "700720", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Miscellaneous", "plan_name": "700720_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Ppo Hmo", "plan_name": "701720", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Ppo Hmo", "plan_name": "701720_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Ms State Emplo", "plan_name": "401457", "standard_charge_dollar": 27.74, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Ms State Emplo", "plan_name": "401457_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Basic Pl", "plan_name": "400100", "standard_charge_dollar": 27.74, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Basic Pl", "plan_name": "400100_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Federal", "plan_name": "400110", "standard_charge_dollar": 27.74, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Federal", "plan_name": "400110_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." } ] } ] }, { "description": "Assay of haptoglobin quant", "code_information": [ { "code": "83010", "type": "CPT" } ], "standard_charges": [ { "gross_charge": 54.07, "minimum": 18.84, "maximum": 18.84, "setting": "both", "payers_information": [ { "payer_name": "Aetna", "plan_name": "700700", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna", "plan_name": "700700_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Miscellaneous", "plan_name": "700720", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total 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"additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Ms State Emplo", "plan_name": "401457_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Basic Pl", "plan_name": "400100", "standard_charge_dollar": 18.84, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Basic Pl", "plan_name": "400100_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Federal", "plan_name": "400110", "standard_charge_dollar": 18.84, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Federal", "plan_name": "400110_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." } ] } ] }, { "description": "Hc haptoglobin", "code_information": [ { "code": "83010", "type": "CPT" } ], "standard_charges": [ { "gross_charge": 54.07, "minimum": 18.84, "maximum": 18.84, "setting": "both", "payers_information": [ { "payer_name": "Aetna", "plan_name": "700700", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna", "plan_name": "700700_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Miscellaneous", "plan_name": "700720", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Miscellaneous", "plan_name": "700720_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Ppo Hmo", "plan_name": "701720", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Ppo Hmo", "plan_name": "701720_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Ms State Emplo", "plan_name": "401457", "standard_charge_dollar": 18.84, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Ms State Emplo", "plan_name": "401457_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Basic Pl", "plan_name": "400100", "standard_charge_dollar": 18.84, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Basic Pl", "plan_name": "400100_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Federal", "plan_name": "400110", "standard_charge_dollar": 18.84, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Federal", "plan_name": "400110_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." } ] } ] }, { "description": "H pylori (c-13) breath", "code_information": [ { "code": "83013", "type": "CPT" } ], "standard_charges": [ { "gross_charge": 150.00, "minimum": 100.93, "maximum": 100.93, "setting": "both", "payers_information": [ { "payer_name": "Aetna", "plan_name": "700700", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna", "plan_name": "700700_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Miscellaneous", "plan_name": "700720", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Miscellaneous", "plan_name": "700720_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Ppo Hmo", "plan_name": "701720", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Ppo Hmo", "plan_name": "701720_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Ms State Emplo", "plan_name": "401457", "standard_charge_dollar": 100.93, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Ms State Emplo", "plan_name": "401457_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Basic Pl", "plan_name": "400100", "standard_charge_dollar": 100.93, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Basic Pl", "plan_name": "400100_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Federal", "plan_name": "400110", "standard_charge_dollar": 100.93, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Federal", "plan_name": "400110_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." } ] } ] }, { "description": "Hc h pylori breath test", "code_information": [ { "code": "83013", "type": "CPT" } ], "standard_charges": [ { "gross_charge": 150.00, "minimum": 100.93, "maximum": 100.93, "setting": "both", "payers_information": [ { "payer_name": "Aetna", "plan_name": "700700", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna", "plan_name": "700700_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Miscellaneous", "plan_name": "700720", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Miscellaneous", "plan_name": "700720_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Ppo Hmo", "plan_name": "701720", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Ppo Hmo", "plan_name": "701720_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Ms State Emplo", "plan_name": "401457", "standard_charge_dollar": 100.93, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Ms State Emplo", "plan_name": "401457_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Basic Pl", "plan_name": "400100", "standard_charge_dollar": 100.93, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Basic Pl", "plan_name": "400100_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Federal", "plan_name": "400110", "standard_charge_dollar": 100.93, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Federal", "plan_name": "400110_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." } ] } ] }, { "description": "H pylori drug admin", "code_information": [ { "code": "83014", "type": "CPT" } ], "standard_charges": [ { "gross_charge": 25.00, "minimum": 11.78, "maximum": 11.78, "setting": "both", "payers_information": [ { "payer_name": "Aetna", "plan_name": "700700", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna", "plan_name": "700700_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Miscellaneous", "plan_name": "700720", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Miscellaneous", "plan_name": "700720_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Ppo Hmo", "plan_name": "701720", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Ppo Hmo", "plan_name": "701720_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Ms State Emplo", "plan_name": "401457", "standard_charge_dollar": 11.78, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Ms State Emplo", "plan_name": "401457_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Basic Pl", "plan_name": "400100", "standard_charge_dollar": 11.78, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Basic Pl", "plan_name": "400100_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Federal", "plan_name": "400110", "standard_charge_dollar": 11.78, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Federal", "plan_name": "400110_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." } ] } ] }, { "description": "Hc h pylori drug admin", "code_information": [ { "code": "83014", "type": "CPT" } ], "standard_charges": [ { "gross_charge": 25.00, "minimum": 11.78, "maximum": 11.78, "setting": "both", "payers_information": [ { "payer_name": "Aetna", "plan_name": "700700", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna", "plan_name": "700700_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Miscellaneous", "plan_name": "700720", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Miscellaneous", "plan_name": "700720_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", 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"count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." } ] } ] }, { "description": "Hemoglobin electrophoresis", "code_information": [ { "code": "83020", "type": "CPT" } ], "standard_charges": [ { "gross_charge": 110.54, "minimum": 19.28, "maximum": 19.28, "setting": "both", "payers_information": [ { "payer_name": "Aetna", "plan_name": "700700", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna", "plan_name": "700700_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Miscellaneous", "plan_name": "700720", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of 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"payer_name": "Bc/Bs Ms State Emplo", "plan_name": "401457", "standard_charge_dollar": 27.06, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Ms State Emplo", "plan_name": "401457_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Basic Pl", "plan_name": "400100", "standard_charge_dollar": 27.06, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Basic Pl", "plan_name": "400100_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Federal", "plan_name": "400110", "standard_charge_dollar": 27.06, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Federal", "plan_name": "400110_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." } ] } ] }, { "description": "Hemoglobin chromotography", "code_information": [ { "code": "83021", "type": "CPT" } ], "standard_charges": [ { "gross_charge": 155.12, "minimum": 27.06, "maximum": 27.06, "setting": "both", "payers_information": [ { "payer_name": "Aetna", "plan_name": "700700", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna", "plan_name": "700700_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Miscellaneous", "plan_name": "700720", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Miscellaneous", "plan_name": "700720_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Ppo Hmo", "plan_name": "701720", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Ppo Hmo", "plan_name": "701720_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Ms State Emplo", "plan_name": "401457", "standard_charge_dollar": 27.06, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Ms State Emplo", "plan_name": "401457_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Basic Pl", "plan_name": "400100", "standard_charge_dollar": 27.06, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Basic Pl", "plan_name": "400100_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Federal", "plan_name": "400110", "standard_charge_dollar": 27.06, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Federal", "plan_name": "400110_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." } ] } ] }, { "description": "Glycosylated hemoglobin test", "code_information": [ { "code": "83036", "type": "CPT" } ], "standard_charges": [ { "gross_charge": 110.00, "minimum": 14.54, "maximum": 14.54, "setting": "both", "payers_information": [ { "payer_name": "Aetna", "plan_name": "700700", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna", "plan_name": "700700_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Miscellaneous", "plan_name": "700720", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Miscellaneous", "plan_name": "700720_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Ppo Hmo", "plan_name": "701720", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data 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"Bc/Bs Of Ms Basic Pl", "plan_name": "400100_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Federal", "plan_name": "400110", "standard_charge_dollar": 14.54, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Federal", "plan_name": "400110_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." } ] } ] }, { "description": "Hc glycosylated hemoglobin", "code_information": [ { "code": "83036", "type": "CPT" } ], "standard_charges": [ { "gross_charge": 110.00, "minimum": 14.54, "maximum": 14.54, "setting": "both", "payers_information": [ { "payer_name": "Aetna", "plan_name": "700700", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna", "plan_name": "700700_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Miscellaneous", "plan_name": "700720", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Miscellaneous", "plan_name": "700720_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Ppo Hmo", "plan_name": "701720", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Ppo Hmo", "plan_name": "701720_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Ms State Emplo", "plan_name": "401457", "standard_charge_dollar": 14.54, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Ms State Emplo", "plan_name": "401457_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Basic Pl", "plan_name": "400100", "standard_charge_dollar": 14.54, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Basic Pl", "plan_name": "400100_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Federal", "plan_name": "400110", "standard_charge_dollar": 14.54, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Federal", "plan_name": "400110_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." } ] } ] }, { "description": "Hc glycosylated hemoglobin", "code_information": [ { "code": "83036", "type": "CPT" } ], "standard_charges": [ { "gross_charge": 110.00, "minimum": 88.00, "maximum": 93.50, "setting": "both", "payers_information": [ { "payer_name": "Aetna", "plan_name": "700700", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "modifiers": "QW", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna", "plan_name": "700700_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Miscellaneous", "plan_name": "700720", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Miscellaneous", "plan_name": "700720_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Ppo Hmo", "plan_name": "701720", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Ppo Hmo", "plan_name": "701720_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Ms State Emplo", "plan_name": "401457", "standard_charge_percentage": 0.80, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Ms State Emplo", "plan_name": "401457_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Basic Pl", "plan_name": "400100", "standard_charge_percentage": 0.85, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Basic Pl", "plan_name": "400100_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Federal", "plan_name": "400110", "standard_charge_percentage": 0.85, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Federal", "plan_name": "400110_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." } ] } ] }, { "description": "Blood methemoglobin assay", "code_information": [ { "code": "83050", "type": "CPT" } ], "standard_charges": [ { "gross_charge": 70.43, "minimum": 10.98, "maximum": 10.98, "setting": "both", "payers_information": [ { "payer_name": "Aetna", "plan_name": "700700", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna", "plan_name": "700700_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Miscellaneous", "plan_name": "700720", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Miscellaneous", "plan_name": "700720_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Ppo Hmo", "plan_name": "701720", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Ppo Hmo", "plan_name": "701720_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Ms State Emplo", "plan_name": "401457", "standard_charge_dollar": 10.98, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Ms State Emplo", "plan_name": "401457_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Basic Pl", "plan_name": "400100", "standard_charge_dollar": 10.98, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Basic Pl", "plan_name": "400100_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Federal", "plan_name": "400110", "standard_charge_dollar": 10.98, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Federal", "plan_name": "400110_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." } ] } ] }, { "description": "Hc methemoglobin quan", "code_information": [ { "code": "83050", "type": "CPT" } ], "standard_charges": [ { "gross_charge": 70.43, "minimum": 10.98, "maximum": 10.98, "setting": "both", "payers_information": [ { "payer_name": "Aetna", "plan_name": "700700", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna", "plan_name": "700700_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Miscellaneous", "plan_name": "700720", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Miscellaneous", "plan_name": "700720_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Ppo Hmo", "plan_name": "701720", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Ppo Hmo", "plan_name": "701720_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Ms State Emplo", "plan_name": "401457", "standard_charge_dollar": 10.98, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Ms State Emplo", "plan_name": "401457_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Basic Pl", "plan_name": "400100", "standard_charge_dollar": 10.98, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Basic Pl", "plan_name": "400100_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Federal", "plan_name": "400110", "standard_charge_dollar": 10.98, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Federal", "plan_name": "400110_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." } ] } ] }, { "description": "Blood sulfhemoglobin assay", "code_information": [ { "code": "83060", "type": "CPT" } ], "standard_charges": [ { "gross_charge": 75.57, "minimum": 4.35, "maximum": 4.35, "setting": "both", "payers_information": [ { "payer_name": "Aetna", "plan_name": "700700", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna", "plan_name": "700700_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Miscellaneous", "plan_name": "700720", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Miscellaneous", "plan_name": "700720_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Ppo Hmo", "plan_name": "701720", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Ppo Hmo", "plan_name": "701720_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Ms State Emplo", "plan_name": "401457", "standard_charge_dollar": 4.35, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Ms State Emplo", "plan_name": "401457_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Basic Pl", "plan_name": "400100", "standard_charge_dollar": 4.35, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Basic Pl", "plan_name": "400100_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Federal", "plan_name": "400110", "standard_charge_dollar": 4.35, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Federal", "plan_name": "400110_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." } ] } ] }, { "description": "Hc sulfhemoglobin bld", "code_information": [ { "code": "83060", "type": "CPT" } ], "standard_charges": [ { "gross_charge": 75.57, "minimum": 4.35, "maximum": 4.35, "setting": "both", "payers_information": [ { "payer_name": "Aetna", "plan_name": "700700", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna", "plan_name": "700700_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Miscellaneous", "plan_name": "700720", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Miscellaneous", "plan_name": "700720_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Ppo Hmo", "plan_name": "701720", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Ppo Hmo", "plan_name": "701720_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Ms State Emplo", "plan_name": "401457", "standard_charge_dollar": 4.35, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Ms State Emplo", "plan_name": "401457_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Basic Pl", "plan_name": "400100", "standard_charge_dollar": 4.35, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Basic Pl", "plan_name": "400100_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Federal", "plan_name": "400110", "standard_charge_dollar": 4.35, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Federal", "plan_name": "400110_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." } ] } ] }, { "description": "Assay of homocystine", "code_information": [ { "code": "83090", "type": "CPT" } ], "standard_charges": [ { "gross_charge": 61.20, "minimum": 25.28, "maximum": 25.28, "setting": "both", "payers_information": [ { "payer_name": "Aetna", "plan_name": "700700", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna", "plan_name": "700700_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Miscellaneous", "plan_name": "700720", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Miscellaneous", "plan_name": "700720_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Ppo Hmo", "plan_name": "701720", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Ppo Hmo", "plan_name": "701720_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Ms State Emplo", "plan_name": "401457", "standard_charge_dollar": 25.28, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Ms State Emplo", "plan_name": "401457_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Basic Pl", "plan_name": "400100", "standard_charge_dollar": 25.28, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Basic Pl", "plan_name": "400100_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Federal", "plan_name": "400110", "standard_charge_dollar": 25.28, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Federal", "plan_name": "400110_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." } ] } ] }, { "description": "Hc homocysteine", "code_information": [ { "code": "83090", "type": "CPT" } ], "standard_charges": [ { "gross_charge": 61.20, "minimum": 25.28, "maximum": 25.28, "setting": "both", "payers_information": [ { "payer_name": "Aetna", "plan_name": "700700", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna", "plan_name": "700700_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Miscellaneous", "plan_name": "700720", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Miscellaneous", "plan_name": "700720_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Ppo Hmo", "plan_name": "701720", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Ppo Hmo", "plan_name": "701720_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Ms State Emplo", "plan_name": "401457", "standard_charge_dollar": 25.28, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Ms State Emplo", "plan_name": "401457_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Basic Pl", "plan_name": "400100", "standard_charge_dollar": 25.28, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Basic Pl", "plan_name": "400100_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Federal", "plan_name": "400110", "standard_charge_dollar": 25.28, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Federal", "plan_name": "400110_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." } ] } ] }, { "description": "Assay of 5-hiaa", "code_information": [ { "code": "83497", "type": "CPT" } ], "standard_charges": [ { "gross_charge": 100.00, "minimum": 19.32, "maximum": 19.32, "setting": "both", "payers_information": [ { "payer_name": "Aetna", "plan_name": "700700", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna", "plan_name": "700700_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Miscellaneous", "plan_name": "700720", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Miscellaneous", "plan_name": "700720_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Ppo Hmo", "plan_name": "701720", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Ppo Hmo", "plan_name": "701720_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Ms State Emplo", "plan_name": "401457", "standard_charge_dollar": 19.32, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Ms State Emplo", "plan_name": "401457_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Basic Pl", "plan_name": "400100", "standard_charge_dollar": 19.32, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Basic Pl", "plan_name": "400100_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Federal", "plan_name": "400110", "standard_charge_dollar": 19.32, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Federal", "plan_name": "400110_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." } ] } ] }, { "description": "Hc 5-hydroxyindoleacetic acid u", "code_information": [ { "code": "83497", "type": "CPT" } ], "standard_charges": [ { "gross_charge": 100.00, "minimum": 19.32, "maximum": 19.32, "setting": "both", "payers_information": [ { "payer_name": "Aetna", "plan_name": "700700", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna", "plan_name": "700700_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Miscellaneous", "plan_name": "700720", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Miscellaneous", "plan_name": "700720_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Ppo Hmo", "plan_name": "701720", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Ppo Hmo", "plan_name": "701720_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Ms State Emplo", "plan_name": "401457", "standard_charge_dollar": 19.32, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Ms State Emplo", "plan_name": "401457_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Basic Pl", "plan_name": "400100", "standard_charge_dollar": 19.32, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Basic Pl", "plan_name": "400100_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Federal", "plan_name": "400110", "standard_charge_dollar": 19.32, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Federal", "plan_name": "400110_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." } ] } ] }, { "description": "Hc ma2 ab elisa (ma2es)", "code_information": [ { "code": "83516", "type": "CPT" } ], "standard_charges": [ { "gross_charge": 675.00, "minimum": 17.28, "maximum": 17.28, "setting": "both", "payers_information": [ { "payer_name": "Aetna", "plan_name": "700700", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna", "plan_name": "700700_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Miscellaneous", "plan_name": "700720", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Miscellaneous", "plan_name": "700720_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Ppo Hmo", "plan_name": "701720", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Ppo Hmo", "plan_name": "701720_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Ms State Emplo", "plan_name": "401457", "standard_charge_dollar": 17.28, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Ms State Emplo", "plan_name": "401457_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Basic Pl", "plan_name": "400100", "standard_charge_dollar": 17.28, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Basic Pl", "plan_name": "400100_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Federal", "plan_name": "400110", "standard_charge_dollar": 17.28, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Federal", "plan_name": "400110_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." } ] } ] }, { "description": "Immunoassay nonantibody", "code_information": [ { "code": "83516", "type": "CPT" } ], "standard_charges": [ { "gross_charge": 675.00, "minimum": 17.28, "maximum": 17.28, "setting": "both", "payers_information": [ { "payer_name": "Aetna", "plan_name": "700700", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna", "plan_name": "700700_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Miscellaneous", "plan_name": "700720", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Miscellaneous", "plan_name": "700720_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Ppo Hmo", "plan_name": "701720", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Ppo Hmo", "plan_name": "701720_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Ms State Emplo", "plan_name": "401457", "standard_charge_dollar": 17.28, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Ms State Emplo", "plan_name": "401457_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Basic Pl", "plan_name": "400100", "standard_charge_dollar": 17.28, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Basic Pl", "plan_name": "400100_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Federal", "plan_name": "400110", "standard_charge_dollar": 17.28, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Federal", "plan_name": "400110_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." } ] } ] }, { "description": "Hc immunoassay quant by ria for f5nul", "code_information": [ { "code": "83519", "type": "CPT" } ], "standard_charges": [ { "gross_charge": 155.00, "minimum": 20.24, "maximum": 20.24, "setting": "both", "payers_information": [ { "payer_name": "Aetna", "plan_name": "700700", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna", "plan_name": "700700_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Miscellaneous", "plan_name": "700720", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Miscellaneous", "plan_name": "700720_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Ppo Hmo", "plan_name": "701720", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Ppo Hmo", "plan_name": "701720_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Ms State Emplo", "plan_name": "401457", "standard_charge_dollar": 20.24, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Ms State Emplo", "plan_name": "401457_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Basic Pl", "plan_name": "400100", "standard_charge_dollar": 20.24, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Basic Pl", "plan_name": "400100_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Federal", "plan_name": "400110", "standard_charge_dollar": 20.24, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Federal", "plan_name": "400110_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." } ] } ] }, { "description": "Ria nonantibody", "code_information": [ { "code": "83519", "type": "CPT" } ], "standard_charges": [ { "gross_charge": 155.00, "minimum": 20.24, "maximum": 20.24, "setting": "both", "payers_information": [ { "payer_name": "Aetna", "plan_name": "700700", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna", "plan_name": "700700_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Miscellaneous", "plan_name": "700720", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Miscellaneous", "plan_name": "700720_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Ppo Hmo", "plan_name": "701720", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Ppo Hmo", "plan_name": "701720_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Ms State Emplo", "plan_name": "401457", "standard_charge_dollar": 20.24, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Ms State Emplo", "plan_name": "401457_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Basic Pl", "plan_name": "400100", "standard_charge_dollar": 20.24, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Basic Pl", "plan_name": "400100_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Federal", "plan_name": "400110", "standard_charge_dollar": 20.24, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Federal", "plan_name": "400110_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." } ] } ] }, { "description": "Hc ustekinumab ab (mayo)", "code_information": [ { "code": "83520", "type": "CPT" } ], "standard_charges": [ { "gross_charge": 324.44, "minimum": 19.39, "maximum": 19.39, "setting": "both", "payers_information": [ { "payer_name": "Aetna", "plan_name": "700700", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna", "plan_name": "700700_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Miscellaneous", "plan_name": "700720", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Miscellaneous", "plan_name": "700720_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Ppo Hmo", "plan_name": "701720", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Ppo Hmo", "plan_name": "701720_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Ms State Emplo", "plan_name": "401457", "standard_charge_dollar": 19.39, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Ms State Emplo", "plan_name": "401457_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Basic Pl", "plan_name": "400100", "standard_charge_dollar": 19.39, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Basic Pl", "plan_name": "400100_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Federal", "plan_name": "400110", "standard_charge_dollar": 19.39, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Federal", "plan_name": "400110_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." } ] } ] }, { "description": "Immunoassay quant nos nonab", "code_information": [ { "code": "83520", "type": "CPT" } ], "standard_charges": [ { "gross_charge": 324.44, "minimum": 19.39, "maximum": 19.39, "setting": "both", "payers_information": [ { "payer_name": "Aetna", "plan_name": "700700", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna", "plan_name": "700700_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Miscellaneous", "plan_name": "700720", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Miscellaneous", "plan_name": "700720_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Ppo Hmo", "plan_name": "701720", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Ppo Hmo", "plan_name": "701720_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Ms State Emplo", "plan_name": "401457", "standard_charge_dollar": 19.39, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Ms State Emplo", "plan_name": "401457_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Basic Pl", "plan_name": "400100", "standard_charge_dollar": 19.39, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Basic Pl", "plan_name": "400100_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Federal", "plan_name": "400110", "standard_charge_dollar": 19.39, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Federal", "plan_name": "400110_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." } ] } ] }, { "description": "Hc immunoglobulin free light chain (fiflc)", "code_information": [ { "code": "83521", "type": "CPT" } ], "standard_charges": [ { "gross_charge": 83.49, "minimum": 66.79, "maximum": 70.97, "setting": "both", "payers_information": [ { "payer_name": "Aetna", "plan_name": "700700", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna", "plan_name": "700700_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Miscellaneous", "plan_name": "700720", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Miscellaneous", "plan_name": "700720_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Ppo Hmo", "plan_name": "701720", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Ppo Hmo", "plan_name": "701720_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Ms State Emplo", "plan_name": "401457", "standard_charge_percentage": 0.80, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Ms State Emplo", "plan_name": "401457_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Basic Pl", "plan_name": "400100", "standard_charge_percentage": 0.85, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Basic Pl", "plan_name": "400100_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Federal", "plan_name": "400110", "standard_charge_percentage": 0.85, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Federal", "plan_name": "400110_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." } ] } ] }, { "description": "Ig light chains free each", "code_information": [ { "code": "83521", "type": "CPT" } ], "standard_charges": [ { "gross_charge": 83.49, "minimum": 66.79, "maximum": 70.97, "setting": "both", "payers_information": [ { "payer_name": "Aetna", "plan_name": "700700", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna", "plan_name": "700700_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Miscellaneous", "plan_name": "700720", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Miscellaneous", "plan_name": "700720_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Ppo Hmo", "plan_name": "701720", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Ppo Hmo", "plan_name": "701720_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Ms State Emplo", "plan_name": "401457", "standard_charge_percentage": 0.80, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Ms State Emplo", "plan_name": "401457_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Basic Pl", "plan_name": "400100", "standard_charge_percentage": 0.85, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Basic Pl", "plan_name": "400100_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Federal", "plan_name": "400110", "standard_charge_percentage": 0.85, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Federal", "plan_name": "400110_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." } ] } ] }, { "description": "Assay of insulin", "code_information": [ { "code": "83525", "type": "CPT" } ], "standard_charges": [ { "gross_charge": 71.00, "minimum": 17.13, "maximum": 17.13, "setting": "both", "payers_information": [ { "payer_name": "Aetna", "plan_name": "700700", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna", "plan_name": "700700_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Miscellaneous", "plan_name": "700720", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Miscellaneous", "plan_name": "700720_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Ppo Hmo", "plan_name": "701720", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Ppo Hmo", "plan_name": "701720_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Ms State Emplo", "plan_name": "401457", "standard_charge_dollar": 17.13, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Ms State Emplo", "plan_name": "401457_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Basic Pl", "plan_name": "400100", "standard_charge_dollar": 17.13, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Basic Pl", "plan_name": "400100_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Federal", "plan_name": "400110", "standard_charge_dollar": 17.13, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Federal", "plan_name": "400110_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." } ] } ] }, { "description": "Hc insulin level", "code_information": [ { "code": "83525", "type": "CPT" } ], "standard_charges": [ { "gross_charge": 71.00, "minimum": 17.13, "maximum": 17.13, "setting": "both", "payers_information": [ { "payer_name": "Aetna", "plan_name": "700700", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna", "plan_name": "700700_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Miscellaneous", "plan_name": "700720", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Miscellaneous", "plan_name": "700720_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Ppo Hmo", "plan_name": "701720", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Ppo Hmo", "plan_name": "701720_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Ms State Emplo", "plan_name": "401457", "standard_charge_dollar": 17.13, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Ms State Emplo", "plan_name": "401457_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Basic Pl", "plan_name": "400100", "standard_charge_dollar": 17.13, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Basic Pl", "plan_name": "400100_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Federal", "plan_name": "400110", "standard_charge_dollar": 17.13, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Federal", "plan_name": "400110_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." } ] } ] }, { "description": "Assay of iron", "code_information": [ { "code": "83540", "type": "CPT" } ], "standard_charges": [ { "gross_charge": 100.00, "minimum": 9.70, "maximum": 9.70, "setting": "both", "payers_information": [ { "payer_name": "Aetna", "plan_name": "700700", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna", "plan_name": "700700_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Miscellaneous", "plan_name": "700720", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Miscellaneous", "plan_name": "700720_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Ppo Hmo", "plan_name": "701720", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Ppo Hmo", "plan_name": "701720_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Ms State Emplo", "plan_name": "401457", "standard_charge_dollar": 9.70, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Ms State Emplo", "plan_name": "401457_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Basic Pl", "plan_name": "400100", "standard_charge_dollar": 9.70, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Basic Pl", "plan_name": "400100_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Federal", "plan_name": "400110", "standard_charge_dollar": 9.70, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Federal", "plan_name": "400110_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." } ] } ] }, { "description": "Hc iron", "code_information": [ { "code": "83540", "type": "CPT" } ], "standard_charges": [ { "gross_charge": 100.00, "minimum": 9.70, "maximum": 9.70, "setting": "both", "payers_information": [ { "payer_name": "Aetna", "plan_name": "700700", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna", "plan_name": "700700_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Miscellaneous", "plan_name": "700720", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Miscellaneous", "plan_name": "700720_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Ppo Hmo", "plan_name": "701720", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Ppo Hmo", "plan_name": "701720_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Ms State Emplo", "plan_name": "401457", "standard_charge_dollar": 9.70, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Ms State Emplo", "plan_name": "401457_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Basic Pl", "plan_name": "400100", "standard_charge_dollar": 9.70, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Basic Pl", "plan_name": "400100_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Federal", "plan_name": "400110", "standard_charge_dollar": 9.70, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Federal", "plan_name": "400110_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." } ] } ] }, { "description": "Hc iron binding capacity", "code_information": [ { "code": "83550", "type": "CPT" } ], "standard_charges": [ { "gross_charge": 90.00, "minimum": 13.10, "maximum": 13.10, "setting": "both", "payers_information": [ { "payer_name": "Aetna", "plan_name": "700700", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna", "plan_name": "700700_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Miscellaneous", "plan_name": "700720", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Miscellaneous", "plan_name": "700720_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Ppo Hmo", "plan_name": "701720", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Ppo Hmo", "plan_name": "701720_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Ms State Emplo", "plan_name": "401457", "standard_charge_dollar": 13.10, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Ms State Emplo", "plan_name": "401457_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Basic Pl", "plan_name": "400100", "standard_charge_dollar": 13.10, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Basic Pl", "plan_name": "400100_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Federal", "plan_name": "400110", "standard_charge_dollar": 13.10, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Federal", "plan_name": "400110_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." } ] } ] }, { "description": "Iron binding test", "code_information": [ { "code": "83550", "type": "CPT" } ], "standard_charges": [ { "gross_charge": 90.00, "minimum": 13.10, "maximum": 13.10, "setting": "both", "payers_information": [ { "payer_name": "Aetna", "plan_name": "700700", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna", "plan_name": "700700_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Miscellaneous", "plan_name": "700720", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Miscellaneous", "plan_name": "700720_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Ppo Hmo", "plan_name": "701720", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Ppo Hmo", "plan_name": "701720_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Ms State Emplo", "plan_name": "401457", "standard_charge_dollar": 13.10, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Ms State Emplo", "plan_name": "401457_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Basic Pl", "plan_name": "400100", "standard_charge_dollar": 13.10, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Basic Pl", "plan_name": "400100_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Federal", "plan_name": "400110", "standard_charge_dollar": 13.10, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Federal", "plan_name": "400110_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." } ] } ] }, { "description": "Assay of lactic acid", "code_information": [ { "code": "83605", "type": "CPT" } ], "standard_charges": [ { "gross_charge": 78.75, "minimum": 8.71, "maximum": 8.71, "setting": "both", "payers_information": [ { "payer_name": "Aetna", "plan_name": "700700", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna", "plan_name": "700700_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Miscellaneous", "plan_name": "700720", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Miscellaneous", "plan_name": "700720_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Ppo Hmo", "plan_name": "701720", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Ppo Hmo", "plan_name": "701720_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Ms State Emplo", "plan_name": "401457", "standard_charge_dollar": 8.71, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Ms State Emplo", "plan_name": "401457_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Basic Pl", "plan_name": "400100", "standard_charge_dollar": 8.71, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Basic Pl", "plan_name": "400100_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Federal", "plan_name": "400110", "standard_charge_dollar": 8.71, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Federal", "plan_name": "400110_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." } ] } ] }, { "description": "Hc lactic acid", "code_information": [ { "code": "83605", "type": "CPT" } ], "standard_charges": [ { "gross_charge": 78.75, "minimum": 8.71, "maximum": 8.71, "setting": "both", "payers_information": [ { "payer_name": "Aetna", "plan_name": "700700", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna", "plan_name": "700700_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Miscellaneous", "plan_name": "700720", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Miscellaneous", "plan_name": "700720_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Ppo Hmo", "plan_name": "701720", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Ppo Hmo", "plan_name": "701720_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Ms State Emplo", "plan_name": "401457", "standard_charge_dollar": 8.71, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Ms State Emplo", "plan_name": "401457_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Basic Pl", "plan_name": "400100", "standard_charge_dollar": 8.71, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Basic Pl", "plan_name": "400100_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Federal", "plan_name": "400110", "standard_charge_dollar": 8.71, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Federal", "plan_name": "400110_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." } ] } ] }, { "description": "Hc ldh serum", "code_information": [ { "code": "83615", "type": "CPT" } ], "standard_charges": [ { "gross_charge": 120.00, "minimum": 9.04, "maximum": 9.04, "setting": "both", "payers_information": [ { "payer_name": "Aetna", "plan_name": "700700", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna", "plan_name": "700700_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Miscellaneous", "plan_name": "700720", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Miscellaneous", "plan_name": "700720_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Ppo Hmo", "plan_name": "701720", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Ppo Hmo", "plan_name": "701720_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Ms State Emplo", "plan_name": "401457", "standard_charge_dollar": 9.04, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Ms State Emplo", "plan_name": "401457_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Basic Pl", "plan_name": "400100", "standard_charge_dollar": 9.04, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Basic Pl", "plan_name": "400100_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Federal", "plan_name": "400110", "standard_charge_dollar": 9.04, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Federal", "plan_name": "400110_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." } ] } ] }, { "description": "Lactate (ld) (ldh) enzyme", "code_information": [ { "code": "83615", "type": "CPT" } ], "standard_charges": [ { "gross_charge": 120.00, "minimum": 9.04, "maximum": 9.04, "setting": "both", "payers_information": [ { "payer_name": "Aetna", "plan_name": "700700", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna", "plan_name": "700700_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Miscellaneous", "plan_name": "700720", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Miscellaneous", "plan_name": "700720_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Ppo Hmo", "plan_name": "701720", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Ppo Hmo", "plan_name": "701720_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Ms State Emplo", "plan_name": "401457", "standard_charge_dollar": 9.04, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Ms State Emplo", "plan_name": "401457_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Basic Pl", "plan_name": "400100", "standard_charge_dollar": 9.04, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Basic Pl", "plan_name": "400100_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Federal", "plan_name": "400110", "standard_charge_dollar": 9.04, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Federal", "plan_name": "400110_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." } ] } ] }, { "description": "Hc lactoferrin fecal qual", "code_information": [ { "code": "83630", "type": "CPT" } ], "standard_charges": [ { "gross_charge": 300.00, "minimum": 29.41, "maximum": 29.41, "setting": "both", "payers_information": [ { "payer_name": "Aetna", "plan_name": "700700", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna", "plan_name": "700700_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Miscellaneous", "plan_name": "700720", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Miscellaneous", "plan_name": "700720_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Ppo Hmo", "plan_name": "701720", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Ppo Hmo", "plan_name": "701720_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Ms State Emplo", "plan_name": "401457", "standard_charge_dollar": 29.41, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Ms State Emplo", "plan_name": "401457_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Basic Pl", "plan_name": "400100", "standard_charge_dollar": 29.41, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Basic Pl", "plan_name": "400100_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Federal", "plan_name": "400110", "standard_charge_dollar": 29.41, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Federal", "plan_name": "400110_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." } ] } ] }, { "description": "Lactoferrin fecal (qual)", "code_information": [ { "code": "83630", "type": "CPT" } ], "standard_charges": [ { "gross_charge": 300.00, "minimum": 29.41, "maximum": 29.41, "setting": "both", "payers_information": [ { "payer_name": "Aetna", "plan_name": "700700", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna", "plan_name": "700700_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Miscellaneous", "plan_name": "700720", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Miscellaneous", "plan_name": "700720_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Ppo Hmo", "plan_name": "701720", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Ppo Hmo", "plan_name": "701720_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Ms State Emplo", "plan_name": "401457", "standard_charge_dollar": 29.41, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Ms State Emplo", "plan_name": "401457_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Basic Pl", "plan_name": "400100", "standard_charge_dollar": 29.41, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Basic Pl", "plan_name": "400100_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Federal", "plan_name": "400110", "standard_charge_dollar": 29.41, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Federal", "plan_name": "400110_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." } ] } ] }, { "description": "Assay of lead", "code_information": [ { "code": "83655", "type": "CPT" } ], "standard_charges": [ { "gross_charge": 61.50, "minimum": 18.14, "maximum": 18.14, "setting": "both", "payers_information": [ { "payer_name": "Aetna", "plan_name": "700700", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna", "plan_name": "700700_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Miscellaneous", "plan_name": "700720", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Miscellaneous", "plan_name": "700720_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Ppo Hmo", "plan_name": "701720", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Ppo Hmo", "plan_name": "701720_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Ms State Emplo", "plan_name": "401457", "standard_charge_dollar": 18.14, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Ms State Emplo", "plan_name": "401457_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Basic Pl", "plan_name": "400100", "standard_charge_dollar": 18.14, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Basic Pl", "plan_name": "400100_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Federal", "plan_name": "400110", "standard_charge_dollar": 18.14, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Federal", "plan_name": "400110_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." } ] } ] }, { "description": "Hc lead", "code_information": [ { "code": "83655", "type": "CPT" } ], "standard_charges": [ { "gross_charge": 61.50, "minimum": 18.14, "maximum": 18.14, "setting": "both", "payers_information": [ { "payer_name": "Aetna", "plan_name": "700700", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna", "plan_name": "700700_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Miscellaneous", "plan_name": "700720", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Miscellaneous", "plan_name": "700720_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Ppo Hmo", "plan_name": "701720", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Ppo Hmo", "plan_name": "701720_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Ms State Emplo", "plan_name": "401457", "standard_charge_dollar": 18.14, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Ms State Emplo", "plan_name": "401457_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Basic Pl", "plan_name": "400100", "standard_charge_dollar": 18.14, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Basic Pl", "plan_name": "400100_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Federal", "plan_name": "400110", "standard_charge_dollar": 18.14, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Federal", "plan_name": "400110_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." } ] } ] }, { "description": "Assay of lipase", "code_information": [ { "code": "83690", "type": "CPT" } ], "standard_charges": [ { "gross_charge": 100.00, "minimum": 10.32, "maximum": 10.32, "setting": "both", "payers_information": [ { "payer_name": "Aetna", "plan_name": "700700", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna", "plan_name": "700700_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Miscellaneous", "plan_name": "700720", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Miscellaneous", "plan_name": "700720_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Ppo Hmo", "plan_name": "701720", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Ppo Hmo", "plan_name": "701720_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Ms State Emplo", "plan_name": "401457", "standard_charge_dollar": 10.32, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Ms State Emplo", "plan_name": "401457_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Basic Pl", "plan_name": "400100", "standard_charge_dollar": 10.32, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Basic Pl", "plan_name": "400100_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Federal", "plan_name": "400110", "standard_charge_dollar": 10.32, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Federal", "plan_name": "400110_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." } ] } ] }, { "description": "Hc lipase", "code_information": [ { "code": "83690", "type": "CPT" } ], "standard_charges": [ { "gross_charge": 100.00, "minimum": 10.32, "maximum": 10.32, "setting": "both", "payers_information": [ { "payer_name": "Aetna", "plan_name": "700700", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna", "plan_name": "700700_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Miscellaneous", "plan_name": "700720", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Miscellaneous", "plan_name": "700720_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Ppo Hmo", "plan_name": "701720", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Ppo Hmo", "plan_name": "701720_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Ms State Emplo", "plan_name": "401457", "standard_charge_dollar": 10.32, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Ms State Emplo", "plan_name": "401457_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Basic Pl", "plan_name": "400100", "standard_charge_dollar": 10.32, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Basic Pl", "plan_name": "400100_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Federal", "plan_name": "400110", "standard_charge_dollar": 10.32, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Federal", "plan_name": "400110_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." } ] } ] }, { "description": "Hc high resoltn fractionatn quan", "code_information": [ { "code": "83701", "type": "CPT" } ], "standard_charges": [ { "gross_charge": 100.00, "minimum": 24.38, "maximum": 24.38, "setting": "both", "payers_information": [ { "payer_name": "Aetna", "plan_name": "700700", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna", "plan_name": "700700_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Miscellaneous", "plan_name": "700720", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Miscellaneous", "plan_name": "700720_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Ppo Hmo", "plan_name": "701720", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Ppo Hmo", "plan_name": "701720_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Ms State Emplo", "plan_name": "401457", "standard_charge_dollar": 24.38, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Ms State Emplo", "plan_name": "401457_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Basic Pl", "plan_name": "400100", "standard_charge_dollar": 24.38, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Basic Pl", "plan_name": "400100_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Federal", "plan_name": "400110", "standard_charge_dollar": 24.38, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Federal", "plan_name": "400110_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." } ] } ] }, { "description": "Lipoprotein bld hr fraction", "code_information": [ { "code": "83701", "type": "CPT" } ], "standard_charges": [ { "gross_charge": 100.00, "minimum": 24.38, "maximum": 24.38, "setting": "both", "payers_information": [ { "payer_name": "Aetna", "plan_name": "700700", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna", "plan_name": "700700_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Miscellaneous", "plan_name": "700720", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Miscellaneous", "plan_name": "700720_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Ppo Hmo", "plan_name": "701720", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Ppo Hmo", "plan_name": "701720_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Ms State Emplo", "plan_name": "401457", "standard_charge_dollar": 24.38, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Ms State Emplo", "plan_name": "401457_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Basic Pl", "plan_name": "400100", "standard_charge_dollar": 24.38, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Basic Pl", "plan_name": "400100_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Federal", "plan_name": "400110", "standard_charge_dollar": 24.38, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Federal", "plan_name": "400110_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." } ] } ] }, { "description": "Hc lipoprotein bld by number", "code_information": [ { "code": "83704", "type": "CPT" } ], "standard_charges": [ { "gross_charge": 118.20, "minimum": 46.15, "maximum": 46.15, "setting": "both", "payers_information": [ { "payer_name": "Aetna", "plan_name": "700700", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna", "plan_name": "700700_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Miscellaneous", "plan_name": "700720", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Miscellaneous", "plan_name": "700720_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Ppo Hmo", "plan_name": "701720", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Ppo Hmo", "plan_name": "701720_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Ms State Emplo", "plan_name": "401457", "standard_charge_dollar": 46.15, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Ms State Emplo", "plan_name": "401457_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Basic Pl", "plan_name": "400100", "standard_charge_dollar": 46.15, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Basic Pl", "plan_name": "400100_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Federal", "plan_name": "400110", "standard_charge_dollar": 46.15, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Federal", "plan_name": "400110_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." } ] } ] }, { "description": "Lipoprotein bld quan part", "code_information": [ { "code": "83704", "type": "CPT" } ], "standard_charges": [ { "gross_charge": 118.20, "minimum": 46.15, "maximum": 46.15, "setting": "both", "payers_information": [ { "payer_name": "Aetna", "plan_name": "700700", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna", "plan_name": "700700_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Miscellaneous", "plan_name": "700720", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Miscellaneous", "plan_name": "700720_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Ppo Hmo", "plan_name": "701720", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Ppo Hmo", "plan_name": "701720_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Ms State Emplo", "plan_name": "401457", "standard_charge_dollar": 46.15, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Ms State Emplo", "plan_name": "401457_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Basic Pl", "plan_name": "400100", "standard_charge_dollar": 46.15, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Basic Pl", "plan_name": "400100_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Federal", "plan_name": "400110", "standard_charge_dollar": 46.15, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Federal", "plan_name": "400110_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." } ] } ] }, { "description": "Assay of lipoprotein", "code_information": [ { "code": "83718", "type": "CPT" } ], "standard_charges": [ { "gross_charge": 54.40, "minimum": 8.19, "maximum": 12.28, "setting": "both", "payers_information": [ { "payer_name": "Aarp", "plan_name": "500102", "standard_charge_dollar": 8.19, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna", "plan_name": "700700", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna", "plan_name": "700700_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Mcare Ffs 6005", "plan_name": "700703", "standard_charge_dollar": 8.19, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Miscellaneous", "plan_name": "700720", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Miscellaneous", "plan_name": "700720_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Ppo Hmo", "plan_name": "701720", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Ppo Hmo", "plan_name": "701720_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Ambetter 68069", "plan_name": "500516", "standard_charge_dollar": 8.19, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Ms State Emplo", "plan_name": "401457", "standard_charge_dollar": 12.28, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Ms State Emplo", "plan_name": "401457_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Basic Pl", "plan_name": "400100", "standard_charge_dollar": 12.28, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Basic Pl", "plan_name": "400100_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Federal", "plan_name": "400110", "standard_charge_dollar": 12.28, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Federal", "plan_name": "400110_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Cigna Healthsprings Ffs", "plan_name": "500064", "standard_charge_dollar": 8.19, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Conseco", "plan_name": "500302", "standard_charge_dollar": 8.19, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Humana Ffs 61101", "plan_name": "500006", "standard_charge_dollar": 8.19, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Medicare A", "plan_name": "100100", "standard_charge_dollar": 8.19, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Medicare A", "plan_name": "100500", "standard_charge_dollar": 8.19, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Medicare Part B Only", "plan_name": "100300", "standard_charge_dollar": 8.19, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Medicare Railroad", "plan_name": "100103", "standard_charge_dollar": 8.19, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Ms Physicians Care N", "plan_name": "714210", "standard_charge_dollar": 10.24, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Peoples Hlth Ffs 72126", "plan_name": "500019", "standard_charge_dollar": 8.19, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Uhc/Secure Horizons", "plan_name": "500449", "standard_charge_dollar": 8.19, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "United Health Care/", "plan_name": "500292", "standard_charge_dollar": 9.25, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "United Healthcare", "plan_name": "750104", "standard_charge_dollar": 9.25, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "United Healthcare Ba", "plan_name": "750090", "standard_charge_dollar": 9.25, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "United Healthcare Me", "plan_name": "501310", "standard_charge_dollar": 8.19, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Windsor Mcare Extra", "plan_name": "500778", "standard_charge_dollar": 8.19, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." } ] } ] }, { "description": "Hc lipoprotein hdl cholesterol", "code_information": [ { "code": "83718", "type": "CPT" } ], "standard_charges": [ { "gross_charge": 54.40, "minimum": 8.19, "maximum": 12.28, "setting": "both", "payers_information": [ { "payer_name": "Aarp", "plan_name": "500102", "standard_charge_dollar": 8.19, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna", "plan_name": "700700", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna", "plan_name": "700700_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Mcare Ffs 6005", "plan_name": "700703", "standard_charge_dollar": 8.19, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Miscellaneous", "plan_name": "700720", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Miscellaneous", "plan_name": "700720_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Ppo Hmo", "plan_name": "701720", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Ppo Hmo", "plan_name": "701720_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Ambetter 68069", "plan_name": "500516", "standard_charge_dollar": 8.19, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Ms State Emplo", "plan_name": "401457", "standard_charge_dollar": 12.28, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Ms State Emplo", "plan_name": "401457_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Basic Pl", "plan_name": "400100", "standard_charge_dollar": 12.28, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Basic Pl", "plan_name": "400100_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Federal", "plan_name": "400110", "standard_charge_dollar": 12.28, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Federal", "plan_name": "400110_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Cigna Healthsprings Ffs", "plan_name": "500064", "standard_charge_dollar": 8.19, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Conseco", "plan_name": "500302", "standard_charge_dollar": 8.19, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Humana Ffs 61101", "plan_name": "500006", "standard_charge_dollar": 8.19, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Medicare A", "plan_name": "100100", "standard_charge_dollar": 8.19, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Medicare A", "plan_name": "100500", "standard_charge_dollar": 8.19, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Medicare Part B Only", "plan_name": "100300", "standard_charge_dollar": 8.19, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Medicare Railroad", "plan_name": "100103", "standard_charge_dollar": 8.19, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Ms Physicians Care N", "plan_name": "714210", "standard_charge_dollar": 10.24, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Peoples Hlth Ffs 72126", "plan_name": "500019", "standard_charge_dollar": 8.19, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Uhc/Secure Horizons", "plan_name": "500449", "standard_charge_dollar": 8.19, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "United Health Care/", "plan_name": "500292", "standard_charge_dollar": 9.25, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "United Healthcare", "plan_name": "750104", "standard_charge_dollar": 9.25, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "United Healthcare Ba", "plan_name": "750090", "standard_charge_dollar": 9.25, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "United Healthcare Me", "plan_name": "501310", "standard_charge_dollar": 8.19, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Windsor Mcare Extra", "plan_name": "500778", "standard_charge_dollar": 8.19, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." } ] } ] }, { "description": "Assay of blood lipoprotein", "code_information": [ { "code": "83721", "type": "CPT" } ], "standard_charges": [ { "gross_charge": 102.00, "minimum": 14.30, "maximum": 14.30, "setting": "both", "payers_information": [ { "payer_name": "Aetna", "plan_name": "700700", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna", "plan_name": "700700_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Miscellaneous", "plan_name": "700720", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Miscellaneous", "plan_name": "700720_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Ppo Hmo", "plan_name": "701720", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Ppo Hmo", "plan_name": "701720_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Ms State Emplo", "plan_name": "401457", "standard_charge_dollar": 14.30, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Ms State Emplo", "plan_name": "401457_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Basic Pl", "plan_name": "400100", "standard_charge_dollar": 14.30, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Basic Pl", "plan_name": "400100_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Federal", "plan_name": "400110", "standard_charge_dollar": 14.30, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Federal", "plan_name": "400110_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." } ] } ] }, { "description": "Hc lipoprotein ldl cholesterol", "code_information": [ { "code": "83721", "type": "CPT" } ], "standard_charges": [ { "gross_charge": 102.00, "minimum": 14.30, "maximum": 14.30, "setting": "both", "payers_information": [ { "payer_name": "Aetna", "plan_name": "700700", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna", "plan_name": "700700_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Miscellaneous", "plan_name": "700720", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Miscellaneous", "plan_name": "700720_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Ppo Hmo", "plan_name": "701720", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Ppo Hmo", "plan_name": "701720_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Ms State Emplo", "plan_name": "401457", "standard_charge_dollar": 14.30, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Ms State Emplo", "plan_name": "401457_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Basic Pl", "plan_name": "400100", "standard_charge_dollar": 14.30, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Basic Pl", "plan_name": "400100_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Federal", "plan_name": "400110", "standard_charge_dollar": 14.30, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Federal", "plan_name": "400110_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." } ] } ] }, { "description": "Assay of magnesium", "code_information": [ { "code": "83735", "type": "CPT" } ], "standard_charges": [ { "gross_charge": 77.14, "minimum": 10.03, "maximum": 10.03, "setting": "both", "payers_information": [ { "payer_name": "Aetna", "plan_name": "700700", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna", "plan_name": "700700_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Miscellaneous", "plan_name": "700720", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Miscellaneous", "plan_name": "700720_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Ppo Hmo", "plan_name": "701720", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Ppo Hmo", "plan_name": "701720_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Ms State Emplo", "plan_name": "401457", "standard_charge_dollar": 10.03, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Ms State Emplo", "plan_name": "401457_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Basic Pl", "plan_name": "400100", "standard_charge_dollar": 10.03, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Basic Pl", "plan_name": "400100_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Federal", "plan_name": "400110", "standard_charge_dollar": 10.03, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Federal", "plan_name": "400110_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." } ] } ] }, { "description": "Hc magnesium stool electrolyte & osmo panel", "code_information": [ { "code": "83735", "type": "CPT" } ], "standard_charges": [ { "gross_charge": 77.14, "minimum": 10.03, "maximum": 10.03, "setting": "both", "payers_information": [ { "payer_name": "Aetna", "plan_name": "700700", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna", "plan_name": "700700_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Miscellaneous", "plan_name": "700720", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Miscellaneous", "plan_name": "700720_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Ppo Hmo", "plan_name": "701720", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Ppo Hmo", "plan_name": "701720_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Ms State Emplo", "plan_name": "401457", "standard_charge_dollar": 10.03, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Ms State Emplo", "plan_name": "401457_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Basic Pl", "plan_name": "400100", "standard_charge_dollar": 10.03, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Basic Pl", "plan_name": "400100_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Federal", "plan_name": "400110", "standard_charge_dollar": 10.03, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Federal", "plan_name": "400110_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." } ] } ] }, { "description": "Hc magnesium stool electrolyte & osmo panel", "code_information": [ { "code": "83735", "type": "CPT" } ], "standard_charges": [ { "gross_charge": 77.14, "minimum": 61.71, "maximum": 65.57, "setting": "both", "payers_information": [ { "payer_name": "Aetna", "plan_name": "700700", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "modifiers": "QW", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna", "plan_name": "700700_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Miscellaneous", "plan_name": "700720", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Miscellaneous", "plan_name": "700720_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Ppo Hmo", "plan_name": "701720", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Ppo Hmo", "plan_name": "701720_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Ms State Emplo", "plan_name": "401457", "standard_charge_percentage": 0.80, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Ms State Emplo", "plan_name": "401457_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Basic Pl", "plan_name": "400100", "standard_charge_percentage": 0.85, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Basic Pl", "plan_name": "400100_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Federal", "plan_name": "400110", "standard_charge_percentage": 0.85, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Federal", "plan_name": "400110_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." } ] } ] }, { "description": "Assay of manganese", "code_information": [ { "code": "83785", "type": "CPT" } ], "standard_charges": [ { "gross_charge": 71.08, "minimum": 26.97, "maximum": 26.97, "setting": "both", "payers_information": [ { "payer_name": "Aetna", "plan_name": "700700", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna", "plan_name": "700700_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Miscellaneous", "plan_name": "700720", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Miscellaneous", "plan_name": "700720_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Ppo Hmo", "plan_name": "701720", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Ppo Hmo", "plan_name": "701720_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Ms State Emplo", "plan_name": "401457", "standard_charge_dollar": 26.97, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Ms State Emplo", "plan_name": "401457_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Basic Pl", "plan_name": "400100", "standard_charge_dollar": 26.97, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Basic Pl", "plan_name": "400100_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Federal", "plan_name": "400110", "standard_charge_dollar": 26.97, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Federal", "plan_name": "400110_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." } ] } ] }, { "description": "Hc manganese", "code_information": [ { "code": "83785", "type": "CPT" } ], "standard_charges": [ { "gross_charge": 71.08, "minimum": 26.97, "maximum": 26.97, "setting": "both", "payers_information": [ { "payer_name": "Aetna", "plan_name": "700700", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna", "plan_name": "700700_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Miscellaneous", "plan_name": "700720", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Miscellaneous", "plan_name": "700720_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Ppo Hmo", "plan_name": "701720", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Ppo Hmo", "plan_name": "701720_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Ms State Emplo", "plan_name": "401457", "standard_charge_dollar": 26.97, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Ms State Emplo", "plan_name": "401457_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Basic Pl", "plan_name": "400100", "standard_charge_dollar": 26.97, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Basic Pl", "plan_name": "400100_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Federal", "plan_name": "400110", "standard_charge_dollar": 26.97, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Federal", "plan_name": "400110_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." } ] } ] }, { "description": "Hc hb variant by mass spec (mass)", "code_information": [ { "code": "83789", "type": "CPT" } ], "standard_charges": [ { "gross_charge": 270.00, "minimum": 27.06, "maximum": 27.06, "setting": "both", "payers_information": [ { "payer_name": "Aetna", "plan_name": "700700", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna", "plan_name": "700700_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Miscellaneous", "plan_name": "700720", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Miscellaneous", "plan_name": "700720_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Ppo Hmo", "plan_name": "701720", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Ppo Hmo", "plan_name": "701720_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Ms State Emplo", "plan_name": "401457", "standard_charge_dollar": 27.06, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Ms State Emplo", "plan_name": "401457_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Basic Pl", "plan_name": "400100", "standard_charge_dollar": 27.06, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Basic Pl", "plan_name": "400100_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Federal", "plan_name": "400110", "standard_charge_dollar": 27.06, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Federal", "plan_name": "400110_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." } ] } ] }, { "description": "Mass spectrometry qual/quan", "code_information": [ { "code": "83789", "type": "CPT" } ], "standard_charges": [ { "gross_charge": 270.00, "minimum": 27.06, "maximum": 27.06, "setting": "both", "payers_information": [ { "payer_name": "Aetna", "plan_name": "700700", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna", "plan_name": "700700_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Miscellaneous", "plan_name": "700720", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Miscellaneous", "plan_name": "700720_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Ppo Hmo", "plan_name": "701720", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Ppo Hmo", "plan_name": "701720_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Ms State Emplo", "plan_name": "401457", "standard_charge_dollar": 27.06, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Ms State Emplo", "plan_name": "401457_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Basic Pl", "plan_name": "400100", "standard_charge_dollar": 27.06, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Basic Pl", "plan_name": "400100_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Federal", "plan_name": "400110", "standard_charge_dollar": 27.06, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Federal", "plan_name": "400110_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." } ] } ] }, { "description": "Assay of mercury", "code_information": [ { "code": "83825", "type": "CPT" } ], "standard_charges": [ { "gross_charge": 85.00, "minimum": 24.35, "maximum": 24.35, "setting": "both", "payers_information": [ { "payer_name": "Aetna", "plan_name": "700700", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna", "plan_name": "700700_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Miscellaneous", "plan_name": "700720", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Miscellaneous", "plan_name": "700720_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Ppo Hmo", "plan_name": "701720", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Ppo Hmo", "plan_name": "701720_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Ms State Emplo", "plan_name": "401457", "standard_charge_dollar": 24.35, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Ms State Emplo", "plan_name": "401457_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Basic Pl", "plan_name": "400100", "standard_charge_dollar": 24.35, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Basic Pl", "plan_name": "400100_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Federal", "plan_name": "400110", "standard_charge_dollar": 24.35, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Federal", "plan_name": "400110_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." } ] } ] }, { "description": "Hc heavy metal mercury urine", "code_information": [ { "code": "83825", "type": "CPT" } ], "standard_charges": [ { "gross_charge": 85.00, "minimum": 24.35, "maximum": 24.35, "setting": "both", "payers_information": [ { "payer_name": "Aetna", "plan_name": "700700", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna", "plan_name": "700700_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Miscellaneous", "plan_name": "700720", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Miscellaneous", "plan_name": "700720_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Ppo Hmo", "plan_name": "701720", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Ppo Hmo", "plan_name": "701720_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Ms State Emplo", "plan_name": "401457", "standard_charge_dollar": 24.35, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Ms State Emplo", "plan_name": "401457_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Basic Pl", "plan_name": "400100", "standard_charge_dollar": 24.35, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Basic Pl", "plan_name": "400100_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Federal", "plan_name": "400110", "standard_charge_dollar": 24.35, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Federal", "plan_name": "400110_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." } ] } ] }, { "description": "Assay of metanephrines", "code_information": [ { "code": "83835", "type": "CPT" } ], "standard_charges": [ { "gross_charge": 265.02, "minimum": 21.76, "maximum": 21.76, "setting": "both", "payers_information": [ { "payer_name": "Aetna", "plan_name": "700700", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna", "plan_name": "700700_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Miscellaneous", "plan_name": "700720", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Miscellaneous", "plan_name": "700720_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Ppo Hmo", "plan_name": "701720", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Ppo Hmo", "plan_name": "701720_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Ms State Emplo", "plan_name": "401457", "standard_charge_dollar": 21.76, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Ms State Emplo", "plan_name": "401457_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Basic Pl", "plan_name": "400100", "standard_charge_dollar": 21.76, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Basic Pl", "plan_name": "400100_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Federal", "plan_name": "400110", "standard_charge_dollar": 21.76, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Federal", "plan_name": "400110_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." } ] } ] }, { "description": "Hc methanephrines 24 hr urine", "code_information": [ { "code": "83835", "type": "CPT" } ], "standard_charges": [ { "gross_charge": 265.02, "minimum": 21.76, "maximum": 21.76, "setting": "both", "payers_information": [ { "payer_name": "Aetna", "plan_name": "700700", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna", "plan_name": "700700_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Miscellaneous", "plan_name": "700720", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Miscellaneous", "plan_name": "700720_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Ppo Hmo", "plan_name": "701720", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Ppo Hmo", "plan_name": "701720_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Ms State Emplo", "plan_name": "401457", "standard_charge_dollar": 21.76, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Ms State Emplo", "plan_name": "401457_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Basic Pl", "plan_name": "400100", "standard_charge_dollar": 21.76, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Basic Pl", "plan_name": "400100_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Federal", "plan_name": "400110", "standard_charge_dollar": 21.76, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Federal", "plan_name": "400110_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." } ] } ] }, { "description": "Assay of myoglobin", "code_information": [ { "code": "83874", "type": "CPT" } ], "standard_charges": [ { "gross_charge": 125.00, "minimum": 19.35, "maximum": 19.35, "setting": "both", "payers_information": [ { "payer_name": "Aetna", "plan_name": "700700", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna", "plan_name": "700700_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Miscellaneous", "plan_name": "700720", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Miscellaneous", "plan_name": "700720_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Ppo Hmo", "plan_name": "701720", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Ppo Hmo", "plan_name": "701720_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Ms State Emplo", "plan_name": "401457", "standard_charge_dollar": 19.35, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Ms State Emplo", "plan_name": "401457_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Basic Pl", "plan_name": "400100", "standard_charge_dollar": 19.35, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Basic Pl", "plan_name": "400100_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Federal", "plan_name": "400110", "standard_charge_dollar": 19.35, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Federal", "plan_name": "400110_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." } ] } ] }, { "description": "Hc myoglogin serum", "code_information": [ { "code": "83874", "type": "CPT" } ], "standard_charges": [ { "gross_charge": 125.00, "minimum": 19.35, "maximum": 19.35, "setting": "both", "payers_information": [ { "payer_name": "Aetna", "plan_name": "700700", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna", "plan_name": "700700_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Miscellaneous", "plan_name": "700720", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Miscellaneous", "plan_name": "700720_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Ppo Hmo", "plan_name": "701720", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Ppo Hmo", "plan_name": "701720_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Ms State Emplo", "plan_name": "401457", "standard_charge_dollar": 19.35, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Ms State Emplo", "plan_name": "401457_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Basic Pl", "plan_name": "400100", "standard_charge_dollar": 19.35, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Basic Pl", "plan_name": "400100_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Federal", "plan_name": "400110", "standard_charge_dollar": 19.35, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Federal", "plan_name": "400110_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." } ] } ] }, { "description": "Assay of natriuretic peptide", "code_information": [ { "code": "83880", "type": "CPT" } ], "standard_charges": [ { "gross_charge": 150.00, "minimum": 50.86, "maximum": 50.86, "setting": "both", "payers_information": [ { "payer_name": "Aetna", "plan_name": "700700", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna", "plan_name": "700700_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Miscellaneous", "plan_name": "700720", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Miscellaneous", "plan_name": "700720_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Ppo Hmo", "plan_name": "701720", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Ppo Hmo", "plan_name": "701720_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Ms State Emplo", "plan_name": "401457", "standard_charge_dollar": 50.86, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Ms State Emplo", "plan_name": "401457_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Basic Pl", "plan_name": "400100", "standard_charge_dollar": 50.86, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Basic Pl", "plan_name": "400100_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Federal", "plan_name": "400110", "standard_charge_dollar": 50.86, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Federal", "plan_name": "400110_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." } ] } ] }, { "description": "Hc natriuretic peptide", "code_information": [ { "code": "83880", "type": "CPT" } ], "standard_charges": [ { "gross_charge": 150.00, "minimum": 50.86, "maximum": 50.86, "setting": "both", "payers_information": [ { "payer_name": "Aetna", "plan_name": "700700", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna", "plan_name": "700700_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Miscellaneous", "plan_name": "700720", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Miscellaneous", "plan_name": "700720_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Ppo Hmo", "plan_name": "701720", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Ppo Hmo", "plan_name": "701720_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Ms State Emplo", "plan_name": "401457", "standard_charge_dollar": 50.86, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Ms State Emplo", "plan_name": "401457_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Basic Pl", "plan_name": "400100", "standard_charge_dollar": 50.86, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Basic Pl", "plan_name": "400100_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Federal", "plan_name": "400110", "standard_charge_dollar": 50.86, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Federal", "plan_name": "400110_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." } ] } ] }, { "description": "Assay nephelometry not spec", "code_information": [ { "code": "83883", "type": "CPT" } ], "standard_charges": [ { "gross_charge": 111.00, "minimum": 20.37, "maximum": 20.37, "setting": "both", "payers_information": [ { "payer_name": "Aetna", "plan_name": "700700", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna", "plan_name": "700700_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Miscellaneous", "plan_name": "700720", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Miscellaneous", "plan_name": "700720_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Ppo Hmo", "plan_name": "701720", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Ppo Hmo", "plan_name": "701720_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Ms State Emplo", "plan_name": "401457", "standard_charge_dollar": 20.37, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Ms State Emplo", "plan_name": "401457_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Basic Pl", "plan_name": "400100", "standard_charge_dollar": 20.37, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Basic Pl", "plan_name": "400100_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Federal", "plan_name": "400110", "standard_charge_dollar": 20.37, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Federal", "plan_name": "400110_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." } ] } ] }, { "description": "Hc kappa free light chains", "code_information": [ { "code": "83883", "type": "CPT" } ], "standard_charges": [ { "gross_charge": 111.00, "minimum": 20.37, "maximum": 20.37, "setting": "both", "payers_information": [ { "payer_name": "Aetna", "plan_name": "700700", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna", "plan_name": "700700_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Miscellaneous", "plan_name": "700720", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Miscellaneous", "plan_name": "700720_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Ppo Hmo", "plan_name": "701720", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Ppo Hmo", "plan_name": "701720_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Ms State Emplo", "plan_name": "401457", "standard_charge_dollar": 20.37, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Ms State Emplo", "plan_name": "401457_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Basic Pl", "plan_name": "400100", "standard_charge_dollar": 20.37, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Basic Pl", "plan_name": "400100_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Federal", "plan_name": "400110", "standard_charge_dollar": 20.37, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Federal", "plan_name": "400110_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." } ] } ] }, { "description": "Hc organic acid single quan", "code_information": [ { "code": "83921", "type": "CPT" } ], "standard_charges": [ { "gross_charge": 120.00, "minimum": 22.78, "maximum": 22.78, "setting": "both", "payers_information": [ { "payer_name": "Aetna", "plan_name": "700700", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna", "plan_name": "700700_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Miscellaneous", "plan_name": "700720", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Miscellaneous", "plan_name": "700720_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Ppo Hmo", "plan_name": "701720", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Ppo Hmo", "plan_name": "701720_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Ms State Emplo", "plan_name": "401457", "standard_charge_dollar": 22.78, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Ms State Emplo", "plan_name": "401457_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Basic Pl", "plan_name": "400100", "standard_charge_dollar": 22.78, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Basic Pl", "plan_name": "400100_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Federal", "plan_name": "400110", "standard_charge_dollar": 22.78, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Federal", "plan_name": "400110_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." } ] } ] }, { "description": "Organic acid single quant", "code_information": [ { "code": "83921", "type": "CPT" } ], "standard_charges": [ { "gross_charge": 120.00, "minimum": 22.78, "maximum": 22.78, "setting": "both", "payers_information": [ { "payer_name": "Aetna", "plan_name": "700700", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna", "plan_name": "700700_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Miscellaneous", "plan_name": "700720", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Miscellaneous", "plan_name": "700720_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Ppo Hmo", "plan_name": "701720", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Ppo Hmo", "plan_name": "701720_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Ms State Emplo", "plan_name": "401457", "standard_charge_dollar": 22.78, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Ms State Emplo", "plan_name": "401457_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Basic Pl", "plan_name": "400100", "standard_charge_dollar": 22.78, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Basic Pl", "plan_name": "400100_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Federal", "plan_name": "400110", "standard_charge_dollar": 22.78, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Federal", "plan_name": "400110_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." } ] } ] }, { "description": "Assay of blood osmolality", "code_information": [ { "code": "83930", "type": "CPT" } ], "standard_charges": [ { "gross_charge": 80.00, "minimum": 9.91, "maximum": 9.91, "setting": "both", "payers_information": [ { "payer_name": "Aetna", "plan_name": "700700", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna", "plan_name": "700700_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Miscellaneous", "plan_name": "700720", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Miscellaneous", "plan_name": "700720_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Ppo Hmo", "plan_name": "701720", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Ppo Hmo", "plan_name": "701720_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Ms State Emplo", "plan_name": "401457", "standard_charge_dollar": 9.91, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Ms State Emplo", "plan_name": "401457_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Basic Pl", "plan_name": "400100", "standard_charge_dollar": 9.91, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Basic Pl", "plan_name": "400100_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Federal", "plan_name": "400110", "standard_charge_dollar": 9.91, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Federal", "plan_name": "400110_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." } ] } ] }, { "description": "Hc osmolality blood", "code_information": [ { "code": "83930", "type": "CPT" } ], "standard_charges": [ { "gross_charge": 80.00, "minimum": 9.91, "maximum": 9.91, "setting": "both", "payers_information": [ { "payer_name": "Aetna", "plan_name": "700700", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna", "plan_name": "700700_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Miscellaneous", "plan_name": "700720", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Miscellaneous", "plan_name": "700720_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Ppo Hmo", "plan_name": "701720", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Ppo Hmo", "plan_name": "701720_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Ms State Emplo", "plan_name": "401457", "standard_charge_dollar": 9.91, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Ms State Emplo", "plan_name": "401457_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Basic Pl", "plan_name": "400100", "standard_charge_dollar": 9.91, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Basic Pl", "plan_name": "400100_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Federal", "plan_name": "400110", "standard_charge_dollar": 9.91, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Federal", "plan_name": "400110_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." } ] } ] }, { "description": "Assay of urine osmolality", "code_information": [ { "code": "83935", "type": "CPT" } ], "standard_charges": [ { "gross_charge": 48.66, "minimum": 10.22, "maximum": 10.22, "setting": "both", "payers_information": [ { "payer_name": "Aetna", "plan_name": "700700", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna", "plan_name": "700700_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Miscellaneous", "plan_name": "700720", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Miscellaneous", "plan_name": "700720_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Ppo Hmo", "plan_name": "701720", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Ppo Hmo", "plan_name": "701720_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Ms State Emplo", "plan_name": "401457", "standard_charge_dollar": 10.22, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Ms State Emplo", "plan_name": "401457_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Basic Pl", "plan_name": "400100", "standard_charge_dollar": 10.22, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Basic Pl", "plan_name": "400100_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Federal", "plan_name": "400110", "standard_charge_dollar": 10.22, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Federal", "plan_name": "400110_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." } ] } ] }, { "description": "Hc osmolality urine", "code_information": [ { "code": "83935", "type": "CPT" } ], "standard_charges": [ { "gross_charge": 48.66, "minimum": 10.22, "maximum": 10.22, "setting": "both", "payers_information": [ { "payer_name": "Aetna", "plan_name": "700700", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna", "plan_name": "700700_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Miscellaneous", "plan_name": "700720", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Miscellaneous", "plan_name": "700720_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Ppo Hmo", "plan_name": "701720", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Ppo Hmo", "plan_name": "701720_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Ms State Emplo", "plan_name": "401457", "standard_charge_dollar": 10.22, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Ms State Emplo", "plan_name": "401457_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Basic Pl", "plan_name": "400100", "standard_charge_dollar": 10.22, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Basic Pl", "plan_name": "400100_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Federal", "plan_name": "400110", "standard_charge_dollar": 10.22, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Federal", "plan_name": "400110_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." } ] } ] }, { "description": "Assay of parathormone", "code_information": [ { "code": "83970", "type": "CPT" } ], "standard_charges": [ { "gross_charge": 147.94, "minimum": 61.85, "maximum": 61.85, "setting": "both", "payers_information": [ { "payer_name": "Aetna", "plan_name": "700700", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna", "plan_name": "700700_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Miscellaneous", "plan_name": "700720", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Miscellaneous", "plan_name": "700720_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Ppo Hmo", "plan_name": "701720", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Ppo Hmo", "plan_name": "701720_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Ms State Emplo", "plan_name": "401457", "standard_charge_dollar": 61.85, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Ms State Emplo", "plan_name": "401457_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Basic Pl", "plan_name": "400100", "standard_charge_dollar": 61.85, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Basic Pl", "plan_name": "400100_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Federal", "plan_name": "400110", "standard_charge_dollar": 61.85, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Federal", "plan_name": "400110_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." } ] } ] }, { "description": "Hc parathyroid hormone", "code_information": [ { "code": "83970", "type": "CPT" } ], "standard_charges": [ { "gross_charge": 147.94, "minimum": 61.85, "maximum": 61.85, "setting": "both", "payers_information": [ { "payer_name": "Aetna", "plan_name": "700700", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna", "plan_name": "700700_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Miscellaneous", "plan_name": "700720", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Miscellaneous", "plan_name": "700720_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Ppo Hmo", "plan_name": "701720", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Ppo Hmo", "plan_name": "701720_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Ms State Emplo", "plan_name": "401457", "standard_charge_dollar": 61.85, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Ms State Emplo", "plan_name": "401457_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Basic Pl", "plan_name": "400100", "standard_charge_dollar": 61.85, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Basic Pl", "plan_name": "400100_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Federal", "plan_name": "400110", "standard_charge_dollar": 61.85, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Federal", "plan_name": "400110_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." } ] } ] }, { "description": "Assay ph body fluid nos", "code_information": [ { "code": "83986", "type": "CPT" } ], "standard_charges": [ { "gross_charge": 120.00, "minimum": 4.51, "maximum": 4.51, "setting": "both", "payers_information": [ { "payer_name": "Aetna", "plan_name": "700700", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna", "plan_name": "700700_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Miscellaneous", "plan_name": "700720", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Miscellaneous", "plan_name": "700720_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Ppo Hmo", "plan_name": "701720", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Ppo Hmo", "plan_name": "701720_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Ms State Emplo", "plan_name": "401457", "standard_charge_dollar": 4.51, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Ms State Emplo", "plan_name": "401457_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Basic Pl", "plan_name": "400100", "standard_charge_dollar": 4.51, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Basic Pl", "plan_name": "400100_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Federal", "plan_name": "400110", "standard_charge_dollar": 4.51, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Federal", "plan_name": "400110_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." } ] } ] }, { "description": "Hc ph stool", "code_information": [ { "code": "83986", "type": "CPT" } ], "standard_charges": [ { "gross_charge": 120.00, "minimum": 4.51, "maximum": 4.51, "setting": "both", "payers_information": [ { "payer_name": "Aetna", "plan_name": "700700", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna", "plan_name": "700700_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Miscellaneous", "plan_name": "700720", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Miscellaneous", "plan_name": "700720_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Ppo Hmo", "plan_name": "701720", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Ppo Hmo", "plan_name": "701720_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Ms State Emplo", "plan_name": "401457", "standard_charge_dollar": 4.51, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Ms State Emplo", "plan_name": "401457_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Basic Pl", "plan_name": "400100", "standard_charge_dollar": 4.51, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Basic Pl", "plan_name": "400100_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Federal", "plan_name": "400110", "standard_charge_dollar": 4.51, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Federal", "plan_name": "400110_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." } ] } ] }, { "description": "Assay for calprotectin fecal", "code_information": [ { "code": "83993", "type": "CPT" } ], "standard_charges": [ { "gross_charge": 300.00, "minimum": 29.41, "maximum": 29.41, "setting": "both", "payers_information": [ { "payer_name": "Aetna", "plan_name": "700700", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna", "plan_name": "700700_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Miscellaneous", "plan_name": "700720", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Miscellaneous", "plan_name": "700720_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Ppo Hmo", "plan_name": "701720", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Ppo Hmo", "plan_name": "701720_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Ms State Emplo", "plan_name": "401457", "standard_charge_dollar": 29.41, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Ms State Emplo", "plan_name": "401457_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Basic Pl", "plan_name": "400100", "standard_charge_dollar": 29.41, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Basic Pl", "plan_name": "400100_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Federal", "plan_name": "400110", "standard_charge_dollar": 29.41, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Federal", "plan_name": "400110_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." } ] } ] }, { "description": "Hc calprotectin fecal", "code_information": [ { "code": "83993", "type": "CPT" } ], "standard_charges": [ { "gross_charge": 300.00, "minimum": 29.41, "maximum": 29.41, "setting": "both", "payers_information": [ { "payer_name": "Aetna", "plan_name": "700700", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna", "plan_name": "700700_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Miscellaneous", "plan_name": "700720", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Miscellaneous", "plan_name": "700720_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Ppo Hmo", "plan_name": "701720", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Ppo Hmo", "plan_name": "701720_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Ms State Emplo", "plan_name": "401457", "standard_charge_dollar": 29.41, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Ms State Emplo", "plan_name": "401457_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Basic Pl", "plan_name": "400100", "standard_charge_dollar": 29.41, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Basic Pl", "plan_name": "400100_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Federal", "plan_name": "400110", "standard_charge_dollar": 29.41, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Federal", "plan_name": "400110_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." } ] } ] }, { "description": "Assay alkaline phosphatase", "code_information": [ { "code": "84075", "type": "CPT" } ], "standard_charges": [ { "gross_charge": 50.00, "minimum": 7.76, "maximum": 7.76, "setting": "both", "payers_information": [ { "payer_name": "Aetna", "plan_name": "700700", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna", "plan_name": "700700_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Miscellaneous", "plan_name": "700720", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Miscellaneous", "plan_name": "700720_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Ppo Hmo", "plan_name": "701720", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Ppo Hmo", "plan_name": "701720_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Ms State Emplo", "plan_name": "401457", "standard_charge_dollar": 7.76, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Ms State Emplo", "plan_name": "401457_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Basic Pl", "plan_name": "400100", "standard_charge_dollar": 7.76, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Basic Pl", "plan_name": "400100_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Federal", "plan_name": "400110", "standard_charge_dollar": 7.76, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Federal", "plan_name": "400110_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." } ] } ] }, { "description": "Hc alkaline phosphatase", "code_information": [ { "code": "84075", "type": "CPT" } ], "standard_charges": [ { "gross_charge": 50.00, "minimum": 7.76, "maximum": 7.76, "setting": "both", "payers_information": [ { "payer_name": "Aetna", "plan_name": "700700", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna", "plan_name": "700700_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Miscellaneous", "plan_name": "700720", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Miscellaneous", "plan_name": "700720_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Ppo Hmo", "plan_name": "701720", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Ppo Hmo", "plan_name": "701720_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Ms State Emplo", "plan_name": "401457", "standard_charge_dollar": 7.76, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Ms State Emplo", "plan_name": "401457_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Basic Pl", "plan_name": "400100", "standard_charge_dollar": 7.76, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Basic Pl", "plan_name": "400100_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Federal", "plan_name": "400110", "standard_charge_dollar": 7.76, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Federal", "plan_name": "400110_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." } ] } ] }, { "description": "Assay alkaline phosphatases", "code_information": [ { "code": "84080", "type": "CPT" } ], "standard_charges": [ { "gross_charge": 100.00, "minimum": 22.15, "maximum": 22.15, "setting": "both", "payers_information": [ { "payer_name": "Aetna", "plan_name": "700700", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna", "plan_name": "700700_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Miscellaneous", "plan_name": "700720", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Miscellaneous", "plan_name": "700720_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Ppo Hmo", "plan_name": "701720", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Ppo Hmo", "plan_name": "701720_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Ms State Emplo", "plan_name": "401457", "standard_charge_dollar": 22.15, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Ms State Emplo", "plan_name": "401457_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Basic Pl", "plan_name": "400100", "standard_charge_dollar": 22.15, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Basic Pl", "plan_name": "400100_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Federal", "plan_name": "400110", "standard_charge_dollar": 22.15, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Federal", "plan_name": "400110_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." } ] } ] }, { "description": "Hc alkaline phosphatase isoenzymes", "code_information": [ { "code": "84080", "type": "CPT" } ], "standard_charges": [ { "gross_charge": 100.00, "minimum": 22.15, "maximum": 22.15, "setting": "both", "payers_information": [ { "payer_name": "Aetna", "plan_name": "700700", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna", "plan_name": "700700_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Miscellaneous", "plan_name": "700720", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Miscellaneous", "plan_name": "700720_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Ppo Hmo", "plan_name": "701720", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Ppo Hmo", "plan_name": "701720_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Ms State Emplo", "plan_name": "401457", "standard_charge_dollar": 22.15, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Ms State Emplo", "plan_name": "401457_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Basic Pl", "plan_name": "400100", "standard_charge_dollar": 22.15, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Basic Pl", "plan_name": "400100_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Federal", "plan_name": "400110", "standard_charge_dollar": 22.15, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Federal", "plan_name": "400110_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." } ] } ] }, { "description": "Assay of phosphorus", "code_information": [ { "code": "84100", "type": "CPT" } ], "standard_charges": [ { "gross_charge": 54.56, "minimum": 7.11, "maximum": 7.11, "setting": "both", "payers_information": [ { "payer_name": "Aetna", "plan_name": "700700", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna", "plan_name": "700700_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Miscellaneous", "plan_name": "700720", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Miscellaneous", "plan_name": "700720_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Ppo Hmo", "plan_name": "701720", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Ppo Hmo", "plan_name": "701720_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Ms State Emplo", "plan_name": "401457", "standard_charge_dollar": 7.11, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Ms State Emplo", "plan_name": "401457_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Basic Pl", "plan_name": "400100", "standard_charge_dollar": 7.11, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Basic Pl", "plan_name": "400100_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Federal", "plan_name": "400110", "standard_charge_dollar": 7.11, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit 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"payer_name": "Aetna Miscellaneous", "plan_name": "700720", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Miscellaneous", "plan_name": "700720_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Ppo Hmo", "plan_name": "701720", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Ppo Hmo", "plan_name": "701720_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Ms State Emplo", "plan_name": "401457", "standard_charge_dollar": 7.11, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Ms State Emplo", "plan_name": "401457_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Basic Pl", "plan_name": "400100", "standard_charge_dollar": 7.11, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Basic Pl", "plan_name": "400100_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Federal", "plan_name": "400110", "standard_charge_dollar": 7.11, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Federal", "plan_name": "400110_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." } ] } ] }, { "description": "Assay of urine phosphorus", "code_information": [ { "code": "84105", "type": "CPT" } ], "standard_charges": [ { "gross_charge": 47.25, "minimum": 7.76, "maximum": 7.76, "setting": "both", "payers_information": [ { "payer_name": "Aetna", "plan_name": "700700", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna", "plan_name": "700700_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": 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"Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Federal", "plan_name": "400110", "standard_charge_dollar": 7.76, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Federal", "plan_name": "400110_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." } ] } ] }, { "description": "Hc phosphorus urine 24 hr", "code_information": [ { "code": "84105", "type": "CPT" } ], "standard_charges": [ { "gross_charge": 47.25, "minimum": 7.76, "maximum": 7.76, "setting": "both", "payers_information": [ { "payer_name": "Aetna", "plan_name": "700700", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna", "plan_name": "700700_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Miscellaneous", "plan_name": "700720", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Miscellaneous", "plan_name": "700720_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Ppo Hmo", "plan_name": "701720", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna 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"standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Federal", "plan_name": "400110", "standard_charge_dollar": 7.76, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Federal", "plan_name": "400110_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." } ] } ] }, { "description": "Assay of serum potassium", "code_information": [ { "code": "84132", "type": "CPT" } ], "standard_charges": [ { "gross_charge": 45.00, "minimum": 6.89, "maximum": 6.89, "setting": "both", "payers_information": [ { "payer_name": "Aetna", "plan_name": "700700", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna", "plan_name": "700700_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Miscellaneous", "plan_name": "700720", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Miscellaneous", "plan_name": "700720_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Ppo Hmo", "plan_name": "701720", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of 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"Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Basic Pl", "plan_name": "400100_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Federal", "plan_name": "400110", "standard_charge_dollar": 6.89, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Federal", "plan_name": "400110_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." } ] } ] }, { "description": "Hc potassium serum", "code_information": [ { "code": "84132", "type": "CPT" } ], "standard_charges": [ { "gross_charge": 45.00, "minimum": 6.89, "maximum": 6.89, "setting": "both", "payers_information": [ { "payer_name": "Aetna", "plan_name": "700700", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna", "plan_name": "700700_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Miscellaneous", "plan_name": "700720", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Miscellaneous", "plan_name": "700720_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Ppo Hmo", "plan_name": "701720", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Ppo Hmo", "plan_name": "701720_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Ms State Emplo", "plan_name": "401457", "standard_charge_dollar": 6.89, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Ms State Emplo", "plan_name": "401457_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Basic Pl", "plan_name": "400100", "standard_charge_dollar": 6.89, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Basic Pl", "plan_name": "400100_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Federal", "plan_name": "400110", "standard_charge_dollar": 6.89, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Federal", "plan_name": "400110_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." } ] } ] }, { "description": "Assay of urine potassium", "code_information": [ { "code": "84133", "type": "CPT" } ], "standard_charges": [ { "gross_charge": 37.59, "minimum": 6.45, "maximum": 6.45, "setting": "both", "payers_information": [ { "payer_name": "Aetna", "plan_name": "700700", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna", "plan_name": "700700_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Miscellaneous", "plan_name": "700720", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Miscellaneous", "plan_name": "700720_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Ppo Hmo", "plan_name": "701720", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Ppo Hmo", "plan_name": "701720_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Ms State Emplo", "plan_name": "401457", "standard_charge_dollar": 6.45, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Ms State Emplo", "plan_name": "401457_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Basic Pl", "plan_name": "400100", "standard_charge_dollar": 6.45, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Basic Pl", "plan_name": "400100_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Federal", "plan_name": "400110", "standard_charge_dollar": 6.45, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Federal", "plan_name": "400110_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." } ] } ] }, { "description": "Hc potassium urine 24hr", "code_information": [ { "code": "84133", "type": "CPT" } ], "standard_charges": [ { "gross_charge": 37.59, "minimum": 6.45, "maximum": 6.45, "setting": "both", "payers_information": [ { "payer_name": "Aetna", "plan_name": "700700", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna", "plan_name": "700700_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Miscellaneous", "plan_name": "700720", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Miscellaneous", "plan_name": "700720_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Ppo Hmo", "plan_name": "701720", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Ppo Hmo", "plan_name": "701720_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Ms State Emplo", "plan_name": "401457", "standard_charge_dollar": 6.45, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Ms State Emplo", "plan_name": "401457_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Basic Pl", "plan_name": "400100", "standard_charge_dollar": 6.45, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Basic Pl", "plan_name": "400100_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Federal", "plan_name": "400110", "standard_charge_dollar": 6.45, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Federal", "plan_name": "400110_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." } ] } ] }, { "description": "Assay of prealbumin", "code_information": [ { "code": "84134", "type": "CPT" } ], "standard_charges": [ { "gross_charge": 100.00, "minimum": 10.47, "maximum": 10.47, "setting": "both", "payers_information": [ { "payer_name": "Aetna", "plan_name": "700700", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna", "plan_name": "700700_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Miscellaneous", "plan_name": "700720", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Miscellaneous", "plan_name": "700720_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Ppo Hmo", "plan_name": "701720", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Ppo Hmo", "plan_name": "701720_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Ms State Emplo", "plan_name": "401457", "standard_charge_dollar": 10.47, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Ms State Emplo", "plan_name": "401457_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Basic Pl", "plan_name": "400100", "standard_charge_dollar": 10.47, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Basic Pl", "plan_name": "400100_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Federal", "plan_name": "400110", "standard_charge_dollar": 10.47, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Federal", "plan_name": "400110_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." } ] } ] }, { "description": "Hc prealbumin", "code_information": [ { "code": "84134", "type": "CPT" } ], "standard_charges": [ { "gross_charge": 100.00, "minimum": 10.47, "maximum": 10.47, "setting": "both", "payers_information": [ { "payer_name": "Aetna", "plan_name": "700700", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna", "plan_name": "700700_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Miscellaneous", "plan_name": "700720", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Miscellaneous", "plan_name": "700720_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Ppo Hmo", "plan_name": "701720", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Ppo Hmo", "plan_name": "701720_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Ms State Emplo", "plan_name": "401457", "standard_charge_dollar": 10.47, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Ms State Emplo", "plan_name": "401457_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Basic Pl", "plan_name": "400100", "standard_charge_dollar": 10.47, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Basic Pl", "plan_name": "400100_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Federal", "plan_name": "400110", "standard_charge_dollar": 10.47, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Federal", "plan_name": "400110_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." } ] } ] }, { "description": "Assay of progesterone", "code_information": [ { "code": "84144", "type": "CPT" } ], "standard_charges": [ { "gross_charge": 73.55, "minimum": 31.26, "maximum": 31.26, "setting": "both", "payers_information": [ { "payer_name": "Aetna", "plan_name": "700700", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna", "plan_name": "700700_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Miscellaneous", "plan_name": "700720", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Miscellaneous", "plan_name": "700720_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Ppo Hmo", "plan_name": "701720", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Ppo Hmo", "plan_name": "701720_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Ms State Emplo", "plan_name": "401457", "standard_charge_dollar": 31.26, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Ms State Emplo", "plan_name": "401457_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Basic Pl", "plan_name": "400100", "standard_charge_dollar": 31.26, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Basic Pl", "plan_name": "400100_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Federal", "plan_name": "400110", "standard_charge_dollar": 31.26, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Federal", "plan_name": "400110_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." } ] } ] }, { "description": "Hc progesterone", "code_information": [ { "code": "84144", "type": "CPT" } ], "standard_charges": [ { "gross_charge": 73.55, "minimum": 31.26, "maximum": 31.26, "setting": "both", "payers_information": [ { "payer_name": "Aetna", "plan_name": "700700", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna", "plan_name": "700700_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Miscellaneous", "plan_name": "700720", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Miscellaneous", "plan_name": "700720_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Ppo Hmo", "plan_name": "701720", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Ppo Hmo", "plan_name": "701720_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Ms State Emplo", "plan_name": "401457", "standard_charge_dollar": 31.26, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Ms State Emplo", "plan_name": "401457_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Basic Pl", "plan_name": "400100", "standard_charge_dollar": 31.26, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Basic Pl", "plan_name": "400100_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Federal", "plan_name": "400110", "standard_charge_dollar": 31.26, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Federal", "plan_name": "400110_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." } ] } ] }, { "description": "Hc procalcitonin", "code_information": [ { "code": "84145", "type": "CPT" } ], "standard_charges": [ { "gross_charge": 300.00, "minimum": 40.14, "maximum": 40.14, "setting": "both", "payers_information": [ { "payer_name": "Aetna", "plan_name": "700700", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna", "plan_name": "700700_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Miscellaneous", "plan_name": "700720", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Miscellaneous", "plan_name": "700720_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Ppo Hmo", "plan_name": "701720", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Ppo Hmo", "plan_name": "701720_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Ms State Emplo", "plan_name": "401457", "standard_charge_dollar": 40.14, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Ms State Emplo", "plan_name": "401457_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Basic Pl", "plan_name": "400100", "standard_charge_dollar": 40.14, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Basic Pl", "plan_name": "400100_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Federal", "plan_name": "400110", "standard_charge_dollar": 40.14, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Federal", "plan_name": "400110_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." } ] } ] }, { "description": "Procalcitonin (pct)", "code_information": [ { "code": "84145", "type": "CPT" } ], "standard_charges": [ { "gross_charge": 300.00, "minimum": 40.14, "maximum": 40.14, "setting": "both", "payers_information": [ { "payer_name": "Aetna", "plan_name": "700700", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna", "plan_name": "700700_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Miscellaneous", "plan_name": "700720", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Miscellaneous", "plan_name": "700720_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Ppo Hmo", "plan_name": "701720", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Ppo Hmo", "plan_name": "701720_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Ms State Emplo", "plan_name": "401457", "standard_charge_dollar": 40.14, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Ms State Emplo", "plan_name": "401457_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Basic Pl", "plan_name": "400100", "standard_charge_dollar": 40.14, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Basic Pl", "plan_name": "400100_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Federal", "plan_name": "400110", "standard_charge_dollar": 40.14, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Federal", "plan_name": "400110_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." } ] } ] }, { "description": "Assay of prolactin", "code_information": [ { "code": "84146", "type": "CPT" } ], "standard_charges": [ { "gross_charge": 89.25, "minimum": 29.04, "maximum": 29.04, "setting": "both", "payers_information": [ { "payer_name": "Aetna", "plan_name": "700700", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna", "plan_name": "700700_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Miscellaneous", "plan_name": "700720", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Miscellaneous", "plan_name": "700720_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Ppo Hmo", "plan_name": "701720", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Ppo Hmo", "plan_name": "701720_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Ms State Emplo", "plan_name": "401457", "standard_charge_dollar": 29.04, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Ms State Emplo", "plan_name": "401457_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Basic Pl", "plan_name": "400100", "standard_charge_dollar": 29.04, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Basic Pl", "plan_name": "400100_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Federal", "plan_name": "400110", "standard_charge_dollar": 29.04, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Federal", "plan_name": "400110_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." } ] } ] }, { "description": "Hc prolactin", "code_information": [ { "code": "84146", "type": "CPT" } ], "standard_charges": [ { "gross_charge": 89.25, "minimum": 29.04, "maximum": 29.04, "setting": "both", "payers_information": [ { "payer_name": "Aetna", "plan_name": "700700", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna", "plan_name": "700700_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Miscellaneous", "plan_name": "700720", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Miscellaneous", "plan_name": "700720_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Ppo Hmo", "plan_name": "701720", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Ppo Hmo", "plan_name": "701720_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Ms State Emplo", "plan_name": "401457", "standard_charge_dollar": 29.04, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Ms State Emplo", "plan_name": "401457_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Basic Pl", "plan_name": "400100", "standard_charge_dollar": 29.04, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Basic Pl", "plan_name": "400100_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Federal", "plan_name": "400110", "standard_charge_dollar": 29.04, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Federal", "plan_name": "400110_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." } ] } ] }, { "description": "Assay of psa total", "code_information": [ { "code": "84153", "type": "CPT" } ], "standard_charges": [ { "gross_charge": 110.00, "minimum": 23.55, "maximum": 23.55, "setting": "both", "payers_information": [ { "payer_name": "Aetna", "plan_name": "700700", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna", "plan_name": "700700_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Miscellaneous", "plan_name": "700720", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Miscellaneous", "plan_name": "700720_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Ppo Hmo", "plan_name": "701720", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Ppo Hmo", "plan_name": "701720_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Ms State Emplo", "plan_name": "401457", "standard_charge_dollar": 23.55, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Ms State Emplo", "plan_name": "401457_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Basic Pl", "plan_name": "400100", "standard_charge_dollar": 23.55, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Basic Pl", "plan_name": "400100_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Federal", "plan_name": "400110", "standard_charge_dollar": 23.55, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Federal", "plan_name": "400110_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." } ] } ] }, { "description": "Hc psa total", "code_information": [ { "code": "84153", "type": "CPT" } ], "standard_charges": [ { "gross_charge": 110.00, "minimum": 23.55, "maximum": 23.55, "setting": "both", "payers_information": [ { "payer_name": "Aetna", "plan_name": "700700", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna", "plan_name": "700700_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Miscellaneous", "plan_name": "700720", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Miscellaneous", "plan_name": "700720_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Ppo Hmo", "plan_name": "701720", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Ppo Hmo", "plan_name": "701720_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Ms State Emplo", "plan_name": "401457", "standard_charge_dollar": 23.55, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Ms State Emplo", "plan_name": "401457_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Basic Pl", "plan_name": "400100", "standard_charge_dollar": 23.55, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Basic Pl", "plan_name": "400100_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Federal", "plan_name": "400110", "standard_charge_dollar": 23.55, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Federal", "plan_name": "400110_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." } ] } ] }, { "description": "Assay of psa free", "code_information": [ { "code": "84154", "type": "CPT" } ], "standard_charges": [ { "gross_charge": 134.50, "minimum": 23.55, "maximum": 23.55, "setting": "both", "payers_information": [ { "payer_name": "Aetna", "plan_name": "700700", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna", "plan_name": "700700_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Miscellaneous", "plan_name": "700720", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Miscellaneous", "plan_name": "700720_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Ppo Hmo", "plan_name": "701720", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Ppo Hmo", "plan_name": "701720_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Ms State Emplo", "plan_name": "401457", "standard_charge_dollar": 23.55, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Ms State Emplo", "plan_name": "401457_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Basic Pl", "plan_name": "400100", "standard_charge_dollar": 23.55, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Basic Pl", "plan_name": "400100_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Federal", "plan_name": "400110", "standard_charge_dollar": 23.55, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Federal", "plan_name": "400110_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." } ] } ] }, { "description": "Hc psa free", "code_information": [ { "code": "84154", "type": "CPT" } ], "standard_charges": [ { "gross_charge": 134.50, "minimum": 23.55, "maximum": 23.55, "setting": "both", "payers_information": [ { "payer_name": "Aetna", "plan_name": "700700", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna", "plan_name": "700700_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Miscellaneous", "plan_name": "700720", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Miscellaneous", "plan_name": "700720_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Ppo Hmo", "plan_name": "701720", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Ppo Hmo", "plan_name": "701720_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Ms State Emplo", "plan_name": "401457", "standard_charge_dollar": 23.55, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Ms State Emplo", "plan_name": "401457_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Basic Pl", "plan_name": "400100", "standard_charge_dollar": 23.55, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Basic Pl", "plan_name": "400100_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Federal", "plan_name": "400110", "standard_charge_dollar": 23.55, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Federal", "plan_name": "400110_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." } ] } ] }, { "description": "Assay of protein serum", "code_information": [ { "code": "84155", "type": "CPT" } ], "standard_charges": [ { "gross_charge": 50.00, "minimum": 5.50, "maximum": 5.50, "setting": "both", "payers_information": [ { "payer_name": "Aetna", "plan_name": "700700", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna", "plan_name": "700700_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Miscellaneous", "plan_name": "700720", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Miscellaneous", "plan_name": "700720_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Ppo Hmo", "plan_name": "701720", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Ppo Hmo", "plan_name": "701720_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Ms State Emplo", "plan_name": "401457", "standard_charge_dollar": 5.50, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Ms State Emplo", "plan_name": "401457_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Basic Pl", "plan_name": "400100", "standard_charge_dollar": 5.50, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Basic Pl", "plan_name": "400100_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Federal", "plan_name": "400110", "standard_charge_dollar": 5.50, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Federal", "plan_name": "400110_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." } ] } ] }, { "description": "Hc protein total", "code_information": [ { "code": "84155", "type": "CPT" } ], "standard_charges": [ { "gross_charge": 50.00, "minimum": 5.50, "maximum": 5.50, "setting": "both", "payers_information": [ { "payer_name": "Aetna", "plan_name": "700700", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna", "plan_name": "700700_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Miscellaneous", "plan_name": "700720", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Miscellaneous", "plan_name": "700720_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Ppo Hmo", "plan_name": "701720", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Ppo Hmo", "plan_name": "701720_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Ms State Emplo", "plan_name": "401457", "standard_charge_dollar": 5.50, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Ms State Emplo", "plan_name": "401457_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Basic Pl", "plan_name": "400100", "standard_charge_dollar": 5.50, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Basic Pl", "plan_name": "400100_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Federal", "plan_name": "400110", "standard_charge_dollar": 5.50, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Federal", "plan_name": "400110_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." } ] } ] }, { "description": "Assay of protein urine", "code_information": [ { "code": "84156", "type": "CPT" } ], "standard_charges": [ { "gross_charge": 80.00, "minimum": 5.50, "maximum": 5.50, "setting": "both", "payers_information": [ { "payer_name": "Aetna", "plan_name": "700700", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna", "plan_name": "700700_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Miscellaneous", "plan_name": "700720", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Miscellaneous", "plan_name": "700720_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Ppo Hmo", "plan_name": "701720", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Ppo Hmo", "plan_name": "701720_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Ms State Emplo", "plan_name": "401457", "standard_charge_dollar": 5.50, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Ms State Emplo", "plan_name": "401457_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Basic Pl", "plan_name": "400100", "standard_charge_dollar": 5.50, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Basic Pl", "plan_name": "400100_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Federal", "plan_name": "400110", "standard_charge_dollar": 5.50, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Federal", "plan_name": "400110_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." } ] } ] }, { "description": "Hc protein urine random", "code_information": [ { "code": "84156", "type": "CPT" } ], "standard_charges": [ { "gross_charge": 80.00, "minimum": 5.50, "maximum": 5.50, "setting": "both", "payers_information": [ { "payer_name": "Aetna", "plan_name": "700700", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna", "plan_name": "700700_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Miscellaneous", "plan_name": "700720", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Miscellaneous", "plan_name": "700720_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Ppo Hmo", "plan_name": "701720", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Ppo Hmo", "plan_name": "701720_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Ms State Emplo", "plan_name": "401457", "standard_charge_dollar": 5.50, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Ms State Emplo", "plan_name": "401457_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Basic Pl", "plan_name": "400100", "standard_charge_dollar": 5.50, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Basic Pl", "plan_name": "400100_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Federal", "plan_name": "400110", "standard_charge_dollar": 5.50, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Federal", "plan_name": "400110_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." } ] } ] }, { "description": "Hc protein electrophoresis", "code_information": [ { "code": "84165", "type": "CPT" } ], "standard_charges": [ { "gross_charge": 120.00, "minimum": 16.09, "maximum": 16.09, "setting": "both", "payers_information": [ { "payer_name": "Aetna", "plan_name": "700700", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna", "plan_name": "700700_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Miscellaneous", "plan_name": "700720", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Miscellaneous", "plan_name": "700720_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Ppo Hmo", "plan_name": "701720", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Ppo Hmo", "plan_name": "701720_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Ms State Emplo", "plan_name": "401457", "standard_charge_dollar": 16.09, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Ms State Emplo", "plan_name": "401457_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Basic Pl", "plan_name": "400100", "standard_charge_dollar": 16.09, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Basic Pl", "plan_name": "400100_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Federal", "plan_name": "400110", "standard_charge_dollar": 16.09, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Federal", "plan_name": "400110_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." } ] } ] }, { "description": "Protein e-phoresis serum", "code_information": [ { "code": "84165", "type": "CPT" } ], "standard_charges": [ { "gross_charge": 120.00, "minimum": 16.09, "maximum": 16.09, "setting": "both", "payers_information": [ { "payer_name": "Aetna", "plan_name": "700700", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna", "plan_name": "700700_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Miscellaneous", "plan_name": "700720", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Miscellaneous", "plan_name": "700720_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Ppo Hmo", "plan_name": "701720", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Ppo Hmo", "plan_name": "701720_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Ms State Emplo", "plan_name": "401457", "standard_charge_dollar": 16.09, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Ms State Emplo", "plan_name": "401457_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Basic Pl", "plan_name": "400100", "standard_charge_dollar": 16.09, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Basic Pl", "plan_name": "400100_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Federal", "plan_name": "400110", "standard_charge_dollar": 16.09, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Federal", "plan_name": "400110_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." } ] } ] }, { "description": "Hc protein electrophoresis urine", "code_information": [ { "code": "84166", "type": "CPT" } ], "standard_charges": [ { "gross_charge": 85.00, "minimum": 25.73, "maximum": 25.73, "setting": "both", "payers_information": [ { "payer_name": "Aetna", "plan_name": "700700", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna", "plan_name": "700700_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Miscellaneous", "plan_name": "700720", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Miscellaneous", "plan_name": "700720_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Ppo Hmo", "plan_name": "701720", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Ppo Hmo", "plan_name": "701720_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Ms State Emplo", "plan_name": "401457", "standard_charge_dollar": 25.73, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Ms State Emplo", "plan_name": "401457_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Basic Pl", "plan_name": "400100", "standard_charge_dollar": 25.73, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Basic Pl", "plan_name": "400100_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Federal", "plan_name": "400110", "standard_charge_dollar": 25.73, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Federal", "plan_name": "400110_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." } ] } ] }, { "description": "Protein e-phoresis/urine/csf", "code_information": [ { "code": "84166", "type": "CPT" } ], "standard_charges": [ { "gross_charge": 85.00, "minimum": 25.73, "maximum": 25.73, "setting": "both", "payers_information": [ { "payer_name": "Aetna", "plan_name": "700700", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna", "plan_name": "700700_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Miscellaneous", "plan_name": "700720", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Miscellaneous", "plan_name": "700720_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Ppo Hmo", "plan_name": "701720", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Ppo Hmo", "plan_name": "701720_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Ms State Emplo", "plan_name": "401457", "standard_charge_dollar": 25.73, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Ms State Emplo", "plan_name": "401457_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Basic Pl", "plan_name": "400100", "standard_charge_dollar": 25.73, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Basic Pl", "plan_name": "400100_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Federal", "plan_name": "400110", "standard_charge_dollar": 25.73, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Federal", "plan_name": "400110_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." } ] } ] }, { "description": "Assay of proinsulin", "code_information": [ { "code": "84206", "type": "CPT" } ], "standard_charges": [ { "gross_charge": 200.00, "minimum": 26.69, "maximum": 26.69, "setting": "both", "payers_information": [ { "payer_name": "Aetna", "plan_name": "700700", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna", "plan_name": "700700_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Miscellaneous", "plan_name": "700720", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Miscellaneous", "plan_name": "700720_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Ppo Hmo", "plan_name": "701720", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Ppo Hmo", "plan_name": "701720_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Ms State Emplo", "plan_name": "401457", "standard_charge_dollar": 26.69, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Ms State Emplo", "plan_name": "401457_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Basic Pl", "plan_name": "400100", "standard_charge_dollar": 26.69, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Basic Pl", "plan_name": "400100_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Federal", "plan_name": "400110", "standard_charge_dollar": 26.69, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Federal", "plan_name": "400110_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." } ] } ] }, { "description": "Hc proinsulin", "code_information": [ { "code": "84206", "type": "CPT" } ], "standard_charges": [ { "gross_charge": 200.00, "minimum": 26.69, "maximum": 26.69, "setting": "both", "payers_information": [ { "payer_name": "Aetna", "plan_name": "700700", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna", "plan_name": "700700_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Miscellaneous", "plan_name": "700720", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Miscellaneous", "plan_name": "700720_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Ppo Hmo", "plan_name": "701720", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Ppo Hmo", "plan_name": "701720_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Ms State Emplo", "plan_name": "401457", "standard_charge_dollar": 26.69, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Ms State Emplo", "plan_name": "401457_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Basic Pl", "plan_name": "400100", "standard_charge_dollar": 26.69, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Basic Pl", "plan_name": "400100_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Federal", "plan_name": "400110", "standard_charge_dollar": 26.69, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Federal", "plan_name": "400110_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." } ] } ] }, { "description": "Assay of vitamin b-6", "code_information": [ { "code": "84207", "type": "CPT" } ], "standard_charges": [ { "gross_charge": 400.00, "minimum": 23.66, "maximum": 23.66, "setting": "both", "payers_information": [ { "payer_name": "Aetna", "plan_name": "700700", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna", "plan_name": "700700_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Miscellaneous", "plan_name": "700720", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Miscellaneous", "plan_name": "700720_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Ppo Hmo", "plan_name": "701720", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Ppo Hmo", "plan_name": "701720_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Ms State Emplo", "plan_name": "401457", "standard_charge_dollar": 23.66, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Ms State Emplo", "plan_name": "401457_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Basic Pl", "plan_name": "400100", "standard_charge_dollar": 23.66, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Basic Pl", "plan_name": "400100_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Federal", "plan_name": "400110", "standard_charge_dollar": 23.66, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Federal", "plan_name": "400110_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." } ] } ] }, { "description": "Hc pyridoxal phosphate vit b6", "code_information": [ { "code": "84207", "type": "CPT" } ], "standard_charges": [ { "gross_charge": 400.00, "minimum": 23.66, "maximum": 23.66, "setting": "both", "payers_information": [ { "payer_name": "Aetna", "plan_name": "700700", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna", "plan_name": "700700_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Miscellaneous", "plan_name": "700720", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Miscellaneous", "plan_name": "700720_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Ppo Hmo", "plan_name": "701720", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Ppo Hmo", "plan_name": "701720_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Ms State Emplo", "plan_name": "401457", "standard_charge_dollar": 23.66, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Ms State Emplo", "plan_name": "401457_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Basic Pl", "plan_name": "400100", "standard_charge_dollar": 23.66, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Basic Pl", "plan_name": "400100_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Federal", "plan_name": "400110", "standard_charge_dollar": 23.66, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Federal", "plan_name": "400110_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." } ] } ] }, { "description": "Assay nonendocrine receptor", "code_information": [ { "code": "84238", "type": "CPT" } ], "standard_charges": [ { "gross_charge": 145.00, "minimum": 54.80, "maximum": 54.80, "setting": "both", "payers_information": [ { "payer_name": "Aetna", "plan_name": "700700", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna", "plan_name": "700700_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Miscellaneous", "plan_name": "700720", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Miscellaneous", "plan_name": "700720_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Ppo Hmo", "plan_name": "701720", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Ppo Hmo", "plan_name": "701720_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Ms State Emplo", "plan_name": "401457", "standard_charge_dollar": 54.80, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Ms State Emplo", "plan_name": "401457_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Basic Pl", "plan_name": "400100", "standard_charge_dollar": 54.80, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Basic Pl", "plan_name": "400100_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Federal", "plan_name": "400110", "standard_charge_dollar": 54.80, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Federal", "plan_name": "400110_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." } ] } ] }, { "description": "Hc receptor assay nonedocrine", "code_information": [ { "code": "84238", "type": "CPT" } ], "standard_charges": [ { "gross_charge": 145.00, "minimum": 54.80, "maximum": 54.80, "setting": "both", "payers_information": [ { "payer_name": "Aetna", "plan_name": "700700", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna", "plan_name": "700700_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Miscellaneous", "plan_name": "700720", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Miscellaneous", "plan_name": "700720_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Ppo Hmo", "plan_name": "701720", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Ppo Hmo", "plan_name": "701720_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Ms State Emplo", "plan_name": "401457", "standard_charge_dollar": 54.80, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Ms State Emplo", "plan_name": "401457_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Basic Pl", "plan_name": "400100", "standard_charge_dollar": 54.80, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Basic Pl", "plan_name": "400100_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Federal", "plan_name": "400110", "standard_charge_dollar": 54.80, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Federal", "plan_name": "400110_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." } ] } ] }, { "description": "Assay of renin", "code_information": [ { "code": "84244", "type": "CPT" } ], "standard_charges": [ { "gross_charge": 101.50, "minimum": 32.96, "maximum": 32.96, "setting": "both", "payers_information": [ { "payer_name": "Aetna", "plan_name": "700700", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna", "plan_name": "700700_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Miscellaneous", "plan_name": "700720", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Miscellaneous", "plan_name": "700720_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Ppo Hmo", "plan_name": "701720", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Ppo Hmo", "plan_name": "701720_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Ms State Emplo", "plan_name": "401457", "standard_charge_dollar": 32.96, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Ms State Emplo", "plan_name": "401457_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Basic Pl", "plan_name": "400100", "standard_charge_dollar": 32.96, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Basic Pl", "plan_name": "400100_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Federal", "plan_name": "400110", "standard_charge_dollar": 32.96, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Federal", "plan_name": "400110_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." } ] } ] }, { "description": "Hc renin", "code_information": [ { "code": "84244", "type": "CPT" } ], "standard_charges": [ { "gross_charge": 101.50, "minimum": 32.96, "maximum": 32.96, "setting": "both", "payers_information": [ { "payer_name": "Aetna", "plan_name": "700700", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna", "plan_name": "700700_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Miscellaneous", "plan_name": "700720", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Miscellaneous", "plan_name": "700720_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Ppo Hmo", "plan_name": "701720", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Ppo Hmo", "plan_name": "701720_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Ms State Emplo", "plan_name": "401457", "standard_charge_dollar": 32.96, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Ms State Emplo", "plan_name": "401457_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Basic Pl", "plan_name": "400100", "standard_charge_dollar": 32.96, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Basic Pl", "plan_name": "400100_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Federal", "plan_name": "400110", "standard_charge_dollar": 32.96, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Federal", "plan_name": "400110_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." } ] } ] }, { "description": "Assay of selenium", "code_information": [ { "code": "84255", "type": "CPT" } ], "standard_charges": [ { "gross_charge": 63.12, "minimum": 38.26, "maximum": 38.26, "setting": "both", "payers_information": [ { "payer_name": "Aetna", "plan_name": "700700", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna", "plan_name": "700700_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Miscellaneous", "plan_name": "700720", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Miscellaneous", "plan_name": "700720_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Ppo Hmo", "plan_name": "701720", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Ppo Hmo", "plan_name": "701720_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Ms State Emplo", "plan_name": "401457", "standard_charge_dollar": 38.26, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Ms State Emplo", "plan_name": "401457_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Basic Pl", "plan_name": "400100", "standard_charge_dollar": 38.26, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Basic Pl", "plan_name": "400100_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Federal", "plan_name": "400110", "standard_charge_dollar": 38.26, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Federal", "plan_name": "400110_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." } ] } ] }, { "description": "Hc selenium", "code_information": [ { "code": "84255", "type": "CPT" } ], "standard_charges": [ { "gross_charge": 63.12, "minimum": 38.26, "maximum": 38.26, "setting": "both", "payers_information": [ { "payer_name": "Aetna", "plan_name": "700700", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna", "plan_name": "700700_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Miscellaneous", "plan_name": "700720", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Miscellaneous", "plan_name": "700720_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Ppo Hmo", "plan_name": "701720", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Ppo Hmo", "plan_name": "701720_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Ms State Emplo", "plan_name": "401457", "standard_charge_dollar": 38.26, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Ms State Emplo", "plan_name": "401457_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Basic Pl", "plan_name": "400100", "standard_charge_dollar": 38.26, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Basic Pl", "plan_name": "400100_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Federal", "plan_name": "400110", "standard_charge_dollar": 38.26, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Federal", "plan_name": "400110_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." } ] } ] }, { "description": "Assay of sex hormone globul", "code_information": [ { "code": "84270", "type": "CPT" } ], "standard_charges": [ { "gross_charge": 92.00, "minimum": 32.57, "maximum": 32.57, "setting": "both", "payers_information": [ { "payer_name": "Aetna", "plan_name": "700700", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna", "plan_name": "700700_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Miscellaneous", "plan_name": "700720", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Miscellaneous", "plan_name": "700720_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Ppo Hmo", "plan_name": "701720", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Ppo Hmo", "plan_name": "701720_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Ms State Emplo", "plan_name": "401457", "standard_charge_dollar": 32.57, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Ms State Emplo", "plan_name": "401457_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Basic Pl", "plan_name": "400100", "standard_charge_dollar": 32.57, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Basic Pl", "plan_name": "400100_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Federal", "plan_name": "400110", "standard_charge_dollar": 32.57, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Federal", "plan_name": "400110_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." } ] } ] }, { "description": "Hc sex hormone binding globulin", "code_information": [ { "code": "84270", "type": "CPT" } ], "standard_charges": [ { "gross_charge": 92.00, "minimum": 32.57, "maximum": 32.57, "setting": "both", "payers_information": [ { "payer_name": "Aetna", "plan_name": "700700", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna", "plan_name": "700700_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Miscellaneous", "plan_name": "700720", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Miscellaneous", "plan_name": "700720_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Ppo Hmo", "plan_name": "701720", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Ppo Hmo", "plan_name": "701720_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Ms State Emplo", "plan_name": "401457", "standard_charge_dollar": 32.57, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Ms State Emplo", "plan_name": "401457_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Basic Pl", "plan_name": "400100", "standard_charge_dollar": 32.57, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Basic Pl", "plan_name": "400100_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Federal", "plan_name": "400110", "standard_charge_dollar": 32.57, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Federal", "plan_name": "400110_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." } ] } ] }, { "description": "Assay of serum sodium", "code_information": [ { "code": "84295", "type": "CPT" } ], "standard_charges": [ { "gross_charge": 40.00, "minimum": 7.22, "maximum": 7.22, "setting": "both", "payers_information": [ { "payer_name": "Aetna", "plan_name": "700700", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna", "plan_name": "700700_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Miscellaneous", "plan_name": "700720", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Miscellaneous", "plan_name": "700720_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Ppo Hmo", "plan_name": "701720", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Ppo Hmo", "plan_name": "701720_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Ms State Emplo", "plan_name": "401457", "standard_charge_dollar": 7.22, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Ms State Emplo", "plan_name": "401457_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Basic Pl", "plan_name": "400100", "standard_charge_dollar": 7.22, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Basic Pl", "plan_name": "400100_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Federal", "plan_name": "400110", "standard_charge_dollar": 7.22, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Federal", "plan_name": "400110_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." } ] } ] }, { "description": "Hc sodium", "code_information": [ { "code": "84295", "type": "CPT" } ], "standard_charges": [ { "gross_charge": 40.00, "minimum": 7.22, "maximum": 7.22, "setting": "both", "payers_information": [ { "payer_name": "Aetna", "plan_name": "700700", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna", "plan_name": "700700_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Miscellaneous", "plan_name": "700720", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Miscellaneous", "plan_name": "700720_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Ppo Hmo", "plan_name": "701720", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Ppo Hmo", "plan_name": "701720_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Ms State Emplo", "plan_name": "401457", "standard_charge_dollar": 7.22, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Ms State Emplo", "plan_name": "401457_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Basic Pl", "plan_name": "400100", "standard_charge_dollar": 7.22, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Basic Pl", "plan_name": "400100_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Federal", "plan_name": "400110", "standard_charge_dollar": 7.22, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Federal", "plan_name": "400110_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." } ] } ] }, { "description": "Assay of urine sodium", "code_information": [ { "code": "84300", "type": "CPT" } ], "standard_charges": [ { "gross_charge": 40.84, "minimum": 7.29, "maximum": 7.29, "setting": "both", "payers_information": [ { "payer_name": "Aetna", "plan_name": "700700", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna", "plan_name": "700700_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Miscellaneous", "plan_name": "700720", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Miscellaneous", "plan_name": "700720_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Ppo Hmo", "plan_name": "701720", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Ppo Hmo", "plan_name": "701720_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Ms State Emplo", "plan_name": "401457", "standard_charge_dollar": 7.29, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Ms State Emplo", "plan_name": "401457_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Basic Pl", "plan_name": "400100", "standard_charge_dollar": 7.29, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Basic Pl", "plan_name": "400100_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Federal", "plan_name": "400110", "standard_charge_dollar": 7.29, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Federal", "plan_name": "400110_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." } ] } ] }, { "description": "Hc sodium urine 24 hr", "code_information": [ { "code": "84300", "type": "CPT" } ], "standard_charges": [ { "gross_charge": 40.84, "minimum": 7.29, "maximum": 7.29, "setting": "both", "payers_information": [ { "payer_name": "Aetna", "plan_name": "700700", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna", "plan_name": "700700_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Miscellaneous", "plan_name": "700720", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Miscellaneous", "plan_name": "700720_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Ppo Hmo", "plan_name": "701720", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Ppo Hmo", "plan_name": "701720_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Ms State Emplo", "plan_name": "401457", "standard_charge_dollar": 7.29, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Ms State Emplo", "plan_name": "401457_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Basic Pl", "plan_name": "400100", "standard_charge_dollar": 7.29, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Basic Pl", "plan_name": "400100_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Federal", "plan_name": "400110", "standard_charge_dollar": 7.29, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Federal", "plan_name": "400110_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." } ] } ] }, { "description": "Assay of sweat sodium", "code_information": [ { "code": "84302", "type": "CPT" } ], "standard_charges": [ { "gross_charge": 55.94, "minimum": 7.29, "maximum": 7.29, "setting": "both", "payers_information": [ { "payer_name": "Aetna", "plan_name": "700700", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna", "plan_name": "700700_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Miscellaneous", "plan_name": "700720", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Miscellaneous", "plan_name": "700720_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Ppo Hmo", "plan_name": "701720", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Ppo Hmo", "plan_name": "701720_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Ms State Emplo", "plan_name": "401457", "standard_charge_dollar": 7.29, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Ms State Emplo", "plan_name": "401457_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Basic Pl", "plan_name": "400100", "standard_charge_dollar": 7.29, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Basic Pl", "plan_name": "400100_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Federal", "plan_name": "400110", "standard_charge_dollar": 7.29, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Federal", "plan_name": "400110_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." } ] } ] }, { "description": "Hc sodium stool", "code_information": [ { "code": "84302", "type": "CPT" } ], "standard_charges": [ { "gross_charge": 55.94, "minimum": 7.29, "maximum": 7.29, "setting": "both", "payers_information": [ { "payer_name": "Aetna", "plan_name": "700700", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna", "plan_name": "700700_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Miscellaneous", "plan_name": "700720", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Miscellaneous", "plan_name": "700720_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Ppo Hmo", "plan_name": "701720", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Ppo Hmo", "plan_name": "701720_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Ms State Emplo", "plan_name": "401457", "standard_charge_dollar": 7.29, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Ms State Emplo", "plan_name": "401457_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Basic Pl", "plan_name": "400100", "standard_charge_dollar": 7.29, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Basic Pl", "plan_name": "400100_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Federal", "plan_name": "400110", "standard_charge_dollar": 7.29, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Federal", "plan_name": "400110_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." } ] } ] }, { "description": "Assay of somatomedin", "code_information": [ { "code": "84305", "type": "CPT" } ], "standard_charges": [ { "gross_charge": 119.00, "minimum": 31.86, "maximum": 31.86, "setting": "both", "payers_information": [ { "payer_name": "Aetna", "plan_name": "700700", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna", "plan_name": "700700_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Miscellaneous", "plan_name": "700720", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Miscellaneous", "plan_name": "700720_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Ppo Hmo", "plan_name": "701720", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Ppo Hmo", "plan_name": "701720_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Ms State Emplo", "plan_name": "401457", "standard_charge_dollar": 31.86, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Ms State Emplo", "plan_name": "401457_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Basic Pl", "plan_name": "400100", "standard_charge_dollar": 31.86, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Basic Pl", "plan_name": "400100_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Federal", "plan_name": "400110", "standard_charge_dollar": 31.86, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Federal", "plan_name": "400110_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." } ] } ] }, { "description": "Hc insulin like growth factor i", "code_information": [ { "code": "84305", "type": "CPT" } ], "standard_charges": [ { "gross_charge": 119.00, "minimum": 31.86, "maximum": 31.86, "setting": "both", "payers_information": [ { "payer_name": "Aetna", "plan_name": "700700", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna", "plan_name": "700700_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Miscellaneous", "plan_name": "700720", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Miscellaneous", "plan_name": "700720_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Ppo Hmo", "plan_name": "701720", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Ppo Hmo", "plan_name": "701720_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Ms State Emplo", "plan_name": "401457", "standard_charge_dollar": 31.86, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Ms State Emplo", "plan_name": "401457_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Basic Pl", "plan_name": "400100", "standard_charge_dollar": 31.86, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Basic Pl", "plan_name": "400100_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Federal", "plan_name": "400110", "standard_charge_dollar": 31.86, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Federal", "plan_name": "400110_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." } ] } ] }, { "description": "Hc sugars single qual ea", "code_information": [ { "code": "84376", "type": "CPT" } ], "standard_charges": [ { "gross_charge": 111.20, "minimum": 8.24, "maximum": 8.24, "setting": "both", "payers_information": [ { "payer_name": "Aetna", "plan_name": "700700", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna", "plan_name": "700700_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Miscellaneous", "plan_name": "700720", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Miscellaneous", "plan_name": "700720_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Ppo Hmo", "plan_name": "701720", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Ppo Hmo", "plan_name": "701720_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Ms State Emplo", "plan_name": "401457", "standard_charge_dollar": 8.24, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Ms State Emplo", "plan_name": "401457_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Basic Pl", "plan_name": "400100", "standard_charge_dollar": 8.24, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Basic Pl", "plan_name": "400100_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Federal", "plan_name": "400110", "standard_charge_dollar": 8.24, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Federal", "plan_name": "400110_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." } ] } ] }, { "description": "Sugars single qual", "code_information": [ { "code": "84376", "type": "CPT" } ], "standard_charges": [ { "gross_charge": 111.20, "minimum": 8.24, "maximum": 8.24, "setting": "both", "payers_information": [ { "payer_name": "Aetna", "plan_name": "700700", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna", "plan_name": "700700_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Miscellaneous", "plan_name": "700720", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Miscellaneous", "plan_name": "700720_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Ppo Hmo", "plan_name": "701720", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Ppo Hmo", "plan_name": "701720_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Ms State Emplo", "plan_name": "401457", "standard_charge_dollar": 8.24, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Ms State Emplo", "plan_name": "401457_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Basic Pl", "plan_name": "400100", "standard_charge_dollar": 8.24, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Basic Pl", "plan_name": "400100_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Federal", "plan_name": "400110", "standard_charge_dollar": 8.24, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Federal", "plan_name": "400110_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." } ] } ] }, { "description": "Hc sugars mono di&oligos mlt qualitative each spec", "code_information": [ { "code": "84377", "type": "CPT" } ], "standard_charges": [ { "gross_charge": 111.20, "minimum": 8.24, "maximum": 8.24, "setting": "both", "payers_information": [ { "payer_name": "Aetna", "plan_name": "700700", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna", "plan_name": "700700_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Miscellaneous", "plan_name": "700720", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Miscellaneous", "plan_name": "700720_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Ppo Hmo", "plan_name": "701720", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Ppo Hmo", "plan_name": "701720_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Ms State Emplo", "plan_name": "401457", "standard_charge_dollar": 8.24, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Ms State Emplo", "plan_name": "401457_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Basic Pl", "plan_name": "400100", "standard_charge_dollar": 8.24, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Basic Pl", "plan_name": "400100_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Federal", "plan_name": "400110", "standard_charge_dollar": 8.24, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Federal", "plan_name": "400110_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." } ] } ] }, { "description": "Sugars multiple qual", "code_information": [ { "code": "84377", "type": "CPT" } ], "standard_charges": [ { "gross_charge": 111.20, "minimum": 8.24, "maximum": 8.24, "setting": "both", "payers_information": [ { "payer_name": "Aetna", "plan_name": "700700", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna", "plan_name": "700700_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Miscellaneous", "plan_name": "700720", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Miscellaneous", "plan_name": "700720_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Ppo Hmo", "plan_name": "701720", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Ppo Hmo", "plan_name": "701720_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Ms State Emplo", "plan_name": "401457", "standard_charge_dollar": 8.24, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Ms State Emplo", "plan_name": "401457_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Basic Pl", "plan_name": "400100", "standard_charge_dollar": 8.24, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Basic Pl", "plan_name": "400100_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Federal", "plan_name": "400110", "standard_charge_dollar": 8.24, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Federal", "plan_name": "400110_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." } ] } ] }, { "description": "Assay of free testosterone", "code_information": [ { "code": "84402", "type": "CPT" } ], "standard_charges": [ { "gross_charge": 100.50, "minimum": 38.16, "maximum": 38.16, "setting": "both", "payers_information": [ { "payer_name": "Aetna", "plan_name": "700700", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna", "plan_name": "700700_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Miscellaneous", "plan_name": "700720", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Miscellaneous", "plan_name": "700720_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Ppo Hmo", "plan_name": "701720", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Ppo Hmo", "plan_name": "701720_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Ms State Emplo", "plan_name": "401457", "standard_charge_dollar": 38.16, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Ms State Emplo", "plan_name": "401457_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Basic Pl", "plan_name": "400100", "standard_charge_dollar": 38.16, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Basic Pl", "plan_name": "400100_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Federal", "plan_name": "400110", "standard_charge_dollar": 38.16, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Federal", "plan_name": "400110_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." } ] } ] }, { "description": "Hc free testosterone", "code_information": [ { "code": "84402", "type": "CPT" } ], "standard_charges": [ { "gross_charge": 100.50, "minimum": 38.16, "maximum": 38.16, "setting": "both", "payers_information": [ { "payer_name": "Aetna", "plan_name": "700700", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna", "plan_name": "700700_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Miscellaneous", "plan_name": "700720", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Miscellaneous", "plan_name": "700720_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Ppo Hmo", "plan_name": "701720", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Ppo Hmo", "plan_name": "701720_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Ms State Emplo", "plan_name": "401457", "standard_charge_dollar": 38.16, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Ms State Emplo", "plan_name": "401457_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Basic Pl", "plan_name": "400100", "standard_charge_dollar": 38.16, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Basic Pl", "plan_name": "400100_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Federal", "plan_name": "400110", "standard_charge_dollar": 38.16, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Federal", "plan_name": "400110_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." } ] } ] }, { "description": "Assay of total testosterone", "code_information": [ { "code": "84403", "type": "CPT" } ], "standard_charges": [ { "gross_charge": 123.50, "minimum": 38.69, "maximum": 38.69, "setting": "both", "payers_information": [ { "payer_name": "Aetna", "plan_name": "700700", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna", "plan_name": "700700_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Miscellaneous", "plan_name": "700720", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Miscellaneous", "plan_name": "700720_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Ppo Hmo", "plan_name": "701720", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Ppo Hmo", "plan_name": "701720_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Ms State Emplo", "plan_name": "401457", "standard_charge_dollar": 38.69, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Ms State Emplo", "plan_name": "401457_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Basic Pl", "plan_name": "400100", "standard_charge_dollar": 38.69, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Basic Pl", "plan_name": "400100_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Federal", "plan_name": "400110", "standard_charge_dollar": 38.69, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Federal", "plan_name": "400110_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." } ] } ] }, { "description": "Hc total testosterone", "code_information": [ { "code": "84403", "type": "CPT" } ], "standard_charges": [ { "gross_charge": 123.50, "minimum": 38.69, "maximum": 38.69, "setting": "both", "payers_information": [ { "payer_name": "Aetna", "plan_name": "700700", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna", "plan_name": "700700_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Miscellaneous", "plan_name": "700720", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Miscellaneous", "plan_name": "700720_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Ppo Hmo", "plan_name": "701720", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Ppo Hmo", "plan_name": "701720_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Ms State Emplo", "plan_name": "401457", "standard_charge_dollar": 38.69, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Ms State Emplo", "plan_name": "401457_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Basic Pl", "plan_name": "400100", "standard_charge_dollar": 38.69, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Basic Pl", "plan_name": "400100_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Federal", "plan_name": "400110", "standard_charge_dollar": 38.69, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Federal", "plan_name": "400110_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." } ] } ] }, { "description": "Assay of vitamin b-1", "code_information": [ { "code": "84425", "type": "CPT" } ], "standard_charges": [ { "gross_charge": 200.00, "minimum": 23.66, "maximum": 23.66, "setting": "both", "payers_information": [ { "payer_name": "Aetna", "plan_name": "700700", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna", "plan_name": "700700_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Miscellaneous", "plan_name": "700720", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Miscellaneous", "plan_name": "700720_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Ppo Hmo", "plan_name": "701720", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Ppo Hmo", "plan_name": "701720_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Ms State Emplo", "plan_name": "401457", "standard_charge_dollar": 23.66, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Ms State Emplo", "plan_name": "401457_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Basic Pl", "plan_name": "400100", "standard_charge_dollar": 23.66, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Basic Pl", "plan_name": "400100_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Federal", "plan_name": "400110", "standard_charge_dollar": 23.66, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Federal", "plan_name": "400110_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." } ] } ] }, { "description": "Hc thiamine vit b1", "code_information": [ { "code": "84425", "type": "CPT" } ], "standard_charges": [ { "gross_charge": 200.00, "minimum": 23.66, "maximum": 23.66, "setting": "both", "payers_information": [ { "payer_name": "Aetna", "plan_name": "700700", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna", "plan_name": "700700_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Miscellaneous", "plan_name": "700720", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Miscellaneous", "plan_name": "700720_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Ppo Hmo", "plan_name": "701720", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Ppo Hmo", "plan_name": "701720_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Ms State Emplo", "plan_name": "401457", "standard_charge_dollar": 23.66, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Ms State Emplo", "plan_name": "401457_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Basic Pl", "plan_name": "400100", "standard_charge_dollar": 23.66, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Basic Pl", "plan_name": "400100_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Federal", "plan_name": "400110", "standard_charge_dollar": 23.66, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Federal", "plan_name": "400110_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." } ] } ] }, { "description": "Assay of thyroglobulin", "code_information": [ { "code": "84432", "type": "CPT" } ], "standard_charges": [ { "gross_charge": 297.60, "minimum": 13.50, "maximum": 13.50, "setting": "both", "payers_information": [ { "payer_name": "Aetna", "plan_name": "700700", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna", "plan_name": "700700_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Miscellaneous", "plan_name": "700720", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Miscellaneous", "plan_name": "700720_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Ppo Hmo", "plan_name": "701720", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Ppo Hmo", "plan_name": "701720_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Ms State Emplo", "plan_name": "401457", "standard_charge_dollar": 13.50, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Ms State Emplo", "plan_name": "401457_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Basic Pl", "plan_name": "400100", "standard_charge_dollar": 13.50, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Basic Pl", "plan_name": "400100_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Federal", "plan_name": "400110", "standard_charge_dollar": 13.50, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Federal", "plan_name": "400110_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." } ] } ] }, { "description": "Hc thyroglobulin mass spec (tgms)", "code_information": [ { "code": "84432", "type": "CPT" } ], "standard_charges": [ { "gross_charge": 297.60, "minimum": 13.50, "maximum": 13.50, "setting": "both", "payers_information": [ { "payer_name": "Aetna", "plan_name": "700700", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna", "plan_name": "700700_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Miscellaneous", "plan_name": "700720", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Miscellaneous", "plan_name": "700720_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Ppo Hmo", "plan_name": "701720", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Ppo Hmo", "plan_name": "701720_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Ms State Emplo", "plan_name": "401457", "standard_charge_dollar": 13.50, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Ms State Emplo", "plan_name": "401457_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Basic Pl", "plan_name": "400100", "standard_charge_dollar": 13.50, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Basic Pl", "plan_name": "400100_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Federal", "plan_name": "400110", "standard_charge_dollar": 13.50, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Federal", "plan_name": "400110_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." } ] } ] }, { "description": "Asy thiopurin s-mthyltrnsfrs", "code_information": [ { "code": "84433", "type": "CPT" } ], "standard_charges": [ { "gross_charge": 477.30, "minimum": 381.84, "maximum": 405.71, "setting": "both", "payers_information": [ { "payer_name": "Aetna", "plan_name": "700700", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna", "plan_name": "700700_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Miscellaneous", "plan_name": "700720", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Miscellaneous", "plan_name": "700720_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Ppo Hmo", "plan_name": "701720", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Ppo Hmo", "plan_name": "701720_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Ms State Emplo", "plan_name": "401457", "standard_charge_percentage": 0.80, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Ms State Emplo", "plan_name": "401457_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Basic Pl", "plan_name": "400100", "standard_charge_percentage": 0.85, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Basic Pl", "plan_name": "400100_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Federal", "plan_name": "400110", "standard_charge_percentage": 0.85, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Federal", "plan_name": "400110_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." } ] } ] }, { "description": "Hc thiopurine methyltransfe act rbc(mtpmt3)", "code_information": [ { "code": "84433", "type": "CPT" } ], "standard_charges": [ { "gross_charge": 477.30, "minimum": 381.84, "maximum": 405.71, "setting": "both", "payers_information": [ { "payer_name": "Aetna", "plan_name": "700700", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna", "plan_name": "700700_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Miscellaneous", "plan_name": "700720", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Miscellaneous", "plan_name": "700720_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Ppo Hmo", "plan_name": "701720", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Ppo Hmo", "plan_name": "701720_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Ms State Emplo", "plan_name": "401457", "standard_charge_percentage": 0.80, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Ms State Emplo", "plan_name": "401457_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Basic Pl", "plan_name": "400100", "standard_charge_percentage": 0.85, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Basic Pl", "plan_name": "400100_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Federal", "plan_name": "400110", "standard_charge_percentage": 0.85, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Federal", "plan_name": "400110_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." } ] } ] }, { "description": "Assay of total thyroxine", "code_information": [ { "code": "84436", "type": "CPT" } ], "standard_charges": [ { "gross_charge": 79.85, "minimum": 10.29, "maximum": 10.29, "setting": "both", "payers_information": [ { "payer_name": "Aetna", "plan_name": "700700", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna", "plan_name": "700700_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Miscellaneous", "plan_name": "700720", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Miscellaneous", "plan_name": "700720_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Ppo Hmo", "plan_name": "701720", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Ppo Hmo", "plan_name": "701720_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Ms State Emplo", "plan_name": "401457", "standard_charge_dollar": 10.29, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Ms State Emplo", "plan_name": "401457_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Basic Pl", "plan_name": "400100", "standard_charge_dollar": 10.29, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Basic Pl", "plan_name": "400100_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Federal", "plan_name": "400110", "standard_charge_dollar": 10.29, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Federal", "plan_name": "400110_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." } ] } ] }, { "description": "Hc thyroxine total", "code_information": [ { "code": "84436", "type": "CPT" } ], "standard_charges": [ { "gross_charge": 79.85, "minimum": 10.29, "maximum": 10.29, "setting": "both", "payers_information": [ { "payer_name": "Aetna", "plan_name": "700700", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna", "plan_name": "700700_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Miscellaneous", "plan_name": "700720", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Miscellaneous", "plan_name": "700720_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Ppo Hmo", "plan_name": "701720", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Ppo Hmo", "plan_name": "701720_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Ms State Emplo", "plan_name": "401457", "standard_charge_dollar": 10.29, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Ms State Emplo", "plan_name": "401457_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Basic Pl", "plan_name": "400100", "standard_charge_dollar": 10.29, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Basic Pl", "plan_name": "400100_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Federal", "plan_name": "400110", "standard_charge_dollar": 10.29, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Federal", "plan_name": "400110_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." } ] } ] }, { "description": "Assay of free thyroxine", "code_information": [ { "code": "84439", "type": "CPT" } ], "standard_charges": [ { "gross_charge": 100.00, "minimum": 13.51, "maximum": 13.51, "setting": "both", "payers_information": [ { "payer_name": "Aetna", "plan_name": "700700", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna", "plan_name": "700700_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Miscellaneous", "plan_name": "700720", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Miscellaneous", "plan_name": "700720_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Ppo Hmo", "plan_name": "701720", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Ppo Hmo", "plan_name": "701720_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Ms State Emplo", "plan_name": "401457", "standard_charge_dollar": 13.51, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Ms State Emplo", "plan_name": "401457_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Basic Pl", "plan_name": "400100", "standard_charge_dollar": 13.51, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Basic Pl", "plan_name": "400100_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Federal", "plan_name": "400110", "standard_charge_dollar": 13.51, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Federal", "plan_name": "400110_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." } ] } ] }, { "description": "Hc thyroxine free", "code_information": [ { "code": "84439", "type": "CPT" } ], "standard_charges": [ { "gross_charge": 100.00, "minimum": 13.51, "maximum": 13.51, "setting": "both", "payers_information": [ { "payer_name": "Aetna", "plan_name": "700700", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna", "plan_name": "700700_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Miscellaneous", "plan_name": "700720", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Miscellaneous", "plan_name": "700720_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Ppo Hmo", "plan_name": "701720", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Ppo Hmo", "plan_name": "701720_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Ms State Emplo", "plan_name": "401457", "standard_charge_dollar": 13.51, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Ms State Emplo", "plan_name": "401457_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Basic Pl", "plan_name": "400100", "standard_charge_dollar": 13.51, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Basic Pl", "plan_name": "400100_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Federal", "plan_name": "400110", "standard_charge_dollar": 13.51, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Federal", "plan_name": "400110_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." } ] } ] }, { "description": "Assay thyroid stim hormone", "code_information": [ { "code": "84443", "type": "CPT" } ], "standard_charges": [ { "gross_charge": 175.00, "minimum": 24.37, "maximum": 24.37, "setting": "both", "payers_information": [ { "payer_name": "Aetna", "plan_name": "700700", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna", "plan_name": "700700_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Miscellaneous", "plan_name": "700720", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Miscellaneous", "plan_name": "700720_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Ppo Hmo", "plan_name": "701720", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Ppo Hmo", "plan_name": "701720_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Ms State Emplo", "plan_name": "401457", "standard_charge_dollar": 24.37, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Ms State Emplo", "plan_name": "401457_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Basic Pl", "plan_name": "400100", "standard_charge_dollar": 24.37, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Basic Pl", "plan_name": "400100_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Federal", "plan_name": "400110", "standard_charge_dollar": 24.37, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Federal", "plan_name": "400110_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." } ] } ] }, { "description": "Hc tsh", "code_information": [ { "code": "84443", "type": "CPT" } ], "standard_charges": [ { "gross_charge": 175.00, "minimum": 24.37, "maximum": 24.37, "setting": "both", "payers_information": [ { "payer_name": "Aetna", "plan_name": "700700", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna", "plan_name": "700700_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Miscellaneous", "plan_name": "700720", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Miscellaneous", "plan_name": "700720_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Ppo Hmo", "plan_name": "701720", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Ppo Hmo", "plan_name": "701720_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Ms State Emplo", "plan_name": "401457", "standard_charge_dollar": 24.37, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Ms State Emplo", "plan_name": "401457_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Basic Pl", "plan_name": "400100", "standard_charge_dollar": 24.37, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Basic Pl", "plan_name": "400100_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Federal", "plan_name": "400110", "standard_charge_dollar": 24.37, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Federal", "plan_name": "400110_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." } ] } ] }, { "description": "Assay of tsi globulin", "code_information": [ { "code": "84445", "type": "CPT" } ], "standard_charges": [ { "gross_charge": 165.50, "minimum": 36.42, "maximum": 36.42, "setting": "both", "payers_information": [ { "payer_name": "Aetna", "plan_name": "700700", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna", "plan_name": "700700_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Miscellaneous", "plan_name": "700720", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Miscellaneous", "plan_name": "700720_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Ppo Hmo", "plan_name": "701720", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Ppo Hmo", "plan_name": "701720_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Ms State Emplo", "plan_name": "401457", "standard_charge_dollar": 36.42, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Ms State Emplo", "plan_name": "401457_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Basic Pl", "plan_name": "400100", "standard_charge_dollar": 36.42, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Basic Pl", "plan_name": "400100_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Federal", "plan_name": "400110", "standard_charge_dollar": 36.42, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Federal", "plan_name": "400110_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." } ] } ] }, { "description": "Hc thyroid stimulating immunoglobuli", "code_information": [ { "code": "84445", "type": "CPT" } ], "standard_charges": [ { "gross_charge": 165.50, "minimum": 36.42, "maximum": 36.42, "setting": "both", "payers_information": [ { "payer_name": "Aetna", "plan_name": "700700", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna", "plan_name": "700700_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Miscellaneous", "plan_name": "700720", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Miscellaneous", "plan_name": "700720_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Ppo Hmo", "plan_name": "701720", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Ppo Hmo", "plan_name": "701720_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Ms State Emplo", "plan_name": "401457", "standard_charge_dollar": 36.42, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Ms State Emplo", "plan_name": "401457_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Basic Pl", "plan_name": "400100", "standard_charge_dollar": 36.42, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Basic Pl", "plan_name": "400100_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Federal", "plan_name": "400110", "standard_charge_dollar": 36.42, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Federal", "plan_name": "400110_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." } ] } ] }, { "description": "Assay of vitamin e", "code_information": [ { "code": "84446", "type": "CPT" } ], "standard_charges": [ { "gross_charge": 71.00, "minimum": 21.24, "maximum": 21.24, "setting": "both", "payers_information": [ { "payer_name": "Aetna", "plan_name": "700700", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna", "plan_name": "700700_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Miscellaneous", "plan_name": "700720", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Miscellaneous", "plan_name": "700720_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Ppo Hmo", "plan_name": "701720", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Ppo Hmo", "plan_name": "701720_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Ms State Emplo", "plan_name": "401457", "standard_charge_dollar": 21.24, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Ms State Emplo", "plan_name": "401457_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Basic Pl", "plan_name": "400100", "standard_charge_dollar": 21.24, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Basic Pl", "plan_name": "400100_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Federal", "plan_name": "400110", "standard_charge_dollar": 21.24, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Federal", "plan_name": "400110_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." } ] } ] }, { "description": "Hc tocopheral alpha vit e", "code_information": [ { "code": "84446", "type": "CPT" } ], "standard_charges": [ { "gross_charge": 71.00, "minimum": 21.24, "maximum": 21.24, "setting": "both", "payers_information": [ { "payer_name": "Aetna", "plan_name": "700700", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna", "plan_name": "700700_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Miscellaneous", "plan_name": "700720", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Miscellaneous", "plan_name": "700720_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Ppo Hmo", "plan_name": "701720", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Ppo Hmo", "plan_name": "701720_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Ms State Emplo", "plan_name": "401457", "standard_charge_dollar": 21.24, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Ms State Emplo", "plan_name": "401457_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Basic Pl", "plan_name": "400100", "standard_charge_dollar": 21.24, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Basic Pl", "plan_name": "400100_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Federal", "plan_name": "400110", "standard_charge_dollar": 21.24, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Federal", "plan_name": "400110_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." } ] } ] }, { "description": "Hc transferase ast sgot", "code_information": [ { "code": "84450", "type": "CPT" } ], "standard_charges": [ { "gross_charge": 40.00, "minimum": 7.76, "maximum": 7.76, "setting": "both", "payers_information": [ { "payer_name": "Aetna", "plan_name": "700700", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna", "plan_name": "700700_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Miscellaneous", "plan_name": "700720", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Miscellaneous", "plan_name": "700720_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Ppo Hmo", "plan_name": "701720", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Ppo Hmo", "plan_name": "701720_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Ms State Emplo", "plan_name": "401457", "standard_charge_dollar": 7.76, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Ms State Emplo", "plan_name": "401457_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Basic Pl", "plan_name": "400100", "standard_charge_dollar": 7.76, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Basic Pl", "plan_name": "400100_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Federal", "plan_name": "400110", "standard_charge_dollar": 7.76, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Federal", "plan_name": "400110_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." } ] } ] }, { "description": "Transferase (ast) (sgot)", "code_information": [ { "code": "84450", "type": "CPT" } ], "standard_charges": [ { "gross_charge": 40.00, "minimum": 7.76, "maximum": 7.76, "setting": "both", "payers_information": [ { "payer_name": "Aetna", "plan_name": "700700", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna", "plan_name": "700700_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Miscellaneous", "plan_name": "700720", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Miscellaneous", "plan_name": "700720_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Ppo Hmo", "plan_name": "701720", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Ppo Hmo", "plan_name": "701720_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Ms State Emplo", "plan_name": "401457", "standard_charge_dollar": 7.76, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Ms State Emplo", "plan_name": "401457_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Basic Pl", "plan_name": "400100", "standard_charge_dollar": 7.76, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Basic Pl", "plan_name": "400100_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Federal", "plan_name": "400110", "standard_charge_dollar": 7.76, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Federal", "plan_name": "400110_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." } ] } ] }, { "description": "Alanine amino (alt) (sgpt)", "code_information": [ { "code": "84460", "type": "CPT" } ], "standard_charges": [ { "gross_charge": 40.00, "minimum": 7.94, "maximum": 7.94, "setting": "both", "payers_information": [ { "payer_name": "Aetna", "plan_name": "700700", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna", "plan_name": "700700_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Miscellaneous", "plan_name": "700720", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Miscellaneous", "plan_name": "700720_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Ppo Hmo", "plan_name": "701720", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Ppo Hmo", "plan_name": "701720_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Ms State Emplo", "plan_name": "401457", "standard_charge_dollar": 7.94, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Ms State Emplo", "plan_name": "401457_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Basic Pl", "plan_name": "400100", "standard_charge_dollar": 7.94, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Basic Pl", "plan_name": "400100_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Federal", "plan_name": "400110", "standard_charge_dollar": 7.94, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Federal", "plan_name": "400110_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." } ] } ] }, { "description": "Hc transferace alt sgpt", "code_information": [ { "code": "84460", "type": "CPT" } ], "standard_charges": [ { "gross_charge": 40.00, "minimum": 7.94, "maximum": 7.94, "setting": "both", "payers_information": [ { "payer_name": "Aetna", "plan_name": "700700", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna", "plan_name": "700700_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Miscellaneous", "plan_name": "700720", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Miscellaneous", "plan_name": "700720_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Ppo Hmo", "plan_name": "701720", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Ppo Hmo", "plan_name": "701720_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Ms State Emplo", "plan_name": "401457", "standard_charge_dollar": 7.94, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Ms State Emplo", "plan_name": "401457_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Basic Pl", "plan_name": "400100", "standard_charge_dollar": 7.94, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Basic Pl", "plan_name": "400100_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Federal", "plan_name": "400110", "standard_charge_dollar": 7.94, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Federal", "plan_name": "400110_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." } ] } ] }, { "description": "Assay of transferrin", "code_information": [ { "code": "84466", "type": "CPT" } ], "standard_charges": [ { "gross_charge": 49.77, "minimum": 8.71, "maximum": 8.71, "setting": "both", "payers_information": [ { "payer_name": "Aetna", "plan_name": "700700", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna", "plan_name": "700700_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Miscellaneous", "plan_name": "700720", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Miscellaneous", "plan_name": "700720_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Ppo Hmo", "plan_name": "701720", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Ppo Hmo", "plan_name": "701720_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Ms State Emplo", "plan_name": "401457", "standard_charge_dollar": 8.71, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Ms State Emplo", "plan_name": "401457_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Basic Pl", "plan_name": "400100", "standard_charge_dollar": 8.71, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Basic Pl", "plan_name": "400100_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Federal", "plan_name": "400110", "standard_charge_dollar": 8.71, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Federal", "plan_name": "400110_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." } ] } ] }, { "description": "Hc transferrin", "code_information": [ { "code": "84466", "type": "CPT" } ], "standard_charges": [ { "gross_charge": 49.77, "minimum": 8.71, "maximum": 8.71, "setting": "both", "payers_information": [ { "payer_name": "Aetna", "plan_name": "700700", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna", "plan_name": "700700_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Miscellaneous", "plan_name": "700720", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Miscellaneous", "plan_name": "700720_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Ppo Hmo", "plan_name": "701720", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Ppo Hmo", "plan_name": "701720_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Ms State Emplo", "plan_name": "401457", "standard_charge_dollar": 8.71, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Ms State Emplo", "plan_name": "401457_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Basic Pl", "plan_name": "400100", "standard_charge_dollar": 8.71, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Basic Pl", "plan_name": "400100_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Federal", "plan_name": "400110", "standard_charge_dollar": 8.71, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Federal", "plan_name": "400110_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." } ] } ] }, { "description": "Assay of triglycerides", "code_information": [ { "code": "84478", "type": "CPT" } ], "standard_charges": [ { "gross_charge": 37.17, "minimum": 5.74, "maximum": 8.61, "setting": "both", "payers_information": [ { "payer_name": "Aarp", "plan_name": "500102", "standard_charge_dollar": 5.74, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna", "plan_name": "700700", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna", "plan_name": "700700_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Mcare Ffs 6005", "plan_name": "700703", "standard_charge_dollar": 5.74, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Miscellaneous", "plan_name": "700720", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Miscellaneous", "plan_name": "700720_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Ppo Hmo", "plan_name": "701720", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Ppo Hmo", "plan_name": "701720_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Ambetter 68069", "plan_name": "500516", "standard_charge_dollar": 5.74, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Ms State Emplo", "plan_name": "401457", "standard_charge_dollar": 8.61, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Ms State Emplo", "plan_name": "401457_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Basic Pl", "plan_name": "400100", "standard_charge_dollar": 8.61, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Basic Pl", "plan_name": "400100_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Federal", "plan_name": "400110", "standard_charge_dollar": 8.61, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Federal", "plan_name": "400110_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Cigna Healthsprings Ffs", "plan_name": "500064", "standard_charge_dollar": 5.74, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Conseco", "plan_name": "500302", "standard_charge_dollar": 5.74, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Humana Ffs 61101", "plan_name": "500006", "standard_charge_dollar": 5.74, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Medicare A", "plan_name": "100100", "standard_charge_dollar": 5.74, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Medicare A", "plan_name": "100500", "standard_charge_dollar": 5.74, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Medicare Part B Only", "plan_name": "100300", "standard_charge_dollar": 5.74, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Medicare Railroad", "plan_name": "100103", "standard_charge_dollar": 5.74, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Ms Physicians Care N", "plan_name": "714210", "standard_charge_dollar": 7.18, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Peoples Hlth Ffs 72126", "plan_name": "500019", "standard_charge_dollar": 5.74, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Uhc/Secure Horizons", "plan_name": "500449", "standard_charge_dollar": 5.74, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "United Health Care/", "plan_name": "500292", "standard_charge_dollar": 6.49, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "United Healthcare", "plan_name": "750104", "standard_charge_dollar": 6.49, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "United Healthcare Ba", "plan_name": "750090", "standard_charge_dollar": 6.49, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "United Healthcare Me", "plan_name": "501310", "standard_charge_dollar": 5.74, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Windsor Mcare Extra", "plan_name": "500778", "standard_charge_dollar": 5.74, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." } ] } ] }, { "description": "Hc triglycerides", "code_information": [ { "code": "84478", "type": "CPT" } ], "standard_charges": [ { "gross_charge": 37.17, "minimum": 5.74, "maximum": 8.61, "setting": "both", "payers_information": [ { "payer_name": "Aarp", "plan_name": "500102", "standard_charge_dollar": 5.74, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna", "plan_name": "700700", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna", "plan_name": "700700_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Mcare Ffs 6005", "plan_name": "700703", "standard_charge_dollar": 5.74, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Miscellaneous", "plan_name": "700720", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Miscellaneous", "plan_name": "700720_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Ppo Hmo", "plan_name": "701720", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Ppo Hmo", "plan_name": "701720_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Ambetter 68069", "plan_name": "500516", "standard_charge_dollar": 5.74, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Ms State Emplo", "plan_name": "401457", "standard_charge_dollar": 8.61, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Ms State Emplo", "plan_name": "401457_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Basic Pl", "plan_name": "400100", "standard_charge_dollar": 8.61, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Basic Pl", "plan_name": "400100_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Federal", "plan_name": "400110", "standard_charge_dollar": 8.61, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Federal", "plan_name": "400110_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Cigna Healthsprings Ffs", "plan_name": "500064", "standard_charge_dollar": 5.74, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Conseco", "plan_name": "500302", "standard_charge_dollar": 5.74, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Humana Ffs 61101", "plan_name": "500006", "standard_charge_dollar": 5.74, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Medicare A", "plan_name": "100100", "standard_charge_dollar": 5.74, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Medicare A", "plan_name": "100500", "standard_charge_dollar": 5.74, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Medicare Part B Only", "plan_name": "100300", "standard_charge_dollar": 5.74, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Medicare Railroad", "plan_name": "100103", "standard_charge_dollar": 5.74, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Ms Physicians Care N", "plan_name": "714210", "standard_charge_dollar": 7.18, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Peoples Hlth Ffs 72126", "plan_name": "500019", "standard_charge_dollar": 5.74, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Uhc/Secure Horizons", "plan_name": "500449", "standard_charge_dollar": 5.74, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "United Health Care/", "plan_name": "500292", "standard_charge_dollar": 6.49, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "United Healthcare", "plan_name": "750104", "standard_charge_dollar": 6.49, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "United Healthcare Ba", "plan_name": "750090", "standard_charge_dollar": 6.49, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "United Healthcare Me", "plan_name": "501310", "standard_charge_dollar": 5.74, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Windsor Mcare Extra", "plan_name": "500778", "standard_charge_dollar": 5.74, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." } ] } ] }, { "description": "Assay of thyroid (t3 or t4)", "code_information": [ { "code": "84479", "type": "CPT" } ], "standard_charges": [ { "gross_charge": 93.60, "minimum": 9.69, "maximum": 9.69, "setting": "both", "payers_information": [ { "payer_name": "Aetna", "plan_name": "700700", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna", "plan_name": "700700_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Miscellaneous", "plan_name": "700720", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Miscellaneous", "plan_name": "700720_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Ppo Hmo", "plan_name": "701720", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Ppo Hmo", "plan_name": "701720_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Ms State Emplo", "plan_name": "401457", "standard_charge_dollar": 9.69, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Ms State Emplo", "plan_name": "401457_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Basic Pl", "plan_name": "400100", "standard_charge_dollar": 9.69, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Basic Pl", "plan_name": "400100_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Federal", "plan_name": "400110", "standard_charge_dollar": 9.69, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Federal", "plan_name": "400110_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." } ] } ] }, { "description": "Hc t3 or t4 uptake or thbr", "code_information": [ { "code": "84479", "type": "CPT" } ], "standard_charges": [ { "gross_charge": 93.60, "minimum": 9.69, "maximum": 9.69, "setting": "both", "payers_information": [ { "payer_name": "Aetna", "plan_name": "700700", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna", "plan_name": "700700_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Miscellaneous", "plan_name": "700720", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Miscellaneous", "plan_name": "700720_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Ppo Hmo", "plan_name": "701720", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Ppo Hmo", "plan_name": "701720_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Ms State Emplo", "plan_name": "401457", "standard_charge_dollar": 9.69, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Ms State Emplo", "plan_name": "401457_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Basic Pl", "plan_name": "400100", "standard_charge_dollar": 9.69, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Basic Pl", "plan_name": "400100_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Federal", "plan_name": "400110", "standard_charge_dollar": 9.69, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Federal", "plan_name": "400110_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." } ] } ] }, { "description": "Assay triiodothyronine (t3)", "code_information": [ { "code": "84480", "type": "CPT" } ], "standard_charges": [ { "gross_charge": 142.00, "minimum": 21.24, "maximum": 21.24, "setting": "both", "payers_information": [ { "payer_name": "Aetna", "plan_name": "700700", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna", "plan_name": "700700_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Miscellaneous", "plan_name": "700720", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Miscellaneous", "plan_name": "700720_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Ppo Hmo", "plan_name": "701720", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Ppo Hmo", "plan_name": "701720_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Ms State Emplo", "plan_name": "401457", "standard_charge_dollar": 21.24, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Ms State Emplo", "plan_name": "401457_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Basic Pl", "plan_name": "400100", "standard_charge_dollar": 21.24, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Basic Pl", "plan_name": "400100_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Federal", "plan_name": "400110", "standard_charge_dollar": 21.24, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Federal", "plan_name": "400110_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." } ] } ] }, { "description": "Hc t3 total", "code_information": [ { "code": "84480", "type": "CPT" } ], "standard_charges": [ { "gross_charge": 142.00, "minimum": 21.24, "maximum": 21.24, "setting": "both", "payers_information": [ { "payer_name": "Aetna", "plan_name": "700700", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna", "plan_name": "700700_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Miscellaneous", "plan_name": "700720", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Miscellaneous", "plan_name": "700720_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Ppo Hmo", "plan_name": "701720", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Ppo Hmo", "plan_name": "701720_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Ms State Emplo", "plan_name": "401457", "standard_charge_dollar": 21.24, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Ms State Emplo", "plan_name": "401457_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Basic Pl", "plan_name": "400100", "standard_charge_dollar": 21.24, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Basic Pl", "plan_name": "400100_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Federal", "plan_name": "400110", "standard_charge_dollar": 21.24, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Federal", "plan_name": "400110_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." } ] } ] }, { "description": "Free assay (ft-3)", "code_information": [ { "code": "84481", "type": "CPT" } ], "standard_charges": [ { "gross_charge": 150.00, "minimum": 25.38, "maximum": 25.38, "setting": "both", "payers_information": [ { "payer_name": "Aetna", "plan_name": "700700", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna", "plan_name": "700700_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Miscellaneous", "plan_name": "700720", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Miscellaneous", "plan_name": "700720_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Ppo Hmo", "plan_name": "701720", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Ppo Hmo", "plan_name": "701720_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Ms State Emplo", "plan_name": "401457", "standard_charge_dollar": 25.38, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Ms State Emplo", "plan_name": "401457_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Basic Pl", "plan_name": "400100", "standard_charge_dollar": 25.38, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Basic Pl", "plan_name": "400100_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Federal", "plan_name": "400110", "standard_charge_dollar": 25.38, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Federal", "plan_name": "400110_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." } ] } ] }, { "description": "Hc t3 free", "code_information": [ { "code": "84481", "type": "CPT" } ], "standard_charges": [ { "gross_charge": 150.00, "minimum": 25.38, "maximum": 25.38, "setting": "both", "payers_information": [ { "payer_name": "Aetna", "plan_name": "700700", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna", "plan_name": "700700_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Miscellaneous", "plan_name": "700720", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Miscellaneous", "plan_name": "700720_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Ppo Hmo", "plan_name": "701720", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Ppo Hmo", "plan_name": "701720_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Ms State Emplo", "plan_name": "401457", "standard_charge_dollar": 25.38, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Ms State Emplo", "plan_name": "401457_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Basic Pl", "plan_name": "400100", "standard_charge_dollar": 25.38, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Basic Pl", "plan_name": "400100_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Federal", "plan_name": "400110", "standard_charge_dollar": 25.38, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Federal", "plan_name": "400110_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." } ] } ] }, { "description": "Hc t3 reverse", "code_information": [ { "code": "84482", "type": "CPT" } ], "standard_charges": [ { "gross_charge": 150.00, "minimum": 23.62, "maximum": 23.62, "setting": "both", "payers_information": [ { "payer_name": "Aetna", "plan_name": "700700", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna", "plan_name": "700700_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Miscellaneous", "plan_name": "700720", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Miscellaneous", "plan_name": "700720_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Ppo Hmo", "plan_name": "701720", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Ppo Hmo", "plan_name": "701720_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Ms State Emplo", "plan_name": "401457", "standard_charge_dollar": 23.62, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Ms State Emplo", "plan_name": "401457_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Basic Pl", "plan_name": "400100", "standard_charge_dollar": 23.62, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Basic Pl", "plan_name": "400100_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Federal", "plan_name": "400110", "standard_charge_dollar": 23.62, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Federal", "plan_name": "400110_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." } ] } ] }, { "description": "T3 reverse", "code_information": [ { "code": "84482", "type": "CPT" } ], "standard_charges": [ { "gross_charge": 150.00, "minimum": 23.62, "maximum": 23.62, "setting": "both", "payers_information": [ { "payer_name": "Aetna", "plan_name": "700700", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna", "plan_name": "700700_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Miscellaneous", "plan_name": "700720", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Miscellaneous", "plan_name": "700720_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Ppo Hmo", "plan_name": "701720", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Ppo Hmo", "plan_name": "701720_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Ms State Emplo", "plan_name": "401457", "standard_charge_dollar": 23.62, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Ms State Emplo", "plan_name": "401457_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Basic Pl", "plan_name": "400100", "standard_charge_dollar": 23.62, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Basic Pl", "plan_name": "400100_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Federal", "plan_name": "400110", "standard_charge_dollar": 23.62, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Federal", "plan_name": "400110_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." } ] } ] }, { "description": "Assay of troponin quant", "code_information": [ { "code": "84484", "type": "CPT" } ], "standard_charges": [ { "gross_charge": 100.00, "minimum": 14.74, "maximum": 14.74, "setting": "both", "payers_information": [ { "payer_name": "Aetna", "plan_name": "700700", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna", "plan_name": "700700_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Miscellaneous", "plan_name": "700720", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Miscellaneous", "plan_name": "700720_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Ppo Hmo", "plan_name": "701720", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Ppo Hmo", "plan_name": "701720_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Ms State Emplo", "plan_name": "401457", "standard_charge_dollar": 14.74, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Ms State Emplo", "plan_name": "401457_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Basic Pl", "plan_name": "400100", "standard_charge_dollar": 14.74, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Basic Pl", "plan_name": "400100_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Federal", "plan_name": "400110", "standard_charge_dollar": 14.74, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Federal", "plan_name": "400110_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." } ] } ] }, { "description": "Hc troponin", "code_information": [ { "code": "84484", "type": "CPT" } ], "standard_charges": [ { "gross_charge": 100.00, "minimum": 14.74, "maximum": 14.74, "setting": "both", "payers_information": [ { "payer_name": "Aetna", "plan_name": "700700", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna", "plan_name": "700700_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Miscellaneous", "plan_name": "700720", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Miscellaneous", "plan_name": "700720_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Ppo Hmo", "plan_name": "701720", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Ppo Hmo", "plan_name": "701720_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Ms State Emplo", "plan_name": "401457", "standard_charge_dollar": 14.74, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Ms State Emplo", "plan_name": "401457_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Basic Pl", "plan_name": "400100", "standard_charge_dollar": 14.74, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Basic Pl", "plan_name": "400100_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Federal", "plan_name": "400110", "standard_charge_dollar": 14.74, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Federal", "plan_name": "400110_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." } ] } ] }, { "description": "Assay of urea nitrogen", "code_information": [ { "code": "84520", "type": "CPT" } ], "standard_charges": [ { "gross_charge": 50.00, "minimum": 5.92, "maximum": 5.92, "setting": "both", "payers_information": [ { "payer_name": "Aetna", "plan_name": "700700", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna", "plan_name": "700700_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Miscellaneous", "plan_name": "700720", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Miscellaneous", "plan_name": "700720_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Ppo Hmo", "plan_name": "701720", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Ppo Hmo", "plan_name": "701720_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Ms State Emplo", "plan_name": "401457", "standard_charge_dollar": 5.92, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Ms State Emplo", "plan_name": "401457_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Basic Pl", "plan_name": "400100", "standard_charge_dollar": 5.92, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Basic Pl", "plan_name": "400100_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Federal", "plan_name": "400110", "standard_charge_dollar": 5.92, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Federal", "plan_name": "400110_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." } ] } ] }, { "description": "Hc urea nitrogen quan", "code_information": [ { "code": "84520", "type": "CPT" } ], "standard_charges": [ { "gross_charge": 50.00, "minimum": 5.92, "maximum": 5.92, "setting": "both", "payers_information": [ { "payer_name": "Aetna", "plan_name": "700700", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna", "plan_name": "700700_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Miscellaneous", "plan_name": "700720", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Miscellaneous", "plan_name": "700720_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Ppo Hmo", "plan_name": "701720", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Ppo Hmo", "plan_name": "701720_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Ms State Emplo", "plan_name": "401457", "standard_charge_dollar": 5.92, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Ms State Emplo", "plan_name": "401457_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Basic Pl", "plan_name": "400100", "standard_charge_dollar": 5.92, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Basic Pl", "plan_name": "400100_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Federal", "plan_name": "400110", "standard_charge_dollar": 5.92, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Federal", "plan_name": "400110_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." } ] } ] }, { "description": "Assay of urine/urea-n", "code_information": [ { "code": "84540", "type": "CPT" } ], "standard_charges": [ { "gross_charge": 85.00, "minimum": 7.12, "maximum": 7.12, "setting": "both", "payers_information": [ { "payer_name": "Aetna", "plan_name": "700700", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna", "plan_name": "700700_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Miscellaneous", "plan_name": "700720", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Miscellaneous", "plan_name": "700720_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Ppo Hmo", "plan_name": "701720", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Ppo Hmo", "plan_name": "701720_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Ms State Emplo", "plan_name": "401457", "standard_charge_dollar": 7.12, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Ms State Emplo", "plan_name": "401457_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Basic Pl", "plan_name": "400100", "standard_charge_dollar": 7.12, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Basic Pl", "plan_name": "400100_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Federal", "plan_name": "400110", "standard_charge_dollar": 7.12, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Federal", "plan_name": "400110_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." } ] } ] }, { "description": "Hc urea ntriogen urine 24 hr", "code_information": [ { "code": "84540", "type": "CPT" } ], "standard_charges": [ { "gross_charge": 85.00, "minimum": 7.12, "maximum": 7.12, "setting": "both", "payers_information": [ { "payer_name": "Aetna", "plan_name": "700700", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna", "plan_name": "700700_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Miscellaneous", "plan_name": "700720", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Miscellaneous", "plan_name": "700720_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Ppo Hmo", "plan_name": "701720", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Ppo Hmo", "plan_name": "701720_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Ms State Emplo", "plan_name": "401457", "standard_charge_dollar": 7.12, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Ms State Emplo", "plan_name": "401457_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Basic Pl", "plan_name": "400100", "standard_charge_dollar": 7.12, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Basic Pl", "plan_name": "400100_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Federal", "plan_name": "400110", "standard_charge_dollar": 7.12, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Federal", "plan_name": "400110_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." } ] } ] }, { "description": "Assay of blood/uric acid", "code_information": [ { "code": "84550", "type": "CPT" } ], "standard_charges": [ { "gross_charge": 60.00, "minimum": 6.78, "maximum": 6.78, "setting": "both", "payers_information": [ { "payer_name": "Aetna", "plan_name": "700700", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna", "plan_name": "700700_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Miscellaneous", "plan_name": "700720", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Miscellaneous", "plan_name": "700720_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Ppo Hmo", "plan_name": "701720", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Ppo Hmo", "plan_name": "701720_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Ms State Emplo", "plan_name": "401457", "standard_charge_dollar": 6.78, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Ms State Emplo", "plan_name": "401457_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Basic Pl", "plan_name": "400100", "standard_charge_dollar": 6.78, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Basic Pl", "plan_name": "400100_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Federal", "plan_name": "400110", "standard_charge_dollar": 6.78, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Federal", "plan_name": "400110_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." } ] } ] }, { "description": "Hc uric acid blood", "code_information": [ { "code": "84550", "type": "CPT" } ], "standard_charges": [ { "gross_charge": 60.00, "minimum": 6.78, "maximum": 6.78, "setting": "both", "payers_information": [ { "payer_name": "Aetna", "plan_name": "700700", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna", "plan_name": "700700_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Miscellaneous", "plan_name": "700720", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Miscellaneous", "plan_name": "700720_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Ppo Hmo", "plan_name": "701720", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Ppo Hmo", "plan_name": "701720_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Ms State Emplo", "plan_name": "401457", "standard_charge_dollar": 6.78, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Ms State Emplo", "plan_name": "401457_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Basic Pl", "plan_name": "400100", "standard_charge_dollar": 6.78, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Basic Pl", "plan_name": "400100_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Federal", "plan_name": "400110", "standard_charge_dollar": 6.78, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Federal", "plan_name": "400110_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." } ] } ] }, { "description": "Assay of urine/uric acid", "code_information": [ { "code": "84560", "type": "CPT" } ], "standard_charges": [ { "gross_charge": 75.00, "minimum": 7.12, "maximum": 7.12, "setting": "both", "payers_information": [ { "payer_name": "Aetna", "plan_name": "700700", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna", "plan_name": "700700_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Miscellaneous", "plan_name": "700720", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Miscellaneous", "plan_name": "700720_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Ppo Hmo", "plan_name": "701720", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Ppo Hmo", "plan_name": "701720_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Ms State Emplo", "plan_name": "401457", "standard_charge_dollar": 7.12, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Ms State Emplo", "plan_name": "401457_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Basic Pl", "plan_name": "400100", "standard_charge_dollar": 7.12, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Basic Pl", "plan_name": "400100_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Federal", "plan_name": "400110", "standard_charge_dollar": 7.12, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Federal", "plan_name": "400110_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." } ] } ] }, { "description": "Hc uric acid urine", "code_information": [ { "code": "84560", "type": "CPT" } ], "standard_charges": [ { "gross_charge": 75.00, "minimum": 7.12, "maximum": 7.12, "setting": "both", "payers_information": [ { "payer_name": "Aetna", "plan_name": "700700", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna", "plan_name": "700700_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Miscellaneous", "plan_name": "700720", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Miscellaneous", "plan_name": "700720_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Ppo Hmo", "plan_name": "701720", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Ppo Hmo", "plan_name": "701720_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Ms State Emplo", "plan_name": "401457", "standard_charge_dollar": 7.12, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Ms State Emplo", "plan_name": "401457_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Basic Pl", "plan_name": "400100", "standard_charge_dollar": 7.12, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Basic Pl", "plan_name": "400100_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Federal", "plan_name": "400110", "standard_charge_dollar": 7.12, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Federal", "plan_name": "400110_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." } ] } ] }, { "description": "Assay of urine vma", "code_information": [ { "code": "84585", "type": "CPT" } ], "standard_charges": [ { "gross_charge": 70.29, "minimum": 21.76, "maximum": 21.76, "setting": "both", "payers_information": [ { "payer_name": "Aetna", "plan_name": "700700", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna", "plan_name": "700700_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Miscellaneous", "plan_name": "700720", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Miscellaneous", "plan_name": "700720_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Ppo Hmo", "plan_name": "701720", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Ppo Hmo", "plan_name": "701720_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Ms State Emplo", "plan_name": "401457", "standard_charge_dollar": 21.76, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Ms State Emplo", "plan_name": "401457_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Basic Pl", "plan_name": "400100", "standard_charge_dollar": 21.76, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Basic Pl", "plan_name": "400100_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Federal", "plan_name": "400110", "standard_charge_dollar": 21.76, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Federal", "plan_name": "400110_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." } ] } ] }, { "description": "Hc vma urine", "code_information": [ { "code": "84585", "type": "CPT" } ], "standard_charges": [ { "gross_charge": 70.29, "minimum": 21.76, "maximum": 21.76, "setting": "both", "payers_information": [ { "payer_name": "Aetna", "plan_name": "700700", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna", "plan_name": "700700_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Miscellaneous", "plan_name": "700720", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Miscellaneous", "plan_name": "700720_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Ppo Hmo", "plan_name": "701720", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Ppo Hmo", "plan_name": "701720_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Ms State Emplo", "plan_name": "401457", "standard_charge_dollar": 21.76, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Ms State Emplo", "plan_name": "401457_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Basic Pl", "plan_name": "400100", "standard_charge_dollar": 21.76, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Basic Pl", "plan_name": "400100_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Federal", "plan_name": "400110", "standard_charge_dollar": 21.76, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Federal", "plan_name": "400110_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." } ] } ] }, { "description": "Assay of vitamin a", "code_information": [ { "code": "84590", "type": "CPT" } ], "standard_charges": [ { "gross_charge": 173.00, "minimum": 17.39, "maximum": 17.39, "setting": "both", "payers_information": [ { "payer_name": "Aetna", "plan_name": "700700", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna", "plan_name": "700700_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Miscellaneous", "plan_name": "700720", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Miscellaneous", "plan_name": "700720_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Ppo Hmo", "plan_name": "701720", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Ppo Hmo", "plan_name": "701720_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Ms State Emplo", "plan_name": "401457", "standard_charge_dollar": 17.39, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Ms State Emplo", "plan_name": "401457_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Basic Pl", "plan_name": "400100", "standard_charge_dollar": 17.39, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Basic Pl", "plan_name": "400100_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Federal", "plan_name": "400110", "standard_charge_dollar": 17.39, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Federal", "plan_name": "400110_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." } ] } ] }, { "description": "Hc vitamin a", "code_information": [ { "code": "84590", "type": "CPT" } ], "standard_charges": [ { "gross_charge": 173.00, "minimum": 17.39, "maximum": 17.39, "setting": "both", "payers_information": [ { "payer_name": "Aetna", "plan_name": "700700", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna", "plan_name": "700700_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Miscellaneous", "plan_name": "700720", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Miscellaneous", "plan_name": "700720_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Ppo Hmo", "plan_name": "701720", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Ppo Hmo", "plan_name": "701720_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Ms State Emplo", "plan_name": "401457", "standard_charge_dollar": 17.39, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Ms State Emplo", "plan_name": "401457_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Basic Pl", "plan_name": "400100", "standard_charge_dollar": 17.39, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Basic Pl", "plan_name": "400100_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Federal", "plan_name": "400110", "standard_charge_dollar": 17.39, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Federal", "plan_name": "400110_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." } ] } ] }, { "description": "Assay of nos vitamin", "code_information": [ { "code": "84591", "type": "CPT" } ], "standard_charges": [ { "gross_charge": 335.60, "minimum": 17.39, "maximum": 17.39, "setting": "both", "payers_information": [ { "payer_name": "Aetna", "plan_name": "700700", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna", "plan_name": "700700_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Miscellaneous", "plan_name": "700720", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Miscellaneous", "plan_name": "700720_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Ppo Hmo", "plan_name": "701720", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Ppo Hmo", "plan_name": "701720_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Ms State Emplo", "plan_name": "401457", "standard_charge_dollar": 17.39, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Ms State Emplo", "plan_name": "401457_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Basic Pl", "plan_name": "400100", "standard_charge_dollar": 17.39, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Basic Pl", "plan_name": "400100_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Federal", "plan_name": "400110", "standard_charge_dollar": 17.39, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Federal", "plan_name": "400110_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." } ] } ] }, { "description": "Hc vitamin b3 (niacin)", "code_information": [ { "code": "84591", "type": "CPT" } ], "standard_charges": [ { "gross_charge": 335.60, "minimum": 17.39, "maximum": 17.39, "setting": "both", "payers_information": [ { "payer_name": "Aetna", "plan_name": "700700", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna", "plan_name": "700700_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Miscellaneous", "plan_name": "700720", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Miscellaneous", "plan_name": "700720_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Ppo Hmo", "plan_name": "701720", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Ppo Hmo", "plan_name": "701720_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Ms State Emplo", "plan_name": "401457", "standard_charge_dollar": 17.39, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Ms State Emplo", "plan_name": "401457_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Basic Pl", "plan_name": "400100", "standard_charge_dollar": 17.39, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Basic Pl", "plan_name": "400100_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Federal", "plan_name": "400110", "standard_charge_dollar": 17.39, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Federal", "plan_name": "400110_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." } ] } ] }, { "description": "Assay of vitamin k", "code_information": [ { "code": "84597", "type": "CPT" } ], "standard_charges": [ { "gross_charge": 200.00, "minimum": 20.56, "maximum": 20.56, "setting": "both", "payers_information": [ { "payer_name": "Aetna", "plan_name": "700700", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna", "plan_name": "700700_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Miscellaneous", "plan_name": "700720", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Miscellaneous", "plan_name": "700720_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Ppo Hmo", "plan_name": "701720", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Ppo Hmo", "plan_name": "701720_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Ms State Emplo", "plan_name": "401457", "standard_charge_dollar": 20.56, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Ms State Emplo", "plan_name": "401457_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Basic Pl", "plan_name": "400100", "standard_charge_dollar": 20.56, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Basic Pl", "plan_name": "400100_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Federal", "plan_name": "400110", "standard_charge_dollar": 20.56, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Federal", "plan_name": "400110_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." } ] } ] }, { "description": "Hc vitamin k", "code_information": [ { "code": "84597", "type": "CPT" } ], "standard_charges": [ { "gross_charge": 200.00, "minimum": 20.56, "maximum": 20.56, "setting": "both", "payers_information": [ { "payer_name": "Aetna", "plan_name": "700700", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna", "plan_name": "700700_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Miscellaneous", "plan_name": "700720", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Miscellaneous", "plan_name": "700720_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Ppo Hmo", "plan_name": "701720", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Ppo Hmo", "plan_name": "701720_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Ms State Emplo", "plan_name": "401457", "standard_charge_dollar": 20.56, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Ms State Emplo", "plan_name": "401457_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Basic Pl", "plan_name": "400100", "standard_charge_dollar": 20.56, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Basic Pl", "plan_name": "400100_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Federal", "plan_name": "400110", "standard_charge_dollar": 20.56, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Federal", "plan_name": "400110_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." } ] } ] }, { "description": "Assay of zinc", "code_information": [ { "code": "84630", "type": "CPT" } ], "standard_charges": [ { "gross_charge": 36.75, "minimum": 17.06, "maximum": 17.06, "setting": "both", "payers_information": [ { "payer_name": "Aetna", "plan_name": "700700", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna", "plan_name": "700700_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Miscellaneous", "plan_name": "700720", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Miscellaneous", "plan_name": "700720_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Ppo Hmo", "plan_name": "701720", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Ppo Hmo", "plan_name": "701720_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Ms State Emplo", "plan_name": "401457", "standard_charge_dollar": 17.06, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Ms State Emplo", "plan_name": "401457_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Basic Pl", "plan_name": "400100", "standard_charge_dollar": 17.06, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Basic Pl", "plan_name": "400100_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Federal", "plan_name": "400110", "standard_charge_dollar": 17.06, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Federal", "plan_name": "400110_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." } ] } ] }, { "description": "Hc zinc", "code_information": [ { "code": "84630", "type": "CPT" } ], "standard_charges": [ { "gross_charge": 36.75, "minimum": 17.06, "maximum": 17.06, "setting": "both", "payers_information": [ { "payer_name": "Aetna", "plan_name": "700700", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna", "plan_name": "700700_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Miscellaneous", "plan_name": "700720", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Miscellaneous", "plan_name": "700720_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Ppo Hmo", "plan_name": "701720", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Ppo Hmo", "plan_name": "701720_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Ms State Emplo", "plan_name": "401457", "standard_charge_dollar": 17.06, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Ms State Emplo", "plan_name": "401457_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Basic Pl", "plan_name": "400100", "standard_charge_dollar": 17.06, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Basic Pl", "plan_name": "400100_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Federal", "plan_name": "400110", "standard_charge_dollar": 17.06, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Federal", "plan_name": "400110_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." } ] } ] }, { "description": "Assay of c-peptide", "code_information": [ { "code": "84681", "type": "CPT" } ], "standard_charges": [ { "gross_charge": 84.36, "minimum": 30.97, "maximum": 30.97, "setting": "both", "payers_information": [ { "payer_name": "Aetna", "plan_name": "700700", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna", "plan_name": "700700_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Miscellaneous", "plan_name": "700720", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Miscellaneous", "plan_name": "700720_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Ppo Hmo", "plan_name": "701720", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Ppo Hmo", "plan_name": "701720_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Ms State Emplo", "plan_name": "401457", "standard_charge_dollar": 30.97, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Ms State Emplo", "plan_name": "401457_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Basic Pl", "plan_name": "400100", "standard_charge_dollar": 30.97, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Basic Pl", "plan_name": "400100_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Federal", "plan_name": "400110", "standard_charge_dollar": 30.97, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Federal", "plan_name": "400110_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." } ] } ] }, { "description": "Hc c-peptide", "code_information": [ { "code": "84681", "type": "CPT" } ], "standard_charges": [ { "gross_charge": 84.36, "minimum": 30.97, "maximum": 30.97, "setting": "both", "payers_information": [ { "payer_name": "Aetna", "plan_name": "700700", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna", "plan_name": "700700_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Miscellaneous", "plan_name": "700720", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Miscellaneous", "plan_name": "700720_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Ppo Hmo", "plan_name": "701720", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Ppo Hmo", "plan_name": "701720_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Ms State Emplo", "plan_name": "401457", "standard_charge_dollar": 30.97, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Ms State Emplo", "plan_name": "401457_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Basic Pl", "plan_name": "400100", "standard_charge_dollar": 30.97, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Basic Pl", "plan_name": "400100_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Federal", "plan_name": "400110", "standard_charge_dollar": 30.97, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Federal", "plan_name": "400110_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." } ] } ] }, { "description": "Chorionic gonadotropin test", "code_information": [ { "code": "84702", "type": "CPT" } ], "standard_charges": [ { "gross_charge": 131.25, "minimum": 13.09, "maximum": 13.09, "setting": "both", "payers_information": [ { "payer_name": "Aetna", "plan_name": "700700", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna", "plan_name": "700700_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Miscellaneous", "plan_name": "700720", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Miscellaneous", "plan_name": "700720_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Ppo Hmo", "plan_name": "701720", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Ppo Hmo", "plan_name": "701720_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Ms State Emplo", "plan_name": "401457", "standard_charge_dollar": 13.09, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Ms State Emplo", "plan_name": "401457_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Basic Pl", "plan_name": "400100", "standard_charge_dollar": 13.09, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Basic Pl", "plan_name": "400100_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Federal", "plan_name": "400110", "standard_charge_dollar": 13.09, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Federal", "plan_name": "400110_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." } ] } ] }, { "description": "Hc hcg quant", "code_information": [ { "code": "84702", "type": "CPT" } ], "standard_charges": [ { "gross_charge": 131.25, "minimum": 13.09, "maximum": 13.09, "setting": "both", "payers_information": [ { "payer_name": "Aetna", "plan_name": "700700", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna", "plan_name": "700700_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Miscellaneous", "plan_name": "700720", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Miscellaneous", "plan_name": "700720_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Ppo Hmo", "plan_name": "701720", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Ppo Hmo", "plan_name": "701720_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Ms State Emplo", "plan_name": "401457", "standard_charge_dollar": 13.09, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Ms State Emplo", "plan_name": "401457_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Basic Pl", "plan_name": "400100", "standard_charge_dollar": 13.09, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Basic Pl", "plan_name": "400100_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Federal", "plan_name": "400110", "standard_charge_dollar": 13.09, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Federal", "plan_name": "400110_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." } ] } ] }, { "description": "Chorionic gonadotropin assay", "code_information": [ { "code": "84703", "type": "CPT" } ], "standard_charges": [ { "gross_charge": 100.00, "minimum": 11.26, "maximum": 11.26, "setting": "both", "payers_information": [ { "payer_name": "Aetna", "plan_name": "700700", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna", "plan_name": "700700_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Miscellaneous", "plan_name": "700720", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Miscellaneous", "plan_name": "700720_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Ppo Hmo", "plan_name": "701720", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Ppo Hmo", "plan_name": "701720_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Ms State Emplo", "plan_name": "401457", "standard_charge_dollar": 11.26, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Ms State Emplo", "plan_name": "401457_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Basic Pl", "plan_name": "400100", "standard_charge_dollar": 11.26, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Basic Pl", "plan_name": "400100_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Federal", "plan_name": "400110", "standard_charge_dollar": 11.26, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Federal", "plan_name": "400110_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." } ] } ] }, { "description": "Hc pregnancy test serum", "code_information": [ { "code": "84703", "type": "CPT" } ], "standard_charges": [ { "gross_charge": 100.00, "minimum": 11.26, "maximum": 11.26, "setting": "both", "payers_information": [ { "payer_name": "Aetna", "plan_name": "700700", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna", "plan_name": "700700_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Miscellaneous", "plan_name": "700720", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Miscellaneous", "plan_name": "700720_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Ppo Hmo", "plan_name": "701720", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Ppo Hmo", "plan_name": "701720_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Ms State Emplo", "plan_name": "401457", "standard_charge_dollar": 11.26, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Ms State Emplo", "plan_name": "401457_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Basic Pl", "plan_name": "400100", "standard_charge_dollar": 11.26, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Basic Pl", "plan_name": "400100_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Federal", "plan_name": "400110", "standard_charge_dollar": 11.26, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Federal", "plan_name": "400110_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." } ] } ] }, { "description": "Clinical chemistry test", "code_information": [ { "code": "84999", "type": "CPT" } ], "standard_charges": [ { "gross_charge": 93.50, "minimum": 53.00, "maximum": 53.00, "setting": "both", "payers_information": [ { "payer_name": "Aetna", "plan_name": "700700", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna", "plan_name": "700700_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Miscellaneous", "plan_name": "700720", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Miscellaneous", "plan_name": "700720_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Ppo Hmo", "plan_name": "701720", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Ppo Hmo", "plan_name": "701720_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Ms State Emplo", "plan_name": "401457", "standard_charge_dollar": 53.00, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Ms State Emplo", "plan_name": "401457_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Basic Pl", "plan_name": "400100", "standard_charge_dollar": 53.00, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Basic Pl", "plan_name": "400100_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Federal", "plan_name": "400110", "standard_charge_dollar": 53.00, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Federal", "plan_name": "400110_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." } ] } ] }, { "description": "Hc potassium stool", "code_information": [ { "code": "84999", "type": "CPT" } ], "standard_charges": [ { "gross_charge": 93.50, "minimum": 53.00, "maximum": 53.00, "setting": "both", "payers_information": [ { "payer_name": "Aetna", "plan_name": "700700", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna", "plan_name": "700700_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Miscellaneous", "plan_name": "700720", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Miscellaneous", "plan_name": "700720_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Ppo Hmo", "plan_name": "701720", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Ppo Hmo", "plan_name": "701720_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Ms State Emplo", "plan_name": "401457", "standard_charge_dollar": 53.00, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Ms State Emplo", "plan_name": "401457_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Basic Pl", "plan_name": "400100", "standard_charge_dollar": 53.00, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Basic Pl", "plan_name": "400100_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Federal", "plan_name": "400110", "standard_charge_dollar": 53.00, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Federal", "plan_name": "400110_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." } ] } ] }, { "description": "Hc hematocrit", "code_information": [ { "code": "85014", "type": "CPT" } ], "standard_charges": [ { "gross_charge": 35.00, "minimum": 3.55, "maximum": 3.55, "setting": "both", "payers_information": [ { "payer_name": "Aetna", "plan_name": "700700", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna", "plan_name": "700700_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Miscellaneous", "plan_name": "700720", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Miscellaneous", "plan_name": "700720_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Ppo Hmo", "plan_name": "701720", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Ppo Hmo", "plan_name": "701720_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Ms State Emplo", "plan_name": "401457", "standard_charge_dollar": 3.55, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Ms State Emplo", "plan_name": "401457_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Basic Pl", "plan_name": "400100", "standard_charge_dollar": 3.55, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Basic Pl", "plan_name": "400100_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Federal", "plan_name": "400110", "standard_charge_dollar": 3.55, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Federal", "plan_name": "400110_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." } ] } ] }, { "description": "Hematocrit", "code_information": [ { "code": "85014", "type": "CPT" } ], "standard_charges": [ { "gross_charge": 35.00, "minimum": 3.55, "maximum": 3.55, "setting": "both", "payers_information": [ { "payer_name": "Aetna", "plan_name": "700700", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna", "plan_name": "700700_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Miscellaneous", "plan_name": "700720", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Miscellaneous", "plan_name": "700720_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Ppo Hmo", "plan_name": "701720", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Ppo Hmo", "plan_name": "701720_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Ms State Emplo", "plan_name": "401457", "standard_charge_dollar": 3.55, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Ms State Emplo", "plan_name": "401457_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Basic Pl", "plan_name": "400100", "standard_charge_dollar": 3.55, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Basic Pl", "plan_name": "400100_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Federal", "plan_name": "400110", "standard_charge_dollar": 3.55, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Federal", "plan_name": "400110_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." } ] } ] }, { "description": "Hc hematocrit", "code_information": [ { "code": "85014", "type": "CPT" } ], "standard_charges": [ { "gross_charge": 35.00, "minimum": 28.00, "maximum": 29.75, "setting": "both", "payers_information": [ { "payer_name": "Aetna", "plan_name": "700700", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "modifiers": "QW", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna", "plan_name": "700700_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Miscellaneous", "plan_name": "700720", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Miscellaneous", "plan_name": "700720_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Ppo Hmo", "plan_name": "701720", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Ppo Hmo", "plan_name": "701720_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Ms State Emplo", "plan_name": "401457", "standard_charge_percentage": 0.80, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Ms State Emplo", "plan_name": "401457_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Basic Pl", "plan_name": "400100", "standard_charge_percentage": 0.85, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Basic Pl", "plan_name": "400100_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Federal", "plan_name": "400110", "standard_charge_percentage": 0.85, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Federal", "plan_name": "400110_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." } ] } ] }, { "description": "Hc hemoglobin", "code_information": [ { "code": "85018", "type": "CPT" } ], "standard_charges": [ { "gross_charge": 35.00, "minimum": 3.55, "maximum": 3.55, "setting": "both", "payers_information": [ { "payer_name": "Aetna", "plan_name": "700700", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna", "plan_name": "700700_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Miscellaneous", "plan_name": "700720", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Miscellaneous", "plan_name": "700720_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Ppo Hmo", "plan_name": "701720", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Ppo Hmo", "plan_name": "701720_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Ms State Emplo", "plan_name": "401457", "standard_charge_dollar": 3.55, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Ms State Emplo", "plan_name": "401457_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Basic Pl", "plan_name": "400100", "standard_charge_dollar": 3.55, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Basic Pl", "plan_name": "400100_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Federal", "plan_name": "400110", "standard_charge_dollar": 3.55, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Federal", "plan_name": "400110_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." } ] } ] }, { "description": "Hemoglobin", "code_information": [ { "code": "85018", "type": "CPT" } ], "standard_charges": [ { "gross_charge": 35.00, "minimum": 3.55, "maximum": 3.55, "setting": "both", "payers_information": [ { "payer_name": "Aetna", "plan_name": "700700", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna", "plan_name": "700700_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Miscellaneous", "plan_name": "700720", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Miscellaneous", "plan_name": "700720_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Ppo Hmo", "plan_name": "701720", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Ppo Hmo", "plan_name": "701720_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Ms State Emplo", "plan_name": "401457", "standard_charge_dollar": 3.55, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Ms State Emplo", "plan_name": "401457_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Basic Pl", "plan_name": "400100", "standard_charge_dollar": 3.55, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Basic Pl", "plan_name": "400100_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Federal", "plan_name": "400110", "standard_charge_dollar": 3.55, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Federal", "plan_name": "400110_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." } ] } ] }, { "description": "Complete cbc w/auto diff wbc", "code_information": [ { "code": "85025", "type": "CPT" } ], "standard_charges": [ { "gross_charge": 85.00, "minimum": 11.65, "maximum": 11.65, "setting": "both", "payers_information": [ { "payer_name": "Aetna", "plan_name": "700700", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna", "plan_name": "700700_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Miscellaneous", "plan_name": "700720", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Miscellaneous", "plan_name": "700720_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Ppo Hmo", "plan_name": "701720", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Ppo Hmo", "plan_name": "701720_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Ms State Emplo", "plan_name": "401457", "standard_charge_dollar": 11.65, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Ms State Emplo", "plan_name": "401457_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Basic Pl", "plan_name": "400100", "standard_charge_dollar": 11.65, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Basic Pl", "plan_name": "400100_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Federal", "plan_name": "400110", "standard_charge_dollar": 11.65, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Federal", "plan_name": "400110_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." } ] } ] }, { "description": "Hc compl cbc w/plt w/auto diff", "code_information": [ { "code": "85025", "type": "CPT" } ], "standard_charges": [ { "gross_charge": 85.00, "minimum": 11.65, "maximum": 11.65, "setting": "both", "payers_information": [ { "payer_name": "Aetna", "plan_name": "700700", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna", "plan_name": "700700_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Miscellaneous", "plan_name": "700720", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Miscellaneous", "plan_name": "700720_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Ppo Hmo", "plan_name": "701720", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Ppo Hmo", "plan_name": "701720_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Ms State Emplo", "plan_name": "401457", "standard_charge_dollar": 11.65, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Ms State Emplo", "plan_name": "401457_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Basic Pl", "plan_name": "400100", "standard_charge_dollar": 11.65, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Basic Pl", "plan_name": "400100_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Federal", "plan_name": "400110", "standard_charge_dollar": 11.65, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Federal", "plan_name": "400110_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." } ] } ] }, { "description": "Complete cbc automated", "code_information": [ { "code": "85027", "type": "CPT" } ], "standard_charges": [ { "gross_charge": 35.00, "minimum": 9.69, "maximum": 9.69, "setting": "both", "payers_information": [ { "payer_name": "Aetna", "plan_name": "700700", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna", "plan_name": "700700_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Miscellaneous", "plan_name": "700720", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Miscellaneous", "plan_name": "700720_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Ppo Hmo", "plan_name": "701720", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Ppo Hmo", "plan_name": "701720_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Ms State Emplo", "plan_name": "401457", "standard_charge_dollar": 9.69, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Ms State Emplo", "plan_name": "401457_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Basic Pl", "plan_name": "400100", "standard_charge_dollar": 9.69, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Basic Pl", "plan_name": "400100_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Federal", "plan_name": "400110", "standard_charge_dollar": 9.69, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Federal", "plan_name": "400110_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." } ] } ] }, { "description": "Hc compl autom cbc w/plt", "code_information": [ { "code": "85027", "type": "CPT" } ], "standard_charges": [ { "gross_charge": 35.00, "minimum": 9.69, "maximum": 9.69, "setting": "both", "payers_information": [ { "payer_name": "Aetna", "plan_name": "700700", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna", "plan_name": "700700_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Miscellaneous", "plan_name": "700720", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Miscellaneous", "plan_name": "700720_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Ppo Hmo", "plan_name": "701720", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Ppo Hmo", "plan_name": "701720_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Ms State Emplo", "plan_name": "401457", "standard_charge_dollar": 9.69, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Ms State Emplo", "plan_name": "401457_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Basic Pl", "plan_name": "400100", "standard_charge_dollar": 9.69, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Basic Pl", "plan_name": "400100_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Federal", "plan_name": "400110", "standard_charge_dollar": 9.69, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Federal", "plan_name": "400110_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." } ] } ] }, { "description": "Automated reticulocyte count", "code_information": [ { "code": "85045", "type": "CPT" } ], "standard_charges": [ { "gross_charge": 15.00, "minimum": 6.00, "maximum": 6.00, "setting": "both", "payers_information": [ { "payer_name": "Aetna", "plan_name": "700700", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna", "plan_name": "700700_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Miscellaneous", "plan_name": "700720", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Miscellaneous", "plan_name": "700720_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Ppo Hmo", "plan_name": "701720", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Ppo Hmo", "plan_name": "701720_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Ms State Emplo", "plan_name": "401457", "standard_charge_dollar": 6.00, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Ms State Emplo", "plan_name": "401457_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Basic Pl", "plan_name": "400100", "standard_charge_dollar": 6.00, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Basic Pl", "plan_name": "400100_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Federal", "plan_name": "400110", "standard_charge_dollar": 6.00, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Federal", "plan_name": "400110_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." } ] } ] }, { "description": "Hc automated reticulocyte ct", "code_information": [ { "code": "85045", "type": "CPT" } ], "standard_charges": [ { "gross_charge": 15.00, "minimum": 6.00, "maximum": 6.00, "setting": "both", "payers_information": [ { "payer_name": "Aetna", "plan_name": "700700", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna", "plan_name": "700700_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Miscellaneous", "plan_name": "700720", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Miscellaneous", "plan_name": "700720_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Ppo Hmo", "plan_name": "701720", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Ppo Hmo", "plan_name": "701720_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Ms State Emplo", "plan_name": "401457", "standard_charge_dollar": 6.00, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Ms State Emplo", "plan_name": "401457_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Basic Pl", "plan_name": "400100", "standard_charge_dollar": 6.00, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Basic Pl", "plan_name": "400100_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Federal", "plan_name": "400110", "standard_charge_dollar": 6.00, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Federal", "plan_name": "400110_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." } ] } ] }, { "description": "Automated leukocyte count", "code_information": [ { "code": "85048", "type": "CPT" } ], "standard_charges": [ { "gross_charge": 35.00, "minimum": 3.81, "maximum": 3.81, "setting": "both", "payers_information": [ { "payer_name": "Aetna", "plan_name": "700700", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna", "plan_name": "700700_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Miscellaneous", "plan_name": "700720", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Miscellaneous", "plan_name": "700720_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Ppo Hmo", "plan_name": "701720", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Ppo Hmo", "plan_name": "701720_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Ms State Emplo", "plan_name": "401457", "standard_charge_dollar": 3.81, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Ms State Emplo", "plan_name": "401457_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Basic Pl", "plan_name": "400100", "standard_charge_dollar": 3.81, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Basic Pl", "plan_name": "400100_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Federal", "plan_name": "400110", "standard_charge_dollar": 3.81, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Federal", "plan_name": "400110_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." } ] } ] }, { "description": "Hc automated wbc", "code_information": [ { "code": "85048", "type": "CPT" } ], "standard_charges": [ { "gross_charge": 35.00, "minimum": 3.81, "maximum": 3.81, "setting": "both", "payers_information": [ { "payer_name": "Aetna", "plan_name": "700700", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna", "plan_name": "700700_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Miscellaneous", "plan_name": "700720", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Miscellaneous", "plan_name": "700720_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Ppo Hmo", "plan_name": "701720", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Ppo Hmo", "plan_name": "701720_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Ms State Emplo", "plan_name": "401457", "standard_charge_dollar": 3.81, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Ms State Emplo", "plan_name": "401457_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Basic Pl", "plan_name": "400100", "standard_charge_dollar": 3.81, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Basic Pl", "plan_name": "400100_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Federal", "plan_name": "400110", "standard_charge_dollar": 3.81, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Federal", "plan_name": "400110_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." } ] } ] }, { "description": "Automated platelet count", "code_information": [ { "code": "85049", "type": "CPT" } ], "standard_charges": [ { "gross_charge": 35.00, "minimum": 6.71, "maximum": 6.71, "setting": "both", "payers_information": [ { "payer_name": "Aetna", "plan_name": "700700", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna", "plan_name": "700700_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Miscellaneous", "plan_name": "700720", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Miscellaneous", "plan_name": "700720_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Ppo Hmo", "plan_name": "701720", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Ppo Hmo", "plan_name": "701720_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Ms State Emplo", "plan_name": "401457", "standard_charge_dollar": 6.71, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Ms State Emplo", "plan_name": "401457_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Basic Pl", "plan_name": "400100", "standard_charge_dollar": 6.71, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Basic Pl", "plan_name": "400100_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Federal", "plan_name": "400110", "standard_charge_dollar": 6.71, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Federal", "plan_name": "400110_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." } ] } ] }, { "description": "Hc automated platelet count", "code_information": [ { "code": "85049", "type": "CPT" } ], "standard_charges": [ { "gross_charge": 35.00, "minimum": 6.71, "maximum": 6.71, "setting": "both", "payers_information": [ { "payer_name": "Aetna", "plan_name": "700700", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna", "plan_name": "700700_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Miscellaneous", "plan_name": "700720", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Miscellaneous", "plan_name": "700720_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Ppo Hmo", "plan_name": "701720", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Ppo Hmo", "plan_name": "701720_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Ms State Emplo", "plan_name": "401457", "standard_charge_dollar": 6.71, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Ms State Emplo", "plan_name": "401457_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Basic Pl", "plan_name": "400100", "standard_charge_dollar": 6.71, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Basic Pl", "plan_name": "400100_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Federal", "plan_name": "400110", "standard_charge_dollar": 6.71, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Federal", "plan_name": "400110_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." } ] } ] }, { "description": "Clot factor viii ahg 1 stage", "code_information": [ { "code": "85240", "type": "CPT" } ], "standard_charges": [ { "gross_charge": 225.86, "minimum": 18.03, "maximum": 18.03, "setting": "both", "payers_information": [ { "payer_name": "Aetna", "plan_name": "700700", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna", "plan_name": "700700_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Miscellaneous", "plan_name": "700720", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Miscellaneous", "plan_name": "700720_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Ppo Hmo", "plan_name": "701720", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Ppo Hmo", "plan_name": "701720_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Ms State Emplo", "plan_name": "401457", "standard_charge_dollar": 18.03, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Ms State Emplo", "plan_name": "401457_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Basic Pl", "plan_name": "400100", "standard_charge_dollar": 18.03, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Basic Pl", "plan_name": "400100_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Federal", "plan_name": "400110", "standard_charge_dollar": 18.03, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Federal", "plan_name": "400110_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." } ] } ] }, { "description": "Hc coag factor viii assay p", "code_information": [ { "code": "85240", "type": "CPT" } ], "standard_charges": [ { "gross_charge": 225.86, "minimum": 18.03, "maximum": 18.03, "setting": "both", "payers_information": [ { "payer_name": "Aetna", "plan_name": "700700", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna", "plan_name": "700700_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Miscellaneous", "plan_name": "700720", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Miscellaneous", "plan_name": "700720_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Ppo Hmo", "plan_name": "701720", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Ppo Hmo", "plan_name": "701720_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Ms State Emplo", "plan_name": "401457", "standard_charge_dollar": 18.03, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Ms State Emplo", "plan_name": "401457_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Basic Pl", "plan_name": "400100", "standard_charge_dollar": 18.03, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Basic Pl", "plan_name": "400100_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Federal", "plan_name": "400110", "standard_charge_dollar": 18.03, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Federal", "plan_name": "400110_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." } ] } ] }, { "description": "Clot factor viii vw antigen", "code_information": [ { "code": "85246", "type": "CPT" } ], "standard_charges": [ { "gross_charge": 275.20, "minimum": 34.38, "maximum": 34.38, "setting": "both", "payers_information": [ { "payer_name": "Aetna", "plan_name": "700700", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna", "plan_name": "700700_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Miscellaneous", "plan_name": "700720", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Miscellaneous", "plan_name": "700720_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Ppo Hmo", "plan_name": "701720", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Ppo Hmo", "plan_name": "701720_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Ms State Emplo", "plan_name": "401457", "standard_charge_dollar": 34.38, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Ms State Emplo", "plan_name": "401457_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Basic Pl", "plan_name": "400100", "standard_charge_dollar": 34.38, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Basic Pl", "plan_name": "400100_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Federal", "plan_name": "400110", "standard_charge_dollar": 34.38, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Federal", "plan_name": "400110_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." } ] } ] }, { "description": "Hc clotting factor viii vwf ag", "code_information": [ { "code": "85246", "type": "CPT" } ], "standard_charges": [ { "gross_charge": 275.20, "minimum": 34.38, "maximum": 34.38, "setting": "both", "payers_information": [ { "payer_name": "Aetna", "plan_name": "700700", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna", "plan_name": "700700_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Miscellaneous", "plan_name": "700720", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Miscellaneous", "plan_name": "700720_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Ppo Hmo", "plan_name": "701720", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Ppo Hmo", "plan_name": "701720_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Ms State Emplo", "plan_name": "401457", "standard_charge_dollar": 34.38, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Ms State Emplo", "plan_name": "401457_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Basic Pl", "plan_name": "400100", "standard_charge_dollar": 34.38, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Basic Pl", "plan_name": "400100_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Federal", "plan_name": "400110", "standard_charge_dollar": 34.38, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Federal", "plan_name": "400110_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." } ] } ] }, { "description": "Antithrombin iii activity", "code_information": [ { "code": "85300", "type": "CPT" } ], "standard_charges": [ { "gross_charge": 103.00, "minimum": 17.77, "maximum": 17.77, "setting": "both", "payers_information": [ { "payer_name": "Aetna", "plan_name": "700700", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna", "plan_name": "700700_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Miscellaneous", "plan_name": "700720", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Miscellaneous", "plan_name": "700720_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Ppo Hmo", "plan_name": "701720", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Ppo Hmo", "plan_name": "701720_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Ms State Emplo", "plan_name": "401457", "standard_charge_dollar": 17.77, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Ms State Emplo", "plan_name": "401457_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Basic Pl", "plan_name": "400100", "standard_charge_dollar": 17.77, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Basic Pl", "plan_name": "400100_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Federal", "plan_name": "400110", "standard_charge_dollar": 17.77, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Federal", "plan_name": "400110_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." } ] } ] }, { "description": "Hc antithrombin iii activity", "code_information": [ { "code": "85300", "type": "CPT" } ], "standard_charges": [ { "gross_charge": 103.00, "minimum": 17.77, "maximum": 17.77, "setting": "both", "payers_information": [ { "payer_name": "Aetna", "plan_name": "700700", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna", "plan_name": "700700_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": 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"401457_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Basic Pl", "plan_name": "400100", "standard_charge_dollar": 18.00, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Basic Pl", "plan_name": "400100_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Federal", "plan_name": "400110", "standard_charge_dollar": 18.00, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Federal", "plan_name": "400110_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." } ] } ] }, { "description": "Hc activated protein c resist", "code_information": [ { "code": "85307", "type": "CPT" } ], "standard_charges": [ { "gross_charge": 171.50, "minimum": 18.00, "maximum": 18.00, "setting": "both", "payers_information": [ { "payer_name": "Aetna", "plan_name": "700700", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna", "plan_name": "700700_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Miscellaneous", "plan_name": "700720", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent 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"additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Ms State Emplo", "plan_name": "401457_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Basic Pl", "plan_name": "400100", "standard_charge_dollar": 18.00, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Basic Pl", "plan_name": "400100_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Federal", "plan_name": "400110", "standard_charge_dollar": 18.00, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Federal", "plan_name": "400110_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." } ] } ] }, { "description": "Factor inhibitor test", "code_information": [ { "code": "85335", "type": "CPT" } ], "standard_charges": [ { "gross_charge": 444.90, "minimum": 18.03, "maximum": 18.03, "setting": "both", "payers_information": [ { "payer_name": "Aetna", "plan_name": "700700", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna", "plan_name": "700700_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Miscellaneous", "plan_name": "700720", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Miscellaneous", "plan_name": "700720_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Ppo Hmo", "plan_name": "701720", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Ppo Hmo", "plan_name": "701720_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Ms State Emplo", "plan_name": "401457", "standard_charge_dollar": 18.03, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Ms State Emplo", "plan_name": "401457_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Basic Pl", "plan_name": "400100", "standard_charge_dollar": 18.03, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Basic Pl", "plan_name": "400100_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Federal", "plan_name": "400110", "standard_charge_dollar": 18.03, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Federal", "plan_name": "400110_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." } ] } ] }, { "description": "Hc coag factor vii inhib sc", "code_information": [ { "code": "85335", "type": "CPT" } ], "standard_charges": [ { "gross_charge": 444.90, "minimum": 18.03, "maximum": 18.03, "setting": "both", "payers_information": [ { "payer_name": "Aetna", "plan_name": "700700", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna", "plan_name": "700700_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Miscellaneous", "plan_name": "700720", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Miscellaneous", "plan_name": "700720_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Ppo Hmo", "plan_name": "701720", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Ppo Hmo", "plan_name": "701720_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Ms State Emplo", "plan_name": "401457", "standard_charge_dollar": 18.03, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Ms State Emplo", "plan_name": "401457_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Basic Pl", "plan_name": "400100", "standard_charge_dollar": 18.03, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Basic Pl", "plan_name": "400100_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Federal", "plan_name": "400110", "standard_charge_dollar": 18.03, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Federal", "plan_name": "400110_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." } ] } ] }, { "description": "Fibrin degradation products", "code_information": [ { "code": "85362", "type": "CPT" } ], "standard_charges": [ { "gross_charge": 70.29, "minimum": 10.32, "maximum": 10.32, "setting": "both", "payers_information": [ { "payer_name": "Aetna", "plan_name": "700700", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna", "plan_name": "700700_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Miscellaneous", "plan_name": "700720", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Miscellaneous", "plan_name": "700720_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Ppo Hmo", "plan_name": "701720", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Ppo Hmo", "plan_name": "701720_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Ms State Emplo", "plan_name": "401457", "standard_charge_dollar": 10.32, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Ms State Emplo", "plan_name": "401457_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Basic Pl", "plan_name": "400100", "standard_charge_dollar": 10.32, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Basic Pl", "plan_name": "400100_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Federal", "plan_name": "400110", "standard_charge_dollar": 10.32, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Federal", "plan_name": "400110_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." } ] } ] }, { "description": "Hc fibrin split products", "code_information": [ { "code": "85362", "type": "CPT" } ], "standard_charges": [ { "gross_charge": 70.29, "minimum": 10.32, "maximum": 10.32, "setting": "both", "payers_information": [ { "payer_name": "Aetna", "plan_name": "700700", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna", "plan_name": "700700_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Miscellaneous", "plan_name": "700720", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Miscellaneous", "plan_name": "700720_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Ppo Hmo", "plan_name": "701720", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Ppo Hmo", "plan_name": "701720_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Ms State Emplo", "plan_name": "401457", "standard_charge_dollar": 10.32, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Ms State Emplo", "plan_name": "401457_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Basic Pl", "plan_name": "400100", "standard_charge_dollar": 10.32, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Basic Pl", "plan_name": "400100_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Federal", "plan_name": "400110", "standard_charge_dollar": 10.32, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Federal", "plan_name": "400110_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." } ] } ] }, { "description": "Fibrinogen test", "code_information": [ { "code": "85366", "type": "CPT" } ], "standard_charges": [ { "gross_charge": 313.66, "minimum": 12.91, "maximum": 12.91, "setting": "both", "payers_information": [ { "payer_name": "Aetna", "plan_name": "700700", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna", "plan_name": "700700_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Miscellaneous", "plan_name": "700720", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Miscellaneous", "plan_name": "700720_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Ppo Hmo", "plan_name": "701720", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Ppo Hmo", "plan_name": "701720_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Ms State Emplo", "plan_name": "401457", "standard_charge_dollar": 12.91, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Ms State Emplo", "plan_name": "401457_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Basic Pl", "plan_name": "400100", "standard_charge_dollar": 12.91, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Basic Pl", "plan_name": "400100_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Federal", "plan_name": "400110", "standard_charge_dollar": 12.91, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Federal", "plan_name": "400110_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." } ] } ] }, { "description": "Hc soluble fibrin monomer", "code_information": [ { "code": "85366", "type": "CPT" } ], "standard_charges": [ { "gross_charge": 313.66, "minimum": 12.91, "maximum": 12.91, "setting": "both", "payers_information": [ { "payer_name": "Aetna", "plan_name": "700700", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna", "plan_name": "700700_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Miscellaneous", "plan_name": "700720", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Miscellaneous", "plan_name": "700720_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Ppo Hmo", "plan_name": "701720", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Ppo Hmo", "plan_name": "701720_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Ms State Emplo", "plan_name": "401457", "standard_charge_dollar": 12.91, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Ms State Emplo", "plan_name": "401457_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Basic Pl", "plan_name": "400100", "standard_charge_dollar": 12.91, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Basic Pl", "plan_name": "400100_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Federal", "plan_name": "400110", "standard_charge_dollar": 12.91, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Federal", "plan_name": "400110_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." } ] } ] }, { "description": "Fibrinogen test", "code_information": [ { "code": "85370", "type": "CPT" } ], "standard_charges": [ { "gross_charge": 100.00, "minimum": 17.02, "maximum": 17.02, "setting": "both", "payers_information": [ { "payer_name": "Aetna", "plan_name": "700700", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna", "plan_name": "700700_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Miscellaneous", "plan_name": "700720", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Miscellaneous", "plan_name": "700720_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Ppo Hmo", "plan_name": "701720", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Ppo Hmo", "plan_name": "701720_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Ms State Emplo", "plan_name": "401457", "standard_charge_dollar": 17.02, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Ms State Emplo", "plan_name": "401457_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Basic Pl", "plan_name": "400100", "standard_charge_dollar": 17.02, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Basic Pl", "plan_name": "400100_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Federal", "plan_name": "400110", "standard_charge_dollar": 17.02, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Federal", "plan_name": "400110_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." } ] } ] }, { "description": "Hc fibrin dgradj splt products quantitative", "code_information": [ { "code": "85370", "type": "CPT" } ], "standard_charges": [ { "gross_charge": 100.00, "minimum": 17.02, "maximum": 17.02, "setting": "both", "payers_information": [ { "payer_name": "Aetna", "plan_name": "700700", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna", "plan_name": "700700_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Miscellaneous", "plan_name": "700720", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Miscellaneous", "plan_name": "700720_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Ppo Hmo", "plan_name": "701720", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Ppo Hmo", "plan_name": "701720_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Ms State Emplo", "plan_name": "401457", "standard_charge_dollar": 17.02, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Ms State Emplo", "plan_name": "401457_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Basic Pl", "plan_name": "400100", "standard_charge_dollar": 17.02, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Basic Pl", "plan_name": "400100_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Federal", "plan_name": "400110", "standard_charge_dollar": 17.02, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Federal", "plan_name": "400110_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." } ] } ] }, { "description": "Fibrin degradation quant", "code_information": [ { "code": "85379", "type": "CPT" } ], "standard_charges": [ { "gross_charge": 131.74, "minimum": 8.99, "maximum": 8.99, "setting": "both", "payers_information": [ { "payer_name": "Aetna", "plan_name": "700700", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna", "plan_name": "700700_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Miscellaneous", "plan_name": "700720", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Miscellaneous", "plan_name": "700720_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Ppo Hmo", "plan_name": "701720", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Ppo Hmo", "plan_name": "701720_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Ms State Emplo", "plan_name": "401457", "standard_charge_dollar": 8.99, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Ms State Emplo", "plan_name": "401457_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Basic Pl", "plan_name": "400100", "standard_charge_dollar": 8.99, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Basic Pl", "plan_name": "400100_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Federal", "plan_name": "400110", "standard_charge_dollar": 8.99, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Federal", "plan_name": "400110_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." } ] } ] }, { "description": "Hc d-dimer p", "code_information": [ { "code": "85379", "type": "CPT" } ], "standard_charges": [ { "gross_charge": 131.74, "minimum": 8.99, "maximum": 8.99, "setting": "both", "payers_information": [ { "payer_name": "Aetna", "plan_name": "700700", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna", "plan_name": "700700_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Miscellaneous", "plan_name": "700720", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Miscellaneous", "plan_name": "700720_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Ppo Hmo", "plan_name": "701720", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Ppo Hmo", "plan_name": "701720_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Ms State Emplo", "plan_name": "401457", "standard_charge_dollar": 8.99, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Ms State Emplo", "plan_name": "401457_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Basic Pl", "plan_name": "400100", "standard_charge_dollar": 8.99, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Basic Pl", "plan_name": "400100_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Federal", "plan_name": "400110", "standard_charge_dollar": 8.99, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Federal", "plan_name": "400110_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." } ] } ] }, { "description": "Fibrinogen activity", "code_information": [ { "code": "85384", "type": "CPT" } ], "standard_charges": [ { "gross_charge": 72.50, "minimum": 12.73, "maximum": 12.73, "setting": "both", "payers_information": [ { "payer_name": "Aetna", "plan_name": "700700", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna", "plan_name": "700700_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Miscellaneous", "plan_name": "700720", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Miscellaneous", "plan_name": "700720_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Ppo Hmo", "plan_name": "701720", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Ppo Hmo", "plan_name": "701720_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Ms State Emplo", "plan_name": "401457", "standard_charge_dollar": 12.73, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Ms State Emplo", "plan_name": "401457_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Basic Pl", "plan_name": "400100", "standard_charge_dollar": 12.73, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Basic Pl", "plan_name": "400100_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Federal", "plan_name": "400110", "standard_charge_dollar": 12.73, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Federal", "plan_name": "400110_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." } ] } ] }, { "description": "Hc fibrinogen activity", "code_information": [ { "code": "85384", "type": "CPT" } ], "standard_charges": [ { "gross_charge": 72.50, "minimum": 12.73, "maximum": 12.73, "setting": "both", "payers_information": [ { "payer_name": "Aetna", "plan_name": "700700", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna", "plan_name": "700700_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Miscellaneous", "plan_name": "700720", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Miscellaneous", "plan_name": "700720_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Ppo Hmo", "plan_name": "701720", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Ppo Hmo", "plan_name": "701720_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Ms State Emplo", "plan_name": "401457", "standard_charge_dollar": 12.73, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Ms State Emplo", "plan_name": "401457_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Basic Pl", "plan_name": "400100", "standard_charge_dollar": 12.73, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Basic Pl", "plan_name": "400100_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Federal", "plan_name": "400110", "standard_charge_dollar": 12.73, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Federal", "plan_name": "400110_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." } ] } ] }, { "description": "Fibrinolysins screen i&r", "code_information": [ { "code": "85390", "type": "CPT" } ], "standard_charges": [ { "gross_charge": 151.60, "minimum": 7.74, "maximum": 7.74, "setting": "both", "payers_information": [ { "payer_name": "Aetna", "plan_name": "700700", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna", "plan_name": "700700_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Miscellaneous", "plan_name": "700720", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Miscellaneous", "plan_name": "700720_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Ppo Hmo", "plan_name": "701720", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Ppo Hmo", "plan_name": "701720_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Ms State Emplo", "plan_name": "401457", "standard_charge_dollar": 7.74, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Ms State Emplo", "plan_name": "401457_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Basic Pl", "plan_name": "400100", "standard_charge_dollar": 7.74, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Basic Pl", "plan_name": "400100_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Federal", "plan_name": "400110", "standard_charge_dollar": 7.74, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Federal", "plan_name": "400110_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." } ] } ] }, { "description": "Hc special coagulation interpretation", "code_information": [ { "code": "85390", "type": "CPT" } ], "standard_charges": [ { "gross_charge": 151.60, "minimum": 7.74, "maximum": 7.74, "setting": "both", "payers_information": [ { "payer_name": "Aetna", "plan_name": "700700", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna", "plan_name": "700700_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Miscellaneous", "plan_name": "700720", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Miscellaneous", "plan_name": "700720_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Ppo Hmo", "plan_name": "701720", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Ppo Hmo", "plan_name": "701720_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Ms State Emplo", "plan_name": "401457", "standard_charge_dollar": 7.74, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Ms State Emplo", "plan_name": "401457_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Basic Pl", "plan_name": "400100", "standard_charge_dollar": 7.74, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Basic Pl", "plan_name": "400100_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Federal", "plan_name": "400110", "standard_charge_dollar": 7.74, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Federal", "plan_name": "400110_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." } ] } ] }, { "description": "Clotting funct activity", "code_information": [ { "code": "85397", "type": "CPT" } ], "standard_charges": [ { "gross_charge": 386.00, "minimum": 34.38, "maximum": 34.38, "setting": "both", "payers_information": [ { "payer_name": "Aetna", "plan_name": "700700", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna", "plan_name": "700700_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Miscellaneous", "plan_name": "700720", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Miscellaneous", "plan_name": "700720_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Ppo Hmo", "plan_name": "701720", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Ppo Hmo", "plan_name": "701720_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Ms State Emplo", "plan_name": "401457", "standard_charge_dollar": 34.38, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Ms State Emplo", "plan_name": "401457_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Basic Pl", "plan_name": "400100", "standard_charge_dollar": 34.38, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Basic Pl", "plan_name": "400100_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Federal", "plan_name": "400110", "standard_charge_dollar": 34.38, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Federal", "plan_name": "400110_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." } ] } ] }, { "description": "Hc clotting function activity", "code_information": [ { "code": "85397", "type": "CPT" } ], "standard_charges": [ { "gross_charge": 386.00, "minimum": 34.38, "maximum": 34.38, "setting": "both", "payers_information": [ { "payer_name": "Aetna", "plan_name": "700700", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna", "plan_name": "700700_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Miscellaneous", "plan_name": "700720", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Miscellaneous", "plan_name": "700720_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Ppo Hmo", "plan_name": "701720", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Ppo Hmo", "plan_name": "701720_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Ms State Emplo", "plan_name": "401457", "standard_charge_dollar": 34.38, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Ms State Emplo", "plan_name": "401457_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Basic Pl", "plan_name": "400100", "standard_charge_dollar": 34.38, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Basic Pl", "plan_name": "400100_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Federal", "plan_name": "400110", "standard_charge_dollar": 34.38, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Federal", "plan_name": "400110_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." } ] } ] }, { "description": "Fibrinolytic plasminogen", "code_information": [ { "code": "85415", "type": "CPT" } ], "standard_charges": [ { "gross_charge": 351.90, "minimum": 4.35, "maximum": 4.35, "setting": "both", "payers_information": [ { "payer_name": "Aetna", "plan_name": "700700", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna", "plan_name": "700700_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Miscellaneous", "plan_name": "700720", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Miscellaneous", "plan_name": "700720_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Ppo Hmo", "plan_name": "701720", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Ppo Hmo", "plan_name": "701720_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Ms State Emplo", "plan_name": "401457", "standard_charge_dollar": 4.35, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Ms State Emplo", "plan_name": "401457_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Basic Pl", "plan_name": "400100", "standard_charge_dollar": 4.35, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Basic Pl", "plan_name": "400100_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Federal", "plan_name": "400110", "standard_charge_dollar": 4.35, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Federal", "plan_name": "400110_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." } ] } ] }, { "description": "Hc fbrnlyc factors&inhibitors plsmng activator", "code_information": [ { "code": "85415", "type": "CPT" } ], "standard_charges": [ { "gross_charge": 351.90, "minimum": 4.35, "maximum": 4.35, "setting": "both", "payers_information": [ { "payer_name": "Aetna", "plan_name": "700700", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna", "plan_name": "700700_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Miscellaneous", "plan_name": "700720", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Miscellaneous", "plan_name": "700720_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Ppo Hmo", "plan_name": "701720", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Ppo Hmo", "plan_name": "701720_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Ms State Emplo", "plan_name": "401457", "standard_charge_dollar": 4.35, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Ms State Emplo", "plan_name": "401457_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Basic Pl", "plan_name": "400100", "standard_charge_dollar": 4.35, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Basic Pl", "plan_name": "400100_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Federal", "plan_name": "400110", "standard_charge_dollar": 4.35, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Federal", "plan_name": "400110_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." } ] } ] }, { "description": "Hc platelet neutralization", "code_information": [ { "code": "85597", "type": "CPT" } ], "standard_charges": [ { "gross_charge": 178.88, "minimum": 8.67, "maximum": 8.67, "setting": "both", "payers_information": [ { "payer_name": "Aetna", "plan_name": "700700", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna", "plan_name": "700700_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Miscellaneous", "plan_name": "700720", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Miscellaneous", "plan_name": "700720_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Ppo Hmo", "plan_name": "701720", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Ppo Hmo", "plan_name": "701720_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Ms State Emplo", "plan_name": "401457", "standard_charge_dollar": 8.67, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Ms State Emplo", "plan_name": "401457_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Basic Pl", "plan_name": "400100", "standard_charge_dollar": 8.67, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Basic Pl", "plan_name": "400100_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Federal", "plan_name": "400110", "standard_charge_dollar": 8.67, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Federal", "plan_name": "400110_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." } ] } ] }, { "description": "Phospholipid pltlt neutraliz", "code_information": [ { "code": "85597", "type": "CPT" } ], "standard_charges": [ { "gross_charge": 178.88, "minimum": 8.67, "maximum": 8.67, "setting": "both", "payers_information": [ { "payer_name": "Aetna", "plan_name": "700700", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna", "plan_name": "700700_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Miscellaneous", "plan_name": "700720", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Miscellaneous", "plan_name": "700720_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Ppo Hmo", "plan_name": "701720", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Ppo Hmo", "plan_name": "701720_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Ms State Emplo", "plan_name": "401457", "standard_charge_dollar": 8.67, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Ms State Emplo", "plan_name": "401457_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Basic Pl", "plan_name": "400100", "standard_charge_dollar": 8.67, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Basic Pl", "plan_name": "400100_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Federal", "plan_name": "400110", "standard_charge_dollar": 8.67, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Federal", "plan_name": "400110_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." } ] } ] }, { "description": "Hc hexagonl lupus anticoagulant (hexla)", "code_information": [ { "code": "85598", "type": "CPT" } ], "standard_charges": [ { "gross_charge": 265.02, "minimum": 8.67, "maximum": 8.67, "setting": "both", "payers_information": [ { "payer_name": "Aetna", "plan_name": "700700", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna", "plan_name": "700700_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Miscellaneous", "plan_name": "700720", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Miscellaneous", "plan_name": "700720_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Ppo Hmo", "plan_name": "701720", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Ppo Hmo", "plan_name": "701720_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Ms State Emplo", "plan_name": "401457", "standard_charge_dollar": 8.67, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Ms State Emplo", "plan_name": "401457_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Basic Pl", "plan_name": "400100", "standard_charge_dollar": 8.67, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Basic Pl", "plan_name": "400100_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Federal", "plan_name": "400110", "standard_charge_dollar": 8.67, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Federal", "plan_name": "400110_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." } ] } ] }, { "description": "Hexagnal phosph pltlt neutrl", "code_information": [ { "code": "85598", "type": "CPT" } ], "standard_charges": [ { "gross_charge": 265.02, "minimum": 8.67, "maximum": 8.67, "setting": "both", "payers_information": [ { "payer_name": "Aetna", "plan_name": "700700", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna", "plan_name": "700700_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Miscellaneous", "plan_name": "700720", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Miscellaneous", "plan_name": "700720_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Ppo Hmo", "plan_name": "701720", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Ppo Hmo", "plan_name": "701720_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Ms State Emplo", "plan_name": "401457", "standard_charge_dollar": 8.67, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Ms State Emplo", "plan_name": "401457_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Basic Pl", "plan_name": "400100", "standard_charge_dollar": 8.67, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Basic Pl", "plan_name": "400100_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Federal", "plan_name": "400110", "standard_charge_dollar": 8.67, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Federal", "plan_name": "400110_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." } ] } ] }, { "description": "Hc prothrombin time", "code_information": [ { "code": "85610", "type": "CPT" } ], "standard_charges": [ { "gross_charge": 45.00, "minimum": 5.90, "maximum": 5.90, "setting": "both", "payers_information": [ { "payer_name": "Aetna", "plan_name": "700700", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna", "plan_name": "700700_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Miscellaneous", "plan_name": "700720", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Miscellaneous", "plan_name": "700720_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Ppo Hmo", "plan_name": "701720", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Ppo Hmo", "plan_name": "701720_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Ms State Emplo", "plan_name": "401457", "standard_charge_dollar": 5.90, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Ms State Emplo", "plan_name": "401457_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Basic Pl", "plan_name": "400100", "standard_charge_dollar": 5.90, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Basic Pl", "plan_name": "400100_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Federal", "plan_name": "400110", "standard_charge_dollar": 5.90, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Federal", "plan_name": "400110_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." } ] } ] }, { "description": "Prothrombin time", "code_information": [ { "code": "85610", "type": "CPT" } ], "standard_charges": [ { "gross_charge": 45.00, "minimum": 5.90, "maximum": 5.90, "setting": "both", "payers_information": [ { "payer_name": "Aetna", "plan_name": "700700", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna", "plan_name": "700700_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Miscellaneous", "plan_name": "700720", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Miscellaneous", "plan_name": "700720_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Ppo Hmo", "plan_name": "701720", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Ppo Hmo", "plan_name": "701720_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Ms State Emplo", "plan_name": "401457", "standard_charge_dollar": 5.90, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Ms State Emplo", "plan_name": "401457_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Basic Pl", "plan_name": "400100", "standard_charge_dollar": 5.90, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Basic Pl", "plan_name": "400100_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Federal", "plan_name": "400110", "standard_charge_dollar": 5.90, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Federal", "plan_name": "400110_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." } ] } ] }, { "description": "Hc prothrombin time", "code_information": [ { "code": "85610", "type": "CPT" } ], "standard_charges": [ { "gross_charge": 45.00, "minimum": 36.00, "maximum": 38.25, "setting": "both", "payers_information": [ { "payer_name": "Aetna", "plan_name": "700700", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "modifiers": "QW", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna", "plan_name": "700700_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Miscellaneous", "plan_name": "700720", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Miscellaneous", "plan_name": "700720_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Ppo Hmo", "plan_name": "701720", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Ppo Hmo", "plan_name": "701720_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Ms State Emplo", "plan_name": "401457", "standard_charge_percentage": 0.80, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Ms State Emplo", "plan_name": "401457_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Basic Pl", "plan_name": "400100", "standard_charge_percentage": 0.85, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Basic Pl", "plan_name": "400100_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Federal", "plan_name": "400110", "standard_charge_percentage": 0.85, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Federal", "plan_name": "400110_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." } ] } ] }, { "description": "Hc drvvt mix", "code_information": [ { "code": "85613", "type": "CPT" } ], "standard_charges": [ { "gross_charge": 167.36, "minimum": 8.71, "maximum": 8.71, "setting": "both", "payers_information": [ { "payer_name": "Aetna", "plan_name": "700700", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna", "plan_name": "700700_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Miscellaneous", "plan_name": "700720", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Miscellaneous", "plan_name": "700720_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Ppo Hmo", "plan_name": "701720", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Ppo Hmo", "plan_name": "701720_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Ms State Emplo", "plan_name": "401457", "standard_charge_dollar": 8.71, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Ms State Emplo", "plan_name": "401457_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Basic Pl", "plan_name": "400100", "standard_charge_dollar": 8.71, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Basic Pl", "plan_name": "400100_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Federal", "plan_name": "400110", "standard_charge_dollar": 8.71, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Federal", "plan_name": "400110_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." } ] } ] }, { "description": "Russell viper venom diluted", "code_information": [ { "code": "85613", "type": "CPT" } ], "standard_charges": [ { "gross_charge": 167.36, "minimum": 8.71, "maximum": 8.71, "setting": "both", "payers_information": [ { "payer_name": "Aetna", "plan_name": "700700", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna", "plan_name": "700700_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Miscellaneous", "plan_name": "700720", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Miscellaneous", "plan_name": "700720_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Ppo Hmo", "plan_name": "701720", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Ppo Hmo", "plan_name": "701720_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Ms State Emplo", "plan_name": "401457", "standard_charge_dollar": 8.71, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Ms State Emplo", "plan_name": "401457_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Basic Pl", "plan_name": "400100", "standard_charge_dollar": 8.71, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Basic Pl", "plan_name": "400100_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Federal", "plan_name": "400110", "standard_charge_dollar": 8.71, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Federal", "plan_name": "400110_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." } ] } ] }, { "description": "Hc sed rate nonautomated", "code_information": [ { "code": "85651", "type": "CPT" } ], "standard_charges": [ { "gross_charge": 50.00, "minimum": 5.31, "maximum": 5.31, "setting": "both", "payers_information": [ { "payer_name": "Aetna", "plan_name": "700700", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna", "plan_name": "700700_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Miscellaneous", "plan_name": "700720", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Miscellaneous", "plan_name": "700720_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Ppo Hmo", "plan_name": "701720", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Ppo Hmo", "plan_name": "701720_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Ms State Emplo", "plan_name": "401457", "standard_charge_dollar": 5.31, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Ms State Emplo", "plan_name": "401457_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Basic Pl", "plan_name": "400100", "standard_charge_dollar": 5.31, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Basic Pl", "plan_name": "400100_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Federal", "plan_name": "400110", "standard_charge_dollar": 5.31, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Federal", "plan_name": "400110_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." } ] } ] }, { "description": "Rbc sed rate nonautomated", "code_information": [ { "code": "85651", "type": "CPT" } ], "standard_charges": [ { "gross_charge": 50.00, "minimum": 5.31, "maximum": 5.31, "setting": "both", "payers_information": [ { "payer_name": "Aetna", "plan_name": "700700", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna", "plan_name": "700700_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Miscellaneous", "plan_name": "700720", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Miscellaneous", "plan_name": "700720_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Ppo Hmo", "plan_name": "701720", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Ppo Hmo", "plan_name": "701720_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Ms State Emplo", "plan_name": "401457", "standard_charge_dollar": 5.31, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Ms State Emplo", "plan_name": "401457_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Basic Pl", "plan_name": "400100", "standard_charge_dollar": 5.31, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Basic Pl", "plan_name": "400100_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Federal", "plan_name": "400110", "standard_charge_dollar": 5.31, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Federal", "plan_name": "400110_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." } ] } ] }, { "description": "Hc sickling of rbc reduction", "code_information": [ { "code": "85660", "type": "CPT" } ], "standard_charges": [ { "gross_charge": 125.00, "minimum": 8.26, "maximum": 8.26, "setting": "both", "payers_information": [ { "payer_name": "Aetna", "plan_name": "700700", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna", "plan_name": "700700_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Miscellaneous", "plan_name": "700720", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Miscellaneous", "plan_name": "700720_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Ppo Hmo", "plan_name": "701720", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Ppo Hmo", "plan_name": "701720_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Ms State Emplo", "plan_name": "401457", "standard_charge_dollar": 8.26, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Ms State Emplo", "plan_name": "401457_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Basic Pl", "plan_name": "400100", "standard_charge_dollar": 8.26, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Basic Pl", "plan_name": "400100_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Federal", "plan_name": "400110", "standard_charge_dollar": 8.26, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Federal", "plan_name": "400110_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." } ] } ] }, { "description": "Rbc sickle cell test", "code_information": [ { "code": "85660", "type": "CPT" } ], "standard_charges": [ { "gross_charge": 125.00, "minimum": 8.26, "maximum": 8.26, "setting": "both", "payers_information": [ { "payer_name": "Aetna", "plan_name": "700700", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna", "plan_name": "700700_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Miscellaneous", "plan_name": "700720", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Miscellaneous", "plan_name": "700720_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Ppo Hmo", "plan_name": "701720", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Ppo Hmo", "plan_name": "701720_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Ms State Emplo", "plan_name": "401457", "standard_charge_dollar": 8.26, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Ms State Emplo", "plan_name": "401457_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Basic Pl", "plan_name": "400100", "standard_charge_dollar": 8.26, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Basic Pl", "plan_name": "400100_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Federal", "plan_name": "400110", "standard_charge_dollar": 8.26, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Federal", "plan_name": "400110_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." } ] } ] }, { "description": "Hc thrombin time plasma", "code_information": [ { "code": "85670", "type": "CPT" } ], "standard_charges": [ { "gross_charge": 100.00, "minimum": 8.65, "maximum": 8.65, "setting": "both", "payers_information": [ { "payer_name": "Aetna", "plan_name": "700700", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna", "plan_name": "700700_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Miscellaneous", "plan_name": "700720", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Miscellaneous", "plan_name": "700720_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Ppo Hmo", "plan_name": "701720", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Ppo Hmo", "plan_name": "701720_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Ms State Emplo", "plan_name": "401457", "standard_charge_dollar": 8.65, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Ms State Emplo", "plan_name": "401457_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Basic Pl", "plan_name": "400100", "standard_charge_dollar": 8.65, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Basic Pl", "plan_name": "400100_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Federal", "plan_name": "400110", "standard_charge_dollar": 8.65, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Federal", "plan_name": "400110_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." } ] } ] }, { "description": "Thrombin time plasma", "code_information": [ { "code": "85670", "type": "CPT" } ], "standard_charges": [ { "gross_charge": 100.00, "minimum": 8.65, "maximum": 8.65, "setting": "both", "payers_information": [ { "payer_name": "Aetna", "plan_name": "700700", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna", "plan_name": "700700_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Miscellaneous", "plan_name": "700720", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Miscellaneous", "plan_name": "700720_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Ppo Hmo", "plan_name": "701720", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Ppo Hmo", "plan_name": "701720_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Ms State Emplo", "plan_name": "401457", "standard_charge_dollar": 8.65, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Ms State Emplo", "plan_name": "401457_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Basic Pl", "plan_name": "400100", "standard_charge_dollar": 8.65, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Basic Pl", "plan_name": "400100_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Federal", "plan_name": "400110", "standard_charge_dollar": 8.65, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Federal", "plan_name": "400110_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." } ] } ] }, { "description": "Hc ptt plasma or whole bld", "code_information": [ { "code": "85730", "type": "CPT" } ], "standard_charges": [ { "gross_charge": 75.00, "minimum": 9.00, "maximum": 9.00, "setting": "both", "payers_information": [ { "payer_name": "Aetna", "plan_name": "700700", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna", "plan_name": "700700_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Miscellaneous", "plan_name": "700720", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Miscellaneous", "plan_name": "700720_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Ppo Hmo", "plan_name": "701720", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Ppo Hmo", "plan_name": "701720_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Ms State Emplo", "plan_name": "401457", "standard_charge_dollar": 9.00, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Ms State Emplo", "plan_name": "401457_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Basic Pl", "plan_name": "400100", "standard_charge_dollar": 9.00, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Basic Pl", "plan_name": "400100_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Federal", "plan_name": "400110", "standard_charge_dollar": 9.00, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Federal", "plan_name": "400110_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." } ] } ] }, { "description": "Thromboplastin time partial", "code_information": [ { "code": "85730", "type": "CPT" } ], "standard_charges": [ { "gross_charge": 75.00, "minimum": 9.00, "maximum": 9.00, "setting": "both", "payers_information": [ { "payer_name": "Aetna", "plan_name": "700700", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna", "plan_name": "700700_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Miscellaneous", "plan_name": "700720", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Miscellaneous", "plan_name": "700720_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Ppo Hmo", "plan_name": "701720", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Ppo Hmo", "plan_name": "701720_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Ms State Emplo", "plan_name": "401457", "standard_charge_dollar": 9.00, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Ms State Emplo", "plan_name": "401457_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Basic Pl", "plan_name": "400100", "standard_charge_dollar": 9.00, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Basic Pl", "plan_name": "400100_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Federal", "plan_name": "400110", "standard_charge_dollar": 9.00, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Federal", "plan_name": "400110_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." } ] } ] }, { "description": "Allergen specific igg", "code_information": [ { "code": "86001", "type": "CPT" } ], "standard_charges": [ { "gross_charge": 99.60, "minimum": 7.82, "maximum": 7.82, "setting": "both", "payers_information": [ { "payer_name": "Aetna", "plan_name": "700700", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna", "plan_name": "700700_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Miscellaneous", "plan_name": "700720", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Miscellaneous", "plan_name": "700720_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Ppo Hmo", "plan_name": "701720", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Ppo Hmo", "plan_name": "701720_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Ms State Emplo", "plan_name": "401457", "standard_charge_dollar": 7.82, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Ms State Emplo", "plan_name": "401457_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Basic Pl", "plan_name": "400100", "standard_charge_dollar": 7.82, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Basic Pl", "plan_name": "400100_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Federal", "plan_name": "400110", "standard_charge_dollar": 7.82, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Federal", "plan_name": "400110_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." } ] } ] }, { "description": "Hc igg spec allergens quan/semiquan (fbarg)", "code_information": [ { "code": "86001", "type": "CPT" } ], "standard_charges": [ { "gross_charge": 99.60, "minimum": 7.82, "maximum": 7.82, "setting": "both", "payers_information": [ { "payer_name": "Aetna", "plan_name": "700700", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna", "plan_name": "700700_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Miscellaneous", "plan_name": "700720", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Miscellaneous", "plan_name": "700720_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Ppo Hmo", "plan_name": "701720", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Ppo Hmo", "plan_name": "701720_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Ms State Emplo", "plan_name": "401457", "standard_charge_dollar": 7.82, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Ms State Emplo", "plan_name": "401457_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Basic Pl", "plan_name": "400100", "standard_charge_dollar": 7.82, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Basic Pl", "plan_name": "400100_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Federal", "plan_name": "400110", "standard_charge_dollar": 7.82, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Federal", "plan_name": "400110_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." } ] } ] }, { "description": "Allg spec ige crude xtrc ea", "code_information": [ { "code": "86003", "type": "CPT" } ], "standard_charges": [ { "gross_charge": 112.12, "minimum": 7.82, "maximum": 7.82, "setting": "both", "payers_information": [ { "payer_name": "Aetna", "plan_name": "700700", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna", "plan_name": "700700_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Miscellaneous", "plan_name": "700720", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Miscellaneous", "plan_name": "700720_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Ppo Hmo", "plan_name": "701720", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Ppo Hmo", "plan_name": "701720_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Ms State Emplo", "plan_name": "401457", "standard_charge_dollar": 7.82, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Ms State Emplo", "plan_name": "401457_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Basic Pl", "plan_name": "400100", "standard_charge_dollar": 7.82, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Basic Pl", "plan_name": "400100_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Federal", "plan_name": "400110", "standard_charge_dollar": 7.82, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Federal", "plan_name": "400110_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." } ] } ] }, { "description": "Hc allergy carmine/red dye (mfcrde)", "code_information": [ { "code": "86003", "type": "CPT" } ], "standard_charges": [ { "gross_charge": 112.12, "minimum": 7.82, "maximum": 7.82, "setting": "both", "payers_information": [ { "payer_name": "Aetna", "plan_name": "700700", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna", "plan_name": "700700_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Miscellaneous", "plan_name": "700720", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Miscellaneous", "plan_name": "700720_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Ppo Hmo", "plan_name": "701720", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Ppo Hmo", "plan_name": "701720_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Ms State Emplo", "plan_name": "401457", "standard_charge_dollar": 7.82, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Ms State Emplo", "plan_name": "401457_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Basic Pl", "plan_name": "400100", "standard_charge_dollar": 7.82, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Basic Pl", "plan_name": "400100_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Federal", "plan_name": "400110", "standard_charge_dollar": 7.82, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Federal", "plan_name": "400110_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." } ] } ] }, { "description": "Allg spec ige recomb ea", "code_information": [ { "code": "86008", "type": "CPT" } ], "standard_charges": [ { "gross_charge": 103.94, "minimum": 24.35, "maximum": 24.35, "setting": "both", "payers_information": [ { "payer_name": "Aetna", "plan_name": "700700", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna", "plan_name": "700700_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Miscellaneous", "plan_name": "700720", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Miscellaneous", "plan_name": "700720_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Ppo Hmo", "plan_name": "701720", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Ppo Hmo", "plan_name": "701720_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Ms State Emplo", "plan_name": "401457", "standard_charge_dollar": 24.35, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Ms State Emplo", "plan_name": "401457_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Basic Pl", "plan_name": "400100", "standard_charge_dollar": 24.35, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Basic Pl", "plan_name": "400100_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Federal", "plan_name": "400110", "standard_charge_dollar": 24.35, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Federal", "plan_name": "400110_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." } ] } ] }, { "description": "Hc allergen specific ige (apgal)", "code_information": [ { "code": "86008", "type": "CPT" } ], "standard_charges": [ { "gross_charge": 103.94, "minimum": 24.35, "maximum": 24.35, "setting": "both", "payers_information": [ { "payer_name": "Aetna", "plan_name": "700700", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna", "plan_name": "700700_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Miscellaneous", "plan_name": "700720", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Miscellaneous", "plan_name": "700720_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Ppo Hmo", "plan_name": "701720", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Ppo Hmo", "plan_name": "701720_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Ms State Emplo", "plan_name": "401457", "standard_charge_dollar": 24.35, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Ms State Emplo", "plan_name": "401457_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Basic Pl", "plan_name": "400100", "standard_charge_dollar": 24.35, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Basic Pl", "plan_name": "400100_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Federal", "plan_name": "400110", "standard_charge_dollar": 24.35, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Federal", "plan_name": "400110_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." } ] } ] }, { "description": "Actin antibody each", "code_information": [ { "code": "86015", "type": "CPT" } ], "standard_charges": [ { "gross_charge": 86.50, "minimum": 69.20, "maximum": 73.53, "setting": "both", "payers_information": [ { "payer_name": "Aetna", "plan_name": "700700", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna", "plan_name": "700700_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Miscellaneous", "plan_name": "700720", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Miscellaneous", "plan_name": "700720_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Ppo Hmo", "plan_name": "701720", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Ppo Hmo", "plan_name": "701720_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Ms State Emplo", "plan_name": "401457", "standard_charge_percentage": 0.80, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Ms State Emplo", "plan_name": "401457_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Basic Pl", "plan_name": "400100", "standard_charge_percentage": 0.85, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Basic Pl", "plan_name": "400100_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Federal", "plan_name": "400110", "standard_charge_percentage": 0.85, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Federal", "plan_name": "400110_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." } ] } ] }, { "description": "Hc actin smooth muscle antibody ea", "code_information": [ { "code": "86015", "type": "CPT" } ], "standard_charges": [ { "gross_charge": 86.50, "minimum": 69.20, "maximum": 73.53, "setting": "both", "payers_information": [ { "payer_name": "Aetna", "plan_name": "700700", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna", "plan_name": "700700_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Miscellaneous", "plan_name": "700720", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Miscellaneous", "plan_name": "700720_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Ppo Hmo", "plan_name": "701720", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Ppo Hmo", "plan_name": "701720_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Ms State Emplo", "plan_name": "401457", "standard_charge_percentage": 0.80, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Ms State Emplo", "plan_name": "401457_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Basic Pl", "plan_name": "400100", "standard_charge_percentage": 0.85, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Basic Pl", "plan_name": "400100_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Federal", "plan_name": "400110", "standard_charge_percentage": 0.85, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Federal", "plan_name": "400110_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." } ] } ] }, { "description": "Anca screen each antibody", "code_information": [ { "code": "86036", "type": "CPT" } ], "standard_charges": [ { "gross_charge": 46.30, "minimum": 37.04, "maximum": 39.36, "setting": "both", "payers_information": [ { "payer_name": "Aetna", "plan_name": "700700", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna", "plan_name": "700700_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Miscellaneous", "plan_name": "700720", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Miscellaneous", "plan_name": "700720_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Ppo Hmo", "plan_name": "701720", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Ppo Hmo", "plan_name": "701720_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Ms State Emplo", "plan_name": "401457", "standard_charge_percentage": 0.80, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Ms State Emplo", "plan_name": "401457_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Basic Pl", "plan_name": "400100", "standard_charge_percentage": 0.85, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Basic Pl", "plan_name": "400100_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Federal", "plan_name": "400110", "standard_charge_percentage": 0.85, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Federal", "plan_name": "400110_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." } ] } ] }, { "description": "Hc cytoplasmic neutrophil ab (manca)", "code_information": [ { "code": "86036", "type": "CPT" } ], "standard_charges": [ { "gross_charge": 46.30, "minimum": 37.04, "maximum": 39.36, "setting": "both", "payers_information": [ { "payer_name": "Aetna", "plan_name": "700700", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna", "plan_name": "700700_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Miscellaneous", "plan_name": "700720", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Miscellaneous", "plan_name": "700720_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Ppo Hmo", "plan_name": "701720", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Ppo Hmo", "plan_name": "701720_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Ms State Emplo", "plan_name": "401457", "standard_charge_percentage": 0.80, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Ms State Emplo", "plan_name": "401457_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Basic Pl", "plan_name": "400100", "standard_charge_percentage": 0.85, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Basic Pl", "plan_name": "400100_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Federal", "plan_name": "400110", "standard_charge_percentage": 0.85, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Federal", "plan_name": "400110_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." } ] } ] }, { "description": "Antinuclear antibodies", "code_information": [ { "code": "86038", "type": "CPT" } ], "standard_charges": [ { "gross_charge": 86.50, "minimum": 14.38, "maximum": 14.38, "setting": "both", "payers_information": [ { "payer_name": "Aetna", "plan_name": "700700", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna", "plan_name": "700700_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Miscellaneous", "plan_name": "700720", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Miscellaneous", "plan_name": "700720_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Ppo Hmo", "plan_name": "701720", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Ppo Hmo", "plan_name": "701720_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Ms State Emplo", "plan_name": "401457", "standard_charge_dollar": 14.38, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Ms State Emplo", "plan_name": "401457_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Basic Pl", "plan_name": "400100", "standard_charge_dollar": 14.38, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Basic Pl", "plan_name": "400100_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Federal", "plan_name": "400110", "standard_charge_dollar": 14.38, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Federal", "plan_name": "400110_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." } ] } ] }, { "description": "Hc antinuclear ab ana", "code_information": [ { "code": "86038", "type": "CPT" } ], "standard_charges": [ { "gross_charge": 86.50, "minimum": 14.38, "maximum": 14.38, "setting": "both", "payers_information": [ { "payer_name": "Aetna", "plan_name": "700700", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna", "plan_name": "700700_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Miscellaneous", "plan_name": "700720", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Miscellaneous", "plan_name": "700720_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Ppo Hmo", "plan_name": "701720", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Ppo Hmo", "plan_name": "701720_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Ms State Emplo", "plan_name": "401457", "standard_charge_dollar": 14.38, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Ms State Emplo", "plan_name": "401457_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Basic Pl", "plan_name": "400100", "standard_charge_dollar": 14.38, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Basic Pl", "plan_name": "400100_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Federal", "plan_name": "400110", "standard_charge_dollar": 14.38, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Federal", "plan_name": "400110_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." } ] } ] }, { "description": "Acetylcholn rcptr bndng antb", "code_information": [ { "code": "86041", "type": "CPT" } ], "standard_charges": [ { "gross_charge": 233.38, "minimum": 186.70, "maximum": 198.37, "setting": "both", "payers_information": [ { "payer_name": "Aetna", "plan_name": "700700", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna", "plan_name": "700700_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Miscellaneous", "plan_name": "700720", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna 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"plan_name": "401457_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Basic Pl", "plan_name": "400100", "standard_charge_percentage": 0.85, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Basic Pl", "plan_name": "400100_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Federal", "plan_name": "400110", "standard_charge_percentage": 0.85, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Federal", "plan_name": "400110_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." } ] } ] }, { "description": "Hc achr binding ab", "code_information": [ { "code": "86041", "type": "CPT" } ], "standard_charges": [ { "gross_charge": 233.38, "minimum": 186.70, "maximum": 198.37, "setting": "both", "payers_information": [ { "payer_name": "Aetna", "plan_name": "700700", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna", "plan_name": "700700_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Miscellaneous", "plan_name": "700720", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Miscellaneous", "plan_name": "700720_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Ppo Hmo", "plan_name": "701720", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Ppo Hmo", "plan_name": "701720_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Ms State Emplo", "plan_name": "401457", "standard_charge_percentage": 0.80, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Ms State Emplo", "plan_name": "401457_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Basic Pl", "plan_name": "400100", "standard_charge_percentage": 0.85, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Basic Pl", "plan_name": "400100_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Federal", "plan_name": "400110", "standard_charge_percentage": 0.85, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Federal", "plan_name": "400110_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." } ] } ] }, { "description": "Acetylcholn rcptr modlg antb", "code_information": [ { "code": "86043", "type": "CPT" } ], "standard_charges": [ { "gross_charge": 175.04, "minimum": 140.03, "maximum": 148.78, "setting": "both", "payers_information": [ { "payer_name": "Aetna", "plan_name": "700700", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna", "plan_name": "700700_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Miscellaneous", "plan_name": "700720", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Miscellaneous", "plan_name": "700720_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Ppo Hmo", "plan_name": "701720", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Ppo Hmo", "plan_name": "701720_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Ms State Emplo", "plan_name": "401457", "standard_charge_percentage": 0.80, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Ms State Emplo", "plan_name": "401457_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Basic Pl", "plan_name": "400100", "standard_charge_percentage": 0.85, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Basic Pl", "plan_name": "400100_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Federal", "plan_name": "400110", "standard_charge_percentage": 0.85, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Federal", "plan_name": "400110_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." } ] } ] }, { "description": "Hc acetylcholine receptor modulating antibody", "code_information": [ { "code": "86043", "type": "CPT" } ], "standard_charges": [ { "gross_charge": 175.04, "minimum": 140.03, "maximum": 148.78, "setting": "both", "payers_information": [ { "payer_name": "Aetna", "plan_name": "700700", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna", "plan_name": "700700_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Miscellaneous", "plan_name": "700720", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Miscellaneous", "plan_name": "700720_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Ppo Hmo", "plan_name": "701720", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of 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billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Basic Pl", "plan_name": "400100_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Federal", "plan_name": "400110", "standard_charge_percentage": 0.85, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Federal", "plan_name": "400110_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." } ] } ] }, { "description": "Antistreptolysin o titer", "code_information": [ { "code": "86060", "type": "CPT" } ], "standard_charges": [ { "gross_charge": 126.40, "minimum": 4.35, "maximum": 4.35, "setting": "both", "payers_information": [ { "payer_name": "Aetna", "plan_name": "700700", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna", "plan_name": "700700_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Miscellaneous", "plan_name": "700720", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Miscellaneous", "plan_name": "700720_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Ppo Hmo", "plan_name": "701720", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Ppo Hmo", "plan_name": "701720_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Ms State Emplo", "plan_name": "401457", "standard_charge_dollar": 4.35, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Ms State Emplo", "plan_name": "401457_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Basic Pl", "plan_name": "400100", "standard_charge_dollar": 4.35, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Basic Pl", "plan_name": "400100_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Federal", "plan_name": "400110", "standard_charge_dollar": 4.35, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Federal", "plan_name": "400110_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." } ] } ] }, { "description": "Hc antistreptolysin o titer", "code_information": [ { "code": "86060", "type": "CPT" } ], "standard_charges": [ { "gross_charge": 126.40, "minimum": 4.35, "maximum": 4.35, "setting": "both", "payers_information": [ { "payer_name": "Aetna", "plan_name": "700700", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna", "plan_name": "700700_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Miscellaneous", "plan_name": "700720", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Miscellaneous", "plan_name": "700720_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Ppo Hmo", "plan_name": "701720", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Ppo Hmo", "plan_name": "701720_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Ms State Emplo", "plan_name": "401457", "standard_charge_dollar": 4.35, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Ms State Emplo", "plan_name": "401457_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Basic Pl", "plan_name": "400100", "standard_charge_dollar": 4.35, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Basic Pl", "plan_name": "400100_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Federal", "plan_name": "400110", "standard_charge_dollar": 4.35, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Federal", "plan_name": "400110_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." } ] } ] }, { "description": "C-reactive protein", "code_information": [ { "code": "86140", "type": "CPT" } ], "standard_charges": [ { "gross_charge": 80.00, "minimum": 6.96, "maximum": 6.96, "setting": "both", "payers_information": [ { "payer_name": "Aetna", "plan_name": "700700", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna", "plan_name": "700700_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Miscellaneous", "plan_name": "700720", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Miscellaneous", "plan_name": "700720_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Ppo Hmo", "plan_name": "701720", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Ppo Hmo", "plan_name": "701720_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Ms State Emplo", "plan_name": "401457", "standard_charge_dollar": 6.96, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Ms State Emplo", "plan_name": "401457_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Basic Pl", "plan_name": "400100", "standard_charge_dollar": 6.96, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Basic Pl", "plan_name": "400100_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Federal", "plan_name": "400110", "standard_charge_dollar": 6.96, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Federal", "plan_name": "400110_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." } ] } ] }, { "description": "Hc c reactive protein", "code_information": [ { "code": "86140", "type": "CPT" } ], "standard_charges": [ { "gross_charge": 80.00, "minimum": 6.96, "maximum": 6.96, "setting": "both", "payers_information": [ { "payer_name": "Aetna", "plan_name": "700700", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna", "plan_name": "700700_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Miscellaneous", "plan_name": "700720", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Miscellaneous", "plan_name": "700720_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Ppo Hmo", "plan_name": "701720", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Ppo Hmo", "plan_name": "701720_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Ms State Emplo", "plan_name": "401457", "standard_charge_dollar": 6.96, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Ms State Emplo", "plan_name": "401457_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Basic Pl", "plan_name": "400100", "standard_charge_dollar": 6.96, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Basic Pl", "plan_name": "400100_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Federal", "plan_name": "400110", "standard_charge_dollar": 6.96, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Federal", "plan_name": "400110_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." } ] } ] }, { "description": "C-reactive protein hs", "code_information": [ { "code": "86141", "type": "CPT" } ], "standard_charges": [ { "gross_charge": 72.00, "minimum": 19.39, "maximum": 19.39, "setting": "both", "payers_information": [ { "payer_name": "Aetna", "plan_name": "700700", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna", "plan_name": "700700_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Miscellaneous", "plan_name": "700720", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Miscellaneous", "plan_name": "700720_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Ppo Hmo", "plan_name": "701720", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Ppo Hmo", "plan_name": "701720_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Ms State Emplo", "plan_name": "401457", "standard_charge_dollar": 19.39, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Ms State Emplo", "plan_name": "401457_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Basic Pl", "plan_name": "400100", "standard_charge_dollar": 19.39, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Basic Pl", "plan_name": "400100_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Federal", "plan_name": "400110", "standard_charge_dollar": 19.39, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Federal", "plan_name": "400110_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." } ] } ] }, { "description": "Hc c reactive protein high sensitivity", "code_information": [ { "code": "86141", "type": "CPT" } ], "standard_charges": [ { "gross_charge": 72.00, "minimum": 19.39, "maximum": 19.39, "setting": "both", "payers_information": [ { "payer_name": "Aetna", "plan_name": "700700", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna", "plan_name": "700700_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Miscellaneous", "plan_name": "700720", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Miscellaneous", "plan_name": "700720_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Ppo Hmo", "plan_name": "701720", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Ppo Hmo", "plan_name": "701720_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Ms State Emplo", "plan_name": "401457", "standard_charge_dollar": 19.39, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Ms State Emplo", "plan_name": "401457_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Basic Pl", "plan_name": "400100", "standard_charge_dollar": 19.39, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Basic Pl", "plan_name": "400100_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Federal", "plan_name": "400110", "standard_charge_dollar": 19.39, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Federal", "plan_name": "400110_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." } ] } ] }, { "description": "Complement antigen", "code_information": [ { "code": "86160", "type": "CPT" } ], "standard_charges": [ { "gross_charge": 150.00, "minimum": 17.44, "maximum": 17.44, "setting": "both", "payers_information": [ { "payer_name": "Aetna", "plan_name": "700700", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna", "plan_name": "700700_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Miscellaneous", "plan_name": "700720", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Miscellaneous", "plan_name": "700720_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Ppo Hmo", "plan_name": "701720", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Ppo Hmo", "plan_name": "701720_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Ms State Emplo", "plan_name": "401457", "standard_charge_dollar": 17.44, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Ms State Emplo", "plan_name": "401457_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Basic Pl", "plan_name": "400100", "standard_charge_dollar": 17.44, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Basic Pl", "plan_name": "400100_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Federal", "plan_name": "400110", "standard_charge_dollar": 17.44, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Federal", "plan_name": "400110_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." } ] } ] }, { "description": "Hc c3", "code_information": [ { "code": "86160", "type": "CPT" } ], "standard_charges": [ { "gross_charge": 150.00, "minimum": 17.44, "maximum": 17.44, "setting": "both", "payers_information": [ { "payer_name": "Aetna", "plan_name": "700700", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna", "plan_name": "700700_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Miscellaneous", "plan_name": "700720", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Miscellaneous", "plan_name": "700720_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Ppo Hmo", "plan_name": "701720", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Ppo Hmo", "plan_name": "701720_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Ms State Emplo", "plan_name": "401457", "standard_charge_dollar": 17.44, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Ms State Emplo", "plan_name": "401457_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Basic Pl", "plan_name": "400100", "standard_charge_dollar": 17.44, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Basic Pl", "plan_name": "400100_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Federal", "plan_name": "400110", "standard_charge_dollar": 17.44, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Federal", "plan_name": "400110_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." } ] } ] }, { "description": "Ccp antibody", "code_information": [ { "code": "86200", "type": "CPT" } ], "standard_charges": [ { "gross_charge": 80.00, "minimum": 19.39, "maximum": 19.39, "setting": "both", "payers_information": [ { "payer_name": "Aetna", "plan_name": "700700", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna", "plan_name": "700700_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Miscellaneous", "plan_name": "700720", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Miscellaneous", "plan_name": "700720_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Ppo Hmo", "plan_name": "701720", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Ppo Hmo", "plan_name": "701720_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Ms State Emplo", "plan_name": "401457", "standard_charge_dollar": 19.39, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Ms State Emplo", "plan_name": "401457_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Basic Pl", "plan_name": "400100", "standard_charge_dollar": 19.39, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Basic Pl", "plan_name": "400100_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Federal", "plan_name": "400110", "standard_charge_dollar": 19.39, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Federal", "plan_name": "400110_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." } ] } ] }, { "description": "Hc ccp antibody", "code_information": [ { "code": "86200", "type": "CPT" } ], "standard_charges": [ { "gross_charge": 80.00, "minimum": 19.39, "maximum": 19.39, "setting": "both", "payers_information": [ { "payer_name": "Aetna", "plan_name": "700700", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna", "plan_name": "700700_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Miscellaneous", "plan_name": "700720", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Miscellaneous", "plan_name": "700720_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Ppo Hmo", "plan_name": "701720", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Ppo Hmo", "plan_name": "701720_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Ms State Emplo", "plan_name": "401457", "standard_charge_dollar": 19.39, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Ms State Emplo", "plan_name": "401457_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Basic Pl", "plan_name": "400100", "standard_charge_dollar": 19.39, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Basic Pl", "plan_name": "400100_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Federal", "plan_name": "400110", "standard_charge_dollar": 19.39, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Federal", "plan_name": "400110_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." } ] } ] }, { "description": "Deoxyribonuclease antibody", "code_information": [ { "code": "86215", "type": "CPT" } ], "standard_charges": [ { "gross_charge": 48.52, "minimum": 19.86, "maximum": 19.86, "setting": "both", "payers_information": [ { "payer_name": "Aetna", "plan_name": "700700", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna", "plan_name": "700700_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Miscellaneous", "plan_name": "700720", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Miscellaneous", "plan_name": "700720_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Ppo Hmo", "plan_name": "701720", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Ppo Hmo", "plan_name": "701720_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Ms State Emplo", "plan_name": "401457", "standard_charge_dollar": 19.86, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Ms State Emplo", "plan_name": "401457_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Basic Pl", "plan_name": "400100", "standard_charge_dollar": 19.86, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Basic Pl", "plan_name": "400100_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Federal", "plan_name": "400110", "standard_charge_dollar": 19.86, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Federal", "plan_name": "400110_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." } ] } ] }, { "description": "Hc dna antibody", "code_information": [ { "code": "86215", "type": "CPT" } ], "standard_charges": [ { "gross_charge": 48.52, "minimum": 19.86, "maximum": 19.86, "setting": "both", "payers_information": [ { "payer_name": "Aetna", "plan_name": "700700", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna", "plan_name": "700700_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Miscellaneous", "plan_name": "700720", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Miscellaneous", "plan_name": "700720_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Ppo Hmo", "plan_name": "701720", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Ppo Hmo", "plan_name": "701720_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Ms State Emplo", "plan_name": "401457", "standard_charge_dollar": 19.86, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Ms State Emplo", "plan_name": "401457_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Basic Pl", "plan_name": "400100", "standard_charge_dollar": 19.86, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Basic Pl", "plan_name": "400100_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Federal", "plan_name": "400110", "standard_charge_dollar": 19.86, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Federal", "plan_name": "400110_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." } ] } ] }, { "description": "Dna antibody native", "code_information": [ { "code": "86225", "type": "CPT" } ], "standard_charges": [ { "gross_charge": 106.00, "minimum": 20.58, "maximum": 20.58, "setting": "both", "payers_information": [ { "payer_name": "Aetna", "plan_name": "700700", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna", "plan_name": "700700_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Miscellaneous", "plan_name": "700720", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Miscellaneous", "plan_name": "700720_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Ppo Hmo", "plan_name": "701720", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Ppo Hmo", "plan_name": "701720_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Ms State Emplo", "plan_name": "401457", "standard_charge_dollar": 20.58, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Ms State Emplo", "plan_name": "401457_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Basic Pl", "plan_name": "400100", "standard_charge_dollar": 20.58, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Basic Pl", "plan_name": "400100_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Federal", "plan_name": "400110", "standard_charge_dollar": 20.58, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Federal", "plan_name": "400110_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." } ] } ] }, { "description": "Hc anti-dna antibody", "code_information": [ { "code": "86225", "type": "CPT" } ], "standard_charges": [ { "gross_charge": 106.00, "minimum": 20.58, "maximum": 20.58, "setting": "both", "payers_information": [ { "payer_name": "Aetna", "plan_name": "700700", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna", "plan_name": "700700_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Miscellaneous", "plan_name": "700720", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Miscellaneous", "plan_name": "700720_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Ppo Hmo", "plan_name": "701720", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Ppo Hmo", "plan_name": "701720_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Ms State Emplo", "plan_name": "401457", "standard_charge_dollar": 20.58, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Ms State Emplo", "plan_name": "401457_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Basic Pl", "plan_name": "400100", "standard_charge_dollar": 20.58, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Basic Pl", "plan_name": "400100_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Federal", "plan_name": "400110", "standard_charge_dollar": 20.58, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Federal", "plan_name": "400110_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." } ] } ] }, { "description": "Ema each ig class", "code_information": [ { "code": "86231", "type": "CPT" } ], "standard_charges": [ { "gross_charge": 157.50, "minimum": 126.00, "maximum": 133.88, "setting": "both", "payers_information": [ { "payer_name": "Aetna", "plan_name": "700700", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna", "plan_name": "700700_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Miscellaneous", "plan_name": "700720", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Miscellaneous", "plan_name": "700720_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Ppo Hmo", "plan_name": "701720", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Ppo Hmo", "plan_name": "701720_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Ms State Emplo", "plan_name": "401457", "standard_charge_percentage": 0.80, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Ms State Emplo", "plan_name": "401457_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Basic Pl", "plan_name": "400100", "standard_charge_percentage": 0.85, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Basic Pl", "plan_name": "400100_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Federal", "plan_name": "400110", "standard_charge_percentage": 0.85, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Federal", "plan_name": "400110_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." } ] } ] }, { "description": "Hc endomysial antibody", "code_information": [ { "code": "86231", "type": "CPT" } ], "standard_charges": [ { "gross_charge": 157.50, "minimum": 126.00, "maximum": 133.88, "setting": "both", "payers_information": [ { "payer_name": "Aetna", "plan_name": "700700", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna", "plan_name": "700700_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Miscellaneous", "plan_name": "700720", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Miscellaneous", "plan_name": "700720_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Ppo Hmo", "plan_name": "701720", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Ppo Hmo", "plan_name": "701720_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Ms State Emplo", "plan_name": "401457", "standard_charge_percentage": 0.80, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Ms State Emplo", "plan_name": "401457_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Basic Pl", "plan_name": "400100", "standard_charge_percentage": 0.85, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Basic Pl", "plan_name": "400100_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Federal", "plan_name": "400110", "standard_charge_percentage": 0.85, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Federal", "plan_name": "400110_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." } ] } ] }, { "description": "Hc scl 70 ab igg", "code_information": [ { "code": "86235", "type": "CPT" } ], "standard_charges": [ { "gross_charge": 97.00, "minimum": 26.87, "maximum": 26.87, "setting": "both", "payers_information": [ { "payer_name": "Aetna", "plan_name": "700700", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna", "plan_name": "700700_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Miscellaneous", "plan_name": "700720", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Miscellaneous", "plan_name": "700720_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Ppo Hmo", "plan_name": "701720", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Ppo Hmo", "plan_name": "701720_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Ms State Emplo", "plan_name": "401457", "standard_charge_dollar": 26.87, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Ms State Emplo", "plan_name": "401457_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Basic Pl", "plan_name": "400100", "standard_charge_dollar": 26.87, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Basic Pl", "plan_name": "400100_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Federal", "plan_name": "400110", "standard_charge_dollar": 26.87, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Federal", "plan_name": "400110_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." } ] } ] }, { "description": "Nuclear antigen antibody", "code_information": [ { "code": "86235", "type": "CPT" } ], "standard_charges": [ { "gross_charge": 97.00, "minimum": 26.87, "maximum": 26.87, "setting": "both", "payers_information": [ { "payer_name": "Aetna", "plan_name": "700700", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna", "plan_name": "700700_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Miscellaneous", "plan_name": "700720", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Miscellaneous", "plan_name": "700720_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Ppo Hmo", "plan_name": "701720", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Ppo Hmo", "plan_name": "701720_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Ms State Emplo", "plan_name": "401457", "standard_charge_dollar": 26.87, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Ms State Emplo", "plan_name": "401457_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Basic Pl", "plan_name": "400100", "standard_charge_dollar": 26.87, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Basic Pl", "plan_name": "400100_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Federal", "plan_name": "400110", "standard_charge_dollar": 26.87, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Federal", "plan_name": "400110_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." } ] } ] }, { "description": "Dgp antibody each ig class", "code_information": [ { "code": "86258", "type": "CPT" } ], "standard_charges": [ { "gross_charge": 53.00, "minimum": 42.40, "maximum": 45.05, "setting": "both", "payers_information": [ { "payer_name": "Aetna", "plan_name": "700700", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna", "plan_name": "700700_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Miscellaneous", "plan_name": "700720", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Miscellaneous", "plan_name": "700720_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Ppo Hmo", "plan_name": "701720", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Ppo Hmo", "plan_name": "701720_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Ms State Emplo", "plan_name": "401457", "standard_charge_percentage": 0.80, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Ms State Emplo", "plan_name": "401457_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Basic Pl", "plan_name": "400100", "standard_charge_percentage": 0.85, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Basic Pl", "plan_name": "400100_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Federal", "plan_name": "400110", "standard_charge_percentage": 0.85, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Federal", "plan_name": "400110_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." } ] } ] }, { "description": "Hc gliadin antibody", "code_information": [ { "code": "86258", "type": "CPT" } ], "standard_charges": [ { "gross_charge": 53.00, "minimum": 42.40, "maximum": 45.05, "setting": "both", "payers_information": [ { "payer_name": "Aetna", "plan_name": "700700", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna", "plan_name": "700700_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Miscellaneous", "plan_name": "700720", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Miscellaneous", "plan_name": "700720_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Ppo Hmo", "plan_name": "701720", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Ppo Hmo", "plan_name": "701720_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Ms State Emplo", "plan_name": "401457", "standard_charge_percentage": 0.80, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Ms State Emplo", "plan_name": "401457_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Basic Pl", "plan_name": "400100", "standard_charge_percentage": 0.85, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Basic Pl", "plan_name": "400100_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Federal", "plan_name": "400110", "standard_charge_percentage": 0.85, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Federal", "plan_name": "400110_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." } ] } ] }, { "description": "Hc ca 27-29", "code_information": [ { "code": "86300", "type": "CPT" } ], "standard_charges": [ { "gross_charge": 145.00, "minimum": 23.55, "maximum": 23.55, "setting": "both", "payers_information": [ { "payer_name": "Aetna", "plan_name": "700700", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna", "plan_name": "700700_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Miscellaneous", "plan_name": "700720", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Miscellaneous", "plan_name": "700720_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Ppo Hmo", "plan_name": "701720", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Ppo Hmo", "plan_name": "701720_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Ms State Emplo", "plan_name": "401457", "standard_charge_dollar": 23.55, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Ms State Emplo", "plan_name": "401457_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Basic Pl", "plan_name": "400100", "standard_charge_dollar": 23.55, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Basic Pl", "plan_name": "400100_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Federal", "plan_name": "400110", "standard_charge_dollar": 23.55, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Federal", "plan_name": "400110_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." } ] } ] }, { "description": "Immunoassay tumor ca 15-3", "code_information": [ { "code": "86300", "type": "CPT" } ], "standard_charges": [ { "gross_charge": 145.00, "minimum": 23.55, "maximum": 23.55, "setting": "both", "payers_information": [ { "payer_name": "Aetna", "plan_name": "700700", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna", "plan_name": "700700_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Miscellaneous", "plan_name": "700720", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Miscellaneous", "plan_name": "700720_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Ppo Hmo", "plan_name": "701720", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Ppo Hmo", "plan_name": "701720_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Ms State Emplo", "plan_name": "401457", "standard_charge_dollar": 23.55, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Ms State Emplo", "plan_name": "401457_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Basic Pl", "plan_name": "400100", "standard_charge_dollar": 23.55, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Basic Pl", "plan_name": "400100_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Federal", "plan_name": "400110", "standard_charge_dollar": 23.55, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Federal", "plan_name": "400110_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." } ] } ] }, { "description": "Hc ia quant ca 19-9", "code_information": [ { "code": "86301", "type": "CPT" } ], "standard_charges": [ { "gross_charge": 63.00, "minimum": 23.55, "maximum": 23.55, "setting": "both", "payers_information": [ { "payer_name": "Aetna", "plan_name": "700700", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna", "plan_name": "700700_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Miscellaneous", "plan_name": "700720", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Miscellaneous", "plan_name": "700720_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Ppo Hmo", "plan_name": "701720", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Ppo Hmo", "plan_name": "701720_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Ms State Emplo", "plan_name": "401457", "standard_charge_dollar": 23.55, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Ms State Emplo", "plan_name": "401457_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Basic Pl", "plan_name": "400100", "standard_charge_dollar": 23.55, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Basic Pl", "plan_name": "400100_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Federal", "plan_name": "400110", "standard_charge_dollar": 23.55, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Federal", "plan_name": "400110_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." } ] } ] }, { "description": "Immunoassay tumor ca 19-9", "code_information": [ { "code": "86301", "type": "CPT" } ], "standard_charges": [ { "gross_charge": 63.00, "minimum": 23.55, "maximum": 23.55, "setting": "both", "payers_information": [ { "payer_name": "Aetna", "plan_name": "700700", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna", "plan_name": "700700_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Miscellaneous", "plan_name": "700720", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Miscellaneous", "plan_name": "700720_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Ppo Hmo", "plan_name": "701720", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Ppo Hmo", "plan_name": "701720_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Ms State Emplo", "plan_name": "401457", "standard_charge_dollar": 23.55, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Ms State Emplo", "plan_name": "401457_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Basic Pl", "plan_name": "400100", "standard_charge_dollar": 23.55, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Basic Pl", "plan_name": "400100_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Federal", "plan_name": "400110", "standard_charge_dollar": 23.55, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Federal", "plan_name": "400110_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." } ] } ] }, { "description": "Hc ia quant ca 125", "code_information": [ { "code": "86304", "type": "CPT" } ], "standard_charges": [ { "gross_charge": 79.80, "minimum": 23.55, "maximum": 23.55, "setting": "both", "payers_information": [ { "payer_name": "Aetna", "plan_name": "700700", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna", "plan_name": "700700_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Miscellaneous", "plan_name": "700720", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Miscellaneous", "plan_name": "700720_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Ppo Hmo", "plan_name": "701720", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Ppo Hmo", "plan_name": "701720_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Ms State Emplo", "plan_name": "401457", "standard_charge_dollar": 23.55, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Ms State Emplo", "plan_name": "401457_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Basic Pl", "plan_name": "400100", "standard_charge_dollar": 23.55, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Basic Pl", "plan_name": "400100_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Federal", "plan_name": "400110", "standard_charge_dollar": 23.55, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Federal", "plan_name": "400110_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." } ] } ] }, { "description": "Immunoassay tumor ca 125", "code_information": [ { "code": "86304", "type": "CPT" } ], "standard_charges": [ { "gross_charge": 79.80, "minimum": 23.55, "maximum": 23.55, "setting": "both", "payers_information": [ { "payer_name": "Aetna", "plan_name": "700700", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna", "plan_name": "700700_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Miscellaneous", "plan_name": "700720", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Miscellaneous", "plan_name": "700720_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Ppo Hmo", "plan_name": "701720", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Ppo Hmo", "plan_name": "701720_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Ms State Emplo", "plan_name": "401457", "standard_charge_dollar": 23.55, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Ms State Emplo", "plan_name": "401457_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Basic Pl", "plan_name": "400100", "standard_charge_dollar": 23.55, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Basic Pl", "plan_name": "400100_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Federal", "plan_name": "400110", "standard_charge_dollar": 23.55, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Federal", "plan_name": "400110_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." } ] } ] }, { "description": "Hc heterophile ab screen", "code_information": [ { "code": "86308", "type": "CPT" } ], "standard_charges": [ { "gross_charge": 65.00, "minimum": 7.76, "maximum": 7.76, "setting": "both", "payers_information": [ { "payer_name": "Aetna", "plan_name": "700700", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna", "plan_name": "700700_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Miscellaneous", "plan_name": "700720", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Miscellaneous", "plan_name": "700720_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Ppo Hmo", "plan_name": "701720", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Ppo Hmo", "plan_name": "701720_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Ms State Emplo", "plan_name": "401457", "standard_charge_dollar": 7.76, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Ms State Emplo", "plan_name": "401457_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Basic Pl", "plan_name": "400100", "standard_charge_dollar": 7.76, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Basic Pl", "plan_name": "400100_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Federal", "plan_name": "400110", "standard_charge_dollar": 7.76, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Federal", "plan_name": "400110_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." } ] } ] }, { "description": "Heterophile antibody screen", "code_information": [ { "code": "86308", "type": "CPT" } ], "standard_charges": [ { "gross_charge": 65.00, "minimum": 7.76, "maximum": 7.76, "setting": "both", "payers_information": [ { "payer_name": "Aetna", "plan_name": "700700", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna", "plan_name": "700700_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Miscellaneous", "plan_name": "700720", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Miscellaneous", "plan_name": "700720_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Ppo Hmo", "plan_name": "701720", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of 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"Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Basic Pl", "plan_name": "400100_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Federal", "plan_name": "400110", "standard_charge_dollar": 7.76, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Federal", "plan_name": "400110_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." } ] } ] }, { "description": "Hc heterophile ab screen", "code_information": [ { "code": "86308", "type": "CPT" } ], "standard_charges": [ { "gross_charge": 65.00, "minimum": 52.00, "maximum": 55.25, "setting": "both", "payers_information": [ { "payer_name": "Aetna", "plan_name": "700700", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "modifiers": "QW", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna", "plan_name": "700700_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Miscellaneous", "plan_name": "700720", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Miscellaneous", "plan_name": "700720_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed 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"payer_name": "Bc/Bs Of Ms Basic Pl", "plan_name": "400100", "standard_charge_percentage": 0.85, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Basic Pl", "plan_name": "400100_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Federal", "plan_name": "400110", "standard_charge_percentage": 0.85, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Federal", "plan_name": "400110_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." } ] } ] }, { "description": "Hc chromogranin a", "code_information": [ { "code": "86316", "type": "CPT" } ], "standard_charges": [ { "gross_charge": 100.00, "minimum": 23.55, "maximum": 23.55, "setting": "both", "payers_information": [ { "payer_name": "Aetna", "plan_name": "700700", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna", "plan_name": "700700_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Miscellaneous", "plan_name": "700720", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Miscellaneous", "plan_name": "700720_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Ppo Hmo", "plan_name": "701720", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Ppo Hmo", "plan_name": "701720_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Ms State Emplo", "plan_name": "401457", "standard_charge_dollar": 23.55, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Ms State Emplo", "plan_name": "401457_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Basic Pl", "plan_name": "400100", "standard_charge_dollar": 23.55, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Basic Pl", "plan_name": "400100_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Federal", "plan_name": "400110", "standard_charge_dollar": 23.55, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Federal", "plan_name": "400110_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." } ] } ] }, { "description": "Immunoassay tumor other", "code_information": [ { "code": "86316", "type": "CPT" } ], "standard_charges": [ { "gross_charge": 100.00, "minimum": 23.55, "maximum": 23.55, "setting": "both", "payers_information": [ { "payer_name": "Aetna", "plan_name": "700700", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna", "plan_name": "700700_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Miscellaneous", "plan_name": "700720", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Miscellaneous", "plan_name": "700720_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Ppo Hmo", "plan_name": "701720", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Ppo Hmo", "plan_name": "701720_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Ms State Emplo", "plan_name": "401457", "standard_charge_dollar": 23.55, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Ms State Emplo", "plan_name": "401457_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Basic Pl", "plan_name": "400100", "standard_charge_dollar": 23.55, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Basic Pl", "plan_name": "400100_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Federal", "plan_name": "400110", "standard_charge_dollar": 23.55, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Federal", "plan_name": "400110_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." } ] } ] }, { "description": "Hc ia infectious agent ab quant", "code_information": [ { "code": "86317", "type": "CPT" } ], "standard_charges": [ { "gross_charge": 16.98, "minimum": 22.46, "maximum": 22.46, "setting": "both", "payers_information": [ { "payer_name": "Aetna", "plan_name": "700700", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna", "plan_name": "700700_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Miscellaneous", "plan_name": "700720", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Miscellaneous", "plan_name": "700720_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Ppo Hmo", "plan_name": "701720", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Ppo Hmo", "plan_name": "701720_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Ms State Emplo", "plan_name": "401457", "standard_charge_dollar": 22.46, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Ms State Emplo", "plan_name": "401457_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Basic Pl", "plan_name": "400100", "standard_charge_dollar": 22.46, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Basic Pl", "plan_name": "400100_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Federal", "plan_name": "400110", "standard_charge_dollar": 22.46, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Federal", "plan_name": "400110_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." } ] } ] }, { "description": "Immunoassay infectious agent", "code_information": [ { "code": "86317", "type": "CPT" } ], "standard_charges": [ { "gross_charge": 16.98, "minimum": 22.46, "maximum": 22.46, "setting": "both", "payers_information": [ { "payer_name": "Aetna", "plan_name": "700700", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna", "plan_name": "700700_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Miscellaneous", "plan_name": "700720", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Miscellaneous", "plan_name": "700720_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Ppo Hmo", "plan_name": "701720", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Ppo Hmo", "plan_name": "701720_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Ms State Emplo", "plan_name": "401457", "standard_charge_dollar": 22.46, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Ms State Emplo", "plan_name": "401457_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Basic Pl", "plan_name": "400100", "standard_charge_dollar": 22.46, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Basic Pl", "plan_name": "400100_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Federal", "plan_name": "400110", "standard_charge_dollar": 22.46, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Federal", "plan_name": "400110_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." } ] } ] }, { "description": "Hc aspergillus igg precipitins pnl (mfaspg)", "code_information": [ { "code": "86331", "type": "CPT" } ], "standard_charges": [ { "gross_charge": 31.16, "minimum": 17.95, "maximum": 17.95, "setting": "both", "payers_information": [ { "payer_name": "Aetna", "plan_name": "700700", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna", "plan_name": "700700_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Miscellaneous", "plan_name": "700720", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Miscellaneous", "plan_name": "700720_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Ppo Hmo", "plan_name": "701720", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Ppo Hmo", "plan_name": "701720_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Ms State Emplo", "plan_name": "401457", "standard_charge_dollar": 17.95, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Ms State Emplo", "plan_name": "401457_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Basic Pl", "plan_name": "400100", "standard_charge_dollar": 17.95, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Basic Pl", "plan_name": "400100_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Federal", "plan_name": "400110", "standard_charge_dollar": 17.95, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Federal", "plan_name": "400110_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." } ] } ] }, { "description": "Immunodiffusion ouchterlony", "code_information": [ { "code": "86331", "type": "CPT" } ], "standard_charges": [ { "gross_charge": 31.16, "minimum": 17.95, "maximum": 17.95, "setting": "both", "payers_information": [ { "payer_name": "Aetna", "plan_name": "700700", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna", "plan_name": "700700_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Miscellaneous", "plan_name": "700720", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Miscellaneous", "plan_name": "700720_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Ppo Hmo", "plan_name": "701720", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Ppo Hmo", "plan_name": "701720_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Ms State Emplo", "plan_name": "401457", "standard_charge_dollar": 17.95, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Ms State Emplo", "plan_name": "401457_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Basic Pl", "plan_name": "400100", "standard_charge_dollar": 17.95, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Basic Pl", "plan_name": "400100_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Federal", "plan_name": "400110", "standard_charge_dollar": 17.95, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Federal", "plan_name": "400110_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." } ] } ] }, { "description": "Hc immunofix e-phoresis urine", "code_information": [ { "code": "86335", "type": "CPT" } ], "standard_charges": [ { "gross_charge": 189.20, "minimum": 43.97, "maximum": 43.97, "setting": "both", "payers_information": [ { "payer_name": "Aetna", "plan_name": "700700", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna", "plan_name": "700700_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Miscellaneous", "plan_name": "700720", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Miscellaneous", "plan_name": "700720_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Ppo Hmo", "plan_name": "701720", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Ppo Hmo", "plan_name": "701720_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Ms State Emplo", "plan_name": "401457", "standard_charge_dollar": 43.97, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Ms State Emplo", "plan_name": "401457_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Basic Pl", "plan_name": "400100", "standard_charge_dollar": 43.97, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Basic Pl", "plan_name": "400100_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Federal", "plan_name": "400110", "standard_charge_dollar": 43.97, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Federal", "plan_name": "400110_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." } ] } ] }, { "description": "Immunfix e-phorsis/urine/csf", "code_information": [ { "code": "86335", "type": "CPT" } ], "standard_charges": [ { "gross_charge": 189.20, "minimum": 43.97, "maximum": 43.97, "setting": "both", "payers_information": [ { "payer_name": "Aetna", "plan_name": "700700", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna", "plan_name": "700700_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Miscellaneous", "plan_name": "700720", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Miscellaneous", "plan_name": "700720_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Ppo Hmo", "plan_name": "701720", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Ppo Hmo", "plan_name": "701720_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Ms State Emplo", "plan_name": "401457", "standard_charge_dollar": 43.97, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Ms State Emplo", "plan_name": "401457_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Basic Pl", "plan_name": "400100", "standard_charge_dollar": 43.97, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Basic Pl", "plan_name": "400100_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Federal", "plan_name": "400110", "standard_charge_dollar": 43.97, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Federal", "plan_name": "400110_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." } ] } ] }, { "description": "Hc gad65 ab", "code_information": [ { "code": "86341", "type": "CPT" } ], "standard_charges": [ { "gross_charge": 157.72, "minimum": 29.65, "maximum": 29.65, "setting": "both", "payers_information": [ { "payer_name": "Aetna", "plan_name": "700700", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna", "plan_name": "700700_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Miscellaneous", "plan_name": "700720", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Miscellaneous", "plan_name": "700720_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Ppo Hmo", "plan_name": "701720", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Ppo Hmo", "plan_name": "701720_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Ms State Emplo", "plan_name": "401457", "standard_charge_dollar": 29.65, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Ms State Emplo", "plan_name": "401457_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Basic Pl", "plan_name": "400100", "standard_charge_dollar": 29.65, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Basic Pl", "plan_name": "400100_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Federal", "plan_name": "400110", "standard_charge_dollar": 29.65, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Federal", "plan_name": "400110_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." } ] } ] }, { "description": "Islet cell antibody", "code_information": [ { "code": "86341", "type": "CPT" } ], "standard_charges": [ { "gross_charge": 157.72, "minimum": 29.65, "maximum": 29.65, "setting": "both", "payers_information": [ { "payer_name": "Aetna", "plan_name": "700700", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna", "plan_name": "700700_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Miscellaneous", "plan_name": "700720", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Miscellaneous", "plan_name": "700720_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Ppo Hmo", "plan_name": "701720", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Ppo Hmo", "plan_name": "701720_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Ms State Emplo", "plan_name": "401457", "standard_charge_dollar": 29.65, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Ms State Emplo", "plan_name": "401457_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Basic Pl", "plan_name": "400100", "standard_charge_dollar": 29.65, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Basic Pl", "plan_name": "400100_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Federal", "plan_name": "400110", "standard_charge_dollar": 29.65, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Federal", "plan_name": "400110_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." } ] } ] }, { "description": "Hc leukocyte histamine release test lhr", "code_information": [ { "code": "86343", "type": "CPT" } ], "standard_charges": [ { "gross_charge": 320.00, "minimum": 18.68, "maximum": 18.68, "setting": "both", "payers_information": [ { "payer_name": "Aetna", "plan_name": "700700", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna", "plan_name": "700700_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Miscellaneous", "plan_name": "700720", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Miscellaneous", "plan_name": "700720_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Ppo Hmo", "plan_name": "701720", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Ppo Hmo", "plan_name": "701720_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Ms State Emplo", "plan_name": "401457", "standard_charge_dollar": 18.68, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Ms State Emplo", "plan_name": "401457_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Basic Pl", "plan_name": "400100", "standard_charge_dollar": 18.68, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Basic Pl", "plan_name": "400100_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Federal", "plan_name": "400110", "standard_charge_dollar": 18.68, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Federal", "plan_name": "400110_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." } ] } ] }, { "description": "Leukocyte histamine release", "code_information": [ { "code": "86343", "type": "CPT" } ], "standard_charges": [ { "gross_charge": 320.00, "minimum": 18.68, "maximum": 18.68, "setting": "both", "payers_information": [ { "payer_name": "Aetna", "plan_name": "700700", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna", "plan_name": "700700_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Miscellaneous", "plan_name": "700720", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Miscellaneous", "plan_name": "700720_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Ppo Hmo", "plan_name": "701720", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Ppo Hmo", "plan_name": "701720_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Ms State Emplo", "plan_name": "401457", "standard_charge_dollar": 18.68, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Ms State Emplo", "plan_name": "401457_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Basic Pl", "plan_name": "400100", "standard_charge_dollar": 18.68, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Basic Pl", "plan_name": "400100_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Federal", "plan_name": "400110", "standard_charge_dollar": 18.68, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Federal", "plan_name": "400110_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." } ] } ] }, { "description": "B cells total count", "code_information": [ { "code": "86355", "type": "CPT" } ], "standard_charges": [ { "gross_charge": 113.19, "minimum": 24.29, "maximum": 24.29, "setting": "both", "payers_information": [ { "payer_name": "Aetna", "plan_name": "700700", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna", "plan_name": "700700_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Miscellaneous", "plan_name": "700720", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Miscellaneous", "plan_name": "700720_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Ppo Hmo", "plan_name": "701720", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Ppo Hmo", "plan_name": "701720_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Ms State Emplo", "plan_name": "401457", "standard_charge_dollar": 24.29, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Ms State Emplo", "plan_name": "401457_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Basic Pl", "plan_name": "400100", "standard_charge_dollar": 24.29, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Basic Pl", "plan_name": "400100_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Federal", "plan_name": "400110", "standard_charge_dollar": 24.29, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Federal", "plan_name": "400110_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." } ] } ] }, { "description": "Hc b cells total count", "code_information": [ { "code": "86355", "type": "CPT" } ], "standard_charges": [ { "gross_charge": 113.19, "minimum": 24.29, "maximum": 24.29, "setting": "both", "payers_information": [ { "payer_name": "Aetna", "plan_name": "700700", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna", "plan_name": "700700_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Miscellaneous", "plan_name": "700720", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Miscellaneous", "plan_name": "700720_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Ppo Hmo", "plan_name": "701720", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Ppo Hmo", "plan_name": "701720_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Ms State Emplo", "plan_name": "401457", "standard_charge_dollar": 24.29, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Ms State Emplo", "plan_name": "401457_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Basic Pl", "plan_name": "400100", "standard_charge_dollar": 24.29, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Basic Pl", "plan_name": "400100_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Federal", "plan_name": "400110", "standard_charge_dollar": 24.29, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Federal", "plan_name": "400110_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." } ] } ] }, { "description": "Hc mononuclear cell ag quan (tcp)", "code_information": [ { "code": "86356", "type": "CPT" } ], "standard_charges": [ { "gross_charge": 116.84, "minimum": 40.12, "maximum": 40.12, "setting": "both", "payers_information": [ { "payer_name": "Aetna", "plan_name": "700700", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna", "plan_name": "700700_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Miscellaneous", "plan_name": "700720", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Miscellaneous", "plan_name": "700720_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Ppo Hmo", "plan_name": "701720", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Ppo Hmo", "plan_name": "701720_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Ms State Emplo", "plan_name": "401457", "standard_charge_dollar": 40.12, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Ms State Emplo", "plan_name": "401457_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Basic Pl", "plan_name": "400100", "standard_charge_dollar": 40.12, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Basic Pl", "plan_name": "400100_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Federal", "plan_name": "400110", "standard_charge_dollar": 40.12, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Federal", "plan_name": "400110_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." } ] } ] }, { "description": "Mononuclear cell antigen", "code_information": [ { "code": "86356", "type": "CPT" } ], "standard_charges": [ { "gross_charge": 116.84, "minimum": 40.12, "maximum": 40.12, "setting": "both", "payers_information": [ { "payer_name": "Aetna", "plan_name": "700700", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna", "plan_name": "700700_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Miscellaneous", "plan_name": "700720", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Miscellaneous", "plan_name": "700720_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Ppo Hmo", "plan_name": "701720", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Ppo Hmo", "plan_name": "701720_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Ms State Emplo", "plan_name": "401457", "standard_charge_dollar": 40.12, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Ms State Emplo", "plan_name": "401457_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Basic Pl", "plan_name": "400100", "standard_charge_dollar": 40.12, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Basic Pl", "plan_name": "400100_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Federal", "plan_name": "400110", "standard_charge_dollar": 40.12, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Federal", "plan_name": "400110_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." } ] } ] }, { "description": "Hc natural killer cells", "code_information": [ { "code": "86357", "type": "CPT" } ], "standard_charges": [ { "gross_charge": 113.19, "minimum": 24.29, "maximum": 24.29, "setting": "both", "payers_information": [ { "payer_name": "Aetna", "plan_name": "700700", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna", "plan_name": "700700_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Miscellaneous", "plan_name": "700720", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Miscellaneous", "plan_name": "700720_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Ppo Hmo", "plan_name": "701720", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Ppo Hmo", "plan_name": "701720_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Ms State Emplo", "plan_name": "401457", "standard_charge_dollar": 24.29, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Ms State Emplo", "plan_name": "401457_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Basic Pl", "plan_name": "400100", "standard_charge_dollar": 24.29, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Basic Pl", "plan_name": "400100_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Federal", "plan_name": "400110", "standard_charge_dollar": 24.29, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Federal", "plan_name": "400110_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." } ] } ] }, { "description": "Nk cells total count", "code_information": [ { "code": "86357", "type": "CPT" } ], "standard_charges": [ { "gross_charge": 113.19, "minimum": 24.29, "maximum": 24.29, "setting": "both", "payers_information": [ { "payer_name": "Aetna", "plan_name": "700700", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna", "plan_name": "700700_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Miscellaneous", "plan_name": "700720", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Miscellaneous", "plan_name": "700720_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Ppo Hmo", "plan_name": "701720", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Ppo Hmo", "plan_name": "701720_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Ms State Emplo", "plan_name": "401457", "standard_charge_dollar": 24.29, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Ms State Emplo", "plan_name": "401457_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Basic Pl", "plan_name": "400100", "standard_charge_dollar": 24.29, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Basic Pl", "plan_name": "400100_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Federal", "plan_name": "400110", "standard_charge_dollar": 24.29, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Federal", "plan_name": "400110_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." } ] } ] }, { "description": "Hc t cells total count", "code_information": [ { "code": "86359", "type": "CPT" } ], "standard_charges": [ { "gross_charge": 113.19, "minimum": 24.29, "maximum": 24.29, "setting": "both", "payers_information": [ { "payer_name": "Aetna", "plan_name": "700700", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna", "plan_name": "700700_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Miscellaneous", "plan_name": "700720", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Miscellaneous", "plan_name": "700720_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Ppo Hmo", "plan_name": "701720", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Ppo Hmo", "plan_name": "701720_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Ms State Emplo", "plan_name": "401457", "standard_charge_dollar": 24.29, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Ms State Emplo", "plan_name": "401457_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Basic Pl", "plan_name": "400100", "standard_charge_dollar": 24.29, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Basic Pl", "plan_name": "400100_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Federal", "plan_name": "400110", "standard_charge_dollar": 24.29, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Federal", "plan_name": "400110_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." } ] } ] }, { "description": "T cells total count", "code_information": [ { "code": "86359", "type": "CPT" } ], "standard_charges": [ { "gross_charge": 113.19, "minimum": 24.29, "maximum": 24.29, "setting": "both", "payers_information": [ { "payer_name": "Aetna", "plan_name": "700700", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna", "plan_name": "700700_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Miscellaneous", "plan_name": "700720", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Miscellaneous", "plan_name": "700720_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Ppo Hmo", "plan_name": "701720", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Ppo Hmo", "plan_name": "701720_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Ms State Emplo", "plan_name": "401457", "standard_charge_dollar": 24.29, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Ms State Emplo", "plan_name": "401457_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Basic Pl", "plan_name": "400100", "standard_charge_dollar": 24.29, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Basic Pl", "plan_name": "400100_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Federal", "plan_name": "400110", "standard_charge_dollar": 24.29, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Federal", "plan_name": "400110_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." } ] } ] }, { "description": "Hc t cells absolute cd4 & cd8 ct", "code_information": [ { "code": "86360", "type": "CPT" } ], "standard_charges": [ { "gross_charge": 140.94, "minimum": 24.29, "maximum": 24.29, "setting": "both", "payers_information": [ { "payer_name": "Aetna", "plan_name": "700700", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna", "plan_name": "700700_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Miscellaneous", "plan_name": "700720", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Miscellaneous", "plan_name": "700720_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Ppo Hmo", "plan_name": "701720", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Ppo Hmo", "plan_name": "701720_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Ms State Emplo", "plan_name": "401457", "standard_charge_dollar": 24.29, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Ms State Emplo", "plan_name": "401457_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Basic Pl", "plan_name": "400100", "standard_charge_dollar": 24.29, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Basic Pl", "plan_name": "400100_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Federal", "plan_name": "400110", "standard_charge_dollar": 24.29, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Federal", "plan_name": "400110_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." } ] } ] }, { "description": "T cell absolute count/ratio", "code_information": [ { "code": "86360", "type": "CPT" } ], "standard_charges": [ { "gross_charge": 140.94, "minimum": 24.29, "maximum": 24.29, "setting": "both", "payers_information": [ { "payer_name": "Aetna", "plan_name": "700700", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna", "plan_name": "700700_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Miscellaneous", "plan_name": "700720", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Miscellaneous", "plan_name": "700720_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Ppo Hmo", "plan_name": "701720", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Ppo Hmo", "plan_name": "701720_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Ms State Emplo", "plan_name": "401457", "standard_charge_dollar": 24.29, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Ms State Emplo", "plan_name": "401457_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Basic Pl", "plan_name": "400100", "standard_charge_dollar": 24.29, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Basic Pl", "plan_name": "400100_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Federal", "plan_name": "400110", "standard_charge_dollar": 24.29, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Federal", "plan_name": "400110_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." } ] } ] }, { "description": "Hc tissue transglutaminase (ttg) igg", "code_information": [ { "code": "86364", "type": "CPT" } ], "standard_charges": [ { "gross_charge": 67.98, "minimum": 54.38, "maximum": 57.78, "setting": "both", "payers_information": [ { "payer_name": "Aetna", "plan_name": "700700", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna", "plan_name": "700700_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Miscellaneous", "plan_name": "700720", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Miscellaneous", "plan_name": "700720_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Ppo Hmo", "plan_name": "701720", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Ppo Hmo", "plan_name": "701720_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Ms State Emplo", "plan_name": "401457", "standard_charge_percentage": 0.80, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Ms State Emplo", "plan_name": "401457_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Basic Pl", "plan_name": "400100", "standard_charge_percentage": 0.85, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Basic Pl", "plan_name": "400100_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Federal", "plan_name": "400110", "standard_charge_percentage": 0.85, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Federal", "plan_name": "400110_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." } ] } ] }, { "description": "Tiss trnsgltmnase ea ig clas", "code_information": [ { "code": "86364", "type": "CPT" } ], "standard_charges": [ { "gross_charge": 67.98, "minimum": 54.38, "maximum": 57.78, "setting": "both", "payers_information": [ { "payer_name": "Aetna", "plan_name": "700700", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna", "plan_name": "700700_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Miscellaneous", "plan_name": "700720", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Miscellaneous", "plan_name": "700720_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Ppo Hmo", "plan_name": "701720", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Ppo Hmo", "plan_name": "701720_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Ms State Emplo", "plan_name": "401457", "standard_charge_percentage": 0.80, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Ms State Emplo", "plan_name": "401457_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Basic Pl", "plan_name": "400100", "standard_charge_percentage": 0.85, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Basic Pl", "plan_name": "400100_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Federal", "plan_name": "400110", "standard_charge_percentage": 0.85, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Federal", "plan_name": "400110_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." } ] } ] }, { "description": "Hc muscle-specific kinase antibody", "code_information": [ { "code": "86366", "type": "CPT" } ], "standard_charges": [ { "gross_charge": 1020.00, "minimum": 816.00, "maximum": 867.00, "setting": "both", "payers_information": [ { "payer_name": "Aetna", "plan_name": "700700", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna", "plan_name": "700700_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Miscellaneous", "plan_name": "700720", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Miscellaneous", "plan_name": "700720_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Ppo Hmo", "plan_name": "701720", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Ppo Hmo", "plan_name": "701720_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Ms State Emplo", "plan_name": "401457", "standard_charge_percentage": 0.80, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Ms State Emplo", "plan_name": "401457_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Basic Pl", "plan_name": "400100", "standard_charge_percentage": 0.85, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Basic Pl", "plan_name": "400100_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Federal", "plan_name": "400110", "standard_charge_percentage": 0.85, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Federal", "plan_name": "400110_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." } ] } ] }, { "description": "Muscle-specific kinase antb", "code_information": [ { "code": "86366", "type": "CPT" } ], "standard_charges": [ { "gross_charge": 1020.00, "minimum": 816.00, "maximum": 867.00, "setting": "both", "payers_information": [ { "payer_name": "Aetna", "plan_name": "700700", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna", "plan_name": "700700_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Miscellaneous", "plan_name": "700720", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Miscellaneous", "plan_name": "700720_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Ppo Hmo", "plan_name": "701720", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Ppo Hmo", "plan_name": "701720_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Ms State Emplo", "plan_name": "401457", "standard_charge_percentage": 0.80, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Ms State Emplo", "plan_name": "401457_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Basic Pl", "plan_name": "400100", "standard_charge_percentage": 0.85, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Basic Pl", "plan_name": "400100_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Federal", "plan_name": "400110", "standard_charge_percentage": 0.85, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Federal", "plan_name": "400110_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." } ] } ] }, { "description": "Hc microsomal ab lkm ab", "code_information": [ { "code": "86376", "type": "CPT" } ], "standard_charges": [ { "gross_charge": 120.00, "minimum": 16.52, "maximum": 16.52, "setting": "both", "payers_information": [ { "payer_name": "Aetna", "plan_name": "700700", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna", "plan_name": "700700_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Miscellaneous", "plan_name": "700720", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Miscellaneous", "plan_name": "700720_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Ppo Hmo", "plan_name": "701720", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Ppo Hmo", "plan_name": "701720_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Ms State Emplo", "plan_name": "401457", "standard_charge_dollar": 16.52, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Ms State Emplo", "plan_name": "401457_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Basic Pl", "plan_name": "400100", "standard_charge_dollar": 16.52, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Basic Pl", "plan_name": "400100_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Federal", "plan_name": "400110", "standard_charge_dollar": 16.52, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Federal", "plan_name": "400110_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." } ] } ] }, { "description": "Microsomal antibody each", "code_information": [ { "code": "86376", "type": "CPT" } ], "standard_charges": [ { "gross_charge": 120.00, "minimum": 16.52, "maximum": 16.52, "setting": "both", "payers_information": [ { "payer_name": "Aetna", "plan_name": "700700", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna", "plan_name": "700700_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Miscellaneous", "plan_name": "700720", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Miscellaneous", "plan_name": "700720_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Ppo Hmo", "plan_name": "701720", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Ppo Hmo", "plan_name": "701720_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Ms State Emplo", "plan_name": "401457", "standard_charge_dollar": 16.52, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Ms State Emplo", "plan_name": "401457_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Basic Pl", "plan_name": "400100", "standard_charge_dollar": 16.52, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Basic Pl", "plan_name": "400100_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Federal", "plan_name": "400110", "standard_charge_dollar": 16.52, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Federal", "plan_name": "400110_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." } ] } ] }, { "description": "Hc mitochondrial antibody each", "code_information": [ { "code": "86381", "type": "CPT" } ], "standard_charges": [ { "gross_charge": 61.50, "minimum": 49.20, "maximum": 52.28, "setting": "both", "payers_information": [ { "payer_name": "Aetna", "plan_name": "700700", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna", "plan_name": "700700_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Miscellaneous", "plan_name": "700720", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Miscellaneous", "plan_name": "700720_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Ppo Hmo", "plan_name": "701720", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Ppo Hmo", "plan_name": "701720_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Ms State Emplo", "plan_name": "401457", "standard_charge_percentage": 0.80, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Ms State Emplo", "plan_name": "401457_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Basic Pl", "plan_name": "400100", "standard_charge_percentage": 0.85, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Basic Pl", "plan_name": "400100_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Federal", "plan_name": "400110", "standard_charge_percentage": 0.85, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Federal", "plan_name": "400110_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." } ] } ] }, { "description": "Mitochondrial antibody each", "code_information": [ { "code": "86381", "type": "CPT" } ], "standard_charges": [ { "gross_charge": 61.50, "minimum": 49.20, "maximum": 52.28, "setting": "both", "payers_information": [ { "payer_name": "Aetna", "plan_name": "700700", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna", "plan_name": "700700_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Miscellaneous", "plan_name": "700720", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Miscellaneous", "plan_name": "700720_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Ppo Hmo", "plan_name": "701720", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Ppo Hmo", "plan_name": "701720_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Ms State Emplo", "plan_name": "401457", "standard_charge_percentage": 0.80, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Ms State Emplo", "plan_name": "401457_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Basic Pl", "plan_name": "400100", "standard_charge_percentage": 0.85, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Basic Pl", "plan_name": "400100_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Federal", "plan_name": "400110", "standard_charge_percentage": 0.85, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Federal", "plan_name": "400110_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." } ] } ] }, { "description": "Hc poliovirus 13 ab viral neutral (mfpolo)", "code_information": [ { "code": "86382", "type": "CPT" } ], "standard_charges": [ { "gross_charge": 152.72, "minimum": 11.90, "maximum": 11.90, "setting": "both", "payers_information": [ { "payer_name": "Aetna", "plan_name": "700700", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna", "plan_name": "700700_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Miscellaneous", "plan_name": "700720", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Miscellaneous", "plan_name": "700720_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Ppo Hmo", "plan_name": "701720", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Ppo Hmo", "plan_name": "701720_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Ms State Emplo", "plan_name": "401457", "standard_charge_dollar": 11.90, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Ms State Emplo", "plan_name": "401457_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Basic Pl", "plan_name": "400100", "standard_charge_dollar": 11.90, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Basic Pl", "plan_name": "400100_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Federal", "plan_name": "400110", "standard_charge_dollar": 11.90, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Federal", "plan_name": "400110_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." } ] } ] }, { "description": "Neutralization test viral", "code_information": [ { "code": "86382", "type": "CPT" } ], "standard_charges": [ { "gross_charge": 152.72, "minimum": 11.90, "maximum": 11.90, "setting": "both", "payers_information": [ { "payer_name": "Aetna", "plan_name": "700700", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna", "plan_name": "700700_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Miscellaneous", "plan_name": "700720", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Miscellaneous", "plan_name": "700720_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Ppo Hmo", "plan_name": "701720", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Ppo Hmo", "plan_name": "701720_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Ms State Emplo", "plan_name": "401457", "standard_charge_dollar": 11.90, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Ms State Emplo", "plan_name": "401457_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Basic Pl", "plan_name": "400100", "standard_charge_dollar": 11.90, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Basic Pl", "plan_name": "400100_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Federal", "plan_name": "400110", "standard_charge_dollar": 11.90, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Federal", "plan_name": "400110_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." } ] } ] }, { "description": "Hc rheumatoid factor qualitative", "code_information": [ { "code": "86430", "type": "CPT" } ], "standard_charges": [ { "gross_charge": 59.50, "minimum": 8.50, "maximum": 8.50, "setting": "both", "payers_information": [ { "payer_name": "Aetna", "plan_name": "700700", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna", "plan_name": "700700_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Miscellaneous", "plan_name": "700720", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Miscellaneous", "plan_name": "700720_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Ppo Hmo", "plan_name": "701720", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Ppo Hmo", "plan_name": "701720_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Ms State Emplo", "plan_name": "401457", "standard_charge_dollar": 8.50, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Ms State Emplo", "plan_name": "401457_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Basic Pl", "plan_name": "400100", "standard_charge_dollar": 8.50, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Basic Pl", "plan_name": "400100_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Federal", "plan_name": "400110", "standard_charge_dollar": 8.50, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Federal", "plan_name": "400110_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." } ] } ] }, { "description": "Rheumatoid factor test qual", "code_information": [ { "code": "86430", "type": "CPT" } ], "standard_charges": [ { "gross_charge": 59.50, "minimum": 8.50, "maximum": 8.50, "setting": "both", "payers_information": [ { "payer_name": "Aetna", "plan_name": "700700", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna", "plan_name": "700700_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Miscellaneous", "plan_name": "700720", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Miscellaneous", "plan_name": "700720_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Ppo Hmo", "plan_name": "701720", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Ppo Hmo", "plan_name": "701720_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Ms State Emplo", "plan_name": "401457", "standard_charge_dollar": 8.50, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Ms State Emplo", "plan_name": "401457_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Basic Pl", "plan_name": "400100", "standard_charge_dollar": 8.50, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Basic Pl", "plan_name": "400100_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Federal", "plan_name": "400110", "standard_charge_dollar": 8.50, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Federal", "plan_name": "400110_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." } ] } ] }, { "description": "Hc rheumatoid factor quant", "code_information": [ { "code": "86431", "type": "CPT" } ], "standard_charges": [ { "gross_charge": 60.00, "minimum": 8.50, "maximum": 8.50, "setting": "both", "payers_information": [ { "payer_name": "Aetna", "plan_name": "700700", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna", "plan_name": "700700_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Miscellaneous", "plan_name": "700720", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Miscellaneous", "plan_name": "700720_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Ppo Hmo", "plan_name": "701720", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Ppo Hmo", "plan_name": "701720_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Ms State Emplo", "plan_name": "401457", "standard_charge_dollar": 8.50, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Ms State Emplo", "plan_name": "401457_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Basic Pl", "plan_name": "400100", "standard_charge_dollar": 8.50, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Basic Pl", "plan_name": "400100_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Federal", "plan_name": "400110", "standard_charge_dollar": 8.50, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Federal", "plan_name": "400110_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." } ] } ] }, { "description": "Rheumatoid factor quant", "code_information": [ { "code": "86431", "type": "CPT" } ], "standard_charges": [ { "gross_charge": 60.00, "minimum": 8.50, "maximum": 8.50, "setting": "both", "payers_information": [ { "payer_name": "Aetna", "plan_name": "700700", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna", "plan_name": "700700_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Miscellaneous", "plan_name": "700720", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Miscellaneous", "plan_name": "700720_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Ppo Hmo", "plan_name": "701720", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Ppo Hmo", "plan_name": "701720_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Ms State Emplo", "plan_name": "401457", "standard_charge_dollar": 8.50, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Ms State Emplo", "plan_name": "401457_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Basic Pl", "plan_name": "400100", "standard_charge_dollar": 8.50, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Basic Pl", "plan_name": "400100_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Federal", "plan_name": "400110", "standard_charge_dollar": 8.50, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Federal", "plan_name": "400110_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." } ] } ] }, { "description": "Hc quantiferon tb gold", "code_information": [ { "code": "86480", "type": "CPT" } ], "standard_charges": [ { "gross_charge": 224.56, "minimum": 92.87, "maximum": 92.87, "setting": "both", "payers_information": [ { "payer_name": "Aetna", "plan_name": "700700", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna", "plan_name": "700700_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Miscellaneous", "plan_name": "700720", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Miscellaneous", "plan_name": "700720_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Ppo Hmo", "plan_name": "701720", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Ppo Hmo", "plan_name": "701720_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Ms State Emplo", "plan_name": "401457", "standard_charge_dollar": 92.87, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Ms State Emplo", "plan_name": "401457_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Basic Pl", "plan_name": "400100", "standard_charge_dollar": 92.87, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Basic Pl", "plan_name": "400100_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Federal", "plan_name": "400110", "standard_charge_dollar": 92.87, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Federal", "plan_name": "400110_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." } ] } ] }, { "description": "Tb test cell immun measure", "code_information": [ { "code": "86480", "type": "CPT" } ], "standard_charges": [ { "gross_charge": 224.56, "minimum": 92.87, "maximum": 92.87, "setting": "both", "payers_information": [ { "payer_name": "Aetna", "plan_name": "700700", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna", "plan_name": "700700_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Miscellaneous", "plan_name": "700720", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Miscellaneous", "plan_name": "700720_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Ppo Hmo", "plan_name": "701720", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Ppo Hmo", "plan_name": "701720_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Ms State Emplo", "plan_name": "401457", "standard_charge_dollar": 92.87, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Ms State Emplo", "plan_name": "401457_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Basic Pl", "plan_name": "400100", "standard_charge_dollar": 92.87, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Basic Pl", "plan_name": "400100_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Federal", "plan_name": "400110", "standard_charge_dollar": 92.87, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Federal", "plan_name": "400110_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." } ] } ] }, { "description": "Hc skin test tb id", "code_information": [ { "code": "86580", "type": "CPT" } ], "standard_charges": [ { "gross_charge": 26.00, "minimum": 13.87, "maximum": 28.04, "setting": "both", "payers_information": [ { "payer_name": "Aarp", "plan_name": "500102", "standard_charge_dollar": 22.43, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna", "plan_name": "700700", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna", "plan_name": "700700_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Mcare Ffs 6005", "plan_name": "700703", "standard_charge_dollar": 22.43, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Miscellaneous", "plan_name": "700720", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Miscellaneous", "plan_name": "700720_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Ppo Hmo", "plan_name": "701720", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Ppo Hmo", "plan_name": "701720_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Ambetter 68069", "plan_name": "500516", "standard_charge_dollar": 22.43, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Ms State Emplo", "plan_name": "401457", "standard_charge_dollar": 13.87, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Ms State Emplo", "plan_name": "401457_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Basic Pl", "plan_name": "400100", "standard_charge_dollar": 13.87, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Basic Pl", "plan_name": "400100_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Federal", "plan_name": "400110", "standard_charge_dollar": 13.87, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Federal", "plan_name": "400110_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Cigna Healthsprings Ffs", "plan_name": "500064", "standard_charge_dollar": 22.43, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Conseco", "plan_name": "500302", "standard_charge_dollar": 22.43, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Humana Ffs 61101", "plan_name": "500006", "standard_charge_dollar": 22.43, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Medicare A", "plan_name": "100100", "standard_charge_dollar": 22.43, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Medicare A", "plan_name": "100500", "standard_charge_dollar": 22.43, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Medicare Part B Only", "plan_name": "100300", "standard_charge_dollar": 22.43, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Medicare Railroad", "plan_name": "100103", "standard_charge_dollar": 22.43, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Ms Physicians Care N", "plan_name": "714210", "standard_charge_dollar": 28.04, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Peoples Hlth Ffs 72126", "plan_name": "500019", "standard_charge_dollar": 22.43, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Uhc/Secure Horizons", "plan_name": "500449", "standard_charge_dollar": 22.43, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "United Health Care/", "plan_name": "500292", "standard_charge_dollar": 25.35, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "United Healthcare", "plan_name": "750104", "standard_charge_dollar": 25.35, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "United Healthcare Ba", "plan_name": "750090", "standard_charge_dollar": 25.35, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "United Healthcare Me", "plan_name": "501310", "standard_charge_dollar": 22.43, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Windsor Mcare Extra", "plan_name": "500778", "standard_charge_dollar": 22.43, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." } ] } ] }, { "description": "Tb intradermal test", "code_information": [ { "code": "86580", "type": "CPT" } ], "standard_charges": [ { "gross_charge": 26.00, "minimum": 13.87, "maximum": 28.04, "setting": "both", "payers_information": [ { "payer_name": "Aarp", "plan_name": "500102", "standard_charge_dollar": 22.43, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna", "plan_name": "700700", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna", "plan_name": "700700_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Mcare Ffs 6005", "plan_name": "700703", "standard_charge_dollar": 22.43, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Miscellaneous", "plan_name": "700720", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Miscellaneous", "plan_name": "700720_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Ppo Hmo", "plan_name": "701720", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Ppo Hmo", "plan_name": "701720_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Ambetter 68069", "plan_name": "500516", "standard_charge_dollar": 22.43, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Ms State Emplo", "plan_name": "401457", "standard_charge_dollar": 13.87, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Ms State Emplo", "plan_name": "401457_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Basic Pl", "plan_name": "400100", "standard_charge_dollar": 13.87, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Basic Pl", "plan_name": "400100_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Federal", "plan_name": "400110", "standard_charge_dollar": 13.87, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Federal", "plan_name": "400110_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Cigna Healthsprings Ffs", "plan_name": "500064", "standard_charge_dollar": 22.43, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Conseco", "plan_name": "500302", "standard_charge_dollar": 22.43, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Humana Ffs 61101", "plan_name": "500006", "standard_charge_dollar": 22.43, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Medicare A", "plan_name": "100100", "standard_charge_dollar": 22.43, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Medicare A", "plan_name": "100500", "standard_charge_dollar": 22.43, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Medicare Part B Only", "plan_name": "100300", "standard_charge_dollar": 22.43, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Medicare Railroad", "plan_name": "100103", "standard_charge_dollar": 22.43, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Ms Physicians Care N", "plan_name": "714210", "standard_charge_dollar": 28.04, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Peoples Hlth Ffs 72126", "plan_name": "500019", "standard_charge_dollar": 22.43, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Uhc/Secure Horizons", "plan_name": "500449", "standard_charge_dollar": 22.43, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "United Health Care/", "plan_name": "500292", "standard_charge_dollar": 25.35, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "United Healthcare", "plan_name": "750104", "standard_charge_dollar": 25.35, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "United Healthcare Ba", "plan_name": "750090", "standard_charge_dollar": 25.35, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "United Healthcare Me", "plan_name": "501310", "standard_charge_dollar": 22.43, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Windsor Mcare Extra", "plan_name": "500778", "standard_charge_dollar": 22.43, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." } ] } ] }, { "description": "Hc skin test tb id", "code_information": [ { "code": "86580", "type": "CPT" } ], "standard_charges": [ { "gross_charge": 26.00, "minimum": 20.80, "maximum": 28.04, "setting": "both", "payers_information": [ { "payer_name": "Aarp", "plan_name": "500102", "standard_charge_dollar": 22.43, "count": "0", "methodology": "fee schedule", "modifiers": "QW", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna", "plan_name": "700700", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna", "plan_name": "700700_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Mcare Ffs 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"payer_name": "United Healthcare", "plan_name": "750104", "standard_charge_dollar": 25.35, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "United Healthcare Ba", "plan_name": "750090", "standard_charge_dollar": 25.35, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "United Healthcare Me", "plan_name": "501310", "standard_charge_dollar": 22.43, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Windsor Mcare Extra", "plan_name": "500778", "standard_charge_dollar": 22.43, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." } ] } ] }, { "description": "Tuberculin ppd 5 tub. unit/0.1 ml intradermal injection solution [8259]", 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"plan_name": "700703", "standard_charge_dollar": 22.43, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Miscellaneous", "plan_name": "700720", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Miscellaneous", "plan_name": "700720_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Ppo Hmo", "plan_name": "701720", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Ppo Hmo", "plan_name": "701720_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Ambetter 68069", "plan_name": "500516", "standard_charge_dollar": 22.43, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Ms State Emplo", "plan_name": "401457", "standard_charge_dollar": 13.87, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Ms State Emplo", "plan_name": "401457_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Basic Pl", "plan_name": "400100", "standard_charge_dollar": 13.87, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Basic Pl", "plan_name": "400100_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Federal", "plan_name": "400110", "standard_charge_dollar": 13.87, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Federal", "plan_name": "400110_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Cigna Healthsprings Ffs", "plan_name": "500064", "standard_charge_dollar": 22.43, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Conseco", "plan_name": "500302", "standard_charge_dollar": 22.43, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Humana Ffs 61101", "plan_name": "500006", "standard_charge_dollar": 22.43, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Medicare A", "plan_name": "100100", "standard_charge_dollar": 22.43, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Medicare A", "plan_name": "100500", "standard_charge_dollar": 22.43, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Medicare Part B Only", "plan_name": "100300", "standard_charge_dollar": 22.43, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Medicare Railroad", "plan_name": "100103", "standard_charge_dollar": 22.43, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Ms Physicians Care N", "plan_name": "714210", "standard_charge_dollar": 28.04, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Peoples Hlth Ffs 72126", "plan_name": "500019", "standard_charge_dollar": 22.43, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Uhc/Secure Horizons", "plan_name": "500449", "standard_charge_dollar": 22.43, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "United Health Care/", "plan_name": "500292", "standard_charge_dollar": 25.35, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "United Healthcare", "plan_name": "750104", "standard_charge_dollar": 25.35, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "United Healthcare Ba", "plan_name": "750090", "standard_charge_dollar": 25.35, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "United Healthcare Me", "plan_name": "501310", "standard_charge_dollar": 22.43, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Windsor Mcare Extra", "plan_name": "500778", "standard_charge_dollar": 22.43, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." } ] } ] }, { "description": "Hc syphilis test nontrep qual (rrprs)", "code_information": [ { "code": "86592", "type": "CPT" } ], "standard_charges": [ { "gross_charge": 100.96, "minimum": 4.27, "maximum": 6.40, "setting": "both", "payers_information": [ { "payer_name": "Aarp", "plan_name": "500102", "standard_charge_dollar": 4.27, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna", "plan_name": "700700", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna", "plan_name": "700700_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Mcare Ffs 6005", "plan_name": "700703", "standard_charge_dollar": 4.27, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Miscellaneous", "plan_name": "700720", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Miscellaneous", "plan_name": "700720_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Ppo Hmo", "plan_name": "701720", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Ppo Hmo", "plan_name": "701720_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Ambetter 68069", "plan_name": "500516", "standard_charge_dollar": 4.27, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Ms State Emplo", "plan_name": "401457", "standard_charge_dollar": 6.40, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Ms State Emplo", "plan_name": "401457_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Basic Pl", "plan_name": "400100", "standard_charge_dollar": 6.40, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Basic Pl", "plan_name": "400100_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Federal", "plan_name": "400110", "standard_charge_dollar": 6.40, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Federal", "plan_name": "400110_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Cigna Healthsprings Ffs", "plan_name": "500064", "standard_charge_dollar": 4.27, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Conseco", "plan_name": "500302", "standard_charge_dollar": 4.27, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Humana Ffs 61101", "plan_name": "500006", "standard_charge_dollar": 4.27, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Medicare A", "plan_name": "100100", "standard_charge_dollar": 4.27, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Medicare A", "plan_name": "100500", "standard_charge_dollar": 4.27, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Medicare Part B Only", "plan_name": "100300", "standard_charge_dollar": 4.27, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Medicare Railroad", "plan_name": "100103", "standard_charge_dollar": 4.27, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Ms Physicians Care N", "plan_name": "714210", "standard_charge_dollar": 5.34, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Peoples Hlth Ffs 72126", "plan_name": "500019", "standard_charge_dollar": 4.27, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Uhc/Secure Horizons", "plan_name": "500449", "standard_charge_dollar": 4.27, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "United Health Care/", "plan_name": "500292", "standard_charge_dollar": 4.83, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "United Healthcare", "plan_name": "750104", "standard_charge_dollar": 4.83, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "United Healthcare Ba", "plan_name": "750090", "standard_charge_dollar": 4.83, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "United Healthcare Me", "plan_name": "501310", "standard_charge_dollar": 4.27, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Windsor Mcare Extra", "plan_name": "500778", "standard_charge_dollar": 4.27, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." } ] } ] }, { "description": "Syphilis test non-trep qual", "code_information": [ { "code": "86592", "type": "CPT" } ], "standard_charges": [ { "gross_charge": 100.96, "minimum": 4.27, "maximum": 6.40, "setting": "both", "payers_information": [ { "payer_name": "Aarp", "plan_name": "500102", "standard_charge_dollar": 4.27, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna", "plan_name": "700700", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna", "plan_name": "700700_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Mcare Ffs 6005", "plan_name": "700703", "standard_charge_dollar": 4.27, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Miscellaneous", "plan_name": "700720", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Miscellaneous", "plan_name": "700720_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Ppo Hmo", "plan_name": "701720", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Ppo Hmo", "plan_name": "701720_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Ambetter 68069", "plan_name": "500516", "standard_charge_dollar": 4.27, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Ms State Emplo", "plan_name": "401457", "standard_charge_dollar": 6.40, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Ms State Emplo", "plan_name": "401457_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Basic Pl", "plan_name": "400100", "standard_charge_dollar": 6.40, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Basic Pl", "plan_name": "400100_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Federal", "plan_name": "400110", "standard_charge_dollar": 6.40, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Federal", "plan_name": "400110_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Cigna Healthsprings Ffs", "plan_name": "500064", "standard_charge_dollar": 4.27, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Conseco", "plan_name": "500302", "standard_charge_dollar": 4.27, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Humana Ffs 61101", "plan_name": "500006", "standard_charge_dollar": 4.27, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Medicare A", "plan_name": "100100", "standard_charge_dollar": 4.27, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Medicare A", "plan_name": "100500", "standard_charge_dollar": 4.27, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Medicare Part B Only", "plan_name": "100300", "standard_charge_dollar": 4.27, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Medicare Railroad", "plan_name": "100103", "standard_charge_dollar": 4.27, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Ms Physicians Care N", "plan_name": "714210", "standard_charge_dollar": 5.34, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Peoples Hlth Ffs 72126", "plan_name": "500019", "standard_charge_dollar": 4.27, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Uhc/Secure Horizons", "plan_name": "500449", "standard_charge_dollar": 4.27, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "United Health Care/", "plan_name": "500292", "standard_charge_dollar": 4.83, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "United Healthcare", "plan_name": "750104", "standard_charge_dollar": 4.83, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "United Healthcare Ba", "plan_name": "750090", "standard_charge_dollar": 4.83, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "United Healthcare Me", "plan_name": "501310", "standard_charge_dollar": 4.27, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Windsor Mcare Extra", "plan_name": "500778", "standard_charge_dollar": 4.27, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." } ] } ] }, { "description": "Hc syphilis test nontrep quan", "code_information": [ { "code": "86593", "type": "CPT" } ], "standard_charges": [ { "gross_charge": 51.71, "minimum": 4.40, "maximum": 6.59, "setting": "both", "payers_information": [ { "payer_name": "Aarp", "plan_name": "500102", "standard_charge_dollar": 4.40, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna", "plan_name": "700700", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna", "plan_name": "700700_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Mcare Ffs 6005", "plan_name": "700703", "standard_charge_dollar": 4.40, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Miscellaneous", "plan_name": "700720", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Miscellaneous", "plan_name": "700720_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Ppo Hmo", "plan_name": "701720", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Ppo Hmo", "plan_name": "701720_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Ambetter 68069", "plan_name": "500516", "standard_charge_dollar": 4.40, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Ms State Emplo", "plan_name": "401457", "standard_charge_dollar": 6.59, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Ms State Emplo", "plan_name": "401457_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Basic Pl", "plan_name": "400100", "standard_charge_dollar": 6.59, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Basic Pl", "plan_name": "400100_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Federal", "plan_name": "400110", "standard_charge_dollar": 6.59, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Federal", "plan_name": "400110_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Cigna Healthsprings Ffs", "plan_name": "500064", "standard_charge_dollar": 4.40, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Conseco", "plan_name": "500302", "standard_charge_dollar": 4.40, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Humana Ffs 61101", "plan_name": "500006", "standard_charge_dollar": 4.40, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Medicare A", "plan_name": "100100", "standard_charge_dollar": 4.40, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Medicare A", "plan_name": "100500", "standard_charge_dollar": 4.40, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Medicare Part B Only", "plan_name": "100300", "standard_charge_dollar": 4.40, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Medicare Railroad", "plan_name": "100103", "standard_charge_dollar": 4.40, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Ms Physicians Care N", "plan_name": "714210", "standard_charge_dollar": 5.50, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Peoples Hlth Ffs 72126", "plan_name": "500019", "standard_charge_dollar": 4.40, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Uhc/Secure Horizons", "plan_name": "500449", "standard_charge_dollar": 4.40, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "United Health Care/", "plan_name": "500292", "standard_charge_dollar": 4.97, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "United Healthcare", "plan_name": "750104", "standard_charge_dollar": 4.97, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "United Healthcare Ba", "plan_name": "750090", "standard_charge_dollar": 4.97, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "United Healthcare Me", "plan_name": "501310", "standard_charge_dollar": 4.40, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Windsor Mcare Extra", "plan_name": "500778", "standard_charge_dollar": 4.40, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." } ] } ] }, { "description": "Syphilis test non-trep quant", "code_information": [ { "code": "86593", "type": "CPT" } ], "standard_charges": [ { "gross_charge": 51.71, "minimum": 4.40, "maximum": 6.59, "setting": "both", "payers_information": [ { "payer_name": "Aarp", "plan_name": "500102", "standard_charge_dollar": 4.40, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna", "plan_name": "700700", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna", "plan_name": "700700_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Mcare Ffs 6005", "plan_name": "700703", "standard_charge_dollar": 4.40, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Miscellaneous", "plan_name": "700720", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Miscellaneous", "plan_name": "700720_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Ppo Hmo", "plan_name": "701720", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Ppo Hmo", "plan_name": "701720_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Ambetter 68069", "plan_name": "500516", "standard_charge_dollar": 4.40, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Ms State Emplo", "plan_name": "401457", "standard_charge_dollar": 6.59, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Ms State Emplo", "plan_name": "401457_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Basic Pl", "plan_name": "400100", "standard_charge_dollar": 6.59, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Basic Pl", "plan_name": "400100_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Federal", "plan_name": "400110", "standard_charge_dollar": 6.59, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Federal", "plan_name": "400110_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Cigna Healthsprings Ffs", "plan_name": "500064", "standard_charge_dollar": 4.40, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Conseco", "plan_name": "500302", "standard_charge_dollar": 4.40, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Humana Ffs 61101", "plan_name": "500006", "standard_charge_dollar": 4.40, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Medicare A", "plan_name": "100100", "standard_charge_dollar": 4.40, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Medicare A", "plan_name": "100500", "standard_charge_dollar": 4.40, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Medicare Part B Only", "plan_name": "100300", "standard_charge_dollar": 4.40, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Medicare Railroad", "plan_name": "100103", "standard_charge_dollar": 4.40, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Ms Physicians Care N", "plan_name": "714210", "standard_charge_dollar": 5.50, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Peoples Hlth Ffs 72126", "plan_name": "500019", "standard_charge_dollar": 4.40, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Uhc/Secure Horizons", "plan_name": "500449", "standard_charge_dollar": 4.40, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "United Health Care/", "plan_name": "500292", "standard_charge_dollar": 4.97, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "United Healthcare", "plan_name": "750104", "standard_charge_dollar": 4.97, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "United Healthcare Ba", "plan_name": "750090", "standard_charge_dollar": 4.97, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "United Healthcare Me", "plan_name": "501310", "standard_charge_dollar": 4.40, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Windsor Mcare Extra", "plan_name": "500778", "standard_charge_dollar": 4.40, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." } ] } ] }, { "description": "Hc ab lymes wb confirm", "code_information": [ { "code": "86617", "type": "CPT" } ], "standard_charges": [ { "gross_charge": 91.50, "minimum": 15.88, "maximum": 15.88, "setting": "both", "payers_information": [ { "payer_name": "Aetna", "plan_name": "700700", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna", "plan_name": "700700_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Miscellaneous", "plan_name": "700720", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Miscellaneous", "plan_name": "700720_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Ppo Hmo", "plan_name": "701720", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Ppo Hmo", "plan_name": "701720_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Ms State Emplo", "plan_name": "401457", "standard_charge_dollar": 15.88, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Ms State Emplo", "plan_name": "401457_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Basic Pl", "plan_name": "400100", "standard_charge_dollar": 15.88, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Basic Pl", "plan_name": "400100_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Federal", "plan_name": "400110", "standard_charge_dollar": 15.88, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Federal", "plan_name": "400110_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." } ] } ] }, { "description": "Lyme disease antibody", "code_information": [ { "code": "86617", "type": "CPT" } ], "standard_charges": [ { "gross_charge": 91.50, "minimum": 15.88, "maximum": 15.88, "setting": "both", "payers_information": [ { "payer_name": "Aetna", "plan_name": "700700", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna", "plan_name": "700700_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Miscellaneous", "plan_name": "700720", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Miscellaneous", "plan_name": "700720_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Ppo Hmo", "plan_name": "701720", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Ppo Hmo", "plan_name": "701720_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Ms State Emplo", "plan_name": "401457", "standard_charge_dollar": 15.88, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Ms State Emplo", "plan_name": "401457_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Basic Pl", "plan_name": "400100", "standard_charge_dollar": 15.88, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Basic Pl", "plan_name": "400100_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Federal", "plan_name": "400110", "standard_charge_dollar": 15.88, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Federal", "plan_name": "400110_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." } ] } ] }, { "description": "Hc borrelia burgdorferi", "code_information": [ { "code": "86618", "type": "CPT" } ], "standard_charges": [ { "gross_charge": 226.01, "minimum": 23.55, "maximum": 23.55, "setting": "both", "payers_information": [ { "payer_name": "Aetna", "plan_name": "700700", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna", "plan_name": "700700_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Miscellaneous", "plan_name": "700720", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Miscellaneous", "plan_name": "700720_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Ppo Hmo", "plan_name": "701720", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Ppo Hmo", "plan_name": "701720_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Ms State Emplo", "plan_name": "401457", "standard_charge_dollar": 23.55, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Ms State Emplo", "plan_name": "401457_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Basic Pl", "plan_name": "400100", "standard_charge_dollar": 23.55, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Basic Pl", "plan_name": "400100_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Federal", "plan_name": "400110", "standard_charge_dollar": 23.55, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Federal", "plan_name": "400110_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." } ] } ] }, { "description": "Lyme disease antibody", "code_information": [ { "code": "86618", "type": "CPT" } ], "standard_charges": [ { "gross_charge": 226.01, "minimum": 23.55, "maximum": 23.55, "setting": "both", "payers_information": [ { "payer_name": "Aetna", "plan_name": "700700", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna", "plan_name": "700700_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Miscellaneous", "plan_name": "700720", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Miscellaneous", "plan_name": "700720_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Ppo Hmo", "plan_name": "701720", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Ppo Hmo", "plan_name": "701720_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Ms State Emplo", "plan_name": "401457", "standard_charge_dollar": 23.55, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Ms State Emplo", "plan_name": "401457_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Basic Pl", "plan_name": "400100", "standard_charge_dollar": 23.55, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Basic Pl", "plan_name": "400100_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Federal", "plan_name": "400110", "standard_charge_dollar": 23.55, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Federal", "plan_name": "400110_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." } ] } ] }, { "description": "Cmv antibody", "code_information": [ { "code": "86644", "type": "CPT" } ], "standard_charges": [ { "gross_charge": 58.80, "minimum": 21.57, "maximum": 21.57, "setting": "both", "payers_information": [ { "payer_name": "Aetna", "plan_name": "700700", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna", "plan_name": "700700_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Miscellaneous", "plan_name": "700720", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Miscellaneous", "plan_name": "700720_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Ppo Hmo", "plan_name": "701720", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Ppo Hmo", "plan_name": "701720_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Ms State Emplo", "plan_name": "401457", "standard_charge_dollar": 21.57, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Ms State Emplo", "plan_name": "401457_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Basic Pl", "plan_name": "400100", "standard_charge_dollar": 21.57, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Basic Pl", "plan_name": "400100_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit 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"plan_name": "701720_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Ms State Emplo", "plan_name": "401457", "standard_charge_dollar": 21.57, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Ms State Emplo", "plan_name": "401457_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Basic Pl", "plan_name": "400100", "standard_charge_dollar": 21.57, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Basic Pl", "plan_name": "400100_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Federal", "plan_name": "400110", "standard_charge_dollar": 21.57, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Federal", "plan_name": "400110_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." } ] } ] }, { "description": "Cmv antibody igm", "code_information": [ { "code": "86645", "type": "CPT" } ], "standard_charges": [ { "gross_charge": 58.80, "minimum": 23.55, "maximum": 23.55, "setting": "both", "payers_information": [ { "payer_name": "Aetna", "plan_name": "700700", "standard_charge_percentage": 80.0, "count": "0", 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"Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Basic Pl", "plan_name": "400100_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Federal", "plan_name": "400110", "standard_charge_dollar": 23.55, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Federal", "plan_name": "400110_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." } ] } ] }, { "description": "Hc cytomegalovirus igm", "code_information": [ { "code": "86645", "type": "CPT" } ], "standard_charges": [ { "gross_charge": 58.80, "minimum": 23.55, "maximum": 23.55, "setting": "both", 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"payer_name": "Aetna Ppo Hmo", "plan_name": "701720", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Ppo Hmo", "plan_name": "701720_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Ms State Emplo", "plan_name": "401457", "standard_charge_dollar": 23.55, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Ms State Emplo", "plan_name": "401457_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Basic Pl", "plan_name": "400100", "standard_charge_dollar": 23.55, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Basic Pl", "plan_name": "400100_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Federal", "plan_name": "400110", "standard_charge_dollar": 23.55, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Federal", "plan_name": "400110_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." } ] } ] }, { "description": "Epstein-barr antibody", "code_information": [ { "code": "86663", "type": "CPT" } ], "standard_charges": [ { "gross_charge": 112.00, "minimum": 19.66, "maximum": 19.66, "setting": "both", "payers_information": [ { "payer_name": "Aetna", "plan_name": "700700", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna", "plan_name": "700700_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Miscellaneous", "plan_name": "700720", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Miscellaneous", "plan_name": "700720_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Ppo Hmo", "plan_name": "701720", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Ppo Hmo", "plan_name": "701720_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Ms State Emplo", "plan_name": "401457", "standard_charge_dollar": 19.66, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Ms State Emplo", "plan_name": "401457_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Basic Pl", "plan_name": "400100", "standard_charge_dollar": 19.66, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Basic Pl", "plan_name": "400100_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Federal", "plan_name": "400110", "standard_charge_dollar": 19.66, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Federal", "plan_name": "400110_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." } ] } ] }, { "description": "Hc epv early ag", "code_information": [ { "code": "86663", "type": "CPT" } ], "standard_charges": [ { "gross_charge": 112.00, "minimum": 19.66, "maximum": 19.66, "setting": "both", "payers_information": [ { "payer_name": "Aetna", "plan_name": "700700", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna", "plan_name": "700700_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Miscellaneous", "plan_name": "700720", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Miscellaneous", "plan_name": "700720_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Ppo Hmo", "plan_name": "701720", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Ppo Hmo", "plan_name": "701720_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Ms State Emplo", "plan_name": "401457", "standard_charge_dollar": 19.66, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Ms State Emplo", "plan_name": "401457_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Basic Pl", "plan_name": "400100", "standard_charge_dollar": 19.66, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Basic Pl", "plan_name": "400100_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Federal", "plan_name": "400110", "standard_charge_dollar": 19.66, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Federal", "plan_name": "400110_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." } ] } ] }, { "description": "Epstein-barr nuclear antigen", "code_information": [ { "code": "86664", "type": "CPT" } ], "standard_charges": [ { "gross_charge": 50.00, "minimum": 22.92, "maximum": 22.92, "setting": "both", "payers_information": [ { "payer_name": "Aetna", "plan_name": "700700", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna", "plan_name": "700700_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Miscellaneous", "plan_name": "700720", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Miscellaneous", "plan_name": "700720_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Ppo Hmo", "plan_name": "701720", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Ppo Hmo", "plan_name": "701720_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Ms State Emplo", "plan_name": "401457", "standard_charge_dollar": 22.92, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Ms State Emplo", "plan_name": "401457_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Basic Pl", "plan_name": "400100", "standard_charge_dollar": 22.92, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Basic Pl", "plan_name": "400100_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Federal", "plan_name": "400110", "standard_charge_dollar": 22.92, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Federal", "plan_name": "400110_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." } ] } ] }, { "description": "Hc epv nuclear ag", "code_information": [ { "code": "86664", "type": "CPT" } ], "standard_charges": [ { "gross_charge": 50.00, "minimum": 22.92, "maximum": 22.92, "setting": "both", "payers_information": [ { "payer_name": "Aetna", "plan_name": "700700", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna", "plan_name": "700700_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Miscellaneous", "plan_name": "700720", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Miscellaneous", "plan_name": "700720_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Ppo Hmo", "plan_name": "701720", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Ppo Hmo", "plan_name": "701720_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Ms State Emplo", "plan_name": "401457", "standard_charge_dollar": 22.92, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Ms State Emplo", "plan_name": "401457_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Basic Pl", "plan_name": "400100", "standard_charge_dollar": 22.92, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Basic Pl", "plan_name": "400100_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Federal", "plan_name": "400110", "standard_charge_dollar": 22.92, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Federal", "plan_name": "400110_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." } ] } ] }, { "description": "Epstein-barr capsid vca", "code_information": [ { "code": "86665", "type": "CPT" } ], "standard_charges": [ { "gross_charge": 54.42, "minimum": 23.55, "maximum": 23.55, "setting": "both", "payers_information": [ { "payer_name": "Aetna", "plan_name": "700700", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna", "plan_name": "700700_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Miscellaneous", "plan_name": "700720", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Miscellaneous", "plan_name": "700720_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Ppo Hmo", "plan_name": "701720", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Ppo Hmo", "plan_name": "701720_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Ms State Emplo", "plan_name": "401457", "standard_charge_dollar": 23.55, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Ms State Emplo", "plan_name": "401457_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Basic Pl", "plan_name": "400100", "standard_charge_dollar": 23.55, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Basic Pl", "plan_name": "400100_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Federal", "plan_name": "400110", "standard_charge_dollar": 23.55, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Federal", "plan_name": "400110_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." } ] } ] }, { "description": "Hc ebv viral capsid vca", "code_information": [ { "code": "86665", "type": "CPT" } ], "standard_charges": [ { "gross_charge": 54.42, "minimum": 23.55, "maximum": 23.55, "setting": "both", "payers_information": [ { "payer_name": "Aetna", "plan_name": "700700", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna", "plan_name": "700700_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Miscellaneous", "plan_name": "700720", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Miscellaneous", "plan_name": "700720_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Ppo Hmo", "plan_name": "701720", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Ppo Hmo", "plan_name": "701720_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Ms State Emplo", "plan_name": "401457", "standard_charge_dollar": 23.55, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Ms State Emplo", "plan_name": "401457_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Basic Pl", "plan_name": "400100", "standard_charge_dollar": 23.55, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Basic Pl", "plan_name": "400100_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Federal", "plan_name": "400110", "standard_charge_dollar": 23.55, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Federal", "plan_name": "400110_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." } ] } ] }, { "description": "Ehrlichia antibody", "code_information": [ { "code": "86666", "type": "CPT" } ], "standard_charges": [ { "gross_charge": 59.75, "minimum": 15.26, "maximum": 15.26, "setting": "both", "payers_information": [ { "payer_name": "Aetna", "plan_name": "700700", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna", "plan_name": "700700_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Miscellaneous", "plan_name": "700720", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Miscellaneous", "plan_name": "700720_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Ppo Hmo", "plan_name": "701720", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Ppo Hmo", "plan_name": "701720_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Ms State Emplo", "plan_name": "401457", "standard_charge_dollar": 15.26, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Ms State Emplo", "plan_name": "401457_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Basic Pl", "plan_name": "400100", "standard_charge_dollar": 15.26, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Basic Pl", "plan_name": "400100_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Federal", "plan_name": "400110", "standard_charge_dollar": 15.26, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Federal", "plan_name": "400110_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." } ] } ] }, { "description": "Hc ehrlichia", "code_information": [ { "code": "86666", "type": "CPT" } ], "standard_charges": [ { "gross_charge": 59.75, "minimum": 15.26, "maximum": 15.26, "setting": "both", "payers_information": [ { "payer_name": "Aetna", "plan_name": "700700", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna", "plan_name": "700700_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Miscellaneous", "plan_name": "700720", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Miscellaneous", "plan_name": "700720_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Ppo Hmo", "plan_name": "701720", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Ppo Hmo", "plan_name": "701720_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Ms State Emplo", "plan_name": "401457", "standard_charge_dollar": 15.26, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Ms State Emplo", "plan_name": "401457_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Basic Pl", "plan_name": "400100", "standard_charge_dollar": 15.26, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Basic Pl", "plan_name": "400100_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Federal", "plan_name": "400110", "standard_charge_dollar": 15.26, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Federal", "plan_name": "400110_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." } ] } ] }, { "description": "Hc hepatitis delta agent", "code_information": [ { "code": "86692", "type": "CPT" } ], "standard_charges": [ { "gross_charge": 156.00, "minimum": 22.85, "maximum": 22.85, "setting": "both", "payers_information": [ { "payer_name": "Aetna", "plan_name": "700700", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna", "plan_name": "700700_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Miscellaneous", "plan_name": "700720", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Miscellaneous", "plan_name": "700720_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Ppo Hmo", "plan_name": "701720", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Ppo Hmo", "plan_name": "701720_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Ms State Emplo", "plan_name": "401457", "standard_charge_dollar": 22.85, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Ms State Emplo", "plan_name": "401457_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Basic Pl", "plan_name": "400100", "standard_charge_dollar": 22.85, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Basic Pl", "plan_name": "400100_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Federal", "plan_name": "400110", "standard_charge_dollar": 22.85, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Federal", "plan_name": "400110_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." } ] } ] }, { "description": "Hepatitis delta agent antbdy", "code_information": [ { "code": "86692", "type": "CPT" } ], "standard_charges": [ { "gross_charge": 156.00, "minimum": 22.85, "maximum": 22.85, "setting": "both", "payers_information": [ { "payer_name": "Aetna", "plan_name": "700700", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna", "plan_name": "700700_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Miscellaneous", "plan_name": "700720", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Miscellaneous", "plan_name": "700720_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Ppo Hmo", "plan_name": "701720", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Ppo Hmo", "plan_name": "701720_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Ms State Emplo", "plan_name": "401457", "standard_charge_dollar": 22.85, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Ms State Emplo", "plan_name": "401457_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Basic Pl", "plan_name": "400100", "standard_charge_dollar": 22.85, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Basic Pl", "plan_name": "400100_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Federal", "plan_name": "400110", "standard_charge_dollar": 22.85, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Federal", "plan_name": "400110_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." } ] } ] }, { "description": "Hc herpes simplex type 1", "code_information": [ { "code": "86695", "type": "CPT" } ], "standard_charges": [ { "gross_charge": 39.57, "minimum": 19.77, "maximum": 19.77, "setting": "both", "payers_information": [ { "payer_name": "Aetna", "plan_name": "700700", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna", "plan_name": "700700_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Miscellaneous", "plan_name": "700720", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Miscellaneous", "plan_name": "700720_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Ppo Hmo", "plan_name": "701720", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Ppo Hmo", "plan_name": "701720_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Ms State Emplo", "plan_name": "401457", "standard_charge_dollar": 19.77, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Ms State Emplo", "plan_name": "401457_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Basic Pl", "plan_name": "400100", "standard_charge_dollar": 19.77, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Basic Pl", "plan_name": "400100_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Federal", "plan_name": "400110", "standard_charge_dollar": 19.77, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Federal", "plan_name": "400110_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." } ] } ] }, { "description": "Herpes simplex type 1 test", "code_information": [ { "code": "86695", "type": "CPT" } ], "standard_charges": [ { "gross_charge": 39.57, "minimum": 19.77, "maximum": 19.77, "setting": "both", "payers_information": [ { "payer_name": "Aetna", "plan_name": "700700", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna", "plan_name": "700700_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Miscellaneous", "plan_name": "700720", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Miscellaneous", "plan_name": "700720_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Ppo Hmo", "plan_name": "701720", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Ppo Hmo", "plan_name": "701720_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Ms State Emplo", "plan_name": "401457", "standard_charge_dollar": 19.77, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Ms State Emplo", "plan_name": "401457_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Basic Pl", "plan_name": "400100", "standard_charge_dollar": 19.77, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Basic Pl", "plan_name": "400100_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Federal", "plan_name": "400110", "standard_charge_dollar": 19.77, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Federal", "plan_name": "400110_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." } ] } ] }, { "description": "Hc herpes simplex type 2", "code_information": [ { "code": "86696", "type": "CPT" } ], "standard_charges": [ { "gross_charge": 60.00, "minimum": 29.01, "maximum": 29.01, "setting": "both", "payers_information": [ { "payer_name": "Aetna", "plan_name": "700700", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to 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amounts." }, { "payer_name": "Aetna Ppo Hmo", "plan_name": "701720_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Ms State Emplo", "plan_name": "401457", "standard_charge_dollar": 29.01, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Ms State Emplo", "plan_name": "401457_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Basic Pl", "plan_name": "400100", "standard_charge_dollar": 29.01, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Basic Pl", "plan_name": "400100_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Federal", "plan_name": "400110", "standard_charge_dollar": 29.01, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Federal", "plan_name": "400110_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." } ] } ] }, { "description": "Herpes simplex type 2 test", "code_information": [ { "code": "86696", "type": "CPT" } ], "standard_charges": [ { "gross_charge": 60.00, "minimum": 29.01, "maximum": 29.01, "setting": "both", "payers_information": [ { "payer_name": "Aetna", "plan_name": "700700", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna", "plan_name": "700700_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Miscellaneous", "plan_name": "700720", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Miscellaneous", "plan_name": "700720_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Ppo Hmo", "plan_name": "701720", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Ppo Hmo", "plan_name": "701720_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Ms State Emplo", "plan_name": "401457", "standard_charge_dollar": 29.01, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Ms State Emplo", "plan_name": "401457_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Basic Pl", "plan_name": "400100", "standard_charge_dollar": 29.01, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Basic Pl", "plan_name": "400100_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Federal", "plan_name": "400110", "standard_charge_dollar": 29.01, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Federal", "plan_name": "400110_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." } ] } ] }, { "description": "Hc hiv-1", "code_information": [ { "code": "86701", "type": "CPT" } ], "standard_charges": [ { "gross_charge": 130.78, "minimum": 13.32, "maximum": 13.32, "setting": "both", "payers_information": [ { "payer_name": "Aetna", "plan_name": "700700", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna", "plan_name": "700700_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Miscellaneous", "plan_name": "700720", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Miscellaneous", "plan_name": "700720_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Ppo Hmo", "plan_name": "701720", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Ppo Hmo", "plan_name": "701720_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Ms State Emplo", "plan_name": "401457", "standard_charge_dollar": 13.32, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Ms State Emplo", "plan_name": "401457_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Basic Pl", "plan_name": "400100", "standard_charge_dollar": 13.32, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Basic Pl", "plan_name": "400100_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Federal", "plan_name": "400110", "standard_charge_dollar": 13.32, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Federal", "plan_name": "400110_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." } ] } ] }, { "description": "Hiv-1antibody", "code_information": [ { "code": "86701", "type": "CPT" } ], "standard_charges": [ { "gross_charge": 130.78, "minimum": 13.32, "maximum": 13.32, "setting": "both", "payers_information": [ { "payer_name": "Aetna", "plan_name": "700700", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna", "plan_name": "700700_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Miscellaneous", "plan_name": "700720", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Miscellaneous", "plan_name": "700720_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Ppo Hmo", "plan_name": "701720", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Ppo Hmo", "plan_name": "701720_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Ms State Emplo", "plan_name": "401457", "standard_charge_dollar": 13.32, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Ms State Emplo", "plan_name": "401457_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Basic Pl", "plan_name": "400100", "standard_charge_dollar": 13.32, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Basic Pl", "plan_name": "400100_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Federal", "plan_name": "400110", "standard_charge_dollar": 13.32, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Federal", "plan_name": "400110_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." } ] } ] }, { "description": "Hc hiv-2", "code_information": [ { "code": "86702", "type": "CPT" } ], "standard_charges": [ { "gross_charge": 199.00, "minimum": 18.25, "maximum": 18.25, "setting": "both", "payers_information": [ { "payer_name": "Aetna", "plan_name": "700700", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna", "plan_name": "700700_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Miscellaneous", "plan_name": "700720", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Miscellaneous", "plan_name": "700720_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Ppo Hmo", "plan_name": "701720", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Ppo Hmo", "plan_name": "701720_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Ms State Emplo", "plan_name": "401457", "standard_charge_dollar": 18.25, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Ms State Emplo", "plan_name": "401457_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Basic Pl", "plan_name": "400100", "standard_charge_dollar": 18.25, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Basic Pl", "plan_name": "400100_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Federal", "plan_name": "400110", "standard_charge_dollar": 18.25, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Federal", "plan_name": "400110_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." } ] } ] }, { "description": "Hiv-2 antibody", "code_information": [ { "code": "86702", "type": "CPT" } ], "standard_charges": [ { "gross_charge": 199.00, "minimum": 18.25, "maximum": 18.25, "setting": "both", "payers_information": [ { "payer_name": "Aetna", "plan_name": "700700", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna", "plan_name": "700700_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Miscellaneous", "plan_name": "700720", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Miscellaneous", "plan_name": "700720_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Ppo Hmo", "plan_name": "701720", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Ppo Hmo", "plan_name": "701720_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Ms State Emplo", "plan_name": "401457", "standard_charge_dollar": 18.25, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Ms State Emplo", "plan_name": "401457_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Basic Pl", "plan_name": "400100", "standard_charge_dollar": 18.25, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Basic Pl", "plan_name": "400100_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Federal", "plan_name": "400110", "standard_charge_dollar": 18.25, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Federal", "plan_name": "400110_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." } ] } ] }, { "description": "Hc hepatitis b core ab", "code_information": [ { "code": "86704", "type": "CPT" } ], "standard_charges": [ { "gross_charge": 76.00, "minimum": 17.42, "maximum": 17.42, "setting": "both", "payers_information": [ { "payer_name": "Aetna", "plan_name": "700700", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna", "plan_name": "700700_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Miscellaneous", "plan_name": "700720", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Miscellaneous", "plan_name": "700720_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Ppo Hmo", "plan_name": "701720", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Ppo Hmo", "plan_name": "701720_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Ms State Emplo", "plan_name": "401457", "standard_charge_dollar": 17.42, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Ms State Emplo", "plan_name": "401457_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Basic Pl", "plan_name": "400100", "standard_charge_dollar": 17.42, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Basic Pl", "plan_name": "400100_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Federal", "plan_name": "400110", "standard_charge_dollar": 17.42, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Federal", "plan_name": "400110_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." } ] } ] }, { "description": "Hep b core antibody total", "code_information": [ { "code": "86704", "type": "CPT" } ], "standard_charges": [ { "gross_charge": 76.00, "minimum": 17.42, "maximum": 17.42, "setting": "both", "payers_information": [ { "payer_name": "Aetna", "plan_name": "700700", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna", "plan_name": "700700_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Miscellaneous", "plan_name": "700720", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Miscellaneous", "plan_name": "700720_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Ppo Hmo", "plan_name": "701720", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Ppo Hmo", "plan_name": "701720_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Ms State Emplo", "plan_name": "401457", "standard_charge_dollar": 17.42, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Ms State Emplo", "plan_name": "401457_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Basic Pl", "plan_name": "400100", "standard_charge_dollar": 17.42, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Basic Pl", "plan_name": "400100_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Federal", "plan_name": "400110", "standard_charge_dollar": 17.42, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Federal", "plan_name": "400110_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." } ] } ] }, { "description": "Hc hepatitis b surface ab", "code_information": [ { "code": "86706", "type": "CPT" } ], "standard_charges": [ { "gross_charge": 67.50, "minimum": 16.09, "maximum": 16.09, "setting": "both", "payers_information": [ { "payer_name": "Aetna", "plan_name": "700700", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna", "plan_name": "700700_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Miscellaneous", "plan_name": "700720", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Miscellaneous", "plan_name": "700720_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Ppo Hmo", "plan_name": "701720", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Ppo Hmo", "plan_name": "701720_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Ms State Emplo", "plan_name": "401457", "standard_charge_dollar": 16.09, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Ms State Emplo", "plan_name": "401457_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Basic Pl", "plan_name": "400100", "standard_charge_dollar": 16.09, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Basic Pl", "plan_name": "400100_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Federal", "plan_name": "400110", "standard_charge_dollar": 16.09, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Federal", "plan_name": "400110_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." } ] } ] }, { "description": "Hep b surface antibody", "code_information": [ { "code": "86706", "type": "CPT" } ], "standard_charges": [ { "gross_charge": 67.50, "minimum": 16.09, "maximum": 16.09, "setting": "both", "payers_information": [ { "payer_name": "Aetna", "plan_name": "700700", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna", "plan_name": "700700_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Miscellaneous", "plan_name": "700720", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Miscellaneous", "plan_name": "700720_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Ppo Hmo", "plan_name": "701720", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Ppo Hmo", "plan_name": "701720_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Ms State Emplo", "plan_name": "401457", "standard_charge_dollar": 16.09, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Ms State Emplo", "plan_name": "401457_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Basic Pl", "plan_name": "400100", "standard_charge_dollar": 16.09, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Basic Pl", "plan_name": "400100_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Federal", "plan_name": "400110", "standard_charge_dollar": 16.09, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Federal", "plan_name": "400110_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." } ] } ] }, { "description": "Hc hepatitis be antibody", "code_information": [ { "code": "86707", "type": "CPT" } ], "standard_charges": [ { "gross_charge": 77.96, "minimum": 17.34, "maximum": 17.34, "setting": "both", "payers_information": [ { "payer_name": "Aetna", "plan_name": "700700", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna", "plan_name": "700700_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Miscellaneous", "plan_name": "700720", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Miscellaneous", "plan_name": "700720_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Ppo Hmo", "plan_name": "701720", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Ppo Hmo", "plan_name": "701720_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Ms State Emplo", "plan_name": "401457", "standard_charge_dollar": 17.34, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Ms State Emplo", "plan_name": "401457_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Basic Pl", "plan_name": "400100", "standard_charge_dollar": 17.34, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Basic Pl", "plan_name": "400100_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Federal", "plan_name": "400110", "standard_charge_dollar": 17.34, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Federal", "plan_name": "400110_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." } ] } ] }, { "description": "Hepatitis be antibody", "code_information": [ { "code": "86707", "type": "CPT" } ], "standard_charges": [ { "gross_charge": 77.96, "minimum": 17.34, "maximum": 17.34, "setting": "both", "payers_information": [ { "payer_name": "Aetna", "plan_name": "700700", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna", "plan_name": "700700_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Miscellaneous", "plan_name": "700720", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Miscellaneous", "plan_name": "700720_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Ppo Hmo", "plan_name": "701720", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Ppo Hmo", "plan_name": "701720_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Ms State Emplo", "plan_name": "401457", "standard_charge_dollar": 17.34, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Ms State Emplo", "plan_name": "401457_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Basic Pl", "plan_name": "400100", "standard_charge_dollar": 17.34, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Basic Pl", "plan_name": "400100_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Federal", "plan_name": "400110", "standard_charge_dollar": 17.34, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Federal", "plan_name": "400110_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." } ] } ] }, { "description": "Hc hepatitis a antibody", "code_information": [ { "code": "86708", "type": "CPT" } ], "standard_charges": [ { "gross_charge": 100.00, "minimum": 18.56, "maximum": 18.56, "setting": "both", "payers_information": [ { "payer_name": "Aetna", "plan_name": "700700", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna", "plan_name": "700700_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Miscellaneous", "plan_name": "700720", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Miscellaneous", "plan_name": "700720_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Ppo Hmo", "plan_name": "701720", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Ppo Hmo", "plan_name": "701720_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Ms State Emplo", "plan_name": "401457", "standard_charge_dollar": 18.56, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Ms State Emplo", "plan_name": "401457_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Basic Pl", "plan_name": "400100", "standard_charge_dollar": 18.56, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Basic Pl", "plan_name": "400100_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Federal", "plan_name": "400110", "standard_charge_dollar": 18.56, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Federal", "plan_name": "400110_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." } ] } ] }, { "description": "Hepatitis a antibody", "code_information": [ { "code": "86708", "type": "CPT" } ], "standard_charges": [ { "gross_charge": 100.00, "minimum": 18.56, "maximum": 18.56, "setting": "both", "payers_information": [ { "payer_name": "Aetna", "plan_name": "700700", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna", "plan_name": "700700_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Miscellaneous", "plan_name": "700720", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Miscellaneous", "plan_name": "700720_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Ppo Hmo", "plan_name": "701720", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Ppo Hmo", "plan_name": "701720_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Ms State Emplo", "plan_name": "401457", "standard_charge_dollar": 18.56, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Ms State Emplo", "plan_name": "401457_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Basic Pl", "plan_name": "400100", "standard_charge_dollar": 18.56, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Basic Pl", "plan_name": "400100_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Federal", "plan_name": "400110", "standard_charge_dollar": 18.56, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Federal", "plan_name": "400110_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." } ] } ] }, { "description": "Hc hepatitis a ab igm", "code_information": [ { "code": "86709", "type": "CPT" } ], "standard_charges": [ { "gross_charge": 200.00, "minimum": 12.65, "maximum": 12.65, "setting": "both", "payers_information": [ { "payer_name": "Aetna", "plan_name": "700700", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna", "plan_name": "700700_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Miscellaneous", "plan_name": "700720", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Miscellaneous", "plan_name": "700720_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Ppo Hmo", "plan_name": "701720", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Ppo Hmo", "plan_name": "701720_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Ms State Emplo", "plan_name": "401457", "standard_charge_dollar": 12.65, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Ms State Emplo", "plan_name": "401457_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Basic Pl", "plan_name": "400100", "standard_charge_dollar": 12.65, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Basic Pl", "plan_name": "400100_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Federal", "plan_name": "400110", "standard_charge_dollar": 12.65, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Federal", "plan_name": "400110_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." } ] } ] }, { "description": "Hepatitis a igm antibody", "code_information": [ { "code": "86709", "type": "CPT" } ], "standard_charges": [ { "gross_charge": 200.00, "minimum": 12.65, "maximum": 12.65, "setting": "both", "payers_information": [ { "payer_name": "Aetna", "plan_name": "700700", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna", "plan_name": "700700_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Miscellaneous", "plan_name": "700720", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Miscellaneous", "plan_name": "700720_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Ppo Hmo", "plan_name": "701720", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate 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Basic Pl", "plan_name": "400100_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Federal", "plan_name": "400110", "standard_charge_dollar": 12.65, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Federal", "plan_name": "400110_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." } ] } ] }, { "description": "Hc legionella ab", "code_information": [ { "code": "86713", "type": "CPT" } ], "standard_charges": [ { "gross_charge": 63.00, "minimum": 22.94, "maximum": 22.94, "setting": "both", "payers_information": [ { "payer_name": "Aetna", "plan_name": "700700", 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"standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Ppo Hmo", "plan_name": "701720_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Ms State Emplo", "plan_name": "401457", "standard_charge_dollar": 22.94, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Ms State Emplo", "plan_name": "401457_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Basic Pl", "plan_name": "400100", "standard_charge_dollar": 22.94, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Basic Pl", "plan_name": "400100_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Federal", "plan_name": "400110", "standard_charge_dollar": 22.94, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Federal", "plan_name": "400110_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." } ] } ] }, { "description": "Legionella antibody", "code_information": [ { "code": "86713", "type": "CPT" } ], "standard_charges": [ { 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"additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Ppo Hmo", "plan_name": "701720", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Ppo Hmo", "plan_name": "701720_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Ms State Emplo", "plan_name": "401457", "standard_charge_dollar": 22.94, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Ms State Emplo", "plan_name": "401457_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Basic Pl", "plan_name": "400100", "standard_charge_dollar": 22.94, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Basic Pl", "plan_name": "400100_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Federal", "plan_name": "400110", "standard_charge_dollar": 22.94, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Federal", "plan_name": "400110_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." } ] } ] }, { "description": "Hc mumps ab igg", "code_information": [ { "code": "86735", "type": "CPT" } ], "standard_charges": [ { "gross_charge": 50.00, "minimum": 19.55, "maximum": 19.55, "setting": "both", "payers_information": [ { "payer_name": "Aetna", "plan_name": "700700", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna", "plan_name": "700700_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Miscellaneous", "plan_name": "700720", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Miscellaneous", "plan_name": "700720_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Ppo Hmo", "plan_name": "701720", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Ppo Hmo", "plan_name": "701720_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Ms State Emplo", "plan_name": "401457", "standard_charge_dollar": 19.55, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Ms State Emplo", "plan_name": "401457_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Basic Pl", "plan_name": "400100", "standard_charge_dollar": 19.55, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Basic Pl", "plan_name": "400100_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Federal", "plan_name": "400110", "standard_charge_dollar": 19.55, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Federal", "plan_name": "400110_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." } ] } ] }, { "description": "Mumps antibody", "code_information": [ { "code": "86735", "type": "CPT" } ], "standard_charges": [ { "gross_charge": 50.00, "minimum": 19.55, "maximum": 19.55, "setting": "both", "payers_information": [ { "payer_name": "Aetna", "plan_name": "700700", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna", "plan_name": "700700_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Miscellaneous", "plan_name": "700720", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Miscellaneous", "plan_name": "700720_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Ppo Hmo", "plan_name": "701720", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Ppo Hmo", "plan_name": "701720_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Ms State Emplo", "plan_name": "401457", "standard_charge_dollar": 19.55, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Ms State Emplo", "plan_name": "401457_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Basic Pl", "plan_name": "400100", "standard_charge_dollar": 19.55, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Basic Pl", "plan_name": "400100_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Federal", "plan_name": "400110", "standard_charge_dollar": 19.55, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Federal", "plan_name": "400110_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." } ] } ] }, { "description": "Hc m pneumoniae ab igm s by ifa", "code_information": [ { "code": "86738", "type": "CPT" } ], "standard_charges": [ { "gross_charge": 120.94, "minimum": 19.84, "maximum": 19.84, "setting": "both", "payers_information": [ { "payer_name": "Aetna", "plan_name": "700700", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna", "plan_name": "700700_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Miscellaneous", "plan_name": "700720", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Miscellaneous", "plan_name": "700720_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Ppo Hmo", "plan_name": "701720", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Ppo Hmo", "plan_name": "701720_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Ms State Emplo", "plan_name": "401457", "standard_charge_dollar": 19.84, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Ms State Emplo", "plan_name": "401457_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Basic Pl", "plan_name": "400100", "standard_charge_dollar": 19.84, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Basic Pl", "plan_name": "400100_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Federal", "plan_name": "400110", "standard_charge_dollar": 19.84, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Federal", "plan_name": "400110_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." } ] } ] }, { "description": "Mycoplasma antibody", "code_information": [ { "code": "86738", "type": "CPT" } ], "standard_charges": [ { "gross_charge": 120.94, "minimum": 19.84, "maximum": 19.84, "setting": "both", "payers_information": [ { "payer_name": "Aetna", "plan_name": "700700", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna", "plan_name": "700700_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Miscellaneous", "plan_name": "700720", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Miscellaneous", "plan_name": "700720_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Ppo Hmo", "plan_name": "701720", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Ppo Hmo", "plan_name": "701720_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Ms State Emplo", "plan_name": "401457", "standard_charge_dollar": 19.84, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Ms State Emplo", "plan_name": "401457_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Basic Pl", "plan_name": "400100", "standard_charge_dollar": 19.84, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Basic Pl", "plan_name": "400100_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Federal", "plan_name": "400110", "standard_charge_dollar": 19.84, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Federal", "plan_name": "400110_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." } ] } ] }, { "description": "Hc babesia microti igg", "code_information": [ { "code": "86753", "type": "CPT" } ], "standard_charges": [ { "gross_charge": 113.00, "minimum": 18.56, "maximum": 18.56, "setting": "both", "payers_information": [ { "payer_name": "Aetna", "plan_name": "700700", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna", "plan_name": "700700_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Miscellaneous", "plan_name": "700720", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Miscellaneous", "plan_name": "700720_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Ppo Hmo", "plan_name": "701720", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Ppo Hmo", "plan_name": "701720_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Ms State Emplo", "plan_name": "401457", "standard_charge_dollar": 18.56, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Ms State Emplo", "plan_name": "401457_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Basic Pl", "plan_name": "400100", "standard_charge_dollar": 18.56, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Basic Pl", "plan_name": "400100_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Federal", "plan_name": "400110", "standard_charge_dollar": 18.56, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Federal", "plan_name": "400110_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." } ] } ] }, { "description": "Protozoa antibody nos", "code_information": [ { "code": "86753", "type": "CPT" } ], "standard_charges": [ { "gross_charge": 113.00, "minimum": 18.56, "maximum": 18.56, "setting": "both", "payers_information": [ { "payer_name": "Aetna", "plan_name": "700700", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna", "plan_name": "700700_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Miscellaneous", "plan_name": "700720", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Miscellaneous", "plan_name": "700720_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Ppo Hmo", "plan_name": "701720", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Ppo Hmo", "plan_name": "701720_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Ms State Emplo", "plan_name": "401457", "standard_charge_dollar": 18.56, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Ms State Emplo", "plan_name": "401457_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Basic Pl", "plan_name": "400100", "standard_charge_dollar": 18.56, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Basic Pl", "plan_name": "400100_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Federal", "plan_name": "400110", "standard_charge_dollar": 18.56, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Federal", "plan_name": "400110_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." } ] } ] }, { "description": "Hc rickettsia", "code_information": [ { "code": "86757", "type": "CPT" } ], "standard_charges": [ { "gross_charge": 58.05, "minimum": 29.01, "maximum": 29.01, "setting": "both", "payers_information": [ { "payer_name": "Aetna", "plan_name": "700700", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna", "plan_name": "700700_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Miscellaneous", "plan_name": "700720", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Miscellaneous", "plan_name": "700720_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Ppo Hmo", "plan_name": "701720", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Ppo Hmo", "plan_name": "701720_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Ms State Emplo", "plan_name": "401457", "standard_charge_dollar": 29.01, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Ms State Emplo", "plan_name": "401457_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Basic Pl", "plan_name": "400100", "standard_charge_dollar": 29.01, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Basic Pl", "plan_name": "400100_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Federal", "plan_name": "400110", "standard_charge_dollar": 29.01, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Federal", "plan_name": "400110_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." } ] } ] }, { "description": "Rickettsia antibody", "code_information": [ { "code": "86757", "type": "CPT" } ], "standard_charges": [ { "gross_charge": 58.05, "minimum": 29.01, "maximum": 29.01, "setting": "both", "payers_information": [ { "payer_name": "Aetna", "plan_name": "700700", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna", "plan_name": "700700_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Miscellaneous", "plan_name": "700720", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Miscellaneous", "plan_name": "700720_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Ppo Hmo", "plan_name": "701720", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Ppo Hmo", "plan_name": "701720_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Ms State Emplo", "plan_name": "401457", "standard_charge_dollar": 29.01, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Ms State Emplo", "plan_name": "401457_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Basic Pl", "plan_name": "400100", "standard_charge_dollar": 29.01, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Basic Pl", "plan_name": "400100_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Federal", "plan_name": "400110", "standard_charge_dollar": 29.01, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Federal", "plan_name": "400110_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." } ] } ] }, { "description": "Hc rubella (blood bank)", "code_information": [ { "code": "86762", "type": "CPT" } ], "standard_charges": [ { "gross_charge": 51.50, "minimum": 21.57, "maximum": 21.57, "setting": "both", "payers_information": [ { "payer_name": "Aetna", "plan_name": "700700", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna", "plan_name": "700700_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Miscellaneous", "plan_name": "700720", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Miscellaneous", "plan_name": "700720_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Ppo Hmo", "plan_name": "701720", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Ppo Hmo", "plan_name": "701720_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Ms State Emplo", "plan_name": "401457", "standard_charge_dollar": 21.57, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Ms State Emplo", "plan_name": "401457_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Basic Pl", "plan_name": "400100", "standard_charge_dollar": 21.57, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Basic Pl", "plan_name": "400100_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Federal", "plan_name": "400110", "standard_charge_dollar": 21.57, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Federal", "plan_name": "400110_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." } ] } ] }, { "description": "Rubella antibody", "code_information": [ { "code": "86762", "type": "CPT" } ], "standard_charges": [ { "gross_charge": 51.50, "minimum": 21.57, "maximum": 21.57, "setting": "both", "payers_information": [ { "payer_name": "Aetna", "plan_name": "700700", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna", "plan_name": "700700_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Miscellaneous", "plan_name": "700720", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Miscellaneous", "plan_name": "700720_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Ppo Hmo", "plan_name": "701720", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Ppo Hmo", "plan_name": "701720_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Ms State Emplo", "plan_name": "401457", "standard_charge_dollar": 21.57, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Ms State Emplo", "plan_name": "401457_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Basic Pl", "plan_name": "400100", "standard_charge_dollar": 21.57, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Basic Pl", "plan_name": "400100_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Federal", "plan_name": "400110", "standard_charge_dollar": 21.57, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Federal", "plan_name": "400110_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." } ] } ] }, { "description": "Hc rubeola ab igg", "code_information": [ { "code": "86765", "type": "CPT" } ], "standard_charges": [ { "gross_charge": 50.00, "minimum": 19.31, "maximum": 19.31, "setting": "both", "payers_information": [ { "payer_name": "Aetna", "plan_name": "700700", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna", "plan_name": "700700_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Miscellaneous", "plan_name": "700720", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Miscellaneous", "plan_name": "700720_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Ppo Hmo", "plan_name": "701720", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Ppo Hmo", "plan_name": "701720_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Ms State Emplo", "plan_name": "401457", "standard_charge_dollar": 19.31, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Ms State Emplo", "plan_name": "401457_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Basic Pl", "plan_name": "400100", "standard_charge_dollar": 19.31, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Basic Pl", "plan_name": "400100_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Federal", "plan_name": "400110", "standard_charge_dollar": 19.31, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Federal", "plan_name": "400110_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." } ] } ] }, { "description": "Rubeola antibody", "code_information": [ { "code": "86765", "type": "CPT" } ], "standard_charges": [ { "gross_charge": 50.00, "minimum": 19.31, "maximum": 19.31, "setting": "both", "payers_information": [ { "payer_name": "Aetna", "plan_name": "700700", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna", "plan_name": "700700_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Miscellaneous", "plan_name": "700720", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Miscellaneous", "plan_name": "700720_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Ppo Hmo", "plan_name": "701720", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Ppo Hmo", "plan_name": "701720_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Ms State Emplo", "plan_name": "401457", "standard_charge_dollar": 19.31, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Ms State Emplo", "plan_name": "401457_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Basic Pl", "plan_name": "400100", "standard_charge_dollar": 19.31, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Basic Pl", "plan_name": "400100_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Federal", "plan_name": "400110", "standard_charge_dollar": 19.31, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Federal", "plan_name": "400110_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." } ] } ] }, { "description": "Hc sars-cov-2 igg antibody s", "code_information": [ { "code": "86769", "type": "CPT" } ], "standard_charges": [ { "gross_charge": 125.00, "minimum": 42.13, "maximum": 106.25, "setting": "both", "payers_information": [ { "payer_name": "Aarp", "plan_name": "500102", "standard_charge_dollar": 42.13, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna", "plan_name": "700700", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna", "plan_name": "700700_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Mcare Ffs 6005", "plan_name": "700703", "standard_charge_dollar": 42.13, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Miscellaneous", "plan_name": "700720", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Miscellaneous", "plan_name": "700720_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Ppo Hmo", "plan_name": "701720", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Ppo Hmo", "plan_name": "701720_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Ambetter 68069", "plan_name": "500516", "standard_charge_dollar": 42.13, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Ms State Emplo", "plan_name": "401457", "standard_charge_percentage": 0.80, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Ms State Emplo", "plan_name": "401457_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Basic Pl", "plan_name": "400100", "standard_charge_percentage": 0.85, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Basic Pl", "plan_name": "400100_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Federal", "plan_name": "400110", "standard_charge_percentage": 0.85, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Federal", "plan_name": "400110_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Cigna Healthsprings Ffs", "plan_name": "500064", "standard_charge_dollar": 42.13, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Conseco", "plan_name": "500302", "standard_charge_dollar": 42.13, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Humana Ffs 61101", "plan_name": "500006", "standard_charge_dollar": 42.13, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Medicare A", "plan_name": "100100", "standard_charge_dollar": 42.13, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Medicare A", "plan_name": "100500", "standard_charge_dollar": 42.13, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Medicare Part B Only", "plan_name": "100300", "standard_charge_dollar": 42.13, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Medicare Railroad", "plan_name": "100103", "standard_charge_dollar": 42.13, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Ms Physicians Care N", "plan_name": "714210", "standard_charge_dollar": 52.66, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Peoples Hlth Ffs 72126", "plan_name": "500019", "standard_charge_dollar": 42.13, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Uhc/Secure Horizons", "plan_name": "500449", "standard_charge_dollar": 42.13, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "United Health Care/", "plan_name": "500292", "standard_charge_dollar": 47.61, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "United Healthcare", "plan_name": "750104", "standard_charge_dollar": 47.61, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "United Healthcare Ba", "plan_name": "750090", "standard_charge_dollar": 47.61, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "United Healthcare Me", "plan_name": "501310", "standard_charge_dollar": 42.13, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Windsor Mcare Extra", "plan_name": "500778", "standard_charge_dollar": 42.13, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." } ] } ] }, { "description": "Sars-cov-2 covid-19 antibody", "code_information": [ { "code": "86769", "type": "CPT" } ], "standard_charges": [ { "gross_charge": 125.00, "minimum": 42.13, "maximum": 106.25, "setting": "both", "payers_information": [ { "payer_name": "Aarp", "plan_name": "500102", "standard_charge_dollar": 42.13, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna", "plan_name": "700700", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna", "plan_name": "700700_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Mcare Ffs 6005", "plan_name": "700703", "standard_charge_dollar": 42.13, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Miscellaneous", "plan_name": "700720", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Miscellaneous", "plan_name": "700720_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Ppo Hmo", "plan_name": "701720", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Ppo Hmo", "plan_name": "701720_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Ambetter 68069", "plan_name": "500516", "standard_charge_dollar": 42.13, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Ms State Emplo", "plan_name": "401457", "standard_charge_percentage": 0.80, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Ms State Emplo", "plan_name": "401457_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Basic Pl", "plan_name": "400100", "standard_charge_percentage": 0.85, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Basic Pl", "plan_name": "400100_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Federal", "plan_name": "400110", "standard_charge_percentage": 0.85, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Federal", "plan_name": "400110_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Cigna Healthsprings Ffs", "plan_name": "500064", "standard_charge_dollar": 42.13, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Conseco", "plan_name": "500302", "standard_charge_dollar": 42.13, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Humana Ffs 61101", "plan_name": "500006", "standard_charge_dollar": 42.13, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Medicare A", "plan_name": "100100", "standard_charge_dollar": 42.13, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Medicare A", "plan_name": "100500", "standard_charge_dollar": 42.13, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Medicare Part B Only", "plan_name": "100300", "standard_charge_dollar": 42.13, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Medicare Railroad", "plan_name": "100103", "standard_charge_dollar": 42.13, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Ms Physicians Care N", "plan_name": "714210", "standard_charge_dollar": 52.66, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Peoples Hlth Ffs 72126", "plan_name": "500019", "standard_charge_dollar": 42.13, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Uhc/Secure Horizons", "plan_name": "500449", "standard_charge_dollar": 42.13, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "United Health Care/", "plan_name": "500292", "standard_charge_dollar": 47.61, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "United Healthcare", "plan_name": "750104", "standard_charge_dollar": 47.61, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "United Healthcare Ba", "plan_name": "750090", "standard_charge_dollar": 47.61, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "United Healthcare Me", "plan_name": "501310", "standard_charge_dollar": 42.13, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Windsor Mcare Extra", "plan_name": "500778", "standard_charge_dollar": 42.13, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." } ] } ] }, { "description": "Hc toxoplasma gondii igg abs", "code_information": [ { "code": "86777", "type": "CPT" } ], "standard_charges": [ { "gross_charge": 43.96, "minimum": 21.57, "maximum": 21.57, "setting": "both", "payers_information": [ { "payer_name": "Aetna", "plan_name": "700700", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna", "plan_name": "700700_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Miscellaneous", "plan_name": "700720", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Miscellaneous", "plan_name": "700720_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Ppo Hmo", "plan_name": "701720", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Ppo Hmo", "plan_name": "701720_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Ms State Emplo", "plan_name": "401457", "standard_charge_dollar": 21.57, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Ms State Emplo", "plan_name": "401457_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Basic Pl", "plan_name": "400100", "standard_charge_dollar": 21.57, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Basic Pl", "plan_name": "400100_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Federal", "plan_name": "400110", "standard_charge_dollar": 21.57, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Federal", "plan_name": "400110_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." } ] } ] }, { "description": "Toxoplasma antibody", "code_information": [ { "code": "86777", "type": "CPT" } ], "standard_charges": [ { "gross_charge": 43.96, "minimum": 21.57, "maximum": 21.57, "setting": "both", "payers_information": [ { "payer_name": "Aetna", "plan_name": "700700", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna", "plan_name": "700700_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Miscellaneous", "plan_name": "700720", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Miscellaneous", "plan_name": "700720_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Ppo Hmo", "plan_name": "701720", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Ppo Hmo", "plan_name": "701720_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Ms State Emplo", "plan_name": "401457", "standard_charge_dollar": 21.57, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Ms State Emplo", "plan_name": "401457_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Basic Pl", "plan_name": "400100", "standard_charge_dollar": 21.57, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Basic Pl", "plan_name": "400100_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Federal", "plan_name": "400110", "standard_charge_dollar": 21.57, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Federal", "plan_name": "400110_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." } ] } ] }, { "description": "Hc toxoplasma ab igm s", "code_information": [ { "code": "86778", "type": "CPT" } ], "standard_charges": [ { "gross_charge": 83.00, "minimum": 21.58, "maximum": 21.58, "setting": "both", "payers_information": [ { "payer_name": "Aetna", "plan_name": "700700", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna", "plan_name": "700700_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Miscellaneous", "plan_name": "700720", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Miscellaneous", "plan_name": "700720_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Ppo Hmo", "plan_name": "701720", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Ppo Hmo", "plan_name": "701720_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Ms State Emplo", "plan_name": "401457", "standard_charge_dollar": 21.58, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Ms State Emplo", "plan_name": "401457_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Basic Pl", "plan_name": "400100", "standard_charge_dollar": 21.58, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Basic Pl", "plan_name": "400100_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Federal", "plan_name": "400110", "standard_charge_dollar": 21.58, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Federal", "plan_name": "400110_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." } ] } ] }, { "description": "Toxoplasma antibody igm", "code_information": [ { "code": "86778", "type": "CPT" } ], "standard_charges": [ { "gross_charge": 83.00, "minimum": 21.58, "maximum": 21.58, "setting": "both", "payers_information": [ { "payer_name": "Aetna", "plan_name": "700700", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna", "plan_name": "700700_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Miscellaneous", "plan_name": "700720", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Miscellaneous", "plan_name": "700720_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Ppo Hmo", "plan_name": "701720", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Ppo Hmo", "plan_name": "701720_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Ms State Emplo", "plan_name": "401457", "standard_charge_dollar": 21.58, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Ms State Emplo", "plan_name": "401457_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Basic Pl", "plan_name": "400100", "standard_charge_dollar": 21.58, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Basic Pl", "plan_name": "400100_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Federal", "plan_name": "400110", "standard_charge_dollar": 21.58, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Federal", "plan_name": "400110_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." } ] } ] }, { "description": "Hc syphilis ab by tp-pa (mtppa)", "code_information": [ { "code": "86780", "type": "CPT" } ], "standard_charges": [ { "gross_charge": 105.08, "minimum": 13.24, "maximum": 19.83, "setting": "both", "payers_information": [ { "payer_name": "Aarp", "plan_name": "500102", "standard_charge_dollar": 13.24, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna", "plan_name": "700700", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna", "plan_name": "700700_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Mcare Ffs 6005", "plan_name": "700703", "standard_charge_dollar": 13.24, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Miscellaneous", "plan_name": "700720", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Miscellaneous", "plan_name": "700720_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Ppo Hmo", "plan_name": "701720", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Ppo Hmo", "plan_name": "701720_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Ambetter 68069", "plan_name": "500516", "standard_charge_dollar": 13.24, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Ms State Emplo", "plan_name": "401457", "standard_charge_dollar": 19.83, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Ms State Emplo", "plan_name": "401457_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Basic Pl", "plan_name": "400100", "standard_charge_dollar": 19.83, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Basic Pl", "plan_name": "400100_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Federal", "plan_name": "400110", "standard_charge_dollar": 19.83, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Federal", "plan_name": "400110_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Cigna Healthsprings Ffs", "plan_name": "500064", "standard_charge_dollar": 13.24, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Conseco", "plan_name": "500302", "standard_charge_dollar": 13.24, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Humana Ffs 61101", "plan_name": "500006", "standard_charge_dollar": 13.24, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Medicare A", "plan_name": "100100", "standard_charge_dollar": 13.24, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Medicare A", "plan_name": "100500", "standard_charge_dollar": 13.24, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Medicare Part B Only", "plan_name": "100300", "standard_charge_dollar": 13.24, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Medicare Railroad", "plan_name": "100103", "standard_charge_dollar": 13.24, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Ms Physicians Care N", "plan_name": "714210", "standard_charge_dollar": 16.55, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Peoples Hlth Ffs 72126", "plan_name": "500019", "standard_charge_dollar": 13.24, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Uhc/Secure Horizons", "plan_name": "500449", "standard_charge_dollar": 13.24, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "United Health Care/", "plan_name": "500292", "standard_charge_dollar": 14.96, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "United Healthcare", "plan_name": "750104", "standard_charge_dollar": 14.96, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "United Healthcare Ba", "plan_name": "750090", "standard_charge_dollar": 14.96, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "United Healthcare Me", "plan_name": "501310", "standard_charge_dollar": 13.24, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Windsor Mcare Extra", "plan_name": "500778", "standard_charge_dollar": 13.24, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." } ] } ] }, { "description": "Treponema pallidum", "code_information": [ { "code": "86780", "type": "CPT" } ], "standard_charges": [ { "gross_charge": 105.08, "minimum": 13.24, "maximum": 19.83, "setting": "both", "payers_information": [ { "payer_name": "Aarp", "plan_name": "500102", "standard_charge_dollar": 13.24, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna", "plan_name": "700700", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna", "plan_name": "700700_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Mcare Ffs 6005", "plan_name": "700703", "standard_charge_dollar": 13.24, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Miscellaneous", "plan_name": "700720", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Miscellaneous", "plan_name": "700720_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Ppo Hmo", "plan_name": "701720", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Ppo Hmo", "plan_name": "701720_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Ambetter 68069", "plan_name": "500516", "standard_charge_dollar": 13.24, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Ms State Emplo", "plan_name": "401457", "standard_charge_dollar": 19.83, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Ms State Emplo", "plan_name": "401457_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Basic Pl", "plan_name": "400100", "standard_charge_dollar": 19.83, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Basic Pl", "plan_name": "400100_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Federal", "plan_name": "400110", "standard_charge_dollar": 19.83, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Federal", "plan_name": "400110_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Cigna Healthsprings Ffs", "plan_name": "500064", "standard_charge_dollar": 13.24, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Conseco", "plan_name": "500302", "standard_charge_dollar": 13.24, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Humana Ffs 61101", "plan_name": "500006", "standard_charge_dollar": 13.24, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Medicare A", "plan_name": "100100", "standard_charge_dollar": 13.24, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Medicare A", "plan_name": "100500", "standard_charge_dollar": 13.24, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Medicare Part B Only", "plan_name": "100300", "standard_charge_dollar": 13.24, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Medicare Railroad", "plan_name": "100103", "standard_charge_dollar": 13.24, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Ms Physicians Care N", "plan_name": "714210", "standard_charge_dollar": 16.55, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Peoples Hlth Ffs 72126", "plan_name": "500019", "standard_charge_dollar": 13.24, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Uhc/Secure Horizons", "plan_name": "500449", "standard_charge_dollar": 13.24, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "United Health Care/", "plan_name": "500292", "standard_charge_dollar": 14.96, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "United Healthcare", "plan_name": "750104", "standard_charge_dollar": 14.96, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "United Healthcare Ba", "plan_name": "750090", "standard_charge_dollar": 14.96, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "United Healthcare Me", "plan_name": "501310", "standard_charge_dollar": 13.24, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Windsor Mcare Extra", "plan_name": "500778", "standard_charge_dollar": 13.24, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." } ] } ] }, { "description": "Hc varicella zoster ab", "code_information": [ { "code": "86787", "type": "CPT" } ], "standard_charges": [ { "gross_charge": 100.00, "minimum": 19.31, "maximum": 19.31, "setting": "both", "payers_information": [ { "payer_name": "Aetna", "plan_name": "700700", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna", "plan_name": "700700_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Miscellaneous", "plan_name": "700720", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Miscellaneous", "plan_name": "700720_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Ppo Hmo", "plan_name": "701720", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Ppo Hmo", "plan_name": "701720_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Ms State Emplo", "plan_name": "401457", "standard_charge_dollar": 19.31, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Ms State Emplo", "plan_name": "401457_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Basic Pl", "plan_name": "400100", "standard_charge_dollar": 19.31, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Basic Pl", "plan_name": "400100_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Federal", "plan_name": "400110", "standard_charge_dollar": 19.31, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Federal", "plan_name": "400110_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." } ] } ] }, { "description": "Varicella-zoster antibody", "code_information": [ { "code": "86787", "type": "CPT" } ], "standard_charges": [ { "gross_charge": 100.00, "minimum": 19.31, "maximum": 19.31, "setting": "both", "payers_information": [ { "payer_name": "Aetna", "plan_name": "700700", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna", "plan_name": "700700_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Miscellaneous", "plan_name": "700720", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Miscellaneous", "plan_name": "700720_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Ppo Hmo", "plan_name": "701720", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Ppo Hmo", "plan_name": "701720_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Ms State Emplo", "plan_name": "401457", "standard_charge_dollar": 19.31, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Ms State Emplo", "plan_name": "401457_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Basic Pl", "plan_name": "400100", "standard_charge_dollar": 19.31, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Basic Pl", "plan_name": "400100_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Federal", "plan_name": "400110", "standard_charge_dollar": 19.31, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Federal", "plan_name": "400110_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." } ] } ] }, { "description": "Hc anti-thyroglobulin ab", "code_information": [ { "code": "86800", "type": "CPT" } ], "standard_charges": [ { "gross_charge": 90.00, "minimum": 13.50, "maximum": 13.50, "setting": "both", "payers_information": [ { "payer_name": "Aetna", "plan_name": "700700", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna", "plan_name": "700700_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Miscellaneous", "plan_name": "700720", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Miscellaneous", "plan_name": "700720_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Ppo Hmo", "plan_name": "701720", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Ppo Hmo", "plan_name": "701720_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Ms State Emplo", "plan_name": "401457", "standard_charge_dollar": 13.50, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Ms State Emplo", "plan_name": "401457_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Basic Pl", "plan_name": "400100", "standard_charge_dollar": 13.50, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Basic Pl", "plan_name": "400100_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Federal", "plan_name": "400110", "standard_charge_dollar": 13.50, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Federal", "plan_name": "400110_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." } ] } ] }, { "description": "Thyroglobulin antibody", "code_information": [ { "code": "86800", "type": "CPT" } ], "standard_charges": [ { "gross_charge": 90.00, "minimum": 13.50, "maximum": 13.50, "setting": "both", "payers_information": [ { "payer_name": "Aetna", "plan_name": "700700", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna", "plan_name": "700700_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Miscellaneous", "plan_name": "700720", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Miscellaneous", "plan_name": "700720_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Ppo Hmo", "plan_name": "701720", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Ppo Hmo", "plan_name": "701720_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Ms State Emplo", "plan_name": "401457", "standard_charge_dollar": 13.50, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Ms State Emplo", "plan_name": "401457_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Basic Pl", "plan_name": "400100", "standard_charge_dollar": 13.50, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Basic Pl", "plan_name": "400100_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Federal", "plan_name": "400110", "standard_charge_dollar": 13.50, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Federal", "plan_name": "400110_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." } ] } ] }, { "description": "Hc hepatitis c antibody", "code_information": [ { "code": "86803", "type": "CPT" } ], "standard_charges": [ { "gross_charge": 106.00, "minimum": 17.48, "maximum": 17.48, "setting": "both", "payers_information": [ { "payer_name": "Aetna", "plan_name": "700700", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna", "plan_name": "700700_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Miscellaneous", "plan_name": "700720", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Miscellaneous", "plan_name": "700720_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Ppo Hmo", "plan_name": "701720", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Ppo Hmo", "plan_name": "701720_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Ms State Emplo", "plan_name": "401457", "standard_charge_dollar": 17.48, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Ms State Emplo", "plan_name": "401457_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Basic Pl", "plan_name": "400100", "standard_charge_dollar": 17.48, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Basic Pl", "plan_name": "400100_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Federal", "plan_name": "400110", "standard_charge_dollar": 17.48, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Federal", "plan_name": "400110_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." } ] } ] }, { "description": "Hepatitis c ab test", "code_information": [ { "code": "86803", "type": "CPT" } ], "standard_charges": [ { "gross_charge": 106.00, "minimum": 17.48, "maximum": 17.48, "setting": "both", "payers_information": [ { "payer_name": "Aetna", "plan_name": "700700", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna", "plan_name": "700700_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Miscellaneous", "plan_name": "700720", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Miscellaneous", "plan_name": "700720_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Ppo Hmo", "plan_name": "701720", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Ppo Hmo", "plan_name": "701720_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Ms State Emplo", "plan_name": "401457", "standard_charge_dollar": 17.48, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Ms State Emplo", "plan_name": "401457_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Basic Pl", "plan_name": "400100", "standard_charge_dollar": 17.48, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Basic Pl", "plan_name": "400100_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Federal", "plan_name": "400110", "standard_charge_dollar": 17.48, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Federal", "plan_name": "400110_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." } ] } ] }, { "description": "Hc hla typing single ag", "code_information": [ { "code": "86812", "type": "CPT" } ], "standard_charges": [ { "gross_charge": 157.50, "minimum": 38.68, "maximum": 38.68, "setting": "both", "payers_information": [ { "payer_name": "Aetna", "plan_name": "700700", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna", "plan_name": "700700_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Miscellaneous", "plan_name": "700720", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Miscellaneous", "plan_name": "700720_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Ppo Hmo", "plan_name": "701720", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Ppo Hmo", "plan_name": "701720_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Ms State Emplo", "plan_name": "401457", "standard_charge_dollar": 38.68, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Ms State Emplo", "plan_name": "401457_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Basic Pl", "plan_name": "400100", "standard_charge_dollar": 38.68, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Basic Pl", "plan_name": "400100_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Federal", "plan_name": "400110", "standard_charge_dollar": 38.68, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Federal", "plan_name": "400110_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." } ] } ] }, { "description": "Hla typing a b or c", "code_information": [ { "code": "86812", "type": "CPT" } ], "standard_charges": [ { "gross_charge": 157.50, "minimum": 38.68, "maximum": 38.68, "setting": "both", "payers_information": [ { "payer_name": "Aetna", "plan_name": "700700", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna", "plan_name": "700700_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Miscellaneous", "plan_name": "700720", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Miscellaneous", "plan_name": "700720_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Ppo Hmo", "plan_name": "701720", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Ppo Hmo", "plan_name": "701720_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Ms State Emplo", "plan_name": "401457", "standard_charge_dollar": 38.68, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Ms State Emplo", "plan_name": "401457_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Basic Pl", "plan_name": "400100", "standard_charge_dollar": 38.68, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Basic Pl", "plan_name": "400100_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Federal", "plan_name": "400110", "standard_charge_dollar": 38.68, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Federal", "plan_name": "400110_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." } ] } ] }, { "description": "Hc rbc ab screen ea techiq", "code_information": [ { "code": "86850", "type": "CPT" } ], "standard_charges": [ { "gross_charge": 100.00, "minimum": 43.65, "maximum": 61.18, "setting": "both", "payers_information": [ { "payer_name": "Aarp", "plan_name": "500102", "standard_charge_dollar": 48.95, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna", "plan_name": "700700", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna", "plan_name": "700700_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Mcare Ffs 6005", "plan_name": "700703", "standard_charge_dollar": 48.95, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Miscellaneous", "plan_name": "700720", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Miscellaneous", "plan_name": "700720_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Ppo Hmo", "plan_name": "701720", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Ppo Hmo", "plan_name": "701720_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Ambetter 68069", "plan_name": "500516", "standard_charge_dollar": 48.95, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Ms State Emplo", "plan_name": "401457", "standard_charge_dollar": 43.65, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Ms State Emplo", "plan_name": "401457_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Basic Pl", "plan_name": "400100", "standard_charge_dollar": 43.65, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Basic Pl", "plan_name": "400100_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Federal", "plan_name": "400110", "standard_charge_dollar": 43.65, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Federal", "plan_name": "400110_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Cigna Healthsprings Ffs", "plan_name": "500064", "standard_charge_dollar": 48.95, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Conseco", "plan_name": "500302", "standard_charge_dollar": 48.95, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Humana Ffs 61101", "plan_name": "500006", "standard_charge_dollar": 48.95, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Medicare A", "plan_name": "100100", "standard_charge_dollar": 48.95, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Medicare A", "plan_name": "100500", "standard_charge_dollar": 48.95, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Medicare Part B Only", "plan_name": "100300", "standard_charge_dollar": 48.95, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Medicare Railroad", "plan_name": "100103", "standard_charge_dollar": 48.95, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Ms Physicians Care N", "plan_name": "714210", "standard_charge_dollar": 61.18, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Peoples Hlth Ffs 72126", "plan_name": "500019", "standard_charge_dollar": 48.95, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Uhc/Secure Horizons", "plan_name": "500449", "standard_charge_dollar": 48.95, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "United Health Care/", "plan_name": "500292", "standard_charge_dollar": 55.31, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "United Healthcare", "plan_name": "750104", "standard_charge_dollar": 55.31, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "United Healthcare Ba", "plan_name": "750090", "standard_charge_dollar": 55.31, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "United Healthcare Me", "plan_name": "501310", "standard_charge_dollar": 48.95, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Windsor Mcare Extra", "plan_name": "500778", "standard_charge_dollar": 48.95, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." } ] } ] }, { "description": "Rbc antibody screen", "code_information": [ { "code": "86850", "type": "CPT" } ], "standard_charges": [ { "gross_charge": 100.00, "minimum": 43.65, "maximum": 61.18, "setting": "both", "payers_information": [ { "payer_name": "Aarp", "plan_name": "500102", "standard_charge_dollar": 48.95, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna", "plan_name": "700700", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna", "plan_name": "700700_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Mcare Ffs 6005", "plan_name": "700703", "standard_charge_dollar": 48.95, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Miscellaneous", "plan_name": "700720", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Miscellaneous", "plan_name": "700720_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Ppo Hmo", "plan_name": "701720", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Ppo Hmo", "plan_name": "701720_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Ambetter 68069", "plan_name": "500516", "standard_charge_dollar": 48.95, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Ms State Emplo", "plan_name": "401457", "standard_charge_dollar": 43.65, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Ms State Emplo", "plan_name": "401457_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Basic Pl", "plan_name": "400100", "standard_charge_dollar": 43.65, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Basic Pl", "plan_name": "400100_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Federal", "plan_name": "400110", "standard_charge_dollar": 43.65, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Federal", "plan_name": "400110_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Cigna Healthsprings Ffs", "plan_name": "500064", "standard_charge_dollar": 48.95, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Conseco", "plan_name": "500302", "standard_charge_dollar": 48.95, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Humana Ffs 61101", "plan_name": "500006", "standard_charge_dollar": 48.95, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Medicare A", "plan_name": "100100", "standard_charge_dollar": 48.95, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Medicare A", "plan_name": "100500", "standard_charge_dollar": 48.95, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Medicare Part B Only", "plan_name": "100300", "standard_charge_dollar": 48.95, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Medicare Railroad", "plan_name": "100103", "standard_charge_dollar": 48.95, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Ms Physicians Care N", "plan_name": "714210", "standard_charge_dollar": 61.18, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Peoples Hlth Ffs 72126", "plan_name": "500019", "standard_charge_dollar": 48.95, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Uhc/Secure Horizons", "plan_name": "500449", "standard_charge_dollar": 48.95, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "United Health Care/", "plan_name": "500292", "standard_charge_dollar": 55.31, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "United Healthcare", "plan_name": "750104", "standard_charge_dollar": 55.31, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "United Healthcare Ba", "plan_name": "750090", "standard_charge_dollar": 55.31, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "United Healthcare Me", "plan_name": "501310", "standard_charge_dollar": 48.95, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Windsor Mcare Extra", "plan_name": "500778", "standard_charge_dollar": 48.95, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." } ] } ] }, { "description": "Blood typing serologic abo", "code_information": [ { "code": "86900", "type": "CPT" } ], "standard_charges": [ { "gross_charge": 50.00, "minimum": 59.98, "maximum": 147.60, "setting": "both", "payers_information": [ { "payer_name": "Aarp", "plan_name": "500102", "standard_charge_dollar": 118.08, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna", "plan_name": "700700", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna", "plan_name": "700700_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Mcare Ffs 6005", "plan_name": "700703", "standard_charge_dollar": 118.08, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Miscellaneous", "plan_name": "700720", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Miscellaneous", "plan_name": "700720_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Ppo Hmo", "plan_name": "701720", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Ppo Hmo", "plan_name": "701720_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Ambetter 68069", "plan_name": "500516", "standard_charge_dollar": 118.08, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Ms State Emplo", "plan_name": "401457", "standard_charge_dollar": 59.98, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Ms State Emplo", "plan_name": "401457_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Basic Pl", "plan_name": "400100", "standard_charge_dollar": 59.98, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Basic Pl", "plan_name": "400100_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Federal", "plan_name": "400110", "standard_charge_dollar": 59.98, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Federal", "plan_name": "400110_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Cigna Healthsprings Ffs", "plan_name": "500064", "standard_charge_dollar": 118.08, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Conseco", "plan_name": "500302", "standard_charge_dollar": 118.08, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Humana Ffs 61101", "plan_name": "500006", "standard_charge_dollar": 118.08, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Medicare A", "plan_name": "100100", "standard_charge_dollar": 118.08, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Medicare A", "plan_name": "100500", "standard_charge_dollar": 118.08, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Medicare Part B Only", "plan_name": "100300", "standard_charge_dollar": 118.08, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Medicare Railroad", "plan_name": "100103", "standard_charge_dollar": 118.08, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Ms Physicians Care N", "plan_name": "714210", "standard_charge_dollar": 147.60, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Peoples Hlth Ffs 72126", "plan_name": "500019", "standard_charge_dollar": 118.08, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Uhc/Secure Horizons", "plan_name": "500449", "standard_charge_dollar": 118.08, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "United Health Care/", "plan_name": "500292", "standard_charge_dollar": 133.43, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "United Healthcare", "plan_name": "750104", "standard_charge_dollar": 133.43, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "United Healthcare Ba", "plan_name": "750090", "standard_charge_dollar": 133.43, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "United Healthcare Me", "plan_name": "501310", "standard_charge_dollar": 118.08, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Windsor Mcare Extra", "plan_name": "500778", "standard_charge_dollar": 118.08, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." } ] } ] }, { "description": "Hc blood typing serologic abo", "code_information": [ { "code": "86900", "type": "CPT" } ], "standard_charges": [ { "gross_charge": 50.00, "minimum": 59.98, "maximum": 147.60, "setting": "both", "payers_information": [ { "payer_name": "Aarp", "plan_name": "500102", "standard_charge_dollar": 118.08, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna", "plan_name": "700700", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna", "plan_name": "700700_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Mcare Ffs 6005", "plan_name": "700703", "standard_charge_dollar": 118.08, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Miscellaneous", "plan_name": "700720", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Miscellaneous", "plan_name": "700720_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Ppo Hmo", "plan_name": "701720", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Ppo Hmo", "plan_name": "701720_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Ambetter 68069", "plan_name": "500516", "standard_charge_dollar": 118.08, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Ms State Emplo", "plan_name": "401457", "standard_charge_dollar": 59.98, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Ms State Emplo", "plan_name": "401457_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Basic Pl", "plan_name": "400100", "standard_charge_dollar": 59.98, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Basic Pl", "plan_name": "400100_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Federal", "plan_name": "400110", "standard_charge_dollar": 59.98, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Federal", "plan_name": "400110_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Cigna Healthsprings Ffs", "plan_name": "500064", "standard_charge_dollar": 118.08, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Conseco", "plan_name": "500302", "standard_charge_dollar": 118.08, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Humana Ffs 61101", "plan_name": "500006", "standard_charge_dollar": 118.08, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Medicare A", "plan_name": "100100", "standard_charge_dollar": 118.08, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Medicare A", "plan_name": "100500", "standard_charge_dollar": 118.08, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Medicare Part B Only", "plan_name": "100300", "standard_charge_dollar": 118.08, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Medicare Railroad", "plan_name": "100103", "standard_charge_dollar": 118.08, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Ms Physicians Care N", "plan_name": "714210", "standard_charge_dollar": 147.60, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Peoples Hlth Ffs 72126", "plan_name": "500019", "standard_charge_dollar": 118.08, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Uhc/Secure Horizons", "plan_name": "500449", "standard_charge_dollar": 118.08, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "United Health Care/", "plan_name": "500292", "standard_charge_dollar": 133.43, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "United Healthcare", "plan_name": "750104", "standard_charge_dollar": 133.43, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "United Healthcare Ba", "plan_name": "750090", "standard_charge_dollar": 133.43, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "United Healthcare Me", "plan_name": "501310", "standard_charge_dollar": 118.08, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Windsor Mcare Extra", "plan_name": "500778", "standard_charge_dollar": 118.08, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." } ] } ] }, { "description": "Blood typing serologic rh(d)", "code_information": [ { "code": "86901", "type": "CPT" } ], "standard_charges": [ { "gross_charge": 47.00, "minimum": 31.21, "maximum": 44.94, "setting": "both", "payers_information": [ { "payer_name": "Aarp", "plan_name": "500102", "standard_charge_dollar": 35.96, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna", "plan_name": "700700", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna", "plan_name": "700700_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Mcare Ffs 6005", "plan_name": "700703", "standard_charge_dollar": 35.96, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Miscellaneous", "plan_name": "700720", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Miscellaneous", "plan_name": "700720_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Ppo Hmo", "plan_name": "701720", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Ppo Hmo", "plan_name": "701720_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Ambetter 68069", "plan_name": "500516", "standard_charge_dollar": 35.96, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Ms State Emplo", "plan_name": "401457", "standard_charge_dollar": 31.21, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Ms State Emplo", "plan_name": "401457_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Basic Pl", "plan_name": "400100", "standard_charge_dollar": 31.21, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Basic Pl", "plan_name": "400100_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Federal", "plan_name": "400110", "standard_charge_dollar": 31.21, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Federal", "plan_name": "400110_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Cigna Healthsprings Ffs", "plan_name": "500064", "standard_charge_dollar": 35.96, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Conseco", "plan_name": "500302", "standard_charge_dollar": 35.96, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Humana Ffs 61101", "plan_name": "500006", "standard_charge_dollar": 35.96, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Medicare A", "plan_name": "100100", "standard_charge_dollar": 35.96, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Medicare A", "plan_name": "100500", "standard_charge_dollar": 35.96, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Medicare Part B Only", "plan_name": "100300", "standard_charge_dollar": 35.96, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Medicare Railroad", "plan_name": "100103", "standard_charge_dollar": 35.96, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Ms Physicians Care N", "plan_name": "714210", "standard_charge_dollar": 44.94, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Peoples Hlth Ffs 72126", "plan_name": "500019", "standard_charge_dollar": 35.96, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Uhc/Secure Horizons", "plan_name": "500449", "standard_charge_dollar": 35.96, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "United Health Care/", "plan_name": "500292", "standard_charge_dollar": 40.63, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "United Healthcare", "plan_name": "750104", "standard_charge_dollar": 40.63, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "United Healthcare Ba", "plan_name": "750090", "standard_charge_dollar": 40.63, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "United Healthcare Me", "plan_name": "501310", "standard_charge_dollar": 35.96, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Windsor Mcare Extra", "plan_name": "500778", "standard_charge_dollar": 35.96, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." } ] } ] }, { "description": "Hc blood typing rh d", "code_information": [ { "code": "86901", "type": "CPT" } ], "standard_charges": [ { "gross_charge": 47.00, "minimum": 31.21, "maximum": 44.94, "setting": "both", "payers_information": [ { "payer_name": "Aarp", "plan_name": "500102", "standard_charge_dollar": 35.96, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna", "plan_name": "700700", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna", "plan_name": "700700_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Mcare Ffs 6005", "plan_name": "700703", "standard_charge_dollar": 35.96, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Miscellaneous", "plan_name": "700720", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Miscellaneous", "plan_name": "700720_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Ppo Hmo", "plan_name": "701720", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Ppo Hmo", "plan_name": "701720_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Ambetter 68069", "plan_name": "500516", "standard_charge_dollar": 35.96, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Ms State Emplo", "plan_name": "401457", "standard_charge_dollar": 31.21, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Ms State Emplo", "plan_name": "401457_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Basic Pl", "plan_name": "400100", "standard_charge_dollar": 31.21, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Basic Pl", "plan_name": "400100_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Federal", "plan_name": "400110", "standard_charge_dollar": 31.21, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Federal", "plan_name": "400110_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Cigna Healthsprings Ffs", "plan_name": "500064", "standard_charge_dollar": 35.96, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Conseco", "plan_name": "500302", "standard_charge_dollar": 35.96, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Humana Ffs 61101", "plan_name": "500006", "standard_charge_dollar": 35.96, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Medicare A", "plan_name": "100100", "standard_charge_dollar": 35.96, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Medicare A", "plan_name": "100500", "standard_charge_dollar": 35.96, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Medicare Part B Only", "plan_name": "100300", "standard_charge_dollar": 35.96, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Medicare Railroad", "plan_name": "100103", "standard_charge_dollar": 35.96, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Ms Physicians Care N", "plan_name": "714210", "standard_charge_dollar": 44.94, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Peoples Hlth Ffs 72126", "plan_name": "500019", "standard_charge_dollar": 35.96, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Uhc/Secure Horizons", "plan_name": "500449", "standard_charge_dollar": 35.96, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "United Health Care/", "plan_name": "500292", "standard_charge_dollar": 40.63, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "United Healthcare", "plan_name": "750104", "standard_charge_dollar": 40.63, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "United Healthcare Ba", "plan_name": "750090", "standard_charge_dollar": 40.63, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "United Healthcare Me", "plan_name": "501310", "standard_charge_dollar": 35.96, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Windsor Mcare Extra", "plan_name": "500778", "standard_charge_dollar": 35.96, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." } ] } ] }, { "description": "Blood typing rbc antigens", "code_information": [ { "code": "86905", "type": "CPT" } ], "standard_charges": [ { "gross_charge": 555.00, "minimum": 202.32, "maximum": 411.91, "setting": "both", "payers_information": [ { "payer_name": "Aarp", "plan_name": "500102", "standard_charge_dollar": 329.53, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna", "plan_name": "700700", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna", "plan_name": "700700_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Mcare Ffs 6005", "plan_name": "700703", "standard_charge_dollar": 329.53, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Miscellaneous", "plan_name": "700720", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Miscellaneous", "plan_name": "700720_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Ppo Hmo", "plan_name": "701720", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Ppo Hmo", "plan_name": "701720_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Ambetter 68069", "plan_name": "500516", "standard_charge_dollar": 329.53, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Ms State Emplo", "plan_name": "401457", "standard_charge_dollar": 202.32, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Ms State Emplo", "plan_name": "401457_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Basic Pl", "plan_name": "400100", "standard_charge_dollar": 202.32, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Basic Pl", "plan_name": "400100_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Federal", "plan_name": "400110", "standard_charge_dollar": 202.32, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Federal", "plan_name": "400110_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Cigna Healthsprings Ffs", "plan_name": "500064", "standard_charge_dollar": 329.53, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Conseco", "plan_name": "500302", "standard_charge_dollar": 329.53, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Humana Ffs 61101", "plan_name": "500006", "standard_charge_dollar": 329.53, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Medicare A", "plan_name": "100100", "standard_charge_dollar": 329.53, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Medicare A", "plan_name": "100500", "standard_charge_dollar": 329.53, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Medicare Part B Only", "plan_name": "100300", "standard_charge_dollar": 329.53, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Medicare Railroad", "plan_name": "100103", "standard_charge_dollar": 329.53, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Ms Physicians Care N", "plan_name": "714210", "standard_charge_dollar": 411.91, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Peoples Hlth Ffs 72126", "plan_name": "500019", "standard_charge_dollar": 329.53, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Uhc/Secure Horizons", "plan_name": "500449", "standard_charge_dollar": 329.53, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "United Health Care/", "plan_name": "500292", "standard_charge_dollar": 372.37, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "United Healthcare", "plan_name": "750104", "standard_charge_dollar": 372.37, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "United Healthcare Ba", "plan_name": "750090", "standard_charge_dollar": 372.37, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "United Healthcare Me", "plan_name": "501310", "standard_charge_dollar": 329.53, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Windsor Mcare Extra", "plan_name": "500778", "standard_charge_dollar": 329.53, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." } ] } ] }, { "description": "Hc phenotype (ls)", "code_information": [ { "code": "86905", "type": "CPT" } ], "standard_charges": [ { "gross_charge": 555.00, "minimum": 202.32, "maximum": 411.91, "setting": "both", "payers_information": [ { "payer_name": "Aarp", "plan_name": "500102", "standard_charge_dollar": 329.53, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna", "plan_name": "700700", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna", "plan_name": "700700_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Mcare Ffs 6005", "plan_name": "700703", "standard_charge_dollar": 329.53, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Miscellaneous", "plan_name": "700720", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Miscellaneous", "plan_name": "700720_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Ppo Hmo", "plan_name": "701720", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Ppo Hmo", "plan_name": "701720_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Ambetter 68069", "plan_name": "500516", "standard_charge_dollar": 329.53, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Ms State Emplo", "plan_name": "401457", "standard_charge_dollar": 202.32, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Ms State Emplo", "plan_name": "401457_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Basic Pl", "plan_name": "400100", "standard_charge_dollar": 202.32, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Basic Pl", "plan_name": "400100_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Federal", "plan_name": "400110", "standard_charge_dollar": 202.32, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Federal", "plan_name": "400110_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Cigna Healthsprings Ffs", "plan_name": "500064", "standard_charge_dollar": 329.53, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Conseco", "plan_name": "500302", "standard_charge_dollar": 329.53, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Humana Ffs 61101", "plan_name": "500006", "standard_charge_dollar": 329.53, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Medicare A", "plan_name": "100100", "standard_charge_dollar": 329.53, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Medicare A", "plan_name": "100500", "standard_charge_dollar": 329.53, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Medicare Part B Only", "plan_name": "100300", "standard_charge_dollar": 329.53, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Medicare Railroad", "plan_name": "100103", "standard_charge_dollar": 329.53, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Ms Physicians Care N", "plan_name": "714210", "standard_charge_dollar": 411.91, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Peoples Hlth Ffs 72126", "plan_name": "500019", "standard_charge_dollar": 329.53, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Uhc/Secure Horizons", "plan_name": "500449", "standard_charge_dollar": 329.53, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "United Health Care/", "plan_name": "500292", "standard_charge_dollar": 372.37, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "United Healthcare", "plan_name": "750104", "standard_charge_dollar": 372.37, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "United Healthcare Ba", "plan_name": "750090", "standard_charge_dollar": 372.37, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "United Healthcare Me", "plan_name": "501310", "standard_charge_dollar": 329.53, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Windsor Mcare Extra", "plan_name": "500778", "standard_charge_dollar": 329.53, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." } ] } ] }, { "description": "Compatibility test spin", "code_information": [ { "code": "86920", "type": "CPT" } ], "standard_charges": [ { "gross_charge": 175.00, "minimum": 114.21, "maximum": 196.22, "setting": "both", "payers_information": [ { "payer_name": "Aarp", "plan_name": "500102", "standard_charge_dollar": 156.98, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna", "plan_name": "700700", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna", "plan_name": "700700_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Mcare Ffs 6005", "plan_name": "700703", "standard_charge_dollar": 156.98, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Miscellaneous", "plan_name": "700720", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Miscellaneous", "plan_name": "700720_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Ppo Hmo", "plan_name": "701720", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Ppo Hmo", "plan_name": "701720_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Ambetter 68069", "plan_name": "500516", "standard_charge_dollar": 156.98, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Ms State Emplo", "plan_name": "401457", "standard_charge_dollar": 114.21, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Ms State Emplo", "plan_name": "401457_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Basic Pl", "plan_name": "400100", "standard_charge_dollar": 114.21, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Basic Pl", "plan_name": "400100_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Federal", "plan_name": "400110", "standard_charge_dollar": 114.21, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Federal", "plan_name": "400110_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Cigna Healthsprings Ffs", "plan_name": "500064", "standard_charge_dollar": 156.98, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Conseco", "plan_name": "500302", "standard_charge_dollar": 156.98, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Humana Ffs 61101", "plan_name": "500006", "standard_charge_dollar": 156.98, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Medicare A", "plan_name": "100100", "standard_charge_dollar": 156.98, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Medicare A", "plan_name": "100500", "standard_charge_dollar": 156.98, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Medicare Part B Only", "plan_name": "100300", "standard_charge_dollar": 156.98, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Medicare Railroad", "plan_name": "100103", "standard_charge_dollar": 156.98, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Ms Physicians Care N", "plan_name": "714210", "standard_charge_dollar": 196.22, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Peoples Hlth Ffs 72126", "plan_name": "500019", "standard_charge_dollar": 156.98, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Uhc/Secure Horizons", "plan_name": "500449", "standard_charge_dollar": 156.98, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "United Health Care/", "plan_name": "500292", "standard_charge_dollar": 177.38, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "United Healthcare", "plan_name": "750104", "standard_charge_dollar": 177.38, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "United Healthcare Ba", "plan_name": "750090", "standard_charge_dollar": 177.38, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "United Healthcare Me", "plan_name": "501310", "standard_charge_dollar": 156.98, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Windsor Mcare Extra", "plan_name": "500778", "standard_charge_dollar": 156.98, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." } ] } ] }, { "description": "Hc compatibility test spin", "code_information": [ { "code": "86920", "type": "CPT" } ], "standard_charges": [ { "gross_charge": 175.00, "minimum": 114.21, "maximum": 196.22, "setting": "both", "payers_information": [ { "payer_name": "Aarp", "plan_name": "500102", "standard_charge_dollar": 156.98, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna", "plan_name": "700700", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna", "plan_name": "700700_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Mcare Ffs 6005", "plan_name": "700703", "standard_charge_dollar": 156.98, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Miscellaneous", "plan_name": "700720", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Miscellaneous", "plan_name": "700720_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Ppo Hmo", "plan_name": "701720", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Ppo Hmo", "plan_name": "701720_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Ambetter 68069", "plan_name": "500516", "standard_charge_dollar": 156.98, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Ms State Emplo", "plan_name": "401457", "standard_charge_dollar": 114.21, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Ms State Emplo", "plan_name": "401457_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Basic Pl", "plan_name": "400100", "standard_charge_dollar": 114.21, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Basic Pl", "plan_name": "400100_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Federal", "plan_name": "400110", "standard_charge_dollar": 114.21, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Federal", "plan_name": "400110_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Cigna Healthsprings Ffs", "plan_name": "500064", "standard_charge_dollar": 156.98, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Conseco", "plan_name": "500302", "standard_charge_dollar": 156.98, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Humana Ffs 61101", "plan_name": "500006", "standard_charge_dollar": 156.98, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Medicare A", "plan_name": "100100", "standard_charge_dollar": 156.98, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Medicare A", "plan_name": "100500", "standard_charge_dollar": 156.98, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Medicare Part B Only", "plan_name": "100300", "standard_charge_dollar": 156.98, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Medicare Railroad", "plan_name": "100103", "standard_charge_dollar": 156.98, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Ms Physicians Care N", "plan_name": "714210", "standard_charge_dollar": 196.22, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Peoples Hlth Ffs 72126", "plan_name": "500019", "standard_charge_dollar": 156.98, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Uhc/Secure Horizons", "plan_name": "500449", "standard_charge_dollar": 156.98, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "United Health Care/", "plan_name": "500292", "standard_charge_dollar": 177.38, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "United Healthcare", "plan_name": "750104", "standard_charge_dollar": 177.38, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "United Healthcare Ba", "plan_name": "750090", "standard_charge_dollar": 177.38, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "United Healthcare Me", "plan_name": "501310", "standard_charge_dollar": 156.98, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Windsor Mcare Extra", "plan_name": "500778", "standard_charge_dollar": 156.98, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." } ] } ] }, { "description": "Compatibility test antiglob", "code_information": [ { "code": "86922", "type": "CPT" } ], "standard_charges": [ { "gross_charge": 175.00, "minimum": 114.21, "maximum": 196.22, "setting": "both", "payers_information": [ { "payer_name": "Aarp", "plan_name": "500102", "standard_charge_dollar": 156.98, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna", "plan_name": "700700", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna", "plan_name": "700700_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Mcare Ffs 6005", "plan_name": "700703", "standard_charge_dollar": 156.98, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Miscellaneous", "plan_name": "700720", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Miscellaneous", "plan_name": "700720_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Ppo Hmo", "plan_name": "701720", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Ppo Hmo", "plan_name": "701720_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Ambetter 68069", "plan_name": "500516", "standard_charge_dollar": 156.98, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Ms State Emplo", "plan_name": "401457", "standard_charge_dollar": 114.21, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Ms State Emplo", "plan_name": "401457_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Basic Pl", "plan_name": "400100", "standard_charge_dollar": 114.21, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Basic Pl", "plan_name": "400100_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Federal", "plan_name": "400110", "standard_charge_dollar": 114.21, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Federal", "plan_name": "400110_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Cigna Healthsprings Ffs", "plan_name": "500064", "standard_charge_dollar": 156.98, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Conseco", "plan_name": "500302", "standard_charge_dollar": 156.98, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Humana Ffs 61101", "plan_name": "500006", "standard_charge_dollar": 156.98, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Medicare A", "plan_name": "100100", "standard_charge_dollar": 156.98, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Medicare A", "plan_name": "100500", "standard_charge_dollar": 156.98, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Medicare Part B Only", "plan_name": "100300", "standard_charge_dollar": 156.98, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Medicare Railroad", "plan_name": "100103", "standard_charge_dollar": 156.98, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Ms Physicians Care N", "plan_name": "714210", "standard_charge_dollar": 196.22, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Peoples Hlth Ffs 72126", "plan_name": "500019", "standard_charge_dollar": 156.98, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Uhc/Secure Horizons", "plan_name": "500449", "standard_charge_dollar": 156.98, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "United Health Care/", "plan_name": "500292", "standard_charge_dollar": 177.38, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "United Healthcare", "plan_name": "750104", "standard_charge_dollar": 177.38, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "United Healthcare Ba", "plan_name": "750090", "standard_charge_dollar": 177.38, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "United Healthcare Me", "plan_name": "501310", "standard_charge_dollar": 156.98, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Windsor Mcare Extra", "plan_name": "500778", "standard_charge_dollar": 156.98, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." } ] } ] }, { "description": "Hc complete crossmatch", "code_information": [ { "code": "86922", "type": "CPT" } ], "standard_charges": [ { "gross_charge": 175.00, "minimum": 114.21, "maximum": 196.22, "setting": "both", "payers_information": [ { "payer_name": "Aarp", "plan_name": "500102", "standard_charge_dollar": 156.98, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna", "plan_name": "700700", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna", "plan_name": "700700_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Mcare Ffs 6005", "plan_name": "700703", "standard_charge_dollar": 156.98, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Miscellaneous", "plan_name": "700720", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Miscellaneous", "plan_name": "700720_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Ppo Hmo", "plan_name": "701720", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Ppo Hmo", "plan_name": "701720_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Ambetter 68069", "plan_name": "500516", "standard_charge_dollar": 156.98, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Ms State Emplo", "plan_name": "401457", "standard_charge_dollar": 114.21, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Ms State Emplo", "plan_name": "401457_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Basic Pl", "plan_name": "400100", "standard_charge_dollar": 114.21, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Basic Pl", "plan_name": "400100_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Federal", "plan_name": "400110", "standard_charge_dollar": 114.21, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Federal", "plan_name": "400110_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Cigna Healthsprings Ffs", "plan_name": "500064", "standard_charge_dollar": 156.98, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Conseco", "plan_name": "500302", "standard_charge_dollar": 156.98, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Humana Ffs 61101", "plan_name": "500006", "standard_charge_dollar": 156.98, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Medicare A", "plan_name": "100100", "standard_charge_dollar": 156.98, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Medicare A", "plan_name": "100500", "standard_charge_dollar": 156.98, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Medicare Part B Only", "plan_name": "100300", "standard_charge_dollar": 156.98, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Medicare Railroad", "plan_name": "100103", "standard_charge_dollar": 156.98, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Ms Physicians Care N", "plan_name": "714210", "standard_charge_dollar": 196.22, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Peoples Hlth Ffs 72126", "plan_name": "500019", "standard_charge_dollar": 156.98, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Uhc/Secure Horizons", "plan_name": "500449", "standard_charge_dollar": 156.98, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "United Health Care/", "plan_name": "500292", "standard_charge_dollar": 177.38, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "United Healthcare", "plan_name": "750104", "standard_charge_dollar": 177.38, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "United Healthcare Ba", "plan_name": "750090", "standard_charge_dollar": 177.38, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "United Healthcare Me", "plan_name": "501310", "standard_charge_dollar": 156.98, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Windsor Mcare Extra", "plan_name": "500778", "standard_charge_dollar": 156.98, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." } ] } ] }, { "description": "Hc pretreat rbc enzymes", "code_information": [ { "code": "86971", "type": "CPT" } ], "standard_charges": [ { "gross_charge": 436.89, "minimum": 156.98, "maximum": 202.32, "setting": "both", "payers_information": [ { "payer_name": "Aarp", "plan_name": "500102", "standard_charge_dollar": 156.98, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna", "plan_name": "700700", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna", "plan_name": "700700_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Mcare Ffs 6005", "plan_name": "700703", "standard_charge_dollar": 156.98, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Miscellaneous", "plan_name": "700720", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Miscellaneous", "plan_name": "700720_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Ppo Hmo", "plan_name": "701720", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Ppo Hmo", "plan_name": "701720_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Ambetter 68069", "plan_name": "500516", "standard_charge_dollar": 156.98, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Ms State Emplo", "plan_name": "401457", "standard_charge_dollar": 202.32, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Ms State Emplo", "plan_name": "401457_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Basic Pl", "plan_name": "400100", "standard_charge_dollar": 202.32, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Basic Pl", "plan_name": "400100_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Federal", "plan_name": "400110", "standard_charge_dollar": 202.32, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Federal", "plan_name": "400110_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Cigna Healthsprings Ffs", "plan_name": "500064", "standard_charge_dollar": 156.98, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Conseco", "plan_name": "500302", "standard_charge_dollar": 156.98, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Humana Ffs 61101", "plan_name": "500006", "standard_charge_dollar": 156.98, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Medicare A", "plan_name": "100100", "standard_charge_dollar": 156.98, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Medicare A", "plan_name": "100500", "standard_charge_dollar": 156.98, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Medicare Part B Only", "plan_name": "100300", "standard_charge_dollar": 156.98, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Medicare Railroad", "plan_name": "100103", "standard_charge_dollar": 156.98, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Ms Physicians Care N", "plan_name": "714210", "standard_charge_dollar": 196.22, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Peoples Hlth Ffs 72126", "plan_name": "500019", "standard_charge_dollar": 156.98, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Uhc/Secure Horizons", "plan_name": "500449", "standard_charge_dollar": 156.98, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "United Health Care/", "plan_name": "500292", "standard_charge_dollar": 177.38, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "United Healthcare", "plan_name": "750104", "standard_charge_dollar": 177.38, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "United Healthcare Ba", "plan_name": "750090", "standard_charge_dollar": 177.38, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "United Healthcare Me", "plan_name": "501310", "standard_charge_dollar": 156.98, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Windsor Mcare Extra", "plan_name": "500778", "standard_charge_dollar": 156.98, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." } ] } ] }, { "description": "Rbc pretx incubatj w/enzymes", "code_information": [ { "code": "86971", "type": "CPT" } ], "standard_charges": [ { "gross_charge": 436.89, "minimum": 156.98, "maximum": 202.32, "setting": "both", "payers_information": [ { "payer_name": "Aarp", "plan_name": "500102", "standard_charge_dollar": 156.98, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna", "plan_name": "700700", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna", "plan_name": "700700_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Mcare Ffs 6005", "plan_name": "700703", "standard_charge_dollar": 156.98, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Miscellaneous", "plan_name": "700720", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Miscellaneous", "plan_name": "700720_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Ppo Hmo", "plan_name": "701720", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Ppo Hmo", "plan_name": "701720_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Ambetter 68069", "plan_name": "500516", "standard_charge_dollar": 156.98, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Ms State Emplo", "plan_name": "401457", "standard_charge_dollar": 202.32, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Ms State Emplo", "plan_name": "401457_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Basic Pl", "plan_name": "400100", "standard_charge_dollar": 202.32, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Basic Pl", "plan_name": "400100_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Federal", "plan_name": "400110", "standard_charge_dollar": 202.32, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Federal", "plan_name": "400110_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Cigna Healthsprings Ffs", "plan_name": "500064", "standard_charge_dollar": 156.98, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Conseco", "plan_name": "500302", "standard_charge_dollar": 156.98, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Humana Ffs 61101", "plan_name": "500006", "standard_charge_dollar": 156.98, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Medicare A", "plan_name": "100100", "standard_charge_dollar": 156.98, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Medicare A", "plan_name": "100500", "standard_charge_dollar": 156.98, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Medicare Part B Only", "plan_name": "100300", "standard_charge_dollar": 156.98, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Medicare Railroad", "plan_name": "100103", "standard_charge_dollar": 156.98, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Ms Physicians Care N", "plan_name": "714210", "standard_charge_dollar": 196.22, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Peoples Hlth Ffs 72126", "plan_name": "500019", "standard_charge_dollar": 156.98, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Uhc/Secure Horizons", "plan_name": "500449", "standard_charge_dollar": 156.98, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "United Health Care/", "plan_name": "500292", "standard_charge_dollar": 177.38, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "United Healthcare", "plan_name": "750104", "standard_charge_dollar": 177.38, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "United Healthcare Ba", "plan_name": "750090", "standard_charge_dollar": 177.38, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "United Healthcare Me", "plan_name": "501310", "standard_charge_dollar": 156.98, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Windsor Mcare Extra", "plan_name": "500778", "standard_charge_dollar": 156.98, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." } ] } ] }, { "description": "Blood culture for bacteria", "code_information": [ { "code": "87040", "type": "CPT" } ], "standard_charges": [ { "gross_charge": 100.00, "minimum": 15.48, "maximum": 15.48, "setting": "both", "payers_information": [ { "payer_name": "Aetna", "plan_name": "700700", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna", "plan_name": "700700_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Miscellaneous", "plan_name": "700720", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Miscellaneous", "plan_name": "700720_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Ppo Hmo", "plan_name": "701720", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Ppo Hmo", "plan_name": "701720_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Ms State Emplo", "plan_name": "401457", "standard_charge_dollar": 15.48, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Ms State Emplo", "plan_name": "401457_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Basic Pl", "plan_name": "400100", "standard_charge_dollar": 15.48, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Basic Pl", "plan_name": "400100_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Federal", "plan_name": "400110", "standard_charge_dollar": 15.48, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Federal", "plan_name": "400110_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." } ] } ] }, { "description": "Hc cult blood pediatric", "code_information": [ { "code": "87040", "type": "CPT" } ], "standard_charges": [ { "gross_charge": 100.00, "minimum": 15.48, "maximum": 15.48, "setting": "both", "payers_information": [ { "payer_name": "Aetna", "plan_name": "700700", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna", "plan_name": "700700_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Miscellaneous", "plan_name": "700720", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Miscellaneous", "plan_name": "700720_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Ppo Hmo", "plan_name": "701720", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Ppo Hmo", "plan_name": "701720_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Ms State Emplo", "plan_name": "401457", "standard_charge_dollar": 15.48, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Ms State Emplo", "plan_name": "401457_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Basic Pl", "plan_name": "400100", "standard_charge_dollar": 15.48, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Basic Pl", "plan_name": "400100_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Federal", "plan_name": "400110", "standard_charge_dollar": 15.48, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Federal", "plan_name": "400110_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." } ] } ] }, { "description": "Feces culture aerobic bact", "code_information": [ { "code": "87045", "type": "CPT" } ], "standard_charges": [ { "gross_charge": 91.50, "minimum": 14.15, "maximum": 14.15, "setting": "both", "payers_information": [ { "payer_name": "Aetna", "plan_name": "700700", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna", "plan_name": "700700_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Miscellaneous", "plan_name": "700720", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Miscellaneous", "plan_name": "700720_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Ppo Hmo", "plan_name": "701720", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Ppo Hmo", "plan_name": "701720_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Ms State Emplo", "plan_name": "401457", "standard_charge_dollar": 14.15, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Ms State Emplo", "plan_name": "401457_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Basic Pl", "plan_name": "400100", "standard_charge_dollar": 14.15, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Basic Pl", "plan_name": "400100_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Federal", "plan_name": "400110", "standard_charge_dollar": 14.15, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Federal", "plan_name": "400110_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." } ] } ] }, { "description": "Hc aerob bacteria culture stool", "code_information": [ { "code": "87045", "type": "CPT" } ], "standard_charges": [ { "gross_charge": 91.50, "minimum": 14.15, "maximum": 14.15, "setting": "both", "payers_information": [ { "payer_name": "Aetna", "plan_name": "700700", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna", "plan_name": "700700_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Miscellaneous", "plan_name": "700720", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna 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"401457_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Basic Pl", "plan_name": "400100", "standard_charge_dollar": 14.15, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Basic Pl", "plan_name": "400100_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Federal", "plan_name": "400110", "standard_charge_dollar": 14.15, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Federal", "plan_name": "400110_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." } ] } ] }, { "description": "Hc culture stool vibrio", "code_information": [ { "code": "87046", "type": "CPT" } ], "standard_charges": [ { "gross_charge": 180.00, "minimum": 14.15, "maximum": 14.15, "setting": "both", "payers_information": [ { "payer_name": "Aetna", "plan_name": "700700", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna", "plan_name": "700700_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Miscellaneous", "plan_name": "700720", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Miscellaneous", "plan_name": "700720_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Ppo Hmo", "plan_name": "701720", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Ppo Hmo", "plan_name": "701720_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Ms State Emplo", "plan_name": "401457", "standard_charge_dollar": 14.15, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Ms State Emplo", "plan_name": "401457_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Basic Pl", "plan_name": "400100", "standard_charge_dollar": 14.15, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Basic Pl", "plan_name": "400100_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Federal", "plan_name": "400110", "standard_charge_dollar": 14.15, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Federal", "plan_name": "400110_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." } ] } ] }, { "description": "Stool cultr aerobic bact ea", "code_information": [ { "code": "87046", "type": "CPT" } ], "standard_charges": [ { "gross_charge": 180.00, "minimum": 14.15, "maximum": 14.15, "setting": "both", "payers_information": [ { "payer_name": "Aetna", "plan_name": "700700", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna", "plan_name": "700700_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Miscellaneous", "plan_name": "700720", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Miscellaneous", "plan_name": "700720_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Ppo Hmo", "plan_name": "701720", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Ppo Hmo", "plan_name": "701720_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Ms State Emplo", "plan_name": "401457", "standard_charge_dollar": 14.15, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Ms State Emplo", "plan_name": "401457_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Basic Pl", "plan_name": "400100", "standard_charge_dollar": 14.15, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Basic Pl", "plan_name": "400100_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Federal", "plan_name": "400110", "standard_charge_dollar": 14.15, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Federal", "plan_name": "400110_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." } ] } ] }, { "description": "Culture othr specimn aerobic", "code_information": [ { "code": "87070", "type": "CPT" } ], "standard_charges": [ { "gross_charge": 120.00, "minimum": 12.91, "maximum": 12.91, "setting": "both", "payers_information": [ { "payer_name": "Aetna", "plan_name": "700700", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna", "plan_name": "700700_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Miscellaneous", "plan_name": "700720", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Miscellaneous", "plan_name": "700720_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Ppo Hmo", "plan_name": "701720", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Ppo Hmo", "plan_name": "701720_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Ms State Emplo", "plan_name": "401457", "standard_charge_dollar": 12.91, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Ms State Emplo", "plan_name": "401457_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Basic Pl", "plan_name": "400100", "standard_charge_dollar": 12.91, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Basic Pl", "plan_name": "400100_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Federal", "plan_name": "400110", "standard_charge_dollar": 12.91, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Federal", "plan_name": "400110_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." } ] } ] }, { "description": "Hc culture cath tip", "code_information": [ { "code": "87070", "type": "CPT" } ], "standard_charges": [ { "gross_charge": 120.00, "minimum": 12.91, "maximum": 12.91, "setting": "both", "payers_information": [ { "payer_name": "Aetna", "plan_name": "700700", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna", "plan_name": "700700_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Miscellaneous", "plan_name": "700720", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Miscellaneous", "plan_name": "700720_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Ppo Hmo", "plan_name": "701720", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Ppo Hmo", "plan_name": "701720_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Ms State Emplo", "plan_name": "401457", "standard_charge_dollar": 12.91, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Ms State Emplo", "plan_name": "401457_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Basic Pl", "plan_name": "400100", "standard_charge_dollar": 12.91, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Basic Pl", "plan_name": "400100_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Federal", "plan_name": "400110", "standard_charge_dollar": 12.91, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Federal", "plan_name": "400110_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." } ] } ] }, { "description": "Cultr bacteria except blood", "code_information": [ { "code": "87075", "type": "CPT" } ], "standard_charges": [ { "gross_charge": 82.32, "minimum": 14.19, "maximum": 14.19, "setting": "both", "payers_information": [ { "payer_name": "Aetna", "plan_name": "700700", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna", "plan_name": "700700_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Miscellaneous", "plan_name": "700720", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Miscellaneous", "plan_name": "700720_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Ppo Hmo", "plan_name": "701720", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Ppo Hmo", "plan_name": "701720_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Ms State Emplo", "plan_name": "401457", "standard_charge_dollar": 14.19, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Ms State Emplo", "plan_name": "401457_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Basic Pl", "plan_name": "400100", "standard_charge_dollar": 14.19, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Basic Pl", "plan_name": "400100_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Federal", "plan_name": "400110", "standard_charge_dollar": 14.19, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Federal", "plan_name": "400110_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." } ] } ] }, { "description": "Hc culture anaerobic", "code_information": [ { "code": "87075", "type": "CPT" } ], "standard_charges": [ { "gross_charge": 82.32, "minimum": 14.19, "maximum": 14.19, "setting": "both", "payers_information": [ { "payer_name": "Aetna", "plan_name": "700700", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna", "plan_name": "700700_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Miscellaneous", "plan_name": "700720", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Miscellaneous", "plan_name": "700720_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Ppo Hmo", "plan_name": "701720", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Ppo Hmo", "plan_name": "701720_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Ms State Emplo", "plan_name": "401457", "standard_charge_dollar": 14.19, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Ms State Emplo", "plan_name": "401457_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Basic Pl", "plan_name": "400100", "standard_charge_dollar": 14.19, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Basic Pl", "plan_name": "400100_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Federal", "plan_name": "400110", "standard_charge_dollar": 14.19, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Federal", "plan_name": "400110_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." } ] } ] }, { "description": "Culture anaerobe ident each", "code_information": [ { "code": "87076", "type": "CPT" } ], "standard_charges": [ { "gross_charge": 336.26, "minimum": 10.48, "maximum": 10.48, "setting": "both", "payers_information": [ { "payer_name": "Aetna", "plan_name": "700700", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna", "plan_name": "700700_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Miscellaneous", "plan_name": "700720", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Miscellaneous", "plan_name": "700720_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Ppo Hmo", "plan_name": "701720", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Ppo Hmo", "plan_name": "701720_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Ms State Emplo", "plan_name": "401457", "standard_charge_dollar": 10.48, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Ms State Emplo", "plan_name": "401457_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Basic Pl", "plan_name": "400100", "standard_charge_dollar": 10.48, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Basic Pl", "plan_name": "400100_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Federal", "plan_name": "400110", "standard_charge_dollar": 10.48, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Federal", "plan_name": "400110_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." } ] } ] }, { "description": "Hc anaerobic isolate id", "code_information": [ { "code": "87076", "type": "CPT" } ], "standard_charges": [ { "gross_charge": 336.26, "minimum": 10.48, "maximum": 10.48, "setting": "both", "payers_information": [ { "payer_name": "Aetna", "plan_name": "700700", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna", "plan_name": "700700_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Miscellaneous", "plan_name": "700720", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Miscellaneous", "plan_name": "700720_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Ppo Hmo", "plan_name": "701720", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Ppo Hmo", "plan_name": "701720_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Ms State Emplo", "plan_name": "401457", "standard_charge_dollar": 10.48, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Ms State Emplo", "plan_name": "401457_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Basic Pl", "plan_name": "400100", "standard_charge_dollar": 10.48, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Basic Pl", "plan_name": "400100_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Federal", "plan_name": "400110", "standard_charge_dollar": 10.48, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Federal", "plan_name": "400110_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." } ] } ] }, { "description": "Culture aerobic identify", "code_information": [ { "code": "87077", "type": "CPT" } ], "standard_charges": [ { "gross_charge": 87.00, "minimum": 10.48, "maximum": 10.48, "setting": "both", "payers_information": [ { "payer_name": "Aetna", "plan_name": "700700", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna", "plan_name": "700700_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Miscellaneous", "plan_name": "700720", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Miscellaneous", "plan_name": "700720_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Ppo Hmo", "plan_name": "701720", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Ppo Hmo", "plan_name": "701720_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Ms State Emplo", "plan_name": "401457", "standard_charge_dollar": 10.48, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Ms State Emplo", "plan_name": "401457_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Basic Pl", "plan_name": "400100", "standard_charge_dollar": 10.48, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Basic Pl", "plan_name": "400100_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Federal", "plan_name": "400110", "standard_charge_dollar": 10.48, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Federal", "plan_name": "400110_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." } ] } ] }, { "description": "Hc bacterial id panel (gid)", "code_information": [ { "code": "87077", "type": "CPT" } ], "standard_charges": [ { "gross_charge": 87.00, "minimum": 10.48, "maximum": 10.48, "setting": "both", "payers_information": [ { "payer_name": "Aetna", "plan_name": "700700", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna", "plan_name": "700700_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Miscellaneous", "plan_name": "700720", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Miscellaneous", "plan_name": "700720_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Ppo Hmo", "plan_name": "701720", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Ppo Hmo", "plan_name": "701720_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Ms State Emplo", "plan_name": "401457", "standard_charge_dollar": 10.48, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Ms State Emplo", "plan_name": "401457_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Basic Pl", "plan_name": "400100", "standard_charge_dollar": 10.48, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Basic Pl", "plan_name": "400100_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Federal", "plan_name": "400110", "standard_charge_dollar": 10.48, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Federal", "plan_name": "400110_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." } ] } ] }, { "description": "Culture screen only", "code_information": [ { "code": "87081", "type": "CPT" } ], "standard_charges": [ { "gross_charge": 80.00, "minimum": 9.93, "maximum": 9.93, "setting": "both", "payers_information": [ { "payer_name": "Aetna", "plan_name": "700700", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna", "plan_name": "700700_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Miscellaneous", "plan_name": "700720", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Miscellaneous", "plan_name": "700720_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Ppo Hmo", "plan_name": "701720", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Ppo Hmo", "plan_name": "701720_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Ms State Emplo", "plan_name": "401457", "standard_charge_dollar": 9.93, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Ms State Emplo", "plan_name": "401457_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Basic Pl", "plan_name": "400100", "standard_charge_dollar": 9.93, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Basic Pl", "plan_name": "400100_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Federal", "plan_name": "400110", "standard_charge_dollar": 9.93, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Federal", "plan_name": "400110_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." } ] } ] }, { "description": "Hc culture mrsa", "code_information": [ { "code": "87081", "type": "CPT" } ], "standard_charges": [ { "gross_charge": 80.00, "minimum": 9.93, "maximum": 9.93, "setting": "both", "payers_information": [ { "payer_name": "Aetna", "plan_name": "700700", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna", "plan_name": "700700_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Miscellaneous", "plan_name": "700720", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Miscellaneous", "plan_name": "700720_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Ppo Hmo", "plan_name": "701720", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Ppo Hmo", "plan_name": "701720_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Ms State Emplo", "plan_name": "401457", "standard_charge_dollar": 9.93, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Ms State Emplo", "plan_name": "401457_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Basic Pl", "plan_name": "400100", "standard_charge_dollar": 9.93, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Basic Pl", "plan_name": "400100_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Federal", "plan_name": "400110", "standard_charge_dollar": 9.93, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Federal", "plan_name": "400110_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." } ] } ] }, { "description": "Hc bact culture urine quan ct", "code_information": [ { "code": "87086", "type": "CPT" } ], "standard_charges": [ { "gross_charge": 75.00, "minimum": 12.10, "maximum": 12.10, "setting": "both", "payers_information": [ { "payer_name": "Aetna", "plan_name": "700700", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna", "plan_name": "700700_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Miscellaneous", "plan_name": "700720", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Miscellaneous", "plan_name": "700720_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Ppo Hmo", "plan_name": "701720", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Ppo Hmo", "plan_name": "701720_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Ms State Emplo", "plan_name": "401457", "standard_charge_dollar": 12.10, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Ms State Emplo", "plan_name": "401457_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Basic Pl", "plan_name": "400100", "standard_charge_dollar": 12.10, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Basic Pl", "plan_name": "400100_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Federal", "plan_name": "400110", "standard_charge_dollar": 12.10, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Federal", "plan_name": "400110_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." } ] } ] }, { "description": "Urine culture/colony count", "code_information": [ { "code": "87086", "type": "CPT" } ], "standard_charges": [ { "gross_charge": 75.00, "minimum": 12.10, "maximum": 12.10, "setting": "both", "payers_information": [ { "payer_name": "Aetna", "plan_name": "700700", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna", "plan_name": "700700_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Miscellaneous", "plan_name": "700720", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Miscellaneous", "plan_name": "700720_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Ppo Hmo", "plan_name": "701720", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Ppo Hmo", "plan_name": "701720_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Ms State Emplo", "plan_name": "401457", "standard_charge_dollar": 12.10, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Ms State Emplo", "plan_name": "401457_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Basic Pl", "plan_name": "400100", "standard_charge_dollar": 12.10, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Basic Pl", "plan_name": "400100_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Federal", "plan_name": "400110", "standard_charge_dollar": 12.10, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Federal", "plan_name": "400110_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." } ] } ] }, { "description": "Hc urine bacterial culture single test", "code_information": [ { "code": "87088", "type": "CPT" } ], "standard_charges": [ { "gross_charge": 75.00, "minimum": 12.13, "maximum": 12.13, "setting": "both", "payers_information": [ { "payer_name": "Aetna", "plan_name": "700700", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna", "plan_name": "700700_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Miscellaneous", "plan_name": "700720", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Miscellaneous", "plan_name": "700720_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Ppo Hmo", "plan_name": "701720", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Ppo Hmo", "plan_name": "701720_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Ms State Emplo", "plan_name": "401457", "standard_charge_dollar": 12.13, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Ms State Emplo", "plan_name": "401457_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Basic Pl", "plan_name": "400100", "standard_charge_dollar": 12.13, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Basic Pl", "plan_name": "400100_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Federal", "plan_name": "400110", "standard_charge_dollar": 12.13, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Federal", "plan_name": "400110_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." } ] } ] }, { "description": "Urine bacteria culture", "code_information": [ { "code": "87088", "type": "CPT" } ], "standard_charges": [ { "gross_charge": 75.00, "minimum": 12.13, "maximum": 12.13, "setting": "both", "payers_information": [ { "payer_name": "Aetna", "plan_name": "700700", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna", "plan_name": "700700_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Miscellaneous", "plan_name": "700720", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Miscellaneous", "plan_name": "700720_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Ppo Hmo", "plan_name": "701720", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Ppo Hmo", "plan_name": "701720_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Ms State Emplo", "plan_name": "401457", "standard_charge_dollar": 12.13, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Ms State Emplo", "plan_name": "401457_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Basic Pl", "plan_name": "400100", "standard_charge_dollar": 12.13, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Basic Pl", "plan_name": "400100_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Federal", "plan_name": "400110", "standard_charge_dollar": 12.13, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Federal", "plan_name": "400110_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." } ] } ] }, { "description": "Hc cult fungus w/ p id skin hr nl", "code_information": [ { "code": "87101", "type": "CPT" } ], "standard_charges": [ { "gross_charge": 56.22, "minimum": 11.55, "maximum": 11.55, "setting": "both", "payers_information": [ { "payer_name": "Aetna", "plan_name": "700700", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna", "plan_name": "700700_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Miscellaneous", "plan_name": "700720", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Miscellaneous", "plan_name": "700720_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Ppo Hmo", "plan_name": "701720", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Ppo Hmo", "plan_name": "701720_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Ms State Emplo", "plan_name": "401457", "standard_charge_dollar": 11.55, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Ms State Emplo", "plan_name": "401457_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Basic Pl", "plan_name": "400100", "standard_charge_dollar": 11.55, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Basic Pl", "plan_name": "400100_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Federal", "plan_name": "400110", "standard_charge_dollar": 11.55, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Federal", "plan_name": "400110_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." } ] } ] }, { "description": "Skin fungi culture", "code_information": [ { "code": "87101", "type": "CPT" } ], "standard_charges": [ { "gross_charge": 56.22, "minimum": 11.55, "maximum": 11.55, "setting": "both", "payers_information": [ { "payer_name": "Aetna", "plan_name": "700700", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna", "plan_name": "700700_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Miscellaneous", "plan_name": "700720", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Miscellaneous", "plan_name": "700720_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Ppo Hmo", "plan_name": "701720", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Ppo Hmo", "plan_name": "701720_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Ms State Emplo", "plan_name": "401457", "standard_charge_dollar": 11.55, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Ms State Emplo", "plan_name": "401457_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Basic Pl", "plan_name": "400100", "standard_charge_dollar": 11.55, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Basic Pl", "plan_name": "400100_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Federal", "plan_name": "400110", "standard_charge_dollar": 11.55, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Federal", "plan_name": "400110_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." } ] } ] }, { "description": "Fungus isolation culture", "code_information": [ { "code": "87102", "type": "CPT" } ], "standard_charges": [ { "gross_charge": 100.00, "minimum": 12.60, "maximum": 12.60, "setting": "both", "payers_information": [ { "payer_name": "Aetna", "plan_name": "700700", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna", "plan_name": "700700_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Miscellaneous", "plan_name": "700720", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Miscellaneous", "plan_name": "700720_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Ppo Hmo", "plan_name": "701720", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Ppo Hmo", "plan_name": "701720_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Ms State Emplo", "plan_name": "401457", "standard_charge_dollar": 12.60, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Ms State Emplo", "plan_name": "401457_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Basic Pl", "plan_name": "400100", "standard_charge_dollar": 12.60, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Basic Pl", "plan_name": "400100_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Federal", "plan_name": "400110", "standard_charge_dollar": 12.60, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Federal", "plan_name": "400110_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." } ] } ] }, { "description": "Hc fungus culture not blood", "code_information": [ { "code": "87102", "type": "CPT" } ], "standard_charges": [ { "gross_charge": 100.00, "minimum": 12.60, "maximum": 12.60, "setting": "both", "payers_information": [ { "payer_name": "Aetna", "plan_name": "700700", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna", "plan_name": "700700_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Miscellaneous", "plan_name": "700720", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Miscellaneous", "plan_name": "700720_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Ppo Hmo", "plan_name": "701720", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Ppo Hmo", "plan_name": "701720_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Ms State Emplo", "plan_name": "401457", "standard_charge_dollar": 12.60, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Ms State Emplo", "plan_name": "401457_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Basic Pl", "plan_name": "400100", "standard_charge_dollar": 12.60, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Basic Pl", "plan_name": "400100_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Federal", "plan_name": "400110", "standard_charge_dollar": 12.60, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Federal", "plan_name": "400110_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." } ] } ] }, { "description": "Fungi identification yeast", "code_information": [ { "code": 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data to calculate allowed amounts." } ] } ] }, { "description": "Hc culture refer id fungus yeast", "code_information": [ { "code": "87106", "type": "CPT" } ], "standard_charges": [ { "gross_charge": 190.00, "minimum": 15.48, "maximum": 15.48, "setting": "both", "payers_information": [ { "payer_name": "Aetna", "plan_name": "700700", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna", "plan_name": "700700_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Miscellaneous", "plan_name": "700720", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Miscellaneous", "plan_name": "700720_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Ppo Hmo", "plan_name": "701720", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Ppo Hmo", "plan_name": "701720_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Ms State Emplo", "plan_name": "401457", "standard_charge_dollar": 15.48, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Ms State Emplo", "plan_name": "401457_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Basic Pl", "plan_name": "400100", "standard_charge_dollar": 15.48, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Basic Pl", "plan_name": "400100_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Federal", "plan_name": "400110", "standard_charge_dollar": 15.48, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Federal", "plan_name": "400110_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." } ] } ] }, { "description": "Hc arthropod identification mbug", "code_information": [ { "code": "87168", "type": "CPT" } ], "standard_charges": [ { "gross_charge": 119.20, "minimum": 6.40, "maximum": 6.40, "setting": "both", "payers_information": [ { "payer_name": "Aetna", "plan_name": "700700", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna", "plan_name": "700700_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Miscellaneous", "plan_name": "700720", "standard_charge_percentage": 80.0, 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"methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Ms State Emplo", "plan_name": "401457_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Basic Pl", "plan_name": "400100", "standard_charge_dollar": 6.40, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Basic Pl", "plan_name": "400100_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Federal", "plan_name": "400110", "standard_charge_dollar": 6.40, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Federal", "plan_name": "400110_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." } ] } ] }, { "description": "Macroscopic exam arthropod", "code_information": [ { "code": "87168", "type": "CPT" } ], "standard_charges": [ { "gross_charge": 119.20, "minimum": 6.40, "maximum": 6.40, "setting": "both", "payers_information": [ { "payer_name": "Aetna", "plan_name": "700700", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna", "plan_name": "700700_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient 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calculate allowed amounts." }, { "payer_name": "Bc/Bs Ms State Emplo", "plan_name": "401457", "standard_charge_dollar": 6.40, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Ms State Emplo", "plan_name": "401457_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Basic Pl", "plan_name": "400100", "standard_charge_dollar": 6.40, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Basic Pl", "plan_name": "400100_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Federal", "plan_name": "400110", "standard_charge_dollar": 6.40, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Federal", "plan_name": "400110_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." } ] } ] }, { "description": "Hc macroscopic examination parasite", "code_information": [ { "code": "87169", "type": "CPT" } ], "standard_charges": [ { "gross_charge": 119.20, "minimum": 6.40, "maximum": 6.40, "setting": "both", "payers_information": [ { "payer_name": "Aetna", "plan_name": "700700", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna", "plan_name": "700700_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Miscellaneous", "plan_name": "700720", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Miscellaneous", "plan_name": "700720_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Ppo Hmo", "plan_name": "701720", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Ppo Hmo", "plan_name": "701720_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Ms State Emplo", "plan_name": "401457", "standard_charge_dollar": 6.40, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Ms State Emplo", "plan_name": "401457_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Basic Pl", "plan_name": "400100", "standard_charge_dollar": 6.40, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Basic Pl", "plan_name": "400100_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Federal", "plan_name": "400110", "standard_charge_dollar": 6.40, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Federal", "plan_name": "400110_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." } ] } ] }, { "description": "Macroscopic exam parasite", "code_information": [ { "code": "87169", "type": "CPT" } ], "standard_charges": [ { "gross_charge": 119.20, "minimum": 6.40, "maximum": 6.40, "setting": "both", "payers_information": [ { "payer_name": "Aetna", "plan_name": "700700", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna", "plan_name": "700700_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Miscellaneous", "plan_name": "700720", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Miscellaneous", "plan_name": "700720_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Ppo Hmo", "plan_name": "701720", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Ppo Hmo", "plan_name": "701720_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Ms State Emplo", "plan_name": "401457", "standard_charge_dollar": 6.40, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Ms State Emplo", "plan_name": "401457_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Basic Pl", "plan_name": "400100", "standard_charge_dollar": 6.40, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Basic Pl", "plan_name": "400100_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Federal", "plan_name": "400110", "standard_charge_dollar": 6.40, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Federal", "plan_name": "400110_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." } ] } ] }, { "description": "Hc ova & parasites dir smr w id", "code_information": [ { "code": "87177", "type": "CPT" } ], "standard_charges": [ { "gross_charge": 41.01, "minimum": 13.33, "maximum": 13.33, "setting": "both", "payers_information": [ { "payer_name": "Aetna", "plan_name": "700700", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna", "plan_name": "700700_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Miscellaneous", "plan_name": "700720", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Miscellaneous", "plan_name": "700720_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Ppo Hmo", "plan_name": "701720", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Ppo Hmo", "plan_name": "701720_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Ms State Emplo", "plan_name": "401457", "standard_charge_dollar": 13.33, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Ms State Emplo", "plan_name": "401457_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Basic Pl", "plan_name": "400100", "standard_charge_dollar": 13.33, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Basic Pl", "plan_name": "400100_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Federal", "plan_name": "400110", "standard_charge_dollar": 13.33, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Federal", "plan_name": "400110_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." } ] } ] }, { "description": "Ova and parasites smears", "code_information": [ { "code": "87177", "type": "CPT" } ], "standard_charges": [ { "gross_charge": 41.01, "minimum": 13.33, "maximum": 13.33, "setting": "both", "payers_information": [ { "payer_name": "Aetna", "plan_name": "700700", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna", "plan_name": "700700_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Miscellaneous", "plan_name": "700720", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Miscellaneous", "plan_name": "700720_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Ppo Hmo", "plan_name": "701720", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Ppo Hmo", "plan_name": "701720_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Ms State Emplo", "plan_name": "401457", "standard_charge_dollar": 13.33, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Ms State Emplo", "plan_name": "401457_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Basic Pl", "plan_name": "400100", "standard_charge_dollar": 13.33, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Basic Pl", "plan_name": "400100_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Federal", "plan_name": "400110", "standard_charge_dollar": 13.33, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Federal", "plan_name": "400110_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." } ] } ] }, { "description": "Hc mic- susceptibility aerobic mayo only", "code_information": [ { "code": "87186", "type": "CPT" } ], "standard_charges": [ { "gross_charge": 130.82, "minimum": 12.96, "maximum": 12.96, "setting": "both", "payers_information": [ { "payer_name": "Aetna", "plan_name": "700700", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna", "plan_name": "700700_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Miscellaneous", "plan_name": "700720", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Miscellaneous", "plan_name": "700720_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Ppo Hmo", "plan_name": "701720", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Ppo Hmo", "plan_name": "701720_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Ms State Emplo", "plan_name": "401457", "standard_charge_dollar": 12.96, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Ms State Emplo", "plan_name": "401457_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Basic Pl", "plan_name": "400100", "standard_charge_dollar": 12.96, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Basic Pl", "plan_name": "400100_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Federal", "plan_name": "400110", "standard_charge_dollar": 12.96, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Federal", "plan_name": "400110_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." } ] } ] }, { "description": "Microbe susceptible mic", "code_information": [ { "code": "87186", "type": "CPT" } ], "standard_charges": [ { "gross_charge": 130.82, "minimum": 12.96, "maximum": 12.96, "setting": "both", "payers_information": [ { "payer_name": "Aetna", "plan_name": "700700", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna", "plan_name": "700700_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Miscellaneous", "plan_name": "700720", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Miscellaneous", "plan_name": "700720_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Ppo Hmo", "plan_name": "701720", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Ppo Hmo", "plan_name": "701720_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Ms State Emplo", "plan_name": "401457", "standard_charge_dollar": 12.96, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Ms State Emplo", "plan_name": "401457_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Basic Pl", "plan_name": "400100", "standard_charge_dollar": 12.96, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Basic Pl", "plan_name": "400100_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Federal", "plan_name": "400110", "standard_charge_dollar": 12.96, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Federal", "plan_name": "400110_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." } ] } ] }, { "description": "Hc gram stain", "code_information": [ { "code": "87205", "type": "CPT" } ], "standard_charges": [ { "gross_charge": 75.00, "minimum": 6.40, "maximum": 6.40, "setting": "both", "payers_information": [ { "payer_name": "Aetna", "plan_name": "700700", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna", "plan_name": "700700_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Miscellaneous", "plan_name": "700720", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Miscellaneous", "plan_name": "700720_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Ppo Hmo", "plan_name": "701720", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Ppo Hmo", "plan_name": "701720_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Ms State Emplo", "plan_name": "401457", "standard_charge_dollar": 6.40, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Ms State Emplo", "plan_name": "401457_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Basic Pl", "plan_name": "400100", "standard_charge_dollar": 6.40, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Basic Pl", "plan_name": "400100_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Federal", "plan_name": "400110", "standard_charge_dollar": 6.40, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Federal", "plan_name": "400110_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." } ] } ] }, { "description": "Smear gram stain", "code_information": [ { "code": "87205", "type": "CPT" } ], "standard_charges": [ { "gross_charge": 75.00, "minimum": 6.40, "maximum": 6.40, "setting": "both", "payers_information": [ { "payer_name": "Aetna", "plan_name": "700700", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna", "plan_name": "700700_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Miscellaneous", "plan_name": "700720", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Miscellaneous", "plan_name": "700720_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Ppo Hmo", "plan_name": "701720", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Ppo Hmo", "plan_name": "701720_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Ms State Emplo", "plan_name": "401457", "standard_charge_dollar": 6.40, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Ms State Emplo", "plan_name": "401457_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Basic Pl", "plan_name": "400100", "standard_charge_dollar": 6.40, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Basic Pl", "plan_name": "400100_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Federal", "plan_name": "400110", "standard_charge_dollar": 6.40, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Federal", "plan_name": "400110_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." } ] } ] }, { "description": "Hc afb smear mayo", "code_information": [ { "code": "87206", "type": "CPT" } ], "standard_charges": [ { "gross_charge": 45.18, "minimum": 8.06, "maximum": 8.06, "setting": "both", "payers_information": [ { "payer_name": "Aetna", "plan_name": "700700", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna", "plan_name": "700700_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Miscellaneous", "plan_name": "700720", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Miscellaneous", "plan_name": "700720_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Ppo Hmo", "plan_name": "701720", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Ppo Hmo", "plan_name": "701720_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Ms State Emplo", "plan_name": "401457", "standard_charge_dollar": 8.06, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Ms State Emplo", "plan_name": "401457_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Basic Pl", "plan_name": "400100", "standard_charge_dollar": 8.06, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Basic Pl", "plan_name": "400100_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Federal", "plan_name": "400110", "standard_charge_dollar": 8.06, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Federal", "plan_name": "400110_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." } ] } ] }, { "description": "Smear fluorescent/acid stai", "code_information": [ { "code": "87206", "type": "CPT" } ], "standard_charges": [ { "gross_charge": 45.18, "minimum": 8.06, "maximum": 8.06, "setting": "both", "payers_information": [ { "payer_name": "Aetna", "plan_name": "700700", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna", "plan_name": "700700_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Miscellaneous", "plan_name": "700720", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Miscellaneous", "plan_name": "700720_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Ppo Hmo", "plan_name": "701720", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Ppo Hmo", "plan_name": "701720_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Ms State Emplo", "plan_name": "401457", "standard_charge_dollar": 8.06, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Ms State Emplo", "plan_name": "401457_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Basic Pl", "plan_name": "400100", "standard_charge_dollar": 8.06, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Basic Pl", "plan_name": "400100_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Federal", "plan_name": "400110", "standard_charge_dollar": 8.06, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Federal", "plan_name": "400110_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." } ] } ] }, { "description": "Hc smear complex stain", "code_information": [ { "code": "87209", "type": "CPT" } ], "standard_charges": [ { "gross_charge": 55.22, "minimum": 26.94, "maximum": 26.94, "setting": "both", "payers_information": [ { "payer_name": "Aetna", "plan_name": "700700", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna", "plan_name": "700700_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Miscellaneous", "plan_name": "700720", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Miscellaneous", "plan_name": "700720_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Ppo Hmo", "plan_name": "701720", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Ppo Hmo", "plan_name": "701720_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Ms State Emplo", "plan_name": "401457", "standard_charge_dollar": 26.94, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Ms State Emplo", "plan_name": "401457_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Basic Pl", "plan_name": "400100", "standard_charge_dollar": 26.94, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Basic Pl", "plan_name": "400100_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Federal", "plan_name": "400110", "standard_charge_dollar": 26.94, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Federal", "plan_name": "400110_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." } ] } ] }, { "description": "Smear complex stain", "code_information": [ { "code": "87209", "type": "CPT" } ], "standard_charges": [ { "gross_charge": 55.22, "minimum": 26.94, "maximum": 26.94, "setting": "both", "payers_information": [ { "payer_name": "Aetna", "plan_name": "700700", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna", "plan_name": "700700_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Miscellaneous", "plan_name": "700720", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Miscellaneous", "plan_name": "700720_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Ppo Hmo", "plan_name": "701720", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Ppo Hmo", "plan_name": "701720_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Ms State Emplo", "plan_name": "401457", "standard_charge_dollar": 26.94, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Ms State Emplo", "plan_name": "401457_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Basic Pl", "plan_name": "400100", "standard_charge_dollar": 26.94, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Basic Pl", "plan_name": "400100_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Federal", "plan_name": "400110", "standard_charge_dollar": 26.94, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Federal", "plan_name": "400110_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." } ] } ] }, { "description": "Hc smear infectious wet mount", "code_information": [ { "code": "87210", "type": "CPT" } ], "standard_charges": [ { "gross_charge": 30.00, "minimum": 6.40, "maximum": 6.40, "setting": "both", "payers_information": [ { "payer_name": "Aetna", "plan_name": "700700", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna", "plan_name": "700700_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Miscellaneous", "plan_name": "700720", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Miscellaneous", "plan_name": "700720_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Ppo Hmo", "plan_name": "701720", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Ppo Hmo", "plan_name": "701720_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Ms State Emplo", "plan_name": "401457", "standard_charge_dollar": 6.40, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Ms State Emplo", "plan_name": "401457_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Basic Pl", "plan_name": "400100", "standard_charge_dollar": 6.40, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Basic Pl", "plan_name": "400100_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Federal", "plan_name": "400110", "standard_charge_dollar": 6.40, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Federal", "plan_name": "400110_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." } ] } ] }, { "description": "Smear wet mount saline/ink", "code_information": [ { "code": "87210", "type": "CPT" } ], "standard_charges": [ { "gross_charge": 30.00, "minimum": 6.40, "maximum": 6.40, "setting": "both", "payers_information": [ { "payer_name": "Aetna", "plan_name": "700700", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna", "plan_name": "700700_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Miscellaneous", "plan_name": "700720", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Miscellaneous", "plan_name": "700720_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Ppo Hmo", "plan_name": "701720", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Ppo Hmo", "plan_name": "701720_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Ms State Emplo", "plan_name": "401457", "standard_charge_dollar": 6.40, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Ms State Emplo", "plan_name": "401457_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Basic Pl", "plan_name": "400100", "standard_charge_dollar": 6.40, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Basic Pl", "plan_name": "400100_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Federal", "plan_name": "400110", "standard_charge_dollar": 6.40, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Federal", "plan_name": "400110_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." } ] } ] }, { "description": "Hc smear infectious wet mount", "code_information": [ { "code": "87210", "type": "CPT" } ], "standard_charges": [ { "gross_charge": 30.00, "minimum": 24.00, "maximum": 25.50, "setting": "both", "payers_information": [ { "payer_name": "Aetna", "plan_name": "700700", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "modifiers": "QW", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna", "plan_name": "700700_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Miscellaneous", "plan_name": "700720", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Miscellaneous", "plan_name": "700720_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Ppo Hmo", "plan_name": "701720", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Ppo Hmo", "plan_name": "701720_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Ms State Emplo", "plan_name": "401457", "standard_charge_percentage": 0.80, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Ms State Emplo", "plan_name": "401457_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Basic Pl", "plan_name": "400100", "standard_charge_percentage": 0.85, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Basic Pl", "plan_name": "400100_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Federal", "plan_name": "400110", "standard_charge_percentage": 0.85, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Federal", "plan_name": "400110_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." } ] } ] }, { "description": "Hc koh prep skin hair nails", "code_information": [ { "code": "87220", "type": "CPT" } ], "standard_charges": [ { "gross_charge": 45.50, "minimum": 6.40, "maximum": 6.40, "setting": "both", "payers_information": [ { "payer_name": "Aetna", "plan_name": "700700", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna", "plan_name": "700700_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Miscellaneous", "plan_name": "700720", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Miscellaneous", "plan_name": "700720_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Ppo Hmo", "plan_name": "701720", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Ppo Hmo", "plan_name": "701720_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Ms State Emplo", "plan_name": "401457", "standard_charge_dollar": 6.40, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Ms State Emplo", "plan_name": "401457_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Basic Pl", "plan_name": "400100", "standard_charge_dollar": 6.40, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Basic Pl", "plan_name": "400100_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Federal", "plan_name": "400110", "standard_charge_dollar": 6.40, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Federal", "plan_name": "400110_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." } ] } ] }, { "description": "Tissue exam for fungi", "code_information": [ { "code": "87220", "type": "CPT" } ], "standard_charges": [ { "gross_charge": 45.50, "minimum": 6.40, "maximum": 6.40, "setting": "both", "payers_information": [ { "payer_name": "Aetna", "plan_name": "700700", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna", "plan_name": "700700_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Miscellaneous", "plan_name": "700720", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Miscellaneous", "plan_name": "700720_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Ppo Hmo", "plan_name": "701720", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Ppo Hmo", "plan_name": "701720_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Ms State Emplo", "plan_name": "401457", "standard_charge_dollar": 6.40, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Ms State Emplo", "plan_name": "401457_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Basic Pl", "plan_name": "400100", "standard_charge_dollar": 6.40, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Basic Pl", "plan_name": "400100_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Federal", "plan_name": "400110", "standard_charge_dollar": 6.40, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Federal", "plan_name": "400110_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." } ] } ] }, { "description": "Aspergillus ag ia", "code_information": [ { "code": "87305", "type": "CPT" } ], "standard_charges": [ { "gross_charge": 139.30, "minimum": 17.96, "maximum": 17.96, "setting": "both", "payers_information": [ { "payer_name": "Aetna", "plan_name": "700700", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna", "plan_name": "700700_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Miscellaneous", "plan_name": "700720", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Miscellaneous", "plan_name": "700720_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Ppo Hmo", "plan_name": "701720", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Ppo Hmo", "plan_name": "701720_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Ms State Emplo", "plan_name": "401457", "standard_charge_dollar": 17.96, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Ms State Emplo", "plan_name": "401457_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Basic Pl", "plan_name": "400100", "standard_charge_dollar": 17.96, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Basic Pl", "plan_name": "400100_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Federal", "plan_name": "400110", "standard_charge_dollar": 17.96, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Federal", "plan_name": "400110_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." } ] } ] }, { "description": "Hc aspergillus ag ai", "code_information": [ { "code": "87305", "type": "CPT" } ], "standard_charges": [ { "gross_charge": 139.30, "minimum": 17.96, "maximum": 17.96, "setting": "both", "payers_information": [ { "payer_name": "Aetna", "plan_name": "700700", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna", "plan_name": "700700_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Miscellaneous", "plan_name": "700720", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Miscellaneous", "plan_name": "700720_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Ppo Hmo", "plan_name": "701720", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Ppo Hmo", "plan_name": "701720_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Ms State Emplo", "plan_name": "401457", "standard_charge_dollar": 17.96, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Ms State Emplo", "plan_name": "401457_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Basic Pl", "plan_name": "400100", "standard_charge_dollar": 17.96, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Basic Pl", "plan_name": "400100_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Federal", "plan_name": "400110", "standard_charge_dollar": 17.96, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Federal", "plan_name": "400110_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." } ] } ] }, { "description": "Clostridium ag ia", "code_information": [ { "code": "87324", "type": "CPT" } ], "standard_charges": [ { "gross_charge": 85.00, "minimum": 17.96, "maximum": 17.96, "setting": "both", "payers_information": [ { "payer_name": "Aetna", "plan_name": "700700", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna", "plan_name": "700700_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Miscellaneous", "plan_name": "700720", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Miscellaneous", "plan_name": "700720_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Ppo Hmo", "plan_name": "701720", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Ppo Hmo", "plan_name": "701720_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Ms State Emplo", "plan_name": "401457", "standard_charge_dollar": 17.96, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Ms State Emplo", "plan_name": "401457_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Basic Pl", "plan_name": "400100", "standard_charge_dollar": 17.96, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Basic Pl", "plan_name": "400100_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Federal", "plan_name": "400110", "standard_charge_dollar": 17.96, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Federal", "plan_name": "400110_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." } ] } ] }, { "description": "Hc c. difficile toxin", "code_information": [ { "code": "87324", "type": "CPT" } ], "standard_charges": [ { "gross_charge": 85.00, "minimum": 17.96, "maximum": 17.96, "setting": "both", "payers_information": [ { "payer_name": "Aetna", "plan_name": "700700", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna", "plan_name": "700700_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Miscellaneous", "plan_name": "700720", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Miscellaneous", "plan_name": "700720_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Ppo Hmo", "plan_name": "701720", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Ppo Hmo", "plan_name": "701720_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Ms State Emplo", "plan_name": "401457", "standard_charge_dollar": 17.96, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Ms State Emplo", "plan_name": "401457_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Basic Pl", "plan_name": "400100", "standard_charge_dollar": 17.96, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Basic Pl", "plan_name": "400100_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Federal", "plan_name": "400110", "standard_charge_dollar": 17.96, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Federal", "plan_name": "400110_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." } ] } ] }, { "description": "Cryptosporidium ag ia", "code_information": [ { "code": "87328", "type": "CPT" } ], "standard_charges": [ { "gross_charge": 41.46, "minimum": 17.96, "maximum": 17.96, "setting": "both", "payers_information": [ { "payer_name": "Aetna", "plan_name": "700700", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna", "plan_name": "700700_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Miscellaneous", "plan_name": "700720", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Miscellaneous", "plan_name": "700720_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Ppo Hmo", "plan_name": "701720", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Ppo Hmo", "plan_name": "701720_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Ms State Emplo", "plan_name": "401457", "standard_charge_dollar": 17.96, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Ms State Emplo", "plan_name": "401457_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Basic Pl", "plan_name": "400100", "standard_charge_dollar": 17.96, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Basic Pl", "plan_name": "400100_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Federal", "plan_name": "400110", "standard_charge_dollar": 17.96, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Federal", "plan_name": "400110_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." } ] } ] }, { "description": "Hc cryptosporidum ag ai", "code_information": [ { "code": "87328", "type": "CPT" } ], "standard_charges": [ { "gross_charge": 41.46, "minimum": 17.96, "maximum": 17.96, "setting": "both", "payers_information": [ { "payer_name": "Aetna", "plan_name": "700700", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna", "plan_name": "700700_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Miscellaneous", "plan_name": "700720", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Miscellaneous", "plan_name": "700720_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Ppo Hmo", "plan_name": "701720", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Ppo Hmo", "plan_name": "701720_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Ms State Emplo", "plan_name": "401457", "standard_charge_dollar": 17.96, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Ms State Emplo", "plan_name": "401457_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Basic Pl", "plan_name": "400100", "standard_charge_dollar": 17.96, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Basic Pl", "plan_name": "400100_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Federal", "plan_name": "400110", "standard_charge_dollar": 17.96, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Federal", "plan_name": "400110_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." } ] } ] }, { "description": "Giardia ag ia", "code_information": [ { "code": "87329", "type": "CPT" } ], "standard_charges": [ { "gross_charge": 40.00, "minimum": 17.96, "maximum": 17.96, "setting": "both", "payers_information": [ { "payer_name": "Aetna", "plan_name": "700700", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna", "plan_name": "700700_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Miscellaneous", "plan_name": "700720", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Miscellaneous", "plan_name": "700720_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Ppo Hmo", "plan_name": "701720", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Ppo Hmo", "plan_name": "701720_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Ms State Emplo", "plan_name": "401457", "standard_charge_dollar": 17.96, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Ms State Emplo", "plan_name": "401457_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Basic Pl", "plan_name": "400100", "standard_charge_dollar": 17.96, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Basic Pl", "plan_name": "400100_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Federal", "plan_name": "400110", "standard_charge_dollar": 17.96, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Federal", "plan_name": "400110_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." } ] } ] }, { "description": "Hc giardia ag ai", "code_information": [ { "code": "87329", "type": "CPT" } ], "standard_charges": [ { "gross_charge": 40.00, "minimum": 17.96, "maximum": 17.96, "setting": "both", "payers_information": [ { "payer_name": "Aetna", "plan_name": "700700", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna", "plan_name": "700700_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Miscellaneous", "plan_name": "700720", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Miscellaneous", "plan_name": "700720_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Ppo Hmo", "plan_name": "701720", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Ppo Hmo", "plan_name": "701720_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Ms State Emplo", "plan_name": "401457", "standard_charge_dollar": 17.96, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Ms State Emplo", "plan_name": "401457_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Basic Pl", "plan_name": "400100", "standard_charge_dollar": 17.96, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Basic Pl", "plan_name": "400100_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Federal", "plan_name": "400110", "standard_charge_dollar": 17.96, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Federal", "plan_name": "400110_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." } ] } ] }, { "description": "Hc hep b surface ag", "code_information": [ { "code": "87340", "type": "CPT" } ], "standard_charges": [ { "gross_charge": 46.00, "minimum": 13.90, "maximum": 13.90, "setting": "both", "payers_information": [ { "payer_name": "Aetna", "plan_name": "700700", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna", "plan_name": "700700_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Miscellaneous", "plan_name": "700720", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Miscellaneous", "plan_name": "700720_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Ppo Hmo", "plan_name": "701720", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Ppo Hmo", "plan_name": "701720_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Ms State Emplo", "plan_name": "401457", "standard_charge_dollar": 13.90, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Ms State Emplo", "plan_name": "401457_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Basic Pl", "plan_name": "400100", "standard_charge_dollar": 13.90, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Basic Pl", "plan_name": "400100_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Federal", "plan_name": "400110", "standard_charge_dollar": 13.90, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Federal", "plan_name": "400110_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." } ] } ] }, { "description": "Hepatitis b surface ag ia", "code_information": [ { "code": "87340", "type": "CPT" } ], "standard_charges": [ { "gross_charge": 46.00, "minimum": 13.90, "maximum": 13.90, "setting": "both", "payers_information": [ { "payer_name": "Aetna", "plan_name": "700700", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna", "plan_name": "700700_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Miscellaneous", "plan_name": "700720", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Miscellaneous", "plan_name": "700720_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Ppo Hmo", "plan_name": "701720", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Ppo Hmo", "plan_name": "701720_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Ms State Emplo", "plan_name": "401457", "standard_charge_dollar": 13.90, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Ms State Emplo", "plan_name": "401457_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Basic Pl", "plan_name": "400100", "standard_charge_dollar": 13.90, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Basic Pl", "plan_name": "400100_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Federal", "plan_name": "400110", "standard_charge_dollar": 13.90, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Federal", "plan_name": "400110_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." } ] } ] }, { "description": "Hc hep b surface ag neutralztn", "code_information": [ { "code": "87341", "type": "CPT" } ], "standard_charges": [ { "gross_charge": 117.12, "minimum": 13.90, "maximum": 13.90, "setting": "both", "payers_information": [ { "payer_name": "Aetna", "plan_name": "700700", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna", "plan_name": "700700_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Miscellaneous", "plan_name": "700720", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Miscellaneous", "plan_name": "700720_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Ppo Hmo", "plan_name": "701720", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Ppo Hmo", "plan_name": "701720_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Ms State Emplo", "plan_name": "401457", "standard_charge_dollar": 13.90, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Ms State Emplo", "plan_name": "401457_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Basic Pl", "plan_name": "400100", "standard_charge_dollar": 13.90, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Basic Pl", "plan_name": "400100_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Federal", "plan_name": "400110", "standard_charge_dollar": 13.90, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Federal", "plan_name": "400110_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." } ] } ] }, { "description": "Hepatitis b surface ag ia", "code_information": [ { "code": "87341", "type": "CPT" } ], "standard_charges": [ { "gross_charge": 117.12, "minimum": 13.90, "maximum": 13.90, "setting": "both", "payers_information": [ { "payer_name": "Aetna", "plan_name": "700700", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna", "plan_name": "700700_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Miscellaneous", "plan_name": "700720", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Miscellaneous", "plan_name": "700720_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Ppo Hmo", "plan_name": "701720", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Ppo Hmo", "plan_name": "701720_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Ms State Emplo", "plan_name": "401457", "standard_charge_dollar": 13.90, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Ms State Emplo", "plan_name": "401457_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Basic Pl", "plan_name": "400100", "standard_charge_dollar": 13.90, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Basic Pl", "plan_name": "400100_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Federal", "plan_name": "400110", "standard_charge_dollar": 13.90, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Federal", "plan_name": "400110_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." } ] } ] }, { "description": "Hc hep be ag", "code_information": [ { "code": "87350", "type": "CPT" } ], "standard_charges": [ { "gross_charge": 77.96, "minimum": 17.27, "maximum": 17.27, "setting": "both", "payers_information": [ { "payer_name": "Aetna", "plan_name": "700700", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna", "plan_name": "700700_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Miscellaneous", "plan_name": "700720", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Miscellaneous", "plan_name": "700720_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Ppo Hmo", "plan_name": "701720", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Ppo Hmo", "plan_name": "701720_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Ms State Emplo", "plan_name": "401457", "standard_charge_dollar": 17.27, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Ms State Emplo", "plan_name": "401457_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Basic Pl", "plan_name": "400100", "standard_charge_dollar": 17.27, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Basic Pl", "plan_name": "400100_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Federal", "plan_name": "400110", "standard_charge_dollar": 17.27, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Federal", "plan_name": "400110_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." } ] } ] }, { "description": "Hepatitis be ag ia", "code_information": [ { "code": "87350", "type": "CPT" } ], "standard_charges": [ { "gross_charge": 77.96, "minimum": 17.27, "maximum": 17.27, "setting": "both", "payers_information": [ { "payer_name": "Aetna", "plan_name": "700700", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna", "plan_name": "700700_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Miscellaneous", "plan_name": "700720", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Miscellaneous", "plan_name": "700720_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Ppo Hmo", "plan_name": "701720", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Ppo Hmo", "plan_name": "701720_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Ms State Emplo", "plan_name": "401457", "standard_charge_dollar": 17.27, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Ms State Emplo", "plan_name": "401457_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Basic Pl", "plan_name": "400100", "standard_charge_dollar": 17.27, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Basic Pl", "plan_name": "400100_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Federal", "plan_name": "400110", "standard_charge_dollar": 17.27, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Federal", "plan_name": "400110_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." } ] } ] }, { "description": "Hc hiv-1 ag w/hiv 1 & hiv 2 ab", "code_information": [ { "code": "87389", "type": "CPT" } ], "standard_charges": [ { "gross_charge": 84.00, "minimum": 36.08, "maximum": 36.08, "setting": "both", "payers_information": [ { "payer_name": "Aetna", "plan_name": "700700", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna", "plan_name": "700700_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Miscellaneous", "plan_name": "700720", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Miscellaneous", "plan_name": "700720_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Ppo Hmo", "plan_name": "701720", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Ppo Hmo", "plan_name": "701720_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Ms State Emplo", "plan_name": "401457", "standard_charge_dollar": 36.08, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Ms State Emplo", "plan_name": "401457_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Basic Pl", "plan_name": "400100", "standard_charge_dollar": 36.08, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Basic Pl", "plan_name": "400100_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Federal", "plan_name": "400110", "standard_charge_dollar": 36.08, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Federal", "plan_name": "400110_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." } ] } ] }, { "description": "Hiv-1 ag w/hiv-1 & hiv-2 ab", "code_information": [ { "code": "87389", "type": "CPT" } ], "standard_charges": [ { "gross_charge": 84.00, "minimum": 36.08, "maximum": 36.08, "setting": "both", "payers_information": [ { "payer_name": "Aetna", "plan_name": "700700", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna", "plan_name": "700700_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Miscellaneous", "plan_name": "700720", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Miscellaneous", "plan_name": "700720_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Ppo Hmo", "plan_name": "701720", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Ppo Hmo", "plan_name": "701720_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Ms State Emplo", "plan_name": "401457", "standard_charge_dollar": 36.08, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Ms State Emplo", "plan_name": "401457_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Basic Pl", "plan_name": "400100", "standard_charge_dollar": 36.08, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Basic Pl", "plan_name": "400100_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Federal", "plan_name": "400110", "standard_charge_dollar": 36.08, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Federal", "plan_name": "400110_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." } ] } ] }, { "description": "Ag detect nos ia mult", "code_information": [ { "code": "87449", "type": "CPT" } ], "standard_charges": [ { "gross_charge": 328.00, "minimum": 17.96, "maximum": 17.96, "setting": "both", "payers_information": [ { "payer_name": "Aetna", "plan_name": "700700", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna", "plan_name": "700700_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Miscellaneous", "plan_name": "700720", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Miscellaneous", "plan_name": "700720_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Ppo Hmo", "plan_name": "701720", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Ppo Hmo", "plan_name": "701720_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Ms State Emplo", "plan_name": "401457", "standard_charge_dollar": 17.96, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Ms State Emplo", "plan_name": "401457_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Basic Pl", "plan_name": "400100", "standard_charge_dollar": 17.96, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Basic Pl", "plan_name": "400100_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Federal", "plan_name": "400110", "standard_charge_dollar": 17.96, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Federal", "plan_name": "400110_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." } ] } ] }, { "description": "Hc blastomyces antigen", "code_information": [ { "code": "87449", "type": "CPT" } ], "standard_charges": [ { "gross_charge": 328.00, "minimum": 17.96, "maximum": 17.96, "setting": "both", "payers_information": [ { "payer_name": "Aetna", "plan_name": "700700", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna", "plan_name": "700700_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Miscellaneous", "plan_name": "700720", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit 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"payer_name": "Aetna Ppo Hmo", "plan_name": "701720", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Ppo Hmo", "plan_name": "701720_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Ms State Emplo", "plan_name": "401457", "standard_charge_dollar": 52.58, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Ms State Emplo", "plan_name": "401457_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Basic Pl", "plan_name": "400100", "standard_charge_dollar": 52.58, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Basic Pl", "plan_name": "400100_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Federal", "plan_name": "400110", "standard_charge_dollar": 52.58, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Federal", "plan_name": "400110_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." } ] } ] }, { "description": "Hc cmv pcr fluid", "code_information": [ { "code": "87496", 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"additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Basic Pl", "plan_name": "400100", "standard_charge_dollar": 52.58, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Basic Pl", "plan_name": "400100_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Federal", "plan_name": "400110", "standard_charge_dollar": 52.58, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Federal", "plan_name": "400110_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit 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"payer_name": "Aetna Miscellaneous", "plan_name": "700720_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Ppo Hmo", "plan_name": "701720", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Ppo Hmo", "plan_name": "701720_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Ms State Emplo", "plan_name": "401457", "standard_charge_dollar": 52.59, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Ms State Emplo", "plan_name": "401457_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Basic Pl", "plan_name": "400100", "standard_charge_dollar": 52.59, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Basic Pl", "plan_name": "400100_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Federal", "plan_name": "400110", "standard_charge_dollar": 52.59, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Federal", "plan_name": "400110_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." } ] } ] }, { "description": "Hc cmv pcr detection plasma", "code_information": [ { "code": "87497", "type": "CPT" } ], "standard_charges": [ { "gross_charge": 350.00, "minimum": 52.59, "maximum": 52.59, "setting": "both", "payers_information": [ { "payer_name": "Aetna", "plan_name": "700700", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna", "plan_name": "700700_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Miscellaneous", "plan_name": "700720", "standard_charge_percentage": 80.0, 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{ "payer_name": "Bc/Bs Of Ms Federal", "plan_name": "400110", "standard_charge_dollar": 120.44, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Federal", "plan_name": "400110_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." } ] } ] }, { "description": "Influenza dna amp probe", "code_information": [ { "code": "87502", "type": "CPT" } ], "standard_charges": [ { "gross_charge": 105.00, "minimum": 120.44, "maximum": 120.44, "setting": "both", "payers_information": [ { "payer_name": "Aetna", "plan_name": "700700", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna", "plan_name": "700700_1", 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"standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Ms State Emplo", "plan_name": "401457", "standard_charge_dollar": 120.44, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Ms State Emplo", "plan_name": "401457_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Basic Pl", "plan_name": "400100", "standard_charge_dollar": 120.44, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Basic Pl", "plan_name": "400100_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Federal", "plan_name": "400110", "standard_charge_dollar": 120.44, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Federal", "plan_name": "400110_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." } ] } ] }, { "description": "Hc gastrointestinal panel (gi panel)", "code_information": [ { "code": "87507", "type": "CPT" } ], "standard_charges": [ { "gross_charge": 907.60, "minimum": 624.53, "maximum": 624.53, "setting": "both", "payers_information": [ { "payer_name": "Aetna", "plan_name": "700700", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent 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to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Basic Pl", "plan_name": "400100_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Federal", "plan_name": "400110", "standard_charge_dollar": 624.53, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Federal", "plan_name": "400110_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." } ] } ] }, { "description": "Iadna-dna/rna probe tq 12-25", "code_information": [ { "code": "87507", "type": "CPT" } ], "standard_charges": [ { "gross_charge": 907.60, "minimum": 624.53, "maximum": 624.53, "setting": "both", "payers_information": [ { "payer_name": "Aetna", "plan_name": "700700", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna", "plan_name": "700700_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Miscellaneous", "plan_name": "700720", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Miscellaneous", "plan_name": "700720_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Ppo Hmo", "plan_name": "701720", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Ppo Hmo", "plan_name": "701720_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Ms State Emplo", "plan_name": "401457", "standard_charge_dollar": 624.53, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Ms State Emplo", "plan_name": "401457_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Basic Pl", "plan_name": "400100", "standard_charge_dollar": 624.53, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Basic Pl", "plan_name": "400100_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Federal", "plan_name": "400110", "standard_charge_dollar": 624.53, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Federal", "plan_name": "400110_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." } ] } ] }, { "description": "Hc hep b na quant", "code_information": [ { "code": "87517", "type": "CPT" } ], "standard_charges": [ { "gross_charge": 295.00, "minimum": 52.59, "maximum": 52.59, "setting": "both", "payers_information": [ { "payer_name": "Aetna", "plan_name": "700700", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna", "plan_name": "700700_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Miscellaneous", "plan_name": "700720", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Miscellaneous", "plan_name": "700720_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent 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"additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Basic Pl", "plan_name": "400100", "standard_charge_dollar": 52.59, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Basic Pl", "plan_name": "400100_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Federal", "plan_name": "400110", "standard_charge_dollar": 52.59, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Federal", "plan_name": "400110_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." } ] } ] }, { "description": "Hepatitis b dna quant", "code_information": [ { "code": "87517", "type": "CPT" } ], "standard_charges": [ { "gross_charge": 295.00, "minimum": 52.59, "maximum": 52.59, "setting": "both", "payers_information": [ { "payer_name": "Aetna", "plan_name": "700700", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna", "plan_name": "700700_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Miscellaneous", "plan_name": "700720", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Miscellaneous", "plan_name": "700720_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Ppo Hmo", "plan_name": "701720", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Ppo Hmo", "plan_name": "701720_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Ms State Emplo", "plan_name": "401457", "standard_charge_dollar": 52.59, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Ms State Emplo", "plan_name": "401457_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Basic Pl", "plan_name": "400100", "standard_charge_dollar": 52.59, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Basic Pl", "plan_name": "400100_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Federal", "plan_name": "400110", "standard_charge_dollar": 52.59, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Federal", "plan_name": "400110_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." } ] } ] }, { "description": "Hc hcv rna by pcr quantitative", "code_information": [ { "code": "87522", "type": "CPT" } ], "standard_charges": [ { "gross_charge": 225.00, "minimum": 52.59, "maximum": 52.59, "setting": "both", "payers_information": [ { "payer_name": "Aetna", "plan_name": "700700", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna", "plan_name": "700700_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Miscellaneous", "plan_name": "700720", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Miscellaneous", "plan_name": "700720_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Ppo Hmo", "plan_name": "701720", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Ppo Hmo", "plan_name": "701720_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Ms State Emplo", "plan_name": "401457", "standard_charge_dollar": 52.59, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Ms State Emplo", "plan_name": "401457_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Basic Pl", "plan_name": "400100", "standard_charge_dollar": 52.59, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Basic Pl", "plan_name": "400100_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Federal", "plan_name": "400110", "standard_charge_dollar": 52.59, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Federal", "plan_name": "400110_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." } ] } ] }, { "description": "Hepatitis c revrs trnscrpj", "code_information": [ { "code": "87522", "type": "CPT" } ], "standard_charges": [ { "gross_charge": 225.00, "minimum": 52.59, "maximum": 52.59, "setting": "both", "payers_information": [ { "payer_name": "Aetna", "plan_name": "700700", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna", "plan_name": "700700_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Miscellaneous", "plan_name": "700720", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Miscellaneous", "plan_name": "700720_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Ppo Hmo", "plan_name": "701720", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Ppo Hmo", "plan_name": "701720_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Ms State Emplo", "plan_name": "401457", "standard_charge_dollar": 52.59, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Ms State Emplo", "plan_name": "401457_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Basic Pl", "plan_name": "400100", "standard_charge_dollar": 52.59, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Basic Pl", "plan_name": "400100_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Federal", "plan_name": "400110", "standard_charge_dollar": 52.59, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Federal", "plan_name": "400110_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." } ] } ] }, { "description": "Hc herpes simplx virus 1 dna", "code_information": [ { "code": "87529", "type": "CPT" } ], "standard_charges": [ { "gross_charge": 105.29, "minimum": 52.58, "maximum": 52.58, "setting": "both", "payers_information": [ { "payer_name": "Aetna", "plan_name": "700700", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna", "plan_name": "700700_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Miscellaneous", "plan_name": "700720", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Miscellaneous", "plan_name": "700720_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Ppo Hmo", "plan_name": "701720", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Ppo Hmo", "plan_name": "701720_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Ms State Emplo", "plan_name": "401457", "standard_charge_dollar": 52.58, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Ms State Emplo", "plan_name": "401457_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Basic Pl", "plan_name": "400100", "standard_charge_dollar": 52.58, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Basic Pl", "plan_name": "400100_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Federal", "plan_name": "400110", "standard_charge_dollar": 52.58, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Federal", "plan_name": "400110_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." } ] } ] }, { "description": "Hsv dna amp probe", "code_information": [ { "code": "87529", "type": "CPT" } ], "standard_charges": [ { "gross_charge": 105.29, "minimum": 52.58, "maximum": 52.58, "setting": "both", "payers_information": [ { "payer_name": "Aetna", "plan_name": "700700", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna", "plan_name": "700700_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Miscellaneous", "plan_name": "700720", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Miscellaneous", "plan_name": "700720_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Ppo Hmo", "plan_name": "701720", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Ppo Hmo", "plan_name": "701720_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Ms State Emplo", "plan_name": "401457", "standard_charge_dollar": 52.58, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Ms State Emplo", "plan_name": "401457_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Basic Pl", "plan_name": "400100", "standard_charge_dollar": 52.58, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Basic Pl", "plan_name": "400100_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Federal", "plan_name": "400110", "standard_charge_dollar": 52.58, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Federal", "plan_name": "400110_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." } ] } ] }, { "description": "Hc hiv 1 rna probe", "code_information": [ { "code": "87535", "type": "CPT" } ], "standard_charges": [ { "gross_charge": 105.16, "minimum": 52.58, "maximum": 52.58, "setting": "both", "payers_information": [ { "payer_name": "Aetna", "plan_name": "700700", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna", "plan_name": "700700_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Miscellaneous", "plan_name": "700720", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Miscellaneous", "plan_name": "700720_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Ppo Hmo", "plan_name": "701720", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Ppo Hmo", "plan_name": "701720_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Ms State Emplo", "plan_name": "401457", "standard_charge_dollar": 52.58, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Ms State Emplo", "plan_name": "401457_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Basic Pl", "plan_name": "400100", "standard_charge_dollar": 52.58, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Basic Pl", "plan_name": "400100_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Federal", "plan_name": "400110", "standard_charge_dollar": 52.58, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Federal", "plan_name": "400110_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." } ] } ] }, { "description": "Hiv-1 probe&reverse trnscrpj", "code_information": [ { "code": "87535", "type": "CPT" } ], "standard_charges": [ { "gross_charge": 105.16, "minimum": 52.58, "maximum": 52.58, "setting": "both", "payers_information": [ { "payer_name": "Aetna", "plan_name": "700700", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna", "plan_name": "700700_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Miscellaneous", "plan_name": "700720", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Miscellaneous", "plan_name": "700720_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Ppo Hmo", "plan_name": "701720", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Ppo Hmo", "plan_name": "701720_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Ms State Emplo", "plan_name": "401457", "standard_charge_dollar": 52.58, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Ms State Emplo", "plan_name": "401457_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Basic Pl", "plan_name": "400100", "standard_charge_dollar": 52.58, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Basic Pl", "plan_name": "400100_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Federal", "plan_name": "400110", "standard_charge_dollar": 52.58, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Federal", "plan_name": "400110_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." } ] } ] }, { "description": "Hc quant rna pcr", "code_information": [ { "code": "87536", "type": "CPT" } ], "standard_charges": [ { "gross_charge": 200.00, "minimum": 120.44, "maximum": 120.44, "setting": "both", "payers_information": [ { "payer_name": "Aetna", "plan_name": "700700", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna", "plan_name": "700700_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Miscellaneous", "plan_name": "700720", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Miscellaneous", "plan_name": "700720_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Ppo Hmo", "plan_name": "701720", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Ppo Hmo", "plan_name": "701720_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Ms State Emplo", "plan_name": "401457", "standard_charge_dollar": 120.44, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Ms State Emplo", "plan_name": "401457_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Basic Pl", "plan_name": "400100", "standard_charge_dollar": 120.44, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Basic Pl", "plan_name": "400100_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Federal", "plan_name": "400110", "standard_charge_dollar": 120.44, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Federal", "plan_name": "400110_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." } ] } ] }, { "description": "Hiv-1 quant&revrse trnscrpj", "code_information": [ { "code": "87536", "type": "CPT" } ], "standard_charges": [ { "gross_charge": 200.00, "minimum": 120.44, "maximum": 120.44, "setting": "both", "payers_information": [ { "payer_name": "Aetna", "plan_name": "700700", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna", "plan_name": "700700_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Miscellaneous", "plan_name": "700720", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Miscellaneous", "plan_name": "700720_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Ppo Hmo", "plan_name": "701720", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Ppo Hmo", "plan_name": "701720_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Ms State Emplo", "plan_name": "401457", "standard_charge_dollar": 120.44, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Ms State Emplo", "plan_name": "401457_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Basic Pl", "plan_name": "400100", "standard_charge_dollar": 120.44, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Basic Pl", "plan_name": "400100_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Federal", "plan_name": "400110", "standard_charge_dollar": 120.44, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Federal", "plan_name": "400110_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." } ] } ] }, { "description": "Hc hiv 2 rna probe", "code_information": [ { "code": "87538", "type": "CPT" } ], "standard_charges": [ { "gross_charge": 105.16, "minimum": 52.58, "maximum": 52.58, "setting": "both", "payers_information": [ { "payer_name": "Aetna", "plan_name": "700700", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna", "plan_name": "700700_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Miscellaneous", "plan_name": "700720", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Miscellaneous", "plan_name": "700720_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Ppo Hmo", "plan_name": "701720", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Ppo Hmo", "plan_name": "701720_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Ms State Emplo", "plan_name": "401457", "standard_charge_dollar": 52.58, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Ms State Emplo", "plan_name": "401457_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Basic Pl", "plan_name": "400100", "standard_charge_dollar": 52.58, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Basic Pl", "plan_name": "400100_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Federal", "plan_name": "400110", "standard_charge_dollar": 52.58, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Federal", "plan_name": "400110_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." } ] } ] }, { "description": "Hiv-2 probe&revrse trnscripj", "code_information": [ { "code": "87538", "type": "CPT" } ], "standard_charges": [ { "gross_charge": 105.16, "minimum": 52.58, "maximum": 52.58, "setting": "both", "payers_information": [ { "payer_name": "Aetna", "plan_name": "700700", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna", "plan_name": "700700_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Miscellaneous", "plan_name": "700720", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Miscellaneous", "plan_name": "700720_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Ppo Hmo", "plan_name": "701720", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Ppo Hmo", "plan_name": "701720_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Ms State Emplo", "plan_name": "401457", "standard_charge_dollar": 52.58, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Ms State Emplo", "plan_name": "401457_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Basic Pl", "plan_name": "400100", "standard_charge_dollar": 52.58, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Basic Pl", "plan_name": "400100_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Federal", "plan_name": "400110", "standard_charge_dollar": 52.58, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Federal", "plan_name": "400110_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." } ] } ] }, { "description": "Hc genprobe-gc", "code_information": [ { "code": "87591", "type": "CPT" } ], "standard_charges": [ { "gross_charge": 105.27, "minimum": 52.58, "maximum": 52.58, "setting": "both", "payers_information": [ { "payer_name": "Aetna", "plan_name": "700700", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna", "plan_name": "700700_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Miscellaneous", "plan_name": "700720", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Miscellaneous", "plan_name": "700720_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Ppo Hmo", "plan_name": "701720", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Ppo Hmo", "plan_name": "701720_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Ms State Emplo", "plan_name": "401457", "standard_charge_dollar": 52.58, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Ms State Emplo", "plan_name": "401457_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Basic Pl", "plan_name": "400100", "standard_charge_dollar": 52.58, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Basic Pl", "plan_name": "400100_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Federal", "plan_name": "400110", "standard_charge_dollar": 52.58, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Federal", "plan_name": "400110_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." } ] } ] }, { "description": "N.gonorrhoeae dna amp prob", "code_information": [ { "code": "87591", "type": "CPT" } ], "standard_charges": [ { "gross_charge": 105.27, "minimum": 52.58, "maximum": 52.58, "setting": "both", "payers_information": [ { "payer_name": "Aetna", "plan_name": "700700", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna", "plan_name": "700700_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Miscellaneous", "plan_name": "700720", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Miscellaneous", "plan_name": "700720_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Ppo Hmo", "plan_name": "701720", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Ppo Hmo", "plan_name": "701720_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Ms State Emplo", "plan_name": "401457", "standard_charge_dollar": 52.58, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Ms State Emplo", "plan_name": "401457_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Basic Pl", "plan_name": "400100", "standard_charge_dollar": 52.58, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Basic Pl", "plan_name": "400100_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Federal", "plan_name": "400110", "standard_charge_dollar": 52.58, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Federal", "plan_name": "400110_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." } ] } ] }, { "description": "Hc resp syncytial virus amplified probe t", "code_information": [ { "code": "87634", "type": "CPT" } ], 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charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Ppo Hmo", "plan_name": "701720", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Ppo Hmo", "plan_name": "701720_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Ms State Emplo", "plan_name": "401457", "standard_charge_percentage": 0.80, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Ms State Emplo", "plan_name": "401457_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Basic Pl", "plan_name": "400100", "standard_charge_percentage": 0.85, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Basic Pl", "plan_name": "400100_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Federal", "plan_name": "400110", "standard_charge_percentage": 0.85, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Federal", "plan_name": "400110_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." } ] } ] }, { "description": "Rsv dna/rna amp probe", "code_information": [ { "code": "87634", "type": "CPT" } ], "standard_charges": [ { "gross_charge": 85.00, "minimum": 68.00, "maximum": 72.25, "setting": "both", "payers_information": [ { "payer_name": "Aetna", "plan_name": "700700", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna", "plan_name": "700700_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Miscellaneous", "plan_name": "700720", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Miscellaneous", "plan_name": "700720_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Ppo Hmo", "plan_name": "701720", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Ppo Hmo", "plan_name": "701720_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Ms State Emplo", "plan_name": "401457", "standard_charge_percentage": 0.80, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Ms State Emplo", "plan_name": "401457_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Basic Pl", "plan_name": "400100", "standard_charge_percentage": 0.85, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Basic Pl", "plan_name": "400100_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Federal", "plan_name": "400110", "standard_charge_percentage": 0.85, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Federal", "plan_name": "400110_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." } ] } ] }, { "description": "Hc resp syncytial virus amplified probe t", "code_information": [ { "code": "87634", "type": "CPT" } ], "standard_charges": [ { "gross_charge": 85.00, "minimum": 68.00, "maximum": 72.25, "setting": "both", "payers_information": [ { "payer_name": "Aetna", "plan_name": "700700", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "modifiers": "QW", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna", "plan_name": "700700_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Miscellaneous", "plan_name": "700720", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Miscellaneous", "plan_name": "700720_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Ppo Hmo", "plan_name": "701720", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Ppo Hmo", "plan_name": "701720_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Ms State Emplo", "plan_name": "401457", "standard_charge_percentage": 0.80, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Ms State Emplo", "plan_name": "401457_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Basic Pl", "plan_name": "400100", "standard_charge_percentage": 0.85, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Basic Pl", "plan_name": "400100_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Federal", "plan_name": "400110", "standard_charge_percentage": 0.85, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Federal", "plan_name": "400110_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." } ] } ] }, { "description": "Hc covid-19 qual pcr", "code_information": [ { "code": "87635", "type": "CPT" } ], "standard_charges": [ { "gross_charge": 175.00, "minimum": 51.31, "maximum": 148.75, "setting": "both", "payers_information": [ { "payer_name": "Aarp", "plan_name": "500102", "standard_charge_dollar": 51.31, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna", "plan_name": "700700", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna", "plan_name": "700700_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Mcare Ffs 6005", "plan_name": "700703", "standard_charge_dollar": 51.31, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Miscellaneous", "plan_name": "700720", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Miscellaneous", "plan_name": "700720_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Ppo Hmo", "plan_name": "701720", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Ppo Hmo", "plan_name": "701720_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Ambetter 68069", "plan_name": "500516", "standard_charge_dollar": 51.31, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Ms State Emplo", "plan_name": "401457", "standard_charge_percentage": 0.80, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Ms State Emplo", "plan_name": "401457_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Basic Pl", "plan_name": "400100", "standard_charge_percentage": 0.85, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Basic Pl", "plan_name": "400100_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Federal", "plan_name": "400110", "standard_charge_percentage": 0.85, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Federal", "plan_name": "400110_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Cigna Healthsprings Ffs", "plan_name": "500064", "standard_charge_dollar": 51.31, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Conseco", "plan_name": "500302", "standard_charge_dollar": 51.31, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Humana Ffs 61101", "plan_name": "500006", "standard_charge_dollar": 51.31, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Medicare A", "plan_name": "100100", "standard_charge_dollar": 51.31, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Medicare A", "plan_name": "100500", "standard_charge_dollar": 51.31, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Medicare Part B Only", "plan_name": "100300", "standard_charge_dollar": 51.31, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Medicare Railroad", "plan_name": "100103", "standard_charge_dollar": 51.31, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Ms Physicians Care N", "plan_name": "714210", "standard_charge_dollar": 64.14, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Peoples Hlth Ffs 72126", "plan_name": "500019", "standard_charge_dollar": 51.31, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Uhc/Secure Horizons", "plan_name": "500449", "standard_charge_dollar": 51.31, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "United Health Care/", "plan_name": "500292", "standard_charge_dollar": 57.98, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "United Healthcare", "plan_name": "750104", "standard_charge_dollar": 57.98, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "United Healthcare Ba", "plan_name": "750090", "standard_charge_dollar": 57.98, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "United Healthcare Me", "plan_name": "501310", "standard_charge_dollar": 51.31, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Windsor Mcare Extra", "plan_name": "500778", "standard_charge_dollar": 51.31, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." } ] } ] }, { "description": "Sars-cov-2 covid-19 amp prb", "code_information": [ { "code": "87635", "type": "CPT" } ], "standard_charges": [ { "gross_charge": 175.00, "minimum": 51.31, "maximum": 148.75, "setting": "both", "payers_information": [ { "payer_name": "Aarp", "plan_name": "500102", "standard_charge_dollar": 51.31, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna", "plan_name": "700700", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna", "plan_name": "700700_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Mcare Ffs 6005", "plan_name": "700703", "standard_charge_dollar": 51.31, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Miscellaneous", "plan_name": "700720", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Miscellaneous", "plan_name": "700720_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Ppo Hmo", "plan_name": "701720", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Ppo Hmo", "plan_name": "701720_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Ambetter 68069", "plan_name": "500516", "standard_charge_dollar": 51.31, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Ms State Emplo", "plan_name": "401457", "standard_charge_percentage": 0.80, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Ms State Emplo", "plan_name": "401457_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Basic Pl", "plan_name": "400100", "standard_charge_percentage": 0.85, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Basic Pl", "plan_name": "400100_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Federal", "plan_name": "400110", "standard_charge_percentage": 0.85, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Federal", "plan_name": "400110_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Cigna Healthsprings Ffs", "plan_name": "500064", "standard_charge_dollar": 51.31, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Conseco", "plan_name": "500302", "standard_charge_dollar": 51.31, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Humana Ffs 61101", "plan_name": "500006", "standard_charge_dollar": 51.31, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Medicare A", "plan_name": "100100", "standard_charge_dollar": 51.31, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Medicare A", "plan_name": "100500", "standard_charge_dollar": 51.31, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Medicare Part B Only", "plan_name": "100300", "standard_charge_dollar": 51.31, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Medicare Railroad", "plan_name": "100103", "standard_charge_dollar": 51.31, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Ms Physicians Care N", "plan_name": "714210", "standard_charge_dollar": 64.14, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Peoples Hlth Ffs 72126", "plan_name": "500019", "standard_charge_dollar": 51.31, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Uhc/Secure Horizons", "plan_name": "500449", "standard_charge_dollar": 51.31, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "United Health Care/", "plan_name": "500292", "standard_charge_dollar": 57.98, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "United Healthcare", "plan_name": "750104", "standard_charge_dollar": 57.98, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "United Healthcare Ba", "plan_name": "750090", "standard_charge_dollar": 57.98, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "United Healthcare Me", "plan_name": "501310", "standard_charge_dollar": 51.31, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Windsor Mcare Extra", "plan_name": "500778", "standard_charge_dollar": 51.31, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." } ] } ] }, { "description": "Hc sars-cov-2 covid-19 amp prb", "code_information": [ { "code": "87635", "type": "CPT" } ], "standard_charges": [ { "gross_charge": 175.00, "minimum": 51.31, "maximum": 148.75, "setting": "both", "payers_information": [ { "payer_name": "Aarp", "plan_name": "500102", "standard_charge_dollar": 51.31, "count": "0", "methodology": "fee schedule", "modifiers": "QW", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna", "plan_name": "700700", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna", "plan_name": "700700_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Mcare Ffs 6005", "plan_name": "700703", "standard_charge_dollar": 51.31, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Miscellaneous", "plan_name": "700720", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Miscellaneous", "plan_name": "700720_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Ppo Hmo", "plan_name": "701720", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Ppo Hmo", "plan_name": "701720_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Ambetter 68069", "plan_name": "500516", "standard_charge_dollar": 51.31, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Ms State Emplo", "plan_name": "401457", "standard_charge_percentage": 0.80, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Ms State Emplo", "plan_name": "401457_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Basic Pl", "plan_name": "400100", "standard_charge_percentage": 0.85, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Basic Pl", "plan_name": "400100_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Federal", "plan_name": "400110", "standard_charge_percentage": 0.85, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Federal", "plan_name": "400110_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Cigna Healthsprings Ffs", "plan_name": "500064", "standard_charge_dollar": 51.31, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Conseco", "plan_name": "500302", "standard_charge_dollar": 51.31, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Humana Ffs 61101", "plan_name": "500006", "standard_charge_dollar": 51.31, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Medicare A", "plan_name": "100100", "standard_charge_dollar": 51.31, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Medicare A", "plan_name": "100500", "standard_charge_dollar": 51.31, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Medicare Part B Only", "plan_name": "100300", "standard_charge_dollar": 51.31, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Medicare Railroad", "plan_name": "100103", "standard_charge_dollar": 51.31, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Ms Physicians Care N", "plan_name": "714210", "standard_charge_dollar": 64.14, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Peoples Hlth Ffs 72126", "plan_name": "500019", "standard_charge_dollar": 51.31, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Uhc/Secure Horizons", "plan_name": "500449", "standard_charge_dollar": 51.31, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "United Health Care/", "plan_name": "500292", "standard_charge_dollar": 57.98, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "United Healthcare", "plan_name": "750104", "standard_charge_dollar": 57.98, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "United Healthcare Ba", "plan_name": "750090", "standard_charge_dollar": 57.98, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "United Healthcare Me", "plan_name": "501310", "standard_charge_dollar": 51.31, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Windsor Mcare Extra", "plan_name": "500778", "standard_charge_dollar": 51.31, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." } ] } ] }, { "description": "Hc strep a ampli probe", "code_information": [ { "code": "87651", "type": "CPT" } ], "standard_charges": [ { "gross_charge": 55.00, "minimum": 52.58, "maximum": 52.58, "setting": "both", "payers_information": [ { "payer_name": "Aetna", "plan_name": "700700", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna", "plan_name": "700700_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Miscellaneous", "plan_name": "700720", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Miscellaneous", "plan_name": "700720_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Ppo Hmo", "plan_name": "701720", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Ppo Hmo", "plan_name": "701720_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Ms State Emplo", "plan_name": "401457", "standard_charge_dollar": 52.58, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Ms State Emplo", "plan_name": "401457_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Basic Pl", "plan_name": "400100", "standard_charge_dollar": 52.58, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Basic Pl", "plan_name": "400100_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Federal", "plan_name": "400110", "standard_charge_dollar": 52.58, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Federal", "plan_name": "400110_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." } ] } ] }, { "description": "Strep a dna amp probe", "code_information": [ { "code": "87651", "type": "CPT" } ], "standard_charges": [ { "gross_charge": 55.00, "minimum": 52.58, "maximum": 52.58, "setting": "both", "payers_information": [ { "payer_name": "Aetna", "plan_name": "700700", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna", "plan_name": "700700_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Miscellaneous", "plan_name": "700720", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Miscellaneous", "plan_name": "700720_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Ppo Hmo", "plan_name": "701720", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Ppo Hmo", "plan_name": "701720_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Ms State Emplo", "plan_name": "401457", "standard_charge_dollar": 52.58, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Ms State Emplo", "plan_name": "401457_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Basic Pl", "plan_name": "400100", "standard_charge_dollar": 52.58, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Basic Pl", "plan_name": "400100_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Federal", "plan_name": "400110", "standard_charge_dollar": 52.58, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Federal", "plan_name": "400110_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." } ] } ] }, { "description": "Hc strep a ampli probe", "code_information": [ { "code": "87651", "type": "CPT" } ], "standard_charges": [ { "gross_charge": 55.00, "minimum": 44.00, "maximum": 46.75, "setting": "both", "payers_information": [ { "payer_name": "Aetna", "plan_name": "700700", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "modifiers": "QW", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna", "plan_name": "700700_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Miscellaneous", "plan_name": "700720", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Miscellaneous", "plan_name": "700720_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Ppo Hmo", "plan_name": "701720", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Ppo Hmo", "plan_name": "701720_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Ms State Emplo", "plan_name": "401457", "standard_charge_percentage": 0.80, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Ms State Emplo", "plan_name": "401457_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Basic Pl", "plan_name": "400100", "standard_charge_percentage": 0.85, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Basic Pl", "plan_name": "400100_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Federal", "plan_name": "400110", "standard_charge_percentage": 0.85, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Federal", "plan_name": "400110_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." } ] } ] }, { "description": "Hc genprobe trichomonas", "code_information": [ { "code": "87661", "type": "CPT" } ], "standard_charges": [ { "gross_charge": 150.00, "minimum": 52.58, "maximum": 52.58, "setting": "both", "payers_information": [ { "payer_name": "Aetna", "plan_name": "700700", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna", "plan_name": "700700_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Miscellaneous", "plan_name": "700720", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Miscellaneous", "plan_name": "700720_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Ppo Hmo", "plan_name": "701720", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Ppo Hmo", "plan_name": "701720_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Ms State Emplo", "plan_name": "401457", "standard_charge_dollar": 52.58, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Ms State Emplo", "plan_name": "401457_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Basic Pl", "plan_name": "400100", "standard_charge_dollar": 52.58, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Basic Pl", "plan_name": "400100_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Federal", "plan_name": "400110", "standard_charge_dollar": 52.58, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Federal", "plan_name": "400110_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." } ] } ] }, { "description": "Trichomonas vaginalis amplif", "code_information": [ { "code": "87661", "type": "CPT" } ], "standard_charges": [ { "gross_charge": 150.00, "minimum": 52.58, "maximum": 52.58, "setting": "both", "payers_information": [ { "payer_name": "Aetna", "plan_name": "700700", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna", "plan_name": "700700_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Miscellaneous", "plan_name": "700720", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Miscellaneous", "plan_name": "700720_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Ppo Hmo", "plan_name": "701720", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Ppo Hmo", "plan_name": "701720_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Ms State Emplo", "plan_name": "401457", "standard_charge_dollar": 52.58, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Ms State Emplo", "plan_name": "401457_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Basic Pl", "plan_name": "400100", "standard_charge_dollar": 52.58, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Basic Pl", "plan_name": "400100_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Federal", "plan_name": "400110", "standard_charge_dollar": 52.58, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Federal", "plan_name": "400110_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." } ] } ] }, { "description": "Detect agent nos dna amp", "code_information": [ { "code": "87798", "type": "CPT" } ], "standard_charges": [ { "gross_charge": 675.00, "minimum": 52.58, "maximum": 52.58, "setting": "both", "payers_information": [ { "payer_name": "Aetna", "plan_name": "700700", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna", "plan_name": "700700_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Miscellaneous", "plan_name": "700720", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Miscellaneous", "plan_name": "700720_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Ppo Hmo", "plan_name": "701720", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Ppo Hmo", "plan_name": "701720_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Ms State Emplo", "plan_name": "401457", "standard_charge_dollar": 52.58, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Ms State Emplo", "plan_name": "401457_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Basic Pl", "plan_name": "400100", "standard_charge_dollar": 52.58, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Basic Pl", "plan_name": "400100_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Federal", "plan_name": "400110", "standard_charge_dollar": 52.58, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Federal", "plan_name": "400110_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." } ] } ] }, { "description": "Hc mumps virus rna qual rt-pcr", "code_information": [ { "code": "87798", "type": "CPT" } ], "standard_charges": [ { "gross_charge": 675.00, "minimum": 52.58, "maximum": 52.58, "setting": "both", "payers_information": [ { "payer_name": "Aetna", "plan_name": "700700", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna", "plan_name": "700700_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Miscellaneous", "plan_name": "700720", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Miscellaneous", "plan_name": "700720_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Ppo Hmo", "plan_name": "701720", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Ppo Hmo", "plan_name": "701720_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Ms State Emplo", "plan_name": "401457", "standard_charge_dollar": 52.58, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Ms State Emplo", "plan_name": "401457_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Basic Pl", "plan_name": "400100", "standard_charge_dollar": 52.58, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Basic Pl", "plan_name": "400100_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Federal", "plan_name": "400110", "standard_charge_dollar": 52.58, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Federal", "plan_name": "400110_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." } ] } ] }, { "description": "Detect agent nos dna quant", "code_information": [ { "code": "87799", "type": "CPT" } ], "standard_charges": [ { "gross_charge": 182.90, "minimum": 30.03, "maximum": 30.03, "setting": "both", "payers_information": [ { "payer_name": "Aetna", "plan_name": "700700", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna", "plan_name": "700700_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Miscellaneous", "plan_name": "700720", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Miscellaneous", "plan_name": "700720_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Ppo Hmo", "plan_name": "701720", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Ppo Hmo", "plan_name": "701720_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Ms State Emplo", "plan_name": "401457", "standard_charge_dollar": 30.03, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Ms State Emplo", "plan_name": "401457_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Basic Pl", "plan_name": "400100", "standard_charge_dollar": 30.03, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Basic Pl", "plan_name": "400100_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Federal", "plan_name": "400110", "standard_charge_dollar": 30.03, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Federal", "plan_name": "400110_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." } ] } ] }, { "description": "Hc ebv dna quant pcr", "code_information": [ { "code": "87799", "type": "CPT" } ], "standard_charges": [ { "gross_charge": 182.90, "minimum": 30.03, "maximum": 30.03, "setting": "both", "payers_information": [ { "payer_name": "Aetna", "plan_name": "700700", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna", "plan_name": "700700_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Miscellaneous", "plan_name": "700720", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Miscellaneous", "plan_name": "700720_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Ppo Hmo", "plan_name": "701720", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Ppo Hmo", "plan_name": "701720_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Ms State Emplo", "plan_name": "401457", "standard_charge_dollar": 30.03, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Ms State Emplo", "plan_name": "401457_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Basic Pl", "plan_name": "400100", "standard_charge_dollar": 30.03, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Basic Pl", "plan_name": "400100_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Federal", "plan_name": "400110", "standard_charge_dollar": 30.03, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Federal", "plan_name": "400110_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." } ] } ] }, { "description": "Hc influenza a antigen", "code_information": [ { "code": "87804", "type": "CPT" } ], "standard_charges": [ { "gross_charge": 38.00, "minimum": 17.96, "maximum": 17.96, "setting": "both", "payers_information": [ { "payer_name": "Aetna", "plan_name": "700700", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." 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"standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Federal", "plan_name": "400110", "standard_charge_dollar": 17.96, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Federal", "plan_name": "400110_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." } ] } ] }, { "description": "Influenza assay w/optic", "code_information": [ { "code": "87804", "type": "CPT" } ], "standard_charges": [ { "gross_charge": 38.00, "minimum": 17.96, "maximum": 17.96, "setting": "both", "payers_information": [ { "payer_name": "Aetna", "plan_name": "700700", "standard_charge_percentage": 80.0, "count": "0", 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"payer_name": "Bc/Bs Of Ms Basic Pl", "plan_name": "400100", "standard_charge_percentage": 0.85, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Basic Pl", "plan_name": "400100_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Federal", "plan_name": "400110", "standard_charge_percentage": 0.85, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Federal", "plan_name": "400110_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." } ] } ] 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"plan_name": "401457", "standard_charge_dollar": 17.96, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Ms State Emplo", "plan_name": "401457_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Basic Pl", "plan_name": "400100", "standard_charge_dollar": 17.96, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Basic Pl", "plan_name": "400100_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Federal", "plan_name": "400110", "standard_charge_dollar": 17.96, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Federal", "plan_name": "400110_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." } ] } ] }, { "description": "Strep a assay w/optic", "code_information": [ { "code": "87880", "type": "CPT" } ], "standard_charges": [ { "gross_charge": 45.00, "minimum": 17.96, "maximum": 17.96, "setting": "both", "payers_information": [ { "payer_name": "Aetna", "plan_name": "700700", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna", "plan_name": "700700_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Miscellaneous", "plan_name": "700720", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Miscellaneous", "plan_name": "700720_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Ppo Hmo", "plan_name": "701720", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Ppo Hmo", "plan_name": "701720_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total 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"Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Federal", "plan_name": "400110", "standard_charge_dollar": 17.96, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Federal", "plan_name": "400110_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." } ] } ] }, { "description": "Hc strep a assay w/optic", "code_information": [ { "code": "87880", "type": "CPT" } ], "standard_charges": [ { "gross_charge": 45.00, "minimum": 36.00, "maximum": 38.25, "setting": "both", "payers_information": [ { "payer_name": "Aetna", "plan_name": "700700", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "modifiers": "QW", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna", "plan_name": "700700_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Miscellaneous", "plan_name": "700720", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Miscellaneous", "plan_name": "700720_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Ppo Hmo", "plan_name": "701720", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Ppo Hmo", "plan_name": "701720_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Ms State Emplo", "plan_name": "401457", "standard_charge_percentage": 0.80, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Ms State Emplo", "plan_name": "401457_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Basic Pl", "plan_name": "400100", "standard_charge_percentage": 0.85, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Basic Pl", "plan_name": "400100_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Federal", "plan_name": "400110", "standard_charge_percentage": 0.85, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Federal", "plan_name": "400110_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." } ] } ] }, { "description": "Genotype dna/rna hep c", "code_information": [ { "code": "87902", "type": "CPT" } ], "standard_charges": [ { "gross_charge": 386.18, "minimum": 353.47, "maximum": 353.47, "setting": "both", "payers_information": [ { "payer_name": "Aetna", "plan_name": "700700", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna", "plan_name": "700700_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Miscellaneous", "plan_name": "700720", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Miscellaneous", "plan_name": "700720_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Ppo Hmo", "plan_name": "701720", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Ppo Hmo", "plan_name": "701720_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Ms State Emplo", "plan_name": "401457", "standard_charge_dollar": 353.47, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Ms State Emplo", "plan_name": "401457_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Basic Pl", "plan_name": "400100", "standard_charge_dollar": 353.47, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Basic Pl", "plan_name": "400100_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Federal", "plan_name": "400110", "standard_charge_dollar": 353.47, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Federal", "plan_name": "400110_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." } ] } ] }, { "description": "Hc hepatitis c genotype", "code_information": [ { "code": "87902", "type": "CPT" } ], "standard_charges": [ { "gross_charge": 386.18, "minimum": 353.47, "maximum": 353.47, "setting": "both", "payers_information": [ { "payer_name": "Aetna", "plan_name": "700700", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna", "plan_name": "700700_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Miscellaneous", "plan_name": "700720", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Miscellaneous", "plan_name": "700720_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Ppo Hmo", "plan_name": "701720", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Ppo Hmo", "plan_name": "701720_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Ms State Emplo", "plan_name": "401457", "standard_charge_dollar": 353.47, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Ms State Emplo", "plan_name": "401457_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Basic Pl", "plan_name": "400100", "standard_charge_dollar": 353.47, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Basic Pl", "plan_name": "400100_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Federal", "plan_name": "400110", "standard_charge_dollar": 353.47, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Federal", "plan_name": "400110_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." } ] } ] }, { "description": "Cytopath fl nongyn smears", "code_information": [ { "code": "88104", "type": "CPT" } ], "standard_charges": [ { "gross_charge": 75.00, "minimum": 31.21, "maximum": 44.94, "setting": "both", "payers_information": [ { "payer_name": "Aarp", "plan_name": "500102", "standard_charge_dollar": 35.96, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna", "plan_name": "700700", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna", "plan_name": "700700_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Mcare Ffs 6005", "plan_name": "700703", "standard_charge_dollar": 35.96, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Miscellaneous", "plan_name": "700720", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Miscellaneous", "plan_name": "700720_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Ppo Hmo", "plan_name": "701720", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Ppo Hmo", "plan_name": "701720_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Ambetter 68069", "plan_name": "500516", "standard_charge_dollar": 35.96, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Ms State Emplo", "plan_name": "401457", "standard_charge_dollar": 31.21, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Ms State Emplo", "plan_name": "401457_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Basic Pl", "plan_name": "400100", "standard_charge_dollar": 31.21, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Basic Pl", "plan_name": "400100_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Federal", "plan_name": "400110", "standard_charge_dollar": 31.21, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Federal", "plan_name": "400110_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Cigna Healthsprings Ffs", "plan_name": "500064", "standard_charge_dollar": 35.96, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Conseco", "plan_name": "500302", "standard_charge_dollar": 35.96, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Humana Ffs 61101", "plan_name": "500006", "standard_charge_dollar": 35.96, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Medicare A", "plan_name": "100100", "standard_charge_dollar": 35.96, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Medicare A", "plan_name": "100500", "standard_charge_dollar": 35.96, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Medicare Part B Only", "plan_name": "100300", "standard_charge_dollar": 35.96, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Medicare Railroad", "plan_name": "100103", "standard_charge_dollar": 35.96, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Ms Physicians Care N", "plan_name": "714210", "standard_charge_dollar": 44.94, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Peoples Hlth Ffs 72126", "plan_name": "500019", "standard_charge_dollar": 35.96, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Uhc/Secure Horizons", "plan_name": "500449", "standard_charge_dollar": 35.96, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "United Health Care/", "plan_name": "500292", "standard_charge_dollar": 40.63, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "United Healthcare", "plan_name": "750104", "standard_charge_dollar": 40.63, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "United Healthcare Ba", "plan_name": "750090", "standard_charge_dollar": 40.63, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "United Healthcare Me", "plan_name": "501310", "standard_charge_dollar": 35.96, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Windsor Mcare Extra", "plan_name": "500778", "standard_charge_dollar": 35.96, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." } ] } ] }, { "description": "Hc cytology fluid", "code_information": [ { "code": "88104", "type": "CPT" } ], "standard_charges": [ { "gross_charge": 75.00, "minimum": 31.21, "maximum": 44.94, "setting": "both", "payers_information": [ { "payer_name": "Aarp", "plan_name": "500102", "standard_charge_dollar": 35.96, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna", "plan_name": "700700", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna", "plan_name": "700700_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Mcare Ffs 6005", "plan_name": "700703", "standard_charge_dollar": 35.96, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Miscellaneous", "plan_name": "700720", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Miscellaneous", "plan_name": "700720_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Ppo Hmo", "plan_name": "701720", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Ppo Hmo", "plan_name": "701720_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Ambetter 68069", "plan_name": "500516", "standard_charge_dollar": 35.96, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Ms State Emplo", "plan_name": "401457", "standard_charge_dollar": 31.21, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Ms State Emplo", "plan_name": "401457_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Basic Pl", "plan_name": "400100", "standard_charge_dollar": 31.21, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Basic Pl", "plan_name": "400100_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Federal", "plan_name": "400110", "standard_charge_dollar": 31.21, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Federal", "plan_name": "400110_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Cigna Healthsprings Ffs", "plan_name": "500064", "standard_charge_dollar": 35.96, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Conseco", "plan_name": "500302", "standard_charge_dollar": 35.96, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Humana Ffs 61101", "plan_name": "500006", "standard_charge_dollar": 35.96, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Medicare A", "plan_name": "100100", "standard_charge_dollar": 35.96, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Medicare A", "plan_name": "100500", "standard_charge_dollar": 35.96, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Medicare Part B Only", "plan_name": "100300", "standard_charge_dollar": 35.96, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Medicare Railroad", "plan_name": "100103", "standard_charge_dollar": 35.96, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Ms Physicians Care N", "plan_name": "714210", "standard_charge_dollar": 44.94, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Peoples Hlth Ffs 72126", "plan_name": "500019", "standard_charge_dollar": 35.96, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Uhc/Secure Horizons", "plan_name": "500449", "standard_charge_dollar": 35.96, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "United Health Care/", "plan_name": "500292", "standard_charge_dollar": 40.63, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "United Healthcare", "plan_name": "750104", "standard_charge_dollar": 40.63, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "United Healthcare Ba", "plan_name": "750090", "standard_charge_dollar": 40.63, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "United Healthcare Me", "plan_name": "501310", "standard_charge_dollar": 35.96, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Windsor Mcare Extra", "plan_name": "500778", "standard_charge_dollar": 35.96, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." } ] } ] }, { "description": "Cytopath concentrate tech", "code_information": [ { "code": "88108", "type": "CPT" } ], "standard_charges": [ { "gross_charge": 77.96, "minimum": 31.21, "maximum": 44.94, "setting": "both", "payers_information": [ { "payer_name": "Aarp", "plan_name": "500102", "standard_charge_dollar": 35.96, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna", "plan_name": "700700", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna", "plan_name": "700700_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Mcare Ffs 6005", "plan_name": "700703", "standard_charge_dollar": 35.96, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Miscellaneous", "plan_name": "700720", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Miscellaneous", "plan_name": "700720_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Ppo Hmo", "plan_name": "701720", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Ppo Hmo", "plan_name": "701720_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Ambetter 68069", "plan_name": "500516", "standard_charge_dollar": 35.96, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Ms State Emplo", "plan_name": "401457", "standard_charge_dollar": 31.21, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Ms State Emplo", "plan_name": "401457_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Basic Pl", "plan_name": "400100", "standard_charge_dollar": 31.21, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Basic Pl", "plan_name": "400100_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Federal", "plan_name": "400110", "standard_charge_dollar": 31.21, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Federal", "plan_name": "400110_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Cigna Healthsprings Ffs", "plan_name": "500064", "standard_charge_dollar": 35.96, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Conseco", "plan_name": "500302", "standard_charge_dollar": 35.96, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Humana Ffs 61101", "plan_name": "500006", "standard_charge_dollar": 35.96, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Medicare A", "plan_name": "100100", "standard_charge_dollar": 35.96, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Medicare A", "plan_name": "100500", "standard_charge_dollar": 35.96, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Medicare Part B Only", "plan_name": "100300", "standard_charge_dollar": 35.96, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Medicare Railroad", "plan_name": "100103", "standard_charge_dollar": 35.96, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Ms Physicians Care N", "plan_name": "714210", "standard_charge_dollar": 44.94, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Peoples Hlth Ffs 72126", "plan_name": "500019", "standard_charge_dollar": 35.96, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Uhc/Secure Horizons", "plan_name": "500449", "standard_charge_dollar": 35.96, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "United Health Care/", "plan_name": "500292", "standard_charge_dollar": 40.63, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "United Healthcare", "plan_name": "750104", "standard_charge_dollar": 40.63, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "United Healthcare Ba", "plan_name": "750090", "standard_charge_dollar": 40.63, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "United Healthcare Me", "plan_name": "501310", "standard_charge_dollar": 35.96, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Windsor Mcare Extra", "plan_name": "500778", "standard_charge_dollar": 35.96, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." } ] } ] }, { "description": "Hc cytopath concent tech smr interp", "code_information": [ { "code": "88108", "type": "CPT" } ], "standard_charges": [ { "gross_charge": 77.96, "minimum": 31.21, "maximum": 44.94, "setting": "both", "payers_information": [ { "payer_name": "Aarp", "plan_name": "500102", "standard_charge_dollar": 35.96, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna", "plan_name": "700700", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna", "plan_name": "700700_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Mcare Ffs 6005", "plan_name": "700703", "standard_charge_dollar": 35.96, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Miscellaneous", "plan_name": "700720", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Miscellaneous", "plan_name": "700720_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Ppo Hmo", "plan_name": "701720", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Ppo Hmo", "plan_name": "701720_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Ambetter 68069", "plan_name": "500516", "standard_charge_dollar": 35.96, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Ms State Emplo", "plan_name": "401457", "standard_charge_dollar": 31.21, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Ms State Emplo", "plan_name": "401457_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Basic Pl", "plan_name": "400100", "standard_charge_dollar": 31.21, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Basic Pl", "plan_name": "400100_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Federal", "plan_name": "400110", "standard_charge_dollar": 31.21, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Federal", "plan_name": "400110_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Cigna Healthsprings Ffs", "plan_name": "500064", "standard_charge_dollar": 35.96, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Conseco", "plan_name": "500302", "standard_charge_dollar": 35.96, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Humana Ffs 61101", "plan_name": "500006", "standard_charge_dollar": 35.96, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Medicare A", "plan_name": "100100", "standard_charge_dollar": 35.96, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Medicare A", "plan_name": "100500", "standard_charge_dollar": 35.96, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Medicare Part B Only", "plan_name": "100300", "standard_charge_dollar": 35.96, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Medicare Railroad", "plan_name": "100103", "standard_charge_dollar": 35.96, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Ms Physicians Care N", "plan_name": "714210", "standard_charge_dollar": 44.94, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Peoples Hlth Ffs 72126", "plan_name": "500019", "standard_charge_dollar": 35.96, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Uhc/Secure Horizons", "plan_name": "500449", "standard_charge_dollar": 35.96, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "United Health Care/", "plan_name": "500292", "standard_charge_dollar": 40.63, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "United Healthcare", "plan_name": "750104", "standard_charge_dollar": 40.63, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "United Healthcare Ba", "plan_name": "750090", "standard_charge_dollar": 40.63, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "United Healthcare Me", "plan_name": "501310", "standard_charge_dollar": 35.96, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Windsor Mcare Extra", "plan_name": "500778", "standard_charge_dollar": 35.96, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." } ] } ] }, { "description": "Hc tissue cult neo disorder solid (io w20300)", "code_information": [ { "code": "88239", "type": "CPT" } ], "standard_charges": [ { "gross_charge": 398.00, "minimum": 221.05, "maximum": 221.05, "setting": "both", "payers_information": [ { "payer_name": "Aetna", "plan_name": "700700", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna", "plan_name": "700700_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Miscellaneous", "plan_name": "700720", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Miscellaneous", "plan_name": "700720_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Ppo Hmo", "plan_name": "701720", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Ppo Hmo", "plan_name": "701720_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Ms State Emplo", "plan_name": "401457", "standard_charge_dollar": 221.05, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Ms State Emplo", "plan_name": "401457_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Basic Pl", "plan_name": "400100", "standard_charge_dollar": 221.05, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Basic Pl", "plan_name": "400100_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Federal", "plan_name": "400110", "standard_charge_dollar": 221.05, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Federal", "plan_name": "400110_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." } ] } ] }, { "description": "Tissue culture tumor", "code_information": [ { "code": "88239", "type": "CPT" } ], "standard_charges": [ { "gross_charge": 398.00, "minimum": 221.05, "maximum": 221.05, "setting": "both", "payers_information": [ { "payer_name": "Aetna", "plan_name": "700700", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna", "plan_name": "700700_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Miscellaneous", "plan_name": "700720", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Miscellaneous", "plan_name": "700720_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Ppo Hmo", "plan_name": "701720", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Ppo Hmo", "plan_name": "701720_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Ms State Emplo", "plan_name": "401457", "standard_charge_dollar": 221.05, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Ms State Emplo", "plan_name": "401457_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Basic Pl", "plan_name": "400100", "standard_charge_dollar": 221.05, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Basic Pl", "plan_name": "400100_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Federal", "plan_name": "400110", "standard_charge_dollar": 221.05, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Federal", "plan_name": "400110_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." } ] } ] }, { "description": "Cytogenetics dna probe", "code_information": [ { "code": "88271", "type": "CPT" } ], "standard_charges": [ { "gross_charge": 195.93, "minimum": 32.09, "maximum": 32.09, "setting": "both", "payers_information": [ { "payer_name": "Aetna", "plan_name": "700700", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna", "plan_name": "700700_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Miscellaneous", "plan_name": "700720", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Miscellaneous", "plan_name": "700720_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Ppo Hmo", "plan_name": "701720", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Ppo Hmo", "plan_name": "701720_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Ms State Emplo", "plan_name": "401457", "standard_charge_dollar": 32.09, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Ms State Emplo", "plan_name": "401457_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Basic Pl", "plan_name": "400100", "standard_charge_dollar": 32.09, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Basic Pl", "plan_name": "400100_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Federal", "plan_name": "400110", "standard_charge_dollar": 32.09, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Federal", "plan_name": "400110_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." } ] } ] }, { "description": "Hc mole cytogen; dna probe ea (eg fish)", "code_information": [ { "code": "88271", "type": "CPT" } ], "standard_charges": [ { "gross_charge": 195.93, "minimum": 32.09, "maximum": 32.09, "setting": "both", "payers_information": [ { "payer_name": "Aetna", "plan_name": "700700", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna", "plan_name": "700700_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Miscellaneous", "plan_name": "700720", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Miscellaneous", "plan_name": "700720_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Ppo Hmo", "plan_name": "701720", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Ppo Hmo", "plan_name": "701720_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Ms State Emplo", "plan_name": "401457", "standard_charge_dollar": 32.09, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Ms State Emplo", "plan_name": "401457_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Basic Pl", "plan_name": "400100", "standard_charge_dollar": 32.09, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Basic Pl", "plan_name": "400100_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Federal", "plan_name": "400110", "standard_charge_dollar": 32.09, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Federal", "plan_name": "400110_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." } ] } ] }, { "description": "Cytogenetics 100-300", "code_information": [ { "code": "88275", "type": "CPT" } ], "standard_charges": [ { "gross_charge": 452.89, "minimum": 60.17, "maximum": 60.17, "setting": "both", "payers_information": [ { "payer_name": "Aetna", "plan_name": "700700", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna", "plan_name": "700700_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Miscellaneous", "plan_name": "700720", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Miscellaneous", "plan_name": "700720_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Ppo Hmo", "plan_name": "701720", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Ppo Hmo", "plan_name": "701720_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Ms State Emplo", "plan_name": "401457", "standard_charge_dollar": 60.17, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Ms State Emplo", "plan_name": "401457_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Basic Pl", "plan_name": "400100", "standard_charge_dollar": 60.17, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Basic Pl", "plan_name": "400100_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Federal", "plan_name": "400110", "standard_charge_dollar": 60.17, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Federal", "plan_name": "400110_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." } ] } ] }, { "description": "Hc molecular cytog 100-300 (cllmf)", "code_information": [ { "code": "88275", "type": "CPT" } ], "standard_charges": [ { "gross_charge": 452.89, "minimum": 60.17, "maximum": 60.17, "setting": "both", "payers_information": [ { "payer_name": "Aetna", "plan_name": "700700", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna", "plan_name": "700700_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Miscellaneous", "plan_name": "700720", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Miscellaneous", "plan_name": "700720_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Ppo Hmo", "plan_name": "701720", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Ppo Hmo", "plan_name": "701720_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Ms State Emplo", "plan_name": "401457", "standard_charge_dollar": 60.17, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Ms State Emplo", "plan_name": "401457_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Basic Pl", "plan_name": "400100", "standard_charge_dollar": 60.17, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Basic Pl", "plan_name": "400100_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Federal", "plan_name": "400110", "standard_charge_dollar": 60.17, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Federal", "plan_name": "400110_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." } ] } ] }, { "description": "Hc surg pathology level 1", "code_information": [ { "code": "88300", "type": "CPT" } ], "standard_charges": [ { "gross_charge": 50.00, "minimum": 22.43, "maximum": 31.21, "setting": "both", "payers_information": [ { "payer_name": "Aarp", "plan_name": "500102", "standard_charge_dollar": 22.43, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna", "plan_name": "700700", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna", "plan_name": "700700_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Mcare Ffs 6005", "plan_name": "700703", "standard_charge_dollar": 22.43, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Miscellaneous", "plan_name": "700720", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Miscellaneous", "plan_name": "700720_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Ppo Hmo", "plan_name": "701720", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Ppo Hmo", "plan_name": "701720_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Ambetter 68069", "plan_name": "500516", "standard_charge_dollar": 22.43, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Ms State Emplo", "plan_name": "401457", "standard_charge_dollar": 31.21, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Ms State Emplo", "plan_name": "401457_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Basic Pl", "plan_name": "400100", "standard_charge_dollar": 31.21, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Basic Pl", "plan_name": "400100_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Federal", "plan_name": "400110", "standard_charge_dollar": 31.21, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Federal", "plan_name": "400110_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Cigna Healthsprings Ffs", "plan_name": "500064", "standard_charge_dollar": 22.43, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Conseco", "plan_name": "500302", "standard_charge_dollar": 22.43, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Humana Ffs 61101", "plan_name": "500006", "standard_charge_dollar": 22.43, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Medicare A", "plan_name": "100100", "standard_charge_dollar": 22.43, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Medicare A", "plan_name": "100500", "standard_charge_dollar": 22.43, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Medicare Part B Only", "plan_name": "100300", "standard_charge_dollar": 22.43, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Medicare Railroad", "plan_name": "100103", "standard_charge_dollar": 22.43, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Ms Physicians Care N", "plan_name": "714210", "standard_charge_dollar": 28.04, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Peoples Hlth Ffs 72126", "plan_name": "500019", "standard_charge_dollar": 22.43, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Uhc/Secure Horizons", "plan_name": "500449", "standard_charge_dollar": 22.43, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "United Health Care/", "plan_name": "500292", "standard_charge_dollar": 25.35, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "United Healthcare", "plan_name": "750104", "standard_charge_dollar": 25.35, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "United Healthcare Ba", "plan_name": "750090", "standard_charge_dollar": 25.35, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "United Healthcare Me", "plan_name": "501310", "standard_charge_dollar": 22.43, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Windsor Mcare Extra", "plan_name": "500778", "standard_charge_dollar": 22.43, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." } ] } ] }, { "description": "Surgical path gross", "code_information": [ { "code": "88300", "type": "CPT" } ], "standard_charges": [ { "gross_charge": 50.00, "minimum": 22.43, "maximum": 31.21, "setting": "both", "payers_information": [ { "payer_name": "Aarp", "plan_name": "500102", "standard_charge_dollar": 22.43, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna", "plan_name": "700700", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna", "plan_name": "700700_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Mcare Ffs 6005", "plan_name": "700703", "standard_charge_dollar": 22.43, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Miscellaneous", "plan_name": "700720", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Miscellaneous", "plan_name": "700720_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Ppo Hmo", "plan_name": "701720", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Ppo Hmo", "plan_name": "701720_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Ambetter 68069", "plan_name": "500516", "standard_charge_dollar": 22.43, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Ms State Emplo", "plan_name": "401457", "standard_charge_dollar": 31.21, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Ms State Emplo", "plan_name": "401457_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Basic Pl", "plan_name": "400100", "standard_charge_dollar": 31.21, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Basic Pl", "plan_name": "400100_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Federal", "plan_name": "400110", "standard_charge_dollar": 31.21, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Federal", "plan_name": "400110_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Cigna Healthsprings Ffs", "plan_name": "500064", "standard_charge_dollar": 22.43, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Conseco", "plan_name": "500302", "standard_charge_dollar": 22.43, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Humana Ffs 61101", "plan_name": "500006", "standard_charge_dollar": 22.43, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Medicare A", "plan_name": "100100", "standard_charge_dollar": 22.43, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Medicare A", "plan_name": "100500", "standard_charge_dollar": 22.43, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Medicare Part B Only", "plan_name": "100300", "standard_charge_dollar": 22.43, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Medicare Railroad", "plan_name": "100103", "standard_charge_dollar": 22.43, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Ms Physicians Care N", "plan_name": "714210", "standard_charge_dollar": 28.04, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Peoples Hlth Ffs 72126", "plan_name": "500019", "standard_charge_dollar": 22.43, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Uhc/Secure Horizons", "plan_name": "500449", "standard_charge_dollar": 22.43, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "United Health Care/", "plan_name": "500292", "standard_charge_dollar": 25.35, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "United Healthcare", "plan_name": "750104", "standard_charge_dollar": 25.35, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "United Healthcare Ba", "plan_name": "750090", "standard_charge_dollar": 25.35, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "United Healthcare Me", "plan_name": "501310", "standard_charge_dollar": 22.43, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Windsor Mcare Extra", "plan_name": "500778", "standard_charge_dollar": 22.43, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." } ] } ] }, { "description": "Hc surg path level iii", "code_information": [ { "code": "88304", "type": "CPT" } ], "standard_charges": [ { "gross_charge": 135.00, "minimum": 43.65, "maximum": 61.18, "setting": "both", "payers_information": [ { "payer_name": "Aarp", "plan_name": "500102", "standard_charge_dollar": 48.95, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna", "plan_name": "700700", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna", "plan_name": "700700_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Mcare Ffs 6005", "plan_name": "700703", "standard_charge_dollar": 48.95, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Miscellaneous", "plan_name": "700720", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Miscellaneous", "plan_name": "700720_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Ppo Hmo", "plan_name": "701720", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Ppo Hmo", "plan_name": "701720_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Ambetter 68069", "plan_name": "500516", "standard_charge_dollar": 48.95, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Ms State Emplo", "plan_name": "401457", "standard_charge_dollar": 43.65, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Ms State Emplo", "plan_name": "401457_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Basic Pl", "plan_name": "400100", "standard_charge_dollar": 43.65, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Basic Pl", "plan_name": "400100_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Federal", "plan_name": "400110", "standard_charge_dollar": 43.65, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Federal", "plan_name": "400110_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Cigna Healthsprings Ffs", "plan_name": "500064", "standard_charge_dollar": 48.95, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Conseco", "plan_name": "500302", "standard_charge_dollar": 48.95, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Humana Ffs 61101", "plan_name": "500006", "standard_charge_dollar": 48.95, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Medicare A", "plan_name": "100100", "standard_charge_dollar": 48.95, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Medicare A", "plan_name": "100500", "standard_charge_dollar": 48.95, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Medicare Part B Only", "plan_name": "100300", "standard_charge_dollar": 48.95, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Medicare Railroad", "plan_name": "100103", "standard_charge_dollar": 48.95, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Ms Physicians Care N", "plan_name": "714210", "standard_charge_dollar": 61.18, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Peoples Hlth Ffs 72126", "plan_name": "500019", "standard_charge_dollar": 48.95, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Uhc/Secure Horizons", "plan_name": "500449", "standard_charge_dollar": 48.95, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "United Health Care/", "plan_name": "500292", "standard_charge_dollar": 55.31, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "United Healthcare", "plan_name": "750104", "standard_charge_dollar": 55.31, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "United Healthcare Ba", "plan_name": "750090", "standard_charge_dollar": 55.31, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "United Healthcare Me", "plan_name": "501310", "standard_charge_dollar": 48.95, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Windsor Mcare Extra", "plan_name": "500778", "standard_charge_dollar": 48.95, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." } ] } ] }, { "description": "Tissue exam by pathologist", "code_information": [ { "code": "88304", "type": "CPT" } ], "standard_charges": [ { "gross_charge": 135.00, "minimum": 43.65, "maximum": 61.18, "setting": "both", "payers_information": [ { "payer_name": "Aarp", "plan_name": "500102", "standard_charge_dollar": 48.95, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna", "plan_name": "700700", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna", "plan_name": "700700_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Mcare Ffs 6005", "plan_name": "700703", "standard_charge_dollar": 48.95, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Miscellaneous", "plan_name": "700720", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Miscellaneous", "plan_name": "700720_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Ppo Hmo", "plan_name": "701720", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Ppo Hmo", "plan_name": "701720_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Ambetter 68069", "plan_name": "500516", "standard_charge_dollar": 48.95, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Ms State Emplo", "plan_name": "401457", "standard_charge_dollar": 43.65, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Ms State Emplo", "plan_name": "401457_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Basic Pl", "plan_name": "400100", "standard_charge_dollar": 43.65, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Basic Pl", "plan_name": "400100_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Federal", "plan_name": "400110", "standard_charge_dollar": 43.65, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Federal", "plan_name": "400110_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Cigna Healthsprings Ffs", "plan_name": "500064", "standard_charge_dollar": 48.95, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Conseco", "plan_name": "500302", "standard_charge_dollar": 48.95, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Humana Ffs 61101", "plan_name": "500006", "standard_charge_dollar": 48.95, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Medicare A", "plan_name": "100100", "standard_charge_dollar": 48.95, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Medicare A", "plan_name": "100500", "standard_charge_dollar": 48.95, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Medicare Part B Only", "plan_name": "100300", "standard_charge_dollar": 48.95, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Medicare Railroad", "plan_name": "100103", "standard_charge_dollar": 48.95, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Ms Physicians Care N", "plan_name": "714210", "standard_charge_dollar": 61.18, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Peoples Hlth Ffs 72126", "plan_name": "500019", "standard_charge_dollar": 48.95, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Uhc/Secure Horizons", "plan_name": "500449", "standard_charge_dollar": 48.95, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "United Health Care/", "plan_name": "500292", "standard_charge_dollar": 55.31, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "United Healthcare", "plan_name": "750104", "standard_charge_dollar": 55.31, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "United Healthcare Ba", "plan_name": "750090", "standard_charge_dollar": 55.31, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "United Healthcare Me", "plan_name": "501310", "standard_charge_dollar": 48.95, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Windsor Mcare Extra", "plan_name": "500778", "standard_charge_dollar": 48.95, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." } ] } ] }, { "description": "Hc surg path level iv", "code_information": [ { "code": "88305", "type": "CPT" } ], "standard_charges": [ { "gross_charge": 150.00, "minimum": 43.65, "maximum": 61.18, "setting": "both", "payers_information": [ { "payer_name": "Aarp", "plan_name": "500102", "standard_charge_dollar": 48.95, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna", "plan_name": "700700", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna", "plan_name": "700700_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Mcare Ffs 6005", "plan_name": "700703", "standard_charge_dollar": 48.95, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Miscellaneous", "plan_name": "700720", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Miscellaneous", "plan_name": "700720_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Ppo Hmo", "plan_name": "701720", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Ppo Hmo", "plan_name": "701720_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Ambetter 68069", "plan_name": "500516", "standard_charge_dollar": 48.95, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Ms State Emplo", "plan_name": "401457", "standard_charge_dollar": 43.65, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Ms State Emplo", "plan_name": "401457_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Basic Pl", "plan_name": "400100", "standard_charge_dollar": 43.65, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Basic Pl", "plan_name": "400100_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Federal", "plan_name": "400110", "standard_charge_dollar": 43.65, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Federal", "plan_name": "400110_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Cigna Healthsprings Ffs", "plan_name": "500064", "standard_charge_dollar": 48.95, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Conseco", "plan_name": "500302", "standard_charge_dollar": 48.95, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Humana Ffs 61101", "plan_name": "500006", "standard_charge_dollar": 48.95, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Medicare A", "plan_name": "100100", "standard_charge_dollar": 48.95, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Medicare A", "plan_name": "100500", "standard_charge_dollar": 48.95, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Medicare Part B Only", "plan_name": "100300", "standard_charge_dollar": 48.95, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Medicare Railroad", "plan_name": "100103", "standard_charge_dollar": 48.95, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Ms Physicians Care N", "plan_name": "714210", "standard_charge_dollar": 61.18, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Peoples Hlth Ffs 72126", "plan_name": "500019", "standard_charge_dollar": 48.95, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Uhc/Secure Horizons", "plan_name": "500449", "standard_charge_dollar": 48.95, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "United Health Care/", "plan_name": "500292", "standard_charge_dollar": 55.31, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "United Healthcare", "plan_name": "750104", "standard_charge_dollar": 55.31, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "United Healthcare Ba", "plan_name": "750090", "standard_charge_dollar": 55.31, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "United Healthcare Me", "plan_name": "501310", "standard_charge_dollar": 48.95, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Windsor Mcare Extra", "plan_name": "500778", "standard_charge_dollar": 48.95, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." } ] } ] }, { "description": "Tissue exam by pathologist", "code_information": [ { "code": "88305", "type": "CPT" } ], "standard_charges": [ { "gross_charge": 150.00, "minimum": 43.65, "maximum": 61.18, "setting": "both", "payers_information": [ { "payer_name": "Aarp", "plan_name": "500102", "standard_charge_dollar": 48.95, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna", "plan_name": "700700", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna", "plan_name": "700700_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Mcare Ffs 6005", "plan_name": "700703", "standard_charge_dollar": 48.95, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Miscellaneous", "plan_name": "700720", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Miscellaneous", "plan_name": "700720_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Ppo Hmo", "plan_name": "701720", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Ppo Hmo", "plan_name": "701720_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Ambetter 68069", "plan_name": "500516", "standard_charge_dollar": 48.95, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Ms State Emplo", "plan_name": "401457", "standard_charge_dollar": 43.65, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Ms State Emplo", "plan_name": "401457_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Basic Pl", "plan_name": "400100", "standard_charge_dollar": 43.65, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Basic Pl", "plan_name": "400100_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Federal", "plan_name": "400110", "standard_charge_dollar": 43.65, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Federal", "plan_name": "400110_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Cigna Healthsprings Ffs", "plan_name": "500064", "standard_charge_dollar": 48.95, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Conseco", "plan_name": "500302", "standard_charge_dollar": 48.95, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Humana Ffs 61101", "plan_name": "500006", "standard_charge_dollar": 48.95, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Medicare A", "plan_name": "100100", "standard_charge_dollar": 48.95, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Medicare A", "plan_name": "100500", "standard_charge_dollar": 48.95, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Medicare Part B Only", "plan_name": "100300", "standard_charge_dollar": 48.95, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Medicare Railroad", "plan_name": "100103", "standard_charge_dollar": 48.95, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Ms Physicians Care N", "plan_name": "714210", "standard_charge_dollar": 61.18, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Peoples Hlth Ffs 72126", "plan_name": "500019", "standard_charge_dollar": 48.95, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Uhc/Secure Horizons", "plan_name": "500449", "standard_charge_dollar": 48.95, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "United Health Care/", "plan_name": "500292", "standard_charge_dollar": 55.31, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "United Healthcare", "plan_name": "750104", "standard_charge_dollar": 55.31, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "United Healthcare Ba", "plan_name": "750090", "standard_charge_dollar": 55.31, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "United Healthcare Me", "plan_name": "501310", "standard_charge_dollar": 48.95, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Windsor Mcare Extra", "plan_name": "500778", "standard_charge_dollar": 48.95, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." } ] } ] }, { "description": "Decalcify tissue", "code_information": [ { "code": "88311", "type": "CPT" } ], "standard_charges": [ { "gross_charge": 27.50, "minimum": 8.75, "maximum": 8.75, "setting": "both", "payers_information": [ { "payer_name": "Aetna", "plan_name": "700700", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna", "plan_name": "700700_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Miscellaneous", "plan_name": "700720", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Miscellaneous", "plan_name": "700720_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Ppo Hmo", "plan_name": "701720", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Ppo Hmo", "plan_name": "701720_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Ms State Emplo", "plan_name": "401457", "standard_charge_dollar": 8.75, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Ms State Emplo", "plan_name": "401457_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Basic Pl", "plan_name": "400100", "standard_charge_dollar": 8.75, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Basic Pl", "plan_name": "400100_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Federal", "plan_name": "400110", "standard_charge_dollar": 8.75, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Federal", "plan_name": "400110_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." } ] } ] }, { "description": "Hc decalcification procedure", "code_information": [ { "code": "88311", "type": "CPT" } ], "standard_charges": [ { "gross_charge": 27.50, "minimum": 8.75, "maximum": 8.75, "setting": "both", "payers_information": [ { "payer_name": "Aetna", "plan_name": "700700", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna", "plan_name": "700700_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Miscellaneous", "plan_name": "700720", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Miscellaneous", "plan_name": "700720_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Ppo Hmo", "plan_name": "701720", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Ppo Hmo", "plan_name": "701720_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Ms State Emplo", "plan_name": "401457", "standard_charge_dollar": 8.75, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Ms State Emplo", "plan_name": "401457_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Basic Pl", "plan_name": "400100", "standard_charge_dollar": 8.75, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Basic Pl", "plan_name": "400100_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Federal", "plan_name": "400110", "standard_charge_dollar": 8.75, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Federal", "plan_name": "400110_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." } ] } ] }, { "description": "Hc special stains group 1", "code_information": [ { "code": "88312", "type": "CPT" } ], "standard_charges": [ { "gross_charge": 125.00, "minimum": 43.65, "maximum": 61.18, "setting": "both", "payers_information": [ { "payer_name": "Aarp", "plan_name": "500102", "standard_charge_dollar": 48.95, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna", "plan_name": "700700", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna", "plan_name": "700700_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Mcare Ffs 6005", "plan_name": "700703", "standard_charge_dollar": 48.95, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Miscellaneous", "plan_name": "700720", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Miscellaneous", "plan_name": "700720_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Ppo Hmo", "plan_name": "701720", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Ppo Hmo", "plan_name": "701720_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Ambetter 68069", "plan_name": "500516", "standard_charge_dollar": 48.95, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Ms State Emplo", "plan_name": "401457", "standard_charge_dollar": 43.65, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Ms State Emplo", "plan_name": "401457_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Basic Pl", "plan_name": "400100", "standard_charge_dollar": 43.65, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Basic Pl", "plan_name": "400100_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Federal", "plan_name": "400110", "standard_charge_dollar": 43.65, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Federal", "plan_name": "400110_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Cigna Healthsprings Ffs", "plan_name": "500064", "standard_charge_dollar": 48.95, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Conseco", "plan_name": "500302", "standard_charge_dollar": 48.95, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Humana Ffs 61101", "plan_name": "500006", "standard_charge_dollar": 48.95, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Medicare A", "plan_name": "100100", "standard_charge_dollar": 48.95, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Medicare A", "plan_name": "100500", "standard_charge_dollar": 48.95, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Medicare Part B Only", "plan_name": "100300", "standard_charge_dollar": 48.95, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Medicare Railroad", "plan_name": "100103", "standard_charge_dollar": 48.95, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Ms Physicians Care N", "plan_name": "714210", "standard_charge_dollar": 61.18, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Peoples Hlth Ffs 72126", "plan_name": "500019", "standard_charge_dollar": 48.95, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Uhc/Secure Horizons", "plan_name": "500449", "standard_charge_dollar": 48.95, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "United Health Care/", "plan_name": "500292", "standard_charge_dollar": 55.31, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "United Healthcare", "plan_name": "750104", "standard_charge_dollar": 55.31, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "United Healthcare Ba", "plan_name": "750090", "standard_charge_dollar": 55.31, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "United Healthcare Me", "plan_name": "501310", "standard_charge_dollar": 48.95, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Windsor Mcare Extra", "plan_name": "500778", "standard_charge_dollar": 48.95, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." } ] } ] }, { "description": "Special stains group 1", "code_information": [ { "code": "88312", "type": "CPT" } ], "standard_charges": [ { "gross_charge": 125.00, "minimum": 43.65, "maximum": 61.18, "setting": "both", "payers_information": [ { "payer_name": "Aarp", "plan_name": "500102", "standard_charge_dollar": 48.95, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna", "plan_name": "700700", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna", "plan_name": "700700_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Mcare Ffs 6005", "plan_name": "700703", "standard_charge_dollar": 48.95, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Miscellaneous", "plan_name": "700720", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Miscellaneous", "plan_name": "700720_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Ppo Hmo", "plan_name": "701720", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Ppo Hmo", "plan_name": "701720_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Ambetter 68069", "plan_name": "500516", "standard_charge_dollar": 48.95, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Ms State Emplo", "plan_name": "401457", "standard_charge_dollar": 43.65, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Ms State Emplo", "plan_name": "401457_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Basic Pl", "plan_name": "400100", "standard_charge_dollar": 43.65, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Basic Pl", "plan_name": "400100_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Federal", "plan_name": "400110", "standard_charge_dollar": 43.65, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Federal", "plan_name": "400110_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Cigna Healthsprings Ffs", "plan_name": "500064", "standard_charge_dollar": 48.95, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Conseco", "plan_name": "500302", "standard_charge_dollar": 48.95, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Humana Ffs 61101", "plan_name": "500006", "standard_charge_dollar": 48.95, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Medicare A", "plan_name": "100100", "standard_charge_dollar": 48.95, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Medicare A", "plan_name": "100500", "standard_charge_dollar": 48.95, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Medicare Part B Only", "plan_name": "100300", "standard_charge_dollar": 48.95, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Medicare Railroad", "plan_name": "100103", "standard_charge_dollar": 48.95, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Ms Physicians Care N", "plan_name": "714210", "standard_charge_dollar": 61.18, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Peoples Hlth Ffs 72126", "plan_name": "500019", "standard_charge_dollar": 48.95, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Uhc/Secure Horizons", "plan_name": "500449", "standard_charge_dollar": 48.95, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "United Health Care/", "plan_name": "500292", "standard_charge_dollar": 55.31, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "United Healthcare", "plan_name": "750104", "standard_charge_dollar": 55.31, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "United Healthcare Ba", "plan_name": "750090", "standard_charge_dollar": 55.31, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "United Healthcare Me", "plan_name": "501310", "standard_charge_dollar": 48.95, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Windsor Mcare Extra", "plan_name": "500778", "standard_charge_dollar": 48.95, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." } ] } ] }, { "description": "Hc special stains group 2", "code_information": [ { "code": "88313", "type": "CPT" } ], "standard_charges": [ { "gross_charge": 210.00, "minimum": 31.21, "maximum": 147.60, "setting": "both", "payers_information": [ { "payer_name": "Aarp", "plan_name": "500102", "standard_charge_dollar": 118.08, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna", "plan_name": "700700", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna", "plan_name": "700700_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Mcare Ffs 6005", "plan_name": "700703", "standard_charge_dollar": 118.08, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Miscellaneous", "plan_name": "700720", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Miscellaneous", "plan_name": "700720_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Ppo Hmo", "plan_name": "701720", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Ppo Hmo", "plan_name": "701720_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Ambetter 68069", "plan_name": "500516", "standard_charge_dollar": 118.08, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Ms State Emplo", "plan_name": "401457", "standard_charge_dollar": 31.21, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Ms State Emplo", "plan_name": "401457_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Basic Pl", "plan_name": "400100", "standard_charge_dollar": 31.21, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Basic Pl", "plan_name": "400100_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Federal", "plan_name": "400110", "standard_charge_dollar": 31.21, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Federal", "plan_name": "400110_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Cigna Healthsprings Ffs", "plan_name": "500064", "standard_charge_dollar": 118.08, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Conseco", "plan_name": "500302", "standard_charge_dollar": 118.08, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Humana Ffs 61101", "plan_name": "500006", "standard_charge_dollar": 118.08, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Medicare A", "plan_name": "100100", "standard_charge_dollar": 118.08, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Medicare A", "plan_name": "100500", "standard_charge_dollar": 118.08, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Medicare Part B Only", "plan_name": "100300", "standard_charge_dollar": 118.08, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Medicare Railroad", "plan_name": "100103", "standard_charge_dollar": 118.08, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Ms Physicians Care N", "plan_name": "714210", "standard_charge_dollar": 147.60, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Peoples Hlth Ffs 72126", "plan_name": "500019", "standard_charge_dollar": 118.08, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Uhc/Secure Horizons", "plan_name": "500449", "standard_charge_dollar": 118.08, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "United Health Care/", "plan_name": "500292", "standard_charge_dollar": 133.43, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "United Healthcare", "plan_name": "750104", "standard_charge_dollar": 133.43, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "United Healthcare Ba", "plan_name": "750090", "standard_charge_dollar": 133.43, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "United Healthcare Me", "plan_name": "501310", "standard_charge_dollar": 118.08, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Windsor Mcare Extra", "plan_name": "500778", "standard_charge_dollar": 118.08, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." } ] } ] }, { "description": "Special stains group 2", "code_information": [ { "code": "88313", "type": "CPT" } ], "standard_charges": [ { "gross_charge": 210.00, "minimum": 31.21, "maximum": 147.60, "setting": "both", "payers_information": [ { "payer_name": "Aarp", "plan_name": "500102", "standard_charge_dollar": 118.08, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna", "plan_name": "700700", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna", "plan_name": "700700_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Mcare Ffs 6005", "plan_name": "700703", "standard_charge_dollar": 118.08, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Miscellaneous", "plan_name": "700720", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Miscellaneous", "plan_name": "700720_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Ppo Hmo", "plan_name": "701720", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Ppo Hmo", "plan_name": "701720_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Ambetter 68069", "plan_name": "500516", "standard_charge_dollar": 118.08, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Ms State Emplo", "plan_name": "401457", "standard_charge_dollar": 31.21, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Ms State Emplo", "plan_name": "401457_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Basic Pl", "plan_name": "400100", "standard_charge_dollar": 31.21, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Basic Pl", "plan_name": "400100_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Federal", "plan_name": "400110", "standard_charge_dollar": 31.21, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Federal", "plan_name": "400110_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Cigna Healthsprings Ffs", "plan_name": "500064", "standard_charge_dollar": 118.08, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Conseco", "plan_name": "500302", "standard_charge_dollar": 118.08, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Humana Ffs 61101", "plan_name": "500006", "standard_charge_dollar": 118.08, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Medicare A", "plan_name": "100100", "standard_charge_dollar": 118.08, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Medicare A", "plan_name": "100500", "standard_charge_dollar": 118.08, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Medicare Part B Only", "plan_name": "100300", "standard_charge_dollar": 118.08, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Medicare Railroad", "plan_name": "100103", "standard_charge_dollar": 118.08, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Ms Physicians Care N", "plan_name": "714210", "standard_charge_dollar": 147.60, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Peoples Hlth Ffs 72126", "plan_name": "500019", "standard_charge_dollar": 118.08, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Uhc/Secure Horizons", "plan_name": "500449", "standard_charge_dollar": 118.08, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "United Health Care/", "plan_name": "500292", "standard_charge_dollar": 133.43, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "United Healthcare", "plan_name": "750104", "standard_charge_dollar": 133.43, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "United Healthcare Ba", "plan_name": "750090", "standard_charge_dollar": 133.43, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "United Healthcare Me", "plan_name": "501310", "standard_charge_dollar": 118.08, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Windsor Mcare Extra", "plan_name": "500778", "standard_charge_dollar": 118.08, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." } ] } ] }, { "description": "Hc ihc multiplex stain (ihmpc)", "code_information": [ { "code": "88344", "type": "CPT" } ], "standard_charges": [ { "gross_charge": 454.20, "minimum": 202.32, "maximum": 411.91, "setting": "both", "payers_information": [ { "payer_name": "Aarp", "plan_name": "500102", "standard_charge_dollar": 329.53, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna", "plan_name": "700700", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna", "plan_name": "700700_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Mcare Ffs 6005", "plan_name": "700703", "standard_charge_dollar": 329.53, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Miscellaneous", "plan_name": "700720", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Miscellaneous", "plan_name": "700720_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Ppo Hmo", "plan_name": "701720", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Ppo Hmo", "plan_name": "701720_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Ambetter 68069", "plan_name": "500516", "standard_charge_dollar": 329.53, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Ms State Emplo", "plan_name": "401457", "standard_charge_dollar": 202.32, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Ms State Emplo", "plan_name": "401457_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Basic Pl", "plan_name": "400100", "standard_charge_dollar": 202.32, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Basic Pl", "plan_name": "400100_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Federal", "plan_name": "400110", "standard_charge_dollar": 202.32, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Federal", "plan_name": "400110_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Cigna Healthsprings Ffs", "plan_name": "500064", "standard_charge_dollar": 329.53, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Conseco", "plan_name": "500302", "standard_charge_dollar": 329.53, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Humana Ffs 61101", "plan_name": "500006", "standard_charge_dollar": 329.53, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Medicare A", "plan_name": "100100", "standard_charge_dollar": 329.53, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Medicare A", "plan_name": "100500", "standard_charge_dollar": 329.53, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Medicare Part B Only", "plan_name": "100300", "standard_charge_dollar": 329.53, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Medicare Railroad", "plan_name": "100103", "standard_charge_dollar": 329.53, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Ms Physicians Care N", "plan_name": "714210", "standard_charge_dollar": 411.91, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Peoples Hlth Ffs 72126", "plan_name": "500019", "standard_charge_dollar": 329.53, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Uhc/Secure Horizons", "plan_name": "500449", "standard_charge_dollar": 329.53, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "United Health Care/", "plan_name": "500292", "standard_charge_dollar": 372.37, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "United Healthcare", "plan_name": "750104", "standard_charge_dollar": 372.37, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "United Healthcare Ba", "plan_name": "750090", "standard_charge_dollar": 372.37, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "United Healthcare Me", "plan_name": "501310", "standard_charge_dollar": 329.53, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Windsor Mcare Extra", "plan_name": "500778", "standard_charge_dollar": 329.53, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." } ] } ] }, { "description": "Immunohisto antibody slide", "code_information": [ { "code": "88344", "type": "CPT" } ], "standard_charges": [ { "gross_charge": 454.20, "minimum": 202.32, "maximum": 411.91, "setting": "both", "payers_information": [ { "payer_name": "Aarp", "plan_name": "500102", "standard_charge_dollar": 329.53, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna", "plan_name": "700700", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna", "plan_name": "700700_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Mcare Ffs 6005", "plan_name": "700703", "standard_charge_dollar": 329.53, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Miscellaneous", "plan_name": "700720", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Miscellaneous", "plan_name": "700720_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Ppo Hmo", "plan_name": "701720", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Ppo Hmo", "plan_name": "701720_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Ambetter 68069", "plan_name": "500516", "standard_charge_dollar": 329.53, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Ms State Emplo", "plan_name": "401457", "standard_charge_dollar": 202.32, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Ms State Emplo", "plan_name": "401457_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Basic Pl", "plan_name": "400100", "standard_charge_dollar": 202.32, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Basic Pl", "plan_name": "400100_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Federal", "plan_name": "400110", "standard_charge_dollar": 202.32, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Federal", "plan_name": "400110_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Cigna Healthsprings Ffs", "plan_name": "500064", "standard_charge_dollar": 329.53, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Conseco", "plan_name": "500302", "standard_charge_dollar": 329.53, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Humana Ffs 61101", "plan_name": "500006", "standard_charge_dollar": 329.53, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Medicare A", "plan_name": "100100", "standard_charge_dollar": 329.53, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Medicare A", "plan_name": "100500", "standard_charge_dollar": 329.53, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Medicare Part B Only", "plan_name": "100300", "standard_charge_dollar": 329.53, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Medicare Railroad", "plan_name": "100103", "standard_charge_dollar": 329.53, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Ms Physicians Care N", "plan_name": "714210", "standard_charge_dollar": 411.91, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Peoples Hlth Ffs 72126", "plan_name": "500019", "standard_charge_dollar": 329.53, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Uhc/Secure Horizons", "plan_name": "500449", "standard_charge_dollar": 329.53, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "United Health Care/", "plan_name": "500292", "standard_charge_dollar": 372.37, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "United Healthcare", "plan_name": "750104", "standard_charge_dollar": 372.37, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "United Healthcare Ba", "plan_name": "750090", "standard_charge_dollar": 372.37, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "United Healthcare Me", "plan_name": "501310", "standard_charge_dollar": 329.53, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Windsor Mcare Extra", "plan_name": "500778", "standard_charge_dollar": 329.53, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." } ] } ] }, { "description": "Hc morp ana tumor immuno.man gx1 (io w20171)", "code_information": [ { "code": "88360", "type": "CPT" } ], "standard_charges": [ { "gross_charge": 230.72, "minimum": 156.98, "maximum": 202.32, "setting": "both", "payers_information": [ { "payer_name": "Aarp", "plan_name": "500102", "standard_charge_dollar": 156.98, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna", "plan_name": "700700", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna", "plan_name": "700700_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Mcare Ffs 6005", "plan_name": "700703", "standard_charge_dollar": 156.98, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Miscellaneous", "plan_name": "700720", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Miscellaneous", "plan_name": "700720_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Ppo Hmo", "plan_name": "701720", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Ppo Hmo", "plan_name": "701720_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Ambetter 68069", "plan_name": "500516", "standard_charge_dollar": 156.98, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Ms State Emplo", "plan_name": "401457", "standard_charge_dollar": 202.32, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Ms State Emplo", "plan_name": "401457_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Basic Pl", "plan_name": "400100", "standard_charge_dollar": 202.32, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Basic Pl", "plan_name": "400100_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Federal", "plan_name": "400110", "standard_charge_dollar": 202.32, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Federal", "plan_name": "400110_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Cigna Healthsprings Ffs", "plan_name": "500064", "standard_charge_dollar": 156.98, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Conseco", "plan_name": "500302", "standard_charge_dollar": 156.98, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Humana Ffs 61101", "plan_name": "500006", "standard_charge_dollar": 156.98, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Medicare A", "plan_name": "100100", "standard_charge_dollar": 156.98, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Medicare A", "plan_name": "100500", "standard_charge_dollar": 156.98, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Medicare Part B Only", "plan_name": "100300", "standard_charge_dollar": 156.98, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Medicare Railroad", "plan_name": "100103", "standard_charge_dollar": 156.98, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Ms Physicians Care N", "plan_name": "714210", "standard_charge_dollar": 196.22, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Peoples Hlth Ffs 72126", "plan_name": "500019", "standard_charge_dollar": 156.98, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Uhc/Secure Horizons", "plan_name": "500449", "standard_charge_dollar": 156.98, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "United Health Care/", "plan_name": "500292", "standard_charge_dollar": 177.38, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "United Healthcare", "plan_name": "750104", "standard_charge_dollar": 177.38, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "United Healthcare Ba", "plan_name": "750090", "standard_charge_dollar": 177.38, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "United Healthcare Me", "plan_name": "501310", "standard_charge_dollar": 156.98, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Windsor Mcare Extra", "plan_name": "500778", "standard_charge_dollar": 156.98, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." } ] } ] }, { "description": "Tumor immunohistochem/manual", "code_information": [ { "code": "88360", "type": "CPT" } ], "standard_charges": [ { "gross_charge": 230.72, "minimum": 156.98, "maximum": 202.32, "setting": "both", "payers_information": [ { "payer_name": "Aarp", "plan_name": "500102", "standard_charge_dollar": 156.98, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna", "plan_name": "700700", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna", "plan_name": "700700_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Mcare Ffs 6005", "plan_name": "700703", "standard_charge_dollar": 156.98, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Miscellaneous", "plan_name": "700720", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Miscellaneous", "plan_name": "700720_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Ppo Hmo", "plan_name": "701720", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Ppo Hmo", "plan_name": "701720_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Ambetter 68069", "plan_name": "500516", "standard_charge_dollar": 156.98, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Ms State Emplo", "plan_name": "401457", "standard_charge_dollar": 202.32, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Ms State Emplo", "plan_name": "401457_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Basic Pl", "plan_name": "400100", "standard_charge_dollar": 202.32, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Basic Pl", "plan_name": "400100_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Federal", "plan_name": "400110", "standard_charge_dollar": 202.32, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Federal", "plan_name": "400110_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Cigna Healthsprings Ffs", "plan_name": "500064", "standard_charge_dollar": 156.98, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Conseco", "plan_name": "500302", "standard_charge_dollar": 156.98, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Humana Ffs 61101", "plan_name": "500006", "standard_charge_dollar": 156.98, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Medicare A", "plan_name": "100100", "standard_charge_dollar": 156.98, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Medicare A", "plan_name": "100500", "standard_charge_dollar": 156.98, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Medicare Part B Only", "plan_name": "100300", "standard_charge_dollar": 156.98, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Medicare Railroad", "plan_name": "100103", "standard_charge_dollar": 156.98, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Ms Physicians Care N", "plan_name": "714210", "standard_charge_dollar": 196.22, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Peoples Hlth Ffs 72126", "plan_name": "500019", "standard_charge_dollar": 156.98, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Uhc/Secure Horizons", "plan_name": "500449", "standard_charge_dollar": 156.98, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "United Health Care/", "plan_name": "500292", "standard_charge_dollar": 177.38, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "United Healthcare", "plan_name": "750104", "standard_charge_dollar": 177.38, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "United Healthcare Ba", "plan_name": "750090", "standard_charge_dollar": 177.38, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "United Healthcare Me", "plan_name": "501310", "standard_charge_dollar": 156.98, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Windsor Mcare Extra", "plan_name": "500778", "standard_charge_dollar": 156.98, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." } ] } ] }, { "description": "Hc her2 breast (md) (io) tc chg", "code_information": [ { "code": "88377", "type": "CPT" } ], "standard_charges": [ { "gross_charge": 432.81, "minimum": 114.21, "maximum": 196.22, "setting": "both", "payers_information": [ { "payer_name": "Aarp", "plan_name": "500102", "standard_charge_dollar": 156.98, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna", "plan_name": "700700", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna", "plan_name": "700700_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Mcare Ffs 6005", "plan_name": "700703", "standard_charge_dollar": 156.98, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Miscellaneous", "plan_name": "700720", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Miscellaneous", "plan_name": "700720_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Ppo Hmo", "plan_name": "701720", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Ppo Hmo", "plan_name": "701720_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Ambetter 68069", "plan_name": "500516", "standard_charge_dollar": 156.98, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Ms State Emplo", "plan_name": "401457", "standard_charge_dollar": 114.21, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Ms State Emplo", "plan_name": "401457_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Basic Pl", "plan_name": "400100", "standard_charge_dollar": 114.21, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Basic Pl", "plan_name": "400100_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Federal", "plan_name": "400110", "standard_charge_dollar": 114.21, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Federal", "plan_name": "400110_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Cigna Healthsprings Ffs", "plan_name": "500064", "standard_charge_dollar": 156.98, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Conseco", "plan_name": "500302", "standard_charge_dollar": 156.98, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Humana Ffs 61101", "plan_name": "500006", "standard_charge_dollar": 156.98, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Medicare A", "plan_name": "100100", "standard_charge_dollar": 156.98, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Medicare A", "plan_name": "100500", "standard_charge_dollar": 156.98, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Medicare Part B Only", "plan_name": "100300", "standard_charge_dollar": 156.98, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Medicare Railroad", "plan_name": "100103", "standard_charge_dollar": 156.98, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Ms Physicians Care N", "plan_name": "714210", "standard_charge_dollar": 196.22, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Peoples Hlth Ffs 72126", "plan_name": "500019", "standard_charge_dollar": 156.98, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Uhc/Secure Horizons", "plan_name": "500449", "standard_charge_dollar": 156.98, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "United Health Care/", "plan_name": "500292", "standard_charge_dollar": 177.38, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "United Healthcare", "plan_name": "750104", "standard_charge_dollar": 177.38, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "United Healthcare Ba", "plan_name": "750090", "standard_charge_dollar": 177.38, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "United Healthcare Me", "plan_name": "501310", "standard_charge_dollar": 156.98, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Windsor Mcare Extra", "plan_name": "500778", "standard_charge_dollar": 156.98, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." } ] } ] }, { "description": "M/phmtrc alys ishquant/semiq", "code_information": [ { "code": "88377", "type": "CPT" } ], "standard_charges": [ { "gross_charge": 432.81, "minimum": 114.21, "maximum": 196.22, "setting": "both", "payers_information": [ { "payer_name": "Aarp", "plan_name": "500102", "standard_charge_dollar": 156.98, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna", "plan_name": "700700", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna", "plan_name": "700700_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Mcare Ffs 6005", "plan_name": "700703", "standard_charge_dollar": 156.98, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Miscellaneous", "plan_name": "700720", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Miscellaneous", "plan_name": "700720_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Ppo Hmo", "plan_name": "701720", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Ppo Hmo", "plan_name": "701720_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Ambetter 68069", "plan_name": "500516", "standard_charge_dollar": 156.98, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Ms State Emplo", "plan_name": "401457", "standard_charge_dollar": 114.21, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Ms State Emplo", "plan_name": "401457_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Basic Pl", "plan_name": "400100", "standard_charge_dollar": 114.21, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Basic Pl", "plan_name": "400100_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Federal", "plan_name": "400110", "standard_charge_dollar": 114.21, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Federal", "plan_name": "400110_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Cigna Healthsprings Ffs", "plan_name": "500064", "standard_charge_dollar": 156.98, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Conseco", "plan_name": "500302", "standard_charge_dollar": 156.98, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Humana Ffs 61101", "plan_name": "500006", "standard_charge_dollar": 156.98, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Medicare A", "plan_name": "100100", "standard_charge_dollar": 156.98, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Medicare A", "plan_name": "100500", "standard_charge_dollar": 156.98, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Medicare Part B Only", "plan_name": "100300", "standard_charge_dollar": 156.98, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Medicare Railroad", "plan_name": "100103", "standard_charge_dollar": 156.98, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Ms Physicians Care N", "plan_name": "714210", "standard_charge_dollar": 196.22, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Peoples Hlth Ffs 72126", "plan_name": "500019", "standard_charge_dollar": 156.98, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Uhc/Secure Horizons", "plan_name": "500449", "standard_charge_dollar": 156.98, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "United Health Care/", "plan_name": "500292", "standard_charge_dollar": 177.38, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "United Healthcare", "plan_name": "750104", "standard_charge_dollar": 177.38, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "United Healthcare Ba", "plan_name": "750090", "standard_charge_dollar": 177.38, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "United Healthcare Me", "plan_name": "501310", "standard_charge_dollar": 156.98, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Windsor Mcare Extra", "plan_name": "500778", "standard_charge_dollar": 156.98, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." } ] } ] }, { "description": "Body fluid cell count", "code_information": [ { "code": "89051", "type": "CPT" } ], "standard_charges": [ { "gross_charge": 125.00, "minimum": 8.25, "maximum": 8.25, "setting": "both", "payers_information": [ { "payer_name": "Aetna", "plan_name": "700700", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna", "plan_name": "700700_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Miscellaneous", "plan_name": "700720", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Miscellaneous", "plan_name": "700720_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Ppo Hmo", "plan_name": "701720", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Ppo Hmo", "plan_name": "701720_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Ms State Emplo", "plan_name": "401457", "standard_charge_dollar": 8.25, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Ms State Emplo", "plan_name": "401457_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Basic Pl", "plan_name": "400100", "standard_charge_dollar": 8.25, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Basic Pl", "plan_name": "400100_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Federal", "plan_name": "400110", "standard_charge_dollar": 8.25, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Federal", "plan_name": "400110_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." } ] } ] }, { "description": "Hc fluid exam serous cell ct", "code_information": [ { "code": "89051", "type": "CPT" } ], "standard_charges": [ { "gross_charge": 125.00, "minimum": 8.25, "maximum": 8.25, "setting": "both", "payers_information": [ { "payer_name": "Aetna", "plan_name": "700700", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna", "plan_name": "700700_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Miscellaneous", "plan_name": "700720", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Miscellaneous", "plan_name": "700720_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Ppo Hmo", "plan_name": "701720", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Ppo Hmo", "plan_name": "701720_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Ms State Emplo", "plan_name": "401457", "standard_charge_dollar": 8.25, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Ms State Emplo", "plan_name": "401457_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Basic Pl", "plan_name": "400100", "standard_charge_dollar": 8.25, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Basic Pl", "plan_name": "400100_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Federal", "plan_name": "400110", "standard_charge_dollar": 8.25, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Federal", "plan_name": "400110_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." } ] } ] }, { "description": "Hc fecal leuko qual or semiquan", "code_information": [ { "code": "89055", "type": "CPT" } ], "standard_charges": [ { "gross_charge": 75.00, "minimum": 6.40, "maximum": 6.40, "setting": "both", "payers_information": [ { "payer_name": "Aetna", "plan_name": "700700", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna", "plan_name": "700700_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Miscellaneous", "plan_name": "700720", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Miscellaneous", "plan_name": "700720_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Ppo Hmo", "plan_name": "701720", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Ppo Hmo", "plan_name": "701720_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Ms State Emplo", "plan_name": "401457", "standard_charge_dollar": 6.40, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Ms State Emplo", "plan_name": "401457_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Basic Pl", "plan_name": "400100", "standard_charge_dollar": 6.40, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Basic Pl", "plan_name": "400100_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Federal", "plan_name": "400110", "standard_charge_dollar": 6.40, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Federal", "plan_name": "400110_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." } ] } ] }, { "description": "Leukocyte assessment fecal", "code_information": [ { "code": "89055", "type": "CPT" } ], "standard_charges": [ { "gross_charge": 75.00, "minimum": 6.40, "maximum": 6.40, "setting": "both", "payers_information": [ { "payer_name": "Aetna", "plan_name": "700700", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna", "plan_name": "700700_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Miscellaneous", "plan_name": "700720", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Miscellaneous", "plan_name": "700720_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Ppo Hmo", "plan_name": "701720", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Ppo Hmo", "plan_name": "701720_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Ms State Emplo", "plan_name": "401457", "standard_charge_dollar": 6.40, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Ms State Emplo", "plan_name": "401457_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Basic Pl", "plan_name": "400100", "standard_charge_dollar": 6.40, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Basic Pl", "plan_name": "400100_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Federal", "plan_name": "400110", "standard_charge_dollar": 6.40, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Federal", "plan_name": "400110_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." } ] } ] }, { "description": "Exam synovial fluid crystals", "code_information": [ { "code": "89060", "type": "CPT" } ], "standard_charges": [ { "gross_charge": 80.00, "minimum": 10.73, "maximum": 10.73, "setting": "both", "payers_information": [ { "payer_name": "Aetna", "plan_name": "700700", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna", "plan_name": "700700_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Miscellaneous", "plan_name": "700720", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Miscellaneous", "plan_name": "700720_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Ppo Hmo", "plan_name": "701720", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Ppo Hmo", "plan_name": "701720_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Ms State Emplo", "plan_name": "401457", "standard_charge_dollar": 10.73, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Ms State Emplo", "plan_name": "401457_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Basic Pl", "plan_name": "400100", "standard_charge_dollar": 10.73, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Basic Pl", "plan_name": "400100_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Federal", "plan_name": "400110", "standard_charge_dollar": 10.73, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Federal", "plan_name": "400110_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." } ] } ] }, { "description": "Hc microscopic crystal id", "code_information": [ { "code": "89060", "type": "CPT" } ], "standard_charges": [ { "gross_charge": 80.00, "minimum": 10.73, "maximum": 10.73, "setting": "both", "payers_information": [ { "payer_name": "Aetna", "plan_name": "700700", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna", "plan_name": "700700_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", 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}, { "payer_name": "Conseco", "plan_name": "500302", "standard_charge_dollar": 143.22, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Humana Ffs 61101", "plan_name": "500006", "standard_charge_dollar": 143.22, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Medicare A", "plan_name": "100100", "standard_charge_dollar": 143.22, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Medicare A", "plan_name": "100500", "standard_charge_dollar": 143.22, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Medicare Part B Only", "plan_name": "100300", "standard_charge_dollar": 143.22, "count": "0", "methodology": 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"standard_charge_dollar": 143.22, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." } ] } ] }, { "description": "Hepatitis b immune globulin greatr than 312 unit/ml intramuscular soln [10183]", "drug_information": { "unit": 1.00, "type": "ML" }, "code_information": [ { "code": "90371", "type": "CPT" }, { "code": "69800-4202-1", "type": "NDC" } ], "standard_charges": [ { "gross_charge": 784.85, "minimum": 128.71, "maximum": 179.03, "setting": "both", "payers_information": [ { "payer_name": "Aarp", "plan_name": "500102", "standard_charge_dollar": 143.22, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna", "plan_name": "700700", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna", "plan_name": "700700_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Mcare Ffs 6005", "plan_name": "700703", "standard_charge_dollar": 143.22, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Miscellaneous", "plan_name": "700720", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Miscellaneous", "plan_name": "700720_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Ppo Hmo", "plan_name": "701720", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Ppo Hmo", "plan_name": "701720_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Ambetter 68069", "plan_name": "500516", "standard_charge_dollar": 143.22, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Ms State Emplo", "plan_name": "401457", "standard_charge_dollar": 128.71, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Ms State Emplo", "plan_name": "401457_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Basic Pl", "plan_name": "400100", "standard_charge_dollar": 128.71, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Basic Pl", "plan_name": "400100_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Federal", "plan_name": "400110", "standard_charge_dollar": 128.71, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Federal", "plan_name": "400110_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent 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"payer_name": "Medicare A", "plan_name": "100500", "standard_charge_dollar": 143.22, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Medicare Part B Only", "plan_name": "100300", "standard_charge_dollar": 143.22, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Medicare Railroad", "plan_name": "100103", "standard_charge_dollar": 143.22, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Ms Physicians Care N", "plan_name": "714210", "standard_charge_dollar": 179.03, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Peoples Hlth Ffs 72126", "plan_name": "500019", "standard_charge_dollar": 143.22, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Uhc/Secure Horizons", "plan_name": "500449", "standard_charge_dollar": 143.22, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "United Health Care/", "plan_name": "500292", "standard_charge_dollar": 161.84, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "United Healthcare", "plan_name": "750104", "standard_charge_dollar": 161.84, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "United Healthcare Ba", "plan_name": "750090", "standard_charge_dollar": 161.84, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "United Healthcare Me", "plan_name": "501310", "standard_charge_dollar": 143.22, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Windsor Mcare Extra", "plan_name": "500778", "standard_charge_dollar": 143.22, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." } ] } ] }, { "description": "Hepatitis b immune globulin > 1560 unit/5 ml intramuscular solution [91047]", "drug_information": { "unit": 5.00, "type": "ML" }, "code_information": [ { "code": "90371", "type": "CPT" }, { "code": "69800-4203-1", "type": "NDC" } ], "standard_charges": [ { "gross_charge": 3654.05, "minimum": 128.71, "maximum": 179.03, "setting": "both", "payers_information": [ { "payer_name": "Aarp", "plan_name": "500102", "standard_charge_dollar": 143.22, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna", "plan_name": "700700", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna", "plan_name": "700700_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Mcare Ffs 6005", "plan_name": "700703", "standard_charge_dollar": 143.22, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Miscellaneous", "plan_name": "700720", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Miscellaneous", "plan_name": "700720_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Ppo Hmo", "plan_name": "701720", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Ppo Hmo", "plan_name": "701720_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Ambetter 68069", "plan_name": "500516", "standard_charge_dollar": 143.22, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Ms State Emplo", "plan_name": "401457", "standard_charge_dollar": 128.71, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Ms State Emplo", "plan_name": "401457_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Basic Pl", "plan_name": "400100", "standard_charge_dollar": 128.71, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Basic Pl", "plan_name": "400100_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Federal", "plan_name": "400110", "standard_charge_dollar": 128.71, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Federal", "plan_name": "400110_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Cigna Healthsprings Ffs", "plan_name": "500064", "standard_charge_dollar": 143.22, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Conseco", "plan_name": "500302", "standard_charge_dollar": 143.22, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Humana Ffs 61101", "plan_name": "500006", "standard_charge_dollar": 143.22, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Medicare A", "plan_name": "100100", "standard_charge_dollar": 143.22, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Medicare A", "plan_name": "100500", "standard_charge_dollar": 143.22, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Medicare Part B Only", "plan_name": "100300", "standard_charge_dollar": 143.22, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Medicare Railroad", "plan_name": "100103", "standard_charge_dollar": 143.22, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Ms Physicians Care N", "plan_name": "714210", "standard_charge_dollar": 179.03, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Peoples Hlth Ffs 72126", "plan_name": "500019", "standard_charge_dollar": 143.22, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Uhc/Secure Horizons", "plan_name": "500449", "standard_charge_dollar": 143.22, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "United Health Care/", "plan_name": "500292", "standard_charge_dollar": 161.84, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "United Healthcare", "plan_name": "750104", "standard_charge_dollar": 161.84, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "United Healthcare Ba", "plan_name": "750090", "standard_charge_dollar": 161.84, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "United Healthcare Me", "plan_name": "501310", "standard_charge_dollar": 143.22, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Windsor Mcare Extra", "plan_name": "500778", "standard_charge_dollar": 143.22, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." } ] } ] }, { "description": "Rabies immune globulin (pf) 300 unit/ml intramuscular solution [183101]", "drug_information": { "unit": 1.00, "type": "ML" }, "code_information": [ { "code": "90375", "type": "CPT" }, { "code": "13533-318-01", "type": "NDC" } ], "standard_charges": [ { "gross_charge": 2735.61, "minimum": 289.28, "maximum": 362.39, "setting": "both", "payers_information": [ { "payer_name": "Aarp", "plan_name": "500102", "standard_charge_dollar": 289.91, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna", "plan_name": "700700", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna", "plan_name": "700700_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Mcare Ffs 6005", "plan_name": "700703", "standard_charge_dollar": 289.91, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Miscellaneous", "plan_name": "700720", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Miscellaneous", "plan_name": "700720_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Ppo Hmo", "plan_name": "701720", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Ppo Hmo", "plan_name": "701720_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Ambetter 68069", "plan_name": "500516", "standard_charge_dollar": 289.91, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Ms State Emplo", "plan_name": "401457", "standard_charge_dollar": 289.28, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Ms State Emplo", "plan_name": "401457_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Basic Pl", "plan_name": "400100", "standard_charge_dollar": 289.28, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Basic Pl", "plan_name": "400100_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Federal", "plan_name": "400110", "standard_charge_dollar": 289.28, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Federal", "plan_name": "400110_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Cigna Healthsprings Ffs", "plan_name": "500064", "standard_charge_dollar": 289.91, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Conseco", "plan_name": "500302", "standard_charge_dollar": 289.91, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Humana Ffs 61101", "plan_name": "500006", "standard_charge_dollar": 289.91, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Medicare A", "plan_name": "100100", "standard_charge_dollar": 289.91, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Medicare A", "plan_name": "100500", "standard_charge_dollar": 289.91, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Medicare Part B Only", "plan_name": "100300", "standard_charge_dollar": 289.91, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Medicare Railroad", "plan_name": "100103", "standard_charge_dollar": 289.91, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Ms Physicians Care N", "plan_name": "714210", "standard_charge_dollar": 362.39, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Peoples Hlth Ffs 72126", "plan_name": "500019", "standard_charge_dollar": 289.91, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Uhc/Secure Horizons", "plan_name": "500449", "standard_charge_dollar": 289.91, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "United Health Care/", "plan_name": "500292", "standard_charge_dollar": 327.60, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "United Healthcare", "plan_name": "750104", "standard_charge_dollar": 327.60, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "United Healthcare Ba", "plan_name": "750090", "standard_charge_dollar": 327.60, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "United Healthcare Me", "plan_name": "501310", "standard_charge_dollar": 289.91, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Windsor Mcare Extra", "plan_name": "500778", "standard_charge_dollar": 289.91, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." } ] } ] }, { "description": "Rabies immune globulin (pf) 300 unit/ml intramuscular solution [183101]", "drug_information": { "unit": 5.00, "type": "ML" }, "code_information": [ { "code": "90375", "type": "CPT" }, { "code": "13533-318-05", "type": "NDC" } ], "standard_charges": [ { "gross_charge": 13677.93, "minimum": 289.28, "maximum": 362.39, "setting": "both", "payers_information": [ { "payer_name": "Aarp", "plan_name": "500102", "standard_charge_dollar": 289.91, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna", "plan_name": "700700", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna", "plan_name": "700700_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Mcare Ffs 6005", "plan_name": "700703", "standard_charge_dollar": 289.91, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Miscellaneous", "plan_name": "700720", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Miscellaneous", "plan_name": "700720_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Ppo Hmo", "plan_name": "701720", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Ppo Hmo", "plan_name": "701720_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Ambetter 68069", "plan_name": "500516", "standard_charge_dollar": 289.91, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Ms State Emplo", "plan_name": "401457", "standard_charge_dollar": 289.28, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Ms State Emplo", "plan_name": "401457_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Basic Pl", "plan_name": "400100", "standard_charge_dollar": 289.28, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Basic Pl", "plan_name": "400100_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Federal", "plan_name": "400110", "standard_charge_dollar": 289.28, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Federal", "plan_name": "400110_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Cigna Healthsprings Ffs", "plan_name": "500064", "standard_charge_dollar": 289.91, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Conseco", "plan_name": "500302", "standard_charge_dollar": 289.91, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Humana Ffs 61101", "plan_name": "500006", "standard_charge_dollar": 289.91, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Medicare A", "plan_name": "100100", "standard_charge_dollar": 289.91, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Medicare A", "plan_name": "100500", "standard_charge_dollar": 289.91, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Medicare Part B Only", "plan_name": "100300", "standard_charge_dollar": 289.91, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Medicare Railroad", "plan_name": "100103", "standard_charge_dollar": 289.91, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Ms Physicians Care N", "plan_name": "714210", "standard_charge_dollar": 362.39, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Peoples Hlth Ffs 72126", "plan_name": "500019", "standard_charge_dollar": 289.91, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Uhc/Secure Horizons", "plan_name": "500449", "standard_charge_dollar": 289.91, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "United Health Care/", "plan_name": "500292", "standard_charge_dollar": 327.60, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "United Healthcare", "plan_name": "750104", "standard_charge_dollar": 327.60, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "United Healthcare Ba", "plan_name": "750090", "standard_charge_dollar": 327.60, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "United Healthcare Me", "plan_name": "501310", "standard_charge_dollar": 289.91, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Windsor Mcare Extra", "plan_name": "500778", "standard_charge_dollar": 289.91, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." } ] } ] }, { "description": "Rabies immune globulin (pf) 300 unit/ml intramuscular solution [183101]", "drug_information": { "unit": 1.00, "type": "ML" }, "code_information": [ { "code": "90375", "type": "CPT" }, { "code": "13533-318-10", "type": "NDC" } ], "standard_charges": [ { "gross_charge": 2735.61, "minimum": 289.28, "maximum": 362.39, "setting": "both", "payers_information": [ { "payer_name": "Aarp", "plan_name": "500102", "standard_charge_dollar": 289.91, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna", "plan_name": "700700", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna", "plan_name": "700700_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Mcare Ffs 6005", "plan_name": "700703", "standard_charge_dollar": 289.91, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Miscellaneous", "plan_name": "700720", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Miscellaneous", "plan_name": "700720_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Ppo Hmo", "plan_name": "701720", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Ppo Hmo", "plan_name": "701720_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Ambetter 68069", "plan_name": "500516", "standard_charge_dollar": 289.91, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Ms State Emplo", "plan_name": "401457", "standard_charge_dollar": 289.28, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Ms State Emplo", "plan_name": "401457_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Basic Pl", "plan_name": "400100", "standard_charge_dollar": 289.28, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Basic Pl", "plan_name": "400100_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Federal", "plan_name": "400110", "standard_charge_dollar": 289.28, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Federal", "plan_name": "400110_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Cigna Healthsprings Ffs", "plan_name": "500064", "standard_charge_dollar": 289.91, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Conseco", "plan_name": "500302", "standard_charge_dollar": 289.91, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Humana Ffs 61101", "plan_name": "500006", "standard_charge_dollar": 289.91, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Medicare A", "plan_name": "100100", "standard_charge_dollar": 289.91, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Medicare A", "plan_name": "100500", "standard_charge_dollar": 289.91, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Medicare Part B Only", "plan_name": "100300", "standard_charge_dollar": 289.91, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Medicare Railroad", "plan_name": "100103", "standard_charge_dollar": 289.91, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Ms Physicians Care N", "plan_name": "714210", "standard_charge_dollar": 362.39, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Peoples Hlth Ffs 72126", "plan_name": "500019", "standard_charge_dollar": 289.91, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Uhc/Secure Horizons", "plan_name": "500449", "standard_charge_dollar": 289.91, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "United Health Care/", "plan_name": "500292", "standard_charge_dollar": 327.60, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "United Healthcare", "plan_name": "750104", "standard_charge_dollar": 327.60, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "United Healthcare Ba", "plan_name": "750090", "standard_charge_dollar": 327.60, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "United Healthcare Me", "plan_name": "501310", "standard_charge_dollar": 289.91, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Windsor Mcare Extra", "plan_name": "500778", "standard_charge_dollar": 289.91, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." } ] } ] }, { "description": "Rabies immune globulin (pf) 300 unit/ml intramuscular solution [183101]", "drug_information": { "unit": 5.00, "type": "ML" }, "code_information": [ { "code": "90375", "type": "CPT" }, { "code": "13533-318-50", "type": "NDC" } ], "standard_charges": [ { "gross_charge": 13677.93, "minimum": 289.28, "maximum": 362.39, "setting": "both", "payers_information": [ { "payer_name": "Aarp", "plan_name": "500102", "standard_charge_dollar": 289.91, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna", "plan_name": "700700", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna", "plan_name": "700700_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Mcare Ffs 6005", "plan_name": "700703", "standard_charge_dollar": 289.91, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Miscellaneous", "plan_name": "700720", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Miscellaneous", "plan_name": "700720_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Ppo Hmo", "plan_name": "701720", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Ppo Hmo", "plan_name": "701720_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Ambetter 68069", "plan_name": "500516", "standard_charge_dollar": 289.91, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Ms State Emplo", "plan_name": "401457", "standard_charge_dollar": 289.28, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Ms State Emplo", "plan_name": "401457_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Basic Pl", "plan_name": "400100", "standard_charge_dollar": 289.28, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Basic Pl", "plan_name": "400100_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Federal", "plan_name": "400110", "standard_charge_dollar": 289.28, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Federal", "plan_name": "400110_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Cigna Healthsprings Ffs", "plan_name": "500064", "standard_charge_dollar": 289.91, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Conseco", "plan_name": "500302", "standard_charge_dollar": 289.91, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Humana Ffs 61101", "plan_name": "500006", "standard_charge_dollar": 289.91, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Medicare A", "plan_name": "100100", "standard_charge_dollar": 289.91, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Medicare A", "plan_name": "100500", "standard_charge_dollar": 289.91, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Medicare Part B Only", "plan_name": "100300", "standard_charge_dollar": 289.91, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Medicare Railroad", "plan_name": "100103", "standard_charge_dollar": 289.91, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Ms Physicians Care N", "plan_name": "714210", "standard_charge_dollar": 362.39, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Peoples Hlth Ffs 72126", "plan_name": "500019", "standard_charge_dollar": 289.91, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Uhc/Secure Horizons", "plan_name": "500449", "standard_charge_dollar": 289.91, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "United Health Care/", "plan_name": "500292", "standard_charge_dollar": 327.60, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "United Healthcare", "plan_name": "750104", "standard_charge_dollar": 327.60, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "United Healthcare Ba", "plan_name": "750090", "standard_charge_dollar": 327.60, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "United Healthcare Me", "plan_name": "501310", "standard_charge_dollar": 289.91, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Windsor Mcare Extra", "plan_name": "500778", "standard_charge_dollar": 289.91, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." } ] } ] }, { "description": "Hc admin immunization 1 vaccine", "code_information": [ { "code": "90471", "type": "CPT" } ], "standard_charges": [ { "gross_charge": 143.00, "minimum": 65.20, "maximum": 121.55, "setting": "both", "payers_information": [ { "payer_name": "Aarp", "plan_name": "500102", "standard_charge_dollar": 65.20, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna", "plan_name": "700700", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna", "plan_name": "700700_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Mcare Ffs 6005", "plan_name": "700703", "standard_charge_dollar": 65.20, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Miscellaneous", "plan_name": "700720", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Miscellaneous", "plan_name": "700720_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Ppo Hmo", "plan_name": "701720", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Ppo Hmo", "plan_name": "701720_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Ambetter 68069", "plan_name": "500516", "standard_charge_dollar": 65.20, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Ms State Emplo", "plan_name": "401457", "standard_charge_percentage": 0.80, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Ms State Emplo", "plan_name": "401457_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Basic Pl", "plan_name": "400100", "standard_charge_percentage": 0.85, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Basic Pl", "plan_name": "400100_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Federal", "plan_name": "400110", "standard_charge_percentage": 0.85, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Federal", "plan_name": "400110_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Cigna Healthsprings Ffs", "plan_name": "500064", "standard_charge_dollar": 65.20, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Conseco", "plan_name": "500302", "standard_charge_dollar": 65.20, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Humana Ffs 61101", "plan_name": "500006", "standard_charge_dollar": 65.20, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Medicare A", "plan_name": "100100", "standard_charge_dollar": 65.20, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Medicare A", "plan_name": "100500", "standard_charge_dollar": 65.20, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Medicare Part B Only", "plan_name": "100300", "standard_charge_dollar": 65.20, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Medicare Railroad", "plan_name": "100103", "standard_charge_dollar": 65.20, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Ms Physicians Care N", "plan_name": "714210", "standard_charge_dollar": 81.50, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Peoples Hlth Ffs 72126", "plan_name": "500019", "standard_charge_dollar": 65.20, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Uhc/Secure Horizons", "plan_name": "500449", "standard_charge_dollar": 65.20, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "United Health Care/", "plan_name": "500292", "standard_charge_dollar": 73.67, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "United Healthcare", "plan_name": "750104", "standard_charge_dollar": 73.67, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "United Healthcare Ba", "plan_name": "750090", "standard_charge_dollar": 73.67, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "United Healthcare Me", "plan_name": "501310", "standard_charge_dollar": 65.20, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Windsor Mcare Extra", "plan_name": "500778", "standard_charge_dollar": 65.20, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." } ] } ] }, { "description": "Immunization admin", "code_information": [ { "code": "90471", "type": "CPT" } ], "standard_charges": [ { "gross_charge": 143.00, "minimum": 65.20, "maximum": 121.55, "setting": "both", "payers_information": [ { "payer_name": "Aarp", "plan_name": "500102", "standard_charge_dollar": 65.20, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna", "plan_name": "700700", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna", "plan_name": "700700_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Mcare Ffs 6005", "plan_name": "700703", "standard_charge_dollar": 65.20, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Miscellaneous", "plan_name": "700720", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Miscellaneous", "plan_name": "700720_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Ppo Hmo", "plan_name": "701720", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Ppo Hmo", "plan_name": "701720_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Ambetter 68069", "plan_name": "500516", "standard_charge_dollar": 65.20, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Ms State Emplo", "plan_name": "401457", "standard_charge_percentage": 0.80, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Ms State Emplo", "plan_name": "401457_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Basic Pl", "plan_name": "400100", "standard_charge_percentage": 0.85, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Basic Pl", "plan_name": "400100_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Federal", "plan_name": "400110", "standard_charge_percentage": 0.85, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { 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"payer_name": "Bc/Bs Ms State Emplo", "plan_name": "401457", "standard_charge_percentage": 0.80, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Ms State Emplo", "plan_name": "401457_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Basic Pl", "plan_name": "400100", "standard_charge_percentage": 0.85, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Basic Pl", "plan_name": "400100_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { 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calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Federal", "plan_name": "400110_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." } ] } ] }, { "description": "Meningoco cyw-135 vacc 1 of 2(pf) 5 mcg x3/0.5 ml(final) im solution [169652]", "drug_information": { "unit": 0.50, "type": "ML" }, "code_information": [ { "code": "90620", "type": "CPT" }, { "code": "58160-959-01", "type": "NDC" } ], "standard_charges": [ { "gross_charge": 674.09, "minimum": 148.90, "maximum": 148.90, "setting": "both", "payers_information": [ { "payer_name": "Aetna", "plan_name": "700700", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna", "plan_name": "700700_1", "standard_charge_percentage": 100.0, "count": 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charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Federal", "plan_name": "400110", "standard_charge_dollar": 148.90, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Federal", "plan_name": "400110_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." } ] } ] }, { "description": "Meningococcal b vac4-cmp 50 mcg-50 mcg-50 mcg-25 mcg/0.5ml im syringe [168940]", "drug_information": { "unit": 0.50, "type": "ML" }, "code_information": [ { "code": "90620", "type": "CPT" }, { "code": "58160-976-20", "type": "NDC" } ], "standard_charges": [ { "gross_charge": 1052.50, "minimum": 148.90, "maximum": 148.90, "setting": "both", "payers_information": [ { "payer_name": "Aetna", "plan_name": 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"additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Ppo Hmo", "plan_name": "701720_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Ms State Emplo", "plan_name": "401457", "standard_charge_dollar": 123.15, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Ms State Emplo", "plan_name": "401457_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Basic Pl", "plan_name": "400100", "standard_charge_dollar": 123.15, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Basic Pl", "plan_name": "400100_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Federal", "plan_name": "400110", "standard_charge_dollar": 123.15, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Federal", "plan_name": "400110_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." } ] } ] }, { "description": "Rabies vaccine purified chicken embryo cell (pf) 2.5 unit im susp [22120]", "drug_information": { "unit": 1.00, "type": "EA" }, "code_information": [ { "code": "90675", "type": "CPT" }, { "code": "50632-010-01", "type": "NDC" } ], "standard_charges": [ { "gross_charge": 1657.93, "minimum": 312.86, "maximum": 397.09, "setting": "both", "payers_information": [ { "payer_name": "Aarp", "plan_name": "500102", "standard_charge_dollar": 317.67, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna", "plan_name": "700700", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna", "plan_name": "700700_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Mcare Ffs 6005", "plan_name": "700703", "standard_charge_dollar": 317.67, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Miscellaneous", "plan_name": "700720", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Miscellaneous", "plan_name": "700720_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Ppo Hmo", "plan_name": "701720", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Ppo Hmo", "plan_name": "701720_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Ambetter 68069", "plan_name": "500516", "standard_charge_dollar": 317.67, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Ms State Emplo", "plan_name": "401457", "standard_charge_dollar": 312.86, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Ms State Emplo", "plan_name": "401457_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Basic Pl", "plan_name": "400100", "standard_charge_dollar": 312.86, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Basic Pl", "plan_name": "400100_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Federal", "plan_name": "400110", "standard_charge_dollar": 312.86, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Federal", "plan_name": "400110_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Cigna Healthsprings Ffs", "plan_name": "500064", "standard_charge_dollar": 317.67, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Conseco", "plan_name": "500302", "standard_charge_dollar": 317.67, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Humana Ffs 61101", "plan_name": "500006", "standard_charge_dollar": 317.67, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Medicare A", "plan_name": "100100", "standard_charge_dollar": 317.67, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Medicare A", "plan_name": "100500", "standard_charge_dollar": 317.67, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Medicare Part B Only", "plan_name": "100300", "standard_charge_dollar": 317.67, "count": "0", "methodology": "fee schedule", "additional_payer_notes": 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"fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." } ] } ] }, { "description": "Rabies vaccine purified chicken embryo cell (pf) 2.5 unit im susp [22120]", "drug_information": { "unit": 1.00, "type": "EA" }, "code_information": [ { "code": "90675", "type": "CPT" }, { "code": "58160-964-12", "type": "NDC" } ], "standard_charges": [ { "gross_charge": 1518.27, "minimum": 312.86, "maximum": 397.09, "setting": "both", "payers_information": [ { "payer_name": "Aarp", "plan_name": "500102", "standard_charge_dollar": 317.67, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna", "plan_name": "700700", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna", "plan_name": "700700_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Mcare Ffs 6005", "plan_name": "700703", "standard_charge_dollar": 317.67, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Miscellaneous", "plan_name": "700720", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Miscellaneous", "plan_name": "700720_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Ppo Hmo", "plan_name": "701720", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Ppo Hmo", "plan_name": "701720_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Ambetter 68069", "plan_name": "500516", "standard_charge_dollar": 317.67, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Ms State Emplo", "plan_name": "401457", "standard_charge_dollar": 312.86, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Ms State Emplo", "plan_name": "401457_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Basic Pl", "plan_name": "400100", "standard_charge_dollar": 312.86, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Basic Pl", "plan_name": "400100_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Federal", "plan_name": "400110", "standard_charge_dollar": 312.86, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Federal", "plan_name": "400110_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Cigna Healthsprings Ffs", "plan_name": "500064", "standard_charge_dollar": 317.67, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Conseco", "plan_name": "500302", "standard_charge_dollar": 317.67, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Humana Ffs 61101", "plan_name": "500006", "standard_charge_dollar": 317.67, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Medicare A", "plan_name": "100100", "standard_charge_dollar": 317.67, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Medicare A", "plan_name": "100500", "standard_charge_dollar": 317.67, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Medicare Part B Only", "plan_name": "100300", "standard_charge_dollar": 317.67, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Medicare Railroad", "plan_name": "100103", "standard_charge_dollar": 317.67, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Ms Physicians Care N", "plan_name": "714210", "standard_charge_dollar": 397.09, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Peoples Hlth Ffs 72126", "plan_name": "500019", "standard_charge_dollar": 317.67, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Uhc/Secure Horizons", "plan_name": "500449", "standard_charge_dollar": 317.67, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "United Health Care/", "plan_name": "500292", "standard_charge_dollar": 358.97, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "United Healthcare", "plan_name": "750104", "standard_charge_dollar": 358.97, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "United Healthcare Ba", "plan_name": "750090", "standard_charge_dollar": 358.97, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "United Healthcare Me", "plan_name": "501310", "standard_charge_dollar": 317.67, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Windsor Mcare Extra", "plan_name": "500778", "standard_charge_dollar": 317.67, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." } ] } ] }, { "description": "Rabies vaccine purified chicken embryo cell (pf) 2.5 unit im susp [22120]", "drug_information": { "unit": 1.00, "type": "EA" }, "code_information": [ { "code": "90675", "type": "CPT" }, { "code": "58160-966-01", "type": "NDC" } ], "standard_charges": [ { "gross_charge": 1518.27, "minimum": 312.86, "maximum": 397.09, "setting": "both", "payers_information": [ { "payer_name": "Aarp", "plan_name": "500102", "standard_charge_dollar": 317.67, "count": "0", "methodology": "fee schedule", "additional_payer_notes": 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}, { "payer_name": "Aetna Miscellaneous", "plan_name": "700720_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Ppo Hmo", "plan_name": "701720", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Ppo Hmo", "plan_name": "701720_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Ambetter 68069", "plan_name": "500516", "standard_charge_dollar": 317.67, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Ms State Emplo", "plan_name": "401457", "standard_charge_dollar": 312.86, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Ms State Emplo", "plan_name": "401457_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Basic Pl", "plan_name": "400100", "standard_charge_dollar": 312.86, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Basic Pl", "plan_name": "400100_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Federal", "plan_name": "400110", "standard_charge_dollar": 312.86, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Federal", "plan_name": "400110_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Cigna Healthsprings Ffs", "plan_name": "500064", "standard_charge_dollar": 317.67, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Conseco", "plan_name": "500302", "standard_charge_dollar": 317.67, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Humana Ffs 61101", "plan_name": "500006", "standard_charge_dollar": 317.67, "count": "0", "methodology": "fee schedule", 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"additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Ms State Emplo", "plan_name": "401457", "standard_charge_dollar": 188.94, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Ms State Emplo", "plan_name": "401457_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Basic Pl", "plan_name": "400100", "standard_charge_dollar": 188.94, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Basic Pl", "plan_name": "400100_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Federal", "plan_name": "400110", "standard_charge_dollar": 188.94, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Federal", "plan_name": "400110_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Cigna Healthsprings Ffs", "plan_name": "500064", "standard_charge_dollar": 374.26, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Conseco", "plan_name": "500302", "standard_charge_dollar": 374.26, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Humana Ffs 61101", "plan_name": "500006", "standard_charge_dollar": 374.26, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Medicare A", "plan_name": "100100", "standard_charge_dollar": 374.26, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Medicare A", "plan_name": "100500", "standard_charge_dollar": 374.26, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Medicare Part B Only", "plan_name": "100300", "standard_charge_dollar": 374.26, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Medicare Railroad", "plan_name": "100103", "standard_charge_dollar": 374.26, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Ms Physicians Care N", "plan_name": "714210", "standard_charge_dollar": 467.83, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Peoples Hlth Ffs 72126", "plan_name": "500019", "standard_charge_dollar": 374.26, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Uhc/Secure Horizons", "plan_name": "500449", "standard_charge_dollar": 374.26, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "United Health Care/", "plan_name": "500292", "standard_charge_dollar": 422.91, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "United Healthcare", "plan_name": "750104", "standard_charge_dollar": 422.91, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "United Healthcare Ba", "plan_name": "750090", "standard_charge_dollar": 422.91, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "United Healthcare Me", "plan_name": "501310", "standard_charge_dollar": 374.26, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Windsor Mcare Extra", "plan_name": "500778", "standard_charge_dollar": 374.26, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." } ] } ] }, { "description": "Psytx w pt 60 minutes", "code_information": [ { "code": "90837", "type": "CPT" } ], "standard_charges": [ { "gross_charge": 300.00, "minimum": 188.94, "maximum": 467.83, "setting": "both", "payers_information": [ { "payer_name": "Aarp", "plan_name": "500102", "standard_charge_dollar": 374.26, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna", "plan_name": "700700", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna", "plan_name": "700700_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Mcare Ffs 6005", "plan_name": "700703", "standard_charge_dollar": 374.26, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Miscellaneous", "plan_name": "700720", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Miscellaneous", "plan_name": "700720_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Ppo Hmo", "plan_name": "701720", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Ppo Hmo", "plan_name": "701720_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Ambetter 68069", "plan_name": "500516", "standard_charge_dollar": 374.26, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Ms State Emplo", "plan_name": "401457", "standard_charge_dollar": 188.94, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Ms State Emplo", "plan_name": "401457_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Basic Pl", "plan_name": "400100", "standard_charge_dollar": 188.94, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Basic Pl", "plan_name": "400100_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Federal", "plan_name": "400110", "standard_charge_dollar": 188.94, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Federal", "plan_name": "400110_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Cigna Healthsprings Ffs", "plan_name": "500064", "standard_charge_dollar": 374.26, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Conseco", "plan_name": "500302", "standard_charge_dollar": 374.26, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Humana Ffs 61101", "plan_name": "500006", "standard_charge_dollar": 374.26, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Medicare A", "plan_name": "100100", "standard_charge_dollar": 374.26, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Medicare A", "plan_name": "100500", "standard_charge_dollar": 374.26, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Medicare Part B Only", "plan_name": "100300", "standard_charge_dollar": 374.26, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Medicare Railroad", "plan_name": "100103", "standard_charge_dollar": 374.26, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Ms Physicians Care N", "plan_name": "714210", "standard_charge_dollar": 467.83, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Peoples Hlth Ffs 72126", "plan_name": "500019", "standard_charge_dollar": 374.26, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Uhc/Secure Horizons", "plan_name": "500449", "standard_charge_dollar": 374.26, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "United Health Care/", "plan_name": "500292", "standard_charge_dollar": 422.91, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "United Healthcare", "plan_name": "750104", "standard_charge_dollar": 422.91, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "United Healthcare Ba", "plan_name": "750090", "standard_charge_dollar": 422.91, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "United Healthcare Me", "plan_name": "501310", "standard_charge_dollar": 374.26, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Windsor Mcare Extra", "plan_name": "500778", "standard_charge_dollar": 374.26, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." } ] } ] }, { "description": "Group psychotherapy", "code_information": [ { "code": "90853", "type": "CPT" } ], "standard_charges": [ { "gross_charge": 350.00, "minimum": 105.35, "maximum": 467.83, "setting": "both", "payers_information": [ { "payer_name": "Aarp", "plan_name": "500102", "standard_charge_dollar": 374.26, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna", "plan_name": "700700", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna", "plan_name": "700700_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Mcare Ffs 6005", "plan_name": "700703", "standard_charge_dollar": 374.26, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Miscellaneous", "plan_name": "700720", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Miscellaneous", "plan_name": "700720_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Ppo Hmo", "plan_name": "701720", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Ppo Hmo", "plan_name": "701720_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Ambetter 68069", "plan_name": "500516", "standard_charge_dollar": 374.26, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Ms State Emplo", "plan_name": "401457", "standard_charge_dollar": 105.35, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Ms State Emplo", "plan_name": "401457_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Basic Pl", "plan_name": "400100", "standard_charge_dollar": 105.35, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Basic Pl", "plan_name": "400100_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Federal", "plan_name": "400110", "standard_charge_dollar": 105.35, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Federal", "plan_name": "400110_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Cigna Healthsprings Ffs", "plan_name": "500064", "standard_charge_dollar": 374.26, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Conseco", "plan_name": "500302", "standard_charge_dollar": 374.26, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Humana Ffs 61101", "plan_name": "500006", "standard_charge_dollar": 374.26, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Medicare A", "plan_name": "100100", "standard_charge_dollar": 374.26, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Medicare A", "plan_name": "100500", "standard_charge_dollar": 374.26, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Medicare Part B Only", "plan_name": "100300", "standard_charge_dollar": 374.26, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Medicare Railroad", "plan_name": "100103", "standard_charge_dollar": 374.26, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Ms Physicians Care N", "plan_name": "714210", "standard_charge_dollar": 467.83, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Peoples Hlth Ffs 72126", "plan_name": "500019", "standard_charge_dollar": 374.26, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Uhc/Secure Horizons", "plan_name": "500449", "standard_charge_dollar": 374.26, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "United Health Care/", "plan_name": "500292", "standard_charge_dollar": 422.91, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "United Healthcare", "plan_name": "750104", "standard_charge_dollar": 422.91, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "United Healthcare Ba", "plan_name": "750090", "standard_charge_dollar": 422.91, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "United Healthcare Me", "plan_name": "501310", "standard_charge_dollar": 374.26, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Windsor Mcare Extra", "plan_name": "500778", "standard_charge_dollar": 374.26, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." } ] } ] }, { "description": "Hc group psychotherapy", "code_information": [ { "code": "90853", "type": "CPT" } ], "standard_charges": [ { "gross_charge": 350.00, "minimum": 105.35, "maximum": 467.83, "setting": "both", "payers_information": [ { "payer_name": "Aarp", "plan_name": "500102", "standard_charge_dollar": 374.26, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna", "plan_name": "700700", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna", "plan_name": "700700_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Mcare Ffs 6005", "plan_name": "700703", "standard_charge_dollar": 374.26, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Miscellaneous", "plan_name": "700720", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Miscellaneous", "plan_name": "700720_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Ppo Hmo", "plan_name": "701720", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Ppo Hmo", "plan_name": "701720_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Ambetter 68069", "plan_name": "500516", "standard_charge_dollar": 374.26, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Ms State Emplo", "plan_name": "401457", "standard_charge_dollar": 105.35, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Ms State Emplo", "plan_name": "401457_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Basic Pl", "plan_name": "400100", "standard_charge_dollar": 105.35, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Basic Pl", "plan_name": "400100_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Federal", "plan_name": "400110", "standard_charge_dollar": 105.35, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Federal", "plan_name": "400110_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Cigna Healthsprings Ffs", "plan_name": "500064", "standard_charge_dollar": 374.26, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Conseco", "plan_name": "500302", "standard_charge_dollar": 374.26, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Humana Ffs 61101", "plan_name": "500006", "standard_charge_dollar": 374.26, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Medicare A", "plan_name": "100100", "standard_charge_dollar": 374.26, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Medicare A", "plan_name": "100500", "standard_charge_dollar": 374.26, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Medicare Part B Only", "plan_name": "100300", "standard_charge_dollar": 374.26, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Medicare Railroad", "plan_name": "100103", "standard_charge_dollar": 374.26, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Ms Physicians Care N", "plan_name": "714210", "standard_charge_dollar": 467.83, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Peoples Hlth Ffs 72126", "plan_name": "500019", "standard_charge_dollar": 374.26, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Uhc/Secure Horizons", "plan_name": "500449", "standard_charge_dollar": 374.26, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "United Health Care/", "plan_name": "500292", "standard_charge_dollar": 422.91, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "United Healthcare", "plan_name": "750104", "standard_charge_dollar": 422.91, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "United Healthcare Ba", "plan_name": "750090", "standard_charge_dollar": 422.91, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "United Healthcare Me", "plan_name": "501310", "standard_charge_dollar": 374.26, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Windsor Mcare Extra", "plan_name": "500778", "standard_charge_dollar": 374.26, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." } ] } ] }, { "description": "Covid vacc 2024-25 (12 yrs up) (moderna)(pf) 50 mcg/0.5 ml im syringe [508018]", "drug_information": { "unit": 0.50, "type": "ML" }, "code_information": [ { "code": "91322", "type": "CPT" }, { "code": "80777-110-96", "type": "NDC" } ], "standard_charges": [ { "gross_charge": 709.00, "minimum": 567.20, "maximum": 602.65, "setting": "both", "payers_information": [ { "payer_name": "Aetna", "plan_name": "700700", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna", "plan_name": "700700_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Miscellaneous", "plan_name": "700720", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Miscellaneous", "plan_name": "700720_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Ppo Hmo", "plan_name": "701720", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Ppo Hmo", "plan_name": "701720_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Ms State Emplo", "plan_name": "401457", "standard_charge_percentage": 0.80, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Ms State Emplo", "plan_name": "401457_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Basic Pl", "plan_name": "400100", "standard_charge_percentage": 0.85, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Basic Pl", "plan_name": "400100_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Federal", "plan_name": "400110", "standard_charge_percentage": 0.85, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Federal", "plan_name": "400110_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." } ] } ] }, { "description": "Hc speech/hearing therapy indiv", "code_information": [ { "code": "92507", "type": "CPT" } ], "standard_charges": [ { "gross_charge": 200.00, "minimum": 70.08, "maximum": 87.60, "setting": "both", "payers_information": [ { "payer_name": "Aarp", "plan_name": "500102", "standard_charge_dollar": 70.08, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna", "plan_name": "700700", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna", "plan_name": "700700_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Mcare Ffs 6005", "plan_name": "700703", "standard_charge_dollar": 70.08, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Miscellaneous", "plan_name": "700720", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Miscellaneous", "plan_name": "700720_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Ppo Hmo", "plan_name": "701720", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Ppo Hmo", "plan_name": "701720_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Ambetter 68069", "plan_name": "500516", "standard_charge_dollar": 70.08, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Ms State Emplo", "plan_name": "401457", "standard_charge_dollar": 86.16, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Ms State Emplo", "plan_name": "401457_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Basic Pl", "plan_name": "400100", "standard_charge_dollar": 86.16, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Basic Pl", "plan_name": "400100_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Federal", "plan_name": "400110", "standard_charge_dollar": 86.16, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Federal", "plan_name": "400110_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Cigna Healthsprings Ffs", "plan_name": "500064", "standard_charge_dollar": 70.08, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Conseco", "plan_name": "500302", "standard_charge_dollar": 70.08, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Humana Ffs 61101", "plan_name": "500006", "standard_charge_dollar": 70.08, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Medicare A", "plan_name": "100100", "standard_charge_dollar": 70.08, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Medicare A", "plan_name": "100500", "standard_charge_dollar": 70.08, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Medicare Part B Only", "plan_name": "100300", "standard_charge_dollar": 70.08, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Medicare Railroad", "plan_name": "100103", "standard_charge_dollar": 70.08, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Ms Physicians Care N", "plan_name": "714210", "standard_charge_dollar": 87.60, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Peoples Hlth Ffs 72126", "plan_name": "500019", "standard_charge_dollar": 70.08, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Uhc/Secure Horizons", "plan_name": "500449", "standard_charge_dollar": 70.08, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "United Health Care/", "plan_name": "500292", "standard_charge_dollar": 79.19, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "United Healthcare", "plan_name": "750104", "standard_charge_dollar": 79.19, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "United Healthcare Ba", "plan_name": "750090", "standard_charge_dollar": 79.19, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "United Healthcare Me", "plan_name": "501310", "standard_charge_dollar": 70.08, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Windsor Mcare Extra", "plan_name": "500778", "standard_charge_dollar": 70.08, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." } ] } ] }, { "description": "Speech/hearing therapy", "code_information": [ { "code": "92507", "type": "CPT" } ], "standard_charges": [ { "gross_charge": 200.00, "minimum": 70.08, "maximum": 87.60, "setting": "both", "payers_information": [ { "payer_name": "Aarp", "plan_name": "500102", "standard_charge_dollar": 70.08, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna", "plan_name": "700700", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna", "plan_name": "700700_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Mcare Ffs 6005", "plan_name": "700703", "standard_charge_dollar": 70.08, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Miscellaneous", "plan_name": "700720", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Miscellaneous", "plan_name": "700720_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Ppo Hmo", "plan_name": "701720", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Ppo Hmo", "plan_name": "701720_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Ambetter 68069", "plan_name": "500516", "standard_charge_dollar": 70.08, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Ms State Emplo", "plan_name": "401457", "standard_charge_dollar": 86.16, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Ms State Emplo", "plan_name": "401457_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Basic Pl", "plan_name": "400100", "standard_charge_dollar": 86.16, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Basic Pl", "plan_name": "400100_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Federal", "plan_name": "400110", "standard_charge_dollar": 86.16, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Federal", "plan_name": "400110_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Cigna Healthsprings Ffs", "plan_name": "500064", "standard_charge_dollar": 70.08, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Conseco", "plan_name": "500302", "standard_charge_dollar": 70.08, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Humana Ffs 61101", "plan_name": "500006", "standard_charge_dollar": 70.08, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Medicare A", "plan_name": "100100", "standard_charge_dollar": 70.08, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Medicare A", "plan_name": "100500", "standard_charge_dollar": 70.08, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Medicare Part B Only", "plan_name": "100300", "standard_charge_dollar": 70.08, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Medicare Railroad", "plan_name": "100103", "standard_charge_dollar": 70.08, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Ms Physicians Care N", "plan_name": "714210", "standard_charge_dollar": 87.60, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Peoples Hlth Ffs 72126", "plan_name": "500019", "standard_charge_dollar": 70.08, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Uhc/Secure Horizons", "plan_name": "500449", "standard_charge_dollar": 70.08, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "United Health Care/", "plan_name": "500292", "standard_charge_dollar": 79.19, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "United Healthcare", "plan_name": "750104", "standard_charge_dollar": 79.19, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "United Healthcare Ba", "plan_name": "750090", "standard_charge_dollar": 79.19, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "United Healthcare Me", "plan_name": "501310", "standard_charge_dollar": 70.08, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Windsor Mcare Extra", "plan_name": "500778", "standard_charge_dollar": 70.08, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." } ] } ] }, { "description": "Hc speech sound lang comprehen", "code_information": [ { "code": "92523", "type": "CPT" } ], "standard_charges": [ { "gross_charge": 300.00, "minimum": 185.00, "maximum": 260.69, "setting": "both", "payers_information": [ { "payer_name": "Aarp", "plan_name": "500102", "standard_charge_dollar": 208.55, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna", "plan_name": "700700", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna", "plan_name": "700700_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Mcare Ffs 6005", "plan_name": "700703", "standard_charge_dollar": 208.55, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Miscellaneous", "plan_name": "700720", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Miscellaneous", "plan_name": "700720_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Ppo Hmo", "plan_name": "701720", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Ppo Hmo", "plan_name": "701720_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Ambetter 68069", "plan_name": "500516", "standard_charge_dollar": 208.55, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Ms State Emplo", "plan_name": "401457", "standard_charge_dollar": 185.00, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Ms State Emplo", "plan_name": "401457_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Basic Pl", "plan_name": "400100", "standard_charge_dollar": 185.00, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Basic Pl", "plan_name": "400100_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Federal", "plan_name": "400110", "standard_charge_dollar": 185.00, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Federal", "plan_name": "400110_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Cigna Healthsprings Ffs", "plan_name": "500064", "standard_charge_dollar": 208.55, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Conseco", "plan_name": "500302", "standard_charge_dollar": 208.55, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Humana Ffs 61101", "plan_name": "500006", "standard_charge_dollar": 208.55, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Medicare A", "plan_name": "100100", "standard_charge_dollar": 208.55, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Medicare A", "plan_name": "100500", "standard_charge_dollar": 208.55, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Medicare Part B Only", "plan_name": "100300", "standard_charge_dollar": 208.55, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Medicare Railroad", "plan_name": "100103", "standard_charge_dollar": 208.55, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Ms Physicians Care N", "plan_name": "714210", "standard_charge_dollar": 260.69, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Peoples Hlth Ffs 72126", "plan_name": "500019", "standard_charge_dollar": 208.55, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Uhc/Secure Horizons", "plan_name": "500449", "standard_charge_dollar": 208.55, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "United Health Care/", "plan_name": "500292", "standard_charge_dollar": 235.66, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "United Healthcare", "plan_name": "750104", "standard_charge_dollar": 235.66, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "United Healthcare Ba", "plan_name": "750090", "standard_charge_dollar": 235.66, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "United Healthcare Me", "plan_name": "501310", "standard_charge_dollar": 208.55, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Windsor Mcare Extra", "plan_name": "500778", "standard_charge_dollar": 208.55, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." } ] } ] }, { "description": "Speech sound lang comprehen", "code_information": [ { "code": "92523", "type": "CPT" } ], "standard_charges": [ { "gross_charge": 300.00, "minimum": 185.00, "maximum": 260.69, "setting": "both", "payers_information": [ { "payer_name": "Aarp", "plan_name": "500102", "standard_charge_dollar": 208.55, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna", "plan_name": "700700", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna", "plan_name": "700700_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Mcare Ffs 6005", "plan_name": "700703", "standard_charge_dollar": 208.55, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Miscellaneous", "plan_name": "700720", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Miscellaneous", "plan_name": "700720_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Ppo Hmo", "plan_name": "701720", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Ppo Hmo", "plan_name": "701720_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Ambetter 68069", "plan_name": "500516", "standard_charge_dollar": 208.55, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Ms State Emplo", "plan_name": "401457", "standard_charge_dollar": 185.00, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Ms State Emplo", "plan_name": "401457_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Basic Pl", "plan_name": "400100", "standard_charge_dollar": 185.00, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Basic Pl", "plan_name": "400100_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Federal", "plan_name": "400110", "standard_charge_dollar": 185.00, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Federal", "plan_name": "400110_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Cigna Healthsprings Ffs", "plan_name": "500064", "standard_charge_dollar": 208.55, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Conseco", "plan_name": "500302", "standard_charge_dollar": 208.55, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Humana Ffs 61101", "plan_name": "500006", "standard_charge_dollar": 208.55, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Medicare A", "plan_name": "100100", "standard_charge_dollar": 208.55, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Medicare A", "plan_name": "100500", "standard_charge_dollar": 208.55, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Medicare Part B Only", "plan_name": "100300", "standard_charge_dollar": 208.55, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Medicare Railroad", "plan_name": "100103", "standard_charge_dollar": 208.55, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Ms Physicians Care N", "plan_name": "714210", "standard_charge_dollar": 260.69, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Peoples Hlth Ffs 72126", "plan_name": "500019", "standard_charge_dollar": 208.55, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Uhc/Secure Horizons", "plan_name": "500449", "standard_charge_dollar": 208.55, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "United Health Care/", "plan_name": "500292", "standard_charge_dollar": 235.66, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "United Healthcare", "plan_name": "750104", "standard_charge_dollar": 235.66, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "United Healthcare Ba", "plan_name": "750090", "standard_charge_dollar": 235.66, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "United Healthcare Me", "plan_name": "501310", "standard_charge_dollar": 208.55, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Windsor Mcare Extra", "plan_name": "500778", "standard_charge_dollar": 208.55, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." } ] } ] }, { "description": "Behavral qualit analys voice", "code_information": [ { "code": "92524", "type": "CPT" } ], "standard_charges": [ { "gross_charge": 350.00, "minimum": 93.00, "maximum": 125.00, "setting": "both", "payers_information": [ { "payer_name": "Aarp", "plan_name": "500102", "standard_charge_dollar": 100.00, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna", "plan_name": "700700", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna", "plan_name": "700700_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Mcare Ffs 6005", "plan_name": "700703", "standard_charge_dollar": 100.00, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Miscellaneous", "plan_name": "700720", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Miscellaneous", "plan_name": "700720_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Ppo Hmo", "plan_name": "701720", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Ppo Hmo", "plan_name": "701720_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Ambetter 68069", "plan_name": "500516", "standard_charge_dollar": 100.00, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Ms State Emplo", "plan_name": "401457", "standard_charge_dollar": 93.00, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Ms State Emplo", "plan_name": "401457_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Basic Pl", "plan_name": "400100", "standard_charge_dollar": 93.00, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Basic Pl", "plan_name": "400100_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Federal", "plan_name": "400110", "standard_charge_dollar": 93.00, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Federal", "plan_name": "400110_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Cigna Healthsprings Ffs", "plan_name": "500064", "standard_charge_dollar": 100.00, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Conseco", "plan_name": "500302", "standard_charge_dollar": 100.00, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Humana Ffs 61101", "plan_name": "500006", "standard_charge_dollar": 100.00, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Medicare A", "plan_name": "100100", "standard_charge_dollar": 100.00, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Medicare A", "plan_name": "100500", "standard_charge_dollar": 100.00, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Medicare Part B Only", "plan_name": "100300", "standard_charge_dollar": 100.00, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Medicare Railroad", "plan_name": "100103", "standard_charge_dollar": 100.00, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Ms Physicians Care N", "plan_name": "714210", "standard_charge_dollar": 125.00, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Peoples Hlth Ffs 72126", "plan_name": "500019", "standard_charge_dollar": 100.00, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Uhc/Secure Horizons", "plan_name": "500449", "standard_charge_dollar": 100.00, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "United Health Care/", "plan_name": "500292", "standard_charge_dollar": 113.00, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "United Healthcare", "plan_name": "750104", "standard_charge_dollar": 113.00, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "United Healthcare Ba", "plan_name": "750090", "standard_charge_dollar": 113.00, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "United Healthcare Me", "plan_name": "501310", "standard_charge_dollar": 100.00, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Windsor Mcare Extra", "plan_name": "500778", "standard_charge_dollar": 100.00, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." } ] } ] }, { "description": "Hc behavrl qual analy voice", "code_information": [ { "code": "92524", "type": "CPT" } ], "standard_charges": [ { "gross_charge": 350.00, "minimum": 93.00, "maximum": 125.00, "setting": "both", "payers_information": [ { "payer_name": "Aarp", "plan_name": "500102", "standard_charge_dollar": 100.00, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna", "plan_name": "700700", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna", "plan_name": "700700_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Mcare Ffs 6005", "plan_name": "700703", "standard_charge_dollar": 100.00, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Miscellaneous", "plan_name": "700720", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Miscellaneous", "plan_name": "700720_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Ppo Hmo", "plan_name": "701720", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Ppo Hmo", "plan_name": "701720_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Ambetter 68069", "plan_name": "500516", "standard_charge_dollar": 100.00, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Ms State Emplo", "plan_name": "401457", "standard_charge_dollar": 93.00, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Ms State Emplo", "plan_name": "401457_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Basic Pl", "plan_name": "400100", "standard_charge_dollar": 93.00, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Basic Pl", "plan_name": "400100_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Federal", "plan_name": "400110", "standard_charge_dollar": 93.00, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Federal", "plan_name": "400110_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Cigna Healthsprings Ffs", "plan_name": "500064", "standard_charge_dollar": 100.00, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Conseco", "plan_name": "500302", "standard_charge_dollar": 100.00, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Humana Ffs 61101", "plan_name": "500006", "standard_charge_dollar": 100.00, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Medicare A", "plan_name": "100100", "standard_charge_dollar": 100.00, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Medicare A", "plan_name": "100500", "standard_charge_dollar": 100.00, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Medicare Part B Only", "plan_name": "100300", "standard_charge_dollar": 100.00, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Medicare Railroad", "plan_name": "100103", "standard_charge_dollar": 100.00, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Ms Physicians Care N", "plan_name": "714210", "standard_charge_dollar": 125.00, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Peoples Hlth Ffs 72126", "plan_name": "500019", "standard_charge_dollar": 100.00, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Uhc/Secure Horizons", "plan_name": "500449", "standard_charge_dollar": 100.00, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "United Health Care/", "plan_name": "500292", "standard_charge_dollar": 113.00, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "United Healthcare", "plan_name": "750104", "standard_charge_dollar": 113.00, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "United Healthcare Ba", "plan_name": "750090", "standard_charge_dollar": 113.00, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "United Healthcare Me", "plan_name": "501310", "standard_charge_dollar": 100.00, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Windsor Mcare Extra", "plan_name": "500778", "standard_charge_dollar": 100.00, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." } ] } ] }, { "description": "Hc st swallowing therapy", "code_information": [ { "code": "92526", "type": "CPT" } ], "standard_charges": [ { "gross_charge": 125.00, "minimum": 76.89, "maximum": 96.11, "setting": "both", "payers_information": [ { "payer_name": "Aarp", "plan_name": "500102", "standard_charge_dollar": 76.89, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna", "plan_name": "700700", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna", "plan_name": "700700_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Mcare Ffs 6005", "plan_name": "700703", "standard_charge_dollar": 76.89, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Miscellaneous", "plan_name": "700720", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Miscellaneous", "plan_name": "700720_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Ppo Hmo", "plan_name": "701720", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Ppo Hmo", "plan_name": "701720_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Ambetter 68069", "plan_name": "500516", "standard_charge_dollar": 76.89, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Ms State Emplo", "plan_name": "401457", "standard_charge_dollar": 93.53, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Ms State Emplo", "plan_name": "401457_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Basic Pl", "plan_name": "400100", "standard_charge_dollar": 93.53, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Basic Pl", "plan_name": "400100_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Federal", "plan_name": "400110", "standard_charge_dollar": 93.53, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Federal", "plan_name": "400110_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Cigna Healthsprings Ffs", "plan_name": "500064", "standard_charge_dollar": 76.89, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Conseco", "plan_name": "500302", "standard_charge_dollar": 76.89, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Humana Ffs 61101", "plan_name": "500006", "standard_charge_dollar": 76.89, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Medicare A", "plan_name": "100100", "standard_charge_dollar": 76.89, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Medicare A", "plan_name": "100500", "standard_charge_dollar": 76.89, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Medicare Part B Only", "plan_name": "100300", "standard_charge_dollar": 76.89, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Medicare Railroad", "plan_name": "100103", "standard_charge_dollar": 76.89, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Ms Physicians Care N", "plan_name": "714210", "standard_charge_dollar": 96.11, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Peoples Hlth Ffs 72126", "plan_name": "500019", "standard_charge_dollar": 76.89, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Uhc/Secure Horizons", "plan_name": "500449", "standard_charge_dollar": 76.89, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "United Health Care/", "plan_name": "500292", "standard_charge_dollar": 86.89, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "United Healthcare", "plan_name": "750104", "standard_charge_dollar": 86.89, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "United Healthcare Ba", "plan_name": "750090", "standard_charge_dollar": 86.89, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "United Healthcare Me", "plan_name": "501310", "standard_charge_dollar": 76.89, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Windsor Mcare Extra", "plan_name": "500778", "standard_charge_dollar": 76.89, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." } ] } ] }, { "description": "Oral function therapy", "code_information": [ { "code": "92526", "type": "CPT" } ], "standard_charges": [ { "gross_charge": 125.00, "minimum": 76.89, "maximum": 96.11, "setting": "both", "payers_information": [ { "payer_name": "Aarp", "plan_name": "500102", "standard_charge_dollar": 76.89, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna", "plan_name": "700700", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna", "plan_name": "700700_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Mcare Ffs 6005", "plan_name": "700703", "standard_charge_dollar": 76.89, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Miscellaneous", "plan_name": "700720", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Miscellaneous", "plan_name": "700720_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Ppo Hmo", "plan_name": "701720", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Ppo Hmo", "plan_name": "701720_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Ambetter 68069", "plan_name": "500516", "standard_charge_dollar": 76.89, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Ms State Emplo", "plan_name": "401457", "standard_charge_dollar": 93.53, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Ms State Emplo", "plan_name": "401457_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Basic Pl", "plan_name": "400100", "standard_charge_dollar": 93.53, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Basic Pl", "plan_name": "400100_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Federal", "plan_name": "400110", "standard_charge_dollar": 93.53, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Federal", "plan_name": "400110_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Cigna Healthsprings Ffs", "plan_name": "500064", "standard_charge_dollar": 76.89, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Conseco", "plan_name": "500302", "standard_charge_dollar": 76.89, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Humana Ffs 61101", "plan_name": "500006", "standard_charge_dollar": 76.89, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Medicare A", "plan_name": "100100", "standard_charge_dollar": 76.89, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Medicare A", "plan_name": "100500", "standard_charge_dollar": 76.89, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Medicare Part B Only", "plan_name": "100300", "standard_charge_dollar": 76.89, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Medicare Railroad", "plan_name": "100103", "standard_charge_dollar": 76.89, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Ms Physicians Care N", "plan_name": "714210", "standard_charge_dollar": 96.11, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Peoples Hlth Ffs 72126", "plan_name": "500019", "standard_charge_dollar": 76.89, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Uhc/Secure Horizons", "plan_name": "500449", "standard_charge_dollar": 76.89, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "United Health Care/", "plan_name": "500292", "standard_charge_dollar": 86.89, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "United Healthcare", "plan_name": "750104", "standard_charge_dollar": 86.89, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "United Healthcare Ba", "plan_name": "750090", "standard_charge_dollar": 86.89, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "United Healthcare Me", "plan_name": "501310", "standard_charge_dollar": 76.89, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Windsor Mcare Extra", "plan_name": "500778", "standard_charge_dollar": 76.89, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." } ] } ] }, { "description": "Evaluate swallowing function", "code_information": [ { "code": "92610", "type": "CPT" } ], "standard_charges": [ { "gross_charge": 200.00, "minimum": 64.82, "maximum": 81.03, "setting": "both", "payers_information": [ { "payer_name": "Aarp", "plan_name": "500102", "standard_charge_dollar": 64.82, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna", "plan_name": "700700", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna", "plan_name": "700700_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Mcare Ffs 6005", "plan_name": "700703", "standard_charge_dollar": 64.82, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Miscellaneous", "plan_name": "700720", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Miscellaneous", "plan_name": "700720_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Ppo Hmo", "plan_name": "701720", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Ppo Hmo", "plan_name": "701720_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Ambetter 68069", "plan_name": "500516", "standard_charge_dollar": 64.82, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Ms State Emplo", "plan_name": "401457", "standard_charge_dollar": 80.28, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Ms State Emplo", "plan_name": "401457_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Basic Pl", "plan_name": "400100", "standard_charge_dollar": 80.28, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Basic Pl", "plan_name": "400100_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Federal", "plan_name": "400110", "standard_charge_dollar": 80.28, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Federal", "plan_name": "400110_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Cigna Healthsprings Ffs", "plan_name": "500064", "standard_charge_dollar": 64.82, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Conseco", "plan_name": "500302", "standard_charge_dollar": 64.82, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Humana Ffs 61101", "plan_name": "500006", "standard_charge_dollar": 64.82, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Medicare A", "plan_name": "100100", "standard_charge_dollar": 64.82, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Medicare A", "plan_name": "100500", "standard_charge_dollar": 64.82, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Medicare Part B Only", "plan_name": "100300", "standard_charge_dollar": 64.82, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Medicare Railroad", "plan_name": "100103", "standard_charge_dollar": 64.82, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Ms Physicians Care N", "plan_name": "714210", "standard_charge_dollar": 81.03, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Peoples Hlth Ffs 72126", "plan_name": "500019", "standard_charge_dollar": 64.82, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Uhc/Secure Horizons", "plan_name": "500449", "standard_charge_dollar": 64.82, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "United Health Care/", "plan_name": "500292", "standard_charge_dollar": 73.25, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "United Healthcare", "plan_name": "750104", "standard_charge_dollar": 73.25, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "United Healthcare Ba", "plan_name": "750090", "standard_charge_dollar": 73.25, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "United Healthcare Me", "plan_name": "501310", "standard_charge_dollar": 64.82, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Windsor Mcare Extra", "plan_name": "500778", "standard_charge_dollar": 64.82, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." } ] } ] }, { "description": "Hc evaluate swallowing function", "code_information": [ { "code": "92610", "type": "CPT" } ], "standard_charges": [ { "gross_charge": 200.00, "minimum": 64.82, "maximum": 81.03, "setting": "both", "payers_information": [ { "payer_name": "Aarp", "plan_name": "500102", "standard_charge_dollar": 64.82, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna", "plan_name": "700700", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna", "plan_name": "700700_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Mcare Ffs 6005", "plan_name": "700703", "standard_charge_dollar": 64.82, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Miscellaneous", "plan_name": "700720", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Miscellaneous", "plan_name": "700720_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Ppo Hmo", "plan_name": "701720", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Ppo Hmo", "plan_name": "701720_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Ambetter 68069", "plan_name": "500516", "standard_charge_dollar": 64.82, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Ms State Emplo", "plan_name": "401457", "standard_charge_dollar": 80.28, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Ms State Emplo", "plan_name": "401457_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Basic Pl", "plan_name": "400100", "standard_charge_dollar": 80.28, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Basic Pl", "plan_name": "400100_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Federal", "plan_name": "400110", "standard_charge_dollar": 80.28, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Federal", "plan_name": "400110_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Cigna Healthsprings Ffs", "plan_name": "500064", "standard_charge_dollar": 64.82, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Conseco", "plan_name": "500302", "standard_charge_dollar": 64.82, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Humana Ffs 61101", "plan_name": "500006", "standard_charge_dollar": 64.82, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Medicare A", "plan_name": "100100", "standard_charge_dollar": 64.82, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Medicare A", "plan_name": "100500", "standard_charge_dollar": 64.82, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Medicare Part B Only", "plan_name": "100300", "standard_charge_dollar": 64.82, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Medicare Railroad", "plan_name": "100103", "standard_charge_dollar": 64.82, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Ms Physicians Care N", "plan_name": "714210", "standard_charge_dollar": 81.03, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Peoples Hlth Ffs 72126", "plan_name": "500019", "standard_charge_dollar": 64.82, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Uhc/Secure Horizons", "plan_name": "500449", "standard_charge_dollar": 64.82, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "United Health Care/", "plan_name": "500292", "standard_charge_dollar": 73.25, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "United Healthcare", "plan_name": "750104", "standard_charge_dollar": 73.25, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "United Healthcare Ba", "plan_name": "750090", "standard_charge_dollar": 73.25, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "United Healthcare Me", "plan_name": "501310", "standard_charge_dollar": 64.82, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Windsor Mcare Extra", "plan_name": "500778", "standard_charge_dollar": 64.82, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." } ] } ] }, { "description": "Hc cpr", "code_information": [ { "code": "92950", "type": "CPT" } ], "standard_charges": [ { "gross_charge": 637.00, "minimum": 285.26, "maximum": 541.45, "setting": "both", "payers_information": [ { "payer_name": "Aarp", "plan_name": "500102", "standard_charge_dollar": 285.26, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna", "plan_name": "700700", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna", "plan_name": "700700_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Mcare Ffs 6005", "plan_name": "700703", "standard_charge_dollar": 285.26, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Miscellaneous", "plan_name": "700720", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Miscellaneous", "plan_name": "700720_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Ppo Hmo", "plan_name": "701720", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Ppo Hmo", "plan_name": "701720_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Ambetter 68069", "plan_name": "500516", "standard_charge_dollar": 285.26, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Ms State Emplo", "plan_name": "401457", "standard_charge_percentage": 0.80, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Ms State Emplo", "plan_name": "401457_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Basic Pl", "plan_name": "400100", "standard_charge_percentage": 0.85, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Basic Pl", "plan_name": "400100_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Federal", "plan_name": "400110", "standard_charge_percentage": 0.85, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Federal", "plan_name": "400110_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Cigna Healthsprings Ffs", "plan_name": "500064", "standard_charge_dollar": 285.26, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Conseco", "plan_name": "500302", "standard_charge_dollar": 285.26, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Humana Ffs 61101", "plan_name": "500006", "standard_charge_dollar": 285.26, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Medicare A", "plan_name": "100100", "standard_charge_dollar": 285.26, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Medicare A", "plan_name": "100500", "standard_charge_dollar": 285.26, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Medicare Part B Only", "plan_name": "100300", "standard_charge_dollar": 285.26, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Medicare Railroad", "plan_name": "100103", "standard_charge_dollar": 285.26, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Ms Physicians Care N", "plan_name": "714210", "standard_charge_dollar": 356.58, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Peoples Hlth Ffs 72126", "plan_name": "500019", "standard_charge_dollar": 285.26, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Uhc/Secure Horizons", "plan_name": "500449", "standard_charge_dollar": 285.26, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "United Health Care/", "plan_name": "500292", "standard_charge_dollar": 322.35, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "United Healthcare", "plan_name": "750104", "standard_charge_dollar": 322.35, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "United Healthcare Ba", "plan_name": "750090", "standard_charge_dollar": 322.35, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "United Healthcare Me", "plan_name": "501310", "standard_charge_dollar": 285.26, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Windsor Mcare Extra", "plan_name": "500778", "standard_charge_dollar": 285.26, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." } ] } ] }, { "description": "Heart/lung resuscitation cpr", "code_information": [ { "code": "92950", "type": "CPT" } ], "standard_charges": [ { "gross_charge": 637.00, "minimum": 285.26, "maximum": 541.45, "setting": "both", "payers_information": [ { "payer_name": "Aarp", "plan_name": "500102", "standard_charge_dollar": 285.26, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna", "plan_name": "700700", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna", "plan_name": "700700_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Mcare Ffs 6005", "plan_name": "700703", "standard_charge_dollar": 285.26, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Miscellaneous", "plan_name": "700720", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Miscellaneous", "plan_name": "700720_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Ppo Hmo", "plan_name": "701720", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Ppo Hmo", "plan_name": "701720_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Ambetter 68069", "plan_name": "500516", "standard_charge_dollar": 285.26, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Ms State Emplo", "plan_name": "401457", "standard_charge_percentage": 0.80, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Ms State Emplo", "plan_name": "401457_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Basic Pl", "plan_name": "400100", "standard_charge_percentage": 0.85, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Basic Pl", "plan_name": "400100_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Federal", "plan_name": "400110", "standard_charge_percentage": 0.85, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Federal", "plan_name": "400110_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Cigna Healthsprings Ffs", "plan_name": "500064", "standard_charge_dollar": 285.26, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Conseco", "plan_name": "500302", "standard_charge_dollar": 285.26, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Humana Ffs 61101", "plan_name": "500006", "standard_charge_dollar": 285.26, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Medicare A", "plan_name": "100100", "standard_charge_dollar": 285.26, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Medicare A", "plan_name": "100500", "standard_charge_dollar": 285.26, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Medicare Part B Only", "plan_name": "100300", "standard_charge_dollar": 285.26, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Medicare Railroad", "plan_name": "100103", "standard_charge_dollar": 285.26, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Ms Physicians Care N", "plan_name": "714210", "standard_charge_dollar": 356.58, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Peoples Hlth Ffs 72126", "plan_name": "500019", "standard_charge_dollar": 285.26, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Uhc/Secure Horizons", "plan_name": "500449", "standard_charge_dollar": 285.26, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "United Health Care/", "plan_name": "500292", "standard_charge_dollar": 322.35, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "United Healthcare", "plan_name": "750104", "standard_charge_dollar": 322.35, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "United Healthcare Ba", "plan_name": "750090", "standard_charge_dollar": 322.35, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "United Healthcare Me", "plan_name": "501310", "standard_charge_dollar": 285.26, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Windsor Mcare Extra", "plan_name": "500778", "standard_charge_dollar": 285.26, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." } ] } ] }, { "description": "Hc er temporary external pacing", "code_information": [ { "code": "92953", "type": "CPT" } ], "standard_charges": [ { "gross_charge": 231.00, "minimum": 721.71, "maximum": 964.86, "setting": "both", "payers_information": [ { "payer_name": "Aarp", "plan_name": "500102", "standard_charge_dollar": 771.89, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna", "plan_name": "700700", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna", "plan_name": "700700_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Mcare Ffs 6005", "plan_name": "700703", "standard_charge_dollar": 771.89, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Miscellaneous", "plan_name": "700720", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Miscellaneous", "plan_name": "700720_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Ppo Hmo", "plan_name": "701720", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Ppo Hmo", "plan_name": "701720_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Ambetter 68069", "plan_name": "500516", "standard_charge_dollar": 771.89, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Ms State Emplo", "plan_name": "401457", "standard_charge_dollar": 721.71, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Ms State Emplo", "plan_name": "401457_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Basic Pl", "plan_name": "400100", "standard_charge_dollar": 721.71, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Basic Pl", "plan_name": "400100_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Federal", "plan_name": "400110", "standard_charge_dollar": 721.71, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Federal", "plan_name": "400110_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Cigna Healthsprings Ffs", "plan_name": "500064", "standard_charge_dollar": 771.89, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Conseco", "plan_name": "500302", "standard_charge_dollar": 771.89, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Humana Ffs 61101", "plan_name": "500006", "standard_charge_dollar": 771.89, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Medicare A", "plan_name": "100100", "standard_charge_dollar": 771.89, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Medicare A", "plan_name": "100500", "standard_charge_dollar": 771.89, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Medicare Part B Only", "plan_name": "100300", "standard_charge_dollar": 771.89, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Medicare Railroad", "plan_name": "100103", "standard_charge_dollar": 771.89, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Ms Physicians Care N", "plan_name": "714210", "standard_charge_dollar": 964.86, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Peoples Hlth Ffs 72126", "plan_name": "500019", "standard_charge_dollar": 771.89, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Uhc/Secure Horizons", "plan_name": "500449", "standard_charge_dollar": 771.89, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "United Health Care/", "plan_name": "500292", "standard_charge_dollar": 872.23, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "United Healthcare", "plan_name": "750104", "standard_charge_dollar": 872.23, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "United Healthcare Ba", "plan_name": "750090", "standard_charge_dollar": 872.23, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "United Healthcare Me", "plan_name": "501310", "standard_charge_dollar": 771.89, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Windsor Mcare Extra", "plan_name": "500778", "standard_charge_dollar": 771.89, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." } ] } ] }, { "description": "Temporary external pacing", "code_information": [ { "code": "92953", "type": "CPT" } ], "standard_charges": [ { "gross_charge": 231.00, "minimum": 721.71, "maximum": 964.86, "setting": "both", "payers_information": [ { "payer_name": "Aarp", "plan_name": "500102", "standard_charge_dollar": 771.89, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna", "plan_name": "700700", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna", "plan_name": "700700_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Mcare Ffs 6005", "plan_name": "700703", "standard_charge_dollar": 771.89, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Miscellaneous", "plan_name": "700720", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Miscellaneous", "plan_name": "700720_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Ppo Hmo", "plan_name": "701720", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Ppo Hmo", "plan_name": "701720_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Ambetter 68069", "plan_name": "500516", "standard_charge_dollar": 771.89, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Ms State Emplo", "plan_name": "401457", "standard_charge_dollar": 721.71, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Ms State Emplo", "plan_name": "401457_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Basic Pl", "plan_name": "400100", "standard_charge_dollar": 721.71, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Basic Pl", "plan_name": "400100_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Federal", "plan_name": "400110", "standard_charge_dollar": 721.71, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Federal", "plan_name": "400110_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Cigna Healthsprings Ffs", "plan_name": "500064", "standard_charge_dollar": 771.89, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Conseco", "plan_name": "500302", "standard_charge_dollar": 771.89, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Humana Ffs 61101", "plan_name": "500006", "standard_charge_dollar": 771.89, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Medicare A", "plan_name": "100100", "standard_charge_dollar": 771.89, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Medicare A", "plan_name": "100500", "standard_charge_dollar": 771.89, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Medicare Part B Only", "plan_name": "100300", "standard_charge_dollar": 771.89, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Medicare Railroad", "plan_name": "100103", "standard_charge_dollar": 771.89, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Ms Physicians Care N", "plan_name": "714210", "standard_charge_dollar": 964.86, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Peoples Hlth Ffs 72126", "plan_name": "500019", "standard_charge_dollar": 771.89, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Uhc/Secure Horizons", "plan_name": "500449", "standard_charge_dollar": 771.89, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "United Health Care/", "plan_name": "500292", "standard_charge_dollar": 872.23, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "United Healthcare", "plan_name": "750104", "standard_charge_dollar": 872.23, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "United Healthcare Ba", "plan_name": "750090", "standard_charge_dollar": 872.23, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "United Healthcare Me", "plan_name": "501310", "standard_charge_dollar": 771.89, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Windsor Mcare Extra", "plan_name": "500778", "standard_charge_dollar": 771.89, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." } ] } ] }, { "description": "Electrocardiogram tracing", "code_information": [ { "code": "93005", "type": "CPT" } ], "standard_charges": [ { "gross_charge": 200.00, "minimum": 54.41, "maximum": 81.80, "setting": "both", "payers_information": [ { "payer_name": "Aarp", "plan_name": "500102", "standard_charge_dollar": 54.41, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna", "plan_name": "700700", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna", "plan_name": "700700_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Mcare Ffs 6005", "plan_name": "700703", "standard_charge_dollar": 54.41, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Miscellaneous", "plan_name": "700720", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Miscellaneous", "plan_name": "700720_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Ppo Hmo", "plan_name": "701720", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Ppo Hmo", "plan_name": "701720_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Ambetter 68069", "plan_name": "500516", "standard_charge_dollar": 54.41, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Ms State Emplo", "plan_name": "401457", "standard_charge_dollar": 81.80, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Ms State Emplo", "plan_name": "401457_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Basic Pl", "plan_name": "400100", "standard_charge_dollar": 81.80, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Basic Pl", "plan_name": "400100_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Federal", "plan_name": "400110", "standard_charge_dollar": 81.80, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Federal", "plan_name": "400110_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Cigna Healthsprings Ffs", "plan_name": "500064", "standard_charge_dollar": 54.41, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Conseco", "plan_name": "500302", "standard_charge_dollar": 54.41, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Humana Ffs 61101", "plan_name": "500006", "standard_charge_dollar": 54.41, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Medicare A", "plan_name": "100100", "standard_charge_dollar": 54.41, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Medicare A", "plan_name": "100500", "standard_charge_dollar": 54.41, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Medicare Part B Only", "plan_name": "100300", "standard_charge_dollar": 54.41, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Medicare Railroad", "plan_name": "100103", "standard_charge_dollar": 54.41, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Ms Physicians Care N", "plan_name": "714210", "standard_charge_dollar": 68.02, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Peoples Hlth Ffs 72126", "plan_name": "500019", "standard_charge_dollar": 54.41, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Uhc/Secure Horizons", "plan_name": "500449", "standard_charge_dollar": 54.41, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "United Health Care/", "plan_name": "500292", "standard_charge_dollar": 61.49, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "United Healthcare", "plan_name": "750104", "standard_charge_dollar": 61.49, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "United Healthcare Ba", "plan_name": "750090", "standard_charge_dollar": 61.49, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "United Healthcare Me", "plan_name": "501310", "standard_charge_dollar": 54.41, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Windsor Mcare Extra", "plan_name": "500778", "standard_charge_dollar": 54.41, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." } ] } ] }, { "description": "Hc ekg 12 lead tracing only", "code_information": [ { "code": "93005", "type": "CPT" } ], "standard_charges": [ { "gross_charge": 200.00, "minimum": 54.41, "maximum": 81.80, "setting": "both", "payers_information": [ { "payer_name": "Aarp", "plan_name": "500102", "standard_charge_dollar": 54.41, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna", "plan_name": "700700", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna", "plan_name": "700700_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Mcare Ffs 6005", "plan_name": "700703", "standard_charge_dollar": 54.41, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Miscellaneous", "plan_name": "700720", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Miscellaneous", "plan_name": "700720_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Ppo Hmo", "plan_name": "701720", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Ppo Hmo", "plan_name": "701720_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Ambetter 68069", "plan_name": "500516", "standard_charge_dollar": 54.41, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Ms State Emplo", "plan_name": "401457", "standard_charge_dollar": 81.80, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Ms State Emplo", "plan_name": "401457_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Basic Pl", "plan_name": "400100", "standard_charge_dollar": 81.80, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Basic Pl", "plan_name": "400100_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Federal", "plan_name": "400110", "standard_charge_dollar": 81.80, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Federal", "plan_name": "400110_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Cigna Healthsprings Ffs", "plan_name": "500064", "standard_charge_dollar": 54.41, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Conseco", "plan_name": "500302", "standard_charge_dollar": 54.41, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Humana Ffs 61101", "plan_name": "500006", "standard_charge_dollar": 54.41, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Medicare A", "plan_name": "100100", "standard_charge_dollar": 54.41, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Medicare A", "plan_name": "100500", "standard_charge_dollar": 54.41, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Medicare Part B Only", "plan_name": "100300", "standard_charge_dollar": 54.41, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Medicare Railroad", "plan_name": "100103", "standard_charge_dollar": 54.41, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Ms Physicians Care N", "plan_name": "714210", "standard_charge_dollar": 68.02, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Peoples Hlth Ffs 72126", "plan_name": "500019", "standard_charge_dollar": 54.41, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Uhc/Secure Horizons", "plan_name": "500449", "standard_charge_dollar": 54.41, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "United Health Care/", "plan_name": "500292", "standard_charge_dollar": 61.49, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "United Healthcare", "plan_name": "750104", "standard_charge_dollar": 61.49, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "United Healthcare Ba", "plan_name": "750090", "standard_charge_dollar": 61.49, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "United Healthcare Me", "plan_name": "501310", "standard_charge_dollar": 54.41, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Windsor Mcare Extra", "plan_name": "500778", "standard_charge_dollar": 54.41, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." } ] } ] }, { "description": "Ecg monit/reprt up to 48 hrs", "code_information": [ { "code": "93225", "type": "CPT" } ], "standard_charges": [ { "gross_charge": 250.00, "minimum": 149.97, "maximum": 149.97, "setting": "both", "payers_information": [ { "payer_name": "Aetna", "plan_name": "700700", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna", "plan_name": "700700_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Miscellaneous", "plan_name": "700720", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Miscellaneous", "plan_name": "700720_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Ppo Hmo", "plan_name": "701720", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Ppo Hmo", "plan_name": "701720_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Ms State Emplo", "plan_name": "401457", "standard_charge_dollar": 149.97, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Ms State Emplo", "plan_name": "401457_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Basic Pl", "plan_name": "400100", "standard_charge_dollar": 149.97, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Basic Pl", "plan_name": "400100_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Federal", "plan_name": "400110", "standard_charge_dollar": 149.97, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Federal", "plan_name": "400110_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." } ] } ] }, { "description": "Hc ecg monitor recording up to 48hrs", "code_information": [ { "code": "93225", "type": "CPT" } ], "standard_charges": [ { "gross_charge": 250.00, "minimum": 149.97, "maximum": 149.97, "setting": "both", "payers_information": [ { "payer_name": "Aetna", "plan_name": "700700", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna", "plan_name": "700700_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Miscellaneous", "plan_name": "700720", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Miscellaneous", "plan_name": "700720_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Ppo Hmo", "plan_name": "701720", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Ppo Hmo", "plan_name": "701720_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Ms State Emplo", "plan_name": "401457", "standard_charge_dollar": 149.97, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Ms State Emplo", "plan_name": "401457_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Basic Pl", "plan_name": "400100", "standard_charge_dollar": 149.97, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Basic Pl", "plan_name": "400100_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Federal", "plan_name": "400110", "standard_charge_dollar": 149.97, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Federal", "plan_name": "400110_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." } ] } ] }, { "description": "Ext ecg>48hr<7d recording", "code_information": [ { "code": "93242", "type": "CPT" } ], "standard_charges": [ { "gross_charge": 250.00, "minimum": 200.00, "maximum": 212.50, "setting": "both", "payers_information": [ { "payer_name": "Aetna", "plan_name": "700700", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna", "plan_name": "700700_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Miscellaneous", "plan_name": "700720", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Miscellaneous", "plan_name": "700720_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Ppo Hmo", "plan_name": "701720", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Ppo Hmo", "plan_name": "701720_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Ms State Emplo", "plan_name": "401457", "standard_charge_percentage": 0.80, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Ms State Emplo", "plan_name": "401457_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Basic Pl", "plan_name": "400100", "standard_charge_percentage": 0.85, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Basic Pl", "plan_name": "400100_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Federal", "plan_name": "400110", "standard_charge_percentage": 0.85, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Federal", "plan_name": "400110_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." } ] } ] }, { "description": "Hc ext ecg>48hr<7d recording", "code_information": [ { "code": "93242", "type": "CPT" } ], "standard_charges": [ { "gross_charge": 250.00, "minimum": 200.00, "maximum": 212.50, "setting": "both", "payers_information": [ { "payer_name": "Aetna", "plan_name": "700700", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna", "plan_name": "700700_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Miscellaneous", "plan_name": "700720", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Miscellaneous", "plan_name": "700720_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Ppo Hmo", "plan_name": "701720", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Ppo Hmo", "plan_name": "701720_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Ms State Emplo", "plan_name": "401457", "standard_charge_percentage": 0.80, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Ms State Emplo", "plan_name": "401457_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Basic Pl", "plan_name": "400100", "standard_charge_percentage": 0.85, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Basic Pl", "plan_name": "400100_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Federal", "plan_name": "400110", "standard_charge_percentage": 0.85, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Federal", "plan_name": "400110_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." } ] } ] }, { "description": "Hc echo 2d w/spec/color/complete", "code_information": [ { "code": "93306", "type": "CPT" } ], "standard_charges": [ { "gross_charge": 1300.00, "minimum": 1040.00, "maximum": 1105.00, "setting": "both", "payers_information": [ { "payer_name": "Aetna", "plan_name": "700700", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna", "plan_name": "700700_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Miscellaneous", "plan_name": "700720", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Miscellaneous", "plan_name": "700720_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Ppo Hmo", "plan_name": "701720", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Ppo Hmo", "plan_name": "701720_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Ms State Emplo", "plan_name": "401457", "standard_charge_percentage": 0.80, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Ms State Emplo", "plan_name": "401457_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Basic Pl", "plan_name": "400100", "standard_charge_percentage": 0.85, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Basic Pl", "plan_name": "400100_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Federal", "plan_name": "400110", "standard_charge_percentage": 0.85, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Federal", "plan_name": "400110_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." } ] } ] }, { "description": "Tte w/doppler complete", "code_information": [ { "code": "93306", "type": "CPT" } ], "standard_charges": [ { "gross_charge": 1300.00, "minimum": 1040.00, "maximum": 1105.00, "setting": "both", "payers_information": [ { "payer_name": "Aetna", "plan_name": "700700", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna", "plan_name": "700700_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Miscellaneous", "plan_name": "700720", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Miscellaneous", "plan_name": "700720_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Ppo Hmo", "plan_name": "701720", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Ppo Hmo", "plan_name": "701720_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Ms State Emplo", "plan_name": "401457", "standard_charge_percentage": 0.80, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Ms State Emplo", "plan_name": "401457_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Basic Pl", "plan_name": "400100", "standard_charge_percentage": 0.85, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Basic Pl", "plan_name": "400100_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Federal", "plan_name": "400110", "standard_charge_percentage": 0.85, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Federal", "plan_name": "400110_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." } ] } ] }, { "description": "Hc echo 2d m mode f/u ltd wo cntr", "code_information": [ { "code": "93308", "type": "CPT" } ], "standard_charges": [ { "gross_charge": 300.00, "minimum": 240.00, "maximum": 255.00, "setting": "both", "payers_information": [ { "payer_name": "Aetna", "plan_name": "700700", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna", "plan_name": "700700_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Miscellaneous", "plan_name": "700720", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Miscellaneous", "plan_name": "700720_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Ppo Hmo", "plan_name": "701720", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Ppo Hmo", "plan_name": "701720_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Ms State Emplo", "plan_name": "401457", "standard_charge_percentage": 0.80, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Ms State Emplo", "plan_name": "401457_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Basic Pl", "plan_name": "400100", "standard_charge_percentage": 0.85, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Basic Pl", "plan_name": "400100_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Federal", "plan_name": "400110", "standard_charge_percentage": 0.85, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Federal", "plan_name": "400110_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." } ] } ] }, { "description": "Tte f-up or lmtd", "code_information": [ { "code": "93308", "type": "CPT" } ], "standard_charges": [ { "gross_charge": 300.00, "minimum": 240.00, "maximum": 255.00, "setting": "both", "payers_information": [ { "payer_name": "Aetna", "plan_name": "700700", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna", "plan_name": "700700_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Miscellaneous", "plan_name": "700720", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Miscellaneous", "plan_name": "700720_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Ppo Hmo", "plan_name": "701720", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Ppo Hmo", "plan_name": "701720_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Ms State Emplo", "plan_name": "401457", "standard_charge_percentage": 0.80, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Ms State Emplo", "plan_name": "401457_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Basic Pl", "plan_name": "400100", "standard_charge_percentage": 0.85, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Basic Pl", "plan_name": "400100_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Federal", "plan_name": "400110", "standard_charge_percentage": 0.85, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Federal", "plan_name": "400110_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." } ] } ] }, { "description": "Extracranial bilat study", "code_information": [ { "code": "93880", "type": "CPT" } ], "standard_charges": [ { "gross_charge": 600.00, "minimum": 480.00, "maximum": 510.00, "setting": "both", "payers_information": [ { "payer_name": "Aetna", "plan_name": "700700", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna", "plan_name": "700700_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Miscellaneous", "plan_name": "700720", 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"standard_charge_percentage": 0.80, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Ms State Emplo", "plan_name": "401457_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Basic Pl", "plan_name": "400100", "standard_charge_percentage": 0.85, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Basic Pl", "plan_name": "400100_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Federal", "plan_name": "400110", "standard_charge_percentage": 0.85, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Federal", "plan_name": "400110_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." } ] } ] }, { "description": "Hc carotid duplex scan bilat", "code_information": [ { "code": "93880", "type": "CPT" } ], "standard_charges": [ { "gross_charge": 600.00, "minimum": 480.00, "maximum": 510.00, "setting": "both", "payers_information": [ { "payer_name": "Aetna", "plan_name": "700700", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna", "plan_name": "700700_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Miscellaneous", "plan_name": "700720", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Miscellaneous", "plan_name": "700720_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Ppo Hmo", "plan_name": "701720", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Ppo Hmo", "plan_name": "701720_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Ms State Emplo", "plan_name": "401457", "standard_charge_percentage": 0.80, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Ms State Emplo", "plan_name": "401457_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Basic Pl", "plan_name": "400100", "standard_charge_percentage": 0.85, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Basic Pl", "plan_name": "400100_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Federal", "plan_name": "400110", "standard_charge_percentage": 0.85, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Federal", "plan_name": "400110_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." } ] } ] }, { "description": "Extracranial uni/ltd study", "code_information": [ { "code": "93882", "type": "CPT" } ], "standard_charges": [ { "gross_charge": 204.50, "minimum": 163.60, "maximum": 173.83, "setting": "both", "payers_information": [ { "payer_name": "Aetna", "plan_name": "700700", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of 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"additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Ppo Hmo", "plan_name": "701720_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Ms State Emplo", "plan_name": "401457", "standard_charge_percentage": 0.80, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Ms State Emplo", "plan_name": "401457_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Basic Pl", "plan_name": "400100", "standard_charge_percentage": 0.85, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Basic Pl", "plan_name": "400100_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Federal", "plan_name": "400110", "standard_charge_percentage": 0.85, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Federal", "plan_name": "400110_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." } ] } ] }, { "description": "Hc carotid duplex scan unilat", "code_information": [ { "code": "93882", "type": "CPT" } ], "standard_charges": [ { "gross_charge": 204.50, 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"Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Ppo Hmo", "plan_name": "701720", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Ppo Hmo", "plan_name": "701720_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Ms State Emplo", "plan_name": "401457", "standard_charge_percentage": 0.80, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Ms State Emplo", "plan_name": "401457_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Basic Pl", "plan_name": "400100", "standard_charge_percentage": 0.85, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Basic Pl", "plan_name": "400100_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Federal", "plan_name": "400110", "standard_charge_percentage": 0.85, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Federal", "plan_name": "400110_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." } ] } ] }, { "description": "Hc upper/lowr extr art 2 levels", "code_information": [ { "code": "93922", "type": "CPT" } ], "standard_charges": [ { "gross_charge": 500.00, "minimum": 149.97, "maximum": 149.97, "setting": "both", "payers_information": [ { "payer_name": "Aetna", "plan_name": "700700", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna", "plan_name": "700700_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Miscellaneous", "plan_name": "700720", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Miscellaneous", "plan_name": "700720_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Ppo Hmo", "plan_name": "701720", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Ppo Hmo", "plan_name": "701720_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Ms State Emplo", "plan_name": "401457", "standard_charge_dollar": 149.97, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Ms State Emplo", "plan_name": "401457_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Basic Pl", "plan_name": "400100", "standard_charge_dollar": 149.97, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Basic Pl", "plan_name": "400100_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Federal", "plan_name": "400110", "standard_charge_dollar": 149.97, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Federal", "plan_name": "400110_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." } ] } ] }, { "description": "Upr/l xtremity art 2 levels", "code_information": [ { "code": "93922", "type": "CPT" } ], "standard_charges": [ { "gross_charge": 500.00, "minimum": 149.97, "maximum": 149.97, "setting": "both", "payers_information": [ { "payer_name": "Aetna", "plan_name": "700700", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna", "plan_name": "700700_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Miscellaneous", "plan_name": "700720", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Miscellaneous", "plan_name": "700720_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Ppo Hmo", "plan_name": "701720", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Ppo Hmo", "plan_name": "701720_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Ms State Emplo", "plan_name": "401457", "standard_charge_dollar": 149.97, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Ms State Emplo", "plan_name": "401457_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Basic Pl", "plan_name": "400100", "standard_charge_dollar": 149.97, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Basic Pl", "plan_name": "400100_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Federal", "plan_name": "400110", "standard_charge_dollar": 149.97, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Federal", "plan_name": "400110_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." } ] } ] }, { "description": "Hc duplex l extrem art/bpg bilat", "code_information": [ { "code": "93925", "type": "CPT" } ], "standard_charges": [ { "gross_charge": 950.00, "minimum": 760.00, "maximum": 807.50, "setting": "both", "payers_information": [ { "payer_name": "Aetna", "plan_name": "700700", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna", "plan_name": "700700_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Miscellaneous", "plan_name": "700720", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Miscellaneous", "plan_name": "700720_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Ppo Hmo", "plan_name": "701720", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Ppo Hmo", "plan_name": "701720_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Ms State Emplo", "plan_name": "401457", "standard_charge_percentage": 0.80, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Ms State Emplo", "plan_name": "401457_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Basic Pl", "plan_name": "400100", "standard_charge_percentage": 0.85, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Basic Pl", "plan_name": "400100_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Federal", "plan_name": "400110", "standard_charge_percentage": 0.85, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Federal", "plan_name": "400110_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." } ] } ] }, { "description": "Lower extremity study", "code_information": [ { "code": "93925", "type": "CPT" } ], "standard_charges": [ { "gross_charge": 950.00, "minimum": 760.00, "maximum": 807.50, "setting": "both", "payers_information": [ { "payer_name": "Aetna", "plan_name": "700700", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna", "plan_name": "700700_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Miscellaneous", "plan_name": "700720", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Miscellaneous", "plan_name": "700720_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Ppo Hmo", "plan_name": "701720", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Ppo Hmo", "plan_name": "701720_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Ms State Emplo", "plan_name": "401457", "standard_charge_percentage": 0.80, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Ms State Emplo", "plan_name": "401457_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Basic Pl", "plan_name": "400100", "standard_charge_percentage": 0.85, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Basic Pl", "plan_name": "400100_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Federal", "plan_name": "400110", "standard_charge_percentage": 0.85, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Federal", "plan_name": "400110_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." } ] } ] }, { "description": "Hc duplex l extrem art/bpg unilat", "code_information": [ { "code": "93926", "type": "CPT" } ], "standard_charges": [ { "gross_charge": 650.00, "minimum": 520.00, "maximum": 552.50, "setting": "both", "payers_information": [ { "payer_name": "Aetna", "plan_name": "700700", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna", "plan_name": "700700_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Miscellaneous", "plan_name": "700720", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Miscellaneous", "plan_name": "700720_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Ppo Hmo", "plan_name": "701720", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Ppo Hmo", "plan_name": "701720_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Ms State Emplo", "plan_name": "401457", "standard_charge_percentage": 0.80, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Ms State Emplo", "plan_name": "401457_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Basic Pl", "plan_name": "400100", "standard_charge_percentage": 0.85, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Basic Pl", "plan_name": "400100_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Federal", "plan_name": "400110", "standard_charge_percentage": 0.85, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Federal", "plan_name": "400110_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." } ] } ] }, { "description": "Lower extremity 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"standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Ppo Hmo", "plan_name": "701720", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Ppo Hmo", "plan_name": "701720_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Ms State Emplo", "plan_name": "401457", "standard_charge_percentage": 0.80, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Ms State Emplo", "plan_name": "401457_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Basic Pl", "plan_name": "400100", "standard_charge_percentage": 0.85, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Basic Pl", "plan_name": "400100_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Federal", "plan_name": "400110", "standard_charge_percentage": 0.85, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Federal", "plan_name": "400110_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." } ] } ] }, { "description": "Hc duplex u extrem art/bpg bilat", "code_information": [ { "code": "93930", "type": "CPT" } ], "standard_charges": [ { "gross_charge": 301.00, "minimum": 240.80, "maximum": 255.85, "setting": "both", "payers_information": [ { "payer_name": "Aetna", "plan_name": "700700", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna", "plan_name": "700700_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Miscellaneous", "plan_name": "700720", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Miscellaneous", "plan_name": "700720_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Ppo Hmo", "plan_name": "701720", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Ppo Hmo", "plan_name": "701720_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Ms State Emplo", "plan_name": "401457", "standard_charge_percentage": 0.80, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Ms State Emplo", "plan_name": "401457_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Basic Pl", "plan_name": "400100", "standard_charge_percentage": 0.85, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Basic Pl", "plan_name": "400100_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Federal", "plan_name": "400110", "standard_charge_percentage": 0.85, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Federal", "plan_name": "400110_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." } ] } ] }, { "description": "Upper extremity study", "code_information": [ { "code": "93930", "type": "CPT" } ], "standard_charges": [ { "gross_charge": 301.00, "minimum": 240.80, "maximum": 255.85, "setting": "both", "payers_information": [ { "payer_name": "Aetna", "plan_name": "700700", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna", "plan_name": "700700_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Miscellaneous", "plan_name": "700720", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Miscellaneous", "plan_name": "700720_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Ppo Hmo", "plan_name": "701720", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Ppo Hmo", "plan_name": "701720_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Ms State Emplo", "plan_name": "401457", "standard_charge_percentage": 0.80, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Ms State Emplo", "plan_name": "401457_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Basic Pl", "plan_name": "400100", "standard_charge_percentage": 0.85, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Basic Pl", "plan_name": "400100_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Federal", "plan_name": "400110", "standard_charge_percentage": 0.85, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Federal", "plan_name": "400110_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." } ] } ] }, { "description": "Hc duplex u extrem art/bpg unilat", "code_information": [ { "code": "93931", "type": "CPT" } ], "standard_charges": [ { "gross_charge": 650.00, "minimum": 520.00, "maximum": 552.50, "setting": "both", "payers_information": [ { "payer_name": "Aetna", "plan_name": "700700", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna", "plan_name": "700700_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Miscellaneous", "plan_name": "700720", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Miscellaneous", "plan_name": "700720_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Ppo Hmo", "plan_name": "701720", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Ppo Hmo", "plan_name": "701720_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Ms State Emplo", "plan_name": "401457", "standard_charge_percentage": 0.80, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Ms State Emplo", "plan_name": "401457_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Basic Pl", "plan_name": "400100", "standard_charge_percentage": 0.85, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Basic Pl", "plan_name": "400100_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Federal", "plan_name": "400110", "standard_charge_percentage": 0.85, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Federal", "plan_name": "400110_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." } ] } ] }, { "description": "Upper extremity study", "code_information": [ { "code": "93931", "type": "CPT" } ], "standard_charges": [ { "gross_charge": 650.00, "minimum": 520.00, "maximum": 552.50, "setting": "both", "payers_information": [ { "payer_name": "Aetna", "plan_name": "700700", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna", "plan_name": "700700_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Miscellaneous", "plan_name": "700720", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Miscellaneous", "plan_name": "700720_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Ppo Hmo", "plan_name": "701720", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Ppo Hmo", "plan_name": "701720_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Ms State Emplo", "plan_name": "401457", "standard_charge_percentage": 0.80, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Ms State Emplo", "plan_name": "401457_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Basic Pl", "plan_name": "400100", "standard_charge_percentage": 0.85, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Basic Pl", "plan_name": "400100_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Federal", "plan_name": "400110", "standard_charge_percentage": 0.85, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Federal", "plan_name": "400110_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." } ] } ] }, { "description": "Extremity study", "code_information": [ { "code": "93970", "type": "CPT" } ], "standard_charges": [ { "gross_charge": 800.00, "minimum": 640.00, "maximum": 680.00, "setting": "both", "payers_information": [ { "payer_name": "Aetna", "plan_name": "700700", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna", "plan_name": "700700_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Miscellaneous", "plan_name": "700720", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Miscellaneous", "plan_name": "700720_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Ppo Hmo", "plan_name": "701720", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Ppo Hmo", "plan_name": "701720_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Ms State Emplo", "plan_name": "401457", "standard_charge_percentage": 0.80, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Ms State Emplo", "plan_name": "401457_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Basic Pl", "plan_name": "400100", "standard_charge_percentage": 0.85, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Basic Pl", "plan_name": "400100_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Federal", "plan_name": "400110", "standard_charge_percentage": 0.85, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Federal", "plan_name": "400110_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." } ] } ] }, { "description": "Hc duplex scan ext vein bilat", "code_information": [ { "code": "93970", "type": "CPT" } ], "standard_charges": [ { "gross_charge": 800.00, "minimum": 640.00, "maximum": 680.00, "setting": "both", "payers_information": [ { "payer_name": "Aetna", "plan_name": "700700", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna", "plan_name": "700700_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Miscellaneous", "plan_name": "700720", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Miscellaneous", "plan_name": "700720_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Ppo Hmo", "plan_name": "701720", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Ppo Hmo", "plan_name": "701720_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Ms State Emplo", "plan_name": "401457", "standard_charge_percentage": 0.80, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Ms State Emplo", "plan_name": "401457_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Basic Pl", "plan_name": "400100", "standard_charge_percentage": 0.85, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Basic Pl", "plan_name": "400100_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Federal", "plan_name": "400110", "standard_charge_percentage": 0.85, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Federal", "plan_name": "400110_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." } ] } ] }, { "description": "Extremity study", "code_information": [ { "code": "93971", "type": "CPT" } ], "standard_charges": [ { "gross_charge": 350.00, "minimum": 280.00, "maximum": 297.50, "setting": "both", "payers_information": [ { "payer_name": "Aetna", "plan_name": "700700", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna", "plan_name": "700700_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Miscellaneous", "plan_name": "700720", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Miscellaneous", "plan_name": "700720_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Ppo Hmo", "plan_name": "701720", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Ppo Hmo", "plan_name": "701720_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Ms State Emplo", "plan_name": "401457", "standard_charge_percentage": 0.80, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Ms State Emplo", "plan_name": "401457_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Basic Pl", "plan_name": "400100", "standard_charge_percentage": 0.85, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Basic Pl", "plan_name": "400100_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Federal", "plan_name": "400110", "standard_charge_percentage": 0.85, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Federal", "plan_name": "400110_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." } ] } ] }, { "description": "Hc duplex scan ext vein unilat/limited", "code_information": [ { "code": "93971", "type": "CPT" } ], "standard_charges": [ { "gross_charge": 350.00, "minimum": 280.00, "maximum": 297.50, "setting": "both", "payers_information": [ { "payer_name": "Aetna", "plan_name": "700700", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna", "plan_name": "700700_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Miscellaneous", "plan_name": "700720", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Miscellaneous", "plan_name": "700720_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Ppo Hmo", "plan_name": "701720", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Ppo Hmo", "plan_name": "701720_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Ms State Emplo", "plan_name": "401457", "standard_charge_percentage": 0.80, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Ms State Emplo", "plan_name": "401457_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Basic Pl", "plan_name": "400100", "standard_charge_percentage": 0.85, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Basic Pl", "plan_name": "400100_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Federal", "plan_name": "400110", "standard_charge_percentage": 0.85, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Federal", "plan_name": "400110_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." } ] } ] }, { "description": "Hc duplx scn abd/pel/retro complt", "code_information": [ { "code": "93975", "type": "CPT" } ], "standard_charges": [ { "gross_charge": 550.00, "minimum": 440.00, "maximum": 467.50, "setting": "both", "payers_information": [ { "payer_name": "Aetna", "plan_name": "700700", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna", "plan_name": "700700_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Miscellaneous", "plan_name": "700720", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Miscellaneous", "plan_name": "700720_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Ppo Hmo", "plan_name": "701720", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Ppo Hmo", "plan_name": "701720_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Ms State Emplo", "plan_name": "401457", "standard_charge_percentage": 0.80, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Ms State Emplo", "plan_name": "401457_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Basic Pl", "plan_name": "400100", "standard_charge_percentage": 0.85, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Basic Pl", "plan_name": "400100_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Federal", "plan_name": "400110", "standard_charge_percentage": 0.85, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Federal", "plan_name": "400110_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." } ] } ] }, { "description": "Vascular study", "code_information": [ { "code": "93975", "type": "CPT" } ], "standard_charges": [ { "gross_charge": 550.00, "minimum": 440.00, "maximum": 467.50, "setting": "both", "payers_information": [ { "payer_name": "Aetna", "plan_name": "700700", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna", "plan_name": "700700_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Miscellaneous", "plan_name": "700720", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Miscellaneous", "plan_name": "700720_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Ppo Hmo", "plan_name": "701720", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Ppo Hmo", "plan_name": "701720_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Ms State Emplo", "plan_name": "401457", "standard_charge_percentage": 0.80, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Ms State Emplo", "plan_name": "401457_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Basic Pl", "plan_name": "400100", "standard_charge_percentage": 0.85, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Basic Pl", "plan_name": "400100_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Federal", "plan_name": "400110", "standard_charge_percentage": 0.85, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Federal", "plan_name": "400110_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." } ] } ] }, { "description": "Hc duplx scn abd/pel/retro limitd", "code_information": [ { "code": "93976", "type": "CPT" } ], "standard_charges": [ { "gross_charge": 240.00, "minimum": 192.00, "maximum": 204.00, "setting": "both", "payers_information": [ { "payer_name": "Aetna", "plan_name": "700700", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna", "plan_name": "700700_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Miscellaneous", "plan_name": "700720", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Miscellaneous", "plan_name": "700720_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Ppo Hmo", "plan_name": "701720", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Ppo Hmo", "plan_name": "701720_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Ms State Emplo", "plan_name": "401457", "standard_charge_percentage": 0.80, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Ms State Emplo", "plan_name": "401457_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Basic Pl", "plan_name": "400100", "standard_charge_percentage": 0.85, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Basic Pl", "plan_name": "400100_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Federal", "plan_name": "400110", "standard_charge_percentage": 0.85, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Federal", "plan_name": "400110_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." } ] } ] }, { "description": "Vascular study", "code_information": [ { "code": "93976", "type": "CPT" } ], "standard_charges": [ { "gross_charge": 240.00, "minimum": 192.00, "maximum": 204.00, "setting": "both", "payers_information": [ { "payer_name": "Aetna", "plan_name": "700700", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna", "plan_name": "700700_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Miscellaneous", "plan_name": "700720", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Miscellaneous", "plan_name": "700720_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Ppo Hmo", "plan_name": "701720", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Ppo Hmo", "plan_name": "701720_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Ms State Emplo", "plan_name": "401457", "standard_charge_percentage": 0.80, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Ms State Emplo", "plan_name": "401457_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Basic Pl", "plan_name": "400100", "standard_charge_percentage": 0.85, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Basic Pl", "plan_name": "400100_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Federal", "plan_name": "400110", "standard_charge_percentage": 0.85, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Federal", "plan_name": "400110_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." } ] } ] }, { "description": "Hc duplx scn aorta/ivc/grft comp", "code_information": [ { "code": "93978", "type": "CPT" } ], "standard_charges": [ { "gross_charge": 409.00, "minimum": 327.20, "maximum": 347.65, "setting": "both", "payers_information": [ { "payer_name": "Aetna", "plan_name": "700700", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna", "plan_name": "700700_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Miscellaneous", "plan_name": "700720", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Miscellaneous", "plan_name": "700720_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Ppo Hmo", "plan_name": "701720", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Ppo Hmo", "plan_name": "701720_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Ms State Emplo", "plan_name": "401457", "standard_charge_percentage": 0.80, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Ms State Emplo", "plan_name": "401457_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Basic Pl", "plan_name": "400100", "standard_charge_percentage": 0.85, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Basic Pl", "plan_name": "400100_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Federal", "plan_name": "400110", "standard_charge_percentage": 0.85, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Federal", "plan_name": "400110_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." } ] } ] }, { "description": "Vascular study", "code_information": [ { "code": "93978", "type": "CPT" } ], "standard_charges": [ { "gross_charge": 409.00, "minimum": 327.20, "maximum": 347.65, "setting": "both", "payers_information": [ { "payer_name": "Aetna", "plan_name": "700700", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna", "plan_name": "700700_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Miscellaneous", "plan_name": "700720", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Miscellaneous", "plan_name": "700720_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Ppo Hmo", "plan_name": "701720", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Ppo Hmo", "plan_name": "701720_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Ms State Emplo", "plan_name": "401457", "standard_charge_percentage": 0.80, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Ms State Emplo", "plan_name": "401457_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Basic Pl", "plan_name": "400100", "standard_charge_percentage": 0.85, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Basic Pl", "plan_name": "400100_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Federal", "plan_name": "400110", "standard_charge_percentage": 0.85, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Federal", "plan_name": "400110_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." } ] } ] }, { "description": "Hc vent mgmt inpt initial day", "code_information": [ { "code": "94002", "type": "CPT" } ], "standard_charges": [ { "gross_charge": 1200.00, "minimum": 635.66, "maximum": 635.66, "setting": "both", "payers_information": [ { "payer_name": "Aetna", "plan_name": "700700", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna", "plan_name": "700700_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Miscellaneous", "plan_name": "700720", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Miscellaneous", "plan_name": "700720_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Ppo Hmo", "plan_name": "701720", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Ppo Hmo", "plan_name": "701720_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Ms State Emplo", "plan_name": "401457", "standard_charge_dollar": 635.66, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Ms State Emplo", "plan_name": "401457_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Basic Pl", "plan_name": "400100", "standard_charge_dollar": 635.66, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Basic Pl", "plan_name": "400100_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Federal", "plan_name": "400110", "standard_charge_dollar": 635.66, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Federal", "plan_name": "400110_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." } ] } ] }, { "description": "Vent mgmt inpat init day", "code_information": [ { "code": "94002", "type": "CPT" } ], "standard_charges": [ { "gross_charge": 1200.00, "minimum": 635.66, "maximum": 635.66, "setting": "both", "payers_information": [ { "payer_name": "Aetna", "plan_name": "700700", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna", "plan_name": "700700_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Miscellaneous", "plan_name": "700720", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Miscellaneous", "plan_name": "700720_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Ppo Hmo", "plan_name": "701720", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Ppo Hmo", "plan_name": "701720_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Ms State Emplo", "plan_name": "401457", "standard_charge_dollar": 635.66, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Ms State Emplo", "plan_name": "401457_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Basic Pl", "plan_name": "400100", "standard_charge_dollar": 635.66, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Basic Pl", "plan_name": "400100_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Federal", "plan_name": "400110", "standard_charge_dollar": 635.66, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Federal", "plan_name": "400110_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." } ] } ] }, { "description": "Breathing capacity test", "code_information": [ { "code": "94010", "type": "CPT" } ], "standard_charges": [ { "gross_charge": 199.00, "minimum": 194.63, "maximum": 194.63, "setting": "both", "payers_information": [ { "payer_name": "Aetna", "plan_name": "700700", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna", "plan_name": "700700_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Miscellaneous", "plan_name": "700720", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Miscellaneous", "plan_name": "700720_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Ppo Hmo", "plan_name": "701720", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Ppo Hmo", "plan_name": "701720_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Ms State Emplo", "plan_name": "401457", "standard_charge_dollar": 194.63, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Ms State Emplo", "plan_name": "401457_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Basic Pl", "plan_name": "400100", "standard_charge_dollar": 194.63, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Basic Pl", "plan_name": "400100_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Federal", "plan_name": "400110", "standard_charge_dollar": 194.63, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Federal", "plan_name": "400110_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." } ] } ] }, { "description": "Hc spirometry", "code_information": [ { "code": "94010", "type": "CPT" } ], "standard_charges": [ { "gross_charge": 199.00, "minimum": 194.63, "maximum": 194.63, "setting": "both", "payers_information": [ { "payer_name": "Aetna", "plan_name": "700700", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna", "plan_name": "700700_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Miscellaneous", "plan_name": "700720", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Miscellaneous", "plan_name": "700720_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Ppo Hmo", "plan_name": "701720", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Ppo Hmo", "plan_name": "701720_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Ms State Emplo", "plan_name": "401457", "standard_charge_dollar": 194.63, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Ms State Emplo", "plan_name": "401457_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Basic Pl", "plan_name": "400100", "standard_charge_dollar": 194.63, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Basic Pl", "plan_name": "400100_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Federal", "plan_name": "400110", "standard_charge_dollar": 194.63, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Federal", "plan_name": "400110_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." } ] } ] }, { "description": "Evaluation of wheezing", "code_information": [ { "code": "94060", "type": "CPT" } ], "standard_charges": [ { "gross_charge": 300.00, "minimum": 240.00, "maximum": 255.00, "setting": "both", "payers_information": [ { "payer_name": "Aetna", "plan_name": "700700", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna", "plan_name": "700700_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Miscellaneous", "plan_name": "700720", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Miscellaneous", "plan_name": "700720_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Ppo Hmo", "plan_name": "701720", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Ppo Hmo", "plan_name": "701720_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Ms State Emplo", "plan_name": "401457", "standard_charge_percentage": 0.80, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Ms State Emplo", "plan_name": "401457_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Basic Pl", "plan_name": "400100", "standard_charge_percentage": 0.85, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Basic Pl", "plan_name": "400100_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Federal", "plan_name": "400110", "standard_charge_percentage": 0.85, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Federal", "plan_name": "400110_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." } ] } ] }, { "description": "Hc spirometry pre/post dilator", "code_information": [ { "code": "94060", "type": "CPT" } ], "standard_charges": [ { "gross_charge": 300.00, "minimum": 240.00, "maximum": 255.00, "setting": "both", "payers_information": [ { "payer_name": "Aetna", "plan_name": "700700", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna", "plan_name": "700700_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Miscellaneous", "plan_name": "700720", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Miscellaneous", "plan_name": "700720_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Ppo Hmo", "plan_name": "701720", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Ppo Hmo", "plan_name": "701720_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Ms State Emplo", "plan_name": "401457", "standard_charge_percentage": 0.80, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Ms State Emplo", "plan_name": "401457_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Basic Pl", "plan_name": "400100", "standard_charge_percentage": 0.85, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Basic Pl", "plan_name": "400100_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Federal", "plan_name": "400110", "standard_charge_percentage": 0.85, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Federal", "plan_name": "400110_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." } ] } ] }, { "description": "Hc flow vol loop", "code_information": [ { "code": "94375", "type": "CPT" } ], "standard_charges": [ { "gross_charge": 250.00, "minimum": 330.53, "maximum": 330.53, "setting": "both", "payers_information": [ { "payer_name": "Aetna", "plan_name": "700700", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna", "plan_name": "700700_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Miscellaneous", "plan_name": "700720", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Miscellaneous", "plan_name": "700720_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Ppo Hmo", "plan_name": "701720", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Ppo Hmo", "plan_name": "701720_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Ms State Emplo", "plan_name": "401457", "standard_charge_dollar": 330.53, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Ms State Emplo", "plan_name": "401457_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Basic Pl", "plan_name": "400100", "standard_charge_dollar": 330.53, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Basic Pl", "plan_name": "400100_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Federal", "plan_name": "400110", "standard_charge_dollar": 330.53, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Federal", "plan_name": "400110_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." } ] } ] }, { "description": "Respiratory flow volume loop", "code_information": [ { "code": "94375", "type": "CPT" } ], "standard_charges": [ { "gross_charge": 250.00, "minimum": 330.53, "maximum": 330.53, "setting": "both", "payers_information": [ { "payer_name": "Aetna", "plan_name": "700700", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna", "plan_name": "700700_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Miscellaneous", "plan_name": "700720", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Miscellaneous", "plan_name": "700720_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Ppo Hmo", "plan_name": "701720", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Ppo Hmo", "plan_name": "701720_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Ms State Emplo", "plan_name": "401457", "standard_charge_dollar": 330.53, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Ms State Emplo", "plan_name": "401457_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Basic Pl", "plan_name": "400100", "standard_charge_dollar": 330.53, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Basic Pl", "plan_name": "400100_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Federal", "plan_name": "400110", "standard_charge_dollar": 330.53, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Federal", "plan_name": "400110_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." } ] } ] }, { "description": "Airway inhalation treatment", "code_information": [ { "code": "94640", "type": "CPT" } ], "standard_charges": [ { "gross_charge": 100.00, "minimum": 243.03, "maximum": 243.03, "setting": "both", "payers_information": [ { "payer_name": "Aetna", "plan_name": "700700", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna", "plan_name": "700700_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Miscellaneous", "plan_name": "700720", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Miscellaneous", "plan_name": "700720_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Ppo Hmo", "plan_name": "701720", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Ppo Hmo", "plan_name": "701720_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Ms State Emplo", "plan_name": "401457", "standard_charge_dollar": 243.03, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Ms State Emplo", "plan_name": "401457_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Basic Pl", "plan_name": "400100", "standard_charge_dollar": 243.03, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Basic Pl", "plan_name": "400100_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Federal", "plan_name": "400110", "standard_charge_dollar": 243.03, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Federal", "plan_name": "400110_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." } ] } ] }, { "description": "Hc airway inhalation treatment", "code_information": [ { "code": "94640", "type": "CPT" } ], "standard_charges": [ { "gross_charge": 100.00, "minimum": 243.03, "maximum": 243.03, "setting": "both", "payers_information": [ { "payer_name": "Aetna", "plan_name": "700700", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna", "plan_name": "700700_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Miscellaneous", "plan_name": "700720", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Miscellaneous", "plan_name": "700720_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Ppo Hmo", "plan_name": "701720", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Ppo Hmo", "plan_name": "701720_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Ms State Emplo", "plan_name": "401457", "standard_charge_dollar": 243.03, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Ms State Emplo", "plan_name": "401457_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Basic Pl", "plan_name": "400100", "standard_charge_dollar": 243.03, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Basic Pl", "plan_name": "400100_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Federal", "plan_name": "400110", "standard_charge_dollar": 243.03, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Federal", "plan_name": "400110_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." } ] } ] }, { "description": "Cbt 1st hour", "code_information": [ { "code": "94644", "type": "CPT" } ], "standard_charges": [ { "gross_charge": 210.00, "minimum": 149.97, "maximum": 149.97, "setting": "both", "payers_information": [ { "payer_name": "Aetna", "plan_name": "700700", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna", "plan_name": "700700_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Miscellaneous", "plan_name": "700720", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Miscellaneous", "plan_name": "700720_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Ppo Hmo", "plan_name": "701720", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Ppo Hmo", "plan_name": "701720_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Ms State Emplo", "plan_name": "401457", "standard_charge_dollar": 149.97, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Ms State Emplo", "plan_name": "401457_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Basic Pl", "plan_name": "400100", "standard_charge_dollar": 149.97, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Basic Pl", "plan_name": "400100_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Federal", "plan_name": "400110", "standard_charge_dollar": 149.97, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Federal", "plan_name": "400110_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." } ] } ] }, { "description": "Hc cont inhalation tx 1st hr", "code_information": [ { "code": "94644", "type": "CPT" } ], "standard_charges": [ { "gross_charge": 210.00, "minimum": 149.97, "maximum": 149.97, "setting": "both", "payers_information": [ { "payer_name": "Aetna", "plan_name": "700700", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna", "plan_name": "700700_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Miscellaneous", "plan_name": "700720", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Miscellaneous", "plan_name": "700720_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Ppo Hmo", "plan_name": "701720", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Ppo Hmo", "plan_name": "701720_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Ms State Emplo", "plan_name": "401457", "standard_charge_dollar": 149.97, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Ms State Emplo", "plan_name": "401457_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Basic Pl", "plan_name": "400100", "standard_charge_dollar": 149.97, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Basic Pl", "plan_name": "400100_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Federal", "plan_name": "400110", "standard_charge_dollar": 149.97, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Federal", "plan_name": "400110_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." } ] } ] }, { "description": "Cbt each addl hour", "code_information": [ { "code": "94645", "type": "CPT" } ], "standard_charges": [ { "gross_charge": 25.00, "minimum": 14.52, "maximum": 14.52, "setting": "both", "payers_information": [ { "payer_name": "Aetna", "plan_name": "700700", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna", "plan_name": "700700_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Miscellaneous", "plan_name": "700720", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Miscellaneous", "plan_name": "700720_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Ppo Hmo", "plan_name": "701720", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Ppo Hmo", "plan_name": "701720_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Ms State Emplo", "plan_name": "401457", "standard_charge_dollar": 14.52, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Ms State Emplo", "plan_name": "401457_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Basic Pl", "plan_name": "400100", "standard_charge_dollar": 14.52, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Basic Pl", "plan_name": "400100_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Federal", "plan_name": "400110", "standard_charge_dollar": 14.52, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Federal", "plan_name": "400110_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." } ] } ] }, { "description": "Hc cont inhalation tx ea addl hr", "code_information": [ { "code": "94645", "type": "CPT" } ], "standard_charges": [ { "gross_charge": 25.00, "minimum": 14.52, "maximum": 14.52, "setting": "both", "payers_information": [ { "payer_name": "Aetna", "plan_name": "700700", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna", "plan_name": "700700_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Miscellaneous", "plan_name": "700720", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Miscellaneous", "plan_name": "700720_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Ppo Hmo", "plan_name": "701720", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Ppo Hmo", "plan_name": "701720_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Ms State Emplo", "plan_name": "401457", "standard_charge_dollar": 14.52, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Ms State Emplo", "plan_name": "401457_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Basic Pl", "plan_name": "400100", "standard_charge_dollar": 14.52, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Basic Pl", "plan_name": "400100_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Federal", "plan_name": "400110", "standard_charge_dollar": 14.52, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Federal", "plan_name": "400110_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." } ] } ] }, { "description": "Hc cpap initiation and mgmt", "code_information": [ { "code": "94660", "type": "CPT" } ], "standard_charges": [ { "gross_charge": 150.00, "minimum": 243.03, "maximum": 243.03, "setting": "both", "payers_information": [ { "payer_name": "Aetna", "plan_name": "700700", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna", "plan_name": "700700_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Miscellaneous", "plan_name": "700720", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Miscellaneous", "plan_name": "700720_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Ppo Hmo", "plan_name": "701720", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Ppo Hmo", "plan_name": "701720_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Ms State Emplo", "plan_name": "401457", "standard_charge_dollar": 243.03, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Ms State Emplo", "plan_name": "401457_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Basic Pl", "plan_name": "400100", "standard_charge_dollar": 243.03, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Basic Pl", "plan_name": "400100_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Federal", "plan_name": "400110", "standard_charge_dollar": 243.03, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Federal", "plan_name": "400110_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." } ] } ] }, { "description": "Pos airway pressure cpap", "code_information": [ { "code": "94660", "type": "CPT" } ], "standard_charges": [ { "gross_charge": 150.00, "minimum": 243.03, "maximum": 243.03, "setting": "both", "payers_information": [ { "payer_name": "Aetna", "plan_name": "700700", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna", "plan_name": "700700_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Miscellaneous", "plan_name": "700720", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Miscellaneous", "plan_name": "700720_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Ppo Hmo", "plan_name": "701720", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Ppo Hmo", "plan_name": "701720_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Ms State Emplo", "plan_name": "401457", "standard_charge_dollar": 243.03, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Ms State Emplo", "plan_name": "401457_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Basic Pl", "plan_name": "400100", "standard_charge_dollar": 243.03, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Basic Pl", "plan_name": "400100_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Federal", "plan_name": "400110", "standard_charge_dollar": 243.03, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Federal", "plan_name": "400110_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." } ] } ] }, { "description": "Evaluate pt use of inhaler", "code_information": [ { "code": "94664", "type": "CPT" } ], "standard_charges": [ { "gross_charge": 325.00, "minimum": 243.03, "maximum": 243.03, "setting": "both", "payers_information": [ { "payer_name": "Aetna", "plan_name": "700700", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna", "plan_name": "700700_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Miscellaneous", "plan_name": "700720", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Miscellaneous", "plan_name": "700720_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Ppo Hmo", "plan_name": "701720", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Ppo Hmo", "plan_name": "701720_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Ms State Emplo", "plan_name": "401457", "standard_charge_dollar": 243.03, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Ms State Emplo", "plan_name": "401457_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Basic Pl", "plan_name": "400100", "standard_charge_dollar": 243.03, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Basic Pl", "plan_name": "400100_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Federal", "plan_name": "400110", "standard_charge_dollar": 243.03, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Federal", "plan_name": "400110_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." } ] } ] }, { "description": "Hc mdi dose inhaler instruction", "code_information": [ { "code": "94664", "type": "CPT" } ], "standard_charges": [ { "gross_charge": 325.00, "minimum": 243.03, "maximum": 243.03, "setting": "both", "payers_information": [ { "payer_name": "Aetna", "plan_name": "700700", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna", "plan_name": "700700_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Miscellaneous", "plan_name": "700720", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Miscellaneous", "plan_name": "700720_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Ppo Hmo", "plan_name": "701720", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Ppo Hmo", "plan_name": "701720_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Ms State Emplo", "plan_name": "401457", "standard_charge_dollar": 243.03, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Ms State Emplo", "plan_name": "401457_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Basic Pl", "plan_name": "400100", "standard_charge_dollar": 243.03, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Basic Pl", "plan_name": "400100_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Federal", "plan_name": "400110", "standard_charge_dollar": 243.03, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Federal", "plan_name": "400110_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." } ] } ] }, { "description": "Chest wall manipulation", "code_information": [ { "code": "94667", "type": "CPT" } ], "standard_charges": [ { "gross_charge": 259.00, "minimum": 149.97, "maximum": 149.97, "setting": "both", "payers_information": [ { "payer_name": "Aetna", "plan_name": "700700", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna", "plan_name": "700700_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Miscellaneous", "plan_name": "700720", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Miscellaneous", "plan_name": "700720_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Ppo Hmo", "plan_name": "701720", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Ppo Hmo", "plan_name": "701720_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Ms State Emplo", "plan_name": "401457", "standard_charge_dollar": 149.97, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Ms State Emplo", "plan_name": "401457_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Basic Pl", "plan_name": "400100", "standard_charge_dollar": 149.97, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Basic Pl", "plan_name": "400100_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Federal", "plan_name": "400110", "standard_charge_dollar": 149.97, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Federal", "plan_name": "400110_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." } ] } ] }, { "description": "Hc chest wall manipulation init", "code_information": [ { "code": "94667", "type": "CPT" } ], "standard_charges": [ { "gross_charge": 259.00, "minimum": 149.97, "maximum": 149.97, "setting": "both", "payers_information": [ { "payer_name": "Aetna", "plan_name": "700700", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna", "plan_name": "700700_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Miscellaneous", "plan_name": "700720", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Miscellaneous", "plan_name": "700720_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Ppo Hmo", "plan_name": "701720", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Ppo Hmo", "plan_name": "701720_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Ms State Emplo", "plan_name": "401457", "standard_charge_dollar": 149.97, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Ms State Emplo", "plan_name": "401457_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Basic Pl", "plan_name": "400100", "standard_charge_dollar": 149.97, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Basic Pl", "plan_name": "400100_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Federal", "plan_name": "400110", "standard_charge_dollar": 149.97, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Federal", "plan_name": "400110_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." } ] } ] }, { "description": "Chest wall manipulation", "code_information": [ { "code": "94668", "type": "CPT" } ], "standard_charges": [ { "gross_charge": 259.00, "minimum": 81.80, "maximum": 81.80, "setting": "both", "payers_information": [ { "payer_name": "Aetna", "plan_name": "700700", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna", "plan_name": "700700_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Miscellaneous", "plan_name": "700720", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Miscellaneous", "plan_name": "700720_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Ppo Hmo", "plan_name": "701720", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Ppo Hmo", "plan_name": "701720_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Ms State Emplo", "plan_name": "401457", "standard_charge_dollar": 81.80, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Ms State Emplo", "plan_name": "401457_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Basic Pl", "plan_name": "400100", "standard_charge_dollar": 81.80, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Basic Pl", "plan_name": "400100_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Federal", "plan_name": "400110", "standard_charge_dollar": 81.80, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Federal", "plan_name": "400110_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." } ] } ] }, { "description": "Hc chest wall manipulation subq", "code_information": [ { "code": "94668", "type": "CPT" } ], "standard_charges": [ { "gross_charge": 259.00, "minimum": 81.80, "maximum": 81.80, "setting": "both", "payers_information": [ { "payer_name": "Aetna", "plan_name": "700700", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna", "plan_name": "700700_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Miscellaneous", "plan_name": "700720", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Miscellaneous", "plan_name": "700720_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Ppo Hmo", "plan_name": "701720", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Ppo Hmo", "plan_name": "701720_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Ms State Emplo", "plan_name": "401457", "standard_charge_dollar": 81.80, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Ms State Emplo", "plan_name": "401457_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Basic Pl", "plan_name": "400100", "standard_charge_dollar": 81.80, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Basic Pl", "plan_name": "400100_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Federal", "plan_name": "400110", "standard_charge_dollar": 81.80, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Federal", "plan_name": "400110_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." } ] } ] }, { "description": "Hc pulse ox single determination", "code_information": [ { "code": "94760", "type": "CPT" } ], "standard_charges": [ { "gross_charge": 60.00, "minimum": 48.00, "maximum": 51.00, "setting": "both", "payers_information": [ { "payer_name": "Aetna", "plan_name": "700700", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna", "plan_name": "700700_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Miscellaneous", "plan_name": "700720", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Miscellaneous", "plan_name": "700720_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Ppo Hmo", "plan_name": "701720", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Ppo Hmo", "plan_name": "701720_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Ms State Emplo", "plan_name": "401457", "standard_charge_percentage": 0.80, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Ms State Emplo", "plan_name": "401457_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Basic Pl", "plan_name": "400100", "standard_charge_percentage": 0.85, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Basic Pl", "plan_name": "400100_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Federal", "plan_name": "400110", "standard_charge_percentage": 0.85, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Federal", "plan_name": "400110_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." } ] } ] }, { "description": "Measure blood oxygen level", "code_information": [ { "code": "94760", "type": "CPT" } ], "standard_charges": [ { "gross_charge": 60.00, "minimum": 48.00, "maximum": 51.00, "setting": "both", "payers_information": [ { "payer_name": "Aetna", "plan_name": "700700", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna", "plan_name": "700700_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Miscellaneous", "plan_name": "700720", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Miscellaneous", "plan_name": "700720_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Ppo Hmo", "plan_name": "701720", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Ppo Hmo", "plan_name": "701720_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Ms State Emplo", "plan_name": "401457", "standard_charge_percentage": 0.80, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Ms State Emplo", "plan_name": "401457_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Basic Pl", "plan_name": "400100", "standard_charge_percentage": 0.85, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Basic Pl", "plan_name": "400100_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Federal", "plan_name": "400110", "standard_charge_percentage": 0.85, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Federal", "plan_name": "400110_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." } ] } ] }, { "description": "Hc pulse ox cont overnight", "code_information": [ { "code": "94762", "type": "CPT" } ], "standard_charges": [ { "gross_charge": 243.00, "minimum": 194.63, "maximum": 194.63, "setting": "both", "payers_information": [ { "payer_name": "Aetna", "plan_name": "700700", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna", "plan_name": "700700_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Miscellaneous", "plan_name": "700720", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Miscellaneous", "plan_name": "700720_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Ppo Hmo", "plan_name": "701720", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Ppo Hmo", "plan_name": "701720_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Ms State Emplo", "plan_name": "401457", "standard_charge_dollar": 194.63, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Ms State Emplo", "plan_name": "401457_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Basic Pl", "plan_name": "400100", "standard_charge_dollar": 194.63, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Basic Pl", "plan_name": "400100_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Federal", "plan_name": "400110", "standard_charge_dollar": 194.63, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Federal", "plan_name": "400110_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." } ] } ] }, { "description": "Measure blood oxygen level", "code_information": [ { "code": "94762", "type": "CPT" } ], "standard_charges": [ { "gross_charge": 243.00, "minimum": 194.63, "maximum": 194.63, "setting": "both", "payers_information": [ { "payer_name": "Aetna", "plan_name": "700700", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna", "plan_name": "700700_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Miscellaneous", "plan_name": "700720", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Miscellaneous", "plan_name": "700720_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Ppo Hmo", "plan_name": "701720", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Ppo Hmo", "plan_name": "701720_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Ms State Emplo", "plan_name": "401457", "standard_charge_dollar": 194.63, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Ms State Emplo", "plan_name": "401457_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Basic Pl", "plan_name": "400100", "standard_charge_dollar": 194.63, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Basic Pl", "plan_name": "400100_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Federal", "plan_name": "400110", "standard_charge_dollar": 194.63, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Federal", "plan_name": "400110_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." } ] } ] }, { "description": "Hc htd high flow nsl cann init day", "code_information": [ { "code": "94799", "type": "CPT" } ], "standard_charges": [ { "gross_charge": 63.00, "minimum": 194.63, "maximum": 194.63, "setting": "both", "payers_information": [ { "payer_name": "Aetna", "plan_name": "700700", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna", "plan_name": "700700_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Miscellaneous", "plan_name": "700720", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Miscellaneous", "plan_name": "700720_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Ppo Hmo", "plan_name": "701720", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Ppo Hmo", "plan_name": "701720_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Ms State Emplo", "plan_name": "401457", "standard_charge_dollar": 194.63, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Ms State Emplo", "plan_name": "401457_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Basic Pl", "plan_name": "400100", "standard_charge_dollar": 194.63, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Basic Pl", "plan_name": "400100_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Federal", "plan_name": "400110", "standard_charge_dollar": 194.63, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Federal", "plan_name": "400110_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." } ] } ] }, { "description": "Pulmonary service/procedure", "code_information": [ { "code": "94799", "type": "CPT" } ], "standard_charges": [ { "gross_charge": 63.00, "minimum": 194.63, "maximum": 194.63, "setting": "both", "payers_information": [ { "payer_name": "Aetna", "plan_name": "700700", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna", "plan_name": "700700_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Miscellaneous", "plan_name": "700720", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Miscellaneous", "plan_name": "700720_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Ppo Hmo", "plan_name": "701720", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Ppo Hmo", "plan_name": "701720_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Ms State Emplo", "plan_name": "401457", "standard_charge_dollar": 194.63, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Ms State Emplo", "plan_name": "401457_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Basic Pl", "plan_name": "400100", "standard_charge_dollar": 194.63, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Basic Pl", "plan_name": "400100_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Federal", "plan_name": "400110", "standard_charge_dollar": 194.63, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Federal", "plan_name": "400110_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." } ] } ] }, { "description": "Hc immunotherapy one injection", "code_information": [ { "code": "95115", "type": "CPT" } ], "standard_charges": [ { "gross_charge": 90.00, "minimum": 72.00, "maximum": 76.50, "setting": "both", "payers_information": [ { "payer_name": "Aetna", "plan_name": "700700", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna", "plan_name": "700700_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Miscellaneous", "plan_name": "700720", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Miscellaneous", "plan_name": "700720_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Ppo Hmo", "plan_name": "701720", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Ppo Hmo", "plan_name": "701720_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Ms State Emplo", "plan_name": "401457", "standard_charge_percentage": 0.80, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Ms State Emplo", "plan_name": "401457_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Basic Pl", "plan_name": "400100", "standard_charge_percentage": 0.85, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Basic Pl", "plan_name": "400100_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient 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"payer_name": "Aetna Ppo Hmo", "plan_name": "701720_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Ms State Emplo", "plan_name": "401457", "standard_charge_percentage": 0.80, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Ms State Emplo", "plan_name": "401457_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Basic Pl", "plan_name": "400100", "standard_charge_percentage": 0.85, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Basic Pl", "plan_name": "400100_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Federal", "plan_name": "400110", "standard_charge_percentage": 0.85, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Federal", "plan_name": "400110_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." } ] } ] }, { "description": "Hc immunotherapy 2+ injections", "code_information": [ { "code": "95117", "type": "CPT" } ], "standard_charges": [ { "gross_charge": 106.00, "minimum": 84.80, "maximum": 90.10, "setting": "both", "payers_information": [ { 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"plan_name": "701720", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Ppo Hmo", "plan_name": "701720_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Ms State Emplo", "plan_name": "401457", "standard_charge_percentage": 0.80, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Ms State Emplo", "plan_name": "401457_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Basic Pl", "plan_name": "400100", "standard_charge_percentage": 0.85, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Basic Pl", "plan_name": "400100_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Federal", "plan_name": "400110", "standard_charge_percentage": 0.85, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Federal", "plan_name": "400110_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." } ] } ] }, { "description": "Immunotherapy 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"standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Basic Pl", "plan_name": "400100", "standard_charge_percentage": 0.85, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Basic Pl", "plan_name": "400100_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Federal", "plan_name": "400110", "standard_charge_percentage": 0.85, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Federal", "plan_name": "400110_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." } ] } ] }, { "description": "Cognitive test by hc pro", "code_information": [ { "code": "96125", "type": "CPT" } ], "standard_charges": [ { "gross_charge": 200.00, "minimum": 125.62, "maximum": 125.62, "setting": "both", "payers_information": [ { "payer_name": "Aetna", "plan_name": "700700", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna", "plan_name": "700700_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Miscellaneous", "plan_name": "700720", "standard_charge_percentage": 80.0, 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"methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Ms State Emplo", "plan_name": "401457_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Basic Pl", "plan_name": "400100", "standard_charge_dollar": 125.62, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Basic Pl", "plan_name": "400100_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Federal", "plan_name": "400110", "standard_charge_dollar": 125.62, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Federal", "plan_name": "400110_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." } ] } ] }, { "description": "Hc cognitive test by hc pro", "code_information": [ { "code": "96125", "type": "CPT" } ], "standard_charges": [ { "gross_charge": 200.00, "minimum": 125.62, "maximum": 125.62, "setting": "both", "payers_information": [ { "payer_name": "Aetna", "plan_name": "700700", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna", "plan_name": "700700_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Miscellaneous", "plan_name": "700720", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Miscellaneous", "plan_name": "700720_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Ppo Hmo", "plan_name": "701720", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Ppo Hmo", "plan_name": "701720_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient 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{ "payer_name": "Bc/Bs Of Ms Federal", "plan_name": "400110", "standard_charge_dollar": 125.62, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Federal", "plan_name": "400110_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." } ] } ] }, { "description": "Hc infusion hydration initial", "code_information": [ { "code": "96360", "type": "CPT" } ], "standard_charges": [ { "gross_charge": 435.00, "minimum": 348.00, "maximum": 369.75, "setting": "both", "payers_information": [ { "payer_name": "Aetna", "plan_name": "700700", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna", "plan_name": "700700_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Miscellaneous", "plan_name": "700720", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Miscellaneous", "plan_name": "700720_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Ppo Hmo", "plan_name": "701720", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Ppo Hmo", "plan_name": "701720_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Ms State Emplo", "plan_name": "401457", "standard_charge_percentage": 0.80, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Ms State Emplo", "plan_name": "401457_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Basic Pl", "plan_name": "400100", "standard_charge_percentage": 0.85, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Basic Pl", "plan_name": "400100_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Federal", "plan_name": "400110", "standard_charge_percentage": 0.85, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Federal", "plan_name": "400110_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." } ] } ] }, { "description": "Hydration iv infusion init", "code_information": [ { "code": "96360", "type": "CPT" } ], "standard_charges": [ { "gross_charge": 435.00, "minimum": 348.00, "maximum": 369.75, "setting": "both", "payers_information": [ { "payer_name": "Aetna", "plan_name": "700700", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna", "plan_name": "700700_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Miscellaneous", "plan_name": "700720", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Miscellaneous", "plan_name": "700720_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Ppo Hmo", "plan_name": "701720", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Ppo Hmo", "plan_name": "701720_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Ms State Emplo", "plan_name": "401457", "standard_charge_percentage": 0.80, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Ms State Emplo", "plan_name": "401457_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Basic Pl", "plan_name": "400100", "standard_charge_percentage": 0.85, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Basic Pl", "plan_name": "400100_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Federal", "plan_name": "400110", "standard_charge_percentage": 0.85, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Federal", "plan_name": "400110_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." } ] } ] }, { "description": "Hc infus hydra addtl hr", "code_information": [ { "code": "96361", "type": "CPT" } ], "standard_charges": [ { "gross_charge": 96.00, "minimum": 76.80, "maximum": 81.60, "setting": "both", "payers_information": [ { "payer_name": "Aetna", "plan_name": "700700", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna", "plan_name": "700700_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Miscellaneous", "plan_name": "700720", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Miscellaneous", "plan_name": "700720_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Ppo Hmo", "plan_name": "701720", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Ppo Hmo", "plan_name": "701720_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Ms State Emplo", "plan_name": "401457", "standard_charge_percentage": 0.80, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Ms State Emplo", "plan_name": "401457_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Basic Pl", "plan_name": "400100", "standard_charge_percentage": 0.85, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Basic Pl", "plan_name": "400100_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Federal", "plan_name": "400110", "standard_charge_percentage": 0.85, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Federal", "plan_name": "400110_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." } ] } ] }, { "description": "Hydrate iv infusion add-on", "code_information": [ { "code": "96361", "type": "CPT" } ], "standard_charges": [ { "gross_charge": 96.00, "minimum": 76.80, "maximum": 81.60, "setting": "both", "payers_information": [ { "payer_name": "Aetna", "plan_name": "700700", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna", "plan_name": "700700_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Miscellaneous", "plan_name": "700720", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed 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"additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Ms State Emplo", "plan_name": "401457_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Basic Pl", "plan_name": "400100", "standard_charge_percentage": 0.85, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Basic Pl", "plan_name": "400100_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Federal", "plan_name": "400110", "standard_charge_percentage": 0.85, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Federal", "plan_name": "400110_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." } ] } ] }, { "description": "Hc iv infusion initial up to 1hr", "code_information": [ { "code": "96365", "type": "CPT" } ], "standard_charges": [ { "gross_charge": 435.00, "minimum": 348.00, "maximum": 369.75, "setting": "both", "payers_information": [ { "payer_name": "Aetna", "plan_name": "700700", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna", "plan_name": "700700_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Miscellaneous", "plan_name": "700720", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Miscellaneous", "plan_name": "700720_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Ppo Hmo", "plan_name": "701720", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Ppo Hmo", "plan_name": "701720_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Ms State Emplo", "plan_name": "401457", "standard_charge_percentage": 0.80, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Ms State Emplo", "plan_name": "401457_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Basic Pl", "plan_name": "400100", "standard_charge_percentage": 0.85, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Basic Pl", "plan_name": "400100_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Federal", "plan_name": "400110", "standard_charge_percentage": 0.85, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Federal", "plan_name": "400110_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." } ] } ] }, { "description": "Ther/proph/diag iv inf init", "code_information": [ { "code": "96365", "type": "CPT" } ], "standard_charges": [ { "gross_charge": 435.00, "minimum": 348.00, "maximum": 369.75, "setting": "both", "payers_information": [ { "payer_name": "Aetna", "plan_name": "700700", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna", "plan_name": "700700_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Miscellaneous", "plan_name": "700720", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Miscellaneous", "plan_name": "700720_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Ppo Hmo", "plan_name": "701720", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Ppo Hmo", "plan_name": "701720_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Ms State Emplo", "plan_name": "401457", "standard_charge_percentage": 0.80, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Ms State Emplo", "plan_name": "401457_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Basic Pl", "plan_name": "400100", "standard_charge_percentage": 0.85, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Basic Pl", "plan_name": "400100_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Federal", "plan_name": "400110", "standard_charge_percentage": 0.85, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Federal", "plan_name": "400110_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." } ] } ] }, { "description": "Hc infusion ea addtl hr", "code_information": [ { "code": "96366", "type": "CPT" } ], "standard_charges": [ { "gross_charge": 96.00, "minimum": 76.80, "maximum": 81.60, "setting": "both", "payers_information": [ { "payer_name": "Aetna", "plan_name": "700700", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna", "plan_name": "700700_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Miscellaneous", "plan_name": "700720", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Miscellaneous", "plan_name": "700720_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Ppo Hmo", "plan_name": "701720", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Ppo Hmo", "plan_name": "701720_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Ms State Emplo", "plan_name": "401457", "standard_charge_percentage": 0.80, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Ms State Emplo", "plan_name": "401457_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Basic Pl", "plan_name": "400100", "standard_charge_percentage": 0.85, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Basic Pl", "plan_name": "400100_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Federal", "plan_name": "400110", "standard_charge_percentage": 0.85, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Federal", "plan_name": "400110_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." } ] } ] }, { "description": "Ther/proph/diag iv inf addon", "code_information": [ { "code": "96366", "type": "CPT" } ], "standard_charges": [ { "gross_charge": 96.00, "minimum": 76.80, "maximum": 81.60, "setting": "both", "payers_information": [ { "payer_name": "Aetna", "plan_name": "700700", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna", "plan_name": "700700_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Miscellaneous", "plan_name": "700720", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Miscellaneous", "plan_name": "700720_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Ppo Hmo", "plan_name": "701720", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Ppo Hmo", "plan_name": "701720_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Ms State Emplo", "plan_name": "401457", "standard_charge_percentage": 0.80, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Ms State Emplo", "plan_name": "401457_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Basic Pl", "plan_name": "400100", "standard_charge_percentage": 0.85, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Basic Pl", "plan_name": "400100_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Federal", "plan_name": "400110", "standard_charge_percentage": 0.85, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Federal", "plan_name": "400110_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." } ] } ] }, { "description": "Hc infus seq new drug up to 1hr", "code_information": [ { "code": "96367", "type": "CPT" } ], "standard_charges": [ { "gross_charge": 143.00, "minimum": 114.40, "maximum": 121.55, "setting": "both", "payers_information": [ { "payer_name": "Aetna", "plan_name": "700700", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna", "plan_name": "700700_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Miscellaneous", "plan_name": "700720", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Miscellaneous", "plan_name": "700720_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Ppo Hmo", "plan_name": "701720", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Ppo Hmo", "plan_name": "701720_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Ms State Emplo", "plan_name": "401457", "standard_charge_percentage": 0.80, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Ms State Emplo", "plan_name": "401457_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Basic Pl", "plan_name": "400100", "standard_charge_percentage": 0.85, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Basic Pl", "plan_name": "400100_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Federal", "plan_name": "400110", "standard_charge_percentage": 0.85, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Federal", "plan_name": "400110_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." } ] } ] }, { "description": "Tx/proph/dg addl seq iv inf", "code_information": [ { "code": "96367", "type": "CPT" } ], "standard_charges": [ { "gross_charge": 143.00, "minimum": 114.40, "maximum": 121.55, "setting": "both", "payers_information": [ { "payer_name": "Aetna", "plan_name": "700700", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna", "plan_name": "700700_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Miscellaneous", "plan_name": "700720", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Miscellaneous", "plan_name": "700720_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Ppo Hmo", "plan_name": "701720", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Ppo Hmo", "plan_name": "701720_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Ms State Emplo", "plan_name": "401457", "standard_charge_percentage": 0.80, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Ms State Emplo", "plan_name": "401457_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Basic Pl", "plan_name": "400100", "standard_charge_percentage": 0.85, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Basic Pl", "plan_name": "400100_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient 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"payer_name": "Bc/Bs Of Ms Basic Pl", "plan_name": "400100_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Federal", "plan_name": "400110", "standard_charge_percentage": 0.85, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Federal", "plan_name": "400110_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." } ] } ] }, { "description": "Ther/diag concurrent inf", "code_information": [ { "code": "96368", "type": "CPT" } ], "standard_charges": [ { "gross_charge": 55.00, "minimum": 44.00, "maximum": 46.75, "setting": "both", "payers_information": [ { "payer_name": 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"additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Federal", "plan_name": "400110_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." } ] } ] }, { "description": "Hc injection im or subq", "code_information": [ { "code": "96372", "type": "CPT" } ], "standard_charges": [ { "gross_charge": 45.00, "minimum": 36.00, "maximum": 38.25, "setting": "both", "payers_information": [ { "payer_name": "Aetna", "plan_name": "700700", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "modifiers": "QW", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna", "plan_name": "700700_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Miscellaneous", "plan_name": "700720", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Miscellaneous", "plan_name": "700720_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Ppo Hmo", "plan_name": "701720", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Ppo Hmo", "plan_name": "701720_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Ms State Emplo", "plan_name": "401457", "standard_charge_percentage": 0.80, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Ms State Emplo", "plan_name": "401457_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Basic Pl", "plan_name": "400100", "standard_charge_percentage": 0.85, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Basic Pl", "plan_name": "400100_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Federal", "plan_name": "400110", "standard_charge_percentage": 0.85, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Federal", "plan_name": "400110_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." } ] } ] }, { "description": "Hc injection iv push init", "code_information": [ { "code": "96374", "type": "CPT" } ], "standard_charges": [ { "gross_charge": 110.00, "minimum": 88.00, "maximum": 93.50, "setting": "both", "payers_information": [ { "payer_name": "Aetna", "plan_name": "700700", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna", "plan_name": "700700_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Miscellaneous", "plan_name": "700720", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Miscellaneous", "plan_name": "700720_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Ppo Hmo", "plan_name": "701720", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data 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calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Basic Pl", "plan_name": "400100_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Federal", "plan_name": "400110", "standard_charge_percentage": 0.85, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Federal", "plan_name": "400110_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." } ] } ] }, { "description": "Ther/proph/diag inj iv push", "code_information": [ { "code": "96374", "type": "CPT" } ], "standard_charges": [ { "gross_charge": 110.00, "minimum": 88.00, "maximum": 93.50, "setting": "both", "payers_information": [ { "payer_name": "Aetna", "plan_name": "700700", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna", "plan_name": "700700_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Miscellaneous", "plan_name": "700720", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Miscellaneous", "plan_name": "700720_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Ppo Hmo", "plan_name": "701720", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Ppo Hmo", "plan_name": "701720_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Ms State Emplo", "plan_name": "401457", "standard_charge_percentage": 0.80, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Ms State Emplo", "plan_name": "401457_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Basic Pl", "plan_name": "400100", "standard_charge_percentage": 0.85, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Basic Pl", "plan_name": "400100_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Federal", "plan_name": "400110", "standard_charge_percentage": 0.85, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Federal", "plan_name": "400110_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." } ] } ] }, { "description": "Hc ivp addtl seq new drug", "code_information": [ { "code": "96375", "type": "CPT" } ], "standard_charges": [ { "gross_charge": 75.00, "minimum": 60.00, "maximum": 63.75, "setting": "both", "payers_information": [ { "payer_name": "Aetna", "plan_name": "700700", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna", "plan_name": "700700_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Miscellaneous", "plan_name": "700720", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Miscellaneous", "plan_name": "700720_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Ppo Hmo", "plan_name": "701720", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Ppo Hmo", "plan_name": "701720_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Ms State Emplo", "plan_name": "401457", "standard_charge_percentage": 0.80, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Ms State Emplo", "plan_name": "401457_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Basic Pl", "plan_name": "400100", "standard_charge_percentage": 0.85, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Basic Pl", "plan_name": "400100_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Federal", "plan_name": "400110", "standard_charge_percentage": 0.85, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Federal", "plan_name": "400110_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." } ] } ] }, { "description": "Tx/pro/dx inj new drug addon", "code_information": [ { "code": "96375", "type": "CPT" } ], "standard_charges": [ { "gross_charge": 75.00, "minimum": 60.00, "maximum": 63.75, "setting": "both", "payers_information": [ { "payer_name": "Aetna", "plan_name": "700700", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna", "plan_name": "700700_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Miscellaneous", "plan_name": "700720", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Miscellaneous", "plan_name": "700720_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Ppo Hmo", "plan_name": "701720", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Ppo Hmo", "plan_name": "701720_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Ms State Emplo", "plan_name": "401457", "standard_charge_percentage": 0.80, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Ms State Emplo", "plan_name": "401457_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Basic Pl", "plan_name": "400100", "standard_charge_percentage": 0.85, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Basic Pl", "plan_name": "400100_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Federal", "plan_name": "400110", "standard_charge_percentage": 0.85, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Federal", "plan_name": "400110_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." } ] } ] }, { "description": "Hc ivp addtl seq same drug >30min", "code_information": [ { "code": "96376", "type": "CPT" } ], "standard_charges": [ { "gross_charge": 60.00, "minimum": 48.00, "maximum": 51.00, "setting": "both", "payers_information": [ { "payer_name": "Aetna", "plan_name": "700700", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna", "plan_name": "700700_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total 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"additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Ms State Emplo", "plan_name": "401457", "standard_charge_percentage": 0.80, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Ms State Emplo", "plan_name": "401457_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Basic Pl", "plan_name": "400100", "standard_charge_percentage": 0.85, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Basic Pl", "plan_name": "400100_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Federal", "plan_name": "400110", "standard_charge_percentage": 0.85, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Federal", "plan_name": "400110_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." } ] } ] }, { "description": "Tx/pro/dx inj same drug adon", "code_information": [ { "code": "96376", "type": "CPT" } ], "standard_charges": [ { "gross_charge": 60.00, "minimum": 48.00, "maximum": 51.00, "setting": "both", "payers_information": [ { "payer_name": "Aetna", "plan_name": "700700", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna", "plan_name": "700700_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Miscellaneous", "plan_name": "700720", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Miscellaneous", "plan_name": "700720_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Ppo Hmo", "plan_name": "701720", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Ppo Hmo", "plan_name": "701720_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Ms State Emplo", "plan_name": "401457", "standard_charge_percentage": 0.80, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Ms State Emplo", "plan_name": "401457_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Basic Pl", "plan_name": "400100", "standard_charge_percentage": 0.85, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Basic Pl", "plan_name": "400100_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Federal", "plan_name": "400110", "standard_charge_percentage": 0.85, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Federal", "plan_name": "400110_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." } ] } ] }, { "description": "Hc irrigation of vad", "code_information": [ { "code": "96523", "type": "CPT" } ], "standard_charges": [ { "gross_charge": 161.00, "minimum": 81.80, "maximum": 81.80, "setting": "both", "payers_information": [ { "payer_name": "Aetna", "plan_name": "700700", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna", "plan_name": "700700_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Miscellaneous", "plan_name": "700720", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Miscellaneous", "plan_name": "700720_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Ppo Hmo", "plan_name": "701720", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Ppo Hmo", "plan_name": "701720_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Ms State Emplo", "plan_name": "401457", "standard_charge_dollar": 81.80, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Ms State Emplo", "plan_name": "401457_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Basic Pl", "plan_name": "400100", "standard_charge_dollar": 81.80, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Basic Pl", "plan_name": "400100_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Federal", "plan_name": "400110", "standard_charge_dollar": 81.80, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Federal", "plan_name": "400110_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." } ] } ] }, { "description": "Irrig drug delivery device", "code_information": [ { "code": "96523", "type": "CPT" } ], "standard_charges": [ { "gross_charge": 161.00, "minimum": 81.80, "maximum": 81.80, "setting": "both", "payers_information": [ { "payer_name": "Aetna", "plan_name": "700700", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna", "plan_name": "700700_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Miscellaneous", "plan_name": "700720", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Miscellaneous", "plan_name": "700720_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Ppo Hmo", "plan_name": "701720", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Ppo Hmo", "plan_name": "701720_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Ms State Emplo", "plan_name": "401457", "standard_charge_dollar": 81.80, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Ms State Emplo", "plan_name": "401457_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Basic Pl", "plan_name": "400100", "standard_charge_dollar": 81.80, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Basic Pl", "plan_name": "400100_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Federal", "plan_name": "400110", "standard_charge_dollar": 81.80, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Federal", "plan_name": "400110_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." } ] } ] }, { "description": "Hc pt mechanical traction therapy", "code_information": [ { "code": "97012", "type": "CPT" } ], "standard_charges": [ { "gross_charge": 30.00, "minimum": 17.68, "maximum": 17.68, "setting": "both", "payers_information": [ { "payer_name": "Aetna", "plan_name": "700700", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna", "plan_name": "700700_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Miscellaneous", "plan_name": "700720", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Miscellaneous", "plan_name": "700720_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Ppo Hmo", "plan_name": "701720", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Ppo Hmo", "plan_name": "701720_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Ms State Emplo", "plan_name": "401457", "standard_charge_dollar": 17.68, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Ms State Emplo", "plan_name": "401457_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Basic Pl", "plan_name": "400100", "standard_charge_dollar": 17.68, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Basic Pl", "plan_name": "400100_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Federal", "plan_name": "400110", "standard_charge_dollar": 17.68, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Federal", "plan_name": "400110_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." } ] } ] }, { "description": "Mechanical traction therapy", "code_information": [ { "code": "97012", "type": "CPT" } ], "standard_charges": [ { "gross_charge": 30.00, "minimum": 17.68, "maximum": 17.68, "setting": "both", "payers_information": [ { "payer_name": "Aetna", "plan_name": "700700", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna", "plan_name": "700700_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Miscellaneous", "plan_name": "700720", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Miscellaneous", "plan_name": "700720_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Ppo Hmo", "plan_name": "701720", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Ppo Hmo", "plan_name": "701720_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Ms State Emplo", "plan_name": "401457", "standard_charge_dollar": 17.68, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Ms State Emplo", "plan_name": "401457_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Basic Pl", "plan_name": "400100", "standard_charge_dollar": 17.68, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Basic Pl", "plan_name": "400100_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Federal", "plan_name": "400110", "standard_charge_dollar": 17.68, "count": "0", "methodology": "fee schedule", 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"payer_name": "Aetna Miscellaneous", "plan_name": "700720_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Ppo Hmo", "plan_name": "701720", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Ppo Hmo", "plan_name": "701720_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Ms State Emplo", "plan_name": "401457", "standard_charge_dollar": 13.88, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Ms State Emplo", "plan_name": "401457_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Basic Pl", "plan_name": "400100", "standard_charge_dollar": 13.88, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Basic Pl", "plan_name": "400100_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Federal", "plan_name": "400110", "standard_charge_dollar": 13.88, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Federal", "plan_name": "400110_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." } ] } ] }, { "description": "Hc pt therapy exercise ea 15 min", "code_information": [ { "code": "97110", "type": "CPT" } ], "standard_charges": [ { "gross_charge": 60.00, "minimum": 35.08, "maximum": 35.08, "setting": "both", "payers_information": [ { "payer_name": "Aetna", "plan_name": "700700", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna", "plan_name": "700700_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Miscellaneous", "plan_name": "700720", "standard_charge_percentage": 80.0, 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"methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Ms State Emplo", "plan_name": "401457_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Basic Pl", "plan_name": "400100", "standard_charge_dollar": 35.08, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Basic Pl", "plan_name": "400100_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Federal", "plan_name": "400110", "standard_charge_dollar": 35.08, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Federal", "plan_name": "400110_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." } ] } ] }, { "description": "Therapeutic exercises", "code_information": [ { "code": "97110", "type": "CPT" } ], "standard_charges": [ { "gross_charge": 60.00, "minimum": 35.08, "maximum": 35.08, "setting": "both", "payers_information": [ { "payer_name": "Aetna", "plan_name": "700700", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna", "plan_name": "700700_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit 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calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Basic Pl", "plan_name": "400100_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Federal", "plan_name": "400110", "standard_charge_dollar": 36.51, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Federal", "plan_name": "400110_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." } ] } ] }, { "description": "Gait training therapy", "code_information": [ { "code": "97116", "type": "CPT" } ], "standard_charges": [ { "gross_charge": 110.00, "minimum": 30.67, "maximum": 30.67, "setting": "both", "payers_information": [ { 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"plan_name": "701720", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Ppo Hmo", "plan_name": "701720_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Ms State Emplo", "plan_name": "401457", "standard_charge_dollar": 30.67, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Ms State Emplo", "plan_name": "401457_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Basic Pl", "plan_name": "400100", "standard_charge_dollar": 30.67, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Basic Pl", "plan_name": "400100_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Federal", "plan_name": "400110", "standard_charge_dollar": 30.67, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Federal", "plan_name": "400110_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." } ] } ] }, { "description": "Hc pt gait training ea 15 min", "code_information": [ { "code": "97116", "type": 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"additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Basic Pl", "plan_name": "400100", "standard_charge_dollar": 30.67, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Basic Pl", "plan_name": "400100_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Federal", "plan_name": "400110", "standard_charge_dollar": 30.67, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Federal", "plan_name": "400110_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." } ] } ] }, { "description": "Hc ot therapy message ea 15 min", "code_information": [ { "code": "97124", "type": "CPT" } ], "standard_charges": [ { "gross_charge": 69.00, "minimum": 28.25, "maximum": 28.25, "setting": "both", "payers_information": [ { "payer_name": "Aetna", "plan_name": "700700", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna", "plan_name": "700700_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Miscellaneous", "plan_name": "700720", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Miscellaneous", "plan_name": "700720_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Ppo Hmo", "plan_name": "701720", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Ppo Hmo", "plan_name": "701720_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Ms State Emplo", "plan_name": "401457", "standard_charge_dollar": 28.25, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Ms State Emplo", "plan_name": "401457_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Basic Pl", "plan_name": "400100", "standard_charge_dollar": 28.25, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Basic Pl", "plan_name": "400100_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Federal", "plan_name": "400110", "standard_charge_dollar": 28.25, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Federal", "plan_name": "400110_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." } ] } ] }, { "description": "Massage therapy", "code_information": [ { "code": "97124", "type": "CPT" } ], "standard_charges": [ { "gross_charge": 69.00, "minimum": 28.25, "maximum": 28.25, "setting": "both", "payers_information": [ { "payer_name": "Aetna", "plan_name": "700700", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna", "plan_name": "700700_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Miscellaneous", "plan_name": "700720", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Miscellaneous", "plan_name": "700720_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Ppo Hmo", "plan_name": "701720", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Ppo Hmo", "plan_name": "701720_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Ms State Emplo", "plan_name": "401457", "standard_charge_dollar": 28.25, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Ms State Emplo", "plan_name": "401457_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Basic Pl", "plan_name": "400100", "standard_charge_dollar": 28.25, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Basic Pl", "plan_name": "400100_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Federal", "plan_name": "400110", "standard_charge_dollar": 28.25, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Federal", "plan_name": "400110_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." } ] } ] }, { "description": "Hc ther ivntj cog funcj cntct 1st 15 minutes", "code_information": [ { "code": "97129", "type": "CPT" } ], "standard_charges": [ { "gross_charge": 175.00, "minimum": 140.00, "maximum": 148.75, "setting": "both", "payers_information": [ { "payer_name": "Aetna", "plan_name": "700700", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna", "plan_name": "700700_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Miscellaneous", "plan_name": "700720", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Miscellaneous", "plan_name": "700720_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Ppo Hmo", "plan_name": "701720", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Ppo Hmo", "plan_name": "701720_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Ms State Emplo", "plan_name": "401457", "standard_charge_percentage": 0.80, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Ms State Emplo", "plan_name": "401457_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Basic Pl", "plan_name": "400100", "standard_charge_percentage": 0.85, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Basic Pl", "plan_name": "400100_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Federal", "plan_name": "400110", "standard_charge_percentage": 0.85, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Federal", "plan_name": "400110_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." } ] } ] }, { "description": "Ther ivntj 1st 15 min", "code_information": [ { "code": "97129", "type": "CPT" } ], "standard_charges": [ { "gross_charge": 175.00, "minimum": 140.00, "maximum": 148.75, "setting": "both", "payers_information": [ { "payer_name": "Aetna", "plan_name": "700700", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna", "plan_name": "700700_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Miscellaneous", "plan_name": "700720", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Miscellaneous", "plan_name": "700720_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Ppo Hmo", "plan_name": "701720", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Ppo Hmo", "plan_name": "701720_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Ms State Emplo", "plan_name": "401457", "standard_charge_percentage": 0.80, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Ms State Emplo", "plan_name": "401457_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Basic Pl", "plan_name": "400100", "standard_charge_percentage": 0.85, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Basic Pl", "plan_name": "400100_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Federal", "plan_name": "400110", "standard_charge_percentage": 0.85, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Federal", "plan_name": "400110_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." } ] } ] }, { "description": "Hc ther ivntj cog funcj cntct ea addl 15 minutes", "code_information": [ { "code": "97130", "type": "CPT" } ], "standard_charges": [ { "gross_charge": 75.00, "minimum": 60.00, "maximum": 63.75, "setting": "both", "payers_information": [ { "payer_name": "Aetna", "plan_name": "700700", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna", "plan_name": "700700_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Miscellaneous", "plan_name": "700720", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Miscellaneous", "plan_name": "700720_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Ppo Hmo", "plan_name": "701720", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Ppo Hmo", "plan_name": "701720_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Ms State Emplo", "plan_name": "401457", "standard_charge_percentage": 0.80, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Ms State Emplo", "plan_name": "401457_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Basic Pl", "plan_name": "400100", "standard_charge_percentage": 0.85, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Basic Pl", "plan_name": "400100_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Federal", "plan_name": "400110", "standard_charge_percentage": 0.85, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Federal", "plan_name": "400110_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." } ] } ] }, { "description": "Ther ivntj ea addl 15 min", "code_information": [ { "code": "97130", "type": "CPT" } ], "standard_charges": [ { "gross_charge": 75.00, "minimum": 60.00, "maximum": 63.75, "setting": "both", "payers_information": [ { "payer_name": "Aetna", "plan_name": "700700", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna", "plan_name": "700700_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Miscellaneous", "plan_name": "700720", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Miscellaneous", "plan_name": "700720_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Ppo Hmo", "plan_name": "701720", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Ppo Hmo", "plan_name": "701720_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Ms State Emplo", "plan_name": "401457", "standard_charge_percentage": 0.80, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Ms State Emplo", "plan_name": "401457_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Basic Pl", "plan_name": "400100", "standard_charge_percentage": 0.85, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Basic Pl", "plan_name": "400100_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Federal", "plan_name": "400110", "standard_charge_percentage": 0.85, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Federal", "plan_name": "400110_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." } ] } ] }, { "description": "Hc pt manual therapy ea 15 min", "code_information": [ { "code": "97140", "type": "CPT" } ], "standard_charges": [ { "gross_charge": 100.00, "minimum": 32.62, "maximum": 32.62, "setting": "both", "payers_information": [ { "payer_name": "Aetna", "plan_name": "700700", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna", "plan_name": "700700_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Miscellaneous", "plan_name": "700720", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Miscellaneous", "plan_name": "700720_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Ppo Hmo", "plan_name": "701720", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Ppo Hmo", "plan_name": "701720_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Ms State Emplo", "plan_name": "401457", "standard_charge_dollar": 32.62, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Ms State Emplo", "plan_name": "401457_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Basic Pl", "plan_name": "400100", "standard_charge_dollar": 32.62, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Basic Pl", "plan_name": "400100_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Federal", "plan_name": "400110", "standard_charge_dollar": 32.62, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Federal", "plan_name": "400110_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." } ] } ] }, { "description": "Manual therapy 1/> regions", "code_information": [ { "code": "97140", "type": "CPT" } ], "standard_charges": [ { "gross_charge": 100.00, "minimum": 32.62, "maximum": 32.62, "setting": "both", "payers_information": [ { "payer_name": "Aetna", "plan_name": "700700", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna", "plan_name": "700700_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Miscellaneous", "plan_name": "700720", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Miscellaneous", "plan_name": "700720_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Ppo Hmo", "plan_name": "701720", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Ppo Hmo", "plan_name": "701720_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Ms State Emplo", "plan_name": "401457", "standard_charge_dollar": 32.62, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Ms State Emplo", "plan_name": "401457_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Basic Pl", "plan_name": "400100", "standard_charge_dollar": 32.62, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Basic Pl", "plan_name": "400100_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Federal", "plan_name": "400110", "standard_charge_dollar": 32.62, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Federal", "plan_name": "400110_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." } ] } ] }, { "description": "Hc pt eval low complex 20min", "code_information": [ { "code": "97161", "type": "CPT" } ], "standard_charges": [ { "gross_charge": 200.00, "minimum": 86.62, "maximum": 86.62, "setting": "both", "payers_information": [ { "payer_name": "Aetna", "plan_name": "700700", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna", "plan_name": "700700_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Miscellaneous", "plan_name": "700720", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Miscellaneous", "plan_name": "700720_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Ppo Hmo", "plan_name": "701720", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Ppo Hmo", "plan_name": "701720_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Ms State Emplo", "plan_name": "401457", "standard_charge_dollar": 86.62, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Ms State Emplo", "plan_name": "401457_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Basic Pl", "plan_name": "400100", "standard_charge_dollar": 86.62, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Basic Pl", "plan_name": "400100_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Federal", "plan_name": "400110", "standard_charge_dollar": 86.62, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Federal", "plan_name": "400110_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." } ] } ] }, { "description": "Pt eval low complex 20 min", "code_information": [ { "code": "97161", "type": "CPT" } ], "standard_charges": [ { "gross_charge": 200.00, "minimum": 86.62, "maximum": 86.62, "setting": "both", "payers_information": [ { "payer_name": "Aetna", "plan_name": "700700", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna", "plan_name": "700700_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Miscellaneous", "plan_name": "700720", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Miscellaneous", "plan_name": "700720_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Ppo Hmo", "plan_name": "701720", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Ppo Hmo", "plan_name": "701720_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Ms State Emplo", "plan_name": "401457", "standard_charge_dollar": 86.62, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Ms State Emplo", "plan_name": "401457_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Basic Pl", "plan_name": "400100", "standard_charge_dollar": 86.62, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Basic Pl", "plan_name": "400100_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Federal", "plan_name": "400110", "standard_charge_dollar": 86.62, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Federal", "plan_name": "400110_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." } ] } ] }, { "description": "Hc pt eval mod complex 30 min", "code_information": [ { "code": "97162", "type": "CPT" } ], "standard_charges": [ { "gross_charge": 250.00, "minimum": 86.62, "maximum": 86.62, "setting": "both", "payers_information": [ { "payer_name": "Aetna", "plan_name": "700700", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna", "plan_name": "700700_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Miscellaneous", "plan_name": "700720", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Miscellaneous", "plan_name": "700720_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Ppo Hmo", "plan_name": "701720", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Ppo Hmo", "plan_name": "701720_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Ms State Emplo", "plan_name": "401457", "standard_charge_dollar": 86.62, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Ms State Emplo", "plan_name": "401457_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Basic Pl", "plan_name": "400100", "standard_charge_dollar": 86.62, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Basic Pl", "plan_name": "400100_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Federal", "plan_name": "400110", "standard_charge_dollar": 86.62, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Federal", "plan_name": "400110_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." } ] } ] }, { "description": "Pt eval mod complex 30 min", "code_information": [ { "code": "97162", "type": "CPT" } ], "standard_charges": [ { "gross_charge": 250.00, "minimum": 86.62, "maximum": 86.62, "setting": "both", "payers_information": [ { "payer_name": "Aetna", "plan_name": "700700", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna", "plan_name": "700700_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Miscellaneous", "plan_name": "700720", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Miscellaneous", "plan_name": "700720_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Ppo Hmo", "plan_name": "701720", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Ppo Hmo", "plan_name": "701720_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Ms State Emplo", "plan_name": "401457", "standard_charge_dollar": 86.62, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Ms State Emplo", "plan_name": "401457_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Basic Pl", "plan_name": "400100", "standard_charge_dollar": 86.62, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Basic Pl", "plan_name": "400100_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Federal", "plan_name": "400110", "standard_charge_dollar": 86.62, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Federal", "plan_name": "400110_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." } ] } ] }, { "description": "Hc pt re-eval revise poc 20 min", "code_information": [ { "code": "97164", "type": "CPT" } ], "standard_charges": [ { "gross_charge": 160.00, "minimum": 58.50, "maximum": 58.50, "setting": "both", "payers_information": [ { "payer_name": "Aetna", "plan_name": "700700", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna", "plan_name": "700700_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Miscellaneous", "plan_name": "700720", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Miscellaneous", "plan_name": "700720_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Ppo Hmo", "plan_name": "701720", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Ppo Hmo", "plan_name": "701720_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Ms State Emplo", "plan_name": "401457", "standard_charge_dollar": 58.50, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Ms State Emplo", "plan_name": "401457_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Basic Pl", "plan_name": "400100", "standard_charge_dollar": 58.50, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Basic Pl", "plan_name": "400100_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Federal", "plan_name": "400110", "standard_charge_dollar": 58.50, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Federal", "plan_name": "400110_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." } ] } ] }, { "description": "Pt re-eval est plan care", "code_information": [ { "code": "97164", "type": "CPT" } ], "standard_charges": [ { "gross_charge": 160.00, "minimum": 58.50, "maximum": 58.50, "setting": "both", "payers_information": [ { "payer_name": "Aetna", "plan_name": "700700", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna", "plan_name": "700700_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Miscellaneous", "plan_name": "700720", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Miscellaneous", "plan_name": "700720_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Ppo Hmo", "plan_name": "701720", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Ppo Hmo", "plan_name": "701720_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Ms State Emplo", "plan_name": "401457", "standard_charge_dollar": 58.50, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Ms State Emplo", "plan_name": "401457_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Basic Pl", "plan_name": "400100", "standard_charge_dollar": 58.50, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Basic Pl", "plan_name": "400100_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Federal", "plan_name": "400110", "standard_charge_dollar": 58.50, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Federal", "plan_name": "400110_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." } ] } ] }, { "description": "Hc ot eval low complex 30min", "code_information": [ { "code": "97165", "type": "CPT" } ], "standard_charges": [ { "gross_charge": 200.00, "minimum": 84.12, "maximum": 84.12, "setting": "both", "payers_information": [ { "payer_name": "Aetna", "plan_name": "700700", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna", "plan_name": "700700_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Miscellaneous", "plan_name": "700720", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Miscellaneous", "plan_name": "700720_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Ppo Hmo", "plan_name": "701720", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Ppo Hmo", "plan_name": "701720_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Ms State Emplo", "plan_name": "401457", "standard_charge_dollar": 84.12, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Ms State Emplo", "plan_name": "401457_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Basic Pl", "plan_name": "400100", "standard_charge_dollar": 84.12, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Basic Pl", "plan_name": "400100_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Federal", "plan_name": "400110", "standard_charge_dollar": 84.12, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Federal", "plan_name": "400110_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." } ] } ] }, { "description": "Ot eval low complex 30 min", "code_information": [ { "code": "97165", "type": "CPT" } ], "standard_charges": [ { "gross_charge": 200.00, "minimum": 84.12, "maximum": 84.12, "setting": "both", "payers_information": [ { "payer_name": "Aetna", "plan_name": "700700", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna", "plan_name": "700700_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Miscellaneous", "plan_name": "700720", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Miscellaneous", "plan_name": "700720_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Ppo Hmo", "plan_name": "701720", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Ppo Hmo", "plan_name": "701720_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Ms State Emplo", "plan_name": "401457", "standard_charge_dollar": 84.12, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Ms State Emplo", "plan_name": "401457_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Basic Pl", "plan_name": "400100", "standard_charge_dollar": 84.12, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Basic Pl", "plan_name": "400100_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Federal", "plan_name": "400110", "standard_charge_dollar": 84.12, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Federal", "plan_name": "400110_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." } ] } ] }, { "description": "Hc pt functional activ ea 15 min", "code_information": [ { "code": "97530", "type": "CPT" } ], "standard_charges": [ { "gross_charge": 80.00, "minimum": 37.69, "maximum": 37.69, "setting": "both", "payers_information": [ { "payer_name": "Aetna", "plan_name": "700700", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna", "plan_name": "700700_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Miscellaneous", "plan_name": "700720", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Miscellaneous", "plan_name": "700720_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Ppo Hmo", "plan_name": "701720", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Ppo Hmo", "plan_name": "701720_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Ms State Emplo", "plan_name": "401457", "standard_charge_dollar": 37.69, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Ms State Emplo", "plan_name": "401457_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Basic Pl", "plan_name": "400100", "standard_charge_dollar": 37.69, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Basic Pl", "plan_name": "400100_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Federal", "plan_name": "400110", "standard_charge_dollar": 37.69, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Federal", "plan_name": "400110_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." } ] } ] }, { "description": "Therapeutic activities", "code_information": [ { "code": "97530", "type": "CPT" } ], "standard_charges": [ { "gross_charge": 80.00, "minimum": 37.69, "maximum": 37.69, "setting": "both", "payers_information": [ { "payer_name": "Aetna", "plan_name": "700700", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna", "plan_name": "700700_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Miscellaneous", "plan_name": "700720", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Miscellaneous", "plan_name": "700720_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Ppo Hmo", "plan_name": "701720", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Ppo Hmo", "plan_name": "701720_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Ms State Emplo", "plan_name": "401457", "standard_charge_dollar": 37.69, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Ms State Emplo", "plan_name": "401457_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Basic Pl", "plan_name": "400100", "standard_charge_dollar": 37.69, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Basic Pl", "plan_name": "400100_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Federal", "plan_name": "400110", "standard_charge_dollar": 37.69, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Federal", "plan_name": "400110_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." } ] } ] }, { "description": "Hc ot sensory integration", "code_information": [ { "code": "97533", "type": "CPT" } ], "standard_charges": [ { "gross_charge": 175.00, "minimum": 31.96, "maximum": 31.96, "setting": "both", "payers_information": [ { "payer_name": "Aetna", "plan_name": "700700", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna", "plan_name": "700700_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Miscellaneous", "plan_name": "700720", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Miscellaneous", "plan_name": "700720_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Ppo Hmo", "plan_name": "701720", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Ppo Hmo", "plan_name": "701720_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Ms State Emplo", "plan_name": "401457", "standard_charge_dollar": 31.96, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Ms State Emplo", "plan_name": "401457_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Basic Pl", "plan_name": "400100", "standard_charge_dollar": 31.96, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Basic Pl", "plan_name": "400100_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Federal", "plan_name": "400110", "standard_charge_dollar": 31.96, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Federal", "plan_name": "400110_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." } ] } ] }, { "description": "Sensory integration", 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100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Ppo Hmo", "plan_name": "701720", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Ppo Hmo", "plan_name": "701720_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Ms State Emplo", "plan_name": "401457", "standard_charge_dollar": 31.96, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Ms State Emplo", "plan_name": "401457_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Basic Pl", "plan_name": "400100", "standard_charge_dollar": 31.96, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Basic Pl", "plan_name": "400100_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Federal", "plan_name": "400110", "standard_charge_dollar": 31.96, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Federal", "plan_name": "400110_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." } ] } ] }, { "description": "Hc ot self mgmt training ea 15 min", "code_information": [ { "code": "97535", "type": "CPT" } ], "standard_charges": [ { "gross_charge": 85.00, "minimum": 37.59, "maximum": 37.59, "setting": "both", "payers_information": [ { "payer_name": "Aetna", "plan_name": "700700", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna", "plan_name": "700700_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Miscellaneous", "plan_name": "700720", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Miscellaneous", "plan_name": "700720_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Ppo Hmo", "plan_name": "701720", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Ppo Hmo", "plan_name": "701720_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Ms State Emplo", "plan_name": "401457", "standard_charge_dollar": 37.59, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Ms State Emplo", "plan_name": "401457_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Basic Pl", "plan_name": "400100", "standard_charge_dollar": 37.59, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Basic Pl", "plan_name": "400100_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Federal", "plan_name": "400110", "standard_charge_dollar": 37.59, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Federal", "plan_name": "400110_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." } ] } ] }, { "description": "Self care mngment training", "code_information": [ { "code": "97535", "type": "CPT" } ], "standard_charges": [ { "gross_charge": 85.00, "minimum": 37.59, "maximum": 37.59, "setting": "both", "payers_information": [ { "payer_name": "Aetna", "plan_name": "700700", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna", "plan_name": "700700_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Miscellaneous", "plan_name": "700720", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Miscellaneous", "plan_name": "700720_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Ppo Hmo", "plan_name": "701720", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Ppo Hmo", "plan_name": "701720_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Ms State Emplo", "plan_name": "401457", "standard_charge_dollar": 37.59, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Ms State Emplo", "plan_name": "401457_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Basic Pl", "plan_name": "400100", "standard_charge_dollar": 37.59, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Basic Pl", "plan_name": "400100_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Federal", "plan_name": "400110", "standard_charge_dollar": 37.59, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Federal", "plan_name": "400110_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." } ] } ] }, { "description": "Hc pt wheelchair mgmt train 15 min", "code_information": [ { "code": "97542", "type": "CPT" } ], "standard_charges": [ { "gross_charge": 74.00, "minimum": 31.00, "maximum": 31.00, "setting": "both", "payers_information": [ { "payer_name": "Aetna", "plan_name": "700700", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna", "plan_name": "700700_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Miscellaneous", "plan_name": "700720", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Miscellaneous", "plan_name": "700720_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Ppo Hmo", "plan_name": "701720", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Ppo Hmo", "plan_name": "701720_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Ms State Emplo", "plan_name": "401457", "standard_charge_dollar": 31.00, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Ms State Emplo", "plan_name": "401457_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Basic Pl", "plan_name": "400100", "standard_charge_dollar": 31.00, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Basic Pl", "plan_name": "400100_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Federal", "plan_name": "400110", "standard_charge_dollar": 31.00, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Federal", "plan_name": "400110_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." } ] } ] }, { "description": "Wheelchair mngment training", "code_information": [ { "code": "97542", "type": "CPT" } ], "standard_charges": [ { "gross_charge": 74.00, "minimum": 31.00, "maximum": 31.00, "setting": "both", "payers_information": [ { "payer_name": "Aetna", "plan_name": "700700", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna", "plan_name": "700700_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Miscellaneous", "plan_name": "700720", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Miscellaneous", "plan_name": "700720_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Ppo Hmo", "plan_name": "701720", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Ppo Hmo", "plan_name": "701720_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Ms State Emplo", "plan_name": "401457", "standard_charge_dollar": 31.00, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Ms State Emplo", "plan_name": "401457_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Basic Pl", "plan_name": "400100", "standard_charge_dollar": 31.00, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Basic Pl", "plan_name": "400100_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Federal", "plan_name": "400110", "standard_charge_dollar": 31.00, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Federal", "plan_name": "400110_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." } ] } ] }, { "description": "Caregiver traing 1st 30 min", "code_information": [ { "code": "97550", "type": "CPT" } ], "standard_charges": [ { "gross_charge": 50.00, "minimum": 40.00, "maximum": 42.50, "setting": "both", "payers_information": [ { "payer_name": "Aetna", "plan_name": "700700", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna", "plan_name": "700700_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Miscellaneous", "plan_name": "700720", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Miscellaneous", "plan_name": "700720_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Ppo Hmo", "plan_name": "701720", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Ppo Hmo", "plan_name": "701720_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Ms State Emplo", "plan_name": "401457", "standard_charge_percentage": 0.80, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Ms State Emplo", "plan_name": "401457_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Basic Pl", "plan_name": "400100", "standard_charge_percentage": 0.85, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Basic Pl", "plan_name": "400100_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Federal", "plan_name": "400110", "standard_charge_percentage": 0.85, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Federal", "plan_name": "400110_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." } ] } ] }, { "description": "Hc caregiver training 1st 30min", "code_information": [ { "code": "97550", "type": "CPT" } ], "standard_charges": [ { "gross_charge": 50.00, "minimum": 40.00, "maximum": 42.50, "setting": "both", "payers_information": [ { "payer_name": "Aetna", "plan_name": "700700", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna", "plan_name": "700700_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Miscellaneous", "plan_name": "700720", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Miscellaneous", "plan_name": "700720_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Ppo Hmo", "plan_name": "701720", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Ppo Hmo", "plan_name": "701720_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Ms State Emplo", "plan_name": "401457", "standard_charge_percentage": 0.80, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Ms State Emplo", "plan_name": "401457_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Basic Pl", "plan_name": "400100", "standard_charge_percentage": 0.85, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Basic Pl", "plan_name": "400100_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Federal", "plan_name": "400110", "standard_charge_percentage": 0.85, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Federal", "plan_name": "400110_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." } ] } ] }, { "description": "Caregiver traing ea addl 15", "code_information": [ { "code": "97551", "type": "CPT" } ], "standard_charges": [ { "gross_charge": 25.00, "minimum": 20.00, "maximum": 21.25, "setting": "both", "payers_information": [ { "payer_name": "Aetna", "plan_name": "700700", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna", "plan_name": "700700_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Miscellaneous", "plan_name": "700720", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient 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calculate allowed amounts." }, { "payer_name": "Bc/Bs Ms State Emplo", "plan_name": "401457_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Basic Pl", "plan_name": "400100", "standard_charge_percentage": 0.85, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Basic Pl", "plan_name": "400100_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Federal", "plan_name": "400110", "standard_charge_percentage": 0.85, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Federal", "plan_name": "400110_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." } ] } ] }, { "description": "Hc caregiver training ea addl 15", "code_information": [ { "code": "97551", "type": "CPT" } ], "standard_charges": [ { "gross_charge": 25.00, "minimum": 20.00, "maximum": 21.25, "setting": "both", "payers_information": [ { "payer_name": "Aetna", "plan_name": "700700", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna", "plan_name": "700700_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Miscellaneous", "plan_name": "700720", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Miscellaneous", "plan_name": "700720_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Ppo Hmo", "plan_name": "701720", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Ppo Hmo", "plan_name": "701720_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Ms State Emplo", "plan_name": "401457", "standard_charge_percentage": 0.80, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Ms State Emplo", "plan_name": "401457_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Basic Pl", "plan_name": "400100", "standard_charge_percentage": 0.85, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Basic Pl", "plan_name": "400100_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Federal", "plan_name": "400110", "standard_charge_percentage": 0.85, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Federal", "plan_name": "400110_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." } ] } ] }, { "description": "Group caregiver training", "code_information": [ { "code": "97552", "type": "CPT" } ], "standard_charges": [ { "gross_charge": 60.00, "minimum": 48.00, "maximum": 51.00, "setting": "both", "payers_information": [ { "payer_name": "Aetna", "plan_name": "700700", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna", "plan_name": "700700_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Miscellaneous", "plan_name": "700720", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Miscellaneous", "plan_name": "700720_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Ppo Hmo", "plan_name": "701720", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Ppo Hmo", "plan_name": "701720_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Ms State Emplo", "plan_name": "401457", "standard_charge_percentage": 0.80, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Ms State Emplo", "plan_name": "401457_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Basic Pl", "plan_name": "400100", "standard_charge_percentage": 0.85, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Basic Pl", "plan_name": "400100_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Federal", "plan_name": "400110", "standard_charge_percentage": 0.85, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Federal", "plan_name": "400110_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." } ] } ] }, { "description": "Hc group caregiver training", "code_information": [ { "code": "97552", "type": "CPT" } ], "standard_charges": [ { "gross_charge": 60.00, "minimum": 48.00, "maximum": 51.00, "setting": "both", "payers_information": [ { "payer_name": "Aetna", "plan_name": "700700", 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"standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Ppo Hmo", "plan_name": "701720_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Ms State Emplo", "plan_name": "401457", "standard_charge_percentage": 0.80, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Ms State Emplo", "plan_name": "401457_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Basic Pl", "plan_name": "400100", "standard_charge_percentage": 0.85, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Basic Pl", "plan_name": "400100_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Federal", "plan_name": "400110", "standard_charge_percentage": 0.85, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Federal", "plan_name": "400110_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." } ] } ] }, { "description": "Hc slctv wnd debridem 20 cm or <", 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100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Ppo Hmo", "plan_name": "701720", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Ppo Hmo", "plan_name": "701720_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Ms State Emplo", "plan_name": "401457", "standard_charge_dollar": 26.11, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Ms State Emplo", "plan_name": "401457_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Basic Pl", "plan_name": "400100", "standard_charge_dollar": 26.11, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Basic Pl", "plan_name": "400100_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Federal", "plan_name": "400110", "standard_charge_dollar": 26.11, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Federal", "plan_name": "400110_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." } ] } ] }, { "description": "Rmvl devital tis 20 cm/<", "code_information": [ { "code": "97597", "type": "CPT" } ], "standard_charges": [ { "gross_charge": 260.00, "minimum": 26.11, "maximum": 26.11, "setting": "both", "payers_information": [ { "payer_name": "Aetna", "plan_name": "700700", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna", "plan_name": "700700_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Miscellaneous", "plan_name": "700720", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Miscellaneous", "plan_name": "700720_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Ppo Hmo", "plan_name": "701720", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Ppo Hmo", "plan_name": "701720_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Ms State Emplo", "plan_name": "401457", "standard_charge_dollar": 26.11, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Ms State Emplo", "plan_name": "401457_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Basic Pl", "plan_name": "400100", "standard_charge_dollar": 26.11, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Basic Pl", "plan_name": "400100_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Federal", "plan_name": "400110", "standard_charge_dollar": 26.11, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Federal", "plan_name": "400110_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." } ] } ] }, { "description": "Hc slctv wnd debridem ea addl 20 cm", "code_information": [ { "code": "97598", "type": "CPT" } ], "standard_charges": [ { "gross_charge": 335.00, "minimum": 12.26, "maximum": 12.26, "setting": "both", "payers_information": [ { "payer_name": "Aetna", "plan_name": "700700", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna", "plan_name": "700700_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Miscellaneous", "plan_name": "700720", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Miscellaneous", "plan_name": "700720_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Ppo Hmo", "plan_name": "701720", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Ppo Hmo", "plan_name": "701720_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Ms State Emplo", "plan_name": "401457", "standard_charge_dollar": 12.26, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Ms State Emplo", "plan_name": "401457_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Basic Pl", "plan_name": "400100", "standard_charge_dollar": 12.26, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Basic Pl", "plan_name": "400100_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Federal", "plan_name": "400110", "standard_charge_dollar": 12.26, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Federal", "plan_name": "400110_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." } ] } ] }, { "description": "Rmvl devital tis addl 20cm/<", "code_information": [ { "code": "97598", "type": "CPT" } ], "standard_charges": [ { "gross_charge": 335.00, "minimum": 12.26, "maximum": 12.26, "setting": "both", "payers_information": [ { "payer_name": "Aetna", "plan_name": "700700", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna", "plan_name": "700700_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Miscellaneous", "plan_name": "700720", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Miscellaneous", "plan_name": "700720_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Ppo Hmo", "plan_name": "701720", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Ppo Hmo", "plan_name": "701720_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Ms State Emplo", "plan_name": "401457", "standard_charge_dollar": 12.26, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Ms State Emplo", "plan_name": "401457_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Basic Pl", "plan_name": "400100", "standard_charge_dollar": 12.26, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Basic Pl", "plan_name": "400100_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Federal", "plan_name": "400110", "standard_charge_dollar": 12.26, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Federal", "plan_name": "400110_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." } ] } ] }, { "description": "Hc non slctv wnd debridement", "code_information": [ { "code": "97602", "type": "CPT" } ], "standard_charges": [ { "gross_charge": 187.00, "minimum": 229.58, "maximum": 229.58, "setting": "both", "payers_information": [ { "payer_name": "Aetna", "plan_name": "700700", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna", "plan_name": "700700_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Miscellaneous", "plan_name": "700720", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Miscellaneous", "plan_name": "700720_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Ppo Hmo", "plan_name": "701720", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Ppo Hmo", "plan_name": "701720_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Ms State Emplo", "plan_name": "401457", "standard_charge_dollar": 229.58, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Ms State Emplo", "plan_name": "401457_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Basic Pl", "plan_name": "400100", "standard_charge_dollar": 229.58, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Basic Pl", "plan_name": "400100_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Federal", "plan_name": "400110", "standard_charge_dollar": 229.58, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Federal", "plan_name": "400110_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." } ] } ] }, { "description": "Wound(s) care non-selective", "code_information": [ { "code": "97602", "type": "CPT" } ], "standard_charges": [ { "gross_charge": 187.00, "minimum": 229.58, "maximum": 229.58, "setting": "both", "payers_information": [ { "payer_name": "Aetna", "plan_name": "700700", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna", "plan_name": "700700_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Miscellaneous", "plan_name": "700720", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Miscellaneous", "plan_name": "700720_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Ppo Hmo", "plan_name": "701720", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Ppo Hmo", "plan_name": "701720_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Ms State Emplo", "plan_name": "401457", "standard_charge_dollar": 229.58, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Ms State Emplo", "plan_name": "401457_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Basic Pl", "plan_name": "400100", "standard_charge_dollar": 229.58, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Basic Pl", "plan_name": "400100_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Federal", "plan_name": "400110", "standard_charge_dollar": 229.58, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Federal", "plan_name": "400110_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." } ] } ] }, { "description": "Hc non slctv wnd debridement", "code_information": [ { "code": "97602", "type": "CPT" } ], "standard_charges": [ { "gross_charge": 748.00, "minimum": 598.40, "maximum": 635.80, "setting": "both", "payers_information": [ { "payer_name": "Aetna", "plan_name": "700700", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "modifiers": "50", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna", "plan_name": "700700_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Miscellaneous", "plan_name": "700720", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Miscellaneous", "plan_name": "700720_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Ppo Hmo", "plan_name": "701720", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Ppo Hmo", "plan_name": "701720_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Ms State Emplo", "plan_name": "401457", "standard_charge_percentage": 0.80, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Ms State Emplo", "plan_name": "401457_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Basic Pl", "plan_name": "400100", "standard_charge_percentage": 0.85, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Basic Pl", "plan_name": "400100_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Federal", "plan_name": "400110", "standard_charge_percentage": 0.85, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Federal", "plan_name": "400110_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." } ] } ] }, { "description": "Hc vac wound tx 50 sqcm or <", "code_information": [ { "code": "97605", "type": "CPT" } ], "standard_charges": [ { "gross_charge": 450.00, "minimum": 229.58, "maximum": 229.58, "setting": "both", "payers_information": [ { "payer_name": "Aetna", "plan_name": "700700", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna", "plan_name": "700700_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Miscellaneous", "plan_name": "700720", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Miscellaneous", "plan_name": "700720_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Ppo Hmo", "plan_name": "701720", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Ppo Hmo", "plan_name": "701720_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Ms State Emplo", "plan_name": "401457", "standard_charge_dollar": 229.58, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Ms State Emplo", "plan_name": "401457_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Basic Pl", "plan_name": "400100", "standard_charge_dollar": 229.58, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Basic Pl", "plan_name": "400100_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Federal", "plan_name": "400110", "standard_charge_dollar": 229.58, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Federal", "plan_name": "400110_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." } ] } ] }, { "description": "Neg press wound tx <=50 cm", "code_information": [ { "code": "97605", "type": "CPT" } ], "standard_charges": [ { "gross_charge": 450.00, "minimum": 229.58, "maximum": 229.58, "setting": "both", "payers_information": [ { "payer_name": "Aetna", "plan_name": "700700", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna", "plan_name": "700700_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Miscellaneous", "plan_name": "700720", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Miscellaneous", "plan_name": "700720_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Ppo Hmo", "plan_name": "701720", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Ppo Hmo", "plan_name": "701720_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Ms State Emplo", "plan_name": "401457", "standard_charge_dollar": 229.58, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Ms State Emplo", "plan_name": "401457_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Basic Pl", "plan_name": "400100", "standard_charge_dollar": 229.58, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Basic Pl", "plan_name": "400100_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Federal", "plan_name": "400110", "standard_charge_dollar": 229.58, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Federal", "plan_name": "400110_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." } ] } ] }, { "description": "Hc vac wound tx >50 sq cm", "code_information": [ { "code": "97606", "type": "CPT" } ], "standard_charges": [ { "gross_charge": 550.00, "minimum": 438.74, "maximum": 438.74, "setting": "both", "payers_information": [ { "payer_name": "Aetna", "plan_name": "700700", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna", "plan_name": "700700_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Miscellaneous", "plan_name": "700720", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Miscellaneous", "plan_name": "700720_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Ppo Hmo", "plan_name": "701720", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Ppo Hmo", "plan_name": "701720_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Ms State Emplo", "plan_name": "401457", "standard_charge_dollar": 438.74, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Ms State Emplo", "plan_name": "401457_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Basic Pl", "plan_name": "400100", "standard_charge_dollar": 438.74, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Basic Pl", "plan_name": "400100_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Federal", "plan_name": "400110", "standard_charge_dollar": 438.74, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Federal", "plan_name": "400110_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." } ] } ] }, { "description": "Neg press wound tx >50 cm", "code_information": [ { "code": "97606", "type": "CPT" } ], "standard_charges": [ { "gross_charge": 550.00, "minimum": 438.74, "maximum": 438.74, "setting": "both", "payers_information": [ { "payer_name": "Aetna", "plan_name": "700700", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna", "plan_name": "700700_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Miscellaneous", "plan_name": "700720", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Miscellaneous", "plan_name": "700720_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Ppo Hmo", "plan_name": "701720", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Ppo Hmo", "plan_name": "701720_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Ms State Emplo", "plan_name": "401457", "standard_charge_dollar": 438.74, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Ms State Emplo", "plan_name": "401457_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Basic Pl", "plan_name": "400100", "standard_charge_dollar": 438.74, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Basic Pl", "plan_name": "400100_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Federal", "plan_name": "400110", "standard_charge_dollar": 438.74, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Federal", "plan_name": "400110_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." } ] } ] }, { "description": "Hc neg press wd <=50cm non-dme", "code_information": [ { "code": "97607", "type": "CPT" } ], "standard_charges": [ { "gross_charge": 400.00, "minimum": 168.06, "maximum": 168.06, "setting": "both", "payers_information": [ { "payer_name": "Aetna", "plan_name": "700700", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna", "plan_name": "700700_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Miscellaneous", "plan_name": "700720", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Miscellaneous", "plan_name": "700720_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Ppo Hmo", "plan_name": "701720", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Ppo Hmo", "plan_name": "701720_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Ms State Emplo", "plan_name": "401457", "standard_charge_dollar": 168.06, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Ms State Emplo", "plan_name": "401457_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Basic Pl", "plan_name": "400100", "standard_charge_dollar": 168.06, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Basic Pl", "plan_name": "400100_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Federal", "plan_name": "400110", "standard_charge_dollar": 168.06, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Federal", "plan_name": "400110_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." } ] } ] }, { "description": "Neg press wnd tx <=50 sq cm", "code_information": [ { "code": "97607", "type": "CPT" } ], "standard_charges": [ { "gross_charge": 400.00, "minimum": 168.06, "maximum": 168.06, "setting": "both", "payers_information": [ { "payer_name": "Aetna", "plan_name": "700700", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna", "plan_name": "700700_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Miscellaneous", "plan_name": "700720", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Miscellaneous", "plan_name": "700720_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Ppo Hmo", "plan_name": "701720", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Ppo Hmo", "plan_name": "701720_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Ms State Emplo", "plan_name": "401457", "standard_charge_dollar": 168.06, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Ms State Emplo", "plan_name": "401457_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Basic Pl", "plan_name": "400100", "standard_charge_dollar": 168.06, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Basic Pl", "plan_name": "400100_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Federal", "plan_name": "400110", "standard_charge_dollar": 168.06, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Federal", "plan_name": "400110_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." } ] } ] }, { "description": "Hc neg press wd >50cm non-dme", "code_information": [ { "code": "97608", "type": "CPT" } ], "standard_charges": [ { "gross_charge": 400.00, "minimum": 168.06, "maximum": 168.06, "setting": "both", "payers_information": [ { "payer_name": "Aetna", "plan_name": "700700", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna", "plan_name": "700700_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Miscellaneous", "plan_name": "700720", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Miscellaneous", "plan_name": "700720_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Ppo Hmo", "plan_name": "701720", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Ppo Hmo", "plan_name": "701720_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Ms State Emplo", "plan_name": "401457", "standard_charge_dollar": 168.06, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Ms State Emplo", "plan_name": "401457_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Basic Pl", "plan_name": "400100", "standard_charge_dollar": 168.06, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Basic Pl", "plan_name": "400100_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Federal", "plan_name": "400110", "standard_charge_dollar": 168.06, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Federal", "plan_name": "400110_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." } ] } ] }, { "description": "Neg press wound tx >50 cm", "code_information": [ { "code": "97608", "type": "CPT" } ], "standard_charges": [ { "gross_charge": 400.00, "minimum": 168.06, "maximum": 168.06, "setting": "both", "payers_information": [ { "payer_name": "Aetna", "plan_name": "700700", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna", "plan_name": "700700_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Miscellaneous", "plan_name": "700720", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Miscellaneous", "plan_name": "700720_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Ppo Hmo", "plan_name": "701720", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Ppo Hmo", "plan_name": "701720_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Ms State Emplo", "plan_name": "401457", "standard_charge_dollar": 168.06, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Ms State Emplo", "plan_name": "401457_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Basic Pl", "plan_name": "400100", "standard_charge_dollar": 168.06, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Basic Pl", "plan_name": "400100_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Federal", "plan_name": "400110", "standard_charge_dollar": 168.06, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Federal", "plan_name": "400110_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." } ] } ] }, { "description": "Hc phlebotomy therapeutic", "code_information": [ { "code": "99195", "type": "CPT" } ], "standard_charges": [ { "gross_charge": 140.00, "minimum": 81.80, "maximum": 81.80, "setting": "both", "payers_information": [ { "payer_name": "Aetna", "plan_name": "700700", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna", "plan_name": "700700_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Miscellaneous", "plan_name": "700720", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Miscellaneous", "plan_name": "700720_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Ppo Hmo", "plan_name": "701720", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Ppo Hmo", "plan_name": "701720_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Ms State Emplo", "plan_name": "401457", "standard_charge_dollar": 81.80, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Ms State Emplo", "plan_name": "401457_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Basic Pl", "plan_name": "400100", "standard_charge_dollar": 81.80, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Basic Pl", "plan_name": "400100_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Federal", "plan_name": "400110", "standard_charge_dollar": 81.80, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Federal", "plan_name": "400110_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." } ] } ] }, { "description": "Phlebotomy", "code_information": [ { "code": "99195", "type": "CPT" } ], "standard_charges": [ { "gross_charge": 140.00, "minimum": 81.80, "maximum": 81.80, "setting": "both", "payers_information": [ { "payer_name": "Aetna", "plan_name": "700700", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna", "plan_name": "700700_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Miscellaneous", "plan_name": "700720", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Miscellaneous", "plan_name": "700720_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Ppo Hmo", "plan_name": "701720", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Ppo Hmo", "plan_name": "701720_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Ms State Emplo", "plan_name": "401457", "standard_charge_dollar": 81.80, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Ms State Emplo", "plan_name": "401457_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Basic Pl", "plan_name": "400100", "standard_charge_dollar": 81.80, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Basic Pl", "plan_name": "400100_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Federal", "plan_name": "400110", "standard_charge_dollar": 81.80, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Federal", "plan_name": "400110_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." } ] } ] }, { "description": "Hc office op new sf mdm 15-29 min", "code_information": [ { "code": "99202", "type": "CPT" } ], "standard_charges": [ { "gross_charge": 262.00, "minimum": 55.04, "maximum": 55.04, "setting": "both", "payers_information": [ { "payer_name": "Aetna", "plan_name": "700700", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna", "plan_name": "700700_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Miscellaneous", "plan_name": "700720", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Miscellaneous", "plan_name": "700720_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Ppo Hmo", "plan_name": "701720", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Ppo Hmo", "plan_name": "701720_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Ms State Emplo", "plan_name": "401457", "standard_charge_dollar": 55.04, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Ms State Emplo", "plan_name": "401457_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Basic Pl", "plan_name": "400100", "standard_charge_dollar": 55.04, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Basic Pl", "plan_name": "400100_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Federal", "plan_name": "400110", "standard_charge_dollar": 55.04, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Federal", "plan_name": "400110_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." } ] } ] }, { "description": "Office/outpatient visit new", "code_information": [ { "code": "99202", "type": "CPT" } ], "standard_charges": [ { "gross_charge": 262.00, "minimum": 55.04, "maximum": 55.04, "setting": "both", "payers_information": [ { "payer_name": "Aetna", "plan_name": "700700", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna", "plan_name": "700700_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Miscellaneous", "plan_name": "700720", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Miscellaneous", "plan_name": "700720_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Ppo Hmo", "plan_name": "701720", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Ppo Hmo", "plan_name": "701720_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Ms State Emplo", "plan_name": "401457", "standard_charge_dollar": 55.04, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Ms State Emplo", "plan_name": "401457_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Basic Pl", "plan_name": "400100", "standard_charge_dollar": 55.04, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Basic Pl", "plan_name": "400100_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Federal", "plan_name": "400110", "standard_charge_dollar": 55.04, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Federal", "plan_name": "400110_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." } ] } ] }, { "description": "Hc office visit new level 3", "code_information": [ { "code": "99203", "type": "CPT" } ], "standard_charges": [ { "gross_charge": 301.00, "minimum": 83.12, "maximum": 83.12, "setting": "both", "payers_information": [ { "payer_name": "Aetna", "plan_name": "700700", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna", "plan_name": "700700_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Miscellaneous", "plan_name": "700720", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Miscellaneous", "plan_name": "700720_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Ppo Hmo", "plan_name": "701720", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Ppo Hmo", "plan_name": "701720_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Ms State Emplo", "plan_name": "401457", "standard_charge_dollar": 83.12, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Ms State Emplo", "plan_name": "401457_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Basic Pl", "plan_name": "400100", "standard_charge_dollar": 83.12, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Basic Pl", "plan_name": "400100_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Federal", "plan_name": "400110", "standard_charge_dollar": 83.12, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Federal", "plan_name": "400110_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." } ] } ] }, { "description": "Office/outpatient visit new", "code_information": [ { "code": "99203", "type": "CPT" } ], "standard_charges": [ { "gross_charge": 301.00, "minimum": 83.12, "maximum": 83.12, "setting": "both", "payers_information": [ { "payer_name": "Aetna", "plan_name": "700700", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna", "plan_name": "700700_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Miscellaneous", "plan_name": "700720", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Miscellaneous", "plan_name": "700720_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Ppo Hmo", "plan_name": "701720", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Ppo Hmo", "plan_name": "701720_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Ms State Emplo", "plan_name": "401457", "standard_charge_dollar": 83.12, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Ms State Emplo", "plan_name": "401457_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Basic Pl", "plan_name": "400100", "standard_charge_dollar": 83.12, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Basic Pl", "plan_name": "400100_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Federal", "plan_name": "400110", "standard_charge_dollar": 83.12, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Federal", "plan_name": "400110_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." } ] } ] }, { "description": "Hc office visit new level 4", "code_information": [ { "code": "99204", "type": "CPT" } ], "standard_charges": [ { "gross_charge": 438.00, "minimum": 141.26, "maximum": 141.26, "setting": "both", "payers_information": [ { "payer_name": "Aetna", "plan_name": "700700", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna", "plan_name": "700700_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Miscellaneous", "plan_name": "700720", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Miscellaneous", "plan_name": "700720_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Ppo Hmo", "plan_name": "701720", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Ppo Hmo", "plan_name": "701720_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Ms State Emplo", "plan_name": "401457", "standard_charge_dollar": 141.26, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Ms State Emplo", "plan_name": "401457_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Basic Pl", "plan_name": "400100", "standard_charge_dollar": 141.26, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Basic Pl", "plan_name": "400100_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Federal", "plan_name": "400110", "standard_charge_dollar": 141.26, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Federal", "plan_name": "400110_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." } ] } ] }, { "description": "Office/outpatient visit new", "code_information": [ { "code": "99204", "type": "CPT" } ], "standard_charges": [ { "gross_charge": 438.00, "minimum": 141.26, "maximum": 141.26, "setting": "both", "payers_information": [ { "payer_name": "Aetna", "plan_name": "700700", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna", "plan_name": "700700_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Miscellaneous", "plan_name": "700720", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Miscellaneous", "plan_name": "700720_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Ppo Hmo", "plan_name": "701720", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Ppo Hmo", "plan_name": "701720_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Ms State Emplo", "plan_name": "401457", "standard_charge_dollar": 141.26, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Ms State Emplo", "plan_name": "401457_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Basic Pl", "plan_name": "400100", "standard_charge_dollar": 141.26, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Basic Pl", "plan_name": "400100_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Federal", "plan_name": "400110", "standard_charge_dollar": 141.26, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Federal", "plan_name": "400110_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." } ] } ] }, { "description": "Hc office visit new level 5", "code_information": [ { "code": "99205", "type": "CPT" } ], "standard_charges": [ { "gross_charge": 438.00, "minimum": 183.95, "maximum": 183.95, "setting": "both", "payers_information": [ { "payer_name": "Aetna", "plan_name": "700700", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna", "plan_name": "700700_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Miscellaneous", "plan_name": "700720", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Miscellaneous", "plan_name": "700720_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Ppo Hmo", "plan_name": "701720", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Ppo Hmo", "plan_name": "701720_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Ms State Emplo", "plan_name": "401457", "standard_charge_dollar": 183.95, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Ms State Emplo", "plan_name": "401457_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Basic Pl", "plan_name": "400100", "standard_charge_dollar": 183.95, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Basic Pl", "plan_name": "400100_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Federal", "plan_name": "400110", "standard_charge_dollar": 183.95, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Federal", "plan_name": "400110_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." } ] } ] }, { "description": "Office/outpatient visit new", "code_information": [ { "code": "99205", "type": "CPT" } ], "standard_charges": [ { "gross_charge": 438.00, "minimum": 183.95, "maximum": 183.95, "setting": "both", "payers_information": [ { "payer_name": "Aetna", "plan_name": "700700", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna", "plan_name": "700700_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Miscellaneous", "plan_name": "700720", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Miscellaneous", "plan_name": "700720_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Ppo Hmo", "plan_name": "701720", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Ppo Hmo", "plan_name": "701720_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Ms State Emplo", "plan_name": "401457", "standard_charge_dollar": 183.95, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Ms State Emplo", "plan_name": "401457_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Basic Pl", "plan_name": "400100", "standard_charge_dollar": 183.95, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Basic Pl", "plan_name": "400100_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Federal", "plan_name": "400110", "standard_charge_dollar": 183.95, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Federal", "plan_name": "400110_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." } ] } ] }, { "description": "Hc office visit est level 1", "code_information": [ { "code": "99211", "type": "CPT" } ], "standard_charges": [ { "gross_charge": 262.00, "minimum": 10.14, "maximum": 10.14, "setting": "both", "payers_information": [ { "payer_name": "Aetna", "plan_name": "700700", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna", "plan_name": "700700_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Miscellaneous", "plan_name": "700720", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Miscellaneous", "plan_name": "700720_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Ppo Hmo", "plan_name": "701720", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Ppo Hmo", "plan_name": "701720_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Ms State Emplo", "plan_name": "401457", "standard_charge_dollar": 10.14, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Ms State Emplo", "plan_name": "401457_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Basic Pl", "plan_name": "400100", "standard_charge_dollar": 10.14, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Basic Pl", "plan_name": "400100_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Federal", "plan_name": "400110", "standard_charge_dollar": 10.14, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Federal", "plan_name": "400110_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." } ] } ] }, { "description": "Office/outpatient visit est", "code_information": [ { "code": "99211", "type": "CPT" } ], "standard_charges": [ { "gross_charge": 262.00, "minimum": 10.14, "maximum": 10.14, "setting": "both", "payers_information": [ { "payer_name": "Aetna", "plan_name": "700700", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna", "plan_name": "700700_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Miscellaneous", "plan_name": "700720", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Miscellaneous", "plan_name": "700720_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Ppo Hmo", "plan_name": "701720", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Ppo Hmo", "plan_name": "701720_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Ms State Emplo", "plan_name": "401457", "standard_charge_dollar": 10.14, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Ms State Emplo", "plan_name": "401457_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Basic Pl", "plan_name": "400100", "standard_charge_dollar": 10.14, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Basic Pl", "plan_name": "400100_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Federal", "plan_name": "400110", "standard_charge_dollar": 10.14, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Federal", "plan_name": "400110_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." } ] } ] }, { "description": "Hc office visit est level 2", "code_information": [ { "code": "99212", "type": "CPT" } ], "standard_charges": [ { "gross_charge": 262.00, "minimum": 27.78, "maximum": 27.78, "setting": "both", "payers_information": [ { "payer_name": "Aetna", "plan_name": "700700", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna", "plan_name": "700700_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Miscellaneous", "plan_name": "700720", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Miscellaneous", "plan_name": "700720_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Ppo Hmo", "plan_name": "701720", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Ppo Hmo", "plan_name": "701720_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Ms State Emplo", "plan_name": "401457", "standard_charge_dollar": 27.78, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Ms State Emplo", "plan_name": "401457_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Basic Pl", "plan_name": "400100", "standard_charge_dollar": 27.78, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Basic Pl", "plan_name": "400100_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Federal", "plan_name": "400110", "standard_charge_dollar": 27.78, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Federal", "plan_name": "400110_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." } ] } ] }, { "description": "Office/outpatient visit est", "code_information": [ { "code": "99212", "type": "CPT" } ], "standard_charges": [ { "gross_charge": 262.00, "minimum": 27.78, "maximum": 27.78, "setting": "both", "payers_information": [ { "payer_name": "Aetna", "plan_name": "700700", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna", "plan_name": "700700_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Miscellaneous", "plan_name": "700720", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Miscellaneous", "plan_name": "700720_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Ppo Hmo", "plan_name": "701720", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Ppo Hmo", "plan_name": "701720_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Ms State Emplo", "plan_name": "401457", "standard_charge_dollar": 27.78, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Ms State Emplo", "plan_name": "401457_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Basic Pl", "plan_name": "400100", "standard_charge_dollar": 27.78, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Basic Pl", "plan_name": "400100_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Federal", "plan_name": "400110", "standard_charge_dollar": 27.78, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Federal", "plan_name": "400110_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." } ] } ] }, { "description": "Hc office visit est level 3", "code_information": [ { "code": "99213", "type": "CPT" } ], "standard_charges": [ { "gross_charge": 301.00, "minimum": 55.77, "maximum": 55.77, "setting": "both", "payers_information": [ { "payer_name": "Aetna", "plan_name": "700700", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna", "plan_name": "700700_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Miscellaneous", "plan_name": "700720", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Miscellaneous", "plan_name": "700720_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Ppo Hmo", "plan_name": "701720", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Ppo Hmo", "plan_name": "701720_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Ms State Emplo", "plan_name": "401457", "standard_charge_dollar": 55.77, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Ms State Emplo", "plan_name": "401457_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Basic Pl", "plan_name": "400100", "standard_charge_dollar": 55.77, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Basic Pl", "plan_name": "400100_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Federal", "plan_name": "400110", "standard_charge_dollar": 55.77, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Federal", "plan_name": "400110_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." } ] } ] }, { "description": "Office/outpatient visit est", "code_information": [ { "code": "99213", "type": "CPT" } ], "standard_charges": [ { "gross_charge": 301.00, "minimum": 55.77, "maximum": 55.77, "setting": "both", "payers_information": [ { "payer_name": "Aetna", "plan_name": "700700", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna", "plan_name": "700700_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Miscellaneous", "plan_name": "700720", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Miscellaneous", "plan_name": "700720_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Ppo Hmo", "plan_name": "701720", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Ppo Hmo", "plan_name": "701720_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Ms State Emplo", "plan_name": "401457", "standard_charge_dollar": 55.77, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Ms State Emplo", "plan_name": "401457_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Basic Pl", "plan_name": "400100", "standard_charge_dollar": 55.77, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Basic Pl", "plan_name": "400100_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Federal", "plan_name": "400110", "standard_charge_dollar": 55.77, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Federal", "plan_name": "400110_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." } ] } ] }, { "description": "Hc office visit est level 3", "code_information": [ { "code": "99213", "type": "CPT" } ], "standard_charges": [ { "gross_charge": 301.00, "minimum": 240.80, "maximum": 255.85, "setting": "both", "payers_information": [ { "payer_name": "Aetna", "plan_name": "700700", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "modifiers": "QW", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna", "plan_name": "700700_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Miscellaneous", "plan_name": "700720", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Miscellaneous", "plan_name": "700720_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Ppo Hmo", "plan_name": "701720", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Ppo Hmo", "plan_name": "701720_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Ms State Emplo", "plan_name": "401457", "standard_charge_percentage": 0.80, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Ms State Emplo", "plan_name": "401457_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Basic Pl", "plan_name": "400100", "standard_charge_percentage": 0.85, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Basic Pl", "plan_name": "400100_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Federal", "plan_name": "400110", "standard_charge_percentage": 0.85, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Federal", "plan_name": "400110_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." } ] } ] }, { "description": "Hc office visit est level 4", "code_information": [ { "code": "99214", "type": "CPT" } ], "standard_charges": [ { "gross_charge": 438.00, "minimum": 86.12, "maximum": 86.12, "setting": "both", "payers_information": [ { "payer_name": "Aetna", "plan_name": "700700", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna", "plan_name": "700700_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Miscellaneous", "plan_name": "700720", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Miscellaneous", "plan_name": "700720_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Ppo Hmo", "plan_name": "701720", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Ppo Hmo", "plan_name": "701720_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Ms State Emplo", "plan_name": "401457", "standard_charge_dollar": 86.12, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Ms State Emplo", "plan_name": "401457_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Basic Pl", "plan_name": "400100", "standard_charge_dollar": 86.12, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Basic Pl", "plan_name": "400100_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Federal", "plan_name": "400110", "standard_charge_dollar": 86.12, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Federal", "plan_name": "400110_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." } ] } ] }, { "description": "Office/outpatient visit est", "code_information": [ { "code": "99214", "type": "CPT" } ], "standard_charges": [ { "gross_charge": 438.00, "minimum": 86.12, "maximum": 86.12, "setting": "both", "payers_information": [ { "payer_name": "Aetna", "plan_name": "700700", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna", "plan_name": "700700_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Miscellaneous", "plan_name": "700720", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Miscellaneous", "plan_name": "700720_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Ppo Hmo", "plan_name": "701720", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Ppo Hmo", "plan_name": "701720_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Ms State Emplo", "plan_name": "401457", "standard_charge_dollar": 86.12, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Ms State Emplo", "plan_name": "401457_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Basic Pl", "plan_name": "400100", "standard_charge_dollar": 86.12, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Basic Pl", "plan_name": "400100_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Federal", "plan_name": "400110", "standard_charge_dollar": 86.12, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Federal", "plan_name": "400110_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." } ] } ] }, { "description": "Hc office visit est level 5", "code_information": [ { "code": "99215", "type": "CPT" } ], "standard_charges": [ { "gross_charge": 438.00, "minimum": 121.62, "maximum": 121.62, "setting": "both", "payers_information": [ { "payer_name": "Aetna", "plan_name": "700700", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna", "plan_name": "700700_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Miscellaneous", "plan_name": "700720", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Miscellaneous", "plan_name": "700720_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Ppo Hmo", "plan_name": "701720", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Ppo Hmo", "plan_name": "701720_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Ms State Emplo", "plan_name": "401457", "standard_charge_dollar": 121.62, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Ms State Emplo", "plan_name": "401457_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Basic Pl", "plan_name": "400100", "standard_charge_dollar": 121.62, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Basic Pl", "plan_name": "400100_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Federal", "plan_name": "400110", "standard_charge_dollar": 121.62, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Federal", "plan_name": "400110_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." } ] } ] }, { "description": "Office/outpatient visit est", "code_information": [ { "code": "99215", "type": "CPT" } ], "standard_charges": [ { "gross_charge": 438.00, "minimum": 121.62, "maximum": 121.62, "setting": "both", "payers_information": [ { "payer_name": "Aetna", "plan_name": "700700", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna", "plan_name": "700700_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Miscellaneous", "plan_name": "700720", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Miscellaneous", "plan_name": "700720_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Ppo Hmo", "plan_name": "701720", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Ppo Hmo", "plan_name": "701720_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Ms State Emplo", "plan_name": "401457", "standard_charge_dollar": 121.62, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Ms State Emplo", "plan_name": "401457_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Basic Pl", "plan_name": "400100", "standard_charge_dollar": 121.62, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Basic Pl", "plan_name": "400100_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Federal", "plan_name": "400110", "standard_charge_dollar": 121.62, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Federal", "plan_name": "400110_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." } ] } ] }, { "description": "Emergency dept visit", "code_information": [ { "code": "99281", "type": "CPT" } ], "standard_charges": [ { "gross_charge": 150.00, "minimum": 67.47, "maximum": 67.47, "setting": "both", "payers_information": [ { "payer_name": "Aetna", "plan_name": "700700", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna", "plan_name": "700700_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Miscellaneous", "plan_name": "700720", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Miscellaneous", "plan_name": "700720_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Ppo Hmo", "plan_name": "701720", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Ppo Hmo", "plan_name": "701720_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Ms State Emplo", "plan_name": "401457", "standard_charge_dollar": 67.47, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Ms State Emplo", "plan_name": "401457_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Basic Pl", "plan_name": "400100", "standard_charge_dollar": 67.47, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Basic Pl", "plan_name": "400100_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Federal", "plan_name": "400110", "standard_charge_dollar": 67.47, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Federal", "plan_name": "400110_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." } ] } ] }, { "description": "Hc er visit level 1 -25", "code_information": [ { "code": "99281", "type": "CPT" } ], "standard_charges": [ { "gross_charge": 150.00, "minimum": 67.47, "maximum": 67.47, "setting": "both", "payers_information": [ { "payer_name": "Aetna", "plan_name": "700700", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna", "plan_name": "700700_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Miscellaneous", "plan_name": "700720", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Miscellaneous", "plan_name": "700720_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Ppo Hmo", "plan_name": "701720", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Ppo Hmo", "plan_name": "701720_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Ms State Emplo", "plan_name": "401457", "standard_charge_dollar": 67.47, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Ms State Emplo", "plan_name": "401457_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Basic Pl", "plan_name": "400100", "standard_charge_dollar": 67.47, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Basic Pl", "plan_name": "400100_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Federal", "plan_name": "400110", "standard_charge_dollar": 67.47, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Federal", "plan_name": "400110_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." } ] } ] }, { "description": "Emergency dept visit", "code_information": [ { "code": "99282", "type": "CPT" } ], "standard_charges": [ { "gross_charge": 200.00, "minimum": 122.56, "maximum": 122.56, "setting": "both", "payers_information": [ { "payer_name": "Aetna", "plan_name": "700700", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna", "plan_name": "700700_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Miscellaneous", "plan_name": "700720", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Miscellaneous", "plan_name": "700720_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Ppo Hmo", "plan_name": "701720", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Ppo Hmo", "plan_name": "701720_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Ms State Emplo", "plan_name": "401457", "standard_charge_dollar": 122.56, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Ms State Emplo", "plan_name": "401457_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Basic Pl", "plan_name": "400100", "standard_charge_dollar": 122.56, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Basic Pl", "plan_name": "400100_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Federal", "plan_name": "400110", "standard_charge_dollar": 122.56, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Federal", "plan_name": "400110_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." } ] } ] }, { "description": "Hc er visit level 2", "code_information": [ { "code": "99282", "type": "CPT" } ], "standard_charges": [ { "gross_charge": 200.00, "minimum": 122.56, "maximum": 122.56, "setting": "both", "payers_information": [ { "payer_name": "Aetna", "plan_name": "700700", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna", "plan_name": "700700_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Miscellaneous", "plan_name": "700720", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Miscellaneous", "plan_name": "700720_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Ppo Hmo", "plan_name": "701720", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Ppo Hmo", "plan_name": "701720_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Ms State Emplo", "plan_name": "401457", "standard_charge_dollar": 122.56, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Ms State Emplo", "plan_name": "401457_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Basic Pl", "plan_name": "400100", "standard_charge_dollar": 122.56, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Basic Pl", "plan_name": "400100_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Federal", "plan_name": "400110", "standard_charge_dollar": 122.56, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Federal", "plan_name": "400110_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." } ] } ] }, { "description": "Emergency dept visit", "code_information": [ { "code": "99283", "type": "CPT" } ], "standard_charges": [ { "gross_charge": 300.00, "minimum": 221.29, "maximum": 221.29, "setting": "both", "payers_information": [ { "payer_name": "Aetna", "plan_name": "700700", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna", "plan_name": "700700_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Miscellaneous", "plan_name": "700720", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Miscellaneous", "plan_name": "700720_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Ppo Hmo", "plan_name": "701720", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Ppo Hmo", "plan_name": "701720_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Ms State Emplo", "plan_name": "401457", "standard_charge_dollar": 221.29, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Ms State Emplo", "plan_name": "401457_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Basic Pl", "plan_name": "400100", "standard_charge_dollar": 221.29, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Basic Pl", "plan_name": "400100_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Federal", "plan_name": "400110", "standard_charge_dollar": 221.29, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Federal", "plan_name": "400110_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." } ] } ] }, { "description": "Hc er visit level 3", "code_information": [ { "code": "99283", "type": "CPT" } ], "standard_charges": [ { "gross_charge": 300.00, "minimum": 221.29, "maximum": 221.29, "setting": "both", "payers_information": [ { "payer_name": "Aetna", "plan_name": "700700", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna", "plan_name": "700700_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Miscellaneous", "plan_name": "700720", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Miscellaneous", "plan_name": "700720_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Ppo Hmo", "plan_name": "701720", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Ppo Hmo", "plan_name": "701720_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Ms State Emplo", "plan_name": "401457", "standard_charge_dollar": 221.29, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Ms State Emplo", "plan_name": "401457_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Basic Pl", "plan_name": "400100", "standard_charge_dollar": 221.29, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Basic Pl", "plan_name": "400100_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Federal", "plan_name": "400110", "standard_charge_dollar": 221.29, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Federal", "plan_name": "400110_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." } ] } ] }, { "description": "Emergency dept visit", "code_information": [ { "code": "99284", "type": "CPT" } ], "standard_charges": [ { "gross_charge": 425.00, "minimum": 365.50, "maximum": 365.50, "setting": "both", "payers_information": [ { "payer_name": "Aetna", "plan_name": "700700", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna", "plan_name": "700700_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Miscellaneous", "plan_name": "700720", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Miscellaneous", "plan_name": "700720_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Ppo Hmo", "plan_name": "701720", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Ppo Hmo", "plan_name": "701720_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Ms State Emplo", "plan_name": "401457", "standard_charge_dollar": 365.50, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Ms State Emplo", "plan_name": "401457_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Basic Pl", "plan_name": "400100", "standard_charge_dollar": 365.50, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Basic Pl", "plan_name": "400100_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Federal", "plan_name": "400110", "standard_charge_dollar": 365.50, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Federal", "plan_name": "400110_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." } ] } ] }, { "description": "Hc er visit level 4", "code_information": [ { "code": "99284", "type": "CPT" } ], "standard_charges": [ { "gross_charge": 425.00, "minimum": 365.50, "maximum": 365.50, "setting": "both", "payers_information": [ { "payer_name": "Aetna", "plan_name": "700700", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna", "plan_name": "700700_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Miscellaneous", "plan_name": "700720", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Miscellaneous", "plan_name": "700720_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Ppo Hmo", "plan_name": "701720", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Ppo Hmo", "plan_name": "701720_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Ms State Emplo", "plan_name": "401457", "standard_charge_dollar": 365.50, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Ms State Emplo", "plan_name": "401457_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Basic Pl", "plan_name": "400100", "standard_charge_dollar": 365.50, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Basic Pl", "plan_name": "400100_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Federal", "plan_name": "400110", "standard_charge_dollar": 365.50, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Federal", "plan_name": "400110_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." } ] } ] }, { "description": "Emergency dept visit", "code_information": [ { "code": "99285", "type": "CPT" } ], "standard_charges": [ { "gross_charge": 500.00, "minimum": 537.38, "maximum": 537.38, "setting": "both", "payers_information": [ { "payer_name": "Aetna", "plan_name": "700700", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna", "plan_name": "700700_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Miscellaneous", "plan_name": "700720", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Miscellaneous", "plan_name": "700720_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Ppo Hmo", "plan_name": "701720", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Ppo Hmo", "plan_name": "701720_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Ms State Emplo", "plan_name": "401457", "standard_charge_dollar": 537.38, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Ms State Emplo", "plan_name": "401457_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Basic Pl", "plan_name": "400100", "standard_charge_dollar": 537.38, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Basic Pl", "plan_name": "400100_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Federal", "plan_name": "400110", "standard_charge_dollar": 537.38, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Federal", "plan_name": "400110_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." } ] } ] }, { "description": "Hc er visit level 5", "code_information": [ { "code": "99285", "type": "CPT" } ], "standard_charges": [ { "gross_charge": 500.00, "minimum": 537.38, "maximum": 537.38, "setting": "both", "payers_information": [ { "payer_name": "Aetna", "plan_name": "700700", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna", "plan_name": "700700_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Miscellaneous", "plan_name": "700720", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Miscellaneous", "plan_name": "700720_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Ppo Hmo", "plan_name": "701720", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Ppo Hmo", "plan_name": "701720_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Ms State Emplo", "plan_name": "401457", "standard_charge_dollar": 537.38, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Ms State Emplo", "plan_name": "401457_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Basic Pl", "plan_name": "400100", "standard_charge_dollar": 537.38, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Basic Pl", "plan_name": "400100_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Federal", "plan_name": "400110", "standard_charge_dollar": 537.38, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Federal", "plan_name": "400110_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." } ] } ] }, { "description": "Critical care first hour", "code_information": [ { "code": "99291", "type": "CPT" } ], "standard_charges": [ { "gross_charge": 1200.00, "minimum": 755.56, "maximum": 755.56, "setting": "both", "payers_information": [ { "payer_name": "Aetna", "plan_name": "700700", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna", "plan_name": "700700_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Miscellaneous", "plan_name": "700720", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Miscellaneous", "plan_name": "700720_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Ppo Hmo", "plan_name": "701720", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Ppo Hmo", "plan_name": "701720_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Ms State Emplo", "plan_name": "401457", "standard_charge_dollar": 755.56, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Ms State Emplo", "plan_name": "401457_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Basic Pl", "plan_name": "400100", "standard_charge_dollar": 755.56, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Basic Pl", "plan_name": "400100_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Federal", "plan_name": "400110", "standard_charge_dollar": 755.56, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Federal", "plan_name": "400110_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." } ] } ] }, { "description": "Hc er critical care 1st hr", "code_information": [ { "code": "99291", "type": "CPT" } ], "standard_charges": [ { "gross_charge": 1200.00, "minimum": 755.56, "maximum": 755.56, "setting": "both", "payers_information": [ { "payer_name": "Aetna", "plan_name": "700700", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna", "plan_name": "700700_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Miscellaneous", "plan_name": "700720", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Miscellaneous", "plan_name": "700720_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Ppo Hmo", "plan_name": "701720", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Ppo Hmo", "plan_name": "701720_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Ms State Emplo", "plan_name": "401457", "standard_charge_dollar": 755.56, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Ms State Emplo", "plan_name": "401457_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Basic Pl", "plan_name": "400100", "standard_charge_dollar": 755.56, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Basic Pl", "plan_name": "400100_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Federal", "plan_name": "400110", "standard_charge_dollar": 755.56, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Federal", "plan_name": "400110_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." } ] } ] }, { "description": "Behav chng smoking 3-10 min", "code_information": [ { "code": "99406", "type": "CPT" } ], "standard_charges": [ { "gross_charge": 47.00, "minimum": 13.53, "maximum": 13.53, "setting": "both", "payers_information": [ { "payer_name": "Aetna", "plan_name": "700700", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna", "plan_name": "700700_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Miscellaneous", "plan_name": "700720", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Miscellaneous", "plan_name": "700720_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Ppo Hmo", "plan_name": "701720", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Ppo Hmo", "plan_name": "701720_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Ms State Emplo", "plan_name": "401457", "standard_charge_dollar": 13.53, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Ms State Emplo", "plan_name": "401457_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Basic Pl", "plan_name": "400100", "standard_charge_dollar": 13.53, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Basic Pl", "plan_name": "400100_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Federal", "plan_name": "400110", "standard_charge_dollar": 13.53, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Federal", "plan_name": "400110_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." } ] } ] }, { "description": "Hc behavior chng smoking indiv 3 -10 mins", "code_information": [ { "code": "99406", "type": "CPT" } ], "standard_charges": [ { "gross_charge": 47.00, "minimum": 13.53, "maximum": 13.53, "setting": "both", "payers_information": [ { "payer_name": "Aetna", "plan_name": "700700", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna", "plan_name": "700700_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Miscellaneous", "plan_name": "700720", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", 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remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Ms State Emplo", "plan_name": "401457_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Basic Pl", "plan_name": "400100", "standard_charge_dollar": 13.53, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Basic Pl", "plan_name": "400100_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Federal", "plan_name": "400110", "standard_charge_dollar": 13.53, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Federal", "plan_name": "400110_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." } ] } ] }, { "description": "Behav chng smoking > 10 min", "code_information": [ { "code": "99407", "type": "CPT" } ], "standard_charges": [ { "gross_charge": 47.00, "minimum": 28.25, "maximum": 28.25, "setting": "both", "payers_information": [ { "payer_name": "Aetna", "plan_name": "700700", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna", "plan_name": "700700_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Miscellaneous", "plan_name": "700720", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Miscellaneous", "plan_name": "700720_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Ppo Hmo", "plan_name": "701720", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Ppo Hmo", "plan_name": "701720_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Ms State Emplo", "plan_name": "401457", "standard_charge_dollar": 28.25, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Ms State Emplo", "plan_name": "401457_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Basic Pl", "plan_name": "400100", "standard_charge_dollar": 28.25, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Basic Pl", "plan_name": "400100_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Federal", "plan_name": "400110", "standard_charge_dollar": 28.25, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Federal", "plan_name": "400110_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." } ] } ] }, { "description": "Hc ces prevent counseling indiv > 10 mins", "code_information": [ { "code": "99407", "type": "CPT" } ], "standard_charges": [ { "gross_charge": 47.00, "minimum": 28.25, "maximum": 28.25, "setting": "both", "payers_information": [ { "payer_name": "Aetna", "plan_name": "700700", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna", "plan_name": "700700_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of 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charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Ms State Emplo", "plan_name": "401457", "standard_charge_dollar": 28.25, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Ms State Emplo", "plan_name": "401457_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Basic Pl", "plan_name": "400100", "standard_charge_dollar": 28.25, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Basic Pl", "plan_name": "400100_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Federal", "plan_name": "400110", "standard_charge_dollar": 28.25, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Federal", "plan_name": "400110_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." } ] } ] }, { "description": "Lidocaine 4 % topical patch [108212]", "drug_information": { "unit": 1.00, "type": "EA" }, "code_information": [ { "code": "A9270", "type": "HCPCS" }, { "code": "0536-1202-07", "type": "NDC" } ], "standard_charges": [ { "gross_charge": 7.50, "minimum": 8.04, "maximum": 8.04, "setting": "both", "payers_information": [ { "payer_name": "Aetna", "plan_name": "700700", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent 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"additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Ppo Hmo", "plan_name": "701720_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Ms State Emplo", "plan_name": "401457", "standard_charge_dollar": 8.04, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Ms State Emplo", "plan_name": "401457_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Basic Pl", "plan_name": "400100", "standard_charge_dollar": 8.04, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Basic Pl", "plan_name": "400100_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Federal", "plan_name": "400110", "standard_charge_dollar": 8.04, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Federal", "plan_name": "400110_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." } ] } ] }, { "description": "Lidocaine 4 % topical patch [108212]", "drug_information": { "unit": 1.00, "type": "EA" }, "code_information": [ { "code": "A9270", "type": "HCPCS" }, { "code": "46581-830-01", "type": "NDC" } ], "standard_charges": [ { "gross_charge": 15.08, "minimum": 8.04, "maximum": 8.04, "setting": "both", "payers_information": [ { "payer_name": "Aetna", "plan_name": "700700", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna", "plan_name": "700700_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Miscellaneous", "plan_name": "700720", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Miscellaneous", "plan_name": "700720_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Ppo Hmo", "plan_name": "701720", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Ppo Hmo", "plan_name": "701720_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Ms State Emplo", "plan_name": "401457", "standard_charge_dollar": 8.04, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Ms State Emplo", "plan_name": "401457_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Basic Pl", "plan_name": "400100", "standard_charge_dollar": 8.04, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Basic Pl", "plan_name": "400100_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Federal", "plan_name": "400110", "standard_charge_dollar": 8.04, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Federal", "plan_name": "400110_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." } ] } ] }, { "description": "Technetium tc 99m sestamibi - cardiolite [40840057]", "drug_information": { "unit": 1.00, "type": "EA" }, "code_information": [ { "code": "A9500", "type": "HCPCS" }, { "code": "99999-0001-69", "type": "NDC" } ], "standard_charges": [ { "gross_charge": 248.28, "minimum": 198.62, "maximum": 211.04, "setting": "both", "payers_information": [ { "payer_name": "Aetna", "plan_name": "700700", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna", "plan_name": "700700_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Miscellaneous", "plan_name": "700720", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Miscellaneous", "plan_name": "700720_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Ppo Hmo", "plan_name": "701720", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Ppo Hmo", "plan_name": "701720_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Ms State Emplo", "plan_name": "401457", "standard_charge_percentage": 0.80, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Ms State Emplo", "plan_name": "401457_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Basic Pl", "plan_name": "400100", "standard_charge_percentage": 0.85, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Basic Pl", "plan_name": "400100_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Federal", "plan_name": "400110", "standard_charge_percentage": 0.85, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Federal", "plan_name": "400110_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." } ] } ] }, { "description": "Technetium tc99m tetrofosmin [530003]", "drug_information": { "unit": 1.00, "type": "EA" }, "code_information": [ { "code": "A9502", "type": "HCPCS" }, { "code": "99999-0001-60", "type": "NDC" } ], "standard_charges": [ { "gross_charge": 182.50, "minimum": 146.00, "maximum": 155.13, "setting": "both", "payers_information": [ { "payer_name": "Aetna", "plan_name": "700700", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna", "plan_name": "700700_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Miscellaneous", "plan_name": "700720", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Miscellaneous", "plan_name": "700720_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Ppo Hmo", "plan_name": "701720", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Ppo Hmo", "plan_name": "701720_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Ms State Emplo", "plan_name": "401457", "standard_charge_percentage": 0.80, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Ms State Emplo", "plan_name": "401457_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Basic Pl", "plan_name": "400100", "standard_charge_percentage": 0.85, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Basic Pl", "plan_name": "400100_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Federal", "plan_name": "400110", "standard_charge_percentage": 0.85, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Federal", "plan_name": "400110_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." } ] } ] }, { "description": "Technetium tc99m tetrofosmin [530003]", "drug_information": { "unit": 1.00, "type": "EA" }, "code_information": [ { "code": "A9502", "type": "HCPCS" }, { "code": "17156-026-30", "type": "NDC" } ], "standard_charges": [ { "gross_charge": 182.50, "minimum": 146.00, "maximum": 155.13, "setting": "both", "payers_information": [ { "payer_name": "Aetna", "plan_name": "700700", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna", "plan_name": "700700_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Miscellaneous", "plan_name": "700720", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Miscellaneous", "plan_name": "700720_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Ppo Hmo", 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State Emplo", "plan_name": "401457_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Basic Pl", "plan_name": "400100", "standard_charge_dollar": 38.56, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Basic Pl", "plan_name": "400100_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Federal", "plan_name": "400110", "standard_charge_dollar": 38.56, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Federal", "plan_name": "400110_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." } ] } ] }, { "description": "Technetium tc99m exametazime [530009]", "drug_information": { "unit": 1.00, "type": "EA" }, "code_information": [ { "code": "A9521", "type": "HCPCS" }, { "code": "17156-025-05", "type": "NDC" } ], "standard_charges": [ { "gross_charge": 7643.84, "minimum": 6115.07, "maximum": 6497.26, "setting": "both", "payers_information": [ { "payer_name": "Aetna", "plan_name": "700700", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna", "plan_name": "700700_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed 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"payer_name": "Bc/Bs Ms State Emplo", "plan_name": "401457", "standard_charge_percentage": 0.80, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Ms State Emplo", "plan_name": "401457_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Basic Pl", "plan_name": "400100", "standard_charge_percentage": 0.85, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Basic Pl", "plan_name": "400100_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Federal", "plan_name": "400110", "standard_charge_percentage": 0.85, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Federal", "plan_name": "400110_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." } ] } ] }, { "description": "Sodium iodide-131 diagnostic capsule [530015]", "drug_information": { "unit": 1.00, "type": "EA" }, "code_information": [ { "code": "A9528", "type": "HCPCS" }, { "code": "69208-000-00", "type": "NDC" } ], "standard_charges": [ { "gross_charge": 272.29, "minimum": 217.83, "maximum": 231.45, "setting": "both", "payers_information": [ { "payer_name": "Aetna", "plan_name": "700700", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed 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"additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Ppo Hmo", "plan_name": "701720_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Ms State Emplo", "plan_name": "401457", "standard_charge_percentage": 0.80, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Ms State Emplo", "plan_name": "401457_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Basic Pl", "plan_name": "400100", "standard_charge_percentage": 0.85, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Basic Pl", "plan_name": "400100_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Federal", "plan_name": "400110", "standard_charge_percentage": 0.85, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Federal", "plan_name": "400110_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." } ] } ] }, { "description": "Technetium tc 99m mebrofenin [40840063]", "drug_information": { "unit": 1.00, "type": "EA" }, "code_information": [ { "code": "A9537", "type": "HCPCS" }, { "code": "0270-0083-20", "type": "NDC" } ], "standard_charges": [ { "gross_charge": 168.90, "minimum": 135.12, "maximum": 143.57, "setting": "both", "payers_information": [ { "payer_name": "Aetna", "plan_name": "700700", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna", "plan_name": "700700_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Miscellaneous", "plan_name": "700720", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Miscellaneous", "plan_name": "700720_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Ppo Hmo", "plan_name": "701720", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Ppo Hmo", "plan_name": "701720_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Ms State Emplo", "plan_name": "401457", "standard_charge_percentage": 0.80, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Ms State Emplo", "plan_name": "401457_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Basic Pl", "plan_name": "400100", "standard_charge_percentage": 0.85, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Basic Pl", "plan_name": "400100_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Federal", "plan_name": "400110", "standard_charge_percentage": 0.85, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Federal", "plan_name": "400110_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." } ] } ] }, { "description": "Technetium tc 99m pyrophosphate [40840067]", "drug_information": { "unit": 1.00, "type": "EA" }, "code_information": [ { "code": "A9538", "type": "HCPCS" }, { "code": "45567-0060-1", "type": "NDC" } ], "standard_charges": [ { "gross_charge": 261.40, "minimum": 209.12, "maximum": 222.19, "setting": "both", "payers_information": [ { "payer_name": "Aetna", "plan_name": "700700", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna", "plan_name": "700700_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed 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"payer_name": "Bc/Bs Ms State Emplo", "plan_name": "401457", "standard_charge_percentage": 0.80, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Ms State Emplo", "plan_name": "401457_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Basic Pl", "plan_name": "400100", "standard_charge_percentage": 0.85, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Basic Pl", "plan_name": "400100_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Federal", "plan_name": "400110", "standard_charge_percentage": 0.85, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Federal", "plan_name": "400110_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." } ] } ] }, { "description": "Technetium tc99m pentetate [530001]", "drug_information": { "unit": 1.00, "type": "EA" }, "code_information": [ { "code": "A9539", "type": "HCPCS" }, { "code": "65174-288-05", "type": "NDC" } ], "standard_charges": [ { "gross_charge": 267.12, "minimum": 213.70, "maximum": 227.05, "setting": "both", "payers_information": [ { "payer_name": "Aetna", "plan_name": "700700", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna", "plan_name": "700700_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Miscellaneous", "plan_name": "700720", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Miscellaneous", "plan_name": "700720_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Ppo Hmo", "plan_name": "701720", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Ppo Hmo", "plan_name": "701720_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Ms State Emplo", "plan_name": "401457", "standard_charge_percentage": 0.80, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Ms State Emplo", "plan_name": "401457_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Basic Pl", "plan_name": "400100", "standard_charge_percentage": 0.85, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Basic Pl", "plan_name": "400100_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Federal", "plan_name": "400110", "standard_charge_percentage": 0.85, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Federal", "plan_name": "400110_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." } ] } ] }, { "description": "Technetium tc99m albumin aggregated [530017]", "drug_information": { "unit": 1.00, "type": "EA" }, "code_information": [ { "code": "A9540", "type": "HCPCS" }, { "code": "65174-270-30", "type": "NDC" } ], "standard_charges": [ { "gross_charge": 150.00, "minimum": 120.00, "maximum": 127.50, "setting": "both", "payers_information": [ { "payer_name": "Aetna", "plan_name": "700700", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna", "plan_name": "700700_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Miscellaneous", "plan_name": "700720", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Miscellaneous", "plan_name": "700720_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Ppo Hmo", "plan_name": "701720", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Ppo Hmo", "plan_name": "701720_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Ms State Emplo", "plan_name": "401457", "standard_charge_percentage": 0.80, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Ms State Emplo", "plan_name": "401457_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Basic Pl", "plan_name": "400100", "standard_charge_percentage": 0.85, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Basic Pl", "plan_name": "400100_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Federal", "plan_name": "400110", "standard_charge_percentage": 0.85, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Federal", "plan_name": "400110_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." } ] } ] }, { "description": "Pentetate indium disodium in-111 1.5 mci/1.5 ml intrathecal solution [155573]", "drug_information": { "unit": 1.00, "type": "EA" }, "code_information": [ { "code": "A9548", "type": "HCPCS" }, { "code": "17156-251-08", "type": "NDC" } ], "standard_charges": [ { "gross_charge": 8381.57, "minimum": 715.29, "maximum": 7124.33, "setting": "both", "payers_information": [ { "payer_name": "Aarp", "plan_name": "500102", "standard_charge_dollar": 715.29, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna", "plan_name": "700700", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna", "plan_name": "700700_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Mcare Ffs 6005", "plan_name": "700703", "standard_charge_dollar": 715.29, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Miscellaneous", "plan_name": "700720", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Miscellaneous", "plan_name": "700720_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Ppo Hmo", "plan_name": "701720", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Ppo Hmo", "plan_name": "701720_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Ambetter 68069", "plan_name": "500516", "standard_charge_dollar": 715.29, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Ms State Emplo", "plan_name": "401457", "standard_charge_percentage": 0.80, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Ms State Emplo", "plan_name": "401457_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Basic Pl", "plan_name": "400100", "standard_charge_percentage": 0.85, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Basic Pl", "plan_name": "400100_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Federal", "plan_name": "400110", "standard_charge_percentage": 0.85, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Federal", "plan_name": "400110_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Cigna Healthsprings Ffs", "plan_name": "500064", "standard_charge_dollar": 715.29, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Conseco", "plan_name": "500302", "standard_charge_dollar": 715.29, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Humana Ffs 61101", "plan_name": "500006", "standard_charge_dollar": 715.29, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Medicare A", "plan_name": "100100", "standard_charge_dollar": 715.29, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Medicare A", "plan_name": "100500", "standard_charge_dollar": 715.29, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Medicare Part B Only", "plan_name": "100300", "standard_charge_dollar": 715.29, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Medicare Railroad", "plan_name": "100103", "standard_charge_dollar": 715.29, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Ms Physicians Care N", "plan_name": "714210", "standard_charge_dollar": 894.11, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Peoples Hlth Ffs 72126", "plan_name": "500019", "standard_charge_dollar": 715.29, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Uhc/Secure Horizons", "plan_name": "500449", "standard_charge_dollar": 715.29, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "United Health Care/", "plan_name": "500292", "standard_charge_dollar": 808.28, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "United Healthcare", "plan_name": "750104", "standard_charge_dollar": 808.28, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "United Healthcare Ba", "plan_name": "750090", "standard_charge_dollar": 808.28, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "United Healthcare Me", "plan_name": "501310", "standard_charge_dollar": 715.29, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Windsor Mcare Extra", "plan_name": "500778", "standard_charge_dollar": 715.29, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." } ] } ] }, { "description": "Fludeoxyglucose f18 fdg [530005]", "drug_information": { "unit": 1.00, "type": "EA" }, "code_information": [ { "code": "A9552", "type": "HCPCS" }, { "code": "99999-0002-43", "type": "NDC" } ], "standard_charges": [ { "gross_charge": 650.00, "minimum": 520.00, "maximum": 552.50, "setting": "both", "payers_information": [ { "payer_name": "Aetna", "plan_name": "700700", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna", "plan_name": "700700_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Miscellaneous", "plan_name": "700720", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Miscellaneous", "plan_name": "700720_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Ppo Hmo", "plan_name": "701720", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Ppo Hmo", "plan_name": "701720_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Ms State Emplo", "plan_name": "401457", "standard_charge_percentage": 0.80, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Ms State Emplo", "plan_name": "401457_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Basic Pl", "plan_name": "400100", "standard_charge_percentage": 0.85, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Basic Pl", "plan_name": "400100_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Federal", "plan_name": "400110", "standard_charge_percentage": 0.85, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Federal", "plan_name": "400110_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." } ] } ] }, { "description": "Gallium citrate ga 67 [40840060]", "drug_information": { "unit": 1.00, "type": "EA" }, "code_information": [ { "code": "A9556", "type": 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80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Ppo Hmo", "plan_name": "701720_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Ambetter 68069", "plan_name": "500516", "standard_charge_dollar": 683.80, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Ms State Emplo", "plan_name": "401457", "standard_charge_percentage": 0.80, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Ms State Emplo", "plan_name": "401457_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": 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}, { "payer_name": "Medicare A", "plan_name": "100500", "standard_charge_dollar": 683.80, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Medicare Part B Only", "plan_name": "100300", "standard_charge_dollar": 683.80, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Medicare Railroad", "plan_name": "100103", "standard_charge_dollar": 683.80, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Ms Physicians Care N", "plan_name": "714210", "standard_charge_dollar": 854.75, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Peoples Hlth Ffs 72126", "plan_name": "500019", "standard_charge_dollar": 683.80, 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charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna", "plan_name": "700700_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Miscellaneous", "plan_name": "700720", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Miscellaneous", "plan_name": "700720_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Ppo Hmo", "plan_name": "701720", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", 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"plan_name": "700720_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Ppo Hmo", "plan_name": "701720", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Ppo Hmo", "plan_name": "701720_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Ms State Emplo", "plan_name": "401457", "standard_charge_percentage": 0.80, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Ms State Emplo", "plan_name": "401457_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Basic Pl", "plan_name": "400100", "standard_charge_percentage": 0.85, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Basic Pl", "plan_name": "400100_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Federal", "plan_name": "400110", "standard_charge_percentage": 0.85, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Federal", "plan_name": "400110_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." } ] } ] }, { "description": "Technetium tc 99m mertiatide [40840068]", "drug_information": { "unit": 1.00, "type": "EA" }, "code_information": [ { "code": "A9562", "type": "HCPCS" }, { "code": "69945-096-20", "type": "NDC" } ], "standard_charges": [ { "gross_charge": 1406.25, "minimum": 1125.00, "maximum": 1195.31, "setting": "both", "payers_information": [ { "payer_name": "Aetna", "plan_name": "700700", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna", "plan_name": "700700_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to 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amounts." }, { "payer_name": "Bc/Bs Of Ms Federal", "plan_name": "400110", "standard_charge_percentage": 0.85, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Federal", "plan_name": "400110_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." } ] } ] }, { "description": "Indium 111-pentetreotide 3 mci/ml-10 mcg intravenous kit [13545]", "drug_information": { "unit": 1.00, "type": "EA" }, "code_information": [ { "code": "A9572", "type": "HCPCS" }, { "code": "69945-050-40", "type": "NDC" } ], "standard_charges": [ { "gross_charge": 18406.25, "minimum": 1914.61, "maximum": 15645.31, "setting": "both", "payers_information": [ { "payer_name": "Aarp", "plan_name": "500102", "standard_charge_dollar": 1914.61, "count": "0", 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"plan_name": "500006", "standard_charge_dollar": 1914.61, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Medicare A", "plan_name": "100100", "standard_charge_dollar": 1914.61, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Medicare A", "plan_name": "100500", "standard_charge_dollar": 1914.61, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Medicare Part B Only", "plan_name": "100300", "standard_charge_dollar": 1914.61, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Medicare Railroad", "plan_name": "100103", "standard_charge_dollar": 1914.61, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Ms Physicians Care N", "plan_name": "714210", "standard_charge_dollar": 2393.26, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Peoples Hlth Ffs 72126", "plan_name": "500019", "standard_charge_dollar": 1914.61, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Uhc/Secure Horizons", "plan_name": "500449", "standard_charge_dollar": 1914.61, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "United Health Care/", "plan_name": "500292", "standard_charge_dollar": 2163.51, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "United Healthcare", "plan_name": "750104", "standard_charge_dollar": 2163.51, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "United Healthcare Ba", "plan_name": "750090", "standard_charge_dollar": 2163.51, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "United Healthcare Me", "plan_name": "501310", "standard_charge_dollar": 1914.61, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Windsor Mcare Extra", "plan_name": "500778", "standard_charge_dollar": 1914.61, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." } ] } ] }, { "description": "Gadoterate meglumine 0.5 mmol/ml (376.9 mg/ml) intravenous solution [163788]", "drug_information": { "unit": 10.00, "type": "ML" }, "code_information": [ { "code": "A9575", "type": "HCPCS" }, { "code": "0407-2943-01", "type": "NDC" } ], "standard_charges": [ { "gross_charge": 250.00, "minimum": 200.00, "maximum": 212.50, "setting": "both", "payers_information": [ { "payer_name": "Aetna", "plan_name": "700700", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna", "plan_name": "700700_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Miscellaneous", "plan_name": "700720", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed 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"payer_name": "Bc/Bs Ms State Emplo", "plan_name": "401457_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Basic Pl", "plan_name": "400100", "standard_charge_percentage": 0.85, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Basic Pl", "plan_name": "400100_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Federal", "plan_name": "400110", "standard_charge_percentage": 0.85, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Federal", "plan_name": "400110_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." } ] } ] }, { "description": "Gadoterate meglumine 0.5 mmol/ml (376.9 mg/ml) intravenous solution [163788]", "drug_information": { "unit": 15.00, "type": "ML" }, "code_information": [ { "code": "A9575", "type": "HCPCS" }, { "code": "0407-2943-02", "type": "NDC" } ], "standard_charges": [ { "gross_charge": 450.00, "minimum": 360.00, "maximum": 382.50, "setting": "both", "payers_information": [ { "payer_name": "Aetna", "plan_name": "700700", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna", "plan_name": "700700_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of 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charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Ms State Emplo", "plan_name": "401457", "standard_charge_percentage": 0.80, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Ms State Emplo", "plan_name": "401457_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Basic Pl", "plan_name": "400100", "standard_charge_percentage": 0.85, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Basic Pl", "plan_name": "400100_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Federal", "plan_name": "400110", "standard_charge_percentage": 0.85, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Federal", "plan_name": "400110_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." } ] } ] }, { "description": "Gadoterate meglumine 0.5 mmol/ml (376.9 mg/ml) intravenous solution [163788]", "drug_information": { "unit": 20.00, "type": "ML" }, "code_information": [ { "code": "A9575", "type": "HCPCS" }, { "code": "0407-2943-05", "type": "NDC" } ], "standard_charges": [ { "gross_charge": 500.00, "minimum": 400.00, "maximum": 425.00, "setting": "both", "payers_information": [ { "payer_name": "Aetna", "plan_name": "700700", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna", "plan_name": "700700_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Miscellaneous", "plan_name": "700720", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Miscellaneous", "plan_name": "700720_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Ppo Hmo", "plan_name": "701720", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Ppo Hmo", "plan_name": "701720_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Ms State Emplo", "plan_name": "401457", "standard_charge_percentage": 0.80, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Ms State Emplo", "plan_name": "401457_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Basic Pl", "plan_name": "400100", "standard_charge_percentage": 0.85, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Basic Pl", "plan_name": "400100_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Federal", "plan_name": "400110", "standard_charge_percentage": 0.85, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Federal", "plan_name": "400110_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." } ] } ] }, { "description": "Gadodiamide 5 mmol/10 ml (287 mg/ml) intravenous solution [11929]", "drug_information": { "unit": 10.00, "type": "ML" }, "code_information": [ { "code": "A9579", "type": "HCPCS" }, { "code": "0407-0690-10", "type": "NDC" } ], "standard_charges": [ { "gross_charge": 284.30, "minimum": 227.44, "maximum": 241.66, "setting": "both", "payers_information": [ { "payer_name": "Aetna", "plan_name": "700700", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna", "plan_name": "700700_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Miscellaneous", "plan_name": "700720", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data 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allowed amounts." }, { "payer_name": "Bc/Bs Ms State Emplo", "plan_name": "401457_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Basic Pl", "plan_name": "400100", "standard_charge_percentage": 0.85, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Basic Pl", "plan_name": "400100_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Federal", "plan_name": "400110", "standard_charge_percentage": 0.85, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate 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"Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Federal", "plan_name": "400110", "standard_charge_dollar": 15.60, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Federal", "plan_name": "400110_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." } ] } ] }, { "description": "Gadoxetate 0.25 mmol/ml (181.43 mg/ml) intravenous solution [93574]", "drug_information": { "unit": 10.00, "type": "ML" }, "code_information": [ { "code": "A9581", "type": "HCPCS" }, { "code": "50419-320-05", "type": "NDC" } ], "standard_charges": [ { "gross_charge": 709.80, "minimum": 15.60, "maximum": 15.60, "setting": "both", "payers_information": [ { "payer_name": "Aetna", "plan_name": "700700", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna", "plan_name": "700700_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Miscellaneous", "plan_name": "700720", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Miscellaneous", "plan_name": "700720_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Ppo Hmo", "plan_name": "701720", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Ppo Hmo", "plan_name": "701720_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Ms State Emplo", "plan_name": "401457", "standard_charge_dollar": 15.60, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Ms State Emplo", "plan_name": "401457_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Basic Pl", "plan_name": "400100", "standard_charge_dollar": 15.60, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Basic Pl", "plan_name": "400100_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Federal", "plan_name": "400110", "standard_charge_dollar": 15.60, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Federal", "plan_name": "400110_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." } ] } ] }, { "description": "Ioflupane i 123 5 mci/2.5 ml (185 mbq/2.5 ml) intravenous solution [151403]", "drug_information": { "unit": 1.00, "type": "EA" }, "code_information": [ { "code": "A9584", "type": "HCPCS" }, { "code": "17156-210-01", "type": "NDC" } ], "standard_charges": [ { "gross_charge": 4974.20, "minimum": 1388.02, "maximum": 2271.17, "setting": "both", "payers_information": [ { "payer_name": "Aarp", "plan_name": "500102", "standard_charge_dollar": 1388.02, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna", "plan_name": "700700", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna", "plan_name": "700700_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Mcare Ffs 6005", "plan_name": "700703", "standard_charge_dollar": 1388.02, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Miscellaneous", "plan_name": "700720", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Miscellaneous", "plan_name": "700720_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Ppo Hmo", "plan_name": "701720", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Ppo Hmo", "plan_name": "701720_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Ambetter 68069", "plan_name": "500516", "standard_charge_dollar": 1388.02, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Ms State Emplo", "plan_name": "401457", "standard_charge_dollar": 2271.17, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Ms State Emplo", "plan_name": "401457_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Basic Pl", "plan_name": "400100", "standard_charge_dollar": 2271.17, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Basic Pl", "plan_name": "400100_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Federal", "plan_name": "400110", "standard_charge_dollar": 2271.17, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Federal", "plan_name": "400110_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Cigna Healthsprings Ffs", "plan_name": "500064", "standard_charge_dollar": 1388.02, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Conseco", "plan_name": "500302", "standard_charge_dollar": 1388.02, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Humana Ffs 61101", "plan_name": "500006", "standard_charge_dollar": 1388.02, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Medicare A", "plan_name": "100100", "standard_charge_dollar": 1388.02, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Medicare A", "plan_name": "100500", "standard_charge_dollar": 1388.02, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Medicare Part B Only", "plan_name": "100300", "standard_charge_dollar": 1388.02, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Medicare Railroad", "plan_name": "100103", "standard_charge_dollar": 1388.02, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Ms Physicians Care N", "plan_name": "714210", "standard_charge_dollar": 1735.03, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Peoples Hlth Ffs 72126", "plan_name": "500019", "standard_charge_dollar": 1388.02, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Uhc/Secure Horizons", "plan_name": "500449", "standard_charge_dollar": 1388.02, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "United Health Care/", "plan_name": "500292", "standard_charge_dollar": 1568.46, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "United Healthcare", "plan_name": "750104", "standard_charge_dollar": 1568.46, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "United Healthcare Ba", "plan_name": "750090", "standard_charge_dollar": 1568.46, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "United Healthcare Me", "plan_name": "501310", "standard_charge_dollar": 1388.02, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Windsor Mcare Extra", "plan_name": "500778", "standard_charge_dollar": 1388.02, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." } ] } ] }, { "description": "Kit for the preparation of ga-68-dotatate 40 mcg intravenous soln [178446]", "drug_information": { "unit": 1.00, "type": "EA" }, "code_information": [ { "code": "A9587", "type": "HCPCS" }, { "code": "69488-001-40", "type": "NDC" } ], "standard_charges": [ { "gross_charge": 15000.00, "minimum": 51.09, "maximum": 63.86, "setting": "both", "payers_information": [ { "payer_name": "Aarp", "plan_name": "500102", "standard_charge_dollar": 51.09, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna", "plan_name": "700700", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna", "plan_name": "700700_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Mcare Ffs 6005", "plan_name": "700703", "standard_charge_dollar": 51.09, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Miscellaneous", "plan_name": "700720", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Miscellaneous", "plan_name": "700720_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Ppo Hmo", "plan_name": "701720", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Ppo Hmo", "plan_name": "701720_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Ambetter 68069", "plan_name": "500516", "standard_charge_dollar": 51.09, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Ms State Emplo", "plan_name": "401457", "standard_charge_dollar": 60.45, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Ms State Emplo", "plan_name": "401457_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Basic Pl", "plan_name": "400100", "standard_charge_dollar": 60.45, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Basic Pl", "plan_name": "400100_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Federal", "plan_name": "400110", "standard_charge_dollar": 60.45, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Federal", "plan_name": "400110_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Cigna Healthsprings Ffs", "plan_name": "500064", "standard_charge_dollar": 51.09, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Conseco", "plan_name": "500302", "standard_charge_dollar": 51.09, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Humana Ffs 61101", "plan_name": "500006", "standard_charge_dollar": 51.09, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Medicare A", "plan_name": "100100", "standard_charge_dollar": 51.09, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Medicare A", "plan_name": "100500", "standard_charge_dollar": 51.09, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Medicare Part B Only", "plan_name": "100300", "standard_charge_dollar": 51.09, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Medicare Railroad", "plan_name": "100103", "standard_charge_dollar": 51.09, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Ms Physicians Care N", "plan_name": "714210", "standard_charge_dollar": 63.86, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Peoples Hlth Ffs 72126", "plan_name": "500019", "standard_charge_dollar": 51.09, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Uhc/Secure Horizons", "plan_name": "500449", "standard_charge_dollar": 51.09, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "United Health Care/", "plan_name": "500292", "standard_charge_dollar": 57.73, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "United Healthcare", "plan_name": "750104", "standard_charge_dollar": 57.73, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "United Healthcare Ba", "plan_name": "750090", "standard_charge_dollar": 57.73, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "United Healthcare Me", "plan_name": "501310", "standard_charge_dollar": 51.09, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Windsor Mcare Extra", "plan_name": "500778", "standard_charge_dollar": 51.09, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." } ] } ] }, { "description": "Fluciclovine f18 10 mci (370 mbq) intravenous solution [183167]", "drug_information": { "unit": 1.00, "type": "EA" }, "code_information": [ { "code": "A9588", "type": "HCPCS" }, { "code": "69932-001-01", "type": "NDC" } ], "standard_charges": [ { "gross_charge": 20110.00, "minimum": 268.42, "maximum": 352.80, "setting": "both", "payers_information": [ { "payer_name": "Aarp", "plan_name": "500102", "standard_charge_dollar": 268.42, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna", "plan_name": "700700", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna", "plan_name": "700700_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Mcare Ffs 6005", "plan_name": "700703", "standard_charge_dollar": 268.42, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Miscellaneous", "plan_name": "700720", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Miscellaneous", "plan_name": "700720_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Ppo Hmo", "plan_name": "701720", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Ppo Hmo", "plan_name": "701720_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Ambetter 68069", "plan_name": "500516", "standard_charge_dollar": 268.42, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Ms State Emplo", "plan_name": "401457", "standard_charge_dollar": 352.80, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Ms State Emplo", "plan_name": "401457_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Basic Pl", "plan_name": "400100", "standard_charge_dollar": 352.80, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Basic Pl", "plan_name": "400100_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Federal", "plan_name": "400110", "standard_charge_dollar": 352.80, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Federal", "plan_name": "400110_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Cigna Healthsprings Ffs", "plan_name": "500064", "standard_charge_dollar": 268.42, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Conseco", "plan_name": "500302", "standard_charge_dollar": 268.42, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Humana Ffs 61101", "plan_name": "500006", "standard_charge_dollar": 268.42, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Medicare A", "plan_name": "100100", "standard_charge_dollar": 268.42, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Medicare A", "plan_name": "100500", "standard_charge_dollar": 268.42, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Medicare Part B Only", "plan_name": "100300", "standard_charge_dollar": 268.42, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Medicare Railroad", "plan_name": "100103", "standard_charge_dollar": 268.42, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Ms Physicians Care N", "plan_name": "714210", "standard_charge_dollar": 335.53, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Peoples Hlth Ffs 72126", "plan_name": "500019", "standard_charge_dollar": 268.42, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Uhc/Secure Horizons", "plan_name": "500449", "standard_charge_dollar": 268.42, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "United Health Care/", "plan_name": "500292", "standard_charge_dollar": 303.31, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "United Healthcare", "plan_name": "750104", "standard_charge_dollar": 303.31, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "United Healthcare Ba", "plan_name": "750090", "standard_charge_dollar": 303.31, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "United Healthcare Me", "plan_name": "501310", "standard_charge_dollar": 268.42, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Windsor Mcare Extra", "plan_name": "500778", "standard_charge_dollar": 268.42, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." } ] } ] }, { "description": "Copper cu-64 dotatate 148 mbq/4 ml (4 mci/4 ml) intravenous solution [191788]", "drug_information": { "unit": 1.00, "type": "EA" }, "code_information": [ { "code": "A9592", "type": "HCPCS" }, { "code": "69945-064-01", "type": "NDC" } ], "standard_charges": [ { "gross_charge": 19250.00, "minimum": 595.10, "maximum": 16362.50, "setting": "both", "payers_information": [ { "payer_name": "Aarp", "plan_name": "500102", "standard_charge_dollar": 595.10, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna", "plan_name": "700700", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna", "plan_name": "700700_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Mcare Ffs 6005", "plan_name": "700703", "standard_charge_dollar": 595.10, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Miscellaneous", "plan_name": "700720", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Miscellaneous", "plan_name": "700720_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Ppo Hmo", "plan_name": "701720", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Ppo Hmo", "plan_name": "701720_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Ambetter 68069", "plan_name": "500516", "standard_charge_dollar": 595.10, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Ms State Emplo", "plan_name": "401457", "standard_charge_percentage": 0.80, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Ms State Emplo", "plan_name": "401457_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Basic Pl", "plan_name": "400100", "standard_charge_percentage": 0.85, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Basic Pl", "plan_name": "400100_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Federal", "plan_name": "400110", "standard_charge_percentage": 0.85, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Federal", "plan_name": "400110_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Cigna Healthsprings Ffs", "plan_name": "500064", "standard_charge_dollar": 595.10, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Conseco", "plan_name": "500302", "standard_charge_dollar": 595.10, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Humana Ffs 61101", "plan_name": "500006", "standard_charge_dollar": 595.10, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Medicare A", "plan_name": "100100", "standard_charge_dollar": 595.10, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Medicare A", "plan_name": "100500", "standard_charge_dollar": 595.10, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Medicare Part B Only", "plan_name": "100300", "standard_charge_dollar": 595.10, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Medicare Railroad", "plan_name": "100103", "standard_charge_dollar": 595.10, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Ms Physicians Care N", "plan_name": "714210", "standard_charge_dollar": 743.88, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Peoples Hlth Ffs 72126", "plan_name": "500019", "standard_charge_dollar": 595.10, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Uhc/Secure Horizons", "plan_name": "500449", "standard_charge_dollar": 595.10, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "United Health Care/", "plan_name": "500292", "standard_charge_dollar": 672.46, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "United Healthcare", "plan_name": "750104", "standard_charge_dollar": 672.46, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "United Healthcare Ba", "plan_name": "750090", "standard_charge_dollar": 672.46, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "United Healthcare Me", "plan_name": "501310", "standard_charge_dollar": 595.10, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Windsor Mcare Extra", "plan_name": "500778", "standard_charge_dollar": 595.10, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." } ] } ] }, { "description": "Piflufolastat f 18 37 mbq/ml to 2960 mbq/ml (1-80 mci/ml) iv solution [194154]", "drug_information": { "unit": 1.00, "type": "EA" }, "code_information": [ { "code": "A9595", "type": "HCPCS" }, { "code": "71258-022-01", "type": "NDC" } ], "standard_charges": [ { "gross_charge": 18136.85, "minimum": 332.44, "maximum": 15416.32, "setting": "both", "payers_information": [ { "payer_name": "Aarp", "plan_name": "500102", "standard_charge_dollar": 332.44, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna", "plan_name": "700700", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna", "plan_name": "700700_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Mcare Ffs 6005", "plan_name": "700703", "standard_charge_dollar": 332.44, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Miscellaneous", "plan_name": "700720", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Miscellaneous", "plan_name": "700720_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Ppo Hmo", "plan_name": "701720", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Ppo Hmo", "plan_name": "701720_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Ambetter 68069", "plan_name": "500516", "standard_charge_dollar": 332.44, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Ms State Emplo", "plan_name": "401457", "standard_charge_percentage": 0.80, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Ms State Emplo", "plan_name": "401457_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Basic Pl", "plan_name": "400100", "standard_charge_percentage": 0.85, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Basic Pl", "plan_name": "400100_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Federal", "plan_name": "400110", "standard_charge_percentage": 0.85, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Federal", "plan_name": "400110_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Cigna Healthsprings Ffs", "plan_name": "500064", "standard_charge_dollar": 332.44, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Conseco", "plan_name": "500302", "standard_charge_dollar": 332.44, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Humana Ffs 61101", "plan_name": "500006", "standard_charge_dollar": 332.44, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Medicare A", "plan_name": "100100", "standard_charge_dollar": 332.44, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Medicare A", "plan_name": "100500", "standard_charge_dollar": 332.44, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Medicare Part B Only", "plan_name": "100300", "standard_charge_dollar": 332.44, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Medicare Railroad", "plan_name": "100103", "standard_charge_dollar": 332.44, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Ms Physicians Care N", "plan_name": "714210", "standard_charge_dollar": 415.55, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Peoples Hlth Ffs 72126", "plan_name": "500019", "standard_charge_dollar": 332.44, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Uhc/Secure Horizons", "plan_name": "500449", "standard_charge_dollar": 332.44, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "United Health Care/", "plan_name": "500292", "standard_charge_dollar": 375.66, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "United Healthcare", "plan_name": "750104", "standard_charge_dollar": 375.66, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "United Healthcare Ba", "plan_name": "750090", "standard_charge_dollar": 375.66, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "United Healthcare Me", "plan_name": "501310", "standard_charge_dollar": 332.44, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Windsor Mcare Extra", "plan_name": "500778", "standard_charge_dollar": 332.44, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." } ] } ] }, { "description": "Ga-68-gozetotide 25 mcg intravenous solution [195952]", "drug_information": { "unit": 1.00, "type": "EA" }, "code_information": [ { "code": "A9596", "type": "HCPCS" }, { "code": "74725-100-25", "type": "NDC" } ], "standard_charges": [ { "gross_charge": 19778.40, "minimum": 944.47, "maximum": 16811.64, "setting": "both", "payers_information": [ { "payer_name": "Aarp", "plan_name": "500102", "standard_charge_dollar": 944.47, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna", "plan_name": "700700", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna", "plan_name": "700700_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Mcare Ffs 6005", "plan_name": "700703", "standard_charge_dollar": 944.47, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Miscellaneous", "plan_name": "700720", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Miscellaneous", "plan_name": "700720_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Ppo Hmo", "plan_name": "701720", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Ppo Hmo", "plan_name": "701720_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Ambetter 68069", "plan_name": "500516", "standard_charge_dollar": 944.47, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Ms State Emplo", "plan_name": "401457", "standard_charge_percentage": 0.80, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Ms State Emplo", "plan_name": "401457_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Basic Pl", "plan_name": "400100", "standard_charge_percentage": 0.85, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Basic Pl", "plan_name": "400100_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Federal", "plan_name": "400110", "standard_charge_percentage": 0.85, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Federal", "plan_name": "400110_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Cigna Healthsprings Ffs", "plan_name": "500064", "standard_charge_dollar": 944.47, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Conseco", "plan_name": "500302", "standard_charge_dollar": 944.47, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Humana Ffs 61101", "plan_name": "500006", "standard_charge_dollar": 944.47, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Medicare A", "plan_name": "100100", "standard_charge_dollar": 944.47, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Medicare A", "plan_name": "100500", "standard_charge_dollar": 944.47, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Medicare Part B Only", "plan_name": "100300", "standard_charge_dollar": 944.47, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Medicare Railroad", "plan_name": "100103", "standard_charge_dollar": 944.47, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Ms Physicians Care N", "plan_name": "714210", "standard_charge_dollar": 1180.58, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Peoples Hlth Ffs 72126", "plan_name": "500019", "standard_charge_dollar": 944.47, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Uhc/Secure Horizons", "plan_name": "500449", "standard_charge_dollar": 944.47, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "United Health Care/", "plan_name": "500292", "standard_charge_dollar": 1067.25, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "United Healthcare", "plan_name": "750104", "standard_charge_dollar": 1067.25, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "United Healthcare Ba", "plan_name": "750090", "standard_charge_dollar": 1067.25, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "United Healthcare Me", "plan_name": "501310", "standard_charge_dollar": 944.47, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Windsor Mcare Extra", "plan_name": "500778", "standard_charge_dollar": 944.47, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." } ] } ] }, { "description": "Radium ra 223 dichlor 1100 kbq/ml (30 microcurie/ml) intravenous soln [162685]", "drug_information": { "unit": 6.00, "type": "ML" }, "code_information": [ { "code": "A9606", "type": "HCPCS" }, { "code": "50419-208-01", "type": "NDC" } ], "standard_charges": [ { "gross_charge": 850768.80, "minimum": 122.93, "maximum": 211.33, "setting": "both", "payers_information": [ { "payer_name": "Aarp", "plan_name": "500102", "standard_charge_dollar": 169.06, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna", "plan_name": "700700", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna", "plan_name": "700700_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Mcare Ffs 6005", "plan_name": "700703", "standard_charge_dollar": 169.06, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Miscellaneous", "plan_name": "700720", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Miscellaneous", "plan_name": "700720_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Ppo Hmo", "plan_name": "701720", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Ppo Hmo", "plan_name": "701720_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Ambetter 68069", "plan_name": "500516", "standard_charge_dollar": 169.06, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Ms State Emplo", "plan_name": "401457", "standard_charge_dollar": 122.93, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Ms State Emplo", "plan_name": "401457_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Basic Pl", "plan_name": "400100", "standard_charge_dollar": 122.93, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Basic Pl", "plan_name": "400100_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Federal", "plan_name": "400110", "standard_charge_dollar": 122.93, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Federal", "plan_name": "400110_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Cigna Healthsprings Ffs", "plan_name": "500064", "standard_charge_dollar": 169.06, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Conseco", "plan_name": "500302", "standard_charge_dollar": 169.06, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Humana Ffs 61101", "plan_name": "500006", "standard_charge_dollar": 169.06, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Medicare A", "plan_name": "100100", "standard_charge_dollar": 169.06, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Medicare A", "plan_name": "100500", "standard_charge_dollar": 169.06, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Medicare Part B Only", "plan_name": "100300", "standard_charge_dollar": 169.06, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Medicare Railroad", "plan_name": "100103", "standard_charge_dollar": 169.06, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Ms Physicians Care N", "plan_name": "714210", "standard_charge_dollar": 211.33, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Peoples Hlth Ffs 72126", "plan_name": "500019", "standard_charge_dollar": 169.06, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Uhc/Secure Horizons", "plan_name": "500449", "standard_charge_dollar": 169.06, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "United Health Care/", "plan_name": "500292", "standard_charge_dollar": 191.04, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "United Healthcare", "plan_name": "750104", "standard_charge_dollar": 191.04, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "United Healthcare Ba", "plan_name": "750090", "standard_charge_dollar": 191.04, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "United Healthcare Me", "plan_name": "501310", "standard_charge_dollar": 169.06, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Windsor Mcare Extra", "plan_name": "500778", "standard_charge_dollar": 169.06, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." } ] } ] }, { "description": "Lutetium lu-177 vipivotide tetraxetan 27 mci/ml (1000 mbq/ml) iv soln [196465]", "drug_information": { "unit": 1.00, "type": "EA" }, "code_information": [ { "code": "A9607", "type": "HCPCS" }, { "code": "69488-010-61", "type": "NDC" } ], "standard_charges": [ { "gross_charge": 227587.50, "minimum": 220.04, "maximum": 193449.38, "setting": "both", "payers_information": [ { "payer_name": "Aarp", "plan_name": "500102", "standard_charge_dollar": 220.04, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna", "plan_name": "700700", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna", "plan_name": "700700_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Mcare Ffs 6005", "plan_name": "700703", "standard_charge_dollar": 220.04, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Miscellaneous", "plan_name": "700720", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Miscellaneous", "plan_name": "700720_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Ppo Hmo", "plan_name": "701720", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Ppo Hmo", "plan_name": "701720_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Ambetter 68069", "plan_name": "500516", "standard_charge_dollar": 220.04, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Ms State Emplo", "plan_name": "401457", "standard_charge_percentage": 0.80, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Ms State Emplo", "plan_name": "401457_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Basic Pl", "plan_name": "400100", "standard_charge_percentage": 0.85, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Basic Pl", "plan_name": "400100_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Federal", "plan_name": "400110", "standard_charge_percentage": 0.85, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Federal", "plan_name": "400110_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Cigna Healthsprings Ffs", "plan_name": "500064", "standard_charge_dollar": 220.04, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Conseco", "plan_name": "500302", "standard_charge_dollar": 220.04, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Humana Ffs 61101", "plan_name": "500006", "standard_charge_dollar": 220.04, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Medicare A", "plan_name": "100100", "standard_charge_dollar": 220.04, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Medicare A", "plan_name": "100500", "standard_charge_dollar": 220.04, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Medicare Part B Only", "plan_name": "100300", "standard_charge_dollar": 220.04, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Medicare Railroad", "plan_name": "100103", "standard_charge_dollar": 220.04, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Ms Physicians Care N", "plan_name": "714210", "standard_charge_dollar": 275.05, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Peoples Hlth Ffs 72126", "plan_name": "500019", "standard_charge_dollar": 220.04, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Uhc/Secure Horizons", "plan_name": "500449", "standard_charge_dollar": 220.04, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "United Health Care/", "plan_name": "500292", "standard_charge_dollar": 248.64, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "United Healthcare", "plan_name": "750104", "standard_charge_dollar": 248.64, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "United Healthcare Ba", "plan_name": "750090", "standard_charge_dollar": 248.64, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "United Healthcare Me", "plan_name": "501310", "standard_charge_dollar": 220.04, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Windsor Mcare Extra", "plan_name": "500778", "standard_charge_dollar": 220.04, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." } ] } ] }, { "description": "Lacosamide 200 mg/20 ml intravenous solution [96972]", "drug_information": { "unit": 20.00, "type": "ML" }, "code_information": [ { "code": "C9254", "type": "HCPCS" }, { "code": "0131-1810-67", "type": "NDC" } ], "standard_charges": [ { "gross_charge": 895.56, "minimum": 0.16, "maximum": 0.16, "setting": "both", "payers_information": [ { "payer_name": "Aetna", "plan_name": "700700", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna", "plan_name": "700700_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Miscellaneous", "plan_name": "700720", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Miscellaneous", "plan_name": "700720_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Ppo Hmo", "plan_name": "701720", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Ppo Hmo", "plan_name": "701720_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Ms State Emplo", "plan_name": "401457", "standard_charge_dollar": 0.16, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Ms State Emplo", "plan_name": "401457_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Basic Pl", "plan_name": "400100", "standard_charge_dollar": 0.16, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Basic Pl", "plan_name": "400100_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Federal", "plan_name": "400110", "standard_charge_dollar": 0.16, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Federal", "plan_name": "400110_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." } ] } ] }, { "description": "Admin influenza virus vac", "code_information": [ { "code": "G0008", "type": "HCPCS" } ], "standard_charges": [ { "gross_charge": 143.00, "minimum": 42.27, "maximum": 121.55, "setting": "both", "payers_information": [ { "payer_name": "Aarp", "plan_name": "500102", "standard_charge_dollar": 42.27, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna", "plan_name": "700700", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna", "plan_name": "700700_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Mcare Ffs 6005", "plan_name": "700703", "standard_charge_dollar": 42.27, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Miscellaneous", "plan_name": "700720", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Miscellaneous", "plan_name": "700720_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Ppo Hmo", "plan_name": "701720", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Ppo Hmo", "plan_name": "701720_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Ambetter 68069", "plan_name": "500516", "standard_charge_dollar": 42.27, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Ms State Emplo", "plan_name": "401457", "standard_charge_percentage": 0.80, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Ms State Emplo", "plan_name": "401457_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Basic Pl", "plan_name": "400100", "standard_charge_percentage": 0.85, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Basic Pl", "plan_name": "400100_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Federal", "plan_name": "400110", "standard_charge_percentage": 0.85, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Federal", "plan_name": "400110_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Cigna Healthsprings Ffs", "plan_name": "500064", "standard_charge_dollar": 42.27, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Conseco", "plan_name": "500302", "standard_charge_dollar": 42.27, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Humana Ffs 61101", "plan_name": "500006", "standard_charge_dollar": 42.27, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Medicare A", "plan_name": "100100", "standard_charge_dollar": 42.27, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Medicare A", "plan_name": "100500", "standard_charge_dollar": 42.27, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Medicare Part B Only", "plan_name": "100300", "standard_charge_dollar": 42.27, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Medicare Railroad", "plan_name": "100103", "standard_charge_dollar": 42.27, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Ms Physicians Care N", "plan_name": "714210", "standard_charge_dollar": 52.83, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Peoples Hlth Ffs 72126", "plan_name": "500019", "standard_charge_dollar": 42.27, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Uhc/Secure Horizons", "plan_name": "500449", "standard_charge_dollar": 42.27, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "United Health Care/", "plan_name": "500292", "standard_charge_dollar": 47.76, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "United Healthcare", "plan_name": "750104", "standard_charge_dollar": 47.76, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "United Healthcare Ba", "plan_name": "750090", "standard_charge_dollar": 47.76, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "United Healthcare Me", "plan_name": "501310", "standard_charge_dollar": 42.27, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Windsor Mcare Extra", "plan_name": "500778", "standard_charge_dollar": 42.27, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." } ] } ] }, { "description": "Hc influenza vaccine admin", "code_information": [ { "code": "G0008", "type": "HCPCS" } ], "standard_charges": [ { "gross_charge": 143.00, "minimum": 42.27, "maximum": 121.55, "setting": "both", "payers_information": [ { "payer_name": "Aarp", "plan_name": "500102", "standard_charge_dollar": 42.27, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna", "plan_name": "700700", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna", "plan_name": "700700_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Mcare Ffs 6005", "plan_name": "700703", "standard_charge_dollar": 42.27, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Miscellaneous", "plan_name": "700720", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Miscellaneous", "plan_name": "700720_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Ppo Hmo", "plan_name": "701720", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Ppo Hmo", "plan_name": "701720_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Ambetter 68069", "plan_name": "500516", "standard_charge_dollar": 42.27, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Ms State Emplo", "plan_name": "401457", "standard_charge_percentage": 0.80, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Ms State Emplo", "plan_name": "401457_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Basic Pl", "plan_name": "400100", "standard_charge_percentage": 0.85, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Basic Pl", "plan_name": "400100_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Federal", "plan_name": "400110", "standard_charge_percentage": 0.85, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Federal", "plan_name": "400110_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Cigna Healthsprings Ffs", "plan_name": "500064", "standard_charge_dollar": 42.27, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Conseco", "plan_name": "500302", "standard_charge_dollar": 42.27, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Humana Ffs 61101", "plan_name": "500006", "standard_charge_dollar": 42.27, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Medicare A", "plan_name": "100100", "standard_charge_dollar": 42.27, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Medicare A", "plan_name": "100500", "standard_charge_dollar": 42.27, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Medicare Part B Only", "plan_name": "100300", "standard_charge_dollar": 42.27, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Medicare Railroad", "plan_name": "100103", "standard_charge_dollar": 42.27, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Ms Physicians Care N", "plan_name": "714210", "standard_charge_dollar": 52.83, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Peoples Hlth Ffs 72126", "plan_name": "500019", "standard_charge_dollar": 42.27, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Uhc/Secure Horizons", "plan_name": "500449", "standard_charge_dollar": 42.27, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "United Health Care/", "plan_name": "500292", "standard_charge_dollar": 47.76, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "United Healthcare", "plan_name": "750104", "standard_charge_dollar": 47.76, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "United Healthcare Ba", "plan_name": "750090", "standard_charge_dollar": 47.76, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "United Healthcare Me", "plan_name": "501310", "standard_charge_dollar": 42.27, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Windsor Mcare Extra", "plan_name": "500778", "standard_charge_dollar": 42.27, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." } ] } ] }, { "description": "Admin pneumococcal vaccine", "code_information": [ { "code": "G0009", "type": "HCPCS" } ], "standard_charges": [ { "gross_charge": 143.00, "minimum": 42.27, "maximum": 121.55, "setting": "both", "payers_information": [ { "payer_name": "Aarp", "plan_name": "500102", "standard_charge_dollar": 42.27, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna", "plan_name": "700700", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna", "plan_name": "700700_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Mcare Ffs 6005", "plan_name": "700703", "standard_charge_dollar": 42.27, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Miscellaneous", "plan_name": "700720", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Miscellaneous", "plan_name": "700720_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Ppo Hmo", "plan_name": "701720", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Ppo Hmo", "plan_name": "701720_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Ambetter 68069", "plan_name": "500516", "standard_charge_dollar": 42.27, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Ms State Emplo", "plan_name": "401457", "standard_charge_percentage": 0.80, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Ms State Emplo", "plan_name": "401457_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Basic Pl", "plan_name": "400100", "standard_charge_percentage": 0.85, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Basic Pl", "plan_name": "400100_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Federal", "plan_name": "400110", "standard_charge_percentage": 0.85, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Federal", "plan_name": "400110_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Cigna Healthsprings Ffs", "plan_name": "500064", "standard_charge_dollar": 42.27, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Conseco", "plan_name": "500302", "standard_charge_dollar": 42.27, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Humana Ffs 61101", "plan_name": "500006", "standard_charge_dollar": 42.27, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Medicare A", "plan_name": "100100", "standard_charge_dollar": 42.27, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Medicare A", "plan_name": "100500", "standard_charge_dollar": 42.27, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Medicare Part B Only", "plan_name": "100300", "standard_charge_dollar": 42.27, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Medicare Railroad", "plan_name": "100103", "standard_charge_dollar": 42.27, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Ms Physicians Care N", "plan_name": "714210", "standard_charge_dollar": 52.83, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Peoples Hlth Ffs 72126", "plan_name": "500019", "standard_charge_dollar": 42.27, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Uhc/Secure Horizons", "plan_name": "500449", "standard_charge_dollar": 42.27, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "United Health Care/", "plan_name": "500292", "standard_charge_dollar": 47.76, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "United Healthcare", "plan_name": "750104", "standard_charge_dollar": 47.76, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "United Healthcare Ba", "plan_name": "750090", "standard_charge_dollar": 47.76, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "United Healthcare Me", "plan_name": "501310", "standard_charge_dollar": 42.27, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Windsor Mcare Extra", "plan_name": "500778", "standard_charge_dollar": 42.27, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." } ] } ] }, { "description": "Hc pneumococcal vaccine admin", "code_information": [ { "code": "G0009", "type": "HCPCS" } ], "standard_charges": [ { "gross_charge": 143.00, "minimum": 42.27, "maximum": 121.55, "setting": "both", "payers_information": [ { "payer_name": "Aarp", "plan_name": "500102", "standard_charge_dollar": 42.27, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna", "plan_name": "700700", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna", "plan_name": "700700_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Mcare Ffs 6005", "plan_name": "700703", "standard_charge_dollar": 42.27, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Miscellaneous", "plan_name": "700720", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Miscellaneous", "plan_name": "700720_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Ppo Hmo", "plan_name": "701720", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Ppo Hmo", "plan_name": "701720_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Ambetter 68069", "plan_name": "500516", "standard_charge_dollar": 42.27, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Ms State Emplo", "plan_name": "401457", "standard_charge_percentage": 0.80, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Ms State Emplo", "plan_name": "401457_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Basic Pl", "plan_name": "400100", "standard_charge_percentage": 0.85, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Basic Pl", "plan_name": "400100_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Federal", "plan_name": "400110", "standard_charge_percentage": 0.85, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Federal", "plan_name": "400110_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Cigna Healthsprings Ffs", "plan_name": "500064", "standard_charge_dollar": 42.27, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Conseco", "plan_name": "500302", "standard_charge_dollar": 42.27, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Humana Ffs 61101", "plan_name": "500006", "standard_charge_dollar": 42.27, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Medicare A", "plan_name": "100100", "standard_charge_dollar": 42.27, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Medicare A", "plan_name": "100500", "standard_charge_dollar": 42.27, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Medicare Part B Only", "plan_name": "100300", "standard_charge_dollar": 42.27, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Medicare Railroad", "plan_name": "100103", "standard_charge_dollar": 42.27, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Ms Physicians Care N", "plan_name": "714210", "standard_charge_dollar": 52.83, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Peoples Hlth Ffs 72126", "plan_name": "500019", "standard_charge_dollar": 42.27, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Uhc/Secure Horizons", "plan_name": "500449", "standard_charge_dollar": 42.27, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "United Health Care/", "plan_name": "500292", "standard_charge_dollar": 47.76, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "United Healthcare", "plan_name": "750104", "standard_charge_dollar": 47.76, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "United Healthcare Ba", "plan_name": "750090", "standard_charge_dollar": 47.76, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "United Healthcare Me", "plan_name": "501310", "standard_charge_dollar": 42.27, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Windsor Mcare Extra", "plan_name": "500778", "standard_charge_dollar": 42.27, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." } ] } ] }, { "description": "Admin hepatitis b vaccine", "code_information": [ { "code": "G0010", "type": "HCPCS" } ], "standard_charges": [ { "gross_charge": 71.00, "minimum": 14.80, "maximum": 52.83, "setting": "both", "payers_information": [ { "payer_name": "Aarp", "plan_name": "500102", "standard_charge_dollar": 42.27, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna", "plan_name": "700700", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna", "plan_name": "700700_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Mcare Ffs 6005", "plan_name": "700703", "standard_charge_dollar": 42.27, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Miscellaneous", "plan_name": "700720", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Miscellaneous", "plan_name": "700720_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Ppo Hmo", "plan_name": "701720", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Ppo Hmo", "plan_name": "701720_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Ambetter 68069", "plan_name": "500516", "standard_charge_dollar": 42.27, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Ms State Emplo", "plan_name": "401457", "standard_charge_dollar": 14.80, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Ms State Emplo", "plan_name": "401457_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Basic Pl", "plan_name": "400100", "standard_charge_dollar": 14.80, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Basic Pl", "plan_name": "400100_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Federal", "plan_name": "400110", "standard_charge_dollar": 14.80, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Federal", "plan_name": "400110_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Cigna Healthsprings Ffs", "plan_name": "500064", "standard_charge_dollar": 42.27, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Conseco", "plan_name": "500302", "standard_charge_dollar": 42.27, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Humana Ffs 61101", "plan_name": "500006", "standard_charge_dollar": 42.27, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Medicare A", "plan_name": "100100", "standard_charge_dollar": 42.27, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Medicare A", "plan_name": "100500", "standard_charge_dollar": 42.27, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Medicare Part B Only", "plan_name": "100300", "standard_charge_dollar": 42.27, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Medicare Railroad", "plan_name": "100103", "standard_charge_dollar": 42.27, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Ms Physicians Care N", "plan_name": "714210", "standard_charge_dollar": 52.83, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Peoples Hlth Ffs 72126", "plan_name": "500019", "standard_charge_dollar": 42.27, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Uhc/Secure Horizons", "plan_name": "500449", "standard_charge_dollar": 42.27, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "United Health Care/", "plan_name": "500292", "standard_charge_dollar": 47.76, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "United Healthcare", "plan_name": "750104", "standard_charge_dollar": 47.76, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "United Healthcare Ba", "plan_name": "750090", "standard_charge_dollar": 47.76, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "United Healthcare Me", "plan_name": "501310", "standard_charge_dollar": 42.27, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Windsor Mcare Extra", "plan_name": "500778", "standard_charge_dollar": 42.27, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." } ] } ] }, { "description": "Hc hep b vaccine admin subsequent", "code_information": [ { "code": "G0010", "type": "HCPCS" } ], "standard_charges": [ { "gross_charge": 71.00, "minimum": 14.80, "maximum": 52.83, "setting": "both", "payers_information": [ { "payer_name": "Aarp", "plan_name": "500102", "standard_charge_dollar": 42.27, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna", "plan_name": "700700", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna", "plan_name": "700700_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Mcare Ffs 6005", "plan_name": "700703", "standard_charge_dollar": 42.27, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Miscellaneous", "plan_name": "700720", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Miscellaneous", "plan_name": "700720_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Ppo Hmo", "plan_name": "701720", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Ppo Hmo", "plan_name": "701720_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Ambetter 68069", "plan_name": "500516", "standard_charge_dollar": 42.27, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Ms State Emplo", "plan_name": "401457", "standard_charge_dollar": 14.80, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Ms State Emplo", "plan_name": "401457_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Basic Pl", "plan_name": "400100", "standard_charge_dollar": 14.80, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Basic Pl", "plan_name": "400100_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Federal", "plan_name": "400110", "standard_charge_dollar": 14.80, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Federal", "plan_name": "400110_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Cigna Healthsprings Ffs", "plan_name": "500064", "standard_charge_dollar": 42.27, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Conseco", "plan_name": "500302", "standard_charge_dollar": 42.27, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Humana Ffs 61101", "plan_name": "500006", "standard_charge_dollar": 42.27, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Medicare A", "plan_name": "100100", "standard_charge_dollar": 42.27, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Medicare A", "plan_name": "100500", "standard_charge_dollar": 42.27, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Medicare Part B Only", "plan_name": "100300", "standard_charge_dollar": 42.27, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Medicare Railroad", "plan_name": "100103", "standard_charge_dollar": 42.27, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Ms Physicians Care N", "plan_name": "714210", "standard_charge_dollar": 52.83, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Peoples Hlth Ffs 72126", "plan_name": "500019", "standard_charge_dollar": 42.27, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Uhc/Secure Horizons", "plan_name": "500449", "standard_charge_dollar": 42.27, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "United Health Care/", "plan_name": "500292", "standard_charge_dollar": 47.76, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "United Healthcare", "plan_name": "750104", "standard_charge_dollar": 47.76, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "United Healthcare Ba", "plan_name": "750090", "standard_charge_dollar": 47.76, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "United Healthcare Me", "plan_name": "501310", "standard_charge_dollar": 42.27, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Windsor Mcare Extra", "plan_name": "500778", "standard_charge_dollar": 42.27, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." } ] } ] }, { "description": "Hc psa screening", "code_information": [ { "code": "G0103", "type": "HCPCS" } ], "standard_charges": [ { "gross_charge": 110.00, "minimum": 19.31, "maximum": 24.62, "setting": "both", "payers_information": [ { "payer_name": "Aarp", "plan_name": "500102", "standard_charge_dollar": 19.31, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna", "plan_name": "700700", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna", "plan_name": "700700_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Mcare Ffs 6005", "plan_name": "700703", "standard_charge_dollar": 19.31, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Miscellaneous", "plan_name": "700720", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Miscellaneous", "plan_name": "700720_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Ppo Hmo", "plan_name": "701720", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Ppo Hmo", "plan_name": "701720_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Ambetter 68069", "plan_name": "500516", "standard_charge_dollar": 19.31, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Ms State Emplo", "plan_name": "401457", "standard_charge_dollar": 24.62, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Ms State Emplo", "plan_name": "401457_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Basic Pl", "plan_name": "400100", "standard_charge_dollar": 24.62, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Basic Pl", "plan_name": "400100_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Federal", "plan_name": "400110", "standard_charge_dollar": 24.62, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Federal", "plan_name": "400110_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Cigna Healthsprings Ffs", "plan_name": "500064", "standard_charge_dollar": 19.31, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Conseco", "plan_name": "500302", "standard_charge_dollar": 19.31, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Humana Ffs 61101", "plan_name": "500006", "standard_charge_dollar": 19.31, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Medicare A", "plan_name": "100100", "standard_charge_dollar": 19.31, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Medicare A", "plan_name": "100500", "standard_charge_dollar": 19.31, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Medicare Part B Only", "plan_name": "100300", "standard_charge_dollar": 19.31, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Medicare Railroad", "plan_name": "100103", "standard_charge_dollar": 19.31, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Ms Physicians Care N", "plan_name": "714210", "standard_charge_dollar": 24.14, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Peoples Hlth Ffs 72126", "plan_name": "500019", "standard_charge_dollar": 19.31, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Uhc/Secure Horizons", "plan_name": "500449", "standard_charge_dollar": 19.31, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "United Health Care/", "plan_name": "500292", "standard_charge_dollar": 21.82, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "United Healthcare", "plan_name": "750104", "standard_charge_dollar": 21.82, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "United Healthcare Ba", "plan_name": "750090", "standard_charge_dollar": 21.82, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "United Healthcare Me", "plan_name": "501310", "standard_charge_dollar": 19.31, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Windsor Mcare Extra", "plan_name": "500778", "standard_charge_dollar": 19.31, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." } ] } ] }, { "description": "Psa screening", "code_information": [ { "code": "G0103", "type": "HCPCS" } ], "standard_charges": [ { "gross_charge": 110.00, "minimum": 19.31, "maximum": 24.62, "setting": "both", "payers_information": [ { "payer_name": "Aarp", "plan_name": "500102", "standard_charge_dollar": 19.31, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna", "plan_name": "700700", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna", "plan_name": "700700_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Mcare Ffs 6005", "plan_name": "700703", "standard_charge_dollar": 19.31, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Miscellaneous", "plan_name": "700720", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Miscellaneous", "plan_name": "700720_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Ppo Hmo", "plan_name": "701720", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Ppo Hmo", "plan_name": "701720_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Ambetter 68069", "plan_name": "500516", "standard_charge_dollar": 19.31, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Ms State Emplo", "plan_name": "401457", "standard_charge_dollar": 24.62, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Ms State Emplo", "plan_name": "401457_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Basic Pl", "plan_name": "400100", "standard_charge_dollar": 24.62, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Basic Pl", "plan_name": "400100_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Federal", "plan_name": "400110", "standard_charge_dollar": 24.62, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Federal", "plan_name": "400110_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Cigna Healthsprings Ffs", "plan_name": "500064", "standard_charge_dollar": 19.31, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Conseco", "plan_name": "500302", "standard_charge_dollar": 19.31, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Humana Ffs 61101", "plan_name": "500006", "standard_charge_dollar": 19.31, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Medicare A", "plan_name": "100100", "standard_charge_dollar": 19.31, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Medicare A", "plan_name": "100500", "standard_charge_dollar": 19.31, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Medicare Part B Only", "plan_name": "100300", "standard_charge_dollar": 19.31, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Medicare Railroad", "plan_name": "100103", "standard_charge_dollar": 19.31, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Ms Physicians Care N", "plan_name": "714210", "standard_charge_dollar": 24.14, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Peoples Hlth Ffs 72126", "plan_name": "500019", "standard_charge_dollar": 19.31, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Uhc/Secure Horizons", "plan_name": "500449", "standard_charge_dollar": 19.31, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "United Health Care/", "plan_name": "500292", "standard_charge_dollar": 21.82, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "United Healthcare", "plan_name": "750104", "standard_charge_dollar": 21.82, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "United Healthcare Ba", "plan_name": "750090", "standard_charge_dollar": 21.82, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "United Healthcare Me", "plan_name": "501310", "standard_charge_dollar": 19.31, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Windsor Mcare Extra", "plan_name": "500778", "standard_charge_dollar": 19.31, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." } ] } ] }, { "description": "Hc trim dystrophic nails any num", "code_information": [ { "code": "G0127", "type": "HCPCS" } ], "standard_charges": [ { "gross_charge": 91.00, "minimum": 54.41, "maximum": 81.80, "setting": "both", "payers_information": [ { "payer_name": "Aarp", "plan_name": "500102", "standard_charge_dollar": 54.41, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna", "plan_name": "700700", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna", "plan_name": "700700_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Mcare Ffs 6005", "plan_name": "700703", "standard_charge_dollar": 54.41, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Miscellaneous", "plan_name": "700720", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Miscellaneous", "plan_name": "700720_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Ppo Hmo", "plan_name": "701720", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Ppo Hmo", "plan_name": "701720_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Ambetter 68069", "plan_name": "500516", "standard_charge_dollar": 54.41, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Ms State Emplo", "plan_name": "401457", "standard_charge_dollar": 81.80, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Ms State Emplo", "plan_name": "401457_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Basic Pl", "plan_name": "400100", "standard_charge_dollar": 81.80, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Basic Pl", "plan_name": "400100_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Federal", "plan_name": "400110", "standard_charge_dollar": 81.80, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Federal", "plan_name": "400110_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Cigna Healthsprings Ffs", "plan_name": "500064", "standard_charge_dollar": 54.41, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Conseco", "plan_name": "500302", "standard_charge_dollar": 54.41, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Humana Ffs 61101", "plan_name": "500006", "standard_charge_dollar": 54.41, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Medicare A", "plan_name": "100100", "standard_charge_dollar": 54.41, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Medicare A", "plan_name": "100500", "standard_charge_dollar": 54.41, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Medicare Part B Only", "plan_name": "100300", "standard_charge_dollar": 54.41, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Medicare Railroad", "plan_name": "100103", "standard_charge_dollar": 54.41, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Ms Physicians Care N", "plan_name": "714210", "standard_charge_dollar": 68.02, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Peoples Hlth Ffs 72126", "plan_name": "500019", "standard_charge_dollar": 54.41, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Uhc/Secure Horizons", "plan_name": "500449", "standard_charge_dollar": 54.41, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "United Health Care/", "plan_name": "500292", "standard_charge_dollar": 61.49, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "United Healthcare", "plan_name": "750104", "standard_charge_dollar": 61.49, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "United Healthcare Ba", "plan_name": "750090", "standard_charge_dollar": 61.49, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "United Healthcare Me", "plan_name": "501310", "standard_charge_dollar": 54.41, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Windsor Mcare Extra", "plan_name": "500778", "standard_charge_dollar": 54.41, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." } ] } ] }, { "description": "Trim nail(s)", "code_information": [ { "code": "G0127", "type": "HCPCS" } ], "standard_charges": [ { "gross_charge": 91.00, "minimum": 54.41, "maximum": 81.80, "setting": "both", "payers_information": [ { "payer_name": "Aarp", "plan_name": "500102", "standard_charge_dollar": 54.41, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna", "plan_name": "700700", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna", "plan_name": "700700_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Mcare Ffs 6005", "plan_name": "700703", "standard_charge_dollar": 54.41, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Miscellaneous", "plan_name": "700720", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Miscellaneous", "plan_name": "700720_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Ppo Hmo", "plan_name": "701720", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Ppo Hmo", "plan_name": "701720_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Ambetter 68069", "plan_name": "500516", "standard_charge_dollar": 54.41, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Ms State Emplo", "plan_name": "401457", "standard_charge_dollar": 81.80, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Ms State Emplo", "plan_name": "401457_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Basic Pl", "plan_name": "400100", "standard_charge_dollar": 81.80, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Basic Pl", "plan_name": "400100_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Federal", "plan_name": "400110", "standard_charge_dollar": 81.80, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Federal", "plan_name": "400110_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Cigna Healthsprings Ffs", "plan_name": "500064", "standard_charge_dollar": 54.41, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Conseco", "plan_name": "500302", "standard_charge_dollar": 54.41, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Humana Ffs 61101", "plan_name": "500006", "standard_charge_dollar": 54.41, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Medicare A", "plan_name": "100100", "standard_charge_dollar": 54.41, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Medicare A", "plan_name": "100500", "standard_charge_dollar": 54.41, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Medicare Part B Only", "plan_name": "100300", "standard_charge_dollar": 54.41, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Medicare Railroad", "plan_name": "100103", "standard_charge_dollar": 54.41, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Ms Physicians Care N", "plan_name": "714210", "standard_charge_dollar": 68.02, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Peoples Hlth Ffs 72126", "plan_name": "500019", "standard_charge_dollar": 54.41, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Uhc/Secure Horizons", "plan_name": "500449", "standard_charge_dollar": 54.41, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "United Health Care/", "plan_name": "500292", "standard_charge_dollar": 61.49, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "United Healthcare", "plan_name": "750104", "standard_charge_dollar": 61.49, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "United Healthcare Ba", "plan_name": "750090", "standard_charge_dollar": 61.49, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "United Healthcare Me", "plan_name": "501310", "standard_charge_dollar": 54.41, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Windsor Mcare Extra", "plan_name": "500778", "standard_charge_dollar": 54.41, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." } ] } ] }, { "description": "Elec stim other than wound", "code_information": [ { "code": "G0283", "type": "HCPCS" } ], "standard_charges": [ { "gross_charge": 25.00, "minimum": 11.31, "maximum": 14.79, "setting": "both", "payers_information": [ { "payer_name": "Aarp", "plan_name": "500102", "standard_charge_dollar": 11.31, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna", "plan_name": "700700", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna", "plan_name": "700700_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Mcare Ffs 6005", "plan_name": "700703", "standard_charge_dollar": 11.31, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Miscellaneous", "plan_name": "700720", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Miscellaneous", "plan_name": "700720_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Ppo Hmo", "plan_name": "701720", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Ppo Hmo", "plan_name": "701720_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Ambetter 68069", "plan_name": "500516", "standard_charge_dollar": 11.31, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Ms State Emplo", "plan_name": "401457", "standard_charge_dollar": 14.79, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Ms State Emplo", "plan_name": "401457_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Basic Pl", "plan_name": "400100", "standard_charge_dollar": 14.79, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Basic Pl", "plan_name": "400100_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Federal", "plan_name": "400110", "standard_charge_dollar": 14.79, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Federal", "plan_name": "400110_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Cigna Healthsprings Ffs", "plan_name": "500064", "standard_charge_dollar": 11.31, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Conseco", "plan_name": "500302", "standard_charge_dollar": 11.31, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Humana Ffs 61101", "plan_name": "500006", "standard_charge_dollar": 11.31, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Medicare A", "plan_name": "100100", "standard_charge_dollar": 11.31, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Medicare A", "plan_name": "100500", "standard_charge_dollar": 11.31, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Medicare Part B Only", "plan_name": "100300", "standard_charge_dollar": 11.31, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Medicare Railroad", "plan_name": "100103", "standard_charge_dollar": 11.31, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Ms Physicians Care N", "plan_name": "714210", "standard_charge_dollar": 14.14, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Peoples Hlth Ffs 72126", "plan_name": "500019", "standard_charge_dollar": 11.31, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Uhc/Secure Horizons", "plan_name": "500449", "standard_charge_dollar": 11.31, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "United Health Care/", "plan_name": "500292", "standard_charge_dollar": 12.78, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "United Healthcare", "plan_name": "750104", "standard_charge_dollar": 12.78, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "United Healthcare Ba", "plan_name": "750090", "standard_charge_dollar": 12.78, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "United Healthcare Me", "plan_name": "501310", "standard_charge_dollar": 11.31, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Windsor Mcare Extra", "plan_name": "500778", "standard_charge_dollar": 11.31, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." } ] } ] }, { "description": "Hc electrical stimulation", "code_information": [ { "code": "G0283", "type": "HCPCS" } ], "standard_charges": [ { "gross_charge": 25.00, "minimum": 11.31, "maximum": 14.79, "setting": "both", "payers_information": [ { "payer_name": "Aarp", "plan_name": "500102", "standard_charge_dollar": 11.31, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna", "plan_name": "700700", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna", "plan_name": "700700_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Mcare Ffs 6005", "plan_name": "700703", "standard_charge_dollar": 11.31, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Miscellaneous", "plan_name": "700720", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Miscellaneous", "plan_name": "700720_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Ppo Hmo", "plan_name": "701720", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Ppo Hmo", "plan_name": "701720_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Ambetter 68069", "plan_name": "500516", "standard_charge_dollar": 11.31, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Ms State Emplo", "plan_name": "401457", "standard_charge_dollar": 14.79, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Ms State Emplo", "plan_name": "401457_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Basic Pl", "plan_name": "400100", "standard_charge_dollar": 14.79, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Basic Pl", "plan_name": "400100_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Federal", "plan_name": "400110", "standard_charge_dollar": 14.79, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Federal", "plan_name": "400110_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Cigna Healthsprings Ffs", "plan_name": "500064", "standard_charge_dollar": 11.31, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Conseco", "plan_name": "500302", "standard_charge_dollar": 11.31, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Humana Ffs 61101", "plan_name": "500006", "standard_charge_dollar": 11.31, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Medicare A", "plan_name": "100100", "standard_charge_dollar": 11.31, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Medicare A", "plan_name": "100500", "standard_charge_dollar": 11.31, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Medicare Part B Only", "plan_name": "100300", "standard_charge_dollar": 11.31, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Medicare Railroad", "plan_name": "100103", "standard_charge_dollar": 11.31, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Ms Physicians Care N", "plan_name": "714210", "standard_charge_dollar": 14.14, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Peoples Hlth Ffs 72126", "plan_name": "500019", "standard_charge_dollar": 11.31, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Uhc/Secure Horizons", "plan_name": "500449", "standard_charge_dollar": 11.31, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "United Health Care/", "plan_name": "500292", "standard_charge_dollar": 12.78, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "United Healthcare", "plan_name": "750104", "standard_charge_dollar": 12.78, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "United Healthcare Ba", "plan_name": "750090", "standard_charge_dollar": 12.78, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "United Healthcare Me", "plan_name": "501310", "standard_charge_dollar": 11.31, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Windsor Mcare Extra", "plan_name": "500778", "standard_charge_dollar": 11.31, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." } ] } ] }, { "description": "Fecal blood scrn immunoassay", "code_information": [ { "code": "G0328", "type": "HCPCS" } ], "standard_charges": [ { "gross_charge": 47.76, "minimum": 14.11, "maximum": 22.56, "setting": "both", "payers_information": [ { "payer_name": "Aarp", "plan_name": "500102", "standard_charge_dollar": 18.05, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna", "plan_name": "700700", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna", "plan_name": "700700_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Mcare Ffs 6005", "plan_name": "700703", "standard_charge_dollar": 18.05, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Miscellaneous", "plan_name": "700720", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Miscellaneous", "plan_name": "700720_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Ppo Hmo", "plan_name": "701720", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Ppo Hmo", "plan_name": "701720_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Ambetter 68069", "plan_name": "500516", "standard_charge_dollar": 18.05, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Ms State Emplo", "plan_name": "401457", "standard_charge_dollar": 14.11, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Ms State Emplo", "plan_name": "401457_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Basic Pl", "plan_name": "400100", "standard_charge_dollar": 14.11, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Basic Pl", "plan_name": "400100_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Federal", "plan_name": "400110", "standard_charge_dollar": 14.11, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Federal", "plan_name": "400110_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Cigna Healthsprings Ffs", "plan_name": "500064", "standard_charge_dollar": 18.05, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Conseco", "plan_name": "500302", "standard_charge_dollar": 18.05, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Humana Ffs 61101", "plan_name": "500006", "standard_charge_dollar": 18.05, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Medicare A", "plan_name": "100100", "standard_charge_dollar": 18.05, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Medicare A", "plan_name": "100500", "standard_charge_dollar": 18.05, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Medicare Part B Only", "plan_name": "100300", "standard_charge_dollar": 18.05, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Medicare Railroad", "plan_name": "100103", "standard_charge_dollar": 18.05, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Ms Physicians Care N", "plan_name": "714210", "standard_charge_dollar": 22.56, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Peoples Hlth Ffs 72126", "plan_name": "500019", "standard_charge_dollar": 18.05, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Uhc/Secure Horizons", "plan_name": "500449", "standard_charge_dollar": 18.05, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "United Health Care/", "plan_name": "500292", "standard_charge_dollar": 20.40, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "United Healthcare", "plan_name": "750104", "standard_charge_dollar": 20.40, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "United Healthcare Ba", "plan_name": "750090", "standard_charge_dollar": 20.40, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "United Healthcare Me", "plan_name": "501310", "standard_charge_dollar": 18.05, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Windsor Mcare Extra", "plan_name": "500778", "standard_charge_dollar": 18.05, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." } ] } ] }, { "description": "Hc fob screening", "code_information": [ { "code": "G0328", "type": "HCPCS" } ], "standard_charges": [ { "gross_charge": 47.76, "minimum": 14.11, "maximum": 22.56, "setting": "both", "payers_information": [ { "payer_name": "Aarp", "plan_name": "500102", "standard_charge_dollar": 18.05, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna", "plan_name": "700700", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna", "plan_name": "700700_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Mcare Ffs 6005", "plan_name": "700703", "standard_charge_dollar": 18.05, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Miscellaneous", "plan_name": "700720", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Miscellaneous", "plan_name": "700720_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Ppo Hmo", "plan_name": "701720", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Ppo Hmo", "plan_name": "701720_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Ambetter 68069", "plan_name": "500516", "standard_charge_dollar": 18.05, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Ms State Emplo", "plan_name": "401457", "standard_charge_dollar": 14.11, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Ms State Emplo", "plan_name": "401457_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Basic Pl", "plan_name": "400100", "standard_charge_dollar": 14.11, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Basic Pl", "plan_name": "400100_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Federal", "plan_name": "400110", "standard_charge_dollar": 14.11, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Federal", "plan_name": "400110_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Cigna Healthsprings Ffs", "plan_name": "500064", "standard_charge_dollar": 18.05, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Conseco", "plan_name": "500302", "standard_charge_dollar": 18.05, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Humana Ffs 61101", "plan_name": "500006", "standard_charge_dollar": 18.05, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Medicare A", "plan_name": "100100", "standard_charge_dollar": 18.05, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Medicare A", "plan_name": "100500", "standard_charge_dollar": 18.05, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Medicare Part B Only", "plan_name": "100300", "standard_charge_dollar": 18.05, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Medicare Railroad", "plan_name": "100103", "standard_charge_dollar": 18.05, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Ms Physicians Care N", "plan_name": "714210", "standard_charge_dollar": 22.56, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Peoples Hlth Ffs 72126", "plan_name": "500019", "standard_charge_dollar": 18.05, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Uhc/Secure Horizons", "plan_name": "500449", "standard_charge_dollar": 18.05, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "United Health Care/", "plan_name": "500292", "standard_charge_dollar": 20.40, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "United Healthcare", "plan_name": "750104", "standard_charge_dollar": 20.40, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "United Healthcare Ba", "plan_name": "750090", "standard_charge_dollar": 20.40, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "United Healthcare Me", "plan_name": "501310", "standard_charge_dollar": 18.05, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Windsor Mcare Extra", "plan_name": "500778", "standard_charge_dollar": 18.05, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." } ] } ] }, { "description": "Hc observation carve-out - cardiology", "code_information": [ { "code": "G0378", "type": "HCPCS" } ], "standard_charges": [ { "gross_charge": 30.00, "minimum": 24.00, "maximum": 25.50, "setting": "both", "payers_information": [ { "payer_name": "Aetna", "plan_name": "700700", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna", "plan_name": "700700_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Miscellaneous", "plan_name": "700720", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Miscellaneous", "plan_name": "700720_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Ppo Hmo", "plan_name": "701720", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Ppo Hmo", "plan_name": "701720_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Ms State Emplo", "plan_name": "401457", "standard_charge_percentage": 0.80, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Ms State Emplo", "plan_name": "401457_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Basic Pl", "plan_name": "400100", "standard_charge_percentage": 0.85, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Basic Pl", "plan_name": "400100_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Federal", "plan_name": "400110", "standard_charge_percentage": 0.85, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Federal", "plan_name": "400110_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." } ] } ] }, { "description": "Hospital observation per hr", "code_information": [ { "code": "G0378", "type": "HCPCS" } ], "standard_charges": [ { "gross_charge": 30.00, "minimum": 24.00, "maximum": 25.50, "setting": "both", "payers_information": [ { "payer_name": "Aetna", "plan_name": "700700", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna", "plan_name": "700700_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Miscellaneous", "plan_name": "700720", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Miscellaneous", "plan_name": "700720_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Ppo Hmo", "plan_name": "701720", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Ppo Hmo", "plan_name": "701720_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Ms State Emplo", "plan_name": "401457", "standard_charge_percentage": 0.80, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Ms State Emplo", "plan_name": "401457_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Basic Pl", "plan_name": "400100", "standard_charge_percentage": 0.85, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Basic Pl", "plan_name": "400100_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Federal", "plan_name": "400110", "standard_charge_percentage": 0.85, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Federal", "plan_name": "400110_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." } ] } ] }, { "description": "Direct refer hospital observ", "code_information": [ { "code": "G0379", "type": "HCPCS" } ], "standard_charges": [ { "gross_charge": 1500.00, "minimum": 537.38, "maximum": 702.05, "setting": "both", "payers_information": [ { "payer_name": "Aarp", "plan_name": "500102", "standard_charge_dollar": 561.64, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna", "plan_name": "700700", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna", "plan_name": "700700_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Mcare Ffs 6005", "plan_name": "700703", "standard_charge_dollar": 561.64, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Miscellaneous", "plan_name": "700720", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Miscellaneous", "plan_name": "700720_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Ppo Hmo", "plan_name": "701720", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Ppo Hmo", "plan_name": "701720_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Ambetter 68069", "plan_name": "500516", "standard_charge_dollar": 561.64, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Ms State Emplo", "plan_name": "401457", "standard_charge_dollar": 537.38, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Ms State Emplo", "plan_name": "401457_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Basic Pl", "plan_name": "400100", "standard_charge_dollar": 537.38, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Basic Pl", "plan_name": "400100_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Federal", "plan_name": "400110", "standard_charge_dollar": 537.38, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Federal", "plan_name": "400110_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Cigna Healthsprings Ffs", "plan_name": "500064", "standard_charge_dollar": 561.64, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Conseco", "plan_name": "500302", "standard_charge_dollar": 561.64, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Humana Ffs 61101", "plan_name": "500006", "standard_charge_dollar": 561.64, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Medicare A", "plan_name": "100100", "standard_charge_dollar": 561.64, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Medicare A", "plan_name": "100500", "standard_charge_dollar": 561.64, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Medicare Part B Only", "plan_name": "100300", "standard_charge_dollar": 561.64, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Medicare Railroad", "plan_name": "100103", "standard_charge_dollar": 561.64, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Ms Physicians Care N", "plan_name": "714210", "standard_charge_dollar": 702.05, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Peoples Hlth Ffs 72126", "plan_name": "500019", "standard_charge_dollar": 561.64, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Uhc/Secure Horizons", "plan_name": "500449", "standard_charge_dollar": 561.64, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "United Health Care/", "plan_name": "500292", "standard_charge_dollar": 634.66, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "United Healthcare", "plan_name": "750104", "standard_charge_dollar": 634.66, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "United Healthcare Ba", "plan_name": "750090", "standard_charge_dollar": 634.66, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "United Healthcare Me", "plan_name": "501310", "standard_charge_dollar": 561.64, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Windsor Mcare Extra", "plan_name": "500778", "standard_charge_dollar": 561.64, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." } ] } ] }, { "description": "Hc direct admit hosp observation", "code_information": [ { "code": "G0379", "type": "HCPCS" } ], "standard_charges": [ { "gross_charge": 1500.00, "minimum": 537.38, "maximum": 702.05, "setting": "both", "payers_information": [ { "payer_name": "Aarp", "plan_name": "500102", "standard_charge_dollar": 561.64, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna", "plan_name": "700700", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna", "plan_name": "700700_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Mcare Ffs 6005", "plan_name": "700703", "standard_charge_dollar": 561.64, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Miscellaneous", "plan_name": "700720", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Miscellaneous", "plan_name": "700720_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Ppo Hmo", "plan_name": "701720", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Ppo Hmo", "plan_name": "701720_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Ambetter 68069", "plan_name": "500516", "standard_charge_dollar": 561.64, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Ms State Emplo", "plan_name": "401457", "standard_charge_dollar": 537.38, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Ms State Emplo", "plan_name": "401457_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Basic Pl", "plan_name": "400100", "standard_charge_dollar": 537.38, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Basic Pl", "plan_name": "400100_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Federal", "plan_name": "400110", "standard_charge_dollar": 537.38, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Federal", "plan_name": "400110_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Cigna Healthsprings Ffs", "plan_name": "500064", "standard_charge_dollar": 561.64, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Conseco", "plan_name": "500302", "standard_charge_dollar": 561.64, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Humana Ffs 61101", "plan_name": "500006", "standard_charge_dollar": 561.64, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Medicare A", "plan_name": "100100", "standard_charge_dollar": 561.64, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Medicare A", "plan_name": "100500", "standard_charge_dollar": 561.64, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Medicare Part B Only", "plan_name": "100300", "standard_charge_dollar": 561.64, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Medicare Railroad", "plan_name": "100103", "standard_charge_dollar": 561.64, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Ms Physicians Care N", "plan_name": "714210", "standard_charge_dollar": 702.05, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Peoples Hlth Ffs 72126", "plan_name": "500019", "standard_charge_dollar": 561.64, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Uhc/Secure Horizons", "plan_name": "500449", "standard_charge_dollar": 561.64, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "United Health Care/", "plan_name": "500292", "standard_charge_dollar": 634.66, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "United Healthcare", "plan_name": "750104", "standard_charge_dollar": 634.66, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "United Healthcare Ba", "plan_name": "750090", "standard_charge_dollar": 634.66, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "United Healthcare Me", "plan_name": "501310", "standard_charge_dollar": 561.64, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Windsor Mcare Extra", "plan_name": "500778", "standard_charge_dollar": 561.64, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." } ] } ] }, { "description": "Hc trauma response level 1", "code_information": [ { "code": "G0390", "type": "HCPCS" } ], "standard_charges": [ { "gross_charge": 500.00, "minimum": 400.00, "maximum": 1515.14, "setting": "both", "payers_information": [ { "payer_name": "Aarp", "plan_name": "500102", "standard_charge_dollar": 1212.12, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna", "plan_name": "700700", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna", "plan_name": "700700_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Mcare Ffs 6005", "plan_name": "700703", "standard_charge_dollar": 1212.12, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Miscellaneous", "plan_name": "700720", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Miscellaneous", "plan_name": "700720_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Ppo Hmo", "plan_name": "701720", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Ppo Hmo", "plan_name": "701720_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Ambetter 68069", "plan_name": "500516", "standard_charge_dollar": 1212.12, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Ms State Emplo", "plan_name": "401457", "standard_charge_percentage": 0.80, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Ms State Emplo", "plan_name": "401457_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Basic Pl", "plan_name": "400100", "standard_charge_percentage": 0.85, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Basic Pl", "plan_name": "400100_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Federal", "plan_name": "400110", "standard_charge_percentage": 0.85, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Federal", "plan_name": "400110_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Cigna Healthsprings Ffs", "plan_name": "500064", "standard_charge_dollar": 1212.12, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Conseco", "plan_name": "500302", "standard_charge_dollar": 1212.12, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Humana Ffs 61101", "plan_name": "500006", "standard_charge_dollar": 1212.12, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Medicare A", "plan_name": "100100", "standard_charge_dollar": 1212.12, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Medicare A", "plan_name": "100500", "standard_charge_dollar": 1212.12, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Medicare Part B Only", "plan_name": "100300", "standard_charge_dollar": 1212.12, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Medicare Railroad", "plan_name": "100103", "standard_charge_dollar": 1212.12, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Ms Physicians Care N", "plan_name": "714210", "standard_charge_dollar": 1515.14, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Peoples Hlth Ffs 72126", "plan_name": "500019", "standard_charge_dollar": 1212.12, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Uhc/Secure Horizons", "plan_name": "500449", "standard_charge_dollar": 1212.12, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "United Health Care/", "plan_name": "500292", "standard_charge_dollar": 1369.69, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "United Healthcare", "plan_name": "750104", "standard_charge_dollar": 1369.69, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "United Healthcare Ba", "plan_name": "750090", "standard_charge_dollar": 1369.69, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "United Healthcare Me", "plan_name": "501310", "standard_charge_dollar": 1212.12, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Windsor Mcare Extra", "plan_name": "500778", "standard_charge_dollar": 1212.12, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." } ] } ] }, { "description": "Trauma respons w/hosp criti", "code_information": [ { "code": "G0390", "type": "HCPCS" } ], "standard_charges": [ { "gross_charge": 500.00, "minimum": 400.00, "maximum": 1515.14, "setting": "both", "payers_information": [ { "payer_name": "Aarp", "plan_name": "500102", "standard_charge_dollar": 1212.12, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna", "plan_name": "700700", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna", "plan_name": "700700_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Mcare Ffs 6005", "plan_name": "700703", "standard_charge_dollar": 1212.12, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Miscellaneous", "plan_name": "700720", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Miscellaneous", "plan_name": "700720_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Ppo Hmo", "plan_name": "701720", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Ppo Hmo", "plan_name": "701720_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Ambetter 68069", "plan_name": "500516", "standard_charge_dollar": 1212.12, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Ms State Emplo", "plan_name": "401457", "standard_charge_percentage": 0.80, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Ms State Emplo", "plan_name": "401457_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Basic Pl", "plan_name": "400100", "standard_charge_percentage": 0.85, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Basic Pl", "plan_name": "400100_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Federal", "plan_name": "400110", "standard_charge_percentage": 0.85, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Federal", "plan_name": "400110_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Cigna Healthsprings Ffs", "plan_name": "500064", "standard_charge_dollar": 1212.12, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Conseco", "plan_name": "500302", "standard_charge_dollar": 1212.12, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Humana Ffs 61101", "plan_name": "500006", "standard_charge_dollar": 1212.12, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Medicare A", "plan_name": "100100", "standard_charge_dollar": 1212.12, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Medicare A", "plan_name": "100500", "standard_charge_dollar": 1212.12, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Medicare Part B Only", "plan_name": "100300", "standard_charge_dollar": 1212.12, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Medicare Railroad", "plan_name": "100103", "standard_charge_dollar": 1212.12, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Ms Physicians Care N", "plan_name": "714210", "standard_charge_dollar": 1515.14, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Peoples Hlth Ffs 72126", "plan_name": "500019", "standard_charge_dollar": 1212.12, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Uhc/Secure Horizons", "plan_name": "500449", "standard_charge_dollar": 1212.12, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "United Health Care/", "plan_name": "500292", "standard_charge_dollar": 1369.69, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "United Healthcare", "plan_name": "750104", "standard_charge_dollar": 1369.69, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "United Healthcare Ba", "plan_name": "750090", "standard_charge_dollar": 1369.69, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "United Healthcare Me", "plan_name": "501310", "standard_charge_dollar": 1212.12, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Windsor Mcare Extra", "plan_name": "500778", "standard_charge_dollar": 1212.12, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." } ] } ] }, { "description": "Hc hospital op clinic visit", "code_information": [ { "code": "G0463", "type": "HCPCS" } ], "standard_charges": [ { "gross_charge": 337.75, "minimum": 117.22, "maximum": 147.57, "setting": "both", "payers_information": [ { "payer_name": "Aarp", "plan_name": "500102", "standard_charge_dollar": 118.05, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna", "plan_name": "700700", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna", "plan_name": "700700_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Mcare Ffs 6005", "plan_name": "700703", "standard_charge_dollar": 118.05, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Miscellaneous", "plan_name": "700720", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Miscellaneous", "plan_name": "700720_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Ppo Hmo", "plan_name": "701720", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Ppo Hmo", "plan_name": "701720_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Ambetter 68069", "plan_name": "500516", "standard_charge_dollar": 118.05, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Ms State Emplo", "plan_name": "401457", "standard_charge_dollar": 117.22, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Ms State Emplo", "plan_name": "401457_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Basic Pl", "plan_name": "400100", "standard_charge_dollar": 117.22, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Basic Pl", "plan_name": "400100_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Federal", "plan_name": "400110", "standard_charge_dollar": 117.22, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Federal", "plan_name": "400110_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Cigna Healthsprings Ffs", "plan_name": "500064", "standard_charge_dollar": 118.05, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Conseco", "plan_name": "500302", "standard_charge_dollar": 118.05, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Humana Ffs 61101", "plan_name": "500006", "standard_charge_dollar": 118.05, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Medicare A", "plan_name": "100100", "standard_charge_dollar": 118.05, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Medicare A", "plan_name": "100500", "standard_charge_dollar": 118.05, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Medicare Part B Only", "plan_name": "100300", "standard_charge_dollar": 118.05, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Medicare Railroad", "plan_name": "100103", "standard_charge_dollar": 118.05, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Ms Physicians Care N", "plan_name": "714210", "standard_charge_dollar": 147.57, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Peoples Hlth Ffs 72126", "plan_name": "500019", "standard_charge_dollar": 118.05, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Uhc/Secure Horizons", "plan_name": "500449", "standard_charge_dollar": 118.05, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "United Health Care/", "plan_name": "500292", "standard_charge_dollar": 133.40, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "United Healthcare", "plan_name": "750104", "standard_charge_dollar": 133.40, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "United Healthcare Ba", "plan_name": "750090", "standard_charge_dollar": 133.40, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "United Healthcare Me", "plan_name": "501310", "standard_charge_dollar": 118.05, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Windsor Mcare Extra", "plan_name": "500778", "standard_charge_dollar": 118.05, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." } ] } ] }, { "description": "Hospital outpt clinic visit", "code_information": [ { "code": "G0463", "type": "HCPCS" } ], "standard_charges": [ { "gross_charge": 337.75, "minimum": 117.22, "maximum": 147.57, "setting": "both", "payers_information": [ { "payer_name": "Aarp", "plan_name": "500102", "standard_charge_dollar": 118.05, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna", "plan_name": "700700", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna", "plan_name": "700700_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Mcare Ffs 6005", "plan_name": "700703", "standard_charge_dollar": 118.05, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Miscellaneous", "plan_name": "700720", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Miscellaneous", "plan_name": "700720_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Ppo Hmo", "plan_name": "701720", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Ppo Hmo", "plan_name": "701720_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Ambetter 68069", "plan_name": "500516", "standard_charge_dollar": 118.05, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Ms State Emplo", "plan_name": "401457", "standard_charge_dollar": 117.22, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Ms State Emplo", "plan_name": "401457_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Basic Pl", "plan_name": "400100", "standard_charge_dollar": 117.22, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Basic Pl", "plan_name": "400100_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Federal", "plan_name": "400110", "standard_charge_dollar": 117.22, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Federal", "plan_name": "400110_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Cigna Healthsprings Ffs", "plan_name": "500064", "standard_charge_dollar": 118.05, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Conseco", "plan_name": "500302", "standard_charge_dollar": 118.05, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Humana Ffs 61101", "plan_name": "500006", "standard_charge_dollar": 118.05, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Medicare A", "plan_name": "100100", "standard_charge_dollar": 118.05, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Medicare A", "plan_name": "100500", "standard_charge_dollar": 118.05, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Medicare Part B Only", "plan_name": "100300", "standard_charge_dollar": 118.05, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Medicare Railroad", "plan_name": "100103", "standard_charge_dollar": 118.05, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Ms Physicians Care N", "plan_name": "714210", "standard_charge_dollar": 147.57, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Peoples Hlth Ffs 72126", "plan_name": "500019", "standard_charge_dollar": 118.05, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Uhc/Secure Horizons", "plan_name": "500449", "standard_charge_dollar": 118.05, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "United Health Care/", "plan_name": "500292", "standard_charge_dollar": 133.40, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "United Healthcare", "plan_name": "750104", "standard_charge_dollar": 133.40, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "United Healthcare Ba", "plan_name": "750090", "standard_charge_dollar": 133.40, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "United Healthcare Me", "plan_name": "501310", "standard_charge_dollar": 118.05, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Windsor Mcare Extra", "plan_name": "500778", "standard_charge_dollar": 118.05, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." } ] } ] }, { "description": "Autolog prp diab wound ulcer", "code_information": [ { "code": "G0465", "type": "HCPCS" } ], "standard_charges": [ { "gross_charge": 2791.00, "minimum": 1675.70, "maximum": 2372.35, "setting": "both", "payers_information": [ { "payer_name": "Aarp", "plan_name": "500102", "standard_charge_dollar": 1675.70, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna", "plan_name": "700700", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna", "plan_name": "700700_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Mcare Ffs 6005", "plan_name": "700703", "standard_charge_dollar": 1675.70, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Miscellaneous", "plan_name": "700720", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Miscellaneous", "plan_name": "700720_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Ppo Hmo", "plan_name": "701720", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Ppo Hmo", "plan_name": "701720_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Ambetter 68069", "plan_name": "500516", "standard_charge_dollar": 1675.70, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Ms State Emplo", "plan_name": "401457", "standard_charge_percentage": 0.80, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Ms State Emplo", "plan_name": "401457_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Basic Pl", "plan_name": "400100", "standard_charge_percentage": 0.85, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Basic Pl", "plan_name": "400100_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Federal", "plan_name": "400110", "standard_charge_percentage": 0.85, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Federal", "plan_name": "400110_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Cigna Healthsprings Ffs", "plan_name": "500064", "standard_charge_dollar": 1675.70, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Conseco", "plan_name": "500302", "standard_charge_dollar": 1675.70, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Humana Ffs 61101", "plan_name": "500006", "standard_charge_dollar": 1675.70, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Medicare A", "plan_name": "100100", "standard_charge_dollar": 1675.70, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Medicare A", "plan_name": "100500", "standard_charge_dollar": 1675.70, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Medicare Part B Only", "plan_name": "100300", "standard_charge_dollar": 1675.70, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Medicare Railroad", "plan_name": "100103", "standard_charge_dollar": 1675.70, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Ms Physicians Care N", "plan_name": "714210", "standard_charge_dollar": 2094.63, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Peoples Hlth Ffs 72126", "plan_name": "500019", "standard_charge_dollar": 1675.70, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Uhc/Secure Horizons", "plan_name": "500449", "standard_charge_dollar": 1675.70, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "United Health Care/", "plan_name": "500292", "standard_charge_dollar": 1893.54, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "United Healthcare", "plan_name": "750104", "standard_charge_dollar": 1893.54, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "United Healthcare Ba", "plan_name": "750090", "standard_charge_dollar": 1893.54, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "United Healthcare Me", "plan_name": "501310", "standard_charge_dollar": 1675.70, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Windsor Mcare Extra", "plan_name": "500778", "standard_charge_dollar": 1675.70, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." } ] } ] }, { "description": "Hc autologus prp for ulcers", "code_information": [ { "code": "G0465", "type": "HCPCS" } ], "standard_charges": [ { "gross_charge": 2791.00, "minimum": 1675.70, "maximum": 2372.35, "setting": "both", "payers_information": [ { "payer_name": "Aarp", "plan_name": "500102", "standard_charge_dollar": 1675.70, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna", "plan_name": "700700", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna", "plan_name": "700700_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Mcare Ffs 6005", "plan_name": "700703", "standard_charge_dollar": 1675.70, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Miscellaneous", "plan_name": "700720", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Miscellaneous", "plan_name": "700720_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Ppo Hmo", "plan_name": "701720", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Ppo Hmo", "plan_name": "701720_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Ambetter 68069", "plan_name": "500516", "standard_charge_dollar": 1675.70, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Ms State Emplo", "plan_name": "401457", "standard_charge_percentage": 0.80, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Ms State Emplo", "plan_name": "401457_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Basic Pl", "plan_name": "400100", "standard_charge_percentage": 0.85, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Basic Pl", "plan_name": "400100_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Federal", "plan_name": "400110", "standard_charge_percentage": 0.85, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Federal", "plan_name": "400110_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Cigna Healthsprings Ffs", "plan_name": "500064", "standard_charge_dollar": 1675.70, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Conseco", "plan_name": "500302", "standard_charge_dollar": 1675.70, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Humana Ffs 61101", "plan_name": "500006", "standard_charge_dollar": 1675.70, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Medicare A", "plan_name": "100100", "standard_charge_dollar": 1675.70, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Medicare A", "plan_name": "100500", "standard_charge_dollar": 1675.70, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Medicare Part B Only", "plan_name": "100300", "standard_charge_dollar": 1675.70, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Medicare Railroad", "plan_name": "100103", "standard_charge_dollar": 1675.70, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Ms Physicians Care N", "plan_name": "714210", "standard_charge_dollar": 2094.63, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Peoples Hlth Ffs 72126", "plan_name": "500019", "standard_charge_dollar": 1675.70, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Uhc/Secure Horizons", "plan_name": "500449", "standard_charge_dollar": 1675.70, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "United Health Care/", "plan_name": "500292", "standard_charge_dollar": 1893.54, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "United Healthcare", "plan_name": "750104", "standard_charge_dollar": 1893.54, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "United Healthcare Ba", "plan_name": "750090", "standard_charge_dollar": 1893.54, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "United Healthcare Me", "plan_name": "501310", "standard_charge_dollar": 1675.70, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Windsor Mcare Extra", "plan_name": "500778", "standard_charge_dollar": 1675.70, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." } ] } ] }, { "description": "Drug test def 1-7 classes", "code_information": [ { "code": "G0480", "type": "HCPCS" } ], "standard_charges": [ { "gross_charge": 286.00, "minimum": 119.00, "maximum": 119.00, "setting": "both", "payers_information": [ { "payer_name": "Aetna", "plan_name": "700700", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna", "plan_name": "700700_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Miscellaneous", "plan_name": "700720", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Miscellaneous", "plan_name": "700720_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Ppo Hmo", "plan_name": "701720", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Ppo Hmo", "plan_name": "701720_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Ms State Emplo", "plan_name": "401457", "standard_charge_dollar": 119.00, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Ms State Emplo", "plan_name": "401457_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Basic Pl", "plan_name": "400100", "standard_charge_dollar": 119.00, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Basic Pl", "plan_name": "400100_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Federal", "plan_name": "400110", "standard_charge_dollar": 119.00, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Federal", "plan_name": "400110_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." } ] } ] }, { "description": "Hc drug test def 1-7 classes", "code_information": [ { "code": "G0480", "type": "HCPCS" } ], "standard_charges": [ { "gross_charge": 286.00, "minimum": 119.00, "maximum": 119.00, "setting": "both", "payers_information": [ { "payer_name": "Aetna", "plan_name": "700700", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna", "plan_name": "700700_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Miscellaneous", "plan_name": "700720", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Miscellaneous", "plan_name": "700720_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Ppo Hmo", "plan_name": "701720", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Ppo Hmo", "plan_name": "701720_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Ms State Emplo", "plan_name": "401457", "standard_charge_dollar": 119.00, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Ms State Emplo", "plan_name": "401457_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Basic Pl", "plan_name": "400100", "standard_charge_dollar": 119.00, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Basic Pl", "plan_name": "400100_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Federal", "plan_name": "400110", "standard_charge_dollar": 119.00, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Federal", "plan_name": "400110_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." } ] } ] }, { "description": "Drug test def 8-14 classes", "code_information": [ { "code": "G0481", "type": "HCPCS" } ], "standard_charges": [ { "gross_charge": 391.00, "minimum": 184.00, "maximum": 184.00, "setting": "both", "payers_information": [ { "payer_name": "Aetna", "plan_name": "700700", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna", "plan_name": "700700_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Miscellaneous", "plan_name": "700720", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Miscellaneous", "plan_name": "700720_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Ppo Hmo", "plan_name": "701720", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Ppo Hmo", "plan_name": "701720_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Ms State Emplo", "plan_name": "401457", "standard_charge_dollar": 184.00, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Ms State Emplo", "plan_name": "401457_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Basic Pl", "plan_name": "400100", "standard_charge_dollar": 184.00, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Basic Pl", "plan_name": "400100_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Federal", "plan_name": "400110", "standard_charge_dollar": 184.00, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Federal", "plan_name": "400110_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." } ] } ] }, { "description": "Hc drug test def 8-14 classes", "code_information": [ { "code": "G0481", "type": "HCPCS" } ], "standard_charges": [ { "gross_charge": 391.00, "minimum": 184.00, "maximum": 184.00, "setting": "both", "payers_information": [ { "payer_name": "Aetna", "plan_name": "700700", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna", "plan_name": "700700_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Miscellaneous", "plan_name": "700720", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Miscellaneous", "plan_name": "700720_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Ppo Hmo", "plan_name": "701720", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Ppo Hmo", "plan_name": "701720_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Ms State Emplo", "plan_name": "401457", "standard_charge_dollar": 184.00, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Ms State Emplo", "plan_name": "401457_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Basic Pl", "plan_name": "400100", "standard_charge_dollar": 184.00, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Basic Pl", "plan_name": "400100_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Federal", "plan_name": "400110", "standard_charge_dollar": 184.00, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Federal", "plan_name": "400110_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." } ] } ] }, { "description": "Drug test def 15-21 classes", "code_information": [ { "code": "G0482", "type": "HCPCS" } ], "standard_charges": [ { "gross_charge": 497.00, "minimum": 249.00, "maximum": 249.00, "setting": "both", "payers_information": [ { "payer_name": "Aetna", "plan_name": "700700", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna", "plan_name": "700700_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Miscellaneous", "plan_name": "700720", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Miscellaneous", "plan_name": "700720_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Ppo Hmo", "plan_name": "701720", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Ppo Hmo", "plan_name": "701720_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Ms State Emplo", "plan_name": "401457", "standard_charge_dollar": 249.00, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Ms State Emplo", "plan_name": "401457_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Basic Pl", "plan_name": "400100", "standard_charge_dollar": 249.00, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Basic Pl", "plan_name": "400100_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Federal", "plan_name": "400110", "standard_charge_dollar": 249.00, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Federal", "plan_name": "400110_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." } ] } ] }, { "description": "Hc drug test def 15-21 classes", "code_information": [ { "code": "G0482", "type": "HCPCS" } ], "standard_charges": [ { "gross_charge": 497.00, "minimum": 249.00, "maximum": 249.00, "setting": "both", "payers_information": [ { "payer_name": "Aetna", "plan_name": "700700", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna", "plan_name": "700700_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Miscellaneous", "plan_name": "700720", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Miscellaneous", "plan_name": "700720_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Ppo Hmo", "plan_name": "701720", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Ppo Hmo", "plan_name": "701720_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Ms State Emplo", "plan_name": "401457", "standard_charge_dollar": 249.00, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Ms State Emplo", "plan_name": "401457_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Basic Pl", "plan_name": "400100", "standard_charge_dollar": 249.00, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Basic Pl", "plan_name": "400100_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Federal", "plan_name": "400110", "standard_charge_dollar": 249.00, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Federal", "plan_name": "400110_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." } ] } ] }, { "description": "Drug test def 22+ classes", "code_information": [ { "code": "G0483", "type": "HCPCS" } ], "standard_charges": [ { "gross_charge": 617.00, "minimum": 322.00, "maximum": 322.00, "setting": "both", "payers_information": [ { "payer_name": "Aetna", "plan_name": "700700", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna", "plan_name": "700700_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Miscellaneous", "plan_name": "700720", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Miscellaneous", "plan_name": "700720_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Ppo Hmo", "plan_name": "701720", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Ppo Hmo", "plan_name": "701720_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Ms State Emplo", "plan_name": "401457", "standard_charge_dollar": 322.00, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Ms State Emplo", "plan_name": "401457_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Basic Pl", "plan_name": "400100", "standard_charge_dollar": 322.00, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Basic Pl", "plan_name": "400100_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Federal", "plan_name": "400110", "standard_charge_dollar": 322.00, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Federal", "plan_name": "400110_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." } ] } ] }, { "description": "Hc drug test def 22+ classes", "code_information": [ { "code": "G0483", "type": "HCPCS" } ], "standard_charges": [ { "gross_charge": 617.00, "minimum": 322.00, "maximum": 322.00, "setting": "both", "payers_information": [ { "payer_name": "Aetna", "plan_name": "700700", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna", "plan_name": "700700_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Miscellaneous", "plan_name": "700720", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Miscellaneous", "plan_name": "700720_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Ppo Hmo", "plan_name": "701720", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Ppo Hmo", "plan_name": "701720_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Ms State Emplo", "plan_name": "401457", "standard_charge_dollar": 322.00, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Ms State Emplo", "plan_name": "401457_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Basic Pl", "plan_name": "400100", "standard_charge_dollar": 322.00, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Basic Pl", "plan_name": "400100_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Federal", "plan_name": "400110", "standard_charge_dollar": 322.00, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Federal", "plan_name": "400110_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." } ] } ] }, { "description": "Abatacept (with maltose) 250 mg intravenous solution [70287]", "drug_information": { "unit": 1.00, "type": "EA" }, "code_information": [ { "code": "J0129", "type": "HCPCS" }, { "code": "0003-2187-13", "type": "NDC" } ], "standard_charges": [ { "gross_charge": 6266.25, "minimum": 36.43, "maximum": 54.23, "setting": "both", "payers_information": [ { "payer_name": "Aarp", "plan_name": "500102", "standard_charge_dollar": 43.38, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna", "plan_name": "700700", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna", "plan_name": "700700_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Mcare Ffs 6005", "plan_name": "700703", "standard_charge_dollar": 43.38, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Miscellaneous", "plan_name": "700720", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Miscellaneous", "plan_name": "700720_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Ppo Hmo", "plan_name": "701720", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Ppo Hmo", "plan_name": "701720_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Ambetter 68069", "plan_name": "500516", "standard_charge_dollar": 43.38, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Ms State Emplo", "plan_name": "401457", "standard_charge_dollar": 36.43, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Ms State Emplo", "plan_name": "401457_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Basic Pl", "plan_name": "400100", "standard_charge_dollar": 36.43, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Basic Pl", "plan_name": "400100_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Federal", "plan_name": "400110", "standard_charge_dollar": 36.43, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Federal", "plan_name": "400110_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Cigna Healthsprings Ffs", "plan_name": "500064", "standard_charge_dollar": 43.38, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Conseco", "plan_name": "500302", "standard_charge_dollar": 43.38, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Humana Ffs 61101", "plan_name": "500006", "standard_charge_dollar": 43.38, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Medicare A", "plan_name": "100100", "standard_charge_dollar": 43.38, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Medicare A", "plan_name": "100500", "standard_charge_dollar": 43.38, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Medicare Part B Only", "plan_name": "100300", "standard_charge_dollar": 43.38, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Medicare Railroad", "plan_name": "100103", "standard_charge_dollar": 43.38, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Ms Physicians Care N", "plan_name": "714210", "standard_charge_dollar": 54.23, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Peoples Hlth Ffs 72126", "plan_name": "500019", "standard_charge_dollar": 43.38, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Uhc/Secure Horizons", "plan_name": "500449", "standard_charge_dollar": 43.38, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "United Health Care/", "plan_name": "500292", "standard_charge_dollar": 49.02, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "United Healthcare", "plan_name": "750104", "standard_charge_dollar": 49.02, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "United Healthcare Ba", "plan_name": "750090", "standard_charge_dollar": 49.02, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "United Healthcare Me", "plan_name": "501310", "standard_charge_dollar": 43.38, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Windsor Mcare Extra", "plan_name": "500778", "standard_charge_dollar": 43.38, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." } ] } ] }, { "description": "Acetaminophen 1000 mg/100 ml (10 mg/ml) intravenous solution [150591]", "drug_information": { "unit": 100.00, "type": "ML" }, "code_information": [ { "code": "J0131", "type": "HCPCS" }, { "code": "0781-3156-06", "type": "NDC" } ], "standard_charges": [ { "gross_charge": 305.06, "minimum": 0.34, "maximum": 0.34, "setting": "both", "payers_information": [ { "payer_name": "Aetna", "plan_name": "700700", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna", "plan_name": "700700_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Miscellaneous", "plan_name": "700720", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Miscellaneous", "plan_name": "700720_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Ppo Hmo", "plan_name": "701720", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Ppo Hmo", "plan_name": "701720_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Ms State Emplo", "plan_name": "401457", "standard_charge_dollar": 0.34, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Ms State Emplo", "plan_name": "401457_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Basic Pl", "plan_name": "400100", "standard_charge_dollar": 0.34, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Basic Pl", "plan_name": "400100_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Federal", "plan_name": "400110", "standard_charge_dollar": 0.34, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Federal", "plan_name": "400110_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." } ] } ] }, { "description": "Acetaminophen 1000 mg/100 ml (10 mg/ml) intravenous solution [150591]", "drug_information": { "unit": 100.00, "type": "ML" }, "code_information": [ { "code": "J0131", "type": "HCPCS" }, { "code": "24201-100-01", "type": "NDC" } ], 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"payer_name": "Bc/Bs Ms State Emplo", "plan_name": "401457_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Basic Pl", "plan_name": "400100", "standard_charge_percentage": 0.85, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Basic Pl", "plan_name": "400100_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Federal", "plan_name": "400110", "standard_charge_percentage": 0.85, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { 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"additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Ms State Emplo", "plan_name": "401457", "standard_charge_percentage": 0.80, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Ms State Emplo", "plan_name": "401457_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Basic Pl", "plan_name": "400100", "standard_charge_percentage": 0.85, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Basic Pl", "plan_name": "400100_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Federal", "plan_name": "400110", "standard_charge_percentage": 0.85, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Federal", "plan_name": "400110_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." } ] } ] }, { "description": "Adenosine (diagnostic) 3 mg/ml intravenous solution [15330]", "drug_information": { "unit": 30.00, "type": "ML" }, "code_information": [ { "code": "J0153", "type": "HCPCS" }, { "code": "17478-544-30", "type": "NDC" } ], "standard_charges": [ { "gross_charge": 638.25, "minimum": 510.60, "maximum": 542.51, "setting": "both", "payers_information": [ { "payer_name": "Aetna", "plan_name": 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"standard_charge_percentage": 0.85, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Basic Pl", "plan_name": "400100_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Federal", "plan_name": "400110", "standard_charge_percentage": 0.85, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Federal", "plan_name": "400110_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." } ] } ] }, { "description": "Sodium thiosulfate 12.5 gram/50 ml (250 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}, { "payer_name": "Aetna Mcare Ffs 6005", "plan_name": "700703", "standard_charge_dollar": 87.39, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Miscellaneous", "plan_name": "700720", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Miscellaneous", "plan_name": "700720_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Ppo Hmo", "plan_name": "701720", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Ppo Hmo", "plan_name": "701720_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Ambetter 68069", "plan_name": "500516", "standard_charge_dollar": 87.39, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Ms State Emplo", "plan_name": "401457", "standard_charge_percentage": 0.80, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Ms State Emplo", "plan_name": "401457_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Basic Pl", "plan_name": "400100", "standard_charge_percentage": 0.85, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Basic Pl", "plan_name": "400100_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Federal", "plan_name": "400110", "standard_charge_percentage": 0.85, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Federal", "plan_name": "400110_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Cigna Healthsprings Ffs", "plan_name": "500064", "standard_charge_dollar": 87.39, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Conseco", "plan_name": "500302", "standard_charge_dollar": 87.39, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Humana Ffs 61101", "plan_name": "500006", "standard_charge_dollar": 87.39, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Medicare A", "plan_name": "100100", "standard_charge_dollar": 87.39, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Medicare A", "plan_name": "100500", "standard_charge_dollar": 87.39, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Medicare Part B Only", "plan_name": "100300", "standard_charge_dollar": 87.39, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Medicare Railroad", "plan_name": "100103", "standard_charge_dollar": 87.39, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Ms Physicians Care N", "plan_name": "714210", "standard_charge_dollar": 109.24, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Peoples Hlth Ffs 72126", "plan_name": "500019", "standard_charge_dollar": 87.39, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Uhc/Secure Horizons", "plan_name": "500449", "standard_charge_dollar": 87.39, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "United Health Care/", "plan_name": "500292", "standard_charge_dollar": 98.75, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "United Healthcare", "plan_name": "750104", "standard_charge_dollar": 98.75, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "United Healthcare Ba", "plan_name": "750090", "standard_charge_dollar": 98.75, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "United Healthcare Me", "plan_name": "501310", "standard_charge_dollar": 87.39, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Windsor Mcare Extra", "plan_name": "500778", "standard_charge_dollar": 87.39, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." } ] } ] }, { "description": "Patisiran (lipid complex) 2 mg/ml intravenous solution [185060]", "drug_information": { "unit": 5.00, "type": "ML" }, "code_information": [ { "code": "J0222", "type": "HCPCS" }, { "code": "71336-1000-1", "type": "NDC" } ], "standard_charges": [ { "gross_charge": 44032.50, "minimum": 99.04, "maximum": 37427.63, "setting": "both", "payers_information": [ { "payer_name": "Aarp", "plan_name": "500102", "standard_charge_dollar": 99.04, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna", "plan_name": "700700", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna", "plan_name": "700700_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Mcare Ffs 6005", "plan_name": "700703", "standard_charge_dollar": 99.04, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Miscellaneous", "plan_name": "700720", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Miscellaneous", "plan_name": "700720_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Ppo Hmo", "plan_name": "701720", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Ppo Hmo", "plan_name": "701720_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Ambetter 68069", "plan_name": "500516", "standard_charge_dollar": 99.04, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Ms State Emplo", "plan_name": "401457", "standard_charge_percentage": 0.80, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Ms State Emplo", "plan_name": "401457_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Basic Pl", "plan_name": "400100", "standard_charge_percentage": 0.85, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Basic Pl", "plan_name": "400100_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Federal", "plan_name": "400110", "standard_charge_percentage": 0.85, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Federal", "plan_name": "400110_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Cigna Healthsprings Ffs", "plan_name": "500064", "standard_charge_dollar": 99.04, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Conseco", "plan_name": "500302", "standard_charge_dollar": 99.04, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Humana Ffs 61101", "plan_name": "500006", "standard_charge_dollar": 99.04, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Medicare A", "plan_name": "100100", "standard_charge_dollar": 99.04, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Medicare A", "plan_name": "100500", "standard_charge_dollar": 99.04, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Medicare Part B Only", "plan_name": "100300", "standard_charge_dollar": 99.04, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Medicare Railroad", "plan_name": "100103", "standard_charge_dollar": 99.04, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Ms Physicians Care N", "plan_name": "714210", "standard_charge_dollar": 123.80, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Peoples Hlth Ffs 72126", "plan_name": "500019", "standard_charge_dollar": 99.04, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Uhc/Secure Horizons", "plan_name": "500449", "standard_charge_dollar": 99.04, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "United Health Care/", "plan_name": "500292", "standard_charge_dollar": 111.92, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "United Healthcare", "plan_name": "750104", "standard_charge_dollar": 111.92, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "United Healthcare Ba", "plan_name": "750090", "standard_charge_dollar": 111.92, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "United Healthcare Me", "plan_name": "501310", "standard_charge_dollar": 99.04, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Windsor Mcare Extra", "plan_name": "500778", "standard_charge_dollar": 99.04, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." } ] } ] }, { "description": "Vutrisiran 25 mg/0.5 ml subcutaneous syringe [197128]", "drug_information": { "unit": 0.50, "type": "ML" }, "code_information": [ { "code": "J0225", "type": "HCPCS" }, { "code": "71336-1003-1", "type": "NDC" } ], "standard_charges": [ { "gross_charge": 537079.50, "minimum": 4540.32, "maximum": 456517.58, "setting": "both", "payers_information": [ { "payer_name": "Aarp", "plan_name": "500102", "standard_charge_dollar": 4540.32, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna", "plan_name": "700700", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna", "plan_name": "700700_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Mcare Ffs 6005", "plan_name": "700703", "standard_charge_dollar": 4540.32, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Miscellaneous", "plan_name": "700720", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Miscellaneous", "plan_name": "700720_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Ppo Hmo", "plan_name": "701720", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Ppo Hmo", "plan_name": "701720_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Ambetter 68069", "plan_name": "500516", "standard_charge_dollar": 4540.32, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Ms State Emplo", "plan_name": "401457", "standard_charge_percentage": 0.80, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Ms State Emplo", "plan_name": "401457_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Basic Pl", "plan_name": "400100", "standard_charge_percentage": 0.85, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Basic Pl", "plan_name": "400100_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Federal", "plan_name": "400110", "standard_charge_percentage": 0.85, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Federal", "plan_name": "400110_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Cigna Healthsprings Ffs", "plan_name": "500064", "standard_charge_dollar": 4540.32, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Conseco", "plan_name": "500302", "standard_charge_dollar": 4540.32, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Humana Ffs 61101", "plan_name": "500006", "standard_charge_dollar": 4540.32, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Medicare A", "plan_name": "100100", "standard_charge_dollar": 4540.32, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Medicare A", "plan_name": "100500", "standard_charge_dollar": 4540.32, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Medicare Part B Only", "plan_name": "100300", "standard_charge_dollar": 4540.32, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Medicare Railroad", "plan_name": "100103", "standard_charge_dollar": 4540.32, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Ms Physicians Care N", "plan_name": "714210", "standard_charge_dollar": 5675.40, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Peoples Hlth Ffs 72126", "plan_name": "500019", "standard_charge_dollar": 4540.32, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Uhc/Secure Horizons", "plan_name": "500449", "standard_charge_dollar": 4540.32, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "United Health Care/", "plan_name": "500292", "standard_charge_dollar": 5130.56, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "United Healthcare", "plan_name": "750104", "standard_charge_dollar": 5130.56, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "United Healthcare Ba", "plan_name": "750090", "standard_charge_dollar": 5130.56, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "United Healthcare Me", "plan_name": "501310", "standard_charge_dollar": 4540.32, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Windsor Mcare Extra", "plan_name": "500778", "standard_charge_dollar": 4540.32, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." } ] } ] }, { "description": "Remdesivir 100 mg intravenous powder for solution [190257]", "drug_information": { "unit": 1.00, "type": "EA" }, "code_information": [ { "code": "J0248", "type": "HCPCS" }, { "code": "61958-2901-2", "type": "NDC" } ], "standard_charges": [ { "gross_charge": 2401.23, "minimum": 6.35, "maximum": 2041.05, "setting": "both", "payers_information": [ { "payer_name": "Aarp", "plan_name": "500102", "standard_charge_dollar": 6.35, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna", "plan_name": "700700", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna", "plan_name": "700700_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Mcare Ffs 6005", "plan_name": "700703", "standard_charge_dollar": 6.35, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Miscellaneous", "plan_name": "700720", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Miscellaneous", "plan_name": "700720_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Ppo Hmo", "plan_name": "701720", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Ppo Hmo", "plan_name": "701720_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Ambetter 68069", "plan_name": "500516", "standard_charge_dollar": 6.35, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Ms State Emplo", "plan_name": "401457", "standard_charge_percentage": 0.80, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Ms State Emplo", "plan_name": "401457_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Basic Pl", "plan_name": "400100", "standard_charge_percentage": 0.85, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Basic Pl", "plan_name": "400100_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Federal", "plan_name": "400110", "standard_charge_percentage": 0.85, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Federal", "plan_name": "400110_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Cigna Healthsprings Ffs", "plan_name": "500064", "standard_charge_dollar": 6.35, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Conseco", "plan_name": "500302", "standard_charge_dollar": 6.35, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Humana Ffs 61101", "plan_name": "500006", "standard_charge_dollar": 6.35, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Medicare A", "plan_name": "100100", "standard_charge_dollar": 6.35, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Medicare A", "plan_name": "100500", "standard_charge_dollar": 6.35, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Medicare Part B Only", "plan_name": "100300", "standard_charge_dollar": 6.35, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Medicare Railroad", "plan_name": "100103", "standard_charge_dollar": 6.35, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Ms Physicians Care N", "plan_name": "714210", "standard_charge_dollar": 7.94, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Peoples Hlth Ffs 72126", "plan_name": "500019", "standard_charge_dollar": 6.35, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Uhc/Secure Horizons", "plan_name": "500449", "standard_charge_dollar": 6.35, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "United Health Care/", "plan_name": "500292", "standard_charge_dollar": 7.18, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "United Healthcare", "plan_name": "750104", "standard_charge_dollar": 7.18, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "United Healthcare Ba", "plan_name": "750090", "standard_charge_dollar": 7.18, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": 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"additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Ms State Emplo", "plan_name": "401457", "standard_charge_percentage": 0.80, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Ms State Emplo", "plan_name": "401457_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Basic Pl", "plan_name": "400100", "standard_charge_percentage": 0.85, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Basic Pl", "plan_name": "400100_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", 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[9065]", "drug_information": { "unit": 9.00, "type": "ML" }, "code_information": [ { "code": "J0282", "type": "HCPCS" }, { "code": "67457-153-09", "type": "NDC" } ], "standard_charges": [ { "gross_charge": 47.21, "minimum": 37.77, "maximum": 40.13, "setting": "both", "payers_information": [ { "payer_name": "Aetna", "plan_name": "700700", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna", "plan_name": "700700_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Miscellaneous", "plan_name": "700720", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed 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"payer_name": "Bc/Bs Ms State Emplo", "plan_name": "401457_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Basic Pl", "plan_name": "400100", "standard_charge_percentage": 0.85, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Basic Pl", "plan_name": "400100_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Federal", "plan_name": "400110", "standard_charge_percentage": 0.85, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Federal", "plan_name": "400110_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." } ] } ] }, { "description": "Amiodarone 50 mg/ml intravenous solution [9065]", "drug_information": { "unit": 18.00, "type": "ML" }, "code_information": [ { "code": "J0282", "type": "HCPCS" }, { "code": "67457-153-18", "type": "NDC" } ], "standard_charges": [ { "gross_charge": 91.17, "minimum": 72.94, "maximum": 77.49, "setting": "both", "payers_information": [ { "payer_name": "Aetna", "plan_name": "700700", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna", "plan_name": "700700_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", 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"additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Ms State Emplo", "plan_name": "401457", "standard_charge_percentage": 0.80, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Ms State Emplo", "plan_name": "401457_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Basic Pl", "plan_name": "400100", "standard_charge_percentage": 0.85, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Basic Pl", "plan_name": "400100_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Federal", "plan_name": "400110", "standard_charge_percentage": 0.85, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Federal", "plan_name": "400110_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." } ] } ] }, { "description": "Amiodarone 50 mg/ml intravenous solution [9065]", "drug_information": { "unit": 9.00, "type": "ML" }, "code_information": [ { "code": "J0282", "type": "HCPCS" }, { "code": "67457-153-99", "type": "NDC" } ], "standard_charges": [ { "gross_charge": 47.21, "minimum": 37.77, "maximum": 40.13, "setting": "both", "payers_information": [ { "payer_name": "Aetna", "plan_name": "700700", 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"standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Ppo Hmo", "plan_name": "701720_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Ms State Emplo", "plan_name": "401457", "standard_charge_percentage": 0.80, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Ms State Emplo", "plan_name": "401457_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Basic Pl", "plan_name": "400100", "standard_charge_percentage": 0.85, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Basic Pl", "plan_name": "400100_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Federal", "plan_name": "400110", "standard_charge_percentage": 0.85, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Federal", "plan_name": "400110_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." } ] } ] }, { "description": "Amiodarone 150 mg/100 ml (1.5 mg/ml) in 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allowed amounts." }, { "payer_name": "Bc/Bs Ms State Emplo", "plan_name": "401457_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Basic Pl", "plan_name": "400100", "standard_charge_percentage": 0.85, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Basic Pl", "plan_name": "400100_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Federal", "plan_name": "400110", "standard_charge_percentage": 0.85, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Federal", "plan_name": "400110_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." } ] } ] }, { "description": "Amiodarone 360 mg/200 ml (1.8 mg/ml) in dextrose iso-osmotic iv [151606]", "drug_information": { "unit": 200.00, "type": "ML" }, "code_information": [ { "code": "J0283", "type": "HCPCS" }, { "code": "43066-360-20", "type": "NDC" } ], "standard_charges": [ { "gross_charge": 287.96, "minimum": 230.37, "maximum": 244.77, "setting": "both", "payers_information": [ { "payer_name": "Aetna", "plan_name": "700700", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna", "plan_name": "700700_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Miscellaneous", "plan_name": "700720", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Miscellaneous", "plan_name": "700720_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Ppo Hmo", "plan_name": "701720", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Ppo Hmo", "plan_name": "701720_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Ms State Emplo", "plan_name": "401457", "standard_charge_percentage": 0.80, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Ms State Emplo", "plan_name": "401457_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Basic Pl", "plan_name": "400100", "standard_charge_percentage": 0.85, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Basic Pl", "plan_name": "400100_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Federal", "plan_name": "400110", "standard_charge_percentage": 0.85, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Federal", "plan_name": "400110_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." } ] } ] }, { "description": "Amphotericin b liposome 50 mg intravenous suspension [21900]", "drug_information": { "unit": 1.00, "type": "EA" }, "code_information": [ { "code": "J0289", "type": "HCPCS" }, { "code": "0469-3051-30", "type": "NDC" } ], "standard_charges": [ { "gross_charge": 1453.40, "minimum": 23.31, "maximum": 36.64, "setting": "both", "payers_information": [ { "payer_name": "Aarp", "plan_name": "500102", "standard_charge_dollar": 23.31, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna", "plan_name": "700700", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna", "plan_name": "700700_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Mcare Ffs 6005", "plan_name": "700703", "standard_charge_dollar": 23.31, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Miscellaneous", "plan_name": "700720", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Miscellaneous", "plan_name": "700720_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Ppo Hmo", "plan_name": "701720", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Ppo Hmo", "plan_name": "701720_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Ambetter 68069", "plan_name": "500516", "standard_charge_dollar": 23.31, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Ms State Emplo", "plan_name": "401457", "standard_charge_dollar": 36.64, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Ms State Emplo", "plan_name": "401457_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Basic Pl", "plan_name": "400100", "standard_charge_dollar": 36.64, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Basic Pl", "plan_name": "400100_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", 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"drug_information": { "unit": 1.00, "type": "EA" }, "code_information": [ { "code": "J0290", "type": "HCPCS" }, { "code": "0781-3400-78", "type": "NDC" } ], "standard_charges": [ { "gross_charge": 19.23, "minimum": 15.38, "maximum": 16.35, "setting": "both", "payers_information": [ { "payer_name": "Aetna", "plan_name": "700700", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna", "plan_name": "700700_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Miscellaneous", "plan_name": "700720", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { 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"standard_charge_dollar": 54.97, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Ms State Emplo", "plan_name": "401457", "standard_charge_dollar": 38.77, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Ms State Emplo", "plan_name": "401457_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Basic Pl", "plan_name": "400100", "standard_charge_dollar": 38.77, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Basic Pl", "plan_name": "400100_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Federal", "plan_name": "400110", "standard_charge_dollar": 38.77, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Federal", "plan_name": "400110_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Cigna Healthsprings Ffs", "plan_name": "500064", "standard_charge_dollar": 54.97, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Conseco", "plan_name": "500302", "standard_charge_dollar": 54.97, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Humana Ffs 61101", "plan_name": "500006", "standard_charge_dollar": 54.97, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Medicare A", "plan_name": "100100", "standard_charge_dollar": 54.97, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Medicare A", "plan_name": "100500", "standard_charge_dollar": 54.97, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Medicare Part B Only", "plan_name": "100300", "standard_charge_dollar": 54.97, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Medicare Railroad", "plan_name": "100103", "standard_charge_dollar": 54.97, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Ms Physicians Care N", "plan_name": "714210", "standard_charge_dollar": 68.71, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Peoples Hlth Ffs 72126", "plan_name": "500019", "standard_charge_dollar": 54.97, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Uhc/Secure Horizons", "plan_name": "500449", "standard_charge_dollar": 54.97, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "United Health Care/", "plan_name": "500292", "standard_charge_dollar": 62.12, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "United Healthcare", "plan_name": "750104", "standard_charge_dollar": 62.12, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "United Healthcare Ba", "plan_name": "750090", "standard_charge_dollar": 62.12, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "United Healthcare Me", "plan_name": "501310", "standard_charge_dollar": 54.97, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Windsor Mcare Extra", "plan_name": "500778", "standard_charge_dollar": 54.97, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." } ] } ] }, { "description": "Belimumab 400 mg intravenous solution [150987]", "drug_information": { "unit": 1.00, "type": "EA" }, "code_information": [ { "code": "J0490", "type": "HCPCS" }, { "code": "49401-102-01", "type": "NDC" } ], "standard_charges": [ { "gross_charge": 9162.95, "minimum": 38.77, "maximum": 68.71, "setting": "both", "payers_information": [ { "payer_name": "Aarp", "plan_name": "500102", "standard_charge_dollar": 54.97, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna", "plan_name": "700700", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna", "plan_name": "700700_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Mcare Ffs 6005", "plan_name": "700703", "standard_charge_dollar": 54.97, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Miscellaneous", "plan_name": "700720", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Miscellaneous", "plan_name": "700720_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Ppo Hmo", "plan_name": "701720", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Ppo Hmo", "plan_name": "701720_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Ambetter 68069", "plan_name": "500516", "standard_charge_dollar": 54.97, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Ms State Emplo", "plan_name": "401457", "standard_charge_dollar": 38.77, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Ms State Emplo", "plan_name": "401457_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Basic Pl", "plan_name": "400100", "standard_charge_dollar": 38.77, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Basic Pl", "plan_name": "400100_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Federal", "plan_name": "400110", "standard_charge_dollar": 38.77, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Federal", "plan_name": "400110_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Cigna Healthsprings Ffs", "plan_name": "500064", "standard_charge_dollar": 54.97, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Conseco", "plan_name": "500302", "standard_charge_dollar": 54.97, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Humana Ffs 61101", "plan_name": "500006", "standard_charge_dollar": 54.97, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Medicare A", "plan_name": "100100", "standard_charge_dollar": 54.97, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Medicare A", "plan_name": "100500", "standard_charge_dollar": 54.97, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Medicare Part B Only", "plan_name": "100300", "standard_charge_dollar": 54.97, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Medicare Railroad", "plan_name": "100103", "standard_charge_dollar": 54.97, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Ms Physicians Care N", "plan_name": "714210", "standard_charge_dollar": 68.71, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Peoples Hlth Ffs 72126", "plan_name": "500019", "standard_charge_dollar": 54.97, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Uhc/Secure Horizons", "plan_name": "500449", "standard_charge_dollar": 54.97, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "United Health Care/", "plan_name": "500292", "standard_charge_dollar": 62.12, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "United Healthcare", "plan_name": "750104", "standard_charge_dollar": 62.12, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "United Healthcare Ba", "plan_name": "750090", "standard_charge_dollar": 62.12, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "United Healthcare Me", "plan_name": "501310", "standard_charge_dollar": 54.97, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Windsor Mcare Extra", "plan_name": "500778", "standard_charge_dollar": 54.97, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." } ] } ] }, { "description": "Anifrolumab-fnia 300 mg/2 ml (150 mg/ml) intravenous solution [194718]", "drug_information": { "unit": 2.00, "type": "ML" }, "code_information": [ { "code": "J0491", "type": "HCPCS" }, { "code": "0310-3040-00", "type": "NDC" } ], "standard_charges": [ { "gross_charge": 20336.30, "minimum": 17.78, "maximum": 17285.86, "setting": "both", "payers_information": [ { "payer_name": "Aarp", "plan_name": "500102", "standard_charge_dollar": 17.78, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna", "plan_name": "700700", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna", "plan_name": "700700_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Mcare Ffs 6005", "plan_name": "700703", "standard_charge_dollar": 17.78, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Miscellaneous", "plan_name": "700720", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Miscellaneous", "plan_name": "700720_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Ppo Hmo", "plan_name": "701720", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Ppo Hmo", "plan_name": "701720_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Ambetter 68069", "plan_name": "500516", "standard_charge_dollar": 17.78, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Ms State Emplo", "plan_name": "401457", "standard_charge_percentage": 0.80, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Ms State Emplo", "plan_name": "401457_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Basic Pl", "plan_name": "400100", "standard_charge_percentage": 0.85, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Basic Pl", "plan_name": "400100_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Federal", "plan_name": "400110", "standard_charge_percentage": 0.85, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Federal", "plan_name": "400110_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Cigna Healthsprings Ffs", "plan_name": "500064", "standard_charge_dollar": 17.78, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Conseco", "plan_name": "500302", "standard_charge_dollar": 17.78, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Humana Ffs 61101", "plan_name": "500006", "standard_charge_dollar": 17.78, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Medicare A", "plan_name": "100100", "standard_charge_dollar": 17.78, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Medicare A", "plan_name": "100500", "standard_charge_dollar": 17.78, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Medicare Part B Only", "plan_name": "100300", "standard_charge_dollar": 17.78, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Medicare Railroad", "plan_name": "100103", "standard_charge_dollar": 17.78, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Ms Physicians Care N", "plan_name": "714210", "standard_charge_dollar": 22.23, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Peoples Hlth Ffs 72126", "plan_name": "500019", "standard_charge_dollar": 17.78, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Uhc/Secure Horizons", "plan_name": "500449", "standard_charge_dollar": 17.78, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "United Health Care/", "plan_name": "500292", "standard_charge_dollar": 20.09, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "United Healthcare", "plan_name": "750104", "standard_charge_dollar": 20.09, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "United Healthcare Ba", "plan_name": "750090", "standard_charge_dollar": 20.09, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "United Healthcare Me", "plan_name": "501310", "standard_charge_dollar": 17.78, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Windsor Mcare Extra", "plan_name": "500778", "standard_charge_dollar": 17.78, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." } ] } ] }, { "description": "Dicyclomine 10 mg/ml intramuscular solution [2417]", "drug_information": { "unit": 2.00, "type": "ML" }, "code_information": [ { "code": "J0500", "type": "HCPCS" }, { "code": "0641-6173-01", "type": "NDC" } ], "standard_charges": [ { "gross_charge": 258.50, "minimum": 206.80, "maximum": 219.73, "setting": "both", "payers_information": [ { "payer_name": "Aetna", "plan_name": "700700", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna", "plan_name": "700700_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Miscellaneous", "plan_name": "700720", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Miscellaneous", "plan_name": "700720_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Ppo Hmo", "plan_name": "701720", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Ppo Hmo", "plan_name": "701720_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Ms State Emplo", "plan_name": "401457", "standard_charge_percentage": 0.80, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Ms State Emplo", "plan_name": "401457_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Basic Pl", "plan_name": "400100", "standard_charge_percentage": 0.85, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Basic Pl", "plan_name": "400100_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Federal", "plan_name": "400110", "standard_charge_percentage": 0.85, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Federal", "plan_name": "400110_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." } ] } ] }, { "description": "Dicyclomine 10 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"payer_name": "Aetna Miscellaneous", "plan_name": "700720", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Miscellaneous", "plan_name": "700720_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Ppo Hmo", "plan_name": "701720", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Ppo Hmo", "plan_name": "701720_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": 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"standard_charge_dollar": 45.05, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "United Healthcare Me", "plan_name": "501310", "standard_charge_dollar": 39.87, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Windsor Mcare Extra", "plan_name": "500778", "standard_charge_dollar": 39.87, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." } ] } ] }, { "description": "Bivalirudin 250 mg intravenous powder for solution [29396]", "drug_information": { "unit": 1.00, "type": "EA" }, "code_information": [ { "code": "J0583", "type": "HCPCS" }, { "code": "63323-562-10", "type": "NDC" } ], "standard_charges": [ { "gross_charge": 803.18, "minimum": 2.04, "maximum": 2.04, "setting": "both", "payers_information": [ { "payer_name": 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"standard_charge_dollar": 2.04, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Basic Pl", "plan_name": "400100_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Federal", "plan_name": "400110", "standard_charge_dollar": 2.04, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Federal", "plan_name": "400110_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." } ] } ] }, { "description": "Bivalirudin 250 mg intravenous powder for solution [29396]", "drug_information": { 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"payer_name": "Aetna Miscellaneous", "plan_name": "700720", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Miscellaneous", "plan_name": "700720_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Ppo Hmo", "plan_name": "701720", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Ppo Hmo", "plan_name": "701720_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": 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"standard_charge_dollar": 2.04, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Federal", "plan_name": "400110_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." } ] } ] }, { "description": "Bivalirudin 250 mg intravenous powder for solution [29396]", "drug_information": { "unit": 1.00, "type": "EA" }, "code_information": [ { "code": "J0583", "type": "HCPCS" }, { "code": "71288-427-10", "type": "NDC" } ], "standard_charges": [ { "gross_charge": 803.20, "minimum": 2.04, "maximum": 2.04, "setting": "both", "payers_information": [ { "payer_name": "Aetna", "plan_name": "700700", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed 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"payer_name": "Aetna Ppo Hmo", "plan_name": "701720_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Ms State Emplo", "plan_name": "401457", "standard_charge_dollar": 2.04, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Ms State Emplo", "plan_name": "401457_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Basic Pl", "plan_name": "400100", "standard_charge_dollar": 2.04, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Basic Pl", "plan_name": 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"plan_name": "100103", "standard_charge_dollar": 6.48, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Ms Physicians Care N", "plan_name": "714210", "standard_charge_dollar": 8.10, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Peoples Hlth Ffs 72126", "plan_name": "500019", "standard_charge_dollar": 6.48, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Uhc/Secure Horizons", "plan_name": "500449", "standard_charge_dollar": 6.48, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "United Health Care/", "plan_name": "500292", "standard_charge_dollar": 7.32, "count": "0", "methodology": "fee schedule", 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"description": "Butorphanol 1 mg/ml injection solution [9333]", "drug_information": { "unit": 1.00, "type": "ML" }, "code_information": [ { "code": "J0595", "type": "HCPCS" }, { "code": "0409-1623-01", "type": "NDC" } ], "standard_charges": [ { "gross_charge": 132.84, "minimum": 106.27, "maximum": 112.91, "setting": "both", "payers_information": [ { "payer_name": "Aetna", "plan_name": "700700", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna", "plan_name": "700700_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Miscellaneous", "plan_name": "700720", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", 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"additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Federal", "plan_name": "400110_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." } ] } ] }, { "description": "Butorphanol 1 mg/ml injection solution [9333]", "drug_information": { "unit": 1.00, "type": "ML" }, "code_information": [ { "code": "J0595", "type": "HCPCS" }, { "code": "0409-1623-21", "type": "NDC" } ], "standard_charges": [ { "gross_charge": 132.84, "minimum": 106.27, "maximum": 112.91, "setting": "both", "payers_information": [ { "payer_name": "Aetna", "plan_name": "700700", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna", "plan_name": "700700_1", 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"standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Ms State Emplo", "plan_name": "401457", "standard_charge_percentage": 0.80, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Ms State Emplo", "plan_name": "401457_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Basic Pl", "plan_name": "400100", "standard_charge_percentage": 0.85, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Basic Pl", "plan_name": "400100_1", 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"additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Federal", "plan_name": "400110", "standard_charge_percentage": 0.85, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Federal", "plan_name": "400110_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." } ] } ] }, { "description": "Calcium gluconate 100 mg/ml (10 %) intravenous solution [1312]", "drug_information": { "unit": 10.00, "type": "ML" }, "code_information": [ { "code": "J0612", "type": "HCPCS" }, { "code": "63323-360-01", "type": "NDC" } ], "standard_charges": [ { "gross_charge": 50.10, "minimum": 40.08, "maximum": 42.59, "setting": "both", "payers_information": [ { "payer_name": "Aetna", "plan_name": 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"standard_charge_percentage": 0.85, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Basic Pl", "plan_name": "400100_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Federal", "plan_name": "400110", "standard_charge_percentage": 0.85, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Federal", "plan_name": "400110_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." } ] } ] }, { "description": "Calcium gluconate 100 mg/ml (10 %) intravenous solution [1312]", "drug_information": { "unit": 10.00, "type": "ML" }, "code_information": [ { "code": "J0612", "type": "HCPCS" }, { "code": "63323-360-19", "type": "NDC" } ], "standard_charges": [ { "gross_charge": 50.10, "minimum": 40.08, "maximum": 42.59, "setting": "both", "payers_information": [ { "payer_name": "Aetna", "plan_name": "700700", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna", "plan_name": "700700_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Miscellaneous", "plan_name": "700720", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Miscellaneous", "plan_name": "700720_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Ppo Hmo", "plan_name": "701720", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Ppo Hmo", "plan_name": "701720_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Ms State Emplo", "plan_name": "401457", "standard_charge_percentage": 0.80, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Ms State Emplo", "plan_name": "401457_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Basic Pl", "plan_name": "400100", "standard_charge_percentage": 0.85, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Basic Pl", "plan_name": "400100_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Federal", "plan_name": "400110", "standard_charge_percentage": 0.85, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Federal", "plan_name": "400110_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." } ] } ] }, { "description": "Calcium gluconate 1 gram/50 ml in sodium chloride iso-osm iv solution [186382]", "drug_information": { "unit": 50.00, "type": "ML" }, "code_information": [ { "code": "J0613", "type": "HCPCS" }, { "code": "44567-620-01", "type": "NDC" } ], "standard_charges": [ { "gross_charge": 175.62, "minimum": 140.50, "maximum": 149.28, "setting": "both", "payers_information": [ { "payer_name": "Aetna", "plan_name": "700700", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna", "plan_name": "700700_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Miscellaneous", "plan_name": "700720", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Miscellaneous", "plan_name": "700720_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Ppo Hmo", "plan_name": "701720", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Ppo Hmo", "plan_name": "701720_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Ms State Emplo", "plan_name": "401457", "standard_charge_percentage": 0.80, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Ms State Emplo", "plan_name": "401457_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Basic Pl", "plan_name": "400100", "standard_charge_percentage": 0.85, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Basic Pl", "plan_name": "400100_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Federal", "plan_name": "400110", "standard_charge_percentage": 0.85, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Federal", "plan_name": "400110_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." } ] } ] }, { "description": "Calcium gluconate 2 gram/100 ml in sodium chlorideiso-osm iv solution [187668]", "drug_information": { "unit": 100.00, "type": "ML" }, "code_information": [ { "code": "J0613", "type": "HCPCS" }, { "code": "44567-621-01", "type": "NDC" } ], "standard_charges": [ { "gross_charge": 269.44, "minimum": 215.55, "maximum": 229.02, "setting": "both", "payers_information": [ { "payer_name": "Aetna", "plan_name": "700700", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna", "plan_name": "700700_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Miscellaneous", "plan_name": "700720", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Miscellaneous", "plan_name": "700720_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Ppo Hmo", "plan_name": "701720", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Ppo Hmo", "plan_name": "701720_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Ms State Emplo", "plan_name": "401457", "standard_charge_percentage": 0.80, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Ms State Emplo", "plan_name": "401457_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Basic Pl", "plan_name": "400100", "standard_charge_percentage": 0.85, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Basic Pl", "plan_name": "400100_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Federal", "plan_name": "400110", "standard_charge_percentage": 0.85, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Federal", "plan_name": "400110_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." } ] } ] }, { "description": "Calcitonin (salmon) 200 unit/ml injection solution [9347]", "drug_information": { "unit": 2.00, "type": "ML" }, "code_information": [ { "code": "J0630", "type": "HCPCS" }, { "code": "42023-205-01", "type": "NDC" } ], "standard_charges": [ { "gross_charge": 12591.04, "minimum": 899.21, "maximum": 2192.15, "setting": "both", "payers_information": [ { "payer_name": "Aarp", "plan_name": "500102", "standard_charge_dollar": 899.21, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna", "plan_name": "700700", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna", "plan_name": "700700_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Mcare Ffs 6005", "plan_name": "700703", "standard_charge_dollar": 899.21, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Miscellaneous", "plan_name": "700720", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Miscellaneous", "plan_name": "700720_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Ppo Hmo", "plan_name": "701720", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Ppo Hmo", "plan_name": "701720_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Ambetter 68069", "plan_name": "500516", "standard_charge_dollar": 899.21, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Ms State Emplo", "plan_name": "401457", "standard_charge_dollar": 2192.15, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Ms State Emplo", "plan_name": "401457_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Basic Pl", "plan_name": "400100", "standard_charge_dollar": 2192.15, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Basic Pl", "plan_name": "400100_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Federal", "plan_name": "400110", "standard_charge_dollar": 2192.15, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Federal", "plan_name": "400110_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Cigna Healthsprings Ffs", "plan_name": "500064", "standard_charge_dollar": 899.21, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Conseco", "plan_name": "500302", "standard_charge_dollar": 899.21, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Humana Ffs 61101", "plan_name": "500006", "standard_charge_dollar": 899.21, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Medicare A", "plan_name": "100100", "standard_charge_dollar": 899.21, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Medicare A", "plan_name": "100500", "standard_charge_dollar": 899.21, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Medicare Part B Only", "plan_name": "100300", "standard_charge_dollar": 899.21, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Medicare Railroad", "plan_name": "100103", "standard_charge_dollar": 899.21, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Ms Physicians Care N", "plan_name": "714210", "standard_charge_dollar": 1124.01, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Peoples Hlth Ffs 72126", "plan_name": "500019", "standard_charge_dollar": 899.21, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Uhc/Secure Horizons", "plan_name": "500449", "standard_charge_dollar": 899.21, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "United Health Care/", "plan_name": "500292", "standard_charge_dollar": 1016.11, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "United Healthcare", "plan_name": "750104", "standard_charge_dollar": 1016.11, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "United Healthcare Ba", "plan_name": "750090", "standard_charge_dollar": 1016.11, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "United Healthcare Me", "plan_name": "501310", "standard_charge_dollar": 899.21, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Windsor Mcare Extra", "plan_name": "500778", "standard_charge_dollar": 899.21, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." } ] } ] }, { "description": "Calcitonin (salmon) 200 unit/ml injection solution [9347]", "drug_information": { "unit": 2.00, "type": "ML" }, "code_information": [ { "code": "J0630", "type": "HCPCS" }, { "code": "24201-400-02", "type": "NDC" } ], "standard_charges": [ { "gross_charge": 12591.04, "minimum": 899.21, "maximum": 2192.15, "setting": "both", "payers_information": [ { "payer_name": "Aarp", "plan_name": "500102", "standard_charge_dollar": 899.21, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna", "plan_name": "700700", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna", "plan_name": "700700_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Mcare Ffs 6005", "plan_name": "700703", "standard_charge_dollar": 899.21, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Miscellaneous", "plan_name": "700720", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Miscellaneous", "plan_name": "700720_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Ppo Hmo", "plan_name": "701720", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Ppo Hmo", "plan_name": "701720_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Ambetter 68069", "plan_name": "500516", "standard_charge_dollar": 899.21, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Ms State Emplo", "plan_name": "401457", "standard_charge_dollar": 2192.15, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Ms State Emplo", "plan_name": "401457_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Basic Pl", "plan_name": "400100", "standard_charge_dollar": 2192.15, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Basic Pl", "plan_name": "400100_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Federal", "plan_name": "400110", "standard_charge_dollar": 2192.15, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Federal", "plan_name": "400110_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Cigna Healthsprings Ffs", "plan_name": "500064", "standard_charge_dollar": 899.21, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Conseco", "plan_name": "500302", "standard_charge_dollar": 899.21, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Humana Ffs 61101", "plan_name": "500006", "standard_charge_dollar": 899.21, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Medicare A", "plan_name": "100100", "standard_charge_dollar": 899.21, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Medicare A", "plan_name": "100500", "standard_charge_dollar": 899.21, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Medicare Part B Only", "plan_name": "100300", "standard_charge_dollar": 899.21, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Medicare Railroad", "plan_name": "100103", "standard_charge_dollar": 899.21, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Ms Physicians Care N", "plan_name": "714210", "standard_charge_dollar": 1124.01, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Peoples Hlth Ffs 72126", "plan_name": "500019", "standard_charge_dollar": 899.21, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Uhc/Secure Horizons", "plan_name": "500449", "standard_charge_dollar": 899.21, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "United Health Care/", "plan_name": "500292", "standard_charge_dollar": 1016.11, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "United Healthcare", "plan_name": "750104", "standard_charge_dollar": 1016.11, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "United Healthcare Ba", "plan_name": "750090", "standard_charge_dollar": 1016.11, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "United Healthcare Me", "plan_name": "501310", "standard_charge_dollar": 899.21, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Windsor Mcare Extra", "plan_name": "500778", "standard_charge_dollar": 899.21, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." } ] } ] }, { "description": "Leucovorin calcium 200 mg solution for injection [15426]", "drug_information": { "unit": 1.00, "type": "EA" }, "code_information": [ { "code": "J0640", "type": "HCPCS" }, { "code": "25021-815-30", "type": "NDC" } ], "standard_charges": [ { "gross_charge": 392.50, "minimum": 314.00, "maximum": 333.63, "setting": "both", "payers_information": [ { "payer_name": "Aetna", "plan_name": "700700", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna", "plan_name": "700700_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Miscellaneous", "plan_name": "700720", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Miscellaneous", "plan_name": "700720_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Ppo Hmo", 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"additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Federal", "plan_name": "400110", "standard_charge_percentage": 0.85, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Federal", "plan_name": "400110_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." } ] } ] }, { "description": "Levothyroxine 100 mcg intravenous powder for solution [154802]", "drug_information": { "unit": 1.00, "type": "EA" }, "code_information": [ { "code": "J0650", "type": "HCPCS" }, { "code": "70860-451-10", "type": "NDC" } ], "standard_charges": [ { "gross_charge": 472.50, "minimum": 378.00, "maximum": 401.63, "setting": "both", "payers_information": [ { "payer_name": "Aetna", "plan_name": 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"standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Ppo Hmo", "plan_name": "701720_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Ms State Emplo", "plan_name": "401457", "standard_charge_percentage": 0.80, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Ms State Emplo", "plan_name": "401457_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Basic Pl", "plan_name": "400100", "standard_charge_percentage": 0.85, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Basic Pl", "plan_name": "400100_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Federal", "plan_name": "400110", "standard_charge_percentage": 0.85, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Federal", "plan_name": "400110_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." } ] } ] }, { "description": "Levothyroxine 100 mcg intravenous powder for solution [154802]", "drug_information": { "unit": 1.00, "type": "EA" }, "code_information": [ { "code": "J0650", "type": "HCPCS" }, { "code": "42023-201-01", "type": "NDC" } ], "standard_charges": [ { "gross_charge": 496.55, "minimum": 397.24, "maximum": 422.07, "setting": "both", "payers_information": [ { "payer_name": "Aetna", "plan_name": "700700", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna", "plan_name": "700700_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Miscellaneous", "plan_name": "700720", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to 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amounts." }, { "payer_name": "Bc/Bs Ms State Emplo", "plan_name": "401457_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Basic Pl", "plan_name": "400100", "standard_charge_percentage": 0.85, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Basic Pl", "plan_name": "400100_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Federal", "plan_name": "400110", "standard_charge_percentage": 0.85, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed 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"payer_name": "Bc/Bs Ms State Emplo", "plan_name": "401457_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Basic Pl", "plan_name": "400100", "standard_charge_percentage": 0.85, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Basic Pl", "plan_name": "400100_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Federal", "plan_name": "400110", "standard_charge_percentage": 0.85, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Federal", "plan_name": "400110_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Cigna Healthsprings Ffs", "plan_name": "500064", "standard_charge_dollar": 6.40, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Conseco", "plan_name": "500302", "standard_charge_dollar": 6.40, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Humana Ffs 61101", "plan_name": "500006", "standard_charge_dollar": 6.40, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Medicare A", "plan_name": "100100", "standard_charge_dollar": 6.40, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Medicare A", "plan_name": "100500", "standard_charge_dollar": 6.40, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Medicare Part B Only", "plan_name": "100300", "standard_charge_dollar": 6.40, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Medicare Railroad", "plan_name": "100103", "standard_charge_dollar": 6.40, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Ms Physicians Care N", "plan_name": "714210", "standard_charge_dollar": 8.00, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Peoples Hlth Ffs 72126", "plan_name": "500019", "standard_charge_dollar": 6.40, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Uhc/Secure Horizons", "plan_name": "500449", "standard_charge_dollar": 6.40, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "United Health Care/", "plan_name": "500292", "standard_charge_dollar": 7.23, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "United Healthcare", "plan_name": "750104", "standard_charge_dollar": 7.23, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "United Healthcare Ba", "plan_name": "750090", "standard_charge_dollar": 7.23, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "United Healthcare Me", "plan_name": "501310", "standard_charge_dollar": 6.40, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Windsor Mcare Extra", "plan_name": "500778", "standard_charge_dollar": 6.40, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." } ] } ] }, { "description": "Bupivacaine (pf) 0.75 % (7.5 mg/ml) injection solution [1224]", "drug_information": { "unit": 30.00, "type": "ML" }, "code_information": [ { "code": "J0665", "type": "HCPCS" }, { "code": "63323-472-37", "type": "NDC" } ], "standard_charges": [ { "gross_charge": 38.10, "minimum": 30.48, "maximum": 32.39, "setting": "both", "payers_information": [ { "payer_name": "Aetna", "plan_name": "700700", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna", "plan_name": "700700_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Miscellaneous", "plan_name": "700720", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Miscellaneous", "plan_name": "700720_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Ppo Hmo", "plan_name": "701720", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Ppo Hmo", "plan_name": "701720_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Ms State Emplo", "plan_name": "401457", "standard_charge_percentage": 0.80, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Ms State Emplo", "plan_name": "401457_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Basic Pl", "plan_name": "400100", "standard_charge_percentage": 0.85, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Basic Pl", "plan_name": "400100_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Federal", "plan_name": "400110", "standard_charge_percentage": 0.85, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Federal", "plan_name": "400110_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." } ] } ] }, { "description": "Bupivacaine (pf) 0.25 % (2.5 mg/ml) injection solution [1222]", "drug_information": { "unit": 10.00, "type": "ML" }, "code_information": [ { "code": "J0665", "type": "HCPCS" }, { "code": "55150-167-10", "type": "NDC" } ], "standard_charges": [ { "gross_charge": 16.75, "minimum": 13.40, "maximum": 14.24, "setting": "both", "payers_information": [ { "payer_name": "Aetna", "plan_name": "700700", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna", "plan_name": "700700_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Miscellaneous", "plan_name": "700720", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Miscellaneous", "plan_name": "700720_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Ppo Hmo", "plan_name": "701720", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Ppo Hmo", "plan_name": "701720_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Ms State Emplo", "plan_name": "401457", "standard_charge_percentage": 0.80, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Ms State Emplo", "plan_name": "401457_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Basic Pl", "plan_name": "400100", "standard_charge_percentage": 0.85, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Basic Pl", "plan_name": "400100_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Federal", "plan_name": "400110", "standard_charge_percentage": 0.85, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Federal", "plan_name": "400110_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." } ] } ] }, { "description": "Bupivacaine (pf) 0.5 % (5 mg/ml) injection solution [105640]", "drug_information": { "unit": 10.00, "type": "ML" }, "code_information": [ { "code": "J0665", "type": "HCPCS" }, { "code": "55150-169-10", "type": "NDC" } ], "standard_charges": [ { "gross_charge": 18.00, "minimum": 14.40, "maximum": 15.30, "setting": "both", "payers_information": [ { "payer_name": "Aetna", "plan_name": "700700", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna", "plan_name": "700700_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of 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amounts." }, { "payer_name": "Bc/Bs Ms State Emplo", "plan_name": "401457_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Basic Pl", "plan_name": "400100", "standard_charge_percentage": 0.85, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Basic Pl", "plan_name": "400100_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Federal", "plan_name": "400110", "standard_charge_percentage": 0.85, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Federal", "plan_name": "400110_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." } ] } ] }, { "description": "Cefazolin 500 mg solution for injection [1448]", "drug_information": { "unit": 1.00, "type": "EA" }, "code_information": [ { "code": "J0688", "type": "HCPCS" }, { "code": "0143-9923-90", "type": "NDC" } ], "standard_charges": [ { "gross_charge": 12.21, "minimum": 0.98, "maximum": 10.38, "setting": "both", "payers_information": [ { "payer_name": "Aarp", "plan_name": "500102", "standard_charge_dollar": 0.98, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna", "plan_name": "700700", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna", "plan_name": "700700_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Mcare Ffs 6005", "plan_name": "700703", "standard_charge_dollar": 0.98, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Miscellaneous", "plan_name": "700720", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Miscellaneous", "plan_name": "700720_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Ppo Hmo", "plan_name": "701720", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Ppo Hmo", "plan_name": "701720_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Ambetter 68069", "plan_name": "500516", "standard_charge_dollar": 0.98, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Ms State Emplo", "plan_name": "401457", "standard_charge_percentage": 0.80, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Ms State Emplo", "plan_name": "401457_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Basic Pl", "plan_name": "400100", "standard_charge_percentage": 0.85, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Basic Pl", "plan_name": "400100_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Federal", "plan_name": "400110", "standard_charge_percentage": 0.85, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Federal", "plan_name": "400110_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Cigna Healthsprings Ffs", "plan_name": "500064", "standard_charge_dollar": 0.98, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Conseco", "plan_name": "500302", "standard_charge_dollar": 0.98, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Humana Ffs 61101", "plan_name": "500006", "standard_charge_dollar": 0.98, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Medicare A", "plan_name": "100100", "standard_charge_dollar": 0.98, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Medicare A", "plan_name": "100500", "standard_charge_dollar": 0.98, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Medicare Part B Only", "plan_name": "100300", "standard_charge_dollar": 0.98, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Medicare Railroad", "plan_name": "100103", "standard_charge_dollar": 0.98, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Ms Physicians Care N", "plan_name": "714210", "standard_charge_dollar": 1.23, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Peoples Hlth Ffs 72126", "plan_name": "500019", "standard_charge_dollar": 0.98, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Uhc/Secure Horizons", "plan_name": "500449", "standard_charge_dollar": 0.98, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "United Health Care/", "plan_name": "500292", "standard_charge_dollar": 1.11, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "United Healthcare", "plan_name": "750104", "standard_charge_dollar": 1.11, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "United Healthcare Ba", "plan_name": "750090", "standard_charge_dollar": 1.11, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "United Healthcare Me", "plan_name": "501310", "standard_charge_dollar": 0.98, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Windsor Mcare Extra", "plan_name": "500778", "standard_charge_dollar": 0.98, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." } ] } ] }, { "description": "Cefazolin 1 gram solution for injection [1445]", "drug_information": { "unit": 1.00, "type": "EA" }, "code_information": [ { "code": "J0688", "type": "HCPCS" }, { "code": "0143-9924-90", "type": "NDC" } ], "standard_charges": [ { "gross_charge": 14.16, "minimum": 0.98, "maximum": 12.04, "setting": "both", "payers_information": [ { "payer_name": "Aarp", "plan_name": "500102", "standard_charge_dollar": 0.98, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna", "plan_name": "700700", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna", "plan_name": "700700_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Mcare Ffs 6005", "plan_name": "700703", "standard_charge_dollar": 0.98, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Miscellaneous", "plan_name": "700720", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Miscellaneous", "plan_name": "700720_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Ppo Hmo", "plan_name": "701720", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Ppo Hmo", "plan_name": "701720_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Ambetter 68069", "plan_name": "500516", "standard_charge_dollar": 0.98, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Ms State Emplo", "plan_name": "401457", "standard_charge_percentage": 0.80, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Ms State Emplo", "plan_name": "401457_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Basic Pl", "plan_name": "400100", "standard_charge_percentage": 0.85, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Basic Pl", "plan_name": "400100_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Federal", "plan_name": "400110", "standard_charge_percentage": 0.85, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Federal", "plan_name": "400110_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Cigna Healthsprings Ffs", "plan_name": "500064", "standard_charge_dollar": 0.98, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Conseco", "plan_name": "500302", "standard_charge_dollar": 0.98, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Humana Ffs 61101", "plan_name": "500006", "standard_charge_dollar": 0.98, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Medicare A", "plan_name": "100100", "standard_charge_dollar": 0.98, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Medicare A", "plan_name": "100500", "standard_charge_dollar": 0.98, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Medicare Part B Only", "plan_name": "100300", "standard_charge_dollar": 0.98, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Medicare Railroad", "plan_name": "100103", "standard_charge_dollar": 0.98, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Ms Physicians Care N", "plan_name": "714210", "standard_charge_dollar": 1.23, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Peoples Hlth Ffs 72126", "plan_name": "500019", "standard_charge_dollar": 0.98, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Uhc/Secure Horizons", "plan_name": "500449", "standard_charge_dollar": 0.98, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "United Health Care/", "plan_name": "500292", "standard_charge_dollar": 1.11, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "United Healthcare", "plan_name": "750104", "standard_charge_dollar": 1.11, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "United Healthcare Ba", "plan_name": "750090", "standard_charge_dollar": 1.11, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "United Healthcare Me", "plan_name": "501310", "standard_charge_dollar": 0.98, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Windsor Mcare Extra", "plan_name": "500778", "standard_charge_dollar": 0.98, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." } ] } ] }, { "description": "Cefazolin 1 gram/50 ml in dextrose (iso-osmotic) intravenous piggyback [25365]", "drug_information": { "unit": 1.00, "type": "EA" }, "code_information": [ { "code": "J0690", "type": "HCPCS" }, { "code": "0264-3103-11", "type": "NDC" } ], "standard_charges": [ { "gross_charge": 140.43, "minimum": 112.34, "maximum": 119.37, "setting": "both", "payers_information": [ { "payer_name": "Aetna", "plan_name": "700700", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna", "plan_name": "700700_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Miscellaneous", "plan_name": "700720", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Miscellaneous", "plan_name": "700720_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Ppo Hmo", "plan_name": "701720", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Ppo Hmo", "plan_name": "701720_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Ms State Emplo", "plan_name": "401457", "standard_charge_percentage": 0.80, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Ms State Emplo", "plan_name": "401457_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Basic Pl", "plan_name": "400100", "standard_charge_percentage": 0.85, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Basic Pl", "plan_name": "400100_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Federal", "plan_name": "400110", "standard_charge_percentage": 0.85, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Federal", "plan_name": "400110_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." } ] } ] }, { "description": "Cefazolin 2 gram/50 ml in dextrose (iso-osmotic) intravenous piggyback [155956]", "drug_information": { "unit": 1.00, "type": "EA" }, "code_information": [ { "code": "J0690", "type": "HCPCS" }, { "code": "0264-3105-11", "type": "NDC" } ], "standard_charges": [ { "gross_charge": 147.76, "minimum": 118.21, "maximum": 125.60, "setting": "both", "payers_information": [ { "payer_name": "Aetna", "plan_name": "700700", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna", "plan_name": "700700_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Miscellaneous", "plan_name": "700720", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Miscellaneous", "plan_name": "700720_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Ppo Hmo", "plan_name": "701720", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Ppo Hmo", "plan_name": "701720_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Ms State Emplo", "plan_name": "401457", "standard_charge_percentage": 0.80, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Ms State Emplo", "plan_name": "401457_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Basic Pl", "plan_name": "400100", "standard_charge_percentage": 0.85, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Basic Pl", "plan_name": "400100_1", 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"additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Ms State Emplo", "plan_name": "401457_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Basic Pl", "plan_name": "400100", "standard_charge_percentage": 0.85, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Basic Pl", "plan_name": "400100_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Federal", "plan_name": "400110", "standard_charge_percentage": 0.85, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Federal", "plan_name": "400110_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." } ] } ] }, { "description": "Cefepime 2 gram solution for injection [16371]", "drug_information": { "unit": 1.00, "type": "EA" }, "code_information": [ { "code": "J0692", "type": "HCPCS" }, { "code": "0409-9735-10", "type": "NDC" } ], "standard_charges": [ { "gross_charge": 103.45, "minimum": 82.76, "maximum": 87.93, "setting": "both", "payers_information": [ { "payer_name": "Aetna", "plan_name": "700700", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna", "plan_name": "700700_1", 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"standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Ms State Emplo", "plan_name": "401457", "standard_charge_percentage": 0.80, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Ms State Emplo", "plan_name": "401457_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Basic Pl", "plan_name": "400100", "standard_charge_percentage": 0.85, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Basic Pl", "plan_name": "400100_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Federal", "plan_name": "400110", "standard_charge_percentage": 0.85, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Federal", "plan_name": "400110_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." } ] } ] }, { "description": "Cefoxitin 1 gram/50 ml in dextrose iso-osmotic intravenous piggyback [91039]", "drug_information": { "unit": 1.00, "type": "EA" }, "code_information": [ { "code": "J0694", "type": "HCPCS" }, { "code": "0264-3123-11", "type": "NDC" } ], "standard_charges": [ { "gross_charge": 166.08, 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"Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Ppo Hmo", "plan_name": "701720", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Ppo Hmo", "plan_name": "701720_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Ms State Emplo", "plan_name": "401457", "standard_charge_percentage": 0.80, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Ms State Emplo", "plan_name": "401457_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Basic Pl", "plan_name": "400100", "standard_charge_percentage": 0.85, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Basic Pl", "plan_name": "400100_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Federal", "plan_name": "400110", "standard_charge_percentage": 0.85, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Federal", "plan_name": "400110_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." } ] } ] }, { "description": "Cefoxitin 2 gram/50 ml in dextrose(iso-osmotic) intravenous piggyback [91040]", "drug_information": { "unit": 1.00, "type": "EA" }, "code_information": [ { "code": "J0694", "type": "HCPCS" }, { "code": "0264-3125-11", "type": "NDC" } ], "standard_charges": [ { "gross_charge": 231.66, "minimum": 185.33, "maximum": 196.91, "setting": "both", "payers_information": [ { "payer_name": "Aetna", "plan_name": "700700", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna", "plan_name": "700700_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Miscellaneous", "plan_name": "700720", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Miscellaneous", "plan_name": "700720_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Ppo Hmo", "plan_name": "701720", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Ppo Hmo", "plan_name": "701720_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Ms State Emplo", "plan_name": "401457", "standard_charge_percentage": 0.80, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Ms State Emplo", "plan_name": "401457_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Basic Pl", "plan_name": "400100", "standard_charge_percentage": 0.85, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Basic Pl", "plan_name": "400100_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Federal", "plan_name": "400110", "standard_charge_percentage": 0.85, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Federal", "plan_name": "400110_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." } ] } ] }, { "description": "Cefoxitin 2 gram intravenous solution [9463]", "drug_information": { "unit": 1.00, "type": "EA" }, "code_information": [ { "code": "J0694", "type": "HCPCS" }, { "code": "25021-110-20", "type": "NDC" } ], "standard_charges": [ { "gross_charge": 60.00, "minimum": 48.00, "maximum": 51.00, "setting": "both", "payers_information": [ { "payer_name": "Aetna", "plan_name": "700700", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna", "plan_name": "700700_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Miscellaneous", "plan_name": "700720", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Miscellaneous", "plan_name": "700720_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Ppo Hmo", "plan_name": "701720", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Ppo Hmo", "plan_name": "701720_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Ms State Emplo", "plan_name": "401457", "standard_charge_percentage": 0.80, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Ms State Emplo", "plan_name": "401457_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Basic Pl", "plan_name": "400100", "standard_charge_percentage": 0.85, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Basic Pl", "plan_name": "400100_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Federal", "plan_name": "400110", "standard_charge_percentage": 0.85, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Federal", "plan_name": "400110_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." } ] } ] }, { "description": "Cefoxitin 1 gram intravenous solution [9461]", "drug_information": { "unit": 1.00, "type": "EA" }, "code_information": [ { "code": "J0694", "type": "HCPCS" }, { "code": "44567-245-25", "type": "NDC" } ], "standard_charges": [ { "gross_charge": 99.00, "minimum": 79.20, "maximum": 84.15, "setting": "both", "payers_information": [ { "payer_name": "Aetna", "plan_name": "700700", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna", "plan_name": "700700_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Miscellaneous", "plan_name": "700720", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Miscellaneous", "plan_name": "700720_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Ppo Hmo", "plan_name": "701720", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Ppo Hmo", "plan_name": "701720_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Ms State Emplo", "plan_name": "401457", "standard_charge_percentage": 0.80, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Ms State Emplo", "plan_name": "401457_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Basic Pl", "plan_name": "400100", "standard_charge_percentage": 0.85, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Basic Pl", "plan_name": "400100_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Federal", "plan_name": "400110", "standard_charge_percentage": 0.85, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Federal", "plan_name": "400110_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." } ] } ] }, { "description": "Ceftolozane-tazobactam 1.5 gram intravenous solution [168664]", "drug_information": { "unit": 1.00, "type": "EA" }, "code_information": [ { "code": "J0695", "type": "HCPCS" }, { "code": "67919-030-01", "type": "NDC" } ], "standard_charges": [ { "gross_charge": 790.40, "minimum": 4.38, "maximum": 10.05, "setting": "both", "payers_information": [ { "payer_name": "Aarp", "plan_name": "500102", "standard_charge_dollar": 8.04, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna", "plan_name": "700700", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna", "plan_name": "700700_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Mcare Ffs 6005", "plan_name": "700703", "standard_charge_dollar": 8.04, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Miscellaneous", "plan_name": "700720", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Miscellaneous", "plan_name": "700720_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Ppo Hmo", "plan_name": "701720", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Ppo Hmo", "plan_name": "701720_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Ambetter 68069", "plan_name": "500516", "standard_charge_dollar": 8.04, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Ms State Emplo", "plan_name": "401457", "standard_charge_dollar": 4.38, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Ms State Emplo", "plan_name": "401457_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Basic Pl", "plan_name": "400100", "standard_charge_dollar": 4.38, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Basic Pl", "plan_name": "400100_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Federal", "plan_name": "400110", "standard_charge_dollar": 4.38, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Federal", "plan_name": "400110_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Cigna Healthsprings Ffs", "plan_name": "500064", "standard_charge_dollar": 8.04, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Conseco", "plan_name": "500302", "standard_charge_dollar": 8.04, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Humana Ffs 61101", "plan_name": "500006", "standard_charge_dollar": 8.04, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Medicare A", "plan_name": "100100", "standard_charge_dollar": 8.04, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Medicare A", "plan_name": "100500", "standard_charge_dollar": 8.04, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Medicare Part B Only", "plan_name": "100300", "standard_charge_dollar": 8.04, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Medicare Railroad", "plan_name": "100103", "standard_charge_dollar": 8.04, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Ms Physicians Care N", "plan_name": "714210", "standard_charge_dollar": 10.05, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Peoples Hlth Ffs 72126", "plan_name": "500019", "standard_charge_dollar": 8.04, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Uhc/Secure Horizons", "plan_name": "500449", "standard_charge_dollar": 8.04, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "United Health Care/", "plan_name": "500292", "standard_charge_dollar": 9.09, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "United Healthcare", "plan_name": "750104", "standard_charge_dollar": 9.09, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "United Healthcare Ba", "plan_name": "750090", "standard_charge_dollar": 9.09, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "United Healthcare Me", "plan_name": "501310", "standard_charge_dollar": 8.04, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Windsor Mcare Extra", "plan_name": "500778", "standard_charge_dollar": 8.04, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." } ] } ] }, { "description": "Ceftriaxone 500 mg solution for injection [9490]", "drug_information": { "unit": 1.00, "type": "EA" }, "code_information": [ { "code": "J0696", "type": "HCPCS" }, { "code": "44567-700-25", "type": "NDC" } ], "standard_charges": [ { "gross_charge": 13.42, "minimum": 10.74, "maximum": 11.41, "setting": "both", "payers_information": [ { "payer_name": "Aetna", "plan_name": "700700", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna", "plan_name": "700700_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Miscellaneous", "plan_name": "700720", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Miscellaneous", "plan_name": "700720_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Ppo Hmo", "plan_name": "701720", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Ppo Hmo", "plan_name": "701720_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Ms State Emplo", "plan_name": "401457", "standard_charge_percentage": 0.80, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Ms State Emplo", "plan_name": "401457_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Basic Pl", "plan_name": "400100", "standard_charge_percentage": 0.85, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Basic Pl", "plan_name": "400100_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Federal", "plan_name": "400110", "standard_charge_percentage": 0.85, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Federal", "plan_name": "400110_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." } ] } ] }, { "description": "Ceftriaxone 1 gram/50 ml in dextrose (iso-osmot) intravenous piggyback [9492]", "drug_information": { "unit": 1.00, "type": "EA" }, "code_information": [ { "code": "J0696", "type": "HCPCS" }, { "code": "0264-3153-11", "type": "NDC" } ], "standard_charges": [ { "gross_charge": 169.74, "minimum": 135.79, "maximum": 144.28, "setting": "both", "payers_information": [ { "payer_name": "Aetna", "plan_name": "700700", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna", "plan_name": "700700_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Miscellaneous", "plan_name": "700720", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Miscellaneous", "plan_name": "700720_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Ppo Hmo", "plan_name": "701720", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Ppo Hmo", "plan_name": "701720_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Ms State Emplo", "plan_name": "401457", "standard_charge_percentage": 0.80, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Ms State Emplo", "plan_name": "401457_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Basic Pl", "plan_name": "400100", "standard_charge_percentage": 0.85, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Basic Pl", "plan_name": "400100_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Federal", "plan_name": "400110", "standard_charge_percentage": 0.85, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Federal", "plan_name": "400110_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." } ] } ] }, { 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"standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Federal", "plan_name": "400110", "standard_charge_percentage": 0.85, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Federal", "plan_name": "400110_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." } ] } ] }, { "description": "Ceftriaxone 1 gram solution for injection [9487]", "drug_information": { "unit": 1.00, "type": "EA" }, "code_information": [ { "code": "J0696", "type": "HCPCS" }, { "code": "0781-3208-85", "type": "NDC" } ], "standard_charges": [ { "gross_charge": 26.95, "minimum": 21.56, "maximum": 22.91, 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amounts." }, { "payer_name": "Aetna Ppo Hmo", "plan_name": "701720", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Ppo Hmo", "plan_name": "701720_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Ms State Emplo", "plan_name": "401457", "standard_charge_percentage": 0.80, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Ms State Emplo", "plan_name": "401457_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Basic Pl", "plan_name": "400100", "standard_charge_percentage": 0.85, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Basic Pl", "plan_name": "400100_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Federal", "plan_name": "400110", "standard_charge_percentage": 0.85, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Federal", "plan_name": "400110_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." } ] } ] }, { "description": "Ceftriaxone 1 gram solution for injection [9487]", "drug_information": { "unit": 1.00, "type": "EA" }, "code_information": [ { "code": "J0696", "type": "HCPCS" }, { "code": "0781-3208-95", "type": "NDC" } ], "standard_charges": [ { "gross_charge": 40.94, "minimum": 32.75, "maximum": 34.80, "setting": "both", "payers_information": [ { "payer_name": "Aetna", "plan_name": "700700", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna", "plan_name": "700700_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Miscellaneous", "plan_name": "700720", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", 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"additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Ms State Emplo", "plan_name": "401457_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Basic Pl", "plan_name": "400100", "standard_charge_percentage": 0.85, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Basic Pl", "plan_name": "400100_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Federal", "plan_name": "400110", "standard_charge_percentage": 0.85, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Federal", "plan_name": "400110_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." } ] } ] }, { "description": "Cefiderocol 1 gram intravenous solution [189702]", "drug_information": { "unit": 1.00, "type": "EA" }, "code_information": [ { "code": "J0699", "type": "HCPCS" }, { "code": "59630-266-01", "type": "NDC" } ], "standard_charges": [ { "gross_charge": 1033.06, "minimum": 2.28, "maximum": 878.10, "setting": "both", "payers_information": [ { "payer_name": "Aarp", "plan_name": "500102", "standard_charge_dollar": 2.28, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna", "plan_name": "700700", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna", "plan_name": "700700_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Mcare Ffs 6005", "plan_name": "700703", "standard_charge_dollar": 2.28, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Miscellaneous", "plan_name": "700720", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Miscellaneous", "plan_name": "700720_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total 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"Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Ms State Emplo", "plan_name": "401457_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Basic Pl", "plan_name": "400100", "standard_charge_percentage": 0.85, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Basic Pl", "plan_name": "400100_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Federal", "plan_name": "400110", "standard_charge_percentage": 0.85, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Federal", "plan_name": "400110_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Cigna Healthsprings Ffs", "plan_name": "500064", "standard_charge_dollar": 2.28, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Conseco", "plan_name": "500302", "standard_charge_dollar": 2.28, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Humana Ffs 61101", "plan_name": "500006", "standard_charge_dollar": 2.28, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Medicare A", "plan_name": "100100", "standard_charge_dollar": 2.28, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Medicare A", "plan_name": "100500", "standard_charge_dollar": 2.28, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Medicare Part B Only", "plan_name": "100300", "standard_charge_dollar": 2.28, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Medicare Railroad", "plan_name": "100103", "standard_charge_dollar": 2.28, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Ms Physicians Care N", "plan_name": "714210", "standard_charge_dollar": 2.85, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Peoples Hlth Ffs 72126", "plan_name": "500019", "standard_charge_dollar": 2.28, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Uhc/Secure Horizons", "plan_name": "500449", "standard_charge_dollar": 2.28, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "United Health Care/", "plan_name": "500292", "standard_charge_dollar": 2.58, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "United Healthcare", "plan_name": "750104", "standard_charge_dollar": 2.58, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "United Healthcare Ba", "plan_name": "750090", "standard_charge_dollar": 2.58, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "United Healthcare Me", "plan_name": "501310", "standard_charge_dollar": 2.28, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Windsor Mcare Extra", "plan_name": "500778", "standard_charge_dollar": 2.28, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." } ] } ] }, { "description": "Cefiderocol 1 gram intravenous solution [189702]", "drug_information": { "unit": 1.00, "type": "EA" }, "code_information": [ { "code": "J0699", "type": "HCPCS" }, { "code": "59630-266-10", "type": "NDC" } ], "standard_charges": [ { "gross_charge": 1033.06, "minimum": 2.28, "maximum": 878.10, "setting": "both", "payers_information": [ { "payer_name": "Aarp", "plan_name": "500102", "standard_charge_dollar": 2.28, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna", "plan_name": "700700", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna", "plan_name": "700700_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Mcare Ffs 6005", "plan_name": "700703", "standard_charge_dollar": 2.28, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Miscellaneous", "plan_name": "700720", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Miscellaneous", "plan_name": "700720_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Ppo Hmo", "plan_name": "701720", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Ppo Hmo", "plan_name": "701720_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Ambetter 68069", "plan_name": "500516", "standard_charge_dollar": 2.28, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Ms State Emplo", "plan_name": "401457", "standard_charge_percentage": 0.80, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Ms State Emplo", "plan_name": "401457_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Basic Pl", "plan_name": "400100", "standard_charge_percentage": 0.85, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Basic Pl", "plan_name": "400100_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Federal", "plan_name": "400110", "standard_charge_percentage": 0.85, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Federal", "plan_name": "400110_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Cigna Healthsprings Ffs", "plan_name": "500064", "standard_charge_dollar": 2.28, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Conseco", "plan_name": "500302", "standard_charge_dollar": 2.28, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Humana Ffs 61101", "plan_name": "500006", "standard_charge_dollar": 2.28, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Medicare A", "plan_name": "100100", "standard_charge_dollar": 2.28, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Medicare A", "plan_name": "100500", "standard_charge_dollar": 2.28, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Medicare Part B Only", "plan_name": "100300", "standard_charge_dollar": 2.28, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Medicare Railroad", "plan_name": "100103", "standard_charge_dollar": 2.28, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Ms Physicians Care N", "plan_name": "714210", "standard_charge_dollar": 2.85, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Peoples Hlth Ffs 72126", "plan_name": "500019", "standard_charge_dollar": 2.28, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Uhc/Secure Horizons", "plan_name": "500449", "standard_charge_dollar": 2.28, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "United Health Care/", "plan_name": "500292", "standard_charge_dollar": 2.58, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "United Healthcare", "plan_name": "750104", "standard_charge_dollar": 2.58, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "United Healthcare Ba", "plan_name": "750090", "standard_charge_dollar": 2.58, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "United Healthcare Me", "plan_name": "501310", "standard_charge_dollar": 2.28, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Windsor Mcare Extra", "plan_name": "500778", "standard_charge_dollar": 2.28, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." } ] } ] }, { "description": "Betamethasone acetate and sodium phos 6 mg/ml suspension for injection [9266]", "drug_information": { "unit": 5.00, "type": "ML" }, "code_information": [ { "code": "J0702", "type": "HCPCS" }, { "code": "51754-5060-1", "type": "NDC" } ], "standard_charges": [ { "gross_charge": 200.00, "minimum": 160.00, "maximum": 170.00, "setting": "both", "payers_information": [ { "payer_name": "Aetna", "plan_name": "700700", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna", "plan_name": "700700_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Miscellaneous", "plan_name": "700720", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Miscellaneous", "plan_name": "700720_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Ppo Hmo", "plan_name": "701720", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Ppo Hmo", "plan_name": "701720_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Ms State Emplo", "plan_name": "401457", "standard_charge_percentage": 0.80, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Ms State Emplo", "plan_name": "401457_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Basic Pl", "plan_name": "400100", "standard_charge_percentage": 0.85, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Basic Pl", "plan_name": "400100_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Federal", "plan_name": "400110", "standard_charge_percentage": 0.85, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Federal", "plan_name": "400110_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." } ] } ] }, { "description": "Betamethasone acetate and sodium phos 6 mg/ml suspension for injection [9266]", "drug_information": { "unit": 5.00, "type": "ML" }, "code_information": [ { "code": "J0702", "type": "HCPCS" }, { "code": "0517-0720-01", "type": "NDC" } ], "standard_charges": [ { "gross_charge": 275.20, "minimum": 220.16, "maximum": 233.92, "setting": "both", "payers_information": [ { "payer_name": "Aetna", "plan_name": "700700", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna", "plan_name": "700700_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Miscellaneous", "plan_name": "700720", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Miscellaneous", "plan_name": "700720_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Ppo Hmo", "plan_name": "701720", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Ppo Hmo", "plan_name": "701720_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Ms State Emplo", "plan_name": "401457", "standard_charge_percentage": 0.80, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Ms State Emplo", "plan_name": "401457_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Basic Pl", "plan_name": "400100", "standard_charge_percentage": 0.85, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Basic Pl", "plan_name": "400100_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Federal", "plan_name": "400110", "standard_charge_percentage": 0.85, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Federal", "plan_name": "400110_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." } ] } ] }, { "description": "Betamethasone acetate and sodium phos 6 mg/ml suspension for injection [9266]", "drug_information": { "unit": 5.00, "type": "ML" }, "code_information": [ { "code": "J0702", "type": "HCPCS" }, { "code": "78206-118-01", "type": "NDC" } ], "standard_charges": [ { "gross_charge": 195.55, "minimum": 156.44, "maximum": 166.22, "setting": "both", "payers_information": [ { "payer_name": "Aetna", "plan_name": "700700", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna", "plan_name": "700700_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Miscellaneous", "plan_name": "700720", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Miscellaneous", "plan_name": "700720_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Ppo Hmo", "plan_name": "701720", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Ppo Hmo", "plan_name": "701720_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Ms State Emplo", "plan_name": "401457", "standard_charge_percentage": 0.80, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Ms State Emplo", "plan_name": "401457_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Basic Pl", "plan_name": "400100", "standard_charge_percentage": 0.85, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Basic Pl", "plan_name": "400100_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Federal", "plan_name": "400110", "standard_charge_percentage": 0.85, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Federal", "plan_name": "400110_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." } ] } ] }, { "description": "Cefepime 1 gram/50 ml in dextrose 5 % intravenous piggyback [105551]", "drug_information": { "unit": 1.00, "type": "EA" }, "code_information": [ { "code": "J0703", "type": "HCPCS" }, { "code": "0264-3193-11", "type": "NDC" } ], "standard_charges": [ { "gross_charge": 169.74, "minimum": 135.79, "maximum": 144.28, "setting": "both", "payers_information": [ { "payer_name": "Aetna", "plan_name": "700700", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna", "plan_name": "700700_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Miscellaneous", "plan_name": "700720", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Miscellaneous", "plan_name": "700720_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Ppo Hmo", "plan_name": "701720", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Ppo Hmo", "plan_name": "701720_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Ms State Emplo", "plan_name": "401457", "standard_charge_percentage": 0.80, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Ms State Emplo", "plan_name": "401457_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Basic Pl", "plan_name": "400100", "standard_charge_percentage": 0.85, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Basic Pl", "plan_name": "400100_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Federal", "plan_name": "400110", "standard_charge_percentage": 0.85, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Federal", "plan_name": "400110_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." } ] } ] }, { "description": "Ceftaroline fosamil 400 mg intravenous solution [107670]", "drug_information": { "unit": 1.00, "type": "EA" }, "code_information": [ { "code": "J0712", "type": "HCPCS" }, { "code": "0456-0400-01", "type": "NDC" } ], "standard_charges": [ { "gross_charge": 1177.33, "minimum": 3.66, "maximum": 4.99, "setting": "both", "payers_information": [ { "payer_name": "Aarp", "plan_name": "500102", "standard_charge_dollar": 3.99, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna", "plan_name": "700700", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna", "plan_name": "700700_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Mcare Ffs 6005", "plan_name": "700703", "standard_charge_dollar": 3.99, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Miscellaneous", "plan_name": "700720", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Miscellaneous", "plan_name": "700720_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Ppo Hmo", "plan_name": "701720", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Ppo Hmo", "plan_name": "701720_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Ambetter 68069", "plan_name": "500516", "standard_charge_dollar": 3.99, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Ms State Emplo", "plan_name": "401457", "standard_charge_dollar": 3.66, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Ms State Emplo", "plan_name": "401457_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Basic Pl", "plan_name": "400100", "standard_charge_dollar": 3.66, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Basic Pl", "plan_name": "400100_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Federal", "plan_name": "400110", "standard_charge_dollar": 3.66, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Federal", "plan_name": "400110_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Cigna Healthsprings Ffs", "plan_name": "500064", "standard_charge_dollar": 3.99, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Conseco", "plan_name": "500302", "standard_charge_dollar": 3.99, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Humana Ffs 61101", "plan_name": "500006", "standard_charge_dollar": 3.99, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Medicare A", "plan_name": "100100", "standard_charge_dollar": 3.99, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Medicare A", "plan_name": "100500", "standard_charge_dollar": 3.99, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Medicare Part B Only", "plan_name": "100300", "standard_charge_dollar": 3.99, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Medicare Railroad", "plan_name": "100103", "standard_charge_dollar": 3.99, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Ms Physicians Care N", "plan_name": "714210", "standard_charge_dollar": 4.99, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Peoples Hlth Ffs 72126", "plan_name": "500019", "standard_charge_dollar": 3.99, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Uhc/Secure Horizons", "plan_name": "500449", "standard_charge_dollar": 3.99, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "United Health Care/", "plan_name": "500292", "standard_charge_dollar": 4.51, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "United Healthcare", "plan_name": "750104", "standard_charge_dollar": 4.51, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "United Healthcare Ba", "plan_name": "750090", "standard_charge_dollar": 4.51, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "United Healthcare Me", "plan_name": "501310", "standard_charge_dollar": 3.99, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Windsor Mcare Extra", "plan_name": "500778", "standard_charge_dollar": 3.99, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." } ] } ] }, { "description": "Ceftaroline fosamil 400 mg intravenous solution [107670]", "drug_information": { "unit": 1.00, "type": "EA" }, "code_information": [ { "code": "J0712", "type": "HCPCS" }, { "code": "0456-0400-10", "type": "NDC" } ], "standard_charges": [ { "gross_charge": 1177.33, "minimum": 3.66, "maximum": 4.99, "setting": "both", "payers_information": [ { "payer_name": "Aarp", "plan_name": "500102", "standard_charge_dollar": 3.99, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna", "plan_name": "700700", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna", "plan_name": "700700_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Mcare Ffs 6005", "plan_name": "700703", "standard_charge_dollar": 3.99, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Miscellaneous", "plan_name": "700720", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Miscellaneous", "plan_name": "700720_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Ppo Hmo", "plan_name": "701720", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Ppo Hmo", "plan_name": "701720_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Ambetter 68069", "plan_name": "500516", "standard_charge_dollar": 3.99, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Ms State Emplo", "plan_name": "401457", "standard_charge_dollar": 3.66, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Ms State Emplo", "plan_name": "401457_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Basic Pl", "plan_name": "400100", "standard_charge_dollar": 3.66, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Basic Pl", "plan_name": "400100_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Federal", "plan_name": "400110", "standard_charge_dollar": 3.66, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Federal", "plan_name": "400110_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Cigna Healthsprings Ffs", "plan_name": "500064", "standard_charge_dollar": 3.99, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Conseco", "plan_name": "500302", "standard_charge_dollar": 3.99, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Humana Ffs 61101", "plan_name": "500006", "standard_charge_dollar": 3.99, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Medicare A", "plan_name": "100100", "standard_charge_dollar": 3.99, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Medicare A", "plan_name": "100500", "standard_charge_dollar": 3.99, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Medicare Part B Only", "plan_name": "100300", "standard_charge_dollar": 3.99, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Medicare Railroad", "plan_name": "100103", "standard_charge_dollar": 3.99, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Ms Physicians Care N", "plan_name": "714210", "standard_charge_dollar": 4.99, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Peoples Hlth Ffs 72126", "plan_name": "500019", "standard_charge_dollar": 3.99, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Uhc/Secure Horizons", "plan_name": "500449", "standard_charge_dollar": 3.99, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "United Health Care/", "plan_name": "500292", "standard_charge_dollar": 4.51, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "United Healthcare", "plan_name": "750104", "standard_charge_dollar": 4.51, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "United Healthcare Ba", "plan_name": "750090", "standard_charge_dollar": 4.51, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "United Healthcare Me", "plan_name": "501310", "standard_charge_dollar": 3.99, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Windsor Mcare Extra", "plan_name": "500778", "standard_charge_dollar": 3.99, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." } ] } ] }, { "description": "Ceftaroline fosamil 600 mg intravenous solution [107671]", "drug_information": { "unit": 1.00, "type": "EA" }, "code_information": [ { "code": "J0712", "type": "HCPCS" }, { "code": "0456-0600-01", "type": "NDC" } ], "standard_charges": [ { "gross_charge": 1153.18, "minimum": 3.66, "maximum": 4.99, "setting": "both", "payers_information": [ { "payer_name": "Aarp", "plan_name": "500102", "standard_charge_dollar": 3.99, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna", "plan_name": "700700", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna", "plan_name": "700700_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Mcare Ffs 6005", "plan_name": "700703", "standard_charge_dollar": 3.99, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Miscellaneous", "plan_name": "700720", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Miscellaneous", "plan_name": "700720_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Ppo Hmo", "plan_name": "701720", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Ppo Hmo", "plan_name": "701720_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Ambetter 68069", "plan_name": "500516", "standard_charge_dollar": 3.99, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Ms State Emplo", "plan_name": "401457", "standard_charge_dollar": 3.66, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Ms State Emplo", "plan_name": "401457_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Basic Pl", "plan_name": "400100", "standard_charge_dollar": 3.66, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Basic Pl", "plan_name": "400100_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Federal", "plan_name": "400110", "standard_charge_dollar": 3.66, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Federal", "plan_name": "400110_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Cigna Healthsprings Ffs", "plan_name": "500064", "standard_charge_dollar": 3.99, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Conseco", "plan_name": "500302", "standard_charge_dollar": 3.99, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Humana Ffs 61101", "plan_name": "500006", "standard_charge_dollar": 3.99, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Medicare A", "plan_name": "100100", "standard_charge_dollar": 3.99, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Medicare A", "plan_name": "100500", "standard_charge_dollar": 3.99, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Medicare Part B Only", "plan_name": "100300", "standard_charge_dollar": 3.99, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Medicare Railroad", "plan_name": "100103", "standard_charge_dollar": 3.99, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Ms Physicians Care N", "plan_name": "714210", "standard_charge_dollar": 4.99, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Peoples Hlth Ffs 72126", "plan_name": "500019", "standard_charge_dollar": 3.99, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Uhc/Secure Horizons", "plan_name": "500449", "standard_charge_dollar": 3.99, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "United Health Care/", "plan_name": "500292", "standard_charge_dollar": 4.51, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "United Healthcare", "plan_name": "750104", "standard_charge_dollar": 4.51, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "United Healthcare Ba", "plan_name": "750090", "standard_charge_dollar": 4.51, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "United Healthcare Me", "plan_name": "501310", "standard_charge_dollar": 3.99, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Windsor Mcare Extra", "plan_name": "500778", "standard_charge_dollar": 3.99, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." } ] } ] }, { "description": "Ceftaroline fosamil 600 mg intravenous solution [107671]", "drug_information": { "unit": 1.00, "type": "EA" }, "code_information": [ { "code": "J0712", "type": "HCPCS" }, { "code": "0456-0600-10", "type": "NDC" } ], "standard_charges": [ { "gross_charge": 1153.18, "minimum": 3.66, "maximum": 4.99, "setting": "both", "payers_information": [ { "payer_name": "Aarp", "plan_name": "500102", "standard_charge_dollar": 3.99, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna", "plan_name": "700700", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna", "plan_name": "700700_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Mcare Ffs 6005", "plan_name": "700703", "standard_charge_dollar": 3.99, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Miscellaneous", "plan_name": "700720", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Miscellaneous", "plan_name": "700720_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Ppo Hmo", "plan_name": "701720", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Ppo Hmo", "plan_name": "701720_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Ambetter 68069", "plan_name": "500516", "standard_charge_dollar": 3.99, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Ms State Emplo", "plan_name": "401457", "standard_charge_dollar": 3.66, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Ms State Emplo", "plan_name": "401457_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Basic Pl", "plan_name": "400100", "standard_charge_dollar": 3.66, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Basic Pl", "plan_name": "400100_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Federal", "plan_name": "400110", "standard_charge_dollar": 3.66, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Federal", "plan_name": "400110_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Cigna Healthsprings Ffs", "plan_name": "500064", "standard_charge_dollar": 3.99, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Conseco", "plan_name": "500302", "standard_charge_dollar": 3.99, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Humana Ffs 61101", "plan_name": "500006", "standard_charge_dollar": 3.99, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Medicare A", "plan_name": "100100", "standard_charge_dollar": 3.99, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Medicare A", "plan_name": "100500", "standard_charge_dollar": 3.99, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Medicare Part B Only", "plan_name": "100300", "standard_charge_dollar": 3.99, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Medicare Railroad", "plan_name": "100103", "standard_charge_dollar": 3.99, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Ms Physicians Care N", "plan_name": "714210", "standard_charge_dollar": 4.99, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Peoples Hlth Ffs 72126", "plan_name": "500019", "standard_charge_dollar": 3.99, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Uhc/Secure Horizons", "plan_name": "500449", "standard_charge_dollar": 3.99, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "United Health Care/", "plan_name": "500292", "standard_charge_dollar": 4.51, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "United Healthcare", "plan_name": "750104", "standard_charge_dollar": 4.51, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "United Healthcare Ba", "plan_name": "750090", "standard_charge_dollar": 4.51, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "United Healthcare Me", "plan_name": "501310", "standard_charge_dollar": 3.99, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Windsor Mcare Extra", "plan_name": "500778", "standard_charge_dollar": 3.99, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." } ] } ] }, { "description": "Ceftazidime 1 gram solution for injection [9474]", "drug_information": { "unit": 1.00, "type": "EA" }, "code_information": [ { "code": "J0713", "type": "HCPCS" }, { "code": "44567-235-25", "type": "NDC" } ], "standard_charges": [ { "gross_charge": 55.15, "minimum": 44.12, "maximum": 46.88, "setting": "both", "payers_information": [ { "payer_name": "Aetna", "plan_name": "700700", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna", "plan_name": "700700_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Miscellaneous", "plan_name": "700720", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Miscellaneous", "plan_name": "700720_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Ppo Hmo", "plan_name": "701720", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Ppo Hmo", "plan_name": "701720_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Ms State Emplo", "plan_name": "401457", "standard_charge_percentage": 0.80, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Ms State Emplo", "plan_name": "401457_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Basic Pl", "plan_name": "400100", "standard_charge_percentage": 0.85, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Basic Pl", "plan_name": "400100_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Federal", "plan_name": "400110", "standard_charge_percentage": 0.85, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Federal", "plan_name": "400110_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." } ] } ] }, { "description": "Ceftazidime 2 gram solution for injection [9476]", "drug_information": { "unit": 1.00, "type": "EA" }, "code_information": [ { "code": "J0713", "type": "HCPCS" }, { "code": "44567-236-10", "type": "NDC" } ], "standard_charges": [ { "gross_charge": 84.94, "minimum": 67.95, "maximum": 72.20, "setting": "both", "payers_information": [ { "payer_name": "Aetna", "plan_name": "700700", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna", "plan_name": "700700_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Miscellaneous", "plan_name": "700720", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Miscellaneous", "plan_name": "700720_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Ppo Hmo", "plan_name": "701720", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Ppo Hmo", "plan_name": "701720_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Ms State Emplo", "plan_name": "401457", "standard_charge_percentage": 0.80, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Ms State Emplo", "plan_name": "401457_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Basic Pl", "plan_name": "400100", "standard_charge_percentage": 0.85, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Basic Pl", "plan_name": "400100_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Federal", "plan_name": "400110", "standard_charge_percentage": 0.85, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Federal", "plan_name": "400110_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." } ] } ] }, { "description": "Ceftazidime iv syringe 40 mg/ml (neo/ped) [500490]", "drug_information": { "unit": 1.00, "type": "ML" }, "code_information": [ { "code": "J0713", "type": "HCPCS" }, { "code": "99999-0003-07", "type": "NDC" } ], "standard_charges": [ { "gross_charge": 11.00, "minimum": 8.80, "maximum": 9.35, "setting": "both", "payers_information": [ { "payer_name": "Aetna", "plan_name": "700700", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna", "plan_name": "700700_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Miscellaneous", "plan_name": "700720", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Miscellaneous", "plan_name": "700720_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Ppo Hmo", "plan_name": "701720", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Ppo Hmo", "plan_name": "701720_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Ms State Emplo", "plan_name": "401457", "standard_charge_percentage": 0.80, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Ms State Emplo", "plan_name": "401457_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Basic Pl", "plan_name": "400100", "standard_charge_percentage": 0.85, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Basic Pl", "plan_name": "400100_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Federal", "plan_name": "400110", "standard_charge_percentage": 0.85, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Federal", "plan_name": "400110_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." } ] } ] }, { "description": "Ceftazidime-avibactam 2.5 gram intravenous solution [169648]", "drug_information": { "unit": 1.00, "type": "EA" }, "code_information": [ { "code": "J0714", "type": "HCPCS" }, { "code": "0456-2700-01", "type": "NDC" } ], "standard_charges": [ { "gross_charge": 1495.79, "minimum": 71.82, "maximum": 125.63, "setting": "both", "payers_information": [ { "payer_name": "Aarp", "plan_name": "500102", "standard_charge_dollar": 100.50, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna", "plan_name": "700700", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna", "plan_name": "700700_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Mcare Ffs 6005", "plan_name": "700703", "standard_charge_dollar": 100.50, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Miscellaneous", "plan_name": "700720", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Miscellaneous", "plan_name": "700720_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Ppo Hmo", "plan_name": "701720", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Ppo Hmo", "plan_name": "701720_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Ambetter 68069", "plan_name": "500516", "standard_charge_dollar": 100.50, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Ms State Emplo", "plan_name": "401457", "standard_charge_dollar": 71.82, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Ms State Emplo", "plan_name": "401457_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Basic Pl", "plan_name": "400100", "standard_charge_dollar": 71.82, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Basic Pl", "plan_name": "400100_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Federal", "plan_name": "400110", "standard_charge_dollar": 71.82, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Federal", "plan_name": "400110_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Cigna Healthsprings Ffs", "plan_name": "500064", "standard_charge_dollar": 100.50, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Conseco", "plan_name": "500302", "standard_charge_dollar": 100.50, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Humana Ffs 61101", "plan_name": "500006", "standard_charge_dollar": 100.50, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Medicare A", "plan_name": "100100", "standard_charge_dollar": 100.50, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Medicare A", "plan_name": "100500", "standard_charge_dollar": 100.50, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Medicare Part B Only", "plan_name": "100300", "standard_charge_dollar": 100.50, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Medicare Railroad", "plan_name": "100103", "standard_charge_dollar": 100.50, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Ms Physicians Care N", "plan_name": "714210", "standard_charge_dollar": 125.63, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Peoples Hlth Ffs 72126", "plan_name": "500019", "standard_charge_dollar": 100.50, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Uhc/Secure Horizons", "plan_name": "500449", "standard_charge_dollar": 100.50, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "United Health Care/", "plan_name": "500292", "standard_charge_dollar": 113.57, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "United Healthcare", "plan_name": "750104", "standard_charge_dollar": 113.57, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "United Healthcare Ba", "plan_name": "750090", "standard_charge_dollar": 113.57, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "United Healthcare Me", "plan_name": "501310", "standard_charge_dollar": 100.50, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Windsor Mcare Extra", "plan_name": "500778", "standard_charge_dollar": 100.50, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." } ] } ] }, { "description": "Ceftazidime-avibactam 2.5 gram intravenous solution [169648]", "drug_information": { "unit": 1.00, "type": "EA" }, "code_information": [ { "code": "J0714", "type": "HCPCS" }, { "code": "0456-2700-10", "type": "NDC" } ], "standard_charges": [ { "gross_charge": 1495.79, "minimum": 71.82, "maximum": 125.63, "setting": "both", "payers_information": [ { "payer_name": "Aarp", "plan_name": "500102", "standard_charge_dollar": 100.50, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna", "plan_name": "700700", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna", "plan_name": "700700_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Mcare Ffs 6005", "plan_name": "700703", "standard_charge_dollar": 100.50, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Miscellaneous", "plan_name": "700720", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Miscellaneous", "plan_name": "700720_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Ppo Hmo", "plan_name": "701720", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Ppo Hmo", "plan_name": "701720_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Ambetter 68069", "plan_name": "500516", "standard_charge_dollar": 100.50, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Ms State Emplo", "plan_name": "401457", "standard_charge_dollar": 71.82, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Ms State Emplo", "plan_name": "401457_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Basic Pl", "plan_name": "400100", "standard_charge_dollar": 71.82, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Basic Pl", "plan_name": "400100_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Federal", "plan_name": "400110", "standard_charge_dollar": 71.82, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Federal", "plan_name": "400110_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Cigna Healthsprings Ffs", "plan_name": "500064", "standard_charge_dollar": 100.50, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Conseco", "plan_name": "500302", "standard_charge_dollar": 100.50, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Humana Ffs 61101", "plan_name": "500006", "standard_charge_dollar": 100.50, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Medicare A", "plan_name": "100100", "standard_charge_dollar": 100.50, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Medicare A", "plan_name": "100500", "standard_charge_dollar": 100.50, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Medicare Part B Only", "plan_name": "100300", "standard_charge_dollar": 100.50, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Medicare Railroad", "plan_name": "100103", "standard_charge_dollar": 100.50, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Ms Physicians Care N", "plan_name": "714210", "standard_charge_dollar": 125.63, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Peoples Hlth Ffs 72126", "plan_name": "500019", "standard_charge_dollar": 100.50, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Uhc/Secure Horizons", "plan_name": "500449", "standard_charge_dollar": 100.50, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "United Health Care/", "plan_name": "500292", "standard_charge_dollar": 113.57, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "United Healthcare", "plan_name": "750104", "standard_charge_dollar": 113.57, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "United Healthcare Ba", "plan_name": "750090", "standard_charge_dollar": 113.57, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "United Healthcare Me", "plan_name": "501310", "standard_charge_dollar": 100.50, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Windsor Mcare Extra", "plan_name": "500778", "standard_charge_dollar": 100.50, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." } ] } ] }, { "description": "Certolizumab pegol 400 mg/2 ml (200 mg/ml x2) subcutaneous syringe kit [97853]", "drug_information": { "unit": 1.00, "type": "EA" }, "code_information": [ { "code": "J0717", "type": "HCPCS" }, { "code": "50474-710-79", "type": "NDC" } ], "standard_charges": [ { "gross_charge": 25643.70, "minimum": 3.98, "maximum": 9.75, "setting": "both", "payers_information": [ { "payer_name": "Aarp", "plan_name": "500102", "standard_charge_dollar": 3.98, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna", "plan_name": "700700", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna", "plan_name": "700700_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Mcare Ffs 6005", "plan_name": "700703", "standard_charge_dollar": 3.98, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Miscellaneous", "plan_name": "700720", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Miscellaneous", "plan_name": "700720_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Ppo Hmo", "plan_name": "701720", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Ppo Hmo", "plan_name": "701720_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Ambetter 68069", "plan_name": "500516", "standard_charge_dollar": 3.98, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Ms State Emplo", "plan_name": "401457", "standard_charge_dollar": 9.75, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Ms State Emplo", "plan_name": "401457_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Basic Pl", "plan_name": "400100", "standard_charge_dollar": 9.75, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Basic Pl", "plan_name": "400100_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Federal", "plan_name": "400110", "standard_charge_dollar": 9.75, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Federal", "plan_name": "400110_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Cigna Healthsprings Ffs", "plan_name": "500064", "standard_charge_dollar": 3.98, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Conseco", "plan_name": "500302", "standard_charge_dollar": 3.98, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Humana Ffs 61101", "plan_name": "500006", "standard_charge_dollar": 3.98, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Medicare A", "plan_name": "100100", "standard_charge_dollar": 3.98, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Medicare A", "plan_name": "100500", "standard_charge_dollar": 3.98, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Medicare Part B Only", "plan_name": "100300", "standard_charge_dollar": 3.98, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Medicare Railroad", "plan_name": "100103", "standard_charge_dollar": 3.98, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Ms Physicians Care N", "plan_name": "714210", "standard_charge_dollar": 4.98, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Peoples Hlth Ffs 72126", "plan_name": "500019", "standard_charge_dollar": 3.98, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Uhc/Secure Horizons", "plan_name": "500449", "standard_charge_dollar": 3.98, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "United Health Care/", "plan_name": "500292", "standard_charge_dollar": 4.50, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "United Healthcare", "plan_name": "750104", "standard_charge_dollar": 4.50, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "United Healthcare Ba", "plan_name": "750090", "standard_charge_dollar": 4.50, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "United Healthcare Me", "plan_name": "501310", "standard_charge_dollar": 3.98, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Windsor Mcare Extra", "plan_name": "500778", "standard_charge_dollar": 3.98, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." } ] } ] }, { "description": "Certolizumab pegol 400 mg/2 ml (200 mg/ml x2) subcutaneous syringe kit [97853]", "drug_information": { "unit": 1.00, "type": "EA" }, "code_information": [ { "code": "J0717", "type": "HCPCS" }, { "code": "50474-710-81", "type": "NDC" } ], "standard_charges": [ { "gross_charge": 25643.71, "minimum": 3.98, "maximum": 9.75, "setting": "both", "payers_information": [ { "payer_name": "Aarp", "plan_name": "500102", "standard_charge_dollar": 3.98, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data 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}, { "payer_name": "Bc/Bs Ms State Emplo", "plan_name": "401457_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Basic Pl", "plan_name": "400100", "standard_charge_percentage": 0.85, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Basic Pl", "plan_name": "400100_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Federal", "plan_name": "400110", "standard_charge_percentage": 0.85, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Federal", "plan_name": "400110_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." } ] } ] }, { "description": "Ciprofloxacin 400 mg/200 ml in 5 % dextrose intravenous piggyback [9611]", "drug_information": { "unit": 200.00, "type": "ML" }, "code_information": [ { "code": "J0744", "type": "HCPCS" }, { "code": "36000-009-24", "type": "NDC" } ], "standard_charges": [ { "gross_charge": 98.01, "minimum": 78.41, "maximum": 83.31, "setting": "both", "payers_information": [ { "payer_name": "Aetna", "plan_name": "700700", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna", "plan_name": "700700_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of 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1.00, "type": "EA" }, "code_information": [ { "code": "J0834", "type": "HCPCS" }, { "code": "0548-5900-00", "type": "NDC" } ], "standard_charges": [ { "gross_charge": 501.25, "minimum": 102.32, "maximum": 102.32, "setting": "both", "payers_information": [ { "payer_name": "Aetna", "plan_name": "700700", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna", "plan_name": "700700_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Miscellaneous", "plan_name": "700720", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna 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"401457_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Basic Pl", "plan_name": "400100", "standard_charge_dollar": 102.32, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Basic Pl", "plan_name": "400100_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Federal", "plan_name": "400110", "standard_charge_dollar": 102.32, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Federal", "plan_name": "400110_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." } ] } ] }, { "description": "Crotalidae polyval immune fab solution for injection [29313]", "drug_information": { "unit": 1.00, "type": "EA" }, "code_information": [ { "code": "J0840", "type": "HCPCS" }, { "code": "50633-110-11", "type": "NDC" } ], "standard_charges": [ { "gross_charge": 12809.67, "minimum": 1755.81, "maximum": 2467.68, "setting": "both", "payers_information": [ { "payer_name": "Aarp", "plan_name": "500102", "standard_charge_dollar": 1755.81, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna", "plan_name": "700700", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna", "plan_name": "700700_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Mcare Ffs 6005", "plan_name": "700703", "standard_charge_dollar": 1755.81, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Miscellaneous", "plan_name": "700720", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Miscellaneous", "plan_name": "700720_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Ppo Hmo", "plan_name": "701720", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Ppo Hmo", "plan_name": "701720_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Ambetter 68069", "plan_name": "500516", "standard_charge_dollar": 1755.81, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Ms State Emplo", "plan_name": "401457", "standard_charge_dollar": 2467.68, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Ms State Emplo", "plan_name": "401457_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Basic Pl", "plan_name": "400100", "standard_charge_dollar": 2467.68, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Basic Pl", "plan_name": "400100_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Federal", "plan_name": "400110", "standard_charge_dollar": 2467.68, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Federal", "plan_name": "400110_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Cigna Healthsprings Ffs", "plan_name": "500064", "standard_charge_dollar": 1755.81, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Conseco", "plan_name": "500302", "standard_charge_dollar": 1755.81, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Humana Ffs 61101", "plan_name": "500006", "standard_charge_dollar": 1755.81, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Medicare A", "plan_name": "100100", "standard_charge_dollar": 1755.81, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": 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calculate allowed amounts." }, { "payer_name": "United Healthcare Me", "plan_name": "501310", "standard_charge_dollar": 1755.81, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Windsor Mcare Extra", "plan_name": "500778", "standard_charge_dollar": 1755.81, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." } ] } ] }, { "description": "Crotalidae polyval immune fab solution for injection [29313]", "drug_information": { "unit": 1.00, "type": "EA" }, "code_information": [ { "code": "J0840", "type": "HCPCS" }, { "code": "50633-110-12", "type": "NDC" } ], "standard_charges": [ { "gross_charge": 11880.19, "minimum": 1755.81, "maximum": 2467.68, "setting": "both", "payers_information": [ { "payer_name": "Aarp", "plan_name": "500102", "standard_charge_dollar": 1755.81, "count": "0", "methodology": "fee schedule", 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"payer_name": "Bc/Bs Ms State Emplo", "plan_name": "401457", "standard_charge_dollar": 2467.68, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Ms State Emplo", "plan_name": "401457_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Basic Pl", "plan_name": "400100", "standard_charge_dollar": 2467.68, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Basic Pl", "plan_name": "400100_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Federal", "plan_name": "400110", "standard_charge_dollar": 2467.68, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Federal", "plan_name": "400110_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Cigna Healthsprings Ffs", "plan_name": "500064", "standard_charge_dollar": 1755.81, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Conseco", "plan_name": "500302", "standard_charge_dollar": 1755.81, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Humana Ffs 61101", "plan_name": "500006", "standard_charge_dollar": 1755.81, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Medicare A", "plan_name": "100100", "standard_charge_dollar": 1755.81, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Medicare A", "plan_name": "100500", "standard_charge_dollar": 1755.81, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Medicare Part B Only", "plan_name": "100300", "standard_charge_dollar": 1755.81, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Medicare Railroad", "plan_name": "100103", "standard_charge_dollar": 1755.81, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Ms Physicians Care N", "plan_name": "714210", "standard_charge_dollar": 2194.76, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Peoples Hlth Ffs 72126", "plan_name": "500019", "standard_charge_dollar": 1755.81, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Uhc/Secure Horizons", "plan_name": "500449", "standard_charge_dollar": 1755.81, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "United Health Care/", "plan_name": "500292", "standard_charge_dollar": 1984.07, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "United Healthcare", "plan_name": "750104", "standard_charge_dollar": 1984.07, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "United Healthcare Ba", "plan_name": "750090", "standard_charge_dollar": 1984.07, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "United Healthcare Me", "plan_name": "501310", "standard_charge_dollar": 1755.81, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Windsor Mcare Extra", "plan_name": "500778", "standard_charge_dollar": 1755.81, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." } ] } ] }, { "description": "Antivenin crotalidae (equine) solution for injection [185361]", "drug_information": { "unit": 1.00, "type": "EA" }, "code_information": [ { "code": "J0841", "type": "HCPCS" }, { "code": "66621-0790-2", "type": "NDC" } ], "standard_charges": [ { "gross_charge": 4991.19, "minimum": 1043.55, "maximum": 4242.51, "setting": "both", "payers_information": [ { "payer_name": "Aarp", "plan_name": "500102", "standard_charge_dollar": 1043.55, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna", "plan_name": "700700", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna", "plan_name": "700700_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Mcare Ffs 6005", "plan_name": "700703", "standard_charge_dollar": 1043.55, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Miscellaneous", "plan_name": "700720", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Miscellaneous", "plan_name": "700720_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Ppo Hmo", "plan_name": "701720", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Ppo Hmo", "plan_name": "701720_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Ambetter 68069", "plan_name": "500516", "standard_charge_dollar": 1043.55, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Ms State Emplo", "plan_name": "401457", "standard_charge_percentage": 0.80, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Ms State Emplo", "plan_name": "401457_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Basic Pl", "plan_name": "400100", "standard_charge_percentage": 0.85, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Basic Pl", "plan_name": "400100_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Federal", "plan_name": "400110", "standard_charge_percentage": 0.85, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Federal", "plan_name": "400110_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Cigna Healthsprings Ffs", "plan_name": "500064", "standard_charge_dollar": 1043.55, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Conseco", "plan_name": "500302", "standard_charge_dollar": 1043.55, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Humana Ffs 61101", "plan_name": "500006", "standard_charge_dollar": 1043.55, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Medicare A", "plan_name": "100100", "standard_charge_dollar": 1043.55, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Medicare A", "plan_name": "100500", "standard_charge_dollar": 1043.55, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Medicare Part B Only", "plan_name": "100300", "standard_charge_dollar": 1043.55, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Medicare Railroad", "plan_name": "100103", "standard_charge_dollar": 1043.55, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Ms Physicians Care N", "plan_name": "714210", "standard_charge_dollar": 1304.44, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Peoples Hlth Ffs 72126", "plan_name": "500019", "standard_charge_dollar": 1043.55, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Uhc/Secure Horizons", "plan_name": "500449", "standard_charge_dollar": 1043.55, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "United Health Care/", "plan_name": "500292", "standard_charge_dollar": 1179.21, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "United Healthcare", "plan_name": "750104", "standard_charge_dollar": 1179.21, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "United Healthcare Ba", "plan_name": "750090", "standard_charge_dollar": 1179.21, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "United Healthcare Me", "plan_name": "501310", "standard_charge_dollar": 1043.55, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Windsor Mcare Extra", "plan_name": "500778", "standard_charge_dollar": 1043.55, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." } ] } ] }, { "description": "Dalbavancin 500 mg intravenous solution [166441]", "drug_information": { "unit": 1.00, "type": "EA" }, "code_information": [ { "code": "J0875", "type": "HCPCS" }, { "code": "57970-100-01", "type": "NDC" } ], "standard_charges": [ { "gross_charge": 6727.27, "minimum": 14.30, "maximum": 19.46, "setting": "both", "payers_information": [ { "payer_name": "Aarp", "plan_name": "500102", "standard_charge_dollar": 15.57, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna", "plan_name": "700700", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna", "plan_name": "700700_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Mcare Ffs 6005", "plan_name": "700703", "standard_charge_dollar": 15.57, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Miscellaneous", "plan_name": "700720", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Miscellaneous", "plan_name": "700720_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Ppo Hmo", "plan_name": "701720", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Ppo Hmo", "plan_name": "701720_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Ambetter 68069", "plan_name": "500516", "standard_charge_dollar": 15.57, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Ms State Emplo", "plan_name": "401457", "standard_charge_dollar": 14.30, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Ms State Emplo", "plan_name": "401457_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Basic Pl", "plan_name": "400100", "standard_charge_dollar": 14.30, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Basic Pl", "plan_name": "400100_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Federal", "plan_name": "400110", "standard_charge_dollar": 14.30, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Federal", "plan_name": "400110_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Cigna Healthsprings Ffs", "plan_name": "500064", "standard_charge_dollar": 15.57, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Conseco", "plan_name": "500302", "standard_charge_dollar": 15.57, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Humana Ffs 61101", "plan_name": "500006", "standard_charge_dollar": 15.57, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Medicare A", "plan_name": "100100", "standard_charge_dollar": 15.57, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Medicare A", "plan_name": "100500", "standard_charge_dollar": 15.57, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Medicare Part B Only", "plan_name": "100300", "standard_charge_dollar": 15.57, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Medicare Railroad", "plan_name": "100103", "standard_charge_dollar": 15.57, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Ms Physicians Care N", "plan_name": "714210", "standard_charge_dollar": 19.46, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Peoples Hlth Ffs 72126", "plan_name": "500019", "standard_charge_dollar": 15.57, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Uhc/Secure Horizons", "plan_name": "500449", "standard_charge_dollar": 15.57, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "United Health Care/", "plan_name": "500292", "standard_charge_dollar": 17.59, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "United Healthcare", "plan_name": "750104", "standard_charge_dollar": 17.59, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "United Healthcare Ba", "plan_name": "750090", "standard_charge_dollar": 17.59, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "United Healthcare Me", "plan_name": "501310", "standard_charge_dollar": 15.57, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Windsor Mcare Extra", "plan_name": "500778", "standard_charge_dollar": 15.57, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." } ] } ] }, { "description": "Daptomycin 500 mg intravenous solution [36989]", "drug_information": { "unit": 1.00, "type": "EA" }, "code_information": [ { "code": "J0877", "type": "HCPCS" }, { "code": "0409-0122-01", "type": "NDC" } ], "standard_charges": [ { "gross_charge": 371.55, "minimum": 297.24, "maximum": 315.82, "setting": "both", "payers_information": [ { "payer_name": "Aetna", "plan_name": "700700", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna", "plan_name": "700700_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Miscellaneous", "plan_name": "700720", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Miscellaneous", "plan_name": "700720_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Ppo Hmo", "plan_name": "701720", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Ppo Hmo", "plan_name": "701720_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Ms State Emplo", "plan_name": "401457", "standard_charge_percentage": 0.80, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Ms State Emplo", "plan_name": "401457_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Basic Pl", "plan_name": "400100", "standard_charge_percentage": 0.85, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Basic Pl", "plan_name": "400100_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Federal", "plan_name": "400110", "standard_charge_percentage": 0.85, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Federal", "plan_name": "400110_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." } ] } ] }, { "description": "Daptomycin 500 mg intravenous solution [36989]", "drug_information": { "unit": 1.00, "type": "EA" }, "code_information": [ { "code": "J0878", "type": "HCPCS" }, { "code": "67457-941-15", "type": "NDC" } ], "standard_charges": [ { "gross_charge": 167.40, "minimum": 0.86, "maximum": 0.86, "setting": "both", "payers_information": [ { "payer_name": "Aetna", "plan_name": "700700", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna", "plan_name": "700700_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Miscellaneous", "plan_name": "700720", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Miscellaneous", "plan_name": "700720_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Ppo Hmo", "plan_name": "701720", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Ppo Hmo", "plan_name": "701720_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Ms State Emplo", "plan_name": "401457", "standard_charge_dollar": 0.86, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Ms State Emplo", "plan_name": "401457_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Basic Pl", "plan_name": "400100", "standard_charge_dollar": 0.86, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Basic Pl", "plan_name": "400100_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Federal", "plan_name": "400110", "standard_charge_dollar": 0.86, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Federal", "plan_name": "400110_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." } ] } ] }, { "description": "Daptomycin 500 mg intravenous solution [36989]", "drug_information": { "unit": 1.00, "type": "EA" }, "code_information": [ { "code": "J0878", "type": "HCPCS" }, { "code": "67919-012-01", "type": "NDC" } ], "standard_charges": [ { "gross_charge": 2095.15, "minimum": 0.86, "maximum": 0.86, "setting": "both", "payers_information": [ { "payer_name": "Aetna", "plan_name": "700700", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna", "plan_name": "700700_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Miscellaneous", "plan_name": "700720", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Miscellaneous", "plan_name": "700720_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Ppo Hmo", "plan_name": "701720", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Ppo Hmo", "plan_name": "701720_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Ms State Emplo", "plan_name": "401457", "standard_charge_dollar": 0.86, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Ms State Emplo", "plan_name": "401457_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Basic Pl", "plan_name": "400100", "standard_charge_dollar": 0.86, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Basic Pl", "plan_name": "400100_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Federal", "plan_name": "400110", "standard_charge_dollar": 0.86, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Federal", "plan_name": "400110_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." } ] } ] }, { "description": "Darbepoetin alfa 200 mcg/0.4 ml in polysorbate injection syringe [116630]", "drug_information": { "unit": 0.40, "type": "ML" }, "code_information": [ { "code": "J0882", "type": "HCPCS" }, { "code": "55513-028-01", "type": "NDC" } ], "standard_charges": [ { "gross_charge": 6067.39, "minimum": 2.92, "maximum": 7.15, "setting": "both", "payers_information": [ { "payer_name": "Aarp", "plan_name": "500102", "standard_charge_dollar": 2.92, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna", "plan_name": "700700", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna", "plan_name": "700700_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Mcare Ffs 6005", "plan_name": "700703", "standard_charge_dollar": 2.92, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Miscellaneous", "plan_name": "700720", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Miscellaneous", "plan_name": "700720_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Ppo Hmo", "plan_name": "701720", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Ppo Hmo", "plan_name": "701720_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Ambetter 68069", "plan_name": "500516", "standard_charge_dollar": 2.92, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Ms State Emplo", "plan_name": "401457", "standard_charge_dollar": 7.15, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Ms State Emplo", "plan_name": "401457_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Basic Pl", "plan_name": "400100", "standard_charge_dollar": 7.15, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Basic Pl", "plan_name": "400100_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Federal", "plan_name": "400110", "standard_charge_dollar": 7.15, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Federal", "plan_name": "400110_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Cigna Healthsprings Ffs", "plan_name": "500064", "standard_charge_dollar": 2.92, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Conseco", "plan_name": "500302", "standard_charge_dollar": 2.92, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Humana Ffs 61101", "plan_name": "500006", "standard_charge_dollar": 2.92, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Medicare A", "plan_name": "100100", "standard_charge_dollar": 2.92, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Medicare A", "plan_name": "100500", "standard_charge_dollar": 2.92, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Medicare Part B Only", "plan_name": "100300", "standard_charge_dollar": 2.92, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Medicare Railroad", "plan_name": "100103", "standard_charge_dollar": 2.92, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Ms Physicians Care N", "plan_name": "714210", "standard_charge_dollar": 3.65, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Peoples Hlth Ffs 72126", "plan_name": "500019", "standard_charge_dollar": 2.92, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Uhc/Secure Horizons", "plan_name": "500449", "standard_charge_dollar": 2.92, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "United Health Care/", "plan_name": "500292", "standard_charge_dollar": 3.30, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "United Healthcare", "plan_name": "750104", "standard_charge_dollar": 3.30, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "United Healthcare Ba", "plan_name": "750090", "standard_charge_dollar": 3.30, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "United Healthcare Me", "plan_name": "501310", "standard_charge_dollar": 2.92, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Windsor Mcare Extra", "plan_name": "500778", "standard_charge_dollar": 2.92, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." } ] } ] }, { "description": "Darbepoetin alfa 500 mcg/ml in polysorbate injection syringe [76334]", "drug_information": { "unit": 1.00, "type": "ML" }, "code_information": [ { "code": "J0882", "type": "HCPCS" }, { "code": "55513-032-01", "type": "NDC" } ], "standard_charges": [ { "gross_charge": 15168.47, "minimum": 2.92, "maximum": 7.15, "setting": "both", "payers_information": [ { "payer_name": "Aarp", "plan_name": "500102", "standard_charge_dollar": 2.92, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna", "plan_name": "700700", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna", "plan_name": "700700_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Mcare Ffs 6005", "plan_name": "700703", "standard_charge_dollar": 2.92, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna 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"plan_name": "500516", "standard_charge_dollar": 2.92, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Ms State Emplo", "plan_name": "401457", "standard_charge_dollar": 7.15, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Ms State Emplo", "plan_name": "401457_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Basic Pl", "plan_name": "400100", "standard_charge_dollar": 7.15, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Basic Pl", "plan_name": "400100_1", "standard_charge_percentage": 100.0, "count": 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"Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Humana Ffs 61101", "plan_name": "500006", "standard_charge_dollar": 2.92, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Medicare A", "plan_name": "100100", "standard_charge_dollar": 2.92, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Medicare A", "plan_name": "100500", "standard_charge_dollar": 2.92, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Medicare Part B Only", "plan_name": "100300", "standard_charge_dollar": 2.92, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Medicare Railroad", "plan_name": "100103", "standard_charge_dollar": 2.92, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Ms Physicians Care N", "plan_name": "714210", "standard_charge_dollar": 3.65, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Peoples Hlth Ffs 72126", "plan_name": "500019", "standard_charge_dollar": 2.92, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Uhc/Secure Horizons", "plan_name": "500449", "standard_charge_dollar": 2.92, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "United Health Care/", "plan_name": "500292", "standard_charge_dollar": 3.30, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "United Healthcare", "plan_name": "750104", "standard_charge_dollar": 3.30, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "United Healthcare Ba", "plan_name": "750090", "standard_charge_dollar": 3.30, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "United Healthcare Me", "plan_name": "501310", "standard_charge_dollar": 2.92, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Windsor Mcare Extra", "plan_name": "500778", "standard_charge_dollar": 2.92, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." } ] } ] }, { "description": "Darbepoetin alfa 300 mcg/0.6 ml in polysorbate injection syringe [116631]", "drug_information": { "unit": 0.60, "type": "ML" }, "code_information": [ { "code": "J0882", "type": "HCPCS" }, { "code": "55513-111-01", "type": "NDC" } ], "standard_charges": [ { "gross_charge": 9101.08, "minimum": 2.92, "maximum": 7.15, "setting": "both", "payers_information": [ { "payer_name": "Aarp", "plan_name": "500102", "standard_charge_dollar": 2.92, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna", "plan_name": "700700", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna", "plan_name": "700700_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Mcare Ffs 6005", "plan_name": "700703", "standard_charge_dollar": 2.92, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Miscellaneous", "plan_name": "700720", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Miscellaneous", "plan_name": "700720_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Ppo Hmo", "plan_name": "701720", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Ppo Hmo", "plan_name": "701720_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Ambetter 68069", "plan_name": "500516", "standard_charge_dollar": 2.92, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Ms State Emplo", "plan_name": "401457", "standard_charge_dollar": 7.15, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Ms State Emplo", "plan_name": "401457_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Basic Pl", "plan_name": "400100", "standard_charge_dollar": 7.15, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Basic Pl", "plan_name": "400100_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Federal", "plan_name": "400110", "standard_charge_dollar": 7.15, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Federal", "plan_name": "400110_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Cigna Healthsprings Ffs", "plan_name": "500064", "standard_charge_dollar": 2.92, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Conseco", "plan_name": "500302", "standard_charge_dollar": 2.92, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Humana Ffs 61101", "plan_name": "500006", "standard_charge_dollar": 2.92, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Medicare A", "plan_name": "100100", "standard_charge_dollar": 2.92, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Medicare A", "plan_name": "100500", "standard_charge_dollar": 2.92, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Medicare Part B Only", "plan_name": "100300", "standard_charge_dollar": 2.92, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Medicare Railroad", "plan_name": "100103", "standard_charge_dollar": 2.92, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Ms Physicians Care N", "plan_name": "714210", "standard_charge_dollar": 3.65, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Peoples Hlth Ffs 72126", "plan_name": "500019", "standard_charge_dollar": 2.92, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Uhc/Secure Horizons", "plan_name": "500449", "standard_charge_dollar": 2.92, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "United Health Care/", "plan_name": "500292", "standard_charge_dollar": 3.30, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "United Healthcare", "plan_name": "750104", "standard_charge_dollar": 3.30, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "United Healthcare Ba", "plan_name": "750090", "standard_charge_dollar": 3.30, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "United Healthcare Me", "plan_name": "501310", "standard_charge_dollar": 2.92, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Windsor Mcare Extra", "plan_name": "500778", "standard_charge_dollar": 2.92, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." } ] } ] }, { "description": "Argatroban 1 mg/ml in 0.9 % sodium chloride intravenous solution [151444]", "drug_information": { "unit": 50.00, "type": "ML" }, "code_information": [ { "code": "J0883", "type": "HCPCS" }, { "code": "55150-241-01", "type": "NDC" } ], "standard_charges": [ { "gross_charge": 1008.06, "minimum": 0.95, "maximum": 4.36, "setting": "both", "payers_information": [ { "payer_name": "Aarp", "plan_name": "500102", "standard_charge_dollar": 0.95, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna", "plan_name": "700700", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna", "plan_name": "700700_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Mcare Ffs 6005", "plan_name": "700703", "standard_charge_dollar": 0.95, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Miscellaneous", "plan_name": "700720", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Miscellaneous", "plan_name": "700720_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Ppo Hmo", "plan_name": "701720", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Ppo Hmo", "plan_name": "701720_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Ambetter 68069", "plan_name": "500516", "standard_charge_dollar": 0.95, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Ms State Emplo", "plan_name": "401457", "standard_charge_dollar": 4.36, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Ms State Emplo", "plan_name": "401457_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Basic Pl", "plan_name": "400100", "standard_charge_dollar": 4.36, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Basic Pl", "plan_name": "400100_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Federal", "plan_name": "400110", "standard_charge_dollar": 4.36, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Federal", "plan_name": "400110_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Cigna Healthsprings Ffs", "plan_name": "500064", "standard_charge_dollar": 0.95, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Conseco", "plan_name": "500302", "standard_charge_dollar": 0.95, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Humana Ffs 61101", "plan_name": "500006", "standard_charge_dollar": 0.95, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Medicare A", "plan_name": "100100", "standard_charge_dollar": 0.95, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Medicare A", "plan_name": "100500", "standard_charge_dollar": 0.95, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Medicare Part B Only", "plan_name": "100300", "standard_charge_dollar": 0.95, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Medicare Railroad", "plan_name": "100103", "standard_charge_dollar": 0.95, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Ms Physicians Care N", "plan_name": "714210", "standard_charge_dollar": 1.19, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Peoples Hlth Ffs 72126", "plan_name": "500019", "standard_charge_dollar": 0.95, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Uhc/Secure Horizons", "plan_name": "500449", "standard_charge_dollar": 0.95, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "United Health Care/", "plan_name": "500292", "standard_charge_dollar": 1.07, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "United Healthcare", "plan_name": "750104", "standard_charge_dollar": 1.07, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "United Healthcare Ba", "plan_name": "750090", "standard_charge_dollar": 1.07, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "United Healthcare Me", "plan_name": "501310", "standard_charge_dollar": 0.95, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Windsor Mcare Extra", "plan_name": "500778", "standard_charge_dollar": 0.95, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." } ] } ] }, { "description": "Argatroban 1 mg/ml in 0.9 % sodium chloride intravenous solution [151444]", "drug_information": { "unit": 50.00, "type": "ML" }, "code_information": [ { "code": "J0883", "type": "HCPCS" }, { "code": "25021-414-50", "type": "NDC" } ], "standard_charges": [ { "gross_charge": 1022.31, "minimum": 0.95, "maximum": 4.36, "setting": "both", "payers_information": [ { "payer_name": "Aarp", "plan_name": "500102", "standard_charge_dollar": 0.95, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna", "plan_name": "700700", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna", "plan_name": "700700_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Mcare Ffs 6005", "plan_name": "700703", "standard_charge_dollar": 0.95, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Miscellaneous", "plan_name": "700720", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Miscellaneous", "plan_name": "700720_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Ppo Hmo", "plan_name": "701720", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Ppo Hmo", "plan_name": "701720_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Ambetter 68069", "plan_name": "500516", "standard_charge_dollar": 0.95, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Ms State Emplo", "plan_name": "401457", "standard_charge_dollar": 4.36, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Ms State Emplo", "plan_name": "401457_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Basic Pl", "plan_name": "400100", "standard_charge_dollar": 4.36, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Basic Pl", "plan_name": "400100_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Federal", "plan_name": "400110", "standard_charge_dollar": 4.36, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Federal", "plan_name": "400110_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Cigna Healthsprings Ffs", "plan_name": "500064", "standard_charge_dollar": 0.95, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Conseco", "plan_name": "500302", "standard_charge_dollar": 0.95, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Humana Ffs 61101", "plan_name": "500006", "standard_charge_dollar": 0.95, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Medicare A", "plan_name": "100100", "standard_charge_dollar": 0.95, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Medicare A", "plan_name": "100500", "standard_charge_dollar": 0.95, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Medicare Part B Only", "plan_name": "100300", "standard_charge_dollar": 0.95, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Medicare Railroad", "plan_name": "100103", "standard_charge_dollar": 0.95, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Ms Physicians Care N", "plan_name": "714210", "standard_charge_dollar": 1.19, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Peoples Hlth Ffs 72126", "plan_name": "500019", "standard_charge_dollar": 0.95, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Uhc/Secure Horizons", "plan_name": "500449", "standard_charge_dollar": 0.95, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "United Health Care/", "plan_name": "500292", "standard_charge_dollar": 1.07, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "United Healthcare", "plan_name": "750104", "standard_charge_dollar": 1.07, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "United Healthcare Ba", "plan_name": "750090", "standard_charge_dollar": 1.07, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "United Healthcare Me", "plan_name": "501310", "standard_charge_dollar": 0.95, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Windsor Mcare Extra", "plan_name": "500778", "standard_charge_dollar": 0.95, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." } ] } ] }, { "description": "Argatroban 1 mg/ml in 0.9 % sodium chloride intravenous solution [151444]", "drug_information": { "unit": 50.00, "type": "ML" }, "code_information": [ { "code": "J0883", "type": "HCPCS" }, { "code": "65219-429-50", "type": "NDC" } ], "standard_charges": [ { "gross_charge": 958.90, "minimum": 0.95, "maximum": 4.36, "setting": "both", "payers_information": [ { "payer_name": "Aarp", "plan_name": "500102", "standard_charge_dollar": 0.95, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna", "plan_name": "700700", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna", "plan_name": "700700_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Mcare Ffs 6005", "plan_name": "700703", "standard_charge_dollar": 0.95, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Miscellaneous", "plan_name": "700720", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Miscellaneous", "plan_name": "700720_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Ppo Hmo", "plan_name": "701720", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Ppo Hmo", "plan_name": "701720_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Ambetter 68069", "plan_name": "500516", "standard_charge_dollar": 0.95, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Ms State Emplo", "plan_name": "401457", "standard_charge_dollar": 4.36, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Ms State Emplo", "plan_name": "401457_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Basic Pl", "plan_name": "400100", "standard_charge_dollar": 4.36, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Basic Pl", "plan_name": "400100_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Federal", "plan_name": "400110", "standard_charge_dollar": 4.36, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Federal", "plan_name": "400110_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Cigna Healthsprings Ffs", "plan_name": "500064", "standard_charge_dollar": 0.95, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Conseco", "plan_name": "500302", "standard_charge_dollar": 0.95, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Humana Ffs 61101", "plan_name": "500006", "standard_charge_dollar": 0.95, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Medicare A", "plan_name": "100100", "standard_charge_dollar": 0.95, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Medicare A", "plan_name": "100500", "standard_charge_dollar": 0.95, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Medicare Part B Only", "plan_name": "100300", "standard_charge_dollar": 0.95, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Medicare Railroad", "plan_name": "100103", "standard_charge_dollar": 0.95, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Ms Physicians Care N", "plan_name": "714210", "standard_charge_dollar": 1.19, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Peoples Hlth Ffs 72126", "plan_name": "500019", "standard_charge_dollar": 0.95, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Uhc/Secure Horizons", "plan_name": "500449", "standard_charge_dollar": 0.95, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "United Health Care/", "plan_name": "500292", "standard_charge_dollar": 1.07, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "United Healthcare", "plan_name": "750104", "standard_charge_dollar": 1.07, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "United Healthcare Ba", "plan_name": "750090", "standard_charge_dollar": 1.07, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "United Healthcare Me", "plan_name": "501310", "standard_charge_dollar": 0.95, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Windsor Mcare Extra", "plan_name": "500778", "standard_charge_dollar": 0.95, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." } ] } ] }, { "description": "Argatroban 50 mg/50 ml (1 mg/ml) in sodium chloride (iso-osmotic) iv [152259]", "drug_information": { "unit": 50.00, "type": "ML" }, "code_information": [ { "code": "J0883", "type": "HCPCS" }, { "code": "0781-3314-95", "type": "NDC" } ], "standard_charges": [ { "gross_charge": 1126.81, "minimum": 0.95, "maximum": 4.36, "setting": "both", "payers_information": [ { "payer_name": "Aarp", "plan_name": "500102", "standard_charge_dollar": 0.95, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna", "plan_name": "700700", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna", "plan_name": "700700_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Mcare Ffs 6005", "plan_name": "700703", "standard_charge_dollar": 0.95, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Miscellaneous", "plan_name": "700720", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Miscellaneous", "plan_name": "700720_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Ppo Hmo", "plan_name": "701720", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Ppo Hmo", "plan_name": "701720_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Ambetter 68069", "plan_name": "500516", "standard_charge_dollar": 0.95, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Ms State Emplo", "plan_name": "401457", "standard_charge_dollar": 4.36, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Ms State Emplo", "plan_name": "401457_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Basic Pl", "plan_name": "400100", "standard_charge_dollar": 4.36, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Basic Pl", "plan_name": "400100_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Federal", "plan_name": "400110", "standard_charge_dollar": 4.36, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Federal", "plan_name": "400110_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Cigna Healthsprings Ffs", "plan_name": "500064", "standard_charge_dollar": 0.95, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Conseco", "plan_name": "500302", "standard_charge_dollar": 0.95, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Humana Ffs 61101", "plan_name": "500006", "standard_charge_dollar": 0.95, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Medicare A", "plan_name": "100100", "standard_charge_dollar": 0.95, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Medicare A", "plan_name": "100500", "standard_charge_dollar": 0.95, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Medicare Part B Only", "plan_name": "100300", "standard_charge_dollar": 0.95, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Medicare Railroad", "plan_name": "100103", "standard_charge_dollar": 0.95, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Ms Physicians Care N", "plan_name": "714210", "standard_charge_dollar": 1.19, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Peoples Hlth Ffs 72126", "plan_name": "500019", "standard_charge_dollar": 0.95, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Uhc/Secure Horizons", "plan_name": "500449", "standard_charge_dollar": 0.95, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "United Health Care/", "plan_name": "500292", "standard_charge_dollar": 1.07, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "United Healthcare", "plan_name": "750104", "standard_charge_dollar": 1.07, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "United Healthcare Ba", "plan_name": "750090", "standard_charge_dollar": 1.07, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "United Healthcare Me", "plan_name": "501310", "standard_charge_dollar": 0.95, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Windsor Mcare Extra", "plan_name": "500778", "standard_charge_dollar": 0.95, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." } ] } ] }, { "description": "Argatroban 100 mg/ml intravenous solution [28947]", "drug_information": { "unit": 2.50, "type": "ML" }, "code_information": [ { "code": "J0884", "type": "HCPCS" }, { "code": "0078-0930-61", "type": "NDC" } ], "standard_charges": [ { "gross_charge": 6567.50, "minimum": 5254.00, "maximum": 5582.38, "setting": "both", "payers_information": [ { "payer_name": "Aetna", "plan_name": "700700", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna", "plan_name": "700700_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Miscellaneous", "plan_name": "700720", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Miscellaneous", "plan_name": "700720_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Ppo Hmo", "plan_name": "701720", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Ppo 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"payer_name": "Aetna Ppo Hmo", "plan_name": "701720_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Ms State Emplo", "plan_name": "401457", "standard_charge_dollar": 30.37, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Ms State Emplo", "plan_name": "401457_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Basic Pl", "plan_name": "400100", "standard_charge_dollar": 30.37, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Basic Pl", "plan_name": "400100_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Federal", "plan_name": "400110", "standard_charge_dollar": 30.37, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Federal", "plan_name": "400110_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." } ] } ] }, { "description": "Decitabine 50 mg intravenous solution [76364]", "drug_information": { "unit": 1.00, "type": "EA" }, "code_information": [ { "code": "J0894", "type": "HCPCS" }, { "code": "71288-119-20", "type": "NDC" } ], "standard_charges": [ { "gross_charge": 1344.87, "minimum": 30.37, "maximum": 30.37, "setting": "both", "payers_information": [ { "payer_name": "Aetna", "plan_name": "700700", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna", "plan_name": "700700_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Miscellaneous", "plan_name": "700720", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Miscellaneous", "plan_name": "700720_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Ppo Hmo", "plan_name": "701720", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Ppo Hmo", "plan_name": "701720_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Ms State Emplo", "plan_name": "401457", "standard_charge_dollar": 30.37, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Ms State Emplo", "plan_name": "401457_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Basic Pl", "plan_name": "400100", "standard_charge_dollar": 30.37, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Basic Pl", "plan_name": "400100_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Federal", "plan_name": "400110", "standard_charge_dollar": 30.37, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Federal", "plan_name": "400110_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." } ] } ] }, { "description": "Deferoxamine 500 mg solution for injection [9723]", "drug_information": { "unit": 1.00, "type": "EA" }, "code_information": [ { "code": "J0895", "type": "HCPCS" }, { "code": "63323-597-10", "type": "NDC" } ], "standard_charges": [ { "gross_charge": 78.95, "minimum": 12.43, "maximum": 12.43, "setting": "both", "payers_information": [ { "payer_name": "Aetna", "plan_name": "700700", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna", "plan_name": "700700_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Miscellaneous", "plan_name": "700720", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Miscellaneous", "plan_name": "700720_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Ppo Hmo", "plan_name": "701720", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Ppo Hmo", "plan_name": "701720_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Ms State Emplo", "plan_name": "401457", "standard_charge_dollar": 12.43, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Ms State Emplo", "plan_name": "401457_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Basic Pl", "plan_name": "400100", "standard_charge_dollar": 12.43, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Basic Pl", "plan_name": "400100_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Federal", "plan_name": "400110", "standard_charge_dollar": 12.43, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Federal", "plan_name": "400110_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." } ] } ] }, { "description": "Luspatercept-aamt 25 mg subcutaneous solution [188854]", "drug_information": { "unit": 1.00, "type": "EA" }, "code_information": [ { "code": "J0896", "type": "HCPCS" }, { "code": "59572-711-01", "type": "NDC" } ], "standard_charges": [ { "gross_charge": 15525.04, "minimum": 41.24, "maximum": 13196.28, "setting": "both", "payers_information": [ { "payer_name": "Aarp", "plan_name": "500102", "standard_charge_dollar": 41.24, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna", "plan_name": "700700", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna", "plan_name": "700700_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Mcare Ffs 6005", "plan_name": "700703", "standard_charge_dollar": 41.24, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Miscellaneous", "plan_name": "700720", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Miscellaneous", "plan_name": "700720_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Ppo Hmo", "plan_name": "701720", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Ppo Hmo", "plan_name": "701720_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Ambetter 68069", "plan_name": "500516", "standard_charge_dollar": 41.24, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Ms State Emplo", "plan_name": "401457", "standard_charge_percentage": 0.80, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Ms State Emplo", "plan_name": "401457_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Basic Pl", "plan_name": "400100", "standard_charge_percentage": 0.85, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Basic Pl", "plan_name": "400100_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Federal", "plan_name": "400110", "standard_charge_percentage": 0.85, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Federal", "plan_name": "400110_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Cigna Healthsprings Ffs", "plan_name": "500064", "standard_charge_dollar": 41.24, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Conseco", "plan_name": "500302", "standard_charge_dollar": 41.24, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Humana Ffs 61101", "plan_name": "500006", "standard_charge_dollar": 41.24, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Medicare A", "plan_name": "100100", "standard_charge_dollar": 41.24, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Medicare A", "plan_name": "100500", "standard_charge_dollar": 41.24, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Medicare Part B Only", "plan_name": "100300", "standard_charge_dollar": 41.24, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Medicare Railroad", "plan_name": "100103", "standard_charge_dollar": 41.24, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Ms Physicians Care N", "plan_name": "714210", "standard_charge_dollar": 51.55, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Peoples Hlth Ffs 72126", "plan_name": "500019", "standard_charge_dollar": 41.24, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Uhc/Secure Horizons", "plan_name": "500449", "standard_charge_dollar": 41.24, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "United Health Care/", "plan_name": "500292", "standard_charge_dollar": 46.60, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "United Healthcare", "plan_name": "750104", "standard_charge_dollar": 46.60, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "United Healthcare Ba", "plan_name": "750090", "standard_charge_dollar": 46.60, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "United Healthcare Me", "plan_name": "501310", "standard_charge_dollar": 41.24, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Windsor Mcare Extra", "plan_name": "500778", "standard_charge_dollar": 41.24, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." } ] } ] }, { "description": "Denosumab 60 mg/ml subcutaneous syringe [105502]", "drug_information": { "unit": 1.00, "type": "ML" }, "code_information": [ { "code": "J0897", "type": "HCPCS" }, { "code": "55513-710-01", "type": "NDC" } ], "standard_charges": [ { "gross_charge": 6566.55, "minimum": 16.43, "maximum": 34.76, "setting": "both", "payers_information": [ { "payer_name": "Aarp", "plan_name": "500102", "standard_charge_dollar": 27.81, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna", "plan_name": "700700", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna", "plan_name": "700700_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Mcare Ffs 6005", "plan_name": "700703", "standard_charge_dollar": 27.81, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Miscellaneous", "plan_name": "700720", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Miscellaneous", "plan_name": "700720_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Ppo Hmo", "plan_name": "701720", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Ppo Hmo", "plan_name": "701720_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Ambetter 68069", "plan_name": "500516", "standard_charge_dollar": 27.81, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Ms State Emplo", "plan_name": "401457", "standard_charge_dollar": 16.43, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Ms State Emplo", "plan_name": "401457_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Basic Pl", "plan_name": "400100", "standard_charge_dollar": 16.43, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Basic Pl", "plan_name": "400100_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Federal", "plan_name": "400110", "standard_charge_dollar": 16.43, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Federal", "plan_name": "400110_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Cigna Healthsprings Ffs", "plan_name": "500064", "standard_charge_dollar": 27.81, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Conseco", "plan_name": "500302", "standard_charge_dollar": 27.81, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Humana Ffs 61101", "plan_name": "500006", "standard_charge_dollar": 27.81, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Medicare A", "plan_name": "100100", "standard_charge_dollar": 27.81, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Medicare A", "plan_name": "100500", "standard_charge_dollar": 27.81, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Medicare Part B Only", "plan_name": "100300", "standard_charge_dollar": 27.81, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Medicare Railroad", "plan_name": "100103", "standard_charge_dollar": 27.81, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Ms Physicians Care N", "plan_name": "714210", "standard_charge_dollar": 34.76, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Peoples Hlth Ffs 72126", "plan_name": "500019", "standard_charge_dollar": 27.81, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Uhc/Secure Horizons", "plan_name": "500449", "standard_charge_dollar": 27.81, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "United Health Care/", "plan_name": "500292", "standard_charge_dollar": 31.43, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "United Healthcare", "plan_name": "750104", "standard_charge_dollar": 31.43, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "United Healthcare Ba", "plan_name": "750090", "standard_charge_dollar": 31.43, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "United Healthcare Me", "plan_name": "501310", "standard_charge_dollar": 27.81, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Windsor Mcare Extra", "plan_name": "500778", "standard_charge_dollar": 27.81, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." } ] } ] }, { "description": "Denosumab 60 mg/ml subcutaneous syringe [105502]", "drug_information": { "unit": 1.00, "type": "ML" }, "code_information": [ { "code": "J0897", "type": "HCPCS" }, { "code": "55513-710-21", "type": "NDC" } ], "standard_charges": [ { "gross_charge": 7180.20, "minimum": 16.43, "maximum": 34.76, "setting": "both", "payers_information": [ { "payer_name": "Aarp", "plan_name": "500102", "standard_charge_dollar": 27.81, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna", "plan_name": "700700", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna", "plan_name": "700700_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Mcare Ffs 6005", "plan_name": "700703", "standard_charge_dollar": 27.81, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Miscellaneous", "plan_name": "700720", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Miscellaneous", "plan_name": "700720_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Ppo Hmo", "plan_name": "701720", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Ppo Hmo", "plan_name": "701720_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total 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"payer_name": "Bc/Bs Ms State Emplo", "plan_name": "401457_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Basic Pl", "plan_name": "400100", "standard_charge_dollar": 5.28, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Basic Pl", "plan_name": "400100_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Federal", "plan_name": "400110", "standard_charge_dollar": 5.28, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Federal", "plan_name": "400110_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." } ] } ] }, { "description": "Digoxin 250 mcg/ml (0.25 mg/ml) injection solution [108720]", "drug_information": { "unit": 2.00, "type": "ML" }, "code_information": [ { "code": "J1160", "type": "HCPCS" }, { "code": "0641-1410-31", "type": "NDC" } ], "standard_charges": [ { "gross_charge": 33.55, "minimum": 5.28, "maximum": 5.28, "setting": "both", "payers_information": [ { "payer_name": "Aetna", "plan_name": "700700", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna", "plan_name": "700700_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit 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allowed amounts." }, { "payer_name": "Bc/Bs Ms State Emplo", "plan_name": "401457", "standard_charge_dollar": 5.28, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Ms State Emplo", "plan_name": "401457_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Basic Pl", "plan_name": "400100", "standard_charge_dollar": 5.28, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Basic Pl", "plan_name": "400100_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of 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"Bc/Bs Of Ms Basic Pl", "plan_name": "400100_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Federal", "plan_name": "400110", "standard_charge_dollar": 5.28, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Federal", "plan_name": "400110_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." } ] } ] }, { "description": "Digoxin immune fab 40 mg intravenous solution [31432]", "drug_information": { "unit": 1.00, "type": "EA" }, "code_information": [ { "code": "J1162", "type": "HCPCS" }, { "code": "50633-120-11", "type": "NDC" } ], "standard_charges": [ { "gross_charge": 17389.80, 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"payer_name": "Aetna Miscellaneous", "plan_name": "700720", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Miscellaneous", "plan_name": "700720_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Ppo Hmo", "plan_name": "701720", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Ppo Hmo", "plan_name": "701720_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Ambetter 68069", "plan_name": "500516", "standard_charge_dollar": 4968.58, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Ms State Emplo", "plan_name": "401457", "standard_charge_dollar": 2808.96, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Ms State Emplo", "plan_name": "401457_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Basic Pl", "plan_name": "400100", "standard_charge_dollar": 2808.96, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Basic Pl", "plan_name": "400100_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Federal", "plan_name": "400110", "standard_charge_dollar": 2808.96, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Federal", "plan_name": "400110_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Cigna Healthsprings Ffs", "plan_name": "500064", "standard_charge_dollar": 4968.58, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Conseco", "plan_name": "500302", "standard_charge_dollar": 4968.58, "count": "0", 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}, { "payer_name": "Medicare Railroad", "plan_name": "100103", "standard_charge_dollar": 4968.58, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Ms Physicians Care N", "plan_name": "714210", "standard_charge_dollar": 6210.73, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Peoples Hlth Ffs 72126", "plan_name": "500019", "standard_charge_dollar": 4968.58, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Uhc/Secure Horizons", "plan_name": "500449", "standard_charge_dollar": 4968.58, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "United Health Care/", "plan_name": "500292", "standard_charge_dollar": 5614.50, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "United Healthcare", "plan_name": "750104", "standard_charge_dollar": 5614.50, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "United Healthcare Ba", "plan_name": "750090", "standard_charge_dollar": 5614.50, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "United Healthcare Me", "plan_name": "501310", "standard_charge_dollar": 4968.58, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Windsor Mcare Extra", "plan_name": "500778", "standard_charge_dollar": 4968.58, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." } ] } ] }, { "description": "Digoxin immune fab 40 mg intravenous solution [31432]", "drug_information": { "unit": 1.00, "type": "EA" }, "code_information": [ { "code": "J1162", "type": "HCPCS" }, { "code": "50633-121-11", "type": "NDC" } ], "standard_charges": [ { "gross_charge": 17389.80, "minimum": 2808.96, "maximum": 6210.73, "setting": "both", "payers_information": [ { "payer_name": "Aarp", "plan_name": "500102", "standard_charge_dollar": 4968.58, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna", "plan_name": "700700", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna", "plan_name": "700700_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent 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"additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Ppo Hmo", "plan_name": "701720_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Ambetter 68069", "plan_name": "500516", "standard_charge_dollar": 4968.58, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Ms State Emplo", "plan_name": "401457", "standard_charge_dollar": 2808.96, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Ms State Emplo", "plan_name": "401457_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Basic Pl", "plan_name": "400100", "standard_charge_dollar": 2808.96, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Basic Pl", "plan_name": "400100_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Federal", "plan_name": "400110", "standard_charge_dollar": 2808.96, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Federal", "plan_name": "400110_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Cigna Healthsprings Ffs", "plan_name": "500064", "standard_charge_dollar": 4968.58, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Conseco", "plan_name": "500302", "standard_charge_dollar": 4968.58, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Humana Ffs 61101", "plan_name": "500006", "standard_charge_dollar": 4968.58, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Medicare A", "plan_name": "100100", "standard_charge_dollar": 4968.58, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Medicare A", "plan_name": "100500", "standard_charge_dollar": 4968.58, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Medicare Part B Only", "plan_name": "100300", "standard_charge_dollar": 4968.58, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Medicare Railroad", "plan_name": "100103", "standard_charge_dollar": 4968.58, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Ms Physicians Care N", "plan_name": "714210", "standard_charge_dollar": 6210.73, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Peoples Hlth Ffs 72126", "plan_name": "500019", "standard_charge_dollar": 4968.58, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Uhc/Secure Horizons", "plan_name": "500449", "standard_charge_dollar": 4968.58, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "United Health Care/", "plan_name": "500292", "standard_charge_dollar": 5614.50, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "United Healthcare", "plan_name": "750104", "standard_charge_dollar": 5614.50, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "United Healthcare Ba", "plan_name": "750090", "standard_charge_dollar": 5614.50, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "United Healthcare Me", "plan_name": "501310", "standard_charge_dollar": 4968.58, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Windsor Mcare Extra", "plan_name": "500778", "standard_charge_dollar": 4968.58, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." } ] } ] }, { "description": "Phenytoin sodium 50 mg/ml intravenous solution [6256]", "drug_information": { "unit": 5.00, "type": "ML" }, "code_information": [ { "code": "J1165", "type": "HCPCS" }, { "code": "0641-2555-41", "type": "NDC" } ], "standard_charges": [ { "gross_charge": 43.85, "minimum": 35.08, "maximum": 37.27, "setting": "both", "payers_information": [ { "payer_name": "Aetna", "plan_name": "700700", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna", "plan_name": "700700_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Miscellaneous", "plan_name": "700720", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Miscellaneous", "plan_name": "700720_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Ppo Hmo", "plan_name": "701720", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Ppo Hmo", "plan_name": "701720_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Ms State Emplo", "plan_name": "401457", "standard_charge_percentage": 0.80, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Ms State Emplo", "plan_name": "401457_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Basic Pl", "plan_name": "400100", "standard_charge_percentage": 0.85, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Basic 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"standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Ms State Emplo", "plan_name": "401457", "standard_charge_percentage": 0.80, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Ms State Emplo", "plan_name": "401457_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Basic Pl", "plan_name": "400100", "standard_charge_percentage": 0.85, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Basic Pl", "plan_name": "400100_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Federal", "plan_name": "400110", "standard_charge_percentage": 0.85, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Federal", "plan_name": "400110_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." } ] } ] }, { "description": "Diphenhydramine 50 mg/ml injection solution [2508]", "drug_information": { "unit": 1.00, "type": "ML" }, "code_information": [ { "code": "J1200", "type": "HCPCS" }, { "code": "0641-0376-21", "type": "NDC" } ], "standard_charges": [ { "gross_charge": 45.00, "minimum": 36.00, "maximum": 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"additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Ms State Emplo", "plan_name": "401457_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Basic Pl", "plan_name": "400100", "standard_charge_percentage": 0.85, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Basic Pl", "plan_name": "400100_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Federal", "plan_name": "400110", "standard_charge_percentage": 0.85, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Federal", "plan_name": "400110_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." } ] } ] }, { "description": "Diphenhydramine 50 mg/ml injection solution [2508]", "drug_information": { "unit": 1.00, "type": "ML" }, "code_information": [ { "code": "J1200", "type": "HCPCS" }, { "code": "72485-101-01", "type": "NDC" } ], "standard_charges": [ { "gross_charge": 45.00, "minimum": 36.00, "maximum": 38.25, "setting": "both", "payers_information": [ { "payer_name": "Aetna", "plan_name": "700700", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna", "plan_name": "700700_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Miscellaneous", "plan_name": "700720", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Miscellaneous", "plan_name": "700720_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Ppo Hmo", "plan_name": "701720", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Ppo Hmo", "plan_name": "701720_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Ms State Emplo", "plan_name": "401457", "standard_charge_percentage": 0.80, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Ms State Emplo", "plan_name": "401457_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Basic Pl", "plan_name": "400100", "standard_charge_percentage": 0.85, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Basic Pl", "plan_name": "400100_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Federal", "plan_name": "400110", "standard_charge_percentage": 0.85, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Federal", "plan_name": "400110_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." } ] } ] }, { "description": "Diphenhydramine 50 mg/ml injection solution [2508]", "drug_information": { "unit": 1.00, "type": "ML" }, "code_information": [ { "code": "J1200", "type": "HCPCS" }, { "code": "72485-101-25", "type": "NDC" } ], "standard_charges": [ { "gross_charge": 45.00, "minimum": 36.00, "maximum": 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amounts." } ] } ] }, { "description": "Chlorothiazide sodium 500 mg intravenous solution [9526]", "drug_information": { "unit": 1.00, "type": "EA" }, "code_information": [ { "code": "J1205", "type": "HCPCS" }, { "code": "63323-658-20", "type": "NDC" } ], "standard_charges": [ { "gross_charge": 1815.95, "minimum": 191.04, "maximum": 191.04, "setting": "both", "payers_information": [ { "payer_name": "Aetna", "plan_name": "700700", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna", "plan_name": "700700_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Miscellaneous", "plan_name": "700720", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total 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191.04, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Basic Pl", "plan_name": "400100_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Federal", "plan_name": "400110", "standard_charge_dollar": 191.04, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Federal", "plan_name": "400110_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." } ] } ] }, { "description": "Chlorothiazide sodium 500 mg intravenous solution [9526]", "drug_information": { "unit": 1.00, "type": "EA" }, "code_information": [ { "code": "J1205", "type": "HCPCS" }, { "code": "47335-330-40", "type": "NDC" } ], "standard_charges": [ { "gross_charge": 499.00, "minimum": 191.04, "maximum": 191.04, "setting": "both", "payers_information": [ { "payer_name": "Aetna", "plan_name": "700700", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna", "plan_name": "700700_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Miscellaneous", "plan_name": "700720", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Miscellaneous", "plan_name": "700720_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Ppo Hmo", "plan_name": "701720", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Ppo Hmo", "plan_name": "701720_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Ms State Emplo", "plan_name": "401457", "standard_charge_dollar": 191.04, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Ms State Emplo", "plan_name": "401457_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Basic Pl", "plan_name": "400100", "standard_charge_dollar": 191.04, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Basic Pl", "plan_name": "400100_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Federal", "plan_name": "400110", "standard_charge_dollar": 191.04, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Federal", "plan_name": "400110_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." } ] } ] }, { "description": "Chlorothiazide sodium 500 mg intravenous solution [9526]", "drug_information": { "unit": 1.00, "type": "EA" }, "code_information": [ { "code": "J1205", "type": "HCPCS" }, { "code": "0517-1820-01", "type": "NDC" } ], "standard_charges": [ { "gross_charge": 999.90, "minimum": 191.04, "maximum": 191.04, "setting": "both", "payers_information": [ { "payer_name": "Aetna", "plan_name": "700700", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna", "plan_name": "700700_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Miscellaneous", "plan_name": "700720", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Miscellaneous", "plan_name": "700720_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Ppo Hmo", "plan_name": "701720", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Ppo Hmo", "plan_name": "701720_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Ms State Emplo", "plan_name": "401457", "standard_charge_dollar": 191.04, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Ms State Emplo", "plan_name": "401457_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Basic Pl", "plan_name": "400100", "standard_charge_dollar": 191.04, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Basic Pl", "plan_name": "400100_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Federal", "plan_name": "400110", "standard_charge_dollar": 191.04, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Federal", "plan_name": "400110_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." } ] } ] }, { "description": "Dimethyl sulfoxide 50 % intravesical solution [118456]", "drug_information": { "unit": 50.00, "type": "ML" }, "code_information": [ { "code": "J1212", "type": "HCPCS" }, { "code": "67457-177-50", "type": "NDC" } ], "standard_charges": [ { "gross_charge": 3475.00, "minimum": 545.82, "maximum": 893.40, "setting": "both", "payers_information": [ { "payer_name": "Aarp", "plan_name": "500102", "standard_charge_dollar": 714.72, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna", "plan_name": "700700", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna", "plan_name": "700700_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Mcare Ffs 6005", "plan_name": "700703", "standard_charge_dollar": 714.72, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Miscellaneous", "plan_name": "700720", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Miscellaneous", "plan_name": "700720_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Ppo Hmo", "plan_name": "701720", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Ppo Hmo", "plan_name": "701720_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Ambetter 68069", "plan_name": "500516", "standard_charge_dollar": 714.72, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Ms State Emplo", "plan_name": "401457", "standard_charge_dollar": 545.82, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Ms State Emplo", "plan_name": "401457_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Basic Pl", "plan_name": "400100", "standard_charge_dollar": 545.82, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Basic Pl", "plan_name": "400100_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Federal", "plan_name": "400110", "standard_charge_dollar": 545.82, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Federal", "plan_name": "400110_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Cigna Healthsprings Ffs", "plan_name": "500064", "standard_charge_dollar": 714.72, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Conseco", "plan_name": "500302", "standard_charge_dollar": 714.72, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Humana Ffs 61101", "plan_name": "500006", "standard_charge_dollar": 714.72, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Medicare A", "plan_name": "100100", "standard_charge_dollar": 714.72, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Medicare A", "plan_name": "100500", "standard_charge_dollar": 714.72, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Medicare Part B Only", "plan_name": "100300", "standard_charge_dollar": 714.72, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Medicare Railroad", "plan_name": "100103", "standard_charge_dollar": 714.72, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Ms Physicians Care N", "plan_name": "714210", "standard_charge_dollar": 893.40, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Peoples Hlth Ffs 72126", "plan_name": "500019", "standard_charge_dollar": 714.72, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Uhc/Secure Horizons", "plan_name": "500449", "standard_charge_dollar": 714.72, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "United Health Care/", "plan_name": "500292", "standard_charge_dollar": 807.63, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "United Healthcare", "plan_name": "750104", "standard_charge_dollar": 807.63, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "United Healthcare Ba", "plan_name": "750090", "standard_charge_dollar": 807.63, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "United Healthcare Me", "plan_name": "501310", "standard_charge_dollar": 714.72, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Windsor Mcare Extra", "plan_name": "500778", "standard_charge_dollar": 714.72, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." } ] } ] }, { "description": "Dipyridamole 5 mg/ml intravenous solution [9891]", "drug_information": { "unit": 10.00, "type": "ML" }, "code_information": [ { "code": "J1245", "type": "HCPCS" }, { "code": "0641-2569-44", "type": "NDC" } ], "standard_charges": [ { "gross_charge": 100.00, "minimum": 80.00, "maximum": 85.00, "setting": "both", "payers_information": [ { "payer_name": "Aetna", "plan_name": "700700", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna", "plan_name": "700700_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Miscellaneous", "plan_name": "700720", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Miscellaneous", "plan_name": "700720_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Ppo Hmo", "plan_name": "701720", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Ppo Hmo", "plan_name": "701720_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Ms State Emplo", "plan_name": "401457", "standard_charge_percentage": 0.80, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Ms State Emplo", "plan_name": "401457_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Basic Pl", "plan_name": "400100", "standard_charge_percentage": 0.85, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Basic Pl", "plan_name": "400100_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Federal", "plan_name": "400110", "standard_charge_percentage": 0.85, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Federal", "plan_name": "400110_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." } ] } ] }, { "description": "Dobutamine 250 mg/250 ml (1 mg/ml) in 5 % dextrose intravenous [15981]", "drug_information": { "unit": 250.00, "type": "ML" }, "code_information": [ { "code": "J1250", "type": "HCPCS" }, { "code": "0338-1073-02", "type": "NDC" } ], "standard_charges": [ { "gross_charge": 181.56, "minimum": 145.25, "maximum": 154.33, "setting": "both", "payers_information": [ { "payer_name": "Aetna", "plan_name": "700700", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna", "plan_name": "700700_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Miscellaneous", "plan_name": "700720", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Miscellaneous", "plan_name": "700720_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Ppo Hmo", "plan_name": "701720", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Ppo Hmo", "plan_name": "701720_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Ms State Emplo", "plan_name": "401457", "standard_charge_percentage": 0.80, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Ms State Emplo", "plan_name": "401457_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Basic Pl", "plan_name": "400100", "standard_charge_percentage": 0.85, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Basic Pl", "plan_name": "400100_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Federal", "plan_name": "400110", "standard_charge_percentage": 0.85, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Federal", "plan_name": "400110_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." } ] } ] }, { "description": "Dobutamine 500 mg/250 ml (2000 mcg/ml) in 5 % dextrose iv [18315]", "drug_information": { "unit": 250.00, "type": "ML" }, "code_information": [ { "code": "J1250", "type": "HCPCS" }, { "code": "0338-1075-02", "type": "NDC" } ], "standard_charges": [ { "gross_charge": 259.94, "minimum": 207.95, "maximum": 220.95, "setting": "both", "payers_information": [ { "payer_name": "Aetna", "plan_name": "700700", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna", "plan_name": "700700_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Miscellaneous", "plan_name": "700720", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Miscellaneous", "plan_name": "700720_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Ppo Hmo", "plan_name": "701720", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Ppo Hmo", "plan_name": "701720_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Ms State Emplo", "plan_name": "401457", "standard_charge_percentage": 0.80, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Ms State Emplo", "plan_name": "401457_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Basic Pl", "plan_name": "400100", "standard_charge_percentage": 0.85, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Basic Pl", "plan_name": "400100_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Federal", "plan_name": "400110", "standard_charge_percentage": 0.85, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Federal", "plan_name": "400110_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." } ] } ] }, { "description": "Dobutamine 250 mg/20 ml (12.5 mg/ml) intravenous solution [9892]", "drug_information": { "unit": 20.00, "type": "ML" }, "code_information": [ { "code": "J1250", "type": "HCPCS" }, { "code": "0409-2344-01", "type": "NDC" } ], "standard_charges": [ { "gross_charge": 76.90, "minimum": 61.52, "maximum": 65.37, "setting": "both", "payers_information": [ { "payer_name": "Aetna", "plan_name": "700700", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna", "plan_name": "700700_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Miscellaneous", "plan_name": "700720", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Miscellaneous", "plan_name": "700720_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Ppo Hmo", "plan_name": "701720", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Ppo Hmo", "plan_name": "701720_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Ms State Emplo", "plan_name": "401457", "standard_charge_percentage": 0.80, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Ms State Emplo", "plan_name": "401457_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Basic Pl", "plan_name": "400100", "standard_charge_percentage": 0.85, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Basic Pl", "plan_name": "400100_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Federal", "plan_name": "400110", "standard_charge_percentage": 0.85, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Federal", "plan_name": "400110_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." } ] } ] }, { "description": "Dobutamine 250 mg/250 ml (1 mg/ml) in 5 % dextrose intravenous [15981]", "drug_information": { "unit": 250.00, "type": "ML" }, "code_information": [ { "code": "J1250", "type": "HCPCS" }, { "code": "0409-2346-31", "type": "NDC" } ], "standard_charges": [ { "gross_charge": 122.19, "minimum": 97.75, "maximum": 103.86, "setting": "both", "payers_information": [ { "payer_name": "Aetna", "plan_name": "700700", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna", "plan_name": "700700_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Miscellaneous", "plan_name": "700720", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Miscellaneous", "plan_name": "700720_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Ppo Hmo", "plan_name": "701720", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Ppo Hmo", "plan_name": "701720_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Ms State Emplo", "plan_name": "401457", "standard_charge_percentage": 0.80, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Ms State Emplo", "plan_name": "401457_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Basic Pl", "plan_name": "400100", "standard_charge_percentage": 0.85, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Basic Pl", "plan_name": "400100_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Federal", "plan_name": "400110", "standard_charge_percentage": 0.85, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Federal", "plan_name": "400110_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." } ] } ] }, { "description": "Dobutamine 250 mg/250 ml (1 mg/ml) in 5 % dextrose intravenous [15981]", "drug_information": { "unit": 250.00, "type": "ML" }, "code_information": [ { "code": "J1250", "type": "HCPCS" }, { "code": "0409-2346-32", "type": "NDC" } ], "standard_charges": [ { "gross_charge": 122.19, "minimum": 97.75, "maximum": 103.86, "setting": "both", "payers_information": [ { "payer_name": "Aetna", "plan_name": "700700", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna", "plan_name": "700700_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Miscellaneous", "plan_name": "700720", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Miscellaneous", "plan_name": "700720_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Ppo Hmo", "plan_name": "701720", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Ppo Hmo", "plan_name": "701720_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Ms State Emplo", "plan_name": "401457", "standard_charge_percentage": 0.80, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Ms State Emplo", "plan_name": "401457_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Basic Pl", "plan_name": "400100", "standard_charge_percentage": 0.85, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms 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"standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Basic Pl", "plan_name": "400100", "standard_charge_percentage": 0.85, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Basic Pl", "plan_name": "400100_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Federal", "plan_name": "400110", "standard_charge_percentage": 0.85, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Federal", "plan_name": "400110_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." } ] } ] }, { "description": "Dopamine 400 mg/250 ml (1600 mcg/ml) in 5 % dextrose intravenous soln [14845]", "drug_information": { "unit": 250.00, "type": "ML" }, "code_information": [ { "code": "J1265", "type": "HCPCS" }, { "code": "0338-1007-02", "type": "NDC" } ], "standard_charges": [ { "gross_charge": 144.75, "minimum": 115.80, "maximum": 123.04, "setting": "both", "payers_information": [ { "payer_name": "Aetna", "plan_name": "700700", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna", "plan_name": "700700_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Miscellaneous", "plan_name": "700720", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Miscellaneous", "plan_name": "700720_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Ppo Hmo", "plan_name": "701720", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Ppo Hmo", "plan_name": "701720_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Ms State Emplo", "plan_name": "401457", "standard_charge_percentage": 0.80, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Ms State Emplo", "plan_name": "401457_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Basic Pl", "plan_name": "400100", "standard_charge_percentage": 0.85, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Basic Pl", "plan_name": "400100_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Federal", "plan_name": "400110", "standard_charge_percentage": 0.85, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Federal", "plan_name": "400110_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." } ] } ] }, { "description": "Dopamine 800 mg/500 ml (1600 mcg/ml) in 5 % dextrose intravenous soln [118603]", "drug_information": { "unit": 500.00, "type": "ML" }, "code_information": [ { "code": "J1265", "type": "HCPCS" }, { "code": "0338-1007-03", "type": "NDC" } ], "standard_charges": [ { "gross_charge": 183.94, "minimum": 147.15, "maximum": 156.35, "setting": "both", "payers_information": [ { "payer_name": "Aetna", "plan_name": "700700", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna", "plan_name": "700700_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Miscellaneous", "plan_name": "700720", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Miscellaneous", "plan_name": "700720_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Ppo Hmo", "plan_name": "701720", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Ppo Hmo", "plan_name": "701720_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Ms State Emplo", "plan_name": "401457", "standard_charge_percentage": 0.80, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Ms State Emplo", "plan_name": "401457_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Basic Pl", "plan_name": "400100", "standard_charge_percentage": 0.85, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Basic Pl", "plan_name": "400100_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Federal", "plan_name": "400110", "standard_charge_percentage": 0.85, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Federal", "plan_name": "400110_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." } ] } ] }, { "description": "Doxercalciferol 4 mcg/2 ml intravenous solution [28277]", "drug_information": { "unit": 2.00, "type": "ML" }, "code_information": [ { "code": "J1270", "type": "HCPCS" }, { "code": "0409-1330-01", "type": "NDC" } ], "standard_charges": [ { "gross_charge": 20.30, "minimum": 16.24, "maximum": 17.26, "setting": "both", "payers_information": [ { "payer_name": "Aetna", "plan_name": "700700", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna", "plan_name": "700700_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Miscellaneous", "plan_name": "700720", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Miscellaneous", "plan_name": "700720_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Ppo Hmo", "plan_name": "701720", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Ppo Hmo", "plan_name": "701720_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Ms State Emplo", "plan_name": "401457", "standard_charge_percentage": 0.80, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Ms State Emplo", "plan_name": "401457_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Basic Pl", "plan_name": "400100", "standard_charge_percentage": 0.85, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Basic Pl", "plan_name": "400100_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Federal", "plan_name": "400110", "standard_charge_percentage": 0.85, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Federal", "plan_name": "400110_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." } ] } ] }, { "description": "Doxercalciferol 4 mcg/2 ml intravenous solution [28277]", "drug_information": { "unit": 2.00, "type": "ML" }, "code_information": [ { "code": "J1270", "type": "HCPCS" }, { "code": "0409-1330-11", "type": "NDC" } ], "standard_charges": [ { "gross_charge": 20.30, "minimum": 16.24, "maximum": 17.26, "setting": "both", "payers_information": [ { "payer_name": "Aetna", "plan_name": "700700", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna", "plan_name": "700700_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Miscellaneous", "plan_name": "700720", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Miscellaneous", "plan_name": "700720_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Ppo Hmo", "plan_name": "701720", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Ppo Hmo", "plan_name": "701720_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Ms State Emplo", "plan_name": "401457", "standard_charge_percentage": 0.80, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Ms State Emplo", "plan_name": "401457_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Basic Pl", "plan_name": "400100", "standard_charge_percentage": 0.85, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Basic Pl", "plan_name": "400100_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Federal", "plan_name": "400110", "standard_charge_percentage": 0.85, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Federal", "plan_name": "400110_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." } ] } ] }, { "description": "Ecallantide 10 mg/ml (1 ml) subcutaneous solution [100698]", "drug_information": { "unit": 3.00, "type": "ML" }, "code_information": [ { "code": "J1290", "type": "HCPCS" }, { "code": "47783-101-01", "type": "NDC" } ], "standard_charges": [ { "gross_charge": 59365.87, "minimum": 403.98, "maximum": 705.80, "setting": "both", "payers_information": [ { "payer_name": "Aarp", "plan_name": "500102", "standard_charge_dollar": 564.64, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna", "plan_name": "700700", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna", "plan_name": "700700_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Mcare Ffs 6005", "plan_name": "700703", "standard_charge_dollar": 564.64, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Miscellaneous", "plan_name": "700720", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Miscellaneous", "plan_name": "700720_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Ppo Hmo", "plan_name": "701720", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Ppo Hmo", "plan_name": "701720_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Ambetter 68069", "plan_name": "500516", "standard_charge_dollar": 564.64, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Ms State Emplo", "plan_name": "401457", "standard_charge_dollar": 403.98, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Ms State Emplo", "plan_name": "401457_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Basic Pl", "plan_name": "400100", "standard_charge_dollar": 403.98, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Basic Pl", "plan_name": "400100_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Federal", "plan_name": "400110", "standard_charge_dollar": 403.98, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Federal", "plan_name": "400110_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Cigna Healthsprings Ffs", "plan_name": "500064", "standard_charge_dollar": 564.64, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Conseco", "plan_name": "500302", "standard_charge_dollar": 564.64, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Humana Ffs 61101", "plan_name": "500006", "standard_charge_dollar": 564.64, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Medicare A", "plan_name": "100100", "standard_charge_dollar": 564.64, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Medicare A", "plan_name": "100500", "standard_charge_dollar": 564.64, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Medicare Part B Only", "plan_name": "100300", "standard_charge_dollar": 564.64, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Medicare Railroad", "plan_name": "100103", "standard_charge_dollar": 564.64, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Ms Physicians Care N", "plan_name": "714210", "standard_charge_dollar": 705.80, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Peoples Hlth Ffs 72126", "plan_name": "500019", "standard_charge_dollar": 564.64, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Uhc/Secure Horizons", "plan_name": "500449", "standard_charge_dollar": 564.64, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "United Health Care/", "plan_name": "500292", "standard_charge_dollar": 638.04, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "United Healthcare", "plan_name": "750104", "standard_charge_dollar": 638.04, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "United Healthcare Ba", "plan_name": "750090", "standard_charge_dollar": 638.04, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "United Healthcare Me", "plan_name": "501310", "standard_charge_dollar": 564.64, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Windsor Mcare Extra", "plan_name": "500778", "standard_charge_dollar": 564.64, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." } ] } ] }, { "description": "Inclisiran 284 mg/1.5 ml subcutaneous syringe [195753]", "drug_information": { "unit": 1.50, "type": "ML" }, "code_information": [ { "code": "J1306", "type": "HCPCS" }, { "code": "0078-1000-60", "type": "NDC" } ], "standard_charges": [ { "gross_charge": 16806.35, "minimum": 11.24, "maximum": 14285.40, "setting": "both", "payers_information": [ { "payer_name": "Aarp", "plan_name": "500102", "standard_charge_dollar": 11.24, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna", "plan_name": "700700", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna", "plan_name": "700700_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Mcare Ffs 6005", "plan_name": "700703", "standard_charge_dollar": 11.24, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Miscellaneous", "plan_name": "700720", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Miscellaneous", "plan_name": "700720_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Ppo Hmo", "plan_name": "701720", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Ppo Hmo", "plan_name": "701720_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Ambetter 68069", "plan_name": "500516", "standard_charge_dollar": 11.24, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Ms State Emplo", "plan_name": "401457", "standard_charge_percentage": 0.80, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Ms State Emplo", "plan_name": "401457_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Basic Pl", "plan_name": "400100", "standard_charge_percentage": 0.85, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Basic Pl", "plan_name": "400100_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Federal", "plan_name": "400110", "standard_charge_percentage": 0.85, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Federal", "plan_name": "400110_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Cigna Healthsprings Ffs", "plan_name": "500064", "standard_charge_dollar": 11.24, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Conseco", "plan_name": "500302", "standard_charge_dollar": 11.24, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Humana Ffs 61101", "plan_name": "500006", "standard_charge_dollar": 11.24, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Medicare A", "plan_name": "100100", "standard_charge_dollar": 11.24, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Medicare A", "plan_name": "100500", "standard_charge_dollar": 11.24, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Medicare Part B Only", "plan_name": "100300", "standard_charge_dollar": 11.24, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Medicare Railroad", "plan_name": "100103", "standard_charge_dollar": 11.24, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Ms Physicians Care N", "plan_name": "714210", "standard_charge_dollar": 14.05, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Peoples Hlth Ffs 72126", "plan_name": "500019", "standard_charge_dollar": 11.24, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Uhc/Secure Horizons", "plan_name": "500449", "standard_charge_dollar": 11.24, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "United Health Care/", "plan_name": "500292", "standard_charge_dollar": 12.70, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "United Healthcare", "plan_name": "750104", "standard_charge_dollar": 12.70, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "United Healthcare Ba", "plan_name": "750090", "standard_charge_dollar": 12.70, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "United Healthcare Me", "plan_name": "501310", "standard_charge_dollar": 11.24, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Windsor Mcare Extra", "plan_name": "500778", "standard_charge_dollar": 11.24, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." } ] } ] }, { "description": "Epoprostenol (glycine) 0.5 mg intravenous solution [15897]", "drug_information": { "unit": 1.00, "type": "EA" }, "code_information": [ { "code": "J1325", "type": "HCPCS" }, { "code": "0173-0517-00", "type": "NDC" } ], "standard_charges": [ { "gross_charge": 75.13, "minimum": 16.72, "maximum": 16.72, "setting": "both", "payers_information": [ { "payer_name": "Aetna", "plan_name": "700700", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna", "plan_name": "700700_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Miscellaneous", "plan_name": "700720", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Miscellaneous", "plan_name": "700720_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Ppo Hmo", "plan_name": "701720", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Ppo Hmo", "plan_name": "701720_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Ms State Emplo", "plan_name": "401457", "standard_charge_dollar": 16.72, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Ms State Emplo", "plan_name": "401457_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Basic Pl", "plan_name": "400100", "standard_charge_dollar": 16.72, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Basic Pl", "plan_name": "400100_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Federal", "plan_name": "400110", "standard_charge_dollar": 16.72, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Federal", "plan_name": "400110_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." } ] } ] }, { "description": "Epoprostenol (glycine) 1.5 mg intravenous solution [15898]", "drug_information": { "unit": 1.00, "type": "EA" }, "code_information": [ { "code": "J1325", "type": "HCPCS" }, { "code": "0173-0519-00", "type": "NDC" } ], "standard_charges": [ { "gross_charge": 225.70, "minimum": 16.72, "maximum": 16.72, "setting": "both", "payers_information": [ { "payer_name": "Aetna", "plan_name": "700700", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna", "plan_name": "700700_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Miscellaneous", "plan_name": "700720", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Miscellaneous", "plan_name": "700720_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Ppo Hmo", "plan_name": "701720", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Ppo Hmo", "plan_name": "701720_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Ms State Emplo", "plan_name": "401457", "standard_charge_dollar": 16.72, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Ms State Emplo", "plan_name": "401457_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Basic Pl", "plan_name": "400100", "standard_charge_dollar": 16.72, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Basic Pl", "plan_name": "400100_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Federal", "plan_name": "400110", "standard_charge_dollar": 16.72, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Federal", "plan_name": "400110_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." } ] } ] }, { "description": "Eptifibatide 0.75 mg/ml intravenous solution [23123]", "drug_information": { "unit": 100.00, "type": "ML" }, "code_information": [ { "code": "J1327", "type": "HCPCS" }, { "code": "55150-218-99", "type": "NDC" } ], "standard_charges": [ { "gross_charge": 1440.00, "minimum": 36.10, "maximum": 36.10, "setting": "both", "payers_information": [ { "payer_name": "Aetna", "plan_name": "700700", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna", "plan_name": "700700_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Miscellaneous", "plan_name": "700720", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Miscellaneous", "plan_name": "700720_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Ppo Hmo", "plan_name": "701720", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Ppo Hmo", "plan_name": "701720_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Ms State Emplo", "plan_name": "401457", "standard_charge_dollar": 36.10, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Ms State Emplo", "plan_name": "401457_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Basic Pl", "plan_name": "400100", "standard_charge_dollar": 36.10, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Basic Pl", "plan_name": "400100_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Federal", "plan_name": "400110", "standard_charge_dollar": 36.10, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Federal", "plan_name": "400110_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." } ] } ] }, { "description": "Eptifibatide 2 mg/ml intravenous solution [23124]", "drug_information": { "unit": 10.00, "type": "ML" }, "code_information": [ { "code": "J1327", "type": "HCPCS" }, { "code": "55150-219-10", "type": "NDC" } ], "standard_charges": [ { "gross_charge": 364.55, "minimum": 36.10, "maximum": 36.10, "setting": "both", "payers_information": [ { "payer_name": "Aetna", "plan_name": "700700", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna", "plan_name": "700700_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Miscellaneous", "plan_name": "700720", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Miscellaneous", "plan_name": "700720_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Ppo Hmo", "plan_name": "701720", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Ppo Hmo", "plan_name": "701720_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Ms State Emplo", "plan_name": "401457", "standard_charge_dollar": 36.10, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Ms State Emplo", "plan_name": "401457_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Basic Pl", "plan_name": "400100", "standard_charge_dollar": 36.10, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Basic Pl", "plan_name": "400100_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Federal", "plan_name": "400110", "standard_charge_dollar": 36.10, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Federal", "plan_name": "400110_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." } ] } ] }, { "description": "Eptifibatide 0.75 mg/ml intravenous solution [23123]", "drug_information": { "unit": 100.00, "type": "ML" }, "code_information": [ { "code": "J1327", "type": "HCPCS" }, { "code": "25021-408-51", "type": "NDC" } ], "standard_charges": [ { "gross_charge": 1525.00, "minimum": 36.10, "maximum": 36.10, "setting": "both", "payers_information": [ { "payer_name": "Aetna", "plan_name": "700700", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna", "plan_name": "700700_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Miscellaneous", "plan_name": "700720", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Miscellaneous", "plan_name": "700720_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Ppo Hmo", "plan_name": "701720", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Ppo Hmo", "plan_name": "701720_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Ms State Emplo", "plan_name": "401457", "standard_charge_dollar": 36.10, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Ms State Emplo", "plan_name": "401457_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Basic Pl", "plan_name": "400100", "standard_charge_dollar": 36.10, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Basic Pl", "plan_name": "400100_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Federal", "plan_name": "400110", "standard_charge_dollar": 36.10, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Federal", "plan_name": "400110_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." } ] } ] }, { "description": "Eptifibatide 2 mg/ml intravenous solution [23124]", "drug_information": { "unit": 10.00, "type": "ML" }, "code_information": [ { "code": "J1327", "type": "HCPCS" }, { "code": "67457-629-10", "type": "NDC" } ], "standard_charges": [ { "gross_charge": 238.00, "minimum": 36.10, "maximum": 36.10, "setting": "both", "payers_information": [ { "payer_name": "Aetna", "plan_name": "700700", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna", "plan_name": "700700_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Miscellaneous", "plan_name": "700720", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Miscellaneous", "plan_name": "700720_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Ppo Hmo", "plan_name": "701720", "standard_charge_percentage": 80.0, "count": "0", 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data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Federal", "plan_name": "400110_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." } ] } ] }, { "description": "Erythromycin lactobionate 500 mg intravenous solution [2903]", "drug_information": { "unit": 1.00, "type": "EA" }, "code_information": [ { "code": "J1364", "type": "HCPCS" }, { "code": "0409-6476-54", "type": "NDC" } ], "standard_charges": [ { "gross_charge": 422.72, "minimum": 60.03, "maximum": 60.03, "setting": "both", "payers_information": [ { "payer_name": "Aetna", "plan_name": "700700", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna", "plan_name": "700700_1", "standard_charge_percentage": 100.0, "count": "0", 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"percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Ms State Emplo", "plan_name": "401457", "standard_charge_dollar": 60.03, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Ms State Emplo", "plan_name": "401457_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Basic Pl", "plan_name": "400100", "standard_charge_dollar": 60.03, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Basic Pl", "plan_name": "400100_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Federal", "plan_name": "400110", "standard_charge_dollar": 60.03, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Federal", "plan_name": "400110_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." } ] } ] }, { "description": "Erythromycin lactobionate 500 mg intravenous solution [2903]", "drug_information": { "unit": 1.00, "type": "EA" }, "code_information": [ { "code": "J1364", "type": "HCPCS" }, { "code": "0409-6482-01", "type": "NDC" } ], "standard_charges": [ { "gross_charge": 427.43, "minimum": 60.03, "maximum": 60.03, "setting": "both", "payers_information": [ { "payer_name": "Aetna", "plan_name": "700700", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna", "plan_name": "700700_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Miscellaneous", "plan_name": "700720", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Miscellaneous", "plan_name": "700720_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Ppo Hmo", "plan_name": "701720", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Ppo Hmo", "plan_name": "701720_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Ms State Emplo", "plan_name": "401457", "standard_charge_dollar": 60.03, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Ms State Emplo", "plan_name": "401457_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Basic Pl", "plan_name": "400100", "standard_charge_dollar": 60.03, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Basic Pl", "plan_name": "400100_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Federal", "plan_name": "400110", "standard_charge_dollar": 60.03, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Federal", "plan_name": "400110_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." } ] } ] }, { "description": "Erythromycin lactobionate 500 mg intravenous solution [2903]", "drug_information": { "unit": 1.00, "type": "EA" }, "code_information": [ { "code": "J1364", "type": "HCPCS" }, { "code": "0409-6482-11", "type": "NDC" } ], "standard_charges": [ { "gross_charge": 427.43, "minimum": 60.03, "maximum": 60.03, "setting": "both", "payers_information": [ { "payer_name": "Aetna", "plan_name": "700700", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna", "plan_name": "700700_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Miscellaneous", "plan_name": "700720", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Miscellaneous", "plan_name": "700720_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Ppo Hmo", "plan_name": "701720", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Ppo Hmo", "plan_name": "701720_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Ms State Emplo", "plan_name": "401457", "standard_charge_dollar": 60.03, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Ms State Emplo", "plan_name": "401457_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Basic Pl", "plan_name": "400100", "standard_charge_dollar": 60.03, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Basic Pl", "plan_name": "400100_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Federal", "plan_name": "400110", "standard_charge_dollar": 60.03, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Federal", "plan_name": "400110_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." } ] } ] }, { "description": "Conjugated estrogens 25 mg solution for injection [9972]", "drug_information": { "unit": 1.00, "type": "EA" }, "code_information": [ { "code": "J1410", "type": "HCPCS" }, { "code": "0046-0749-05", "type": "NDC" } ], "standard_charges": [ { "gross_charge": 1730.95, "minimum": 252.77, "maximum": 478.61, "setting": "both", "payers_information": [ { "payer_name": "Aarp", "plan_name": "500102", "standard_charge_dollar": 382.89, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna", "plan_name": "700700", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna", "plan_name": "700700_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Mcare Ffs 6005", "plan_name": "700703", "standard_charge_dollar": 382.89, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Miscellaneous", "plan_name": "700720", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Miscellaneous", "plan_name": "700720_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Ppo Hmo", "plan_name": "701720", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Ppo Hmo", "plan_name": "701720_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Ambetter 68069", "plan_name": "500516", "standard_charge_dollar": 382.89, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Ms State Emplo", "plan_name": "401457", "standard_charge_dollar": 252.77, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Ms State Emplo", "plan_name": "401457_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Basic Pl", "plan_name": "400100", "standard_charge_dollar": 252.77, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Basic Pl", "plan_name": "400100_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Federal", "plan_name": "400110", "standard_charge_dollar": 252.77, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Federal", "plan_name": "400110_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Cigna Healthsprings Ffs", "plan_name": "500064", "standard_charge_dollar": 382.89, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Conseco", "plan_name": "500302", "standard_charge_dollar": 382.89, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Humana Ffs 61101", "plan_name": "500006", "standard_charge_dollar": 382.89, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Medicare A", "plan_name": "100100", "standard_charge_dollar": 382.89, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Medicare A", "plan_name": "100500", "standard_charge_dollar": 382.89, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Medicare Part B Only", "plan_name": "100300", "standard_charge_dollar": 382.89, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Medicare Railroad", "plan_name": "100103", "standard_charge_dollar": 382.89, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Ms Physicians Care N", "plan_name": "714210", "standard_charge_dollar": 478.61, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Peoples Hlth Ffs 72126", "plan_name": "500019", "standard_charge_dollar": 382.89, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Uhc/Secure Horizons", "plan_name": "500449", "standard_charge_dollar": 382.89, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "United Health Care/", "plan_name": "500292", "standard_charge_dollar": 432.67, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "United Healthcare", "plan_name": "750104", "standard_charge_dollar": 432.67, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "United Healthcare Ba", "plan_name": "750090", "standard_charge_dollar": 432.67, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "United Healthcare Me", "plan_name": "501310", "standard_charge_dollar": 382.89, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Windsor Mcare Extra", "plan_name": "500778", "standard_charge_dollar": 382.89, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." } ] } ] }, { "description": "Ethanolamine oleate 5 % intravenous solution [9984]", "drug_information": { "unit": 2.00, "type": "ML" }, "code_information": [ { "code": "J1430", "type": "HCPCS" }, { "code": "67871-4790-6", "type": "NDC" } ], "standard_charges": [ { "gross_charge": 2259.32, "minimum": 373.44, "maximum": 622.13, "setting": "both", "payers_information": [ { "payer_name": "Aarp", "plan_name": "500102", "standard_charge_dollar": 497.70, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna", "plan_name": "700700", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna", "plan_name": "700700_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Mcare Ffs 6005", "plan_name": "700703", "standard_charge_dollar": 497.70, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Miscellaneous", "plan_name": "700720", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Miscellaneous", "plan_name": "700720_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Ppo Hmo", "plan_name": "701720", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Ppo Hmo", "plan_name": "701720_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Ambetter 68069", "plan_name": "500516", "standard_charge_dollar": 497.70, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Ms State Emplo", "plan_name": "401457", "standard_charge_dollar": 373.44, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Ms State Emplo", "plan_name": "401457_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Basic Pl", "plan_name": "400100", "standard_charge_dollar": 373.44, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Basic Pl", "plan_name": "400100_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Federal", "plan_name": "400110", "standard_charge_dollar": 373.44, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Federal", "plan_name": "400110_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Cigna Healthsprings Ffs", "plan_name": "500064", "standard_charge_dollar": 497.70, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Conseco", "plan_name": "500302", "standard_charge_dollar": 497.70, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Humana Ffs 61101", "plan_name": "500006", "standard_charge_dollar": 497.70, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Medicare A", "plan_name": "100100", "standard_charge_dollar": 497.70, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Medicare A", "plan_name": "100500", "standard_charge_dollar": 497.70, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Medicare Part B Only", "plan_name": "100300", "standard_charge_dollar": 497.70, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Medicare Railroad", "plan_name": "100103", "standard_charge_dollar": 497.70, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Ms Physicians Care N", "plan_name": "714210", "standard_charge_dollar": 622.13, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Peoples Hlth Ffs 72126", "plan_name": "500019", "standard_charge_dollar": 497.70, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Uhc/Secure Horizons", "plan_name": "500449", "standard_charge_dollar": 497.70, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "United Health Care/", "plan_name": "500292", "standard_charge_dollar": 562.40, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "United Healthcare", "plan_name": "750104", "standard_charge_dollar": 562.40, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "United Healthcare Ba", "plan_name": "750090", "standard_charge_dollar": 562.40, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "United Healthcare Me", "plan_name": "501310", "standard_charge_dollar": 497.70, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Windsor Mcare Extra", "plan_name": "500778", "standard_charge_dollar": 497.70, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." } ] } ] }, { "description": "Ferric derisomaltose 100 mg iron/ml intravenous solution [191443]", "drug_information": { "unit": 10.00, "type": "ML" }, "code_information": [ { "code": "J1437", "type": "HCPCS" }, { "code": "73594-9310-1", "type": "NDC" } ], "standard_charges": [ { "gross_charge": 13005.02, "minimum": 20.83, "maximum": 11054.27, "setting": "both", "payers_information": [ { "payer_name": "Aarp", "plan_name": "500102", "standard_charge_dollar": 20.83, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna", "plan_name": "700700", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna", "plan_name": "700700_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Mcare Ffs 6005", "plan_name": "700703", "standard_charge_dollar": 20.83, "count": "0", "methodology": "fee schedule", 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"additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Ambetter 68069", "plan_name": "500516", "standard_charge_dollar": 20.83, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Ms State Emplo", "plan_name": "401457", "standard_charge_percentage": 0.80, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Ms State Emplo", "plan_name": "401457_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Basic Pl", "plan_name": "400100", "standard_charge_percentage": 0.85, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Basic Pl", "plan_name": "400100_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Federal", "plan_name": "400110", "standard_charge_percentage": 0.85, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Federal", "plan_name": "400110_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Cigna Healthsprings Ffs", "plan_name": "500064", "standard_charge_dollar": 20.83, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit 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"standard_charge_dollar": 20.83, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." } ] } ] }, { "description": "Ferric carboxymaltose 50 mg iron/ml intravenous solution [163490]", "drug_information": { "unit": 15.00, "type": "ML" }, "code_information": [ { "code": "J1439", "type": "HCPCS" }, { "code": "0517-0650-01", "type": "NDC" } ], "standard_charges": [ { "gross_charge": 5248.57, "minimum": 1.13, "maximum": 1.41, "setting": "both", "payers_information": [ { "payer_name": "Aarp", "plan_name": "500102", "standard_charge_dollar": 1.13, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna", "plan_name": "700700", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna", "plan_name": "700700_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Mcare Ffs 6005", "plan_name": "700703", "standard_charge_dollar": 1.13, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Miscellaneous", "plan_name": "700720", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Miscellaneous", "plan_name": "700720_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Ppo Hmo", "plan_name": "701720", 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"methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Basic Pl", "plan_name": "400100", "standard_charge_dollar": 1.18, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Basic Pl", "plan_name": "400100_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Federal", "plan_name": "400110", "standard_charge_dollar": 1.18, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Federal", "plan_name": "400110_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", 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"plan_name": "100500", "standard_charge_dollar": 1.13, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Medicare Part B Only", "plan_name": "100300", "standard_charge_dollar": 1.13, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Medicare Railroad", "plan_name": "100103", "standard_charge_dollar": 1.13, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Ms Physicians Care N", "plan_name": "714210", "standard_charge_dollar": 1.41, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Peoples Hlth Ffs 72126", "plan_name": "500019", "standard_charge_dollar": 1.13, "count": "0", "methodology": "fee schedule", 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"United Healthcare Me", "plan_name": "501310", "standard_charge_dollar": 1.13, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Windsor Mcare Extra", "plan_name": "500778", "standard_charge_dollar": 1.13, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." } ] } ] }, { "description": "Fecal microbiota live-jslm 150 ml rectal suspension enema [198896]", "drug_information": { "unit": 150.00, "type": "ML" }, "code_information": [ { "code": "J1440", "type": "HCPCS" }, { "code": "55566-9800-2", "type": "NDC" } ], "standard_charges": [ { "gross_charge": 42750.00, "minimum": 58.56, "maximum": 36337.50, "setting": "both", "payers_information": [ { "payer_name": "Aarp", "plan_name": "500102", "standard_charge_dollar": 58.56, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to 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Miscellaneous", "plan_name": "700720_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Ppo Hmo", "plan_name": "701720", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Ppo Hmo", "plan_name": "701720_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Ambetter 68069", "plan_name": "500516", "standard_charge_dollar": 58.56, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Ms State Emplo", "plan_name": "401457", "standard_charge_percentage": 0.80, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Ms State Emplo", "plan_name": "401457_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Basic Pl", "plan_name": "400100", "standard_charge_percentage": 0.85, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Basic Pl", "plan_name": "400100_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Federal", "plan_name": "400110", "standard_charge_percentage": 0.85, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Federal", "plan_name": "400110_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Cigna Healthsprings Ffs", "plan_name": "500064", "standard_charge_dollar": 58.56, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Conseco", "plan_name": "500302", "standard_charge_dollar": 58.56, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Humana Ffs 61101", "plan_name": "500006", "standard_charge_dollar": 58.56, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Medicare A", "plan_name": "100100", "standard_charge_dollar": 58.56, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Medicare A", "plan_name": "100500", "standard_charge_dollar": 58.56, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Medicare Part B Only", "plan_name": "100300", "standard_charge_dollar": 58.56, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Medicare Railroad", "plan_name": "100103", "standard_charge_dollar": 58.56, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Ms Physicians Care N", "plan_name": "714210", "standard_charge_dollar": 73.21, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Peoples Hlth Ffs 72126", "plan_name": "500019", "standard_charge_dollar": 58.56, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Uhc/Secure Horizons", "plan_name": "500449", "standard_charge_dollar": 58.56, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "United Health Care/", "plan_name": "500292", "standard_charge_dollar": 66.18, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "United Healthcare", "plan_name": "750104", "standard_charge_dollar": 66.18, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "United Healthcare Ba", "plan_name": "750090", "standard_charge_dollar": 66.18, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "United Healthcare Me", "plan_name": "501310", "standard_charge_dollar": 58.56, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Windsor Mcare Extra", "plan_name": "500778", "standard_charge_dollar": 58.56, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." } ] } ] }, { "description": "Filgrastim 480 mcg/0.8 ml injection syringe [112198]", "drug_information": { "unit": 0.80, "type": "ML" }, "code_information": [ { "code": "J1442", "type": "HCPCS" }, { "code": "55513-209-91", "type": "NDC" } ], "standard_charges": [ { "gross_charge": 2082.92, "minimum": 0.98, "maximum": 1.23, "setting": "both", "payers_information": [ { "payer_name": "Aarp", "plan_name": "500102", "standard_charge_dollar": 0.98, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna", "plan_name": "700700", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna", "plan_name": "700700_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Mcare Ffs 6005", "plan_name": "700703", "standard_charge_dollar": 0.98, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Miscellaneous", "plan_name": "700720", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Miscellaneous", "plan_name": "700720_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Ppo Hmo", "plan_name": "701720", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Ppo Hmo", "plan_name": "701720_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Ambetter 68069", "plan_name": "500516", "standard_charge_dollar": 0.98, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Ms State Emplo", "plan_name": "401457", "standard_charge_dollar": 0.98, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Ms State Emplo", "plan_name": "401457_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Basic Pl", "plan_name": "400100", "standard_charge_dollar": 0.98, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Basic Pl", "plan_name": "400100_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Federal", "plan_name": "400110", "standard_charge_dollar": 0.98, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Federal", "plan_name": "400110_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Cigna Healthsprings Ffs", "plan_name": "500064", "standard_charge_dollar": 0.98, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Conseco", "plan_name": "500302", "standard_charge_dollar": 0.98, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Humana Ffs 61101", "plan_name": "500006", "standard_charge_dollar": 0.98, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Medicare A", "plan_name": "100100", "standard_charge_dollar": 0.98, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Medicare A", "plan_name": "100500", "standard_charge_dollar": 0.98, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Medicare Part B Only", "plan_name": "100300", "standard_charge_dollar": 0.98, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Medicare Railroad", "plan_name": "100103", "standard_charge_dollar": 0.98, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Ms Physicians Care N", "plan_name": "714210", "standard_charge_dollar": 1.23, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Peoples Hlth Ffs 72126", "plan_name": "500019", "standard_charge_dollar": 0.98, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Uhc/Secure Horizons", "plan_name": "500449", "standard_charge_dollar": 0.98, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "United Health Care/", "plan_name": "500292", "standard_charge_dollar": 1.11, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "United Healthcare", "plan_name": "750104", "standard_charge_dollar": 1.11, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "United Healthcare Ba", "plan_name": "750090", "standard_charge_dollar": 1.11, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "United Healthcare Me", "plan_name": "501310", "standard_charge_dollar": 0.98, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Windsor Mcare Extra", "plan_name": "500778", "standard_charge_dollar": 0.98, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." } ] } ] }, { "description": "Filgrastim 300 mcg/ml injection solution [10036]", "drug_information": { "unit": 1.00, "type": "ML" }, "code_information": [ { "code": "J1442", "type": "HCPCS" }, { "code": "55513-530-01", "type": "NDC" } ], "standard_charges": [ { "gross_charge": 1534.81, "minimum": 0.98, "maximum": 1.23, "setting": "both", "payers_information": [ { "payer_name": "Aarp", "plan_name": "500102", "standard_charge_dollar": 0.98, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna", "plan_name": "700700", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna", "plan_name": "700700_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Mcare Ffs 6005", "plan_name": "700703", "standard_charge_dollar": 0.98, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Miscellaneous", "plan_name": "700720", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Miscellaneous", "plan_name": "700720_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Ppo Hmo", "plan_name": "701720", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Ppo Hmo", "plan_name": "701720_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Ambetter 68069", "plan_name": "500516", "standard_charge_dollar": 0.98, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Ms State Emplo", "plan_name": "401457", "standard_charge_dollar": 0.98, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Ms State Emplo", "plan_name": "401457_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Basic Pl", "plan_name": "400100", "standard_charge_dollar": 0.98, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Basic Pl", "plan_name": "400100_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Federal", "plan_name": "400110", "standard_charge_dollar": 0.98, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Federal", "plan_name": "400110_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Cigna Healthsprings Ffs", "plan_name": "500064", "standard_charge_dollar": 0.98, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Conseco", "plan_name": "500302", "standard_charge_dollar": 0.98, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Humana Ffs 61101", "plan_name": "500006", "standard_charge_dollar": 0.98, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Medicare A", "plan_name": "100100", "standard_charge_dollar": 0.98, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Medicare A", "plan_name": "100500", "standard_charge_dollar": 0.98, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Medicare Part B Only", "plan_name": "100300", "standard_charge_dollar": 0.98, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Medicare Railroad", "plan_name": "100103", "standard_charge_dollar": 0.98, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Ms Physicians Care N", "plan_name": "714210", "standard_charge_dollar": 1.23, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Peoples Hlth Ffs 72126", "plan_name": "500019", "standard_charge_dollar": 0.98, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Uhc/Secure Horizons", "plan_name": "500449", "standard_charge_dollar": 0.98, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "United Health Care/", "plan_name": "500292", "standard_charge_dollar": 1.11, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "United Healthcare", "plan_name": "750104", "standard_charge_dollar": 1.11, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "United Healthcare Ba", "plan_name": "750090", "standard_charge_dollar": 1.11, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "United Healthcare Me", "plan_name": "501310", "standard_charge_dollar": 0.98, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Windsor Mcare Extra", "plan_name": "500778", "standard_charge_dollar": 0.98, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." } ] } ] }, { "description": "Filgrastim 300 mcg/ml injection solution [10036]", "drug_information": { "unit": 1.00, "type": "ML" }, "code_information": [ { "code": "J1442", "type": "HCPCS" }, { "code": "55513-530-10", "type": "NDC" } ], "standard_charges": [ { "gross_charge": 1534.81, "minimum": 0.98, "maximum": 1.23, "setting": "both", "payers_information": [ { "payer_name": "Aarp", "plan_name": "500102", "standard_charge_dollar": 0.98, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna", "plan_name": "700700", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna", "plan_name": "700700_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Mcare Ffs 6005", "plan_name": "700703", "standard_charge_dollar": 0.98, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Miscellaneous", "plan_name": "700720", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Miscellaneous", "plan_name": "700720_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Ppo Hmo", "plan_name": "701720", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Ppo Hmo", "plan_name": "701720_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Ambetter 68069", "plan_name": "500516", "standard_charge_dollar": 0.98, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Ms State Emplo", "plan_name": "401457", "standard_charge_dollar": 0.98, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Ms State Emplo", "plan_name": "401457_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Basic Pl", "plan_name": "400100", "standard_charge_dollar": 0.98, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Basic Pl", "plan_name": "400100_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Federal", "plan_name": "400110", "standard_charge_dollar": 0.98, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Federal", "plan_name": "400110_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Cigna Healthsprings Ffs", "plan_name": "500064", "standard_charge_dollar": 0.98, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Conseco", "plan_name": "500302", "standard_charge_dollar": 0.98, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Humana Ffs 61101", "plan_name": "500006", "standard_charge_dollar": 0.98, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Medicare A", "plan_name": "100100", "standard_charge_dollar": 0.98, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Medicare A", "plan_name": "100500", "standard_charge_dollar": 0.98, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Medicare Part B Only", "plan_name": "100300", "standard_charge_dollar": 0.98, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Medicare Railroad", "plan_name": "100103", "standard_charge_dollar": 0.98, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Ms Physicians Care N", "plan_name": "714210", "standard_charge_dollar": 1.23, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Peoples Hlth Ffs 72126", "plan_name": "500019", "standard_charge_dollar": 0.98, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Uhc/Secure Horizons", "plan_name": "500449", "standard_charge_dollar": 0.98, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "United Health Care/", "plan_name": "500292", "standard_charge_dollar": 1.11, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "United Healthcare", "plan_name": "750104", "standard_charge_dollar": 1.11, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "United Healthcare Ba", "plan_name": "750090", "standard_charge_dollar": 1.11, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "United Healthcare Me", "plan_name": "501310", "standard_charge_dollar": 0.98, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Windsor Mcare Extra", "plan_name": "500778", "standard_charge_dollar": 0.98, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." } ] } ] }, { "description": "Filgrastim 480 mcg/1.6 ml injection solution [112757]", "drug_information": { "unit": 1.60, "type": "ML" }, "code_information": [ { "code": "J1442", "type": "HCPCS" }, { "code": "55513-546-01", "type": "NDC" } ], "standard_charges": [ { "gross_charge": 2443.98, "minimum": 0.98, "maximum": 1.23, "setting": "both", "payers_information": [ { "payer_name": "Aarp", "plan_name": "500102", "standard_charge_dollar": 0.98, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna", "plan_name": "700700", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna", "plan_name": "700700_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Mcare Ffs 6005", "plan_name": "700703", "standard_charge_dollar": 0.98, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Miscellaneous", "plan_name": "700720", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Miscellaneous", "plan_name": "700720_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Ppo Hmo", "plan_name": "701720", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Ppo Hmo", "plan_name": "701720_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Ambetter 68069", "plan_name": "500516", "standard_charge_dollar": 0.98, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Ms State Emplo", "plan_name": "401457", "standard_charge_dollar": 0.98, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Ms State Emplo", "plan_name": "401457_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Basic Pl", "plan_name": "400100", "standard_charge_dollar": 0.98, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Basic Pl", "plan_name": "400100_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Federal", "plan_name": "400110", "standard_charge_dollar": 0.98, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Federal", "plan_name": "400110_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Cigna Healthsprings Ffs", "plan_name": "500064", "standard_charge_dollar": 0.98, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Conseco", "plan_name": "500302", "standard_charge_dollar": 0.98, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Humana Ffs 61101", "plan_name": "500006", "standard_charge_dollar": 0.98, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Medicare A", "plan_name": "100100", "standard_charge_dollar": 0.98, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Medicare A", "plan_name": "100500", "standard_charge_dollar": 0.98, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Medicare Part B Only", "plan_name": "100300", "standard_charge_dollar": 0.98, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Medicare Railroad", "plan_name": "100103", "standard_charge_dollar": 0.98, "count": "0", "methodology": "fee 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"payer_name": "United Healthcare", "plan_name": "750104", "standard_charge_dollar": 1.11, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "United Healthcare Ba", "plan_name": "750090", "standard_charge_dollar": 1.11, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "United Healthcare Me", "plan_name": "501310", "standard_charge_dollar": 0.98, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Windsor Mcare Extra", "plan_name": "500778", "standard_charge_dollar": 0.98, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." } ] } ] }, { "description": "Filgrastim 480 mcg/1.6 ml injection solution [112757]", "drug_information": { 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100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Ambetter 68069", "plan_name": "500516", "standard_charge_dollar": 0.98, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Ms State Emplo", "plan_name": "401457", "standard_charge_dollar": 0.98, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Ms State Emplo", "plan_name": "401457_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Basic Pl", "plan_name": "400100", "standard_charge_dollar": 0.98, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Basic Pl", "plan_name": "400100_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Federal", "plan_name": "400110", "standard_charge_dollar": 0.98, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Federal", "plan_name": "400110_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Cigna Healthsprings Ffs", "plan_name": "500064", "standard_charge_dollar": 0.98, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit 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"count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Medicare Railroad", "plan_name": "100103", "standard_charge_dollar": 0.98, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Ms Physicians Care N", "plan_name": "714210", "standard_charge_dollar": 1.23, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Peoples Hlth Ffs 72126", "plan_name": "500019", "standard_charge_dollar": 0.98, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Uhc/Secure Horizons", "plan_name": "500449", "standard_charge_dollar": 0.98, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "United Health Care/", "plan_name": "500292", "standard_charge_dollar": 1.11, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "United Healthcare", "plan_name": "750104", "standard_charge_dollar": 1.11, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "United Healthcare Ba", "plan_name": "750090", "standard_charge_dollar": 1.11, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "United Healthcare Me", "plan_name": "501310", "standard_charge_dollar": 0.98, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Windsor Mcare Extra", "plan_name": "500778", "standard_charge_dollar": 0.98, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." } ] } ] }, { "description": "Tbo-filgrastim 300 mcg/0.5 ml subcutaneous syringe [164698]", "drug_information": { "unit": 0.50, "type": "ML" }, "code_information": [ { "code": "J1447", "type": "HCPCS" }, { "code": "63459-910-11", "type": "NDC" } ], "standard_charges": [ { "gross_charge": 979.31, "minimum": 0.37, "maximum": 0.80, "setting": "both", "payers_information": [ { "payer_name": "Aarp", "plan_name": "500102", "standard_charge_dollar": 0.37, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna", "plan_name": "700700", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna", 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"standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Ppo Hmo", "plan_name": "701720_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Ambetter 68069", "plan_name": "500516", "standard_charge_dollar": 0.37, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Ms State Emplo", "plan_name": "401457", "standard_charge_dollar": 0.80, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Ms State Emplo", "plan_name": "401457_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Basic Pl", "plan_name": "400100", "standard_charge_dollar": 0.80, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Basic Pl", "plan_name": "400100_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Federal", "plan_name": "400110", "standard_charge_dollar": 0.80, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Federal", "plan_name": "400110_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", 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"additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Uhc/Secure Horizons", "plan_name": "500449", "standard_charge_dollar": 0.37, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "United Health Care/", "plan_name": "500292", "standard_charge_dollar": 0.42, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "United Healthcare", "plan_name": "750104", "standard_charge_dollar": 0.42, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "United Healthcare Ba", "plan_name": "750090", "standard_charge_dollar": 0.42, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "United Healthcare Me", "plan_name": "501310", "standard_charge_dollar": 0.37, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Windsor Mcare Extra", "plan_name": "500778", "standard_charge_dollar": 0.37, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." } ] } ] }, { "description": "Tbo-filgrastim 300 mcg/0.5 ml subcutaneous syringe [164698]", "drug_information": { "unit": 0.50, "type": "ML" }, "code_information": [ { "code": "J1447", "type": "HCPCS" }, { "code": "63459-910-12", "type": "NDC" } ], "standard_charges": [ { "gross_charge": 979.31, "minimum": 0.37, "maximum": 0.80, "setting": "both", "payers_information": [ { "payer_name": "Aarp", "plan_name": "500102", "standard_charge_dollar": 0.37, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna", "plan_name": "700700", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna", "plan_name": "700700_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Mcare Ffs 6005", "plan_name": "700703", "standard_charge_dollar": 0.37, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Miscellaneous", "plan_name": "700720", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Miscellaneous", "plan_name": "700720_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Ppo Hmo", "plan_name": "701720", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Ppo Hmo", "plan_name": "701720_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Ambetter 68069", "plan_name": "500516", "standard_charge_dollar": 0.37, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Ms State Emplo", "plan_name": "401457", "standard_charge_dollar": 0.80, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Ms State Emplo", "plan_name": "401457_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Basic Pl", "plan_name": "400100", "standard_charge_dollar": 0.80, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Basic Pl", "plan_name": "400100_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Federal", "plan_name": "400110", "standard_charge_dollar": 0.80, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Federal", "plan_name": "400110_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Cigna Healthsprings Ffs", "plan_name": "500064", "standard_charge_dollar": 0.37, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Conseco", "plan_name": "500302", "standard_charge_dollar": 0.37, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Humana Ffs 61101", "plan_name": "500006", "standard_charge_dollar": 0.37, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Medicare A", "plan_name": "100100", "standard_charge_dollar": 0.37, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Medicare A", "plan_name": "100500", "standard_charge_dollar": 0.37, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Medicare Part B Only", "plan_name": "100300", "standard_charge_dollar": 0.37, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Medicare Railroad", "plan_name": "100103", "standard_charge_dollar": 0.37, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Ms Physicians Care N", "plan_name": "714210", "standard_charge_dollar": 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"standard_charge_percentage": 0.85, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Basic Pl", "plan_name": "400100_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Federal", "plan_name": "400110", "standard_charge_percentage": 0.85, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Federal", "plan_name": "400110_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." } ] } ] }, { "description": "Fluconazole 400 mg/200 ml in sod. chloride(iso) intravenous piggyback [10050]", "drug_information": { "unit": 200.00, "type": "ML" }, "code_information": [ { "code": "J1450", "type": "HCPCS" }, { "code": "69784-003-06", "type": "NDC" } ], "standard_charges": [ { "gross_charge": 115.06, "minimum": 92.05, "maximum": 97.80, "setting": "both", "payers_information": [ { "payer_name": "Aetna", "plan_name": "700700", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna", "plan_name": "700700_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Miscellaneous", "plan_name": "700720", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": 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remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Ms State Emplo", "plan_name": "401457_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Basic Pl", "plan_name": "400100", "standard_charge_percentage": 0.85, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Basic Pl", "plan_name": "400100_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Federal", "plan_name": "400110", "standard_charge_percentage": 0.85, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient 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100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Miscellaneous", "plan_name": "700720", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Miscellaneous", "plan_name": "700720_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Ppo Hmo", "plan_name": "701720", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Ppo Hmo", "plan_name": "701720_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Ms State Emplo", "plan_name": "401457", "standard_charge_percentage": 0.80, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Ms State Emplo", "plan_name": "401457_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Basic Pl", "plan_name": "400100", "standard_charge_percentage": 0.85, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Basic Pl", "plan_name": "400100_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Federal", "plan_name": "400110", "standard_charge_percentage": 0.85, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Federal", "plan_name": "400110_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." } ] } ] }, { "description": "Fluconazole 200 mg/100 ml in sod. chloride (iso) intravenous piggyback [10049]", "drug_information": { "unit": 100.00, "type": "ML" }, "code_information": [ { "code": "J1450", "type": "HCPCS" }, { "code": "25021-184-82", "type": "NDC" } ], "standard_charges": [ { "gross_charge": 258.99, "minimum": 207.19, "maximum": 220.14, "setting": 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"payer_name": "Aetna Ppo Hmo", "plan_name": "701720", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Ppo Hmo", "plan_name": "701720_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Ms State Emplo", "plan_name": "401457", "standard_charge_percentage": 0.80, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Ms State Emplo", "plan_name": "401457_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Basic Pl", "plan_name": "400100", "standard_charge_percentage": 0.85, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Basic Pl", "plan_name": "400100_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Federal", "plan_name": "400110", "standard_charge_percentage": 0.85, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Federal", "plan_name": "400110_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." } ] } ] }, { "description": "Fluconazole 200 mg/100 ml in sod. chloride (iso) intravenous piggyback [10049]", "drug_information": { "unit": 100.00, "type": "ML" }, "code_information": [ { "code": "J1450", "type": "HCPCS" }, { "code": "0338-6046-48", "type": "NDC" } ], "standard_charges": [ { "gross_charge": 258.99, "minimum": 207.19, "maximum": 220.14, "setting": "both", "payers_information": [ { "payer_name": "Aetna", "plan_name": "700700", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna", "plan_name": "700700_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Miscellaneous", "plan_name": "700720", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total 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"additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Ms State Emplo", "plan_name": "401457_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Basic Pl", "plan_name": "400100", "standard_charge_percentage": 0.85, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Basic Pl", "plan_name": "400100_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Federal", "plan_name": "400110", "standard_charge_percentage": 0.85, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Federal", "plan_name": "400110_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." } ] } ] }, { "description": "Fluconazole 100 mg/50 ml in sodium chloride(iso) intravenous piggyback [100721]", "drug_information": { "unit": 50.00, "type": "ML" }, "code_information": [ { "code": "J1450", "type": "HCPCS" }, { "code": "9999-0006-38", "type": "NDC" } ], "standard_charges": [ { "gross_charge": 94.41, "minimum": 75.53, "maximum": 80.25, "setting": "both", "payers_information": [ { "payer_name": "Aetna", "plan_name": "700700", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna", "plan_name": "700700_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Miscellaneous", "plan_name": "700720", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Miscellaneous", "plan_name": "700720_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Ppo Hmo", "plan_name": "701720", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Ppo Hmo", "plan_name": "701720_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Ms State Emplo", "plan_name": "401457", "standard_charge_percentage": 0.80, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Ms State Emplo", "plan_name": "401457_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Basic Pl", "plan_name": "400100", "standard_charge_percentage": 0.85, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Basic Pl", "plan_name": "400100_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Federal", "plan_name": "400110", "standard_charge_percentage": 0.85, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Federal", "plan_name": "400110_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." } ] } ] }, { "description": "Fomepizole 1 gram/ml intravenous solution [22185]", "drug_information": { "unit": 1.50, "type": "ML" }, "code_information": [ { "code": "J1451", "type": "HCPCS" }, { "code": "0517-0710-01", "type": "NDC" } ], "standard_charges": [ { "gross_charge": 10562.80, "minimum": 6.16, "maximum": 10.62, "setting": "both", "payers_information": [ { "payer_name": "Aarp", "plan_name": "500102", "standard_charge_dollar": 6.16, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna", "plan_name": "700700", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna", "plan_name": "700700_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Mcare Ffs 6005", "plan_name": "700703", "standard_charge_dollar": 6.16, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Miscellaneous", "plan_name": "700720", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Miscellaneous", "plan_name": "700720_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Ppo Hmo", "plan_name": "701720", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Ppo Hmo", "plan_name": "701720_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Ambetter 68069", "plan_name": "500516", "standard_charge_dollar": 6.16, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Ms State Emplo", "plan_name": "401457", "standard_charge_dollar": 10.62, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Ms State Emplo", "plan_name": "401457_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Basic Pl", "plan_name": "400100", "standard_charge_dollar": 10.62, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Basic Pl", "plan_name": "400100_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Federal", "plan_name": "400110", "standard_charge_dollar": 10.62, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Federal", "plan_name": "400110_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Cigna Healthsprings Ffs", "plan_name": "500064", "standard_charge_dollar": 6.16, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Conseco", "plan_name": "500302", "standard_charge_dollar": 6.16, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Humana Ffs 61101", "plan_name": "500006", "standard_charge_dollar": 6.16, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Medicare A", "plan_name": "100100", "standard_charge_dollar": 6.16, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Medicare A", "plan_name": "100500", "standard_charge_dollar": 6.16, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Medicare Part B Only", "plan_name": "100300", "standard_charge_dollar": 6.16, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Medicare Railroad", "plan_name": "100103", "standard_charge_dollar": 6.16, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Ms Physicians Care N", "plan_name": "714210", "standard_charge_dollar": 7.70, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Peoples Hlth Ffs 72126", "plan_name": "500019", "standard_charge_dollar": 6.16, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Uhc/Secure Horizons", "plan_name": "500449", "standard_charge_dollar": 6.16, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "United Health Care/", "plan_name": "500292", "standard_charge_dollar": 6.96, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "United Healthcare", "plan_name": "750104", "standard_charge_dollar": 6.96, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "United Healthcare Ba", "plan_name": "750090", "standard_charge_dollar": 6.96, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "United Healthcare Me", "plan_name": "501310", "standard_charge_dollar": 6.16, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Windsor Mcare Extra", "plan_name": "500778", "standard_charge_dollar": 6.16, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." } ] } ] }, { "description": "Fomepizole 1 gram/ml intravenous solution [22185]", "drug_information": { "unit": 1.50, "type": "ML" }, "code_information": [ { "code": "J1451", "type": "HCPCS" }, { "code": "67457-211-02", "type": "NDC" } ], "standard_charges": [ { "gross_charge": 9566.65, "minimum": 6.16, "maximum": 10.62, "setting": "both", "payers_information": [ { "payer_name": "Aarp", "plan_name": "500102", "standard_charge_dollar": 6.16, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna", "plan_name": "700700", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna", "plan_name": "700700_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Mcare Ffs 6005", "plan_name": "700703", "standard_charge_dollar": 6.16, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Miscellaneous", "plan_name": "700720", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Miscellaneous", "plan_name": "700720_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Ppo Hmo", "plan_name": "701720", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Ppo Hmo", "plan_name": "701720_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Ambetter 68069", "plan_name": "500516", "standard_charge_dollar": 6.16, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Ms State Emplo", "plan_name": "401457", "standard_charge_dollar": 10.62, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Ms State Emplo", "plan_name": "401457_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Basic Pl", "plan_name": "400100", "standard_charge_dollar": 10.62, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Basic Pl", "plan_name": "400100_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Federal", "plan_name": "400110", "standard_charge_dollar": 10.62, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Federal", "plan_name": "400110_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Cigna Healthsprings Ffs", "plan_name": "500064", "standard_charge_dollar": 6.16, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Conseco", "plan_name": "500302", "standard_charge_dollar": 6.16, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Humana Ffs 61101", "plan_name": "500006", "standard_charge_dollar": 6.16, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Medicare A", "plan_name": "100100", "standard_charge_dollar": 6.16, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Medicare A", "plan_name": "100500", "standard_charge_dollar": 6.16, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Medicare Part B Only", "plan_name": "100300", "standard_charge_dollar": 6.16, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Medicare Railroad", "plan_name": "100103", "standard_charge_dollar": 6.16, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Ms Physicians Care N", "plan_name": "714210", "standard_charge_dollar": 7.70, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Peoples Hlth Ffs 72126", "plan_name": "500019", "standard_charge_dollar": 6.16, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Uhc/Secure Horizons", "plan_name": "500449", "standard_charge_dollar": 6.16, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "United Health Care/", "plan_name": "500292", "standard_charge_dollar": 6.96, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "United Healthcare", "plan_name": "750104", "standard_charge_dollar": 6.96, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "United Healthcare Ba", "plan_name": "750090", "standard_charge_dollar": 6.96, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "United Healthcare Me", "plan_name": "501310", "standard_charge_dollar": 6.16, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Windsor Mcare Extra", "plan_name": "500778", "standard_charge_dollar": 6.16, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." } ] } ] }, { "description": "Fosaprepitant 150 mg intravenous powder for solution [106783]", "drug_information": { "unit": 1.00, "type": "EA" }, "code_information": [ { "code": "J1453", "type": "HCPCS" }, { "code": "72205-054-01", "type": "NDC" } ], "standard_charges": [ { "gross_charge": 1074.95, "minimum": 1.79, "maximum": 1.79, "setting": "both", "payers_information": [ { "payer_name": "Aetna", "plan_name": "700700", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna", "plan_name": "700700_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Miscellaneous", "plan_name": "700720", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Miscellaneous", "plan_name": "700720_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Ppo Hmo", "plan_name": "701720", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Ppo Hmo", "plan_name": "701720_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Ms State Emplo", "plan_name": "401457", "standard_charge_dollar": 1.79, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Ms State Emplo", "plan_name": "401457_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Basic Pl", "plan_name": "400100", "standard_charge_dollar": 1.79, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Basic Pl", "plan_name": "400100_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Federal", "plan_name": "400110", "standard_charge_dollar": 1.79, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Federal", "plan_name": "400110_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." } ] } ] }, { "description": "Fosaprepitant 150 mg intravenous powder for solution [106783]", "drug_information": { "unit": 1.00, "type": "EA" }, "code_information": [ { "code": "J1453", "type": "HCPCS" }, { "code": "71839-104-01", "type": "NDC" } ], "standard_charges": [ { "gross_charge": 1074.95, "minimum": 1.79, "maximum": 1.79, "setting": "both", "payers_information": [ { "payer_name": "Aetna", "plan_name": "700700", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna", "plan_name": "700700_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Miscellaneous", "plan_name": "700720", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Miscellaneous", "plan_name": "700720_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Ppo Hmo", "plan_name": "701720", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Ppo Hmo", "plan_name": "701720_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Ms State Emplo", "plan_name": "401457", "standard_charge_dollar": 1.79, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Ms State Emplo", "plan_name": "401457_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Basic Pl", "plan_name": "400100", "standard_charge_dollar": 1.79, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Basic Pl", "plan_name": "400100_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Federal", "plan_name": "400110", "standard_charge_dollar": 1.79, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Federal", "plan_name": "400110_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." } ] } ] }, { "description": "Fosaprepitant 150 mg intravenous powder for solution [106783]", "drug_information": { "unit": 1.00, "type": "EA" }, "code_information": [ { "code": "J1453", "type": "HCPCS" }, { "code": "55150-299-01", "type": "NDC" } ], "standard_charges": [ { "gross_charge": 1074.95, "minimum": 1.79, "maximum": 1.79, "setting": "both", "payers_information": [ { "payer_name": "Aetna", "plan_name": "700700", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna", "plan_name": "700700_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Miscellaneous", "plan_name": "700720", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Miscellaneous", "plan_name": "700720_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Ppo Hmo", "plan_name": "701720", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Ppo Hmo", "plan_name": "701720_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Ms State Emplo", "plan_name": "401457", "standard_charge_dollar": 1.79, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Ms State Emplo", "plan_name": "401457_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Basic Pl", "plan_name": "400100", "standard_charge_dollar": 1.79, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Basic Pl", "plan_name": "400100_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Federal", "plan_name": "400110", "standard_charge_dollar": 1.79, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Federal", "plan_name": "400110_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." } ] } ] }, { "description": "Fosaprepitant 150 mg intravenous powder for solution [106783]", "drug_information": { "unit": 1.00, "type": "EA" }, "code_information": [ { "code": "J1453", "type": "HCPCS" }, { "code": "0143-9384-01", "type": "NDC" } ], "standard_charges": [ { "gross_charge": 1074.95, "minimum": 1.79, "maximum": 1.79, "setting": "both", "payers_information": [ { "payer_name": "Aetna", "plan_name": "700700", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna", "plan_name": "700700_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Miscellaneous", "plan_name": "700720", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Miscellaneous", "plan_name": "700720_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Ppo Hmo", "plan_name": "701720", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Ppo Hmo", "plan_name": "701720_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Ms State Emplo", "plan_name": "401457", "standard_charge_dollar": 1.79, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Ms State Emplo", "plan_name": "401457_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Basic Pl", "plan_name": "400100", "standard_charge_dollar": 1.79, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Basic Pl", "plan_name": "400100_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Federal", "plan_name": "400110", "standard_charge_dollar": 1.79, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Federal", "plan_name": "400110_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." } ] } ] }, { "description": "Immune globgamm(igg) 10 %-pro-iga 0 to 50 mcg/ml intravenous solution [170195]", "drug_information": { "unit": 50.00, "type": "ML" }, "code_information": [ { "code": "J1459", "type": "HCPCS" }, { "code": "44206-436-05", "type": "NDC" } ], "standard_charges": [ { "gross_charge": 2144.27, "minimum": 49.18, "maximum": 61.48, "setting": "both", "payers_information": [ { "payer_name": "Aarp", "plan_name": "500102", "standard_charge_dollar": 49.18, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna", "plan_name": "700700", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna", "plan_name": "700700_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Mcare Ffs 6005", "plan_name": "700703", "standard_charge_dollar": 49.18, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Miscellaneous", "plan_name": "700720", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Miscellaneous", "plan_name": "700720_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Ppo Hmo", "plan_name": "701720", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Ppo Hmo", "plan_name": "701720_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Ambetter 68069", "plan_name": "500516", "standard_charge_dollar": 49.18, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Ms State Emplo", "plan_name": "401457", "standard_charge_dollar": 57.86, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Ms State Emplo", "plan_name": "401457_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Basic Pl", "plan_name": "400100", "standard_charge_dollar": 57.86, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Basic Pl", "plan_name": "400100_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Federal", "plan_name": "400110", "standard_charge_dollar": 57.86, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Federal", "plan_name": "400110_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Cigna Healthsprings Ffs", "plan_name": "500064", "standard_charge_dollar": 49.18, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Conseco", "plan_name": "500302", "standard_charge_dollar": 49.18, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Humana Ffs 61101", "plan_name": "500006", "standard_charge_dollar": 49.18, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Medicare A", "plan_name": "100100", "standard_charge_dollar": 49.18, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Medicare A", "plan_name": "100500", "standard_charge_dollar": 49.18, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Medicare Part B Only", "plan_name": "100300", "standard_charge_dollar": 49.18, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Medicare Railroad", "plan_name": "100103", "standard_charge_dollar": 49.18, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Ms Physicians Care N", "plan_name": "714210", "standard_charge_dollar": 61.48, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Peoples Hlth Ffs 72126", "plan_name": "500019", "standard_charge_dollar": 49.18, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Uhc/Secure Horizons", "plan_name": "500449", "standard_charge_dollar": 49.18, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "United Health Care/", "plan_name": "500292", "standard_charge_dollar": 55.57, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "United Healthcare", "plan_name": "750104", "standard_charge_dollar": 55.57, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "United Healthcare Ba", "plan_name": "750090", "standard_charge_dollar": 55.57, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "United Healthcare Me", "plan_name": "501310", "standard_charge_dollar": 49.18, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Windsor Mcare Extra", "plan_name": "500778", "standard_charge_dollar": 49.18, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." } ] } ] }, { "description": "Immune globgamm(igg) 10 %-pro-iga 0 to 50 mcg/ml intravenous solution [170195]", "drug_information": { "unit": 50.00, "type": "ML" }, "code_information": [ { "code": "J1459", "type": "HCPCS" }, { "code": "44206-436-90", "type": "NDC" } ], "standard_charges": [ { "gross_charge": 2144.27, "minimum": 49.18, "maximum": 61.48, "setting": "both", "payers_information": [ { "payer_name": "Aarp", "plan_name": "500102", "standard_charge_dollar": 49.18, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna", "plan_name": "700700", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna", "plan_name": "700700_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Mcare Ffs 6005", "plan_name": "700703", "standard_charge_dollar": 49.18, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Miscellaneous", "plan_name": "700720", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Miscellaneous", "plan_name": "700720_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Ppo Hmo", "plan_name": "701720", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Ppo Hmo", "plan_name": "701720_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Ambetter 68069", "plan_name": "500516", "standard_charge_dollar": 49.18, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Ms State Emplo", "plan_name": "401457", "standard_charge_dollar": 57.86, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Ms State Emplo", "plan_name": "401457_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Basic Pl", "plan_name": "400100", "standard_charge_dollar": 57.86, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Basic Pl", "plan_name": "400100_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Federal", "plan_name": "400110", "standard_charge_dollar": 57.86, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Federal", "plan_name": "400110_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Cigna Healthsprings Ffs", "plan_name": "500064", "standard_charge_dollar": 49.18, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Conseco", "plan_name": "500302", "standard_charge_dollar": 49.18, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Humana Ffs 61101", "plan_name": "500006", "standard_charge_dollar": 49.18, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Medicare A", "plan_name": "100100", "standard_charge_dollar": 49.18, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Medicare A", "plan_name": "100500", "standard_charge_dollar": 49.18, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Medicare Part B Only", "plan_name": "100300", "standard_charge_dollar": 49.18, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Medicare Railroad", "plan_name": "100103", "standard_charge_dollar": 49.18, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Ms Physicians Care N", "plan_name": "714210", "standard_charge_dollar": 61.48, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Peoples Hlth Ffs 72126", "plan_name": "500019", "standard_charge_dollar": 49.18, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Uhc/Secure Horizons", "plan_name": "500449", "standard_charge_dollar": 49.18, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "United Health Care/", "plan_name": "500292", "standard_charge_dollar": 55.57, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "United Healthcare", "plan_name": "750104", "standard_charge_dollar": 55.57, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "United Healthcare Ba", "plan_name": "750090", "standard_charge_dollar": 55.57, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "United Healthcare Me", "plan_name": "501310", "standard_charge_dollar": 49.18, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Windsor Mcare Extra", "plan_name": "500778", "standard_charge_dollar": 49.18, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." } ] } ] }, { "description": "Immune globgamm(igg) 10 %-pro-iga 0 to 50 mcg/ml intravenous solution [170195]", "drug_information": { "unit": 100.00, "type": "ML" }, "code_information": [ { "code": "J1459", "type": "HCPCS" }, { "code": "44206-437-10", "type": "NDC" } ], "standard_charges": [ { "gross_charge": 4288.54, "minimum": 49.18, "maximum": 61.48, "setting": "both", "payers_information": [ { "payer_name": "Aarp", "plan_name": "500102", "standard_charge_dollar": 49.18, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna", "plan_name": "700700", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna", "plan_name": "700700_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Mcare Ffs 6005", "plan_name": "700703", "standard_charge_dollar": 49.18, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Miscellaneous", "plan_name": "700720", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Miscellaneous", "plan_name": "700720_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Ppo Hmo", "plan_name": "701720", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Ppo Hmo", "plan_name": "701720_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Ambetter 68069", "plan_name": "500516", "standard_charge_dollar": 49.18, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Ms State Emplo", "plan_name": "401457", "standard_charge_dollar": 57.86, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Ms State Emplo", "plan_name": "401457_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Basic Pl", "plan_name": "400100", "standard_charge_dollar": 57.86, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Basic Pl", "plan_name": "400100_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Federal", "plan_name": "400110", "standard_charge_dollar": 57.86, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Federal", "plan_name": "400110_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Cigna Healthsprings Ffs", "plan_name": "500064", "standard_charge_dollar": 49.18, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Conseco", "plan_name": "500302", "standard_charge_dollar": 49.18, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Humana Ffs 61101", "plan_name": "500006", "standard_charge_dollar": 49.18, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Medicare A", "plan_name": "100100", "standard_charge_dollar": 49.18, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Medicare A", "plan_name": "100500", "standard_charge_dollar": 49.18, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Medicare Part B Only", "plan_name": "100300", "standard_charge_dollar": 49.18, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Medicare Railroad", "plan_name": "100103", "standard_charge_dollar": 49.18, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Ms Physicians Care N", "plan_name": "714210", "standard_charge_dollar": 61.48, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Peoples Hlth Ffs 72126", "plan_name": "500019", "standard_charge_dollar": 49.18, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Uhc/Secure Horizons", "plan_name": "500449", "standard_charge_dollar": 49.18, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "United Health Care/", "plan_name": "500292", "standard_charge_dollar": 55.57, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "United Healthcare", "plan_name": "750104", "standard_charge_dollar": 55.57, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "United Healthcare Ba", "plan_name": "750090", "standard_charge_dollar": 55.57, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "United Healthcare Me", "plan_name": "501310", "standard_charge_dollar": 49.18, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Windsor Mcare Extra", "plan_name": "500778", "standard_charge_dollar": 49.18, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." } ] } ] }, { "description": "Immune globgamm(igg) 10 %-pro-iga 0 to 50 mcg/ml intravenous solution [170195]", "drug_information": { "unit": 100.00, "type": "ML" }, "code_information": [ { "code": "J1459", "type": "HCPCS" }, { "code": "44206-437-91", "type": "NDC" } ], "standard_charges": [ { "gross_charge": 4288.54, "minimum": 49.18, "maximum": 61.48, "setting": "both", "payers_information": [ { "payer_name": "Aarp", "plan_name": "500102", "standard_charge_dollar": 49.18, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna", "plan_name": "700700", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna", "plan_name": "700700_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Mcare Ffs 6005", "plan_name": "700703", "standard_charge_dollar": 49.18, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Miscellaneous", "plan_name": "700720", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Miscellaneous", "plan_name": "700720_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Ppo Hmo", "plan_name": "701720", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Ppo Hmo", "plan_name": "701720_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Ambetter 68069", "plan_name": "500516", "standard_charge_dollar": 49.18, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Ms State Emplo", "plan_name": "401457", "standard_charge_dollar": 57.86, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Ms State Emplo", "plan_name": "401457_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Basic Pl", "plan_name": "400100", "standard_charge_dollar": 57.86, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Basic Pl", "plan_name": "400100_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Federal", "plan_name": "400110", "standard_charge_dollar": 57.86, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Federal", "plan_name": "400110_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Cigna Healthsprings Ffs", "plan_name": "500064", "standard_charge_dollar": 49.18, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Conseco", "plan_name": "500302", "standard_charge_dollar": 49.18, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Humana Ffs 61101", "plan_name": "500006", "standard_charge_dollar": 49.18, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Medicare A", "plan_name": "100100", "standard_charge_dollar": 49.18, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Medicare A", "plan_name": "100500", "standard_charge_dollar": 49.18, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Medicare Part B Only", "plan_name": "100300", "standard_charge_dollar": 49.18, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Medicare Railroad", "plan_name": "100103", "standard_charge_dollar": 49.18, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Ms Physicians Care N", "plan_name": "714210", "standard_charge_dollar": 61.48, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Peoples Hlth Ffs 72126", "plan_name": "500019", "standard_charge_dollar": 49.18, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Uhc/Secure Horizons", "plan_name": "500449", "standard_charge_dollar": 49.18, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "United Health Care/", "plan_name": "500292", "standard_charge_dollar": 55.57, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "United Healthcare", "plan_name": "750104", "standard_charge_dollar": 55.57, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "United Healthcare Ba", "plan_name": "750090", "standard_charge_dollar": 55.57, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "United Healthcare Me", "plan_name": "501310", "standard_charge_dollar": 49.18, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Windsor Mcare Extra", "plan_name": "500778", "standard_charge_dollar": 49.18, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." } ] } ] }, { "description": "Immune globgamm(igg) 10 %-pro-iga 0 to 50 mcg/ml intravenous solution [170195]", "drug_information": { "unit": 200.00, "type": "ML" }, "code_information": [ { "code": "J1459", "type": "HCPCS" }, { "code": "44206-438-20", "type": "NDC" } ], "standard_charges": [ { "gross_charge": 8577.07, "minimum": 49.18, "maximum": 61.48, "setting": "both", "payers_information": [ { "payer_name": "Aarp", "plan_name": "500102", "standard_charge_dollar": 49.18, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna", "plan_name": "700700", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna", "plan_name": "700700_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Mcare Ffs 6005", "plan_name": "700703", "standard_charge_dollar": 49.18, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Miscellaneous", "plan_name": "700720", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Miscellaneous", "plan_name": "700720_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Ppo Hmo", "plan_name": "701720", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Ppo Hmo", "plan_name": "701720_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Ambetter 68069", "plan_name": "500516", "standard_charge_dollar": 49.18, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Ms State Emplo", "plan_name": "401457", "standard_charge_dollar": 57.86, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Ms State Emplo", "plan_name": "401457_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Basic Pl", "plan_name": "400100", "standard_charge_dollar": 57.86, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Basic Pl", "plan_name": "400100_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Federal", "plan_name": "400110", "standard_charge_dollar": 57.86, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Federal", "plan_name": "400110_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Cigna Healthsprings Ffs", "plan_name": "500064", "standard_charge_dollar": 49.18, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Conseco", "plan_name": "500302", "standard_charge_dollar": 49.18, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Humana Ffs 61101", "plan_name": "500006", "standard_charge_dollar": 49.18, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Medicare A", "plan_name": "100100", "standard_charge_dollar": 49.18, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Medicare A", "plan_name": "100500", "standard_charge_dollar": 49.18, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Medicare Part B Only", "plan_name": "100300", "standard_charge_dollar": 49.18, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Medicare Railroad", "plan_name": "100103", "standard_charge_dollar": 49.18, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Ms Physicians Care N", "plan_name": "714210", "standard_charge_dollar": 61.48, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Peoples Hlth Ffs 72126", "plan_name": "500019", "standard_charge_dollar": 49.18, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Uhc/Secure Horizons", "plan_name": "500449", "standard_charge_dollar": 49.18, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "United Health Care/", "plan_name": "500292", "standard_charge_dollar": 55.57, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "United Healthcare", "plan_name": "750104", "standard_charge_dollar": 55.57, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "United Healthcare Ba", "plan_name": "750090", "standard_charge_dollar": 55.57, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "United Healthcare Me", "plan_name": "501310", "standard_charge_dollar": 49.18, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Windsor Mcare Extra", "plan_name": "500778", "standard_charge_dollar": 49.18, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." } ] } ] }, { "description": "Immune globgamm(igg) 10 %-pro-iga 0 to 50 mcg/ml intravenous solution [170195]", "drug_information": { "unit": 200.00, "type": "ML" }, "code_information": [ { "code": "J1459", "type": "HCPCS" }, { "code": "44206-438-92", "type": "NDC" } ], "standard_charges": [ { "gross_charge": 8577.07, "minimum": 49.18, "maximum": 61.48, "setting": "both", "payers_information": [ { "payer_name": "Aarp", "plan_name": "500102", "standard_charge_dollar": 49.18, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna", "plan_name": "700700", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna", "plan_name": "700700_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Mcare Ffs 6005", "plan_name": "700703", "standard_charge_dollar": 49.18, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Miscellaneous", "plan_name": "700720", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Miscellaneous", "plan_name": "700720_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Ppo Hmo", "plan_name": "701720", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Ppo Hmo", "plan_name": "701720_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Ambetter 68069", "plan_name": "500516", "standard_charge_dollar": 49.18, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Ms State Emplo", "plan_name": "401457", "standard_charge_dollar": 57.86, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Ms State Emplo", "plan_name": "401457_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Basic Pl", "plan_name": "400100", "standard_charge_dollar": 57.86, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Basic Pl", "plan_name": "400100_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Federal", "plan_name": "400110", "standard_charge_dollar": 57.86, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Federal", "plan_name": "400110_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Cigna Healthsprings Ffs", "plan_name": "500064", "standard_charge_dollar": 49.18, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Conseco", "plan_name": "500302", "standard_charge_dollar": 49.18, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Humana Ffs 61101", "plan_name": "500006", "standard_charge_dollar": 49.18, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Medicare A", "plan_name": "100100", "standard_charge_dollar": 49.18, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Medicare A", "plan_name": "100500", "standard_charge_dollar": 49.18, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Medicare Part B Only", "plan_name": "100300", "standard_charge_dollar": 49.18, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Medicare Railroad", "plan_name": "100103", "standard_charge_dollar": 49.18, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Ms Physicians Care N", "plan_name": "714210", "standard_charge_dollar": 61.48, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Peoples Hlth Ffs 72126", "plan_name": "500019", "standard_charge_dollar": 49.18, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Uhc/Secure Horizons", "plan_name": "500449", "standard_charge_dollar": 49.18, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "United Health Care/", "plan_name": "500292", "standard_charge_dollar": 55.57, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "United Healthcare", "plan_name": "750104", "standard_charge_dollar": 55.57, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "United Healthcare Ba", "plan_name": "750090", "standard_charge_dollar": 55.57, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "United Healthcare Me", "plan_name": "501310", "standard_charge_dollar": 49.18, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Windsor Mcare Extra", "plan_name": "500778", "standard_charge_dollar": 49.18, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." } ] } ] }, { "description": "Immune globgamm(igg) 10 %-pro-iga 0 to 50 mcg/ml intravenous solution [170195]", "drug_information": { "unit": 400.00, "type": "ML" }, "code_information": [ { "code": "J1459", "type": "HCPCS" }, { "code": "44206-439-40", "type": "NDC" } ], "standard_charges": [ { "gross_charge": 17154.14, "minimum": 49.18, "maximum": 61.48, "setting": "both", "payers_information": [ { "payer_name": "Aarp", "plan_name": "500102", "standard_charge_dollar": 49.18, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna", "plan_name": "700700", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna", "plan_name": "700700_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Mcare Ffs 6005", "plan_name": "700703", "standard_charge_dollar": 49.18, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Miscellaneous", "plan_name": "700720", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Miscellaneous", "plan_name": "700720_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Ppo Hmo", "plan_name": "701720", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Ppo Hmo", "plan_name": "701720_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Ambetter 68069", "plan_name": "500516", "standard_charge_dollar": 49.18, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Ms State Emplo", "plan_name": "401457", "standard_charge_dollar": 57.86, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Ms State Emplo", "plan_name": "401457_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Basic Pl", "plan_name": "400100", "standard_charge_dollar": 57.86, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Basic Pl", "plan_name": "400100_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Federal", "plan_name": "400110", "standard_charge_dollar": 57.86, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Federal", "plan_name": "400110_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Cigna Healthsprings Ffs", "plan_name": "500064", "standard_charge_dollar": 49.18, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Conseco", "plan_name": "500302", "standard_charge_dollar": 49.18, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Humana Ffs 61101", "plan_name": "500006", "standard_charge_dollar": 49.18, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Medicare A", "plan_name": "100100", "standard_charge_dollar": 49.18, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Medicare A", "plan_name": "100500", "standard_charge_dollar": 49.18, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Medicare Part B Only", "plan_name": "100300", "standard_charge_dollar": 49.18, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Medicare Railroad", "plan_name": "100103", "standard_charge_dollar": 49.18, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Ms Physicians Care N", "plan_name": "714210", "standard_charge_dollar": 61.48, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Peoples 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"plan_name": "401457_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Basic Pl", "plan_name": "400100", "standard_charge_percentage": 0.85, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Basic Pl", "plan_name": "400100_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Federal", "plan_name": "400110", "standard_charge_percentage": 0.85, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Federal", "plan_name": "400110_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." } ] } ] }, { "description": "Gentamicin 100 mg/100 ml in sodium chloride(iso) intravenous piggyback [15908]", "drug_information": { "unit": 100.00, "type": "ML" }, "code_information": [ { "code": "J1580", "type": "HCPCS" }, { "code": "0338-0505-48", "type": "NDC" } ], "standard_charges": [ { "gross_charge": 120.29, "minimum": 96.23, "maximum": 102.25, "setting": "both", "payers_information": [ { "payer_name": "Aetna", "plan_name": "700700", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna", "plan_name": "700700_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Miscellaneous", "plan_name": "700720", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Miscellaneous", "plan_name": "700720_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Ppo Hmo", "plan_name": "701720", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Ppo Hmo", "plan_name": "701720_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Ms State Emplo", "plan_name": "401457", "standard_charge_percentage": 0.80, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Ms State Emplo", "plan_name": "401457_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Basic Pl", "plan_name": "400100", "standard_charge_percentage": 0.85, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Basic Pl", "plan_name": "400100_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Federal", "plan_name": "400110", "standard_charge_percentage": 0.85, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Federal", "plan_name": "400110_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." } ] } ] }, { "description": "Gentamicin 120 mg/100 ml in sodium chloride(iso) intravenous piggyback [114156]", "drug_information": { "unit": 100.00, "type": "ML" }, "code_information": [ { "code": "J1580", "type": "HCPCS" }, { "code": "0338-0507-48", "type": "NDC" } ], "standard_charges": [ { "gross_charge": 118.86, "minimum": 95.09, "maximum": 101.03, "setting": "both", "payers_information": [ { "payer_name": "Aetna", "plan_name": "700700", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna", "plan_name": "700700_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Miscellaneous", "plan_name": "700720", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Miscellaneous", "plan_name": "700720_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Ppo Hmo", "plan_name": "701720", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Ppo Hmo", "plan_name": "701720_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Ms State Emplo", "plan_name": "401457", "standard_charge_percentage": 0.80, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Ms State Emplo", "plan_name": "401457_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Basic Pl", "plan_name": "400100", "standard_charge_percentage": 0.85, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Basic Pl", "plan_name": "400100_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Federal", "plan_name": "400110", "standard_charge_percentage": 0.85, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Federal", "plan_name": "400110_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." } ] } ] }, { "description": "Glycopyrrolate 0.2 mg/ml injection solution [3497]", "drug_information": { "unit": 1.00, "type": "ML" }, "code_information": [ { "code": "J1596", "type": "HCPCS" }, { "code": "0143-9682-01", "type": "NDC" } ], "standard_charges": [ { "gross_charge": 43.26, "minimum": 0.51, "maximum": 36.77, "setting": "both", "payers_information": [ { "payer_name": "Aarp", "plan_name": "500102", "standard_charge_dollar": 0.51, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna", "plan_name": "700700", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna", "plan_name": "700700_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Mcare Ffs 6005", "plan_name": "700703", "standard_charge_dollar": 0.51, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Miscellaneous", "plan_name": "700720", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Miscellaneous", "plan_name": "700720_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Ppo Hmo", "plan_name": "701720", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Ppo Hmo", "plan_name": "701720_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Ambetter 68069", "plan_name": "500516", "standard_charge_dollar": 0.51, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Ms State Emplo", "plan_name": "401457", "standard_charge_percentage": 0.80, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Ms State Emplo", "plan_name": "401457_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Basic Pl", "plan_name": "400100", "standard_charge_percentage": 0.85, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Basic Pl", "plan_name": "400100_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Federal", "plan_name": "400110", "standard_charge_percentage": 0.85, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Federal", "plan_name": "400110_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Cigna Healthsprings Ffs", "plan_name": "500064", "standard_charge_dollar": 0.51, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Conseco", "plan_name": "500302", "standard_charge_dollar": 0.51, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Humana Ffs 61101", "plan_name": "500006", "standard_charge_dollar": 0.51, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Medicare A", "plan_name": "100100", "standard_charge_dollar": 0.51, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Medicare A", "plan_name": "100500", "standard_charge_dollar": 0.51, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Medicare Part B Only", "plan_name": "100300", "standard_charge_dollar": 0.51, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Medicare Railroad", "plan_name": "100103", "standard_charge_dollar": 0.51, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Ms Physicians Care N", "plan_name": "714210", "standard_charge_dollar": 0.64, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Peoples Hlth Ffs 72126", "plan_name": "500019", "standard_charge_dollar": 0.51, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Uhc/Secure Horizons", "plan_name": "500449", "standard_charge_dollar": 0.51, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "United Health Care/", "plan_name": "500292", "standard_charge_dollar": 0.58, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "United Healthcare", "plan_name": "750104", "standard_charge_dollar": 0.58, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "United Healthcare Ba", "plan_name": "750090", "standard_charge_dollar": 0.58, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "United Healthcare Me", "plan_name": "501310", "standard_charge_dollar": 0.51, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Windsor Mcare Extra", "plan_name": "500778", "standard_charge_dollar": 0.51, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." } ] } ] }, { "description": "Glycopyrrolate 0.2 mg/ml injection solution [3497]", "drug_information": { "unit": 1.00, "type": "ML" }, "code_information": [ { "code": "J1596", "type": "HCPCS" }, { "code": "0143-9682-25", "type": "NDC" } ], "standard_charges": [ { "gross_charge": 43.26, "minimum": 0.51, "maximum": 36.77, "setting": "both", "payers_information": [ { "payer_name": "Aarp", "plan_name": "500102", "standard_charge_dollar": 0.51, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna", "plan_name": "700700", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna", "plan_name": "700700_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Mcare Ffs 6005", "plan_name": "700703", "standard_charge_dollar": 0.51, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Miscellaneous", "plan_name": "700720", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Miscellaneous", "plan_name": "700720_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Ppo Hmo", "plan_name": "701720", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Ppo Hmo", "plan_name": "701720_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Ambetter 68069", "plan_name": "500516", "standard_charge_dollar": 0.51, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Ms State Emplo", "plan_name": "401457", "standard_charge_percentage": 0.80, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Ms State Emplo", "plan_name": "401457_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Basic Pl", "plan_name": "400100", "standard_charge_percentage": 0.85, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Basic Pl", "plan_name": "400100_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Federal", "plan_name": "400110", "standard_charge_percentage": 0.85, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Federal", "plan_name": "400110_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Cigna Healthsprings Ffs", "plan_name": "500064", "standard_charge_dollar": 0.51, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Conseco", "plan_name": "500302", "standard_charge_dollar": 0.51, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Humana Ffs 61101", "plan_name": "500006", "standard_charge_dollar": 0.51, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Medicare A", "plan_name": "100100", "standard_charge_dollar": 0.51, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Medicare A", "plan_name": "100500", "standard_charge_dollar": 0.51, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Medicare Part B Only", "plan_name": "100300", "standard_charge_dollar": 0.51, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Medicare Railroad", "plan_name": "100103", "standard_charge_dollar": 0.51, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Ms Physicians Care N", "plan_name": "714210", "standard_charge_dollar": 0.64, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Peoples Hlth Ffs 72126", "plan_name": "500019", "standard_charge_dollar": 0.51, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Uhc/Secure Horizons", "plan_name": "500449", "standard_charge_dollar": 0.51, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "United Health Care/", "plan_name": "500292", "standard_charge_dollar": 0.58, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "United Healthcare", "plan_name": "750104", "standard_charge_dollar": 0.58, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "United Healthcare Ba", "plan_name": "750090", "standard_charge_dollar": 0.58, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "United Healthcare Me", "plan_name": "501310", "standard_charge_dollar": 0.51, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Windsor Mcare Extra", "plan_name": "500778", "standard_charge_dollar": 0.51, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." } ] } ] }, { "description": "Glycopyrrolate 0.2 mg/ml injection solution [3497]", "drug_information": { "unit": 1.00, "type": "ML" }, "code_information": [ { "code": "J1596", "type": "HCPCS" }, { "code": "43547-543-01", "type": "NDC" } ], "standard_charges": [ { "gross_charge": 43.26, "minimum": 0.51, "maximum": 36.77, "setting": "both", "payers_information": [ { "payer_name": "Aarp", "plan_name": "500102", "standard_charge_dollar": 0.51, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna", "plan_name": "700700", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna", "plan_name": "700700_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Mcare Ffs 6005", "plan_name": "700703", "standard_charge_dollar": 0.51, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Miscellaneous", "plan_name": "700720", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Miscellaneous", "plan_name": "700720_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Ppo Hmo", "plan_name": "701720", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Ppo Hmo", "plan_name": "701720_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Ambetter 68069", "plan_name": "500516", "standard_charge_dollar": 0.51, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Ms State Emplo", "plan_name": "401457", "standard_charge_percentage": 0.80, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Ms State Emplo", "plan_name": "401457_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Basic Pl", "plan_name": "400100", "standard_charge_percentage": 0.85, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Basic Pl", "plan_name": "400100_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Federal", "plan_name": "400110", "standard_charge_percentage": 0.85, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Federal", "plan_name": "400110_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Cigna Healthsprings Ffs", "plan_name": "500064", "standard_charge_dollar": 0.51, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Conseco", "plan_name": "500302", "standard_charge_dollar": 0.51, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Humana Ffs 61101", "plan_name": "500006", "standard_charge_dollar": 0.51, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Medicare A", "plan_name": "100100", "standard_charge_dollar": 0.51, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Medicare A", "plan_name": "100500", "standard_charge_dollar": 0.51, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Medicare Part B Only", "plan_name": "100300", "standard_charge_dollar": 0.51, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Medicare Railroad", "plan_name": "100103", "standard_charge_dollar": 0.51, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Ms Physicians Care N", "plan_name": "714210", "standard_charge_dollar": 0.64, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Peoples Hlth Ffs 72126", "plan_name": "500019", "standard_charge_dollar": 0.51, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Uhc/Secure Horizons", "plan_name": "500449", "standard_charge_dollar": 0.51, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "United Health Care/", "plan_name": "500292", "standard_charge_dollar": 0.58, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "United Healthcare", "plan_name": "750104", "standard_charge_dollar": 0.58, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "United Healthcare Ba", "plan_name": "750090", "standard_charge_dollar": 0.58, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "United Healthcare Me", "plan_name": "501310", "standard_charge_dollar": 0.51, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Windsor Mcare Extra", "plan_name": "500778", "standard_charge_dollar": 0.51, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." } ] } ] }, { "description": "Glycopyrrolate 0.2 mg/ml injection solution [3497]", "drug_information": { "unit": 1.00, "type": "ML" }, "code_information": [ { "code": "J1596", "type": "HCPCS" }, { "code": "43547-543-25", "type": "NDC" } ], "standard_charges": [ { "gross_charge": 43.26, "minimum": 0.51, "maximum": 36.77, "setting": "both", "payers_information": [ { "payer_name": "Aarp", "plan_name": "500102", "standard_charge_dollar": 0.51, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna", "plan_name": "700700", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna", "plan_name": "700700_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Mcare Ffs 6005", "plan_name": "700703", "standard_charge_dollar": 0.51, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Miscellaneous", "plan_name": "700720", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Miscellaneous", "plan_name": "700720_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Ppo Hmo", "plan_name": "701720", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Ppo Hmo", "plan_name": "701720_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Ambetter 68069", "plan_name": "500516", "standard_charge_dollar": 0.51, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Ms State Emplo", "plan_name": "401457", "standard_charge_percentage": 0.80, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Ms State Emplo", "plan_name": "401457_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Basic Pl", "plan_name": "400100", "standard_charge_percentage": 0.85, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Basic Pl", "plan_name": "400100_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Federal", "plan_name": "400110", "standard_charge_percentage": 0.85, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Federal", "plan_name": "400110_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Cigna Healthsprings Ffs", "plan_name": "500064", "standard_charge_dollar": 0.51, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Conseco", "plan_name": "500302", "standard_charge_dollar": 0.51, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Humana Ffs 61101", "plan_name": "500006", "standard_charge_dollar": 0.51, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Medicare A", "plan_name": "100100", "standard_charge_dollar": 0.51, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Medicare A", "plan_name": "100500", "standard_charge_dollar": 0.51, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Medicare Part B Only", "plan_name": "100300", "standard_charge_dollar": 0.51, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Medicare Railroad", "plan_name": "100103", "standard_charge_dollar": 0.51, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Ms Physicians Care N", "plan_name": "714210", "standard_charge_dollar": 0.64, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Peoples Hlth Ffs 72126", "plan_name": "500019", "standard_charge_dollar": 0.51, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Uhc/Secure Horizons", "plan_name": "500449", "standard_charge_dollar": 0.51, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "United Health Care/", "plan_name": "500292", "standard_charge_dollar": 0.58, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "United Healthcare", "plan_name": "750104", "standard_charge_dollar": 0.58, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "United Healthcare Ba", "plan_name": "750090", "standard_charge_dollar": 0.58, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "United Healthcare Me", "plan_name": "501310", "standard_charge_dollar": 0.51, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Windsor Mcare Extra", "plan_name": "500778", "standard_charge_dollar": 0.51, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." } ] } ] }, { "description": "Glycopyrrolate 0.2 mg/ml injection solution [3497]", "drug_information": { "unit": 1.00, "type": "ML" }, "code_information": [ { "code": "J1596", "type": "HCPCS" }, { "code": "0781-3825-96", "type": "NDC" } ], "standard_charges": [ { "gross_charge": 14.00, "minimum": 0.51, "maximum": 11.90, "setting": "both", "payers_information": [ { "payer_name": "Aarp", "plan_name": "500102", "standard_charge_dollar": 0.51, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna", "plan_name": "700700", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna", "plan_name": "700700_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Mcare Ffs 6005", "plan_name": "700703", "standard_charge_dollar": 0.51, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Miscellaneous", "plan_name": "700720", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Miscellaneous", "plan_name": "700720_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Ppo Hmo", "plan_name": "701720", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Ppo Hmo", "plan_name": "701720_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Ambetter 68069", "plan_name": "500516", "standard_charge_dollar": 0.51, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Ms State Emplo", "plan_name": "401457", "standard_charge_percentage": 0.80, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Ms State Emplo", "plan_name": "401457_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Basic Pl", "plan_name": "400100", "standard_charge_percentage": 0.85, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Basic Pl", "plan_name": "400100_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Federal", "plan_name": "400110", "standard_charge_percentage": 0.85, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Federal", "plan_name": "400110_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Cigna Healthsprings Ffs", "plan_name": "500064", "standard_charge_dollar": 0.51, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Conseco", "plan_name": "500302", "standard_charge_dollar": 0.51, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Humana Ffs 61101", "plan_name": "500006", "standard_charge_dollar": 0.51, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Medicare A", "plan_name": "100100", "standard_charge_dollar": 0.51, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Medicare A", "plan_name": "100500", "standard_charge_dollar": 0.51, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Medicare Part B Only", "plan_name": "100300", "standard_charge_dollar": 0.51, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Medicare Railroad", "plan_name": "100103", "standard_charge_dollar": 0.51, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Ms Physicians Care N", "plan_name": "714210", "standard_charge_dollar": 0.64, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Peoples Hlth Ffs 72126", "plan_name": "500019", "standard_charge_dollar": 0.51, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Uhc/Secure Horizons", "plan_name": "500449", "standard_charge_dollar": 0.51, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "United Health Care/", "plan_name": "500292", "standard_charge_dollar": 0.58, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "United Healthcare", "plan_name": "750104", "standard_charge_dollar": 0.58, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "United Healthcare Ba", "plan_name": "750090", "standard_charge_dollar": 0.58, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "United Healthcare Me", "plan_name": "501310", "standard_charge_dollar": 0.51, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Windsor Mcare Extra", "plan_name": "500778", "standard_charge_dollar": 0.51, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." } ] } ] }, { "description": "Glycopyrrolate 0.2 mg/ml injection solution [3497]", "drug_information": { "unit": 5.00, "type": "ML" }, "code_information": [ { "code": "J1596", "type": "HCPCS" }, { "code": "60505-6181-0", "type": "NDC" } ], "standard_charges": [ { "gross_charge": 187.30, "minimum": 0.51, "maximum": 159.21, "setting": "both", "payers_information": [ { "payer_name": "Aarp", "plan_name": "500102", "standard_charge_dollar": 0.51, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna", "plan_name": "700700", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna", "plan_name": "700700_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Mcare Ffs 6005", "plan_name": "700703", "standard_charge_dollar": 0.51, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Miscellaneous", "plan_name": "700720", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Miscellaneous", "plan_name": "700720_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Ppo Hmo", "plan_name": "701720", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Ppo Hmo", "plan_name": "701720_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Ambetter 68069", "plan_name": "500516", "standard_charge_dollar": 0.51, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Ms State Emplo", "plan_name": "401457", "standard_charge_percentage": 0.80, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Ms State Emplo", "plan_name": "401457_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Basic Pl", "plan_name": "400100", "standard_charge_percentage": 0.85, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Basic Pl", "plan_name": "400100_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Federal", "plan_name": "400110", "standard_charge_percentage": 0.85, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Federal", "plan_name": "400110_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Cigna Healthsprings Ffs", "plan_name": "500064", "standard_charge_dollar": 0.51, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Conseco", "plan_name": "500302", "standard_charge_dollar": 0.51, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Humana Ffs 61101", "plan_name": "500006", "standard_charge_dollar": 0.51, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Medicare A", "plan_name": "100100", "standard_charge_dollar": 0.51, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Medicare A", "plan_name": "100500", "standard_charge_dollar": 0.51, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Medicare Part B Only", "plan_name": "100300", "standard_charge_dollar": 0.51, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Medicare Railroad", "plan_name": "100103", "standard_charge_dollar": 0.51, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Ms Physicians Care N", "plan_name": "714210", "standard_charge_dollar": 0.64, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Peoples Hlth Ffs 72126", "plan_name": "500019", "standard_charge_dollar": 0.51, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Uhc/Secure Horizons", "plan_name": "500449", "standard_charge_dollar": 0.51, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "United Health Care/", "plan_name": "500292", "standard_charge_dollar": 0.58, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "United Healthcare", "plan_name": "750104", "standard_charge_dollar": 0.58, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "United Healthcare Ba", "plan_name": "750090", "standard_charge_dollar": 0.58, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "United Healthcare Me", "plan_name": "501310", "standard_charge_dollar": 0.51, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Windsor Mcare Extra", "plan_name": "500778", "standard_charge_dollar": 0.51, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." } ] } ] }, { "description": "Glycopyrrolate 0.2 mg/ml injection solution [3497]", "drug_information": { "unit": 5.00, "type": "ML" }, "code_information": [ { "code": "J1596", "type": "HCPCS" }, { "code": "60505-6181-5", "type": "NDC" } ], "standard_charges": [ { "gross_charge": 187.30, "minimum": 0.51, "maximum": 159.21, "setting": "both", "payers_information": [ { "payer_name": "Aarp", "plan_name": "500102", "standard_charge_dollar": 0.51, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna", "plan_name": "700700", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna", "plan_name": "700700_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Mcare Ffs 6005", "plan_name": "700703", "standard_charge_dollar": 0.51, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Miscellaneous", "plan_name": "700720", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Miscellaneous", "plan_name": "700720_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Ppo Hmo", "plan_name": "701720", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Ppo Hmo", "plan_name": "701720_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Ambetter 68069", "plan_name": "500516", "standard_charge_dollar": 0.51, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Ms State Emplo", "plan_name": "401457", "standard_charge_percentage": 0.80, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Ms State Emplo", "plan_name": "401457_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Basic Pl", "plan_name": "400100", "standard_charge_percentage": 0.85, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Basic Pl", "plan_name": "400100_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Federal", "plan_name": "400110", "standard_charge_percentage": 0.85, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Federal", "plan_name": "400110_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Cigna Healthsprings Ffs", "plan_name": "500064", "standard_charge_dollar": 0.51, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Conseco", "plan_name": "500302", "standard_charge_dollar": 0.51, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Humana Ffs 61101", "plan_name": "500006", "standard_charge_dollar": 0.51, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Medicare A", "plan_name": "100100", "standard_charge_dollar": 0.51, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Medicare A", "plan_name": "100500", "standard_charge_dollar": 0.51, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Medicare Part B Only", "plan_name": "100300", "standard_charge_dollar": 0.51, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Medicare Railroad", "plan_name": "100103", "standard_charge_dollar": 0.51, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Ms Physicians Care N", "plan_name": "714210", "standard_charge_dollar": 0.64, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Peoples Hlth Ffs 72126", "plan_name": "500019", "standard_charge_dollar": 0.51, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Uhc/Secure Horizons", "plan_name": "500449", "standard_charge_dollar": 0.51, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "United Health Care/", "plan_name": "500292", "standard_charge_dollar": 0.58, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "United Healthcare", "plan_name": "750104", "standard_charge_dollar": 0.58, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "United Healthcare Ba", "plan_name": "750090", "standard_charge_dollar": 0.58, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "United Healthcare Me", "plan_name": "501310", "standard_charge_dollar": 0.51, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Windsor Mcare Extra", "plan_name": "500778", "standard_charge_dollar": 0.51, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." } ] } ] }, { "description": "Golimumab 12.5 mg/ml intravenous solution [163505]", "drug_information": { "unit": 4.00, "type": "ML" }, "code_information": [ { "code": "J1602", "type": "HCPCS" }, { "code": "57894-350-01", "type": "NDC" } ], "standard_charges": [ { "gross_charge": 8771.45, "minimum": 10.77, "maximum": 33.80, "setting": "both", "payers_information": [ { "payer_name": "Aarp", "plan_name": "500102", "standard_charge_dollar": 10.77, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna", "plan_name": "700700", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna", "plan_name": "700700_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Mcare Ffs 6005", "plan_name": "700703", "standard_charge_dollar": 10.77, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Miscellaneous", "plan_name": "700720", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Miscellaneous", "plan_name": "700720_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Ppo Hmo", "plan_name": "701720", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Ppo Hmo", "plan_name": "701720_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Ambetter 68069", "plan_name": "500516", "standard_charge_dollar": 10.77, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Ms State Emplo", "plan_name": "401457", "standard_charge_dollar": 33.80, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Ms State Emplo", "plan_name": "401457_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Basic Pl", "plan_name": "400100", "standard_charge_dollar": 33.80, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Basic Pl", "plan_name": "400100_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Federal", "plan_name": "400110", "standard_charge_dollar": 33.80, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Federal", "plan_name": "400110_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Cigna Healthsprings Ffs", "plan_name": "500064", "standard_charge_dollar": 10.77, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Conseco", "plan_name": "500302", "standard_charge_dollar": 10.77, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Humana Ffs 61101", "plan_name": "500006", "standard_charge_dollar": 10.77, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Medicare A", "plan_name": "100100", "standard_charge_dollar": 10.77, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Medicare A", "plan_name": "100500", "standard_charge_dollar": 10.77, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Medicare Part B Only", "plan_name": "100300", "standard_charge_dollar": 10.77, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Medicare Railroad", "plan_name": "100103", "standard_charge_dollar": 10.77, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Ms Physicians Care N", "plan_name": "714210", "standard_charge_dollar": 13.46, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Peoples Hlth Ffs 72126", "plan_name": "500019", "standard_charge_dollar": 10.77, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Uhc/Secure Horizons", "plan_name": "500449", "standard_charge_dollar": 10.77, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "United Health Care/", "plan_name": "500292", "standard_charge_dollar": 12.17, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "United Healthcare", "plan_name": "750104", "standard_charge_dollar": 12.17, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "United Healthcare Ba", "plan_name": "750090", "standard_charge_dollar": 12.17, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "United Healthcare Me", "plan_name": "501310", "standard_charge_dollar": 10.77, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Windsor Mcare Extra", "plan_name": "500778", "standard_charge_dollar": 10.77, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." } ] } ] }, { "description": "Glucagon 1 mg solution for injection [109673]", "drug_information": { "unit": 1.00, "type": "EA" }, "code_information": [ { "code": "J1610", "type": "HCPCS" }, { "code": "0002-8031-01", "type": "NDC" } ], "standard_charges": [ { "gross_charge": 1404.00, "minimum": 163.68, "maximum": 238.45, "setting": "both", "payers_information": [ { "payer_name": "Aarp", "plan_name": "500102", "standard_charge_dollar": 190.76, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna", "plan_name": "700700", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna", "plan_name": "700700_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Mcare Ffs 6005", "plan_name": "700703", "standard_charge_dollar": 190.76, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Miscellaneous", "plan_name": "700720", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Miscellaneous", "plan_name": "700720_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Ppo Hmo", "plan_name": "701720", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Ppo Hmo", "plan_name": "701720_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Ambetter 68069", "plan_name": "500516", "standard_charge_dollar": 190.76, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Ms State Emplo", "plan_name": "401457", "standard_charge_dollar": 163.68, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Ms State Emplo", "plan_name": "401457_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Basic Pl", "plan_name": "400100", "standard_charge_dollar": 163.68, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Basic Pl", "plan_name": "400100_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Federal", "plan_name": "400110", "standard_charge_dollar": 163.68, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Federal", "plan_name": "400110_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Cigna Healthsprings Ffs", "plan_name": "500064", "standard_charge_dollar": 190.76, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Conseco", "plan_name": "500302", "standard_charge_dollar": 190.76, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Humana Ffs 61101", "plan_name": "500006", "standard_charge_dollar": 190.76, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Medicare A", "plan_name": "100100", "standard_charge_dollar": 190.76, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Medicare A", "plan_name": "100500", "standard_charge_dollar": 190.76, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Medicare Part B Only", "plan_name": "100300", "standard_charge_dollar": 190.76, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Medicare Railroad", "plan_name": "100103", "standard_charge_dollar": 190.76, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Ms Physicians Care N", "plan_name": "714210", "standard_charge_dollar": 238.45, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Peoples Hlth Ffs 72126", "plan_name": "500019", "standard_charge_dollar": 190.76, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Uhc/Secure Horizons", "plan_name": "500449", "standard_charge_dollar": 190.76, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "United Health Care/", "plan_name": "500292", "standard_charge_dollar": 215.56, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "United Healthcare", "plan_name": "750104", "standard_charge_dollar": 215.56, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "United Healthcare Ba", "plan_name": "750090", "standard_charge_dollar": 215.56, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "United Healthcare Me", "plan_name": "501310", "standard_charge_dollar": 190.76, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Windsor Mcare Extra", "plan_name": "500778", "standard_charge_dollar": 190.76, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." } ] } ] }, { "description": "Glucagon 1 mg solution for injection [109673]", "drug_information": { "unit": 1.00, "type": "EA" }, "code_information": [ { "code": "J1610", "type": "HCPCS" }, { "code": "0548-5850-00", "type": "NDC" } ], "standard_charges": [ { "gross_charge": 1538.45, "minimum": 163.68, "maximum": 238.45, "setting": "both", "payers_information": [ { "payer_name": "Aarp", "plan_name": "500102", "standard_charge_dollar": 190.76, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna", "plan_name": "700700", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna", "plan_name": "700700_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Mcare Ffs 6005", "plan_name": "700703", "standard_charge_dollar": 190.76, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Miscellaneous", "plan_name": "700720", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Miscellaneous", "plan_name": "700720_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Ppo Hmo", "plan_name": "701720", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Ppo Hmo", "plan_name": "701720_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Ambetter 68069", "plan_name": "500516", "standard_charge_dollar": 190.76, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Ms State Emplo", "plan_name": "401457", "standard_charge_dollar": 163.68, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Ms State Emplo", "plan_name": "401457_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Basic Pl", "plan_name": "400100", "standard_charge_dollar": 163.68, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Basic Pl", "plan_name": "400100_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Federal", "plan_name": "400110", "standard_charge_dollar": 163.68, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Federal", "plan_name": "400110_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Cigna Healthsprings Ffs", "plan_name": "500064", "standard_charge_dollar": 190.76, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Conseco", "plan_name": "500302", "standard_charge_dollar": 190.76, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Humana Ffs 61101", "plan_name": "500006", "standard_charge_dollar": 190.76, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Medicare A", "plan_name": "100100", "standard_charge_dollar": 190.76, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Medicare A", "plan_name": "100500", "standard_charge_dollar": 190.76, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Medicare Part B Only", "plan_name": "100300", "standard_charge_dollar": 190.76, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Medicare Railroad", "plan_name": "100103", "standard_charge_dollar": 190.76, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Ms Physicians Care N", "plan_name": "714210", "standard_charge_dollar": 238.45, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Peoples Hlth Ffs 72126", "plan_name": "500019", "standard_charge_dollar": 190.76, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Uhc/Secure Horizons", "plan_name": "500449", "standard_charge_dollar": 190.76, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "United Health Care/", "plan_name": "500292", "standard_charge_dollar": 215.56, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "United Healthcare", "plan_name": "750104", "standard_charge_dollar": 215.56, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "United Healthcare Ba", "plan_name": "750090", "standard_charge_dollar": 215.56, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "United Healthcare Me", "plan_name": "501310", "standard_charge_dollar": 190.76, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Windsor Mcare Extra", "plan_name": "500778", "standard_charge_dollar": 190.76, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." } ] } ] }, { "description": "Glucagon 1 mg/ml solution for injection [119849]", "drug_information": { "unit": 1.00, "type": "EA" }, "code_information": [ { "code": "J1610", "type": "HCPCS" }, { "code": "0597-0053-45", "type": "NDC" } ], "standard_charges": [ { "gross_charge": 858.00, "minimum": 163.68, "maximum": 238.45, "setting": "both", "payers_information": [ { "payer_name": "Aarp", "plan_name": "500102", "standard_charge_dollar": 190.76, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna", "plan_name": "700700", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna", "plan_name": "700700_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Mcare Ffs 6005", "plan_name": "700703", "standard_charge_dollar": 190.76, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Miscellaneous", "plan_name": "700720", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Miscellaneous", "plan_name": "700720_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Ppo Hmo", "plan_name": "701720", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Ppo Hmo", "plan_name": "701720_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Ambetter 68069", "plan_name": "500516", "standard_charge_dollar": 190.76, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Ms State Emplo", "plan_name": "401457", "standard_charge_dollar": 163.68, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Ms State Emplo", "plan_name": "401457_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Basic Pl", "plan_name": "400100", "standard_charge_dollar": 163.68, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Basic Pl", "plan_name": "400100_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Federal", "plan_name": "400110", "standard_charge_dollar": 163.68, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Federal", "plan_name": "400110_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Cigna Healthsprings Ffs", "plan_name": "500064", "standard_charge_dollar": 190.76, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Conseco", "plan_name": "500302", "standard_charge_dollar": 190.76, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Humana Ffs 61101", "plan_name": "500006", "standard_charge_dollar": 190.76, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Medicare A", "plan_name": "100100", "standard_charge_dollar": 190.76, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Medicare A", "plan_name": "100500", "standard_charge_dollar": 190.76, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Medicare Part B Only", "plan_name": "100300", "standard_charge_dollar": 190.76, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Medicare Railroad", "plan_name": "100103", "standard_charge_dollar": 190.76, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Ms Physicians Care N", "plan_name": "714210", "standard_charge_dollar": 238.45, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Peoples Hlth Ffs 72126", "plan_name": "500019", "standard_charge_dollar": 190.76, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Uhc/Secure Horizons", "plan_name": "500449", "standard_charge_dollar": 190.76, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "United Health Care/", "plan_name": "500292", "standard_charge_dollar": 215.56, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "United Healthcare", "plan_name": "750104", "standard_charge_dollar": 215.56, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "United Healthcare Ba", "plan_name": "750090", "standard_charge_dollar": 215.56, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "United Healthcare Me", "plan_name": "501310", "standard_charge_dollar": 190.76, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Windsor Mcare Extra", "plan_name": "500778", "standard_charge_dollar": 190.76, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." } ] } ] }, { "description": "Glucagon hcl 1 mg solution for injection [189508]", "drug_information": { "unit": 1.00, "type": "EA" }, "code_information": [ { "code": "J1611", "type": "HCPCS" }, { "code": "63323-582-82", "type": "NDC" } ], "standard_charges": [ { "gross_charge": 1315.90, "minimum": 150.44, "maximum": 1118.52, "setting": "both", "payers_information": [ { "payer_name": "Aarp", "plan_name": "500102", "standard_charge_dollar": 150.44, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna", "plan_name": "700700", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna", "plan_name": "700700_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Mcare Ffs 6005", "plan_name": "700703", "standard_charge_dollar": 150.44, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Miscellaneous", "plan_name": "700720", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Miscellaneous", "plan_name": "700720_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Ppo Hmo", "plan_name": "701720", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Ppo Hmo", "plan_name": "701720_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Ambetter 68069", "plan_name": "500516", "standard_charge_dollar": 150.44, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Ms State Emplo", "plan_name": "401457", "standard_charge_percentage": 0.80, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Ms State Emplo", "plan_name": "401457_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Basic Pl", "plan_name": "400100", "standard_charge_percentage": 0.85, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Basic Pl", "plan_name": "400100_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Federal", "plan_name": "400110", "standard_charge_percentage": 0.85, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Federal", "plan_name": "400110_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Cigna Healthsprings Ffs", "plan_name": "500064", "standard_charge_dollar": 150.44, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Conseco", "plan_name": "500302", "standard_charge_dollar": 150.44, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Humana Ffs 61101", "plan_name": "500006", "standard_charge_dollar": 150.44, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Medicare A", "plan_name": "100100", "standard_charge_dollar": 150.44, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Medicare A", "plan_name": "100500", "standard_charge_dollar": 150.44, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Medicare Part B Only", "plan_name": "100300", "standard_charge_dollar": 150.44, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Medicare Railroad", "plan_name": "100103", "standard_charge_dollar": 150.44, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Ms Physicians Care N", "plan_name": "714210", "standard_charge_dollar": 188.05, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Peoples Hlth Ffs 72126", "plan_name": "500019", "standard_charge_dollar": 150.44, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Uhc/Secure Horizons", "plan_name": "500449", "standard_charge_dollar": 150.44, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "United Health Care/", "plan_name": "500292", "standard_charge_dollar": 170.00, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "United Healthcare", "plan_name": "750104", "standard_charge_dollar": 170.00, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "United Healthcare Ba", "plan_name": "750090", "standard_charge_dollar": 170.00, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "United Healthcare Me", "plan_name": "501310", "standard_charge_dollar": 150.44, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Windsor Mcare Extra", "plan_name": "500778", "standard_charge_dollar": 150.44, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." } ] } ] }, { "description": "Glucagon hcl 1 mg/ml solution for injection [169979]", "drug_information": { "unit": 1.00, "type": "EA" }, "code_information": [ { "code": "J1611", "type": "HCPCS" }, { "code": "63323-593-03", "type": "NDC" } ], "standard_charges": [ { "gross_charge": 1188.35, "minimum": 150.44, "maximum": 1010.10, "setting": "both", "payers_information": [ { "payer_name": "Aarp", "plan_name": "500102", "standard_charge_dollar": 150.44, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna", "plan_name": "700700", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna", "plan_name": "700700_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Mcare Ffs 6005", "plan_name": "700703", "standard_charge_dollar": 150.44, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Miscellaneous", "plan_name": "700720", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Miscellaneous", "plan_name": "700720_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Ppo Hmo", "plan_name": "701720", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Ppo Hmo", "plan_name": "701720_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Ambetter 68069", "plan_name": "500516", "standard_charge_dollar": 150.44, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Ms State Emplo", "plan_name": "401457", "standard_charge_percentage": 0.80, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Ms State Emplo", "plan_name": "401457_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Basic Pl", "plan_name": "400100", "standard_charge_percentage": 0.85, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": 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"plan_name": "400110_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." } ] } ] }, { "description": "Heparin (porcine) 25000 unit/250 ml (100 unit/ml) in dextrose 5 % iv [15846]", "drug_information": { "unit": 250.00, "type": "ML" }, "code_information": [ { "code": "J1644", "type": "HCPCS" }, { "code": "0264-9587-20", "type": "NDC" } ], "standard_charges": [ { "gross_charge": 150.69, "minimum": 0.62, "maximum": 0.62, "setting": "both", "payers_information": [ { "payer_name": "Aetna", "plan_name": "700700", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna", "plan_name": "700700_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", 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"payer_name": "Aetna Ppo Hmo", "plan_name": "701720", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Ppo Hmo", "plan_name": "701720_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Ambetter 68069", "plan_name": "500516", "standard_charge_dollar": 575.76, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Ms State Emplo", "plan_name": "401457", "standard_charge_dollar": 438.63, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Ms State Emplo", "plan_name": "401457_1", 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remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Ms State Emplo", "plan_name": "401457", "standard_charge_dollar": 438.63, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Ms State Emplo", "plan_name": "401457_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Basic Pl", "plan_name": "400100", "standard_charge_dollar": 438.63, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Basic Pl", "plan_name": "400100_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Federal", "plan_name": "400110", "standard_charge_dollar": 438.63, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Federal", "plan_name": "400110_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Cigna Healthsprings Ffs", "plan_name": "500064", "standard_charge_dollar": 575.76, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Conseco", "plan_name": "500302", "standard_charge_dollar": 575.76, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Humana Ffs 61101", "plan_name": "500006", "standard_charge_dollar": 575.76, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Medicare A", "plan_name": "100100", "standard_charge_dollar": 575.76, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Medicare A", "plan_name": "100500", "standard_charge_dollar": 575.76, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Medicare Part B Only", "plan_name": "100300", "standard_charge_dollar": 575.76, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Medicare Railroad", "plan_name": "100103", "standard_charge_dollar": 575.76, "count": "0", "methodology": "fee schedule", "additional_payer_notes": 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Healthcare", "plan_name": "750104", "standard_charge_dollar": 650.61, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "United Healthcare Ba", "plan_name": "750090", "standard_charge_dollar": 650.61, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "United Healthcare Me", "plan_name": "501310", "standard_charge_dollar": 575.76, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Windsor Mcare Extra", "plan_name": "500778", "standard_charge_dollar": 575.76, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." } ] } ] }, { "description": "Hydrocortisone sod succinate (pf) 250 mg/2 ml solution for injection [119664]", 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{ "payer_name": "Bc/Bs Ms State Emplo", "plan_name": "401457", "standard_charge_dollar": 322.57, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Ms State Emplo", "plan_name": "401457_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Basic Pl", "plan_name": "400100", "standard_charge_dollar": 322.57, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Basic Pl", "plan_name": "400100_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Federal", "plan_name": "400110", "standard_charge_dollar": 322.57, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Federal", "plan_name": "400110_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Cigna Healthsprings Ffs", "plan_name": "500064", "standard_charge_dollar": 125.32, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Conseco", "plan_name": "500302", "standard_charge_dollar": 125.32, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Humana Ffs 61101", "plan_name": "500006", "standard_charge_dollar": 125.32, "count": "0", 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{ "payer_name": "Ms Physicians Care N", "plan_name": "714210", "standard_charge_dollar": 156.65, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Peoples Hlth Ffs 72126", "plan_name": "500019", "standard_charge_dollar": 125.32, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Uhc/Secure Horizons", "plan_name": "500449", "standard_charge_dollar": 125.32, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "United Health Care/", "plan_name": "500292", "standard_charge_dollar": 141.61, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "United Healthcare", "plan_name": "750104", "standard_charge_dollar": 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amounts." }, { "payer_name": "Bc/Bs Of Ms Basic Pl", "plan_name": "400100_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Federal", "plan_name": "400110", "standard_charge_dollar": 113.51, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Federal", "plan_name": "400110_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Cigna Healthsprings Ffs", "plan_name": "500064", "standard_charge_dollar": 30.52, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Conseco", "plan_name": "500302", "standard_charge_dollar": 30.52, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Humana Ffs 61101", "plan_name": "500006", "standard_charge_dollar": 30.52, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Medicare A", "plan_name": "100100", "standard_charge_dollar": 30.52, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Medicare A", "plan_name": "100500", "standard_charge_dollar": 30.52, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Medicare Part B Only", "plan_name": "100300", "standard_charge_dollar": 30.52, "count": "0", "methodology": "fee schedule", 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"payer_name": "United Health Care/", "plan_name": "500292", "standard_charge_dollar": 34.49, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "United Healthcare", "plan_name": "750104", "standard_charge_dollar": 34.49, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "United Healthcare Ba", "plan_name": "750090", "standard_charge_dollar": 34.49, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "United Healthcare Me", "plan_name": "501310", "standard_charge_dollar": 30.52, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Windsor Mcare Extra", "plan_name": "500778", "standard_charge_dollar": 30.52, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." } ] } ] }, { "description": "Iron dextran 50 mg/ml injection solution [184019]", "drug_information": { "unit": 2.00, "type": "ML" }, "code_information": [ { "code": "J1750", "type": "HCPCS" }, { "code": "0023-6082-01", "type": "NDC" } ], "standard_charges": [ { "gross_charge": 167.00, "minimum": 11.54, "maximum": 21.54, "setting": "both", "payers_information": [ { "payer_name": "Aarp", "plan_name": "500102", "standard_charge_dollar": 17.23, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna", "plan_name": "700700", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna", "plan_name": "700700_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Mcare Ffs 6005", "plan_name": "700703", "standard_charge_dollar": 17.23, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Miscellaneous", "plan_name": "700720", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Miscellaneous", "plan_name": "700720_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Ppo Hmo", "plan_name": "701720", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Ppo Hmo", "plan_name": "701720_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Ambetter 68069", "plan_name": "500516", "standard_charge_dollar": 17.23, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Ms State Emplo", "plan_name": "401457", "standard_charge_dollar": 11.54, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Ms State Emplo", "plan_name": "401457_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Basic Pl", "plan_name": "400100", "standard_charge_dollar": 11.54, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Basic Pl", "plan_name": "400100_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Federal", "plan_name": "400110", "standard_charge_dollar": 11.54, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Federal", "plan_name": "400110_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Cigna Healthsprings Ffs", "plan_name": "500064", "standard_charge_dollar": 17.23, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Conseco", "plan_name": "500302", "standard_charge_dollar": 17.23, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Humana Ffs 61101", "plan_name": "500006", "standard_charge_dollar": 17.23, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Medicare A", "plan_name": "100100", "standard_charge_dollar": 17.23, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Medicare A", "plan_name": "100500", "standard_charge_dollar": 17.23, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Medicare Part B Only", "plan_name": "100300", "standard_charge_dollar": 17.23, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Medicare Railroad", "plan_name": "100103", "standard_charge_dollar": 17.23, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Ms Physicians Care N", "plan_name": "714210", "standard_charge_dollar": 21.54, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Peoples Hlth Ffs 72126", "plan_name": "500019", "standard_charge_dollar": 17.23, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Uhc/Secure Horizons", "plan_name": "500449", "standard_charge_dollar": 17.23, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "United Health Care/", "plan_name": "500292", "standard_charge_dollar": 19.47, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "United Healthcare", "plan_name": "750104", "standard_charge_dollar": 19.47, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "United Healthcare Ba", "plan_name": "750090", "standard_charge_dollar": 19.47, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "United Healthcare Me", "plan_name": "501310", "standard_charge_dollar": 17.23, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Windsor Mcare Extra", "plan_name": "500778", "standard_charge_dollar": 17.23, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." } ] } ] }, { "description": "Iron dextran 50 mg/ml injection solution [184019]", "drug_information": { "unit": 2.00, "type": "ML" }, "code_information": [ { "code": "J1750", "type": "HCPCS" }, { "code": "0023-6082-10", "type": "NDC" } ], "standard_charges": [ { "gross_charge": 167.00, "minimum": 11.54, "maximum": 21.54, "setting": "both", "payers_information": [ { "payer_name": "Aarp", "plan_name": "500102", "standard_charge_dollar": 17.23, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna", "plan_name": "700700", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna", "plan_name": "700700_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Mcare Ffs 6005", "plan_name": "700703", "standard_charge_dollar": 17.23, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Miscellaneous", "plan_name": "700720", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Miscellaneous", "plan_name": "700720_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Ppo Hmo", "plan_name": "701720", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Ppo Hmo", "plan_name": "701720_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Ambetter 68069", "plan_name": "500516", "standard_charge_dollar": 17.23, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Ms State Emplo", "plan_name": "401457", "standard_charge_dollar": 11.54, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Ms State Emplo", "plan_name": "401457_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Basic Pl", "plan_name": "400100", "standard_charge_dollar": 11.54, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Basic Pl", "plan_name": "400100_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Federal", "plan_name": "400110", "standard_charge_dollar": 11.54, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Federal", "plan_name": "400110_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Cigna Healthsprings Ffs", "plan_name": "500064", "standard_charge_dollar": 17.23, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Conseco", "plan_name": "500302", "standard_charge_dollar": 17.23, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Humana Ffs 61101", "plan_name": "500006", "standard_charge_dollar": 17.23, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Medicare A", "plan_name": "100100", "standard_charge_dollar": 17.23, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Medicare A", "plan_name": "100500", "standard_charge_dollar": 17.23, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Medicare Part B Only", "plan_name": "100300", "standard_charge_dollar": 17.23, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Medicare Railroad", "plan_name": "100103", "standard_charge_dollar": 17.23, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Ms Physicians Care N", "plan_name": "714210", "standard_charge_dollar": 21.54, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Peoples Hlth Ffs 72126", "plan_name": "500019", "standard_charge_dollar": 17.23, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Uhc/Secure Horizons", "plan_name": "500449", "standard_charge_dollar": 17.23, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "United Health Care/", "plan_name": "500292", "standard_charge_dollar": 19.47, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "United Healthcare", "plan_name": "750104", "standard_charge_dollar": 19.47, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "United Healthcare Ba", "plan_name": "750090", "standard_charge_dollar": 19.47, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "United Healthcare Me", "plan_name": "501310", "standard_charge_dollar": 17.23, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Windsor Mcare Extra", "plan_name": "500778", "standard_charge_dollar": 17.23, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." } ] } ] }, { "description": "Iron sucrose 200 mg iron/10 ml intravenous solution [151050]", "drug_information": { "unit": 10.00, "type": "ML" }, "code_information": [ { "code": "J1756", "type": "HCPCS" }, { "code": "0517-2310-01", "type": "NDC" } ], "standard_charges": [ { 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"additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Ppo Hmo", "plan_name": "701720", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Ppo Hmo", "plan_name": "701720_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Ms State Emplo", "plan_name": "401457", "standard_charge_dollar": 0.34, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Ms State Emplo", "plan_name": "401457_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Basic Pl", "plan_name": "400100", "standard_charge_dollar": 0.34, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Basic Pl", "plan_name": "400100_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Federal", "plan_name": "400110", "standard_charge_dollar": 0.34, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Federal", "plan_name": "400110_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." } ] } ] }, { "description": "Iron sucrose 200 mg iron/10 ml intravenous solution [151050]", "drug_information": { "unit": 10.00, "type": "ML" }, "code_information": [ { "code": "J1756", "type": "HCPCS" }, { "code": "0517-2310-05", "type": "NDC" } ], "standard_charges": [ { "gross_charge": 575.80, "minimum": 0.34, "maximum": 0.34, "setting": "both", "payers_information": [ { "payer_name": "Aetna", "plan_name": "700700", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna", "plan_name": "700700_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Miscellaneous", "plan_name": "700720", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Miscellaneous", "plan_name": "700720_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Ppo Hmo", "plan_name": "701720", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Ppo Hmo", "plan_name": "701720_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Ms State Emplo", "plan_name": "401457", "standard_charge_dollar": 0.34, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Ms State Emplo", "plan_name": "401457_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Basic Pl", "plan_name": "400100", "standard_charge_dollar": 0.34, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Basic Pl", "plan_name": "400100_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Federal", "plan_name": "400110", "standard_charge_dollar": 0.34, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Federal", "plan_name": "400110_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." } ] } ] }, { "description": "Iron sucrose 100 mg iron/5 ml intravenous solution [29132]", "drug_information": { "unit": 5.00, "type": "ML" }, "code_information": [ { "code": "J1756", "type": "HCPCS" }, { "code": "0517-2340-01", "type": "NDC" } ], "standard_charges": [ { "gross_charge": 287.93, "minimum": 0.34, "maximum": 0.34, "setting": "both", "payers_information": [ { "payer_name": "Aetna", "plan_name": "700700", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna", "plan_name": "700700_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Miscellaneous", "plan_name": "700720", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Miscellaneous", "plan_name": "700720_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Ppo Hmo", "plan_name": "701720", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Ppo Hmo", "plan_name": "701720_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Ms State Emplo", "plan_name": "401457", "standard_charge_dollar": 0.34, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Ms State Emplo", "plan_name": "401457_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Basic Pl", "plan_name": "400100", "standard_charge_dollar": 0.34, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Basic Pl", "plan_name": "400100_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Federal", "plan_name": "400110", "standard_charge_dollar": 0.34, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Federal", "plan_name": "400110_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." } ] } ] }, { "description": "Iron sucrose 100 mg iron/5 ml intravenous solution [29132]", "drug_information": { "unit": 5.00, "type": "ML" }, "code_information": [ { "code": "J1756", "type": "HCPCS" }, { "code": "0517-2340-10", "type": "NDC" } ], "standard_charges": [ { "gross_charge": 287.93, "minimum": 0.34, "maximum": 0.34, "setting": "both", "payers_information": [ { "payer_name": "Aetna", "plan_name": "700700", "standard_charge_percentage": 80.0, "count": "0", "methodology": 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charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Ppo Hmo", "plan_name": "701720_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Ms State Emplo", "plan_name": "401457", "standard_charge_dollar": 0.34, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Ms State Emplo", "plan_name": "401457_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Basic Pl", "plan_name": "400100", "standard_charge_dollar": 0.34, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Basic Pl", "plan_name": "400100_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Federal", "plan_name": "400110", "standard_charge_dollar": 0.34, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Federal", "plan_name": "400110_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." } ] } ] }, { "description": "Iron sucrose 100 mg iron/5 ml intravenous solution [29132]", "drug_information": { "unit": 5.00, "type": "ML" }, "code_information": [ { "code": "J1756", "type": "HCPCS" }, { "code": "0517-2340-25", "type": 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billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Ppo Hmo", "plan_name": "701720", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Ppo Hmo", "plan_name": "701720_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Ms State Emplo", "plan_name": "401457", "standard_charge_dollar": 0.34, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Ms State Emplo", "plan_name": "401457_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", 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"0169-7501-11", "type": "NDC" } ], "standard_charges": [ { "gross_charge": 340.20, "minimum": 272.16, "maximum": 289.17, "setting": "both", "payers_information": [ { "payer_name": "Aetna", "plan_name": "700700", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna", "plan_name": "700700_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Miscellaneous", "plan_name": "700720", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Miscellaneous", "plan_name": "700720_1", "standard_charge_percentage": 100.0, "count": "0", 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"Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Basic Pl", "plan_name": "400100_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Federal", "plan_name": "400110", "standard_charge_percentage": 0.85, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Federal", "plan_name": "400110_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." } ] } ] }, { "description": "Insulin u-100 regular human 100 unit/ml injection solution [10289]", "drug_information": { "unit": 10.00, "type": "ML" }, "code_information": [ { "code": "J1815", "type": "HCPCS" }, { "code": "0169-1833-11", "type": "NDC" } ], "standard_charges": [ { "gross_charge": 226.70, "minimum": 181.36, "maximum": 192.70, "setting": "both", "payers_information": [ { "payer_name": "Aetna", "plan_name": "700700", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna", "plan_name": "700700_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Miscellaneous", "plan_name": "700720", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Miscellaneous", "plan_name": "700720_1", 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"standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Basic Pl", "plan_name": "400100", "standard_charge_percentage": 0.85, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Basic Pl", "plan_name": "400100_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Federal", "plan_name": "400110", "standard_charge_percentage": 0.85, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Federal", "plan_name": "400110_1", 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"standard_charge_percentage": 0.85, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Basic Pl", "plan_name": "400100_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Federal", "plan_name": "400110", "standard_charge_percentage": 0.85, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Federal", "plan_name": "400110_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." } ] } ] }, { "description": "Insulin regular 100 unit/100 ml (1 unit/ml) in 0.9 % nacl iv solution [188153]", "drug_information": { "unit": 100.00, "type": "ML" }, "code_information": [ { "code": "J1815", "type": "HCPCS" }, { "code": "0338-0126-12", "type": "NDC" } ], "standard_charges": [ { "gross_charge": 238.09, "minimum": 190.47, "maximum": 202.38, "setting": "both", "payers_information": [ { "payer_name": "Aetna", "plan_name": "700700", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna", "plan_name": "700700_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Miscellaneous", "plan_name": "700720", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Miscellaneous", "plan_name": "700720_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Ppo Hmo", "plan_name": "701720", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Ppo Hmo", "plan_name": "701720_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Ms State Emplo", "plan_name": "401457", "standard_charge_percentage": 0.80, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient 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"count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Miscellaneous", "plan_name": "700720", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Miscellaneous", "plan_name": "700720_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Ppo Hmo", "plan_name": "701720", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Ppo Hmo", "plan_name": "701720_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Ms State Emplo", "plan_name": "401457", "standard_charge_percentage": 0.80, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Ms State Emplo", "plan_name": "401457_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Basic Pl", "plan_name": "400100", "standard_charge_percentage": 0.85, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Basic Pl", "plan_name": "400100_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Federal", "plan_name": "400110", "standard_charge_percentage": 0.85, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Federal", "plan_name": "400110_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." } ] } ] }, { "description": "Insulin human u-100 nph-regulr 70-30 mix 100 unit/ml subcutaneous susp [10286]", "drug_information": { "unit": 10.00, "type": "ML" }, "code_information": [ { "code": "J1815", "type": "HCPCS" }, { "code": "0002-8715-01", "type": "NDC" } ], "standard_charges": [ { "gross_charge": 209.80, "minimum": 167.84, "maximum": 178.33, "setting": "both", "payers_information": [ { "payer_name": "Aetna", "plan_name": "700700", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna", "plan_name": "700700_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Miscellaneous", "plan_name": "700720", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Miscellaneous", "plan_name": "700720_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Ppo Hmo", "plan_name": "701720", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Ppo Hmo", "plan_name": "701720_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Ms State Emplo", "plan_name": "401457", "standard_charge_percentage": 0.80, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Ms State Emplo", "plan_name": "401457_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Basic Pl", "plan_name": "400100", "standard_charge_percentage": 0.85, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Basic Pl", "plan_name": "400100_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Federal", "plan_name": "400110", "standard_charge_percentage": 0.85, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Federal", "plan_name": "400110_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." } ] } ] }, { "description": "Insulin human u-100 nph-regulr 70-30 mix 100 unit/ml subcutaneous susp [10286]", "drug_information": { "unit": 3.00, "type": "ML" }, "code_information": [ { "code": "J1815", "type": "HCPCS" }, { "code": "0002-8715-17", "type": "NDC" } ], "standard_charges": [ { "gross_charge": 66.90, "minimum": 53.52, "maximum": 56.87, "setting": "both", "payers_information": [ { "payer_name": "Aetna", "plan_name": "700700", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna", "plan_name": "700700_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Miscellaneous", "plan_name": "700720", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Miscellaneous", "plan_name": "700720_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Ppo Hmo", "plan_name": "701720", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Ppo Hmo", "plan_name": "701720_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Ms State Emplo", "plan_name": "401457", "standard_charge_percentage": 0.80, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Ms State Emplo", "plan_name": "401457_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Basic Pl", "plan_name": "400100", "standard_charge_percentage": 0.85, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Basic Pl", "plan_name": "400100_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Federal", "plan_name": "400110", "standard_charge_percentage": 0.85, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Federal", "plan_name": "400110_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." } ] } ] }, { "description": "Insulin lispro (u-100) 100 unit/ml subcutaneous pen [111377]", "drug_information": { "unit": 3.00, "type": "ML" }, "code_information": [ { "code": "J1815", "type": "HCPCS" }, { "code": "0002-8799-01", "type": "NDC" } ], "standard_charges": [ { "gross_charge": 149.67, "minimum": 119.74, "maximum": 127.22, "setting": "both", "payers_information": [ { "payer_name": "Aetna", "plan_name": "700700", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna", "plan_name": "700700_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Miscellaneous", "plan_name": "700720", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Miscellaneous", "plan_name": "700720_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Ppo Hmo", "plan_name": "701720", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Ppo Hmo", "plan_name": "701720_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Ms State Emplo", "plan_name": "401457", "standard_charge_percentage": 0.80, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Ms State Emplo", "plan_name": "401457_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Basic Pl", "plan_name": "400100", "standard_charge_percentage": 0.85, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Basic Pl", "plan_name": "400100_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Federal", "plan_name": "400110", "standard_charge_percentage": 0.85, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Federal", "plan_name": "400110_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." } ] } ] }, { "description": "Insulin lispro (u-100) 100 unit/ml subcutaneous pen [111377]", "drug_information": { "unit": 3.00, "type": "ML" }, "code_information": [ { "code": "J1815", "type": "HCPCS" }, { "code": "0002-8799-59", "type": "NDC" } ], "standard_charges": [ { "gross_charge": 149.67, "minimum": 119.74, "maximum": 127.22, "setting": "both", "payers_information": [ { "payer_name": "Aetna", "plan_name": "700700", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna", "plan_name": "700700_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Miscellaneous", "plan_name": "700720", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Miscellaneous", "plan_name": "700720_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Ppo Hmo", "plan_name": "701720", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Ppo Hmo", "plan_name": "701720_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Ms State Emplo", "plan_name": "401457", "standard_charge_percentage": 0.80, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Ms State Emplo", "plan_name": "401457_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Basic Pl", "plan_name": "400100", "standard_charge_percentage": 0.85, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Basic Pl", "plan_name": "400100_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Federal", "plan_name": "400110", "standard_charge_percentage": 0.85, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Federal", "plan_name": "400110_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." } ] } ] }, { "description": "Insulin nph-regular 70-30 u-100 insulin 100 unit/ml subcutaneous pen [115826]", "drug_information": { "unit": 3.00, "type": "ML" }, "code_information": [ { "code": "J1815", "type": "HCPCS" }, { "code": "0002-8803-01", "type": "NDC" } ], "standard_charges": [ { "gross_charge": 132.99, "minimum": 106.39, "maximum": 113.04, "setting": "both", "payers_information": [ { "payer_name": "Aetna", "plan_name": "700700", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna", "plan_name": "700700_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Miscellaneous", "plan_name": "700720", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Miscellaneous", "plan_name": "700720_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Ppo Hmo", "plan_name": "701720", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Ppo Hmo", "plan_name": "701720_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Ms State Emplo", "plan_name": "401457", "standard_charge_percentage": 0.80, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Ms State Emplo", "plan_name": "401457_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Basic Pl", "plan_name": "400100", "standard_charge_percentage": 0.85, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Basic Pl", "plan_name": "400100_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Federal", "plan_name": "400110", "standard_charge_percentage": 0.85, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Federal", "plan_name": "400110_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." } ] } ] }, { "description": "Insulin nph-regular 70-30 u-100 insulin 100 unit/ml subcutaneous pen [115826]", "drug_information": { "unit": 3.00, "type": "ML" }, "code_information": [ { "code": "J1815", "type": "HCPCS" }, { "code": "0002-8803-59", "type": "NDC" } ], "standard_charges": [ { "gross_charge": 132.99, "minimum": 106.39, "maximum": 113.04, "setting": "both", "payers_information": [ { "payer_name": "Aetna", "plan_name": "700700", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna", "plan_name": "700700_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Miscellaneous", "plan_name": "700720", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Miscellaneous", "plan_name": "700720_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Ppo Hmo", "plan_name": "701720", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Ppo Hmo", "plan_name": "701720_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Ms State Emplo", "plan_name": "401457", "standard_charge_percentage": 0.80, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Ms State Emplo", "plan_name": "401457_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Basic Pl", "plan_name": "400100", "standard_charge_percentage": 0.85, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Basic Pl", "plan_name": "400100_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Federal", "plan_name": "400110", "standard_charge_percentage": 0.85, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Federal", "plan_name": "400110_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." } ] } ] }, { "description": "Insulin nph isophane u-100 human 100 unit/ml (3 ml) subcutaneous pen [112517]", "drug_information": { "unit": 3.00, "type": "ML" }, "code_information": [ { "code": "J1815", "type": "HCPCS" }, { "code": "0002-8805-01", "type": "NDC" } ], "standard_charges": [ { "gross_charge": 132.99, "minimum": 106.39, "maximum": 113.04, "setting": "both", "payers_information": [ { "payer_name": "Aetna", "plan_name": "700700", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna", "plan_name": "700700_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Miscellaneous", "plan_name": "700720", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Miscellaneous", "plan_name": "700720_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Ppo Hmo", "plan_name": "701720", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Ppo Hmo", "plan_name": "701720_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Ms State Emplo", "plan_name": "401457", "standard_charge_percentage": 0.80, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Ms State Emplo", "plan_name": "401457_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Basic Pl", "plan_name": "400100", "standard_charge_percentage": 0.85, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Basic Pl", "plan_name": "400100_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Federal", "plan_name": "400110", "standard_charge_percentage": 0.85, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Federal", "plan_name": "400110_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." } ] } ] }, { "description": "Insulin nph isophane u-100 human 100 unit/ml (3 ml) subcutaneous pen [112517]", "drug_information": { "unit": 3.00, "type": "ML" }, "code_information": [ { "code": "J1815", "type": "HCPCS" }, { "code": "0002-8805-59", "type": "NDC" } ], "standard_charges": [ { "gross_charge": 132.99, "minimum": 106.39, "maximum": 113.04, "setting": "both", "payers_information": [ { "payer_name": "Aetna", "plan_name": "700700", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna", "plan_name": "700700_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Miscellaneous", "plan_name": "700720", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Miscellaneous", "plan_name": "700720_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Ppo Hmo", "plan_name": "701720", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Ppo Hmo", "plan_name": "701720_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Ms State Emplo", "plan_name": "401457", "standard_charge_percentage": 0.80, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Ms State Emplo", "plan_name": "401457_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Basic Pl", "plan_name": "400100", "standard_charge_percentage": 0.85, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Basic Pl", "plan_name": "400100_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Federal", "plan_name": "400110", "standard_charge_percentage": 0.85, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Federal", "plan_name": "400110_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." } ] } ] }, { "description": "Insulin lispro (u-100) 100 unit/ml subcutaneous solution [17405]", "drug_information": { "unit": 10.00, "type": "ML" }, "code_information": [ { "code": "J1815", "type": "HCPCS" }, { "code": "0002-7510-01", "type": "NDC" } ], "standard_charges": [ { "gross_charge": 312.30, "minimum": 249.84, "maximum": 265.46, "setting": "both", "payers_information": [ { "payer_name": "Aetna", "plan_name": "700700", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna", "plan_name": "700700_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Miscellaneous", "plan_name": "700720", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Miscellaneous", "plan_name": "700720_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Ppo Hmo", "plan_name": "701720", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Ppo Hmo", "plan_name": "701720_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Ms State Emplo", "plan_name": "401457", "standard_charge_percentage": 0.80, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Ms State Emplo", "plan_name": "401457_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Basic Pl", "plan_name": "400100", "standard_charge_percentage": 0.85, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Basic Pl", "plan_name": "400100_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Federal", "plan_name": "400110", "standard_charge_percentage": 0.85, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Federal", "plan_name": "400110_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." } ] } ] }, { "description": "Insulin lispro (u-100) 100 unit/ml subcutaneous solution [17405]", "drug_information": { "unit": 3.00, "type": "ML" }, "code_information": [ { "code": "J1815", "type": "HCPCS" }, { "code": "0002-7510-17", "type": "NDC" } ], "standard_charges": [ { "gross_charge": 412.05, "minimum": 329.64, "maximum": 350.24, "setting": "both", "payers_information": [ { "payer_name": "Aetna", "plan_name": "700700", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna", "plan_name": "700700_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Miscellaneous", "plan_name": "700720", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Miscellaneous", "plan_name": "700720_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Ppo Hmo", "plan_name": "701720", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Ppo Hmo", "plan_name": "701720_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Ms State Emplo", "plan_name": "401457", "standard_charge_percentage": 0.80, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Ms State Emplo", "plan_name": "401457_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Basic Pl", "plan_name": "400100", "standard_charge_percentage": 0.85, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Basic Pl", "plan_name": "400100_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Federal", "plan_name": "400110", "standard_charge_percentage": 0.85, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Federal", "plan_name": "400110_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." } ] } ] }, { "description": "Insulin lispro protamine-lispro 100 unit/ml (75-25) subcutaneous susp [70693]", "drug_information": { "unit": 10.00, "type": "ML" }, "code_information": [ { "code": "J1815", "type": "HCPCS" }, { "code": "0002-7511-01", "type": "NDC" } ], "standard_charges": [ { "gross_charge": 401.70, "minimum": 321.36, "maximum": 341.45, "setting": "both", "payers_information": [ { "payer_name": "Aetna", "plan_name": "700700", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna", "plan_name": "700700_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Miscellaneous", "plan_name": "700720", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Miscellaneous", "plan_name": "700720_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Ppo Hmo", "plan_name": "701720", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Ppo Hmo", "plan_name": "701720_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Ms State Emplo", "plan_name": "401457", "standard_charge_percentage": 0.80, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Ms State Emplo", "plan_name": "401457_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Basic Pl", "plan_name": "400100", "standard_charge_percentage": 0.85, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Basic Pl", "plan_name": "400100_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Federal", "plan_name": "400110", "standard_charge_percentage": 0.85, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Federal", "plan_name": "400110_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." } ] } ] }, { "description": "Insulin lispro (u-100) 100 unit/ml subcutaneous solution [17405]", "drug_information": { "unit": 3.00, "type": "ML" }, "code_information": [ { "code": "J1815", "type": "HCPCS" }, { "code": "0002-7533-01", "type": "NDC" } ], "standard_charges": [ { "gross_charge": 93.71, "minimum": 74.97, "maximum": 79.65, "setting": "both", "payers_information": [ { "payer_name": "Aetna", "plan_name": "700700", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna", "plan_name": "700700_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Miscellaneous", "plan_name": "700720", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Miscellaneous", "plan_name": "700720_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Ppo Hmo", "plan_name": "701720", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Ppo Hmo", "plan_name": "701720_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Ms State Emplo", "plan_name": "401457", "standard_charge_percentage": 0.80, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Ms State Emplo", "plan_name": "401457_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Basic Pl", "plan_name": "400100", "standard_charge_percentage": 0.85, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Basic Pl", "plan_name": "400100_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Federal", "plan_name": "400110", "standard_charge_percentage": 0.85, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Federal", "plan_name": "400110_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." } ] } ] }, { "description": "Lantus solostar u-100 insulin 100 unit/ml (3 ml) subcutaneous pen [82494]", "drug_information": { "unit": 3.00, "type": "ML" }, "code_information": [ { "code": "J1815", "type": "HCPCS" }, { "code": "0088-2219-01", "type": "NDC" } ], "standard_charges": [ { "gross_charge": 90.66, "minimum": 72.53, "maximum": 77.06, "setting": "both", "payers_information": [ { "payer_name": "Aetna", "plan_name": "700700", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna", "plan_name": "700700_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Miscellaneous", "plan_name": "700720", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Miscellaneous", "plan_name": "700720_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Ppo Hmo", "plan_name": "701720", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Ppo Hmo", "plan_name": "701720_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Ms State Emplo", "plan_name": "401457", "standard_charge_percentage": 0.80, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Ms State Emplo", "plan_name": "401457_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Basic Pl", "plan_name": "400100", "standard_charge_percentage": 0.85, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Basic Pl", "plan_name": "400100_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Federal", "plan_name": "400110", "standard_charge_percentage": 0.85, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Federal", "plan_name": "400110_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." } ] } ] }, { "description": "Lantus solostar u-100 insulin 100 unit/ml (3 ml) subcutaneous pen [82494]", "drug_information": { "unit": 3.00, "type": "ML" }, "code_information": [ { "code": "J1815", "type": "HCPCS" }, { "code": "0088-2219-05", "type": "NDC" } ], "standard_charges": [ { "gross_charge": 90.66, "minimum": 72.53, "maximum": 77.06, "setting": "both", "payers_information": [ { "payer_name": "Aetna", "plan_name": "700700", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna", "plan_name": "700700_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Miscellaneous", "plan_name": "700720", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Miscellaneous", "plan_name": "700720_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Ppo Hmo", "plan_name": "701720", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Ppo Hmo", "plan_name": "701720_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Ms State Emplo", "plan_name": "401457", "standard_charge_percentage": 0.80, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Ms State Emplo", "plan_name": "401457_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Basic Pl", "plan_name": "400100", "standard_charge_percentage": 0.85, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Basic Pl", "plan_name": "400100_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Federal", "plan_name": "400110", "standard_charge_percentage": 0.85, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Federal", "plan_name": "400110_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." } ] } ] }, { "description": "Insulin glargine (u-100) 100 unit/ml subcutaneous solution [28282]", "drug_information": { "unit": 10.00, "type": "ML" }, "code_information": [ { "code": "J1815", "type": "HCPCS" }, { "code": "0088-2220-33", "type": "NDC" } ], "standard_charges": [ { "gross_charge": 302.20, "minimum": 241.76, "maximum": 256.87, "setting": "both", "payers_information": [ { "payer_name": "Aetna", "plan_name": "700700", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna", "plan_name": "700700_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Miscellaneous", "plan_name": "700720", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Miscellaneous", "plan_name": "700720_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Ppo Hmo", "plan_name": "701720", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of 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billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Basic Pl", "plan_name": "400100_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Federal", "plan_name": "400110", "standard_charge_percentage": 0.85, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Federal", "plan_name": "400110_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." } ] } ] }, { "description": "Metronidazole 500 mg/100 ml in sodium chlor(iso) intravenous piggyback [5018]", "drug_information": { "unit": 100.00, "type": "ML" }, "code_information": [ { "code": "J1836", "type": "HCPCS" }, { "code": "0338-1055-48", "type": "NDC" } ], "standard_charges": [ { "gross_charge": 104.31, "minimum": 83.45, "maximum": 88.66, "setting": "both", "payers_information": [ { "payer_name": "Aetna", "plan_name": "700700", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna", "plan_name": "700700_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Miscellaneous", "plan_name": "700720", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Miscellaneous", "plan_name": "700720_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Ppo Hmo", "plan_name": "701720", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Ppo Hmo", "plan_name": "701720_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Ms State Emplo", "plan_name": "401457", "standard_charge_percentage": 0.80, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Ms State Emplo", "plan_name": "401457_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Basic Pl", "plan_name": "400100", "standard_charge_percentage": 0.85, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Basic Pl", "plan_name": "400100_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Federal", "plan_name": "400110", "standard_charge_percentage": 0.85, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Federal", "plan_name": "400110_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." } ] } ] }, { "description": "Metronidazole 500 mg/100 ml in sodium chlor(iso) intravenous piggyback [5018]", "drug_information": { "unit": 100.00, "type": "ML" }, "code_information": [ { "code": "J1836", "type": "HCPCS" }, { "code": "0409-0152-01", "type": "NDC" } ], "standard_charges": [ { "gross_charge": 104.31, "minimum": 83.45, "maximum": 88.66, "setting": "both", "payers_information": [ { "payer_name": "Aetna", "plan_name": "700700", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna", "plan_name": "700700_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Miscellaneous", "plan_name": "700720", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Miscellaneous", "plan_name": "700720_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Ppo Hmo", "plan_name": "701720", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Ppo Hmo", "plan_name": "701720_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Ms State Emplo", "plan_name": "401457", "standard_charge_percentage": 0.80, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Ms State Emplo", "plan_name": "401457_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Basic Pl", "plan_name": "400100", "standard_charge_percentage": 0.85, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Basic Pl", "plan_name": "400100_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Federal", "plan_name": "400110", "standard_charge_percentage": 0.85, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Federal", "plan_name": "400110_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." } ] } ] }, { "description": "Metronidazole 500 mg/100 ml in sodium chlor(iso) intravenous piggyback [5018]", "drug_information": { "unit": 100.00, "type": "ML" }, "code_information": [ { "code": "J1836", "type": "HCPCS" }, { "code": "0409-0152-24", "type": "NDC" } ], "standard_charges": [ { "gross_charge": 104.31, "minimum": 83.45, "maximum": 88.66, "setting": "both", "payers_information": [ { "payer_name": "Aetna", "plan_name": "700700", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna", "plan_name": "700700_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Miscellaneous", "plan_name": "700720", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Miscellaneous", "plan_name": "700720_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Ppo Hmo", "plan_name": "701720", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Ppo Hmo", "plan_name": "701720_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Ms State Emplo", "plan_name": "401457", "standard_charge_percentage": 0.80, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Ms State Emplo", "plan_name": "401457_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Basic Pl", "plan_name": "400100", "standard_charge_percentage": 0.85, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Basic Pl", "plan_name": "400100_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Federal", "plan_name": "400110", "standard_charge_percentage": 0.85, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Federal", "plan_name": "400110_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." } ] } ] }, { "description": "Metronidazole 500 mg/100 ml in sodium chlor(iso) intravenous piggyback [5018]", "drug_information": { "unit": 100.00, "type": "ML" }, "code_information": [ { "code": "J1836", "type": "HCPCS" }, { "code": "0409-7811-37", "type": "NDC" } ], "standard_charges": [ { "gross_charge": 88.19, "minimum": 70.55, "maximum": 74.96, "setting": "both", "payers_information": [ { "payer_name": "Aetna", "plan_name": "700700", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna", "plan_name": "700700_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Miscellaneous", "plan_name": "700720", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Miscellaneous", "plan_name": "700720_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Ppo Hmo", "plan_name": "701720", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Ppo Hmo", "plan_name": "701720_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Ms State Emplo", "plan_name": "401457", "standard_charge_percentage": 0.80, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Ms State Emplo", "plan_name": "401457_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Basic Pl", "plan_name": "400100", "standard_charge_percentage": 0.85, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Basic Pl", "plan_name": "400100_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Federal", "plan_name": "400110", "standard_charge_percentage": 0.85, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Federal", "plan_name": "400110_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." } ] } ] }, { "description": "Metronidazole 500 mg/100 ml in sodium chlor(iso) intravenous piggyback [5018]", "drug_information": { "unit": 100.00, "type": "ML" }, "code_information": [ { "code": "J1836", "type": "HCPCS" }, { "code": "47335-993-01", "type": "NDC" } ], "standard_charges": [ { "gross_charge": 104.31, "minimum": 83.45, "maximum": 88.66, "setting": "both", "payers_information": [ { "payer_name": "Aetna", "plan_name": "700700", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna", "plan_name": "700700_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Miscellaneous", "plan_name": "700720", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Miscellaneous", "plan_name": "700720_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Ppo Hmo", "plan_name": "701720", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Ppo Hmo", "plan_name": "701720_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Ms State Emplo", "plan_name": "401457", "standard_charge_percentage": 0.80, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Ms State Emplo", "plan_name": "401457_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Basic Pl", "plan_name": "400100", "standard_charge_percentage": 0.85, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Basic Pl", "plan_name": "400100_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Federal", "plan_name": "400110", "standard_charge_percentage": 0.85, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Federal", "plan_name": "400110_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." } ] } ] }, { "description": "Ketorolac 15 mg/ml injection solution [22472]", "drug_information": { "unit": 1.00, "type": "ML" }, "code_information": [ { "code": "J1885", "type": "HCPCS" }, { "code": "70860-700-41", "type": "NDC" } ], "standard_charges": [ { "gross_charge": 11.00, "minimum": 0.46, "maximum": 9.35, "setting": "both", "payers_information": [ { "payer_name": "Aarp", "plan_name": "500102", "standard_charge_dollar": 0.46, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna", "plan_name": "700700", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna", "plan_name": "700700_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Mcare Ffs 6005", "plan_name": "700703", "standard_charge_dollar": 0.46, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Miscellaneous", "plan_name": "700720", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Miscellaneous", "plan_name": "700720_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Ppo Hmo", "plan_name": "701720", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Ppo Hmo", "plan_name": "701720_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Ambetter 68069", "plan_name": "500516", "standard_charge_dollar": 0.46, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Ms State Emplo", "plan_name": "401457", "standard_charge_percentage": 0.80, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Ms State Emplo", "plan_name": "401457_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Basic Pl", "plan_name": "400100", "standard_charge_percentage": 0.85, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Basic Pl", "plan_name": "400100_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Federal", "plan_name": "400110", "standard_charge_percentage": 0.85, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Federal", "plan_name": "400110_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Cigna Healthsprings Ffs", "plan_name": "500064", "standard_charge_dollar": 0.46, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Conseco", "plan_name": "500302", "standard_charge_dollar": 0.46, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Humana Ffs 61101", "plan_name": "500006", "standard_charge_dollar": 0.46, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Medicare A", "plan_name": "100100", "standard_charge_dollar": 0.46, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Medicare A", "plan_name": "100500", "standard_charge_dollar": 0.46, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Medicare Part B Only", "plan_name": "100300", "standard_charge_dollar": 0.46, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Medicare Railroad", "plan_name": "100103", "standard_charge_dollar": 0.46, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Ms Physicians Care N", "plan_name": "714210", "standard_charge_dollar": 0.57, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Peoples Hlth Ffs 72126", "plan_name": "500019", "standard_charge_dollar": 0.46, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Uhc/Secure Horizons", "plan_name": "500449", "standard_charge_dollar": 0.46, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "United Health Care/", "plan_name": "500292", "standard_charge_dollar": 0.52, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "United Healthcare", "plan_name": "750104", "standard_charge_dollar": 0.52, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "United Healthcare Ba", "plan_name": "750090", "standard_charge_dollar": 0.52, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "United Healthcare Me", "plan_name": "501310", "standard_charge_dollar": 0.46, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Windsor Mcare Extra", "plan_name": "500778", "standard_charge_dollar": 0.46, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." } ] } ] }, { "description": "Ketorolac 30 mg/ml (1 ml) injection solution [22473]", "drug_information": { "unit": 1.00, "type": "ML" }, "code_information": [ { "code": "J1885", "type": "HCPCS" }, { "code": "70860-701-03", "type": "NDC" } ], "standard_charges": [ { "gross_charge": 11.00, "minimum": 0.46, "maximum": 9.35, "setting": "both", "payers_information": [ { "payer_name": "Aarp", "plan_name": "500102", "standard_charge_dollar": 0.46, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna", "plan_name": "700700", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna", "plan_name": "700700_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Mcare Ffs 6005", "plan_name": "700703", "standard_charge_dollar": 0.46, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Miscellaneous", "plan_name": "700720", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Miscellaneous", "plan_name": "700720_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Ppo Hmo", "plan_name": "701720", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Ppo Hmo", "plan_name": "701720_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Ambetter 68069", "plan_name": "500516", "standard_charge_dollar": 0.46, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Ms State Emplo", "plan_name": "401457", "standard_charge_percentage": 0.80, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Ms State Emplo", "plan_name": "401457_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Basic Pl", "plan_name": "400100", "standard_charge_percentage": 0.85, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Basic Pl", "plan_name": "400100_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Federal", "plan_name": "400110", "standard_charge_percentage": 0.85, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Federal", "plan_name": "400110_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Cigna Healthsprings Ffs", "plan_name": "500064", "standard_charge_dollar": 0.46, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Conseco", "plan_name": "500302", "standard_charge_dollar": 0.46, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Humana Ffs 61101", "plan_name": "500006", "standard_charge_dollar": 0.46, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Medicare A", "plan_name": "100100", "standard_charge_dollar": 0.46, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Medicare A", "plan_name": "100500", "standard_charge_dollar": 0.46, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Medicare Part B Only", "plan_name": "100300", "standard_charge_dollar": 0.46, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Medicare Railroad", "plan_name": "100103", "standard_charge_dollar": 0.46, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Ms Physicians Care N", "plan_name": "714210", "standard_charge_dollar": 0.57, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Peoples Hlth Ffs 72126", "plan_name": "500019", "standard_charge_dollar": 0.46, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Uhc/Secure Horizons", "plan_name": "500449", "standard_charge_dollar": 0.46, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "United Health Care/", "plan_name": "500292", "standard_charge_dollar": 0.52, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "United Healthcare", "plan_name": "750104", "standard_charge_dollar": 0.52, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "United Healthcare Ba", "plan_name": "750090", "standard_charge_dollar": 0.52, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "United Healthcare Me", "plan_name": "501310", "standard_charge_dollar": 0.46, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Windsor Mcare Extra", "plan_name": "500778", "standard_charge_dollar": 0.46, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." } ] } ] }, { "description": "Ketorolac 60 mg/2 ml intramuscular solution [91349]", "drug_information": { "unit": 2.00, "type": "ML" }, "code_information": [ { "code": "J1885", "type": "HCPCS" }, { "code": "70860-701-04", "type": "NDC" } ], "standard_charges": [ { "gross_charge": 12.20, "minimum": 0.46, "maximum": 10.37, "setting": "both", "payers_information": [ { "payer_name": "Aarp", "plan_name": "500102", "standard_charge_dollar": 0.46, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna", "plan_name": "700700", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna", "plan_name": "700700_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Mcare Ffs 6005", "plan_name": "700703", "standard_charge_dollar": 0.46, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Miscellaneous", "plan_name": "700720", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Miscellaneous", "plan_name": "700720_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Ppo Hmo", "plan_name": "701720", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Ppo Hmo", "plan_name": "701720_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Ambetter 68069", "plan_name": "500516", "standard_charge_dollar": 0.46, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Ms State Emplo", "plan_name": "401457", "standard_charge_percentage": 0.80, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Ms State Emplo", "plan_name": "401457_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Basic Pl", "plan_name": "400100", "standard_charge_percentage": 0.85, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Basic Pl", "plan_name": "400100_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Federal", "plan_name": "400110", "standard_charge_percentage": 0.85, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Federal", "plan_name": "400110_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Cigna Healthsprings Ffs", "plan_name": "500064", "standard_charge_dollar": 0.46, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Conseco", "plan_name": "500302", "standard_charge_dollar": 0.46, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Humana Ffs 61101", "plan_name": "500006", "standard_charge_dollar": 0.46, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Medicare A", "plan_name": "100100", "standard_charge_dollar": 0.46, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Medicare A", "plan_name": "100500", "standard_charge_dollar": 0.46, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Medicare Part B Only", "plan_name": "100300", "standard_charge_dollar": 0.46, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Medicare Railroad", "plan_name": "100103", "standard_charge_dollar": 0.46, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Ms Physicians Care N", "plan_name": "714210", "standard_charge_dollar": 0.57, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Peoples Hlth Ffs 72126", "plan_name": "500019", "standard_charge_dollar": 0.46, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Uhc/Secure Horizons", "plan_name": "500449", "standard_charge_dollar": 0.46, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "United Health Care/", "plan_name": "500292", "standard_charge_dollar": 0.52, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "United Healthcare", "plan_name": "750104", "standard_charge_dollar": 0.52, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "United Healthcare Ba", "plan_name": "750090", "standard_charge_dollar": 0.52, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "United Healthcare Me", "plan_name": "501310", "standard_charge_dollar": 0.46, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Windsor Mcare Extra", "plan_name": "500778", "standard_charge_dollar": 0.46, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." } ] } ] }, { "description": "Ketorolac 30 mg/ml (1 ml) injection solution [22473]", "drug_information": { "unit": 1.00, "type": "ML" }, "code_information": [ { "code": "J1885", "type": "HCPCS" }, { "code": "70860-701-41", "type": "NDC" } ], "standard_charges": [ { "gross_charge": 11.00, "minimum": 0.46, "maximum": 9.35, "setting": "both", "payers_information": [ { "payer_name": "Aarp", "plan_name": "500102", "standard_charge_dollar": 0.46, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna", "plan_name": "700700", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna", "plan_name": "700700_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Mcare Ffs 6005", "plan_name": "700703", "standard_charge_dollar": 0.46, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Miscellaneous", "plan_name": "700720", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Miscellaneous", "plan_name": "700720_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Ppo Hmo", "plan_name": "701720", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Ppo Hmo", "plan_name": "701720_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Ambetter 68069", "plan_name": "500516", "standard_charge_dollar": 0.46, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Ms State Emplo", "plan_name": "401457", "standard_charge_percentage": 0.80, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Ms State Emplo", "plan_name": "401457_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Basic Pl", "plan_name": "400100", "standard_charge_percentage": 0.85, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Basic Pl", "plan_name": "400100_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Federal", "plan_name": "400110", "standard_charge_percentage": 0.85, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Federal", "plan_name": "400110_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Cigna Healthsprings Ffs", "plan_name": "500064", "standard_charge_dollar": 0.46, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Conseco", "plan_name": "500302", "standard_charge_dollar": 0.46, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Humana Ffs 61101", "plan_name": "500006", "standard_charge_dollar": 0.46, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Medicare A", "plan_name": "100100", "standard_charge_dollar": 0.46, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Medicare A", "plan_name": "100500", "standard_charge_dollar": 0.46, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Medicare Part B Only", "plan_name": "100300", "standard_charge_dollar": 0.46, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Medicare Railroad", "plan_name": "100103", "standard_charge_dollar": 0.46, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Ms Physicians Care N", "plan_name": "714210", "standard_charge_dollar": 0.57, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Peoples Hlth Ffs 72126", "plan_name": "500019", "standard_charge_dollar": 0.46, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Uhc/Secure Horizons", "plan_name": "500449", "standard_charge_dollar": 0.46, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "United Health Care/", "plan_name": "500292", "standard_charge_dollar": 0.52, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "United Healthcare", "plan_name": "750104", "standard_charge_dollar": 0.52, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "United Healthcare Ba", "plan_name": "750090", "standard_charge_dollar": 0.52, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "United Healthcare Me", "plan_name": "501310", "standard_charge_dollar": 0.46, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Windsor Mcare Extra", "plan_name": "500778", "standard_charge_dollar": 0.46, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." } ] } ] }, { "description": "Ketorolac 60 mg/2 ml intramuscular solution [91349]", "drug_information": { "unit": 2.00, "type": "ML" }, "code_information": [ { "code": "J1885", "type": "HCPCS" }, { "code": "70860-701-42", "type": "NDC" } ], "standard_charges": [ { "gross_charge": 12.20, "minimum": 0.46, "maximum": 10.37, "setting": "both", "payers_information": [ { "payer_name": "Aarp", "plan_name": "500102", "standard_charge_dollar": 0.46, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna", "plan_name": "700700", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna", "plan_name": "700700_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Mcare Ffs 6005", "plan_name": "700703", "standard_charge_dollar": 0.46, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Miscellaneous", "plan_name": "700720", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Miscellaneous", "plan_name": "700720_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Ppo Hmo", "plan_name": "701720", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Ppo Hmo", "plan_name": "701720_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Ambetter 68069", "plan_name": "500516", "standard_charge_dollar": 0.46, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Ms State Emplo", "plan_name": "401457", "standard_charge_percentage": 0.80, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Ms State Emplo", "plan_name": "401457_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Basic Pl", "plan_name": "400100", "standard_charge_percentage": 0.85, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Basic Pl", "plan_name": "400100_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Federal", "plan_name": "400110", "standard_charge_percentage": 0.85, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Federal", "plan_name": "400110_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Cigna Healthsprings Ffs", "plan_name": "500064", "standard_charge_dollar": 0.46, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Conseco", "plan_name": "500302", "standard_charge_dollar": 0.46, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Humana Ffs 61101", "plan_name": "500006", "standard_charge_dollar": 0.46, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Medicare A", "plan_name": "100100", "standard_charge_dollar": 0.46, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Medicare A", "plan_name": "100500", "standard_charge_dollar": 0.46, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Medicare Part B Only", "plan_name": "100300", "standard_charge_dollar": 0.46, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Medicare Railroad", "plan_name": "100103", "standard_charge_dollar": 0.46, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Ms Physicians Care N", "plan_name": "714210", "standard_charge_dollar": 0.57, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Peoples Hlth Ffs 72126", "plan_name": "500019", "standard_charge_dollar": 0.46, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Uhc/Secure Horizons", "plan_name": "500449", "standard_charge_dollar": 0.46, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "United Health Care/", "plan_name": "500292", "standard_charge_dollar": 0.52, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "United Healthcare", "plan_name": "750104", "standard_charge_dollar": 0.52, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "United Healthcare Ba", "plan_name": "750090", "standard_charge_dollar": 0.52, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "United Healthcare Me", "plan_name": "501310", "standard_charge_dollar": 0.46, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Windsor Mcare Extra", "plan_name": "500778", "standard_charge_dollar": 0.46, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." } ] } ] }, { "description": "Ketorolac 30 mg/ml (1 ml) injection solution [22473]", "drug_information": { "unit": 1.00, "type": "ML" }, "code_information": [ { "code": "J1885", "type": "HCPCS" }, { "code": "72266-118-01", "type": "NDC" } ], "standard_charges": [ { "gross_charge": 65.48, "minimum": 0.46, "maximum": 55.66, "setting": "both", "payers_information": [ { "payer_name": "Aarp", "plan_name": "500102", "standard_charge_dollar": 0.46, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna", "plan_name": "700700", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna", "plan_name": "700700_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Mcare Ffs 6005", "plan_name": "700703", "standard_charge_dollar": 0.46, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Miscellaneous", "plan_name": "700720", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Miscellaneous", "plan_name": "700720_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Ppo Hmo", "plan_name": "701720", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Ppo Hmo", "plan_name": "701720_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Ambetter 68069", "plan_name": "500516", "standard_charge_dollar": 0.46, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Ms State Emplo", "plan_name": "401457", "standard_charge_percentage": 0.80, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit 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"100100", "standard_charge_dollar": 0.46, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Medicare A", "plan_name": "100500", "standard_charge_dollar": 0.46, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Medicare Part B Only", "plan_name": "100300", "standard_charge_dollar": 0.46, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Medicare Railroad", "plan_name": "100103", "standard_charge_dollar": 0.46, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Ms Physicians Care N", "plan_name": "714210", "standard_charge_dollar": 0.57, "count": "0", "methodology": "fee schedule", "additional_payer_notes": 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"plan_name": "750090", "standard_charge_dollar": 0.52, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "United Healthcare Me", "plan_name": "501310", "standard_charge_dollar": 0.46, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Windsor Mcare Extra", "plan_name": "500778", "standard_charge_dollar": 0.46, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." } ] } ] }, { "description": "Ketorolac 30 mg/ml (1 ml) injection solution [22473]", "drug_information": { "unit": 1.00, "type": "ML" }, "code_information": [ { "code": "J1885", "type": "HCPCS" }, { "code": "72266-118-25", "type": "NDC" } ], "standard_charges": [ { "gross_charge": 65.48, "minimum": 0.46, "maximum": 55.66, "setting": "both", "payers_information": [ { 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"count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Miscellaneous", "plan_name": "700720_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Ppo Hmo", "plan_name": "701720", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Ppo Hmo", "plan_name": "701720_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Ambetter 68069", "plan_name": "500516", "standard_charge_dollar": 0.46, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Ms State Emplo", "plan_name": "401457", "standard_charge_percentage": 0.80, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Ms State Emplo", "plan_name": "401457_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Basic Pl", "plan_name": "400100", "standard_charge_percentage": 0.85, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Basic Pl", "plan_name": "400100_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": 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"standard_charge_dollar": 0.46, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Ms Physicians Care N", "plan_name": "714210", "standard_charge_dollar": 0.57, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Peoples Hlth Ffs 72126", "plan_name": "500019", "standard_charge_dollar": 0.46, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Uhc/Secure Horizons", "plan_name": "500449", "standard_charge_dollar": 0.46, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "United Health Care/", "plan_name": "500292", "standard_charge_dollar": 0.52, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "United Healthcare", "plan_name": "750104", "standard_charge_dollar": 0.52, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "United Healthcare Ba", "plan_name": "750090", "standard_charge_dollar": 0.52, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "United Healthcare Me", "plan_name": "501310", "standard_charge_dollar": 0.46, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Windsor Mcare Extra", "plan_name": "500778", "standard_charge_dollar": 0.46, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." } ] } ] }, { "description": "Ketorolac 60 mg/2 ml intramuscular solution [91349]", "drug_information": { "unit": 2.00, "type": "ML" }, "code_information": [ { "code": "J1885", "type": "HCPCS" }, { "code": "72266-119-01", "type": "NDC" } ], "standard_charges": [ { "gross_charge": 29.24, "minimum": 0.46, "maximum": 24.85, "setting": "both", "payers_information": [ { "payer_name": "Aarp", "plan_name": "500102", "standard_charge_dollar": 0.46, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna", "plan_name": "700700", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna", "plan_name": "700700_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Mcare Ffs 6005", "plan_name": "700703", "standard_charge_dollar": 0.46, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Miscellaneous", "plan_name": "700720", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Miscellaneous", "plan_name": "700720_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Ppo Hmo", "plan_name": "701720", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Ppo Hmo", "plan_name": "701720_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Ambetter 68069", "plan_name": "500516", "standard_charge_dollar": 0.46, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Ms State Emplo", "plan_name": "401457", "standard_charge_percentage": 0.80, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Ms State Emplo", "plan_name": "401457_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Basic Pl", "plan_name": "400100", "standard_charge_percentage": 0.85, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Basic Pl", "plan_name": "400100_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Federal", "plan_name": "400110", "standard_charge_percentage": 0.85, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Federal", "plan_name": "400110_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Cigna Healthsprings Ffs", "plan_name": "500064", "standard_charge_dollar": 0.46, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Conseco", "plan_name": "500302", "standard_charge_dollar": 0.46, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Humana Ffs 61101", "plan_name": "500006", "standard_charge_dollar": 0.46, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Medicare A", "plan_name": "100100", "standard_charge_dollar": 0.46, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Medicare A", "plan_name": "100500", "standard_charge_dollar": 0.46, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Medicare Part B Only", "plan_name": "100300", "standard_charge_dollar": 0.46, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Medicare Railroad", "plan_name": "100103", "standard_charge_dollar": 0.46, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Ms Physicians Care N", "plan_name": "714210", "standard_charge_dollar": 0.57, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Peoples Hlth Ffs 72126", "plan_name": "500019", "standard_charge_dollar": 0.46, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Uhc/Secure Horizons", "plan_name": "500449", "standard_charge_dollar": 0.46, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "United Health Care/", "plan_name": "500292", "standard_charge_dollar": 0.52, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "United Healthcare", "plan_name": "750104", "standard_charge_dollar": 0.52, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "United Healthcare Ba", "plan_name": "750090", "standard_charge_dollar": 0.52, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "United Healthcare Me", "plan_name": "501310", "standard_charge_dollar": 0.46, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Windsor Mcare Extra", "plan_name": "500778", "standard_charge_dollar": 0.46, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." } ] } ] }, { "description": "Ketorolac 60 mg/2 ml intramuscular solution [91349]", "drug_information": { "unit": 2.00, "type": "ML" }, "code_information": [ { "code": "J1885", "type": "HCPCS" }, { "code": "72266-119-25", "type": "NDC" } ], "standard_charges": [ { "gross_charge": 29.24, "minimum": 0.46, "maximum": 24.85, "setting": "both", "payers_information": [ { "payer_name": "Aarp", "plan_name": "500102", "standard_charge_dollar": 0.46, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna", "plan_name": "700700", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna", "plan_name": "700700_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Mcare Ffs 6005", "plan_name": "700703", "standard_charge_dollar": 0.46, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Miscellaneous", "plan_name": "700720", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Miscellaneous", "plan_name": "700720_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Ppo Hmo", "plan_name": "701720", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Ppo Hmo", "plan_name": "701720_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Ambetter 68069", "plan_name": "500516", "standard_charge_dollar": 0.46, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Ms State Emplo", "plan_name": "401457", "standard_charge_percentage": 0.80, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Ms State Emplo", "plan_name": "401457_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Basic Pl", "plan_name": "400100", "standard_charge_percentage": 0.85, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Basic Pl", "plan_name": "400100_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Federal", "plan_name": "400110", "standard_charge_percentage": 0.85, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Federal", "plan_name": "400110_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Cigna Healthsprings Ffs", "plan_name": "500064", "standard_charge_dollar": 0.46, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Conseco", "plan_name": "500302", "standard_charge_dollar": 0.46, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Humana Ffs 61101", "plan_name": "500006", "standard_charge_dollar": 0.46, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Medicare A", "plan_name": "100100", "standard_charge_dollar": 0.46, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Medicare A", "plan_name": "100500", "standard_charge_dollar": 0.46, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Medicare Part B Only", "plan_name": "100300", "standard_charge_dollar": 0.46, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Medicare Railroad", "plan_name": "100103", "standard_charge_dollar": 0.46, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Ms Physicians Care N", "plan_name": "714210", "standard_charge_dollar": 0.57, "count": "0", "methodology": "fee schedule", "additional_payer_notes": 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"plan_name": "750090", "standard_charge_dollar": 0.52, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "United Healthcare Me", "plan_name": "501310", "standard_charge_dollar": 0.46, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Windsor Mcare Extra", "plan_name": "500778", "standard_charge_dollar": 0.46, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." } ] } ] }, { "description": "Ketorolac 15 mg/ml injection solution [22472]", "drug_information": { "unit": 1.00, "type": "ML" }, "code_information": [ { "code": "J1885", "type": "HCPCS" }, { "code": "72611-719-01", "type": "NDC" } ], "standard_charges": [ { "gross_charge": 11.00, "minimum": 0.46, "maximum": 9.35, "setting": "both", "payers_information": [ { "payer_name": "Aarp", "plan_name": "500102", "standard_charge_dollar": 0.46, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna", "plan_name": "700700", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna", "plan_name": "700700_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Mcare Ffs 6005", "plan_name": "700703", "standard_charge_dollar": 0.46, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Miscellaneous", "plan_name": "700720", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Miscellaneous", "plan_name": "700720_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Ppo Hmo", "plan_name": "701720", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Ppo Hmo", "plan_name": "701720_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Ambetter 68069", "plan_name": "500516", "standard_charge_dollar": 0.46, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Ms State Emplo", "plan_name": "401457", "standard_charge_percentage": 0.80, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Ms State Emplo", "plan_name": "401457_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Basic Pl", "plan_name": "400100", "standard_charge_percentage": 0.85, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Basic Pl", "plan_name": "400100_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": 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"standard_charge_dollar": 0.46, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Ms Physicians Care N", "plan_name": "714210", "standard_charge_dollar": 0.57, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Peoples Hlth Ffs 72126", "plan_name": "500019", "standard_charge_dollar": 0.46, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Uhc/Secure Horizons", "plan_name": "500449", "standard_charge_dollar": 0.46, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "United Health Care/", "plan_name": "500292", "standard_charge_dollar": 0.52, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "United Healthcare", "plan_name": "750104", "standard_charge_dollar": 0.52, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "United Healthcare Ba", "plan_name": "750090", "standard_charge_dollar": 0.52, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "United Healthcare Me", "plan_name": "501310", "standard_charge_dollar": 0.46, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Windsor Mcare Extra", "plan_name": "500778", "standard_charge_dollar": 0.46, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." } ] } ] }, { "description": "Ketorolac 15 mg/ml injection solution [22472]", "drug_information": { "unit": 1.00, "type": "ML" }, "code_information": [ { "code": "J1885", "type": "HCPCS" }, { "code": "72611-719-25", "type": "NDC" } ], "standard_charges": [ { "gross_charge": 11.00, "minimum": 0.46, "maximum": 9.35, "setting": "both", "payers_information": [ { "payer_name": "Aarp", "plan_name": "500102", "standard_charge_dollar": 0.46, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna", "plan_name": "700700", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna", "plan_name": "700700_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to 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"payer_name": "Aetna Ppo Hmo", "plan_name": "701720_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Ambetter 68069", "plan_name": "500516", "standard_charge_dollar": 0.46, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Ms State Emplo", "plan_name": "401457", "standard_charge_percentage": 0.80, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Ms State Emplo", "plan_name": "401457_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Basic Pl", "plan_name": "400100", "standard_charge_percentage": 0.85, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Basic Pl", "plan_name": "400100_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Federal", "plan_name": "400110", "standard_charge_percentage": 0.85, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Federal", "plan_name": "400110_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Cigna Healthsprings Ffs", "plan_name": "500064", "standard_charge_dollar": 0.46, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Conseco", "plan_name": "500302", "standard_charge_dollar": 0.46, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Humana Ffs 61101", "plan_name": "500006", "standard_charge_dollar": 0.46, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Medicare A", "plan_name": "100100", "standard_charge_dollar": 0.46, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Medicare A", "plan_name": "100500", "standard_charge_dollar": 0.46, "count": "0", "methodology": "fee schedule", "additional_payer_notes": 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"plan_name": "500449", "standard_charge_dollar": 0.46, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "United Health Care/", "plan_name": "500292", "standard_charge_dollar": 0.52, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "United Healthcare", "plan_name": "750104", "standard_charge_dollar": 0.52, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "United Healthcare Ba", "plan_name": "750090", "standard_charge_dollar": 0.52, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "United Healthcare Me", "plan_name": "501310", "standard_charge_dollar": 0.46, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Windsor Mcare Extra", "plan_name": "500778", "standard_charge_dollar": 0.46, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." } ] } ] }, { "description": "Ketorolac 30 mg/ml (1 ml) injection solution [22473]", "drug_information": { "unit": 1.00, "type": "ML" }, "code_information": [ { "code": "J1885", "type": "HCPCS" }, { "code": "72611-722-01", "type": "NDC" } ], "standard_charges": [ { "gross_charge": 11.00, "minimum": 0.46, "maximum": 9.35, "setting": "both", "payers_information": [ { "payer_name": "Aarp", "plan_name": "500102", "standard_charge_dollar": 0.46, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna", "plan_name": "700700", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna", "plan_name": "700700_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Mcare Ffs 6005", "plan_name": "700703", "standard_charge_dollar": 0.46, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Miscellaneous", "plan_name": "700720", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Miscellaneous", "plan_name": "700720_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Ppo Hmo", "plan_name": "701720", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Ppo Hmo", "plan_name": "701720_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Ambetter 68069", "plan_name": "500516", "standard_charge_dollar": 0.46, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Ms State Emplo", "plan_name": "401457", "standard_charge_percentage": 0.80, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Ms State Emplo", "plan_name": "401457_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Basic Pl", "plan_name": "400100", "standard_charge_percentage": 0.85, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Basic Pl", "plan_name": "400100_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Federal", "plan_name": "400110", "standard_charge_percentage": 0.85, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Federal", "plan_name": "400110_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Cigna Healthsprings Ffs", "plan_name": "500064", "standard_charge_dollar": 0.46, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Conseco", "plan_name": "500302", "standard_charge_dollar": 0.46, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Humana Ffs 61101", "plan_name": "500006", "standard_charge_dollar": 0.46, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Medicare A", "plan_name": "100100", "standard_charge_dollar": 0.46, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Medicare A", "plan_name": "100500", "standard_charge_dollar": 0.46, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Medicare Part B Only", "plan_name": "100300", "standard_charge_dollar": 0.46, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Medicare Railroad", "plan_name": "100103", "standard_charge_dollar": 0.46, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Ms Physicians Care N", "plan_name": "714210", "standard_charge_dollar": 0.57, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Peoples Hlth Ffs 72126", "plan_name": "500019", "standard_charge_dollar": 0.46, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Uhc/Secure Horizons", "plan_name": "500449", "standard_charge_dollar": 0.46, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "United Health Care/", "plan_name": "500292", "standard_charge_dollar": 0.52, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "United Healthcare", "plan_name": "750104", "standard_charge_dollar": 0.52, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "United Healthcare Ba", "plan_name": "750090", "standard_charge_dollar": 0.52, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "United Healthcare Me", "plan_name": "501310", "standard_charge_dollar": 0.46, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Windsor Mcare Extra", "plan_name": "500778", "standard_charge_dollar": 0.46, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." } ] } ] }, { "description": "Ketorolac 30 mg/ml (1 ml) injection solution [22473]", "drug_information": { "unit": 1.00, "type": "ML" }, "code_information": [ { "code": "J1885", "type": "HCPCS" }, { "code": "72611-722-25", "type": "NDC" } ], "standard_charges": [ { "gross_charge": 11.00, "minimum": 0.46, "maximum": 9.35, "setting": "both", "payers_information": [ { "payer_name": "Aarp", "plan_name": "500102", "standard_charge_dollar": 0.46, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna", "plan_name": "700700", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna", "plan_name": "700700_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Mcare Ffs 6005", "plan_name": "700703", "standard_charge_dollar": 0.46, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Miscellaneous", "plan_name": "700720", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Miscellaneous", "plan_name": "700720_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Ppo Hmo", "plan_name": "701720", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Ppo Hmo", "plan_name": "701720_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Ambetter 68069", "plan_name": "500516", "standard_charge_dollar": 0.46, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Ms State Emplo", "plan_name": "401457", "standard_charge_percentage": 0.80, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Ms State Emplo", "plan_name": "401457_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Basic Pl", "plan_name": "400100", "standard_charge_percentage": 0.85, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Basic Pl", "plan_name": "400100_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": 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"standard_charge_dollar": 0.46, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Ms Physicians Care N", "plan_name": "714210", "standard_charge_dollar": 0.57, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Peoples Hlth Ffs 72126", "plan_name": "500019", "standard_charge_dollar": 0.46, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Uhc/Secure Horizons", "plan_name": "500449", "standard_charge_dollar": 0.46, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "United Health Care/", "plan_name": "500292", "standard_charge_dollar": 0.52, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "United Healthcare", "plan_name": "750104", "standard_charge_dollar": 0.52, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "United Healthcare Ba", "plan_name": "750090", "standard_charge_dollar": 0.52, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "United Healthcare Me", "plan_name": "501310", "standard_charge_dollar": 0.46, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Windsor Mcare Extra", "plan_name": "500778", "standard_charge_dollar": 0.46, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." } ] } ] }, { "description": "Ketorolac 15 mg/ml injection solution [22472]", "drug_information": { "unit": 1.00, "type": "ML" }, "code_information": [ { "code": "J1885", "type": "HCPCS" }, { "code": "63323-161-00", "type": "NDC" } ], "standard_charges": [ { "gross_charge": 34.47, "minimum": 0.46, "maximum": 29.30, "setting": "both", "payers_information": [ { "payer_name": "Aarp", "plan_name": "500102", "standard_charge_dollar": 0.46, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna", "plan_name": "700700", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna", "plan_name": "700700_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Mcare Ffs 6005", "plan_name": "700703", "standard_charge_dollar": 0.46, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Miscellaneous", "plan_name": "700720", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Miscellaneous", "plan_name": "700720_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Ppo Hmo", "plan_name": "701720", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Ppo Hmo", "plan_name": "701720_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Ambetter 68069", "plan_name": "500516", "standard_charge_dollar": 0.46, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Ms State Emplo", "plan_name": "401457", "standard_charge_percentage": 0.80, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Ms State Emplo", "plan_name": "401457_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Basic Pl", "plan_name": "400100", "standard_charge_percentage": 0.85, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Basic Pl", "plan_name": "400100_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Federal", "plan_name": "400110", "standard_charge_percentage": 0.85, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Federal", "plan_name": "400110_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Cigna Healthsprings Ffs", "plan_name": "500064", "standard_charge_dollar": 0.46, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Conseco", "plan_name": "500302", "standard_charge_dollar": 0.46, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Humana Ffs 61101", "plan_name": "500006", "standard_charge_dollar": 0.46, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Medicare A", "plan_name": "100100", "standard_charge_dollar": 0.46, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Medicare A", "plan_name": "100500", "standard_charge_dollar": 0.46, "count": "0", "methodology": "fee schedule", "additional_payer_notes": 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"plan_name": "500449", "standard_charge_dollar": 0.46, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "United Health Care/", "plan_name": "500292", "standard_charge_dollar": 0.52, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "United Healthcare", "plan_name": "750104", "standard_charge_dollar": 0.52, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "United Healthcare Ba", "plan_name": "750090", "standard_charge_dollar": 0.52, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "United Healthcare Me", "plan_name": "501310", "standard_charge_dollar": 0.46, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Windsor Mcare Extra", "plan_name": "500778", "standard_charge_dollar": 0.46, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." } ] } ] }, { "description": "Ketorolac 15 mg/ml injection solution [22472]", "drug_information": { "unit": 1.00, "type": "ML" }, "code_information": [ { "code": "J1885", "type": "HCPCS" }, { "code": "63323-161-01", "type": "NDC" } ], "standard_charges": [ { "gross_charge": 34.47, "minimum": 0.46, "maximum": 29.30, "setting": "both", "payers_information": [ { "payer_name": "Aarp", "plan_name": "500102", "standard_charge_dollar": 0.46, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna", "plan_name": "700700", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna", "plan_name": "700700_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Mcare Ffs 6005", "plan_name": "700703", "standard_charge_dollar": 0.46, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Miscellaneous", "plan_name": "700720", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Miscellaneous", "plan_name": "700720_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Ppo Hmo", "plan_name": "701720", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Ppo Hmo", "plan_name": "701720_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Ambetter 68069", "plan_name": "500516", "standard_charge_dollar": 0.46, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Ms State Emplo", "plan_name": "401457", "standard_charge_percentage": 0.80, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Ms State Emplo", "plan_name": "401457_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Basic Pl", "plan_name": "400100", "standard_charge_percentage": 0.85, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Basic Pl", "plan_name": "400100_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Federal", "plan_name": "400110", "standard_charge_percentage": 0.85, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Federal", "plan_name": "400110_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Cigna Healthsprings Ffs", "plan_name": "500064", "standard_charge_dollar": 0.46, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Conseco", "plan_name": "500302", "standard_charge_dollar": 0.46, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Humana Ffs 61101", "plan_name": "500006", "standard_charge_dollar": 0.46, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Medicare A", "plan_name": "100100", "standard_charge_dollar": 0.46, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Medicare A", "plan_name": "100500", "standard_charge_dollar": 0.46, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Medicare Part B Only", "plan_name": "100300", "standard_charge_dollar": 0.46, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Medicare Railroad", "plan_name": "100103", "standard_charge_dollar": 0.46, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Ms Physicians Care N", "plan_name": "714210", "standard_charge_dollar": 0.57, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Peoples Hlth Ffs 72126", "plan_name": "500019", "standard_charge_dollar": 0.46, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Uhc/Secure Horizons", "plan_name": "500449", "standard_charge_dollar": 0.46, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "United Health Care/", "plan_name": "500292", "standard_charge_dollar": 0.52, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "United Healthcare", "plan_name": "750104", "standard_charge_dollar": 0.52, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "United Healthcare Ba", "plan_name": "750090", "standard_charge_dollar": 0.52, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "United Healthcare Me", "plan_name": "501310", "standard_charge_dollar": 0.46, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Windsor Mcare Extra", "plan_name": "500778", "standard_charge_dollar": 0.46, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." } ] } ] }, { "description": "Ketorolac 15 mg/ml injection solution [22472]", "drug_information": { "unit": 1.00, "type": "ML" }, "code_information": [ { "code": "J1885", "type": "HCPCS" }, { "code": "63323-161-21", "type": "NDC" } ], "standard_charges": [ { "gross_charge": 11.00, "minimum": 0.46, "maximum": 9.35, "setting": "both", "payers_information": [ { "payer_name": "Aarp", "plan_name": "500102", "standard_charge_dollar": 0.46, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna", "plan_name": "700700", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna", "plan_name": "700700_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Mcare Ffs 6005", "plan_name": "700703", "standard_charge_dollar": 0.46, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Miscellaneous", "plan_name": "700720", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Miscellaneous", "plan_name": "700720_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Ppo Hmo", "plan_name": "701720", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Ppo Hmo", "plan_name": "701720_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Ambetter 68069", "plan_name": "500516", "standard_charge_dollar": 0.46, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Ms State Emplo", "plan_name": "401457", "standard_charge_percentage": 0.80, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Ms State Emplo", "plan_name": "401457_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Basic Pl", "plan_name": "400100", "standard_charge_percentage": 0.85, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Basic Pl", "plan_name": "400100_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": 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"standard_charge_dollar": 0.46, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Ms Physicians Care N", "plan_name": "714210", "standard_charge_dollar": 0.57, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Peoples Hlth Ffs 72126", "plan_name": "500019", "standard_charge_dollar": 0.46, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Uhc/Secure Horizons", "plan_name": "500449", "standard_charge_dollar": 0.46, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "United Health Care/", "plan_name": "500292", "standard_charge_dollar": 0.52, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "United Healthcare", "plan_name": "750104", "standard_charge_dollar": 0.52, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "United Healthcare Ba", "plan_name": "750090", "standard_charge_dollar": 0.52, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "United Healthcare Me", "plan_name": "501310", "standard_charge_dollar": 0.46, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Windsor Mcare Extra", "plan_name": "500778", "standard_charge_dollar": 0.46, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." } ] } ] }, { "description": "Ketorolac 30 mg/ml (1 ml) injection solution [22473]", "drug_information": { "unit": 1.00, "type": "ML" }, "code_information": [ { "code": "J1885", "type": "HCPCS" }, { "code": "63323-162-00", "type": "NDC" } ], "standard_charges": [ { "gross_charge": 65.48, "minimum": 0.46, "maximum": 55.66, "setting": "both", "payers_information": [ { "payer_name": "Aarp", "plan_name": "500102", "standard_charge_dollar": 0.46, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna", "plan_name": "700700", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna", "plan_name": "700700_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Mcare Ffs 6005", "plan_name": "700703", "standard_charge_dollar": 0.46, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Miscellaneous", "plan_name": "700720", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Miscellaneous", "plan_name": "700720_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Ppo Hmo", "plan_name": "701720", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Ppo Hmo", "plan_name": "701720_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Ambetter 68069", "plan_name": "500516", "standard_charge_dollar": 0.46, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Ms State Emplo", "plan_name": "401457", "standard_charge_percentage": 0.80, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Ms State Emplo", "plan_name": "401457_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Basic Pl", "plan_name": "400100", "standard_charge_percentage": 0.85, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Basic Pl", "plan_name": "400100_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Federal", "plan_name": "400110", "standard_charge_percentage": 0.85, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Federal", "plan_name": "400110_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Cigna Healthsprings Ffs", "plan_name": "500064", "standard_charge_dollar": 0.46, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Conseco", "plan_name": "500302", "standard_charge_dollar": 0.46, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Humana Ffs 61101", "plan_name": "500006", "standard_charge_dollar": 0.46, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Medicare A", "plan_name": "100100", "standard_charge_dollar": 0.46, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Medicare A", "plan_name": "100500", "standard_charge_dollar": 0.46, "count": "0", "methodology": "fee schedule", "additional_payer_notes": 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"plan_name": "500449", "standard_charge_dollar": 0.46, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "United Health Care/", "plan_name": "500292", "standard_charge_dollar": 0.52, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "United Healthcare", "plan_name": "750104", "standard_charge_dollar": 0.52, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "United Healthcare Ba", "plan_name": "750090", "standard_charge_dollar": 0.52, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "United Healthcare Me", "plan_name": "501310", "standard_charge_dollar": 0.46, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Windsor Mcare Extra", "plan_name": "500778", "standard_charge_dollar": 0.46, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." } ] } ] }, { "description": "Ketorolac 30 mg/ml (1 ml) injection solution [22473]", "drug_information": { "unit": 1.00, "type": "ML" }, "code_information": [ { "code": "J1885", "type": "HCPCS" }, { "code": "63323-162-01", "type": "NDC" } ], "standard_charges": [ { "gross_charge": 65.48, "minimum": 0.46, "maximum": 55.66, "setting": "both", "payers_information": [ { "payer_name": "Aarp", "plan_name": "500102", "standard_charge_dollar": 0.46, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna", "plan_name": "700700", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna", "plan_name": "700700_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Mcare Ffs 6005", "plan_name": "700703", "standard_charge_dollar": 0.46, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Miscellaneous", "plan_name": "700720", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Miscellaneous", "plan_name": "700720_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Ppo Hmo", "plan_name": "701720", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Ppo Hmo", "plan_name": "701720_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Ambetter 68069", "plan_name": "500516", "standard_charge_dollar": 0.46, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Ms State Emplo", "plan_name": "401457", "standard_charge_percentage": 0.80, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Ms State Emplo", "plan_name": "401457_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Basic Pl", "plan_name": "400100", "standard_charge_percentage": 0.85, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Basic Pl", "plan_name": "400100_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Federal", "plan_name": "400110", "standard_charge_percentage": 0.85, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Federal", "plan_name": "400110_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Cigna Healthsprings Ffs", "plan_name": "500064", "standard_charge_dollar": 0.46, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Conseco", "plan_name": "500302", "standard_charge_dollar": 0.46, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Humana Ffs 61101", "plan_name": "500006", "standard_charge_dollar": 0.46, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Medicare A", "plan_name": "100100", "standard_charge_dollar": 0.46, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Medicare A", "plan_name": "100500", "standard_charge_dollar": 0.46, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Medicare Part B Only", "plan_name": "100300", "standard_charge_dollar": 0.46, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Medicare Railroad", "plan_name": "100103", "standard_charge_dollar": 0.46, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Ms Physicians Care N", "plan_name": "714210", "standard_charge_dollar": 0.57, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Peoples Hlth Ffs 72126", "plan_name": "500019", "standard_charge_dollar": 0.46, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Uhc/Secure Horizons", "plan_name": "500449", "standard_charge_dollar": 0.46, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "United Health Care/", "plan_name": "500292", "standard_charge_dollar": 0.52, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "United Healthcare", "plan_name": "750104", "standard_charge_dollar": 0.52, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "United Healthcare Ba", "plan_name": "750090", "standard_charge_dollar": 0.52, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "United Healthcare Me", "plan_name": "501310", "standard_charge_dollar": 0.46, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Windsor Mcare Extra", "plan_name": "500778", "standard_charge_dollar": 0.46, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." } ] } ] }, { "description": "Ketorolac 60 mg/2 ml intramuscular solution [91349]", "drug_information": { "unit": 2.00, "type": "ML" }, "code_information": [ { "code": "J1885", "type": "HCPCS" }, { "code": "63323-162-02", "type": "NDC" } ], "standard_charges": [ { "gross_charge": 50.02, "minimum": 0.46, "maximum": 42.52, "setting": "both", "payers_information": [ { "payer_name": "Aarp", "plan_name": "500102", "standard_charge_dollar": 0.46, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna", "plan_name": "700700", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna", "plan_name": "700700_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Mcare Ffs 6005", "plan_name": "700703", "standard_charge_dollar": 0.46, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Miscellaneous", "plan_name": "700720", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Miscellaneous", "plan_name": "700720_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Ppo Hmo", "plan_name": "701720", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Ppo Hmo", "plan_name": "701720_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Ambetter 68069", "plan_name": "500516", "standard_charge_dollar": 0.46, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Ms State Emplo", "plan_name": "401457", "standard_charge_percentage": 0.80, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Ms State Emplo", "plan_name": "401457_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Basic Pl", "plan_name": "400100", "standard_charge_percentage": 0.85, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Basic Pl", "plan_name": "400100_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Federal", "plan_name": "400110", "standard_charge_percentage": 0.85, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Federal", "plan_name": "400110_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Cigna Healthsprings Ffs", "plan_name": "500064", "standard_charge_dollar": 0.46, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Conseco", "plan_name": "500302", "standard_charge_dollar": 0.46, "count": "0", "methodology": "fee schedule", "additional_payer_notes": 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"standard_charge_dollar": 0.46, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Ms Physicians Care N", "plan_name": "714210", "standard_charge_dollar": 0.57, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Peoples Hlth Ffs 72126", "plan_name": "500019", "standard_charge_dollar": 0.46, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Uhc/Secure Horizons", "plan_name": "500449", "standard_charge_dollar": 0.46, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "United Health Care/", "plan_name": "500292", "standard_charge_dollar": 0.52, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "United Healthcare", "plan_name": "750104", "standard_charge_dollar": 0.52, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "United Healthcare Ba", "plan_name": "750090", "standard_charge_dollar": 0.52, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "United Healthcare Me", "plan_name": "501310", "standard_charge_dollar": 0.46, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Windsor Mcare Extra", "plan_name": "500778", "standard_charge_dollar": 0.46, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." } ] } ] }, { "description": "Ketorolac 60 mg/2 ml intramuscular solution [91349]", "drug_information": { "unit": 2.00, "type": "ML" }, "code_information": [ { "code": "J1885", "type": "HCPCS" }, { "code": "63323-162-03", "type": "NDC" } ], "standard_charges": [ { "gross_charge": 50.02, "minimum": 0.46, "maximum": 42.52, "setting": "both", "payers_information": [ { "payer_name": "Aarp", "plan_name": "500102", "standard_charge_dollar": 0.46, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna", "plan_name": "700700", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna", "plan_name": "700700_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Mcare Ffs 6005", "plan_name": "700703", "standard_charge_dollar": 0.46, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Miscellaneous", "plan_name": "700720", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Miscellaneous", "plan_name": "700720_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Ppo Hmo", "plan_name": "701720", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Ppo Hmo", "plan_name": "701720_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Ambetter 68069", "plan_name": "500516", "standard_charge_dollar": 0.46, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Ms State Emplo", "plan_name": "401457", "standard_charge_percentage": 0.80, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Ms State Emplo", "plan_name": "401457_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Basic Pl", "plan_name": "400100", "standard_charge_percentage": 0.85, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Basic Pl", "plan_name": "400100_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Federal", "plan_name": "400110", "standard_charge_percentage": 0.85, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Federal", "plan_name": "400110_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Cigna Healthsprings Ffs", "plan_name": "500064", "standard_charge_dollar": 0.46, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Conseco", "plan_name": "500302", "standard_charge_dollar": 0.46, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Humana Ffs 61101", "plan_name": "500006", "standard_charge_dollar": 0.46, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Medicare A", "plan_name": "100100", "standard_charge_dollar": 0.46, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Medicare A", "plan_name": "100500", "standard_charge_dollar": 0.46, "count": "0", "methodology": "fee schedule", "additional_payer_notes": 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"plan_name": "500449", "standard_charge_dollar": 0.46, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "United Health Care/", "plan_name": "500292", "standard_charge_dollar": 0.52, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "United Healthcare", "plan_name": "750104", "standard_charge_dollar": 0.52, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "United Healthcare Ba", "plan_name": "750090", "standard_charge_dollar": 0.52, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "United Healthcare Me", "plan_name": "501310", "standard_charge_dollar": 0.46, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Windsor Mcare Extra", "plan_name": "500778", "standard_charge_dollar": 0.46, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." } ] } ] }, { "description": "Ketorolac 30 mg/ml (1 ml) injection solution [22473]", "drug_information": { "unit": 1.00, "type": "ML" }, "code_information": [ { "code": "J1885", "type": "HCPCS" }, { "code": "63323-162-12", "type": "NDC" } ], "standard_charges": [ { "gross_charge": 11.00, "minimum": 0.46, "maximum": 9.35, "setting": "both", "payers_information": [ { "payer_name": "Aarp", "plan_name": "500102", "standard_charge_dollar": 0.46, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna", "plan_name": "700700", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna", "plan_name": "700700_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Mcare Ffs 6005", "plan_name": "700703", "standard_charge_dollar": 0.46, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Miscellaneous", "plan_name": "700720", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Miscellaneous", "plan_name": "700720_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Ppo Hmo", "plan_name": "701720", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Ppo Hmo", "plan_name": "701720_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Ambetter 68069", "plan_name": "500516", "standard_charge_dollar": 0.46, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Ms State Emplo", "plan_name": "401457", "standard_charge_percentage": 0.80, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Ms State Emplo", "plan_name": "401457_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Basic Pl", "plan_name": "400100", "standard_charge_percentage": 0.85, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Basic Pl", "plan_name": "400100_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Federal", "plan_name": "400110", "standard_charge_percentage": 0.85, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Federal", "plan_name": "400110_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Cigna Healthsprings Ffs", "plan_name": "500064", "standard_charge_dollar": 0.46, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Conseco", "plan_name": "500302", "standard_charge_dollar": 0.46, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Humana Ffs 61101", "plan_name": "500006", "standard_charge_dollar": 0.46, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Medicare A", "plan_name": "100100", "standard_charge_dollar": 0.46, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Medicare A", "plan_name": "100500", "standard_charge_dollar": 0.46, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Medicare Part B Only", "plan_name": "100300", "standard_charge_dollar": 0.46, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Medicare Railroad", "plan_name": "100103", "standard_charge_dollar": 0.46, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Ms Physicians Care N", "plan_name": "714210", "standard_charge_dollar": 0.57, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Peoples Hlth Ffs 72126", "plan_name": "500019", "standard_charge_dollar": 0.46, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Uhc/Secure Horizons", "plan_name": "500449", "standard_charge_dollar": 0.46, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "United Health Care/", "plan_name": "500292", "standard_charge_dollar": 0.52, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "United Healthcare", "plan_name": "750104", "standard_charge_dollar": 0.52, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "United Healthcare Ba", "plan_name": "750090", "standard_charge_dollar": 0.52, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "United Healthcare Me", "plan_name": "501310", "standard_charge_dollar": 0.46, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Windsor Mcare Extra", "plan_name": "500778", "standard_charge_dollar": 0.46, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." } ] } ] }, { "description": "Ketorolac 30 mg/ml (1 ml) injection solution [22473]", "drug_information": { "unit": 1.00, "type": "ML" }, "code_information": [ { "code": "J1885", "type": "HCPCS" }, { "code": "63323-162-23", "type": "NDC" } ], "standard_charges": [ { "gross_charge": 11.00, "minimum": 0.46, "maximum": 9.35, "setting": "both", "payers_information": [ { "payer_name": "Aarp", "plan_name": "500102", "standard_charge_dollar": 0.46, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna", "plan_name": "700700", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna", "plan_name": "700700_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Mcare Ffs 6005", "plan_name": "700703", "standard_charge_dollar": 0.46, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Miscellaneous", "plan_name": "700720", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Miscellaneous", "plan_name": "700720_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Ppo Hmo", "plan_name": "701720", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Ppo Hmo", "plan_name": "701720_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Ambetter 68069", "plan_name": "500516", "standard_charge_dollar": 0.46, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Ms State Emplo", "plan_name": "401457", "standard_charge_percentage": 0.80, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Ms State Emplo", "plan_name": "401457_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Basic Pl", "plan_name": "400100", "standard_charge_percentage": 0.85, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Basic Pl", "plan_name": "400100_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Federal", "plan_name": "400110", "standard_charge_percentage": 0.85, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Federal", "plan_name": "400110_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Cigna Healthsprings Ffs", "plan_name": "500064", "standard_charge_dollar": 0.46, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Conseco", "plan_name": "500302", "standard_charge_dollar": 0.46, "count": "0", "methodology": "fee schedule", "additional_payer_notes": 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"standard_charge_dollar": 0.46, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Ms Physicians Care N", "plan_name": "714210", "standard_charge_dollar": 0.57, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Peoples Hlth Ffs 72126", "plan_name": "500019", "standard_charge_dollar": 0.46, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Uhc/Secure Horizons", "plan_name": "500449", "standard_charge_dollar": 0.46, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "United Health Care/", "plan_name": "500292", "standard_charge_dollar": 0.52, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "United Healthcare", "plan_name": "750104", "standard_charge_dollar": 0.52, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "United Healthcare Ba", "plan_name": "750090", "standard_charge_dollar": 0.52, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "United Healthcare Me", "plan_name": "501310", "standard_charge_dollar": 0.46, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Windsor Mcare Extra", "plan_name": "500778", "standard_charge_dollar": 0.46, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." } ] } ] }, { "description": "Ketorolac 15 mg/ml injection solution [22472]", "drug_information": { "unit": 1.00, "type": "ML" }, "code_information": [ { "code": "J1885", "type": "HCPCS" }, { "code": "0409-3793-01", "type": "NDC" } ], "standard_charges": [ { "gross_charge": 34.47, "minimum": 0.46, "maximum": 29.30, "setting": "both", "payers_information": [ { "payer_name": "Aarp", "plan_name": "500102", "standard_charge_dollar": 0.46, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna", "plan_name": "700700", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna", "plan_name": "700700_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Mcare Ffs 6005", "plan_name": "700703", "standard_charge_dollar": 0.46, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Miscellaneous", "plan_name": "700720", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Miscellaneous", "plan_name": "700720_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Ppo Hmo", "plan_name": "701720", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Ppo Hmo", "plan_name": "701720_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Ambetter 68069", "plan_name": "500516", "standard_charge_dollar": 0.46, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Ms State Emplo", "plan_name": "401457", "standard_charge_percentage": 0.80, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Ms State Emplo", "plan_name": "401457_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Basic Pl", "plan_name": "400100", "standard_charge_percentage": 0.85, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Basic Pl", "plan_name": "400100_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Federal", "plan_name": "400110", "standard_charge_percentage": 0.85, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Federal", "plan_name": "400110_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Cigna Healthsprings Ffs", "plan_name": "500064", "standard_charge_dollar": 0.46, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Conseco", "plan_name": "500302", "standard_charge_dollar": 0.46, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Humana Ffs 61101", "plan_name": "500006", "standard_charge_dollar": 0.46, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Medicare A", "plan_name": "100100", "standard_charge_dollar": 0.46, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Medicare A", "plan_name": "100500", "standard_charge_dollar": 0.46, "count": "0", "methodology": "fee schedule", "additional_payer_notes": 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"plan_name": "500449", "standard_charge_dollar": 0.46, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "United Health Care/", "plan_name": "500292", "standard_charge_dollar": 0.52, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "United Healthcare", "plan_name": "750104", "standard_charge_dollar": 0.52, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "United Healthcare Ba", "plan_name": "750090", "standard_charge_dollar": 0.52, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "United Healthcare Me", "plan_name": "501310", "standard_charge_dollar": 0.46, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Windsor Mcare Extra", "plan_name": "500778", "standard_charge_dollar": 0.46, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." } ] } ] }, { "description": "Ketorolac 15 mg/ml injection solution [22472]", "drug_information": { "unit": 1.00, "type": "ML" }, "code_information": [ { "code": "J1885", "type": "HCPCS" }, { "code": "0409-3793-19", "type": "NDC" } ], "standard_charges": [ { "gross_charge": 34.47, "minimum": 0.46, "maximum": 29.30, "setting": "both", "payers_information": [ { "payer_name": "Aarp", "plan_name": "500102", "standard_charge_dollar": 0.46, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna", "plan_name": "700700", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of 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"additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Ppo Hmo", "plan_name": "701720", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Ppo Hmo", "plan_name": "701720_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Ambetter 68069", "plan_name": "500516", "standard_charge_dollar": 0.46, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Ms State Emplo", "plan_name": "401457", "standard_charge_percentage": 0.80, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Ms State Emplo", "plan_name": "401457_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Basic Pl", "plan_name": "400100", "standard_charge_percentage": 0.85, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Basic Pl", "plan_name": "400100_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Federal", "plan_name": "400110", "standard_charge_percentage": 0.85, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Federal", "plan_name": "400110_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Cigna Healthsprings Ffs", "plan_name": "500064", "standard_charge_dollar": 0.46, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Conseco", "plan_name": "500302", "standard_charge_dollar": 0.46, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Humana Ffs 61101", "plan_name": "500006", "standard_charge_dollar": 0.46, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Medicare A", "plan_name": "100100", "standard_charge_dollar": 0.46, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Medicare A", "plan_name": "100500", "standard_charge_dollar": 0.46, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Medicare Part B Only", "plan_name": "100300", "standard_charge_dollar": 0.46, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Medicare Railroad", "plan_name": "100103", "standard_charge_dollar": 0.46, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Ms Physicians Care N", "plan_name": "714210", "standard_charge_dollar": 0.57, "count": "0", "methodology": "fee schedule", "additional_payer_notes": 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"plan_name": "750090", "standard_charge_dollar": 0.52, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "United Healthcare Me", "plan_name": "501310", "standard_charge_dollar": 0.46, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Windsor Mcare Extra", "plan_name": "500778", "standard_charge_dollar": 0.46, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." } ] } ] }, { "description": "Ketorolac 30 mg/ml (1 ml) injection solution [22473]", "drug_information": { "unit": 1.00, "type": "ML" }, "code_information": [ { "code": "J1885", "type": "HCPCS" }, { "code": "0409-3795-01", "type": "NDC" } ], "standard_charges": [ { "gross_charge": 65.48, "minimum": 0.46, "maximum": 55.66, "setting": "both", "payers_information": [ { "payer_name": "Aarp", "plan_name": "500102", "standard_charge_dollar": 0.46, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna", "plan_name": "700700", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna", "plan_name": "700700_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Mcare Ffs 6005", "plan_name": "700703", "standard_charge_dollar": 0.46, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Miscellaneous", "plan_name": "700720", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Miscellaneous", "plan_name": "700720_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Ppo Hmo", "plan_name": "701720", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Ppo Hmo", "plan_name": "701720_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Ambetter 68069", "plan_name": "500516", "standard_charge_dollar": 0.46, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Ms State Emplo", "plan_name": "401457", "standard_charge_percentage": 0.80, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Ms State Emplo", "plan_name": "401457_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Basic Pl", "plan_name": "400100", "standard_charge_percentage": 0.85, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Basic Pl", "plan_name": "400100_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Federal", "plan_name": "400110", "standard_charge_percentage": 0.85, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Federal", "plan_name": "400110_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Cigna Healthsprings Ffs", "plan_name": "500064", "standard_charge_dollar": 0.46, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Conseco", "plan_name": "500302", "standard_charge_dollar": 0.46, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Humana Ffs 61101", "plan_name": "500006", "standard_charge_dollar": 0.46, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Medicare A", "plan_name": "100100", "standard_charge_dollar": 0.46, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Medicare A", "plan_name": "100500", "standard_charge_dollar": 0.46, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Medicare Part B Only", "plan_name": "100300", "standard_charge_dollar": 0.46, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Medicare Railroad", "plan_name": "100103", "standard_charge_dollar": 0.46, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Ms Physicians Care N", "plan_name": "714210", "standard_charge_dollar": 0.57, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Peoples Hlth Ffs 72126", "plan_name": "500019", "standard_charge_dollar": 0.46, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Uhc/Secure Horizons", "plan_name": "500449", "standard_charge_dollar": 0.46, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "United Health Care/", "plan_name": "500292", "standard_charge_dollar": 0.52, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "United Healthcare", "plan_name": "750104", "standard_charge_dollar": 0.52, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "United Healthcare Ba", "plan_name": "750090", "standard_charge_dollar": 0.52, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "United Healthcare Me", "plan_name": "501310", "standard_charge_dollar": 0.46, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Windsor Mcare Extra", "plan_name": "500778", "standard_charge_dollar": 0.46, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." } ] } ] }, { "description": "Ketorolac 30 mg/ml (1 ml) injection solution [22473]", "drug_information": { "unit": 1.00, "type": "ML" }, "code_information": [ { "code": "J1885", "type": "HCPCS" }, { "code": "0409-3795-19", "type": "NDC" } ], "standard_charges": [ { "gross_charge": 65.48, "minimum": 0.46, "maximum": 55.66, "setting": "both", "payers_information": [ { "payer_name": "Aarp", "plan_name": "500102", "standard_charge_dollar": 0.46, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna", "plan_name": "700700", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna", "plan_name": "700700_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Mcare Ffs 6005", "plan_name": "700703", "standard_charge_dollar": 0.46, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Miscellaneous", "plan_name": "700720", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Miscellaneous", "plan_name": "700720_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Ppo Hmo", "plan_name": "701720", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Ppo Hmo", "plan_name": "701720_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Ambetter 68069", "plan_name": "500516", "standard_charge_dollar": 0.46, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Ms State Emplo", "plan_name": "401457", "standard_charge_percentage": 0.80, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Ms State Emplo", "plan_name": "401457_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Basic Pl", "plan_name": "400100", "standard_charge_percentage": 0.85, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Basic Pl", "plan_name": "400100_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Federal", "plan_name": "400110", "standard_charge_percentage": 0.85, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Federal", "plan_name": "400110_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Cigna Healthsprings Ffs", "plan_name": "500064", "standard_charge_dollar": 0.46, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Conseco", "plan_name": "500302", "standard_charge_dollar": 0.46, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Humana Ffs 61101", "plan_name": "500006", "standard_charge_dollar": 0.46, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Medicare A", "plan_name": "100100", "standard_charge_dollar": 0.46, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Medicare A", "plan_name": "100500", "standard_charge_dollar": 0.46, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Medicare Part B Only", "plan_name": "100300", "standard_charge_dollar": 0.46, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Medicare Railroad", "plan_name": "100103", "standard_charge_dollar": 0.46, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Ms Physicians Care N", "plan_name": "714210", "standard_charge_dollar": 0.57, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Peoples Hlth Ffs 72126", "plan_name": "500019", "standard_charge_dollar": 0.46, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Uhc/Secure Horizons", "plan_name": "500449", "standard_charge_dollar": 0.46, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "United Health Care/", "plan_name": "500292", "standard_charge_dollar": 0.52, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "United Healthcare", "plan_name": "750104", "standard_charge_dollar": 0.52, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "United Healthcare Ba", "plan_name": "750090", "standard_charge_dollar": 0.52, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "United Healthcare Me", "plan_name": "501310", "standard_charge_dollar": 0.46, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Windsor Mcare Extra", "plan_name": "500778", "standard_charge_dollar": 0.46, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." } ] } ] }, { "description": "Ketorolac 60 mg/2 ml intramuscular solution [91349]", "drug_information": { "unit": 2.00, "type": "ML" }, "code_information": [ { "code": "J1885", "type": "HCPCS" }, { "code": "0409-3796-01", "type": "NDC" } ], "standard_charges": [ { "gross_charge": 29.24, "minimum": 0.46, "maximum": 24.85, "setting": "both", "payers_information": [ { "payer_name": "Aarp", "plan_name": "500102", "standard_charge_dollar": 0.46, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna", "plan_name": "700700", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna", "plan_name": "700700_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Mcare Ffs 6005", "plan_name": "700703", "standard_charge_dollar": 0.46, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Miscellaneous", "plan_name": "700720", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Miscellaneous", "plan_name": "700720_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Ppo Hmo", "plan_name": "701720", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Ppo Hmo", "plan_name": "701720_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Ambetter 68069", "plan_name": "500516", "standard_charge_dollar": 0.46, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Ms State Emplo", "plan_name": "401457", "standard_charge_percentage": 0.80, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Ms State Emplo", "plan_name": "401457_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Basic Pl", "plan_name": "400100", "standard_charge_percentage": 0.85, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Basic Pl", "plan_name": "400100_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Federal", "plan_name": "400110", "standard_charge_percentage": 0.85, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Federal", "plan_name": "400110_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Cigna Healthsprings Ffs", "plan_name": "500064", "standard_charge_dollar": 0.46, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Conseco", "plan_name": "500302", "standard_charge_dollar": 0.46, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Humana Ffs 61101", "plan_name": "500006", "standard_charge_dollar": 0.46, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Medicare A", "plan_name": "100100", "standard_charge_dollar": 0.46, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Medicare A", "plan_name": "100500", "standard_charge_dollar": 0.46, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Medicare Part B Only", "plan_name": "100300", "standard_charge_dollar": 0.46, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Medicare Railroad", "plan_name": "100103", "standard_charge_dollar": 0.46, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Ms Physicians Care N", "plan_name": "714210", "standard_charge_dollar": 0.57, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Peoples Hlth Ffs 72126", "plan_name": "500019", "standard_charge_dollar": 0.46, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Uhc/Secure Horizons", "plan_name": "500449", "standard_charge_dollar": 0.46, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "United Health Care/", "plan_name": "500292", "standard_charge_dollar": 0.52, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "United Healthcare", "plan_name": "750104", "standard_charge_dollar": 0.52, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "United Healthcare Ba", "plan_name": "750090", "standard_charge_dollar": 0.52, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "United Healthcare Me", "plan_name": "501310", "standard_charge_dollar": 0.46, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Windsor Mcare Extra", "plan_name": "500778", "standard_charge_dollar": 0.46, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." } ] } ] }, { "description": "Ketorolac 60 mg/2 ml intramuscular solution [91349]", "drug_information": { "unit": 2.00, "type": "ML" }, "code_information": [ { "code": "J1885", "type": "HCPCS" }, { "code": "0409-3796-19", "type": "NDC" } ], "standard_charges": [ { "gross_charge": 29.24, "minimum": 0.46, "maximum": 24.85, "setting": "both", "payers_information": [ { "payer_name": "Aarp", "plan_name": "500102", "standard_charge_dollar": 0.46, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna", "plan_name": "700700", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna", "plan_name": "700700_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Mcare Ffs 6005", "plan_name": "700703", "standard_charge_dollar": 0.46, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Miscellaneous", "plan_name": "700720", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Miscellaneous", "plan_name": "700720_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Ppo Hmo", "plan_name": "701720", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Ppo Hmo", "plan_name": "701720_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Ambetter 68069", "plan_name": "500516", "standard_charge_dollar": 0.46, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Ms State Emplo", "plan_name": "401457", "standard_charge_percentage": 0.80, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Ms State Emplo", "plan_name": "401457_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Basic Pl", "plan_name": "400100", "standard_charge_percentage": 0.85, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Basic Pl", "plan_name": "400100_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Federal", "plan_name": "400110", "standard_charge_percentage": 0.85, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Federal", "plan_name": "400110_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Cigna Healthsprings Ffs", "plan_name": "500064", "standard_charge_dollar": 0.46, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Conseco", "plan_name": "500302", "standard_charge_dollar": 0.46, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Humana Ffs 61101", "plan_name": "500006", "standard_charge_dollar": 0.46, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Medicare A", "plan_name": "100100", "standard_charge_dollar": 0.46, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Medicare A", "plan_name": "100500", "standard_charge_dollar": 0.46, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Medicare Part B Only", "plan_name": "100300", "standard_charge_dollar": 0.46, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Medicare Railroad", "plan_name": "100103", "standard_charge_dollar": 0.46, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Ms Physicians Care N", "plan_name": "714210", "standard_charge_dollar": 0.57, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Peoples Hlth Ffs 72126", "plan_name": "500019", "standard_charge_dollar": 0.46, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Uhc/Secure Horizons", "plan_name": "500449", "standard_charge_dollar": 0.46, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "United Health Care/", "plan_name": "500292", "standard_charge_dollar": 0.52, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "United Healthcare", "plan_name": "750104", "standard_charge_dollar": 0.52, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "United Healthcare Ba", "plan_name": "750090", "standard_charge_dollar": 0.52, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "United Healthcare Me", "plan_name": "501310", "standard_charge_dollar": 0.46, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Windsor Mcare Extra", "plan_name": "500778", "standard_charge_dollar": 0.46, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." } ] } ] }, { "description": "Labetalol 5 mg/ml intravenous solution [10372]", "drug_information": { "unit": 20.00, "type": "ML" }, "code_information": [ { "code": "J1920", "type": "HCPCS" }, { "code": "0409-2267-20", "type": "NDC" } ], "standard_charges": [ { "gross_charge": 41.80, "minimum": 33.44, "maximum": 35.53, "setting": "both", "payers_information": [ { "payer_name": "Aetna", "plan_name": "700700", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna", "plan_name": "700700_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Miscellaneous", "plan_name": "700720", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", 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schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Ms State Emplo", "plan_name": "401457", "standard_charge_dollar": 54.25, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Ms State Emplo", "plan_name": "401457_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Basic Pl", "plan_name": "400100", "standard_charge_dollar": 54.25, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Basic Pl", "plan_name": "400100_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Federal", "plan_name": "400110", "standard_charge_dollar": 54.25, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Federal", "plan_name": "400110_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Cigna Healthsprings Ffs", "plan_name": "500064", "standard_charge_dollar": 39.55, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Conseco", "plan_name": "500302", "standard_charge_dollar": 39.55, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Humana Ffs 61101", "plan_name": "500006", "standard_charge_dollar": 39.55, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Medicare A", "plan_name": "100100", "standard_charge_dollar": 39.55, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Medicare A", "plan_name": "100500", "standard_charge_dollar": 39.55, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Medicare Part B Only", "plan_name": "100300", "standard_charge_dollar": 39.55, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Medicare Railroad", "plan_name": "100103", "standard_charge_dollar": 39.55, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Ms Physicians Care N", "plan_name": "714210", "standard_charge_dollar": 49.44, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Peoples Hlth Ffs 72126", "plan_name": "500019", "standard_charge_dollar": 39.55, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Uhc/Secure Horizons", "plan_name": "500449", "standard_charge_dollar": 39.55, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "United Health Care/", "plan_name": "500292", "standard_charge_dollar": 44.69, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "United Healthcare", "plan_name": "750104", "standard_charge_dollar": 44.69, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "United Healthcare Ba", "plan_name": "750090", "standard_charge_dollar": 44.69, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "United Healthcare Me", "plan_name": "501310", "standard_charge_dollar": 39.55, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Windsor Mcare Extra", "plan_name": "500778", "standard_charge_dollar": 39.55, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." } ] } ] }, { "description": "Laronidase 2.9 mg/5 ml intravenous solution [35779]", "drug_information": { "unit": 5.00, "type": "ML" }, "code_information": [ { "code": "J1931", "type": "HCPCS" }, { "code": "58468-0070-1", "type": "NDC" } ], "standard_charges": [ { "gross_charge": 4303.65, "minimum": 28.44, "maximum": 48.26, "setting": "both", "payers_information": [ { "payer_name": "Aarp", "plan_name": "500102", "standard_charge_dollar": 38.61, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna", "plan_name": "700700", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna", "plan_name": "700700_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Mcare Ffs 6005", "plan_name": "700703", "standard_charge_dollar": 38.61, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Miscellaneous", "plan_name": "700720", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Miscellaneous", "plan_name": "700720_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Ppo Hmo", "plan_name": "701720", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Ppo Hmo", "plan_name": "701720_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Ambetter 68069", "plan_name": "500516", "standard_charge_dollar": 38.61, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Ms State Emplo", "plan_name": "401457", "standard_charge_dollar": 28.44, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Ms State Emplo", "plan_name": "401457_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Basic Pl", "plan_name": "400100", "standard_charge_dollar": 28.44, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Basic Pl", "plan_name": "400100_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Federal", "plan_name": "400110", "standard_charge_dollar": 28.44, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Federal", "plan_name": "400110_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Cigna Healthsprings Ffs", "plan_name": "500064", "standard_charge_dollar": 38.61, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Conseco", "plan_name": "500302", "standard_charge_dollar": 38.61, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Humana Ffs 61101", "plan_name": "500006", "standard_charge_dollar": 38.61, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Medicare A", "plan_name": "100100", "standard_charge_dollar": 38.61, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Medicare A", "plan_name": "100500", "standard_charge_dollar": 38.61, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Medicare Part B Only", "plan_name": "100300", "standard_charge_dollar": 38.61, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Medicare Railroad", "plan_name": "100103", "standard_charge_dollar": 38.61, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Ms Physicians Care N", "plan_name": "714210", "standard_charge_dollar": 48.26, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Peoples Hlth Ffs 72126", "plan_name": "500019", "standard_charge_dollar": 38.61, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Uhc/Secure Horizons", "plan_name": "500449", "standard_charge_dollar": 38.61, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "United Health Care/", "plan_name": "500292", "standard_charge_dollar": 43.63, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "United Healthcare", "plan_name": "750104", "standard_charge_dollar": 43.63, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "United Healthcare Ba", "plan_name": "750090", "standard_charge_dollar": 43.63, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "United Healthcare Me", "plan_name": "501310", "standard_charge_dollar": 38.61, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Windsor Mcare Extra", "plan_name": "500778", "standard_charge_dollar": 38.61, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." } ] } ] }, { "description": "Lanreotide 120 mg/0.5 ml subcutaneous syringe [87861]", "drug_information": { "unit": 0.50, "type": "ML" }, "code_information": [ { "code": "J1932", "type": "HCPCS" }, { "code": "69097-870-67", "type": "NDC" } ], "standard_charges": [ { "gross_charge": 33625.05, "minimum": 23.29, "maximum": 28581.29, "setting": "both", "payers_information": [ { "payer_name": "Aarp", "plan_name": "500102", "standard_charge_dollar": 23.29, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna", "plan_name": "700700", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna", "plan_name": "700700_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Mcare Ffs 6005", "plan_name": "700703", "standard_charge_dollar": 23.29, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Miscellaneous", "plan_name": "700720", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Miscellaneous", "plan_name": "700720_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Ppo Hmo", "plan_name": "701720", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Ppo Hmo", "plan_name": "701720_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Ambetter 68069", "plan_name": "500516", "standard_charge_dollar": 23.29, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Ms State Emplo", "plan_name": "401457", "standard_charge_percentage": 0.80, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Ms State Emplo", "plan_name": "401457_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Basic Pl", "plan_name": "400100", "standard_charge_percentage": 0.85, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Basic Pl", "plan_name": "400100_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Federal", "plan_name": "400110", "standard_charge_percentage": 0.85, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Federal", "plan_name": "400110_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Cigna Healthsprings Ffs", "plan_name": "500064", "standard_charge_dollar": 23.29, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Conseco", "plan_name": "500302", "standard_charge_dollar": 23.29, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Humana Ffs 61101", "plan_name": "500006", "standard_charge_dollar": 23.29, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Medicare A", "plan_name": "100100", "standard_charge_dollar": 23.29, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Medicare A", "plan_name": "100500", "standard_charge_dollar": 23.29, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Medicare Part B Only", "plan_name": "100300", "standard_charge_dollar": 23.29, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Medicare Railroad", "plan_name": "100103", "standard_charge_dollar": 23.29, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Ms Physicians Care N", "plan_name": "714210", "standard_charge_dollar": 29.11, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Peoples Hlth Ffs 72126", "plan_name": "500019", "standard_charge_dollar": 23.29, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Uhc/Secure Horizons", "plan_name": "500449", "standard_charge_dollar": 23.29, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "United Health Care/", "plan_name": "500292", "standard_charge_dollar": 26.31, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "United Healthcare", "plan_name": "750104", "standard_charge_dollar": 26.31, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "United Healthcare Ba", "plan_name": "750090", "standard_charge_dollar": 26.31, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "United Healthcare Me", "plan_name": "501310", "standard_charge_dollar": 23.29, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Windsor Mcare Extra", "plan_name": "500778", "standard_charge_dollar": 23.29, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." } ] } ] }, { "description": "Bumetanide 0.25 mg/ml injection solution [9308]", "drug_information": { "unit": 4.00, "type": "ML" }, "code_information": [ { "code": "J1939", "type": "HCPCS" }, { "code": "70860-405-04", "type": "NDC" } ], "standard_charges": [ { "gross_charge": 20.36, "minimum": 0.57, "maximum": 17.31, "setting": "both", "payers_information": [ { "payer_name": "Aarp", "plan_name": "500102", "standard_charge_dollar": 0.57, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna", "plan_name": "700700", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna", "plan_name": "700700_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Mcare Ffs 6005", "plan_name": "700703", "standard_charge_dollar": 0.57, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Miscellaneous", "plan_name": "700720", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Miscellaneous", "plan_name": "700720_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Ppo Hmo", "plan_name": "701720", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Ppo Hmo", "plan_name": "701720_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Ambetter 68069", "plan_name": "500516", "standard_charge_dollar": 0.57, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Ms State Emplo", "plan_name": "401457", "standard_charge_percentage": 0.80, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Ms State Emplo", "plan_name": "401457_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Basic Pl", "plan_name": "400100", "standard_charge_percentage": 0.85, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Basic Pl", "plan_name": "400100_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Federal", "plan_name": "400110", "standard_charge_percentage": 0.85, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Federal", "plan_name": "400110_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Cigna Healthsprings Ffs", "plan_name": "500064", "standard_charge_dollar": 0.57, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Conseco", "plan_name": "500302", "standard_charge_dollar": 0.57, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Humana Ffs 61101", "plan_name": "500006", "standard_charge_dollar": 0.57, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Medicare A", "plan_name": "100100", "standard_charge_dollar": 0.57, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Medicare A", "plan_name": "100500", "standard_charge_dollar": 0.57, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Medicare Part B Only", "plan_name": "100300", "standard_charge_dollar": 0.57, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Medicare Railroad", "plan_name": "100103", "standard_charge_dollar": 0.57, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Ms Physicians Care N", "plan_name": "714210", "standard_charge_dollar": 0.71, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Peoples Hlth Ffs 72126", "plan_name": "500019", "standard_charge_dollar": 0.57, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Uhc/Secure Horizons", "plan_name": "500449", "standard_charge_dollar": 0.57, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "United Health Care/", "plan_name": "500292", "standard_charge_dollar": 0.64, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "United Healthcare", "plan_name": "750104", "standard_charge_dollar": 0.64, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "United Healthcare Ba", "plan_name": "750090", "standard_charge_dollar": 0.64, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "United Healthcare Me", "plan_name": "501310", "standard_charge_dollar": 0.57, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Windsor Mcare Extra", "plan_name": "500778", "standard_charge_dollar": 0.57, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." } ] } ] }, { "description": "Bumetanide 0.25 mg/ml injection solution [9308]", "drug_information": { "unit": 4.00, "type": "ML" }, 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0.57, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Miscellaneous", "plan_name": "700720", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Miscellaneous", "plan_name": "700720_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Ppo Hmo", "plan_name": "701720", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Ppo Hmo", "plan_name": "701720_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Ambetter 68069", "plan_name": "500516", "standard_charge_dollar": 0.57, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Ms State Emplo", "plan_name": "401457", "standard_charge_percentage": 0.80, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Ms State Emplo", "plan_name": "401457_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Basic Pl", "plan_name": "400100", "standard_charge_percentage": 0.85, "count": "0", "methodology": "percent of total billed charges", 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"Windsor Mcare Extra", "plan_name": "500778", "standard_charge_dollar": 0.57, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." } ] } ] }, { "description": "Bumetanide 0.25 mg/ml injection solution [9308]", "drug_information": { "unit": 4.00, "type": "ML" }, "code_information": [ { "code": "J1939", "type": "HCPCS" }, { "code": "0409-1412-04", "type": "NDC" } ], "standard_charges": [ { "gross_charge": 11.00, "minimum": 0.57, "maximum": 9.35, "setting": "both", "payers_information": [ { "payer_name": "Aarp", "plan_name": "500102", "standard_charge_dollar": 0.57, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna", "plan_name": "700700", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna", "plan_name": "700700_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Mcare Ffs 6005", "plan_name": "700703", "standard_charge_dollar": 0.57, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Miscellaneous", "plan_name": "700720", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Miscellaneous", "plan_name": "700720_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Ppo Hmo", "plan_name": "701720", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Ppo Hmo", "plan_name": "701720_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Ambetter 68069", "plan_name": "500516", "standard_charge_dollar": 0.57, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Ms State Emplo", "plan_name": "401457", "standard_charge_percentage": 0.80, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Ms State Emplo", "plan_name": "401457_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Basic Pl", "plan_name": "400100", "standard_charge_percentage": 0.85, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Basic Pl", "plan_name": "400100_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Federal", "plan_name": "400110", "standard_charge_percentage": 0.85, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Federal", "plan_name": "400110_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Cigna Healthsprings Ffs", "plan_name": "500064", "standard_charge_dollar": 0.57, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Conseco", "plan_name": "500302", "standard_charge_dollar": 0.57, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Humana Ffs 61101", "plan_name": "500006", "standard_charge_dollar": 0.57, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Medicare A", "plan_name": "100100", "standard_charge_dollar": 0.57, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Medicare A", "plan_name": "100500", "standard_charge_dollar": 0.57, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Medicare Part B Only", "plan_name": "100300", "standard_charge_dollar": 0.57, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Medicare Railroad", "plan_name": "100103", "standard_charge_dollar": 0.57, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Ms Physicians Care N", "plan_name": "714210", "standard_charge_dollar": 0.71, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Peoples Hlth Ffs 72126", "plan_name": "500019", "standard_charge_dollar": 0.57, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Uhc/Secure Horizons", "plan_name": "500449", "standard_charge_dollar": 0.57, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "United Health Care/", "plan_name": "500292", "standard_charge_dollar": 0.64, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "United Healthcare", "plan_name": "750104", "standard_charge_dollar": 0.64, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "United Healthcare Ba", "plan_name": "750090", "standard_charge_dollar": 0.64, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "United Healthcare Me", "plan_name": "501310", "standard_charge_dollar": 0.57, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Windsor Mcare Extra", "plan_name": "500778", "standard_charge_dollar": 0.57, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." } ] } ] }, { "description": "Bumetanide 0.25 mg/ml injection solution [9308]", "drug_information": { "unit": 4.00, "type": "ML" }, "code_information": [ { "code": "J1939", "type": "HCPCS" }, { "code": "0409-1412-34", "type": "NDC" } ], "standard_charges": [ { "gross_charge": 11.00, "minimum": 0.57, "maximum": 9.35, "setting": "both", "payers_information": [ { "payer_name": "Aarp", "plan_name": "500102", "standard_charge_dollar": 0.57, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna", "plan_name": "700700", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna", "plan_name": "700700_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Mcare Ffs 6005", "plan_name": "700703", "standard_charge_dollar": 0.57, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Miscellaneous", "plan_name": "700720", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Miscellaneous", "plan_name": "700720_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Ppo Hmo", "plan_name": "701720", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Ppo Hmo", "plan_name": "701720_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Ambetter 68069", "plan_name": "500516", "standard_charge_dollar": 0.57, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Ms State Emplo", "plan_name": "401457", "standard_charge_percentage": 0.80, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Ms State Emplo", "plan_name": "401457_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Basic Pl", "plan_name": "400100", "standard_charge_percentage": 0.85, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Basic Pl", "plan_name": "400100_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Federal", "plan_name": "400110", "standard_charge_percentage": 0.85, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Federal", "plan_name": "400110_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Cigna Healthsprings Ffs", "plan_name": "500064", "standard_charge_dollar": 0.57, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Conseco", "plan_name": "500302", "standard_charge_dollar": 0.57, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Humana Ffs 61101", "plan_name": "500006", "standard_charge_dollar": 0.57, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Medicare A", "plan_name": "100100", "standard_charge_dollar": 0.57, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Medicare A", "plan_name": "100500", "standard_charge_dollar": 0.57, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Medicare Part B Only", "plan_name": "100300", "standard_charge_dollar": 0.57, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Medicare Railroad", "plan_name": "100103", "standard_charge_dollar": 0.57, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Ms Physicians Care N", "plan_name": "714210", "standard_charge_dollar": 0.71, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Peoples Hlth Ffs 72126", "plan_name": "500019", "standard_charge_dollar": 0.57, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Uhc/Secure Horizons", "plan_name": "500449", "standard_charge_dollar": 0.57, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "United Health Care/", "plan_name": "500292", "standard_charge_dollar": 0.64, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "United Healthcare", "plan_name": "750104", "standard_charge_dollar": 0.64, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "United Healthcare Ba", "plan_name": "750090", "standard_charge_dollar": 0.64, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "United Healthcare Me", "plan_name": "501310", "standard_charge_dollar": 0.57, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Windsor Mcare Extra", "plan_name": "500778", "standard_charge_dollar": 0.57, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." } ] } ] }, { "description": "Bumetanide 0.25 mg/ml injection solution [9308]", "drug_information": { "unit": 10.00, "type": "ML" }, 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0.57, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Miscellaneous", "plan_name": "700720", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Miscellaneous", "plan_name": "700720_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Ppo Hmo", "plan_name": "701720", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Ppo Hmo", "plan_name": "701720_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": 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"Windsor Mcare Extra", "plan_name": "500778", "standard_charge_dollar": 0.57, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." } ] } ] }, { "description": "Bumetanide 0.25 mg/ml injection solution [9308]", "drug_information": { "unit": 10.00, "type": "ML" }, "code_information": [ { "code": "J1939", "type": "HCPCS" }, { "code": "0641-6007-10", "type": "NDC" } ], "standard_charges": [ { "gross_charge": 25.25, "minimum": 0.57, "maximum": 21.46, "setting": "both", "payers_information": [ { "payer_name": "Aarp", "plan_name": "500102", "standard_charge_dollar": 0.57, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna", "plan_name": "700700", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed 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amounts." }, { "payer_name": "Bc/Bs Ms State Emplo", "plan_name": "401457", "standard_charge_percentage": 0.80, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Ms State Emplo", "plan_name": "401457_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Basic Pl", "plan_name": "400100", "standard_charge_percentage": 0.85, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Basic Pl", "plan_name": "400100_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed 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"Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Ms Physicians Care N", "plan_name": "714210", "standard_charge_dollar": 0.71, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Peoples Hlth Ffs 72126", "plan_name": "500019", "standard_charge_dollar": 0.57, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Uhc/Secure Horizons", "plan_name": "500449", "standard_charge_dollar": 0.57, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "United Health Care/", "plan_name": "500292", "standard_charge_dollar": 0.64, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "United Healthcare", "plan_name": "750104", "standard_charge_dollar": 0.64, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "United Healthcare Ba", "plan_name": "750090", "standard_charge_dollar": 0.64, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "United Healthcare Me", "plan_name": "501310", "standard_charge_dollar": 0.57, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Windsor Mcare Extra", "plan_name": "500778", "standard_charge_dollar": 0.57, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." } ] } ] }, { "description": "Bumetanide 0.25 mg/ml injection solution [9308]", "drug_information": { "unit": 4.00, "type": "ML" }, 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0.57, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Miscellaneous", "plan_name": "700720", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Miscellaneous", "plan_name": "700720_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Ppo Hmo", "plan_name": "701720", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Ppo Hmo", "plan_name": "701720_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Ambetter 68069", "plan_name": "500516", "standard_charge_dollar": 0.57, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Ms State Emplo", "plan_name": "401457", "standard_charge_percentage": 0.80, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Ms State Emplo", "plan_name": "401457_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Basic Pl", "plan_name": "400100", "standard_charge_percentage": 0.85, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Basic Pl", "plan_name": "400100_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Federal", "plan_name": "400110", "standard_charge_percentage": 0.85, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Federal", "plan_name": "400110_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Cigna Healthsprings Ffs", "plan_name": "500064", "standard_charge_dollar": 0.57, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Conseco", "plan_name": "500302", "standard_charge_dollar": 0.57, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Humana Ffs 61101", "plan_name": "500006", "standard_charge_dollar": 0.57, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Medicare A", "plan_name": "100100", "standard_charge_dollar": 0.57, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Medicare A", "plan_name": "100500", "standard_charge_dollar": 0.57, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Medicare Part B Only", "plan_name": "100300", "standard_charge_dollar": 0.57, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Medicare Railroad", "plan_name": "100103", "standard_charge_dollar": 0.57, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Ms Physicians Care N", "plan_name": "714210", "standard_charge_dollar": 0.71, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Peoples Hlth Ffs 72126", "plan_name": "500019", "standard_charge_dollar": 0.57, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Uhc/Secure Horizons", "plan_name": "500449", "standard_charge_dollar": 0.57, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "United Health Care/", "plan_name": "500292", "standard_charge_dollar": 0.64, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "United Healthcare", "plan_name": "750104", "standard_charge_dollar": 0.64, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "United Healthcare Ba", "plan_name": "750090", "standard_charge_dollar": 0.64, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "United Healthcare Me", "plan_name": "501310", "standard_charge_dollar": 0.57, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Windsor Mcare Extra", "plan_name": "500778", "standard_charge_dollar": 0.57, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." } ] } ] }, { "description": "Leuprolide 3.75 mg intramuscular syringe kit [13691]", "drug_information": { "unit": 1.00, "type": "EA" }, "code_information": [ { "code": "J1950", "type": "HCPCS" }, { "code": "0074-3641-03", "type": "NDC" } ], "standard_charges": [ { "gross_charge": 7260.53, "minimum": 1005.12, "maximum": 2087.88, "setting": "both", "payers_information": [ { "payer_name": "Aarp", "plan_name": "500102", "standard_charge_dollar": 1670.30, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna", "plan_name": "700700", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna", "plan_name": "700700_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Mcare Ffs 6005", "plan_name": "700703", "standard_charge_dollar": 1670.30, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Miscellaneous", "plan_name": "700720", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Miscellaneous", "plan_name": "700720_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Ppo Hmo", "plan_name": "701720", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Ppo Hmo", "plan_name": "701720_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Ambetter 68069", "plan_name": "500516", "standard_charge_dollar": 1670.30, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Ms State Emplo", "plan_name": "401457", "standard_charge_dollar": 1005.12, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Ms State Emplo", "plan_name": "401457_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Basic Pl", "plan_name": "400100", "standard_charge_dollar": 1005.12, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Basic Pl", "plan_name": "400100_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Federal", "plan_name": "400110", "standard_charge_dollar": 1005.12, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Federal", "plan_name": "400110_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Cigna Healthsprings Ffs", "plan_name": "500064", "standard_charge_dollar": 1670.30, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Conseco", "plan_name": "500302", "standard_charge_dollar": 1670.30, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Humana Ffs 61101", "plan_name": "500006", "standard_charge_dollar": 1670.30, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Medicare A", "plan_name": "100100", "standard_charge_dollar": 1670.30, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Medicare A", "plan_name": "100500", "standard_charge_dollar": 1670.30, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Medicare Part B Only", "plan_name": "100300", "standard_charge_dollar": 1670.30, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Medicare Railroad", "plan_name": "100103", "standard_charge_dollar": 1670.30, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Ms Physicians Care N", "plan_name": "714210", "standard_charge_dollar": 2087.88, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Peoples Hlth Ffs 72126", "plan_name": "500019", "standard_charge_dollar": 1670.30, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Uhc/Secure Horizons", "plan_name": "500449", "standard_charge_dollar": 1670.30, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "United Health Care/", "plan_name": "500292", "standard_charge_dollar": 1887.44, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "United Healthcare", "plan_name": "750104", "standard_charge_dollar": 1887.44, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "United Healthcare Ba", "plan_name": "750090", "standard_charge_dollar": 1887.44, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "United Healthcare Me", "plan_name": "501310", "standard_charge_dollar": 1670.30, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Windsor Mcare Extra", "plan_name": "500778", "standard_charge_dollar": 1670.30, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." } ] } ] }, { "description": "Leuprolide 11.25 mg (3 month) intramuscular syringe kit [21044]", "drug_information": { "unit": 1.00, "type": "EA" }, "code_information": [ { "code": "J1950", "type": "HCPCS" }, { "code": "0074-3663-03", "type": "NDC" } ], "standard_charges": [ { "gross_charge": 21781.76, "minimum": 1005.12, "maximum": 2087.88, "setting": "both", "payers_information": [ { "payer_name": "Aarp", "plan_name": "500102", "standard_charge_dollar": 1670.30, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna", "plan_name": "700700", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna", "plan_name": "700700_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Mcare Ffs 6005", "plan_name": "700703", "standard_charge_dollar": 1670.30, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Miscellaneous", "plan_name": "700720", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Miscellaneous", "plan_name": "700720_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Ppo Hmo", "plan_name": "701720", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Ppo Hmo", "plan_name": "701720_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Ambetter 68069", "plan_name": "500516", "standard_charge_dollar": 1670.30, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Ms State Emplo", "plan_name": "401457", "standard_charge_dollar": 1005.12, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Ms State Emplo", "plan_name": "401457_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Basic Pl", "plan_name": "400100", "standard_charge_dollar": 1005.12, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Basic Pl", "plan_name": "400100_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Federal", "plan_name": "400110", "standard_charge_dollar": 1005.12, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Federal", "plan_name": "400110_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Cigna Healthsprings Ffs", "plan_name": "500064", "standard_charge_dollar": 1670.30, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Conseco", "plan_name": "500302", "standard_charge_dollar": 1670.30, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Humana Ffs 61101", "plan_name": "500006", "standard_charge_dollar": 1670.30, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Medicare A", "plan_name": "100100", "standard_charge_dollar": 1670.30, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Medicare A", "plan_name": "100500", "standard_charge_dollar": 1670.30, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Medicare Part B Only", "plan_name": "100300", "standard_charge_dollar": 1670.30, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Medicare Railroad", "plan_name": "100103", "standard_charge_dollar": 1670.30, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Ms Physicians Care N", "plan_name": "714210", "standard_charge_dollar": 2087.88, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Peoples Hlth Ffs 72126", "plan_name": "500019", "standard_charge_dollar": 1670.30, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Uhc/Secure Horizons", "plan_name": "500449", "standard_charge_dollar": 1670.30, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "United Health Care/", "plan_name": "500292", "standard_charge_dollar": 1887.44, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "United Healthcare", "plan_name": "750104", "standard_charge_dollar": 1887.44, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "United Healthcare Ba", "plan_name": "750090", "standard_charge_dollar": 1887.44, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "United Healthcare Me", "plan_name": "501310", "standard_charge_dollar": 1670.30, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Windsor Mcare Extra", "plan_name": "500778", "standard_charge_dollar": 1670.30, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." } ] } ] }, { "description": "Levetiracetam 500 mg/5 ml intravenous solution [77195]", "drug_information": { "unit": 5.00, "type": "ML" }, "code_information": [ { "code": "J1953", "type": "HCPCS" }, { "code": "0409-1886-02", "type": "NDC" } ], "standard_charges": [ { "gross_charge": 33.13, "minimum": 0.20, "maximum": 0.20, "setting": "both", "payers_information": [ { "payer_name": "Aetna", "plan_name": "700700", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna", "plan_name": "700700_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Miscellaneous", "plan_name": "700720", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Miscellaneous", "plan_name": "700720_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Ppo Hmo", "plan_name": "701720", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Ppo Hmo", "plan_name": "701720_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Ms State Emplo", "plan_name": "401457", "standard_charge_dollar": 0.20, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Ms State Emplo", "plan_name": "401457_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Basic Pl", "plan_name": "400100", "standard_charge_dollar": 0.20, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Basic Pl", "plan_name": "400100_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Federal", "plan_name": "400110", "standard_charge_dollar": 0.20, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Federal", "plan_name": "400110_1", "standard_charge_percentage": 100.0, 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"standard_charge_dollar": 30.54, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Ms Physicians Care N", "plan_name": "714210", "standard_charge_dollar": 38.18, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Peoples Hlth Ffs 72126", "plan_name": "500019", "standard_charge_dollar": 30.54, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Uhc/Secure Horizons", "plan_name": "500449", "standard_charge_dollar": 30.54, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "United Health Care/", "plan_name": "500292", "standard_charge_dollar": 34.51, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "United Healthcare", "plan_name": "750104", "standard_charge_dollar": 34.51, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "United Healthcare Ba", "plan_name": "750090", "standard_charge_dollar": 34.51, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "United Healthcare Me", "plan_name": "501310", "standard_charge_dollar": 30.54, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Windsor Mcare Extra", "plan_name": "500778", "standard_charge_dollar": 30.54, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." } ] } ] }, { "description": "Meropenem 500 mg intravenous solution [17379]", "drug_information": { "unit": 1.00, "type": "EA" }, "code_information": [ { "code": "J2185", "type": "HCPCS" }, { "code": "0409-1390-21", "type": "NDC" } ], "standard_charges": [ { "gross_charge": 99.76, "minimum": 2.80, "maximum": 2.80, "setting": "both", "payers_information": [ { "payer_name": "Aetna", "plan_name": "700700", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna", "plan_name": "700700_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Miscellaneous", "plan_name": "700720", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Miscellaneous", "plan_name": "700720_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Ppo Hmo", "plan_name": "701720", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Ppo Hmo", "plan_name": "701720_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Ms State Emplo", "plan_name": "401457", "standard_charge_dollar": 2.80, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Ms State Emplo", "plan_name": "401457_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Basic Pl", "plan_name": "400100", "standard_charge_dollar": 2.80, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Basic Pl", "plan_name": "400100_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Federal", "plan_name": "400110", "standard_charge_dollar": 2.80, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Federal", "plan_name": "400110_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." } ] } ] }, { "description": "Meropenem 1 gram intravenous solution [17380]", "drug_information": { "unit": 1.00, "type": "EA" }, "code_information": [ { "code": "J2185", "type": "HCPCS" }, { "code": "0409-1391-21", "type": "NDC" } ], "standard_charges": [ { "gross_charge": 129.40, "minimum": 2.80, "maximum": 2.80, "setting": "both", "payers_information": [ { "payer_name": "Aetna", "plan_name": "700700", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna", "plan_name": "700700_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Miscellaneous", "plan_name": "700720", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Miscellaneous", "plan_name": "700720_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Ppo Hmo", "plan_name": "701720", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Ppo Hmo", "plan_name": "701720_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Ms State Emplo", "plan_name": "401457", "standard_charge_dollar": 2.80, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Ms State Emplo", "plan_name": "401457_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Basic Pl", "plan_name": "400100", "standard_charge_dollar": 2.80, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Basic Pl", "plan_name": "400100_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Federal", "plan_name": "400110", "standard_charge_dollar": 2.80, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Federal", "plan_name": "400110_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." } ] } ] }, { "description": "Meropenem 1 gram intravenous solution [17380]", "drug_information": { "unit": 1.00, "type": "EA" }, "code_information": [ { "code": "J2185", "type": "HCPCS" }, { "code": "55150-208-30", "type": "NDC" } ], "standard_charges": [ { "gross_charge": 71.75, "minimum": 2.80, "maximum": 2.80, "setting": "both", "payers_information": [ { "payer_name": "Aetna", "plan_name": "700700", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna", "plan_name": "700700_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Miscellaneous", "plan_name": "700720", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Miscellaneous", "plan_name": "700720_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Ppo Hmo", "plan_name": "701720", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Ppo Hmo", "plan_name": "701720_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Ms State Emplo", "plan_name": "401457", "standard_charge_dollar": 2.80, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Ms State Emplo", "plan_name": "401457_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Basic Pl", "plan_name": "400100", "standard_charge_dollar": 2.80, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Basic Pl", "plan_name": "400100_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Federal", "plan_name": "400110", "standard_charge_dollar": 2.80, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Federal", "plan_name": "400110_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." } ] } ] }, { "description": "Meropenem 500 mg intravenous solution [17379]", "drug_information": { "unit": 1.00, "type": "EA" }, "code_information": [ { "code": "J2185", "type": "HCPCS" }, { "code": "70594-075-01", "type": "NDC" } ], 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charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Ppo Hmo", "plan_name": "701720", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Ppo Hmo", "plan_name": "701720_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Ms State Emplo", "plan_name": "401457", "standard_charge_dollar": 2.80, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Ms State Emplo", "plan_name": "401457_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Basic Pl", "plan_name": "400100", "standard_charge_dollar": 2.80, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Basic Pl", "plan_name": "400100_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Federal", "plan_name": "400110", "standard_charge_dollar": 2.80, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Federal", "plan_name": "400110_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed 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"additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Miscellaneous", "plan_name": "700720_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Ppo Hmo", "plan_name": "701720", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Ppo Hmo", "plan_name": "701720_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Ms State Emplo", "plan_name": "401457", "standard_charge_dollar": 2.80, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Ms State Emplo", "plan_name": "401457_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Basic Pl", "plan_name": "400100", "standard_charge_dollar": 2.80, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Basic Pl", "plan_name": "400100_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Federal", "plan_name": "400110", "standard_charge_dollar": 2.80, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Federal", "plan_name": "400110_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." } ] } ] }, { "description": "Meropenem 1 gram intravenous solution [17380]", "drug_information": { "unit": 1.00, "type": "EA" }, "code_information": [ { "code": "J2185", "type": "HCPCS" }, { "code": "70594-076-01", "type": "NDC" } ], "standard_charges": [ { "gross_charge": 122.00, "minimum": 2.80, "maximum": 2.80, "setting": "both", "payers_information": [ { "payer_name": "Aetna", "plan_name": "700700", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna", "plan_name": "700700_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Miscellaneous", "plan_name": "700720", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Miscellaneous", "plan_name": "700720_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Ppo Hmo", "plan_name": "701720", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Ppo Hmo", "plan_name": "701720_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Ms State Emplo", "plan_name": "401457", "standard_charge_dollar": 2.80, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Ms State Emplo", "plan_name": "401457_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Basic Pl", "plan_name": "400100", "standard_charge_dollar": 2.80, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Basic Pl", "plan_name": "400100_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Federal", "plan_name": "400110", "standard_charge_dollar": 2.80, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Federal", "plan_name": "400110_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." } ] } ] }, { "description": "Meropenem 1 gram intravenous solution [17380]", "drug_information": { "unit": 1.00, "type": "EA" }, "code_information": [ { "code": "J2185", "type": "HCPCS" }, { "code": "70594-076-02", "type": "NDC" } ], "standard_charges": [ { "gross_charge": 122.00, "minimum": 2.80, "maximum": 2.80, "setting": "both", "payers_information": [ { "payer_name": "Aetna", "plan_name": "700700", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total 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"additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Ppo Hmo", "plan_name": "701720_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Ms State Emplo", "plan_name": "401457", "standard_charge_dollar": 2.80, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Ms State Emplo", "plan_name": "401457_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Basic Pl", "plan_name": "400100", "standard_charge_dollar": 2.80, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to 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"payer_name": "Bc/Bs Of Ms Federal", "plan_name": "400110_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." } ] } ] }, { "description": "Meropenem iv syringe 20 mg/ml (neo/ped) [400255]", "drug_information": { "unit": 1.00, "type": "ML" }, "code_information": [ { "code": "J2185", "type": "HCPCS" }, { "code": "99999-003-14", "type": "NDC" } ], "standard_charges": [ { "gross_charge": 11.00, "minimum": 2.80, "maximum": 2.80, "setting": "both", "payers_information": [ { "payer_name": "Aetna", "plan_name": "700700", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna", "plan_name": "700700_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Miscellaneous", "plan_name": "700720", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Miscellaneous", "plan_name": "700720_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Ppo Hmo", "plan_name": "701720", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Ppo Hmo", "plan_name": "701720_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", 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"plan_name": "400100_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Federal", "plan_name": "400110", "standard_charge_dollar": 1.79, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Federal", "plan_name": "400110_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." } ] } ] }, { "description": "Micafungin 50 mg intravenous solution [41144]", "drug_information": { "unit": 1.00, "type": "EA" }, "code_information": [ { "code": "J2248", "type": "HCPCS" }, { "code": "63323-728-10", "type": "NDC" } ], "standard_charges": [ { "gross_charge": 253.83, "minimum": 1.79, "maximum": 1.79, 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"drug_information": { "unit": 1.00, "type": "EA" }, "code_information": [ { "code": "J2248", "type": "HCPCS" }, { "code": "63323-729-01", "type": "NDC" } ], "standard_charges": [ { "gross_charge": 934.99, "minimum": 1.79, "maximum": 1.79, "setting": "both", "payers_information": [ { "payer_name": "Aetna", "plan_name": "700700", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna", "plan_name": "700700_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Miscellaneous", "plan_name": "700720", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Miscellaneous", "plan_name": "700720_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Ppo Hmo", "plan_name": "701720", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Ppo Hmo", "plan_name": "701720_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Ms State Emplo", "plan_name": "401457", "standard_charge_dollar": 1.79, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Ms State Emplo", "plan_name": "401457_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Basic Pl", "plan_name": "400100", "standard_charge_dollar": 1.79, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Basic Pl", "plan_name": "400100_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Federal", "plan_name": "400110", "standard_charge_dollar": 1.79, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Federal", "plan_name": "400110_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." } ] } ] }, { "description": "Micafungin 50 mg intravenous solution [41144]", "drug_information": { "unit": 1.00, "type": "EA" }, "code_information": [ { "code": "J2248", "type": "HCPCS" }, { "code": "60505-6119-0", "type": "NDC" } ], "standard_charges": [ { "gross_charge": 467.50, "minimum": 1.79, "maximum": 1.79, "setting": "both", "payers_information": [ { "payer_name": "Aetna", "plan_name": "700700", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna", "plan_name": "700700_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed 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"payer_name": "Bc/Bs Ms State Emplo", "plan_name": "401457", "standard_charge_dollar": 1.79, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Ms State Emplo", "plan_name": "401457_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Basic Pl", "plan_name": "400100", "standard_charge_dollar": 1.79, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Basic Pl", "plan_name": "400100_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Federal", 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"payer_name": "Bc/Bs Ms State Emplo", "plan_name": "401457", "standard_charge_dollar": 1.79, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Ms State Emplo", "plan_name": "401457_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Basic Pl", "plan_name": "400100", "standard_charge_dollar": 1.79, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Basic Pl", "plan_name": "400100_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Federal", "plan_name": "400110", "standard_charge_dollar": 1.79, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Federal", "plan_name": "400110_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." } ] } ] }, { "description": "Micafungin 100 mg intravenous solution [77685]", "drug_information": { "unit": 1.00, "type": "EA" }, "code_information": [ { "code": "J2248", "type": "HCPCS" }, { "code": "25021-191-11", "type": "NDC" } ], "standard_charges": [ { "gross_charge": 1140.70, "minimum": 1.79, "maximum": 1.79, "setting": "both", "payers_information": [ { "payer_name": "Aetna", "plan_name": "700700", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to 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"plan_name": "400100_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Federal", "plan_name": "400110", "standard_charge_dollar": 1.79, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Federal", "plan_name": "400110_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." } ] } ] }, { "description": "Micafungin 100 mg intravenous solution [77685]", "drug_information": { "unit": 1.00, "type": "EA" }, "code_information": [ { "code": "J2248", "type": "HCPCS" }, { "code": "0469-3211-10", "type": "NDC" } ], "standard_charges": [ { "gross_charge": 879.45, "minimum": 1.79, "maximum": 1.79, 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Ms Basic Pl", "plan_name": "400100", "standard_charge_dollar": 1.79, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Basic Pl", "plan_name": "400100_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Federal", "plan_name": "400110", "standard_charge_dollar": 1.79, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Federal", "plan_name": "400110_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." } ] } ] }, { "description": "Midazolam (pf) 1 mg/ml injection solution [164805]", "drug_information": { "unit": 5.00, "type": "ML" }, "code_information": [ { "code": "J2250", "type": "HCPCS" }, { "code": "0409-2305-04", "type": "NDC" } ], "standard_charges": [ { "gross_charge": 22.36, "minimum": 17.89, "maximum": 19.01, "setting": "both", "payers_information": [ { "payer_name": "Aetna", "plan_name": "700700", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna", "plan_name": "700700_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Miscellaneous", "plan_name": "700720", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed 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"methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Ms State Emplo", "plan_name": "401457", "standard_charge_dollar": 3.54, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Ms State Emplo", "plan_name": "401457_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Basic Pl", "plan_name": "400100", "standard_charge_dollar": 3.54, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Basic Pl", "plan_name": "400100_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed 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"standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Ppo Hmo", "plan_name": "701720_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Ms State Emplo", "plan_name": "401457", "standard_charge_dollar": 3.54, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Ms State Emplo", "plan_name": "401457_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Basic Pl", "plan_name": "400100", "standard_charge_dollar": 3.54, 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}, { "payer_name": "Bc/Bs Ms State Emplo", "plan_name": "401457_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Basic Pl", "plan_name": "400100", "standard_charge_percentage": 0.85, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Basic Pl", "plan_name": "400100_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Federal", "plan_name": "400110", "standard_charge_percentage": 0.85, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Federal", "plan_name": "400110_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." } ] } ] }, { "description": "Nalbuphine 10 mg/ml injection solution [5339]", "drug_information": { "unit": 1.00, "type": "ML" }, "code_information": [ { "code": "J2300", "type": "HCPCS" }, { "code": "0409-1463-01", "type": "NDC" } ], "standard_charges": [ { "gross_charge": 86.77, "minimum": 69.42, "maximum": 73.75, "setting": "both", "payers_information": [ { "payer_name": "Aetna", "plan_name": "700700", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna", "plan_name": "700700_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Miscellaneous", "plan_name": "700720", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Miscellaneous", "plan_name": "700720_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Ppo Hmo", "plan_name": "701720", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Ppo Hmo", "plan_name": "701720_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", 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"additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Federal", "plan_name": "400110", "standard_charge_percentage": 0.85, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Federal", "plan_name": "400110_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." } ] } ] }, { "description": "Nalbuphine 10 mg/ml injection solution [5339]", "drug_information": { "unit": 1.00, "type": "ML" }, "code_information": [ { "code": "J2300", "type": "HCPCS" }, { "code": "0409-1463-71", "type": "NDC" } ], "standard_charges": [ { "gross_charge": 35.68, "minimum": 28.54, "maximum": 30.33, "setting": "both", "payers_information": [ { "payer_name": "Aetna", "plan_name": "700700", 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"standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Ppo Hmo", "plan_name": "701720_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Ms State Emplo", "plan_name": "401457", "standard_charge_percentage": 0.80, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Ms State Emplo", "plan_name": "401457_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Basic Pl", "plan_name": "400100", "standard_charge_percentage": 0.85, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Basic Pl", "plan_name": "400100_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Federal", "plan_name": "400110", "standard_charge_percentage": 0.85, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Federal", "plan_name": "400110_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." } ] } ] }, { "description": "Nitroglycerin 50 mg/250 ml (200 mcg/ml) 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calculate allowed amounts." }, { "payer_name": "Bc/Bs Ms State Emplo", "plan_name": "401457_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Basic Pl", "plan_name": "400100", "standard_charge_percentage": 0.85, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Basic Pl", "plan_name": "400100_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Federal", "plan_name": "400110", "standard_charge_percentage": 0.85, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Federal", "plan_name": "400110_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." } ] } ] }, { "description": "Risankizumab-rzaa 60 mg/ml intravenous solution [197136]", "drug_information": { "unit": 10.00, "type": "ML" }, "code_information": [ { "code": "J2327", "type": "HCPCS" }, { "code": "0074-5015-01", "type": "NDC" } ], "standard_charges": [ { "gross_charge": 43967.79, "minimum": 13.61, "maximum": 37372.62, "setting": "both", "payers_information": [ { "payer_name": "Aarp", "plan_name": "500102", "standard_charge_dollar": 13.61, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna", "plan_name": "700700", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna", "plan_name": "700700_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Mcare Ffs 6005", "plan_name": "700703", "standard_charge_dollar": 13.61, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Miscellaneous", "plan_name": "700720", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Miscellaneous", "plan_name": "700720_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Ppo Hmo", "plan_name": "701720", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Ppo Hmo", "plan_name": "701720_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Ambetter 68069", "plan_name": "500516", "standard_charge_dollar": 13.61, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Ms State Emplo", "plan_name": "401457", "standard_charge_percentage": 0.80, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Ms State Emplo", "plan_name": "401457_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Basic Pl", "plan_name": "400100", "standard_charge_percentage": 0.85, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Basic Pl", "plan_name": "400100_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Federal", "plan_name": "400110", "standard_charge_percentage": 0.85, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Federal", "plan_name": "400110_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Cigna Healthsprings Ffs", "plan_name": "500064", "standard_charge_dollar": 13.61, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Conseco", "plan_name": "500302", "standard_charge_dollar": 13.61, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Humana Ffs 61101", "plan_name": "500006", "standard_charge_dollar": 13.61, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Medicare A", "plan_name": "100100", "standard_charge_dollar": 13.61, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Medicare A", "plan_name": "100500", "standard_charge_dollar": 13.61, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Medicare Part B Only", "plan_name": "100300", "standard_charge_dollar": 13.61, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Medicare Railroad", "plan_name": "100103", "standard_charge_dollar": 13.61, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Ms Physicians Care N", "plan_name": "714210", "standard_charge_dollar": 17.02, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Peoples Hlth Ffs 72126", "plan_name": "500019", "standard_charge_dollar": 13.61, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Uhc/Secure Horizons", "plan_name": "500449", "standard_charge_dollar": 13.61, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "United Health Care/", "plan_name": "500292", "standard_charge_dollar": 15.38, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "United Healthcare", "plan_name": "750104", "standard_charge_dollar": 15.38, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "United Healthcare Ba", "plan_name": "750090", "standard_charge_dollar": 15.38, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "United Healthcare Me", "plan_name": "501310", "standard_charge_dollar": 13.61, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Windsor Mcare Extra", "plan_name": "500778", "standard_charge_dollar": 13.61, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." } ] } ] }, { "description": "Ocrelizumab 30 mg/ml intravenous solution [181210]", "drug_information": { "unit": 10.00, "type": "ML" }, "code_information": [ { "code": "J2350", "type": "HCPCS" }, { "code": "50242-150-01", "type": "NDC" } ], "standard_charges": [ { "gross_charge": 88395.35, "minimum": 55.09, "maximum": 72.26, 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"description": "Octreotidemicrospheres er 20 mg intramuscular susp extended release [169852]", "drug_information": { "unit": 1.00, "type": "EA" }, "code_information": [ { "code": "J2353", "type": "HCPCS" }, { "code": "0078-0818-81", "type": "NDC" } ], "standard_charges": [ { "gross_charge": 17112.94, "minimum": 168.02, "maximum": 255.74, "setting": "both", "payers_information": [ { "payer_name": "Aarp", "plan_name": "500102", "standard_charge_dollar": 204.59, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna", "plan_name": "700700", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna", "plan_name": "700700_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", 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}, { "payer_name": "Bc/Bs Of Ms Basic Pl", "plan_name": "400100", "standard_charge_dollar": 168.02, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Basic Pl", "plan_name": "400100_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Federal", "plan_name": "400110", "standard_charge_dollar": 168.02, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Federal", "plan_name": "400110_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Cigna Healthsprings Ffs", "plan_name": "500064", "standard_charge_dollar": 204.59, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Conseco", "plan_name": "500302", "standard_charge_dollar": 204.59, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Humana Ffs 61101", "plan_name": "500006", "standard_charge_dollar": 204.59, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Medicare A", "plan_name": "100100", "standard_charge_dollar": 204.59, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Medicare A", "plan_name": "100500", "standard_charge_dollar": 204.59, "count": "0", "methodology": "fee schedule", "additional_payer_notes": 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Horizons", "plan_name": "500449", "standard_charge_dollar": 204.59, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "United Health Care/", "plan_name": "500292", "standard_charge_dollar": 231.19, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "United Healthcare", "plan_name": "750104", "standard_charge_dollar": 231.19, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "United Healthcare Ba", "plan_name": "750090", "standard_charge_dollar": 231.19, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "United Healthcare Me", "plan_name": "501310", "standard_charge_dollar": 204.59, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Windsor Mcare Extra", "plan_name": "500778", "standard_charge_dollar": 204.59, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." } ] } ] }, { "description": "Octreotide acetate 100 mcg/ml injection solution [91279]", "drug_information": { "unit": 1.00, "type": "ML" }, "code_information": [ { "code": "J2354", "type": "HCPCS" }, { "code": "0641-6175-01", "type": "NDC" } ], "standard_charges": [ { "gross_charge": 49.70, "minimum": 39.76, "maximum": 42.25, "setting": "both", "payers_information": [ { "payer_name": "Aetna", "plan_name": "700700", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna", "plan_name": "700700_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Miscellaneous", "plan_name": "700720", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Miscellaneous", "plan_name": "700720_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Ppo Hmo", "plan_name": "701720", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Ppo Hmo", "plan_name": "701720_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Ms State Emplo", "plan_name": "401457", "standard_charge_percentage": 0.80, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Ms State Emplo", "plan_name": "401457_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Basic Pl", "plan_name": "400100", "standard_charge_percentage": 0.85, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Basic Pl", "plan_name": "400100_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Federal", "plan_name": "400110", "standard_charge_percentage": 0.85, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Federal", "plan_name": "400110_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." } ] } ] }, { "description": "Octreotide acetate 100 mcg/ml injection solution [91279]", "drug_information": { "unit": 1.00, "type": "ML" }, "code_information": [ { "code": "J2354", "type": "HCPCS" }, { "code": "0641-6175-10", "type": "NDC" } ], "standard_charges": [ { "gross_charge": 49.70, "minimum": 39.76, "maximum": 42.25, "setting": "both", "payers_information": [ { "payer_name": "Aetna", "plan_name": "700700", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna", "plan_name": "700700_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Miscellaneous", "plan_name": "700720", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Miscellaneous", "plan_name": "700720_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate 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amounts." }, { "payer_name": "Bc/Bs Of Ms Basic Pl", "plan_name": "400100", "standard_charge_percentage": 0.85, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Basic Pl", "plan_name": "400100_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Federal", "plan_name": "400110", "standard_charge_percentage": 0.85, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Federal", "plan_name": "400110_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." } ] } ] }, { "description": "Octreotide acetate 200 mcg/ml injection solution [25123]", "drug_information": { "unit": 5.00, "type": "ML" }, "code_information": [ { "code": "J2354", "type": "HCPCS" }, { "code": "0641-6177-01", "type": "NDC" } ], "standard_charges": [ { "gross_charge": 496.85, "minimum": 397.48, "maximum": 422.32, "setting": "both", "payers_information": [ { "payer_name": "Aetna", "plan_name": "700700", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna", "plan_name": "700700_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Miscellaneous", "plan_name": "700720", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total 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"additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Ms State Emplo", "plan_name": "401457_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Basic Pl", "plan_name": "400100", "standard_charge_percentage": 0.85, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Basic Pl", "plan_name": "400100_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Federal", "plan_name": "400110", "standard_charge_percentage": 0.85, "count": "0", "methodology": "percent of total billed charges", 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"standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Federal", "plan_name": "400110", "standard_charge_percentage": 0.85, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Federal", "plan_name": "400110_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." } ] } ] }, { "description": "Octreotide acetate 200 mcg/ml injection solution [25123]", "drug_information": { "unit": 5.00, "type": "ML" }, "code_information": [ { "code": "J2354", "type": "HCPCS" }, { "code": "63323-378-05", "type": "NDC" } ], "standard_charges": [ { "gross_charge": 606.15, "minimum": 484.92, 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"Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Ppo Hmo", "plan_name": "701720_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Ambetter 68069", "plan_name": "500516", "standard_charge_dollar": 16.28, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Ms State Emplo", "plan_name": "401457", "standard_charge_percentage": 0.80, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Ms State Emplo", "plan_name": "401457_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Basic Pl", "plan_name": "400100", "standard_charge_percentage": 0.85, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Basic Pl", "plan_name": "400100_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Federal", "plan_name": "400110", "standard_charge_percentage": 0.85, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Federal", "plan_name": "400110_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Cigna Healthsprings Ffs", "plan_name": "500064", "standard_charge_dollar": 16.28, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Conseco", "plan_name": "500302", "standard_charge_dollar": 16.28, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Humana Ffs 61101", "plan_name": "500006", "standard_charge_dollar": 16.28, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Medicare A", "plan_name": "100100", "standard_charge_dollar": 16.28, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Medicare A", "plan_name": "100500", "standard_charge_dollar": 16.28, "count": "0", 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allowed amounts." }, { "payer_name": "Uhc/Secure Horizons", "plan_name": "500449", "standard_charge_dollar": 16.28, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "United Health Care/", "plan_name": "500292", "standard_charge_dollar": 18.39, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "United Healthcare", "plan_name": "750104", "standard_charge_dollar": 18.39, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "United Healthcare Ba", "plan_name": "750090", "standard_charge_dollar": 18.39, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "United Healthcare Me", "plan_name": "501310", "standard_charge_dollar": 16.28, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Windsor Mcare Extra", "plan_name": "500778", "standard_charge_dollar": 16.28, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." } ] } ] }, { "description": "Omalizumab 150 mg/ml subcutaneous syringe [185822]", "drug_information": { "unit": 1.00, "type": "ML" }, "code_information": [ { "code": "J2357", "type": "HCPCS" }, { "code": "50242-215-01", "type": "NDC" } ], "standard_charges": [ { "gross_charge": 5547.48, "minimum": 34.74, "maximum": 50.15, "setting": "both", "payers_information": [ { "payer_name": "Aarp", "plan_name": "500102", "standard_charge_dollar": 40.12, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna", "plan_name": "700700", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna", "plan_name": "700700_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Mcare Ffs 6005", "plan_name": "700703", "standard_charge_dollar": 40.12, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Miscellaneous", "plan_name": "700720", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Miscellaneous", "plan_name": "700720_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Ppo Hmo", "plan_name": "701720", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Ppo Hmo", "plan_name": "701720_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Ambetter 68069", "plan_name": "500516", "standard_charge_dollar": 40.12, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Ms State Emplo", "plan_name": "401457", "standard_charge_dollar": 34.74, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Ms State Emplo", "plan_name": "401457_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Basic Pl", "plan_name": "400100", "standard_charge_dollar": 34.74, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Basic Pl", "plan_name": "400100_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Federal", "plan_name": "400110", "standard_charge_dollar": 34.74, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Federal", "plan_name": "400110_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Cigna Healthsprings Ffs", "plan_name": "500064", "standard_charge_dollar": 40.12, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Conseco", "plan_name": "500302", "standard_charge_dollar": 40.12, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Humana Ffs 61101", "plan_name": "500006", "standard_charge_dollar": 40.12, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Medicare A", "plan_name": "100100", "standard_charge_dollar": 40.12, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Medicare A", "plan_name": "100500", "standard_charge_dollar": 40.12, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Medicare Part B Only", "plan_name": "100300", "standard_charge_dollar": 40.12, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Medicare Railroad", "plan_name": "100103", "standard_charge_dollar": 40.12, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Ms Physicians Care N", "plan_name": "714210", "standard_charge_dollar": 50.15, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Peoples Hlth Ffs 72126", "plan_name": "500019", "standard_charge_dollar": 40.12, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Uhc/Secure Horizons", "plan_name": "500449", "standard_charge_dollar": 40.12, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "United Health Care/", "plan_name": "500292", "standard_charge_dollar": 45.34, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "United Healthcare", "plan_name": "750104", "standard_charge_dollar": 45.34, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "United Healthcare Ba", "plan_name": "750090", "standard_charge_dollar": 45.34, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "United Healthcare Me", "plan_name": "501310", "standard_charge_dollar": 40.12, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Windsor Mcare Extra", "plan_name": "500778", "standard_charge_dollar": 40.12, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." } ] } ] }, { "description": "Omalizumab 150 mg subcutaneous solution [36151]", "drug_information": { "unit": 1.00, "type": "EA" }, "code_information": [ { "code": "J2357", "type": "HCPCS" }, { "code": "50242-040-62", "type": "NDC" } ], "standard_charges": [ { "gross_charge": 5547.48, "minimum": 34.74, "maximum": 50.15, "setting": "both", "payers_information": [ { "payer_name": "Aarp", "plan_name": "500102", "standard_charge_dollar": 40.12, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna", "plan_name": "700700", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna", "plan_name": "700700_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Mcare Ffs 6005", "plan_name": "700703", "standard_charge_dollar": 40.12, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Miscellaneous", "plan_name": 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"setting": "both", "payers_information": [ { "payer_name": "Aetna", "plan_name": "700700", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna", "plan_name": "700700_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Miscellaneous", "plan_name": "700720", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Miscellaneous", "plan_name": "700720_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed 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Ms Basic Pl", "plan_name": "400100", "standard_charge_dollar": 0.14, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Basic Pl", "plan_name": "400100_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Federal", "plan_name": "400110", "standard_charge_dollar": 0.14, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Federal", "plan_name": "400110_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." } ] } ] }, { "description": "Ondansetron hcl 2 mg/ml intravenous solution [10777]", "drug_information": { "unit": 20.00, "type": "ML" }, "code_information": [ { "code": "J2405", "type": "HCPCS" }, { "code": "23155-549-31", "type": "NDC" } ], "standard_charges": [ { "gross_charge": 101.20, "minimum": 0.14, "maximum": 0.14, "setting": "both", "payers_information": [ { "payer_name": "Aetna", "plan_name": "700700", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna", "plan_name": "700700_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Miscellaneous", "plan_name": "700720", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Miscellaneous", "plan_name": "700720_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Ppo Hmo", "plan_name": "701720", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Ppo Hmo", "plan_name": "701720_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Ms State Emplo", "plan_name": "401457", "standard_charge_dollar": 0.14, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Ms State Emplo", "plan_name": "401457_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Basic Pl", "plan_name": "400100", "standard_charge_dollar": 0.14, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Basic Pl", "plan_name": "400100_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Federal", "plan_name": "400110", "standard_charge_dollar": 0.14, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Federal", "plan_name": "400110_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." } ] } ] }, { "description": "Ondansetron hcl 2 mg/ml intravenous solution [10777]", "drug_information": { "unit": 20.00, "type": "ML" }, "code_information": [ { "code": "J2405", "type": "HCPCS" }, { "code": "16729-298-05", "type": "NDC" } ], "standard_charges": [ { "gross_charge": 27.50, "minimum": 0.14, "maximum": 0.14, "setting": "both", "payers_information": [ { "payer_name": "Aetna", "plan_name": "700700", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna", "plan_name": "700700_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Miscellaneous", "plan_name": "700720", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Miscellaneous", "plan_name": "700720_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Ppo Hmo", "plan_name": "701720", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Ppo Hmo", "plan_name": "701720_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Ms State Emplo", "plan_name": "401457", "standard_charge_dollar": 0.14, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Ms State Emplo", "plan_name": "401457_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Basic Pl", "plan_name": "400100", "standard_charge_dollar": 0.14, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Basic Pl", "plan_name": "400100_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Federal", "plan_name": "400110", "standard_charge_dollar": 0.14, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Federal", "plan_name": "400110_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." } ] } ] }, { "description": "Ondansetron hcl (pf) 4 mg/2 ml injection solution [105614]", "drug_information": { "unit": 2.00, "type": "ML" }, "code_information": [ { "code": "J2405", "type": "HCPCS" }, { "code": "60505-6130-0", "type": "NDC" } ], "standard_charges": [ { "gross_charge": 11.00, "minimum": 0.14, "maximum": 0.14, "setting": "both", "payers_information": [ { "payer_name": "Aetna", "plan_name": "700700", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit 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amounts." }, { "payer_name": "Aetna Ppo Hmo", "plan_name": "701720_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Ms State Emplo", "plan_name": "401457", "standard_charge_dollar": 0.14, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Ms State Emplo", "plan_name": "401457_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Basic Pl", "plan_name": "400100", "standard_charge_dollar": 0.14, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Basic Pl", "plan_name": "400100_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Federal", "plan_name": "400110", "standard_charge_dollar": 0.14, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Federal", "plan_name": "400110_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." } ] } ] }, { "description": "Ondansetron hcl (pf) 4 mg/2 ml injection solution [105614]", "drug_information": { "unit": 2.00, "type": "ML" }, "code_information": [ { "code": "J2405", "type": "HCPCS" }, { "code": "60505-6130-5", "type": "NDC" } ], "standard_charges": [ { "gross_charge": 11.00, "minimum": 0.14, "maximum": 0.14, "setting": "both", "payers_information": [ { "payer_name": "Aetna", "plan_name": "700700", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna", "plan_name": "700700_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Miscellaneous", "plan_name": "700720", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Miscellaneous", "plan_name": "700720_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Ppo Hmo", "plan_name": "701720", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Ppo Hmo", "plan_name": "701720_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Ms State Emplo", "plan_name": "401457", "standard_charge_dollar": 0.14, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Ms State Emplo", "plan_name": "401457_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Basic Pl", "plan_name": "400100", "standard_charge_dollar": 0.14, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Basic Pl", "plan_name": "400100_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Federal", "plan_name": "400110", "standard_charge_dollar": 0.14, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Federal", "plan_name": "400110_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." } ] } ] }, { "description": "Oritavancin 1200 mg intravenous solution [194075]", "drug_information": { "unit": 1.00, "type": "EA" }, "code_information": [ { "code": "J2406", "type": "HCPCS" }, { "code": "70842-225-01", "type": "NDC" } ], "standard_charges": [ { "gross_charge": 24368.30, "minimum": 42.77, "maximum": 20713.06, "setting": "both", "payers_information": [ { "payer_name": "Aarp", "plan_name": "500102", "standard_charge_dollar": 42.77, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna", "plan_name": "700700", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna", "plan_name": "700700_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Mcare Ffs 6005", "plan_name": "700703", "standard_charge_dollar": 42.77, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Miscellaneous", "plan_name": "700720", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Miscellaneous", "plan_name": "700720_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Ppo Hmo", "plan_name": "701720", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Ppo Hmo", "plan_name": "701720_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Ambetter 68069", "plan_name": "500516", "standard_charge_dollar": 42.77, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Ms State Emplo", "plan_name": "401457", "standard_charge_percentage": 0.80, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Ms State Emplo", "plan_name": "401457_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Basic Pl", "plan_name": "400100", "standard_charge_percentage": 0.85, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Basic Pl", "plan_name": "400100_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Federal", "plan_name": "400110", "standard_charge_percentage": 0.85, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Federal", "plan_name": "400110_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Cigna Healthsprings Ffs", "plan_name": "500064", "standard_charge_dollar": 42.77, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Conseco", "plan_name": "500302", "standard_charge_dollar": 42.77, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Humana Ffs 61101", "plan_name": "500006", "standard_charge_dollar": 42.77, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Medicare A", "plan_name": "100100", "standard_charge_dollar": 42.77, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Medicare A", "plan_name": "100500", "standard_charge_dollar": 42.77, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Medicare Part B Only", "plan_name": "100300", "standard_charge_dollar": 42.77, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Medicare Railroad", "plan_name": "100103", "standard_charge_dollar": 42.77, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Ms Physicians Care N", "plan_name": "714210", "standard_charge_dollar": 53.46, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Peoples Hlth Ffs 72126", "plan_name": "500019", "standard_charge_dollar": 42.77, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Uhc/Secure Horizons", "plan_name": "500449", "standard_charge_dollar": 42.77, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "United Health Care/", "plan_name": "500292", "standard_charge_dollar": 48.33, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "United Healthcare", "plan_name": "750104", "standard_charge_dollar": 48.33, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "United Healthcare Ba", "plan_name": "750090", "standard_charge_dollar": 48.33, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "United Healthcare Me", "plan_name": "501310", "standard_charge_dollar": 42.77, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Windsor Mcare Extra", "plan_name": "500778", "standard_charge_dollar": 42.77, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." } ] } ] }, { "description": "Pamidronate 30 mg/10 ml (3 mg/ml) intravenous solution [32589]", "drug_information": { "unit": 10.00, "type": "ML" }, "code_information": [ { "code": "J2430", "type": "HCPCS" }, { "code": "67457-430-10", "type": "NDC" } ], "standard_charges": [ { "gross_charge": 164.65, "minimum": 18.04, "maximum": 18.04, "setting": "both", "payers_information": [ { "payer_name": "Aetna", "plan_name": "700700", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna", "plan_name": "700700_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Miscellaneous", "plan_name": "700720", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Miscellaneous", "plan_name": "700720_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Ppo Hmo", "plan_name": "701720", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Ppo Hmo", "plan_name": "701720_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Ms State Emplo", "plan_name": "401457", "standard_charge_dollar": 18.04, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Ms State Emplo", "plan_name": "401457_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Basic Pl", "plan_name": "400100", "standard_charge_dollar": 18.04, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Basic Pl", "plan_name": "400100_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Federal", "plan_name": "400110", "standard_charge_dollar": 18.04, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Federal", "plan_name": "400110_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." } ] } ] }, { "description": "Pamidronate 90 mg/10 ml (9 mg/ml) intravenous solution [32855]", "drug_information": { "unit": 10.00, "type": "ML" }, "code_information": [ { "code": "J2430", "type": "HCPCS" }, { "code": "67457-446-10", "type": "NDC" } ], "standard_charges": [ { "gross_charge": 561.30, "minimum": 18.04, "maximum": 18.04, "setting": "both", "payers_information": [ { "payer_name": "Aetna", "plan_name": "700700", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna", "plan_name": "700700_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Miscellaneous", "plan_name": "700720", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Miscellaneous", "plan_name": "700720_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Ppo Hmo", "plan_name": "701720", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Ppo Hmo", "plan_name": "701720_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Ms State Emplo", "plan_name": "401457", "standard_charge_dollar": 18.04, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Ms State Emplo", "plan_name": "401457_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Basic Pl", "plan_name": "400100", "standard_charge_dollar": 18.04, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Basic Pl", "plan_name": "400100_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Federal", "plan_name": "400110", "standard_charge_dollar": 18.04, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Federal", "plan_name": "400110_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." } ] } ] }, { "description": "Pamidronate 30 mg/10 ml (3 mg/ml) intravenous solution [32589]", "drug_information": { "unit": 10.00, "type": "ML" }, "code_information": [ { "code": "J2430", "type": "HCPCS" }, { "code": "61703-324-18", "type": "NDC" } ], "standard_charges": [ { "gross_charge": 140.10, "minimum": 18.04, "maximum": 18.04, "setting": "both", "payers_information": [ { "payer_name": "Aetna", "plan_name": "700700", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna", "plan_name": "700700_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Miscellaneous", "plan_name": "700720", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Miscellaneous", "plan_name": "700720_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Ppo Hmo", "plan_name": "701720", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Ppo Hmo", "plan_name": "701720_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Ms State Emplo", "plan_name": "401457", "standard_charge_dollar": 18.04, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Ms State Emplo", "plan_name": "401457_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Basic Pl", "plan_name": "400100", "standard_charge_dollar": 18.04, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Basic Pl", "plan_name": "400100_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Federal", "plan_name": "400110", "standard_charge_dollar": 18.04, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Federal", "plan_name": "400110_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." } ] } ] }, { "description": "Pamidronate 90 mg/10 ml (9 mg/ml) intravenous solution [32855]", "drug_information": { "unit": 10.00, "type": "ML" }, "code_information": [ { "code": "J2430", "type": "HCPCS" }, { "code": "61703-326-18", "type": "NDC" } ], "standard_charges": [ { "gross_charge": 333.30, "minimum": 18.04, "maximum": 18.04, "setting": "both", "payers_information": [ { "payer_name": "Aetna", "plan_name": "700700", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna", "plan_name": "700700_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Miscellaneous", "plan_name": "700720", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Miscellaneous", "plan_name": "700720_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Ppo Hmo", "plan_name": "701720", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Ppo Hmo", "plan_name": "701720_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Ms State Emplo", "plan_name": "401457", "standard_charge_dollar": 18.04, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Ms State Emplo", "plan_name": "401457_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Basic Pl", "plan_name": "400100", "standard_charge_dollar": 18.04, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Basic Pl", "plan_name": "400100_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Federal", "plan_name": "400110", "standard_charge_dollar": 18.04, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Federal", "plan_name": "400110_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." } ] } ] }, { "description": "Papaverine 30 mg/ml injection solution [6030]", "drug_information": { "unit": 2.00, "type": "ML" }, "code_information": [ { "code": "J2440", "type": "HCPCS" }, { "code": "14789-121-05", "type": "NDC" } ], "standard_charges": [ { "gross_charge": 356.91, "minimum": 285.53, "maximum": 303.37, "setting": "both", "payers_information": [ { "payer_name": "Aetna", "plan_name": "700700", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna", "plan_name": "700700_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Miscellaneous", "plan_name": "700720", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Miscellaneous", "plan_name": "700720_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Ppo Hmo", "plan_name": "701720", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Ppo Hmo", "plan_name": "701720_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Ms State Emplo", "plan_name": "401457", "standard_charge_percentage": 0.80, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Ms State Emplo", "plan_name": "401457_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Basic Pl", "plan_name": "400100", "standard_charge_percentage": 0.85, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Basic Pl", "plan_name": "400100_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Federal", "plan_name": "400110", "standard_charge_percentage": 0.85, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Federal", "plan_name": "400110_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." } ] } ] }, { "description": "Papaverine 30 mg/ml injection solution [6030]", "drug_information": { "unit": 2.00, "type": "ML" }, "code_information": [ { "code": "J2440", "type": "HCPCS" }, { "code": "14789-121-07", "type": "NDC" } ], "standard_charges": [ { "gross_charge": 356.91, "minimum": 285.53, "maximum": 303.37, "setting": "both", "payers_information": [ { "payer_name": "Aetna", "plan_name": "700700", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna", "plan_name": "700700_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Miscellaneous", "plan_name": "700720", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Miscellaneous", "plan_name": "700720_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Ppo Hmo", "plan_name": "701720", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Ppo Hmo", "plan_name": "701720_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Ms State Emplo", "plan_name": "401457", "standard_charge_percentage": 0.80, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Ms State Emplo", "plan_name": "401457_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Basic Pl", "plan_name": "400100", "standard_charge_percentage": 0.85, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Basic Pl", "plan_name": "400100_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Federal", "plan_name": "400110", "standard_charge_percentage": 0.85, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Federal", "plan_name": "400110_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." } ] } ] }, { "description": "Pantoprazole 40 mg intravenous solution [26226]", "drug_information": { "unit": 1.00, "type": "EA" }, "code_information": [ { "code": "J2470", "type": "HCPCS" }, { "code": "55150-202-00", "type": "NDC" } ], "standard_charges": [ { "gross_charge": 32.50, "minimum": 26.00, "maximum": 27.63, "setting": "both", "payers_information": [ { "payer_name": "Aetna", "plan_name": "700700", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna", "plan_name": "700700_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Miscellaneous", "plan_name": "700720", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Miscellaneous", "plan_name": "700720_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Ppo Hmo", "plan_name": "701720", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Ppo Hmo", "plan_name": "701720_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Ms State Emplo", "plan_name": "401457", 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"standard_charge_percentage": 0.85, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Federal", "plan_name": "400110_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." } ] } ] }, { "description": "Pantoprazole 40 mg intravenous solution [26226]", "drug_information": { "unit": 1.00, "type": "EA" }, "code_information": [ { "code": "J2470", "type": "HCPCS" }, { "code": "55150-202-10", "type": "NDC" } ], "standard_charges": [ { "gross_charge": 32.50, "minimum": 26.00, "maximum": 27.63, "setting": "both", "payers_information": [ { "payer_name": "Aetna", "plan_name": "700700", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to 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"additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Ambetter 68069", "plan_name": "500516", "standard_charge_dollar": 19.98, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Ms State Emplo", "plan_name": "401457", "standard_charge_percentage": 0.80, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Ms State Emplo", "plan_name": "401457_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Basic Pl", "plan_name": "400100", "standard_charge_percentage": 0.85, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Basic Pl", "plan_name": "400100_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Federal", "plan_name": "400110", "standard_charge_percentage": 0.85, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Federal", "plan_name": "400110_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Cigna Healthsprings Ffs", "plan_name": "500064", "standard_charge_dollar": 19.98, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit 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19.98, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Medicare Railroad", "plan_name": "100103", "standard_charge_dollar": 19.98, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Ms Physicians Care N", "plan_name": "714210", "standard_charge_dollar": 24.98, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Peoples Hlth Ffs 72126", "plan_name": "500019", "standard_charge_dollar": 19.98, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Uhc/Secure Horizons", "plan_name": "500449", "standard_charge_dollar": 19.98, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit 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"standard_charge_dollar": 19.98, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." } ] } ] }, { "description": "Penicillin g potassium 20 million unit solution for injection [6085]", "drug_information": { "unit": 1.00, "type": "EA" }, "code_information": [ { "code": "J2540", "type": "HCPCS" }, { "code": "70860-127-51", "type": "NDC" } ], "standard_charges": [ { "gross_charge": 539.75, "minimum": 431.80, "maximum": 458.79, "setting": "both", "payers_information": [ { "payer_name": "Aetna", "plan_name": "700700", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna", "plan_name": "700700_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate 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{ "payer_name": "Bc/Bs Of Ms Federal", "plan_name": "400110", "standard_charge_percentage": 0.85, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Federal", "plan_name": "400110_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." } ] } ] }, { "description": "Penicillin g (potassium) iv syringe 50000 units/ml (ped) swmc [5000784]", "drug_information": { "unit": 1.00, "type": "ML" }, "code_information": [ { "code": "J2540", "type": "HCPCS" }, { "code": "9999-0006-63", "type": "NDC" } ], "standard_charges": [ { "gross_charge": 11.00, "minimum": 8.80, "maximum": 9.35, "setting": "both", "payers_information": [ { "payer_name": "Aetna", "plan_name": "700700", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent 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"standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." } ] } ] }, { "description": "Piperacillin-tazobactam 3.375 gram intravenous solution [18303]", "drug_information": { "unit": 1.00, "type": "EA" }, "code_information": [ { "code": "J2543", "type": "HCPCS" }, { "code": "0781-3113-90", "type": "NDC" } ], "standard_charges": [ { "gross_charge": 48.59, "minimum": 38.87, "maximum": 41.30, "setting": "both", "payers_information": [ { "payer_name": "Aetna", "plan_name": "700700", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna", "plan_name": "700700_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to 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"standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." } ] } ] }, { "description": "Desmopressin 4 mcg/ml injection solution [9748]", "drug_information": { "unit": 1.00, "type": "ML" }, "code_information": [ { "code": "J2597", "type": "HCPCS" }, { "code": "69918-899-01", "type": "NDC" } ], "standard_charges": [ { "gross_charge": 359.20, "minimum": 4.49, "maximum": 7.94, "setting": "both", "payers_information": [ { "payer_name": "Aarp", "plan_name": "500102", "standard_charge_dollar": 4.49, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna", "plan_name": "700700", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna", "plan_name": "700700_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Mcare Ffs 6005", "plan_name": "700703", "standard_charge_dollar": 4.49, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Miscellaneous", "plan_name": "700720", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Miscellaneous", "plan_name": "700720_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Ppo Hmo", "plan_name": "701720", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Ppo Hmo", "plan_name": "701720_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Ambetter 68069", "plan_name": "500516", "standard_charge_dollar": 4.49, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Ms State Emplo", "plan_name": "401457", "standard_charge_dollar": 7.94, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Ms State Emplo", "plan_name": "401457_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Basic Pl", "plan_name": "400100", "standard_charge_dollar": 7.94, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Basic Pl", "plan_name": "400100_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Federal", "plan_name": "400110", "standard_charge_dollar": 7.94, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Federal", "plan_name": "400110_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total 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"fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Uhc/Secure Horizons", "plan_name": "500449", "standard_charge_dollar": 4.49, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "United Health Care/", "plan_name": "500292", "standard_charge_dollar": 5.07, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "United Healthcare", "plan_name": "750104", "standard_charge_dollar": 5.07, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "United Healthcare Ba", "plan_name": "750090", "standard_charge_dollar": 5.07, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "United Healthcare Me", "plan_name": "501310", "standard_charge_dollar": 4.49, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Windsor Mcare Extra", "plan_name": "500778", "standard_charge_dollar": 4.49, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." } ] } ] }, { "description": "Desmopressin 4 mcg/ml injection solution [9748]", "drug_information": { "unit": 1.00, "type": "ML" }, "code_information": [ { "code": "J2597", "type": "HCPCS" }, { "code": "69918-899-10", "type": "NDC" } ], "standard_charges": [ { "gross_charge": 359.20, "minimum": 4.49, "maximum": 7.94, "setting": "both", "payers_information": [ { "payer_name": "Aarp", "plan_name": "500102", "standard_charge_dollar": 4.49, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna", "plan_name": "700700", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna", "plan_name": "700700_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Mcare Ffs 6005", "plan_name": "700703", "standard_charge_dollar": 4.49, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Miscellaneous", "plan_name": "700720", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Miscellaneous", "plan_name": "700720_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Ppo Hmo", "plan_name": "701720", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Ppo Hmo", "plan_name": "701720_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Ambetter 68069", "plan_name": "500516", "standard_charge_dollar": 4.49, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Ms State Emplo", "plan_name": "401457", "standard_charge_dollar": 7.94, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Ms State Emplo", "plan_name": "401457_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Basic Pl", "plan_name": "400100", "standard_charge_dollar": 7.94, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Basic Pl", "plan_name": "400100_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Federal", "plan_name": "400110", "standard_charge_dollar": 7.94, "count": "0", 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calculate allowed amounts." }, { "payer_name": "Medicare A", "plan_name": "100100", "standard_charge_dollar": 4.49, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Medicare A", "plan_name": "100500", "standard_charge_dollar": 4.49, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Medicare Part B Only", "plan_name": "100300", "standard_charge_dollar": 4.49, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Medicare Railroad", "plan_name": "100103", "standard_charge_dollar": 4.49, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Ms Physicians Care N", "plan_name": "714210", "standard_charge_dollar": 5.61, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Peoples Hlth Ffs 72126", "plan_name": "500019", "standard_charge_dollar": 4.49, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Uhc/Secure Horizons", "plan_name": "500449", "standard_charge_dollar": 4.49, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "United Health Care/", "plan_name": "500292", "standard_charge_dollar": 5.07, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "United Healthcare", "plan_name": "750104", "standard_charge_dollar": 5.07, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data 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"Aetna Miscellaneous", "plan_name": "700720", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Miscellaneous", "plan_name": "700720_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Ppo Hmo", "plan_name": "701720", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Ppo Hmo", "plan_name": "701720_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Ambetter 68069", "plan_name": "500516", "standard_charge_dollar": 4.49, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Ms State Emplo", "plan_name": "401457", "standard_charge_dollar": 7.94, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Ms State Emplo", "plan_name": "401457_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Basic Pl", "plan_name": "400100", "standard_charge_dollar": 7.94, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Basic Pl", "plan_name": "400100_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Federal", "plan_name": "400110", "standard_charge_dollar": 7.94, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Federal", "plan_name": "400110_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Cigna Healthsprings Ffs", "plan_name": "500064", "standard_charge_dollar": 4.49, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Conseco", "plan_name": "500302", "standard_charge_dollar": 4.49, "count": "0", "methodology": "fee schedule", "additional_payer_notes": 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"standard_charge_dollar": 4.49, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Ms Physicians Care N", "plan_name": "714210", "standard_charge_dollar": 5.61, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Peoples Hlth Ffs 72126", "plan_name": "500019", "standard_charge_dollar": 4.49, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Uhc/Secure Horizons", "plan_name": "500449", "standard_charge_dollar": 4.49, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "United Health Care/", "plan_name": "500292", "standard_charge_dollar": 5.07, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "United Healthcare", "plan_name": "750104", "standard_charge_dollar": 5.07, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "United Healthcare Ba", "plan_name": "750090", "standard_charge_dollar": 5.07, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "United Healthcare Me", "plan_name": "501310", "standard_charge_dollar": 4.49, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Windsor Mcare Extra", "plan_name": "500778", "standard_charge_dollar": 4.49, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." } ] } ] }, { "description": "Desmopressin 4 mcg/ml injection solution [9748]", "drug_information": { "unit": 10.00, "type": "ML" }, "code_information": [ { "code": "J2597", "type": "HCPCS" }, { "code": "70860-454-10", "type": "NDC" } ], "standard_charges": [ { "gross_charge": 3202.50, "minimum": 4.49, "maximum": 7.94, "setting": "both", "payers_information": [ { "payer_name": "Aarp", "plan_name": "500102", "standard_charge_dollar": 4.49, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna", "plan_name": "700700", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna", "plan_name": "700700_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Mcare Ffs 6005", "plan_name": "700703", "standard_charge_dollar": 4.49, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Miscellaneous", "plan_name": "700720", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Miscellaneous", "plan_name": "700720_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Ppo Hmo", "plan_name": "701720", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Ppo Hmo", "plan_name": "701720_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Ambetter 68069", "plan_name": "500516", "standard_charge_dollar": 4.49, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Ms State Emplo", "plan_name": "401457", "standard_charge_dollar": 7.94, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Ms State Emplo", "plan_name": "401457_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Basic Pl", "plan_name": "400100", "standard_charge_dollar": 7.94, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Basic Pl", "plan_name": "400100_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Federal", "plan_name": "400110", "standard_charge_dollar": 7.94, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Federal", "plan_name": "400110_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Cigna Healthsprings Ffs", "plan_name": "500064", "standard_charge_dollar": 4.49, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Conseco", "plan_name": "500302", "standard_charge_dollar": 4.49, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Humana Ffs 61101", "plan_name": "500006", "standard_charge_dollar": 4.49, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Medicare A", "plan_name": "100100", "standard_charge_dollar": 4.49, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Medicare A", "plan_name": "100500", "standard_charge_dollar": 4.49, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Medicare Part B Only", "plan_name": "100300", "standard_charge_dollar": 4.49, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Medicare Railroad", "plan_name": "100103", "standard_charge_dollar": 4.49, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Ms Physicians Care N", "plan_name": "714210", "standard_charge_dollar": 5.61, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Peoples Hlth Ffs 72126", "plan_name": "500019", "standard_charge_dollar": 4.49, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Uhc/Secure Horizons", "plan_name": "500449", "standard_charge_dollar": 4.49, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "United Health Care/", "plan_name": "500292", "standard_charge_dollar": 5.07, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "United Healthcare", "plan_name": "750104", "standard_charge_dollar": 5.07, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "United Healthcare Ba", "plan_name": "750090", "standard_charge_dollar": 5.07, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "United Healthcare Me", "plan_name": "501310", "standard_charge_dollar": 4.49, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Windsor Mcare Extra", "plan_name": "500778", "standard_charge_dollar": 4.49, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." } ] } ] }, { "description": "Desmopressin 4 mcg/ml injection solution [9748]", "drug_information": { "unit": 1.00, "type": "ML" }, "code_information": [ { "code": "J2597", "type": "HCPCS" }, { "code": "43598-931-09", "type": "NDC" } ], "standard_charges": [ { "gross_charge": 359.20, "minimum": 4.49, "maximum": 7.94, "setting": "both", "payers_information": [ { "payer_name": "Aarp", "plan_name": "500102", "standard_charge_dollar": 4.49, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna", "plan_name": "700700", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit 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"payer_name": "Aetna Ppo Hmo", "plan_name": "701720", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Ppo Hmo", "plan_name": "701720_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Ambetter 68069", "plan_name": "500516", "standard_charge_dollar": 4.49, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Ms State Emplo", "plan_name": "401457", "standard_charge_dollar": 7.94, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Ms State Emplo", "plan_name": "401457_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Basic Pl", "plan_name": "400100", "standard_charge_dollar": 7.94, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Basic Pl", "plan_name": "400100_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Federal", "plan_name": "400110", "standard_charge_dollar": 7.94, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Federal", "plan_name": "400110_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Cigna Healthsprings Ffs", "plan_name": "500064", "standard_charge_dollar": 4.49, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Conseco", "plan_name": "500302", "standard_charge_dollar": 4.49, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Humana Ffs 61101", "plan_name": "500006", "standard_charge_dollar": 4.49, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Medicare A", "plan_name": "100100", "standard_charge_dollar": 4.49, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed 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"count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Uhc/Secure Horizons", "plan_name": "500449", "standard_charge_dollar": 4.49, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "United Health Care/", "plan_name": "500292", "standard_charge_dollar": 5.07, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "United Healthcare", "plan_name": "750104", "standard_charge_dollar": 5.07, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "United Healthcare Ba", "plan_name": "750090", "standard_charge_dollar": 5.07, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "United Healthcare Me", "plan_name": "501310", "standard_charge_dollar": 4.49, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Windsor Mcare Extra", "plan_name": "500778", "standard_charge_dollar": 4.49, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." } ] } ] }, { "description": "Vasopressin 20 unit/ml intravenous solution [168205]", "drug_information": { "unit": 1.00, "type": "ML" }, "code_information": [ { "code": "J2598", "type": "HCPCS" }, { "code": "42023-164-01", "type": "NDC" } ], "standard_charges": [ { "gross_charge": 380.95, "minimum": 304.76, "maximum": 323.81, "setting": "both", "payers_information": [ { "payer_name": "Aetna", "plan_name": "700700", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", 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"Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Basic Pl", "plan_name": "400100_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Federal", "plan_name": "400110", "standard_charge_percentage": 0.85, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Federal", "plan_name": "400110_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." } ] } ] }, { "description": "Vasopressin 20 unit/ml intravenous solution [168205]", "drug_information": { "unit": 1.00, "type": "ML" }, "code_information": [ { "code": "J2598", "type": "HCPCS" }, 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"0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Ppo Hmo", "plan_name": "701720", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Ppo Hmo", "plan_name": "701720_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Ms State Emplo", "plan_name": "401457", "standard_charge_percentage": 0.80, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Ms State Emplo", "plan_name": "401457_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Basic Pl", "plan_name": "400100", "standard_charge_percentage": 0.85, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Basic Pl", "plan_name": "400100_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Federal", "plan_name": "400110", "standard_charge_percentage": 0.85, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Federal", "plan_name": "400110_1", "standard_charge_percentage": 100.0, "count": "0", 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"plan_name": "401457", "standard_charge_percentage": 0.80, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Ms State Emplo", "plan_name": "401457_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Basic Pl", "plan_name": "400100", "standard_charge_percentage": 0.85, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Basic Pl", "plan_name": "400100_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Federal", "plan_name": "400110", "standard_charge_percentage": 0.85, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Federal", "plan_name": "400110_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." } ] } ] }, { "description": "Vasopressin 20 unit/ml intravenous solution [168205]", "drug_information": { "unit": 1.00, "type": "ML" }, "code_information": [ { "code": "J2598", "type": "HCPCS" }, { "code": "55150-370-01", "type": "NDC" } ], "standard_charges": [ { "gross_charge": 405.00, "minimum": 324.00, "maximum": 344.25, "setting": "both", "payers_information": [ { "payer_name": "Aetna", "plan_name": "700700", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": 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calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Basic Pl", "plan_name": "400100_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Federal", "plan_name": "400110", "standard_charge_percentage": 0.85, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Federal", "plan_name": "400110_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." } ] } ] }, { "description": "Vasopressin 20 unit/ml intravenous solution [168205]", "drug_information": { "unit": 1.00, "type": "ML" }, "code_information": [ { "code": "J2598", "type": "HCPCS" }, { "code": "63323-930-00", 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"700720", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Miscellaneous", "plan_name": "700720_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Ppo Hmo", "plan_name": "701720", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Ppo Hmo", "plan_name": "701720_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Ms State Emplo", "plan_name": "401457", "standard_charge_percentage": 0.80, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Ms State Emplo", "plan_name": "401457_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Basic Pl", "plan_name": "400100", "standard_charge_percentage": 0.85, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Basic Pl", "plan_name": "400100_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Federal", "plan_name": "400110", "standard_charge_percentage": 0.85, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Federal", "plan_name": "400110_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." } ] } ] }, { "description": "Vasopressin 20 unit/ml intravenous solution [168205]", "drug_information": { "unit": 1.00, "type": "ML" }, "code_information": [ { "code": "J2598", "type": "HCPCS" }, { "code": "0517-1020-01", "type": "NDC" } ], "standard_charges": [ { "gross_charge": 235.15, "minimum": 188.12, "maximum": 199.88, "setting": "both", "payers_information": [ { "payer_name": "Aetna", "plan_name": "700700", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna", "plan_name": "700700_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Miscellaneous", "plan_name": "700720", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Miscellaneous", "plan_name": "700720_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Ppo Hmo", "plan_name": "701720", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Ppo Hmo", "plan_name": "701720_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Ms State Emplo", "plan_name": "401457", "standard_charge_percentage": 0.80, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Ms State Emplo", "plan_name": "401457_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Basic Pl", "plan_name": "400100", "standard_charge_percentage": 0.85, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Basic Pl", "plan_name": "400100_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Federal", "plan_name": "400110", "standard_charge_percentage": 0.85, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Federal", "plan_name": "400110_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." } ] } ] }, { "description": "Progesterone 50 mg/ml intramuscular oil [6597]", "drug_information": { "unit": 10.00, "type": "ML" }, "code_information": [ { "code": "J2675", "type": "HCPCS" }, { "code": "0143-9725-01", "type": "NDC" } ], 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charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Ppo Hmo", "plan_name": "701720", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Ppo Hmo", "plan_name": "701720_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Ms State Emplo", "plan_name": "401457", "standard_charge_percentage": 0.80, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Ms State Emplo", "plan_name": "401457_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Basic Pl", "plan_name": "400100", "standard_charge_percentage": 0.85, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Basic Pl", "plan_name": "400100_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Federal", "plan_name": "400110", "standard_charge_percentage": 0.85, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Federal", "plan_name": "400110_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." } ] } ] }, { "description": "Procainamide 500 mg/ml injection solution [6563]", "drug_information": { "unit": 2.00, "type": "ML" }, "code_information": [ { "code": "J2690", "type": "HCPCS" }, { "code": "0409-1903-01", "type": "NDC" } ], "standard_charges": [ { "gross_charge": 363.81, "minimum": 284.34, "maximum": 355.43, "setting": "both", "payers_information": [ { "payer_name": "Aarp", "plan_name": "500102", "standard_charge_dollar": 284.34, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna", "plan_name": "700700", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna", "plan_name": "700700_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Mcare Ffs 6005", "plan_name": "700703", "standard_charge_dollar": 284.34, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Miscellaneous", "plan_name": "700720", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Miscellaneous", "plan_name": "700720_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Ppo Hmo", "plan_name": "701720", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Ppo Hmo", "plan_name": "701720_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Ambetter 68069", "plan_name": "500516", "standard_charge_dollar": 284.34, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Ms State Emplo", "plan_name": "401457", "standard_charge_percentage": 0.80, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Ms State Emplo", "plan_name": "401457_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Basic Pl", "plan_name": "400100", "standard_charge_percentage": 0.85, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Basic Pl", "plan_name": "400100_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Federal", "plan_name": "400110", "standard_charge_percentage": 0.85, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Federal", "plan_name": "400110_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Cigna Healthsprings Ffs", "plan_name": "500064", "standard_charge_dollar": 284.34, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Conseco", "plan_name": "500302", "standard_charge_dollar": 284.34, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Humana Ffs 61101", "plan_name": "500006", "standard_charge_dollar": 284.34, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Medicare A", "plan_name": "100100", "standard_charge_dollar": 284.34, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Medicare A", "plan_name": "100500", "standard_charge_dollar": 284.34, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Medicare Part B Only", "plan_name": "100300", "standard_charge_dollar": 284.34, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Medicare Railroad", "plan_name": "100103", "standard_charge_dollar": 284.34, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Ms Physicians Care N", "plan_name": "714210", "standard_charge_dollar": 355.43, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Peoples Hlth Ffs 72126", "plan_name": "500019", "standard_charge_dollar": 284.34, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Uhc/Secure Horizons", "plan_name": "500449", "standard_charge_dollar": 284.34, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "United Health Care/", "plan_name": "500292", "standard_charge_dollar": 321.30, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "United Healthcare", "plan_name": "750104", "standard_charge_dollar": 321.30, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "United Healthcare Ba", "plan_name": "750090", "standard_charge_dollar": 321.30, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "United Healthcare Me", "plan_name": "501310", "standard_charge_dollar": 284.34, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Windsor Mcare Extra", "plan_name": "500778", "standard_charge_dollar": 284.34, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." } ] } ] }, { "description": "Procainamide 500 mg/ml injection solution [6563]", "drug_information": { "unit": 2.00, "type": "ML" }, "code_information": [ { "code": "J2690", "type": "HCPCS" }, { "code": "14789-900-02", "type": "NDC" } ], "standard_charges": [ { "gross_charge": 3000.30, "minimum": 284.34, "maximum": 2550.26, "setting": "both", "payers_information": [ { "payer_name": "Aarp", "plan_name": "500102", "standard_charge_dollar": 284.34, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna", "plan_name": "700700", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna", "plan_name": "700700_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Mcare Ffs 6005", "plan_name": "700703", "standard_charge_dollar": 284.34, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Miscellaneous", "plan_name": "700720", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Miscellaneous", "plan_name": "700720_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Ppo Hmo", "plan_name": "701720", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Ppo Hmo", "plan_name": "701720_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Ambetter 68069", "plan_name": "500516", "standard_charge_dollar": 284.34, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Ms State Emplo", "plan_name": "401457", "standard_charge_percentage": 0.80, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Ms State Emplo", "plan_name": "401457_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Basic Pl", "plan_name": "400100", "standard_charge_percentage": 0.85, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Basic Pl", "plan_name": "400100_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Federal", "plan_name": "400110", "standard_charge_percentage": 0.85, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Federal", "plan_name": "400110_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Cigna Healthsprings Ffs", "plan_name": "500064", "standard_charge_dollar": 284.34, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Conseco", "plan_name": "500302", "standard_charge_dollar": 284.34, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Humana Ffs 61101", "plan_name": "500006", "standard_charge_dollar": 284.34, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Medicare A", "plan_name": "100100", "standard_charge_dollar": 284.34, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Medicare A", "plan_name": "100500", "standard_charge_dollar": 284.34, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Medicare Part B Only", "plan_name": "100300", "standard_charge_dollar": 284.34, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Medicare Railroad", "plan_name": "100103", "standard_charge_dollar": 284.34, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Ms Physicians Care N", "plan_name": "714210", "standard_charge_dollar": 355.43, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Peoples Hlth Ffs 72126", "plan_name": "500019", "standard_charge_dollar": 284.34, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Uhc/Secure Horizons", "plan_name": "500449", "standard_charge_dollar": 284.34, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "United Health Care/", "plan_name": "500292", "standard_charge_dollar": 321.30, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "United Healthcare", "plan_name": "750104", "standard_charge_dollar": 321.30, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "United Healthcare Ba", "plan_name": "750090", "standard_charge_dollar": 321.30, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "United Healthcare Me", "plan_name": "501310", "standard_charge_dollar": 284.34, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Windsor Mcare Extra", "plan_name": "500778", "standard_charge_dollar": 284.34, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." } ] } ] }, { "description": "Procainamide 500 mg/ml injection solution [6563]", "drug_information": { "unit": 2.00, "type": "ML" }, "code_information": [ { "code": "J2690", "type": "HCPCS" }, { "code": "14789-900-07", "type": "NDC" } ], "standard_charges": [ { "gross_charge": 3000.30, "minimum": 284.34, "maximum": 2550.26, "setting": "both", "payers_information": [ { "payer_name": "Aarp", "plan_name": "500102", "standard_charge_dollar": 284.34, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna", "plan_name": "700700", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna", "plan_name": "700700_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Mcare Ffs 6005", "plan_name": "700703", "standard_charge_dollar": 284.34, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Miscellaneous", "plan_name": "700720", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Miscellaneous", "plan_name": "700720_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Ppo Hmo", "plan_name": "701720", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Ppo Hmo", "plan_name": "701720_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Ambetter 68069", "plan_name": "500516", "standard_charge_dollar": 284.34, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Ms State Emplo", "plan_name": "401457", "standard_charge_percentage": 0.80, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Ms State Emplo", "plan_name": "401457_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Basic Pl", "plan_name": "400100", "standard_charge_percentage": 0.85, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Basic Pl", "plan_name": "400100_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Federal", "plan_name": "400110", "standard_charge_percentage": 0.85, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Federal", "plan_name": "400110_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Cigna Healthsprings Ffs", "plan_name": "500064", "standard_charge_dollar": 284.34, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Conseco", "plan_name": "500302", "standard_charge_dollar": 284.34, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Humana Ffs 61101", "plan_name": "500006", "standard_charge_dollar": 284.34, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Medicare A", "plan_name": "100100", "standard_charge_dollar": 284.34, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Medicare A", "plan_name": "100500", "standard_charge_dollar": 284.34, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Medicare Part B Only", "plan_name": "100300", "standard_charge_dollar": 284.34, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Medicare Railroad", "plan_name": "100103", "standard_charge_dollar": 284.34, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Ms Physicians Care N", "plan_name": "714210", "standard_charge_dollar": 355.43, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Peoples Hlth Ffs 72126", "plan_name": "500019", "standard_charge_dollar": 284.34, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Uhc/Secure Horizons", "plan_name": "500449", "standard_charge_dollar": 284.34, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "United Health Care/", "plan_name": "500292", "standard_charge_dollar": 321.30, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "United Healthcare", "plan_name": "750104", "standard_charge_dollar": 321.30, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "United Healthcare Ba", "plan_name": "750090", "standard_charge_dollar": 321.30, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "United Healthcare Me", "plan_name": "501310", "standard_charge_dollar": 284.34, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Windsor Mcare Extra", "plan_name": "500778", "standard_charge_dollar": 284.34, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." } ] } ] }, { "description": "Oxacillin 2 gram solution for injection [5926]", "drug_information": { "unit": 1.00, "type": "EA" }, "code_information": [ { "code": "J2700", "type": "HCPCS" }, { "code": "25021-162-24", "type": "NDC" } ], "standard_charges": [ { "gross_charge": 112.50, "minimum": 2.92, "maximum": 2.92, "setting": "both", "payers_information": [ { "payer_name": "Aetna", "plan_name": "700700", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna", "plan_name": "700700_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Miscellaneous", "plan_name": "700720", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Miscellaneous", "plan_name": "700720_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Ppo Hmo", "plan_name": "701720", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Ppo Hmo", "plan_name": "701720_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Ms State Emplo", "plan_name": "401457", "standard_charge_dollar": 2.92, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Ms State Emplo", "plan_name": "401457_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Basic Pl", "plan_name": "400100", "standard_charge_dollar": 2.92, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Basic Pl", "plan_name": "400100_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Federal", "plan_name": "400110", "standard_charge_dollar": 2.92, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Federal", "plan_name": "400110_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." } ] } ] }, { "description": "Propofol 10 mg/ml intravenous emulsion [11150]", "drug_information": { "unit": 100.00, "type": "ML" }, "code_information": [ { "code": "J2704", "type": "HCPCS" }, { "code": "0409-4699-24", "type": "NDC" } ], "standard_charges": [ { "gross_charge": 370.61, "minimum": 0.11, "maximum": 0.11, "setting": "both", "payers_information": [ { "payer_name": "Aetna", "plan_name": "700700", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna", "plan_name": "700700_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Miscellaneous", "plan_name": "700720", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Miscellaneous", "plan_name": "700720_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Ppo Hmo", "plan_name": "701720", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Ppo Hmo", "plan_name": "701720_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Ms State Emplo", "plan_name": "401457", "standard_charge_dollar": 0.11, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Ms State Emplo", "plan_name": "401457_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Basic Pl", "plan_name": "400100", "standard_charge_dollar": 0.11, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Basic Pl", "plan_name": "400100_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Federal", "plan_name": "400110", "standard_charge_dollar": 0.11, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Federal", "plan_name": "400110_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." } ] } ] }, { "description": "Propofol infusion 1000 mg/100 ml [40840026]", "drug_information": { "unit": 100.00, "type": "ML" }, "code_information": [ { "code": "J2704", "type": "HCPCS" }, { "code": "0409-4699-24", "type": "NDC" } ], "standard_charges": [ { "gross_charge": 370.61, "minimum": 0.11, "maximum": 0.11, "setting": "both", "payers_information": [ { "payer_name": "Aetna", "plan_name": "700700", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna", "plan_name": "700700_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Miscellaneous", "plan_name": "700720", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Miscellaneous", "plan_name": "700720_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Ppo Hmo", "plan_name": "701720", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Ppo Hmo", "plan_name": "701720_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Ms State Emplo", "plan_name": "401457", "standard_charge_dollar": 0.11, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Ms State Emplo", "plan_name": "401457_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Basic Pl", "plan_name": "400100", "standard_charge_dollar": 0.11, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Basic Pl", "plan_name": "400100_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Federal", "plan_name": "400110", "standard_charge_dollar": 0.11, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Federal", "plan_name": "400110_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." } ] } ] }, { "description": "Propofol 10 mg/ml intravenous emulsion [11150]", "drug_information": { "unit": 20.00, "type": "ML" }, "code_information": [ { "code": "J2704", "type": "HCPCS" }, { "code": "0409-4699-50", "type": "NDC" } ], "standard_charges": [ { "gross_charge": 21.60, "minimum": 0.11, "maximum": 0.11, "setting": "both", "payers_information": [ { "payer_name": "Aetna", "plan_name": "700700", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna", "plan_name": "700700_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Miscellaneous", "plan_name": "700720", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Miscellaneous", "plan_name": "700720_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Ppo Hmo", "plan_name": "701720", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Ppo Hmo", "plan_name": "701720_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Ms State Emplo", "plan_name": "401457", "standard_charge_dollar": 0.11, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Ms State Emplo", "plan_name": "401457_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Basic Pl", "plan_name": "400100", "standard_charge_dollar": 0.11, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Basic Pl", "plan_name": "400100_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Federal", "plan_name": "400110", "standard_charge_dollar": 0.11, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Federal", "plan_name": "400110_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." } ] } ] }, { "description": "Propofol infusion 1000 mg/100 ml [40840026]", "drug_information": { "unit": 20.00, "type": "ML" }, "code_information": [ { "code": "J2704", "type": "HCPCS" }, { "code": "0409-4699-50", "type": "NDC" } ], "standard_charges": [ { "gross_charge": 21.60, "minimum": 0.11, "maximum": 0.11, "setting": "both", "payers_information": [ { "payer_name": "Aetna", "plan_name": "700700", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna", "plan_name": "700700_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Miscellaneous", "plan_name": "700720", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Miscellaneous", "plan_name": "700720_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Ppo Hmo", "plan_name": "701720", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Ppo Hmo", "plan_name": "701720_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Ms State Emplo", "plan_name": "401457", "standard_charge_dollar": 0.11, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Ms State Emplo", "plan_name": "401457_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Basic Pl", "plan_name": "400100", "standard_charge_dollar": 0.11, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Basic Pl", "plan_name": "400100_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Federal", "plan_name": "400110", "standard_charge_dollar": 0.11, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Federal", "plan_name": "400110_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." } ] } ] }, { "description": "Propofol 10 mg/ml intravenous emulsion [11150]", "drug_information": { "unit": 100.00, "type": "ML" }, "code_information": [ { "code": "J2704", "type": "HCPCS" }, { "code": "0409-4699-54", "type": "NDC" } ], "standard_charges": [ { "gross_charge": 370.61, "minimum": 0.11, "maximum": 0.11, "setting": "both", "payers_information": [ { "payer_name": "Aetna", "plan_name": "700700", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna", "plan_name": "700700_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Miscellaneous", "plan_name": "700720", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Miscellaneous", "plan_name": "700720_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Ppo Hmo", "plan_name": "701720", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Ppo Hmo", "plan_name": "701720_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Ms State Emplo", "plan_name": "401457", "standard_charge_dollar": 0.11, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Ms State Emplo", "plan_name": "401457_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Basic Pl", "plan_name": "400100", "standard_charge_dollar": 0.11, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Basic Pl", "plan_name": "400100_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Federal", "plan_name": "400110", "standard_charge_dollar": 0.11, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Federal", "plan_name": "400110_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." } ] } ] }, { "description": "Propofol infusion 1000 mg/100 ml [40840026]", "drug_information": { "unit": 100.00, "type": "ML" }, "code_information": [ { "code": "J2704", "type": "HCPCS" }, { "code": "0409-4699-54", "type": "NDC" } ], "standard_charges": [ { "gross_charge": 370.61, "minimum": 0.11, "maximum": 0.11, 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"payer_name": "Bc/Bs Ms State Emplo", "plan_name": "401457", "standard_charge_dollar": 0.11, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Ms State Emplo", "plan_name": "401457_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Basic Pl", "plan_name": "400100", "standard_charge_dollar": 0.11, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Basic Pl", "plan_name": "400100_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Federal", "plan_name": "400110", "standard_charge_dollar": 0.11, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Federal", "plan_name": "400110_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." } ] } ] }, { "description": "Propofol 10 mg/ml intravenous emulsion [11150]", "drug_information": { "unit": 20.00, "type": "ML" }, "code_information": [ { "code": "J2704", "type": "HCPCS" }, { "code": "0409-6010-25", "type": "NDC" } ], "standard_charges": [ { "gross_charge": 43.20, "minimum": 0.11, "maximum": 0.11, "setting": "both", "payers_information": [ { "payer_name": "Aetna", "plan_name": "700700", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to 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"plan_name": "400100_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Federal", "plan_name": "400110", "standard_charge_dollar": 0.11, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Federal", "plan_name": "400110_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." } ] } ] }, { "description": "Propofol infusion 1000 mg/100 ml [40840026]", "drug_information": { "unit": 20.00, "type": "ML" }, "code_information": [ { "code": "J2704", "type": "HCPCS" }, { "code": "0409-6010-25", "type": "NDC" } ], "standard_charges": [ { "gross_charge": 43.20, "minimum": 0.11, "maximum": 0.11, 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amounts." }, { "payer_name": "Bc/Bs Of Ms Federal", "plan_name": "400110_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." } ] } ] }, { "description": "Neostigmine methylsulfate 1 mg/ml intravenous solution [163348]", "drug_information": { "unit": 10.00, "type": "ML" }, "code_information": [ { "code": "J2710", "type": "HCPCS" }, { "code": "76014-003-10", "type": "NDC" } ], "standard_charges": [ { "gross_charge": 91.80, "minimum": 73.44, "maximum": 78.03, "setting": "both", "payers_information": [ { "payer_name": "Aetna", "plan_name": "700700", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna", "plan_name": "700700_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Miscellaneous", "plan_name": "700720", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Miscellaneous", "plan_name": "700720_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Ppo Hmo", "plan_name": "701720", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Ppo Hmo", "plan_name": "701720_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Ms State Emplo", "plan_name": "401457", "standard_charge_percentage": 0.80, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Ms State Emplo", "plan_name": "401457_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Basic Pl", "plan_name": "400100", "standard_charge_percentage": 0.85, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Basic Pl", "plan_name": "400100_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Federal", "plan_name": "400110", "standard_charge_percentage": 0.85, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Federal", "plan_name": "400110_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." } ] } ] }, { "description": "Neostigmine methylsulfate 1 mg/ml intravenous solution [163348]", "drug_information": { "unit": 10.00, "type": "ML" }, "code_information": [ { "code": "J2710", "type": "HCPCS" }, { "code": "76014-003-33", "type": "NDC" } ], "standard_charges": [ { "gross_charge": 91.80, "minimum": 73.44, "maximum": 78.03, "setting": "both", "payers_information": [ { "payer_name": "Aetna", "plan_name": "700700", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna", "plan_name": "700700_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Miscellaneous", "plan_name": "700720", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Miscellaneous", "plan_name": "700720_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Ppo Hmo", "plan_name": "701720", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Ppo Hmo", "plan_name": "701720_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Ms State Emplo", "plan_name": "401457", "standard_charge_percentage": 0.80, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Ms State Emplo", "plan_name": "401457_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Basic Pl", "plan_name": "400100", "standard_charge_percentage": 0.85, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Basic Pl", "plan_name": "400100_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Federal", "plan_name": "400110", "standard_charge_percentage": 0.85, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Federal", "plan_name": "400110_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." } ] } ] }, { "description": "Protamine 10 mg/ml intravenous solution [6677]", "drug_information": { "unit": 5.00, "type": "ML" }, "code_information": [ { "code": "J2720", "type": "HCPCS" }, { "code": "63323-229-05", "type": "NDC" } ], "standard_charges": [ { "gross_charge": 78.05, "minimum": 62.44, "maximum": 66.34, "setting": "both", "payers_information": [ { "payer_name": "Aetna", "plan_name": "700700", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna", "plan_name": "700700_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Miscellaneous", "plan_name": "700720", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Miscellaneous", "plan_name": "700720_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Ppo Hmo", "plan_name": "701720", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Ppo Hmo", "plan_name": "701720_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Ms State Emplo", "plan_name": "401457", "standard_charge_percentage": 0.80, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Ms State Emplo", "plan_name": "401457_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Basic Pl", "plan_name": "400100", "standard_charge_percentage": 0.85, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Basic Pl", "plan_name": "400100_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Federal", "plan_name": "400110", "standard_charge_percentage": 0.85, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Federal", "plan_name": "400110_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." } ] } ] }, { "description": "Protamine 10 mg/ml intravenous solution [6677]", "drug_information": { "unit": 25.00, "type": "ML" }, "code_information": [ { "code": "J2720", "type": "HCPCS" }, { "code": "63323-229-30", "type": "NDC" } ], "standard_charges": [ { "gross_charge": 266.75, "minimum": 213.40, "maximum": 226.74, "setting": "both", "payers_information": [ { "payer_name": "Aetna", "plan_name": "700700", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna", "plan_name": "700700_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Miscellaneous", "plan_name": "700720", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Miscellaneous", "plan_name": "700720_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Ppo Hmo", "plan_name": "701720", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Ppo Hmo", "plan_name": "701720_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Ms State Emplo", "plan_name": "401457", "standard_charge_percentage": 0.80, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Ms State Emplo", "plan_name": "401457_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Basic Pl", "plan_name": "400100", "standard_charge_percentage": 0.85, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Basic Pl", "plan_name": "400100_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Federal", "plan_name": "400110", "standard_charge_percentage": 0.85, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Federal", "plan_name": "400110_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." } ] } ] }, { "description": "Pralidoxime 1 gram solution for injection [6462]", "drug_information": { "unit": 1.00, "type": "EA" }, "code_information": [ { "code": "J2730", "type": "HCPCS" }, { "code": "60977-141-01", "type": "NDC" } ], "standard_charges": [ { "gross_charge": 407.75, "minimum": 83.23, "maximum": 83.23, "setting": "both", "payers_information": [ { "payer_name": "Aetna", "plan_name": "700700", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna", "plan_name": "700700_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Miscellaneous", "plan_name": "700720", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Miscellaneous", "plan_name": "700720_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Ppo Hmo", "plan_name": "701720", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Ppo Hmo", "plan_name": "701720_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Ms State Emplo", "plan_name": "401457", "standard_charge_dollar": 83.23, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Ms State Emplo", "plan_name": "401457_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Basic Pl", "plan_name": "400100", "standard_charge_dollar": 83.23, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Basic Pl", "plan_name": "400100_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Federal", "plan_name": "400110", "standard_charge_dollar": 83.23, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Federal", "plan_name": "400110_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." } ] } ] }, { "description": "Pralidoxime 1 gram solution for injection [6462]", "drug_information": { "unit": 1.00, "type": "EA" }, "code_information": [ { "code": "J2730", "type": "HCPCS" }, { "code": "60977-141-27", "type": "NDC" } ], "standard_charges": [ { "gross_charge": 407.75, "minimum": 83.23, "maximum": 83.23, "setting": "both", "payers_information": [ { "payer_name": "Aetna", "plan_name": "700700", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna", "plan_name": "700700_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Miscellaneous", "plan_name": "700720", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Miscellaneous", "plan_name": "700720_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Ppo Hmo", "plan_name": "701720", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Ppo Hmo", "plan_name": "701720_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Ms State Emplo", "plan_name": "401457", "standard_charge_dollar": 83.23, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Ms State Emplo", "plan_name": "401457_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Basic Pl", "plan_name": "400100", "standard_charge_dollar": 83.23, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Basic Pl", "plan_name": "400100_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Federal", "plan_name": "400110", "standard_charge_dollar": 83.23, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Federal", "plan_name": "400110_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." } ] } ] }, { "description": "Phentolamine 5 mg injection solution [10947]", "drug_information": { "unit": 1.00, "type": "EA" }, "code_information": [ { "code": "J2760", "type": "HCPCS" }, { "code": "68094-101-20", "type": "NDC" } ], "standard_charges": [ { "gross_charge": 2954.15, "minimum": 408.00, "maximum": 561.63, "setting": "both", "payers_information": [ { "payer_name": "Aarp", "plan_name": "500102", "standard_charge_dollar": 449.30, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna", "plan_name": "700700", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna", "plan_name": "700700_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Mcare Ffs 6005", "plan_name": "700703", "standard_charge_dollar": 449.30, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Miscellaneous", "plan_name": "700720", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Miscellaneous", "plan_name": "700720_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Ppo Hmo", "plan_name": "701720", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Ppo Hmo", "plan_name": "701720_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Ambetter 68069", "plan_name": "500516", "standard_charge_dollar": 449.30, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Ms State Emplo", "plan_name": "401457", "standard_charge_dollar": 408.00, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Ms State Emplo", "plan_name": "401457_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Basic Pl", "plan_name": "400100", "standard_charge_dollar": 408.00, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Basic Pl", "plan_name": "400100_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Federal", "plan_name": "400110", "standard_charge_dollar": 408.00, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Federal", "plan_name": "400110_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Cigna Healthsprings Ffs", "plan_name": "500064", "standard_charge_dollar": 449.30, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Conseco", "plan_name": "500302", "standard_charge_dollar": 449.30, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Humana Ffs 61101", "plan_name": "500006", "standard_charge_dollar": 449.30, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Medicare A", "plan_name": "100100", "standard_charge_dollar": 449.30, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Medicare A", "plan_name": "100500", "standard_charge_dollar": 449.30, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Medicare Part B Only", "plan_name": "100300", "standard_charge_dollar": 449.30, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Medicare Railroad", "plan_name": "100103", "standard_charge_dollar": 449.30, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Ms Physicians Care N", "plan_name": "714210", "standard_charge_dollar": 561.63, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Peoples Hlth Ffs 72126", "plan_name": "500019", "standard_charge_dollar": 449.30, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Uhc/Secure Horizons", "plan_name": "500449", "standard_charge_dollar": 449.30, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "United Health Care/", "plan_name": "500292", "standard_charge_dollar": 507.71, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "United Healthcare", "plan_name": "750104", "standard_charge_dollar": 507.71, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "United Healthcare Ba", "plan_name": "750090", "standard_charge_dollar": 507.71, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "United Healthcare Me", "plan_name": "501310", "standard_charge_dollar": 449.30, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Windsor Mcare Extra", "plan_name": "500778", "standard_charge_dollar": 449.30, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." } ] } ] }, { "description": "Metoclopramide 5 mg/ml injection solution [5002]", "drug_information": { "unit": 2.00, "type": "ML" }, "code_information": [ { "code": "J2765", "type": "HCPCS" }, { "code": "0409-3414-01", "type": "NDC" } ], "standard_charges": [ { "gross_charge": 14.83, "minimum": 11.86, "maximum": 12.61, "setting": "both", "payers_information": [ { "payer_name": "Aetna", "plan_name": "700700", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna", "plan_name": "700700_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Miscellaneous", "plan_name": "700720", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Miscellaneous", "plan_name": "700720_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Ppo Hmo", "plan_name": "701720", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Ppo Hmo", "plan_name": "701720_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Ms State Emplo", "plan_name": "401457", "standard_charge_percentage": 0.80, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Ms State Emplo", "plan_name": "401457_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Basic Pl", "plan_name": "400100", "standard_charge_percentage": 0.85, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Basic Pl", "plan_name": "400100_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Federal", "plan_name": "400110", "standard_charge_percentage": 0.85, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Federal", "plan_name": "400110_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." } ] } ] }, { "description": "Metoclopramide 5 mg/ml injection solution [5002]", "drug_information": { "unit": 2.00, "type": "ML" }, "code_information": [ { "code": "J2765", "type": "HCPCS" }, { "code": "0409-3414-11", "type": "NDC" } ], 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charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Ppo Hmo", "plan_name": "701720", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Ppo Hmo", "plan_name": "701720_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Ms State Emplo", "plan_name": "401457", "standard_charge_percentage": 0.80, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Ms State Emplo", "plan_name": "401457_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Basic Pl", "plan_name": "400100", "standard_charge_percentage": 0.85, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Basic Pl", "plan_name": "400100_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Federal", "plan_name": "400110", "standard_charge_percentage": 0.85, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Federal", "plan_name": "400110_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." } ] } ] }, { "description": "Metoclopramide 5 mg/ml injection solution [5002]", "drug_information": { "unit": 2.00, "type": "ML" }, "code_information": [ { "code": "J2765", "type": "HCPCS" }, { "code": "0409-3414-18", "type": "NDC" } ], "standard_charges": [ { "gross_charge": 14.83, "minimum": 11.86, "maximum": 12.61, "setting": "both", "payers_information": [ { "payer_name": "Aetna", "plan_name": "700700", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna", "plan_name": "700700_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Miscellaneous", "plan_name": "700720", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Miscellaneous", "plan_name": "700720_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Ppo Hmo", "plan_name": "701720", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Ppo Hmo", "plan_name": "701720_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Ms State Emplo", "plan_name": "401457", "standard_charge_percentage": 0.80, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Ms State Emplo", "plan_name": "401457_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Basic Pl", "plan_name": "400100", "standard_charge_percentage": 0.85, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Basic Pl", "plan_name": "400100_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Federal", "plan_name": "400110", "standard_charge_percentage": 0.85, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Federal", "plan_name": "400110_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." } ] } ] }, { "description": "Metoclopramide 5 mg/ml injection solution [5002]", "drug_information": { "unit": 2.00, "type": "ML" }, "code_information": [ { "code": "J2765", "type": "HCPCS" }, { "code": "0409-3414-21", "type": "NDC" } ], "standard_charges": [ { "gross_charge": 11.00, "minimum": 8.80, "maximum": 9.35, "setting": "both", "payers_information": [ { "payer_name": "Aetna", "plan_name": "700700", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna", "plan_name": "700700_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Miscellaneous", "plan_name": "700720", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Miscellaneous", "plan_name": "700720_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Ppo Hmo", "plan_name": "701720", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Ppo Hmo", "plan_name": "701720_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Ms State Emplo", "plan_name": "401457", "standard_charge_percentage": 0.80, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Ms State Emplo", "plan_name": "401457_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Basic Pl", "plan_name": "400100", "standard_charge_percentage": 0.85, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Basic Pl", "plan_name": "400100_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Federal", "plan_name": "400110", "standard_charge_percentage": 0.85, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Federal", "plan_name": "400110_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." } ] } ] }, { "description": "Rasburicase 1.5 mg intravenous solution [33591]", "drug_information": { "unit": 1.00, "type": "EA" }, "code_information": [ { "code": "J2783", "type": "HCPCS" }, { "code": "0024-5150-10", "type": "NDC" } ], 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data to calculate allowed amounts." }, { "payer_name": "Aetna Miscellaneous", "plan_name": "700720", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Miscellaneous", "plan_name": "700720_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Ppo Hmo", "plan_name": "701720", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Ppo Hmo", "plan_name": "701720_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Ambetter 68069", "plan_name": "500516", "standard_charge_dollar": 370.46, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Ms State Emplo", "plan_name": "401457", "standard_charge_dollar": 241.18, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Ms State Emplo", "plan_name": "401457_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Basic Pl", "plan_name": "400100", "standard_charge_dollar": 241.18, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Basic Pl", "plan_name": "400100_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Federal", "plan_name": "400110", "standard_charge_dollar": 241.18, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Federal", "plan_name": "400110_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Cigna Healthsprings Ffs", "plan_name": "500064", "standard_charge_dollar": 370.46, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Conseco", "plan_name": "500302", "standard_charge_dollar": 370.46, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Humana Ffs 61101", "plan_name": "500006", "standard_charge_dollar": 370.46, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Medicare A", "plan_name": "100100", "standard_charge_dollar": 370.46, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Medicare A", "plan_name": "100500", "standard_charge_dollar": 370.46, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Medicare Part B Only", "plan_name": "100300", "standard_charge_dollar": 370.46, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Medicare Railroad", "plan_name": "100103", "standard_charge_dollar": 370.46, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Ms Physicians Care N", "plan_name": "714210", "standard_charge_dollar": 463.08, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Peoples Hlth Ffs 72126", "plan_name": "500019", "standard_charge_dollar": 370.46, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Uhc/Secure Horizons", "plan_name": "500449", "standard_charge_dollar": 370.46, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "United Health Care/", "plan_name": "500292", "standard_charge_dollar": 418.62, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "United Healthcare", "plan_name": "750104", "standard_charge_dollar": 418.62, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "United Healthcare Ba", "plan_name": "750090", "standard_charge_dollar": 418.62, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "United Healthcare Me", "plan_name": "501310", "standard_charge_dollar": 370.46, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Windsor Mcare Extra", "plan_name": "500778", "standard_charge_dollar": 370.46, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." } ] } ] }, { "description": "Rasburicase 7.5 mg intravenous solution [76868]", "drug_information": { "unit": 1.00, "type": "EA" }, "code_information": [ { "code": "J2783", "type": "HCPCS" }, { "code": "0024-5151-75", "type": "NDC" } ], "standard_charges": [ { "gross_charge": 21519.99, "minimum": 241.18, "maximum": 463.08, "setting": "both", "payers_information": [ { "payer_name": "Aarp", "plan_name": "500102", "standard_charge_dollar": 370.46, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna", "plan_name": "700700", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna", "plan_name": "700700_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Mcare Ffs 6005", "plan_name": "700703", "standard_charge_dollar": 370.46, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Miscellaneous", "plan_name": "700720", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Miscellaneous", "plan_name": "700720_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Ppo Hmo", "plan_name": "701720", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total 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calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Federal", "plan_name": "400110_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." } ] } ] }, { "description": "Alteplase 2 mg intra-catheter solution [31310]", "drug_information": { "unit": 1.00, "type": "EA" }, "code_information": [ { "code": "J2997", "type": "HCPCS" }, { "code": "50242-041-10", "type": "NDC" } ], "standard_charges": [ { "gross_charge": 829.34, "minimum": 65.31, "maximum": 114.33, "setting": "both", "payers_information": [ { "payer_name": "Aarp", "plan_name": "500102", "standard_charge_dollar": 91.46, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna", "plan_name": "700700", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna", "plan_name": "700700_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Mcare Ffs 6005", "plan_name": "700703", "standard_charge_dollar": 91.46, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Miscellaneous", "plan_name": "700720", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Miscellaneous", "plan_name": "700720_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Ppo Hmo", "plan_name": "701720", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Ppo Hmo", "plan_name": "701720_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Ambetter 68069", "plan_name": "500516", "standard_charge_dollar": 91.46, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Ms State Emplo", "plan_name": "401457", "standard_charge_dollar": 65.31, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Ms State Emplo", "plan_name": "401457_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Basic Pl", "plan_name": "400100", "standard_charge_dollar": 65.31, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Basic Pl", "plan_name": "400100_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Federal", "plan_name": "400110", "standard_charge_dollar": 65.31, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Federal", "plan_name": "400110_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Cigna Healthsprings Ffs", "plan_name": "500064", "standard_charge_dollar": 91.46, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Conseco", "plan_name": "500302", "standard_charge_dollar": 91.46, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Humana Ffs 61101", "plan_name": "500006", "standard_charge_dollar": 91.46, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Medicare A", "plan_name": "100100", "standard_charge_dollar": 91.46, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Medicare A", "plan_name": "100500", "standard_charge_dollar": 91.46, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Medicare Part B Only", "plan_name": "100300", "standard_charge_dollar": 91.46, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Medicare Railroad", "plan_name": "100103", "standard_charge_dollar": 91.46, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Ms Physicians Care N", "plan_name": "714210", "standard_charge_dollar": 114.33, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Peoples Hlth Ffs 72126", "plan_name": "500019", "standard_charge_dollar": 91.46, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Uhc/Secure Horizons", "plan_name": "500449", "standard_charge_dollar": 91.46, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "United Health Care/", "plan_name": "500292", "standard_charge_dollar": 103.35, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "United Healthcare", "plan_name": "750104", "standard_charge_dollar": 103.35, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "United Healthcare Ba", "plan_name": "750090", "standard_charge_dollar": 103.35, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "United Healthcare Me", "plan_name": "501310", "standard_charge_dollar": 91.46, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Windsor Mcare Extra", "plan_name": "500778", "standard_charge_dollar": 91.46, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." } ] } ] }, { "description": "Alteplase 2 mg intra-catheter solution [31310]", "drug_information": { "unit": 1.00, "type": "EA" }, "code_information": [ { "code": "J2997", "type": "HCPCS" }, { "code": "50242-041-64", "type": "NDC" } ], "standard_charges": [ { "gross_charge": 829.35, "minimum": 65.31, "maximum": 114.33, "setting": "both", "payers_information": [ { "payer_name": "Aarp", "plan_name": "500102", "standard_charge_dollar": 91.46, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna", "plan_name": "700700", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna", "plan_name": "700700_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Mcare Ffs 6005", "plan_name": "700703", "standard_charge_dollar": 91.46, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Miscellaneous", "plan_name": "700720", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Miscellaneous", "plan_name": "700720_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Ppo Hmo", "plan_name": "701720", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Ppo Hmo", "plan_name": "701720_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Ambetter 68069", "plan_name": "500516", "standard_charge_dollar": 91.46, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Ms State Emplo", "plan_name": "401457", "standard_charge_dollar": 65.31, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Ms State Emplo", "plan_name": "401457_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Basic Pl", "plan_name": "400100", "standard_charge_dollar": 65.31, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Basic Pl", "plan_name": "400100_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Federal", "plan_name": "400110", "standard_charge_dollar": 65.31, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Federal", "plan_name": "400110_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Cigna Healthsprings Ffs", "plan_name": "500064", "standard_charge_dollar": 91.46, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Conseco", "plan_name": "500302", "standard_charge_dollar": 91.46, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Humana Ffs 61101", "plan_name": "500006", "standard_charge_dollar": 91.46, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Medicare A", "plan_name": "100100", "standard_charge_dollar": 91.46, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Medicare A", "plan_name": "100500", "standard_charge_dollar": 91.46, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Medicare Part B Only", "plan_name": "100300", "standard_charge_dollar": 91.46, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Medicare Railroad", "plan_name": "100103", "standard_charge_dollar": 91.46, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Ms Physicians Care N", "plan_name": "714210", "standard_charge_dollar": 114.33, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Peoples Hlth Ffs 72126", "plan_name": "500019", "standard_charge_dollar": 91.46, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Uhc/Secure Horizons", "plan_name": "500449", "standard_charge_dollar": 91.46, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "United Health Care/", "plan_name": "500292", "standard_charge_dollar": 103.35, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "United Healthcare", "plan_name": "750104", "standard_charge_dollar": 103.35, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "United Healthcare Ba", "plan_name": "750090", "standard_charge_dollar": 103.35, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "United Healthcare Me", "plan_name": "501310", "standard_charge_dollar": 91.46, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Windsor Mcare Extra", "plan_name": "500778", "standard_charge_dollar": 91.46, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." } ] } ] }, { "description": "Alteplase 50 mg intravenous solution [9003]", "drug_information": { "unit": 1.00, "type": "EA" }, "code_information": [ { "code": "J2997", "type": "HCPCS" }, { "code": "50242-044-06", "type": "NDC" } ], "standard_charges": [ { "gross_charge": 16638.02, "minimum": 65.31, "maximum": 114.33, "setting": "both", "payers_information": [ { "payer_name": "Aarp", "plan_name": "500102", "standard_charge_dollar": 91.46, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna", "plan_name": "700700", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna", "plan_name": "700700_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Mcare Ffs 6005", "plan_name": "700703", "standard_charge_dollar": 91.46, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Miscellaneous", "plan_name": "700720", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Miscellaneous", "plan_name": "700720_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Ppo Hmo", "plan_name": "701720", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Ppo Hmo", "plan_name": "701720_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Ambetter 68069", "plan_name": "500516", "standard_charge_dollar": 91.46, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Ms State Emplo", "plan_name": "401457", "standard_charge_dollar": 65.31, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Ms State Emplo", "plan_name": "401457_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Basic Pl", "plan_name": "400100", "standard_charge_dollar": 65.31, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Basic Pl", "plan_name": "400100_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Federal", "plan_name": "400110", "standard_charge_dollar": 65.31, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Federal", "plan_name": "400110_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Cigna Healthsprings Ffs", "plan_name": "500064", "standard_charge_dollar": 91.46, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Conseco", "plan_name": "500302", "standard_charge_dollar": 91.46, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Humana Ffs 61101", "plan_name": "500006", "standard_charge_dollar": 91.46, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Medicare A", "plan_name": "100100", "standard_charge_dollar": 91.46, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Medicare A", "plan_name": "100500", "standard_charge_dollar": 91.46, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Medicare Part B Only", "plan_name": "100300", "standard_charge_dollar": 91.46, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Medicare Railroad", "plan_name": "100103", "standard_charge_dollar": 91.46, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Ms Physicians Care N", "plan_name": "714210", "standard_charge_dollar": 114.33, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Peoples Hlth Ffs 72126", "plan_name": "500019", "standard_charge_dollar": 91.46, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Uhc/Secure Horizons", "plan_name": "500449", "standard_charge_dollar": 91.46, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "United Health Care/", "plan_name": "500292", "standard_charge_dollar": 103.35, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "United Healthcare", "plan_name": "750104", "standard_charge_dollar": 103.35, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "United Healthcare Ba", "plan_name": "750090", "standard_charge_dollar": 103.35, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "United Healthcare Me", "plan_name": "501310", "standard_charge_dollar": 91.46, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Windsor Mcare Extra", "plan_name": "500778", "standard_charge_dollar": 91.46, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." } ] } ] }, { "description": "Alteplase 50 mg intravenous solution [9003]", "drug_information": { "unit": 1.00, "type": "EA" }, "code_information": [ { "code": "J2997", "type": "HCPCS" }, { "code": "50242-044-13", "type": "NDC" } ], "standard_charges": [ { "gross_charge": 16638.02, "minimum": 65.31, "maximum": 114.33, "setting": "both", "payers_information": [ { "payer_name": "Aarp", "plan_name": "500102", "standard_charge_dollar": 91.46, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna", "plan_name": "700700", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna", "plan_name": "700700_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Mcare Ffs 6005", "plan_name": "700703", "standard_charge_dollar": 91.46, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Miscellaneous", "plan_name": "700720", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Miscellaneous", "plan_name": "700720_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Ppo Hmo", "plan_name": "701720", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Ppo Hmo", "plan_name": "701720_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Ambetter 68069", "plan_name": "500516", "standard_charge_dollar": 91.46, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Ms State Emplo", "plan_name": "401457", "standard_charge_dollar": 65.31, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Ms State Emplo", "plan_name": "401457_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Basic Pl", "plan_name": "400100", "standard_charge_dollar": 65.31, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Basic Pl", "plan_name": "400100_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Federal", "plan_name": "400110", "standard_charge_dollar": 65.31, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Federal", "plan_name": "400110_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Cigna Healthsprings Ffs", "plan_name": "500064", "standard_charge_dollar": 91.46, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Conseco", "plan_name": "500302", "standard_charge_dollar": 91.46, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Humana Ffs 61101", "plan_name": "500006", "standard_charge_dollar": 91.46, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Medicare A", "plan_name": "100100", "standard_charge_dollar": 91.46, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Medicare A", "plan_name": "100500", "standard_charge_dollar": 91.46, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Medicare Part B Only", "plan_name": "100300", "standard_charge_dollar": 91.46, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Medicare Railroad", "plan_name": "100103", "standard_charge_dollar": 91.46, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Ms Physicians Care N", "plan_name": "714210", "standard_charge_dollar": 114.33, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Peoples Hlth Ffs 72126", "plan_name": "500019", "standard_charge_dollar": 91.46, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Uhc/Secure Horizons", "plan_name": "500449", "standard_charge_dollar": 91.46, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "United Health Care/", "plan_name": "500292", "standard_charge_dollar": 103.35, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "United Healthcare", "plan_name": "750104", "standard_charge_dollar": 103.35, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "United Healthcare Ba", "plan_name": "750090", "standard_charge_dollar": 103.35, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "United Healthcare Me", "plan_name": "501310", "standard_charge_dollar": 91.46, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Windsor Mcare Extra", "plan_name": "500778", "standard_charge_dollar": 91.46, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." } ] } ] }, { "description": "Alteplase 100 mg intravenous solution [9002]", "drug_information": { "unit": 1.00, "type": "EA" }, "code_information": [ { "code": "J2997", "type": "HCPCS" }, { "code": "50242-085-25", "type": "NDC" } ], "standard_charges": [ { "gross_charge": 33276.03, "minimum": 65.31, "maximum": 114.33, "setting": "both", "payers_information": [ { "payer_name": "Aarp", "plan_name": "500102", "standard_charge_dollar": 91.46, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna", "plan_name": "700700", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna", "plan_name": "700700_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Mcare Ffs 6005", "plan_name": "700703", "standard_charge_dollar": 91.46, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Miscellaneous", "plan_name": "700720", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Miscellaneous", "plan_name": "700720_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Ppo Hmo", "plan_name": "701720", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Ppo Hmo", "plan_name": "701720_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Ambetter 68069", "plan_name": "500516", "standard_charge_dollar": 91.46, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Ms State Emplo", "plan_name": "401457", "standard_charge_dollar": 65.31, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Ms State Emplo", "plan_name": "401457_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Basic Pl", "plan_name": "400100", "standard_charge_dollar": 65.31, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Basic Pl", "plan_name": "400100_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Federal", "plan_name": "400110", "standard_charge_dollar": 65.31, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Federal", "plan_name": "400110_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Cigna Healthsprings Ffs", "plan_name": "500064", "standard_charge_dollar": 91.46, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Conseco", "plan_name": "500302", "standard_charge_dollar": 91.46, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Humana Ffs 61101", "plan_name": "500006", "standard_charge_dollar": 91.46, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Medicare A", "plan_name": "100100", "standard_charge_dollar": 91.46, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Medicare A", "plan_name": "100500", "standard_charge_dollar": 91.46, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Medicare Part B Only", "plan_name": "100300", "standard_charge_dollar": 91.46, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Medicare Railroad", "plan_name": "100103", "standard_charge_dollar": 91.46, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Ms Physicians Care N", "plan_name": "714210", "standard_charge_dollar": 114.33, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Peoples Hlth Ffs 72126", "plan_name": "500019", "standard_charge_dollar": 91.46, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Uhc/Secure Horizons", "plan_name": "500449", "standard_charge_dollar": 91.46, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "United Health Care/", "plan_name": "500292", "standard_charge_dollar": 103.35, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "United Healthcare", "plan_name": "750104", "standard_charge_dollar": 103.35, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "United Healthcare Ba", "plan_name": "750090", "standard_charge_dollar": 103.35, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "United Healthcare Me", "plan_name": "501310", "standard_charge_dollar": 91.46, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Windsor Mcare Extra", "plan_name": "500778", "standard_charge_dollar": 91.46, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." } ] } ] }, { "description": "Alteplase 100 mg intravenous solution [9002]", "drug_information": { "unit": 1.00, "type": "EA" }, "code_information": [ { "code": "J2997", "type": "HCPCS" }, { "code": "50242-085-27", "type": "NDC" } ], "standard_charges": [ { "gross_charge": 33276.03, "minimum": 65.31, "maximum": 114.33, "setting": "both", "payers_information": [ { "payer_name": "Aarp", "plan_name": "500102", "standard_charge_dollar": 91.46, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna", "plan_name": "700700", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna", "plan_name": "700700_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Mcare Ffs 6005", "plan_name": "700703", "standard_charge_dollar": 91.46, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Miscellaneous", "plan_name": "700720", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Miscellaneous", "plan_name": "700720_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Ppo Hmo", "plan_name": "701720", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Ppo Hmo", "plan_name": "701720_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Ambetter 68069", "plan_name": "500516", "standard_charge_dollar": 91.46, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Ms State Emplo", "plan_name": "401457", "standard_charge_dollar": 65.31, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Ms State Emplo", "plan_name": "401457_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Basic Pl", "plan_name": "400100", "standard_charge_dollar": 65.31, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Basic Pl", "plan_name": "400100_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Federal", "plan_name": "400110", "standard_charge_dollar": 65.31, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Federal", "plan_name": "400110_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Cigna Healthsprings Ffs", "plan_name": "500064", "standard_charge_dollar": 91.46, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Conseco", "plan_name": "500302", "standard_charge_dollar": 91.46, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Humana Ffs 61101", "plan_name": "500006", "standard_charge_dollar": 91.46, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Medicare A", "plan_name": "100100", "standard_charge_dollar": 91.46, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Medicare A", "plan_name": "100500", "standard_charge_dollar": 91.46, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Medicare Part B Only", "plan_name": "100300", "standard_charge_dollar": 91.46, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Medicare Railroad", "plan_name": "100103", "standard_charge_dollar": 91.46, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Ms Physicians Care N", "plan_name": "714210", "standard_charge_dollar": 114.33, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Peoples Hlth Ffs 72126", "plan_name": "500019", "standard_charge_dollar": 91.46, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Uhc/Secure Horizons", "plan_name": "500449", "standard_charge_dollar": 91.46, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "United Health Care/", "plan_name": "500292", "standard_charge_dollar": 103.35, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "United Healthcare", "plan_name": "750104", "standard_charge_dollar": 103.35, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "United Healthcare Ba", "plan_name": "750090", "standard_charge_dollar": 103.35, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "United Healthcare Me", "plan_name": "501310", "standard_charge_dollar": 91.46, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Windsor Mcare Extra", "plan_name": "500778", "standard_charge_dollar": 91.46, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." } ] } ] }, { "description": "Fentanyl (pf) 10 mcg/ml in 0.9 % sodium chloride intravenous [30807]", "drug_information": { "unit": 250.00, "type": "ML" }, "code_information": [ { "code": "J3010", "type": "HCPCS" }, { "code": "63037-101-05", "type": "NDC" } ], "standard_charges": [ { "gross_charge": 176.81, "minimum": 141.45, "maximum": 150.29, "setting": "both", "payers_information": [ { "payer_name": "Aetna", "plan_name": "700700", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna", "plan_name": "700700_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Miscellaneous", "plan_name": "700720", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Miscellaneous", "plan_name": "700720_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Ppo Hmo", "plan_name": "701720", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Ppo Hmo", "plan_name": "701720_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Ms State Emplo", "plan_name": "401457", "standard_charge_percentage": 0.80, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Ms State Emplo", "plan_name": "401457_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Basic Pl", "plan_name": "400100", "standard_charge_percentage": 0.85, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Basic Pl", "plan_name": "400100_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Federal", "plan_name": "400110", "standard_charge_percentage": 0.85, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Federal", "plan_name": "400110_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." } ] } ] }, { "description": "Fentanyl (pf) 50 mcg/ml injection (wrapped) [5073037]", "drug_information": { "unit": 20.00, "type": "ML" }, "code_information": [ { "code": "J3010", "type": "HCPCS" }, { "code": "63323-806-14", "type": "NDC" } ], "standard_charges": [ { "gross_charge": 140.07, "minimum": 112.06, "maximum": 119.06, "setting": "both", "payers_information": [ { "payer_name": "Aetna", "plan_name": "700700", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna", "plan_name": "700700_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Miscellaneous", "plan_name": "700720", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Miscellaneous", "plan_name": "700720_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Ppo Hmo", "plan_name": "701720", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Ppo Hmo", "plan_name": "701720_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Ms State Emplo", "plan_name": "401457", "standard_charge_percentage": 0.80, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Ms State Emplo", "plan_name": "401457_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Basic Pl", "plan_name": "400100", "standard_charge_percentage": 0.85, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Basic Pl", "plan_name": 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6737.24, "setting": "both", "payers_information": [ { "payer_name": "Aarp", "plan_name": "500102", "standard_charge_dollar": 19.32, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna", "plan_name": "700700", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna", "plan_name": "700700_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Mcare Ffs 6005", "plan_name": "700703", "standard_charge_dollar": 19.32, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Miscellaneous", "plan_name": "700720", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Miscellaneous", "plan_name": "700720_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Ppo Hmo", "plan_name": "701720", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Ppo Hmo", "plan_name": "701720_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Ambetter 68069", "plan_name": "500516", "standard_charge_dollar": 19.32, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Ms State Emplo", "plan_name": "401457", "standard_charge_percentage": 0.80, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Ms State Emplo", "plan_name": "401457_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Basic Pl", "plan_name": "400100", "standard_charge_percentage": 0.85, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Basic Pl", "plan_name": "400100_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Federal", "plan_name": "400110", "standard_charge_percentage": 0.85, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Federal", "plan_name": "400110_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Cigna Healthsprings Ffs", "plan_name": "500064", "standard_charge_dollar": 19.32, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Conseco", "plan_name": "500302", "standard_charge_dollar": 19.32, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Humana Ffs 61101", "plan_name": "500006", "standard_charge_dollar": 19.32, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Medicare A", "plan_name": "100100", "standard_charge_dollar": 19.32, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Medicare A", "plan_name": "100500", "standard_charge_dollar": 19.32, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Medicare Part B Only", "plan_name": "100300", "standard_charge_dollar": 19.32, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Medicare Railroad", "plan_name": "100103", "standard_charge_dollar": 19.32, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Ms Physicians Care N", "plan_name": "714210", "standard_charge_dollar": 24.15, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Peoples Hlth Ffs 72126", "plan_name": "500019", "standard_charge_dollar": 19.32, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Uhc/Secure Horizons", "plan_name": "500449", "standard_charge_dollar": 19.32, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "United Health Care/", "plan_name": "500292", "standard_charge_dollar": 21.83, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "United Healthcare", "plan_name": "750104", "standard_charge_dollar": 21.83, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "United Healthcare Ba", "plan_name": "750090", "standard_charge_dollar": 21.83, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "United Healthcare Me", "plan_name": "501310", "standard_charge_dollar": 19.32, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Windsor Mcare Extra", "plan_name": "500778", "standard_charge_dollar": 19.32, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." } ] } ] }, { "description": "Talquetamab-tgvs 40 mg/ml subcutaneous solution [201879]", "drug_information": { "unit": 1.00, "type": "ML" }, "code_information": [ { "code": "J3055", "type": "HCPCS" }, { "code": "57894-470-01", "type": "NDC" } ], "standard_charges": [ { "gross_charge": 46620.00, "minimum": 64.12, "maximum": 39627.00, "setting": "both", "payers_information": [ { "payer_name": "Aarp", "plan_name": "500102", "standard_charge_dollar": 64.12, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna", "plan_name": "700700", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna", "plan_name": "700700_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Mcare Ffs 6005", "plan_name": "700703", "standard_charge_dollar": 64.12, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Miscellaneous", "plan_name": "700720", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Miscellaneous", "plan_name": "700720_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Ppo Hmo", "plan_name": "701720", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Ppo Hmo", "plan_name": "701720_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Ambetter 68069", "plan_name": "500516", "standard_charge_dollar": 64.12, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Ms State Emplo", "plan_name": "401457", "standard_charge_percentage": 0.80, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Ms State Emplo", "plan_name": "401457_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Basic Pl", "plan_name": "400100", "standard_charge_percentage": 0.85, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Basic Pl", "plan_name": "400100_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Federal", "plan_name": "400110", "standard_charge_percentage": 0.85, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Federal", "plan_name": "400110_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Cigna Healthsprings Ffs", "plan_name": "500064", "standard_charge_dollar": 64.12, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Conseco", "plan_name": "500302", "standard_charge_dollar": 64.12, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Humana Ffs 61101", "plan_name": "500006", "standard_charge_dollar": 64.12, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Medicare A", "plan_name": "100100", "standard_charge_dollar": 64.12, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Medicare A", "plan_name": "100500", "standard_charge_dollar": 64.12, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Medicare Part B Only", "plan_name": "100300", "standard_charge_dollar": 64.12, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Medicare Railroad", "plan_name": "100103", "standard_charge_dollar": 64.12, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Ms Physicians Care N", "plan_name": "714210", "standard_charge_dollar": 80.16, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Peoples Hlth Ffs 72126", "plan_name": "500019", "standard_charge_dollar": 64.12, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Uhc/Secure Horizons", "plan_name": "500449", "standard_charge_dollar": 64.12, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "United Health Care/", "plan_name": "500292", "standard_charge_dollar": 72.46, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "United Healthcare", "plan_name": "750104", "standard_charge_dollar": 72.46, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "United Healthcare Ba", "plan_name": "750090", "standard_charge_dollar": 72.46, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "United Healthcare Me", "plan_name": "501310", "standard_charge_dollar": 64.12, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Windsor Mcare Extra", "plan_name": "500778", "standard_charge_dollar": 64.12, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." } ] } ] }, { "description": "Tenecteplase 50 mg intravenous solution [179517]", "drug_information": { "unit": 1.00, "type": "EA" }, "code_information": [ { "code": "J3101", "type": "HCPCS" }, { "code": "50242-120-47", "type": "NDC" } ], "standard_charges": [ { "gross_charge": 28735.72, "minimum": 94.73, "maximum": 203.08, "setting": "both", "payers_information": [ { "payer_name": "Aarp", "plan_name": "500102", "standard_charge_dollar": 162.46, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna", "plan_name": "700700", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna", "plan_name": "700700_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Mcare Ffs 6005", "plan_name": "700703", "standard_charge_dollar": 162.46, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Miscellaneous", "plan_name": "700720", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Miscellaneous", "plan_name": "700720_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Ppo Hmo", "plan_name": "701720", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Ppo Hmo", "plan_name": "701720_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Ambetter 68069", "plan_name": "500516", "standard_charge_dollar": 162.46, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Ms State Emplo", "plan_name": "401457", "standard_charge_dollar": 94.73, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Ms State Emplo", "plan_name": "401457_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Basic Pl", "plan_name": "400100", "standard_charge_dollar": 94.73, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Basic Pl", "plan_name": "400100_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Federal", "plan_name": "400110", "standard_charge_dollar": 94.73, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Federal", "plan_name": "400110_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Cigna Healthsprings Ffs", "plan_name": "500064", "standard_charge_dollar": 162.46, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Conseco", "plan_name": "500302", "standard_charge_dollar": 162.46, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Humana Ffs 61101", "plan_name": "500006", "standard_charge_dollar": 162.46, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Medicare A", "plan_name": "100100", "standard_charge_dollar": 162.46, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Medicare A", "plan_name": "100500", "standard_charge_dollar": 162.46, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Medicare Part B Only", "plan_name": "100300", "standard_charge_dollar": 162.46, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Medicare Railroad", "plan_name": "100103", "standard_charge_dollar": 162.46, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Ms Physicians Care N", "plan_name": "714210", "standard_charge_dollar": 203.08, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Peoples Hlth Ffs 72126", "plan_name": "500019", "standard_charge_dollar": 162.46, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Uhc/Secure Horizons", "plan_name": "500449", "standard_charge_dollar": 162.46, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "United Health Care/", "plan_name": "500292", "standard_charge_dollar": 183.58, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "United Healthcare", "plan_name": "750104", "standard_charge_dollar": 183.58, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "United Healthcare Ba", "plan_name": "750090", "standard_charge_dollar": 183.58, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "United Healthcare Me", "plan_name": "501310", "standard_charge_dollar": 162.46, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Windsor Mcare Extra", "plan_name": "500778", "standard_charge_dollar": 162.46, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." } ] } ] }, { "description": "Tenecteplase 50 mg intravenous solution [179517]", "drug_information": { "unit": 1.00, "type": "EA" }, "code_information": [ { "code": "J3101", "type": "HCPCS" }, { "code": "50242-037-06", "type": "NDC" } ], "standard_charges": [ { "gross_charge": 28735.72, "minimum": 94.73, "maximum": 203.08, "setting": "both", "payers_information": [ { "payer_name": "Aarp", "plan_name": "500102", "standard_charge_dollar": 162.46, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna", "plan_name": "700700", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna", "plan_name": "700700_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Mcare Ffs 6005", "plan_name": "700703", "standard_charge_dollar": 162.46, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Miscellaneous", "plan_name": "700720", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Miscellaneous", "plan_name": "700720_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Ppo Hmo", "plan_name": "701720", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Ppo Hmo", "plan_name": "701720_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Ambetter 68069", "plan_name": "500516", "standard_charge_dollar": 162.46, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Ms State Emplo", "plan_name": "401457", "standard_charge_dollar": 94.73, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Ms State Emplo", "plan_name": "401457_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Basic Pl", "plan_name": "400100", "standard_charge_dollar": 94.73, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Basic Pl", "plan_name": "400100_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Federal", "plan_name": "400110", "standard_charge_dollar": 94.73, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Federal", "plan_name": "400110_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Cigna Healthsprings Ffs", "plan_name": "500064", "standard_charge_dollar": 162.46, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Conseco", "plan_name": "500302", "standard_charge_dollar": 162.46, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Humana Ffs 61101", "plan_name": "500006", "standard_charge_dollar": 162.46, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Medicare A", "plan_name": "100100", "standard_charge_dollar": 162.46, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Medicare A", "plan_name": "100500", "standard_charge_dollar": 162.46, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Medicare Part B Only", "plan_name": "100300", "standard_charge_dollar": 162.46, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Medicare Railroad", "plan_name": "100103", "standard_charge_dollar": 162.46, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Ms Physicians Care N", "plan_name": "714210", "standard_charge_dollar": 203.08, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Peoples Hlth Ffs 72126", "plan_name": "500019", "standard_charge_dollar": 162.46, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Uhc/Secure Horizons", "plan_name": "500449", "standard_charge_dollar": 162.46, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "United Health Care/", "plan_name": "500292", "standard_charge_dollar": 183.58, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "United Healthcare", "plan_name": "750104", "standard_charge_dollar": 183.58, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "United Healthcare Ba", "plan_name": "750090", "standard_charge_dollar": 183.58, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "United Healthcare Me", "plan_name": "501310", "standard_charge_dollar": 162.46, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Windsor Mcare Extra", "plan_name": "500778", "standard_charge_dollar": 162.46, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." } ] } ] }, { "description": "Terbutaline 1 mg/ml subcutaneous solution [11507]", "drug_information": { "unit": 1.00, "type": "ML" }, "code_information": [ { "code": "J3105", "type": "HCPCS" }, { "code": "63323-665-01", "type": "NDC" } ], "standard_charges": [ { "gross_charge": 120.17, "minimum": 96.14, "maximum": 102.14, "setting": "both", "payers_information": [ { "payer_name": "Aetna", "plan_name": "700700", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna", "plan_name": "700700_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Miscellaneous", "plan_name": "700720", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Miscellaneous", "plan_name": "700720_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Ppo Hmo", "plan_name": "701720", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Ppo Hmo", "plan_name": "701720_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Ms State Emplo", "plan_name": "401457", "standard_charge_percentage": 0.80, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Ms State Emplo", "plan_name": "401457_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Basic Pl", "plan_name": "400100", "standard_charge_percentage": 0.85, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Basic Pl", "plan_name": "400100_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Federal", "plan_name": "400110", "standard_charge_percentage": 0.85, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Federal", "plan_name": "400110_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." } ] } ] }, { "description": "Terbutaline 1 mg/ml subcutaneous solution [11507]", "drug_information": { "unit": 1.00, "type": "ML" }, "code_information": [ { "code": "J3105", "type": "HCPCS" }, { "code": "0143-9746-01", "type": "NDC" } ], "standard_charges": [ { "gross_charge": 24.00, "minimum": 19.20, "maximum": 20.40, "setting": "both", "payers_information": [ { "payer_name": "Aetna", "plan_name": "700700", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna", "plan_name": "700700_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Miscellaneous", "plan_name": "700720", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Miscellaneous", "plan_name": "700720_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Ppo Hmo", "plan_name": "701720", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Ppo Hmo", "plan_name": "701720_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Ms State Emplo", "plan_name": "401457", "standard_charge_percentage": 0.80, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Ms State Emplo", "plan_name": "401457_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Basic Pl", "plan_name": "400100", "standard_charge_percentage": 0.85, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Basic Pl", "plan_name": "400100_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Federal", "plan_name": "400110", "standard_charge_percentage": 0.85, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Federal", "plan_name": "400110_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." } ] } ] }, { "description": "Terbutaline 1 mg/ml subcutaneous solution [11507]", "drug_information": { "unit": 1.00, "type": "ML" }, "code_information": [ { "code": "J3105", "type": "HCPCS" }, { "code": "0143-9746-10", "type": "NDC" } ], "standard_charges": [ { "gross_charge": 24.00, "minimum": 19.20, "maximum": 20.40, "setting": "both", "payers_information": [ { "payer_name": "Aetna", "plan_name": "700700", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna", "plan_name": "700700_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Miscellaneous", "plan_name": "700720", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Miscellaneous", "plan_name": "700720_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Ppo Hmo", "plan_name": "701720", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Ppo Hmo", "plan_name": "701720_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Ms State Emplo", "plan_name": "401457", "standard_charge_percentage": 0.80, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Ms State Emplo", "plan_name": "401457_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Basic Pl", "plan_name": "400100", "standard_charge_percentage": 0.85, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Basic Pl", "plan_name": "400100_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Federal", "plan_name": "400110", "standard_charge_percentage": 0.85, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Federal", "plan_name": "400110_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." } ] } ] }, { "description": "Romosozumab-aqqg 105 mg/1.17 ml subcutaneous syringe [186798]", "drug_information": { "unit": 1.17, "type": "ML" }, "code_information": [ { "code": "J3111", "type": "HCPCS" }, { "code": "55513-880-01", "type": "NDC" } ], "standard_charges": [ { "gross_charge": 4875.46, "minimum": 11.49, "maximum": 4144.14, "setting": "both", "payers_information": [ { "payer_name": "Aarp", "plan_name": "500102", "standard_charge_dollar": 11.49, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna", "plan_name": "700700", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna", "plan_name": "700700_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Mcare Ffs 6005", "plan_name": "700703", "standard_charge_dollar": 11.49, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Miscellaneous", "plan_name": "700720", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Miscellaneous", "plan_name": "700720_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Ppo Hmo", "plan_name": "701720", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Ppo Hmo", "plan_name": "701720_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Ambetter 68069", "plan_name": "500516", "standard_charge_dollar": 11.49, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Ms State Emplo", "plan_name": "401457", "standard_charge_percentage": 0.80, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Ms State Emplo", "plan_name": "401457_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Basic Pl", "plan_name": "400100", "standard_charge_percentage": 0.85, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Basic Pl", "plan_name": "400100_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Federal", "plan_name": "400110", "standard_charge_percentage": 0.85, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Federal", "plan_name": "400110_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Cigna Healthsprings Ffs", "plan_name": "500064", "standard_charge_dollar": 11.49, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Conseco", "plan_name": "500302", "standard_charge_dollar": 11.49, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Humana Ffs 61101", "plan_name": "500006", "standard_charge_dollar": 11.49, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Medicare A", "plan_name": "100100", "standard_charge_dollar": 11.49, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Medicare A", "plan_name": "100500", "standard_charge_dollar": 11.49, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Medicare Part B Only", "plan_name": "100300", "standard_charge_dollar": 11.49, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Medicare Railroad", "plan_name": "100103", "standard_charge_dollar": 11.49, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Ms Physicians Care N", "plan_name": "714210", "standard_charge_dollar": 14.36, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Peoples Hlth Ffs 72126", "plan_name": "500019", "standard_charge_dollar": 11.49, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Uhc/Secure Horizons", "plan_name": "500449", "standard_charge_dollar": 11.49, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "United Health Care/", "plan_name": "500292", "standard_charge_dollar": 12.98, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "United Healthcare", "plan_name": "750104", "standard_charge_dollar": 12.98, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "United Healthcare Ba", "plan_name": "750090", "standard_charge_dollar": 12.98, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "United Healthcare Me", "plan_name": "501310", "standard_charge_dollar": 11.49, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Windsor Mcare Extra", "plan_name": "500778", "standard_charge_dollar": 11.49, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." } ] } ] }, { "description": "Romosozumab-aqqg 210 mg/2.34 ml(105 mg/1.17 ml x2)subcutaneous syringe [186794]", "drug_information": { "unit": 1.17, "type": "ML" }, "code_information": [ { "code": "J3111", "type": "HCPCS" }, { "code": "55513-880-02", "type": "NDC" } ], "standard_charges": [ { "gross_charge": 4875.46, "minimum": 11.49, "maximum": 4144.14, "setting": "both", "payers_information": [ { "payer_name": "Aarp", "plan_name": "500102", "standard_charge_dollar": 11.49, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna", "plan_name": "700700", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna", "plan_name": "700700_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Mcare Ffs 6005", "plan_name": "700703", "standard_charge_dollar": 11.49, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Miscellaneous", "plan_name": "700720", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Miscellaneous", "plan_name": 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0.80, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Ms State Emplo", "plan_name": "401457_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Basic Pl", "plan_name": "400100", "standard_charge_percentage": 0.85, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Basic Pl", "plan_name": "400100_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Federal", "plan_name": "400110", "standard_charge_percentage": 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"standard_charge_dollar": 5.88, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." } ] } ] }, { "description": "Triamcinolone acetonide 40 mg/ml suspension for injection [8120]", "drug_information": { "unit": 1.00, "type": "ML" }, "code_information": [ { "code": "J3301", "type": "HCPCS" }, { "code": "70121-1049-1", "type": "NDC" } ], "standard_charges": [ { "gross_charge": 46.80, "minimum": 37.44, "maximum": 39.78, "setting": "both", "payers_information": [ { "payer_name": "Aetna", "plan_name": "700700", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna", "plan_name": "700700_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed 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"Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Miscellaneous", "plan_name": "700720_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Ppo Hmo", "plan_name": "701720", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Ppo Hmo", "plan_name": "701720_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Ms State Emplo", "plan_name": "401457", "standard_charge_percentage": 0.80, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Ms State Emplo", "plan_name": "401457_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Basic Pl", "plan_name": "400100", "standard_charge_percentage": 0.85, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Basic Pl", "plan_name": "400100_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Federal", "plan_name": "400110", "standard_charge_percentage": 0.85, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient 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100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Miscellaneous", "plan_name": "700720", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Miscellaneous", "plan_name": "700720_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Ppo Hmo", "plan_name": "701720", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Ppo Hmo", "plan_name": "701720_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Ms State Emplo", "plan_name": "401457", "standard_charge_percentage": 0.80, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Ms State Emplo", "plan_name": "401457_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Basic Pl", "plan_name": "400100", "standard_charge_percentage": 0.85, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Basic Pl", "plan_name": "400100_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Federal", "plan_name": "400110", "standard_charge_percentage": 0.85, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Federal", "plan_name": "400110_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." } ] } ] }, { "description": "Magnesium sulfate 1 gram/100 ml in dextrose 5 % intravenous piggyback [16162]", "drug_information": { "unit": 100.00, "type": "ML" }, "code_information": [ { "code": "J3475", "type": "HCPCS" }, { "code": "0264-4400-54", "type": "NDC" } ], "standard_charges": [ { "gross_charge": 110.31, "minimum": 88.25, "maximum": 93.76, "setting": "both", "payers_information": [ { "payer_name": "Aetna", "plan_name": "700700", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna", "plan_name": "700700_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Miscellaneous", "plan_name": "700720", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Miscellaneous", "plan_name": "700720_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Ppo Hmo", "plan_name": "701720", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Ppo Hmo", "plan_name": "701720_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Ms State Emplo", "plan_name": "401457", "standard_charge_percentage": 0.80, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Ms State Emplo", "plan_name": "401457_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Basic Pl", "plan_name": "400100", "standard_charge_percentage": 0.85, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Basic Pl", "plan_name": "400100_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Federal", "plan_name": "400110", "standard_charge_percentage": 0.85, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Federal", "plan_name": "400110_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." } ] } ] }, { "description": "Magnesium sulfate 1 gram/100 ml in dextrose 5 % intravenous piggyback [16162]", "drug_information": { "unit": 100.00, "type": "ML" }, "code_information": [ { "code": "J3475", "type": "HCPCS" }, { "code": "0338-1709-40", "type": "NDC" } ], "standard_charges": [ { "gross_charge": 112.69, "minimum": 90.15, "maximum": 95.79, "setting": "both", "payers_information": [ { "payer_name": "Aetna", "plan_name": "700700", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna", "plan_name": "700700_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Miscellaneous", "plan_name": "700720", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Miscellaneous", "plan_name": "700720_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Ppo Hmo", "plan_name": "701720", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Ppo Hmo", "plan_name": "701720_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Ms State Emplo", "plan_name": "401457", "standard_charge_percentage": 0.80, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Ms State Emplo", "plan_name": "401457_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Basic Pl", "plan_name": "400100", "standard_charge_percentage": 0.85, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Basic Pl", "plan_name": "400100_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Federal", "plan_name": "400110", "standard_charge_percentage": 0.85, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Federal", "plan_name": "400110_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." } ] } ] }, { "description": "Magnesium sulfate 1 gram/100 ml in dextrose 5 % intravenous piggyback [16162]", "drug_information": { "unit": 100.00, "type": "ML" }, "code_information": [ { "code": "J3475", "type": "HCPCS" }, { "code": "0409-6727-11", "type": "NDC" } ], "standard_charges": [ { "gross_charge": 120.76, "minimum": 96.61, "maximum": 102.65, "setting": "both", "payers_information": [ { "payer_name": "Aetna", "plan_name": "700700", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna", "plan_name": "700700_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Miscellaneous", "plan_name": "700720", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Miscellaneous", "plan_name": "700720_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Ppo Hmo", "plan_name": "701720", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Ppo Hmo", "plan_name": "701720_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Ms State Emplo", "plan_name": "401457", "standard_charge_percentage": 0.80, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Ms State Emplo", "plan_name": "401457_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Basic Pl", "plan_name": "400100", "standard_charge_percentage": 0.85, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Basic Pl", "plan_name": "400100_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Federal", "plan_name": "400110", "standard_charge_percentage": 0.85, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Federal", "plan_name": "400110_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." } ] } ] }, { "description": "Magnesium sulfate 1 gram/100 ml in dextrose 5 % intravenous piggyback [16162]", "drug_information": { "unit": 100.00, "type": "ML" }, "code_information": [ { "code": "J3475", "type": "HCPCS" }, { "code": "0409-6727-23", "type": "NDC" } ], "standard_charges": [ { "gross_charge": 120.76, "minimum": 96.61, "maximum": 102.65, "setting": "both", "payers_information": [ { "payer_name": "Aetna", "plan_name": "700700", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna", "plan_name": "700700_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Miscellaneous", "plan_name": "700720", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Miscellaneous", "plan_name": "700720_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Ppo Hmo", "plan_name": "701720", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Ppo Hmo", "plan_name": "701720_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Ms State Emplo", "plan_name": "401457", "standard_charge_percentage": 0.80, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Ms State Emplo", "plan_name": "401457_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Basic Pl", "plan_name": "400100", "standard_charge_percentage": 0.85, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Basic Pl", "plan_name": "400100_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Federal", "plan_name": "400110", "standard_charge_percentage": 0.85, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Federal", "plan_name": "400110_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." } ] } ] }, { "description": "Magnesium sulfate 20 gram/500 ml (4 %) in water intravenous solution [117958]", "drug_information": { "unit": 500.00, "type": "ML" }, "code_information": [ { "code": "J3475", "type": "HCPCS" }, { "code": "0409-6729-03", "type": "NDC" } ], "standard_charges": [ { "gross_charge": 107.94, "minimum": 86.35, "maximum": 91.75, "setting": "both", "payers_information": [ { "payer_name": "Aetna", "plan_name": "700700", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna", "plan_name": "700700_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Miscellaneous", "plan_name": "700720", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Miscellaneous", "plan_name": "700720_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Ppo Hmo", "plan_name": "701720", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Ppo Hmo", "plan_name": "701720_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Ms State Emplo", "plan_name": "401457", "standard_charge_percentage": 0.80, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Ms State Emplo", "plan_name": "401457_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Basic Pl", "plan_name": "400100", "standard_charge_percentage": 0.85, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Basic Pl", "plan_name": "400100_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Federal", "plan_name": "400110", "standard_charge_percentage": 0.85, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Federal", "plan_name": "400110_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." } ] } ] }, { "description": "Magnesium sulfate 40 gram/1000 ml (4 %) in water intravenous solution [117959]", "drug_information": { "unit": 1000.00, "type": "ML" }, "code_information": [ { "code": "J3475", "type": "HCPCS" }, { "code": "0409-6729-09", "type": "NDC" } ], "standard_charges": [ { "gross_charge": 119.81, "minimum": 95.85, "maximum": 101.84, "setting": "both", "payers_information": [ { "payer_name": "Aetna", "plan_name": "700700", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed 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"standard_charge_percentage": 0.85, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Basic Pl", "plan_name": "400100_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Federal", "plan_name": "400110", "standard_charge_percentage": 0.85, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Federal", "plan_name": "400110_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." } ] } ] }, { "description": "Potassium chloride 20 meq/l in 0.9 % 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"description": "Potassium chloride 20 meq/l in 0.45 % sodium chloride intravenous soln [36046]", "drug_information": { "unit": 1000.00, "type": "ML" }, "code_information": [ { "code": "J3480", "type": "HCPCS" }, { "code": "0338-0704-34", "type": "NDC" } ], "standard_charges": [ { "gross_charge": 115.06, "minimum": 92.05, "maximum": 97.80, "setting": "both", "payers_information": [ { "payer_name": "Aetna", "plan_name": "700700", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna", "plan_name": "700700_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Miscellaneous", "plan_name": "700720", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total 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"percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Ms State Emplo", "plan_name": "401457_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Basic Pl", "plan_name": "400100", "standard_charge_percentage": 0.85, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Basic Pl", "plan_name": "400100_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Federal", "plan_name": "400110", "standard_charge_percentage": 0.85, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Federal", "plan_name": "400110_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." } ] } ] }, { "description": "Potassium chloride 20 meq/l in d5-0.9 % sodium chloride intravenous [9795]", "drug_information": { "unit": 1000.00, "type": "ML" }, "code_information": [ { "code": "J3480", "type": "HCPCS" }, { "code": "0338-0803-04", "type": "NDC" } ], "standard_charges": [ { "gross_charge": 129.31, "minimum": 103.45, "maximum": 109.91, "setting": "both", "payers_information": [ { "payer_name": "Aetna", "plan_name": "700700", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna", "plan_name": "700700_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Miscellaneous", "plan_name": "700720", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Miscellaneous", "plan_name": "700720_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Ppo Hmo", "plan_name": "701720", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Ppo Hmo", "plan_name": "701720_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Ms State Emplo", "plan_name": "401457", "standard_charge_percentage": 0.80, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Ms State Emplo", "plan_name": "401457_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Basic Pl", "plan_name": "400100", "standard_charge_percentage": 0.85, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Basic Pl", "plan_name": "400100_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Federal", "plan_name": "400110", "standard_charge_percentage": 0.85, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Federal", "plan_name": "400110_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." } ] } ] }, { "description": "Potassium chloride 20 meq/l-lactated ringers-5 % dextrose intravenous [16014]", "drug_information": { "unit": 1000.00, "type": "ML" }, "code_information": [ { "code": "J3480", "type": "HCPCS" }, { "code": "0338-0811-04", "type": "NDC" } ], "standard_charges": [ { "gross_charge": 134.06, "minimum": 107.25, "maximum": 113.95, "setting": "both", "payers_information": [ { "payer_name": "Aetna", "plan_name": "700700", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna", "plan_name": "700700_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Miscellaneous", "plan_name": "700720", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Miscellaneous", "plan_name": "700720_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", 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"methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Basic Pl", "plan_name": "400100", "standard_charge_percentage": 0.85, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Basic Pl", "plan_name": "400100_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Federal", "plan_name": "400110", "standard_charge_percentage": 0.85, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Federal", "plan_name": "400110_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." } ] } ] }, { "description": "Potassium chloride 2 meq/ml intravenous solution [6429]", "drug_information": { "unit": 10.00, "type": "ML" }, "code_information": [ { "code": "J3480", "type": "HCPCS" }, { "code": "63323-965-10", "type": "NDC" } ], "standard_charges": [ { "gross_charge": 38.10, "minimum": 30.48, "maximum": 32.39, "setting": "both", "payers_information": [ { "payer_name": "Aetna", "plan_name": "700700", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna", "plan_name": "700700_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna 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"plan_name": "400110", "standard_charge_percentage": 0.85, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Federal", "plan_name": "400110_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." } ] } ] }, { "description": "Potassium chloride 2 meq/ml oral solution (nicu) [507304]", "drug_information": { "unit": 20.00, "type": "ML" }, "code_information": [ { "code": "J3480", "type": "HCPCS" }, { "code": "63323-965-20", "type": "NDC" } ], "standard_charges": [ { "gross_charge": 45.80, "minimum": 36.64, "maximum": 38.93, "setting": "both", "payers_information": [ { "payer_name": "Aetna", "plan_name": "700700", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", 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{ "payer_name": "Bc/Bs Of Ms Federal", "plan_name": "400110", "standard_charge_percentage": 0.85, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Federal", "plan_name": "400110_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." } ] } ] }, { "description": "Nafcillin 2 gram solution for injection [5335]", "drug_information": { "unit": 1.00, "type": "EA" }, "code_information": [ { "code": "J3490", "type": "HCPCS" }, { "code": "70860-117-26", "type": "NDC" } ], "standard_charges": [ { "gross_charge": 132.37, "minimum": 105.90, "maximum": 112.51, "setting": "both", "payers_information": [ { "payer_name": "Aetna", "plan_name": "700700", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed 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}, { "payer_name": "Bc/Bs Ms State Emplo", "plan_name": "401457", "standard_charge_percentage": 0.80, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Ms State Emplo", "plan_name": "401457_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Basic Pl", "plan_name": "400100", "standard_charge_percentage": 0.85, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Basic Pl", "plan_name": "400100_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Federal", "plan_name": "400110", "standard_charge_percentage": 0.85, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Federal", "plan_name": "400110_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." } ] } ] }, { "description": "Sugammadex 100 mg/ml intravenous solution [172421]", "drug_information": { "unit": 2.00, "type": "ML" }, "code_information": [ { "code": "J3490", "type": "HCPCS" }, { "code": "0006-5423-02", "type": "NDC" } ], "standard_charges": [ { "gross_charge": 609.79, "minimum": 487.83, "maximum": 518.32, "setting": "both", "payers_information": [ { "payer_name": "Aetna", "plan_name": "700700", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed 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"additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Ppo Hmo", "plan_name": "701720_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Ms State Emplo", "plan_name": "401457", "standard_charge_percentage": 0.80, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Ms State Emplo", "plan_name": "401457_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Basic Pl", "plan_name": "400100", "standard_charge_percentage": 0.85, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Basic Pl", "plan_name": "400100_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Federal", "plan_name": "400110", "standard_charge_percentage": 0.85, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Federal", "plan_name": "400110_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." } ] } ] }, { "description": "Sugammadex 100 mg/ml intravenous solution [172421]", "drug_information": { "unit": 2.00, "type": "ML" }, "code_information": [ { "code": 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{ "payer_name": "Bc/Bs Of Ms Federal", "plan_name": "400110", "standard_charge_percentage": 0.85, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Federal", "plan_name": "400110_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." } ] } ] }, { "description": "Sodium chloride 0.9 % intravenous solution [27838]", "drug_information": { "unit": 500.00, "type": "ML" }, "code_information": [ { "code": "J7040", "type": "HCPCS" }, { "code": "63323-623-75", "type": "NDC" } ], "standard_charges": [ { "gross_charge": 81.81, "minimum": 65.45, "maximum": 69.54, "setting": "both", "payers_information": [ { "payer_name": "Aetna", "plan_name": "700700", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed 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{ "payer_name": "Bc/Bs Of Ms Federal", "plan_name": "400110", "standard_charge_percentage": 0.85, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Federal", "plan_name": "400110_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." } ] } ] }, { "description": "Dextrose 5 % and 0.9 % sodium chloride intravenous solution [9815]", "drug_information": { "unit": 1000.00, "type": "ML" }, "code_information": [ { "code": "J7042", "type": "HCPCS" }, { "code": "0338-0089-04", "type": "NDC" } ], "standard_charges": [ { "gross_charge": 81.81, "minimum": 65.45, "maximum": 69.54, "setting": "both", "payers_information": [ { "payer_name": "Aetna", "plan_name": "700700", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent 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}, { "payer_name": "Bc/Bs Ms State Emplo", "plan_name": "401457", "standard_charge_percentage": 0.80, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Ms State Emplo", "plan_name": "401457_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Basic Pl", "plan_name": "400100", "standard_charge_percentage": 0.85, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Basic Pl", "plan_name": "400100_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Federal", "plan_name": "400110", "standard_charge_percentage": 0.85, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Federal", "plan_name": "400110_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." } ] } ] }, { "description": "Sodium chloride 0.9 % intravenous solution [27838]", "drug_information": { "unit": 250.00, "type": "ML" }, "code_information": [ { "code": "J7050", "type": "HCPCS" }, { "code": "63323-623-74", "type": "NDC" } ], "standard_charges": [ { "gross_charge": 81.81, "minimum": 65.45, "maximum": 69.54, "setting": "both", "payers_information": [ { "payer_name": "Aetna", "plan_name": "700700", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed 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"additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Ppo Hmo", "plan_name": "701720_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Ms State Emplo", "plan_name": "401457", "standard_charge_percentage": 0.80, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Ms State Emplo", "plan_name": "401457_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Basic Pl", "plan_name": "400100", "standard_charge_percentage": 0.85, "count": "0", "methodology": "percent of total billed charges", 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"standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." } ] } ] }, { "description": "Dextrose 5 % in water (d5w) intravenous solution [2364]", "drug_information": { "unit": 1000.00, "type": "ML" }, "code_information": [ { "code": "J7070", "type": "HCPCS" }, { "code": "63323-624-03", "type": "NDC" } ], "standard_charges": [ { "gross_charge": 81.81, "minimum": 65.45, "maximum": 69.54, "setting": "both", "payers_information": [ { "payer_name": "Aetna", "plan_name": "700700", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna", "plan_name": "700700_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to 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amounts." }, { "payer_name": "Bc/Bs Ms State Emplo", "plan_name": "401457", "standard_charge_percentage": 0.80, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Ms State Emplo", "plan_name": "401457_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Basic Pl", "plan_name": "400100", "standard_charge_percentage": 0.85, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Basic Pl", "plan_name": "400100_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Federal", "plan_name": "400110", "standard_charge_percentage": 0.85, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Federal", "plan_name": "400110_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." } ] } ] }, { "description": "Lactated ringers intravenous solution [4318]", "drug_information": { "unit": 500.00, "type": "ML" }, "code_information": [ { "code": "J7120", "type": "HCPCS" }, { "code": "0338-0117-03", "type": "NDC" } ], "standard_charges": [ { "gross_charge": 81.81, "minimum": 65.45, "maximum": 69.54, "setting": "both", "payers_information": [ { "payer_name": "Aetna", "plan_name": "700700", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna", "plan_name": "700700_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Miscellaneous", "plan_name": "700720", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Miscellaneous", "plan_name": "700720_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Ppo Hmo", "plan_name": "701720", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Ppo Hmo", "plan_name": "701720_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Ms State Emplo", "plan_name": "401457", "standard_charge_percentage": 0.80, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Ms State Emplo", "plan_name": "401457_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Basic Pl", "plan_name": "400100", "standard_charge_percentage": 0.85, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Basic Pl", "plan_name": "400100_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Federal", "plan_name": "400110", "standard_charge_percentage": 0.85, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Federal", "plan_name": "400110_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." } ] } ] }, { "description": "Lactated ringers intravenous solution [4318]", "drug_information": { "unit": 1000.00, "type": "ML" }, "code_information": [ { "code": "J7120", "type": "HCPCS" }, { "code": "0338-0117-04", "type": "NDC" } ], "standard_charges": [ { "gross_charge": 81.81, "minimum": 65.45, "maximum": 69.54, "setting": "both", "payers_information": [ { "payer_name": "Aetna", "plan_name": "700700", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna", "plan_name": "700700_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Miscellaneous", "plan_name": "700720", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Miscellaneous", "plan_name": "700720_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Ppo Hmo", "plan_name": "701720", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Ppo Hmo", "plan_name": "701720_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Ms State Emplo", "plan_name": "401457", "standard_charge_percentage": 0.80, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Ms State Emplo", "plan_name": "401457_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Basic Pl", "plan_name": "400100", "standard_charge_percentage": 0.85, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Basic Pl", "plan_name": "400100_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Federal", "plan_name": "400110", "standard_charge_percentage": 0.85, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Federal", "plan_name": "400110_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." } ] } ] }, { "description": "Dextrose 5 % and lactated ringers intravenous solution [9788]", "drug_information": { "unit": 500.00, "type": "ML" }, "code_information": [ { "code": "J7121", "type": "HCPCS" }, { "code": "0338-0125-03", "type": "NDC" } ], "standard_charges": [ { "gross_charge": 81.81, "minimum": 0.94, "maximum": 0.94, "setting": "both", "payers_information": [ { "payer_name": "Aetna", "plan_name": "700700", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna", "plan_name": "700700_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Miscellaneous", "plan_name": "700720", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Miscellaneous", "plan_name": "700720_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Ppo Hmo", "plan_name": "701720", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Ppo Hmo", "plan_name": "701720_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Ms State Emplo", "plan_name": "401457", "standard_charge_dollar": 0.94, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Ms State Emplo", "plan_name": "401457_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Basic Pl", "plan_name": "400100", "standard_charge_dollar": 0.94, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Basic Pl", "plan_name": "400100_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Federal", "plan_name": "400110", "standard_charge_dollar": 0.94, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Federal", "plan_name": "400110_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." } ] } ] }, { "description": "Dextrose 5 % and lactated ringers intravenous solution [9788]", "drug_information": { "unit": 1000.00, "type": "ML" }, "code_information": [ { "code": "J7121", "type": "HCPCS" }, { "code": "0338-0125-04", "type": "NDC" } ], "standard_charges": [ { "gross_charge": 81.81, "minimum": 0.94, "maximum": 0.94, "setting": "both", "payers_information": [ { "payer_name": "Aetna", "plan_name": "700700", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna", "plan_name": "700700_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Miscellaneous", "plan_name": "700720", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Miscellaneous", "plan_name": "700720_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Ppo Hmo", "plan_name": "701720", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Ppo Hmo", "plan_name": "701720_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Ms State Emplo", "plan_name": "401457", "standard_charge_dollar": 0.94, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Ms State Emplo", "plan_name": "401457_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Basic Pl", "plan_name": "400100", "standard_charge_dollar": 0.94, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Basic Pl", "plan_name": "400100_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Federal", "plan_name": "400110", "standard_charge_dollar": 0.94, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Federal", "plan_name": "400110_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." } ] } ] }, { "description": "Sodium chloride 3 % hypertonic intravenous injection solution [7321]", "drug_information": { "unit": 500.00, "type": "ML" }, "code_information": [ { "code": "J7131", "type": "HCPCS" }, { "code": "0338-0054-03", "type": "NDC" } ], "standard_charges": [ { "gross_charge": 112.69, "minimum": 90.15, "maximum": 95.79, "setting": "both", "payers_information": [ { "payer_name": "Aetna", "plan_name": "700700", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna", "plan_name": "700700_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Miscellaneous", "plan_name": "700720", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Miscellaneous", "plan_name": "700720_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Ppo Hmo", "plan_name": "701720", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Ppo Hmo", "plan_name": "701720_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Ms State Emplo", "plan_name": "401457", "standard_charge_percentage": 0.80, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Ms State Emplo", "plan_name": "401457_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Basic Pl", "plan_name": "400100", "standard_charge_percentage": 0.85, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Basic Pl", "plan_name": "400100_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Federal", "plan_name": "400110", "standard_charge_percentage": 0.85, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Federal", "plan_name": "400110_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." } ] } ] }, { "description": "Hum prothrombin cplx (pcc) 4factor 500 unit (400-620 unit) iv solution [166295]", "drug_information": { "unit": 500.00, "type": "UN" }, "code_information": [ { "code": "J7168", "type": "HCPCS" }, { "code": "63833-386-02", "type": "NDC" } ], "standard_charges": [ { "gross_charge": 3577.80, "minimum": 2.18, "maximum": 3041.13, "setting": "both", "payers_information": [ { "payer_name": "Aarp", "plan_name": "500102", "standard_charge_dollar": 2.18, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna", "plan_name": "700700", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna", "plan_name": "700700_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Mcare Ffs 6005", "plan_name": "700703", "standard_charge_dollar": 2.18, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Miscellaneous", "plan_name": "700720", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Miscellaneous", "plan_name": "700720_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Ppo Hmo", "plan_name": "701720", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Ppo Hmo", "plan_name": "701720_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Ambetter 68069", "plan_name": "500516", "standard_charge_dollar": 2.18, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Ms State Emplo", "plan_name": "401457", "standard_charge_percentage": 0.80, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Ms State Emplo", "plan_name": "401457_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Basic Pl", "plan_name": "400100", "standard_charge_percentage": 0.85, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Basic Pl", "plan_name": "400100_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Federal", "plan_name": "400110", "standard_charge_percentage": 0.85, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Federal", "plan_name": "400110_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Cigna Healthsprings Ffs", "plan_name": "500064", "standard_charge_dollar": 2.18, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Conseco", "plan_name": "500302", "standard_charge_dollar": 2.18, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Humana Ffs 61101", "plan_name": "500006", "standard_charge_dollar": 2.18, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Medicare A", "plan_name": "100100", "standard_charge_dollar": 2.18, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Medicare A", "plan_name": "100500", "standard_charge_dollar": 2.18, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Medicare Part B Only", "plan_name": "100300", "standard_charge_dollar": 2.18, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Medicare Railroad", "plan_name": "100103", "standard_charge_dollar": 2.18, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Ms Physicians Care N", "plan_name": "714210", "standard_charge_dollar": 2.73, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Peoples Hlth Ffs 72126", "plan_name": "500019", "standard_charge_dollar": 2.18, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Uhc/Secure Horizons", "plan_name": "500449", "standard_charge_dollar": 2.18, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "United Health Care/", "plan_name": "500292", "standard_charge_dollar": 2.46, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "United Healthcare", "plan_name": "750104", "standard_charge_dollar": 2.46, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "United Healthcare Ba", "plan_name": "750090", "standard_charge_dollar": 2.46, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "United Healthcare Me", "plan_name": "501310", "standard_charge_dollar": 2.18, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Windsor Mcare Extra", "plan_name": "500778", "standard_charge_dollar": 2.18, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." } ] } ] }, { "description": "Hum prothrombin cplx(pcc)4fact 1000 unit (800-1240 unit) iv solution [166702]", "drug_information": { "unit": 1000.00, "type": "UN" }, "code_information": [ { "code": "J7168", "type": "HCPCS" }, { "code": "63833-387-02", "type": "NDC" } ], "standard_charges": [ { "gross_charge": 7155.60, "minimum": 2.18, "maximum": 6082.26, "setting": "both", "payers_information": [ { "payer_name": "Aarp", "plan_name": "500102", "standard_charge_dollar": 2.18, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna", "plan_name": "700700", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna", "plan_name": "700700_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Mcare Ffs 6005", "plan_name": "700703", "standard_charge_dollar": 2.18, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Miscellaneous", "plan_name": "700720", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Miscellaneous", "plan_name": "700720_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Ppo Hmo", "plan_name": "701720", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Ppo Hmo", "plan_name": "701720_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Ambetter 68069", "plan_name": "500516", "standard_charge_dollar": 2.18, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Ms State Emplo", "plan_name": "401457", "standard_charge_percentage": 0.80, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Ms State Emplo", "plan_name": "401457_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Basic Pl", "plan_name": "400100", "standard_charge_percentage": 0.85, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Basic Pl", "plan_name": "400100_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Federal", "plan_name": "400110", "standard_charge_percentage": 0.85, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Federal", "plan_name": "400110_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Cigna Healthsprings Ffs", "plan_name": "500064", "standard_charge_dollar": 2.18, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Conseco", "plan_name": "500302", "standard_charge_dollar": 2.18, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Humana Ffs 61101", "plan_name": "500006", "standard_charge_dollar": 2.18, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Medicare A", "plan_name": "100100", "standard_charge_dollar": 2.18, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Medicare A", "plan_name": "100500", "standard_charge_dollar": 2.18, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Medicare Part B Only", "plan_name": "100300", "standard_charge_dollar": 2.18, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Medicare Railroad", "plan_name": "100103", "standard_charge_dollar": 2.18, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Ms Physicians Care N", "plan_name": "714210", "standard_charge_dollar": 2.73, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Peoples Hlth Ffs 72126", "plan_name": "500019", "standard_charge_dollar": 2.18, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Uhc/Secure Horizons", "plan_name": "500449", "standard_charge_dollar": 2.18, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "United Health Care/", "plan_name": "500292", "standard_charge_dollar": 2.46, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "United Healthcare", "plan_name": "750104", "standard_charge_dollar": 2.46, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "United Healthcare Ba", "plan_name": "750090", "standard_charge_dollar": 2.46, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "United Healthcare Me", "plan_name": "501310", "standard_charge_dollar": 2.18, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Windsor Mcare Extra", "plan_name": "500778", "standard_charge_dollar": 2.18, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." } ] } ] }, { "description": "Hum prothrombin cplx (pcc) 4factor 500 unit (400-620 unit) iv solution [166295]", "drug_information": { "unit": 500.00, "type": "UN" }, "code_information": [ { "code": "J7168", "type": "HCPCS" }, { "code": "63833-396-01", "type": "NDC" } ], "standard_charges": [ { "gross_charge": 6030.00, "minimum": 2.18, "maximum": 5125.50, "setting": "both", "payers_information": [ { "payer_name": "Aarp", "plan_name": "500102", "standard_charge_dollar": 2.18, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna", "plan_name": "700700", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna", "plan_name": "700700_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Mcare Ffs 6005", "plan_name": "700703", "standard_charge_dollar": 2.18, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Miscellaneous", "plan_name": "700720", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Miscellaneous", "plan_name": "700720_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Ppo Hmo", "plan_name": "701720", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Ppo Hmo", "plan_name": "701720_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Ambetter 68069", "plan_name": "500516", "standard_charge_dollar": 2.18, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Ms State Emplo", "plan_name": "401457", "standard_charge_percentage": 0.80, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Ms State Emplo", "plan_name": "401457_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Basic Pl", "plan_name": "400100", "standard_charge_percentage": 0.85, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Basic Pl", "plan_name": "400100_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Federal", "plan_name": "400110", "standard_charge_percentage": 0.85, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Federal", "plan_name": "400110_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Cigna Healthsprings Ffs", "plan_name": "500064", "standard_charge_dollar": 2.18, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Conseco", "plan_name": "500302", "standard_charge_dollar": 2.18, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Humana Ffs 61101", "plan_name": "500006", "standard_charge_dollar": 2.18, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Medicare A", "plan_name": "100100", "standard_charge_dollar": 2.18, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Medicare A", "plan_name": "100500", "standard_charge_dollar": 2.18, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Medicare Part B Only", "plan_name": "100300", "standard_charge_dollar": 2.18, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Medicare Railroad", "plan_name": "100103", "standard_charge_dollar": 2.18, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Ms Physicians Care N", "plan_name": "714210", "standard_charge_dollar": 2.73, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Peoples Hlth Ffs 72126", "plan_name": "500019", "standard_charge_dollar": 2.18, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Uhc/Secure Horizons", "plan_name": "500449", "standard_charge_dollar": 2.18, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "United Health Care/", "plan_name": "500292", "standard_charge_dollar": 2.46, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "United Healthcare", "plan_name": "750104", "standard_charge_dollar": 2.46, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "United Healthcare Ba", "plan_name": "750090", "standard_charge_dollar": 2.46, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "United Healthcare Me", "plan_name": "501310", "standard_charge_dollar": 2.18, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Windsor Mcare Extra", "plan_name": "500778", "standard_charge_dollar": 2.18, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." } ] } ] }, { "description": "Hum prothrombin cplx(pcc)4fact 1000 unit (800-1240 unit) iv solution [166702]", "drug_information": { "unit": 1000.00, "type": "UN" }, "code_information": [ { "code": "J7168", "type": "HCPCS" }, { "code": "63833-397-01", "type": "NDC" } ], "standard_charges": [ { "gross_charge": 12060.00, "minimum": 2.18, "maximum": 10251.00, "setting": "both", "payers_information": [ { "payer_name": "Aarp", "plan_name": "500102", "standard_charge_dollar": 2.18, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna", "plan_name": "700700", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna", "plan_name": "700700_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Mcare Ffs 6005", "plan_name": "700703", "standard_charge_dollar": 2.18, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Miscellaneous", "plan_name": "700720", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Miscellaneous", "plan_name": "700720_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Ppo Hmo", "plan_name": "701720", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Ppo Hmo", "plan_name": "701720_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Ambetter 68069", "plan_name": "500516", "standard_charge_dollar": 2.18, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Ms State Emplo", "plan_name": "401457", "standard_charge_percentage": 0.80, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Ms State Emplo", "plan_name": "401457_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Basic Pl", "plan_name": "400100", "standard_charge_percentage": 0.85, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Basic Pl", "plan_name": "400100_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Federal", "plan_name": "400110", "standard_charge_percentage": 0.85, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Federal", "plan_name": "400110_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Cigna Healthsprings Ffs", "plan_name": "500064", "standard_charge_dollar": 2.18, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Conseco", "plan_name": "500302", "standard_charge_dollar": 2.18, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Humana Ffs 61101", "plan_name": "500006", "standard_charge_dollar": 2.18, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Medicare A", "plan_name": "100100", "standard_charge_dollar": 2.18, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Medicare A", "plan_name": "100500", "standard_charge_dollar": 2.18, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Medicare Part B Only", "plan_name": "100300", "standard_charge_dollar": 2.18, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Medicare Railroad", "plan_name": "100103", "standard_charge_dollar": 2.18, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Ms Physicians Care N", "plan_name": "714210", "standard_charge_dollar": 2.73, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Peoples Hlth Ffs 72126", "plan_name": "500019", "standard_charge_dollar": 2.18, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Uhc/Secure Horizons", "plan_name": "500449", "standard_charge_dollar": 2.18, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "United Health Care/", "plan_name": "500292", "standard_charge_dollar": 2.46, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "United Healthcare", "plan_name": "750104", "standard_charge_dollar": 2.46, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "United Healthcare Ba", "plan_name": "750090", "standard_charge_dollar": 2.46, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "United Healthcare Me", "plan_name": "501310", "standard_charge_dollar": 2.18, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Windsor Mcare Extra", "plan_name": "500778", "standard_charge_dollar": 2.18, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." } ] } ] }, { "description": "Hylan g-f 20 48 mg/6 ml intra-articular syringe [118765]", "drug_information": { "unit": 6.00, "type": "ML" }, "code_information": [ { "code": "J7325", "type": "HCPCS" }, { "code": "58468-0090-03", "type": "NDC" } ], "standard_charges": [ { "gross_charge": 6441.30, "minimum": 9.25, "maximum": 24.88, "setting": "both", "payers_information": [ { "payer_name": "Aarp", "plan_name": "500102", "standard_charge_dollar": 9.25, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna", "plan_name": "700700", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna", "plan_name": "700700_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Mcare Ffs 6005", "plan_name": "700703", "standard_charge_dollar": 9.25, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Miscellaneous", "plan_name": "700720", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", 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data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Ms State Emplo", "plan_name": "401457", "standard_charge_dollar": 24.88, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Ms State Emplo", "plan_name": "401457_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Basic Pl", "plan_name": "400100", "standard_charge_dollar": 24.88, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Basic Pl", "plan_name": "400100_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Federal", "plan_name": "400110", "standard_charge_dollar": 24.88, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Federal", "plan_name": "400110_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Cigna Healthsprings Ffs", "plan_name": "500064", "standard_charge_dollar": 9.25, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Conseco", "plan_name": "500302", "standard_charge_dollar": 9.25, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Humana Ffs 61101", "plan_name": "500006", "standard_charge_dollar": 9.25, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Medicare A", "plan_name": "100100", "standard_charge_dollar": 9.25, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Medicare A", "plan_name": "100500", "standard_charge_dollar": 9.25, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Medicare Part B Only", "plan_name": "100300", "standard_charge_dollar": 9.25, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Medicare Railroad", "plan_name": "100103", "standard_charge_dollar": 9.25, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Ms Physicians Care N", "plan_name": "714210", "standard_charge_dollar": 11.56, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Peoples Hlth Ffs 72126", "plan_name": "500019", "standard_charge_dollar": 9.25, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Uhc/Secure Horizons", "plan_name": "500449", "standard_charge_dollar": 9.25, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "United Health Care/", "plan_name": "500292", "standard_charge_dollar": 10.45, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "United Healthcare", "plan_name": "750104", "standard_charge_dollar": 10.45, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "United Healthcare Ba", "plan_name": "750090", "standard_charge_dollar": 10.45, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "United Healthcare Me", "plan_name": "501310", "standard_charge_dollar": 9.25, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Windsor Mcare Extra", "plan_name": "500778", "standard_charge_dollar": 9.25, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." } ] } ] }, { "description": "Azathioprine 50 mg tablet [9183]", "drug_information": { "unit": 1.00, "type": "EA" }, "code_information": [ { "code": "J7500", "type": "HCPCS" }, { "code": 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"methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Ppo Hmo", "plan_name": "701720", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Ppo Hmo", "plan_name": "701720_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Ms State Emplo", "plan_name": "401457", "standard_charge_percentage": 0.80, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Ms State Emplo", "plan_name": "401457_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Basic Pl", "plan_name": "400100", "standard_charge_percentage": 0.85, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Basic Pl", "plan_name": "400100_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Federal", "plan_name": "400110", "standard_charge_percentage": 0.85, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Federal", "plan_name": "400110_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." } ] } ] }, { "description": "Tacrolimus 0.5 mg capsule immediate-release [24914]", "drug_information": { "unit": 1.00, "type": "EA" }, "code_information": [ { "code": "J7507", "type": "HCPCS" }, { "code": "68084-449-11", "type": "NDC" } ], "standard_charges": [ { "gross_charge": 10.83, "minimum": 3.57, "maximum": 3.57, "setting": "both", "payers_information": [ { "payer_name": "Aetna", "plan_name": "700700", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna", "plan_name": "700700_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Miscellaneous", "plan_name": "700720", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Miscellaneous", "plan_name": "700720_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Ppo Hmo", "plan_name": "701720", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Ppo Hmo", "plan_name": "701720_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Ms State Emplo", "plan_name": "401457", "standard_charge_dollar": 3.57, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Ms State Emplo", "plan_name": "401457_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Basic Pl", "plan_name": "400100", "standard_charge_dollar": 3.57, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Basic Pl", "plan_name": "400100_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Federal", "plan_name": "400110", "standard_charge_dollar": 3.57, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Federal", "plan_name": "400110_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." } ] } ] }, { "description": "Tacrolimus 1 mg capsule immediate-release [12933]", "drug_information": { "unit": 1.00, "type": "EA" }, "code_information": [ { "code": "J7507", "type": "HCPCS" }, { "code": "51079-818-01", "type": "NDC" } ], "standard_charges": [ { "gross_charge": 11.99, "minimum": 3.57, "maximum": 3.57, "setting": "both", "payers_information": [ { "payer_name": "Aetna", "plan_name": "700700", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna", "plan_name": "700700_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Miscellaneous", "plan_name": "700720", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Miscellaneous", "plan_name": "700720_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Ppo Hmo", "plan_name": "701720", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Ppo Hmo", "plan_name": "701720_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Ms State Emplo", "plan_name": "401457", "standard_charge_dollar": 3.57, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Ms State Emplo", "plan_name": "401457_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Basic Pl", "plan_name": "400100", "standard_charge_dollar": 3.57, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Basic Pl", "plan_name": "400100_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Federal", "plan_name": "400110", "standard_charge_dollar": 3.57, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Federal", "plan_name": "400110_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." } ] } ] }, { "description": "Methylprednisolone 4 mg tablet [4993]", "drug_information": { "unit": 1.00, "type": "EA" }, "code_information": [ { "code": "J7509", "type": "HCPCS" }, { "code": "59746-001-06", "type": "NDC" } ], "standard_charges": [ { "gross_charge": 7.50, "minimum": 6.00, "maximum": 6.38, "setting": "both", "payers_information": [ { "payer_name": "Aetna", "plan_name": "700700", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna", "plan_name": "700700_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Miscellaneous", "plan_name": "700720", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Miscellaneous", "plan_name": "700720_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Ppo Hmo", "plan_name": "701720", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Ppo Hmo", "plan_name": "701720_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Ms State Emplo", "plan_name": "401457", "standard_charge_percentage": 0.80, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Ms State Emplo", "plan_name": "401457_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Basic Pl", "plan_name": "400100", "standard_charge_percentage": 0.85, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Basic Pl", "plan_name": "400100_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Federal", "plan_name": "400110", "standard_charge_percentage": 0.85, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Federal", "plan_name": "400110_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." } ] } ] }, { "description": "Methylprednisolone 4 mg tablets in a dose pack [4991]", "drug_information": { "unit": 21.00, "type": "EA" }, "code_information": [ { "code": "J7509", "type": "HCPCS" }, { "code": "42806-400-21", "type": "NDC" } ], "standard_charges": [ { "gross_charge": 30.03, "minimum": 24.02, "maximum": 25.53, "setting": "both", "payers_information": [ { "payer_name": "Aetna", "plan_name": "700700", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna", "plan_name": "700700_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Miscellaneous", "plan_name": "700720", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed 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"methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Ms State Emplo", "plan_name": "401457_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Basic Pl", "plan_name": "400100", "standard_charge_percentage": 0.85, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Basic Pl", "plan_name": "400100_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Federal", "plan_name": "400110", "standard_charge_percentage": 0.85, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Federal", "plan_name": "400110_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." } ] } ] }, { "description": "Prednisone 20 mg tablet [6496]", "drug_information": { "unit": 1.00, "type": "EA" }, "code_information": [ { "code": "J7512", "type": "HCPCS" }, { "code": "0054-0018-20", "type": "NDC" } ], "standard_charges": [ { "gross_charge": 7.50, "minimum": 6.00, "maximum": 6.38, "setting": "both", "payers_information": [ { "payer_name": "Aetna", "plan_name": "700700", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna", "plan_name": 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"standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Ms State Emplo", "plan_name": "401457", "standard_charge_percentage": 0.80, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Ms State Emplo", "plan_name": "401457_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Basic Pl", "plan_name": "400100", "standard_charge_percentage": 0.85, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Basic Pl", "plan_name": "400100_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Federal", "plan_name": "400110", "standard_charge_percentage": 0.85, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Federal", "plan_name": "400110_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." } ] } ] }, { "description": "Prednisone 50 mg tablet [6498]", "drug_information": { "unit": 1.00, "type": "EA" }, "code_information": [ { "code": "J7512", "type": "HCPCS" }, { "code": "0054-0019-20", "type": "NDC" } ], "standard_charges": [ { "gross_charge": 7.50, "minimum": 6.00, "maximum": 6.38, "setting": "both", 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"payer_name": "Bc/Bs Ms State Emplo", "plan_name": "401457", "standard_charge_dollar": 3.18, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Ms State Emplo", "plan_name": "401457_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Basic Pl", "plan_name": "400100", "standard_charge_dollar": 3.18, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Basic Pl", "plan_name": "400100_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Federal", 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"payer_name": "Aetna Ppo Hmo", "plan_name": "701720_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Ms State Emplo", "plan_name": "401457", "standard_charge_dollar": 3.18, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Ms State Emplo", "plan_name": "401457_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Basic Pl", "plan_name": "400100", "standard_charge_dollar": 3.18, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Basic Pl", "plan_name": 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"standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." } ] } ] }, { "description": "Ipratropium bromide 0.02 % solution for inhalation [12580]", "drug_information": { "unit": 2.50, "type": "ML" }, "code_information": [ { "code": "J7644", "type": "HCPCS" }, { "code": "0487-9801-01", "type": "NDC" } ], "standard_charges": [ { "gross_charge": 7.50, "minimum": 2.82, "maximum": 2.82, "setting": "both", "payers_information": [ { "payer_name": "Aetna", "plan_name": "700700", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna", "plan_name": "700700_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate 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}, { "payer_name": "Bc/Bs Ms State Emplo", "plan_name": "401457", "standard_charge_dollar": 2.82, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Ms State Emplo", "plan_name": "401457_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Basic Pl", "plan_name": "400100", "standard_charge_dollar": 2.82, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Basic Pl", "plan_name": "400100_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Federal", "plan_name": "400110", "standard_charge_dollar": 2.82, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Federal", "plan_name": "400110_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." } ] } ] }, { "description": "Ipratropium bromide 0.02 % solution for inhalation [12580]", "drug_information": { "unit": 2.50, "type": "ML" }, "code_information": [ { "code": "J7644", "type": "HCPCS" }, { "code": "76204-100-01", "type": "NDC" } ], "standard_charges": [ { "gross_charge": 7.50, "minimum": 2.82, "maximum": 2.82, "setting": "both", "payers_information": [ { "payer_name": "Aetna", "plan_name": "700700", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data 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"plan_name": "400100_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Federal", "plan_name": "400110", "standard_charge_dollar": 2.82, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Federal", "plan_name": "400110_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." } ] } ] }, { "description": "Ipratropium bromide 0.02 % solution for inhalation [12580]", "drug_information": { "unit": 2.50, "type": "ML" }, "code_information": [ { "code": "J7644", "type": "HCPCS" }, { "code": "76204-100-30", "type": "NDC" } ], "standard_charges": [ { "gross_charge": 7.50, "minimum": 2.82, 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"payer_name": "Bc/Bs Of Ms Basic Pl", "plan_name": "400100", "standard_charge_dollar": 2.82, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Basic Pl", "plan_name": "400100_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Federal", "plan_name": "400110", "standard_charge_dollar": 2.82, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Federal", "plan_name": "400110_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." } ] } ] }, { "description": "Dexamethasone 1 mg/ml 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"additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Miscellaneous", "plan_name": "700720", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Miscellaneous", "plan_name": "700720_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Ppo Hmo", "plan_name": "701720", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Ppo Hmo", "plan_name": "701720_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Ms State Emplo", "plan_name": "401457", "standard_charge_percentage": 0.80, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Ms State Emplo", "plan_name": "401457_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Basic Pl", "plan_name": "400100", "standard_charge_percentage": 0.85, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Basic Pl", "plan_name": "400100_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Federal", "plan_name": "400110", "standard_charge_percentage": 0.85, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Federal", "plan_name": "400110_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." } ] } ] }, { "description": "Dexamethasone 4 mg tablet [2327]", "drug_information": { "unit": 1.00, "type": "EA" }, "code_information": [ { "code": "J8540", "type": "HCPCS" }, { "code": "0054-8175-25", "type": "NDC" } ], "standard_charges": [ { "gross_charge": 7.98, "minimum": 6.38, "maximum": 6.78, "setting": "both", "payers_information": [ { "payer_name": "Aetna", "plan_name": "700700", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna", "plan_name": "700700_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Miscellaneous", "plan_name": "700720", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Miscellaneous", "plan_name": "700720_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Ppo Hmo", "plan_name": "701720", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Ppo Hmo", "plan_name": "701720_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Ms State Emplo", "plan_name": "401457", "standard_charge_percentage": 0.80, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Ms State Emplo", "plan_name": "401457_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Basic Pl", "plan_name": "400100", "standard_charge_percentage": 0.85, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Basic Pl", "plan_name": "400100_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Federal", "plan_name": "400110", "standard_charge_percentage": 0.85, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Federal", "plan_name": "400110_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." } ] } ] }, { "description": "Dexamethasone 2 mg tablet [2326]", "drug_information": { "unit": 1.00, "type": "EA" }, 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"methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." } ] } ] }, { "description": "Bendamustine 100 mg intravenous powder for solution [91300]", "drug_information": { "unit": 1.00, "type": "EA" }, "code_information": [ { "code": "J9033", "type": "HCPCS" }, { "code": "71288-103-20", "type": "NDC" } ], "standard_charges": [ { "gross_charge": 4062.42, "minimum": 1.24, "maximum": 22.33, "setting": "both", "payers_information": [ { "payer_name": "Aarp", "plan_name": "500102", "standard_charge_dollar": 1.24, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna", "plan_name": "700700", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna", "plan_name": "700700_1", 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"count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Ppo Hmo", "plan_name": "701720_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Ambetter 68069", "plan_name": "500516", "standard_charge_dollar": 1.24, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Ms State Emplo", "plan_name": "401457", "standard_charge_dollar": 22.33, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Ms State Emplo", "plan_name": "401457_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Basic Pl", "plan_name": "400100", "standard_charge_dollar": 22.33, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Basic Pl", "plan_name": "400100_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Federal", "plan_name": "400110", "standard_charge_dollar": 22.33, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Federal", "plan_name": "400110_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Cigna Healthsprings Ffs", "plan_name": "500064", "standard_charge_dollar": 1.24, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Conseco", "plan_name": "500302", "standard_charge_dollar": 1.24, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Humana Ffs 61101", "plan_name": "500006", "standard_charge_dollar": 1.24, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Medicare A", "plan_name": "100100", "standard_charge_dollar": 1.24, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Medicare A", "plan_name": "100500", "standard_charge_dollar": 1.24, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Medicare Part B Only", "plan_name": "100300", "standard_charge_dollar": 1.24, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Medicare Railroad", "plan_name": "100103", "standard_charge_dollar": 1.24, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Ms Physicians Care N", "plan_name": "714210", "standard_charge_dollar": 1.55, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Peoples Hlth Ffs 72126", "plan_name": "500019", "standard_charge_dollar": 1.24, "count": "0", "methodology": "fee schedule", 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"United Healthcare Me", "plan_name": "501310", "standard_charge_dollar": 1.24, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Windsor Mcare Extra", "plan_name": "500778", "standard_charge_dollar": 1.24, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." } ] } ] }, { "description": "Bendamustine 25 mg intravenous powder for solution [100581]", "drug_information": { "unit": 1.00, "type": "EA" }, "code_information": [ { "code": "J9033", "type": "HCPCS" }, { "code": "63459-390-08", "type": "NDC" } ], "standard_charges": [ { "gross_charge": 3510.45, "minimum": 1.24, "maximum": 22.33, "setting": "both", "payers_information": [ { "payer_name": "Aarp", "plan_name": "500102", "standard_charge_dollar": 1.24, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna", "plan_name": "700700", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna", "plan_name": "700700_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Mcare Ffs 6005", "plan_name": "700703", "standard_charge_dollar": 1.24, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Miscellaneous", "plan_name": "700720", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Miscellaneous", "plan_name": "700720_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Ppo Hmo", "plan_name": "701720", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Ppo Hmo", "plan_name": "701720_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Ambetter 68069", "plan_name": "500516", "standard_charge_dollar": 1.24, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Ms State Emplo", "plan_name": "401457", "standard_charge_dollar": 22.33, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Ms State Emplo", "plan_name": "401457_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Basic Pl", "plan_name": "400100", "standard_charge_dollar": 22.33, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Basic Pl", "plan_name": "400100_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Federal", "plan_name": "400110", "standard_charge_dollar": 22.33, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Federal", "plan_name": "400110_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Cigna Healthsprings Ffs", "plan_name": "500064", "standard_charge_dollar": 1.24, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Conseco", "plan_name": "500302", "standard_charge_dollar": 1.24, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Humana Ffs 61101", "plan_name": "500006", "standard_charge_dollar": 1.24, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Medicare A", "plan_name": "100100", "standard_charge_dollar": 1.24, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Medicare A", "plan_name": "100500", "standard_charge_dollar": 1.24, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Medicare Part B Only", "plan_name": "100300", "standard_charge_dollar": 1.24, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Medicare Railroad", "plan_name": "100103", "standard_charge_dollar": 1.24, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Ms Physicians Care N", "plan_name": "714210", "standard_charge_dollar": 1.55, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Peoples Hlth Ffs 72126", "plan_name": "500019", "standard_charge_dollar": 1.24, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Uhc/Secure Horizons", "plan_name": "500449", "standard_charge_dollar": 1.24, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "United Health Care/", "plan_name": "500292", "standard_charge_dollar": 1.40, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "United Healthcare", "plan_name": "750104", "standard_charge_dollar": 1.40, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "United Healthcare Ba", "plan_name": "750090", "standard_charge_dollar": 1.40, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "United Healthcare Me", "plan_name": "501310", "standard_charge_dollar": 1.24, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Windsor Mcare Extra", "plan_name": "500778", "standard_charge_dollar": 1.24, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." } ] } ] }, { "description": "Bendamustine 100 mg intravenous powder for solution [91300]", "drug_information": { "unit": 1.00, "type": "EA" }, "code_information": [ { "code": "J9033", "type": "HCPCS" }, { "code": "63459-391-20", "type": "NDC" } ], "standard_charges": [ { "gross_charge": 14041.76, "minimum": 1.24, "maximum": 22.33, "setting": "both", "payers_information": [ { "payer_name": "Aarp", "plan_name": "500102", "standard_charge_dollar": 1.24, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna", "plan_name": "700700", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna", "plan_name": "700700_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Mcare Ffs 6005", "plan_name": "700703", "standard_charge_dollar": 1.24, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Miscellaneous", "plan_name": "700720", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Miscellaneous", "plan_name": "700720_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Ppo Hmo", "plan_name": "701720", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Ppo Hmo", "plan_name": "701720_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Ambetter 68069", "plan_name": "500516", "standard_charge_dollar": 1.24, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Ms State Emplo", "plan_name": "401457", "standard_charge_dollar": 22.33, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Ms State Emplo", "plan_name": "401457_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Basic Pl", "plan_name": "400100", "standard_charge_dollar": 22.33, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Basic Pl", "plan_name": "400100_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Federal", "plan_name": "400110", "standard_charge_dollar": 22.33, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Federal", "plan_name": "400110_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Cigna Healthsprings Ffs", "plan_name": "500064", "standard_charge_dollar": 1.24, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Conseco", "plan_name": "500302", "standard_charge_dollar": 1.24, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Humana Ffs 61101", "plan_name": "500006", "standard_charge_dollar": 1.24, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Medicare A", "plan_name": "100100", "standard_charge_dollar": 1.24, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Medicare A", "plan_name": "100500", "standard_charge_dollar": 1.24, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Medicare Part B Only", "plan_name": "100300", "standard_charge_dollar": 1.24, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Medicare Railroad", "plan_name": "100103", "standard_charge_dollar": 1.24, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Ms Physicians Care N", "plan_name": "714210", "standard_charge_dollar": 1.55, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Peoples Hlth Ffs 72126", "plan_name": "500019", "standard_charge_dollar": 1.24, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Uhc/Secure Horizons", "plan_name": "500449", "standard_charge_dollar": 1.24, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "United Health Care/", "plan_name": "500292", "standard_charge_dollar": 1.40, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "United Healthcare", "plan_name": "750104", "standard_charge_dollar": 1.40, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "United Healthcare Ba", "plan_name": "750090", "standard_charge_dollar": 1.40, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "United Healthcare Me", "plan_name": "501310", "standard_charge_dollar": 1.24, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Windsor Mcare Extra", "plan_name": "500778", "standard_charge_dollar": 1.24, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." } ] } ] }, { "description": "Bleomycin 30 unit solution for injection [17012]", "drug_information": { "unit": 1.00, "type": "EA" }, "code_information": [ { "code": "J9040", "type": "HCPCS" }, { "code": "71288-107-20", "type": "NDC" } ], "standard_charges": [ { "gross_charge": 300.11, "minimum": 42.92, "maximum": 42.92, "setting": "both", "payers_information": [ { "payer_name": "Aetna", "plan_name": "700700", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna", "plan_name": "700700_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Miscellaneous", "plan_name": "700720", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Miscellaneous", "plan_name": "700720_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Ppo Hmo", "plan_name": "701720", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Ppo Hmo", "plan_name": "701720_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Ms State Emplo", "plan_name": "401457", "standard_charge_dollar": 42.92, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient 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remit data to calculate allowed amounts." }, { "payer_name": "Conseco", "plan_name": "500302", "standard_charge_dollar": 248.93, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Humana Ffs 61101", "plan_name": "500006", "standard_charge_dollar": 248.93, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Medicare A", "plan_name": "100100", "standard_charge_dollar": 248.93, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Medicare A", "plan_name": "100500", "standard_charge_dollar": 248.93, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Medicare Part B Only", "plan_name": "100300", "standard_charge_dollar": 248.93, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Medicare Railroad", "plan_name": "100103", "standard_charge_dollar": 248.93, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Ms Physicians Care N", "plan_name": "714210", "standard_charge_dollar": 311.16, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Peoples Hlth Ffs 72126", "plan_name": "500019", "standard_charge_dollar": 248.93, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Uhc/Secure Horizons", "plan_name": "500449", "standard_charge_dollar": 248.93, "count": "0", "methodology": "fee schedule", 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"payer_name": "Windsor Mcare Extra", "plan_name": "500778", "standard_charge_dollar": 248.93, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." } ] } ] }, { "description": "Cabazitaxel 10 mg/ml (first dilution) intravenous solution [105644]", "drug_information": { "unit": 6.00, "type": "ML" }, "code_information": [ { "code": "J9043", "type": "HCPCS" }, { "code": "0024-5824-11", "type": "NDC" } ], "standard_charges": [ { "gross_charge": 49742.99, "minimum": 152.78, "maximum": 277.14, "setting": "both", "payers_information": [ { "payer_name": "Aarp", "plan_name": "500102", "standard_charge_dollar": 221.71, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna", "plan_name": "700700", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna", "plan_name": "700700_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Mcare Ffs 6005", "plan_name": "700703", "standard_charge_dollar": 221.71, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Miscellaneous", "plan_name": "700720", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Miscellaneous", "plan_name": "700720_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Ppo Hmo", "plan_name": "701720", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Ppo Hmo", "plan_name": "701720_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Ambetter 68069", "plan_name": "500516", "standard_charge_dollar": 221.71, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Ms State Emplo", "plan_name": "401457", "standard_charge_dollar": 152.78, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Ms State Emplo", "plan_name": "401457_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Basic Pl", "plan_name": "400100", "standard_charge_dollar": 152.78, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Basic Pl", "plan_name": "400100_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Federal", "plan_name": "400110", "standard_charge_dollar": 152.78, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Federal", "plan_name": "400110_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Cigna Healthsprings Ffs", "plan_name": "500064", "standard_charge_dollar": 221.71, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Conseco", "plan_name": "500302", "standard_charge_dollar": 221.71, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Humana Ffs 61101", "plan_name": "500006", "standard_charge_dollar": 221.71, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Medicare A", "plan_name": "100100", "standard_charge_dollar": 221.71, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Medicare A", "plan_name": "100500", "standard_charge_dollar": 221.71, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Medicare Part B Only", "plan_name": "100300", "standard_charge_dollar": 221.71, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Medicare Railroad", "plan_name": "100103", "standard_charge_dollar": 221.71, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Ms Physicians Care N", "plan_name": "714210", "standard_charge_dollar": 277.14, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Peoples Hlth Ffs 72126", "plan_name": "500019", "standard_charge_dollar": 221.71, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Uhc/Secure Horizons", "plan_name": "500449", "standard_charge_dollar": 221.71, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "United Health Care/", "plan_name": "500292", "standard_charge_dollar": 250.53, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "United Healthcare", "plan_name": "750104", "standard_charge_dollar": 250.53, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "United Healthcare Ba", "plan_name": "750090", "standard_charge_dollar": 250.53, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "United Healthcare Me", "plan_name": "501310", "standard_charge_dollar": 221.71, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Windsor Mcare Extra", "plan_name": "500778", "standard_charge_dollar": 221.71, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." } ] } ] }, { "description": "Carboplatin 10 mg/ml intravenous solution [39265]", "drug_information": { "unit": 60.00, "type": "ML" }, "code_information": [ { "code": "J9045", "type": "HCPCS" }, { "code": "0703-4239-01", "type": "NDC" } ], "standard_charges": [ { "gross_charge": 1050.30, "minimum": 9.55, "maximum": 9.55, "setting": "both", "payers_information": [ { "payer_name": "Aetna", "plan_name": "700700", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna", "plan_name": "700700_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Miscellaneous", "plan_name": "700720", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Miscellaneous", "plan_name": "700720_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Ppo Hmo", "plan_name": "701720", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Ppo Hmo", "plan_name": "701720_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Ms State Emplo", "plan_name": "401457", "standard_charge_dollar": 9.55, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Ms State Emplo", "plan_name": "401457_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Basic Pl", "plan_name": "400100", "standard_charge_dollar": 9.55, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Basic Pl", "plan_name": "400100_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Federal", "plan_name": "400110", "standard_charge_dollar": 9.55, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Federal", "plan_name": "400110_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." } ] } ] }, { "description": "Carboplatin 10 mg/ml intravenous solution [39265]", "drug_information": { "unit": 15.00, "type": "ML" }, 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"700720_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Ppo Hmo", "plan_name": "701720", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Ppo Hmo", "plan_name": "701720_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Ms State Emplo", "plan_name": "401457", "standard_charge_dollar": 9.55, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Ms State Emplo", "plan_name": "401457_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Basic Pl", "plan_name": "400100", "standard_charge_dollar": 9.55, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Basic Pl", "plan_name": "400100_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Federal", "plan_name": "400110", "standard_charge_dollar": 9.55, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Federal", "plan_name": "400110_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." } ] } ] }, { "description": "Carboplatin 10 mg/ml intravenous solution [39265]", "drug_information": { "unit": 60.00, "type": "ML" }, "code_information": [ { "code": "J9045", "type": "HCPCS" }, { "code": "55150-386-01", "type": "NDC" } ], "standard_charges": [ { "gross_charge": 1050.30, "minimum": 9.55, "maximum": 9.55, "setting": "both", "payers_information": [ { "payer_name": "Aetna", "plan_name": "700700", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna", "plan_name": "700700_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna 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"plan_name": "401457", "standard_charge_dollar": 9.55, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Ms State Emplo", "plan_name": "401457_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Basic Pl", "plan_name": "400100", "standard_charge_dollar": 9.55, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Basic Pl", "plan_name": "400100_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Federal", "plan_name": "400110", "standard_charge_dollar": 9.55, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Federal", "plan_name": "400110_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." } ] } ] }, { "description": "Carboplatin 10 mg/ml intravenous solution [39265]", "drug_information": { "unit": 45.00, "type": "ML" }, "code_information": [ { "code": "J9045", "type": "HCPCS" }, { "code": "55150-335-01", "type": "NDC" } ], "standard_charges": [ { "gross_charge": 788.74, "minimum": 9.55, "maximum": 9.55, "setting": "both", "payers_information": [ { "payer_name": "Aetna", "plan_name": "700700", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna", "plan_name": "700700_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Miscellaneous", "plan_name": "700720", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Miscellaneous", "plan_name": "700720_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Ppo Hmo", "plan_name": "701720", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Ppo Hmo", "plan_name": "701720_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Ms State Emplo", "plan_name": "401457", "standard_charge_dollar": 9.55, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Ms State Emplo", "plan_name": "401457_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Basic Pl", "plan_name": "400100", "standard_charge_dollar": 9.55, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Basic Pl", "plan_name": "400100_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Federal", "plan_name": "400110", "standard_charge_dollar": 9.55, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Federal", "plan_name": "400110_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." } ] } ] }, { "description": "Carboplatin 10 mg/ml intravenous solution [39265]", "drug_information": { "unit": 60.00, "type": "ML" }, "code_information": [ { "code": "J9045", "type": "HCPCS" }, { "code": "63323-172-60", "type": "NDC" } ], "standard_charges": [ { "gross_charge": 1050.30, "minimum": 9.55, "maximum": 9.55, "setting": "both", "payers_information": [ { "payer_name": "Aetna", "plan_name": "700700", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna", "plan_name": "700700_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Miscellaneous", "plan_name": "700720", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Miscellaneous", "plan_name": "700720_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Ppo Hmo", "plan_name": "701720", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Ppo Hmo", "plan_name": "701720_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Ms State Emplo", "plan_name": "401457", "standard_charge_dollar": 9.55, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Ms State Emplo", "plan_name": "401457_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Basic Pl", "plan_name": "400100", "standard_charge_dollar": 9.55, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Basic Pl", "plan_name": "400100_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Federal", "plan_name": "400110", "standard_charge_dollar": 9.55, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Federal", "plan_name": "400110_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." } ] } ] }, { "description": "Carboplatin 10 mg/ml intravenous solution [39265]", "drug_information": { "unit": 45.00, "type": "ML" }, "code_information": [ { "code": "J9045", "type": "HCPCS" }, { "code": "61703-339-50", "type": "NDC" } ], "standard_charges": [ { "gross_charge": 788.74, "minimum": 9.55, "maximum": 9.55, "setting": "both", "payers_information": [ { "payer_name": "Aetna", "plan_name": "700700", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna", "plan_name": "700700_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Miscellaneous", "plan_name": "700720", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Miscellaneous", "plan_name": "700720_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Ppo Hmo", "plan_name": "701720", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Ppo Hmo", "plan_name": "701720_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Ms State Emplo", "plan_name": "401457", "standard_charge_dollar": 9.55, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Ms State Emplo", "plan_name": "401457_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Basic Pl", "plan_name": "400100", "standard_charge_dollar": 9.55, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Basic Pl", "plan_name": "400100_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Federal", "plan_name": "400110", "standard_charge_dollar": 9.55, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Federal", "plan_name": "400110_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." } ] } ] }, { "description": "Carboplatin 10 mg/ml intravenous solution [39265]", "drug_information": { "unit": 60.00, "type": "ML" }, "code_information": [ { "code": "J9045", "type": "HCPCS" }, { "code": "61703-339-56", "type": "NDC" } ], "standard_charges": [ { "gross_charge": 1050.30, "minimum": 9.55, "maximum": 9.55, "setting": "both", "payers_information": [ { "payer_name": "Aetna", "plan_name": "700700", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna", "plan_name": "700700_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Miscellaneous", "plan_name": "700720", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Miscellaneous", "plan_name": "700720_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Ppo Hmo", "plan_name": "701720", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Ppo Hmo", "plan_name": "701720_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Ms State Emplo", "plan_name": "401457", "standard_charge_dollar": 9.55, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Ms State Emplo", "plan_name": "401457_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Basic Pl", "plan_name": "400100", "standard_charge_dollar": 9.55, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Basic Pl", "plan_name": "400100_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Federal", "plan_name": "400110", "standard_charge_dollar": 9.55, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Federal", "plan_name": "400110_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." } ] } ] }, { "description": "Carfilzomib 60 mg intravenous solution [158301]", "drug_information": { "unit": 1.00, "type": "EA" }, "code_information": [ { "code": "J9047", "type": "HCPCS" }, { "code": "76075-101-01", "type": "NDC" } ], "standard_charges": [ { "gross_charge": 14026.05, "minimum": 30.66, "maximum": 64.81, "setting": "both", "payers_information": [ { "payer_name": "Aarp", "plan_name": "500102", "standard_charge_dollar": 51.85, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna", "plan_name": "700700", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna", "plan_name": "700700_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Mcare Ffs 6005", "plan_name": "700703", "standard_charge_dollar": 51.85, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Miscellaneous", "plan_name": "700720", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Miscellaneous", "plan_name": "700720_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Ppo Hmo", "plan_name": "701720", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Ppo Hmo", "plan_name": "701720_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Ambetter 68069", "plan_name": "500516", "standard_charge_dollar": 51.85, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Ms State Emplo", "plan_name": "401457", "standard_charge_dollar": 30.66, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Ms State Emplo", "plan_name": "401457_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Basic Pl", "plan_name": "400100", "standard_charge_dollar": 30.66, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Basic Pl", "plan_name": "400100_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Federal", "plan_name": "400110", "standard_charge_dollar": 30.66, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Federal", "plan_name": "400110_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Cigna Healthsprings Ffs", "plan_name": "500064", "standard_charge_dollar": 51.85, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Conseco", "plan_name": "500302", "standard_charge_dollar": 51.85, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Humana Ffs 61101", "plan_name": "500006", "standard_charge_dollar": 51.85, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Medicare A", "plan_name": "100100", "standard_charge_dollar": 51.85, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Medicare A", "plan_name": "100500", "standard_charge_dollar": 51.85, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Medicare Part B Only", "plan_name": "100300", "standard_charge_dollar": 51.85, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Medicare Railroad", "plan_name": "100103", "standard_charge_dollar": 51.85, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Ms Physicians Care N", "plan_name": "714210", "standard_charge_dollar": 64.81, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Peoples Hlth Ffs 72126", "plan_name": "500019", "standard_charge_dollar": 51.85, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Uhc/Secure Horizons", "plan_name": "500449", "standard_charge_dollar": 51.85, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "United Health Care/", "plan_name": "500292", "standard_charge_dollar": 58.59, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "United Healthcare", "plan_name": "750104", "standard_charge_dollar": 58.59, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "United Healthcare Ba", "plan_name": "750090", "standard_charge_dollar": 58.59, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "United Healthcare Me", "plan_name": "501310", "standard_charge_dollar": 51.85, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Windsor Mcare Extra", "plan_name": "500778", "standard_charge_dollar": 51.85, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." } ] } ] }, { "description": "Carfilzomib 30 mg intravenous solution [177693]", "drug_information": { "unit": 1.00, "type": "EA" }, "code_information": [ { "code": "J9047", "type": "HCPCS" }, { "code": "76075-102-01", "type": "NDC" } ], "standard_charges": [ { "gross_charge": 7013.03, "minimum": 30.66, "maximum": 64.81, "setting": "both", "payers_information": [ { "payer_name": "Aarp", "plan_name": "500102", "standard_charge_dollar": 51.85, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna", "plan_name": "700700", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna", "plan_name": "700700_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Mcare Ffs 6005", "plan_name": "700703", "standard_charge_dollar": 51.85, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Miscellaneous", "plan_name": "700720", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Miscellaneous", "plan_name": "700720_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Ppo Hmo", "plan_name": "701720", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Ppo Hmo", "plan_name": "701720_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Ambetter 68069", "plan_name": "500516", "standard_charge_dollar": 51.85, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Ms State Emplo", "plan_name": "401457", "standard_charge_dollar": 30.66, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Ms State Emplo", "plan_name": "401457_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Basic Pl", "plan_name": "400100", "standard_charge_dollar": 30.66, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Basic Pl", "plan_name": "400100_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Federal", "plan_name": "400110", "standard_charge_dollar": 30.66, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Federal", "plan_name": "400110_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Cigna Healthsprings Ffs", "plan_name": "500064", "standard_charge_dollar": 51.85, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Conseco", "plan_name": "500302", "standard_charge_dollar": 51.85, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Humana Ffs 61101", "plan_name": "500006", "standard_charge_dollar": 51.85, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Medicare A", "plan_name": "100100", "standard_charge_dollar": 51.85, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Medicare A", "plan_name": "100500", "standard_charge_dollar": 51.85, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Medicare Part B Only", "plan_name": "100300", "standard_charge_dollar": 51.85, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Medicare Railroad", "plan_name": "100103", "standard_charge_dollar": 51.85, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Ms Physicians Care N", "plan_name": "714210", "standard_charge_dollar": 64.81, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Peoples Hlth Ffs 72126", "plan_name": "500019", "standard_charge_dollar": 51.85, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Uhc/Secure Horizons", "plan_name": "500449", "standard_charge_dollar": 51.85, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "United Health Care/", "plan_name": "500292", "standard_charge_dollar": 58.59, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "United Healthcare", "plan_name": "750104", "standard_charge_dollar": 58.59, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "United Healthcare Ba", "plan_name": "750090", "standard_charge_dollar": 58.59, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "United Healthcare Me", "plan_name": "501310", "standard_charge_dollar": 51.85, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Windsor Mcare Extra", "plan_name": "500778", "standard_charge_dollar": 51.85, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." } ] } ] }, { "description": "Carfilzomib 10 mg intravenous solution [184821]", "drug_information": { "unit": 1.00, "type": "EA" }, "code_information": [ { "code": "J9047", "type": "HCPCS" }, { "code": "76075-103-01", "type": "NDC" } ], "standard_charges": [ { "gross_charge": 2337.66, "minimum": 30.66, "maximum": 64.81, "setting": "both", "payers_information": [ { "payer_name": "Aarp", "plan_name": "500102", "standard_charge_dollar": 51.85, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna", "plan_name": "700700", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna", "plan_name": "700700_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Mcare Ffs 6005", "plan_name": "700703", "standard_charge_dollar": 51.85, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Miscellaneous", "plan_name": "700720", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Miscellaneous", "plan_name": "700720_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Ppo Hmo", "plan_name": "701720", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Ppo Hmo", "plan_name": "701720_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Ambetter 68069", "plan_name": "500516", "standard_charge_dollar": 51.85, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Ms State Emplo", "plan_name": "401457", "standard_charge_dollar": 30.66, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Ms State Emplo", "plan_name": "401457_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Basic Pl", "plan_name": "400100", "standard_charge_dollar": 30.66, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Basic Pl", "plan_name": "400100_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Federal", "plan_name": "400110", "standard_charge_dollar": 30.66, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Federal", "plan_name": "400110_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Cigna Healthsprings Ffs", "plan_name": "500064", "standard_charge_dollar": 51.85, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Conseco", "plan_name": "500302", "standard_charge_dollar": 51.85, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Humana Ffs 61101", "plan_name": "500006", "standard_charge_dollar": 51.85, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Medicare A", "plan_name": "100100", "standard_charge_dollar": 51.85, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Medicare A", "plan_name": "100500", "standard_charge_dollar": 51.85, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Medicare Part B Only", "plan_name": "100300", "standard_charge_dollar": 51.85, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Medicare Railroad", "plan_name": "100103", "standard_charge_dollar": 51.85, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Ms Physicians Care N", "plan_name": "714210", "standard_charge_dollar": 64.81, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Peoples Hlth Ffs 72126", "plan_name": "500019", "standard_charge_dollar": 51.85, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Uhc/Secure Horizons", "plan_name": "500449", "standard_charge_dollar": 51.85, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "United Health Care/", "plan_name": "500292", "standard_charge_dollar": 58.59, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "United Healthcare", "plan_name": "750104", "standard_charge_dollar": 58.59, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "United Healthcare Ba", "plan_name": "750090", "standard_charge_dollar": 58.59, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "United Healthcare Me", "plan_name": "501310", "standard_charge_dollar": 51.85, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Windsor Mcare Extra", "plan_name": "500778", "standard_charge_dollar": 51.85, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." } ] } ] }, { "description": "Cetuximab 200 mg/100 ml intravenous solution [118617]", "drug_information": { "unit": 100.00, "type": "ML" }, "code_information": [ { "code": "J9055", "type": "HCPCS" }, { "code": "66733-958-23", "type": "NDC" } ], "standard_charges": [ { "gross_charge": 6917.40, "minimum": 53.73, "maximum": 96.90, "setting": "both", "payers_information": [ { "payer_name": "Aarp", "plan_name": "500102", "standard_charge_dollar": 77.52, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna", "plan_name": "700700", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna", "plan_name": "700700_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Mcare Ffs 6005", "plan_name": "700703", "standard_charge_dollar": 77.52, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Miscellaneous", "plan_name": "700720", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Miscellaneous", "plan_name": "700720_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Ppo Hmo", "plan_name": "701720", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Ppo Hmo", "plan_name": "701720_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Ambetter 68069", "plan_name": "500516", "standard_charge_dollar": 77.52, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Ms State Emplo", "plan_name": "401457", "standard_charge_dollar": 53.73, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Ms State Emplo", "plan_name": "401457_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Basic Pl", "plan_name": "400100", "standard_charge_dollar": 53.73, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Basic Pl", "plan_name": "400100_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Federal", "plan_name": "400110", "standard_charge_dollar": 53.73, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Federal", "plan_name": "400110_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Cigna Healthsprings Ffs", "plan_name": "500064", "standard_charge_dollar": 77.52, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Conseco", "plan_name": "500302", "standard_charge_dollar": 77.52, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Humana Ffs 61101", "plan_name": "500006", "standard_charge_dollar": 77.52, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Medicare A", "plan_name": "100100", "standard_charge_dollar": 77.52, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Medicare A", "plan_name": "100500", "standard_charge_dollar": 77.52, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Medicare Part B Only", "plan_name": "100300", "standard_charge_dollar": 77.52, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Medicare Railroad", "plan_name": "100103", "standard_charge_dollar": 77.52, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Ms Physicians Care N", "plan_name": "714210", "standard_charge_dollar": 96.90, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Peoples Hlth Ffs 72126", "plan_name": "500019", "standard_charge_dollar": 77.52, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Uhc/Secure Horizons", "plan_name": "500449", "standard_charge_dollar": 77.52, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "United Health Care/", "plan_name": "500292", "standard_charge_dollar": 87.60, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "United Healthcare", "plan_name": "750104", "standard_charge_dollar": 87.60, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "United Healthcare Ba", "plan_name": "750090", "standard_charge_dollar": 87.60, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "United Healthcare Me", "plan_name": "501310", "standard_charge_dollar": 77.52, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Windsor Mcare Extra", "plan_name": "500778", "standard_charge_dollar": 77.52, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." } ] } ] }, { "description": "Bendamustine 25 mg/ml intravenous solution [172565]", "drug_information": { "unit": 4.00, "type": "ML" }, "code_information": [ { "code": "J9056", "type": "HCPCS" }, { "code": "71225-120-01", "type": "NDC" } ], "standard_charges": [ { "gross_charge": 14678.73, "minimum": 24.95, "maximum": 12476.92, "setting": "both", "payers_information": [ { "payer_name": "Aarp", "plan_name": "500102", "standard_charge_dollar": 24.95, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna", "plan_name": "700700", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna", "plan_name": "700700_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Mcare Ffs 6005", "plan_name": "700703", "standard_charge_dollar": 24.95, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Miscellaneous", "plan_name": "700720", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Miscellaneous", "plan_name": "700720_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Ppo Hmo", "plan_name": "701720", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Ppo Hmo", "plan_name": "701720_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Ambetter 68069", "plan_name": "500516", "standard_charge_dollar": 24.95, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Ms State Emplo", "plan_name": "401457", "standard_charge_percentage": 0.80, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Ms State Emplo", "plan_name": "401457_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Basic Pl", "plan_name": "400100", "standard_charge_percentage": 0.85, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Basic Pl", "plan_name": "400100_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Federal", "plan_name": "400110", "standard_charge_percentage": 0.85, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Federal", "plan_name": "400110_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Cigna Healthsprings Ffs", "plan_name": "500064", "standard_charge_dollar": 24.95, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Conseco", "plan_name": "500302", "standard_charge_dollar": 24.95, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Humana Ffs 61101", "plan_name": "500006", "standard_charge_dollar": 24.95, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Medicare A", "plan_name": "100100", "standard_charge_dollar": 24.95, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Medicare A", "plan_name": "100500", "standard_charge_dollar": 24.95, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Medicare Part B Only", "plan_name": "100300", "standard_charge_dollar": 24.95, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Medicare Railroad", "plan_name": "100103", "standard_charge_dollar": 24.95, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Ms Physicians Care N", "plan_name": "714210", "standard_charge_dollar": 31.19, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Peoples Hlth Ffs 72126", "plan_name": "500019", "standard_charge_dollar": 24.95, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Uhc/Secure Horizons", "plan_name": "500449", "standard_charge_dollar": 24.95, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "United Health Care/", "plan_name": "500292", "standard_charge_dollar": 28.20, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "United Healthcare", "plan_name": "750104", "standard_charge_dollar": 28.20, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "United Healthcare Ba", "plan_name": "750090", "standard_charge_dollar": 28.20, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "United Healthcare Me", "plan_name": "501310", "standard_charge_dollar": 24.95, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Windsor Mcare Extra", "plan_name": "500778", "standard_charge_dollar": 24.95, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." } ] } ] }, { "description": "Cisplatin 1 mg/ml intravenous solution [9612]", "drug_information": { "unit": 100.00, "type": "ML" }, "code_information": [ { "code": "J9060", "type": "HCPCS" }, { "code": "72266-253-01", "type": "NDC" } ], "standard_charges": [ { "gross_charge": 297.45, "minimum": 237.96, "maximum": 252.83, "setting": "both", "payers_information": [ { "payer_name": "Aetna", "plan_name": "700700", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna", "plan_name": "700700_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Miscellaneous", "plan_name": "700720", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Miscellaneous", "plan_name": "700720_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Ppo Hmo", "plan_name": "701720", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Ppo Hmo", "plan_name": "701720_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Ms State Emplo", "plan_name": "401457", "standard_charge_percentage": 0.80, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Ms State 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}, { "payer_name": "Bc/Bs Ms State Emplo", "plan_name": "401457", "standard_charge_percentage": 0.80, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Ms State Emplo", "plan_name": "401457_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Basic Pl", "plan_name": "400100", "standard_charge_percentage": 0.85, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Basic Pl", "plan_name": "400100_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Federal", "plan_name": "400110", "standard_charge_percentage": 0.85, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Federal", "plan_name": "400110_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." } ] } ] }, { "description": "Cisplatin 1 mg/ml intravenous solution [9612]", "drug_information": { "unit": 100.00, "type": "ML" }, "code_information": [ { "code": "J9060", "type": "HCPCS" }, { "code": "0143-9505-01", "type": "NDC" } ], "standard_charges": [ { "gross_charge": 297.45, "minimum": 237.96, "maximum": 252.83, "setting": "both", "payers_information": [ { "payer_name": "Aetna", "plan_name": "700700", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna", "plan_name": "700700_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Miscellaneous", "plan_name": "700720", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Miscellaneous", "plan_name": "700720_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Ppo Hmo", "plan_name": "701720", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Ppo Hmo", "plan_name": "701720_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Ms State Emplo", "plan_name": "401457", "standard_charge_percentage": 0.80, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Ms State Emplo", "plan_name": "401457_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Basic Pl", "plan_name": "400100", "standard_charge_percentage": 0.85, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Basic Pl", "plan_name": "400100_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Federal", "plan_name": "400110", "standard_charge_percentage": 0.85, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Federal", "plan_name": "400110_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." } ] } ] }, { "description": "Cyclophosphamide 1 gram intravenous powder for solution [38270]", "drug_information": { "unit": 1.00, "type": "EA" }, "code_information": [ { "code": "J9075", "type": "HCPCS" }, { "code": "25021-248-51", "type": "NDC" } ], "standard_charges": [ { "gross_charge": 3518.33, "minimum": 0.80, "maximum": 2990.58, "setting": "both", "payers_information": [ { "payer_name": "Aarp", "plan_name": "500102", "standard_charge_dollar": 0.80, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna", "plan_name": "700700", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna", "plan_name": "700700_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Mcare Ffs 6005", "plan_name": "700703", "standard_charge_dollar": 0.80, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Miscellaneous", "plan_name": "700720", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Miscellaneous", "plan_name": "700720_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Ppo Hmo", "plan_name": "701720", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Ppo Hmo", "plan_name": "701720_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Ambetter 68069", "plan_name": "500516", "standard_charge_dollar": 0.80, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Ms State Emplo", "plan_name": "401457", "standard_charge_percentage": 0.80, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Ms State Emplo", "plan_name": "401457_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Basic Pl", "plan_name": "400100", "standard_charge_percentage": 0.85, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Basic Pl", "plan_name": "400100_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Federal", "plan_name": "400110", "standard_charge_percentage": 0.85, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Federal", "plan_name": "400110_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Cigna Healthsprings Ffs", "plan_name": "500064", "standard_charge_dollar": 0.80, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Conseco", "plan_name": "500302", "standard_charge_dollar": 0.80, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Humana Ffs 61101", "plan_name": "500006", "standard_charge_dollar": 0.80, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Medicare A", "plan_name": "100100", "standard_charge_dollar": 0.80, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Medicare A", "plan_name": "100500", "standard_charge_dollar": 0.80, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Medicare Part B Only", "plan_name": "100300", "standard_charge_dollar": 0.80, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Medicare Railroad", "plan_name": "100103", "standard_charge_dollar": 0.80, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Ms Physicians Care N", "plan_name": "714210", "standard_charge_dollar": 1.00, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Peoples Hlth Ffs 72126", "plan_name": "500019", "standard_charge_dollar": 0.80, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Uhc/Secure Horizons", "plan_name": "500449", "standard_charge_dollar": 0.80, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "United Health Care/", "plan_name": "500292", "standard_charge_dollar": 0.90, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "United Healthcare", "plan_name": "750104", "standard_charge_dollar": 0.90, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "United Healthcare Ba", "plan_name": "750090", "standard_charge_dollar": 0.90, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "United Healthcare Me", "plan_name": "501310", "standard_charge_dollar": 0.80, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Windsor Mcare Extra", "plan_name": "500778", "standard_charge_dollar": 0.80, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." } ] } ] }, { "description": "Cyclophosphamide 200 mg/ml intravenous solution [191283]", "drug_information": { "unit": 2.50, "type": "ML" }, "code_information": [ { "code": "J9075", "type": "HCPCS" }, { "code": "70860-218-03", "type": "NDC" } ], "standard_charges": [ { "gross_charge": 1606.91, "minimum": 0.80, "maximum": 1365.87, "setting": "both", "payers_information": [ { "payer_name": "Aarp", "plan_name": "500102", "standard_charge_dollar": 0.80, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna", "plan_name": "700700", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna", "plan_name": "700700_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Mcare Ffs 6005", "plan_name": "700703", "standard_charge_dollar": 0.80, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Miscellaneous", "plan_name": "700720", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Miscellaneous", "plan_name": "700720_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Ppo Hmo", "plan_name": "701720", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Ppo Hmo", "plan_name": "701720_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Ambetter 68069", "plan_name": "500516", "standard_charge_dollar": 0.80, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Ms State Emplo", "plan_name": "401457", "standard_charge_percentage": 0.80, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Ms State Emplo", "plan_name": "401457_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Basic Pl", "plan_name": "400100", "standard_charge_percentage": 0.85, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Basic Pl", "plan_name": "400100_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Federal", "plan_name": "400110", "standard_charge_percentage": 0.85, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Federal", "plan_name": "400110_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Cigna Healthsprings Ffs", "plan_name": "500064", "standard_charge_dollar": 0.80, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Conseco", "plan_name": "500302", "standard_charge_dollar": 0.80, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Humana Ffs 61101", "plan_name": "500006", "standard_charge_dollar": 0.80, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Medicare A", "plan_name": "100100", "standard_charge_dollar": 0.80, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Medicare A", "plan_name": "100500", "standard_charge_dollar": 0.80, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Medicare Part B Only", "plan_name": "100300", "standard_charge_dollar": 0.80, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Medicare Railroad", "plan_name": "100103", "standard_charge_dollar": 0.80, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Ms Physicians Care N", "plan_name": "714210", "standard_charge_dollar": 1.00, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Peoples Hlth Ffs 72126", "plan_name": "500019", "standard_charge_dollar": 0.80, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Uhc/Secure Horizons", "plan_name": "500449", "standard_charge_dollar": 0.80, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "United Health Care/", "plan_name": "500292", "standard_charge_dollar": 0.90, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "United Healthcare", "plan_name": "750104", "standard_charge_dollar": 0.90, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "United Healthcare Ba", "plan_name": "750090", "standard_charge_dollar": 0.90, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "United Healthcare Me", "plan_name": "501310", "standard_charge_dollar": 0.80, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Windsor Mcare Extra", "plan_name": "500778", "standard_charge_dollar": 0.80, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." } ] } ] }, { "description": "Cyclophosphamide 200 mg/ml intravenous solution [191283]", "drug_information": { "unit": 5.00, "type": "ML" }, "code_information": [ { "code": "J9075", "type": "HCPCS" }, { "code": "70860-218-05", "type": "NDC" } ], "standard_charges": [ { "gross_charge": 3213.86, "minimum": 0.80, "maximum": 2731.78, "setting": "both", "payers_information": [ { "payer_name": "Aarp", "plan_name": "500102", "standard_charge_dollar": 0.80, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna", "plan_name": "700700", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna", "plan_name": "700700_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Mcare Ffs 6005", "plan_name": "700703", "standard_charge_dollar": 0.80, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Miscellaneous", "plan_name": "700720", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Miscellaneous", "plan_name": "700720_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Ppo Hmo", "plan_name": "701720", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Ppo Hmo", "plan_name": "701720_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Ambetter 68069", "plan_name": "500516", "standard_charge_dollar": 0.80, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Ms State Emplo", "plan_name": "401457", "standard_charge_percentage": 0.80, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Ms State Emplo", "plan_name": "401457_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Basic Pl", "plan_name": "400100", "standard_charge_percentage": 0.85, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Basic Pl", "plan_name": "400100_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Federal", "plan_name": "400110", "standard_charge_percentage": 0.85, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Federal", "plan_name": "400110_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Cigna Healthsprings Ffs", "plan_name": "500064", "standard_charge_dollar": 0.80, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Conseco", "plan_name": "500302", "standard_charge_dollar": 0.80, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Humana Ffs 61101", "plan_name": "500006", "standard_charge_dollar": 0.80, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Medicare A", "plan_name": "100100", "standard_charge_dollar": 0.80, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Medicare A", "plan_name": "100500", "standard_charge_dollar": 0.80, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Medicare Part B Only", "plan_name": "100300", "standard_charge_dollar": 0.80, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Medicare Railroad", "plan_name": "100103", "standard_charge_dollar": 0.80, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Ms Physicians Care N", "plan_name": "714210", "standard_charge_dollar": 1.00, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Peoples Hlth Ffs 72126", "plan_name": "500019", "standard_charge_dollar": 0.80, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Uhc/Secure Horizons", "plan_name": "500449", "standard_charge_dollar": 0.80, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "United Health Care/", "plan_name": "500292", "standard_charge_dollar": 0.90, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "United Healthcare", "plan_name": "750104", "standard_charge_dollar": 0.90, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "United Healthcare Ba", "plan_name": "750090", "standard_charge_dollar": 0.90, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "United Healthcare Me", "plan_name": "501310", "standard_charge_dollar": 0.80, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Windsor Mcare Extra", "plan_name": "500778", "standard_charge_dollar": 0.80, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." } ] } ] }, { "description": "Cyclophosphamide 500 mg intravenous powder for solution [38271]", "drug_information": { "unit": 1.00, "type": "EA" }, "code_information": [ { "code": "J9075", "type": "HCPCS" }, { "code": "81298-8110-1", "type": "NDC" } ], "standard_charges": [ { "gross_charge": 989.91, "minimum": 0.80, "maximum": 841.42, "setting": "both", "payers_information": [ { "payer_name": "Aarp", "plan_name": "500102", "standard_charge_dollar": 0.80, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna", "plan_name": "700700", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna", "plan_name": "700700_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Mcare Ffs 6005", "plan_name": "700703", "standard_charge_dollar": 0.80, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Miscellaneous", "plan_name": "700720", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Miscellaneous", "plan_name": "700720_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Ppo Hmo", "plan_name": "701720", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Ppo Hmo", "plan_name": "701720_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Ambetter 68069", "plan_name": "500516", "standard_charge_dollar": 0.80, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Ms State Emplo", "plan_name": "401457", "standard_charge_percentage": 0.80, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Ms State Emplo", "plan_name": "401457_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Basic Pl", "plan_name": "400100", "standard_charge_percentage": 0.85, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Basic Pl", "plan_name": "400100_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Federal", "plan_name": "400110", "standard_charge_percentage": 0.85, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Federal", "plan_name": "400110_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Cigna Healthsprings Ffs", "plan_name": "500064", "standard_charge_dollar": 0.80, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Conseco", "plan_name": "500302", "standard_charge_dollar": 0.80, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Humana Ffs 61101", "plan_name": "500006", "standard_charge_dollar": 0.80, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Medicare A", "plan_name": "100100", "standard_charge_dollar": 0.80, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Medicare A", "plan_name": "100500", "standard_charge_dollar": 0.80, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Medicare Part B Only", "plan_name": "100300", "standard_charge_dollar": 0.80, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Medicare Railroad", "plan_name": "100103", "standard_charge_dollar": 0.80, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Ms Physicians Care N", "plan_name": "714210", "standard_charge_dollar": 1.00, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Peoples Hlth Ffs 72126", "plan_name": "500019", "standard_charge_dollar": 0.80, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Uhc/Secure Horizons", "plan_name": "500449", "standard_charge_dollar": 0.80, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "United Health Care/", "plan_name": "500292", "standard_charge_dollar": 0.90, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "United Healthcare", "plan_name": "750104", "standard_charge_dollar": 0.90, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "United Healthcare Ba", "plan_name": "750090", "standard_charge_dollar": 0.90, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "United Healthcare Me", "plan_name": "501310", "standard_charge_dollar": 0.80, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Windsor Mcare Extra", "plan_name": "500778", "standard_charge_dollar": 0.80, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." } ] } ] }, { "description": "Cemiplimab-rwlc 50 mg/ml intravenous solution [185431]", "drug_information": { "unit": 7.00, "type": "ML" }, "code_information": [ { "code": "J9119", "type": "HCPCS" }, { "code": "61755-008-01", "type": "NDC" } ], "standard_charges": [ { "gross_charge": 46173.36, "minimum": 28.92, "maximum": 39247.36, "setting": "both", "payers_information": [ { "payer_name": "Aarp", "plan_name": "500102", "standard_charge_dollar": 28.92, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna", "plan_name": "700700", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna", "plan_name": "700700_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Mcare Ffs 6005", "plan_name": "700703", "standard_charge_dollar": 28.92, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Miscellaneous", "plan_name": "700720", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Miscellaneous", "plan_name": "700720_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Ppo Hmo", "plan_name": "701720", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Ppo Hmo", "plan_name": "701720_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Ambetter 68069", "plan_name": "500516", "standard_charge_dollar": 28.92, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Ms State Emplo", "plan_name": "401457", "standard_charge_percentage": 0.80, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Ms State Emplo", "plan_name": "401457_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Basic Pl", "plan_name": "400100", "standard_charge_percentage": 0.85, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Basic Pl", "plan_name": "400100_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Federal", "plan_name": "400110", "standard_charge_percentage": 0.85, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Federal", "plan_name": "400110_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Cigna Healthsprings Ffs", "plan_name": "500064", "standard_charge_dollar": 28.92, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Conseco", "plan_name": "500302", "standard_charge_dollar": 28.92, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Humana Ffs 61101", "plan_name": "500006", "standard_charge_dollar": 28.92, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Medicare A", "plan_name": "100100", "standard_charge_dollar": 28.92, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Medicare A", "plan_name": "100500", "standard_charge_dollar": 28.92, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Medicare Part B Only", "plan_name": "100300", "standard_charge_dollar": 28.92, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Medicare Railroad", "plan_name": "100103", "standard_charge_dollar": 28.92, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Ms Physicians Care N", "plan_name": "714210", "standard_charge_dollar": 36.15, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Peoples Hlth Ffs 72126", "plan_name": "500019", "standard_charge_dollar": 28.92, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Uhc/Secure Horizons", "plan_name": "500449", "standard_charge_dollar": 28.92, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "United Health Care/", "plan_name": "500292", "standard_charge_dollar": 32.68, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "United Healthcare", "plan_name": "750104", "standard_charge_dollar": 32.68, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "United Healthcare Ba", "plan_name": "750090", "standard_charge_dollar": 32.68, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "United Healthcare Me", "plan_name": "501310", "standard_charge_dollar": 28.92, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Windsor Mcare Extra", "plan_name": "500778", "standard_charge_dollar": 28.92, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." } ] } ] }, { "description": "Dacarbazine 200 mg intravenous solution [2091]", "drug_information": { "unit": 1.00, "type": "EA" }, "code_information": [ { "code": "J9130", "type": "HCPCS" }, { "code": "63323-128-20", "type": "NDC" } ], "standard_charges": [ { "gross_charge": 98.92, "minimum": 9.07, "maximum": 9.07, "setting": "both", "payers_information": [ { "payer_name": "Aetna", "plan_name": "700700", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna", "plan_name": "700700_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Miscellaneous", "plan_name": "700720", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Miscellaneous", "plan_name": "700720_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Ppo Hmo", "plan_name": "701720", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Ppo Hmo", "plan_name": "701720_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Ms State Emplo", "plan_name": "401457", "standard_charge_dollar": 9.07, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Ms State Emplo", "plan_name": "401457_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Basic Pl", "plan_name": "400100", "standard_charge_dollar": 9.07, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Basic Pl", "plan_name": "400100_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Federal", "plan_name": "400110", "standard_charge_dollar": 9.07, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Federal", "plan_name": "400110_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." } ] } ] }, { "description": "Dacarbazine 200 mg intravenous solution [2091]", "drug_information": { "unit": 1.00, "type": "EA" }, "code_information": [ { "code": "J9130", "type": "HCPCS" }, { "code": "0143-9245-01", "type": "NDC" } ], "standard_charges": [ { "gross_charge": 98.92, "minimum": 9.07, "maximum": 9.07, "setting": "both", "payers_information": [ { "payer_name": "Aetna", "plan_name": "700700", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna", "plan_name": "700700_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Miscellaneous", "plan_name": "700720", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Miscellaneous", "plan_name": "700720_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Ppo Hmo", "plan_name": "701720", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Ppo Hmo", "plan_name": "701720_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Ms State Emplo", "plan_name": "401457", "standard_charge_dollar": 9.07, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Ms State Emplo", "plan_name": "401457_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Basic Pl", "plan_name": "400100", "standard_charge_dollar": 9.07, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Basic Pl", "plan_name": "400100_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Federal", "plan_name": "400110", "standard_charge_dollar": 9.07, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Federal", "plan_name": "400110_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." } ] } ] }, { "description": "Dacarbazine 200 mg intravenous solution [2091]", "drug_information": { "unit": 1.00, "type": "EA" }, "code_information": [ { "code": "J9130", "type": "HCPCS" }, { "code": "0143-9245-10", "type": "NDC" } ], "standard_charges": [ { "gross_charge": 98.92, "minimum": 9.07, "maximum": 9.07, "setting": "both", "payers_information": [ { "payer_name": "Aetna", "plan_name": "700700", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna", "plan_name": "700700_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Miscellaneous", "plan_name": "700720", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Miscellaneous", "plan_name": "700720_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Ppo Hmo", "plan_name": "701720", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Ppo Hmo", "plan_name": "701720_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Ms State Emplo", "plan_name": "401457", "standard_charge_dollar": 9.07, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Ms State Emplo", "plan_name": "401457_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Basic Pl", "plan_name": "400100", "standard_charge_dollar": 9.07, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Basic Pl", "plan_name": "400100_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Federal", "plan_name": "400110", "standard_charge_dollar": 9.07, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Federal", "plan_name": "400110_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." } ] } ] }, { "description": "Daratumumab 1800 mg-hyaluronidase-fihj 30000 unit/15 ml subcut soln [190369]", "drug_information": { "unit": 15.00, "type": "ML" }, "code_information": [ { "code": "J9144", "type": "HCPCS" }, { "code": "57894-503-01", "type": "NDC" } ], "standard_charges": [ { "gross_charge": 43461.77, "minimum": 52.99, "maximum": 36942.50, "setting": "both", "payers_information": [ { "payer_name": "Aarp", "plan_name": "500102", "standard_charge_dollar": 52.99, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna", "plan_name": "700700", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna", "plan_name": "700700_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Mcare Ffs 6005", "plan_name": "700703", "standard_charge_dollar": 52.99, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Miscellaneous", "plan_name": "700720", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Miscellaneous", "plan_name": "700720_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Ppo Hmo", "plan_name": "701720", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Ppo Hmo", "plan_name": "701720_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Ambetter 68069", "plan_name": "500516", "standard_charge_dollar": 52.99, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Ms State Emplo", "plan_name": "401457", "standard_charge_percentage": 0.80, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Ms State Emplo", "plan_name": "401457_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Basic Pl", "plan_name": "400100", "standard_charge_percentage": 0.85, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Basic Pl", "plan_name": "400100_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Federal", "plan_name": "400110", "standard_charge_percentage": 0.85, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Federal", "plan_name": "400110_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Cigna Healthsprings Ffs", "plan_name": "500064", "standard_charge_dollar": 52.99, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Conseco", "plan_name": "500302", "standard_charge_dollar": 52.99, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Humana Ffs 61101", "plan_name": "500006", "standard_charge_dollar": 52.99, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Medicare A", "plan_name": "100100", "standard_charge_dollar": 52.99, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Medicare A", "plan_name": "100500", "standard_charge_dollar": 52.99, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Medicare Part B Only", "plan_name": "100300", "standard_charge_dollar": 52.99, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Medicare Railroad", "plan_name": "100103", "standard_charge_dollar": 52.99, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Ms Physicians Care N", "plan_name": "714210", "standard_charge_dollar": 66.24, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Peoples Hlth Ffs 72126", "plan_name": "500019", "standard_charge_dollar": 52.99, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Uhc/Secure Horizons", "plan_name": "500449", "standard_charge_dollar": 52.99, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "United Health Care/", "plan_name": "500292", "standard_charge_dollar": 59.88, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "United Healthcare", "plan_name": "750104", "standard_charge_dollar": 59.88, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "United Healthcare Ba", "plan_name": "750090", "standard_charge_dollar": 59.88, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "United Healthcare Me", "plan_name": "501310", "standard_charge_dollar": 52.99, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Windsor Mcare Extra", "plan_name": "500778", "standard_charge_dollar": 52.99, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." } ] } ] }, { "description": "Daratumumab 20 mg/ml intravenous solution [171856]", "drug_information": { "unit": 5.00, "type": "ML" }, "code_information": [ { "code": "J9145", "type": "HCPCS" }, { "code": "57894-502-05", "type": "NDC" } ], "standard_charges": [ { "gross_charge": 3188.66, "minimum": 45.52, "maximum": 84.54, "setting": "both", "payers_information": [ { "payer_name": "Aarp", "plan_name": "500102", "standard_charge_dollar": 67.63, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna", "plan_name": "700700", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna", "plan_name": "700700_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Mcare Ffs 6005", "plan_name": "700703", "standard_charge_dollar": 67.63, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Miscellaneous", "plan_name": "700720", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Miscellaneous", "plan_name": "700720_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Ppo Hmo", "plan_name": "701720", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Ppo Hmo", "plan_name": "701720_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Ambetter 68069", "plan_name": "500516", "standard_charge_dollar": 67.63, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Ms State Emplo", "plan_name": "401457", "standard_charge_dollar": 45.52, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Ms State Emplo", "plan_name": "401457_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Basic Pl", "plan_name": "400100", "standard_charge_dollar": 45.52, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Basic Pl", "plan_name": "400100_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Federal", "plan_name": "400110", "standard_charge_dollar": 45.52, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Federal", "plan_name": "400110_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Cigna Healthsprings Ffs", "plan_name": "500064", "standard_charge_dollar": 67.63, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Conseco", "plan_name": "500302", "standard_charge_dollar": 67.63, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Humana Ffs 61101", "plan_name": "500006", "standard_charge_dollar": 67.63, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Medicare A", "plan_name": "100100", "standard_charge_dollar": 67.63, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Medicare A", "plan_name": "100500", "standard_charge_dollar": 67.63, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Medicare Part B Only", "plan_name": "100300", "standard_charge_dollar": 67.63, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Medicare Railroad", "plan_name": "100103", "standard_charge_dollar": 67.63, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Ms Physicians Care N", "plan_name": "714210", "standard_charge_dollar": 84.54, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Peoples Hlth Ffs 72126", "plan_name": "500019", "standard_charge_dollar": 67.63, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Uhc/Secure Horizons", "plan_name": "500449", "standard_charge_dollar": 67.63, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "United Health Care/", "plan_name": "500292", "standard_charge_dollar": 76.42, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "United Healthcare", "plan_name": "750104", "standard_charge_dollar": 76.42, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "United Healthcare Ba", "plan_name": "750090", "standard_charge_dollar": 76.42, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "United Healthcare Me", "plan_name": "501310", "standard_charge_dollar": 67.63, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Windsor Mcare Extra", "plan_name": "500778", "standard_charge_dollar": 67.63, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." } ] } ] }, { "description": "Daratumumab 20 mg/ml intravenous solution [171856]", "drug_information": { "unit": 20.00, "type": "ML" }, "code_information": [ { "code": "J9145", "type": "HCPCS" }, { "code": "57894-502-20", "type": "NDC" } ], "standard_charges": [ { "gross_charge": 12754.53, "minimum": 45.52, "maximum": 84.54, "setting": "both", "payers_information": [ { "payer_name": "Aarp", "plan_name": "500102", "standard_charge_dollar": 67.63, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna", "plan_name": "700700", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna", "plan_name": "700700_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Mcare Ffs 6005", "plan_name": "700703", "standard_charge_dollar": 67.63, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Miscellaneous", "plan_name": "700720", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Miscellaneous", "plan_name": "700720_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Ppo Hmo", "plan_name": "701720", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Ppo Hmo", "plan_name": "701720_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Ambetter 68069", "plan_name": "500516", "standard_charge_dollar": 67.63, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Ms State Emplo", "plan_name": "401457", "standard_charge_dollar": 45.52, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Ms State Emplo", "plan_name": "401457_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Basic Pl", "plan_name": "400100", "standard_charge_dollar": 45.52, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Basic Pl", "plan_name": "400100_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Federal", "plan_name": "400110", "standard_charge_dollar": 45.52, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Federal", "plan_name": "400110_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Cigna Healthsprings Ffs", "plan_name": "500064", "standard_charge_dollar": 67.63, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Conseco", "plan_name": "500302", "standard_charge_dollar": 67.63, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Humana Ffs 61101", "plan_name": "500006", "standard_charge_dollar": 67.63, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Medicare A", "plan_name": "100100", "standard_charge_dollar": 67.63, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Medicare A", "plan_name": "100500", "standard_charge_dollar": 67.63, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Medicare Part B Only", "plan_name": "100300", "standard_charge_dollar": 67.63, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Medicare Railroad", "plan_name": "100103", "standard_charge_dollar": 67.63, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Ms Physicians Care N", "plan_name": "714210", "standard_charge_dollar": 84.54, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Peoples Hlth Ffs 72126", "plan_name": "500019", "standard_charge_dollar": 67.63, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Uhc/Secure Horizons", "plan_name": "500449", "standard_charge_dollar": 67.63, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "United Health Care/", "plan_name": "500292", "standard_charge_dollar": 76.42, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "United Healthcare", "plan_name": "750104", "standard_charge_dollar": 76.42, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "United Healthcare Ba", "plan_name": "750090", "standard_charge_dollar": 76.42, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "United Healthcare Me", "plan_name": "501310", "standard_charge_dollar": 67.63, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Windsor Mcare Extra", "plan_name": "500778", "standard_charge_dollar": 67.63, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." } ] } ] }, { "description": "Docetaxel 80 mg/4 ml (20 mg/ml) intravenous solution [120029]", "drug_information": { "unit": 4.00, "type": "ML" }, "code_information": [ { "code": "J9171", "type": "HCPCS" }, { "code": "45963-765-52", "type": "NDC" } ], "standard_charges": [ { "gross_charge": 1382.09, "minimum": 12.37, "maximum": 12.37, "setting": "both", "payers_information": [ { "payer_name": "Aetna", "plan_name": "700700", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna", "plan_name": "700700_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Miscellaneous", "plan_name": "700720", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Miscellaneous", "plan_name": "700720_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Ppo Hmo", "plan_name": "701720", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Ppo Hmo", "plan_name": "701720_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Ms State Emplo", "plan_name": "401457", "standard_charge_dollar": 12.37, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Ms State Emplo", "plan_name": "401457_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Basic Pl", "plan_name": "400100", "standard_charge_dollar": 12.37, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Basic Pl", "plan_name": "400100_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Federal", "plan_name": "400110", "standard_charge_dollar": 12.37, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Federal", "plan_name": "400110_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." } ] } ] }, { "description": "Docetaxel 160 mg/8 ml (20 mg/ml) intravenous solution [158430]", "drug_information": { "unit": 8.00, "type": "ML" }, "code_information": [ { "code": "J9171", "type": "HCPCS" }, { "code": "16729-267-65", "type": "NDC" } ], "standard_charges": [ { "gross_charge": 805.54, "minimum": 12.37, "maximum": 12.37, "setting": "both", "payers_information": [ { "payer_name": "Aetna", "plan_name": "700700", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna", "plan_name": "700700_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Miscellaneous", "plan_name": "700720", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Miscellaneous", "plan_name": "700720_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Ppo Hmo", "plan_name": "701720", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Ppo Hmo", "plan_name": "701720_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Ms State Emplo", "plan_name": "401457", "standard_charge_dollar": 12.37, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Ms State Emplo", "plan_name": "401457_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Basic Pl", "plan_name": "400100", "standard_charge_dollar": 12.37, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Basic Pl", "plan_name": "400100_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Federal", "plan_name": "400110", "standard_charge_dollar": 12.37, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Federal", "plan_name": "400110_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." } ] } ] }, { "description": "Docetaxel 160 mg/8 ml (20 mg/ml) intravenous solution [158430]", "drug_information": { "unit": 8.00, "type": "ML" }, "code_information": [ { "code": "J9171", "type": "HCPCS" }, { "code": "67457-781-08", "type": "NDC" } ], "standard_charges": [ { "gross_charge": 1323.32, "minimum": 12.37, "maximum": 12.37, "setting": "both", "payers_information": [ { "payer_name": "Aetna", "plan_name": "700700", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna", "plan_name": "700700_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Miscellaneous", "plan_name": "700720", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Miscellaneous", "plan_name": "700720_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Ppo Hmo", "plan_name": "701720", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Ppo Hmo", "plan_name": "701720_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Ms State Emplo", "plan_name": "401457", "standard_charge_dollar": 12.37, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Ms State Emplo", "plan_name": "401457_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Basic Pl", "plan_name": "400100", "standard_charge_dollar": 12.37, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Basic Pl", "plan_name": "400100_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Federal", "plan_name": "400110", "standard_charge_dollar": 12.37, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Federal", "plan_name": "400110_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." } ] } ] }, { "description": "Durvalumab 50 mg/ml intravenous solution [181308]", "drug_information": { "unit": 2.40, "type": "ML" }, "code_information": [ { "code": "J9173", "type": "HCPCS" }, { "code": "0310-4500-12", "type": "NDC" } ], "standard_charges": [ { "gross_charge": 4333.73, "minimum": 83.87, "maximum": 3683.67, "setting": "both", "payers_information": [ { "payer_name": "Aarp", "plan_name": "500102", "standard_charge_dollar": 83.87, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna", "plan_name": "700700", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna", "plan_name": "700700_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Mcare Ffs 6005", "plan_name": "700703", "standard_charge_dollar": 83.87, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Miscellaneous", "plan_name": "700720", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Miscellaneous", "plan_name": "700720_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Ppo Hmo", "plan_name": "701720", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Ppo Hmo", "plan_name": "701720_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Ambetter 68069", "plan_name": "500516", "standard_charge_dollar": 83.87, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Ms State Emplo", "plan_name": "401457", "standard_charge_percentage": 0.80, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Ms State Emplo", "plan_name": "401457_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Basic Pl", "plan_name": "400100", "standard_charge_percentage": 0.85, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Basic Pl", "plan_name": "400100_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Federal", "plan_name": "400110", "standard_charge_percentage": 0.85, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Federal", "plan_name": "400110_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Cigna Healthsprings Ffs", "plan_name": "500064", "standard_charge_dollar": 83.87, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Conseco", "plan_name": "500302", "standard_charge_dollar": 83.87, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Humana Ffs 61101", "plan_name": "500006", "standard_charge_dollar": 83.87, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Medicare A", "plan_name": "100100", "standard_charge_dollar": 83.87, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Medicare A", "plan_name": "100500", "standard_charge_dollar": 83.87, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Medicare Part B Only", "plan_name": "100300", "standard_charge_dollar": 83.87, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Medicare Railroad", "plan_name": "100103", "standard_charge_dollar": 83.87, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Ms Physicians Care N", "plan_name": "714210", "standard_charge_dollar": 104.84, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Peoples Hlth Ffs 72126", "plan_name": "500019", "standard_charge_dollar": 83.87, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Uhc/Secure Horizons", "plan_name": "500449", "standard_charge_dollar": 83.87, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "United Health Care/", "plan_name": "500292", "standard_charge_dollar": 94.77, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "United Healthcare", "plan_name": "750104", "standard_charge_dollar": 94.77, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "United Healthcare Ba", "plan_name": "750090", "standard_charge_dollar": 94.77, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "United Healthcare Me", "plan_name": "501310", "standard_charge_dollar": 83.87, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Windsor Mcare Extra", "plan_name": "500778", "standard_charge_dollar": 83.87, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." } ] } ] }, { "description": "Durvalumab 50 mg/ml intravenous solution [181308]", "drug_information": { "unit": 10.00, "type": "ML" }, "code_information": [ { "code": "J9173", "type": "HCPCS" }, { "code": "0310-4611-50", "type": "NDC" } ], "standard_charges": [ { "gross_charge": 18057.24, "minimum": 83.87, "maximum": 15348.65, "setting": "both", "payers_information": [ { "payer_name": "Aarp", "plan_name": "500102", "standard_charge_dollar": 83.87, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna", "plan_name": "700700", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna", "plan_name": "700700_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Mcare Ffs 6005", "plan_name": "700703", "standard_charge_dollar": 83.87, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Miscellaneous", "plan_name": "700720", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Miscellaneous", "plan_name": "700720_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Ppo Hmo", "plan_name": "701720", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Ppo Hmo", "plan_name": "701720_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Ambetter 68069", "plan_name": "500516", "standard_charge_dollar": 83.87, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Ms State Emplo", "plan_name": "401457", "standard_charge_percentage": 0.80, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Ms State Emplo", "plan_name": "401457_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Basic Pl", "plan_name": "400100", "standard_charge_percentage": 0.85, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Basic Pl", "plan_name": "400100_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Federal", "plan_name": "400110", "standard_charge_percentage": 0.85, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Federal", "plan_name": "400110_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Cigna Healthsprings Ffs", "plan_name": "500064", "standard_charge_dollar": 83.87, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Conseco", "plan_name": "500302", "standard_charge_dollar": 83.87, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Humana Ffs 61101", "plan_name": "500006", "standard_charge_dollar": 83.87, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Medicare A", "plan_name": "100100", "standard_charge_dollar": 83.87, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Medicare A", "plan_name": "100500", "standard_charge_dollar": 83.87, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Medicare Part B Only", "plan_name": "100300", "standard_charge_dollar": 83.87, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Medicare Railroad", "plan_name": "100103", "standard_charge_dollar": 83.87, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Ms Physicians Care N", "plan_name": "714210", "standard_charge_dollar": 104.84, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Peoples Hlth Ffs 72126", "plan_name": "500019", "standard_charge_dollar": 83.87, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Uhc/Secure Horizons", "plan_name": "500449", "standard_charge_dollar": 83.87, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "United Health Care/", "plan_name": "500292", "standard_charge_dollar": 94.77, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "United Healthcare", "plan_name": "750104", "standard_charge_dollar": 94.77, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "United Healthcare Ba", "plan_name": "750090", "standard_charge_dollar": 94.77, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "United Healthcare Me", "plan_name": "501310", "standard_charge_dollar": 83.87, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Windsor Mcare Extra", "plan_name": "500778", "standard_charge_dollar": 83.87, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." } ] } ] }, { "description": "Elotuzumab 300 mg intravenous solution [172527]", "drug_information": { "unit": 1.00, "type": "EA" }, "code_information": [ { "code": "J9176", "type": "HCPCS" }, { "code": "0003-2291-11", "type": "NDC" } ], "standard_charges": [ { "gross_charge": 9807.39, "minimum": 5.77, "maximum": 9.66, "setting": "both", "payers_information": [ { "payer_name": "Aarp", "plan_name": "500102", "standard_charge_dollar": 7.73, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna", "plan_name": "700700", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna", "plan_name": "700700_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Mcare Ffs 6005", "plan_name": "700703", "standard_charge_dollar": 7.73, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Miscellaneous", "plan_name": "700720", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Miscellaneous", "plan_name": "700720_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Ppo Hmo", "plan_name": "701720", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Ppo Hmo", "plan_name": "701720_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Ambetter 68069", "plan_name": "500516", "standard_charge_dollar": 7.73, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Ms State Emplo", "plan_name": "401457", "standard_charge_dollar": 5.77, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Ms State Emplo", "plan_name": "401457_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Basic Pl", "plan_name": "400100", "standard_charge_dollar": 5.77, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Basic Pl", "plan_name": "400100_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Federal", "plan_name": "400110", "standard_charge_dollar": 5.77, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Federal", "plan_name": "400110_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Cigna Healthsprings Ffs", "plan_name": "500064", "standard_charge_dollar": 7.73, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Conseco", "plan_name": "500302", "standard_charge_dollar": 7.73, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Humana Ffs 61101", "plan_name": "500006", "standard_charge_dollar": 7.73, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Medicare A", "plan_name": "100100", "standard_charge_dollar": 7.73, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Medicare A", "plan_name": "100500", "standard_charge_dollar": 7.73, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Medicare Part B Only", "plan_name": "100300", "standard_charge_dollar": 7.73, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Medicare Railroad", "plan_name": "100103", "standard_charge_dollar": 7.73, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Ms Physicians Care N", "plan_name": "714210", "standard_charge_dollar": 9.66, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Peoples Hlth Ffs 72126", "plan_name": "500019", "standard_charge_dollar": 7.73, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Uhc/Secure Horizons", "plan_name": "500449", "standard_charge_dollar": 7.73, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "United Health Care/", "plan_name": "500292", "standard_charge_dollar": 8.73, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "United Healthcare", "plan_name": "750104", "standard_charge_dollar": 8.73, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "United Healthcare Ba", "plan_name": "750090", "standard_charge_dollar": 8.73, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "United Healthcare Me", "plan_name": "501310", "standard_charge_dollar": 7.73, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Windsor Mcare Extra", "plan_name": "500778", "standard_charge_dollar": 7.73, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." } ] } ] }, { "description": "Etoposide 20 mg/ml intravenous solution [10000]", "drug_information": { "unit": 5.00, "type": "ML" }, "code_information": [ { "code": "J9181", "type": "HCPCS" }, { "code": "0143-9510-01", "type": "NDC" } ], "standard_charges": [ { "gross_charge": 77.99, "minimum": 62.39, "maximum": 66.29, "setting": "both", "payers_information": [ { "payer_name": "Aetna", "plan_name": "700700", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna", "plan_name": "700700_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Miscellaneous", "plan_name": "700720", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Miscellaneous", "plan_name": "700720_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Ppo Hmo", "plan_name": "701720", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Ppo Hmo", "plan_name": "701720_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Ms State Emplo", "plan_name": "401457", "standard_charge_percentage": 0.80, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Ms State Emplo", "plan_name": "401457_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Basic Pl", "plan_name": "400100", "standard_charge_percentage": 0.85, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Basic Pl", "plan_name": "400100_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Federal", "plan_name": "400110", "standard_charge_percentage": 0.85, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Federal", "plan_name": "400110_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." } ] } ] }, { "description": "Etoposide 20 mg/ml intravenous solution [10000]", "drug_information": { "unit": 25.00, "type": "ML" }, "code_information": [ { "code": "J9181", "type": "HCPCS" }, { "code": "63323-104-25", "type": "NDC" } ], "standard_charges": [ { "gross_charge": 341.33, "minimum": 273.06, "maximum": 290.13, "setting": "both", "payers_information": [ { "payer_name": "Aetna", "plan_name": "700700", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna", "plan_name": "700700_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Miscellaneous", "plan_name": "700720", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Miscellaneous", "plan_name": "700720_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Ppo Hmo", "plan_name": "701720", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Ppo Hmo", "plan_name": "701720_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Ms State Emplo", "plan_name": "401457", "standard_charge_percentage": 0.80, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Ms State Emplo", "plan_name": "401457_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Basic Pl", "plan_name": "400100", "standard_charge_percentage": 0.85, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Basic Pl", "plan_name": "400100_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Federal", "plan_name": "400110", "standard_charge_percentage": 0.85, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Federal", "plan_name": "400110_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." } ] } ] }, { "description": "Etoposide 20 mg/ml intravenous solution [10000]", "drug_information": { "unit": 50.00, "type": "ML" }, "code_information": [ { "code": "J9181", "type": "HCPCS" }, { "code": "63323-104-50", "type": "NDC" } ], "standard_charges": [ { "gross_charge": 682.88, "minimum": 546.30, "maximum": 580.45, "setting": "both", "payers_information": [ { "payer_name": "Aetna", "plan_name": "700700", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna", "plan_name": "700700_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Miscellaneous", "plan_name": "700720", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Miscellaneous", "plan_name": "700720_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Ppo Hmo", "plan_name": "701720", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Ppo Hmo", "plan_name": "701720_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Ms State Emplo", "plan_name": "401457", "standard_charge_percentage": 0.80, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Ms State Emplo", "plan_name": "401457_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Basic Pl", "plan_name": "400100", "standard_charge_percentage": 0.85, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Basic Pl", "plan_name": "400100_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Federal", "plan_name": "400110", "standard_charge_percentage": 0.85, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Federal", "plan_name": "400110_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." } ] } ] }, { "description": "Etoposide 20 mg/ml intravenous solution [10000]", "drug_information": { "unit": 5.00, "type": "ML" }, "code_information": [ { "code": "J9181", "type": "HCPCS" }, { "code": "16729-114-31", "type": "NDC" } ], "standard_charges": [ { "gross_charge": 77.99, "minimum": 62.39, "maximum": 66.29, "setting": "both", "payers_information": [ { "payer_name": "Aetna", "plan_name": "700700", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna", "plan_name": "700700_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Miscellaneous", "plan_name": "700720", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Miscellaneous", "plan_name": "700720_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Ppo Hmo", "plan_name": "701720", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Ppo Hmo", "plan_name": "701720_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Ms State Emplo", "plan_name": "401457", "standard_charge_percentage": 0.80, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Ms State Emplo", "plan_name": "401457_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Basic Pl", "plan_name": "400100", "standard_charge_percentage": 0.85, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Basic Pl", "plan_name": "400100_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Federal", "plan_name": "400110", "standard_charge_percentage": 0.85, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Federal", "plan_name": "400110_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." } ] } ] }, { "description": "Fluorouracil 2.5 gram/50 ml intravenous solution [82180]", "drug_information": { "unit": 50.00, "type": "ML" }, "code_information": [ { "code": "J9190", "type": "HCPCS" }, { "code": "16729-276-11", "type": "NDC" } ], "standard_charges": [ { "gross_charge": 277.65, "minimum": 222.12, "maximum": 236.00, "setting": "both", "payers_information": [ { "payer_name": "Aetna", "plan_name": "700700", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna", "plan_name": "700700_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Miscellaneous", "plan_name": "700720", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Miscellaneous", "plan_name": "700720_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Ppo Hmo", "plan_name": "701720", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Ppo Hmo", "plan_name": "701720_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Ms State Emplo", "plan_name": "401457", "standard_charge_percentage": 0.80, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Ms State Emplo", "plan_name": "401457_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Basic Pl", "plan_name": "400100", "standard_charge_percentage": 0.85, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." 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"standard_charge_percentage": 0.85, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Federal", "plan_name": "400110_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." } ] } ] }, { "description": "Fluorouracil 5 gram/100 ml intravenous solution [98249]", "drug_information": { "unit": 100.00, "type": "ML" }, "code_information": [ { "code": "J9190", "type": "HCPCS" }, { "code": "63323-117-61", "type": "NDC" } ], "standard_charges": [ { "gross_charge": 527.85, "minimum": 422.28, "maximum": 448.67, "setting": "both", "payers_information": [ { "payer_name": "Aetna", "plan_name": "700700", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit 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}, { "payer_name": "Bc/Bs Of Ms Basic Pl", "plan_name": "400100_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Federal", "plan_name": "400110", "standard_charge_percentage": 0.85, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Federal", "plan_name": "400110_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." } ] } ] }, { "description": "Fluorouracil 5 gram/100 ml intravenous solution [98249]", "drug_information": { "unit": 100.00, "type": "ML" }, "code_information": [ { "code": "J9190", "type": "HCPCS" }, { "code": "63323-117-69", "type": "NDC" } ], 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}, { "payer_name": "Bc/Bs Of Ms Basic Pl", "plan_name": "400100_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Federal", "plan_name": "400110", "standard_charge_percentage": 0.85, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Federal", "plan_name": "400110_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." } ] } ] }, { "description": "Gemcitabine 1 gram/26.3 ml (38 mg/ml) intravenous solution [154424]", "drug_information": { "unit": 26.30, "type": "ML" }, "code_information": [ { "code": "J9201", "type": "HCPCS" }, { "code": "67457-617-30", "type": "NDC" 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schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Ms State Emplo", "plan_name": "401457_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Basic Pl", "plan_name": "400100", "standard_charge_dollar": 11.52, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Basic Pl", "plan_name": "400100_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Federal", "plan_name": "400110", "standard_charge_dollar": 11.52, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Federal", "plan_name": "400110_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." } ] } ] }, { "description": "Gemcitabine 1 gram/26.3 ml (38 mg/ml) intravenous solution [154424]", "drug_information": { "unit": 26.30, "type": "ML" }, "code_information": [ { "code": "J9201", "type": "HCPCS" }, { "code": "0409-0181-01", "type": "NDC" } ], "standard_charges": [ { "gross_charge": 198.71, "minimum": 11.52, "maximum": 11.52, "setting": "both", "payers_information": [ { "payer_name": "Aetna", "plan_name": "700700", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna", "plan_name": "700700_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Miscellaneous", "plan_name": "700720", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Miscellaneous", "plan_name": "700720_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Ppo Hmo", "plan_name": "701720", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Ppo Hmo", "plan_name": "701720_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Ms State Emplo", "plan_name": "401457", "standard_charge_dollar": 11.52, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Ms State Emplo", "plan_name": "401457_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Basic Pl", "plan_name": "400100", "standard_charge_dollar": 11.52, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Basic Pl", "plan_name": "400100_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Federal", "plan_name": "400110", "standard_charge_dollar": 11.52, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Federal", "plan_name": "400110_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." } ] } ] }, { "description": "Gemcitabine 2 gram/52.6 ml (38 mg/ml) intravenous solution [154425]", "drug_information": { "unit": 52.60, "type": "ML" }, "code_information": [ { "code": "J9201", "type": "HCPCS" }, { "code": "0409-0182-01", "type": "NDC" } ], "standard_charges": [ { "gross_charge": 397.42, "minimum": 11.52, "maximum": 11.52, "setting": "both", "payers_information": [ { "payer_name": "Aetna", "plan_name": "700700", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna", "plan_name": "700700_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Miscellaneous", "plan_name": "700720", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Miscellaneous", "plan_name": "700720_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Ppo Hmo", "plan_name": "701720", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Ppo Hmo", "plan_name": "701720_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Ms State Emplo", "plan_name": "401457", "standard_charge_dollar": 11.52, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Ms State Emplo", "plan_name": "401457_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Basic Pl", "plan_name": "400100", "standard_charge_dollar": 11.52, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Basic Pl", "plan_name": "400100_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Federal", "plan_name": "400110", "standard_charge_dollar": 11.52, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Federal", "plan_name": "400110_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." } ] } ] }, { "description": "Gemcitabine 200 mg/5.26 ml (38 mg/ml) intravenous solution [154426]", "drug_information": { "unit": 5.26, "type": "ML" }, "code_information": [ { "code": "J9201", "type": "HCPCS" }, { "code": "0409-0183-01", "type": "NDC" } ], "standard_charges": [ { "gross_charge": 55.00, "minimum": 11.52, "maximum": 11.52, "setting": "both", "payers_information": [ { "payer_name": "Aetna", "plan_name": "700700", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna", "plan_name": "700700_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Miscellaneous", "plan_name": "700720", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Miscellaneous", "plan_name": "700720_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Ppo Hmo", "plan_name": "701720", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Ppo Hmo", "plan_name": "701720_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Ms State Emplo", "plan_name": "401457", "standard_charge_dollar": 11.52, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Ms State Emplo", "plan_name": "401457_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Basic Pl", "plan_name": "400100", "standard_charge_dollar": 11.52, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Basic Pl", "plan_name": "400100_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Federal", "plan_name": "400110", "standard_charge_dollar": 11.52, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Federal", "plan_name": "400110_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." } ] } ] }, { "description": "Goserelin 3.6 mg subcutaneous implant [10137]", "drug_information": { "unit": 1.00, "type": "EA" }, "code_information": [ { "code": "J9202", "type": "HCPCS" }, { "code": "70720-950-36", "type": "NDC" } ], "standard_charges": [ { "gross_charge": 4258.98, "minimum": 528.48, "maximum": 881.43, "setting": "both", "payers_information": [ { "payer_name": "Aarp", "plan_name": "500102", "standard_charge_dollar": 705.14, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna", "plan_name": "700700", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna", "plan_name": "700700_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Mcare Ffs 6005", "plan_name": "700703", "standard_charge_dollar": 705.14, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Miscellaneous", "plan_name": "700720", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Miscellaneous", "plan_name": "700720_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Ppo Hmo", "plan_name": "701720", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Ppo Hmo", "plan_name": "701720_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Ambetter 68069", "plan_name": "500516", "standard_charge_dollar": 705.14, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Ms State Emplo", "plan_name": "401457", "standard_charge_dollar": 528.48, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Ms State Emplo", "plan_name": "401457_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Basic Pl", "plan_name": "400100", "standard_charge_dollar": 528.48, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Basic Pl", "plan_name": "400100_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Federal", "plan_name": "400110", "standard_charge_dollar": 528.48, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Federal", "plan_name": "400110_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Cigna Healthsprings Ffs", "plan_name": "500064", "standard_charge_dollar": 705.14, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Conseco", "plan_name": "500302", "standard_charge_dollar": 705.14, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Humana Ffs 61101", "plan_name": "500006", "standard_charge_dollar": 705.14, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Medicare A", "plan_name": "100100", "standard_charge_dollar": 705.14, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Medicare A", "plan_name": "100500", "standard_charge_dollar": 705.14, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Medicare Part B Only", "plan_name": "100300", "standard_charge_dollar": 705.14, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Medicare Railroad", "plan_name": "100103", "standard_charge_dollar": 705.14, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Ms Physicians Care N", "plan_name": "714210", "standard_charge_dollar": 881.43, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Peoples Hlth Ffs 72126", "plan_name": "500019", "standard_charge_dollar": 705.14, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Uhc/Secure Horizons", "plan_name": "500449", "standard_charge_dollar": 705.14, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "United Health Care/", "plan_name": "500292", "standard_charge_dollar": 796.81, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "United Healthcare", "plan_name": "750104", "standard_charge_dollar": 796.81, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "United Healthcare Ba", "plan_name": "750090", "standard_charge_dollar": 796.81, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "United Healthcare Me", "plan_name": "501310", "standard_charge_dollar": 705.14, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Windsor Mcare Extra", "plan_name": "500778", "standard_charge_dollar": 705.14, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." } ] } ] }, { "description": "Goserelin 10.8 mg subcutaneous implant [16254]", "drug_information": { "unit": 1.00, "type": "EA" }, "code_information": [ { "code": "J9202", "type": "HCPCS" }, { "code": "70720-951-30", "type": "NDC" } ], "standard_charges": [ { "gross_charge": 11941.20, "minimum": 528.48, "maximum": 881.43, "setting": "both", "payers_information": [ { "payer_name": "Aarp", "plan_name": "500102", "standard_charge_dollar": 705.14, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna", "plan_name": "700700", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna", "plan_name": "700700_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Mcare Ffs 6005", "plan_name": "700703", "standard_charge_dollar": 705.14, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Miscellaneous", "plan_name": "700720", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Miscellaneous", "plan_name": "700720_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Ppo Hmo", "plan_name": "701720", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Ppo Hmo", "plan_name": "701720_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Ambetter 68069", "plan_name": "500516", "standard_charge_dollar": 705.14, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Ms State Emplo", "plan_name": "401457", "standard_charge_dollar": 528.48, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Ms State Emplo", "plan_name": "401457_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Basic Pl", "plan_name": "400100", "standard_charge_dollar": 528.48, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Basic Pl", "plan_name": "400100_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Federal", "plan_name": "400110", "standard_charge_dollar": 528.48, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Federal", "plan_name": "400110_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Cigna Healthsprings Ffs", "plan_name": "500064", "standard_charge_dollar": 705.14, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Conseco", "plan_name": "500302", "standard_charge_dollar": 705.14, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Humana Ffs 61101", "plan_name": "500006", "standard_charge_dollar": 705.14, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Medicare A", "plan_name": "100100", "standard_charge_dollar": 705.14, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Medicare A", "plan_name": "100500", "standard_charge_dollar": 705.14, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Medicare Part B Only", "plan_name": "100300", "standard_charge_dollar": 705.14, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Medicare Railroad", "plan_name": "100103", "standard_charge_dollar": 705.14, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Ms Physicians Care N", "plan_name": "714210", "standard_charge_dollar": 881.43, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Peoples Hlth Ffs 72126", "plan_name": "500019", "standard_charge_dollar": 705.14, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Uhc/Secure Horizons", "plan_name": "500449", "standard_charge_dollar": 705.14, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "United Health Care/", "plan_name": "500292", "standard_charge_dollar": 796.81, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "United Healthcare", "plan_name": "750104", "standard_charge_dollar": 796.81, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "United Healthcare Ba", "plan_name": "750090", "standard_charge_dollar": 796.81, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "United Healthcare Me", "plan_name": "501310", "standard_charge_dollar": 705.14, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Windsor Mcare Extra", "plan_name": "500778", "standard_charge_dollar": 705.14, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." } ] } ] }, { "description": "Irinotecan liposomal 4.3 mg/ml intravenous [171735]", "drug_information": { "unit": 10.00, "type": "ML" }, "code_information": [ { "code": "J9205", "type": "HCPCS" }, { "code": "15054-0043-1", 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"standard_charge_dollar": 65.28, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Humana Ffs 61101", "plan_name": "500006", "standard_charge_dollar": 65.28, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Medicare A", "plan_name": "100100", "standard_charge_dollar": 65.28, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Medicare A", "plan_name": "100500", "standard_charge_dollar": 65.28, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Medicare Part B Only", "plan_name": "100300", "standard_charge_dollar": 65.28, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Medicare Railroad", "plan_name": "100103", "standard_charge_dollar": 65.28, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Ms Physicians Care N", "plan_name": "714210", "standard_charge_dollar": 81.60, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Peoples Hlth Ffs 72126", "plan_name": "500019", "standard_charge_dollar": 65.28, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Uhc/Secure Horizons", "plan_name": "500449", "standard_charge_dollar": 65.28, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "United Health Care/", "plan_name": "500292", "standard_charge_dollar": 73.77, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "United Healthcare", "plan_name": "750104", "standard_charge_dollar": 73.77, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "United Healthcare Ba", "plan_name": "750090", "standard_charge_dollar": 73.77, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "United Healthcare Me", "plan_name": "501310", "standard_charge_dollar": 65.28, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Windsor Mcare Extra", "plan_name": "500778", "standard_charge_dollar": 65.28, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." } ] } ] }, { "description": "Irinotecan 100 mg/5 ml intravenous solution [17450]", "drug_information": { "unit": 5.00, "type": "ML" }, "code_information": [ { "code": "J9206", "type": "HCPCS" }, { "code": "25021-230-05", "type": "NDC" } ], "standard_charges": [ { "gross_charge": 137.97, "minimum": 7.29, "maximum": 7.29, "setting": "both", "payers_information": [ { "payer_name": "Aetna", "plan_name": "700700", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna", "plan_name": "700700_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Miscellaneous", "plan_name": "700720", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Miscellaneous", "plan_name": "700720_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Ppo Hmo", "plan_name": "701720", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Ppo Hmo", "plan_name": "701720_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Ms State Emplo", "plan_name": "401457", "standard_charge_dollar": 7.29, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Ms State Emplo", "plan_name": "401457_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Basic Pl", "plan_name": "400100", "standard_charge_dollar": 7.29, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Basic Pl", "plan_name": "400100_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Federal", "plan_name": "400110", "standard_charge_dollar": 7.29, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Federal", "plan_name": "400110_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." } ] } ] }, { "description": "Irinotecan 100 mg/5 ml intravenous solution [17450]", "drug_information": { "unit": 5.00, "type": "ML" }, "code_information": [ { "code": "J9206", "type": "HCPCS" }, { "code": "45963-614-55", "type": "NDC" } ], "standard_charges": [ { "gross_charge": 185.72, "minimum": 7.29, "maximum": 7.29, "setting": "both", "payers_information": [ { "payer_name": "Aetna", "plan_name": "700700", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna", "plan_name": 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"standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Ms State Emplo", "plan_name": "401457", "standard_charge_dollar": 7.29, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Ms State Emplo", "plan_name": "401457_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Basic Pl", "plan_name": "400100", "standard_charge_dollar": 7.29, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Basic Pl", "plan_name": "400100_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Federal", "plan_name": "400110", "standard_charge_dollar": 7.29, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Federal", "plan_name": "400110_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." } ] } ] }, { "description": "Irinotecan 100 mg/5 ml intravenous solution [17450]", "drug_information": { "unit": 5.00, "type": "ML" }, "code_information": [ { "code": "J9206", "type": "HCPCS" }, { "code": "60505-6128-1", "type": "NDC" } ], "standard_charges": [ { "gross_charge": 185.72, "minimum": 7.29, "maximum": 7.29, "setting": "both", "payers_information": [ { "payer_name": "Aetna", 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"standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Ppo Hmo", "plan_name": "701720_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Ms State Emplo", "plan_name": "401457", "standard_charge_dollar": 7.29, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Ms State Emplo", "plan_name": "401457_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Basic Pl", "plan_name": "400100", "standard_charge_dollar": 7.29, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Basic Pl", "plan_name": "400100_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Federal", "plan_name": "400110", "standard_charge_dollar": 7.29, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Federal", "plan_name": "400110_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." } ] } ] }, { "description": "Irinotecan 100 mg/5 ml intravenous solution [17450]", "drug_information": { "unit": 5.00, "type": "ML" }, "code_information": [ { "code": "J9206", "type": "HCPCS" }, { "code": "70700-170-22", "type": "NDC" } ], "standard_charges": [ { "gross_charge": 185.72, "minimum": 7.29, "maximum": 7.29, "setting": "both", "payers_information": [ { "payer_name": "Aetna", "plan_name": "700700", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna", "plan_name": "700700_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Miscellaneous", "plan_name": "700720", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Miscellaneous", "plan_name": "700720_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Ppo Hmo", "plan_name": "701720", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Ppo Hmo", "plan_name": "701720_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Ms State Emplo", "plan_name": "401457", "standard_charge_dollar": 7.29, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Ms State Emplo", "plan_name": "401457_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Basic Pl", "plan_name": "400100", "standard_charge_dollar": 7.29, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Basic Pl", "plan_name": "400100_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Federal", "plan_name": "400110", "standard_charge_dollar": 7.29, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Federal", "plan_name": "400110_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." } ] } ] }, { "description": "Irinotecan 100 mg/5 ml intravenous solution [17450]", "drug_information": { "unit": 5.00, "type": "ML" }, "code_information": [ { "code": "J9206", "type": "HCPCS" }, { "code": "0143-9701-01", "type": "NDC" } ], "standard_charges": [ { "gross_charge": 185.72, "minimum": 7.29, "maximum": 7.29, "setting": "both", "payers_information": [ { "payer_name": "Aetna", "plan_name": "700700", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna", "plan_name": "700700_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna 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"plan_name": "401457", "standard_charge_dollar": 7.29, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Ms State Emplo", "plan_name": "401457_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Basic Pl", "plan_name": "400100", "standard_charge_dollar": 7.29, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Basic Pl", "plan_name": "400100_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Federal", "plan_name": "400110", "standard_charge_dollar": 7.29, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Federal", "plan_name": "400110_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." } ] } ] }, { "description": "Leuprolide 7.5 mg intramuscular syringe kit [151393]", "drug_information": { "unit": 1.00, "type": "EA" }, "code_information": [ { "code": "J9217", "type": "HCPCS" }, { "code": "0074-3642-03", "type": "NDC" } ], "standard_charges": [ { "gross_charge": 8652.06, "minimum": 172.29, "maximum": 433.62, "setting": "both", "payers_information": [ { "payer_name": "Aarp", "plan_name": "500102", "standard_charge_dollar": 172.29, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna", 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{ "payer_name": "Medicare Railroad", "plan_name": "100103", "standard_charge_dollar": 172.29, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Ms Physicians Care N", "plan_name": "714210", "standard_charge_dollar": 215.36, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Peoples Hlth Ffs 72126", "plan_name": "500019", "standard_charge_dollar": 172.29, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Uhc/Secure Horizons", "plan_name": "500449", "standard_charge_dollar": 172.29, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "United Health Care/", "plan_name": "500292", "standard_charge_dollar": 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"additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Ppo Hmo", "plan_name": "701720_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Ambetter 68069", "plan_name": "500516", "standard_charge_dollar": 172.29, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Ms State Emplo", "plan_name": "401457", "standard_charge_dollar": 433.62, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Ms State Emplo", "plan_name": "401457_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Basic Pl", "plan_name": "400100", "standard_charge_dollar": 433.62, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Basic Pl", "plan_name": "400100_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Federal", "plan_name": "400110", "standard_charge_dollar": 433.62, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Federal", "plan_name": "400110_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Cigna Healthsprings Ffs", "plan_name": "500064", "standard_charge_dollar": 172.29, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Conseco", "plan_name": "500302", "standard_charge_dollar": 172.29, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Humana Ffs 61101", "plan_name": "500006", "standard_charge_dollar": 172.29, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Medicare A", "plan_name": "100100", "standard_charge_dollar": 172.29, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Medicare A", "plan_name": "100500", "standard_charge_dollar": 172.29, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Medicare Part B Only", "plan_name": "100300", "standard_charge_dollar": 172.29, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Medicare Railroad", "plan_name": "100103", "standard_charge_dollar": 172.29, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Ms Physicians Care N", "plan_name": "714210", "standard_charge_dollar": 215.36, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Peoples Hlth Ffs 72126", "plan_name": "500019", "standard_charge_dollar": 172.29, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Uhc/Secure Horizons", "plan_name": "500449", "standard_charge_dollar": 172.29, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "United Health Care/", "plan_name": "500292", "standard_charge_dollar": 194.69, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "United Healthcare", "plan_name": "750104", "standard_charge_dollar": 194.69, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "United Healthcare Ba", "plan_name": "750090", "standard_charge_dollar": 194.69, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "United Healthcare Me", "plan_name": "501310", "standard_charge_dollar": 172.29, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Windsor Mcare Extra", "plan_name": "500778", "standard_charge_dollar": 172.29, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." } ] } ] }, { "description": "Leuprolide 22.5 mg (3 month) subcutaneous syringe [33669]", "drug_information": { "unit": 1.00, "type": "EA" }, "code_information": [ { "code": "J9217", "type": "HCPCS" }, { "code": "62935-227-10", "type": "NDC" } ], "standard_charges": [ { "gross_charge": 6097.82, "minimum": 172.29, "maximum": 433.62, "setting": "both", "payers_information": [ { "payer_name": "Aarp", "plan_name": "500102", "standard_charge_dollar": 172.29, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna", "plan_name": "700700", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna", "plan_name": "700700_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Mcare Ffs 6005", "plan_name": "700703", "standard_charge_dollar": 172.29, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Miscellaneous", "plan_name": "700720", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Miscellaneous", "plan_name": "700720_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Ppo Hmo", "plan_name": "701720", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Ppo Hmo", "plan_name": "701720_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Ambetter 68069", "plan_name": "500516", "standard_charge_dollar": 172.29, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Ms State Emplo", "plan_name": "401457", "standard_charge_dollar": 433.62, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Ms State Emplo", "plan_name": "401457_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Basic Pl", "plan_name": "400100", "standard_charge_dollar": 433.62, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Basic Pl", "plan_name": "400100_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Federal", "plan_name": "400110", "standard_charge_dollar": 433.62, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Federal", "plan_name": "400110_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Cigna Healthsprings Ffs", "plan_name": "500064", "standard_charge_dollar": 172.29, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Conseco", "plan_name": "500302", "standard_charge_dollar": 172.29, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Humana Ffs 61101", "plan_name": "500006", "standard_charge_dollar": 172.29, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Medicare A", "plan_name": "100100", "standard_charge_dollar": 172.29, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Medicare A", "plan_name": "100500", "standard_charge_dollar": 172.29, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Medicare Part B Only", "plan_name": "100300", "standard_charge_dollar": 172.29, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Medicare Railroad", "plan_name": "100103", "standard_charge_dollar": 172.29, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Ms Physicians Care N", "plan_name": "714210", "standard_charge_dollar": 215.36, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Peoples Hlth Ffs 72126", "plan_name": "500019", "standard_charge_dollar": 172.29, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Uhc/Secure Horizons", "plan_name": "500449", "standard_charge_dollar": 172.29, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "United Health Care/", "plan_name": "500292", "standard_charge_dollar": 194.69, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "United Healthcare", "plan_name": "750104", "standard_charge_dollar": 194.69, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "United Healthcare Ba", "plan_name": "750090", "standard_charge_dollar": 194.69, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "United Healthcare Me", "plan_name": "501310", "standard_charge_dollar": 172.29, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Windsor Mcare Extra", "plan_name": "500778", "standard_charge_dollar": 172.29, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." } ] } ] }, { "description": "Leuprolide acetate 45 mg (6 month) subcutaneous syringe [40801]", "drug_information": { "unit": 1.00, "type": "EA" }, "code_information": [ { "code": "J9217", "type": "HCPCS" }, { "code": "62935-453-45", "type": "NDC" } ], "standard_charges": [ { "gross_charge": 13550.65, "minimum": 172.29, "maximum": 433.62, "setting": "both", "payers_information": [ { "payer_name": "Aarp", "plan_name": "500102", "standard_charge_dollar": 172.29, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna", "plan_name": "700700", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna", "plan_name": "700700_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Mcare Ffs 6005", "plan_name": "700703", "standard_charge_dollar": 172.29, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Miscellaneous", "plan_name": "700720", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Miscellaneous", "plan_name": "700720_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Ppo Hmo", "plan_name": "701720", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Ppo Hmo", "plan_name": "701720_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Ambetter 68069", "plan_name": "500516", "standard_charge_dollar": 172.29, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Ms State Emplo", "plan_name": "401457", "standard_charge_dollar": 433.62, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Ms State Emplo", "plan_name": "401457_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Basic Pl", "plan_name": "400100", "standard_charge_dollar": 433.62, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Basic Pl", "plan_name": "400100_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Federal", "plan_name": "400110", "standard_charge_dollar": 433.62, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Federal", "plan_name": "400110_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Cigna Healthsprings Ffs", "plan_name": "500064", "standard_charge_dollar": 172.29, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Conseco", "plan_name": "500302", "standard_charge_dollar": 172.29, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Humana Ffs 61101", "plan_name": "500006", "standard_charge_dollar": 172.29, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Medicare A", "plan_name": "100100", "standard_charge_dollar": 172.29, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Medicare A", "plan_name": "100500", "standard_charge_dollar": 172.29, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Medicare Part B Only", "plan_name": "100300", "standard_charge_dollar": 172.29, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Medicare Railroad", "plan_name": "100103", "standard_charge_dollar": 172.29, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Ms Physicians Care N", "plan_name": "714210", "standard_charge_dollar": 215.36, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Peoples Hlth Ffs 72126", "plan_name": "500019", "standard_charge_dollar": 172.29, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Uhc/Secure Horizons", "plan_name": "500449", "standard_charge_dollar": 172.29, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "United Health Care/", "plan_name": "500292", "standard_charge_dollar": 194.69, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "United Healthcare", "plan_name": "750104", "standard_charge_dollar": 194.69, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "United Healthcare Ba", "plan_name": "750090", "standard_charge_dollar": 194.69, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "United Healthcare Me", "plan_name": "501310", "standard_charge_dollar": 172.29, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Windsor Mcare Extra", "plan_name": "500778", "standard_charge_dollar": 172.29, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." } ] } ] }, { "description": "Leuprolide acetate 45 mg (6 month) subcutaneous syringe [40801]", "drug_information": { "unit": 1.00, "type": "EA" }, "code_information": [ { "code": "J9217", "type": "HCPCS" }, { "code": "62935-454-44", "type": "NDC" } ], "standard_charges": [ { "gross_charge": 13550.65, "minimum": 172.29, "maximum": 433.62, "setting": "both", "payers_information": [ { "payer_name": "Aarp", "plan_name": "500102", "standard_charge_dollar": 172.29, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna", "plan_name": "700700", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna", "plan_name": "700700_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Mcare Ffs 6005", "plan_name": "700703", "standard_charge_dollar": 172.29, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Miscellaneous", "plan_name": "700720", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Miscellaneous", "plan_name": "700720_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Ppo Hmo", "plan_name": "701720", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Ppo Hmo", "plan_name": "701720_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Ambetter 68069", "plan_name": "500516", "standard_charge_dollar": 172.29, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Ms State Emplo", "plan_name": "401457", "standard_charge_dollar": 433.62, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Ms State Emplo", "plan_name": "401457_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Basic Pl", "plan_name": "400100", "standard_charge_dollar": 433.62, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Basic Pl", "plan_name": "400100_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Federal", "plan_name": "400110", "standard_charge_dollar": 433.62, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Federal", "plan_name": "400110_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Cigna Healthsprings Ffs", "plan_name": "500064", "standard_charge_dollar": 172.29, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Conseco", "plan_name": "500302", "standard_charge_dollar": 172.29, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Humana Ffs 61101", "plan_name": "500006", "standard_charge_dollar": 172.29, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Medicare A", "plan_name": "100100", "standard_charge_dollar": 172.29, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Medicare A", "plan_name": "100500", "standard_charge_dollar": 172.29, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Medicare Part B Only", "plan_name": "100300", "standard_charge_dollar": 172.29, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Medicare Railroad", "plan_name": "100103", "standard_charge_dollar": 172.29, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Ms Physicians Care N", "plan_name": "714210", "standard_charge_dollar": 215.36, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Peoples Hlth Ffs 72126", "plan_name": "500019", "standard_charge_dollar": 172.29, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Uhc/Secure Horizons", "plan_name": "500449", "standard_charge_dollar": 172.29, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "United Health Care/", "plan_name": "500292", "standard_charge_dollar": 194.69, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "United Healthcare", "plan_name": "750104", "standard_charge_dollar": 194.69, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "United Healthcare Ba", "plan_name": "750090", "standard_charge_dollar": 194.69, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "United Healthcare Me", "plan_name": "501310", "standard_charge_dollar": 172.29, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Windsor Mcare Extra", "plan_name": "500778", "standard_charge_dollar": 172.29, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." } ] } ] }, { "description": "Lurbinectedin 4 mg intravenous solution [190835]", "drug_information": { "unit": 1.00, "type": "EA" }, "code_information": [ { "code": "J9223", "type": "HCPCS" }, { "code": "68727-712-01", "type": "NDC" } ], "standard_charges": [ { "gross_charge": 35646.21, "minimum": 205.04, "maximum": 30299.28, "setting": "both", "payers_information": [ { "payer_name": "Aarp", "plan_name": "500102", "standard_charge_dollar": 205.04, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna", "plan_name": "700700", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna", "plan_name": "700700_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Mcare Ffs 6005", "plan_name": "700703", "standard_charge_dollar": 205.04, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Miscellaneous", "plan_name": "700720", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Miscellaneous", "plan_name": "700720_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Ppo Hmo", "plan_name": "701720", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Ppo Hmo", "plan_name": "701720_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Ambetter 68069", "plan_name": "500516", "standard_charge_dollar": 205.04, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Ms State Emplo", "plan_name": "401457", "standard_charge_percentage": 0.80, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Ms State Emplo", "plan_name": "401457_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Basic Pl", "plan_name": "400100", "standard_charge_percentage": 0.85, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Basic Pl", "plan_name": "400100_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Federal", "plan_name": "400110", "standard_charge_percentage": 0.85, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Federal", "plan_name": "400110_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Cigna Healthsprings Ffs", "plan_name": "500064", "standard_charge_dollar": 205.04, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Conseco", "plan_name": "500302", "standard_charge_dollar": 205.04, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Humana Ffs 61101", "plan_name": "500006", "standard_charge_dollar": 205.04, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Medicare A", "plan_name": "100100", "standard_charge_dollar": 205.04, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Medicare A", "plan_name": "100500", "standard_charge_dollar": 205.04, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Medicare Part B Only", "plan_name": "100300", "standard_charge_dollar": 205.04, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Medicare Railroad", "plan_name": "100103", "standard_charge_dollar": 205.04, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Ms Physicians Care N", "plan_name": "714210", "standard_charge_dollar": 256.30, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Peoples Hlth Ffs 72126", "plan_name": "500019", "standard_charge_dollar": 205.04, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Uhc/Secure Horizons", "plan_name": "500449", "standard_charge_dollar": 205.04, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "United Health Care/", "plan_name": "500292", "standard_charge_dollar": 231.70, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "United Healthcare", "plan_name": "750104", "standard_charge_dollar": 231.70, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "United Healthcare Ba", "plan_name": "750090", "standard_charge_dollar": 231.70, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "United Healthcare Me", "plan_name": "501310", "standard_charge_dollar": 205.04, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Windsor Mcare Extra", "plan_name": "500778", "standard_charge_dollar": 205.04, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." } ] } ] }, { "description": "Ipilimumab 50 mg/10 ml (5 mg/ml) intravenous solution [151143]", "drug_information": { "unit": 10.00, "type": "ML" }, "code_information": [ { "code": "J9228", "type": "HCPCS" }, { "code": "0003-2327-11", "type": "NDC" } ], "standard_charges": [ { "gross_charge": 38257.97, "minimum": 129.77, "maximum": 225.28, "setting": "both", "payers_information": [ { "payer_name": "Aarp", "plan_name": "500102", "standard_charge_dollar": 180.22, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna", "plan_name": "700700", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna", "plan_name": "700700_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Mcare Ffs 6005", "plan_name": "700703", "standard_charge_dollar": 180.22, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Miscellaneous", "plan_name": "700720", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Miscellaneous", "plan_name": "700720_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Ppo Hmo", "plan_name": "701720", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Ppo Hmo", "plan_name": "701720_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Ambetter 68069", "plan_name": "500516", "standard_charge_dollar": 180.22, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Ms State Emplo", "plan_name": "401457", "standard_charge_dollar": 129.77, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Ms State Emplo", "plan_name": "401457_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Basic Pl", "plan_name": "400100", "standard_charge_dollar": 129.77, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Basic Pl", "plan_name": "400100_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Federal", "plan_name": "400110", "standard_charge_dollar": 129.77, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Federal", "plan_name": "400110_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Cigna Healthsprings Ffs", "plan_name": "500064", "standard_charge_dollar": 180.22, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Conseco", "plan_name": "500302", "standard_charge_dollar": 180.22, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Humana Ffs 61101", "plan_name": "500006", "standard_charge_dollar": 180.22, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Medicare A", "plan_name": "100100", "standard_charge_dollar": 180.22, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Medicare A", "plan_name": "100500", "standard_charge_dollar": 180.22, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Medicare Part B Only", "plan_name": "100300", "standard_charge_dollar": 180.22, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Medicare Railroad", "plan_name": "100103", "standard_charge_dollar": 180.22, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Ms Physicians Care N", "plan_name": "714210", "standard_charge_dollar": 225.28, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Peoples Hlth Ffs 72126", "plan_name": "500019", "standard_charge_dollar": 180.22, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Uhc/Secure Horizons", "plan_name": "500449", "standard_charge_dollar": 180.22, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "United Health Care/", "plan_name": "500292", "standard_charge_dollar": 203.65, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "United Healthcare", "plan_name": "750104", "standard_charge_dollar": 203.65, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "United Healthcare Ba", "plan_name": "750090", "standard_charge_dollar": 203.65, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "United Healthcare Me", "plan_name": "501310", "standard_charge_dollar": 180.22, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Windsor Mcare Extra", "plan_name": "500778", "standard_charge_dollar": 180.22, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." } ] } ] }, { "description": "Ipilimumab 200 mg/40 ml (5 mg/ml) intravenous solution [151144]", "drug_information": { "unit": 40.00, "type": "ML" }, "code_information": [ { "code": "J9228", "type": "HCPCS" }, { "code": "0003-2328-22", "type": "NDC" } ], "standard_charges": [ { "gross_charge": 153031.50, "minimum": 129.77, "maximum": 225.28, "setting": "both", "payers_information": [ { "payer_name": "Aarp", "plan_name": "500102", "standard_charge_dollar": 180.22, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna", "plan_name": "700700", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna", "plan_name": "700700_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Mcare Ffs 6005", "plan_name": "700703", "standard_charge_dollar": 180.22, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Miscellaneous", "plan_name": "700720", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Miscellaneous", "plan_name": "700720_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Ppo Hmo", "plan_name": "701720", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Ppo Hmo", "plan_name": "701720_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Ambetter 68069", "plan_name": "500516", "standard_charge_dollar": 180.22, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Ms State Emplo", "plan_name": "401457", "standard_charge_dollar": 129.77, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Ms State Emplo", "plan_name": "401457_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Basic Pl", "plan_name": "400100", "standard_charge_dollar": 129.77, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Basic Pl", "plan_name": "400100_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Federal", "plan_name": "400110", "standard_charge_dollar": 129.77, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Federal", "plan_name": "400110_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Cigna Healthsprings Ffs", "plan_name": "500064", "standard_charge_dollar": 180.22, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Conseco", "plan_name": "500302", "standard_charge_dollar": 180.22, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Humana Ffs 61101", "plan_name": "500006", "standard_charge_dollar": 180.22, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Medicare A", "plan_name": "100100", "standard_charge_dollar": 180.22, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Medicare A", "plan_name": "100500", "standard_charge_dollar": 180.22, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Medicare Part B Only", "plan_name": "100300", "standard_charge_dollar": 180.22, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Medicare Railroad", "plan_name": "100103", "standard_charge_dollar": 180.22, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Ms Physicians Care N", "plan_name": "714210", "standard_charge_dollar": 225.28, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Peoples Hlth Ffs 72126", "plan_name": "500019", "standard_charge_dollar": 180.22, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Uhc/Secure Horizons", "plan_name": "500449", "standard_charge_dollar": 180.22, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "United Health Care/", "plan_name": "500292", "standard_charge_dollar": 203.65, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "United Healthcare", "plan_name": "750104", "standard_charge_dollar": 203.65, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "United Healthcare Ba", "plan_name": "750090", "standard_charge_dollar": 203.65, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "United Healthcare Me", "plan_name": "501310", "standard_charge_dollar": 180.22, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Windsor Mcare Extra", "plan_name": "500778", "standard_charge_dollar": 180.22, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." } ] } ] }, { "description": "Oxaliplatin 100 mg/20 ml intravenous solution [99612]", "drug_information": { "unit": 20.00, "type": "ML" }, "code_information": [ { "code": "J9263", "type": "HCPCS" }, { "code": "0703-3986-01", "type": "NDC" } ], "standard_charges": [ { "gross_charge": 438.75, "minimum": 0.86, "maximum": 0.86, "setting": "both", "payers_information": [ { "payer_name": "Aetna", "plan_name": "700700", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna", "plan_name": "700700_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Miscellaneous", "plan_name": "700720", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Miscellaneous", "plan_name": "700720_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Ppo Hmo", "plan_name": "701720", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Ppo Hmo", "plan_name": "701720_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Ms State Emplo", "plan_name": "401457", "standard_charge_dollar": 0.86, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Ms State Emplo", "plan_name": "401457_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Basic Pl", "plan_name": "400100", "standard_charge_dollar": 0.86, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Basic Pl", "plan_name": "400100_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Federal", "plan_name": "400110", "standard_charge_dollar": 0.86, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Federal", "plan_name": "400110_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." } ] } ] }, { "description": "Oxaliplatin 100 mg/20 ml intravenous solution [99612]", "drug_information": { "unit": 20.00, "type": "ML" }, "code_information": [ { "code": "J9263", "type": "HCPCS" }, { "code": "0781-3317-80", "type": "NDC" } ], "standard_charges": [ { "gross_charge": 450.00, "minimum": 0.86, "maximum": 0.86, "setting": "both", "payers_information": [ { "payer_name": "Aetna", "plan_name": "700700", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna", "plan_name": "700700_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Miscellaneous", "plan_name": "700720", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Miscellaneous", "plan_name": "700720_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Ppo Hmo", "plan_name": "701720", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Ppo Hmo", "plan_name": "701720_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Ms State Emplo", "plan_name": "401457", "standard_charge_dollar": 0.86, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Ms State Emplo", "plan_name": "401457_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Basic Pl", "plan_name": "400100", "standard_charge_dollar": 0.86, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Basic Pl", "plan_name": "400100_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Federal", "plan_name": "400110", "standard_charge_dollar": 0.86, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Federal", "plan_name": "400110_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." } ] } ] }, { "description": "Oxaliplatin 100 mg/20 ml intravenous solution [99612]", "drug_information": { "unit": 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"401457_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Basic Pl", "plan_name": "400100", "standard_charge_dollar": 0.86, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Basic Pl", "plan_name": "400100_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Federal", "plan_name": "400110", "standard_charge_dollar": 0.86, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Federal", "plan_name": "400110_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." } ] } ] }, { "description": "Oxaliplatin 100 mg/20 ml intravenous solution [99612]", "drug_information": { "unit": 20.00, "type": "ML" }, "code_information": [ { "code": "J9263", "type": "HCPCS" }, { "code": "61703-363-22", "type": "NDC" } ], "standard_charges": [ { "gross_charge": 450.00, "minimum": 0.86, "maximum": 0.86, "setting": "both", "payers_information": [ { "payer_name": "Aetna", "plan_name": "700700", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna", "plan_name": "700700_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": 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Emplo", "plan_name": "401457", "standard_charge_dollar": 0.86, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Ms State Emplo", "plan_name": "401457_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Basic Pl", "plan_name": "400100", "standard_charge_dollar": 0.86, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Basic Pl", "plan_name": "400100_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Federal", "plan_name": "400110", "standard_charge_dollar": 0.86, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Federal", "plan_name": "400110_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." } ] } ] }, { "description": "Oxaliplatin 100 mg/20 ml intravenous solution [99612]", "drug_information": { "unit": 20.00, "type": "ML" }, "code_information": [ { "code": "J9263", "type": "HCPCS" }, { "code": "60505-6132-7", "type": "NDC" } ], "standard_charges": [ { "gross_charge": 450.00, "minimum": 0.86, "maximum": 0.86, "setting": "both", "payers_information": [ { "payer_name": "Aetna", "plan_name": "700700", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed 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"payer_name": "Aetna Ppo Hmo", "plan_name": "701720_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Ms State Emplo", "plan_name": "401457", "standard_charge_dollar": 0.86, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Ms State Emplo", "plan_name": "401457_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Basic Pl", "plan_name": "400100", "standard_charge_dollar": 0.86, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Basic Pl", "plan_name": "400100_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Federal", "plan_name": "400110", "standard_charge_dollar": 0.86, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Federal", "plan_name": "400110_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." } ] } ] }, { "description": "Oxaliplatin 100 mg/20 ml intravenous solution [99612]", "drug_information": { "unit": 20.00, "type": "ML" }, "code_information": [ { "code": "J9263", "type": "HCPCS" }, { "code": "55150-332-01", "type": "NDC" } ], "standard_charges": [ { "gross_charge": 450.00, "minimum": 0.86, "maximum": 0.86, 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amounts." }, { "payer_name": "Aetna Ppo Hmo", "plan_name": "701720", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Ppo Hmo", "plan_name": "701720_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Ms State Emplo", "plan_name": "401457", "standard_charge_dollar": 0.86, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Ms State Emplo", "plan_name": "401457_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Basic Pl", "plan_name": "400100", "standard_charge_dollar": 0.86, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Basic Pl", "plan_name": "400100_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Federal", "plan_name": "400110", "standard_charge_dollar": 0.86, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Federal", "plan_name": "400110_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." } ] } ] }, { "description": "Oxaliplatin 100 mg/20 ml intravenous solution [99612]", "drug_information": { "unit": 20.00, "type": "ML" }, "code_information": [ { "code": "J9263", "type": "HCPCS" }, { "code": "25021-233-20", "type": "NDC" } ], "standard_charges": [ { "gross_charge": 450.00, "minimum": 0.86, "maximum": 0.86, "setting": "both", "payers_information": [ { "payer_name": "Aetna", "plan_name": "700700", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna", "plan_name": "700700_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Miscellaneous", "plan_name": "700720", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed 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State Emplo", "plan_name": "401457_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Basic Pl", "plan_name": "400100", "standard_charge_dollar": 0.86, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Basic Pl", "plan_name": "400100_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Federal", "plan_name": "400110", "standard_charge_dollar": 0.86, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Federal", "plan_name": "400110_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." } ] } ] }, { "description": "Paclitaxel protein-bound 100 mg intravenous suspension [40475]", "drug_information": { "unit": 1.00, "type": "EA" }, "code_information": [ { "code": "J9264", "type": "HCPCS" }, { "code": "68817-134-50", "type": "NDC" } ], "standard_charges": [ { "gross_charge": 6932.52, "minimum": 11.06, "maximum": 16.33, "setting": "both", "payers_information": [ { "payer_name": "Aarp", "plan_name": "500102", "standard_charge_dollar": 13.06, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna", "plan_name": "700700", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed 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Hmo", "plan_name": "701720", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Ppo Hmo", "plan_name": "701720_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Ambetter 68069", "plan_name": "500516", "standard_charge_dollar": 13.06, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Ms State Emplo", "plan_name": "401457", "standard_charge_dollar": 11.06, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Ms State Emplo", "plan_name": "401457_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Basic Pl", "plan_name": "400100", "standard_charge_dollar": 11.06, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Basic Pl", "plan_name": "400100_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Federal", "plan_name": "400110", "standard_charge_dollar": 11.06, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Federal", "plan_name": "400110_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of 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"payer_name": "Medicare A", "plan_name": "100500", "standard_charge_dollar": 13.06, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Medicare Part B Only", "plan_name": "100300", "standard_charge_dollar": 13.06, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Medicare Railroad", "plan_name": "100103", "standard_charge_dollar": 13.06, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Ms Physicians Care N", "plan_name": "714210", "standard_charge_dollar": 16.33, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Peoples Hlth Ffs 72126", "plan_name": "500019", "standard_charge_dollar": 13.06, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Uhc/Secure Horizons", "plan_name": "500449", "standard_charge_dollar": 13.06, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "United Health Care/", "plan_name": "500292", "standard_charge_dollar": 14.76, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "United Healthcare", "plan_name": "750104", "standard_charge_dollar": 14.76, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "United Healthcare Ba", "plan_name": "750090", "standard_charge_dollar": 14.76, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "United Healthcare Me", "plan_name": "501310", "standard_charge_dollar": 13.06, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Windsor Mcare Extra", "plan_name": "500778", "standard_charge_dollar": 13.06, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." } ] } ] }, { "description": "Paclitaxel protein-bound 100 mg intravenous suspension [40475]", "drug_information": { "unit": 1.00, "type": "EA" }, "code_information": [ { "code": "J9264", "type": "HCPCS" }, { "code": "0517-4300-01", "type": "NDC" } ], "standard_charges": [ { "gross_charge": 7049.97, "minimum": 11.06, "maximum": 16.33, "setting": "both", "payers_information": [ { "payer_name": "Aarp", "plan_name": "500102", "standard_charge_dollar": 13.06, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna", "plan_name": "700700", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna", "plan_name": "700700_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Mcare Ffs 6005", "plan_name": "700703", "standard_charge_dollar": 13.06, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Miscellaneous", "plan_name": "700720", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Miscellaneous", "plan_name": "700720_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Ppo Hmo", "plan_name": "701720", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Ppo Hmo", "plan_name": "701720_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Ambetter 68069", "plan_name": "500516", "standard_charge_dollar": 13.06, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Ms State Emplo", "plan_name": "401457", "standard_charge_dollar": 11.06, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Ms State Emplo", "plan_name": "401457_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Basic Pl", "plan_name": "400100", "standard_charge_dollar": 11.06, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Basic Pl", "plan_name": "400100_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Federal", "plan_name": "400110", "standard_charge_dollar": 11.06, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Federal", "plan_name": "400110_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Cigna Healthsprings Ffs", "plan_name": "500064", "standard_charge_dollar": 13.06, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Conseco", "plan_name": "500302", "standard_charge_dollar": 13.06, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Humana Ffs 61101", "plan_name": "500006", "standard_charge_dollar": 13.06, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Medicare A", "plan_name": "100100", "standard_charge_dollar": 13.06, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Medicare A", "plan_name": "100500", "standard_charge_dollar": 13.06, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Medicare Part B Only", "plan_name": "100300", "standard_charge_dollar": 13.06, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Medicare Railroad", "plan_name": "100103", "standard_charge_dollar": 13.06, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Ms Physicians Care N", "plan_name": "714210", "standard_charge_dollar": 16.33, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Peoples Hlth Ffs 72126", "plan_name": "500019", "standard_charge_dollar": 13.06, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Uhc/Secure Horizons", "plan_name": "500449", "standard_charge_dollar": 13.06, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "United Health Care/", "plan_name": "500292", "standard_charge_dollar": 14.76, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "United Healthcare", "plan_name": "750104", "standard_charge_dollar": 14.76, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "United Healthcare Ba", "plan_name": "750090", "standard_charge_dollar": 14.76, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "United Healthcare Me", "plan_name": "501310", "standard_charge_dollar": 13.06, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Windsor Mcare Extra", "plan_name": "500778", "standard_charge_dollar": 13.06, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." } ] } ] }, { "description": "Paclitaxel 6 mg/ml concentrateintravenous [10843]", "drug_information": { "unit": 25.00, "type": "ML" }, "code_information": [ { "code": "J9267", "type": "HCPCS" }, { "code": "0703-3217-01", "type": "NDC" } ], "standard_charges": [ { "gross_charge": 475.20, "minimum": 380.16, "maximum": 403.92, "setting": "both", "payers_information": [ { "payer_name": "Aetna", "plan_name": "700700", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna", "plan_name": "700700_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Miscellaneous", "plan_name": "700720", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Miscellaneous", "plan_name": "700720_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Ppo Hmo", "plan_name": "701720", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Ppo Hmo", "plan_name": "701720_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Ms State Emplo", "plan_name": "401457", "standard_charge_percentage": 0.80, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Ms State Emplo", "plan_name": "401457_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Basic Pl", "plan_name": "400100", "standard_charge_percentage": 0.85, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Basic Pl", "plan_name": "400100_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Federal", "plan_name": "400110", "standard_charge_percentage": 0.85, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Federal", "plan_name": "400110_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." } ] } ] }, { "description": "Paclitaxel 6 mg/ml concentrateintravenous [10843]", "drug_information": { "unit": 50.00, "type": "ML" }, "code_information": [ { "code": "J9267", "type": "HCPCS" }, { "code": "0703-3218-01", "type": "NDC" } ], "standard_charges": [ { "gross_charge": 607.73, "minimum": 486.18, "maximum": 516.57, "setting": "both", "payers_information": [ { "payer_name": "Aetna", "plan_name": "700700", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna", "plan_name": "700700_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Miscellaneous", "plan_name": "700720", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Miscellaneous", "plan_name": "700720_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Ppo Hmo", "plan_name": "701720", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Ppo Hmo", "plan_name": "701720_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Ms State Emplo", "plan_name": "401457", "standard_charge_percentage": 0.80, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Ms State Emplo", "plan_name": "401457_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Basic Pl", "plan_name": "400100", "standard_charge_percentage": 0.85, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Basic Pl", "plan_name": "400100_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Federal", "plan_name": "400110", "standard_charge_percentage": 0.85, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Federal", "plan_name": "400110_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." } ] } ] }, { "description": "Paclitaxel 6 mg/ml concentrateintravenous [10843]", "drug_information": { "unit": 50.00, "type": "ML" }, "code_information": [ { "code": "J9267", "type": "HCPCS" }, { "code": "70860-215-68", "type": "NDC" } ], "standard_charges": [ { "gross_charge": 171.00, "minimum": 136.80, "maximum": 145.35, "setting": "both", "payers_information": [ { "payer_name": "Aetna", "plan_name": "700700", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna", "plan_name": "700700_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Miscellaneous", "plan_name": "700720", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Miscellaneous", "plan_name": "700720_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Ppo Hmo", "plan_name": "701720", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Ppo Hmo", "plan_name": "701720_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Ms State Emplo", "plan_name": "401457", "standard_charge_percentage": 0.80, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Ms State Emplo", "plan_name": "401457_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Basic Pl", "plan_name": "400100", "standard_charge_percentage": 0.85, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Basic Pl", "plan_name": "400100_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Federal", "plan_name": "400110", "standard_charge_percentage": 0.85, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Federal", "plan_name": "400110_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." } ] } ] }, { "description": "Paclitaxel 6 mg/ml concentrateintravenous [10843]", "drug_information": { "unit": 50.00, "type": "ML" }, "code_information": [ { "code": "J9267", "type": "HCPCS" }, { "code": "70860-200-50", "type": "NDC" } ], "standard_charges": [ { "gross_charge": 647.78, "minimum": 518.22, "maximum": 550.61, "setting": "both", "payers_information": [ { "payer_name": "Aetna", "plan_name": "700700", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna", "plan_name": "700700_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Miscellaneous", "plan_name": "700720", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Miscellaneous", "plan_name": "700720_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Ppo Hmo", "plan_name": "701720", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Ppo Hmo", "plan_name": "701720_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Ms State Emplo", "plan_name": "401457", "standard_charge_percentage": 0.80, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Ms State Emplo", "plan_name": "401457_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Basic Pl", "plan_name": "400100", "standard_charge_percentage": 0.85, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Basic Pl", "plan_name": "400100_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Federal", "plan_name": "400110", "standard_charge_percentage": 0.85, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Federal", "plan_name": "400110_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." } ] } ] }, { "description": "Paclitaxel 6 mg/ml concentrateintravenous [10843]", "drug_information": { "unit": 50.00, "type": "ML" }, "code_information": [ { "code": "J9267", "type": "HCPCS" }, { "code": "63323-763-50", "type": "NDC" } ], "standard_charges": [ { "gross_charge": 727.43, "minimum": 581.94, "maximum": 618.32, "setting": "both", "payers_information": [ { "payer_name": "Aetna", "plan_name": "700700", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna", "plan_name": "700700_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Miscellaneous", "plan_name": "700720", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Miscellaneous", "plan_name": "700720_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Ppo Hmo", "plan_name": "701720", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Ppo Hmo", "plan_name": "701720_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Ms State Emplo", "plan_name": "401457", "standard_charge_percentage": 0.80, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Ms State Emplo", "plan_name": "401457_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Basic Pl", "plan_name": "400100", "standard_charge_percentage": 0.85, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Basic Pl", "plan_name": "400100_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Federal", "plan_name": "400110", "standard_charge_percentage": 0.85, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Federal", "plan_name": "400110_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." } ] } ] }, { "description": "Paclitaxel 6 mg/ml concentrateintravenous [10843]", "drug_information": { "unit": 50.00, "type": "ML" }, "code_information": [ { "code": "J9267", "type": "HCPCS" }, { "code": "61703-342-50", "type": "NDC" } ], "standard_charges": [ { "gross_charge": 607.73, "minimum": 486.18, "maximum": 516.57, "setting": "both", "payers_information": [ { "payer_name": "Aetna", "plan_name": "700700", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna", "plan_name": "700700_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Miscellaneous", "plan_name": "700720", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Miscellaneous", "plan_name": "700720_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Ppo Hmo", "plan_name": "701720", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Ppo Hmo", "plan_name": "701720_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Ms State Emplo", "plan_name": "401457", "standard_charge_percentage": 0.80, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Ms State Emplo", "plan_name": "401457_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Basic Pl", "plan_name": "400100", "standard_charge_percentage": 0.85, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Basic Pl", "plan_name": "400100_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Federal", "plan_name": "400110", "standard_charge_percentage": 0.85, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Federal", "plan_name": "400110_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." } ] } ] }, { "description": "Paclitaxel 6 mg/ml concentrateintravenous [10843]", "drug_information": { "unit": 50.00, "type": "ML" }, "code_information": [ { "code": "J9267", "type": "HCPCS" }, { "code": "47781-595-07", "type": "NDC" } ], 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charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Ppo Hmo", "plan_name": "701720", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Ppo Hmo", "plan_name": "701720_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Ms State Emplo", "plan_name": "401457", "standard_charge_percentage": 0.80, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Ms State Emplo", "plan_name": "401457_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Basic Pl", "plan_name": "400100", "standard_charge_percentage": 0.85, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Basic Pl", "plan_name": "400100_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Federal", "plan_name": "400110", "standard_charge_percentage": 0.85, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Federal", "plan_name": "400110_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." } ] } ] }, { "description": "Pembrolizumab 25 mg/ml intravenous solution [169025]", "drug_information": { "unit": 4.00, "type": "ML" }, "code_information": [ { "code": "J9271", "type": "HCPCS" }, { "code": "0006-3026-01", "type": "NDC" } ], "standard_charges": [ { "gross_charge": 25417.22, "minimum": 42.06, "maximum": 74.19, "setting": "both", "payers_information": [ { "payer_name": "Aarp", "plan_name": "500102", "standard_charge_dollar": 59.35, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna", "plan_name": "700700", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna", "plan_name": "700700_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Mcare Ffs 6005", "plan_name": "700703", "standard_charge_dollar": 59.35, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Miscellaneous", "plan_name": "700720", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Miscellaneous", "plan_name": "700720_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Ppo Hmo", "plan_name": "701720", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Ppo Hmo", "plan_name": "701720_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Ambetter 68069", "plan_name": "500516", "standard_charge_dollar": 59.35, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Ms State Emplo", "plan_name": "401457", "standard_charge_dollar": 42.06, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Ms State Emplo", "plan_name": "401457_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Basic Pl", "plan_name": "400100", "standard_charge_dollar": 42.06, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Basic Pl", "plan_name": "400100_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Federal", "plan_name": "400110", "standard_charge_dollar": 42.06, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Federal", "plan_name": "400110_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Cigna Healthsprings Ffs", "plan_name": "500064", "standard_charge_dollar": 59.35, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Conseco", "plan_name": "500302", "standard_charge_dollar": 59.35, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Humana Ffs 61101", "plan_name": "500006", "standard_charge_dollar": 59.35, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Medicare A", "plan_name": "100100", "standard_charge_dollar": 59.35, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Medicare A", "plan_name": "100500", "standard_charge_dollar": 59.35, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Medicare Part B Only", "plan_name": "100300", "standard_charge_dollar": 59.35, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Medicare Railroad", "plan_name": "100103", "standard_charge_dollar": 59.35, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Ms Physicians Care N", "plan_name": "714210", "standard_charge_dollar": 74.19, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Peoples Hlth Ffs 72126", "plan_name": "500019", "standard_charge_dollar": 59.35, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Uhc/Secure Horizons", "plan_name": "500449", "standard_charge_dollar": 59.35, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "United Health Care/", "plan_name": "500292", "standard_charge_dollar": 67.07, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "United Healthcare", "plan_name": "750104", "standard_charge_dollar": 67.07, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "United Healthcare Ba", "plan_name": "750090", "standard_charge_dollar": 67.07, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "United Healthcare Me", "plan_name": "501310", "standard_charge_dollar": 59.35, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Windsor Mcare Extra", "plan_name": "500778", "standard_charge_dollar": 59.35, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." } ] } ] }, { "description": "Pembrolizumab 25 mg/ml intravenous solution [169025]", "drug_information": { "unit": 4.00, "type": "ML" }, "code_information": [ { "code": "J9271", "type": "HCPCS" }, { "code": "0006-3026-04", "type": "NDC" } ], "standard_charges": [ { "gross_charge": 25417.24, "minimum": 42.06, "maximum": 74.19, "setting": "both", "payers_information": [ { "payer_name": "Aarp", "plan_name": "500102", "standard_charge_dollar": 59.35, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna", "plan_name": "700700", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna", "plan_name": "700700_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Mcare Ffs 6005", "plan_name": "700703", "standard_charge_dollar": 59.35, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Miscellaneous", "plan_name": "700720", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Miscellaneous", "plan_name": "700720_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Ppo Hmo", "plan_name": "701720", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Ppo Hmo", "plan_name": "701720_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Ambetter 68069", "plan_name": "500516", "standard_charge_dollar": 59.35, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Ms State Emplo", "plan_name": "401457", "standard_charge_dollar": 42.06, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Ms State Emplo", "plan_name": "401457_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Basic Pl", "plan_name": "400100", "standard_charge_dollar": 42.06, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Basic Pl", "plan_name": "400100_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Federal", "plan_name": "400110", "standard_charge_dollar": 42.06, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Federal", "plan_name": "400110_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Cigna Healthsprings Ffs", "plan_name": "500064", "standard_charge_dollar": 59.35, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Conseco", "plan_name": "500302", "standard_charge_dollar": 59.35, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Humana Ffs 61101", "plan_name": "500006", "standard_charge_dollar": 59.35, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Medicare A", "plan_name": "100100", "standard_charge_dollar": 59.35, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Medicare A", "plan_name": "100500", "standard_charge_dollar": 59.35, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Medicare Part B Only", "plan_name": "100300", "standard_charge_dollar": 59.35, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Medicare Railroad", "plan_name": "100103", "standard_charge_dollar": 59.35, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Ms Physicians Care N", "plan_name": "714210", "standard_charge_dollar": 74.19, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Peoples Hlth Ffs 72126", "plan_name": "500019", "standard_charge_dollar": 59.35, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Uhc/Secure Horizons", "plan_name": "500449", "standard_charge_dollar": 59.35, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "United Health Care/", "plan_name": "500292", "standard_charge_dollar": 67.07, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "United Healthcare", "plan_name": "750104", "standard_charge_dollar": 67.07, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "United Healthcare Ba", "plan_name": "750090", "standard_charge_dollar": 67.07, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "United Healthcare Me", "plan_name": "501310", "standard_charge_dollar": 59.35, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Windsor Mcare Extra", "plan_name": "500778", "standard_charge_dollar": 59.35, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." } ] } ] }, { "description": "Mitomycin 40 mg intravenous solution [10631]", "drug_information": { "unit": 1.00, "type": "EA" }, "code_information": [ { "code": "J9280", "type": "HCPCS" }, { "code": "0143-9280-01", "type": "NDC" } ], "standard_charges": [ { "gross_charge": 12472.07, "minimum": 25.60, "maximum": 217.97, "setting": "both", "payers_information": [ { "payer_name": "Aarp", "plan_name": "500102", "standard_charge_dollar": 25.60, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna", "plan_name": "700700", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna", "plan_name": "700700_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Mcare Ffs 6005", "plan_name": "700703", "standard_charge_dollar": 25.60, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Miscellaneous", "plan_name": "700720", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Miscellaneous", "plan_name": "700720_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Ppo Hmo", "plan_name": "701720", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Ppo Hmo", "plan_name": "701720_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Ambetter 68069", "plan_name": "500516", "standard_charge_dollar": 25.60, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Ms State Emplo", "plan_name": "401457", "standard_charge_dollar": 217.97, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Ms State Emplo", "plan_name": "401457_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Basic Pl", "plan_name": "400100", "standard_charge_dollar": 217.97, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Basic Pl", "plan_name": "400100_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Federal", "plan_name": "400110", "standard_charge_dollar": 217.97, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Federal", "plan_name": "400110_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Cigna Healthsprings Ffs", "plan_name": "500064", "standard_charge_dollar": 25.60, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Conseco", "plan_name": "500302", "standard_charge_dollar": 25.60, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Humana Ffs 61101", "plan_name": "500006", "standard_charge_dollar": 25.60, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Medicare A", "plan_name": "100100", "standard_charge_dollar": 25.60, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Medicare A", "plan_name": "100500", "standard_charge_dollar": 25.60, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Medicare Part B Only", "plan_name": "100300", "standard_charge_dollar": 25.60, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Medicare Railroad", "plan_name": "100103", "standard_charge_dollar": 25.60, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Ms Physicians Care N", "plan_name": "714210", "standard_charge_dollar": 32.00, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Peoples Hlth Ffs 72126", "plan_name": "500019", "standard_charge_dollar": 25.60, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Uhc/Secure Horizons", "plan_name": "500449", "standard_charge_dollar": 25.60, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "United Health Care/", "plan_name": "500292", "standard_charge_dollar": 28.93, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "United Healthcare", "plan_name": "750104", "standard_charge_dollar": 28.93, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "United Healthcare Ba", "plan_name": "750090", "standard_charge_dollar": 28.93, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "United Healthcare Me", "plan_name": "501310", "standard_charge_dollar": 25.60, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Windsor Mcare Extra", "plan_name": "500778", "standard_charge_dollar": 25.60, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." } ] } ] }, { "description": "Mitomycin 40 mg vial for intravesical prep [500470]", "drug_information": { "unit": 1.00, "type": "EA" }, "code_information": [ { "code": "J9280", "type": "HCPCS" }, { "code": "0143-9280-01", "type": "NDC" } ], "standard_charges": [ { "gross_charge": 12472.07, "minimum": 25.60, "maximum": 217.97, "setting": "both", "payers_information": [ { "payer_name": "Aarp", "plan_name": "500102", "standard_charge_dollar": 25.60, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna", "plan_name": "700700", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna", "plan_name": "700700_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Mcare Ffs 6005", "plan_name": "700703", "standard_charge_dollar": 25.60, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Miscellaneous", "plan_name": "700720", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Miscellaneous", "plan_name": "700720_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Ppo Hmo", "plan_name": "701720", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Ppo Hmo", "plan_name": "701720_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Ambetter 68069", "plan_name": "500516", "standard_charge_dollar": 25.60, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Ms State Emplo", "plan_name": "401457", "standard_charge_dollar": 217.97, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Ms State Emplo", "plan_name": "401457_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Basic Pl", "plan_name": "400100", "standard_charge_dollar": 217.97, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Basic Pl", "plan_name": "400100_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Federal", "plan_name": "400110", "standard_charge_dollar": 217.97, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Federal", "plan_name": "400110_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Cigna Healthsprings Ffs", "plan_name": "500064", "standard_charge_dollar": 25.60, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Conseco", "plan_name": "500302", "standard_charge_dollar": 25.60, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Humana Ffs 61101", "plan_name": "500006", "standard_charge_dollar": 25.60, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Medicare A", "plan_name": "100100", "standard_charge_dollar": 25.60, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Medicare A", "plan_name": "100500", "standard_charge_dollar": 25.60, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Medicare Part B Only", "plan_name": "100300", "standard_charge_dollar": 25.60, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Medicare Railroad", "plan_name": "100103", "standard_charge_dollar": 25.60, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Ms Physicians Care N", "plan_name": "714210", "standard_charge_dollar": 32.00, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Peoples Hlth Ffs 72126", "plan_name": "500019", "standard_charge_dollar": 25.60, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Uhc/Secure Horizons", "plan_name": "500449", "standard_charge_dollar": 25.60, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "United Health Care/", "plan_name": "500292", "standard_charge_dollar": 28.93, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "United Healthcare", "plan_name": "750104", "standard_charge_dollar": 28.93, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "United Healthcare Ba", "plan_name": "750090", "standard_charge_dollar": 28.93, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "United Healthcare Me", "plan_name": "501310", "standard_charge_dollar": 25.60, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Windsor Mcare Extra", "plan_name": "500778", "standard_charge_dollar": 25.60, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." } ] } ] }, { "description": "Mitomycin 20 mg intravenous solution [10630]", "drug_information": { "unit": 1.00, "type": "EA" }, "code_information": [ { "code": "J9280", "type": "HCPCS" }, { "code": "55150-451-01", "type": "NDC" } ], "standard_charges": [ { "gross_charge": 5627.30, "minimum": 25.60, "maximum": 217.97, "setting": "both", "payers_information": [ { "payer_name": "Aarp", "plan_name": "500102", "standard_charge_dollar": 25.60, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna", "plan_name": "700700", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna", "plan_name": "700700_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Mcare Ffs 6005", "plan_name": "700703", "standard_charge_dollar": 25.60, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Miscellaneous", "plan_name": "700720", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Miscellaneous", "plan_name": "700720_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Ppo Hmo", "plan_name": "701720", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Ppo Hmo", "plan_name": "701720_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Ambetter 68069", "plan_name": "500516", "standard_charge_dollar": 25.60, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Ms State Emplo", "plan_name": "401457", "standard_charge_dollar": 217.97, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Ms State Emplo", "plan_name": "401457_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Basic Pl", "plan_name": "400100", "standard_charge_dollar": 217.97, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Basic Pl", "plan_name": "400100_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Federal", "plan_name": "400110", "standard_charge_dollar": 217.97, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Federal", "plan_name": "400110_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Cigna Healthsprings Ffs", "plan_name": "500064", "standard_charge_dollar": 25.60, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Conseco", "plan_name": "500302", "standard_charge_dollar": 25.60, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Humana Ffs 61101", "plan_name": "500006", "standard_charge_dollar": 25.60, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Medicare A", "plan_name": "100100", "standard_charge_dollar": 25.60, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Medicare A", "plan_name": "100500", "standard_charge_dollar": 25.60, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Medicare Part B Only", "plan_name": "100300", "standard_charge_dollar": 25.60, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Medicare Railroad", "plan_name": "100103", "standard_charge_dollar": 25.60, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Ms Physicians Care N", "plan_name": "714210", "standard_charge_dollar": 32.00, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Peoples Hlth Ffs 72126", "plan_name": "500019", "standard_charge_dollar": 25.60, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Uhc/Secure Horizons", "plan_name": "500449", "standard_charge_dollar": 25.60, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "United Health Care/", "plan_name": "500292", "standard_charge_dollar": 28.93, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "United Healthcare", "plan_name": "750104", "standard_charge_dollar": 28.93, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "United Healthcare Ba", "plan_name": "750090", "standard_charge_dollar": 28.93, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "United Healthcare Me", "plan_name": "501310", "standard_charge_dollar": 25.60, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Windsor Mcare Extra", "plan_name": "500778", "standard_charge_dollar": 25.60, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." } ] } ] }, { "description": "Mitomycin 5 mg intravenous solution [10632]", "drug_information": { "unit": 1.00, "type": "EA" }, "code_information": [ { "code": "J9280", "type": "HCPCS" }, { "code": "16729-115-05", "type": "NDC" } ], "standard_charges": [ { "gross_charge": 1970.51, "minimum": 25.60, "maximum": 217.97, "setting": "both", "payers_information": [ { "payer_name": "Aarp", "plan_name": "500102", "standard_charge_dollar": 25.60, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna", "plan_name": "700700", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna", "plan_name": "700700_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Mcare Ffs 6005", "plan_name": "700703", "standard_charge_dollar": 25.60, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Miscellaneous", "plan_name": "700720", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Miscellaneous", "plan_name": "700720_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Ppo Hmo", "plan_name": "701720", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Ppo Hmo", "plan_name": "701720_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Ambetter 68069", "plan_name": "500516", "standard_charge_dollar": 25.60, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Ms State Emplo", "plan_name": "401457", "standard_charge_dollar": 217.97, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Ms State Emplo", "plan_name": "401457_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Basic Pl", "plan_name": "400100", "standard_charge_dollar": 217.97, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Basic Pl", "plan_name": "400100_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Federal", "plan_name": "400110", "standard_charge_dollar": 217.97, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Federal", "plan_name": "400110_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Cigna Healthsprings Ffs", "plan_name": "500064", "standard_charge_dollar": 25.60, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Conseco", "plan_name": "500302", "standard_charge_dollar": 25.60, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Humana Ffs 61101", "plan_name": "500006", "standard_charge_dollar": 25.60, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Medicare A", "plan_name": "100100", "standard_charge_dollar": 25.60, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Medicare A", "plan_name": "100500", "standard_charge_dollar": 25.60, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Medicare Part B Only", "plan_name": "100300", "standard_charge_dollar": 25.60, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Medicare Railroad", "plan_name": "100103", "standard_charge_dollar": 25.60, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Ms Physicians Care N", "plan_name": "714210", "standard_charge_dollar": 32.00, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Peoples Hlth Ffs 72126", "plan_name": "500019", "standard_charge_dollar": 25.60, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Uhc/Secure Horizons", "plan_name": "500449", "standard_charge_dollar": 25.60, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "United Health Care/", "plan_name": "500292", "standard_charge_dollar": 28.93, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "United Healthcare", "plan_name": "750104", "standard_charge_dollar": 28.93, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "United Healthcare Ba", "plan_name": "750090", "standard_charge_dollar": 28.93, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "United Healthcare Me", "plan_name": "501310", "standard_charge_dollar": 25.60, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Windsor Mcare Extra", "plan_name": "500778", "standard_charge_dollar": 25.60, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." } ] } ] }, { "description": "Mitomycin 20 mg intravenous solution [10630]", "drug_information": { "unit": 1.00, "type": "EA" }, "code_information": [ { "code": "J9280", "type": "HCPCS" }, { "code": "16729-108-11", "type": "NDC" } ], "standard_charges": [ { "gross_charge": 5627.25, "minimum": 25.60, "maximum": 217.97, "setting": "both", "payers_information": [ { "payer_name": "Aarp", "plan_name": "500102", "standard_charge_dollar": 25.60, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna", "plan_name": "700700", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna", "plan_name": "700700_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Mcare Ffs 6005", "plan_name": "700703", "standard_charge_dollar": 25.60, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Miscellaneous", "plan_name": "700720", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Miscellaneous", "plan_name": "700720_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Ppo Hmo", "plan_name": "701720", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Ppo Hmo", "plan_name": "701720_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Ambetter 68069", "plan_name": "500516", "standard_charge_dollar": 25.60, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Ms State Emplo", "plan_name": "401457", "standard_charge_dollar": 217.97, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Ms State Emplo", "plan_name": "401457_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Basic Pl", "plan_name": "400100", "standard_charge_dollar": 217.97, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Basic Pl", "plan_name": "400100_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Federal", "plan_name": "400110", "standard_charge_dollar": 217.97, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Federal", "plan_name": "400110_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Cigna Healthsprings Ffs", "plan_name": "500064", "standard_charge_dollar": 25.60, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Conseco", "plan_name": "500302", "standard_charge_dollar": 25.60, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Humana Ffs 61101", "plan_name": "500006", "standard_charge_dollar": 25.60, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Medicare A", "plan_name": "100100", "standard_charge_dollar": 25.60, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Medicare A", "plan_name": "100500", "standard_charge_dollar": 25.60, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Medicare Part B Only", "plan_name": "100300", "standard_charge_dollar": 25.60, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Medicare Railroad", "plan_name": "100103", "standard_charge_dollar": 25.60, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Ms Physicians Care N", "plan_name": "714210", "standard_charge_dollar": 32.00, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Peoples Hlth Ffs 72126", "plan_name": "500019", "standard_charge_dollar": 25.60, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Uhc/Secure Horizons", "plan_name": "500449", "standard_charge_dollar": 25.60, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "United Health Care/", "plan_name": "500292", "standard_charge_dollar": 28.93, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "United Healthcare", "plan_name": "750104", "standard_charge_dollar": 28.93, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "United Healthcare Ba", "plan_name": "750090", "standard_charge_dollar": 28.93, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "United Healthcare Me", "plan_name": "501310", "standard_charge_dollar": 25.60, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Windsor Mcare Extra", "plan_name": "500778", "standard_charge_dollar": 25.60, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." } ] } ] }, { "description": "Mitomycin 20 mg intravenous solution [10630]", "drug_information": { "unit": 1.00, "type": "EA" }, "code_information": [ { "code": "J9280", "type": "HCPCS" }, { "code": "67457-519-20", "type": "NDC" } ], "standard_charges": [ { "gross_charge": 2843.91, "minimum": 25.60, "maximum": 217.97, "setting": "both", "payers_information": [ { "payer_name": "Aarp", "plan_name": "500102", "standard_charge_dollar": 25.60, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna", "plan_name": "700700", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna", "plan_name": "700700_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Mcare Ffs 6005", "plan_name": "700703", "standard_charge_dollar": 25.60, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Miscellaneous", "plan_name": "700720", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Miscellaneous", "plan_name": "700720_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Ppo Hmo", "plan_name": "701720", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Ppo Hmo", "plan_name": "701720_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Ambetter 68069", "plan_name": "500516", "standard_charge_dollar": 25.60, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Ms State Emplo", "plan_name": "401457", "standard_charge_dollar": 217.97, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Ms State Emplo", "plan_name": "401457_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Basic Pl", "plan_name": "400100", "standard_charge_dollar": 217.97, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Basic Pl", "plan_name": "400100_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Federal", "plan_name": "400110", "standard_charge_dollar": 217.97, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Federal", "plan_name": "400110_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Cigna Healthsprings Ffs", "plan_name": "500064", "standard_charge_dollar": 25.60, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Conseco", "plan_name": "500302", "standard_charge_dollar": 25.60, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Humana Ffs 61101", "plan_name": "500006", "standard_charge_dollar": 25.60, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Medicare A", "plan_name": "100100", "standard_charge_dollar": 25.60, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Medicare A", "plan_name": "100500", "standard_charge_dollar": 25.60, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Medicare Part B Only", "plan_name": "100300", "standard_charge_dollar": 25.60, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Medicare Railroad", "plan_name": "100103", "standard_charge_dollar": 25.60, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Ms Physicians Care N", "plan_name": "714210", "standard_charge_dollar": 32.00, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Peoples Hlth Ffs 72126", "plan_name": "500019", "standard_charge_dollar": 25.60, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Uhc/Secure Horizons", "plan_name": "500449", "standard_charge_dollar": 25.60, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "United Health Care/", "plan_name": "500292", "standard_charge_dollar": 28.93, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "United Healthcare", "plan_name": "750104", "standard_charge_dollar": 28.93, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "United Healthcare Ba", "plan_name": "750090", "standard_charge_dollar": 28.93, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "United Healthcare Me", "plan_name": "501310", "standard_charge_dollar": 25.60, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Windsor Mcare Extra", "plan_name": "500778", "standard_charge_dollar": 25.60, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." } ] } ] }, { "description": "Pemetrexed disodium 25 mg/ml intravenous solution [197100]", "drug_information": { "unit": 20.00, "type": "ML" }, "code_information": [ { "code": "J9294", "type": "HCPCS" }, { "code": "0409-2188-01", "type": "NDC" } ], "standard_charges": [ { "gross_charge": 2184.30, "minimum": 3.86, "maximum": 1856.66, "setting": "both", "payers_information": [ { "payer_name": "Aarp", "plan_name": "500102", "standard_charge_dollar": 3.86, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna", "plan_name": "700700", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna", "plan_name": "700700_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Mcare Ffs 6005", "plan_name": "700703", "standard_charge_dollar": 3.86, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Miscellaneous", "plan_name": "700720", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Miscellaneous", "plan_name": "700720_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Ppo Hmo", "plan_name": "701720", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Ppo Hmo", "plan_name": "701720_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Ambetter 68069", "plan_name": "500516", "standard_charge_dollar": 3.86, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Ms State Emplo", "plan_name": "401457", "standard_charge_percentage": 0.80, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Ms State Emplo", "plan_name": "401457_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Basic Pl", "plan_name": "400100", "standard_charge_percentage": 0.85, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Basic Pl", "plan_name": "400100_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Federal", "plan_name": "400110", "standard_charge_percentage": 0.85, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Federal", "plan_name": "400110_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Cigna Healthsprings Ffs", "plan_name": "500064", "standard_charge_dollar": 3.86, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Conseco", "plan_name": "500302", "standard_charge_dollar": 3.86, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Humana Ffs 61101", "plan_name": "500006", "standard_charge_dollar": 3.86, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Medicare A", "plan_name": "100100", "standard_charge_dollar": 3.86, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Medicare A", "plan_name": "100500", "standard_charge_dollar": 3.86, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Medicare Part B Only", "plan_name": "100300", "standard_charge_dollar": 3.86, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Medicare Railroad", "plan_name": "100103", "standard_charge_dollar": 3.86, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Ms Physicians Care N", "plan_name": "714210", "standard_charge_dollar": 4.83, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Peoples Hlth Ffs 72126", "plan_name": "500019", "standard_charge_dollar": 3.86, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Uhc/Secure Horizons", "plan_name": "500449", "standard_charge_dollar": 3.86, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "United Health Care/", "plan_name": "500292", "standard_charge_dollar": 4.36, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "United Healthcare", "plan_name": "750104", "standard_charge_dollar": 4.36, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "United Healthcare Ba", "plan_name": "750090", "standard_charge_dollar": 4.36, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "United Healthcare Me", "plan_name": "501310", "standard_charge_dollar": 3.86, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Windsor Mcare Extra", "plan_name": "500778", "standard_charge_dollar": 3.86, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." } ] } ] }, { "description": "Nivolumab 240 mg/24 ml intravenous solution [177359]", "drug_information": { "unit": 24.00, "type": "ML" }, "code_information": [ { "code": "J9299", "type": "HCPCS" }, { "code": "0003-3734-13", "type": "NDC" } ], "standard_charges": [ { "gross_charge": 33561.00, "minimum": 23.72, "maximum": 40.44, "setting": "both", "payers_information": [ { "payer_name": "Aarp", "plan_name": "500102", "standard_charge_dollar": 32.35, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna", "plan_name": "700700", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna", "plan_name": "700700_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Mcare Ffs 6005", "plan_name": "700703", "standard_charge_dollar": 32.35, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Miscellaneous", "plan_name": "700720", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Miscellaneous", "plan_name": "700720_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Ppo Hmo", "plan_name": "701720", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Ppo Hmo", "plan_name": "701720_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Ambetter 68069", "plan_name": "500516", "standard_charge_dollar": 32.35, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Ms State Emplo", "plan_name": "401457", "standard_charge_dollar": 23.72, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Ms State Emplo", "plan_name": "401457_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Basic Pl", "plan_name": "400100", "standard_charge_dollar": 23.72, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Basic Pl", "plan_name": "400100_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Federal", "plan_name": "400110", "standard_charge_dollar": 23.72, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Federal", "plan_name": "400110_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Cigna Healthsprings Ffs", "plan_name": "500064", "standard_charge_dollar": 32.35, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Conseco", "plan_name": "500302", "standard_charge_dollar": 32.35, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Humana Ffs 61101", "plan_name": "500006", "standard_charge_dollar": 32.35, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Medicare A", "plan_name": "100100", "standard_charge_dollar": 32.35, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Medicare A", "plan_name": "100500", "standard_charge_dollar": 32.35, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Medicare Part B Only", "plan_name": "100300", "standard_charge_dollar": 32.35, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Medicare Railroad", "plan_name": "100103", "standard_charge_dollar": 32.35, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Ms Physicians Care N", "plan_name": "714210", "standard_charge_dollar": 40.44, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Peoples Hlth Ffs 72126", "plan_name": "500019", "standard_charge_dollar": 32.35, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Uhc/Secure Horizons", "plan_name": "500449", "standard_charge_dollar": 32.35, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "United Health Care/", "plan_name": "500292", "standard_charge_dollar": 36.56, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "United Healthcare", "plan_name": "750104", "standard_charge_dollar": 36.56, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "United Healthcare Ba", "plan_name": "750090", "standard_charge_dollar": 36.56, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "United Healthcare Me", "plan_name": "501310", "standard_charge_dollar": 32.35, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Windsor Mcare Extra", "plan_name": "500778", "standard_charge_dollar": 32.35, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." } ] } ] }, { "description": "Nivolumab 120 mg/12 ml intravenous solution [194840]", "drug_information": { "unit": 12.00, "type": "ML" }, "code_information": [ { "code": "J9299", "type": "HCPCS" }, { "code": "0003-3756-14", "type": "NDC" } ], "standard_charges": [ { "gross_charge": 16780.45, "minimum": 23.72, "maximum": 40.44, "setting": "both", "payers_information": [ { "payer_name": "Aarp", "plan_name": "500102", "standard_charge_dollar": 32.35, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna", "plan_name": "700700", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna", "plan_name": "700700_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Mcare Ffs 6005", "plan_name": "700703", "standard_charge_dollar": 32.35, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Miscellaneous", "plan_name": "700720", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Miscellaneous", "plan_name": "700720_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Ppo Hmo", "plan_name": "701720", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Ppo Hmo", "plan_name": "701720_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Ambetter 68069", "plan_name": "500516", "standard_charge_dollar": 32.35, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Ms State Emplo", "plan_name": "401457", "standard_charge_dollar": 23.72, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Ms State Emplo", "plan_name": "401457_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Basic Pl", "plan_name": "400100", "standard_charge_dollar": 23.72, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Basic Pl", "plan_name": "400100_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Federal", "plan_name": "400110", "standard_charge_dollar": 23.72, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Federal", "plan_name": "400110_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Cigna Healthsprings Ffs", "plan_name": "500064", "standard_charge_dollar": 32.35, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Conseco", "plan_name": "500302", "standard_charge_dollar": 32.35, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Humana Ffs 61101", "plan_name": "500006", "standard_charge_dollar": 32.35, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Medicare A", "plan_name": "100100", "standard_charge_dollar": 32.35, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Medicare A", "plan_name": "100500", "standard_charge_dollar": 32.35, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Medicare Part B Only", "plan_name": "100300", "standard_charge_dollar": 32.35, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Medicare Railroad", "plan_name": "100103", "standard_charge_dollar": 32.35, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Ms Physicians Care N", "plan_name": "714210", "standard_charge_dollar": 40.44, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Peoples Hlth Ffs 72126", "plan_name": "500019", "standard_charge_dollar": 32.35, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Uhc/Secure Horizons", "plan_name": "500449", "standard_charge_dollar": 32.35, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "United Health Care/", "plan_name": "500292", "standard_charge_dollar": 36.56, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "United Healthcare", "plan_name": "750104", "standard_charge_dollar": 36.56, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "United Healthcare Ba", "plan_name": "750090", "standard_charge_dollar": 36.56, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "United Healthcare Me", "plan_name": "501310", "standard_charge_dollar": 32.35, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Windsor Mcare Extra", "plan_name": "500778", "standard_charge_dollar": 32.35, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." } ] } ] }, { "description": "Nivolumab 40 mg/4 ml intravenous solution [168684]", "drug_information": { "unit": 4.00, "type": "ML" }, "code_information": [ { "code": "J9299", "type": "HCPCS" }, { "code": "0003-3772-11", "type": "NDC" } ], "standard_charges": [ { "gross_charge": 5593.50, "minimum": 23.72, "maximum": 40.44, "setting": "both", "payers_information": [ { "payer_name": "Aarp", "plan_name": "500102", "standard_charge_dollar": 32.35, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna", "plan_name": "700700", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna", "plan_name": "700700_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Mcare Ffs 6005", "plan_name": "700703", "standard_charge_dollar": 32.35, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Miscellaneous", "plan_name": "700720", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Miscellaneous", "plan_name": "700720_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Ppo Hmo", "plan_name": "701720", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Ppo Hmo", "plan_name": "701720_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Ambetter 68069", "plan_name": "500516", "standard_charge_dollar": 32.35, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Ms State Emplo", "plan_name": "401457", "standard_charge_dollar": 23.72, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Ms State Emplo", "plan_name": "401457_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Basic Pl", "plan_name": "400100", "standard_charge_dollar": 23.72, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Basic Pl", "plan_name": "400100_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Federal", "plan_name": "400110", "standard_charge_dollar": 23.72, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Federal", "plan_name": "400110_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Cigna Healthsprings Ffs", "plan_name": "500064", "standard_charge_dollar": 32.35, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Conseco", "plan_name": "500302", "standard_charge_dollar": 32.35, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Humana Ffs 61101", "plan_name": "500006", "standard_charge_dollar": 32.35, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Medicare A", "plan_name": "100100", "standard_charge_dollar": 32.35, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Medicare A", "plan_name": "100500", "standard_charge_dollar": 32.35, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Medicare Part B Only", "plan_name": "100300", "standard_charge_dollar": 32.35, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Medicare Railroad", "plan_name": "100103", "standard_charge_dollar": 32.35, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Ms Physicians Care N", "plan_name": "714210", "standard_charge_dollar": 40.44, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Peoples Hlth Ffs 72126", "plan_name": "500019", "standard_charge_dollar": 32.35, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Uhc/Secure Horizons", "plan_name": "500449", "standard_charge_dollar": 32.35, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "United Health Care/", "plan_name": "500292", "standard_charge_dollar": 36.56, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "United Healthcare", "plan_name": "750104", "standard_charge_dollar": 36.56, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "United Healthcare Ba", "plan_name": "750090", "standard_charge_dollar": 36.56, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "United Healthcare Me", "plan_name": "501310", "standard_charge_dollar": 32.35, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Windsor Mcare Extra", "plan_name": "500778", "standard_charge_dollar": 32.35, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." } ] } ] }, { "description": "Obinutuzumab 1000 mg/40 ml intravenous solution [164585]", "drug_information": { "unit": 40.00, "type": "ML" }, "code_information": [ { "code": "J9301", "type": "HCPCS" }, { "code": "50242-070-01", "type": "NDC" } ], "standard_charges": [ { "gross_charge": 36954.72, "minimum": 53.74, "maximum": 94.01, "setting": "both", "payers_information": [ { "payer_name": "Aarp", "plan_name": "500102", "standard_charge_dollar": 75.21, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna", "plan_name": "700700", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna", "plan_name": "700700_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Mcare Ffs 6005", "plan_name": "700703", "standard_charge_dollar": 75.21, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Miscellaneous", "plan_name": "700720", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Miscellaneous", "plan_name": "700720_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Ppo Hmo", "plan_name": "701720", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Ppo Hmo", "plan_name": "701720_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Ambetter 68069", "plan_name": "500516", "standard_charge_dollar": 75.21, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Ms State Emplo", "plan_name": "401457", "standard_charge_dollar": 53.74, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Ms State Emplo", "plan_name": "401457_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Basic Pl", "plan_name": "400100", "standard_charge_dollar": 53.74, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Basic Pl", "plan_name": "400100_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Federal", "plan_name": "400110", "standard_charge_dollar": 53.74, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Federal", "plan_name": "400110_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Cigna Healthsprings Ffs", "plan_name": "500064", "standard_charge_dollar": 75.21, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Conseco", "plan_name": "500302", "standard_charge_dollar": 75.21, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Humana Ffs 61101", "plan_name": "500006", "standard_charge_dollar": 75.21, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Medicare A", "plan_name": "100100", "standard_charge_dollar": 75.21, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Medicare A", "plan_name": "100500", "standard_charge_dollar": 75.21, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Medicare Part B Only", "plan_name": "100300", "standard_charge_dollar": 75.21, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Medicare Railroad", "plan_name": "100103", "standard_charge_dollar": 75.21, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Ms Physicians Care N", "plan_name": "714210", "standard_charge_dollar": 94.01, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Peoples Hlth Ffs 72126", "plan_name": "500019", "standard_charge_dollar": 75.21, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Uhc/Secure Horizons", "plan_name": "500449", "standard_charge_dollar": 75.21, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "United Health Care/", "plan_name": "500292", "standard_charge_dollar": 84.99, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "United Healthcare", "plan_name": "750104", "standard_charge_dollar": 84.99, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "United Healthcare Ba", "plan_name": "750090", "standard_charge_dollar": 84.99, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "United Healthcare Me", "plan_name": "501310", "standard_charge_dollar": 75.21, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Windsor Mcare Extra", "plan_name": "500778", "standard_charge_dollar": 75.21, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." } ] } ] }, { "description": "Panitumumab 100 mg/5 ml (20 mg/ml) intravenous solution [77484]", "drug_information": { "unit": 5.00, "type": "ML" }, "code_information": [ { "code": "J9303", "type": "HCPCS" }, { "code": "55513-954-01", "type": "NDC" } ], "standard_charges": [ { "gross_charge": 7230.29, "minimum": 104.62, "maximum": 206.15, "setting": "both", "payers_information": [ { "payer_name": "Aarp", "plan_name": "500102", "standard_charge_dollar": 164.92, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna", "plan_name": "700700", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna", "plan_name": "700700_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Mcare Ffs 6005", "plan_name": "700703", "standard_charge_dollar": 164.92, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Miscellaneous", "plan_name": "700720", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Miscellaneous", "plan_name": "700720_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Ppo Hmo", "plan_name": "701720", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Ppo Hmo", "plan_name": "701720_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Ambetter 68069", "plan_name": "500516", "standard_charge_dollar": 164.92, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Ms State Emplo", "plan_name": "401457", "standard_charge_dollar": 104.62, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Ms State Emplo", "plan_name": "401457_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Basic Pl", "plan_name": "400100", "standard_charge_dollar": 104.62, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Basic Pl", "plan_name": "400100_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Federal", "plan_name": "400110", "standard_charge_dollar": 104.62, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Federal", "plan_name": "400110_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Cigna Healthsprings Ffs", "plan_name": "500064", "standard_charge_dollar": 164.92, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Conseco", "plan_name": "500302", "standard_charge_dollar": 164.92, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Humana Ffs 61101", "plan_name": "500006", "standard_charge_dollar": 164.92, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Medicare A", "plan_name": "100100", "standard_charge_dollar": 164.92, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Medicare A", "plan_name": "100500", "standard_charge_dollar": 164.92, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Medicare Part B Only", "plan_name": "100300", "standard_charge_dollar": 164.92, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Medicare Railroad", "plan_name": "100103", "standard_charge_dollar": 164.92, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Ms Physicians Care N", "plan_name": "714210", "standard_charge_dollar": 206.15, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Peoples Hlth Ffs 72126", "plan_name": "500019", "standard_charge_dollar": 164.92, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Uhc/Secure Horizons", "plan_name": "500449", "standard_charge_dollar": 164.92, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "United Health Care/", "plan_name": "500292", "standard_charge_dollar": 186.36, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "United Healthcare", "plan_name": "750104", "standard_charge_dollar": 186.36, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "United Healthcare Ba", "plan_name": "750090", "standard_charge_dollar": 186.36, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "United Healthcare Me", "plan_name": "501310", "standard_charge_dollar": 164.92, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Windsor Mcare Extra", "plan_name": "500778", "standard_charge_dollar": 164.92, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." } ] } ] }, { "description": "Panitumumab 400 mg/20 ml (20 mg/ml) intravenous solution [118465]", "drug_information": { "unit": 20.00, "type": "ML" }, "code_information": [ { "code": "J9303", "type": "HCPCS" }, { "code": "55513-956-01", "type": "NDC" } ], "standard_charges": [ { "gross_charge": 28921.14, "minimum": 104.62, "maximum": 206.15, "setting": "both", "payers_information": [ { "payer_name": "Aarp", "plan_name": "500102", "standard_charge_dollar": 164.92, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna", "plan_name": "700700", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna", "plan_name": "700700_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Mcare Ffs 6005", "plan_name": "700703", "standard_charge_dollar": 164.92, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Miscellaneous", "plan_name": "700720", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Miscellaneous", "plan_name": "700720_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Ppo Hmo", "plan_name": "701720", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Ppo Hmo", "plan_name": "701720_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Ambetter 68069", "plan_name": "500516", "standard_charge_dollar": 164.92, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Ms State Emplo", "plan_name": "401457", "standard_charge_dollar": 104.62, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Ms State Emplo", "plan_name": "401457_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Basic Pl", "plan_name": "400100", "standard_charge_dollar": 104.62, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Basic Pl", "plan_name": "400100_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Federal", "plan_name": "400110", "standard_charge_dollar": 104.62, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Federal", "plan_name": "400110_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Cigna Healthsprings Ffs", "plan_name": "500064", "standard_charge_dollar": 164.92, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Conseco", "plan_name": "500302", "standard_charge_dollar": 164.92, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Humana Ffs 61101", "plan_name": "500006", "standard_charge_dollar": 164.92, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Medicare A", "plan_name": "100100", "standard_charge_dollar": 164.92, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Medicare A", "plan_name": "100500", "standard_charge_dollar": 164.92, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Medicare Part B Only", "plan_name": "100300", "standard_charge_dollar": 164.92, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Medicare Railroad", "plan_name": "100103", "standard_charge_dollar": 164.92, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Ms Physicians Care N", "plan_name": "714210", "standard_charge_dollar": 206.15, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Peoples Hlth Ffs 72126", "plan_name": "500019", "standard_charge_dollar": 164.92, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Uhc/Secure Horizons", "plan_name": "500449", "standard_charge_dollar": 164.92, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "United Health Care/", "plan_name": "500292", "standard_charge_dollar": 186.36, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "United Healthcare", "plan_name": "750104", "standard_charge_dollar": 186.36, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "United Healthcare Ba", "plan_name": "750090", "standard_charge_dollar": 186.36, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "United Healthcare Me", "plan_name": "501310", "standard_charge_dollar": 164.92, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Windsor Mcare Extra", "plan_name": "500778", "standard_charge_dollar": 164.92, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." } ] } ] }, { "description": "Pemetrexed 25 mg/ml intravenous solution [195752]", "drug_information": { "unit": 20.00, "type": "ML" }, "code_information": [ { "code": "J9304", "type": "HCPCS" }, { "code": "42367-531-33", "type": "NDC" } ], "standard_charges": [ { "gross_charge": 19535.40, "minimum": 46.35, "maximum": 16605.09, "setting": "both", "payers_information": [ { "payer_name": "Aarp", "plan_name": "500102", "standard_charge_dollar": 46.35, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna", "plan_name": "700700", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna", "plan_name": "700700_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Mcare Ffs 6005", "plan_name": "700703", "standard_charge_dollar": 46.35, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Miscellaneous", "plan_name": "700720", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Miscellaneous", "plan_name": "700720_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Ppo Hmo", "plan_name": "701720", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Ppo Hmo", "plan_name": "701720_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Ambetter 68069", "plan_name": "500516", "standard_charge_dollar": 46.35, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Ms State Emplo", "plan_name": "401457", "standard_charge_percentage": 0.80, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Ms State Emplo", "plan_name": "401457_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Basic Pl", "plan_name": "400100", "standard_charge_percentage": 0.85, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Basic Pl", "plan_name": "400100_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Federal", "plan_name": "400110", "standard_charge_percentage": 0.85, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Federal", "plan_name": "400110_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Cigna Healthsprings Ffs", "plan_name": "500064", "standard_charge_dollar": 46.35, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Conseco", "plan_name": "500302", "standard_charge_dollar": 46.35, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Humana Ffs 61101", "plan_name": "500006", "standard_charge_dollar": 46.35, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Medicare A", "plan_name": "100100", "standard_charge_dollar": 46.35, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Medicare A", "plan_name": "100500", "standard_charge_dollar": 46.35, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Medicare Part B Only", "plan_name": "100300", "standard_charge_dollar": 46.35, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Medicare Railroad", "plan_name": "100103", "standard_charge_dollar": 46.35, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Ms Physicians Care N", "plan_name": "714210", "standard_charge_dollar": 57.94, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Peoples Hlth Ffs 72126", "plan_name": "500019", "standard_charge_dollar": 46.35, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Uhc/Secure Horizons", "plan_name": "500449", "standard_charge_dollar": 46.35, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "United Health Care/", "plan_name": "500292", "standard_charge_dollar": 52.38, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "United Healthcare", "plan_name": "750104", "standard_charge_dollar": 52.38, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "United Healthcare Ba", "plan_name": "750090", "standard_charge_dollar": 52.38, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "United Healthcare Me", "plan_name": "501310", "standard_charge_dollar": 46.35, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Windsor Mcare Extra", "plan_name": "500778", "standard_charge_dollar": 46.35, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." } ] } ] }, { "description": "Pertuzumab 420 mg/14 ml (30 mg/ml) intravenous solution [157710]", "drug_information": { "unit": 14.00, "type": "ML" }, "code_information": [ { "code": "J9306", "type": "HCPCS" }, { "code": "50242-145-01", "type": "NDC" } ], "standard_charges": [ { "gross_charge": 29264.76, "minimum": 10.18, "maximum": 20.29, "setting": "both", "payers_information": [ { "payer_name": "Aarp", "plan_name": "500102", "standard_charge_dollar": 16.23, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna", "plan_name": "700700", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna", "plan_name": "700700_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Mcare Ffs 6005", "plan_name": "700703", "standard_charge_dollar": 16.23, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Miscellaneous", "plan_name": "700720", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Miscellaneous", "plan_name": "700720_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Ppo Hmo", "plan_name": "701720", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Ppo Hmo", "plan_name": "701720_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Ambetter 68069", "plan_name": "500516", "standard_charge_dollar": 16.23, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Ms State Emplo", "plan_name": "401457", "standard_charge_dollar": 10.18, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Ms State Emplo", "plan_name": "401457_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Basic Pl", "plan_name": "400100", "standard_charge_dollar": 10.18, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Basic Pl", "plan_name": "400100_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Federal", "plan_name": "400110", "standard_charge_dollar": 10.18, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Federal", "plan_name": "400110_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Cigna Healthsprings Ffs", "plan_name": "500064", "standard_charge_dollar": 16.23, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Conseco", "plan_name": "500302", "standard_charge_dollar": 16.23, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Humana Ffs 61101", "plan_name": "500006", "standard_charge_dollar": 16.23, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Medicare A", "plan_name": "100100", "standard_charge_dollar": 16.23, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Medicare A", "plan_name": "100500", "standard_charge_dollar": 16.23, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Medicare Part B Only", "plan_name": "100300", "standard_charge_dollar": 16.23, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Medicare Railroad", "plan_name": "100103", "standard_charge_dollar": 16.23, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Ms Physicians Care N", "plan_name": "714210", "standard_charge_dollar": 20.29, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Peoples Hlth Ffs 72126", "plan_name": "500019", "standard_charge_dollar": 16.23, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Uhc/Secure Horizons", "plan_name": "500449", "standard_charge_dollar": 16.23, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "United Health Care/", "plan_name": "500292", "standard_charge_dollar": 18.34, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "United Healthcare", "plan_name": "750104", "standard_charge_dollar": 18.34, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "United Healthcare Ba", "plan_name": "750090", "standard_charge_dollar": 18.34, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "United Healthcare Me", "plan_name": "501310", "standard_charge_dollar": 16.23, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Windsor Mcare Extra", "plan_name": "500778", "standard_charge_dollar": 16.23, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." } ] } ] }, { "description": "Ramucirumab 10 mg/ml intravenous solution [165874]", "drug_information": { "unit": 10.00, "type": "ML" }, "code_information": [ { "code": "J9308", "type": "HCPCS" }, { "code": "0002-7669-01", "type": "NDC" } ], "standard_charges": [ { "gross_charge": 6403.91, "minimum": 51.45, "maximum": 91.71, "setting": "both", "payers_information": [ { "payer_name": "Aarp", "plan_name": "500102", "standard_charge_dollar": 73.37, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna", "plan_name": "700700", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna", "plan_name": "700700_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Mcare Ffs 6005", "plan_name": "700703", "standard_charge_dollar": 73.37, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Miscellaneous", "plan_name": "700720", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Miscellaneous", "plan_name": "700720_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Ppo Hmo", "plan_name": "701720", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Ppo Hmo", "plan_name": "701720_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Ambetter 68069", "plan_name": "500516", "standard_charge_dollar": 73.37, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Ms State Emplo", "plan_name": "401457", "standard_charge_dollar": 51.45, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Ms State Emplo", "plan_name": "401457_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Basic Pl", "plan_name": "400100", "standard_charge_dollar": 51.45, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Basic Pl", "plan_name": "400100_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Federal", "plan_name": "400110", "standard_charge_dollar": 51.45, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Federal", "plan_name": "400110_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Cigna Healthsprings Ffs", "plan_name": "500064", "standard_charge_dollar": 73.37, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Conseco", "plan_name": "500302", "standard_charge_dollar": 73.37, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Humana Ffs 61101", "plan_name": "500006", "standard_charge_dollar": 73.37, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Medicare A", "plan_name": "100100", "standard_charge_dollar": 73.37, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Medicare A", "plan_name": "100500", "standard_charge_dollar": 73.37, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Medicare Part B Only", "plan_name": "100300", "standard_charge_dollar": 73.37, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Medicare Railroad", "plan_name": "100103", "standard_charge_dollar": 73.37, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Ms Physicians Care N", "plan_name": "714210", "standard_charge_dollar": 91.71, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Peoples Hlth Ffs 72126", "plan_name": "500019", "standard_charge_dollar": 73.37, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Uhc/Secure Horizons", "plan_name": "500449", "standard_charge_dollar": 73.37, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "United Health Care/", "plan_name": "500292", "standard_charge_dollar": 82.91, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "United Healthcare", "plan_name": "750104", "standard_charge_dollar": 82.91, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "United Healthcare Ba", "plan_name": "750090", "standard_charge_dollar": 82.91, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "United Healthcare Me", "plan_name": "501310", "standard_charge_dollar": 73.37, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Windsor Mcare Extra", "plan_name": "500778", "standard_charge_dollar": 73.37, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." } ] } ] }, { "description": "Ramucirumab 10 mg/ml intravenous solution [165874]", "drug_information": { "unit": 50.00, "type": "ML" }, "code_information": [ { "code": "J9308", "type": "HCPCS" }, { "code": "0002-7678-01", "type": "NDC" } ], "standard_charges": [ { "gross_charge": 32019.53, "minimum": 51.45, "maximum": 91.71, "setting": "both", "payers_information": [ { "payer_name": "Aarp", "plan_name": "500102", "standard_charge_dollar": 73.37, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna", "plan_name": "700700", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna", "plan_name": "700700_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Mcare Ffs 6005", "plan_name": "700703", "standard_charge_dollar": 73.37, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Miscellaneous", "plan_name": "700720", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Miscellaneous", "plan_name": "700720_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Ppo Hmo", "plan_name": "701720", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Ppo Hmo", "plan_name": "701720_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Ambetter 68069", "plan_name": "500516", "standard_charge_dollar": 73.37, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Ms State Emplo", "plan_name": "401457", "standard_charge_dollar": 51.45, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Ms State Emplo", "plan_name": "401457_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Basic Pl", "plan_name": "400100", "standard_charge_dollar": 51.45, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Basic Pl", "plan_name": "400100_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Federal", "plan_name": "400110", "standard_charge_dollar": 51.45, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Federal", "plan_name": "400110_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Cigna Healthsprings Ffs", "plan_name": "500064", "standard_charge_dollar": 73.37, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Conseco", "plan_name": "500302", "standard_charge_dollar": 73.37, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Humana Ffs 61101", "plan_name": "500006", "standard_charge_dollar": 73.37, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Medicare A", "plan_name": "100100", "standard_charge_dollar": 73.37, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Medicare A", "plan_name": "100500", "standard_charge_dollar": 73.37, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Medicare Part B Only", "plan_name": "100300", "standard_charge_dollar": 73.37, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Medicare Railroad", "plan_name": "100103", "standard_charge_dollar": 73.37, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Ms Physicians Care N", "plan_name": "714210", "standard_charge_dollar": 91.71, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Peoples Hlth Ffs 72126", "plan_name": "500019", "standard_charge_dollar": 73.37, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Uhc/Secure Horizons", "plan_name": "500449", "standard_charge_dollar": 73.37, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "United Health Care/", "plan_name": "500292", "standard_charge_dollar": 82.91, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "United Healthcare", "plan_name": "750104", "standard_charge_dollar": 82.91, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "United Healthcare Ba", "plan_name": "750090", "standard_charge_dollar": 82.91, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "United Healthcare Me", "plan_name": "501310", "standard_charge_dollar": 73.37, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Windsor Mcare Extra", "plan_name": "500778", "standard_charge_dollar": 73.37, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." } ] } ] }, { "description": "Polatuzumab vedotin-piiq 140 mg intravenous solution [187439]", "drug_information": { "unit": 1.00, "type": "EA" }, "code_information": [ { "code": "J9309", "type": "HCPCS" }, { "code": "50242-105-01", "type": "NDC" } ], "standard_charges": [ { "gross_charge": 70269.16, "minimum": 132.73, "maximum": 59728.79, "setting": "both", "payers_information": [ { "payer_name": "Aarp", "plan_name": "500102", "standard_charge_dollar": 132.73, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna", "plan_name": "700700", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna", "plan_name": "700700_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Mcare Ffs 6005", "plan_name": "700703", "standard_charge_dollar": 132.73, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Miscellaneous", "plan_name": "700720", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Miscellaneous", "plan_name": "700720_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Ppo Hmo", "plan_name": "701720", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Ppo Hmo", "plan_name": "701720_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Ambetter 68069", "plan_name": "500516", "standard_charge_dollar": 132.73, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Ms State Emplo", "plan_name": "401457", "standard_charge_percentage": 0.80, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Ms State Emplo", "plan_name": "401457_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Basic Pl", "plan_name": "400100", "standard_charge_percentage": 0.85, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Basic Pl", "plan_name": "400100_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Federal", "plan_name": "400110", "standard_charge_percentage": 0.85, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Federal", "plan_name": "400110_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Cigna Healthsprings Ffs", "plan_name": "500064", "standard_charge_dollar": 132.73, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Conseco", "plan_name": "500302", "standard_charge_dollar": 132.73, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Humana Ffs 61101", "plan_name": "500006", "standard_charge_dollar": 132.73, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Medicare A", "plan_name": "100100", "standard_charge_dollar": 132.73, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Medicare A", "plan_name": "100500", "standard_charge_dollar": 132.73, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Medicare Part B Only", "plan_name": "100300", "standard_charge_dollar": 132.73, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Medicare Railroad", "plan_name": "100103", "standard_charge_dollar": 132.73, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Ms Physicians Care N", "plan_name": "714210", "standard_charge_dollar": 165.91, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Peoples Hlth Ffs 72126", "plan_name": "500019", "standard_charge_dollar": 132.73, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Uhc/Secure Horizons", "plan_name": "500449", "standard_charge_dollar": 132.73, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "United Health Care/", "plan_name": "500292", "standard_charge_dollar": 149.98, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "United Healthcare", "plan_name": "750104", "standard_charge_dollar": 149.98, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "United Healthcare Ba", "plan_name": "750090", "standard_charge_dollar": 149.98, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "United Healthcare Me", "plan_name": "501310", "standard_charge_dollar": 132.73, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Windsor Mcare Extra", "plan_name": "500778", "standard_charge_dollar": 132.73, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." } ] } ] }, { "description": "Rituximab 10 mg/ml concentrateintravenous [22149]", "drug_information": { "unit": 10.00, "type": "ML" }, "code_information": [ { "code": "J9312", "type": "HCPCS" }, { "code": "50242-051-21", "type": "NDC" } ], "standard_charges": [ { "gross_charge": 4212.63, "minimum": 76.43, "maximum": 3580.74, "setting": "both", "payers_information": [ { "payer_name": "Aarp", "plan_name": "500102", "standard_charge_dollar": 76.43, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna", "plan_name": "700700", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna", "plan_name": "700700_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Mcare Ffs 6005", "plan_name": "700703", "standard_charge_dollar": 76.43, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Miscellaneous", "plan_name": "700720", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Miscellaneous", "plan_name": "700720_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Ppo Hmo", "plan_name": "701720", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Ppo Hmo", "plan_name": "701720_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Ambetter 68069", "plan_name": "500516", "standard_charge_dollar": 76.43, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Ms State Emplo", "plan_name": "401457", "standard_charge_percentage": 0.80, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Ms State Emplo", "plan_name": "401457_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Basic Pl", "plan_name": "400100", "standard_charge_percentage": 0.85, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Basic Pl", "plan_name": "400100_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Federal", "plan_name": "400110", "standard_charge_percentage": 0.85, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Federal", "plan_name": "400110_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Cigna Healthsprings Ffs", "plan_name": "500064", "standard_charge_dollar": 76.43, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Conseco", "plan_name": "500302", "standard_charge_dollar": 76.43, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Humana Ffs 61101", "plan_name": "500006", "standard_charge_dollar": 76.43, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Medicare A", "plan_name": "100100", "standard_charge_dollar": 76.43, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Medicare A", "plan_name": "100500", "standard_charge_dollar": 76.43, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Medicare Part B Only", "plan_name": "100300", "standard_charge_dollar": 76.43, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Medicare Railroad", "plan_name": "100103", "standard_charge_dollar": 76.43, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Ms Physicians Care N", "plan_name": "714210", "standard_charge_dollar": 95.54, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Peoples Hlth Ffs 72126", "plan_name": "500019", "standard_charge_dollar": 76.43, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Uhc/Secure Horizons", "plan_name": "500449", "standard_charge_dollar": 76.43, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "United Health Care/", "plan_name": "500292", "standard_charge_dollar": 86.37, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "United Healthcare", "plan_name": "750104", "standard_charge_dollar": 86.37, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "United Healthcare Ba", "plan_name": "750090", "standard_charge_dollar": 86.37, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "United Healthcare Me", "plan_name": "501310", "standard_charge_dollar": 76.43, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Windsor Mcare Extra", "plan_name": "500778", "standard_charge_dollar": 76.43, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." } ] } ] }, { "description": "Rituximab 10 mg/ml concentrateintravenous [22149]", "drug_information": { "unit": 50.00, "type": "ML" }, "code_information": [ { "code": "J9312", "type": "HCPCS" }, { "code": "50242-053-06", "type": "NDC" } ], "standard_charges": [ { "gross_charge": 21063.15, "minimum": 76.43, "maximum": 17903.68, "setting": "both", "payers_information": [ { "payer_name": "Aarp", "plan_name": "500102", "standard_charge_dollar": 76.43, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna", "plan_name": "700700", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna", "plan_name": "700700_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Mcare Ffs 6005", "plan_name": "700703", "standard_charge_dollar": 76.43, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Miscellaneous", "plan_name": "700720", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Miscellaneous", "plan_name": "700720_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Ppo Hmo", "plan_name": "701720", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Ppo Hmo", "plan_name": "701720_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Ambetter 68069", "plan_name": "500516", "standard_charge_dollar": 76.43, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Ms State Emplo", "plan_name": "401457", "standard_charge_percentage": 0.80, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Ms State Emplo", "plan_name": "401457_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Basic Pl", "plan_name": "400100", "standard_charge_percentage": 0.85, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Basic Pl", "plan_name": "400100_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Federal", "plan_name": "400110", "standard_charge_percentage": 0.85, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Federal", "plan_name": "400110_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Cigna Healthsprings Ffs", "plan_name": "500064", "standard_charge_dollar": 76.43, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Conseco", "plan_name": "500302", "standard_charge_dollar": 76.43, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Humana Ffs 61101", "plan_name": "500006", "standard_charge_dollar": 76.43, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Medicare A", "plan_name": "100100", "standard_charge_dollar": 76.43, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Medicare A", "plan_name": "100500", "standard_charge_dollar": 76.43, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Medicare Part B Only", "plan_name": "100300", "standard_charge_dollar": 76.43, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Medicare Railroad", "plan_name": "100103", "standard_charge_dollar": 76.43, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Ms Physicians Care N", "plan_name": "714210", "standard_charge_dollar": 95.54, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Peoples Hlth Ffs 72126", "plan_name": "500019", "standard_charge_dollar": 76.43, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Uhc/Secure Horizons", "plan_name": "500449", "standard_charge_dollar": 76.43, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "United Health Care/", "plan_name": "500292", "standard_charge_dollar": 86.37, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "United Healthcare", "plan_name": "750104", "standard_charge_dollar": 86.37, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "United Healthcare Ba", "plan_name": "750090", "standard_charge_dollar": 86.37, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "United Healthcare Me", "plan_name": "501310", "standard_charge_dollar": 76.43, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Windsor Mcare Extra", "plan_name": "500778", "standard_charge_dollar": 76.43, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." } ] } ] }, { "description": "Sacituzumab govitecan-hziy 180 mg intravenous solution [190338]", "drug_information": { "unit": 1.00, "type": "EA" }, "code_information": [ { "code": "J9317", "type": "HCPCS" }, { "code": "55135-132-01", "type": "NDC" } ], "standard_charges": [ { "gross_charge": 10778.45, "minimum": 35.80, "maximum": 9161.68, "setting": "both", "payers_information": [ { "payer_name": "Aarp", "plan_name": "500102", "standard_charge_dollar": 35.80, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna", "plan_name": "700700", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna", "plan_name": "700700_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Mcare Ffs 6005", "plan_name": "700703", "standard_charge_dollar": 35.80, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Miscellaneous", "plan_name": "700720", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Miscellaneous", "plan_name": "700720_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Ppo Hmo", "plan_name": "701720", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Ppo Hmo", "plan_name": "701720_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Ambetter 68069", "plan_name": "500516", "standard_charge_dollar": 35.80, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Ms State Emplo", "plan_name": "401457", "standard_charge_percentage": 0.80, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Ms State Emplo", "plan_name": "401457_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Basic Pl", "plan_name": "400100", "standard_charge_percentage": 0.85, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Basic Pl", "plan_name": "400100_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Federal", "plan_name": "400110", "standard_charge_percentage": 0.85, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Federal", "plan_name": "400110_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Cigna Healthsprings Ffs", "plan_name": "500064", "standard_charge_dollar": 35.80, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Conseco", "plan_name": "500302", "standard_charge_dollar": 35.80, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Humana Ffs 61101", "plan_name": "500006", "standard_charge_dollar": 35.80, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Medicare A", "plan_name": "100100", "standard_charge_dollar": 35.80, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Medicare A", "plan_name": "100500", "standard_charge_dollar": 35.80, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Medicare Part B Only", "plan_name": "100300", "standard_charge_dollar": 35.80, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Medicare Railroad", "plan_name": "100103", "standard_charge_dollar": 35.80, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Ms Physicians Care N", "plan_name": "714210", "standard_charge_dollar": 44.75, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Peoples Hlth Ffs 72126", "plan_name": "500019", "standard_charge_dollar": 35.80, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Uhc/Secure Horizons", "plan_name": "500449", "standard_charge_dollar": 35.80, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "United Health Care/", "plan_name": "500292", "standard_charge_dollar": 40.45, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "United Healthcare", "plan_name": "750104", "standard_charge_dollar": 40.45, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "United Healthcare Ba", "plan_name": "750090", "standard_charge_dollar": 40.45, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "United Healthcare Me", "plan_name": "501310", "standard_charge_dollar": 35.80, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Windsor Mcare Extra", "plan_name": "500778", "standard_charge_dollar": 35.80, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." } ] } ] }, { "description": "Efgartigimod alfa-fcab 20 mg/ml intravenous solution [195708]", "drug_information": { "unit": 20.00, "type": "ML" }, "code_information": [ { "code": "J9332", "type": "HCPCS" }, { "code": "73475-3041-5", "type": "NDC" } ], "standard_charges": [ { "gross_charge": 27856.71, "minimum": 29.66, "maximum": 23678.20, "setting": "both", "payers_information": [ { "payer_name": "Aarp", "plan_name": "500102", "standard_charge_dollar": 29.66, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna", "plan_name": "700700", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna", "plan_name": "700700_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Mcare Ffs 6005", "plan_name": "700703", "standard_charge_dollar": 29.66, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Miscellaneous", "plan_name": "700720", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Miscellaneous", "plan_name": "700720_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Ppo Hmo", "plan_name": "701720", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Ppo Hmo", "plan_name": "701720_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Ambetter 68069", "plan_name": "500516", "standard_charge_dollar": 29.66, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Ms State Emplo", "plan_name": "401457", "standard_charge_percentage": 0.80, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Ms State Emplo", "plan_name": "401457_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Basic Pl", "plan_name": "400100", "standard_charge_percentage": 0.85, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Basic Pl", "plan_name": "400100_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Federal", "plan_name": "400110", "standard_charge_percentage": 0.85, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Federal", "plan_name": "400110_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Cigna Healthsprings Ffs", "plan_name": "500064", "standard_charge_dollar": 29.66, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Conseco", "plan_name": "500302", "standard_charge_dollar": 29.66, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Humana Ffs 61101", "plan_name": "500006", "standard_charge_dollar": 29.66, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Medicare A", "plan_name": "100100", "standard_charge_dollar": 29.66, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Medicare A", "plan_name": "100500", "standard_charge_dollar": 29.66, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Medicare Part B Only", "plan_name": "100300", "standard_charge_dollar": 29.66, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Medicare Railroad", "plan_name": "100103", "standard_charge_dollar": 29.66, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Ms Physicians Care N", "plan_name": "714210", "standard_charge_dollar": 37.08, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Peoples Hlth Ffs 72126", "plan_name": "500019", "standard_charge_dollar": 29.66, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Uhc/Secure Horizons", "plan_name": "500449", "standard_charge_dollar": 29.66, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "United Health Care/", "plan_name": "500292", "standard_charge_dollar": 33.52, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "United Healthcare", "plan_name": "750104", "standard_charge_dollar": 33.52, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "United Healthcare Ba", "plan_name": "750090", "standard_charge_dollar": 33.52, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "United Healthcare Me", "plan_name": "501310", "standard_charge_dollar": 29.66, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Windsor Mcare Extra", "plan_name": "500778", "standard_charge_dollar": 29.66, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." } ] } ] }, { "description": "Tafasitamab-cxix 200 mg intravenous solution [191291]", "drug_information": { "unit": 1.00, "type": "EA" }, "code_information": [ { "code": "J9349", "type": "HCPCS" }, { "code": "73535-208-01", "type": "NDC" } ], "standard_charges": [ { "gross_charge": 5320.47, "minimum": 13.93, "maximum": 4522.40, "setting": "both", "payers_information": [ { "payer_name": "Aarp", "plan_name": "500102", "standard_charge_dollar": 13.93, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna", "plan_name": "700700", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna", "plan_name": "700700_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Mcare Ffs 6005", "plan_name": "700703", "standard_charge_dollar": 13.93, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Miscellaneous", "plan_name": "700720", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Miscellaneous", "plan_name": "700720_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Ppo Hmo", "plan_name": "701720", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Ppo Hmo", "plan_name": "701720_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Ambetter 68069", "plan_name": "500516", "standard_charge_dollar": 13.93, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Ms State Emplo", "plan_name": "401457", "standard_charge_percentage": 0.80, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Ms State Emplo", "plan_name": "401457_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Basic Pl", "plan_name": "400100", "standard_charge_percentage": 0.85, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Basic Pl", "plan_name": "400100_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Federal", "plan_name": "400110", "standard_charge_percentage": 0.85, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Federal", "plan_name": "400110_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Cigna Healthsprings Ffs", "plan_name": "500064", "standard_charge_dollar": 13.93, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Conseco", "plan_name": "500302", "standard_charge_dollar": 13.93, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Humana Ffs 61101", "plan_name": "500006", "standard_charge_dollar": 13.93, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Medicare A", "plan_name": "100100", "standard_charge_dollar": 13.93, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Medicare A", "plan_name": "100500", "standard_charge_dollar": 13.93, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Medicare Part B Only", "plan_name": "100300", "standard_charge_dollar": 13.93, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Medicare Railroad", "plan_name": "100103", "standard_charge_dollar": 13.93, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Ms Physicians Care N", "plan_name": "714210", "standard_charge_dollar": 17.41, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Peoples Hlth Ffs 72126", "plan_name": "500019", "standard_charge_dollar": 13.93, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Uhc/Secure Horizons", "plan_name": "500449", "standard_charge_dollar": 13.93, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "United Health Care/", "plan_name": "500292", "standard_charge_dollar": 15.74, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "United Healthcare", "plan_name": "750104", "standard_charge_dollar": 15.74, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "United Healthcare Ba", "plan_name": "750090", "standard_charge_dollar": 15.74, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "United Healthcare Me", "plan_name": "501310", "standard_charge_dollar": 13.93, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Windsor Mcare Extra", "plan_name": "500778", "standard_charge_dollar": 13.93, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." } ] } ] }, { "description": "Topotecan 4 mg/4 ml (1 mg/ml) intravenous solution [150794]", "drug_information": { "unit": 4.00, "type": "ML" }, "code_information": [ { "code": "J9351", "type": "HCPCS" }, { "code": "0409-0302-01", "type": "NDC" } ], "standard_charges": [ { "gross_charge": 303.98, "minimum": 3.48, "maximum": 3.48, "setting": "both", "payers_information": [ { "payer_name": "Aetna", "plan_name": "700700", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna", "plan_name": "700700_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Miscellaneous", "plan_name": "700720", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Miscellaneous", "plan_name": "700720_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Ppo Hmo", "plan_name": "701720", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Ppo Hmo", "plan_name": "701720_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Ms State Emplo", "plan_name": "401457", "standard_charge_dollar": 3.48, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Ms State Emplo", "plan_name": "401457_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Basic Pl", "plan_name": "400100", "standard_charge_dollar": 3.48, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Basic Pl", "plan_name": "400100_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Federal", "plan_name": "400110", "standard_charge_dollar": 3.48, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Federal", "plan_name": "400110_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." } ] } ] }, { "description": "Ado-trastuzumab emtansine 160 mg intravenous solution [161511]", "drug_information": { "unit": 1.00, "type": "EA" }, "code_information": [ { "code": "J9354", "type": "HCPCS" }, { "code": "50242-087-01", "type": "NDC" } ], "standard_charges": [ { "gross_charge": 27919.67, "minimum": 27.02, "maximum": 51.39, "setting": "both", "payers_information": [ { "payer_name": "Aarp", "plan_name": "500102", "standard_charge_dollar": 41.11, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna", "plan_name": "700700", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna", "plan_name": "700700_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Mcare Ffs 6005", "plan_name": "700703", "standard_charge_dollar": 41.11, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Miscellaneous", "plan_name": "700720", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Miscellaneous", "plan_name": "700720_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Ppo Hmo", "plan_name": "701720", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Ppo Hmo", "plan_name": "701720_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Ambetter 68069", "plan_name": "500516", "standard_charge_dollar": 41.11, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Ms State Emplo", "plan_name": "401457", "standard_charge_dollar": 27.02, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Ms State Emplo", "plan_name": "401457_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Basic Pl", "plan_name": "400100", "standard_charge_dollar": 27.02, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Basic Pl", "plan_name": "400100_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Federal", "plan_name": "400110", "standard_charge_dollar": 27.02, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Federal", "plan_name": "400110_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Cigna Healthsprings Ffs", "plan_name": "500064", "standard_charge_dollar": 41.11, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Conseco", "plan_name": "500302", "standard_charge_dollar": 41.11, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Humana Ffs 61101", "plan_name": "500006", "standard_charge_dollar": 41.11, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Medicare A", "plan_name": "100100", "standard_charge_dollar": 41.11, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Medicare A", "plan_name": "100500", "standard_charge_dollar": 41.11, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Medicare Part B Only", "plan_name": "100300", "standard_charge_dollar": 41.11, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Medicare Railroad", "plan_name": "100103", "standard_charge_dollar": 41.11, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Ms Physicians Care N", "plan_name": "714210", "standard_charge_dollar": 51.39, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Peoples Hlth Ffs 72126", "plan_name": "500019", "standard_charge_dollar": 41.11, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Uhc/Secure Horizons", "plan_name": "500449", "standard_charge_dollar": 41.11, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "United Health Care/", "plan_name": "500292", "standard_charge_dollar": 46.45, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "United Healthcare", "plan_name": "750104", "standard_charge_dollar": 46.45, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "United Healthcare Ba", "plan_name": "750090", "standard_charge_dollar": 46.45, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "United Healthcare Me", "plan_name": "501310", "standard_charge_dollar": 41.11, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Windsor Mcare Extra", "plan_name": "500778", "standard_charge_dollar": 41.11, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." } ] } ] }, { "description": "Ado-trastuzumab emtansine 100 mg intravenous solution [161510]", "drug_information": { "unit": 1.00, "type": "EA" }, "code_information": [ { "code": "J9354", "type": "HCPCS" }, { "code": "50242-088-01", "type": "NDC" } ], "standard_charges": [ { "gross_charge": 17449.83, "minimum": 27.02, "maximum": 51.39, "setting": "both", "payers_information": [ { "payer_name": "Aarp", "plan_name": "500102", "standard_charge_dollar": 41.11, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna", "plan_name": "700700", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna", "plan_name": "700700_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Mcare Ffs 6005", "plan_name": "700703", "standard_charge_dollar": 41.11, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Miscellaneous", "plan_name": "700720", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Miscellaneous", "plan_name": "700720_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Ppo Hmo", "plan_name": "701720", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Ppo Hmo", "plan_name": "701720_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Ambetter 68069", "plan_name": "500516", "standard_charge_dollar": 41.11, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Ms State Emplo", "plan_name": "401457", "standard_charge_dollar": 27.02, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Ms State Emplo", "plan_name": "401457_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Basic Pl", "plan_name": "400100", "standard_charge_dollar": 27.02, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Basic Pl", "plan_name": "400100_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Federal", "plan_name": "400110", "standard_charge_dollar": 27.02, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Federal", "plan_name": "400110_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Cigna Healthsprings Ffs", "plan_name": "500064", "standard_charge_dollar": 41.11, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Conseco", "plan_name": "500302", "standard_charge_dollar": 41.11, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Humana Ffs 61101", "plan_name": "500006", "standard_charge_dollar": 41.11, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Medicare A", "plan_name": "100100", "standard_charge_dollar": 41.11, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Medicare A", "plan_name": "100500", "standard_charge_dollar": 41.11, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Medicare Part B Only", "plan_name": "100300", "standard_charge_dollar": 41.11, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Medicare Railroad", "plan_name": "100103", "standard_charge_dollar": 41.11, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Ms Physicians Care N", "plan_name": "714210", "standard_charge_dollar": 51.39, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Peoples Hlth Ffs 72126", "plan_name": "500019", "standard_charge_dollar": 41.11, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Uhc/Secure Horizons", "plan_name": "500449", "standard_charge_dollar": 41.11, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "United Health Care/", "plan_name": "500292", "standard_charge_dollar": 46.45, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "United Healthcare", "plan_name": "750104", "standard_charge_dollar": 46.45, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "United Healthcare Ba", "plan_name": "750090", "standard_charge_dollar": 46.45, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "United Healthcare Me", "plan_name": "501310", "standard_charge_dollar": 41.11, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Windsor Mcare Extra", "plan_name": "500778", "standard_charge_dollar": 41.11, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." } ] } ] }, { "description": "Trastuzumab 150 mg intravenous solution [180988]", "drug_information": { "unit": 1.00, "type": "EA" }, "code_information": [ { "code": "J9355", "type": "HCPCS" }, { "code": "50242-132-01", "type": "NDC" } ], "standard_charges": [ { "gross_charge": 6987.65, "minimum": 75.69, "maximum": 94.61, "setting": "both", "payers_information": [ { "payer_name": "Aarp", "plan_name": "500102", "standard_charge_dollar": 75.69, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna", "plan_name": "700700", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna", "plan_name": "700700_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Mcare Ffs 6005", "plan_name": "700703", "standard_charge_dollar": 75.69, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Miscellaneous", "plan_name": "700720", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Miscellaneous", "plan_name": "700720_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Ppo Hmo", "plan_name": "701720", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Ppo Hmo", "plan_name": "701720_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Ambetter 68069", "plan_name": "500516", "standard_charge_dollar": 75.69, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Ms State Emplo", "plan_name": "401457", "standard_charge_dollar": 88.62, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Ms State Emplo", "plan_name": "401457_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Basic Pl", "plan_name": "400100", "standard_charge_dollar": 88.62, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Basic Pl", "plan_name": "400100_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Federal", "plan_name": "400110", "standard_charge_dollar": 88.62, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Federal", "plan_name": "400110_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Cigna Healthsprings Ffs", "plan_name": "500064", "standard_charge_dollar": 75.69, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Conseco", "plan_name": "500302", "standard_charge_dollar": 75.69, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Humana Ffs 61101", "plan_name": "500006", "standard_charge_dollar": 75.69, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Medicare A", "plan_name": "100100", "standard_charge_dollar": 75.69, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Medicare A", "plan_name": "100500", "standard_charge_dollar": 75.69, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Medicare Part B Only", "plan_name": "100300", "standard_charge_dollar": 75.69, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Medicare Railroad", "plan_name": "100103", "standard_charge_dollar": 75.69, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Ms Physicians Care N", "plan_name": "714210", "standard_charge_dollar": 94.61, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Peoples Hlth Ffs 72126", "plan_name": "500019", "standard_charge_dollar": 75.69, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Uhc/Secure Horizons", "plan_name": "500449", "standard_charge_dollar": 75.69, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "United Health Care/", "plan_name": "500292", "standard_charge_dollar": 85.53, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "United Healthcare", "plan_name": "750104", "standard_charge_dollar": 85.53, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "United Healthcare Ba", "plan_name": "750090", "standard_charge_dollar": 85.53, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "United Healthcare Me", "plan_name": "501310", "standard_charge_dollar": 75.69, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Windsor Mcare Extra", "plan_name": "500778", "standard_charge_dollar": 75.69, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." } ] } ] }, { "description": "Fam-trastuzumab deruxtecan-nxki 100 mg intravenous solution [189246]", "drug_information": { "unit": 1.00, "type": "EA" }, "code_information": [ { "code": "J9358", "type": "HCPCS" }, { "code": "65597-406-01", "type": "NDC" } ], "standard_charges": [ { "gross_charge": 12114.63, "minimum": 28.90, "maximum": 10297.44, "setting": "both", "payers_information": [ { "payer_name": "Aarp", "plan_name": "500102", "standard_charge_dollar": 28.90, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna", "plan_name": "700700", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna", "plan_name": "700700_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Mcare Ffs 6005", "plan_name": "700703", "standard_charge_dollar": 28.90, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Miscellaneous", "plan_name": "700720", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Miscellaneous", "plan_name": "700720_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Ppo Hmo", "plan_name": "701720", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Ppo Hmo", "plan_name": "701720_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Ambetter 68069", "plan_name": "500516", "standard_charge_dollar": 28.90, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Ms State Emplo", "plan_name": "401457", "standard_charge_percentage": 0.80, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Ms State Emplo", "plan_name": "401457_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Basic Pl", "plan_name": "400100", "standard_charge_percentage": 0.85, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Basic Pl", "plan_name": "400100_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Federal", "plan_name": "400110", "standard_charge_percentage": 0.85, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Federal", "plan_name": "400110_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Cigna Healthsprings Ffs", "plan_name": "500064", "standard_charge_dollar": 28.90, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Conseco", "plan_name": "500302", "standard_charge_dollar": 28.90, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Humana Ffs 61101", "plan_name": "500006", "standard_charge_dollar": 28.90, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Medicare A", "plan_name": "100100", "standard_charge_dollar": 28.90, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Medicare A", "plan_name": "100500", "standard_charge_dollar": 28.90, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Medicare Part B Only", "plan_name": "100300", "standard_charge_dollar": 28.90, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Medicare Railroad", "plan_name": "100103", "standard_charge_dollar": 28.90, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Ms Physicians Care N", "plan_name": "714210", "standard_charge_dollar": 36.13, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Peoples Hlth Ffs 72126", "plan_name": "500019", "standard_charge_dollar": 28.90, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Uhc/Secure Horizons", "plan_name": "500449", "standard_charge_dollar": 28.90, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "United Health Care/", "plan_name": "500292", "standard_charge_dollar": 32.66, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "United Healthcare", "plan_name": "750104", "standard_charge_dollar": 32.66, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "United Healthcare Ba", "plan_name": "750090", "standard_charge_dollar": 32.66, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "United Healthcare Me", "plan_name": "501310", "standard_charge_dollar": 28.90, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Windsor Mcare Extra", "plan_name": "500778", "standard_charge_dollar": 28.90, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." } ] } ] }, { "description": "Loncastuximab tesirine-lpyl 10 mg intravenous solution [193774]", "drug_information": { "unit": 1.00, "type": "EA" }, "code_information": [ { "code": "J9359", "type": "HCPCS" }, { "code": "79952-110-01", "type": "NDC" } ], "standard_charges": [ { "gross_charge": 118350.05, "minimum": 212.00, "maximum": 100597.54, "setting": "both", "payers_information": [ { "payer_name": "Aarp", "plan_name": "500102", "standard_charge_dollar": 212.00, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna", "plan_name": "700700", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna", "plan_name": "700700_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Mcare Ffs 6005", "plan_name": "700703", "standard_charge_dollar": 212.00, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Miscellaneous", "plan_name": "700720", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Miscellaneous", "plan_name": "700720_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Ppo Hmo", "plan_name": "701720", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Ppo Hmo", "plan_name": "701720_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Ambetter 68069", "plan_name": "500516", "standard_charge_dollar": 212.00, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Ms State Emplo", "plan_name": "401457", "standard_charge_percentage": 0.80, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Ms State Emplo", "plan_name": "401457_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Basic Pl", "plan_name": "400100", "standard_charge_percentage": 0.85, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Basic Pl", "plan_name": "400100_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Federal", "plan_name": "400110", "standard_charge_percentage": 0.85, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Federal", "plan_name": "400110_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Cigna Healthsprings Ffs", "plan_name": "500064", "standard_charge_dollar": 212.00, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Conseco", "plan_name": "500302", "standard_charge_dollar": 212.00, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Humana Ffs 61101", "plan_name": "500006", "standard_charge_dollar": 212.00, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Medicare A", "plan_name": "100100", "standard_charge_dollar": 212.00, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Medicare A", "plan_name": "100500", "standard_charge_dollar": 212.00, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Medicare Part B Only", "plan_name": "100300", "standard_charge_dollar": 212.00, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Medicare Railroad", "plan_name": "100103", "standard_charge_dollar": 212.00, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Ms Physicians Care N", "plan_name": "714210", "standard_charge_dollar": 265.00, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Peoples Hlth Ffs 72126", "plan_name": "500019", "standard_charge_dollar": 212.00, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Uhc/Secure Horizons", "plan_name": "500449", "standard_charge_dollar": 212.00, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "United Health Care/", "plan_name": "500292", "standard_charge_dollar": 239.56, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "United Healthcare", "plan_name": "750104", "standard_charge_dollar": 239.56, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "United Healthcare Ba", "plan_name": "750090", "standard_charge_dollar": 239.56, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "United Healthcare Me", "plan_name": "501310", "standard_charge_dollar": 212.00, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Windsor Mcare Extra", "plan_name": "500778", "standard_charge_dollar": 212.00, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." } ] } ] }, { "description": "Vinblastine 1 mg/ml intravenous solution [8594]", "drug_information": { "unit": 10.00, "type": "ML" }, "code_information": [ { "code": "J9360", "type": "HCPCS" }, { "code": "63323-278-10", "type": "NDC" } ], "standard_charges": [ { "gross_charge": 243.95, "minimum": 195.16, "maximum": 207.36, "setting": "both", "payers_information": [ { "payer_name": "Aetna", "plan_name": "700700", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna", "plan_name": "700700_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Miscellaneous", "plan_name": "700720", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Miscellaneous", "plan_name": "700720_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Ppo Hmo", "plan_name": "701720", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Ppo Hmo", "plan_name": "701720_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Ms State Emplo", "plan_name": "401457", "standard_charge_percentage": 0.80, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Ms State Emplo", "plan_name": "401457_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Basic Pl", "plan_name": "400100", "standard_charge_percentage": 0.85, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Basic Pl", "plan_name": "400100_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Federal", "plan_name": "400110", "standard_charge_percentage": 0.85, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Federal", "plan_name": "400110_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." } ] } ] }, { "description": "Vincristine 2 mg/2 ml intravenous solution [118463]", "drug_information": { "unit": 2.00, "type": "ML" }, "code_information": [ { "code": "J9370", "type": "HCPCS" }, { "code": "61703-309-16", "type": "NDC" } ], "standard_charges": [ { "gross_charge": 138.51, "minimum": 110.81, "maximum": 117.73, "setting": "both", "payers_information": [ { "payer_name": "Aetna", "plan_name": "700700", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna", "plan_name": "700700_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Miscellaneous", "plan_name": "700720", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Miscellaneous", "plan_name": "700720_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Ppo Hmo", "plan_name": "701720", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Ppo Hmo", "plan_name": "701720_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Ms State Emplo", "plan_name": "401457", "standard_charge_percentage": 0.80, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Ms State Emplo", "plan_name": "401457_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Basic Pl", "plan_name": "400100", "standard_charge_percentage": 0.85, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Basic Pl", "plan_name": "400100_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Federal", "plan_name": "400110", "standard_charge_percentage": 0.85, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Federal", "plan_name": "400110_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." } ] } ] }, { "description": "Vinorelbine 10 mg/ml intravenous solution [14203]", "drug_information": { "unit": 1.00, "type": "ML" }, "code_information": [ { "code": "J9390", "type": "HCPCS" }, { "code": "25021-204-01", "type": "NDC" } ], "standard_charges": [ { "gross_charge": 137.21, "minimum": 19.20, "maximum": 19.20, "setting": "both", "payers_information": [ { "payer_name": "Aetna", "plan_name": "700700", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna", "plan_name": "700700_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Miscellaneous", "plan_name": "700720", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Miscellaneous", "plan_name": "700720_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Ppo Hmo", "plan_name": "701720", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Ppo Hmo", "plan_name": "701720_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Ms State Emplo", "plan_name": "401457", "standard_charge_dollar": 19.20, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Ms State Emplo", "plan_name": "401457_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Basic Pl", "plan_name": "400100", "standard_charge_dollar": 19.20, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Basic Pl", "plan_name": "400100_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Federal", "plan_name": "400110", "standard_charge_dollar": 19.20, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Federal", "plan_name": "400110_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." } ] } ] }, { "description": "Vinorelbine 50 mg/5 ml intravenous 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"additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "United Healthcare", "plan_name": "750104", "standard_charge_dollar": 7.80, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "United Healthcare Ba", "plan_name": "750090", "standard_charge_dollar": 7.80, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "United Healthcare Me", "plan_name": "501310", "standard_charge_dollar": 6.90, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Windsor Mcare Extra", "plan_name": "500778", "standard_charge_dollar": 6.90, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." } ] } ] }, { "description": "Fulvestrant 250 mg/5 ml intramuscular syringe [32767]", "drug_information": { "unit": 5.00, "type": "ML" }, "code_information": [ { "code": "J9395", "type": "HCPCS" }, { "code": "70700-284-98", "type": "NDC" } ], "standard_charges": [ { "gross_charge": 877.50, "minimum": 6.90, "maximum": 89.00, "setting": "both", "payers_information": [ { "payer_name": "Aarp", "plan_name": "500102", "standard_charge_dollar": 6.90, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna", "plan_name": "700700", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna", "plan_name": "700700_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Mcare Ffs 6005", "plan_name": "700703", "standard_charge_dollar": 6.90, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Miscellaneous", "plan_name": "700720", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Miscellaneous", "plan_name": "700720_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Ppo Hmo", "plan_name": "701720", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Ppo Hmo", "plan_name": "701720_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Ambetter 68069", "plan_name": "500516", "standard_charge_dollar": 6.90, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Ms State Emplo", "plan_name": "401457", "standard_charge_dollar": 89.00, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Ms State Emplo", "plan_name": "401457_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Basic Pl", "plan_name": "400100", "standard_charge_dollar": 89.00, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Basic Pl", "plan_name": "400100_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Federal", "plan_name": "400110", "standard_charge_dollar": 89.00, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Federal", "plan_name": "400110_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Cigna Healthsprings Ffs", "plan_name": "500064", "standard_charge_dollar": 6.90, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Conseco", "plan_name": "500302", "standard_charge_dollar": 6.90, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Humana Ffs 61101", "plan_name": "500006", "standard_charge_dollar": 6.90, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Medicare A", "plan_name": "100100", "standard_charge_dollar": 6.90, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Medicare A", "plan_name": "100500", "standard_charge_dollar": 6.90, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Medicare Part B Only", "plan_name": "100300", "standard_charge_dollar": 6.90, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Medicare Railroad", "plan_name": "100103", "standard_charge_dollar": 6.90, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Ms Physicians Care N", "plan_name": "714210", "standard_charge_dollar": 8.63, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Peoples Hlth Ffs 72126", "plan_name": "500019", "standard_charge_dollar": 6.90, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Uhc/Secure Horizons", "plan_name": "500449", "standard_charge_dollar": 6.90, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "United Health Care/", "plan_name": "500292", "standard_charge_dollar": 7.80, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "United Healthcare", "plan_name": "750104", "standard_charge_dollar": 7.80, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "United Healthcare Ba", "plan_name": "750090", "standard_charge_dollar": 7.80, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "United Healthcare Me", "plan_name": "501310", "standard_charge_dollar": 6.90, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Windsor Mcare Extra", "plan_name": "500778", "standard_charge_dollar": 6.90, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." } ] } ] }, { "description": "Ziv-aflibercept 100 mg/4 ml (25 mg/ml) intravenous solution [158644]", "drug_information": { "unit": 4.00, "type": "ML" }, "code_information": [ { "code": "J9400", "type": "HCPCS" }, { "code": "0024-5840-01", "type": "NDC" } ], "standard_charges": [ { "gross_charge": 7200.00, "minimum": 8.30, "maximum": 15.36, "setting": "both", "payers_information": [ { "payer_name": "Aarp", "plan_name": "500102", "standard_charge_dollar": 8.30, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna", "plan_name": "700700", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna", "plan_name": "700700_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Mcare Ffs 6005", "plan_name": "700703", "standard_charge_dollar": 8.30, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Miscellaneous", "plan_name": "700720", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Miscellaneous", "plan_name": "700720_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Ppo Hmo", "plan_name": "701720", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Ppo Hmo", "plan_name": "701720_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Ambetter 68069", "plan_name": "500516", "standard_charge_dollar": 8.30, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Ms State Emplo", "plan_name": "401457", "standard_charge_dollar": 15.36, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Ms State Emplo", "plan_name": "401457_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Basic Pl", "plan_name": "400100", "standard_charge_dollar": 15.36, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Basic Pl", "plan_name": "400100_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Federal", "plan_name": "400110", "standard_charge_dollar": 15.36, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Federal", "plan_name": "400110_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Cigna Healthsprings Ffs", "plan_name": "500064", "standard_charge_dollar": 8.30, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Conseco", "plan_name": "500302", "standard_charge_dollar": 8.30, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Humana Ffs 61101", "plan_name": "500006", "standard_charge_dollar": 8.30, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Medicare A", "plan_name": "100100", "standard_charge_dollar": 8.30, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Medicare A", "plan_name": "100500", "standard_charge_dollar": 8.30, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Medicare Part B Only", "plan_name": "100300", "standard_charge_dollar": 8.30, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Medicare Railroad", "plan_name": "100103", "standard_charge_dollar": 8.30, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Ms Physicians Care N", "plan_name": "714210", "standard_charge_dollar": 10.38, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Peoples Hlth Ffs 72126", "plan_name": "500019", "standard_charge_dollar": 8.30, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Uhc/Secure Horizons", "plan_name": "500449", "standard_charge_dollar": 8.30, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "United Health Care/", "plan_name": "500292", "standard_charge_dollar": 9.38, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "United Healthcare", "plan_name": "750104", "standard_charge_dollar": 9.38, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "United Healthcare Ba", "plan_name": "750090", "standard_charge_dollar": 9.38, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "United Healthcare Me", "plan_name": "501310", "standard_charge_dollar": 8.30, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Windsor Mcare Extra", "plan_name": "500778", "standard_charge_dollar": 8.30, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." } ] } ] }, { "description": "Ziv-aflibercept 200 mg/8 ml (25 mg/ml) intravenous solution [158645]", "drug_information": { "unit": 8.00, "type": "ML" }, "code_information": [ { "code": "J9400", "type": "HCPCS" }, { "code": "0024-5841-01", "type": "NDC" } ], "standard_charges": [ { "gross_charge": 14400.00, "minimum": 8.30, "maximum": 15.36, "setting": "both", "payers_information": [ { "payer_name": "Aarp", "plan_name": "500102", "standard_charge_dollar": 8.30, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna", "plan_name": "700700", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna", "plan_name": "700700_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Mcare Ffs 6005", "plan_name": "700703", "standard_charge_dollar": 8.30, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Miscellaneous", "plan_name": "700720", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Miscellaneous", "plan_name": "700720_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Ppo Hmo", "plan_name": "701720", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Ppo Hmo", "plan_name": "701720_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Ambetter 68069", "plan_name": "500516", "standard_charge_dollar": 8.30, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Ms State Emplo", "plan_name": "401457", "standard_charge_dollar": 15.36, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Ms State Emplo", "plan_name": "401457_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Basic Pl", "plan_name": "400100", "standard_charge_dollar": 15.36, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Basic Pl", "plan_name": "400100_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Federal", "plan_name": "400110", "standard_charge_dollar": 15.36, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Federal", "plan_name": "400110_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Cigna Healthsprings Ffs", "plan_name": "500064", "standard_charge_dollar": 8.30, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Conseco", "plan_name": "500302", "standard_charge_dollar": 8.30, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Humana Ffs 61101", "plan_name": "500006", "standard_charge_dollar": 8.30, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Medicare A", "plan_name": "100100", "standard_charge_dollar": 8.30, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Medicare A", "plan_name": "100500", "standard_charge_dollar": 8.30, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Medicare Part B Only", "plan_name": "100300", "standard_charge_dollar": 8.30, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Medicare Railroad", "plan_name": "100103", "standard_charge_dollar": 8.30, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Ms Physicians Care N", "plan_name": "714210", "standard_charge_dollar": 10.38, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Peoples Hlth Ffs 72126", "plan_name": "500019", "standard_charge_dollar": 8.30, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Uhc/Secure Horizons", "plan_name": "500449", "standard_charge_dollar": 8.30, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "United Health Care/", "plan_name": "500292", "standard_charge_dollar": 9.38, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "United Healthcare", "plan_name": "750104", "standard_charge_dollar": 9.38, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "United Healthcare Ba", "plan_name": "750090", "standard_charge_dollar": 9.38, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "United Healthcare Me", "plan_name": "501310", "standard_charge_dollar": 8.30, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Windsor Mcare Extra", "plan_name": "500778", "standard_charge_dollar": 8.30, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." } ] } ] }, { "description": "Hc rbc leukocyte reduced", "code_information": [ { "code": "P9016", "type": "HCPCS" } ], "standard_charges": [ { "gross_charge": 373.50, "minimum": 166.72, "maximum": 208.41, "setting": "both", "payers_information": [ { "payer_name": "Aarp", "plan_name": "500102", "standard_charge_dollar": 166.72, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna", "plan_name": "700700", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna", "plan_name": "700700_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Mcare Ffs 6005", "plan_name": "700703", "standard_charge_dollar": 166.72, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Miscellaneous", "plan_name": "700720", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Miscellaneous", "plan_name": "700720_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Ppo Hmo", "plan_name": "701720", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Ppo Hmo", "plan_name": "701720_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Ambetter 68069", "plan_name": "500516", "standard_charge_dollar": 166.72, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Ms State Emplo", "plan_name": "401457", "standard_charge_dollar": 204.33, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Ms State Emplo", "plan_name": "401457_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Basic Pl", "plan_name": "400100", "standard_charge_dollar": 204.33, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Basic Pl", "plan_name": "400100_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Federal", "plan_name": "400110", "standard_charge_dollar": 204.33, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Federal", "plan_name": "400110_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Cigna Healthsprings Ffs", "plan_name": "500064", "standard_charge_dollar": 166.72, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Conseco", "plan_name": "500302", "standard_charge_dollar": 166.72, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Humana Ffs 61101", "plan_name": "500006", "standard_charge_dollar": 166.72, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Medicare A", "plan_name": "100100", "standard_charge_dollar": 166.72, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Medicare A", "plan_name": "100500", "standard_charge_dollar": 166.72, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Medicare Part B Only", "plan_name": "100300", "standard_charge_dollar": 166.72, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Medicare Railroad", "plan_name": "100103", "standard_charge_dollar": 166.72, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Ms Physicians Care N", "plan_name": "714210", "standard_charge_dollar": 208.41, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Peoples Hlth Ffs 72126", "plan_name": "500019", "standard_charge_dollar": 166.72, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Uhc/Secure Horizons", "plan_name": "500449", "standard_charge_dollar": 166.72, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "United Health Care/", "plan_name": "500292", "standard_charge_dollar": 188.40, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "United Healthcare", "plan_name": "750104", "standard_charge_dollar": 188.40, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "United Healthcare Ba", "plan_name": "750090", "standard_charge_dollar": 188.40, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "United Healthcare Me", "plan_name": "501310", "standard_charge_dollar": 166.72, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Windsor Mcare Extra", "plan_name": "500778", "standard_charge_dollar": 166.72, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." } ] } ] }, { "description": "Rbc leukocytes reduced", "code_information": [ { "code": "P9016", "type": "HCPCS" } ], "standard_charges": [ { "gross_charge": 373.50, "minimum": 166.72, "maximum": 208.41, "setting": "both", "payers_information": [ { "payer_name": "Aarp", "plan_name": "500102", "standard_charge_dollar": 166.72, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna", "plan_name": "700700", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna", "plan_name": "700700_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Mcare Ffs 6005", "plan_name": "700703", "standard_charge_dollar": 166.72, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Miscellaneous", "plan_name": "700720", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Miscellaneous", "plan_name": "700720_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Ppo Hmo", "plan_name": "701720", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Ppo Hmo", "plan_name": "701720_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Ambetter 68069", "plan_name": "500516", "standard_charge_dollar": 166.72, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Ms State Emplo", "plan_name": "401457", "standard_charge_dollar": 204.33, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Ms State Emplo", "plan_name": "401457_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Basic Pl", "plan_name": "400100", "standard_charge_dollar": 204.33, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Basic Pl", "plan_name": "400100_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Federal", "plan_name": "400110", "standard_charge_dollar": 204.33, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Federal", "plan_name": "400110_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Cigna Healthsprings Ffs", "plan_name": "500064", "standard_charge_dollar": 166.72, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Conseco", "plan_name": "500302", "standard_charge_dollar": 166.72, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Humana Ffs 61101", "plan_name": "500006", "standard_charge_dollar": 166.72, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Medicare A", "plan_name": "100100", "standard_charge_dollar": 166.72, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Medicare A", "plan_name": "100500", "standard_charge_dollar": 166.72, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Medicare Part B Only", "plan_name": "100300", "standard_charge_dollar": 166.72, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Medicare Railroad", "plan_name": "100103", "standard_charge_dollar": 166.72, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Ms Physicians Care N", "plan_name": "714210", "standard_charge_dollar": 208.41, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Peoples Hlth Ffs 72126", "plan_name": "500019", "standard_charge_dollar": 166.72, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Uhc/Secure Horizons", "plan_name": "500449", "standard_charge_dollar": 166.72, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "United Health Care/", "plan_name": "500292", "standard_charge_dollar": 188.40, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "United Healthcare", "plan_name": "750104", "standard_charge_dollar": 188.40, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "United Healthcare Ba", "plan_name": "750090", "standard_charge_dollar": 188.40, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "United Healthcare Me", "plan_name": "501310", "standard_charge_dollar": 166.72, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Windsor Mcare Extra", "plan_name": "500778", "standard_charge_dollar": 166.72, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." } ] } ] }, { "description": "Albumin human 5 % intravenous solution [8982]", "drug_information": { "unit": 250.00, "type": "ML" }, "code_information": [ { "code": "P9045", "type": "HCPCS" }, { "code": "44206-310-25", "type": "NDC" } ], "standard_charges": [ { "gross_charge": 277.75, "minimum": 46.40, "maximum": 66.35, "setting": "both", "payers_information": [ { "payer_name": "Aarp", "plan_name": "500102", "standard_charge_dollar": 53.08, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna", "plan_name": "700700", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna", "plan_name": "700700_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Mcare Ffs 6005", "plan_name": "700703", "standard_charge_dollar": 53.08, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Miscellaneous", "plan_name": "700720", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Miscellaneous", "plan_name": "700720_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Ppo Hmo", "plan_name": "701720", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Ppo Hmo", "plan_name": "701720_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Ambetter 68069", "plan_name": "500516", "standard_charge_dollar": 53.08, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Ms State Emplo", "plan_name": "401457", "standard_charge_dollar": 46.40, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Ms State Emplo", "plan_name": "401457_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Basic Pl", "plan_name": "400100", "standard_charge_dollar": 46.40, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Basic Pl", "plan_name": "400100_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Federal", "plan_name": "400110", "standard_charge_dollar": 46.40, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Federal", "plan_name": "400110_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Cigna Healthsprings Ffs", "plan_name": "500064", "standard_charge_dollar": 53.08, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Conseco", "plan_name": "500302", "standard_charge_dollar": 53.08, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Humana Ffs 61101", "plan_name": "500006", "standard_charge_dollar": 53.08, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Medicare A", "plan_name": "100100", "standard_charge_dollar": 53.08, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Medicare A", "plan_name": "100500", "standard_charge_dollar": 53.08, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Medicare Part B Only", "plan_name": "100300", "standard_charge_dollar": 53.08, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Medicare Railroad", "plan_name": "100103", "standard_charge_dollar": 53.08, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Ms Physicians Care N", "plan_name": "714210", "standard_charge_dollar": 66.35, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Peoples Hlth Ffs 72126", "plan_name": "500019", "standard_charge_dollar": 53.08, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Uhc/Secure Horizons", "plan_name": "500449", "standard_charge_dollar": 53.08, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "United Health Care/", "plan_name": "500292", "standard_charge_dollar": 59.98, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "United Healthcare", "plan_name": "750104", "standard_charge_dollar": 59.98, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "United Healthcare Ba", "plan_name": "750090", "standard_charge_dollar": 59.98, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "United Healthcare Me", "plan_name": "501310", "standard_charge_dollar": 53.08, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Windsor Mcare Extra", "plan_name": "500778", "standard_charge_dollar": 53.08, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." } ] } ] }, { "description": "Albumin human 5 % intravenous solution [8982]", "drug_information": { "unit": 500.00, "type": "ML" }, "code_information": [ { "code": "P9045", "type": "HCPCS" }, { "code": "44206-310-50", "type": "NDC" } ], "standard_charges": [ { "gross_charge": 473.69, "minimum": 46.40, "maximum": 66.35, "setting": "both", "payers_information": [ { "payer_name": "Aarp", "plan_name": "500102", "standard_charge_dollar": 53.08, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna", "plan_name": "700700", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna", "plan_name": "700700_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Mcare Ffs 6005", "plan_name": "700703", "standard_charge_dollar": 53.08, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Miscellaneous", "plan_name": "700720", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Miscellaneous", "plan_name": "700720_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Ppo Hmo", "plan_name": "701720", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Ppo Hmo", "plan_name": "701720_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Ambetter 68069", "plan_name": "500516", "standard_charge_dollar": 53.08, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Ms State Emplo", "plan_name": "401457", "standard_charge_dollar": 46.40, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Ms State Emplo", "plan_name": "401457_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Basic Pl", "plan_name": "400100", "standard_charge_dollar": 46.40, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Basic Pl", "plan_name": "400100_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Federal", "plan_name": "400110", "standard_charge_dollar": 46.40, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Federal", "plan_name": "400110_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Cigna Healthsprings Ffs", "plan_name": "500064", "standard_charge_dollar": 53.08, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Conseco", "plan_name": "500302", "standard_charge_dollar": 53.08, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Humana Ffs 61101", "plan_name": "500006", "standard_charge_dollar": 53.08, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Medicare A", "plan_name": "100100", "standard_charge_dollar": 53.08, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Medicare A", "plan_name": "100500", "standard_charge_dollar": 53.08, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Medicare Part B Only", "plan_name": "100300", "standard_charge_dollar": 53.08, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Medicare Railroad", "plan_name": "100103", "standard_charge_dollar": 53.08, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Ms Physicians Care N", "plan_name": "714210", "standard_charge_dollar": 66.35, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Peoples Hlth Ffs 72126", "plan_name": "500019", "standard_charge_dollar": 53.08, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Uhc/Secure Horizons", "plan_name": "500449", "standard_charge_dollar": 53.08, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "United Health Care/", "plan_name": "500292", "standard_charge_dollar": 59.98, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "United Healthcare", "plan_name": "750104", "standard_charge_dollar": 59.98, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "United Healthcare Ba", "plan_name": "750090", "standard_charge_dollar": 59.98, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "United Healthcare Me", "plan_name": "501310", "standard_charge_dollar": 53.08, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Windsor Mcare Extra", "plan_name": "500778", "standard_charge_dollar": 53.08, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." } ] } ] }, { "description": "Albumin human 5 % intravenous solution [8982]", "drug_information": { "unit": 250.00, "type": "ML" }, "code_information": [ { "code": "P9045", "type": "HCPCS" }, { "code": "44206-310-90", "type": "NDC" } ], "standard_charges": [ { "gross_charge": 277.75, "minimum": 46.40, "maximum": 66.35, "setting": "both", "payers_information": [ { "payer_name": "Aarp", "plan_name": "500102", "standard_charge_dollar": 53.08, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna", "plan_name": "700700", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna", "plan_name": "700700_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Mcare Ffs 6005", "plan_name": "700703", "standard_charge_dollar": 53.08, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Miscellaneous", "plan_name": "700720", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Miscellaneous", "plan_name": "700720_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Ppo Hmo", "plan_name": "701720", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Ppo Hmo", "plan_name": "701720_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Ambetter 68069", "plan_name": "500516", "standard_charge_dollar": 53.08, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Ms State Emplo", "plan_name": "401457", "standard_charge_dollar": 46.40, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Ms State Emplo", "plan_name": "401457_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Basic Pl", "plan_name": "400100", "standard_charge_dollar": 46.40, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Basic Pl", "plan_name": "400100_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Federal", "plan_name": "400110", "standard_charge_dollar": 46.40, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Federal", "plan_name": "400110_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Cigna Healthsprings Ffs", "plan_name": "500064", "standard_charge_dollar": 53.08, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Conseco", "plan_name": "500302", "standard_charge_dollar": 53.08, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Humana Ffs 61101", "plan_name": "500006", "standard_charge_dollar": 53.08, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Medicare A", "plan_name": "100100", "standard_charge_dollar": 53.08, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Medicare A", "plan_name": "100500", "standard_charge_dollar": 53.08, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Medicare Part B Only", "plan_name": "100300", "standard_charge_dollar": 53.08, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Medicare Railroad", "plan_name": "100103", "standard_charge_dollar": 53.08, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Ms Physicians Care N", "plan_name": "714210", "standard_charge_dollar": 66.35, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Peoples Hlth Ffs 72126", "plan_name": "500019", "standard_charge_dollar": 53.08, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Uhc/Secure Horizons", "plan_name": "500449", "standard_charge_dollar": 53.08, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "United Health Care/", "plan_name": "500292", "standard_charge_dollar": 59.98, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "United Healthcare", "plan_name": "750104", "standard_charge_dollar": 59.98, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "United Healthcare Ba", "plan_name": "750090", "standard_charge_dollar": 59.98, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "United Healthcare Me", "plan_name": "501310", "standard_charge_dollar": 53.08, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Windsor Mcare Extra", "plan_name": "500778", "standard_charge_dollar": 53.08, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." } ] } ] }, { "description": "Albumin human 5 % intravenous solution [8982]", "drug_information": { "unit": 500.00, "type": "ML" }, "code_information": [ { "code": "P9045", "type": "HCPCS" }, { "code": "44206-310-91", "type": "NDC" } ], "standard_charges": [ { "gross_charge": 473.69, "minimum": 46.40, "maximum": 66.35, "setting": "both", "payers_information": [ { "payer_name": "Aarp", "plan_name": "500102", "standard_charge_dollar": 53.08, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna", "plan_name": "700700", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna", "plan_name": "700700_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Mcare Ffs 6005", "plan_name": "700703", "standard_charge_dollar": 53.08, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Miscellaneous", "plan_name": "700720", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Miscellaneous", "plan_name": "700720_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Ppo Hmo", "plan_name": "701720", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Ppo Hmo", "plan_name": "701720_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Ambetter 68069", "plan_name": "500516", "standard_charge_dollar": 53.08, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Ms State Emplo", "plan_name": "401457", "standard_charge_dollar": 46.40, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Ms State Emplo", "plan_name": "401457_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Basic Pl", "plan_name": "400100", "standard_charge_dollar": 46.40, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Basic Pl", "plan_name": "400100_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Federal", "plan_name": "400110", "standard_charge_dollar": 46.40, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Federal", "plan_name": "400110_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Cigna Healthsprings Ffs", "plan_name": "500064", "standard_charge_dollar": 53.08, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Conseco", "plan_name": "500302", "standard_charge_dollar": 53.08, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Humana Ffs 61101", "plan_name": "500006", "standard_charge_dollar": 53.08, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Medicare A", "plan_name": "100100", "standard_charge_dollar": 53.08, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Medicare A", "plan_name": "100500", "standard_charge_dollar": 53.08, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Medicare Part B Only", "plan_name": "100300", "standard_charge_dollar": 53.08, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Medicare Railroad", "plan_name": "100103", "standard_charge_dollar": 53.08, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Ms Physicians Care N", "plan_name": "714210", "standard_charge_dollar": 66.35, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Peoples Hlth Ffs 72126", "plan_name": "500019", "standard_charge_dollar": 53.08, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Uhc/Secure Horizons", "plan_name": "500449", "standard_charge_dollar": 53.08, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "United Health Care/", "plan_name": "500292", "standard_charge_dollar": 59.98, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "United Healthcare", "plan_name": "750104", "standard_charge_dollar": 59.98, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "United Healthcare Ba", "plan_name": "750090", "standard_charge_dollar": 59.98, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "United Healthcare Me", "plan_name": "501310", "standard_charge_dollar": 53.08, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Windsor Mcare Extra", "plan_name": "500778", "standard_charge_dollar": 53.08, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." } ] } ] }, { "description": "Albumin human 5 % intravenous solution [8982]", "drug_information": { "unit": 250.00, "type": "ML" }, "code_information": [ { "code": "P9045", "type": "HCPCS" }, { "code": "76125-790-25", "type": "NDC" } ], "standard_charges": [ { "gross_charge": 257.56, "minimum": 46.40, "maximum": 66.35, "setting": "both", "payers_information": [ { "payer_name": "Aarp", "plan_name": "500102", "standard_charge_dollar": 53.08, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna", "plan_name": "700700", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna", "plan_name": "700700_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Mcare Ffs 6005", "plan_name": "700703", "standard_charge_dollar": 53.08, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Miscellaneous", "plan_name": "700720", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Miscellaneous", "plan_name": "700720_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Ppo Hmo", "plan_name": "701720", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Ppo Hmo", "plan_name": "701720_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Ambetter 68069", "plan_name": "500516", "standard_charge_dollar": 53.08, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Ms State Emplo", "plan_name": "401457", "standard_charge_dollar": 46.40, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Ms State Emplo", "plan_name": "401457_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Basic Pl", "plan_name": "400100", "standard_charge_dollar": 46.40, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Basic Pl", "plan_name": "400100_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Federal", "plan_name": "400110", "standard_charge_dollar": 46.40, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Federal", "plan_name": "400110_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Cigna Healthsprings Ffs", "plan_name": "500064", "standard_charge_dollar": 53.08, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Conseco", "plan_name": "500302", "standard_charge_dollar": 53.08, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Humana Ffs 61101", "plan_name": "500006", "standard_charge_dollar": 53.08, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Medicare A", "plan_name": "100100", "standard_charge_dollar": 53.08, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Medicare A", "plan_name": "100500", "standard_charge_dollar": 53.08, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Medicare Part B Only", "plan_name": "100300", "standard_charge_dollar": 53.08, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Medicare Railroad", "plan_name": "100103", "standard_charge_dollar": 53.08, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Ms Physicians Care N", "plan_name": "714210", "standard_charge_dollar": 66.35, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Peoples Hlth Ffs 72126", "plan_name": "500019", "standard_charge_dollar": 53.08, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Uhc/Secure Horizons", "plan_name": "500449", "standard_charge_dollar": 53.08, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "United Health Care/", "plan_name": "500292", "standard_charge_dollar": 59.98, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "United Healthcare", "plan_name": "750104", "standard_charge_dollar": 59.98, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "United Healthcare Ba", "plan_name": "750090", "standard_charge_dollar": 59.98, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "United Healthcare Me", "plan_name": "501310", "standard_charge_dollar": 53.08, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Windsor Mcare Extra", "plan_name": "500778", "standard_charge_dollar": 53.08, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." } ] } ] }, { "description": "Albumin human 25 % intravenous solution [8981]", "drug_information": { "unit": 50.00, "type": "ML" }, "code_information": [ { "code": "P9047", "type": "HCPCS" }, { "code": "44206-251-05", "type": "NDC" } ], "standard_charges": [ { "gross_charge": 206.25, "minimum": 47.34, "maximum": 47.34, "setting": "both", "payers_information": [ { "payer_name": "Aetna", "plan_name": "700700", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna", "plan_name": "700700_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Miscellaneous", "plan_name": "700720", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Miscellaneous", "plan_name": "700720_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Ppo Hmo", "plan_name": "701720", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Ppo Hmo", "plan_name": "701720_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Ms State Emplo", "plan_name": "401457", "standard_charge_dollar": 47.34, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Ms State Emplo", "plan_name": "401457_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Basic Pl", "plan_name": "400100", "standard_charge_dollar": 47.34, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Basic Pl", "plan_name": "400100_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Federal", "plan_name": "400110", "standard_charge_dollar": 47.34, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Federal", "plan_name": "400110_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." } ] } ] }, { "description": "Albumin human 25 % intravenous solution [8981]", "drug_information": { "unit": 100.00, "type": "ML" }, "code_information": [ { "code": "P9047", "type": "HCPCS" }, { "code": "44206-251-10", "type": "NDC" } ], "standard_charges": [ { "gross_charge": 412.50, "minimum": 47.34, "maximum": 47.34, "setting": "both", "payers_information": [ { "payer_name": "Aetna", "plan_name": "700700", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna", "plan_name": "700700_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Miscellaneous", "plan_name": "700720", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Miscellaneous", "plan_name": "700720_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Ppo Hmo", "plan_name": "701720", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Ppo Hmo", "plan_name": "701720_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Ms State Emplo", "plan_name": "401457", "standard_charge_dollar": 47.34, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Ms State Emplo", "plan_name": "401457_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Basic Pl", "plan_name": "400100", "standard_charge_dollar": 47.34, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Basic Pl", "plan_name": "400100_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Federal", "plan_name": "400110", "standard_charge_dollar": 47.34, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Federal", "plan_name": "400110_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." } ] } ] }, { "description": "Albumin human 25 % intravenous solution [8981]", "drug_information": { "unit": 50.00, "type": "ML" }, "code_information": [ { "code": "P9047", "type": "HCPCS" }, { "code": "44206-251-90", "type": "NDC" } ], "standard_charges": [ { "gross_charge": 206.25, "minimum": 47.34, "maximum": 47.34, "setting": "both", "payers_information": [ { "payer_name": "Aetna", "plan_name": "700700", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna", "plan_name": "700700_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Miscellaneous", "plan_name": "700720", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Miscellaneous", "plan_name": "700720_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Ppo Hmo", "plan_name": "701720", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Ppo Hmo", "plan_name": "701720_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Ms State Emplo", "plan_name": "401457", "standard_charge_dollar": 47.34, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Ms State Emplo", "plan_name": "401457_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Basic Pl", "plan_name": "400100", "standard_charge_dollar": 47.34, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Basic Pl", "plan_name": "400100_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Federal", "plan_name": "400110", "standard_charge_dollar": 47.34, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Federal", "plan_name": "400110_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." } ] } ] }, { "description": "Albumin human 25 % intravenous solution [8981]", "drug_information": { "unit": 100.00, "type": "ML" }, "code_information": [ { "code": "P9047", "type": "HCPCS" }, { "code": "44206-251-91", "type": "NDC" } ], "standard_charges": [ { "gross_charge": 412.50, "minimum": 47.34, "maximum": 47.34, "setting": "both", "payers_information": [ { "payer_name": "Aetna", "plan_name": "700700", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna", "plan_name": "700700_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Miscellaneous", "plan_name": "700720", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Miscellaneous", "plan_name": "700720_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Ppo Hmo", "plan_name": "701720", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Ppo Hmo", "plan_name": "701720_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Ms State Emplo", "plan_name": "401457", "standard_charge_dollar": 47.34, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Ms State Emplo", "plan_name": "401457_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Basic Pl", "plan_name": "400100", "standard_charge_dollar": 47.34, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Basic Pl", "plan_name": "400100_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Federal", "plan_name": "400110", "standard_charge_dollar": 47.34, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Federal", "plan_name": "400110_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." } ] } ] }, { "description": "Chlorpromazine 25 mg tablet [1656]", "drug_information": { "unit": 1.00, "type": "EA" }, "code_information": [ { "code": "Q0161", "type": "HCPCS" }, { "code": "50268-163-11", "type": "NDC" } ], "standard_charges": [ { "gross_charge": 21.57, "minimum": 17.26, "maximum": 18.33, "setting": "both", "payers_information": [ { "payer_name": "Aetna", "plan_name": "700700", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna", "plan_name": "700700_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Miscellaneous", "plan_name": "700720", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Miscellaneous", "plan_name": "700720_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Ppo Hmo", "plan_name": "701720", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Ppo Hmo", "plan_name": "701720_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Ms State Emplo", "plan_name": "401457", "standard_charge_percentage": 0.80, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Ms State Emplo", "plan_name": "401457_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Basic Pl", "plan_name": "400100", "standard_charge_percentage": 0.85, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Basic Pl", "plan_name": "400100_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Federal", "plan_name": "400110", "standard_charge_percentage": 0.85, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Federal", "plan_name": "400110_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." } ] } ] }, { "description": "Chlorpromazine 25 mg tablet [1656]", "drug_information": { "unit": 1.00, "type": "EA" }, "code_information": [ { "code": "Q0161", "type": "HCPCS" }, { "code": "70710-1130-1", "type": "NDC" } ], "standard_charges": [ { "gross_charge": 7.50, "minimum": 6.00, "maximum": 6.38, "setting": "both", "payers_information": [ { "payer_name": "Aetna", "plan_name": "700700", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna", "plan_name": "700700_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Miscellaneous", "plan_name": "700720", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Miscellaneous", "plan_name": "700720_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Ppo Hmo", "plan_name": "701720", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Ppo Hmo", "plan_name": "701720_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Ms State Emplo", "plan_name": "401457", "standard_charge_percentage": 0.80, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Ms State Emplo", "plan_name": "401457_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Basic Pl", "plan_name": "400100", "standard_charge_percentage": 0.85, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Basic Pl", "plan_name": "400100_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Federal", "plan_name": "400110", "standard_charge_percentage": 0.85, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Federal", "plan_name": "400110_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." } ] } ] }, { "description": "Ondansetron 4 mg disintegrating tablet [27697]", "drug_information": { "unit": 1.00, "type": "EA" }, "code_information": [ { "code": "Q0162", "type": "HCPCS" }, { "code": "68462-157-13", "type": "NDC" } ], "standard_charges": [ { "gross_charge": 7.50, "minimum": 6.00, "maximum": 6.38, "setting": "both", "payers_information": [ { "payer_name": "Aetna", "plan_name": "700700", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna", "plan_name": "700700_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Miscellaneous", "plan_name": "700720", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Miscellaneous", "plan_name": "700720_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Ppo Hmo", "plan_name": "701720", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Ppo Hmo", "plan_name": "701720_1", 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"payer_name": "Bc/Bs Of Ms Basic Pl", "plan_name": "400100", "standard_charge_percentage": 0.85, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Basic Pl", "plan_name": "400100_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Federal", "plan_name": "400110", "standard_charge_percentage": 0.85, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Federal", "plan_name": "400110_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." } ] } ] 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of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Mcare Ffs 6005", "plan_name": "700703", "standard_charge_dollar": 150.41, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Miscellaneous", "plan_name": "700720", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Miscellaneous", "plan_name": "700720_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Ppo Hmo", "plan_name": "701720", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Ppo Hmo", "plan_name": "701720_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Ambetter 68069", "plan_name": "500516", "standard_charge_dollar": 150.41, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Ms State Emplo", "plan_name": "401457", "standard_charge_dollar": 465.13, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Ms State Emplo", "plan_name": "401457_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Basic Pl", "plan_name": "400100", "standard_charge_dollar": 465.13, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Basic Pl", "plan_name": "400100_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Federal", "plan_name": "400110", "standard_charge_dollar": 465.13, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Federal", "plan_name": "400110_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Cigna Healthsprings Ffs", "plan_name": "500064", "standard_charge_dollar": 150.41, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Conseco", "plan_name": "500302", "standard_charge_dollar": 150.41, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Humana Ffs 61101", "plan_name": "500006", "standard_charge_dollar": 150.41, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Medicare A", "plan_name": "100100", "standard_charge_dollar": 150.41, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Medicare A", "plan_name": "100500", "standard_charge_dollar": 150.41, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Medicare Part B Only", "plan_name": "100300", "standard_charge_dollar": 150.41, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Medicare Railroad", "plan_name": "100103", "standard_charge_dollar": 150.41, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Ms Physicians Care N", "plan_name": "714210", "standard_charge_dollar": 188.01, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Peoples Hlth Ffs 72126", "plan_name": "500019", "standard_charge_dollar": 150.41, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Uhc/Secure Horizons", "plan_name": "500449", "standard_charge_dollar": 150.41, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "United Health Care/", "plan_name": "500292", "standard_charge_dollar": 169.96, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "United Healthcare", "plan_name": "750104", "standard_charge_dollar": 169.96, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "United Healthcare Ba", "plan_name": "750090", "standard_charge_dollar": 169.96, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "United Healthcare Me", "plan_name": "501310", "standard_charge_dollar": 150.41, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Windsor Mcare Extra", "plan_name": "500778", "standard_charge_dollar": 150.41, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." } ] } ] }, { "description": "Doxorubicin pegylated liposomal 2 mg/ml intravenous suspension [27431]", "drug_information": { "unit": 25.00, "type": "ML" }, "code_information": [ { "code": "Q2050", "type": "HCPCS" }, { "code": "43598-541-25", "type": "NDC" } ], "standard_charges": [ { "gross_charge": 7578.00, "minimum": 150.41, "maximum": 465.13, "setting": "both", "payers_information": [ { "payer_name": "Aarp", "plan_name": "500102", "standard_charge_dollar": 150.41, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna", "plan_name": "700700", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna", "plan_name": "700700_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Mcare Ffs 6005", "plan_name": "700703", "standard_charge_dollar": 150.41, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Miscellaneous", "plan_name": "700720", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Miscellaneous", "plan_name": "700720_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Ppo Hmo", "plan_name": "701720", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Ppo Hmo", "plan_name": "701720_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Ambetter 68069", "plan_name": "500516", "standard_charge_dollar": 150.41, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Ms State Emplo", "plan_name": "401457", "standard_charge_dollar": 465.13, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Ms State Emplo", "plan_name": "401457_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Basic Pl", "plan_name": "400100", "standard_charge_dollar": 465.13, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Basic Pl", "plan_name": "400100_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Federal", "plan_name": "400110", "standard_charge_dollar": 465.13, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Federal", "plan_name": "400110_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Cigna Healthsprings Ffs", "plan_name": "500064", "standard_charge_dollar": 150.41, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Conseco", "plan_name": "500302", "standard_charge_dollar": 150.41, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Humana Ffs 61101", "plan_name": "500006", "standard_charge_dollar": 150.41, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Medicare A", "plan_name": "100100", "standard_charge_dollar": 150.41, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Medicare A", "plan_name": "100500", "standard_charge_dollar": 150.41, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Medicare Part B Only", "plan_name": "100300", "standard_charge_dollar": 150.41, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Medicare Railroad", "plan_name": "100103", "standard_charge_dollar": 150.41, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Ms Physicians Care N", "plan_name": "714210", "standard_charge_dollar": 188.01, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Peoples Hlth Ffs 72126", "plan_name": "500019", "standard_charge_dollar": 150.41, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Uhc/Secure Horizons", "plan_name": "500449", "standard_charge_dollar": 150.41, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "United Health Care/", "plan_name": "500292", "standard_charge_dollar": 169.96, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "United Healthcare", "plan_name": "750104", "standard_charge_dollar": 169.96, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "United Healthcare Ba", "plan_name": "750090", "standard_charge_dollar": 169.96, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "United Healthcare Me", "plan_name": "501310", "standard_charge_dollar": 150.41, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Windsor Mcare Extra", "plan_name": "500778", "standard_charge_dollar": 150.41, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." } ] } ] }, { "description": "Doxorubicin pegylated liposomal 2 mg/ml intravenous suspension [27431]", "drug_information": { "unit": 10.00, "type": "ML" }, "code_information": [ { "code": "Q2050", "type": "HCPCS" }, { "code": "47335-049-40", "type": "NDC" } ], "standard_charges": [ { "gross_charge": 2983.46, "minimum": 150.41, "maximum": 465.13, "setting": "both", "payers_information": [ { "payer_name": "Aarp", "plan_name": "500102", "standard_charge_dollar": 150.41, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna", "plan_name": "700700", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna", "plan_name": "700700_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Mcare Ffs 6005", "plan_name": "700703", "standard_charge_dollar": 150.41, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Miscellaneous", "plan_name": "700720", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Miscellaneous", "plan_name": "700720_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Ppo Hmo", "plan_name": "701720", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Ppo Hmo", "plan_name": "701720_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Ambetter 68069", "plan_name": "500516", "standard_charge_dollar": 150.41, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Ms State Emplo", "plan_name": "401457", "standard_charge_dollar": 465.13, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Ms State Emplo", "plan_name": "401457_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Basic Pl", "plan_name": "400100", "standard_charge_dollar": 465.13, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Basic Pl", "plan_name": "400100_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Federal", "plan_name": "400110", "standard_charge_dollar": 465.13, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Federal", "plan_name": "400110_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Cigna Healthsprings Ffs", "plan_name": "500064", "standard_charge_dollar": 150.41, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Conseco", "plan_name": "500302", "standard_charge_dollar": 150.41, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Humana Ffs 61101", "plan_name": "500006", "standard_charge_dollar": 150.41, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Medicare A", "plan_name": "100100", "standard_charge_dollar": 150.41, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Medicare A", "plan_name": "100500", "standard_charge_dollar": 150.41, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Medicare Part B Only", "plan_name": "100300", "standard_charge_dollar": 150.41, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Medicare Railroad", "plan_name": "100103", "standard_charge_dollar": 150.41, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Ms Physicians Care N", "plan_name": "714210", "standard_charge_dollar": 188.01, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Peoples Hlth Ffs 72126", "plan_name": "500019", "standard_charge_dollar": 150.41, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Uhc/Secure Horizons", "plan_name": "500449", "standard_charge_dollar": 150.41, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "United Health Care/", "plan_name": "500292", "standard_charge_dollar": 169.96, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "United Healthcare", "plan_name": "750104", "standard_charge_dollar": 169.96, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "United Healthcare Ba", "plan_name": "750090", "standard_charge_dollar": 169.96, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "United Healthcare Me", "plan_name": "501310", "standard_charge_dollar": 150.41, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Windsor Mcare Extra", "plan_name": "500778", "standard_charge_dollar": 150.41, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." } ] } ] }, { "description": "Hc telehealth facility fee", "code_information": [ { "code": "Q3014", "type": "HCPCS" } ], "standard_charges": [ { "gross_charge": 50.00, "minimum": 15.00, "maximum": 15.00, "setting": "both", "payers_information": [ { "payer_name": "Aetna", "plan_name": "700700", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna", "plan_name": "700700_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Miscellaneous", "plan_name": "700720", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Miscellaneous", "plan_name": "700720_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Ppo Hmo", "plan_name": "701720", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Ppo Hmo", "plan_name": "701720_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Ms State Emplo", "plan_name": "401457", "standard_charge_dollar": 15.00, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Ms State Emplo", "plan_name": "401457_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Basic Pl", "plan_name": "400100", "standard_charge_dollar": 15.00, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Basic Pl", "plan_name": "400100_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Federal", "plan_name": "400110", "standard_charge_dollar": 15.00, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Federal", "plan_name": "400110_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." } ] } ] }, { "description": "Telehealth facility fee", "code_information": [ { "code": "Q3014", "type": "HCPCS" } ], "standard_charges": [ { "gross_charge": 50.00, "minimum": 15.00, "maximum": 15.00, "setting": "both", "payers_information": [ { "payer_name": "Aetna", "plan_name": "700700", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna", "plan_name": "700700_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Miscellaneous", "plan_name": "700720", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of 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"0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna", "plan_name": "700700", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna", "plan_name": "700700_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Mcare Ffs 6005", "plan_name": "700703", "standard_charge_dollar": 15.91, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Miscellaneous", "plan_name": "700720", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", 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allowed amounts." }, { "payer_name": "Ms Physicians Care N", "plan_name": "714210", "standard_charge_dollar": 19.89, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Peoples Hlth Ffs 72126", "plan_name": "500019", "standard_charge_dollar": 15.91, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Uhc/Secure Horizons", "plan_name": "500449", "standard_charge_dollar": 15.91, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "United Health Care/", "plan_name": "500292", "standard_charge_dollar": 17.98, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "United Healthcare", "plan_name": "750104", "standard_charge_dollar": 17.98, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "United Healthcare Ba", "plan_name": "750090", "standard_charge_dollar": 17.98, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "United Healthcare Me", "plan_name": "501310", "standard_charge_dollar": 15.91, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Windsor Mcare Extra", "plan_name": "500778", "standard_charge_dollar": 15.91, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." } ] } ] }, { "description": "Epoetin alfa-epbx 10000 unit/ml injection solution [184190]", "drug_information": { "unit": 1.00, "type": "ML" }, "code_information": 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"methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Miscellaneous", "plan_name": "700720", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Miscellaneous", "plan_name": "700720_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Ppo Hmo", "plan_name": "701720", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Ppo Hmo", "plan_name": "701720_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Ambetter 68069", "plan_name": "500516", "standard_charge_dollar": 0.71, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Ms State Emplo", "plan_name": "401457", "standard_charge_percentage": 0.80, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Ms State Emplo", "plan_name": "401457_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Basic Pl", "plan_name": "400100", "standard_charge_percentage": 0.85, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Basic Pl", "plan_name": "400100_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Federal", "plan_name": "400110", "standard_charge_percentage": 0.85, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Federal", "plan_name": "400110_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Cigna Healthsprings Ffs", "plan_name": "500064", "standard_charge_dollar": 0.71, "count": "0", "methodology": "fee schedule", 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"100300", "standard_charge_dollar": 0.71, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Medicare Railroad", "plan_name": "100103", "standard_charge_dollar": 0.71, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Ms Physicians Care N", "plan_name": "714210", "standard_charge_dollar": 0.89, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Peoples Hlth Ffs 72126", "plan_name": "500019", "standard_charge_dollar": 0.71, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Uhc/Secure Horizons", "plan_name": "500449", "standard_charge_dollar": 0.71, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "United Health Care/", "plan_name": "500292", "standard_charge_dollar": 0.80, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "United Healthcare", "plan_name": "750104", "standard_charge_dollar": 0.80, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "United Healthcare Ba", "plan_name": "750090", "standard_charge_dollar": 0.80, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "United Healthcare Me", "plan_name": "501310", "standard_charge_dollar": 0.71, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Windsor Mcare Extra", "plan_name": "500778", "standard_charge_dollar": 0.71, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." } ] } ] }, { "description": "Epoetin alfa-epbx 10000 unit/ml injection solution [184190]", "drug_information": { "unit": 1.00, "type": "ML" }, "code_information": [ { "code": "Q5105", "type": "HCPCS" }, { "code": "0069-1308-10", "type": "NDC" } ], "standard_charges": [ { "gross_charge": 551.50, "minimum": 0.71, "maximum": 468.78, "setting": "both", "payers_information": [ { "payer_name": "Aarp", "plan_name": "500102", "standard_charge_dollar": 0.71, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna", "plan_name": "700700", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate 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"Aetna Ppo Hmo", "plan_name": "701720", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Ppo Hmo", "plan_name": "701720_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Ambetter 68069", "plan_name": "500516", "standard_charge_dollar": 0.71, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Ms State Emplo", "plan_name": "401457", "standard_charge_percentage": 0.80, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Ms State Emplo", "plan_name": "401457_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Basic Pl", "plan_name": "400100", "standard_charge_percentage": 0.85, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Basic Pl", "plan_name": "400100_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Federal", "plan_name": "400110", "standard_charge_percentage": 0.85, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Federal", "plan_name": "400110_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Cigna Healthsprings Ffs", "plan_name": "500064", "standard_charge_dollar": 0.71, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Conseco", "plan_name": "500302", "standard_charge_dollar": 0.71, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Humana Ffs 61101", "plan_name": "500006", "standard_charge_dollar": 0.71, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Medicare A", "plan_name": "100100", "standard_charge_dollar": 0.71, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Medicare A", "plan_name": "100500", "standard_charge_dollar": 0.71, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Medicare Part B Only", "plan_name": "100300", "standard_charge_dollar": 0.71, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Medicare Railroad", "plan_name": "100103", "standard_charge_dollar": 0.71, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Ms Physicians Care N", "plan_name": "714210", "standard_charge_dollar": 0.89, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Peoples Hlth Ffs 72126", "plan_name": "500019", "standard_charge_dollar": 0.71, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Uhc/Secure Horizons", "plan_name": "500449", "standard_charge_dollar": 0.71, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "United Health Care/", "plan_name": "500292", "standard_charge_dollar": 0.80, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "United Healthcare", "plan_name": "750104", "standard_charge_dollar": 0.80, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "United Healthcare Ba", "plan_name": "750090", "standard_charge_dollar": 0.80, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "United Healthcare Me", "plan_name": "501310", "standard_charge_dollar": 0.71, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Windsor Mcare Extra", "plan_name": "500778", "standard_charge_dollar": 0.71, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." } ] } ] }, { "description": "Epoetin alfa-epbx 40000 unit/ml injection solution [184191]", "drug_information": { "unit": 1.00, "type": "ML" }, "code_information": [ { "code": "Q5105", "type": "HCPCS" }, { "code": "0069-1309-01", "type": "NDC" } ], "standard_charges": [ { "gross_charge": 2206.00, "minimum": 0.71, "maximum": 1875.10, "setting": "both", "payers_information": [ { "payer_name": "Aarp", "plan_name": "500102", "standard_charge_dollar": 0.71, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna", "plan_name": "700700", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna", "plan_name": "700700_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Mcare Ffs 6005", "plan_name": "700703", "standard_charge_dollar": 0.71, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Miscellaneous", "plan_name": "700720", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Miscellaneous", "plan_name": "700720_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Ppo Hmo", "plan_name": "701720", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Ppo Hmo", "plan_name": "701720_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Ambetter 68069", "plan_name": "500516", "standard_charge_dollar": 0.71, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Ms State Emplo", "plan_name": "401457", "standard_charge_percentage": 0.80, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Ms State Emplo", "plan_name": "401457_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Basic Pl", "plan_name": "400100", "standard_charge_percentage": 0.85, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Basic Pl", "plan_name": "400100_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Federal", "plan_name": "400110", "standard_charge_percentage": 0.85, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Federal", "plan_name": "400110_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Cigna Healthsprings Ffs", "plan_name": "500064", "standard_charge_dollar": 0.71, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Conseco", "plan_name": "500302", "standard_charge_dollar": 0.71, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Humana Ffs 61101", "plan_name": "500006", "standard_charge_dollar": 0.71, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Medicare A", "plan_name": "100100", "standard_charge_dollar": 0.71, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Medicare A", "plan_name": "100500", "standard_charge_dollar": 0.71, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Medicare Part B Only", "plan_name": "100300", "standard_charge_dollar": 0.71, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Medicare Railroad", "plan_name": "100103", "standard_charge_dollar": 0.71, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Ms Physicians Care N", "plan_name": "714210", "standard_charge_dollar": 0.89, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Peoples Hlth Ffs 72126", "plan_name": "500019", "standard_charge_dollar": 0.71, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Uhc/Secure Horizons", "plan_name": "500449", "standard_charge_dollar": 0.71, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "United Health Care/", "plan_name": "500292", "standard_charge_dollar": 0.80, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "United Healthcare", "plan_name": "750104", "standard_charge_dollar": 0.80, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "United Healthcare Ba", "plan_name": "750090", "standard_charge_dollar": 0.80, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "United Healthcare Me", "plan_name": "501310", "standard_charge_dollar": 0.71, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Windsor Mcare Extra", "plan_name": "500778", "standard_charge_dollar": 0.71, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." } ] } ] }, { "description": "Epoetin alfa-epbx 40000 unit/ml injection solution [184191]", "drug_information": { "unit": 1.00, "type": "ML" }, "code_information": [ { "code": "Q5105", "type": "HCPCS" }, { "code": "0069-1309-04", "type": "NDC" } ], "standard_charges": [ { "gross_charge": 2206.00, "minimum": 0.71, "maximum": 1875.10, "setting": "both", "payers_information": [ { "payer_name": "Aarp", "plan_name": "500102", "standard_charge_dollar": 0.71, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna", "plan_name": "700700", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna", "plan_name": "700700_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Mcare Ffs 6005", "plan_name": "700703", "standard_charge_dollar": 0.71, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Miscellaneous", "plan_name": "700720", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Miscellaneous", "plan_name": "700720_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Ppo Hmo", "plan_name": "701720", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Ppo Hmo", "plan_name": "701720_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Ambetter 68069", "plan_name": "500516", "standard_charge_dollar": 0.71, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Ms State Emplo", "plan_name": "401457", "standard_charge_percentage": 0.80, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Ms State Emplo", "plan_name": "401457_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Basic Pl", "plan_name": "400100", "standard_charge_percentage": 0.85, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Basic Pl", "plan_name": "400100_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Federal", "plan_name": "400110", "standard_charge_percentage": 0.85, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Federal", "plan_name": "400110_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Cigna Healthsprings Ffs", "plan_name": "500064", "standard_charge_dollar": 0.71, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Conseco", "plan_name": "500302", "standard_charge_dollar": 0.71, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Humana Ffs 61101", "plan_name": "500006", "standard_charge_dollar": 0.71, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Medicare A", "plan_name": "100100", "standard_charge_dollar": 0.71, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Medicare A", "plan_name": "100500", "standard_charge_dollar": 0.71, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Medicare Part B Only", "plan_name": "100300", "standard_charge_dollar": 0.71, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Medicare Railroad", "plan_name": "100103", "standard_charge_dollar": 0.71, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Ms Physicians Care N", "plan_name": "714210", "standard_charge_dollar": 0.89, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Peoples Hlth Ffs 72126", "plan_name": "500019", "standard_charge_dollar": 0.71, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Uhc/Secure Horizons", "plan_name": "500449", "standard_charge_dollar": 0.71, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "United Health Care/", "plan_name": "500292", "standard_charge_dollar": 0.80, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "United Healthcare", "plan_name": "750104", "standard_charge_dollar": 0.80, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "United Healthcare Ba", "plan_name": "750090", "standard_charge_dollar": 0.80, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "United Healthcare Me", "plan_name": "501310", "standard_charge_dollar": 0.71, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Windsor Mcare Extra", "plan_name": "500778", "standard_charge_dollar": 0.71, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." } ] } ] }, { "description": "Epoetin alfa-epbx 20000 unit/ml injection solution [192401]", "drug_information": { "unit": 1.00, "type": "ML" }, "code_information": [ { "code": "Q5105", "type": "HCPCS" }, { "code": "0069-1311-10", "type": "NDC" } ], "standard_charges": [ { "gross_charge": 1103.00, "minimum": 0.71, "maximum": 937.55, "setting": "both", "payers_information": [ { "payer_name": "Aarp", "plan_name": "500102", "standard_charge_dollar": 0.71, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna", "plan_name": "700700", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna", "plan_name": "700700_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Mcare Ffs 6005", "plan_name": "700703", "standard_charge_dollar": 0.71, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Miscellaneous", "plan_name": "700720", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Miscellaneous", "plan_name": "700720_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Ppo Hmo", "plan_name": "701720", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Ppo Hmo", "plan_name": "701720_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Ambetter 68069", "plan_name": "500516", "standard_charge_dollar": 0.71, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Ms State Emplo", "plan_name": "401457", "standard_charge_percentage": 0.80, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Ms State Emplo", "plan_name": "401457_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Basic Pl", "plan_name": "400100", "standard_charge_percentage": 0.85, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Basic Pl", "plan_name": "400100_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Federal", "plan_name": "400110", "standard_charge_percentage": 0.85, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Federal", "plan_name": "400110_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Cigna Healthsprings Ffs", "plan_name": "500064", "standard_charge_dollar": 0.71, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Conseco", "plan_name": "500302", "standard_charge_dollar": 0.71, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Humana Ffs 61101", "plan_name": "500006", "standard_charge_dollar": 0.71, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Medicare A", "plan_name": "100100", "standard_charge_dollar": 0.71, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Medicare A", "plan_name": "100500", "standard_charge_dollar": 0.71, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Medicare Part B Only", "plan_name": "100300", "standard_charge_dollar": 0.71, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Medicare Railroad", "plan_name": "100103", "standard_charge_dollar": 0.71, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Ms Physicians Care N", "plan_name": "714210", "standard_charge_dollar": 0.89, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Peoples Hlth Ffs 72126", "plan_name": "500019", "standard_charge_dollar": 0.71, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Uhc/Secure Horizons", "plan_name": "500449", "standard_charge_dollar": 0.71, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "United Health Care/", "plan_name": "500292", "standard_charge_dollar": 0.80, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "United Healthcare", "plan_name": "750104", "standard_charge_dollar": 0.80, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "United Healthcare Ba", "plan_name": "750090", "standard_charge_dollar": 0.80, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "United Healthcare Me", "plan_name": "501310", "standard_charge_dollar": 0.71, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Windsor Mcare Extra", "plan_name": "500778", "standard_charge_dollar": 0.71, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." } ] } ] }, { "description": "Bevacizumab-awwb 25 mg/ml intravenous solution [187664]", "drug_information": { "unit": 4.00, "type": "ML" }, "code_information": [ { "code": "Q5107", "type": "HCPCS" }, { "code": "55513-206-01", "type": "NDC" } ], "standard_charges": [ { "gross_charge": 3037.73, "minimum": 29.82, "maximum": 2582.07, "setting": "both", "payers_information": [ { "payer_name": "Aarp", "plan_name": "500102", "standard_charge_dollar": 29.82, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna", "plan_name": "700700", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna", "plan_name": "700700_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Mcare Ffs 6005", "plan_name": "700703", "standard_charge_dollar": 29.82, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Miscellaneous", "plan_name": "700720", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Miscellaneous", "plan_name": "700720_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Ppo Hmo", "plan_name": "701720", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Ppo Hmo", "plan_name": "701720_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Ambetter 68069", "plan_name": "500516", "standard_charge_dollar": 29.82, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Ms State Emplo", "plan_name": "401457", "standard_charge_percentage": 0.80, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Ms State Emplo", "plan_name": "401457_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Basic Pl", "plan_name": "400100", "standard_charge_percentage": 0.85, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Basic Pl", "plan_name": "400100_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Federal", "plan_name": "400110", "standard_charge_percentage": 0.85, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Federal", "plan_name": "400110_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Cigna Healthsprings Ffs", "plan_name": "500064", "standard_charge_dollar": 29.82, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Conseco", "plan_name": "500302", "standard_charge_dollar": 29.82, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Humana Ffs 61101", "plan_name": "500006", "standard_charge_dollar": 29.82, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Medicare A", "plan_name": "100100", "standard_charge_dollar": 29.82, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Medicare A", "plan_name": "100500", "standard_charge_dollar": 29.82, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Medicare Part B Only", "plan_name": "100300", "standard_charge_dollar": 29.82, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Medicare Railroad", "plan_name": "100103", "standard_charge_dollar": 29.82, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Ms Physicians Care N", "plan_name": "714210", "standard_charge_dollar": 37.28, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Peoples Hlth Ffs 72126", "plan_name": "500019", "standard_charge_dollar": 29.82, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Uhc/Secure Horizons", "plan_name": "500449", "standard_charge_dollar": 29.82, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "United Health Care/", "plan_name": "500292", "standard_charge_dollar": 33.70, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "United Healthcare", "plan_name": "750104", "standard_charge_dollar": 33.70, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "United Healthcare Ba", "plan_name": "750090", "standard_charge_dollar": 33.70, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "United Healthcare Me", "plan_name": "501310", "standard_charge_dollar": 29.82, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Windsor Mcare Extra", "plan_name": "500778", "standard_charge_dollar": 29.82, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." } ] } ] }, { "description": "Bevacizumab-awwb 25 mg/ml intravenous solution [187664]", "drug_information": { "unit": 16.00, "type": "ML" }, "code_information": [ { "code": "Q5107", "type": "HCPCS" }, { "code": "55513-207-01", "type": "NDC" } ], "standard_charges": [ { "gross_charge": 12150.86, "minimum": 29.82, "maximum": 10328.23, "setting": "both", "payers_information": [ { "payer_name": "Aarp", "plan_name": "500102", "standard_charge_dollar": 29.82, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna", "plan_name": "700700", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna", "plan_name": "700700_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Mcare Ffs 6005", "plan_name": "700703", "standard_charge_dollar": 29.82, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Miscellaneous", "plan_name": "700720", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Miscellaneous", "plan_name": "700720_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Ppo Hmo", "plan_name": "701720", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Ppo Hmo", "plan_name": "701720_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Ambetter 68069", "plan_name": "500516", "standard_charge_dollar": 29.82, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Ms State Emplo", "plan_name": "401457", "standard_charge_percentage": 0.80, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Ms State Emplo", "plan_name": "401457_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Basic Pl", "plan_name": "400100", "standard_charge_percentage": 0.85, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Basic Pl", "plan_name": "400100_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Federal", "plan_name": "400110", "standard_charge_percentage": 0.85, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Federal", "plan_name": "400110_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Cigna Healthsprings Ffs", "plan_name": "500064", "standard_charge_dollar": 29.82, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Conseco", "plan_name": "500302", "standard_charge_dollar": 29.82, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Humana Ffs 61101", "plan_name": "500006", "standard_charge_dollar": 29.82, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Medicare A", "plan_name": "100100", "standard_charge_dollar": 29.82, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Medicare A", "plan_name": "100500", "standard_charge_dollar": 29.82, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Medicare Part B Only", "plan_name": "100300", "standard_charge_dollar": 29.82, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Medicare Railroad", "plan_name": "100103", "standard_charge_dollar": 29.82, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Ms Physicians Care N", "plan_name": "714210", "standard_charge_dollar": 37.28, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Peoples Hlth Ffs 72126", "plan_name": "500019", "standard_charge_dollar": 29.82, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Uhc/Secure Horizons", "plan_name": "500449", "standard_charge_dollar": 29.82, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "United Health Care/", "plan_name": "500292", "standard_charge_dollar": 33.70, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "United Healthcare", "plan_name": "750104", "standard_charge_dollar": 33.70, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "United Healthcare Ba", "plan_name": "750090", "standard_charge_dollar": 33.70, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "United Healthcare Me", "plan_name": "501310", "standard_charge_dollar": 29.82, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Windsor Mcare Extra", "plan_name": "500778", "standard_charge_dollar": 29.82, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." } ] } ] }, { "description": "Pegfilgrastim-jmdb 6 mg/0.6 ml subcutaneous syringe [184556]", "drug_information": { "unit": 0.60, "type": "ML" }, "code_information": [ { "code": "Q5108", "type": "HCPCS" }, { "code": "67457-833-06", "type": "NDC" } ], "standard_charges": [ { "gross_charge": 8391.75, "minimum": 112.90, "maximum": 7132.99, "setting": "both", "payers_information": [ { "payer_name": "Aarp", "plan_name": "500102", "standard_charge_dollar": 112.90, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna", "plan_name": "700700", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna", "plan_name": "700700_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Mcare Ffs 6005", "plan_name": "700703", "standard_charge_dollar": 112.90, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Miscellaneous", "plan_name": "700720", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Miscellaneous", "plan_name": "700720_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Ppo Hmo", "plan_name": "701720", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Ppo Hmo", "plan_name": "701720_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Ambetter 68069", "plan_name": "500516", "standard_charge_dollar": 112.90, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Ms State Emplo", "plan_name": "401457", "standard_charge_percentage": 0.80, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Ms State Emplo", "plan_name": "401457_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Basic Pl", "plan_name": "400100", "standard_charge_percentage": 0.85, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Basic Pl", "plan_name": "400100_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Federal", "plan_name": "400110", "standard_charge_percentage": 0.85, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Federal", "plan_name": "400110_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Cigna Healthsprings Ffs", "plan_name": "500064", "standard_charge_dollar": 112.90, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Conseco", "plan_name": "500302", "standard_charge_dollar": 112.90, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Humana Ffs 61101", "plan_name": "500006", "standard_charge_dollar": 112.90, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Medicare A", "plan_name": "100100", "standard_charge_dollar": 112.90, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Medicare A", "plan_name": "100500", "standard_charge_dollar": 112.90, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Medicare Part B Only", "plan_name": "100300", "standard_charge_dollar": 112.90, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Medicare Railroad", "plan_name": "100103", "standard_charge_dollar": 112.90, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Ms Physicians Care N", "plan_name": "714210", "standard_charge_dollar": 141.13, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Peoples Hlth Ffs 72126", "plan_name": "500019", "standard_charge_dollar": 112.90, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Uhc/Secure Horizons", "plan_name": "500449", "standard_charge_dollar": 112.90, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "United Health Care/", "plan_name": "500292", "standard_charge_dollar": 127.58, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "United Healthcare", "plan_name": "750104", "standard_charge_dollar": 127.58, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "United Healthcare Ba", "plan_name": "750090", "standard_charge_dollar": 127.58, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "United Healthcare Me", "plan_name": "501310", "standard_charge_dollar": 112.90, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Windsor Mcare Extra", "plan_name": "500778", "standard_charge_dollar": 112.90, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." } ] } ] }, { "description": "Filgrastim-aafi 300 mcg/0.5 ml subcutaneous syringe [185058]", "drug_information": { "unit": 0.50, "type": "ML" }, "code_information": [ { "code": "Q5110", "type": "HCPCS" }, { "code": "0069-0291-01", "type": "NDC" } ], "standard_charges": [ { "gross_charge": 851.76, "minimum": 0.29, "maximum": 724.00, "setting": "both", "payers_information": [ { "payer_name": "Aarp", "plan_name": "500102", "standard_charge_dollar": 0.29, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna", "plan_name": "700700", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna", "plan_name": "700700_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Mcare Ffs 6005", "plan_name": "700703", "standard_charge_dollar": 0.29, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Miscellaneous", "plan_name": "700720", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Miscellaneous", "plan_name": "700720_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Ppo Hmo", "plan_name": "701720", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Ppo Hmo", "plan_name": "701720_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Ambetter 68069", "plan_name": "500516", "standard_charge_dollar": 0.29, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Ms State Emplo", "plan_name": "401457", "standard_charge_percentage": 0.80, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Ms State Emplo", "plan_name": "401457_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Basic Pl", "plan_name": "400100", "standard_charge_percentage": 0.85, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Basic Pl", "plan_name": "400100_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Federal", "plan_name": "400110", "standard_charge_percentage": 0.85, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Federal", "plan_name": "400110_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Cigna Healthsprings Ffs", "plan_name": "500064", "standard_charge_dollar": 0.29, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Conseco", "plan_name": "500302", "standard_charge_dollar": 0.29, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Humana Ffs 61101", "plan_name": "500006", "standard_charge_dollar": 0.29, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Medicare A", "plan_name": "100100", "standard_charge_dollar": 0.29, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Medicare A", "plan_name": "100500", "standard_charge_dollar": 0.29, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Medicare Part B Only", "plan_name": "100300", "standard_charge_dollar": 0.29, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Medicare Railroad", "plan_name": "100103", "standard_charge_dollar": 0.29, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Ms Physicians Care N", "plan_name": "714210", "standard_charge_dollar": 0.36, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Peoples Hlth Ffs 72126", "plan_name": "500019", "standard_charge_dollar": 0.29, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Uhc/Secure Horizons", "plan_name": "500449", "standard_charge_dollar": 0.29, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "United Health Care/", "plan_name": "500292", "standard_charge_dollar": 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calculate allowed amounts." } ] } ] }, { "description": "Filgrastim-aafi 300 mcg/0.5 ml subcutaneous syringe [185058]", "drug_information": { "unit": 0.50, "type": "ML" }, "code_information": [ { "code": "Q5110", "type": "HCPCS" }, { "code": "0069-0291-10", "type": "NDC" } ], "standard_charges": [ { "gross_charge": 851.77, "minimum": 0.29, "maximum": 724.00, "setting": "both", "payers_information": [ { "payer_name": "Aarp", "plan_name": "500102", "standard_charge_dollar": 0.29, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna", "plan_name": "700700", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna", "plan_name": "700700_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", 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"standard_charge_dollar": 0.29, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Windsor Mcare Extra", "plan_name": "500778", "standard_charge_dollar": 0.29, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." } ] } ] }, { "description": "Filgrastim-aafi 480 mcg/1.6 ml injection solution [186576]", "drug_information": { "unit": 1.60, "type": "ML" }, "code_information": [ { "code": "Q5110", "type": "HCPCS" }, { "code": "0069-0294-10", "type": "NDC" } ], "standard_charges": [ { "gross_charge": 1408.61, "minimum": 0.29, "maximum": 1197.32, "setting": "both", "payers_information": [ { "payer_name": "Aarp", "plan_name": "500102", "standard_charge_dollar": 0.29, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna", "plan_name": "700700", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna", "plan_name": "700700_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Mcare Ffs 6005", "plan_name": "700703", "standard_charge_dollar": 0.29, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Miscellaneous", "plan_name": "700720", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Miscellaneous", "plan_name": "700720_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Ppo Hmo", "plan_name": "701720", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Ppo Hmo", "plan_name": "701720_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Ambetter 68069", "plan_name": "500516", "standard_charge_dollar": 0.29, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Ms State Emplo", "plan_name": "401457", "standard_charge_percentage": 0.80, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Ms State Emplo", "plan_name": "401457_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Basic Pl", "plan_name": "400100", "standard_charge_percentage": 0.85, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Basic Pl", "plan_name": "400100_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Federal", "plan_name": "400110", "standard_charge_percentage": 0.85, "count": 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"standard_charge_dollar": 0.36, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Peoples Hlth Ffs 72126", "plan_name": "500019", "standard_charge_dollar": 0.29, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Uhc/Secure Horizons", "plan_name": "500449", "standard_charge_dollar": 0.29, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "United Health Care/", "plan_name": "500292", "standard_charge_dollar": 0.33, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "United Healthcare", "plan_name": "750104", "standard_charge_dollar": 0.33, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "United Healthcare Ba", "plan_name": "750090", "standard_charge_dollar": 0.33, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "United Healthcare Me", "plan_name": "501310", "standard_charge_dollar": 0.29, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Windsor Mcare Extra", "plan_name": "500778", "standard_charge_dollar": 0.29, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." } ] } ] }, { "description": "Pegfilgrastim-cbqv 6 mg/0.6 ml subcutaneous syringe [185875]", "drug_information": { "unit": 0.60, "type": "ML" }, "code_information": [ { "code": "Q5111", "type": "HCPCS" }, { "code": "70114-101-01", "type": "NDC" } ], "standard_charges": [ { "gross_charge": 16238.03, "minimum": 163.60, "maximum": 13802.33, "setting": "both", "payers_information": [ { "payer_name": "Aarp", "plan_name": "500102", "standard_charge_dollar": 163.60, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna", "plan_name": "700700", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna", "plan_name": "700700_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Mcare Ffs 6005", "plan_name": "700703", "standard_charge_dollar": 163.60, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate 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}, { "payer_name": "Ambetter 68069", "plan_name": "500516", "standard_charge_dollar": 163.60, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Ms State Emplo", "plan_name": "401457", "standard_charge_percentage": 0.80, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Ms State Emplo", "plan_name": "401457_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Basic Pl", "plan_name": "400100", "standard_charge_percentage": 0.85, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Basic Pl", "plan_name": "400100_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Federal", "plan_name": "400110", "standard_charge_percentage": 0.85, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Federal", "plan_name": "400110_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Cigna Healthsprings Ffs", "plan_name": "500064", "standard_charge_dollar": 163.60, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Conseco", "plan_name": "500302", "standard_charge_dollar": 163.60, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Humana Ffs 61101", "plan_name": "500006", "standard_charge_dollar": 163.60, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Medicare A", "plan_name": "100100", "standard_charge_dollar": 163.60, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Medicare A", "plan_name": "100500", "standard_charge_dollar": 163.60, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Medicare Part B Only", "plan_name": "100300", "standard_charge_dollar": 163.60, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Medicare Railroad", "plan_name": "100103", "standard_charge_dollar": 163.60, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Ms Physicians Care N", "plan_name": "714210", "standard_charge_dollar": 204.50, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Peoples Hlth Ffs 72126", "plan_name": "500019", "standard_charge_dollar": 163.60, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Uhc/Secure Horizons", "plan_name": "500449", "standard_charge_dollar": 163.60, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "United Health Care/", "plan_name": "500292", "standard_charge_dollar": 184.87, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "United Healthcare", "plan_name": "750104", "standard_charge_dollar": 184.87, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "United Healthcare Ba", "plan_name": "750090", "standard_charge_dollar": 184.87, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "United Healthcare Me", "plan_name": "501310", "standard_charge_dollar": 163.60, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Windsor Mcare Extra", "plan_name": "500778", "standard_charge_dollar": 163.60, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." } ] } ] }, { "description": "Pegfilgrastim-cbqv 6 mg/0.6 ml subcutaneous auto-injector [200670]", "drug_information": { "unit": 0.60, "type": "ML" }, "code_information": [ { "code": "Q5111", "type": "HCPCS" }, { "code": "70114-120-01", "type": "NDC" } ], "standard_charges": [ { "gross_charge": 16723.08, "minimum": 163.60, "maximum": 14214.62, "setting": "both", "payers_information": [ { "payer_name": "Aarp", "plan_name": "500102", "standard_charge_dollar": 163.60, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna", "plan_name": "700700", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna", "plan_name": "700700_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Mcare Ffs 6005", "plan_name": "700703", "standard_charge_dollar": 163.60, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Miscellaneous", "plan_name": "700720", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Miscellaneous", "plan_name": "700720_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Ppo Hmo", "plan_name": "701720", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Ppo Hmo", "plan_name": "701720_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Ambetter 68069", "plan_name": "500516", "standard_charge_dollar": 163.60, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Ms State Emplo", "plan_name": "401457", "standard_charge_percentage": 0.80, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Ms State Emplo", "plan_name": "401457_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Basic Pl", "plan_name": "400100", "standard_charge_percentage": 0.85, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Basic Pl", "plan_name": "400100_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Federal", "plan_name": "400110", "standard_charge_percentage": 0.85, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Federal", "plan_name": "400110_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Cigna Healthsprings Ffs", "plan_name": "500064", "standard_charge_dollar": 163.60, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Conseco", "plan_name": "500302", "standard_charge_dollar": 163.60, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Humana Ffs 61101", "plan_name": "500006", "standard_charge_dollar": 163.60, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Medicare A", "plan_name": "100100", "standard_charge_dollar": 163.60, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Medicare A", "plan_name": "100500", "standard_charge_dollar": 163.60, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Medicare Part B Only", "plan_name": "100300", "standard_charge_dollar": 163.60, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Medicare Railroad", "plan_name": "100103", "standard_charge_dollar": 163.60, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Ms Physicians Care N", "plan_name": "714210", "standard_charge_dollar": 204.50, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Peoples Hlth Ffs 72126", "plan_name": "500019", "standard_charge_dollar": 163.60, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Uhc/Secure Horizons", "plan_name": "500449", "standard_charge_dollar": 163.60, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "United Health Care/", "plan_name": "500292", "standard_charge_dollar": 184.87, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "United Healthcare", "plan_name": "750104", "standard_charge_dollar": 184.87, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "United Healthcare Ba", "plan_name": "750090", "standard_charge_dollar": 184.87, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "United Healthcare Me", "plan_name": "501310", "standard_charge_dollar": 163.60, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Windsor Mcare Extra", "plan_name": "500778", "standard_charge_dollar": 163.60, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." } ] } ] }, { "description": "Trastuzumab-dttb 420 mg intravenous solution [190283]", "drug_information": { "unit": 1.00, "type": "EA" }, "code_information": [ { "code": "Q5112", "type": "HCPCS" }, { "code": "78206-148-01", "type": "NDC" } ], "standard_charges": [ { "gross_charge": 16148.25, "minimum": 28.74, "maximum": 13726.01, "setting": "both", "payers_information": [ { "payer_name": "Aarp", "plan_name": "500102", "standard_charge_dollar": 28.74, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna", "plan_name": "700700", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna", "plan_name": "700700_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Mcare Ffs 6005", "plan_name": "700703", "standard_charge_dollar": 28.74, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Miscellaneous", "plan_name": "700720", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Miscellaneous", "plan_name": "700720_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Ppo Hmo", "plan_name": "701720", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Ppo Hmo", "plan_name": "701720_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Ambetter 68069", "plan_name": "500516", "standard_charge_dollar": 28.74, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Ms State Emplo", "plan_name": "401457", "standard_charge_percentage": 0.80, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Ms State Emplo", "plan_name": "401457_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Basic Pl", "plan_name": "400100", "standard_charge_percentage": 0.85, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Basic Pl", "plan_name": "400100_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Federal", "plan_name": "400110", "standard_charge_percentage": 0.85, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Federal", "plan_name": "400110_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Cigna Healthsprings Ffs", "plan_name": "500064", "standard_charge_dollar": 28.74, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Conseco", "plan_name": "500302", "standard_charge_dollar": 28.74, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Humana Ffs 61101", "plan_name": "500006", "standard_charge_dollar": 28.74, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Medicare A", "plan_name": "100100", "standard_charge_dollar": 28.74, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Medicare A", "plan_name": "100500", "standard_charge_dollar": 28.74, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Medicare Part B Only", "plan_name": "100300", "standard_charge_dollar": 28.74, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Medicare Railroad", "plan_name": "100103", "standard_charge_dollar": 28.74, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Ms Physicians Care N", "plan_name": "714210", "standard_charge_dollar": 35.93, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Peoples Hlth Ffs 72126", "plan_name": "500019", "standard_charge_dollar": 28.74, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Uhc/Secure Horizons", "plan_name": "500449", "standard_charge_dollar": 28.74, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "United Health Care/", "plan_name": "500292", "standard_charge_dollar": 32.48, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "United Healthcare", "plan_name": "750104", "standard_charge_dollar": 32.48, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "United Healthcare Ba", "plan_name": "750090", "standard_charge_dollar": 32.48, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "United Healthcare Me", "plan_name": "501310", "standard_charge_dollar": 28.74, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Windsor Mcare Extra", "plan_name": "500778", "standard_charge_dollar": 28.74, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." } ] } ] }, { "description": "Trastuzumab-dkst 420 mg intravenous solution [188749]", "drug_information": { "unit": 1.00, "type": "EA" }, "code_information": [ { "code": "Q5114", "type": "HCPCS" }, { "code": "67457-845-50", "type": "NDC" } ], "standard_charges": [ { "gross_charge": 11812.73, "minimum": 46.82, "maximum": 10040.82, "setting": "both", "payers_information": [ { "payer_name": "Aarp", "plan_name": "500102", "standard_charge_dollar": 46.82, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna", "plan_name": "700700", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna", "plan_name": "700700_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Mcare Ffs 6005", "plan_name": "700703", "standard_charge_dollar": 46.82, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Miscellaneous", "plan_name": "700720", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Miscellaneous", "plan_name": "700720_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Ppo Hmo", "plan_name": "701720", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Ppo Hmo", "plan_name": "701720_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Ambetter 68069", "plan_name": "500516", "standard_charge_dollar": 46.82, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Ms State Emplo", "plan_name": "401457", "standard_charge_percentage": 0.80, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Ms State Emplo", "plan_name": "401457_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Basic Pl", "plan_name": "400100", "standard_charge_percentage": 0.85, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Basic Pl", "plan_name": "400100_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Federal", "plan_name": "400110", "standard_charge_percentage": 0.85, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Federal", "plan_name": "400110_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Cigna Healthsprings Ffs", "plan_name": "500064", "standard_charge_dollar": 46.82, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Conseco", "plan_name": "500302", "standard_charge_dollar": 46.82, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Humana Ffs 61101", "plan_name": "500006", "standard_charge_dollar": 46.82, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Medicare A", "plan_name": "100100", "standard_charge_dollar": 46.82, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Medicare A", "plan_name": "100500", "standard_charge_dollar": 46.82, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Medicare Part B Only", "plan_name": "100300", "standard_charge_dollar": 46.82, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Medicare Railroad", "plan_name": "100103", "standard_charge_dollar": 46.82, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Ms Physicians Care N", "plan_name": "714210", "standard_charge_dollar": 58.53, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Peoples Hlth Ffs 72126", "plan_name": "500019", "standard_charge_dollar": 46.82, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Uhc/Secure Horizons", "plan_name": "500449", "standard_charge_dollar": 46.82, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "United Health Care/", "plan_name": "500292", "standard_charge_dollar": 52.91, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "United Healthcare", "plan_name": "750104", "standard_charge_dollar": 52.91, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "United Healthcare Ba", "plan_name": "750090", "standard_charge_dollar": 52.91, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "United Healthcare Me", "plan_name": "501310", "standard_charge_dollar": 46.82, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Windsor Mcare Extra", "plan_name": "500778", "standard_charge_dollar": 46.82, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." } ] } ] }, { "description": "Trastuzumab-dkst 420 mg intravenous solution [188749]", "drug_information": { "unit": 1.00, "type": "EA" }, "code_information": [ { "code": "Q5114", "type": "HCPCS" }, { "code": "67457-847-44", "type": "NDC" } ], "standard_charges": [ { "gross_charge": 11812.73, "minimum": 46.82, "maximum": 10040.82, "setting": "both", "payers_information": [ { "payer_name": "Aarp", "plan_name": "500102", "standard_charge_dollar": 46.82, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna", "plan_name": "700700", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna", "plan_name": "700700_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Mcare Ffs 6005", "plan_name": "700703", "standard_charge_dollar": 46.82, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Miscellaneous", "plan_name": "700720", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Miscellaneous", "plan_name": "700720_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Ppo Hmo", "plan_name": "701720", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Ppo Hmo", "plan_name": "701720_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Ambetter 68069", "plan_name": "500516", "standard_charge_dollar": 46.82, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Ms State Emplo", "plan_name": "401457", "standard_charge_percentage": 0.80, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Ms State Emplo", "plan_name": "401457_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Basic Pl", "plan_name": "400100", "standard_charge_percentage": 0.85, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Basic Pl", "plan_name": "400100_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Federal", "plan_name": "400110", "standard_charge_percentage": 0.85, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Federal", "plan_name": "400110_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Cigna Healthsprings Ffs", "plan_name": "500064", "standard_charge_dollar": 46.82, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Conseco", "plan_name": "500302", "standard_charge_dollar": 46.82, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Humana Ffs 61101", "plan_name": "500006", "standard_charge_dollar": 46.82, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Medicare A", "plan_name": "100100", "standard_charge_dollar": 46.82, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Medicare A", "plan_name": "100500", "standard_charge_dollar": 46.82, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Medicare Part B Only", "plan_name": "100300", "standard_charge_dollar": 46.82, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Medicare Railroad", "plan_name": "100103", "standard_charge_dollar": 46.82, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Ms Physicians Care N", "plan_name": "714210", "standard_charge_dollar": 58.53, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Peoples Hlth Ffs 72126", "plan_name": "500019", "standard_charge_dollar": 46.82, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Uhc/Secure Horizons", "plan_name": "500449", "standard_charge_dollar": 46.82, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "United Health Care/", "plan_name": "500292", "standard_charge_dollar": 52.91, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "United Healthcare", "plan_name": "750104", "standard_charge_dollar": 52.91, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "United Healthcare Ba", "plan_name": "750090", "standard_charge_dollar": 52.91, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "United Healthcare Me", "plan_name": "501310", "standard_charge_dollar": 46.82, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Windsor Mcare Extra", "plan_name": "500778", "standard_charge_dollar": 46.82, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." } ] } ] }, { "description": "Rituximab-abbs 10 mg/ml intravenous solution [188750]", "drug_information": { "unit": 10.00, "type": "ML" }, "code_information": [ { "code": "Q5115", "type": "HCPCS" }, { "code": "63459-103-10", "type": "NDC" } ], "standard_charges": [ { "gross_charge": 3681.32, "minimum": 34.76, "maximum": 3129.12, "setting": "both", "payers_information": [ { "payer_name": "Aarp", "plan_name": "500102", "standard_charge_dollar": 34.76, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna", "plan_name": "700700", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna", "plan_name": "700700_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Mcare Ffs 6005", "plan_name": "700703", "standard_charge_dollar": 34.76, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Miscellaneous", "plan_name": "700720", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Miscellaneous", "plan_name": "700720_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Ppo Hmo", "plan_name": "701720", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Ppo Hmo", "plan_name": "701720_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Ambetter 68069", "plan_name": "500516", "standard_charge_dollar": 34.76, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Ms State Emplo", "plan_name": "401457", "standard_charge_percentage": 0.80, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Ms State Emplo", "plan_name": "401457_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Basic Pl", "plan_name": "400100", "standard_charge_percentage": 0.85, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Basic Pl", "plan_name": "400100_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Federal", "plan_name": "400110", "standard_charge_percentage": 0.85, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Federal", "plan_name": "400110_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Cigna Healthsprings Ffs", "plan_name": "500064", "standard_charge_dollar": 34.76, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Conseco", "plan_name": "500302", "standard_charge_dollar": 34.76, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Humana Ffs 61101", "plan_name": "500006", "standard_charge_dollar": 34.76, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Medicare A", "plan_name": "100100", "standard_charge_dollar": 34.76, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Medicare A", "plan_name": "100500", "standard_charge_dollar": 34.76, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Medicare Part B Only", "plan_name": "100300", "standard_charge_dollar": 34.76, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Medicare Railroad", "plan_name": "100103", "standard_charge_dollar": 34.76, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Ms Physicians Care N", "plan_name": "714210", "standard_charge_dollar": 43.45, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Peoples Hlth Ffs 72126", "plan_name": "500019", "standard_charge_dollar": 34.76, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Uhc/Secure Horizons", "plan_name": "500449", "standard_charge_dollar": 34.76, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "United Health Care/", "plan_name": "500292", "standard_charge_dollar": 39.28, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "United Healthcare", "plan_name": "750104", "standard_charge_dollar": 39.28, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "United Healthcare Ba", "plan_name": "750090", "standard_charge_dollar": 39.28, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "United Healthcare Me", "plan_name": "501310", "standard_charge_dollar": 34.76, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Windsor Mcare Extra", "plan_name": "500778", "standard_charge_dollar": 34.76, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." } ] } ] }, { "description": "Rituximab-abbs 10 mg/ml intravenous solution [188750]", "drug_information": { "unit": 50.00, "type": "ML" }, "code_information": [ { "code": "Q5115", "type": "HCPCS" }, { "code": "63459-104-50", "type": "NDC" } ], "standard_charges": [ { "gross_charge": 18406.58, "minimum": 34.76, "maximum": 15645.59, "setting": "both", "payers_information": [ { "payer_name": "Aarp", "plan_name": "500102", "standard_charge_dollar": 34.76, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna", "plan_name": "700700", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna", "plan_name": "700700_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Mcare Ffs 6005", "plan_name": "700703", "standard_charge_dollar": 34.76, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Miscellaneous", "plan_name": "700720", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Miscellaneous", "plan_name": "700720_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Ppo Hmo", "plan_name": "701720", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Ppo Hmo", "plan_name": "701720_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Ambetter 68069", "plan_name": "500516", "standard_charge_dollar": 34.76, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Ms State Emplo", "plan_name": "401457", "standard_charge_percentage": 0.80, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Ms State Emplo", "plan_name": "401457_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Basic Pl", "plan_name": "400100", "standard_charge_percentage": 0.85, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Basic Pl", "plan_name": "400100_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Federal", "plan_name": "400110", "standard_charge_percentage": 0.85, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Federal", "plan_name": "400110_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Cigna Healthsprings Ffs", "plan_name": "500064", "standard_charge_dollar": 34.76, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Conseco", "plan_name": "500302", "standard_charge_dollar": 34.76, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Humana Ffs 61101", "plan_name": "500006", "standard_charge_dollar": 34.76, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Medicare A", "plan_name": "100100", "standard_charge_dollar": 34.76, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Medicare A", "plan_name": "100500", "standard_charge_dollar": 34.76, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Medicare Part B Only", "plan_name": "100300", "standard_charge_dollar": 34.76, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Medicare Railroad", "plan_name": "100103", "standard_charge_dollar": 34.76, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Ms Physicians Care N", "plan_name": "714210", "standard_charge_dollar": 43.45, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Peoples Hlth Ffs 72126", "plan_name": "500019", "standard_charge_dollar": 34.76, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Uhc/Secure Horizons", "plan_name": "500449", "standard_charge_dollar": 34.76, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "United Health Care/", "plan_name": "500292", "standard_charge_dollar": 39.28, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "United Healthcare", "plan_name": "750104", "standard_charge_dollar": 39.28, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "United Healthcare Ba", "plan_name": "750090", "standard_charge_dollar": 39.28, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "United Healthcare Me", "plan_name": "501310", "standard_charge_dollar": 34.76, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Windsor Mcare Extra", "plan_name": "500778", "standard_charge_dollar": 34.76, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." } ] } ] }, { "description": "Trastuzumab-qyyp 420 mg intravenous solution [189692]", "drug_information": { "unit": 1.00, "type": "EA" }, "code_information": [ { "code": "Q5116", "type": "HCPCS" }, { "code": "0069-0305-01", "type": "NDC" } ], "standard_charges": [ { "gross_charge": 14763.92, "minimum": 24.93, "maximum": 12549.33, "setting": "both", "payers_information": [ { "payer_name": "Aarp", "plan_name": "500102", "standard_charge_dollar": 24.93, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna", "plan_name": "700700", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna", "plan_name": "700700_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Mcare Ffs 6005", "plan_name": "700703", "standard_charge_dollar": 24.93, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Miscellaneous", "plan_name": "700720", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Miscellaneous", "plan_name": "700720_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Ppo Hmo", "plan_name": "701720", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Ppo Hmo", "plan_name": "701720_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Ambetter 68069", "plan_name": "500516", "standard_charge_dollar": 24.93, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Ms State Emplo", "plan_name": "401457", "standard_charge_percentage": 0.80, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Ms State Emplo", "plan_name": "401457_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Basic Pl", "plan_name": "400100", "standard_charge_percentage": 0.85, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Basic Pl", "plan_name": "400100_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Federal", "plan_name": "400110", "standard_charge_percentage": 0.85, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Federal", "plan_name": "400110_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Cigna Healthsprings Ffs", "plan_name": "500064", "standard_charge_dollar": 24.93, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Conseco", "plan_name": "500302", "standard_charge_dollar": 24.93, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Humana Ffs 61101", "plan_name": "500006", "standard_charge_dollar": 24.93, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Medicare A", "plan_name": "100100", "standard_charge_dollar": 24.93, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Medicare A", "plan_name": "100500", "standard_charge_dollar": 24.93, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Medicare Part B Only", "plan_name": "100300", "standard_charge_dollar": 24.93, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Medicare Railroad", "plan_name": "100103", "standard_charge_dollar": 24.93, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Ms Physicians Care N", "plan_name": "714210", "standard_charge_dollar": 31.16, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Peoples Hlth Ffs 72126", "plan_name": "500019", "standard_charge_dollar": 24.93, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Uhc/Secure Horizons", "plan_name": "500449", "standard_charge_dollar": 24.93, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "United Health Care/", "plan_name": "500292", "standard_charge_dollar": 28.17, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "United Healthcare", "plan_name": "750104", "standard_charge_dollar": 28.17, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "United Healthcare Ba", "plan_name": "750090", "standard_charge_dollar": 28.17, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "United Healthcare Me", "plan_name": "501310", "standard_charge_dollar": 24.93, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Windsor Mcare Extra", "plan_name": "500778", "standard_charge_dollar": 24.93, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." } ] } ] }, { "description": "Trastuzumab-qyyp 420 mg intravenous solution [189692]", "drug_information": { "unit": 1.00, "type": "EA" }, "code_information": [ { "code": "Q5116", "type": "HCPCS" }, { "code": "0069-0306-01", "type": "NDC" } ], "standard_charges": [ { "gross_charge": 14763.92, "minimum": 24.93, "maximum": 12549.33, "setting": "both", "payers_information": [ { "payer_name": "Aarp", "plan_name": "500102", "standard_charge_dollar": 24.93, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna", "plan_name": "700700", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna", "plan_name": "700700_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Mcare Ffs 6005", "plan_name": "700703", "standard_charge_dollar": 24.93, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Miscellaneous", "plan_name": "700720", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Miscellaneous", "plan_name": "700720_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Ppo Hmo", "plan_name": "701720", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Ppo Hmo", "plan_name": "701720_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Ambetter 68069", "plan_name": "500516", "standard_charge_dollar": 24.93, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Ms State Emplo", "plan_name": "401457", "standard_charge_percentage": 0.80, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Ms State Emplo", "plan_name": "401457_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Basic Pl", "plan_name": "400100", "standard_charge_percentage": 0.85, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Basic Pl", "plan_name": "400100_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Federal", "plan_name": "400110", "standard_charge_percentage": 0.85, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Federal", "plan_name": "400110_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Cigna Healthsprings Ffs", "plan_name": "500064", "standard_charge_dollar": 24.93, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Conseco", "plan_name": "500302", "standard_charge_dollar": 24.93, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Humana Ffs 61101", "plan_name": "500006", "standard_charge_dollar": 24.93, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Medicare A", "plan_name": "100100", "standard_charge_dollar": 24.93, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Medicare A", "plan_name": "100500", "standard_charge_dollar": 24.93, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Medicare Part B Only", "plan_name": "100300", "standard_charge_dollar": 24.93, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Medicare Railroad", "plan_name": "100103", "standard_charge_dollar": 24.93, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Ms Physicians Care N", "plan_name": "714210", "standard_charge_dollar": 31.16, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Peoples Hlth Ffs 72126", "plan_name": "500019", "standard_charge_dollar": 24.93, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Uhc/Secure Horizons", "plan_name": "500449", "standard_charge_dollar": 24.93, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "United Health Care/", "plan_name": "500292", "standard_charge_dollar": 28.17, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "United Healthcare", "plan_name": "750104", "standard_charge_dollar": 28.17, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "United Healthcare Ba", "plan_name": "750090", "standard_charge_dollar": 28.17, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "United Healthcare Me", "plan_name": "501310", "standard_charge_dollar": 24.93, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Windsor Mcare Extra", "plan_name": "500778", "standard_charge_dollar": 24.93, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." } ] } ] }, { "description": "Trastuzumab-anns 420 mg intravenous solution [187691]", "drug_information": { "unit": 1.00, "type": "EA" }, "code_information": [ { "code": "Q5117", "type": "HCPCS" }, { "code": "55513-132-01", "type": "NDC" } ], "standard_charges": [ { "gross_charge": 16579.85, "minimum": 27.91, "maximum": 14092.87, "setting": "both", "payers_information": [ { "payer_name": "Aarp", "plan_name": "500102", "standard_charge_dollar": 27.91, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna", "plan_name": "700700", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna", "plan_name": "700700_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Mcare Ffs 6005", "plan_name": "700703", "standard_charge_dollar": 27.91, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Miscellaneous", "plan_name": "700720", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Miscellaneous", "plan_name": "700720_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Ppo Hmo", "plan_name": "701720", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Ppo Hmo", "plan_name": "701720_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Ambetter 68069", "plan_name": "500516", "standard_charge_dollar": 27.91, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Ms State Emplo", "plan_name": "401457", "standard_charge_percentage": 0.80, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Ms State Emplo", "plan_name": "401457_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Basic Pl", "plan_name": "400100", "standard_charge_percentage": 0.85, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Basic Pl", "plan_name": "400100_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Federal", "plan_name": "400110", "standard_charge_percentage": 0.85, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Federal", "plan_name": "400110_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Cigna Healthsprings Ffs", "plan_name": "500064", "standard_charge_dollar": 27.91, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Conseco", "plan_name": "500302", "standard_charge_dollar": 27.91, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Humana Ffs 61101", "plan_name": "500006", "standard_charge_dollar": 27.91, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Medicare A", "plan_name": "100100", "standard_charge_dollar": 27.91, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Medicare A", "plan_name": "100500", "standard_charge_dollar": 27.91, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Medicare Part B Only", "plan_name": "100300", "standard_charge_dollar": 27.91, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Medicare Railroad", "plan_name": "100103", "standard_charge_dollar": 27.91, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Ms Physicians Care N", "plan_name": "714210", "standard_charge_dollar": 34.89, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Peoples Hlth Ffs 72126", "plan_name": "500019", "standard_charge_dollar": 27.91, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Uhc/Secure Horizons", "plan_name": "500449", "standard_charge_dollar": 27.91, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "United Health Care/", "plan_name": "500292", "standard_charge_dollar": 31.54, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "United Healthcare", "plan_name": "750104", "standard_charge_dollar": 31.54, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "United Healthcare Ba", "plan_name": "750090", "standard_charge_dollar": 31.54, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "United Healthcare Me", "plan_name": "501310", "standard_charge_dollar": 27.91, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Windsor Mcare Extra", "plan_name": "500778", "standard_charge_dollar": 27.91, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." } ] } ] }, { "description": "Bevacizumab-bvzr 25 mg/ml intravenous solution [189147]", "drug_information": { "unit": 4.00, "type": "ML" }, "code_information": [ { "code": "Q5118", "type": "HCPCS" }, { "code": "0069-0315-01", "type": "NDC" } ], "standard_charges": [ { "gross_charge": 2385.71, "minimum": 26.94, "maximum": 2027.85, "setting": "both", "payers_information": [ { "payer_name": "Aarp", "plan_name": "500102", "standard_charge_dollar": 26.94, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna", "plan_name": "700700", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna", "plan_name": "700700_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Mcare Ffs 6005", "plan_name": "700703", "standard_charge_dollar": 26.94, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Miscellaneous", "plan_name": "700720", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Miscellaneous", "plan_name": "700720_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Ppo Hmo", "plan_name": "701720", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Ppo Hmo", "plan_name": "701720_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Ambetter 68069", "plan_name": "500516", "standard_charge_dollar": 26.94, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Ms State Emplo", "plan_name": "401457", "standard_charge_percentage": 0.80, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Ms State Emplo", "plan_name": "401457_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Basic Pl", "plan_name": "400100", "standard_charge_percentage": 0.85, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Basic Pl", "plan_name": "400100_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Federal", "plan_name": "400110", "standard_charge_percentage": 0.85, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Federal", "plan_name": "400110_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Cigna Healthsprings Ffs", "plan_name": "500064", "standard_charge_dollar": 26.94, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Conseco", "plan_name": "500302", "standard_charge_dollar": 26.94, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Humana Ffs 61101", "plan_name": "500006", "standard_charge_dollar": 26.94, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Medicare A", "plan_name": "100100", "standard_charge_dollar": 26.94, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Medicare A", "plan_name": "100500", "standard_charge_dollar": 26.94, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Medicare Part B Only", "plan_name": "100300", "standard_charge_dollar": 26.94, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Medicare Railroad", "plan_name": "100103", "standard_charge_dollar": 26.94, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Ms Physicians Care N", "plan_name": "714210", "standard_charge_dollar": 33.68, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Peoples Hlth Ffs 72126", "plan_name": "500019", "standard_charge_dollar": 26.94, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Uhc/Secure Horizons", "plan_name": "500449", "standard_charge_dollar": 26.94, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "United Health Care/", "plan_name": "500292", "standard_charge_dollar": 30.44, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "United Healthcare", "plan_name": "750104", "standard_charge_dollar": 30.44, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "United Healthcare Ba", "plan_name": "750090", "standard_charge_dollar": 30.44, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "United Healthcare Me", "plan_name": "501310", "standard_charge_dollar": 26.94, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Windsor Mcare Extra", "plan_name": "500778", "standard_charge_dollar": 26.94, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." } ] } ] }, { "description": "Bevacizumab-bvzr 25 mg/ml intravenous solution [189147]", "drug_information": { "unit": 16.00, "type": "ML" }, "code_information": [ { "code": "Q5118", "type": "HCPCS" }, { "code": "0069-0342-01", "type": "NDC" } ], "standard_charges": [ { "gross_charge": 9542.90, "minimum": 26.94, "maximum": 8111.47, "setting": "both", "payers_information": [ { "payer_name": "Aarp", "plan_name": "500102", "standard_charge_dollar": 26.94, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna", "plan_name": "700700", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna", "plan_name": "700700_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Mcare Ffs 6005", "plan_name": "700703", "standard_charge_dollar": 26.94, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Miscellaneous", "plan_name": "700720", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Miscellaneous", "plan_name": "700720_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Ppo Hmo", "plan_name": "701720", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Ppo Hmo", "plan_name": "701720_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Ambetter 68069", "plan_name": "500516", "standard_charge_dollar": 26.94, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Ms State Emplo", "plan_name": "401457", "standard_charge_percentage": 0.80, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Ms State Emplo", "plan_name": "401457_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Basic Pl", "plan_name": "400100", "standard_charge_percentage": 0.85, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Basic Pl", "plan_name": "400100_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Federal", "plan_name": "400110", "standard_charge_percentage": 0.85, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Federal", "plan_name": "400110_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Cigna Healthsprings Ffs", "plan_name": "500064", "standard_charge_dollar": 26.94, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Conseco", "plan_name": "500302", "standard_charge_dollar": 26.94, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Humana Ffs 61101", "plan_name": "500006", "standard_charge_dollar": 26.94, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Medicare A", "plan_name": "100100", "standard_charge_dollar": 26.94, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Medicare A", "plan_name": "100500", "standard_charge_dollar": 26.94, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Medicare Part B Only", "plan_name": "100300", "standard_charge_dollar": 26.94, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Medicare Railroad", "plan_name": "100103", "standard_charge_dollar": 26.94, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Ms Physicians Care N", "plan_name": "714210", "standard_charge_dollar": 33.68, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Peoples Hlth Ffs 72126", "plan_name": "500019", "standard_charge_dollar": 26.94, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Uhc/Secure Horizons", "plan_name": "500449", "standard_charge_dollar": 26.94, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "United Health Care/", "plan_name": "500292", "standard_charge_dollar": 30.44, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "United Healthcare", "plan_name": "750104", "standard_charge_dollar": 30.44, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "United Healthcare Ba", "plan_name": "750090", "standard_charge_dollar": 30.44, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "United Healthcare Me", "plan_name": "501310", "standard_charge_dollar": 26.94, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Windsor Mcare Extra", "plan_name": "500778", "standard_charge_dollar": 26.94, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." } ] } ] }, { "description": "Rituximab-pvvr 10 mg/ml intravenous solution [189444]", "drug_information": { "unit": 10.00, "type": "ML" }, "code_information": [ { "code": "Q5119", "type": "HCPCS" }, { "code": "0069-0238-01", "type": "NDC" } ], "standard_charges": [ { "gross_charge": 3120.75, "minimum": 24.94, "maximum": 2652.64, "setting": "both", "payers_information": [ { "payer_name": "Aarp", "plan_name": "500102", "standard_charge_dollar": 24.94, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna", "plan_name": "700700", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna", "plan_name": "700700_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Mcare Ffs 6005", "plan_name": "700703", "standard_charge_dollar": 24.94, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Miscellaneous", "plan_name": "700720", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Miscellaneous", "plan_name": "700720_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Ppo Hmo", "plan_name": "701720", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Ppo Hmo", "plan_name": "701720_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Ambetter 68069", "plan_name": "500516", "standard_charge_dollar": 24.94, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Ms State Emplo", "plan_name": "401457", "standard_charge_percentage": 0.80, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Ms State Emplo", "plan_name": "401457_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Basic Pl", "plan_name": "400100", "standard_charge_percentage": 0.85, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Basic Pl", "plan_name": "400100_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Federal", "plan_name": "400110", "standard_charge_percentage": 0.85, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Federal", "plan_name": "400110_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Cigna Healthsprings Ffs", "plan_name": "500064", "standard_charge_dollar": 24.94, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Conseco", "plan_name": "500302", "standard_charge_dollar": 24.94, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Humana Ffs 61101", "plan_name": "500006", "standard_charge_dollar": 24.94, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Medicare A", "plan_name": "100100", "standard_charge_dollar": 24.94, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Medicare A", "plan_name": "100500", "standard_charge_dollar": 24.94, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Medicare Part B Only", "plan_name": "100300", "standard_charge_dollar": 24.94, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Medicare Railroad", "plan_name": "100103", "standard_charge_dollar": 24.94, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Ms Physicians Care N", "plan_name": "714210", "standard_charge_dollar": 31.18, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Peoples Hlth Ffs 72126", "plan_name": "500019", "standard_charge_dollar": 24.94, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Uhc/Secure Horizons", "plan_name": "500449", "standard_charge_dollar": 24.94, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "United Health Care/", "plan_name": "500292", "standard_charge_dollar": 28.18, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "United Healthcare", "plan_name": "750104", "standard_charge_dollar": 28.18, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "United Healthcare Ba", "plan_name": "750090", "standard_charge_dollar": 28.18, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "United Healthcare Me", "plan_name": "501310", "standard_charge_dollar": 24.94, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Windsor Mcare Extra", "plan_name": "500778", "standard_charge_dollar": 24.94, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." } ] } ] }, { "description": "Rituximab-pvvr 10 mg/ml intravenous solution [189444]", "drug_information": { "unit": 50.00, "type": "ML" }, "code_information": [ { "code": "Q5119", "type": "HCPCS" }, { "code": "0069-0249-01", "type": "NDC" } ], "standard_charges": [ { "gross_charge": 15603.75, "minimum": 24.94, "maximum": 13263.19, "setting": "both", "payers_information": [ { "payer_name": "Aarp", "plan_name": "500102", "standard_charge_dollar": 24.94, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna", "plan_name": "700700", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna", "plan_name": "700700_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Mcare Ffs 6005", "plan_name": "700703", "standard_charge_dollar": 24.94, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Miscellaneous", "plan_name": "700720", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Miscellaneous", "plan_name": "700720_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Ppo Hmo", "plan_name": "701720", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Ppo Hmo", "plan_name": "701720_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Ambetter 68069", "plan_name": "500516", "standard_charge_dollar": 24.94, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Ms State Emplo", "plan_name": "401457", "standard_charge_percentage": 0.80, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Ms State Emplo", "plan_name": "401457_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Basic Pl", "plan_name": "400100", "standard_charge_percentage": 0.85, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Basic Pl", "plan_name": "400100_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Federal", "plan_name": "400110", "standard_charge_percentage": 0.85, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Federal", "plan_name": "400110_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Cigna Healthsprings Ffs", "plan_name": "500064", "standard_charge_dollar": 24.94, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Conseco", "plan_name": "500302", "standard_charge_dollar": 24.94, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Humana Ffs 61101", "plan_name": "500006", "standard_charge_dollar": 24.94, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Medicare A", "plan_name": "100100", "standard_charge_dollar": 24.94, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Medicare A", "plan_name": "100500", "standard_charge_dollar": 24.94, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Medicare Part B Only", "plan_name": "100300", "standard_charge_dollar": 24.94, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Medicare Railroad", "plan_name": "100103", "standard_charge_dollar": 24.94, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Ms Physicians Care N", "plan_name": "714210", "standard_charge_dollar": 31.18, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Peoples Hlth Ffs 72126", "plan_name": "500019", "standard_charge_dollar": 24.94, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Uhc/Secure Horizons", "plan_name": "500449", "standard_charge_dollar": 24.94, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "United Health Care/", "plan_name": "500292", "standard_charge_dollar": 28.18, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "United Healthcare", "plan_name": "750104", "standard_charge_dollar": 28.18, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "United Healthcare Ba", "plan_name": "750090", "standard_charge_dollar": 28.18, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "United Healthcare Me", "plan_name": "501310", "standard_charge_dollar": 24.94, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Windsor Mcare Extra", "plan_name": "500778", "standard_charge_dollar": 24.94, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." } ] } ] }, { "description": "Pegfilgrastim-bmez 6 mg/0.6 ml subcutaneous syringe [188842]", "drug_information": { "unit": 0.60, "type": "ML" }, "code_information": [ { "code": "Q5120", "type": "HCPCS" }, { "code": "61314-866-01", "type": "NDC" } ], "standard_charges": [ { "gross_charge": 15780.63, "minimum": 24.71, "maximum": 13413.54, "setting": "both", "payers_information": [ { "payer_name": "Aarp", "plan_name": "500102", "standard_charge_dollar": 24.71, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna", "plan_name": "700700", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna", "plan_name": "700700_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Mcare Ffs 6005", "plan_name": "700703", "standard_charge_dollar": 24.71, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Miscellaneous", "plan_name": "700720", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Miscellaneous", "plan_name": "700720_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Ppo Hmo", "plan_name": "701720", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Ppo Hmo", "plan_name": "701720_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Ambetter 68069", "plan_name": "500516", "standard_charge_dollar": 24.71, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Ms State Emplo", "plan_name": "401457", "standard_charge_percentage": 0.80, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Ms State Emplo", "plan_name": "401457_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Basic Pl", "plan_name": "400100", "standard_charge_percentage": 0.85, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Basic Pl", "plan_name": "400100_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Federal", "plan_name": "400110", "standard_charge_percentage": 0.85, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Federal", "plan_name": "400110_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Cigna Healthsprings Ffs", "plan_name": "500064", "standard_charge_dollar": 24.71, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Conseco", "plan_name": "500302", "standard_charge_dollar": 24.71, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Humana Ffs 61101", "plan_name": "500006", "standard_charge_dollar": 24.71, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Medicare A", "plan_name": "100100", "standard_charge_dollar": 24.71, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Medicare A", "plan_name": "100500", "standard_charge_dollar": 24.71, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Medicare Part B Only", "plan_name": "100300", "standard_charge_dollar": 24.71, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Medicare Railroad", "plan_name": "100103", "standard_charge_dollar": 24.71, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Ms Physicians Care N", "plan_name": "714210", "standard_charge_dollar": 30.89, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Peoples Hlth Ffs 72126", "plan_name": "500019", "standard_charge_dollar": 24.71, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Uhc/Secure Horizons", "plan_name": "500449", "standard_charge_dollar": 24.71, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "United Health Care/", "plan_name": "500292", "standard_charge_dollar": 27.92, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "United Healthcare", "plan_name": "750104", "standard_charge_dollar": 27.92, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "United Healthcare Ba", "plan_name": "750090", "standard_charge_dollar": 27.92, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "United Healthcare Me", "plan_name": "501310", "standard_charge_dollar": 24.71, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Windsor Mcare Extra", "plan_name": "500778", "standard_charge_dollar": 24.71, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." } ] } ] }, { "description": "Pegfilgrastim-apgf 6 mg/0.6 ml subcutaneous syringe [192364]", "drug_information": { "unit": 0.60, "type": "ML" }, "code_information": [ { "code": "Q5122", "type": "HCPCS" }, { "code": "0069-0324-01", "type": "NDC" } ], "standard_charges": [ { "gross_charge": 15265.71, "minimum": 134.25, "maximum": 12975.85, "setting": "both", "payers_information": [ { "payer_name": "Aarp", "plan_name": "500102", "standard_charge_dollar": 134.25, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna", "plan_name": "700700", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna", "plan_name": "700700_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Mcare Ffs 6005", "plan_name": "700703", "standard_charge_dollar": 134.25, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Miscellaneous", "plan_name": "700720", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Miscellaneous", "plan_name": "700720_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Ppo Hmo", "plan_name": "701720", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Ppo Hmo", "plan_name": "701720_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Ambetter 68069", "plan_name": "500516", "standard_charge_dollar": 134.25, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Ms State Emplo", "plan_name": "401457", "standard_charge_percentage": 0.80, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Ms State Emplo", "plan_name": "401457_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Basic Pl", "plan_name": "400100", "standard_charge_percentage": 0.85, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Basic Pl", "plan_name": "400100_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Federal", "plan_name": "400110", "standard_charge_percentage": 0.85, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Federal", "plan_name": "400110_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Cigna Healthsprings Ffs", "plan_name": "500064", "standard_charge_dollar": 134.25, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Conseco", "plan_name": "500302", "standard_charge_dollar": 134.25, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Humana Ffs 61101", "plan_name": "500006", "standard_charge_dollar": 134.25, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Medicare A", "plan_name": "100100", "standard_charge_dollar": 134.25, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Medicare A", "plan_name": "100500", "standard_charge_dollar": 134.25, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Medicare Part B Only", "plan_name": "100300", "standard_charge_dollar": 134.25, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Medicare Railroad", "plan_name": "100103", "standard_charge_dollar": 134.25, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Ms Physicians Care N", "plan_name": "714210", "standard_charge_dollar": 167.81, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Peoples Hlth Ffs 72126", "plan_name": "500019", "standard_charge_dollar": 134.25, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Uhc/Secure Horizons", "plan_name": "500449", "standard_charge_dollar": 134.25, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "United Health Care/", "plan_name": "500292", "standard_charge_dollar": 151.70, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "United Healthcare", "plan_name": "750104", "standard_charge_dollar": 151.70, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "United Healthcare Ba", "plan_name": "750090", "standard_charge_dollar": 151.70, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "United Healthcare Me", "plan_name": "501310", "standard_charge_dollar": 134.25, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Windsor Mcare Extra", "plan_name": "500778", "standard_charge_dollar": 134.25, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." } ] } ] }, { "description": "Rituximab-arrx 10 mg/ml intravenous solution [192639]", "drug_information": { "unit": 10.00, "type": "ML" }, "code_information": [ { "code": "Q5123", "type": "HCPCS" }, { "code": "55513-224-01", "type": "NDC" } ], "standard_charges": [ { "gross_charge": 2787.87, "minimum": 33.09, "maximum": 2369.69, "setting": "both", "payers_information": [ { "payer_name": "Aarp", "plan_name": "500102", "standard_charge_dollar": 33.09, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna", "plan_name": "700700", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna", "plan_name": "700700_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Mcare Ffs 6005", "plan_name": "700703", "standard_charge_dollar": 33.09, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Miscellaneous", "plan_name": "700720", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Miscellaneous", "plan_name": "700720_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Ppo Hmo", "plan_name": "701720", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Ppo Hmo", "plan_name": "701720_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Ambetter 68069", "plan_name": "500516", "standard_charge_dollar": 33.09, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Ms State Emplo", "plan_name": "401457", "standard_charge_percentage": 0.80, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Ms State Emplo", "plan_name": "401457_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Basic Pl", "plan_name": "400100", "standard_charge_percentage": 0.85, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Basic Pl", "plan_name": "400100_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Federal", "plan_name": "400110", "standard_charge_percentage": 0.85, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Federal", "plan_name": "400110_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Cigna Healthsprings Ffs", "plan_name": "500064", "standard_charge_dollar": 33.09, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Conseco", "plan_name": "500302", "standard_charge_dollar": 33.09, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Humana Ffs 61101", "plan_name": "500006", "standard_charge_dollar": 33.09, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Medicare A", "plan_name": "100100", "standard_charge_dollar": 33.09, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Medicare A", "plan_name": "100500", "standard_charge_dollar": 33.09, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Medicare Part B Only", "plan_name": "100300", "standard_charge_dollar": 33.09, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Medicare Railroad", "plan_name": "100103", "standard_charge_dollar": 33.09, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Ms Physicians Care N", "plan_name": "714210", "standard_charge_dollar": 41.36, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Peoples Hlth Ffs 72126", "plan_name": "500019", "standard_charge_dollar": 33.09, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Uhc/Secure Horizons", "plan_name": "500449", "standard_charge_dollar": 33.09, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "United Health Care/", "plan_name": "500292", "standard_charge_dollar": 37.39, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "United Healthcare", "plan_name": "750104", "standard_charge_dollar": 37.39, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "United Healthcare Ba", "plan_name": "750090", "standard_charge_dollar": 37.39, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "United Healthcare Me", "plan_name": "501310", "standard_charge_dollar": 33.09, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Windsor Mcare Extra", "plan_name": "500778", "standard_charge_dollar": 33.09, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." } ] } ] }, { "description": "Rituximab-arrx 10 mg/ml intravenous solution [192639]", "drug_information": { "unit": 50.00, "type": "ML" }, "code_information": [ { "code": "Q5123", "type": "HCPCS" }, { "code": "55513-326-01", "type": "NDC" } ], "standard_charges": [ { "gross_charge": 13939.35, "minimum": 33.09, "maximum": 11848.45, "setting": "both", "payers_information": [ { "payer_name": "Aarp", "plan_name": "500102", "standard_charge_dollar": 33.09, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna", "plan_name": "700700", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna", "plan_name": "700700_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Mcare Ffs 6005", "plan_name": "700703", "standard_charge_dollar": 33.09, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Miscellaneous", "plan_name": "700720", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Miscellaneous", "plan_name": "700720_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Ppo Hmo", "plan_name": "701720", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Ppo Hmo", "plan_name": "701720_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Ambetter 68069", "plan_name": "500516", "standard_charge_dollar": 33.09, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Ms State Emplo", "plan_name": "401457", "standard_charge_percentage": 0.80, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Ms State Emplo", "plan_name": "401457_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Basic Pl", "plan_name": "400100", "standard_charge_percentage": 0.85, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Basic Pl", "plan_name": "400100_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Federal", "plan_name": "400110", "standard_charge_percentage": 0.85, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Federal", "plan_name": "400110_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Cigna Healthsprings Ffs", "plan_name": "500064", "standard_charge_dollar": 33.09, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Conseco", "plan_name": "500302", "standard_charge_dollar": 33.09, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Humana Ffs 61101", "plan_name": "500006", "standard_charge_dollar": 33.09, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Medicare A", "plan_name": "100100", "standard_charge_dollar": 33.09, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Medicare A", "plan_name": "100500", "standard_charge_dollar": 33.09, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Medicare Part B Only", "plan_name": "100300", "standard_charge_dollar": 33.09, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Medicare Railroad", "plan_name": "100103", "standard_charge_dollar": 33.09, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Ms Physicians Care N", "plan_name": "714210", "standard_charge_dollar": 41.36, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Peoples Hlth Ffs 72126", "plan_name": "500019", "standard_charge_dollar": 33.09, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Uhc/Secure Horizons", "plan_name": "500449", "standard_charge_dollar": 33.09, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "United Health Care/", "plan_name": "500292", "standard_charge_dollar": 37.39, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "United Healthcare", "plan_name": "750104", "standard_charge_dollar": 37.39, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "United Healthcare Ba", "plan_name": "750090", "standard_charge_dollar": 37.39, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "United Healthcare Me", "plan_name": "501310", "standard_charge_dollar": 33.09, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Windsor Mcare Extra", "plan_name": "500778", "standard_charge_dollar": 33.09, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." } ] } ] }, { "description": "Bevacizumab-maly 25 mg/ml intravenous solution [196704]", "drug_information": { "unit": 4.00, "type": "ML" }, "code_information": [ { "code": "Q5126", "type": "HCPCS" }, { "code": "70121-1754-1", "type": "NDC" } ], "standard_charges": [ { "gross_charge": 3128.63, "minimum": 42.18, "maximum": 2659.34, "setting": "both", "payers_information": [ { "payer_name": "Aarp", "plan_name": "500102", "standard_charge_dollar": 42.18, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna", "plan_name": "700700", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna", "plan_name": "700700_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Mcare Ffs 6005", "plan_name": "700703", "standard_charge_dollar": 42.18, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Miscellaneous", "plan_name": "700720", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Miscellaneous", "plan_name": "700720_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Ppo Hmo", "plan_name": "701720", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Ppo Hmo", "plan_name": "701720_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Ambetter 68069", "plan_name": "500516", "standard_charge_dollar": 42.18, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Ms State Emplo", "plan_name": "401457", "standard_charge_percentage": 0.80, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Ms State Emplo", "plan_name": "401457_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Basic Pl", "plan_name": "400100", "standard_charge_percentage": 0.85, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Basic Pl", "plan_name": "400100_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Federal", "plan_name": "400110", "standard_charge_percentage": 0.85, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Federal", "plan_name": "400110_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Cigna Healthsprings Ffs", "plan_name": "500064", "standard_charge_dollar": 42.18, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Conseco", "plan_name": "500302", "standard_charge_dollar": 42.18, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Humana Ffs 61101", "plan_name": "500006", "standard_charge_dollar": 42.18, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Medicare A", "plan_name": "100100", "standard_charge_dollar": 42.18, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Medicare A", "plan_name": "100500", "standard_charge_dollar": 42.18, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Medicare Part B Only", "plan_name": "100300", "standard_charge_dollar": 42.18, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Medicare Railroad", "plan_name": "100103", "standard_charge_dollar": 42.18, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Ms Physicians Care N", "plan_name": "714210", "standard_charge_dollar": 52.73, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Peoples Hlth Ffs 72126", "plan_name": "500019", "standard_charge_dollar": 42.18, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Uhc/Secure Horizons", "plan_name": "500449", "standard_charge_dollar": 42.18, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "United Health Care/", "plan_name": "500292", "standard_charge_dollar": 47.67, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "United Healthcare", "plan_name": "750104", "standard_charge_dollar": 47.67, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "United Healthcare Ba", "plan_name": "750090", "standard_charge_dollar": 47.67, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "United Healthcare Me", "plan_name": "501310", "standard_charge_dollar": 42.18, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Windsor Mcare Extra", "plan_name": "500778", "standard_charge_dollar": 42.18, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." } ] } ] }, { "description": "Bevacizumab-maly 25 mg/ml intravenous solution [196704]", "drug_information": { "unit": 16.00, "type": "ML" }, "code_information": [ { "code": "Q5126", "type": "HCPCS" }, { "code": "70121-1755-1", "type": "NDC" } ], "standard_charges": [ { "gross_charge": 12514.39, "minimum": 42.18, "maximum": 10637.23, "setting": "both", "payers_information": [ { "payer_name": "Aarp", "plan_name": "500102", "standard_charge_dollar": 42.18, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna", "plan_name": "700700", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna", "plan_name": "700700_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Mcare Ffs 6005", "plan_name": "700703", "standard_charge_dollar": 42.18, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Miscellaneous", "plan_name": "700720", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Miscellaneous", "plan_name": "700720_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Ppo Hmo", "plan_name": "701720", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Ppo Hmo", "plan_name": "701720_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Ambetter 68069", "plan_name": "500516", "standard_charge_dollar": 42.18, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Ms State Emplo", "plan_name": "401457", "standard_charge_percentage": 0.80, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Ms State Emplo", "plan_name": "401457_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Basic Pl", "plan_name": "400100", "standard_charge_percentage": 0.85, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Basic Pl", "plan_name": "400100_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Federal", "plan_name": "400110", "standard_charge_percentage": 0.85, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Federal", "plan_name": "400110_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Cigna Healthsprings Ffs", "plan_name": "500064", "standard_charge_dollar": 42.18, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Conseco", "plan_name": "500302", "standard_charge_dollar": 42.18, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Humana Ffs 61101", "plan_name": "500006", "standard_charge_dollar": 42.18, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Medicare A", "plan_name": "100100", "standard_charge_dollar": 42.18, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Medicare A", "plan_name": "100500", "standard_charge_dollar": 42.18, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Medicare Part B Only", "plan_name": "100300", "standard_charge_dollar": 42.18, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Medicare Railroad", "plan_name": "100103", "standard_charge_dollar": 42.18, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Ms Physicians Care N", "plan_name": "714210", "standard_charge_dollar": 52.73, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Peoples Hlth Ffs 72126", "plan_name": "500019", "standard_charge_dollar": 42.18, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Uhc/Secure Horizons", "plan_name": "500449", "standard_charge_dollar": 42.18, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "United Health Care/", "plan_name": "500292", "standard_charge_dollar": 47.67, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "United Healthcare", "plan_name": "750104", "standard_charge_dollar": 47.67, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "United Healthcare Ba", "plan_name": "750090", "standard_charge_dollar": 47.67, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "United Healthcare Me", "plan_name": "501310", "standard_charge_dollar": 42.18, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Windsor Mcare Extra", "plan_name": "500778", "standard_charge_dollar": 42.18, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." } ] } ] }, { "description": "Pegfilgrastim-pbbk 6 mg/0.6 ml subcutaneous syringe [198004]", "drug_information": { "unit": 0.60, "type": "ML" }, "code_information": [ { "code": "Q5130", "type": "HCPCS" }, { "code": "70121-1627-1", "type": "NDC" } ], "standard_charges": [ { "gross_charge": 9723.38, "minimum": 150.37, "maximum": 8264.87, "setting": "both", "payers_information": [ { "payer_name": "Aarp", "plan_name": "500102", "standard_charge_dollar": 150.37, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna", "plan_name": "700700", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna", "plan_name": "700700_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Mcare Ffs 6005", "plan_name": "700703", "standard_charge_dollar": 150.37, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Miscellaneous", "plan_name": "700720", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Miscellaneous", "plan_name": "700720_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Ppo Hmo", "plan_name": "701720", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Ppo Hmo", "plan_name": "701720_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Ambetter 68069", "plan_name": "500516", "standard_charge_dollar": 150.37, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Ms State Emplo", "plan_name": "401457", "standard_charge_percentage": 0.80, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Ms State Emplo", "plan_name": "401457_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Basic Pl", "plan_name": "400100", "standard_charge_percentage": 0.85, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Basic Pl", "plan_name": "400100_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Federal", "plan_name": "400110", "standard_charge_percentage": 0.85, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Federal", "plan_name": "400110_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Cigna Healthsprings Ffs", "plan_name": "500064", "standard_charge_dollar": 150.37, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Conseco", "plan_name": "500302", "standard_charge_dollar": 150.37, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Humana Ffs 61101", "plan_name": "500006", "standard_charge_dollar": 150.37, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Medicare A", "plan_name": "100100", "standard_charge_dollar": 150.37, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Medicare A", "plan_name": "100500", "standard_charge_dollar": 150.37, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Medicare Part B Only", "plan_name": "100300", "standard_charge_dollar": 150.37, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Medicare Railroad", "plan_name": "100103", "standard_charge_dollar": 150.37, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Ms Physicians Care N", "plan_name": "714210", "standard_charge_dollar": 187.97, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Peoples Hlth Ffs 72126", "plan_name": "500019", "standard_charge_dollar": 150.37, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Uhc/Secure Horizons", "plan_name": "500449", "standard_charge_dollar": 150.37, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "United Health Care/", "plan_name": "500292", "standard_charge_dollar": 169.92, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "United Healthcare", "plan_name": "750104", "standard_charge_dollar": 169.92, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "United Healthcare Ba", "plan_name": "750090", "standard_charge_dollar": 169.92, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "United Healthcare Me", "plan_name": "501310", "standard_charge_dollar": 150.37, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Windsor Mcare Extra", "plan_name": "500778", "standard_charge_dollar": 150.37, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." } ] } ] }, { "description": "Diatrizoate meglumine-diatrizoate sodium 66 %-10 % oral solution [9828]", "drug_information": { "unit": 30.00, "type": "ML" }, "code_information": [ { "code": "Q9963", "type": "HCPCS" }, { "code": "0270-0445-35", "type": "NDC" } ], "standard_charges": [ { "gross_charge": 118.85, "minimum": 95.08, "maximum": 101.02, "setting": "both", "payers_information": [ { "payer_name": "Aetna", "plan_name": "700700", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna", "plan_name": "700700_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Miscellaneous", "plan_name": "700720", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Miscellaneous", "plan_name": "700720_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Ppo Hmo", "plan_name": "701720", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Ppo Hmo", "plan_name": "701720_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Ms State Emplo", "plan_name": "401457", "standard_charge_percentage": 0.80, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Ms State Emplo", "plan_name": "401457_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Basic Pl", "plan_name": "400100", "standard_charge_percentage": 0.85, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Basic Pl", "plan_name": "400100_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Federal", "plan_name": "400110", "standard_charge_percentage": 0.85, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Federal", "plan_name": "400110_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." } ] } ] }, { "description": "Diatrizoate meglumine-diatrizoate sodium 66 %-10 % oral solution [9828]", "drug_information": { "unit": 120.00, "type": "ML" }, "code_information": [ { "code": "Q9963", "type": "HCPCS" }, { "code": "0270-0445-40", "type": "NDC" } ], "standard_charges": [ { "gross_charge": 342.57, "minimum": 274.06, "maximum": 291.18, "setting": "both", "payers_information": [ { "payer_name": "Aetna", "plan_name": "700700", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna", "plan_name": "700700_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Miscellaneous", "plan_name": "700720", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Miscellaneous", "plan_name": "700720_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Ppo Hmo", "plan_name": "701720", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Ppo Hmo", "plan_name": "701720_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Ms State Emplo", "plan_name": "401457", "standard_charge_percentage": 0.80, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Ms State Emplo", "plan_name": "401457_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Basic Pl", "plan_name": "400100", "standard_charge_percentage": 0.85, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Basic Pl", "plan_name": "400100_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Federal", "plan_name": "400110", "standard_charge_percentage": 0.85, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Federal", "plan_name": "400110_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." } ] } ] }, { "description": "Iohexol 180 mg iodine/ml intrathecal solution [10319]", "drug_information": { "unit": 10.00, "type": "ML" }, "code_information": [ { "code": "Q9965", "type": "HCPCS" }, { "code": "0407-1411-10", "type": "NDC" } ], "standard_charges": [ { "gross_charge": 188.35, "minimum": 150.68, "maximum": 160.10, "setting": "both", "payers_information": [ { "payer_name": "Aetna", "plan_name": "700700", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna", "plan_name": "700700_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to 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amounts." }, { "payer_name": "Bc/Bs Ms State Emplo", "plan_name": "401457", "standard_charge_percentage": 0.80, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Ms State Emplo", "plan_name": "401457_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Basic Pl", "plan_name": "400100", "standard_charge_percentage": 0.85, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Basic Pl", "plan_name": "400100_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Federal", "plan_name": "400110", "standard_charge_percentage": 0.85, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Federal", "plan_name": "400110_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." } ] } ] }, { "description": "Iohexol 180 mg iodine/ml intrathecal solution [10319]", "drug_information": { "unit": 20.00, "type": "ML" }, "code_information": [ { "code": "Q9965", "type": "HCPCS" }, { "code": "0407-1411-20", "type": "NDC" } ], "standard_charges": [ { "gross_charge": 223.70, "minimum": 178.96, "maximum": 190.15, "setting": "both", "payers_information": [ { "payer_name": "Aetna", "plan_name": "700700", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent 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"additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Ppo Hmo", "plan_name": "701720_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Ms State Emplo", "plan_name": "401457", "standard_charge_percentage": 0.80, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Ms State Emplo", "plan_name": "401457_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Basic Pl", "plan_name": "400100", "standard_charge_percentage": 0.85, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Basic Pl", "plan_name": "400100_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Federal", "plan_name": "400110", "standard_charge_percentage": 0.85, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Federal", "plan_name": "400110_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." } ] } ] }, { "description": "Iodixanol 270 mg iodine/ml intravenous solution [17594]", "drug_information": { "unit": 50.00, "type": "ML" }, "code_information": [ { "code": "Q9966", "type": "HCPCS" }, { "code": "0407-2222-16", "type": "NDC" } ], "standard_charges": [ { "gross_charge": 228.75, "minimum": 183.00, "maximum": 194.44, "setting": "both", "payers_information": [ { "payer_name": "Aetna", "plan_name": "700700", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna", "plan_name": "700700_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Miscellaneous", "plan_name": "700720", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Miscellaneous", "plan_name": "700720_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Ppo Hmo", "plan_name": "701720", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Ppo Hmo", "plan_name": "701720_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Ms State Emplo", "plan_name": "401457", "standard_charge_percentage": 0.80, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Ms State Emplo", "plan_name": "401457_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Basic Pl", "plan_name": "400100", "standard_charge_percentage": 0.85, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Basic Pl", "plan_name": "400100_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Federal", "plan_name": "400110", "standard_charge_percentage": 0.85, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Federal", "plan_name": "400110_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." } ] } ] }, { "description": "Iodixanol 270 mg iodine/ml intravenous solution [17594]", "drug_information": { "unit": 100.00, "type": "ML" }, "code_information": [ { "code": "Q9966", "type": "HCPCS" }, { "code": "0407-2222-17", "type": "NDC" } ], "standard_charges": [ { "gross_charge": 448.00, "minimum": 358.40, "maximum": 380.80, "setting": "both", "payers_information": [ { "payer_name": "Aetna", "plan_name": "700700", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna", "plan_name": "700700_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to 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amounts." }, { "payer_name": "Bc/Bs Ms State Emplo", "plan_name": "401457", "standard_charge_percentage": 0.80, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Ms State Emplo", "plan_name": "401457_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Basic Pl", "plan_name": "400100", "standard_charge_percentage": 0.85, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Basic Pl", "plan_name": "400100_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed 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"Q9967", "type": "HCPCS" }, { "code": "0407-1414-91", "type": "NDC" } ], "standard_charges": [ { "gross_charge": 474.50, "minimum": 379.60, "maximum": 403.33, "setting": "both", "payers_information": [ { "payer_name": "Aetna", "plan_name": "700700", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna", "plan_name": "700700_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Miscellaneous", "plan_name": "700720", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Miscellaneous", "plan_name": "700720_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Ppo Hmo", "plan_name": "701720", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Ppo Hmo", "plan_name": "701720_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Ms State Emplo", "plan_name": "401457", "standard_charge_percentage": 0.80, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Ms State Emplo", "plan_name": "401457_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Basic Pl", "plan_name": "400100", "standard_charge_percentage": 0.85, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Basic Pl", "plan_name": "400100_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Federal", "plan_name": "400110", "standard_charge_percentage": 0.85, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Federal", "plan_name": "400110_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." } ] } ] }, { "description": "Iohexol 350 mg iodine/ml intravenous solution [10323]", "drug_information": { "unit": 500.00, "type": "ML" }, "code_information": [ { "code": "Q9967", "type": "HCPCS" }, { "code": "0407-1414-98", "type": "NDC" } ], "standard_charges": [ { "gross_charge": 2045.00, "minimum": 1636.00, "maximum": 1738.25, "setting": "both", "payers_information": [ { "payer_name": "Aetna", "plan_name": "700700", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna", "plan_name": "700700_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Miscellaneous", "plan_name": "700720", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Miscellaneous", "plan_name": "700720_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Ppo Hmo", "plan_name": "701720", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Ppo Hmo", "plan_name": "701720_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Ms State Emplo", "plan_name": "401457", "standard_charge_percentage": 0.80, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Ms State Emplo", "plan_name": "401457_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Basic Pl", "plan_name": "400100", "standard_charge_percentage": 0.85, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Basic Pl", "plan_name": "400100_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Federal", "plan_name": "400110", "standard_charge_percentage": 0.85, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Federal", "plan_name": "400110_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." } ] } ] }, { "description": "Iodixanol 320 mg iodine/ml intravenous solution [17595]", "drug_information": { "unit": 100.00, "type": "ML" }, "code_information": [ { "code": "Q9967", "type": "HCPCS" }, { "code": "65219-383-10", "type": "NDC" } ], "standard_charges": [ { "gross_charge": 458.50, "minimum": 366.80, "maximum": 389.73, "setting": "both", "payers_information": [ { "payer_name": "Aetna", "plan_name": "700700", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna", "plan_name": "700700_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Miscellaneous", "plan_name": "700720", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Miscellaneous", "plan_name": "700720_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Ppo Hmo", "plan_name": "701720", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Ppo Hmo", "plan_name": "701720_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Ms State Emplo", "plan_name": "401457", "standard_charge_percentage": 0.80, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Ms State Emplo", "plan_name": "401457_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Basic Pl", "plan_name": "400100", "standard_charge_percentage": 0.85, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Basic Pl", "plan_name": "400100_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Federal", "plan_name": "400110", "standard_charge_percentage": 0.85, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Federal", "plan_name": "400110_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." } ] } ] }, { "description": "Methylene blue (antidote) 5 mg/ml intravenous solution [178440]", "drug_information": { "unit": 10.00, "type": "ML" }, "code_information": [ { "code": "Q9968", "type": "HCPCS" }, { "code": "0517-0374-01", "type": "NDC" } ], "standard_charges": [ { "gross_charge": 1102.35, "minimum": 2.55, "maximum": 9.48, "setting": "both", "payers_information": [ { "payer_name": "Aarp", "plan_name": "500102", "standard_charge_dollar": 7.58, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna", "plan_name": "700700", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna", "plan_name": "700700_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Mcare Ffs 6005", "plan_name": "700703", "standard_charge_dollar": 7.58, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Miscellaneous", "plan_name": "700720", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Miscellaneous", "plan_name": "700720_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Ppo Hmo", "plan_name": "701720", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Ppo Hmo", "plan_name": "701720_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Ambetter 68069", "plan_name": "500516", "standard_charge_dollar": 7.58, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Ms State Emplo", "plan_name": "401457", "standard_charge_dollar": 2.55, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Ms State Emplo", "plan_name": "401457_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Basic Pl", "plan_name": "400100", "standard_charge_dollar": 2.55, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Basic Pl", "plan_name": "400100_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Federal", "plan_name": "400110", "standard_charge_dollar": 2.55, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Federal", "plan_name": "400110_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Cigna Healthsprings Ffs", "plan_name": "500064", "standard_charge_dollar": 7.58, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Conseco", "plan_name": "500302", "standard_charge_dollar": 7.58, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Humana Ffs 61101", "plan_name": "500006", "standard_charge_dollar": 7.58, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Medicare A", "plan_name": "100100", "standard_charge_dollar": 7.58, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Medicare A", "plan_name": "100500", "standard_charge_dollar": 7.58, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Medicare Part B Only", "plan_name": "100300", "standard_charge_dollar": 7.58, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Medicare Railroad", "plan_name": "100103", "standard_charge_dollar": 7.58, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Ms Physicians Care N", "plan_name": "714210", "standard_charge_dollar": 9.48, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Peoples Hlth Ffs 72126", "plan_name": "500019", "standard_charge_dollar": 7.58, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Uhc/Secure Horizons", "plan_name": "500449", "standard_charge_dollar": 7.58, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "United Health Care/", "plan_name": "500292", "standard_charge_dollar": 8.57, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "United Healthcare", "plan_name": "750104", "standard_charge_dollar": 8.57, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "United Healthcare Ba", "plan_name": "750090", "standard_charge_dollar": 8.57, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "United Healthcare Me", "plan_name": "501310", "standard_charge_dollar": 7.58, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Windsor Mcare Extra", "plan_name": "500778", "standard_charge_dollar": 7.58, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." } ] } ] }, { "description": "Methylene blue (antidote) 5 mg/ml intravenous solution [178440]", "drug_information": { "unit": 10.00, "type": "ML" }, "code_information": [ { "code": "Q9968", "type": "HCPCS" }, { "code": "0517-0374-05", "type": "NDC" } ], "standard_charges": [ { "gross_charge": 1102.35, "minimum": 2.55, "maximum": 9.48, "setting": "both", "payers_information": [ { "payer_name": "Aarp", "plan_name": "500102", "standard_charge_dollar": 7.58, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna", "plan_name": "700700", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna", "plan_name": "700700_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Mcare Ffs 6005", "plan_name": "700703", "standard_charge_dollar": 7.58, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Miscellaneous", "plan_name": "700720", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Miscellaneous", "plan_name": "700720_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Ppo Hmo", "plan_name": "701720", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Ppo Hmo", "plan_name": "701720_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Ambetter 68069", "plan_name": "500516", "standard_charge_dollar": 7.58, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Ms State Emplo", "plan_name": "401457", "standard_charge_dollar": 2.55, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Ms State Emplo", "plan_name": "401457_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Basic Pl", "plan_name": "400100", "standard_charge_dollar": 2.55, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Basic Pl", "plan_name": "400100_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Federal", "plan_name": "400110", "standard_charge_dollar": 2.55, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Federal", "plan_name": "400110_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Cigna Healthsprings Ffs", "plan_name": "500064", "standard_charge_dollar": 7.58, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Conseco", "plan_name": "500302", "standard_charge_dollar": 7.58, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Humana Ffs 61101", "plan_name": "500006", "standard_charge_dollar": 7.58, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Medicare A", "plan_name": "100100", "standard_charge_dollar": 7.58, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Medicare A", "plan_name": "100500", "standard_charge_dollar": 7.58, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Medicare Part B Only", "plan_name": "100300", "standard_charge_dollar": 7.58, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Medicare Railroad", "plan_name": "100103", "standard_charge_dollar": 7.58, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Ms Physicians Care N", "plan_name": "714210", "standard_charge_dollar": 9.48, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Peoples Hlth Ffs 72126", "plan_name": "500019", "standard_charge_dollar": 7.58, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Uhc/Secure Horizons", "plan_name": "500449", "standard_charge_dollar": 7.58, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "United Health Care/", "plan_name": "500292", "standard_charge_dollar": 8.57, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "United Healthcare", "plan_name": "750104", "standard_charge_dollar": 8.57, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "United Healthcare Ba", "plan_name": "750090", "standard_charge_dollar": 8.57, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "United Healthcare Me", "plan_name": "501310", "standard_charge_dollar": 7.58, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Windsor Mcare Extra", "plan_name": "500778", "standard_charge_dollar": 7.58, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." } ] } ] }, { "description": "Dextrose 5 % and 0.45 % sodium chloride intravenous solution [9814]", "drug_information": { "unit": 500.00, "type": "ML" }, "code_information": [ { "code": "S5010", "type": "HCPCS" }, { "code": "0338-0085-03", "type": "NDC" } ], "standard_charges": [ { "gross_charge": 81.81, "minimum": 6.03, "maximum": 6.03, "setting": "both", "payers_information": [ { "payer_name": "Aetna", "plan_name": "700700", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna", "plan_name": "700700_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Miscellaneous", "plan_name": "700720", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Miscellaneous", "plan_name": "700720_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Ppo Hmo", "plan_name": "701720", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Ppo 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"standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Federal", "plan_name": "400110", "standard_charge_dollar": 6.03, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Federal", "plan_name": "400110_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." } ] } ] }, { "description": "Dextrose 5 % and 0.45 % sodium chloride intravenous solution [9814]", "drug_information": { "unit": 1000.00, "type": "ML" }, "code_information": [ { "code": "S5010", "type": "HCPCS" }, { "code": "0338-0085-04", "type": "NDC" } ], "standard_charges": [ { "gross_charge": 81.81, "minimum": 6.03, "maximum": 6.03, "setting": "both", "payers_information": [ { "payer_name": "Aetna", "plan_name": "700700", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna", "plan_name": "700700_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Miscellaneous", "plan_name": "700720", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Miscellaneous", "plan_name": "700720_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Ppo Hmo", "plan_name": "701720", "standard_charge_percentage": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Aetna Ppo Hmo", "plan_name": "701720_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Ms State Emplo", "plan_name": "401457", "standard_charge_dollar": 6.03, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Ms State Emplo", "plan_name": "401457_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Basic Pl", "plan_name": "400100", "standard_charge_dollar": 6.03, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Basic Pl", "plan_name": "400100_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Federal", "plan_name": "400110", "standard_charge_dollar": 6.03, "count": "0", "methodology": "fee schedule", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." }, { "payer_name": "Bc/Bs Of Ms Federal", "plan_name": "400110_1", "standard_charge_percentage": 100.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Insufficient remit data to calculate allowed amounts." } ] } ] } ] }